Monday, May 29, 2006

Jessie Journal 3

It’s muggy and hot, and I am sweaty and tired. Jenn is in front of me, and we are climbing the hills of La Colonia. This shouldn’t be this hard; I consider myself in shape. It’s gotta be the heat, I tell myself; I haven’t been drinking enough water. We stop for a moment to catch our breath, although my pride hopes that it looks like we are just taking in the view. It is a beautiful view from up here. Ironically, it is possibly one of the only places in the world where the quality of your view is inversely related to how much money you have.

There is poverty in La Colonia. And, although there are exceptions, it seems to deepen the higher up the mountain we travel. At the tops of the hills, we find small houses made of mud and sticks and tarps. The women we interview tell us that they and/or their husbands have very little consistent work. They are worried about having enough money to purchase food and they often feel like they are not able to feed their children enough. Some of them tell us that they have whole days when they do not eat. Their water situation is not good: There are exposed PVC pipes that should, theoretically, deliver water to their houses. Unfortunately, the pump from the well is not great, so they only get water once every eight days. Those people that work must rely on neighbors to gather water and, once gathered, the water is stored in open containers, which is a mosquito’s paradise and, thus, malaria’s breeding ground. And several of the very high houses don’t have water pipes, so those families must carry the water up to their houses.

Sometimes I compare the poverty I witness here to the poverty I saw in Tanzania. This is sort of a strange thought process. Usually I think, well, in Tanzania most poor villages don’t even have water pipes, so La Colonia must be better off. But then I remember that many of those villages are close to natural sources of water. In addition, many rural Tanzanians grow, raise, and hunt the majority of their food. For reasons unclear to me, very few people grow vegetables in La Colonia. Chickens abound, banana trees grow, I’m sure some people hunt and fish, but overall, it seems like many people rely on the market for their food. Thus, I think, perhaps those that still have access to the means of production of food are better off. This thought process degrades into a simplistic “my country is poorer than your country” debate. The reality is that there are people in Tanzania who are impoverished and there are people in La Colonia who are impoverished. The reasons and the resources may be different, but the results are similar: malnutrition and disease.

I think I am becoming calloused, which is something I was hoping to avoid. I notice it the most when I see the reactions of tourists who are witnessing extreme poverty for the first time. Sometimes, I am not shocked by dirty wounds or lack of water. And sometimes I am not horrified by bellies swollen with malnutrition and people dying from treatable diseases. Occasionally I try and use cultural relativism to rationalize poverty: it’s a different way of life than mine, seeing bad in this way of life is assuming my way of life is better. But, no one in the world thinks that parasites and stunted growth are ways of life. There is a middle ground between complete cultural suppression and dire poverty: clean water, enough food, basic health care, and respect are probably a good start. On a side note, it seems that these positive changes are much slower to develop than the negative changes– soda and chips are incorporated into almost every La Colonia family diet, even the poorest families own a television (although some would argue with me about the evilness of t.v.), and trash is a huge problem in the village.

In the end, I hope that my calloused thoughts come and go. I think that it is important to be occasionally overwhelmed by the effects of poverty. And, similarly, I think that feeling guilty can be useful. I also think that being productive is dependent on being able to detach oneself from such thoughts.

Such heavy thoughts. I’d like to end this journal on a more positive note, but it seems that I am stuck. Let’s try this: I have loved this experience. I have met amazing people, from the island, the mainland, and the rest of the world, who are really set on improving the world around them. They have been working at it for years and they aren’t discouraged – well, sometimes they are, but they keep going. They are practical, realistic, hard-working, fun-loving, multi-dimensional people. They have innovative ideas and are willing to peck away at problems over and over again. They aren’t saints and they aren’t failures – they are just trying to do something, anything that is pushing the world in what seems to be a better direction.

And those are my thoughts for the week. Thanks for listening folks. . . it’s been a great time here.

