Final Thoughts

I touched upon a lot throughout this year's blog, but here are some other thoughts about our experiences.

Juan and I had an incredible month here in Nicaragua. The overwhelming thing that we took away was the kindness, generosity, and openness of the Nicaraguan people. We felt completely integrated in our home stay and at the clinic and felt like we were Nicaraguan by the end.

As stated, the homestay was the highlight of the trip. We were welcomed into a Nicaraguan family's life and although we did give them a "gift" for hosting us, they were not even expecting any compensation for hosting us. Their lives may not be rich in material wealth, but they have rich full lives that they are able to enjoy.

Fun at the homestay

Spending quality time with your family and friends for hours every night without any significant daily stress/concerns sounds like a fantasy for most of us, but it is their reality. They still work very hard and often return from work exhausted, but once home, the only task at hand is enjoying each other's company and occasionally fixing a dirt bike.

Having made village life sound like a dream, there are some potential concerns to raise. There are significant gender roles which only very rarely altered. The women spend most of the day cooking and cleaning while the men work and later have fun. As stated, people would come from the surrounding houses to hang out all night, but these were almost primarily men/boys. I presume the women must stay home and tend to the children or housework. Also, homosexuality is not very well accepted and can cause people dealing with it severe distress.

The clinic

There is a lot of room to improve in terms of health care (see below). So while obviously not perfect, in my mind village life is closer to how humans were meant to live than our workaholic, computer screen to TV screen, dollar to dollar, lifestyle.

From a healthcare standpoint, specifically at El Tololar, there is still a lot of work to be done. (See the clinic and the waiting room above.) There is a great basic setup; the entire system is run by the government which is commited to preventative medicine. The vaccination campaign is incredible. A health care provider will go to each and every house/shack throughout the entire country of Nicaragua in order to vaccinate as many children as possible.

Elliot in action at the clinic

We learned that in the past measures were taken to control the rat population in each household at risk in order to reduce the cases of leptospirosis. There is extreme vigilance with reporting epidimiology data, especially infectious disease data. The clinic knows every pregnant woman in the village and what her level of risk is. All of the staff at El Tololar are extremely dedicated to the care of their patients regardless of the obstacles. The set up is in place for great health care delivery, but the resources are simply lagging way behind.

Clinic workers

The clinic at times cannot handle the patient load capacity. The charts are falling apart and near impossible to find when needed. The pharmacy is inadequately stocked and we are often telling patients that they need to go take a bus ride to Leon to buy their chronic medications or go without them. I believe the current system for providing contraception has too many barriers and likely leads to numerous unwanted pregnancies and teen pregnancies.

So from what I saw, the system is in place, the personel is excellent and improvements are constantly being made, but until resources improve and are more consistent the health center in El Tololar will continue to struggle to fully meet the needs of its patients.

Waiting room 

Thanks for reading. Hopefully, I inspired you to hop on a plane and visit the amazing country of Nicaragua!

Week of March 19-23

Our final week of work and living in the village. As always, the time has flown by.

Work this week was mainly at the health center seeing patients. Monday was extremely busy and the health center was working above capacity. Some inspectors from the government came during this time and made many suggestions for improvement, including a massive cleaning of the health center. So, Tuesday, we all stayed after work and did a thorough cleaning of the health center and all of the furniture.

All of the health center staff is great and has fully integrated us into their group, so we still had some fun that afternoon. They also improved their chart filing system immensely after the inspection. One sanitation issue that could be improved is that there is no garbage disposal system. All garbage is burned in controlled personal fires which at times release toxic gas (if burning plastic).

Juan teaching the class
One day, Juan and I went to the local high school and held our focus group regarding teen pregnancy (Juan ran it as my Spanish, while improving is still not at the level to run such a group and he did an excellent job). The students all seemed to be empowered and noted many more negatives than positives to becoming pregnant in adolescence. They seemed to know the options for birth control and knew that all could be obtained from the health center free of charge.
However, they did agree that the system of dispensing birth control (need to have an intake appointment and always talk with 2 people) is a significant barrier. If I return next year, it is something that could easily be improved. On our last day, we had a nice going away meal and all of the staff sent us their extreme gratitude for coming and helping as best we could.

Our homestay continued to be excellent and is definitely one of the highlights of the trip. We pretty much feel like part of the family and the community. We purchased a good volleyball for the family and they liked the present so much that we played volleyball almost non-stop the last few days stopping only to eat. The net consists of a string between trees in their yard. Everyone, including us, is sad that we are leaving soon and it seem apparent that our family and friends in the family are not used to goodbye's. 

