Sunday, November 25, 2007

Max Journal 10

This week has been a bit of a vacation for me as I've had two visitors from the US to entertain. I worked at Peggy's both Monday and Tuesday mostly in the pharmacy filling prescriptions. I'm feeling much more confident in that job as I get to know the organization of the pharmacy and the uses of most of the drugs. I have had a Canadian nurse's aide helping me in the pharmacy, and it has reminded me of how hard it is to utilize short-term unskilled volunteers. She helps me count pills and enter some information in the inventory, but really she mostly just reminds me of how amazing Peggy is to be able to
utilize so many people so graciously when a lot of them really just create more work for her.

On Monday, the psoriasis patient from several weeks ago returned to the clinic looking much better, and I took him down to Peggy's to clean off (this time he was able to shower himself). I was happy to see that he returned when told to and his skin was much better than when I first saw him, but I could tell that he hadn't bathed in days and was probably not going to be able to bathe in the sea as instructed to keep his skin clean, moist, and exfoliated.

I took Wednesday and Thursday off, which worked nicely because Peggy's clinic is always closed on Wednesdays and was closed this Thursday for Thanksgiving. Friday was a pretty normal day filling prescriptions in the pharmacy. I don't think I will ever be a professional pharmacist, but for the time being I do enjoy learning about the drugs.

Outside of clinic hours I have done a few work-related things. On Wednesday I stopped by Los Fuertes with my dad and girlfriend to look for a deaf girl that should receive a hearing aid next week. We had a vague address (above the Adventist Church) and two different names (neither of which was correct) to look for in Los Fuertes, but it ended up being a fun little search. I think especially having my father there helped lend a fresh perspective on the situation; recognizing that tracking someone down in the United States would proceed much differently than here. We found the girl without much trouble and gave her the necessary information, and I felt good about being able to navigate Honduran society to complete at least very
basic messenger tasks.

I have also been chauffeuring a lot of people back and forth around town, which I am happy to do, but I do worry a little bit about the liability involved. I feel comfortable driving on the streets, but I fear that it is just a matter of time before some driver makes a poor decision resulting in an accident. I know that in terms of safety, my driving is probably just as safe as if not more safe than other peoples', but I do feel a slight burden of responsibility being the regular designated driver.

I spent most of my Sunday at Peggy's clinic inventorying new medications that just arrived in a big shipment from the US, which was fun. My girlfriend, Maya , will be taking over for me in Peggy's pharmacy next week as I go back to the Global Healing clinic while Christine visits the mainland, so this afternoon was a good opportunity for Maya to get to know the clinic outside of regular business hours.

Our tutoring project is not going well because the students have not been showing up. Tomorrow we hope to meet with the students and maybe the principal to ask how else we could structure the tutoring to be less of a burden on the students, but I am disappointed that we will not be able to conclude the curricula that we began.

In addition to clinic work this week, I've had a wonderful time hanging out with my visitors and getting to know some of Christine's visitors. We've eaten tasty Indian food, toured Oak Ridge by water taxi, scuba-dived with turtles, had a proper Thanksgiving feast, and fished real "island style." This all makes me realize very clearly how "social tourism" or "voluntourism" can really work to many organizations' advantages, and how non-profits in less picturesque locations have a lot of unique challenges.

Christine Journal 10

Things are going well down here, and we've been having a lot of visitors, which is always fun. Max's dad and girlfriend were here last week, and my mom and sister just came this past weekend. My family will just be here a few days and then is going to the La Ceiba area and Copan ruinas, and I wanted to check with you guys whether it would be okay if I accompanied them a couple of days in Ceiba. I would be out of the clinic on Thursday and Friday of this week, and Peggy has said it's fine if Max leaves her clinic to work in the Global Healing one so there's still an intern there. I'd also be gone the early part of the next week with Jessica and Neri, the patient and mother I took to El Progreso a few weeks ago, to see if we can get Jessica plastic surgery at the clinic in El Progreso. Let me know if it would be okay for me to take those two days to travel a bit with my family, as I completely understand that I have committed to the internship and that it might not be okay to take the time off.