Jerry Journal 7

When she had first arrived some five years ago, I’d like to think that she wasn’t alone. Zeus and Ana, siblings, had been her guides for those first three years. She had raised them since they were young and watched them grow larger and larger by the day, and when Ana was old enough, her slick black coat and youthful eyes attracted so many males that she ended up suffering from a venereal disease. In her third year Ana died of uterine cancer, with a tumor so large that it corroded her stomach.

The very next day Coco arrived at her doorstep, the smartest and ugliest one of them all. By then she had outgrown her clinic from her downstairs bedroom to a fully stocked four room treatment center. One day when she went to visit a neighbor at his home, she had shut the backdoor gate behind her. Zeus and Coco followed, but went around the gate towards the front entrance. As it turned out, a car had hit both of them. Zeus survived.

When I arrived on the island a little more than one and a half months ago, I met Zeus and Taber—the favorite, a year-old blond with perky ears and a comic, playful demeanor. My favorite was Taber too; he was smart enough to open the screen door at least. But over the past several weeks I grew fonder of Zeus. He was not as intelligent as Taber and not as beautiful as him either, but he was simple and loyal, bold and protective, independent and humble. He had followed me whenever I would go to clinic, and would sprawl out lazily in the inn for days. At nights we would hear him outside, never heeding the yells “shut up, Zeus!” When I would read on the porch hammock, he would come up from under me, scratching his back, waiting for me to give him some attention. Zeus and Taber would always travel together, but they were obviously very different. Taber would always come home at night, for one, and we would find Zeus wandering about at random places, at random hours. Taber loved to shower himself in the sea; Zeus never did. Taber would always respond when called and Zeus, well, he only responded to the broom. I had grown to love Zeus’s mannerisms much more; he was his own and not owned; he was a loyal friend but no servant. He had personality.

So when he was lying on the ground outside the house, motionless, eyes gaping, mouth parched, we were waiting for someone to say exactly what we were thinking. She had finally said it, his companion for five, gruesome years—“he’s dead.” But when she checked his heartbeat, he suddenly gagged, choking for the air that wasn’t coming through. And while I was sitting in the back of the truck, his body wiggling in response to every bump in the road, he looked lively to me, his movements, but his eyes were glazed over like emptiness encapsulated in marble. The doctor pronounced him dead five minutes later.

This was the first time someone even mildly close to me had died. I had seen animals die before, people die before, and dissected people even, but how was that going to prepare me for a death of a friend? I had only known him for less than two months, but as I was burying him, my hands blistering over every swing of the pickaxe, every thrust of the shovel, I wondered how she was. Zeus represented all her work here, her five long years of struggle for the people on the island, and it suit him to be buried next to the site of her new hospital, still in construction. She was burying the past. But the funny thing was, I looked at her face and my own, and our expressions were the same, an emotionless smile, a face neither solemn nor apathetic. This was her third burial; her hundredth death; her thousandth loss. How many more deaths I would see? Deaths of patients? Deaths of friends? Deaths of family?

My first real medical experience, in my opinion, so far removed from physicianship that I almost failed to count this experience as my most important and memorable medical lesson. It seemed like just another day on the island, a surreal, lethargic amble of an existence, made of daily changes so continuous that the weeks meld together into one globular whole, until we have realized our time is over and how much of an impact each moment has been.

And what exactly had I learned? I’m still unsure, but as I stared deep into the dark pools of those empty eyes, I had grown a little older, a little sadder, and much more determined.

Jerry Journal 6

Last Wednesday a group of students from a boarding school in Colorado came down to Honduras as part of a senior trip for a class on globalization and anthropology. That morning I took four of them and their teacher with me to monitor infants in the Colonias. We went to each house in Pastor Obence’s partition in Policarpo, checking each infant’s current weight against a growth chart, along with recording data on birth weight, status of vaccinations, history of diarrhea and other common childhood illnesses. Along the way, we referred several kids to Peggy’s clinic, some with asthma and severe coughs, some with scabies, and a few suffering from malnutrition. It was revitalizing to see the children’s happy faces and our own to mirror theirs, in light of a backdrop of sand-dirt beds and tin roofs. Everyone was welcoming, friendly, inviting, although I’m sure our procession of six gringos and one pastor must have been intimidating. On Thursday, the students returned to the Colonias to teach hygiene to the elementary school. They brought soap, toothbrushes, and toothpaste for each of the kids and played Simon Says and a local chicken game. It was a rewarding experience for the kids as well as the students, offering each other a taste of their respective cultures.

