letter home...

I was hoping to be able to keep up with personal correspondence as well as send an occasional blog entry out to you guys. I am finding that for whatever reason, I am not doing so well. This is a letter I wrote last week. My desire to keep everyone informed has overcome my fear of being completely redundant…and my mom read the note and asked me to publish it…there is no better reason than that…Thanks for reading along…

Hey gang…it has been too long and I was feeling like I needed to get in touch…though to be truthful, I don’t have a specific story or message to share…I hope this doesn’t get scattered…with that intro, how can it not…

I just found this from a letter that I started a few weeks ago, but never finished…I guess I can blame the heat…

“…I might come dangerously close to belaboring this point…but it is still hot…really hot…hanging out at 105ish…humid…our poor cat is pregnant, really pregnant…she seems like she groans when she waddles around the yard…even the birds and rats play nearby, knowing she is way too encumbered to exert any authority…the people I work with and the patients are complaining about the heat…I guess it is hot from anyone’s standpoint…dogs in the street are pissed…snakes are even biting more often…everyone is frustrated…come on down!!...”

I am glad to say the rains have started coming more regularly now…our cat had kittens (I’d include a photo, but risk complete ostracization) and the food chain has been re-established in our yard…it is incredible when the rain falls…water to drink and showers to be had…it puts things in perspective…on the less positive side, the puddles have given rise to an angry mosquito horde as well as some pretty impressive mud…the mosquitoes have really cut down on my microscope time…i can’t sit anywhere for a prolonged period without getting eaten alive…I thought my body would acclimate or something…not yet…still waiting

speaking of bug bites…the last time I wrote a really quick tease of a message promising a night off and internet…we had just wrapped up a course for the advanced promoters…I spent the last hour talking about jaundice and Rh isoimmunization…I couldn’t believe it went as well as it did…I was terrified...after getting back to Flores and doing some grocery shopping, things spiraled downward…pretty quickly I started feeling lousy...I went to bed early thinking I was tired…I woke up and immediately knew all was not right….I got the 5 am bus back to our clinic, and was sent to bed on arrival…although there were people keeping a close eye on me, the fevers came late that night…as that was a clinical change, I dragged myself out of bed, shuffled across the yard to the clinic, through an amazing rainstorm (I am not making this up…I swear), I poked myself and took some slides of my blood, and started treatment for malaria. I couldn’t think of anything else that fit my symptoms and for which we had therapy…due to my delirium the slides didn’t turn out very professional(ly?) nor polished, but they were enough, in combination with my slow improvement with treatment to suggest malaria as the diagnosis (although I had been taking prophylaxis…just like my concussion-causing face-plant despite my cranio-protective helmet)… I started to have a glimmer of hope after 3 days of chloroquine, by 5 days out I felt pretty much back to normal…although a colleague found some rum raisin ice cream on day 3 as well, so I am holding out for that as the amazing cure-all…god it was good.

On the plus side, I had 3 days where I didn’t have strength for anything but reading…initially I couldn’t focus on much besides trashy crime novels, but as I started feeling better I read more and more challenging books. I just finished Confessions of an Economic Hit Man by John Perkins. I thought my work abroad would teach me about medicine, Spanish and local culture. I should have been more aware, but wasn’t, that this would include an education in US foreign policy, as it relates to Latin America. Although the bulk of this book took place in the 60s-80s, it is completely pertinent to the situation and the present culture here. It puts some recent current events in a different light (referring more to the present coup in Honduras, and less to Michael Jackson’s demise).

After a five-year hiatus, I just restarted Gabriel Garcia Marquez’s Love in the Time of Cholera. I don’t know if it is the Colombian setting, the story or the style, but I am hooked. What I remembered as a dreary story about a man suffering from unrequited love is still about that, but I am laughing more and enjoying the wording and the characterization much more. There is an expression in Spanish “me cae bien”. (I hope I am not repeating myself…I looked in some older notes to see if I have described it before, but I didn’t find anything…)…it means “to fall well”. medicines, people, events can all “cea” bien o mal (poorly)…a medicine that works and the person gets better “falls well”, whereas a medicine that causes an upset stomach or doesn’t make the person better doesn’t “fall well”. this is a huge reason people stop treatments here. this can happen minutes after the dose, regardless of the medicine and hereafter will always happen…it sort of removes any blame…My point is that for some reason the book seems to be falling much better this time than it did the last time. I guess it is the way I am looking at it...or, alternatively, maybe it is because this edition has Oprah’s approval on the cover. Oh god.

quick question…does anyone know what I am supposed to do about ants in sterile fields?...The other day in clinic I had anesthetized, cleaned and prepared an area around a cut and was focusing on closing a wound (and trying not to drip sweat onto the work space)…slowly, approaching from the corner of my vision…an ant ambled from the picnic table up onto the patients arm, onto the drape and into the wound…he or she was completely immune to my efforts to blow him away or at least off-course…there was an admirable determination there…Flies I can understand, sure…but an ant seemed more intrusive somehow… I grabbed it with a pincer and chucked them both…can anyone send me any evidence-based thoughts or strategies??