This week was a little crazy in the hospital on Monday and Tuesday, as we saw 23 patients (!) on Monday and quite a few on Tuesday. It then slowed down quite dramatically, as we saw four on Wednesday and about three on Thursday. Friday we were back to about twelve, so it was quite different day-to-day. At the beginning of the week, the social service doctor was still here and kind of in-and-out, so Dr. Normandin was seeing most of the patients and it was fairly overwhelming for her. I've been interpreting too, as she's still learning Spanish, so I'm always busy between interpreting and triaging. I'm loving all the time I get to spend with her and the patients, though! And she's heard me give the same schpeal about viral URIs in Spanish that's she's about ready to give one herself.

Dr. Normandin, Peggy, and I went up to visit a patient in La Colonia on Wednesday that really helped put these hospital visits for URIs in perspective, though. The lengths that some of the patients have to go to in order to get to the hospital (especially when it's rained and the roads have turned to mud) are incredible, so even if the kid really does just have a cold, it's really important to still spend time with the family and give them something (like vitamins) to walk away with. The patient that we were visiting lived at the very top of La Colonia, and we were practically rock climbing up the slope to his house. It was a 9-year-old with an end-stage abdominal tumor with inguinal metastasis who had been through a number of courses of chemo on the mainland. He probably weighed 10-15 kilos and often didn't eat because of the pain. We're going to try to get something to ease his pain, and the family seemed really appreciative that we had come to their house to visit them. It was a pretty emotional visit and was hard to see a family living on nearly nothing who had to care for a dying son.

Dr. Charles came back from his trip to Tegucigalpa applying for a new job, and things are back to normal (or as normal as they get) in the hospital. We had the internal medicine doctor give the lunch time talk this week, and Dr. Normandin will have one prepared for this coming week. A new doctor (Dr. Jennifer Cohen) came in on Saturday, so I cleared up the third examining room (or more like section) for her to use, which was a bit tough with the ultrasound machine we still have waiting for someone to be able to use and move to a place where it will be safe.

The math tutoring project seems to be needing a new direction. We went on Tuesday to, again, find all the students had gone home because they had too much work. After speaking with the school's director about how holiday season was especially hard for students with exams and other projects, we decided that we needed to reassess the tutoring sessions and how to best help the students. I think that it's hard for the students to really see how this directly benefits what they're learning in math, as a lot of what we're teaching really does give them the foundation for what they're doing, but it's not so obvious how it helps them with algebra or geometry homework. So, it was disappointing to see no one there again, but we're hoping to meet with them tomorrow to talk about a direction to go with the tutoring and see how we can best be of help.

Thanksgiving was really nice - we had a fun, eclectic group of people for dinner at Dr. Patrick's house. We did potluck style, too, and had all of the Thanksgiving essentials! Everything was delicious and the company was great - volunteers with Peggy and Global Healing, Dr. Raymond and Dr. Charles, Joe Soloman (the chief of police), etc.

Sunday, November 18, 2007

Christine Journal 9

As Max wrote, we have now switched work places, and I'll be in the RVPC for the next few weeks. It's crazy how fast our time is passing, and it's been fun to see so many volunteers come and go. I'm so impressed by Peggy's ability to be so welcoming to each person who comes through when there are so, so many.

I've been enjoying working in the RVPC, although it can be very frustrating and depressing to work in the public hospital due to the politics and lack of resources. Dr. Charles was in Tegucigalpa this week doing job interviews for the jobs he's applying to for next year, so a social service doctor took over for him. The new doctor came in on Sunday, too, so she had a little less orientation than normal, but it is all going well. Even though there were a number of cruise ships this week, the clinic has been pretty busy. The new doctor isn't very comfortable with Spanish, so I've been able to interpret for her this week, which I'm really enjoying. It does make the morning much more hectic, though, since I'm triaging and seeing all the patients with her, but I've been getting there early and trying to triage in any spare time and it's working out.
I've come across a number of interesting medical beliefs while interpreting this week in the clinic, and it's been pretty interesting to hear some of the same beliefs from a number of patients. For example, many people believe that if you sleep with your eyes open you have "bichos," or you get skin infections because of "bad blood." People have been very receptive to the doctor's explanations of disease that go against these beliefs, but it still is an interesting clash of cultures.