On our last night, the family killed a chicken for our going away meal. We took many pictures and they got very excited about the photos! Interestingly, when in a photo, the people here do not smile. The group is always joking and smiling, but all of the photos are with staunch expressions. We wanted to send the family copies of all the photos when we print them, but one issue that we had not expected is that there is no mail, and no mailing addresses, especially in the village.

The only option that we could come up with is to send it via DHL to Leon where it can be picked up and brought to the village. We said our goodbyes and went to Leon after work the next day. We met up with two of our co-workers for dinner and drinks in Leon on our last night in the area.

Now I am at an ecolodge in the cloud forest waiting for my girlfriend Kelly to arrive on Sunday and we have 6 days of vacation to explore Nicaragua. We are probably going to go to Granada and to some relatively remote mountain villages. Obviously, I'm not going to blog that part of the trip, so this will be the final blog entry of daily activities and I will give some concluding thoughts in a subsequent entry.

Week of March 10-18

It has been an exciting 9 days with lots to write about. We had a long Saturday going house to house giving vaccinations as well as brief preventative medicine tips to families and children. It was extremely hot, but we pushed through going to near 30 homes. The best part of this campaign is how welcoming most of the people we visit are. They all pull up enough seats for all of us to sit right away and at times offer us food and drinks. Most seem genuinely grateful for our presence.

Sunday was our free day, and as planned we went to the nearby volcano (Cerro Negro) with our homestay family in a tractor. It was a surreal experience. They attached an old rickety wagon to the back of the tractor, piled 14 people into the wagon and on the tractor and off we went. Riding through dirt/gravel roads through villages, we made our way to the volcano. Towards the end of the ride, the bench on our wagon broke, but we just rearranged our seating and kept going! 

Transportation to Cerra Negro

About an hour and half later we arrived at Cerro Negro. There, we saw many tour groups, and saw many of them astonished at our arrival and taking numerous pictures of us. We hiked the volcano and some of us volcano boarded down it. Surprisingly, most of the family was fearful of boarding down the volcano. We had a picnic lunch and then got ready to head back.

"Volcano boarding"

Back to work on Monday, the vaccination campaign is in full force with at least half of the clinic heading to the village and going house-to-house every day. This leaves the clinic very short staffed all week which is where I stayed (Juan mostly stayed as well, going on the vaccination campaign one day). On Tuesday, Juan, a local doctor, and I ran the clinic, just the three of us. We checked the patients in, evaluated them, gave any needed injections, and filled prescriptions and somehow kept pace with the patients.

House to house vaccination campaign
On Thursday, Juan gave a great talk to a group of high school students regarding domestic violence and abuse. He used to be a teacher and one could tell as it was very well done and he held their attention throughout. On Friday ,as we were closing up, a man walked in with a relatively large laceration on his wrist. We cleaned it up and sutured it as best we could with our supplies. The needle took extreme force to pierce the skin and sterile technique is a relative concept in a village health center (due to resources). Some gloves and clean paper under his hand were about the extent of the sterile technique. The wound closed nicely and he went home with early follow up.

Throughout our time in the clinic, we have obviously noted many issues that could be improved, but many are due to lack of resources. One issue that seems like it could easily be improved is family planning and contraception. Contraception is given with appropriate privacy and is completely free. However, a monthly trek to the clinic/pharmacy is needed for any woman on birth control and for condoms, one must go to the pharmacist and request them and may even get a brief lecture from the doctor before getting them.

Obviously, these can be large barriers to adolescents and Juan and I think there could be some simple improvements to this system. I may even try to undertake this as my project for next year. We are going to go back to the high school next week to discuss some of these issues in a focus group-type setting to assess the feelings of the adolescents and the potential for improvement.

A dust storm

Another issue of interest in the clinic was with one of Juan's patients, who was suicidal and in Juan's opinion, required hospitalization for his personal safety. This is not as easy of a proposition in the village as calling an ambulance and signing a paper. We learned that involuntary commitment in this setting is not fully possible. First, in order to get him to the hospital, the patient had to call a friend or relative to drive him there. Then once there, after the initial evaluation, inpatient treatment was recommended for three days, but the patient did not want this so he returned home. The system is a little different here, to say the least. So far, luckily, the patient is doing slightly better.