we still get sick visitors at all hours…the easy ones are sick…you can see them coming from the gate…it is bad but you get started immediately trying to make things less scary…the more difficult ones for me are the ones who want to be seen, but aren’t really too sick…whether we see them or not isn’t really too defined and depends on lots of factors…how long has the problem been going on…where the family lives…if there is blood, impaired consciousness or a pregnancy involved…nothing like high standards…the other challenge are the patients that feel like they are gravely ill, and are trying to be taken seriously, but everything checks out ok…I try to relax and joke a bit to improve the anxious mood…normally when middle-aged men come in after hours, it is usually pretty urgent…a guy came a few nights ago just as we put dinner on the table…he was screaming and writhing around outside the clinic door…I couldn’t find anything wrong…his history, exam, tests weren’t concerning…from his actions he was pretty convincing, but slowly I began to get the impression he was hoping for more attention…I didn’t need to hear more than…”this is the pig flu! I know it…”…”its not? how about HIV? do I have that??” I think that’s when his wife lost her conviction as well…I decided to drag a cot out of the salon, elevate his feet and give him 15 minutes to see what happened…in the mean-time the Christian church next door started kicking…and it is right next door…it has microphones, huge speakers and not one person that sings on-key…this used to be funny, but it is nearly every night…it is difficult to have phone conversations and sometimes I need to wait for a break to hear breaths sounds…anyway…the church got going, as I crossed the yard from the kitchen to the clinic…the patient promptly rolled over and vomited…”that music gets me pretty sick too” I mentioned, with a smile…my Guatemalan colleague laughed as unbeknownst to me, the husband and wife had just divulged that they had recently and proudly joined the fore-mentioned church…yep, can’t put a price on valuable international ties I am developing here…smooth…

I was finally able to talk with my sister tonight…I was asking about current events… she mentioned she saw that the Utah bars are now public access…I remember before leaving that people were planning pub-crawls and parties…ahhh…I hope you guys had fun…I feel really far away sometimes…it is funny the unpredictability of things that bring that feeling on…though friends on a main st. jaunt definitely would…or maybe it was just the heat…

brian

yesterday...

Good morning!

6am and all is well. I have a steaming cup of coffee as well as a potential day off, in front of me. I can’t believe I have been here a month. The constant exposure to new illnesses and problems has broadened my knowledge and made me feel more confident. When I am practicing here, it is humbling to realize, on a global scale, just how limiting a formal pediatric education is. At home, I can’t think of a better job for me, but here, I encounter so much that I haven’t seen since medical school…Jumping from one environment to another has kept me on my toes.

This is my second 6-month stint volunteering with health care promoters. Last year I spent my time in Colombia, and now I am in Guatemala. Both sites are affiliated with a non-profit organization in California, Concern America (concernamerica.org). Concern helps find volunteers and supports programs around the world. The programs themselves are run locally in the specific country by people from the area. Health care promoters form the basis of an effective health system especially in geographically challenging regions were finances, and distribution of medical care is scarce. They are lay-people that are elected by their communities to serve as the local health provider. We are one of a few groups that educates promoters, helps establish sustainable and affordable pharmacologic access, and acts as a consult service for more challenging cases. The educational site in Petén has been functioning in this capacity since the mid- 1990’s. In addition to teaching classes to the learning promoters, we also teach advanced courses to sustain and improve the abilities of the promoters who have been practicing for years. Some of the advanced promoters also learn how to teach and slowly take over the teaching of the newer promoters. Above the lectures we also have clinic 4 times a week. This not only serves the local people here, but also, more importantly, allows more experienced promoters and asesores (me) to work alongside learing promoters and teach along the way. There are many parallels between my work here and the learning and teaching I do with medical students and residents at the children’s hospital in Salt Lake City.

I love waking up early the days when we have courses here. Two wonderfully colorful older women arrive the night before to start preparing food for the promoters coming to learn. They get wood and start the fire, begin to cook the beans and corn and also prepare homemade chili (hot sauce). On the day of the course, the corn gets ground into masa, shaped into tortillas, thrown over the heat and eaten…Hot off the comal (a flat grittle-like metal surface). As of now my tortillas have steadily improved, but I am still WAY behind the curve. Not only am I on the slow side, but also my pre- and post-grill tortillas are misshapen with sub-optimal thickness and uniformity…kind of like the ugly ducklings of the litter…the kind ladies move my “art” a little to the side, I think they want consumers to know these tortillas were clearly not their product or responsibility. The Spanish verb for this act is sensibly “tortillar”, well, it is when done properly, I think the word for what I do is probably too obscene to print.

(can you guess which two are mine?)

As I mentioned in the last blog, I am feeling like a kid in a candy store in the clinic. We are responsible for everything. From history taking, vital signs and the exam to laboratory evaluation, microscope studies and treatment. It is really fulfilling. Especially when you realize that we are teaching people to do this in their home communities, far from more official care. I mentioned that people come from all over and at all hours. The environment is stressful, as there is not defined “down-time”, but it has formed a cohesive unit for the people that live and work here. There is partnership in everything.

In clinic yesterday, I saw a 70+ year old woman who really scared me. She was sick. I have been seeing and getting used to taking care of lots of bleeding and painful injuries, but I haven’t seen to many legitimately sick older people. She was accompanied by her husband, who was very caring and concerned. Her grandson walked with her everywhere and wouldn’t leave her side. Despite her high fever and ill-appearance she smiled when I mentioned how attentive her family was. I did everything I could think of; in the end, I couldn’t find anything treatable wrong with her. I told her I would come by her house later that night. “I think she needs a doctor.”