We had a few cases this week that highlighted the island's gaps in medical care. One boy's mom claimed that he had to sit very close to the TV and turn it to its highest volume to see and hear well, so we wanted to get him sight and hearing exams, which shouldn't be too difficult. However, according to the social service doctor, there was nowhere to get them in the public hospital.

Another child had a fused sagittal suture, meaning his head was growing front to back, but not expanding on the sides. What was interesting was that the mother never mentioned that in the list of reasons she had come in, so I don't know if she had been told in the past that there was nothing she could do about it or what the history was. Dr. Normandin, the current doctor in the clinic, said that in the US you would just send the baby to the neurologist and probably break up his skull bones to let them set back together correctly, but there aren't any specialists on the island that could do such a procedure. We ended up referring him to the mainland, so hopefully they'll be able to take care of it. It's probably just going to be a cosmetic problem for the baby, but there is a possibility of increased intracranial pressure, and so it's really important to get it checked out by a specialist.

Tutoring went well on Tuesday - we had four students and four tutors, so we were still one-on-one. The girl I'm working with seems really interested and I'm really looking forward to being with her for the next few weeks and seeing her progress. Thursday, though, was quite a let-down. We got the tutors together and were driving over to the school when one tuttee called us (about 10 minutes before we were to start) to tell us she couldn't attend. And then we got a text message from another. However, when we showed up, it turned out that they had all gone home to study for a test they had the next day, so we had made a trip out to French Harbor for nothing. We'll talk with the students on Tuesday and re-assess their interest in the program, but it was pretty frustrating. I think the hard part about it is that it does seem like extra work to them, since we are really working on math concepts that precede what they're learning but that they may not see as really helpful at the moment. We'll see what they say on Tuesday, though, in terms of their commitments and interest, since we're really there to help them.

We have now moved into the apartment under Peggy's house, which is really nice and it's fun to be living downstairs from her.

Max Journal 9

I've had a good first week at Peggy's Clinic now that Christine is working every day at the Global Healing Clinic. I started the week out with Betty in the pharmacy filling drug orders and running some random jobs around town. Betty the pharmacist left for the United States on Wednesday, so since then I have been the official pharmacist for Peggy's clinic. It is a little amazing that I am practicing a profession that requires a graduate degree to practice in the United States. On Wednesday I went into the Global Healing clinic in the morning and bought food for the Wednesday lunch conference before I went to pick up some donations from the Carnival Valor cruise ship. The security precautions at the cruise ship dock are pretty amazing and the cruise ship culture seems very alien to Roatan, but after a few hours of struggling I was able to drive out onto the dock to pick up a few boxes of donated clothing. The cruise ships play such a large role in Roatan's economy that it is almost offensive to suggest that
they should be outlawed, but it is a thought that crosses many visitor's minds. Peggy's clinic has been slower because we have only one volunteer doctor, and Betty is gone so the pharmacy is quiet and a little lonely. This weekend my girlfriend and father arrived from the States for a visit, so I am understandably distracted and will keep this update short. I look forward to getting better at the pharmacy job and learning more about the drugs that we use here.

Sunday, November 11, 2007

Max Journal 8

I started out the week by holding down the fort at the Global Healing clinic while Christine was still on the mainland. There was no volunteer physician so I worked alone with Charles until Wednesday when I switched to working at Peggy's. We moved efficiently through a pretty high patient volume, and I was honestly impressed at how many patients Charles could see on his own in such a short amount of time. Charles is applying for jobs for after finishing his second Global Healing Fellowship in December, so he has been frantically preparing a heap of paperwork. I wonder if there is a functional reason why "diplomas" certifying participation in conferences and continuing medical education courses are so important here. It seems like a never-ending occupation of a lot of doctors to get many pieces of paper with the appropriate stamps and signatures to certify and acclaim them for their accomplishments. To a certain extent I think the obsession with "diploms" and "reconicimientos" is cultural (some people just like physical representations of their accomplishments), but I also wonder if there are big problems with forgery of certificates.