Since my arrival on the island, I hadn’t really noticed a big disparity in between Roatán culture and American culture. At first I thought they were fairly similar; most people on the island believe in Christianity of some sort, and there was no apparent native religion or set of unified cultural beliefs present. I’ve slowly begun to recognize the large differences in life here, differences that were so painstakingly obvious but were covered by a thin veneer of Western influence. Marriage and sexuality, for example, is very third-world. I was talking to a friend of mine the other day about this topic and he told me he lost his virginity at eight years at a fifteen year-old. “Second grade!” I exclaimed. Sexuality had been made so evident, even to the prepubescent. He was telling me that it was extremely rare for a man to abstain or have few sexual encounters (his brother being one, and ridiculed often because of it), as the opportunities were endless—older women, younger girls, married women, gringos, even (the other night he had an encounter with a married thirty-one year-old gringo; he is only seventeen). He said that he practiced safe sex as much as he could, but mostly when it was visual—when he could see the pubic lice. Often he wouldn’t have access to condoms, and who knows how prevalent STDs are on the island. Most peculiarly, when I asked him about his religious beliefs, he said that he was Christian, like most islanders, and he did believe that premarital sex was a sin. However, he explained, he would be forgiven no matter how many times he committed the sin, so it was fine for him to keep on doing what he was doing.

I blame American media. I hadn’t know how much of an influence it was until coming here; our movies, our TV shows, our music videos are broadcasted all over the world, and what they see is what they think is standard American practice. They see the clearly-explicit sexual innuendos of our media and obey it. I was talking to a Russian friend earlier this morning and he said that the Russians think that all Americans are fat because of McDonalds advertising. Kenfor, who is only nine and is one of the kindest kids of his age that I’ve ever met, wishes to be a professional fighter (he loves WWE). My aforementioned friend says that he plans on getting a 6mm gun, and although he says that he doesn’t want to kill people, he has no qualms about doing it. After all, our violence-filled media substantiates gun possession as an essential tool, does it not?

On a mild tangent, I believe that third-world medical practice is different from American medicine. In America, doctors have a disincentive to treat due to the threat malpractice suits. Here, the islanders are grateful for whatever treatment we can give, whatever advice we have, and even in instances of death the family members are thankful for our service. Going from house to house, monitoring blood pressure and sugar, I realize that we are not treating Americans; we are treating the third-world, people who are in great need and always thirsty for guidance, for assistance in what little ways we can give. I don’t think we should deny them of that even in our incomplete medical knowledge. It is true that I am not a doctor, but neither was Peggy when she first treated her patients, nor everyone’s favorite doctor, Paul Farmer, when he treated the Haitians. I’m not saying we should go around treating people without the experience or chancing the communication of fallible information, but I don’t think our student status should stop us from taking an active interest in each community member’s lives, in doing more than our job description requires, and in taking calculated risks for the betterment of the people here. It is not only required of us as future doctors, but as future leaders as well. We are here for the patients, most importantly, and not to impress heads of state or influential people. I think this is an important reminder, especially in a place where it is easy to forget the baseness of the human condition and fall into the magnanimity of failures which cloud creativity for possible solutions.

Tuesday, May 23, 2006

Jessie Journal 2

Children are great. I mean, most people love children and those that don’t still enjoy them from a distance. And for the most part, children all over the world* run on the same principles: they smile at you if you smile at them, unless they are 18 months old, in which case, they cry; they find repetition hilariously exciting, and they think that stickers are just about the coolest things on the face of this planet. But sometimes you meet a child that just strikes you – a little boy whose frightened, huge eyes haunt you or a little girl who is just glowing with happiness, like the one I met a few days ago. She had a round face and a round belly and her hair was pulled into two little round puff balls on the top of her head. She was missing about four of her upper teeth, all from the right side and she had a make-you-feel-warm-and-fuzzy-inside smile. Plus just about the cutest high pitched giggle. And she was a spinner – I mean that figuratively and literally. She was spinning with energy and she was expressing that energy by spinning. She kept running over and giving me a huge hug, and then speaking very earnestly in her very own language. I was completely taken with her.

