Reports from Guatemala

“I want to.. but my husband..”
- Women at the VIA clinic, when talking about family planning

I attended a one-day VIA jornada to the Chimaltenango area, specifically San Lorenzo El Tejar, about 45 min from Antigua. The jornada was lead by Dra Oviedo and her nurse Lorena Chanco and we were supposed to start at 8 and work till 12, but in reality the schedule is dictated by the number of women that showed up. We set up two clinics and, assisted by the local doctora, saw about 48 women. Each woman underwent the visualization with acetic acid for precancerous lesions, as well as a mandatory pap smear. The government is still a bit unsure about the validity of the VIA, so many puestos de salud still prefer the pap smear despite it’s ineffeciency (ie women have to return for their results, then make another appt to be treated if necessary).

The exam itself is very simple - inundate the cervix with acetic acid for a minute and observe using the naked eye. And therein lies the problem - the diagnosis is very subjective and the detection of precancer relies completely on the training and confidence of the practitioner. It took me at least 3 patients to even see the “matriz”, a normal clear white lining around the cervix. Then the hard part was distinguishing the normal matriz from an abnormal one: if the white areas are larger than normal, off-center, or had jagged edges. By the end of the day, I still wasn’t sure that I could see the precancer lesions (Dra Oviedo found 1 in every 10 women), much less make a diagnosis.

One interesting issue brought up was the issue of family planning, often times a source of conflict between husband and wife. These women had 5-8 children on average, one even had 10 children. A girl of my age came in, 21, and she had already had 3 children. (And there I was, standing there watching her exam, still perceiving myself as in transit from child to adult.) Some women were interested in family planning, but almost all said that their husbands were not. Some women had come to get tested without even telling their husbands, for fear that they would not allow it. The machoism is very prevalent here, with men making decisions for their wives without understanding the extent of the situation, if acknowledging the health risks at all. The women had little or no say, and the female doctors present could only offer encouragement. Despite their expertise, they are still women first, and thus their words would not hold enough weight to sway a stubborn husband.

When we went to meet with WINGS, a women’s health organization, Emily (Sarah’s friend, our contact) made an important point. Education and empowerment so far has been focused predominantly on women. But educating men on women’s issues is just as important, because ultimately they are the ones who make many decisions in family settings. They have a new program, specifically for educating men, and have ended up with amazing results, including men health promoters who are aware of the importance of women’s health and willing to talk with their peers about it.

“We’re modern”

Last Thursday afternoon, I did another one of our discussions/lessons. I had looked up information on maternal and infant health from the book “Where There Is No Doctor”. Many of the points were very important, if not obvious. Information on my outline included the importance of breast-feeding, when children should start eating solid foods, and care of the mother before and after pregnancy. As I went through the points and tried to elicit some kind of response or discussion from the mothers, I got a lot of nods and stares (boredom?). I repeatedly asked “what do you think? In your community, what are the traditions or typical habits in -insert-situation-here?” Finally, at the point when I mentioned that all people participating in the birth of the child (midwife, aunts, mothers, etc) should wear gloves, a woman spoke up and broke the awkwardness. “Yes.. the whole doctor team wears gloves. We’re modern, you know? We go to hospitals.”

At this point, I realized my major mistake. Here I was, talking to a group of women who brought themselves and their family in to see a team of visiting American surgeons. These women are involved in the modern medical system, have seen doctors, and probably know more about health and nutrition than me, just from experience. The book that I was following, as pointed out later by a Peace Corps volunteer friend, was really for communities where there is no doctor, or even a prometor de salud, a national health representative. These women, on the other hand, live in towns that were visited by the jornadas and specifically were referred to Antigua for their surgery. These are not women of communities that have yet to be exposed to “modern” medicine, as in delivery rooms and pill medication. Instead, these are women who brought their family to the visiting surgical teams because they understood the importance of health care. These are the women who already know about nutrition for their babies, from personal and collective community experience passed on generations before books were written. As the saying goes, I was preaching to the choir.

My notes all of a sudden seemed condescending, belittling, and quite useless.

“We work with what we have.”

We just returned from visiting Dra Oviedo at the local Centro De Salud outside of Antigua. Dra Oviedo has been working with the VIA-Cryo program at Obras Sociales for about two years now, doing jornadas and clinics at OS and the centro. Usually, her jornadas are one-day trips, where she sees about 100 patients a day. Her experience with the program was very helpful for us to further narrow down the formulary to the minimally required materials.

As we went down our list of “required” items, many times, she raised her eyebrows in surprise. “Well, we don’t have that.. so we use this instead.” Her substitute was often a common item, such as donated patient robes cut up into pieces to use as a cushion instead of FIP’s chucks, these thicker cotton pads. Also, FIP would buy large cotton swabs from the US and use those in the exam - but these are expensive and cannot be found in Guatemala. Therefore, Dra Ovieda and her staff make their own large cotton swabs by rolling more cotton around smaller swabs. Much of the “in case” medication we had on the list she agreed with, but added as a side note that oftentimes she just brought whatever free medication was available. Her resourcefulness and experience made me feel that FIP is quite lucky in its funding, donations, and connections - how great for the doctors and nurses that train with FIP!