Christine got home thoroughly exhausted from her journey on Tuesday, and I was happy to have her company again. I think she made good friends with the mom and baby, met some interesting medical professionals on the mainland, and learned a lot about international medicine in Honduras. On Thursday I worked in the pharmacy at Peggy's and went to the ferry dock to pick up a patient that didn't end up coming. This patient was supposed to come to get an excisional biopsy from an ENT doctor working at Peggy's, which would have been an unusual reversal of the standard shipment of Roatan's patients to the
mainland to receive specialized care.

On Thursday evening Peggy, Christine, Becky (a future Global Healing intern) and I responded to a car accident near Sandy Bay. We were with Peggy when she received a call that one of the carpenters working at her clinic had totaled his car and his wife who was in the passenger seat was unresponsive. By the time we arrived on the scene, the passenger was awake and ready to leave, but we skipped over about every protocol that I ever learned in EMT class and walked her to the passenger seat of our parked pick-up truck. I was amazed that we didn't even have a spine board to provide some degree of immobilization, and I can only imagine how people who are not personal friends with Peggy deal with traumatic emergencies on the island.
Because there were no emergency services (police, fire, nor ambulance) on the scene, traffic continued passing by us on the narrow two-lane road. As we were slowly pulling out into traffic, I committed the cardinal sin of emergency response: I put myself and the other responders in danger by colliding with a passing taxi. Honestly, the cab swerved at me and in an American traffic court I'm sure that I could have reasonably argued my innocence, but in the moment none of that mattered because now there were two accidents and still no formal system for sorting anything out. I didn't even know if there was a tow truck on the island. I sent Peggy, Christine, Becky, and the patient to the clinic in the truck and I stayed behind to sort things out with the cab driver. As it turned out we had hardly collided at all and I had rather miraculously managed to snap his bumper off without denting or scratching it at all, so we talked it out and settled with a small amount of cash and a handshake and without further legal complications. I was very relieved when I got home and learned that the passenger was without serious injury and our hectic night was coming to a close with no more than a few scrapes, bruises, and some property damage.

Friday at the clinic was fun as I showed Becky around the pharmacy and celebrated Betty the pharmacist's birthday. Around 9:15 a.m. I received a phone call from a friend of mine in Coxen Hole who is a middle-aged woman that recently moved to Roatan from the United States to start a spa/beauty salon. She was very upset as she hurriedly told me about a man in her home who had some serious skin problem and needed urgent medical assistance. I managed to ascertain over the phone that it was not really a real emergent problem (no respiratory distress, no impairment of circulation or sensation), and I instructed
her to put him in a cab and send him to the clinic. About an hour later I received another call from my friend stating that there had been no available cabs (cruise ship day!) and asking if I could come pick him up. I drove to her home (cautiously after the previous night's debacle) and arrived to find a 41-year old man in a lot of pain as the skin all over his body appeared to be peeling off. I drove (still cautiously) back to the clinic and learned that he was from Diamond Rock (a Black Islander community on the far east end of Roatan), he had had skin problems for just over a year, and he had come to Coxen Hole the previous day to go to the hospital and had been sent away then and again on Friday morning for unclear reasons. Apparently he knew my friend through a mutual acquaintance and, lacking other recourse, had hobbled all the way across town on badly swollen feet from the hospital to her house and had collapsed on her floor. I arrived at the clinic and asked the patient to remain in the
car as I prepared a treatment room and announced to the doctors his arrival (the clinic has no functioning landline telephone and I was unable to reach anyone via cell phone on the way over, which is a problem in and of itself). By the time I had a room prepared and retrieved the wheelchair to help him in, the security guard had helped him out of the car and onto the clinic porch, so I wheeled him through the clinic in front of a crowd of raised eyes. Some other volunteers rather-inappropriately left their workplaces in the clinic and rushed to take pictures of him while ostensibly "triaging him" and I felt like I had brought him into a very uncomfortable position, but of course at the time this was the price of much-needed urgent medical attention. This feeling touches on a characteristic of American medical care that many people have commented on: the objectification of patients and their diseases. While I cannot imagine taking pictures of a patient without a specific medical excuse (for instance to consult with other doctors regarding the case), I have often appreciated being called in by a doctor to teach me something from a patient's condition. The truth is that as a student of medicine and of public health, I walk a delicate line between learning from and treating patients, and different people have different ideas of what is "appropriate" treatment of a patient.