This story is going somewhere. See, after I triaged her, the mother requested to see Dr. Charles specifically. When he brought her in, she said, “I know you.” He looked perplexed because he did not recognize her. “I know you,” she said. “Were you working in the hospital in San Pedro Sula three years ago?” Dr. Charles nodded, “I was working as an intern there.” She proceeded to tell him that three years ago he delivered her baby (who grew up into the ridiculously happy girl I described above). Dr. Charles remembered her – it was a complicated birth (placenta previa), there was no surgeon available to operate, and no one was stepping in to help the mother who was hemorrhaging. Dr. Charles stepped in to save the day and three years later he was lucky enough to witness the difference he had made in someone’s life. Ahh. . .I just can’t wait to be a doctor.

Moving on, this has been an interesting week filled with lots of discussions and events that make me wonder what should be the role of foreign assistance from the first world (alien assistance, if you will). There are so many people who have a strong passion to help others. It’s usually stated as a desire to “help those less fortunate” or “serve the underserved (or underprivileged, or disadvantaged. . really, take your pick). But this altruistic drive seems to come from a place of arrogance. Actually, I think there is no seems about it - it does come from a place of arrogance – perhaps not intentional or malicious arrogance, but implicit in the concept of help is the belief that you know something that others don’t, and that something is superior, and I would define that as arrogant. Thus, there is a certain paradox in this world of aid: Most people wanting to help others are not arrogant, but the act of helping is arrogant.

So what then? Why am I down here? Why do I want to dedicate my life to working with underserved populations? How does my belief (or at least my desire to believe) that no one person or culture is superior to another reconcile with my interest in helping others. Usually I can gloss things over and push through them, telling myself that I am different because I want to work with underserved populations, not help; I tell myself that I am different because I recognize this inherent arrogance. But really I am just playing word games. Perhaps the answers lie in the reality that the world is shrinking (trite, I know) and first world countries need to learn from other cultures some of the more intangible things that we don’t do very well (like raising children, eating better, caring for the elderly). We also need to teach those usually more tangible things we do well (like clean water, gender equality, and, my favorite, health). A genuine give and take. And perhaps the truth is for all of us working in seemingly altruistic fields to cast off our cloaks of martyrdom and admit that we do what we do for selfish reasons: to learn and grow, to feel good about what we do, because we enjoy learning about other cultures, because we like feeling superior – whatever the reason is. After all, biology teaches us that there is no such thing as true altruism. It’s all for the betterment of the genes.

Speaking of genes, although I miss my jeans, I highly recommend not bringing any jeans down here. It’s hotter than hot. I wake up wishing that clothes were never invented (and really, it is ridiculous that we wear clothes down here). And I brought all of the wrong clothes. If you are reading this and planning to come down here, just know that whatever you are thinking of bringing you should put it aside and bring something cooler.

Well, it’s about 7:00 and the sun has just set: the sky is a warm grey with a streak of pink running through it (nature does the best color coordinating), Ray Charles is singing Georgia, and Jenn and I are going to head over to the West End for a late dinner. So, no more silly liberal school educated thoughts for me – I’m signing off. G’night, Sianora, Ciao, Buenas noches.

*my version of all over the world being the few countries, including my own, that I have spent some time in.

Monday, May 08, 2006

Jerry Journal 5

A little bit about what’s been going on in Roatán, and what I’ve been up to.