Clinic wound down and we were cleaning up from lunch. I was in the yard when a young girl ran around the corner of the clinic. “My friend just took a medicine and now she blew up like a balloon and can’t breathe.” Hmmmm…sure enough. A miserable looking, swollen-faced teenager came surrounded and led by a large group of family and friends. I have never given epinephrine for a severe reaction before; that usually happens before I am involved. For awhile, I think my heart was racing faster than hers, I was certainly sweating more. I gave it and she gave a massive inhale/gasp…I nearly fell over…was that a good gasp?? a REALLY bad gasp?? then her mouth turned up into a smile and her eyes lit up below swollen lids…ok, kind of romanticized, but it seemed that way to my relieved self. Her friends relaxed and there was a social gathering outside the clinic around her cot. Teenagers and family just hanging out, talking about their swollen friend. We watched her for 45 minutes, gave her meds and education about allergies and sent her on her way, with instructions to come back quickly for any signs of repeated swelling or problems breathing.

I remembered the older lady. I asked my colleague the way to the cemetery, she told me she lived there…next to it at least…”alongside” being the critical part). She told me to go straight down the street all the way and then turn right. This was much more funny at the time, but the word for straight and right are so close in Spanish, that I got pretty lost. After a completely meandering course, I found her home eventually. Her husband was outside and concerned. Her fever had stopped, but her diarrhea had gotten a bit worse and she had started vomiting. When I asked for a poop sample earlier in the day, I had a nagging feeling the container might be an issue. The family had cut off the bottle of a clear soda bottle and tied a piece of paper to act as a cover. She actually looked a little better. So there I am…riding down a rocky, dusty dirt-road on a tired bike with 2 half-inflated tires…one hand on the handle-bars and one holding a crinkled, worn plastic bottle containing what I hoped were answers. I was avoiding the jarring rocks and divots in the road, gazing at the purples and oranges of the sunset, and balancing the slushy sample. I was actually feeling really content.

I swerved to avoid a toddler learning to walk. I approached three dogs that began to eye me fairly ominously. “no way”…yep…All three simultaneously erupted with bared teeth, aggressive barking and nipping at my heels. “really?!?”…As I stood on the rickety pedals, the sample somehow did not leap over the edges and I managed to stay vertical and just far enough ahead of the dogs to make them loose interest. I arrived home feeling like I needed to finish my work with the sample before I ate dinner. It made sense at the time.

As I was looking under the microscope, one of the cooks tapped me on the shoulder and gave me a big hug. “don’t forget to eat.” The sample looked ok, nothing too ominous. I would go visit tomorrow morning. I washed my hands at the outdoor sink (pila), and turned around. The cooks had left my black beans, cheese, steaming tortillas and coffee on a plate next to the smoldering fire.

a pretty great day...

I hope this finds you well and happy. Sending positive thoughts…

Brian

Where´s the shade??

Hello, hello…

I hope this finds you all well…I am happy, healthy and content here in Las Cruces, Guatemala. Although…I am hot. Super hot…

I’ve been wondering how to continue this letter to you guys. I was really tempted just to jump right in, but my sister reminded me that I haven’t ended the Colombia part yet. Good point.

As a reminder, you can read the previous entries at briangood.blogspot.com or on my facebook page at the bottom left. I haven’t reread them so I am not exactly sure where I left off. I hope I didn’t leave a big cliff-hanger that I am neglecting.

My last month in Colombia was incredible. It seemed nearly like a final exam, with the stressful preparation, the execution and the quiet feeling of achievement. I was nervous leading up to it, as I was to be the primary medical care-giver for the project. Alan, Julie and their son Gregory had left the country as had been planned. Melanie and I kept the program going. I designed and taught a course in childhood illnesses and then Melanie, Ismael and I traveled up a river basin and visited 5 communities. This photo was taken by Melanie as Ismael, a promoter and I spent an hour clearing debris to get our boat upriver.
The people we met and treated were fantastic, and the scenery unique, but we got back to Riosucio completely worn out. For me this developed into a pretty lousy illness that made my last few days in Riosucio full of napping and hazy memories. By the time I flew back home, I was starting to feel better.

(side note…Everyone has been asking about Ismael and my feet…Ismael is doing well and is happy as ever and my feet healed well…eventually. There was a small bump in the road with one of my feet. I developed a pretty unique (to me) ulcer. I had a doctor colleague look at it and take some samples. She wasn’t as impressed as I was, and the microscopic testing was negative for anything noteworthy…and it has since completely resolved…I didn’t take a photo.)

Though I hadn’t been away for very long, the return home felt surreal. I was happy with what I had accomplished, excited to see family and friends, but scared to death about working and teaching in the children’s hospital. I wasn’t sure how interested the residents were going to be about my improving knowledge of health promoter training and low-resource medicine. I knew that was not going to be the priority for patients’ families. After a few days in Boston with family and attending my high school reunion, I arrived in Utah late Sunday night. My truck registration was WAY expired. Despite valiant efforts from a close friend, the Utah heat had done a number on some plants. Besides that, I was sort of late for work. I went into the office on Tuesday and started taking care of kids again on Wednesday. Wow. A huge leap.