Anyway, back to the case...the doctor decided that the most immediate treatment necessary would be a warm bath to moisturize and exfoliate the dry peeling skin. The clinic does have a working shower and a water heater, but because the inpatient wards haven't opened yet there is no demand for hot water so the boiler was turned off and no hot water was available. The nearest available shower was at a motel owned by a friend of Peggy's, so I drove the patient over there. I then entered the shower fully clothed with the now naked patient and proceeded to abrade the dead skin off of his entire body for 45 minutes. It can only be described as an unusually intimate encounter between strangers that I have since reflected a lot on. The severe psoriasis that affected him was an extreme auto-immune disease that had only one probable explanation. As I washed every inch of his body and learned more about him than I may have ever wished to, I felt like I was finally doing what I came here to do: helping someone. He felt tremendous relief as his skin regained moisture and after the shower when we applied Vaseline and hydrocortisone to his entire body. As the water dripped down my face and I looked at my soaking wet leather shoes flecked with bits of dead skin, I started to reconsider what it means for me to help another person. There is a little more to this story than I can include here (ask me about some interesting tattoos when we meet someday), but I can say that that 45 minute shower taught me a lot about myself and the meaning of altruism. After that industrial-strength exfoliation, he dressed in some new clothing and left feeling like a whole new person. I gave him cab fare, various creams and soaps, a few medications and vitamins, and strict instructions to bathe twice weekly in the sea and return to the clinic in two weeks. I hope he does come back.

After that overly stimulating Thursday and Friday, I enjoyed a Saturday swimming at West Bay Beach and baking pretzels at home followed by eating Sunday brunch with the new Global Healing resident and scuba diving.

On Tuesday and Thursday afternoons we finally were able to get our much-awaited tutoring program started, which has been a lot of fun. The students we are working with lack some amazingly fundamental math skills, but are really very bright students that I feel we can help a lot. I look forward to continuing this tutoring for the rest of the time that we're here and I hope that the other tutors and students are enjoying it as much as I am. Alright, this seems like plenty of text for now. I hope you had an exciting week too.

Oh, and I'd like to say a big "thank you" for your personal response to my and Christine's journal entries. I can only imagine how busy you both are, but after spending a while going through many of the same trials and tribulations that you both have experienced here, I greatly appreciated reading some of your perspectives on things. I also really enjoyed meeting the new resident from Dartmouth this morning, so I hope that she – as a young female doctor – has an overall good experience with Global Healing. Thanks again and I'll talk at you again next week.

Thursday, November 08, 2007

Christine Journal 8

Max and I have reached our halfway point of working by ourselves in each clinic, so we switched places on Thursday. Peggy’s clinic is closed on Wednesdays, so I got to go to the hospital to hear Dr. Dominguez’s talk (part of the weekly lectures Global Healing tries to put on) on developmental displasia of the hip. He was a great speaker and the talk was interesting to hear, so that was fun.

Dr. Welcome had to go to Tegucigalpa to interview for jobs for the coming year, so there is now a social service doctor (Dr. Andres Ordóñez) in his place until he comes back either late next week or the following week. He’s a nice guy and knows the hospital very well, obviously, so I think it will be fine, although the new pediatrician came in today and hopefully he’ll give her a good orientation tomorrow. He does seem to take his time in the morning, though, and especially now that I know how it feels to arrive early in the morning at a clinic and not be seen until the afternoon, I do wish that patients could be seen starting a little earlier. We’ll see what the schedule this week is like.

There weren’t really any unusual cases this week in clinic, but I’m enjoying being in the Global Healing clinic so far, although it can be frustrating working in the public health system. For example, for some reason the lab decided to stop doing stool exams and urine tests this week, and a patient referred there from our clinic came back without anything to help us diagnose his illness, which was frustrating.