There are currently two projects with the community of Las Colonias, made up of Policarpo and Balfate. These residents are mainly Spanish-speaking Latinos from the mainland that immigrated to Roatán not too long ago after the hurricanes. They live in shacks, in mud/wood houses, and have running water only for two hours every ten days. The housekeeper for Peggy, Earma, lives there and is also one of the 8 community volunteers that we train to monitor high risk infants. We check for diarrhea, respiratory illnesses, and malnutrition, among other things. My goal is to see that they monitor the infants correctly by going with them for the first couple of times and to make sure that they go every month. The project also gathers data on these infants to use as grant material and research data. These are collected monthly and input in a database. We’ve already had two meetings, and I’m planning on going with a volunteer this Wednesday on his rounds.

The other project in Las Colonias is establishing a waste disposal system. The area does not have trash cans, so it is littered with garbage that the garbage men don't want to pick up. Our goal is to make dumpsters out of barrels with holes in them (so the residents won't use them for water storage) and situate them around a wooden fence so the dogs can't get in. We have already located about 15 spots where we need to put these 78 barrels. Our current objective is to get the materials ready by next week; a group of thirteen students from a private boarding school in Colorado is coming down, and I'm thinking of putting them to work on this project. We can use the free labor, but first we need the wood so that it can dry by the time they arrive.

Another project is one regarding hypertension and diabetes in Flowers Bay. The community volunteers there are already trained also; we just need to start monitoring. We had our last meeting yesterday about how to take blood pressure, and today we accompanied one volunteer on her rounds. The objective is to raise awareness in the area and to successfully identify and treat high-risk diabetic and hypertensive individuals.

Our newsletter was written and finished yesterday, with five articles on Global Healing activities. Also, the Global Healing president will be coming down to Roatán next week to assess healthcare needs and resource distribution.

As a pharmacist in Peggy’s clinic, I have learned all about medications and treatment. Sorting her donations, organizing her pharmacy, and working in the morning have made the highly eclectic medical vernacular much more accessible. Last week we went over all her medications and threw out/burned the expired ones. The Ministry of Health came by last Friday and closed down another pharmacy due to expired medications (as well as fining $2000). We decided not to risk holding on to expired medications. But I’m not sure what the Ministry of Health did is noble; after all, expired medications, with a possible decrease in efficacy, are better than no medication at all, right?

I'm also planning a categorizing system for triaging in her clinic. I’ve made a spreadsheet so that it will be easier for the nurses to locate the names/numbers of patients. There has been a large problem organizing the card system that we have now since some of the nurses don’t know the alphabet. Plus, this way, finding names and entering them will be much easier. I need go through over a thousand cards and teach the nurses how to use the database by Monday.

Lastly, Peggy's new hospital needs to be built. Her current clinic is only four rooms borrowed from SonRise Missionary Inn. I'm working on writing grant proposals to the Gates Foundation to get funding for the completion of the project and, hopefully, its sustainability as well. Peggy introduced me to a couple of contacts that are already working on the project; hopefully I can help them do the research they need (as they are currently living in the US) and write the proposal.

Jaime left today. We went ziplining in West Bay to see her off.

Saturday, May 06, 2006

Jessie Journal 1

My first week at the clinic went surprisingly smoothly, given the regression of my communication skills to about age two. My Spanish is slowly returning – forgotten words pop up at random times and, if I am lucky, I am able to correctly match a pronoun and tense with the proper verb conjugation. I’ve discovered that the secret is to simultaneously focus and relax and to remember by not trying to remember. That and if I speak slowly, other people respond more slowly – I always think that by speaking fast, I will convince people that I am fluent in Spanish. Of course, I end up being in trouble if I actually succeed in that, because then people speak to me as if I am fluent in Spanish, which I’m not. Thus, I often end up nodding my head and smiling, and occasionally laughing for good measure without understanding a word that I heard.

The clinic is great – witnessing what public health care is like in Honduras, interacting with patients, learning about what the most common ailments are on Roatan, and having 4 enthusiastic teachers eager to share their knowledge (Dr. Charles, Dr. Jamie, Dr. Gross, and Dr. Kristen). A month is a very short time in the world of public health, so it is nice to have some projects to plug in to: tomorrow and Saturday I am helping with the Flowers Bay Health Volunteer Diabetes project. Next week, I am helping the midwife, Bernadette, with a family planning/birth control activity. In addition, I hope to help Jenn in La Colonia with some of her research – I look forward to seeing that area and meeting some if its residents. Peggy Stranges, a nurse from Ohio who has incredible energy, vision, and follow-through, continues to provide me with a wonderful education about the difficulties facing island health care and the politics that, unfortunately, permeate it.