The easiest part of the winter turned out to be the work at the hospital. I loved it. The kids were pretty sick, but teaching and learning along-side the residents and med students really made me happy. I had difficulty juggling my new job, trying to re-connect with friends, and continue to do the activities I enjoy. Looking back, I had an amazing winter. I met some great new people, made some incredible new memories with old friends…egad…bordering on cheesy, huh?? Moving on…

I arrived in Guatemala over a week ago. Due to my new-found contentment with hospital work and Salt Lake City, I was reticent to leave. My last few weeks at home were fun, but had a definite somber overtone. As did my arrival here, despite the wonderful welcome.

I am currently in Las Cruces, Peten, Guatemala. It is in the Northeast portion of the country, not too far from the Mayan ruins of Tikal and the neat little town of Flores. Looking back, when I first took the bus to Las Cruces in 2002 at the recommendation of a friend of a friend, I had no idea I was meeting people that would eventually become such close friends and teach me work that would form such a large part of my career.
We had planned that I would return here this year to help with the large number of health promoters that are being trained in this region. I will be working with Susan, who visited Colombia last year and about whom I wrote. She is a wealth of tropical health knowledge and enthusiastic about clinical medicine. Her life and approach to clinical care are inspiring. I am fortunate to be here working alongside her.


Our home here serves as a clinic, pharmacy, teaching center, as well as a spot for sleeping, cooking and cleaning. Here is the view as you walk up our driveway. The teaching area is on the left; Susan’s room is on the right, kitchen straight ahead. I have my own room in a building in the back. Mira is currently living in a room behind the kitchen.

Mira was 7 when we first met; she had just moved from the US to the clinic with her mom. She loved to dance and sing and was well on her way to being bi-lingual. She has grown into an energetic, grounded woman, who is actually an accomplished health promoter as well. On our way home from dinner last night she identified a child who needed sutures, injected local anesthetic and stitched his chin. Pretty impressive. She also has been very helpful in advancing my Spanish. “Mira…why did the instructor just say the man gave HIV to a half an orange??” When she stopped giggling she clarified that the saying meant “his better half…” Thank you Mira. She is leaving here next week to live with her mom in the US and finish high school there. We will miss her energy and attitude. (here she is picking lemons for lemonade, you can just see her white pants.)

We have clinic at our home four days a week. (ok…this might be funny to those who knew that my paid full-time job required less clinic days than that…)…On a recent “off- day”, Mira and I volunteered…umm…were volunteered…to clean the water tank. There weren’t many people vying for the opportunity. We drink rain water that collects from our gutters and gets stored in a massive tank.
As the current hot, dry season is wearing on, the water level was slowly decreasing, and the water itself was getting fairly funky. It was kind of brown and didn’t smell all that good. A huge flood this winter had deposited an abnormal amount of mud in the tank (the last time I checked, there were some impressive flood photos on our website, concernamerica.org). Mira and I got some ladders, buckets, brushes and bleach, went over the top and into the muck. It wasn’t the most romantic view of international medicine, but we felt productive. After clearing out 5 large frogs, Mira shrieked…”something just sucked onto my foot!”…the small windowless cement tank didn’t allow her voluminous proclamation much escape. As our hearing recovered, we emptied the rest of the water out, muddy bucket-full at a time…and found nothing…the exact form of the ankle-kissing beastie is still unknown…

Each clinic day, we have patients lining up in the early morning to be seen.
Running a clinic here allows the continual opportunity to train the promoters clinically, as an adjunct to their lectures. Yawning, stretching, shuffling outside in pj’s, toothbrush in mouth…I bet we look pretty good, and certainly professional and completely reputable. When we don’t have active clinic we are trying to prepare courses or medicine (or clean water tanks, do laundry…fun stuff). We are always available for emergent cases. People come to our kitchen door from miles around with most problems, urgent or otherwise. I can’t believe the amount and severity of trauma I have seen, just in the past week. My suturing and microscope skills are improving. Yesterday in the midst of a busy clinic, I realized that I was completely happy. I am being challenged. The ability to practice medicine here with limited resources is effective. Working this way and passing whatever knowledge I have on to others are both rewards in and of themselves. Somewhere in the past week my reticence about leaving has faded and I am looking ahead to 6 amazing months…stay tuned…

a walk in the woods...

Sending along a happy hello from Colombia!

Thank you for the great feedback; it is easier to write something when people enjoy it.

My spirits are great and my body is healthy. Sorry about the foot picture. In the face of everything else, a few bug bites didn’t seem too disturbing. I apologize, I’ll try to limit that kind of sharing. My feet are still healing well.

In the 3 weeks since my last entry we have held a course for the promoters, hosted two engineers that work in applied technology, and I completed a monumental community-visit trip.

Alan taught the course in essential medicines. My role was primarily as a student. I am trying to learn as much as I can about teaching in general and the more I know about what the promoters are learning; the more I am able to focus what I teach.

Applied technology is a great field. Just as I am working with a medical model to teach people in communities how to address health issues where they live, there are engineers that do the same with technology. There are a number of avenues of their work: water systems, solar power, and stove construction (to move away from open wood fire pollution in homes). As technology and sanitation lead to disease prevention, we often work in concert. I really love working with people with similar goals. It was a great visit.