Dra Oviedo then invited us along to one of their jornadas next week to Chimaltenango (20min from Antigua central), so we can get a chance to see exactly what VIA-Cryo is. Next week is going to be quite exciting!

subject: the power of women

Thursday afternoon we had our first “lesson” to the patients at the Casa de Fe. It was mainly on nutrition, or how to eat a balanced meal with the foods found in Guatemala. I went around the Casa rounding up women of all ages, inviting them to a “charla” on nutrition. We sat around one of the comedor tables on stools and I introduced myself, emphasizing that they probably knew a lot more than I did. And how true! I technically “taught” for about 15-30min, emphasizing the importance of getting vegetables and fruits into the diet, but realistically, most of the time the women led the discussion. It was great! I had cutouts of different foods (rice, beans, fruits, eggs - 29 foods I assumed could be found in Guatemala) and we had fun arranging and rearranging different meals. They talked about different recipes they use, how you can use both the leaves, branches, and roots of the cassava plant, how they prepare certain dishes, what their favorite dishes were, etc. I told them about how the water used to boil vegetables can also be a soup. They continually pointed out how beans and rice with tortillas are the normal meal, and things like eggs and vegetables were harder to come by. They all said they have herbs though, so I encouraged them to add as much green as they could into their diet. They shared local cooking techniques and exchanged rumors (”my brother said that his friend ate 18 chilis to relieve ulcers” - incorrect perceptions and rumors is a topic we really need to tackle!). Then, the conversation launched into their favorite dishes and how to prepare them. After an hour of talking, I felt myself getting very hungry and could almost taste the buttered corn with tomatoes in my mouth!

The amazing thing about Fe en Practica (FIP) is that they bring in patients from all over Guatemala. Around the table, we had women from rural pueblos from El Peten and the coast next to each other, each with their own local language and traditions. United by Spanish, they were able to learn from each other (and I from all of them) and hopefully bring it back to their own towns.

After the chat, I realized some major things.
1 - Women are so powerful. They run the house, feed the family, and raise the next generation. Put them together and the knowledge passed on from ages ago suddenly flows across the country through a common bond of womanhood.
2 - We need to have a lesson clarifying misconceptions and rumors
3 - We need a lesson on childhood nutrition, ideally from prenatal, through infant, and up to primary school age
4 - I really enjoyed just sitting around and talking with them about daily life; hopefully I can do it more often!

18 June 2008

Finding a dental education video has proven to be quite a challenge!!! This is one component of the dental hygiene education program that Faith In Practice is really looking to obtain. They want to be able to play a video describing proper dental care in their dental clinics and at Casa de Fe to reach a larger population. Casa de Fe is a place where patients, who have traveled very far to have medical work performed in Antigua, can rest and recuperate before they have to make the long trip back home (often many hours on a crowded public bus). Casa de Fe also works to find people in rural Guatemala that need specialized medical procedures and arranges for them to travel to Antigua to find the care that they need.

Searching the Internet, there are a number of videos available in Spanish, but none of them have been culturally relevant. We need a video that teaches proper brushing technique, discusses the cause of tooth decay and periodontal disease, and provides an overview of the role of nutrition in dental health. This is all very basic information that we are trying to convey. The problem with the Spanish-language videos I’ve found on the Internet is that they include excessive information that is not appropriate for our audience. For example, for people who don’t have access to regular dental care or even sometimes toothbrushes and toothpaste, showing a video that discusses cosmetic dentistry procedures is not appropriate. It is not realistic to recommend that rural Guatemalans visit a dentist every 6 months for a cleaning. Instead, it would be much more helpful to discus location-relevant information. For example, the book “Where There Is No Doctor” recommends that if toothbrushes are not available, a makeshift toothbrush can be created by shredding the end of a twig to act as a brush, and sharpening the other end to clean between teeth. I’ll keep looking for a video that includes this type of information, but I would be happy to find a video that just covers the basics of dental hygiene without the excess of culturally irrelevant information. 

13 June 2008 

At the moment, Tiffany and I are working on three simultaneous projects! And each project has multiple facets! For example, for the VIA/Cryo project, we’re developing a list of needed materials for weeklong clinics, daylong clinics, and teaching sessions. We’re also going to design an insert system for the trunks that are used to transport the VIA/Cryo materials. Along with the formularies we’re developing, we’re creating a set of informative documents. These documents will be used to help the hospitals that are instituting the VIA/Cryo programs. One document contains tips for publicizing clinics, another contains a list of materials that are needed for administering VIA/Cryo and where the hospitals can reorder these products. And this is just the first project! For the dental hygiene education program, we are working to gather information about what already exists in Guatemala. I’ve spent hours looking on the web for organizations that are doing dental work in Guatemala. There are a number of programs that bring dentists down here to work in rural areas for a short period of time, and many say that they are working on promoting dental hygiene education, but none of them elaborate on how exactly they implement the education programs. So, I’ve been sending out e-mails to organizations, inquiring as to what their education program is composed of. We’ll see what type of replies I get back! 

Capacitation.