Although the tutoring program started on Tuesday, I was in La Ceiba so didn’t start until Thursday. I think it will go really well – we had five students on Thursday with five tutors, so it worked out perfectly. We’re still expecting a few more to join the program, but we might also be able to get a few more tutors, including the new Global Healing resident. The girl I worked with is an honor student, and was very bright and fun to work with. She seemed genuinely interested in learning the material, which makes the tutoring so much more worthwhile.

We had an eventful night on Thursday (see Max’s journal for even more eventfull-ness), as someone who works with Peggy got in a car accident with his wife. There was a large truck stopped in the middle of the road without any lights on it, and by the time he saw it, it was too late to swerve. So he hit it front on, and, luckily, both he and his wife are fine. They called Peggy, though, to come help the wife, who had slammed her head into the dashboard and needed some medical attention. We went to the crash site, where there were no police, ambulances, or anything, something you’d never see in the states. Peggy said that it’s practically useless to call an ambulance, as they can take hours to get there and were even shopping at Eldon’s once when she tried to call them. So, we took the wife up to the clinic and Dr. Patrick examined her. She had no bleeding, but had had a concussion. Dr. Patrick highly doubts that she has any kind of internal bleeding, but it’s impossible to tell on the island without any kind of brain imaging. So, the whole night was a powerful reminder of how limited medicine is on the island and how people can really suffer from it.

Outside of clinic, I’ve gotten to go back and visit Neri, Jessica (the patient I took to the mainland), and the family, and really love being able to spend time with them. I just really hope they don’t get too overwhelmed with all the different medications Jessica has to use, since it is a lot to keep track of (some every six hours, some every 4, etc.). Max and I also finally went on our first SCUBA dive today, which was lots of fun!

Wednesday, November 07, 2007

Christine Journal 7

I just got back last night from a really interesting trip to La Ceiba and El Progreso, during which I accompanied a Roatan high school student to the SAT test in Ceiba and a mother and one-year-old daughter to an ophthalmologist in Progreso and a dermatologist in Ceiba. The trip as a whole really opened my eyes to how other organizations in Honduras work and provide health care to the country.

I left with Nurian, a recent high school graduate from Roatan, on the ferry on Friday, leaving behind rain on Roatan and heading into it in La Ceiba. She had been to take the test in La Ceiba the May before, so knew the drill pretty well. She'd also been studying for the test in the time leading up to it, receiving private tutoring from Shelli, a volunteer with Peggy who is here for the year. I think she was feeling pretty prepared, which was great. As I dropped her off, I was remembering how nervous I was about the test, as it was something that I had known was important since I was in middle school. It was great to see how calm Nurian was, and how much it was really just her own motivation that had gotten her there, not an expectation that her school, family, friends, etc. had for her since she was younger. She felt really good about how it had gone, so I'm really happy about that. The test was administered at a bilingual school that was opened for the children of the Standard Fruit Company's workers who came from the USA, and apparently is still the best (and most expensive, as they apparently charge in US dollars) school in the city.

I spent Saturday night alone in La Ceiba after Nurian left to go back on the afternoon ferry and before Neri and Jessica came in on Sunday morning, which was relaxing. I went to meet the ferry on Sunday morning and was happy to see that Neri and Jessica arrived safe and sound. I had spent Saturday talking with a few people who work in La Ceiba, and we were able to get a ride with a group from an orphanage who were bringing two boys to get operations at the eye clinic. We were able to wait at Dr. Black's house in the morning before we left for El Progreso after lunch, and it was great to be able to talk with Dr. Black about his experiences and work in Honduras. His observations were really interesting in the context of my experiences throughout the trip, so I?ll reflect on those after I talk about how the doctors? appointments go.

We drove to El Progreso with the ?tio? from the orphanage (the father figure for the kids) and two eleven-year-olds, who were all really fun to travel with. The kids were really curious about everything, asking lots of questions about things we passed and making good conversation, and we took a little detour through Tela, so it was an enjoyable trip. We arrived safe and sound at a house that rents rooms and sells food in front of the eye clinic, and although they had not received our reservations (the clinic was supposed to make them for us), they had a couple of rooms. The woman told us if it was our first time at the clinic, we had to be there at 5 am, so we woke up bright and early and left before breakfast, only to wait until 1 pm to be seen by the doctor. It made me really appreciate the patients that wait so long at the clinic to be seen, and it was also a bit frustrating that they weren?t able to tell us about when we would be seen so we could leave and get something to eat.