I describe our recent community-visit trip as monumental, but it was really business as usual for my colleagues here. For me it was HUGE!! For the first time I traveled without a more experienced medical person. Additionally, my friend and experienced motorista, Ismael, was unavailable as he was working with the technology crew. So Ismael’s son and two advanced health promoters and I set out for an 8 day trip to visit a new river basin. We are helping four health promoters and communities in this area, but this was the first support visit.

In the week leading up to our departure we completed the bulk of the organizing: buying and planning food for meals, packing medicine, and thinking about the needs of the communities. I was feeling super-responsible and as the departure date approached, a mild, dull anxiety grew. Alan was helpful and I had plenty of time to prepare…and I suppose, to dwell a bit too much. I think the worst part was packing the medicine. I had no idea what we might encounter, medically or other-wise. Looking back at my list of things to remember is comical: scalpels, dish soap, plastic bucket, twine, sleeping pad. More than once, I put a medicine in the box and thought, “oh wow…I hope I don’t need that” “hmmm…what does that thing do?” I created an emergency kit. I threw in urinary catheters, ones that seemed elephantine compared to the pediatric tubes I am more accustomed to…I brought IV fluid, suture, adrenaline, needles and syringes, whatever I could find that seemed potentially remotely useful. I loaded up. I bet if this were a movie it would be that cool scene, when the psyche/montage music starts and the protagonist (I don’t know if I can put myself in that role or not) studies/trains/readies equipment in preparation for some sort of climax…yeah…well…it wasn’t really like that at all…picture me in a dark store-room sweating and praying I wouldn’t forget anything…absolutely dramatic.

Early Saturday morning, we set out. Despite being completely busy, Alan saw us off. We had breakfast and lunch cooked for us in containers, courtesy of Ismael’s wife. There is nothing like eating chicken and rice in a small boat in a Colombian river and wondering what the week had in store for us.

Though demanding, our week did settle into a decent routine and a comfortable rhythm. We would arrive in a community and meet with the health committee and discuss their concerns. Later in the same day, we would meet with the entire community (whoever was interested) and describe our program and try to increase their understanding of our goals and the role of their health promoter. The following day we would wake up early and start seeing patients. Sometimes this happened in a school, sometimes in the room where we had slept, wherever was available. (this photo shows an advanced promoter teaching a student...they are on my bed). The next morning we would leave for a new community and the home of a different promoter. This was usually by boat, but there was one notable two hour hike/swim through swamp. Ok, I didn’t swim, but I truly have never seen mud like that.

The hike in question came on day #3, between the first and second communities. As it was early in the trip we had lots of fuel for the motor, 5 boxes of medicine and a full compliment of food. We the option of loading up the boat, driving for an hour, then unloading everything for an hour hike, and leaving the boat and fuel on the shore. The other option was a 2 hour hike, which everyone in the community described as “pantano feo” (really, really bad walking through swamp)…that was kind of impressionable, as in general, Colombians are pretty durable travelers. As no-one in the community could convince us there was a safe place for the boat and fuel, we opted for the swamp. I was quietly completely jazzed. We found horses to help with our supplies, but needed to split up the medicine again, aiming for 2-3 boxes. We trimmed our bulk additionally by leaving clothing and food and hit the trail. I guess this would be a redo of the “medicine-choosing” scene…completely ruining the effect from the original energy-building montage. That may be why there aren’t too many movies about this work. I faired pretty well early on. Then we hit deep mud. Everyone else seemed to glide over it, while I got fairly (completely) mired. I do need to add here that I indeed chucked clothing and supplies from my pack, but I was not about to leave any books behind. My feet were falling fairly heavily and sticking into soft ground. I smiled to myself, thinking that my fear of fatigue was much less than my fear of not having good resources with me here. At one point I sank to my knee; I was done. A good friend was walking behind me and tried to pull me out. We then realized the immense and sinister spines on the logs surrounding my boot. I didn’t have a location to act as a fulcrum, I was hopeless. Humbling. I pulled my foot out of my submerged boot and stood balancing on one foot while my friend found a stick and started digging. It took about 5 minutes. I buried it pretty well, I guess. I am so thankful to be able to work with these promoters.

The health promoters here often thank me for being here and mention my patience. To me, they are the patient ones. My Spanish still demands the listener’s full attention. They talk with me, trying to teach me about their country, their culture, their food, their language. They laugh with me and dig out my boot or correct my speech. In some ways I am a teacher here, but in many more ways, I am a student. The promoters have lives and need to be productive to support their families. Their communities are investing in their ability to learn. They attend to sick people at all hours. They are completely comfortable in a huge variety of conditions. I was walking with a community member and he shared a wonderful compliment, “your friends, the promoters, are good campesinos (people who are able and comfortable in the outdoors)”. I thought that was great, especially because doctors traditionally lean a bit toward the “less capable in the outdoors” end of things. I am making generalizations, I know.

Well, we made it to the next community and the week continued. The whole trip turned out to be a huge bonding experience (despite feeling completely lost language-wise). My three colleagues used language with each other that I couldn’t make much headway with¨..."hey…is that in my dictionary?” after a smile and a “nope”, they would describe what I missed. I have no idea when I will use this new cache of vocabulary.

Despite the difficult work, I often wondered how neat it would be to have 3 other close friends with me. When was the last time I was on an 8-day boat/camping trip? I really can’t believe this is my job.