I decided to participate in this internship primarily because I wanted to experience working/volunteering in another country (specifically in a developing nation). I have spent time in other developing countries as a student and as one of those gringos toting around a huge backpack, and I have always said (somewhat naively) that, as a doctor, I hope to work in international health. This internship gives me a chance to shed a bit of that naiveté and test such a theory out. And. . .so far so good! Becoming involved in something beyond the tourist’s eye has, already proven worlds more rewarding than studying or traveling. More than that, I have greater confidence when talking to locals and I feel more established in the community (and how quickly that happened – in less than two days the local baleada seller knew me by name and a few days after that, her daughter had me in the kitchen learning how to make baleadas). I love not living on the tourists’ path - I spend the beginning and end of my day saying good morning and good night to the same people. Rather than always feeling like an outsider observing others, my daily life occurs in conjunction with the daily lives of my neighbors, taxi drivers, patients, and store venders. So this is a good way to be in another country – I think it will be difficult to ever travel another way.

Today is Thursday May 4th, which means that I have been in Roatan for thirteen days. It’s hard to believe that I’ve been here that long and it’s hard to believe that I’ve only been here for thirteen days. Time seems to absorb itself down here. The sun rises at the same time every morning, the wind blows in the same direction every afternoon, and the dogs bark at the same things every night. Things you can count on down here: there are always people awake later than you and up earlier than you; nothing happens when you think it is going to happen; if you say hello to someone on the street, they will say hello back to you; if you are a woman, the second question your taxi driver will ask is “Are you married?”; the internet will be down at least once during the day; freshly-made tortillas taste absolutely amazing. Life on this island is great.

Jerry Journal 4

On Wednesday, I went out to the mayor’s office to discuss public health matters on the island with Nora and Miss Peggy. As a politician, he was flawless. We got very little accomplished; throughout the meeting, I was squirming in the leather-bound sofa hoping that someone would get to the point. Politics is a terrible game to play for those who are dissatisfied with the status quo. I had passed out in boredom somewhere in the middle of the meeting, as I had realized the futility of discussing the importance of well-managed health care to a businessman, but as we exited the municipal building, I begun to think of this experience not as a failure, but as a lesson in perseverance and preparation.

Of course, there’s always the problem of whether or not we should go to the government for help. Being a gringo, I have no idea what the system is like down here, but a native doctor, who had worked for the municipality during his social service years, said that going to the government means that we would be government-owned, that they would have full control on our (the people’s) operations and management of the health care system. I heard that several months ago the mayor had cut the already-dwindling hospital budget in half, to a mere $500 a month (we don’t even have a defibrillator on the island!), while the police gets $1800 monthly for food only.

When we were done with meeting the mayor, Peggy seemed disgusted over his remark of her alleged partisanship. The previous mayor had provided Peggy with funding for Dr. Raymond’s salary. How temporal and situational political deals are, I thought. Now that the Liberals are out of power, donations alone pay for Raymond’s salary—and Peggy still owes him.

There is no other limiting factor to the establishment of the Peggy’s new clinic, complete with a birthing center, lab equipment, a community meeting room, a kitchen, an office for Raymond, and several treatment rooms, than that of money. I had decided to help Peggy with getting that so her clinic can be built. We have all the logistics ready—the floor plans for the clinic are complete, the construction workers are hired, the materials are waiting to be shipped. In addition to working on the waste disposal and infant monitoring project in Las Colonias, the diabetic and hypertensive education project in Flowers Bay, in working on RCPHI’s sustainability and communicability, in Peggy’s clinic as a pharmacy technician/janitor, as a personal secretary, day planner, and computer technician for Peggy’s life, I have started to write grant proposals and marketing/advertising schemes to help with the filling the $55,000 hole we need to insure adequate health provision on Roatan.