The clinic was started by an American ophthalmologist missionary, was in a pretty nice building, and seemed to be staffed mainly by Hondurans. There was a visiting American pediatric ophthalmologist for the week, which is why we were all there, but she seemed to be pretty overwhelmed with all of the patients. When we were finally seen, she didn't ask many questions about the history of Jessica's eye problems, but did tell us pretty quickly that she did not have cataracts. It turns out that her cornea is being scratched by her eyelashes, as her eyelids are pressing too hard against her eyes. She did let us know that they would have a plastic surgeon at the clinic in early December, and also gave some antibiotic drop prescriptions for Jessica since she apparently also had an infection, but it was a little disappointing to go all that way to find out she did not need cataract surgery. It's good to finally know what's wrong, though. All in all, I was not very impressed by the care at the clinic. The American doctor didn't speak very good Spanish, and, as I said before, didn't ask many questions. She left the Honduran doctor to explain to the mother what Jessica had, but he used very complicated medical terms that neither she nor I understood, so I had to tell her what I had picked up as the American doctor was working so that she could know what was going on.

We left there on Monday afternoon by bus, as the two boys from the orphanage were sticking around for surgery on Wednesday. We arrived in La Ceiba at night to pouring rain and flooding streets, but safely made it to Dr. Black?s house, where he sent someone with us to check into a hotel he recommended. It was such a help to have him as a contact in La Ceiba, as well as to have the group from the orphanage with us in El Progreso, and it really showed how helpful and important it is for different NGOs to work together and let each other know about opportunities, etc.

On Monday morning we got a few blood tests done for Jessica that the opthamologist had sent for, and it really made me wish there was a way for us to know what tests she had already gotten. Neri said they had done many tests on her, but couldn?t remember what they were, and we wanted to get them done before coming back to Roatan, as Roatan couldn't doing some of them, so we just went ahead and got them. I think in the future it would be good to make a copy of the patient's file to bring on trips like this one so that there isn't any overlap and the doctors can better see the patient's medical history. I don't know if this is possible, but I'll look into it.

We saw a dermatologist in La Ceiba that Dr. Raymond from Peggy?s had recommended, and he seemed to be really good. He was not able to diagnose a specific skin disease, but did explain very clearly to Neri everything that he was thinking. He said that since it is congenital, he doesn?t really think it will ever go away, but that it may get better as she gets older. He also looked at her eyes and agreed that the cornea was being scratched, but also with just a few questions was able to discover that Jessica slept with her eyes open (her mom usually closed them), so her cornea is probably also getting dried out. He prescribed her lubricating eye drops for that, which he was very surprised the American ophthalmologist had not done. He also explained very clearly how important it was for Neri to use the eye drops, as her eyes need light to enter to develop nerves that will be critical in her sight later on. He prescribed some soap and creams for Jessica's skin, as well.

I think that it was hard for Neri to hear that there wasn't really anything we could do for the skin condition, but she is up to go back in December for the plastic surgeon's visit to hopefully fix the eye problem.

The trip and my previous experiences here have really showed me the importance of talking with patients and trying to spend as much time as possible with them. As I traveled with Neri she told me a lot about the history of Jessica?s skin and eye conditions that I noticed she did not share with doctors unless asked specific questions or given enough time to really give a complete answer. I?ve also noticed while interpreting at Peggy?s clinic that the patients won?t mention something to the doctor when he or she?s asking questions, but when he or she leaves for a minute and I just stay and chat, they?ll bring up other important information. Dr. Black complained that he no longer works with missionary groups because they will try to brag about how many people they saw in one day, when really they?re not giving very quality care to their patients, and I can really see how just spending that extra few minutes with a patient to chat or ask them more questions can make a big difference in the quality of care they receive.