I think I described our visits in a previous blog and I don’t want to be repetitive. We usually sleep in a community building and eat food that we bring but is cooked for us. The community buildings usually do not have cooking facilities and we are usually working and don’t have time to prepare food. The food is pretty fun for me, though I should say that the planning was a bit of a challenge. We were all hungry growing guys: 3 Colombians and myself. I am only just learning local traditions of what to eat and when. All the food had to be portable and as none of the communities have power, the food needed to tolerate ambient temperature for the entire trip. We ate lots of rice. MOUNTAINS, three meals a day. Plaintains. Oatmeal. Lentils. Beans. Sugar. Oil. Tuna. Canned meat. Eggs (though they didn’t quite survive the swamp portion)…Hmmm. Two communities up-graded the food we gave them to cook with fresh hen and freshly picked rice. We ate Olympic quantities of cheese as well. I don’t really know the science of it, but it deserves a description. (I don’t have a picture yet…) It doesn’t need to be cold (I hope), because it is normally kept on top of store counters. It is white and might almost be described as cottage cheese, but it is a solid block. Both of the French women that I live with here get completely nauseous at the sight/thought of it. We have tried to hide a small bit in lasagna, and they sense it and pick it out. It feels a bit like squeaky Styrofoam in your mouth. Yep, we devoured a huge amounts. I would get back from handing over the food and someone would inevitably ask me “what are we eating tonight?” “what is the liga (substantial food-usually meat)?”. Then I would review the food plan, followed usually a bit of silence, then a slight nod, “bien”. Pheeeww…passed another small test. Here it is really late and we are having dinner, cheese and pasta soup.

We are planning for one if not two more trips before I come home. I’ll keep you posted. We came back to Apartadó this week so that I could write a grant application. I finished and sent it yesterday. I have been cooking more and more. I really like it.

I hope your summer is going well. Food and gas prices have been climbing here too. It is kind of frightening.

Thinking of you,
bg

p.s… AND…I didn’t know where to put this…if anyone is reading this from East Greenwich High School…class of 1988…it would be great to see you at the reunion this October…

Rolling along...

I made it through the week!! Well, that is kind of dramatic, but I am riding a wave of relief…Last Sunday, as I mentioned, the promoters came to Rio Sucio for a week of courses and learning. Since I have been here with Alan and Julie, I have known that I needed to organize and teach a course in child development. I knew when I accepted this job that I would have to teach, but to do it in June caught me a little by surprise, well…scared me to death. The longer I was here it always seemed to be a cloud on the horizon. I felt that it was a bench-mark of sorts. But I had time to organize and prepare I had helpful people around to ask questions. Today we finished the week. I spent much time reading and studying in Spanish, writing out what I needed to say, learning vocabulary, and thinking up logical class flow. I was pleasantly surprised. I know the promoters learned something from the course, but they were really patient with me and my Spanish. I had a great, enthusiastic group. Here is a photo of us on the last day. I am the one that looks kind of anemic, and also who feels like the weight of the world has been lifted off his shoulders. I know my teaching and language will get better …

Yahoo!!

We head out for more community visits the middle of this coming week. Tomorrow is reserved for laundry, cleaning the house and trying to relax a bit, but those days never seem to go as planned. And we have to get ready to move, as we are changing homes before we set out to the campo…

I began that note nearly 2 weeks ago…time flies …we have moved into a bigger space, and we just got back from a fantastic trip up a smaller river basin. We visited 3 communities. Ismael organized us and had his hands full driving the boat. Susana, John and I worked on the medical end of things. It was a great trip. Smooth. As the river was known to wind through trees and be generally difficult to navigate, we used a smaller boat and a smaller motor to make the trip more manageable. It was still pretty tight. The river was thankfully slow during that portion of our week.

As the first promoter we visited is fairly new, this was the first visit of our group to the community. We arrived at the river’s end to find that the community was another 20 minutes by foot…we quickly prioritized the medical equipment and went hiking through the mud.

We left the remainder sealed in plastic bins under a thick plastic tarp and palm leaves. The rest of the visit went well. The meeting with the community reinforced the job the promoter had been doing. We organized to see patients the following day. We normally bring staple food for someone to cook for us while we are working. Usually we eat some combination of plaintain bananas, rice, a root vegetable (yucca, carrot, potato, onion) and some protein (bean, lentil)…This is a photo of us going to dinner our first night there.

Clinic the next day was busy, but with three physicians, completely manageable. With one promoter we were able to show her anything interesting we found. That way she could learn from the three of us fairly simultaneously. We finished clinic a little early and walked through the jungle to see the rest of the community and go for a swim in a wonderful river. The next morning we packed and left very early in the morning as we had a 5-6 hour trip ahead of us to reach the next community. Back down the winding river…we saw tons of bird species, monkeys, fish…

That is a quick view into a normal community visit. Each community is unique with different issues. I feel lucky to be able to work as closely with the promoters as I do.

I am still healthy, but check out these feet!! I swear I couldn’t feel the flies that did this at all.

There as been a small debate in the house, but those in the know say the fly that does this could have laid some eggs inside of me, soon to hatch into larvae…that was over a week ago, I used some medicine and my feet have almost returned to normal. I still have the little dark dots as the blood-thinner that the fly uses caused a small amount of bleeding under the skin, which takes longer to heal...the swelling is completely gone…mom, I am fine.