Yesterday Dra Pati took us to Retalhueleu (Reu for short), a town about 3.5 hrs away where FIP was planning to host their next VIA-Cryo training course. One of the important aspects of VIA-Cryo is the “capacitacion” of centros de salud, or local outposts of the national healthcare system. Capacitacion would probably be loosely translated as enabling and empowering, in the sense that FIP provides a training course on visualization with acetic acid and cryotherapy to help start off a VIA-cryo program at a local hospital.
I summed up to goal as: to help the local hospital/organization begin their own Visual Inspection with Acetic Acid – Cryotherapy (VIA-Cryo) cervical cancer screening & treatment program, in hopes that they subsequently become self-sustaining programs, providing care to local and neighboring towns, reporting back to FIP with monthly updates. To the doctors and nurses who pass, FIP grants a cryotherapy gun and some basic information/equipment, as well as the backing of the organization. In return, the hospitals must maintain a dedicated staff to the program and provide monthly totals to FIP.

In Reu, we met with the hospital director and administrator to discuss the details (in Spanish, what a beautiful language) and I took notes. Sarah hopes to be able to create a document of goals and guidelines that we can give to future institutions FIP wants to partner with - on the expectations of the hospital, participants, FIP’s role, etc. The meeting was quite productive and the adminsitration seemed to eager to begin the program, with only slight hitches (cost, meals, etc). After the meeting, the director showed us around the hospital to the rooms they could potentially use, as well as a brand-new surgical room and delivery room. I have never seen anything so shiny before. Compared to the Ecuadorian counterparts I’ve seen, those rooms were luxurious. They were large rooms with plenty of space to move around and up-to-date equipment, including a room specifically dedicated to the autoclave. There was even a hand-washing station for doctors that had knee-height buttons to turn the water on and off! It was a beautiful sight, really.

I never really liked coffee before last week. But then we landed in Guatemala and I’ve discovered the global addiction. Guatemalan coffee isn’t the bitter coffee in the states - instead, it has a rich coffee-bean smell, sweet and smooth. Our host family (or at least, the apartment we’re living at) has this coffee mixed with wheat to decrease caffeine content, so you get the coffee with a slight wheat flavor in it. They also have champurradas, a biscotti-type cookie that tastes incredible when dunked in coffee. Our host mom, Janet, is an amazing chef and Meagan and I have resorted to joining a gym in order to keep up with our indulgences!

Aside from food, we’ve also been working quite hard here. Meagan talked about the dental education project we’re doing, and I’ll cover the VIA-Cryo one. VIA-Cryo, paired with the prueba rapida, is an immediate detection and treatment of precancerous lesions in the cervix. It consists of an acetic acid visual test then treatment with cryotherapy. FIP currently has training courses for doctors, nurses, and clinics from all over Guatemala and also conducts jornadas, or medical mission trips, to rural towns in Guatemala. There they administer free prueba rapidas and VIA-Cryo treatments to women who qualify.

Our job is organizational, almost along the lines of the Lab-In-A-Backpack. The VIA-Cryo requires a lot of random equipment and medication. Previously, the FIP teams scrambled around collecting the materials they think they might need, in quantities they think may be sufficient for the week-long jornadas. Working with Dr Pati, we’ve collected a list of all the equipment and determined the necessary amounts of each. We made seperate lists for the week-long trips, the week-long course, and the 1-day clinics.

Our next job is to go to the warehouse, make an inventory of all the available equipment, and then collect what is necessary for a one-week trip. Hopefully, we can bring it all back to Joe’s apartment (our workspace), organize the materials, and pack them systematically into these large trunks FIP uses. Ideally, we would create a standard set of items in the trunks, arranging them neatly, so that for future jornadas and courses, FIP teams would simply have to grab a trunk and have everything ready inside. It sounds a lot easier said then done, trust me.

As a side project to the trunks, we are also recruited to create advertisments and “propoganda” for the prueba rapida and the VIA-cryo clinics. Balancing this along with the dental education, and still fitting in time for cafe y champurradas, Meagan and I find ourselves hard at work!

Written on 10 June 2008I absolutely love how productive these internships allow us to be! We arrived in Guatemala at midnight on Sunday and on Monday morning we met with the organization Faith In Practice to discus the possible projects we could accomplish during our stay. Within our fist 24 hours in Antigua, we determined that we will be working on educational materials for the dental hygiene program that Faith In Practice is implementing both in Antigua and in rural Guatemalan villages. They already are sending traveling dental clinics out to remote regions of Guatemala, but they want to incorporate an educational component into the outreach trips. We will research the materials that are currently available, brainstorm possible new components, and put together a kit to present at schools as well as a second set of activities to be implemented in the dental clinics. I’m really excited that we can use some of the skill we learned when putting together the health education curriculum for Terrier Rouge, Haiti. It will also be a challenge because I do not have an extensive knowledge of dental hygiene beyond what I’ve learned at the dentist. I’ll have to research the components of a successful dental hygiene education program. We are also working in a new society, so we’ll have to ensure that the materials we find are culturally appropriate. This will be a lot of work, but I’m very excited to begin!