As for our life after work, village life continues to treat us well. We feel completely comfortable with our homestay family. We continue to play lots of baseball with them along with some other makeshift games,such as basketball, and volleyball. We talk and hang out right up until we go to bed every night, often sharing as much as we can about each other's cultures as possible. After work on Tuesday, Juan and I went to the city on the bus to use the Internet, planning to return on the evening bus. We underestimated the time in getting to the bus and missed it. We scrambled and got a cab to take us to the road that goes into our village, but it's a poor dirt road, so did not ask him to drive us in.

It's about 5 km from this point to our house. We began walking and soon a pickup truck came by offering us a partial ride. When he needed to turn, his friend in another truck drove by and we hopped in with him for a short portion. This left us within a 30 minute walk to the house. Our family was worried about us and sent their kids on dirt bikes to pick us up. So through the kindness of the village, we took 3 forms of transportation to cover the 5 kilometers!

We had this past weekend off, so Juan and I decided to leave the dry, hot, dusty area near Leon and headed north to the city of Matagalpa. Apparently, the express bus required reservations for seats and was full, so we had to stand, packed in ridiculously tight, for the 2.5 hour ride. On the bright side, it costs only $3. We met some German medical students working in Leon on the bus and hung out with them in Matagalpa. It is a nice town surrounded by mountains, but nothing too memorable.

View from our hike at Selva Negra

On Saturday, we hopped another bus to a eco-lodge/coffee farm called Selva Negra. This hotel was pretty amazing and we had a hot shower for the first time since leaving the US. The hotel is in a cloud forest, far enough from the road that engine noises can't be heard. There is a gorgeous lagoon where the restaurant is perched and we may have been the only non-couple there as it is a quite romantic place! We took a pretty significant hike and then relaxed and hung out with a nice Canadian couple.

Sunday, we toured the farm and coffee plantation, and took a short hike, but after much effort and following the howls, were able to spot a group of howler monkeys and proceeded to have monkey feces thrown at us. We then had to begin the journey back to Leon. We were told that there was no reservations on the way back, but this was incorrect and we ended up standing again for the journey back to Leon. We stocked up on water, I worked hard to type this blog up and we prepared for our final week in the village!

Week of March 5-9

At this point we have become extremely comfortable with our new surroundings and home. From now on, I will summarize the week and hit some highlights.....

Our homestay

Our Nicaraguan host family has fully accepted us into their lives. We play baseball with them at twilight and basketball with them after dark almost every night. Our surrogate mother, Isabelle, cooks us three amazing meals per day and we hang out nightly with the entire family and all of their friends who live nearby. Although fully interacting with them is still difficult for me as I am not fluent in Spanish, I still feel that I have been able to connect with them very well.

Nightly baseball

Juan and I both are amazed that despite their apparent lack of resources and money, their lives appear at least as full and happy as the average American life (even middle/upper class). They are extremely close with their family and spend time with their close family and friends every night. While they do work hard, they return home at a reasonable hour (well before dinner in time for the evening baseball/soccer game). But they do have to use a cold bucket bath shower everyday :)

Home visit

Our average day consists of waking at sunrise, going to the clinic (a 30 min walk from our house), helping to clean the clinic from the dust that blew in over the night, and then starting the day of work. They are currently in the midst of a country wide vaccination campaign so our days have alternated from working in the clinic to going house to house on foot giving vaccinations and antiparasitic pills to every child we find. At times, I have worked alone seeing my own patients and precepting with Dr. Urrutia.

Juan with fresh mangos!
And perhaps, the best part of the El Tololar clinic in March: when we need a snack, we walk outside and grab a fresh mango off the ground! After work, there is a seemingly daily baseball and/or basketball game. Then, we have a great wood fire cooked meal usually consisting of beans, rice, tortilla, and some sort of meat. One night was the eldest son's birthday, so the mother killed two chickens for the celebratory feast.

(I am writing this entry on Friday, March 9.) We came to Leon after work today to get some Internet access and re-stock our water supply. We head back tomorrow for a day of work going house to house in the vaccination campaign and then on Sunday plan to go with the family up the nearby volcano in their tractor and sled down the gravel side on a wooden plank (we did this last year with a tourist agency).

Sunday, March 4

We woke up for sunrise, visited the crater again and then headed down the mountain. I returned to Leon and met up with Juan by mid-day. It was oppressively hot, so we decided to head to the beach. We had some amazing fresh fish and hung out for a few hours before returning to Leon for a quiet night and got ready for the following week in El Tololar.