We have just returned to Apartadó. Alan will be teaching a course next week and is getting ready for that. I need to plan my next course which will start in September. I also am anxious to catch up on people and news from home.

Please take care…
Brian

I have been feeling like I need to write something recently, but I hadn’t quite figured out a topic until one found me…we ate an early dinner tonight, and as the humidity and ants are doing a number on the lap-top I’ve been using, I took a walk down to the clinic to use a different computer and to get some studying done…

I received a great email from an old friend this week…we haven’t been in contact for years…she had been catching up by reading my blog posts…she thought that as I keep mentioning clergy in my stories that I must be doing a religious mission…that made me realize that I haven’t really described my work to everyone…I better set that straight, huh??

I also better straighten out the fact that despite photographic evidence to the contrary, I am still young on the inside. I have shaved since this photo and all is well.

I am working for the Pastoral Social for the Dioceses of Apartado in Colombia. This is the social arm of the Catholic Church dioceses which includes the area where I am living. We work exclusively in this regard. But I didn’t find them on my own. The support for the volunteers is provided by Concern America (situated in California and Chicago); which is a non-profit, non-religious, and non-governmental group. That is why the majority of our local contacts are church-related, but our work is not. Our work benefits the church as we improve the medical care in their jurisdiction and they help us with transportation, and occasional space for working and lodging. THAT is why I needed to ring the bell and wait for a priest to answer the door.

If what I am doing has an official title it would be a teacher and advocate for health promoters. The idea of educating local people to act as medical care-givers in a community far-removed from official medical services is not new. As I mentioned before, Susana is working with the same model in Guatemala and Juan is in Mexico. It has been proven effective all over the world. My colleague Alan created the program locally just over 5 years ago. The program has grown slowly, but steadily. He has his wife Julie and his close friend from Riosucio, Ismael, doing a massive amount of work concerning logistics and transportation; but he has done the majority of the medical portion single-handedly. I can’t fathom how much work it has taken. Now there are roughly 3 levels of health promoters, living in nearly 30 communities along the Atrato River and its tributaries in Northern Colombia. As I am so new to the project, the best thing I can do is learn Spanish as quickly as possible and start teaching medicine to the promoters.

Our primary goal is education. The promoters leave their homes for weeks on end to come to Riosucio to learn from us. If Alan is alone here he spends a week teaching a specific course to a specific level, but as we have 3 others physicians here presently, all the promoters have been convening here for three different courses…the last series included the gastro-intestinal system for the first level, advanced suture and trauma for the second level and eye diseases and treatment for the 3rd level. As we had a larger group in Riosucio than we could fit into our small classroom, we used the 3 separate classrooms across the river. They have adequate space, but no electricity or bathrooms...yep... Here we are crossing to the other side for morning lessons. The classrooms are the small group of buildings in the background.

Here is Alan teaching IV access. I needed two tries to find Alan´s vein, the promotors, on the other hand, did great! All the other classroom photos from the week have a pig dissection or pig suturing...I figured I would leave those out...

ummm...sorry about the tease, but this photo kept crashing the computer...I´ll send this post without it...

That was about 3 weeks ago. All the promoters will arrive back in Riosucio next Sunday, June 15th. The first level will learn the respiratory system, the second will be wowed while they absorb growth, development, immunizations, and illnesses of childhood, the most experienced group will learn neurology and auto-immune illnesses. Here is a picture of Susan at our kitchen table working on a game illustrating the life cycle of different worms.

(Alan and Julie have spent a long time fixing up their home. It is a really nice place to stay. The kitchen is in the background, the three bedrooms are along the wall on the left. On my last visit, we lived downstairs as this upstairs’ floor had burned down.)

Each course adds to the promotors´ knowledge as they go back to their village and practice. They are volunteers and are busy. They have families to care for, food to grow and harvest, and other jobs to complete. As much as I admire how much Alan has accomplished, I am completely impressed by the work and dedication of the promoters. The amount of experience with classrooms and structured learning varies. A challenge for me will be structuring a course that is practical and helpful. I have been planning this course steadily and have enjoyed coming up with games and activities to make the concepts more real, understandable, and hopefully more memorable. I am scared stiff. I think I have a knack for teaching, and I am certainly comfortable with the subject matter. The scary part centers on teaching pediatrics with my present 4 year-old Spanish vocabulary. I hope I am exaggerating. I also hope no one was wondering how that is different than me teaching pediatrics in English.

Besides structured coursework, we also complete visits to the communities. I love this even more than the teaching, primarily because it combines teaching and medicine with traveling and camping. We work hard in the communities, but for me the reward is meeting people and seeing places that I would have no opportunity to encounter other-wise.

As I mentioned, the towns are along small river valleys, accessible only by boat or by foot. In each of the communities that I have visited we have been put up in an open-walled platform with a roof. We set up our camping mattresses, our mosquito nets and we are good to go.