Something else that Dr. Black mentioned that has gotten me thinking is that the Honduran government can use the groups of medical missionaries who come down to perform specialty surgeries or other medical procedures and consults as an excuse to not develop their own medical infrastructure. Since the groups are filling in the gaps that the public system has, the government sees no need to develop in those areas on their own. So, I started thinking about somewhere like Peggy's clinic and how it can fit into this kind of situation. On the one hand, Peggy's clinic is doing great things by trying to provide a quality of care that is not available on the island. On the other hand, the public hospital can use the clinic to get specific medications they may not stock and, as Peggy's grows, may even start sending people over there for operations or in-patient care. However, if Peggy's clinic (or any specialty group who comes down to Honduras) is providing a level of care that the public health didn't seem to be getting close to (or trying to get close to) before she began, does it hurt the public health system? But doesn't it also hurt the people if such brigades or clinics are not started, as they really are filling in a gap that the public health system is not fixing on its own?

I'll be starting my time in the pediatric clinic, and look forward to getting to understand the public health system better!

Max Journal 7

This week I have been working as usual at RVPC and we seem to finally be getting back in the swing of things after the strike. Anita finished her last week here and we saw patients every day. The patient load has been pretty moderate, which keeps things relatively calm in the clinic. The rainy weather and the arrival of lucrative cruise ships keep patients away on any given day.

Probably the most interesting case of the week was a mother that brought in her son with a speech delay. The boy was almost four years old and didn't say anything while I was in the room with him, but apparently mumbled something when he was with Anita. His sister is around two years old and speaks well, so his mother is starting to worry. A few things about this situation were interesting to me. First of all, as far as we know, the mother didn't bring her child to see anyone until now, which seems like a long time to wait. Secondly, the diagnostic tools that Anita used to try to get a hold on the child's condition intrigued me. The mother didn't think the child had any trouble hearing, but she also said that when he did talk it sounded like a "deaf person." We can't do a real hearing test in the clinic, but by saying things when the boy is looking away you can test his reaction to sound, and by asking him to complete simple tasks you can test his hearing and some of his comprehension. The mother also said that he plays normally with the other kids in the neighborhood, which suggests that he is not severely mentally delayed, but rather that he might really just have a speech impediment. Also, during most of the time that the patient was in the clinic, which was most of the morning, Dr. Charles was unavailable to help Anita. Diagnosing a speech impediment is understandably difficult for a non-native speaker. The last thing worth mentioning is what the next step is. The boy needs a hearing test and possibly some sort of more detailed mental exam to evaluate the full extent of his developmental delay. Then he will need some sort of speech therapy, which as far as I know is unavailable on the island. I hope we are able to follow-up with this boy and see that he gets the attention he needs to fulfill his potential for speech.

From a more philosophical perspective, I've been thinking a lot about the relationship between the Roatan Volunteer Pediatric Clinic, the Roatan Hospital administration, and the other sources of medical care on the island. Anita tried for several weeks to participate in rounds at the hospital, but she always received some excuse why she couldn't (they'd already happened, they weren't happening, or they were happening later). This made me think more about whether the hospital really welcomes Global Healing there at all. From one perspective, I can fully understand why anybody would get tired of outsiders continually coming into their workplace and telling them that they are doing everything wrong, and in that sense I think that Global Healing should be careful about delivering criticism to the hospital. And from a completely other perspective, the resistance to change within the hospital is amazing. A certain amount of the problem can be blamed on a large bureaucratic public health system that the hospital must function within, but that cannot be the complete story. The number of small fixable problems in the hospital and the presence of people trying to fix them combined with the lack of fixing going on suggests that there are people *actively resisting* change. It should come as no surprise to me to see corruption in public administration here in Central America, but people fighting real improvement in the hospital nonetheless affects me.

Anyway, on a more upbeat note, I a dropped a patient with congenital cataracts off at the ferry terminal this morning to go to La Ceiba to meet Christine and travel with her to get corrective surgery in El Progreso, a city between here and San Pedro Sula. Christine is doing most of the actual work to make this happen for baby Jessica, but I hope all goes well and I see them soon back here in Roatan. You probably won't hear from Christine for a while because she's on the road, but I'll let you know if anything comes up.