Saturday, March 3

Although Juan was not able to come on the hike to the volcano. I went alone with a group of Germans and two American guides. It was a relatively tough hike up the volcano with numerous exposed, extremely hot parts. The views were spectacular.

Volcano Telica

At the top, we set up camp, right near the crater although with the warm weather and lack of bugs, several of us including myself simply slept outside. We watched the sunset then walked to the crater. It did not come out well on film, but there is a huge crater with lava at the base and tons of sulfurous smoke spewing out of the crater. We returned for some dinner and a campfire and had an early night.

Friday, March 2

Today was a normal clinic day. I again mostly shadowed Dr. Urrutia, but she let me see a few patients on my own. Again, the patient panel is mostly upper respiratory issues due to the wind blowing up incredible amounts of dust. Anyone who states they have a fever gets checked for malaria. One patient with prolonged fever gets sent to Leon for labwork to check for dengue fever.

Juan gives a talk at the local school regarding teenage pregnancy that he states went very well. We head back to Leon after work via the bus. As it is still early, we stop at a hotel with a pool to get some relaxation. Back in Leon, we had a few drinks and planned our hike to a volcano the following day.

Thursday, March 1

Carrying supplies to our house

At about 4 am, seemingly every bird in the village awoke and began making as much noise as possible making sleeping rather difficult. We fully awoke around 5:30, took bath bucket showers and met the doctor who lives right near us to walk back to the clinic.

Today is a home visit day. We head out on foot going house by house. We check on all members of the household, give an anti-parasitic, and address any issues. We go to about ten homes throughout the day. All of the people we visit are incredibly welcoming, giving us seats and often some food. Most are relatively healthy, but there are some chronic diseases including diabetes and hypertension. We head back to our house in the afternoon for some relaxation and reading. The surrounding community again arrives after dinner and we have another large basketball game to conclude the evening.

Wednesday, February 29

We returned to the clinic via one bus that goes to El Tololar (leaves at 6:30 am, returning at 12:30 pm). Today was a normal clinic day. I shadowed Dr. Urrutia today. Unfortunately nobody except me speaks hardly a word of English. While I do speak and understand a lot of Spanish, I am not fluent, so it is a challenge that will hopefully improve throughout the month. We see about 15 patients, many for upper respiratory issues due to the dust or pregnancy.

Juan works on a presentation to give to adolescents regarding adolescent pregnancy (which is a huge issue in the village) and sees a few consults. After the day of work, we head to our homestay. The family is incredibly welcoming and the mother, Isabelle, cooks all of our meals. It is obviously an extremely basic house, with a bucket bath shower and an outhouse. There is one fuzzy television and numerous animals roaming around including chickens, pigs, geese, turkeys, dogs, and more. The family consists of two daughters and two sons and both parents.

View from our homestay house

The women are home most of the day and the men all work together in Leon. When the men return, we all eat dinner and then about ten other people from the village begin to arrive, relatives and friends. Everyone comes over to hang out and talk for the remainder of the night. We also had a long basketball game on a makeshift hoop leaning on a tractor. Eventually, the game ends and we all head to bed.

Makeshift basketball hoop

Tuesday, February 28

Today, we met the medical director who had arranged transport for us and our bags to the village. We briefly met our host family and then went to the clinic. It is the same clinic that we were at last year and an extremely basic clinic, with one full time doctor, Dr. Urrutia, and one temporary doctor who is completing her social service requirement.

Our clinic

There are two nurses and occasionally a dentist. There is an extremely basic pharmacy with about 40 medications. Today, we were oriented to the clinic and our expectations for the month. It was a day to catch up on paperwork at the clinic, so we did not do anything clinical. We returned to Leon at night to pick up some more supplies and make some last preparations.

Monday, February 27

We both left our respective houses. We arrived in Managua about mid-day and hopped on a bus to Leon which went without incident. We stayed at a hostel well known to us, El Tortuga Booluda. We just settled in, bought some supplies, and had a nice dinner.

Welcome to My Global Health Track Blog for Year Number 2!

This year, it is only Juan-Carlos Ramos (Psychology fellow) and me together in these blog entries. We are going to work in the village health center at the small village of El Tololar, which is where we had visited last year. We are planning on doing a homestay with a family in the village for the majority of our time there.

Therefore, my Internet access will be minimal, so have patience with blog updates. Pictures are lacking a bit currently as I did not bring my computer back to town and thus only have my Iphone pictures to send. Juan will try to add more details on the parts specific to him with the next update.