The large majority of the towns do not have electricity, and water for washing and other things is provided by the river. We spend these visits with the local promoter talking about town needs: water sanitation, mosquito prevention, creation of latrines, and vaccination. We also see ill people in the community. This is very different from the clinic at home. As our priority is the education of the promoter, we see all patients with the promoter. What we teach depends on the promoter’s level. With an early promoter we might work on history-taking, examination, or obtaining vital signs, while with another we might talk about the sequellae of diabetes mellitus or the specifics of treating emergent hypertension. The promoters improve steadily and it is great to watch and be a part of the progress, not only for the promoter as a person and care-giver, but for the community. It is our goal that eventually some promoters will become teachers and form the foundation of a solid, sustainable medical care system for this remote part of the world.

That is what we are doing in a nut-shell. I am so proud to be doing this. It seems completely worth-while. I realize that my 2 months of work here pales compared to the years and even decades of experience of my 3 current colleagues. It feels strange even to sound like I am doing anything more than just starting to help out. I am humbled.

Thinking of you…hoping all is well...
bg

I made it!!!

Hello!

This is WAY overdue…my apologies…we just got back from a 8-day trip working with some of the health promoters in their communities. I will write about my work and the trip in the next few days…the note below is something I began writing ages ago, but never sent. I am pushed for time tonight to finish this and get to the computer with internet access before it closes. Please excuse any mistakes…AND...the line is super slow here...so I am not sure I can include any photos...

It is Wednesday night; May 21…we have been in Riosucio for 5-6 days. Our trip from Apartadó was blissfully uneventful. Despite waiting for a few hours for our boat to leave, nothing unanticipated happened: nothing broke down; we didn’t run out of fuel, the crossing of the Gulf of Urabá to the Rio Atrato was as calm as it has ever been.

It feels great to be back in Riosucio. Its energy and people make it unique. I am now staying in the home of Alan and Julie, both colleagues in this project. I lived with them during my last visit here. John and Susan are here working as well; they are visiting from Mexico and Guatemala (during their vacation). I have mentioned them earlier, and I am glad there are here. We are sharing a 3 bedroom apartment. Gregory, the 2 year old, has many friends in town that play on the partially enclosed (completely safe) balcony. Despite what sounds like a crowded situation, living is easy; I enjoy my days and the company.

Realizing that I have only just returned and knowing that my views will change and undoubtedly become more accurate, I wanted to describe Riosucio as I am seeing it again with fresh eyes.

Riosucio has a pulse all its own. Currently it is raining and after 9 o’clock. Without straining I can hear the rain falling on our tin roof, a group of men smacking dominoes on the playing table across the street, the amplified speakers playing vallanato music a few houses away. This morning different speakers began playing religious music before 5 a.m. Then when I was drinking coffee on our balcony at 6:45ish a large man walked down the street verbally berating the owner of the early morning music. The ironic part is that it happens every morning.

People live very closely here, not just in location. 11,000 people living next to a river which frequently floods. There is a cell-phone tower and fairly consistent electricity, but water is a commodity. The river is used by the majority for bathing, washing laundry, using the bathroom, and even drinking. This photo doesn´t quite do it justice, but here you go. The closet-looking things on the rafts (balsas) in the photo are used for privacy for the toilet, there is also a woman washing something on the balsa nearest the camera.

It is more accurate to say drinking water is a commodity. The seasons are just changing, we are moving from the dry summer to the rainy fall/winter. It does rain daily and the river is slowly rising. Right now, there is 1-2 blocks of solid ground/mud next to the river, and the remainder of the depth of the town is under water.

People are anticipating that what is left will be submerged in the next few weeks. The walkways to reach homes and to go shopping are planks balanced above the water. Before the angry gentlemen walked under the balcony this morning, I saw a woman, with her hair in curlers, wrapped in a towel, with her recently-cleaned laundry and dishes in her arms walking on planks from the river back to her home.

Before I forget, I wanted to write a quick blurb on traveling to poorer countries. I am certainly not an expert, but every time I get re-acquainted with living outside the U.S., I forget the interesting subtle differences that soon become normal and lose their interest. On a resourceful level, it is true, clean water does dictate so much of our habits here. We buy our drinking water in 12 liter hard plastic jugs and fill our pitchers and glasses directly from that. We have gutters on the roof which drain rain water into a 2000 liter tank. This tank has alum in it which acts as a water clarifier (settles out the large impurities and dirt). We use this for cooking, washing dishes, and bathing. Any water that we cook with needs to be boiled as well (there are other animals that use our roof too). So it works great for coffee, tea, pasta etc. If we use the rain water for washing dishes, then we add bleach to it first. Finally bathing…to save water, we stand in a large plastic bin. We have a small bucket filled with rain water and we repeatedly dip a small bowl in the water to get wet, then to soap up and eventually to rinse. The soapy water that we stand in is then brought upstairs in buckets and used to flush the toilet (pour the water into the front bowl). I don’t want to go much further along this line…but there are a few notables…toilet seats are a rarity…more cracks and crevasses to keep clean, I guess… ...go on...I know, but when I thought of that phrase, it made me laugh, so I kept it in…The other interesting thing is that nothing non-human goes in the toilet. There are small trash cans for everything else. I guess they are much kinder to their sewer plumbing than we are at home.

I sleep under mosquito netting every night. It keeps the mosquitoes and biting bugs away, and hopefully keeps me healthy. On a neat note, when here in Riosucio, we no longer have to do laundry by hand...though it isn´t quite what you´d expect...here is a photo of me wrestling with my laundry...

Alright…I am going to run to the computer place…I hope this finds you happy and healthy…I think of home often, but all is well…

bg