Day 11 (Feb. 26): Final Hours, Final Thoughts

Think of a pristine environment that has never seen human footprints and what an impact people have when they settle that area. Species become extinct and that lansdcape changes forever. Globally, we just learned that the last Bengali tiger was killed and what a sense of loss I felt knowing that those majestic creatures will never roam the earth again.

I hope that my trip to Nicaragua did not have that kind of negative impact. Did local people's perspective on their own life change when they laid their eyes upon me and my colleagues? Did they suddenly see what they don't have because I am there? Because I saw the beauty of their caring community which I do not have in the States? In the end, I hope my curiosity and giving nature does not take a piece of someone's personal light, their hope.

Not only did our trip to Nicaragua create a new lens in which to view our own world, but we grew as a family. As we sat around a round dining table in Managua discussing our final "ah-ha" moments and general issues we had with the trip, we realized how extraordinary our team had performed. There were so few things we wanted to change and how minute those details were.

I want to use this space to dedicate a few lines to the integral roles we each played. Not only a necessity, but definitely a source of humor. If you want to know more about global health, please contact one of us or embark on your own service adventure!

My tribute to the 2012 global health family: Dr. Anna Doubeni, mother hen, leader and global health guru:  Monica Agarwal, PGY-1, collector of fine pottery; Christopher Chang, PGY-1, the human calculator and assistant to the sandwich maker extraordinaire; Shannon Demas (aka "Shannon Pocket, Polly Pocket") impromptu discotheque DJ; Serena Hon, PGY-1, "trip snactician" and sandwich maker extraordinaire; Stephanie Muriglan, PGY-1, blogger with some difficulty standing upright.

Brendan Scanlon: lo alto y blanco, photo journalist and future Quesillo salesman; Jason Schweitzer, our "voice" giving us real insight into Nicaraguan culture

Day 10 (Feb. 25): Top notch research at CIDS (El Centro de Investigación en Demografía y Salud)

As if witnessing the level of health care delivered in a country with few resources was not enough to make me proud to have been a part of this journey, CIDS was truly jaw-dropping.  I have an extensive background in research and can appreciate the solid design and data collection of CIDS Demographic Surveillance System Database.

Dr. Manuel Salazar took the time to explain how their sophisticated computer program is loaded with an extraordinary amount of data where it is quite easy to propose a research question and be able to locate a randomized sample of the population that one wishes to study.  There are many checks and balances to the fieldwork, where researchers return to the community to fill in missing data.  Some of their published topics include traffic accident clusters, gender-race violence, sex education, suicide and HIV.  He was kind enough to even provide us with copies of more recent publications.

Toward the end of our discussion, Dr. Salazar explained how he was excited to invite the UMass Global Health fellows back to conduct research in our third year.  He explained that the medical schools’ masters program includes a two-week intensive course where students are taught epidemiology and are able to design and complete a pilot research study in these two weeks. With our month, he could ensure that we had enough background on setting up our project to ensure success in completing a sophisticated global health research project. I think we all left there thinking we had won the lottery!

Day 9 (Feb. 24): Vaccinations and Sex Education

We returned to the local school in El Tololar to vaccinate 12 year olds against MMR. After receiving their vaccinations, the children were quite excited and comparing arms. Following the vaccinations, we led three classrooms in reproductive education. With the older group, ages 14-16, we divided the males from females, and conducted a safe, private forum for them to ask questions. There are few things more beautiful in life than watching kids transform when offered new knowledge.

The girls I worked with all agreed that they never had anyone to safely ask these personal questions about their bodies. I watched them become empowered, given the courage to say no to sex because they now knew the consequences of having intercourse before they are ready or without protection against pregnancy and STIs. Someone finally told them how and why to say no.

Two memorable quotes were:

"Girls get pregnant because they do not have the knowledge, we will get pregnant now only when we want to."

"There are guys who respect you and your decision and guys you send walking."

After our visit to the schools, we went into the community to speak to the people. One thing I noticed today about myself is sometimes my naive vision needs to be shattered.  Although sometimes hidden, the struggle and hard times ARE apparent on the faces in El Tololar.  One villager recounted stories of his neighbors and friends who are dying of kidney disease and how he may eventually be affected himself, but has to work despite the risk. There is fear and stress in this difficult environment, but they make their lives, their community as rich as possible under these difficult circumstances.

Day 8 (Feb. 23): A Long Walk Through El Tololar

We are walking several kilometers to a more remote sector in El Tololar.  It is 90+ degrees of dry heat, walking along a road covered in volcanic ash, crossing an even dustier riverbed that is impassible in the wet season to the most poor portion of the community we will see. Bright colored clothing contrast the dust of poverty.

A girl is washing clothing, smiling at me while I watch her deliberate movements. I sense pride in her work, her shirt and skirt are clean against the dusty background. Judging by the amount of dust covering my own body, washing clothes is a frequent activity in these parts. In the background, children in school are playing in their blue and white uniforms. The girl is no longer attending school, needed at home for the family’s survival. 

Carlos, a nurse from the health post, is going from home to home looking for a brigadista to serve this sector, while reinforcing education on leptospirosis and clean well water.  He is encouraging the people here to cover their well with plastic to avoid illness, but the people ask who will provide the expensive plastic to accomplish this.  My heart sinks as Carlos explains how he told the community to cover the well last year as well, but they have not done this because they cannot purchase a simple plastic tarp.

In a way, I feel guilty thinking of all of the waste I see at home and how that waste would be such a resource here.  I know I cannot change the situation, but it has further changed my perspective on my own resources.

Day 7 (Feb. 22): Health Post in El Tololar

In the morning, we walk over to the hospital to meet our transportation to the rural community of El Tololar, where we will visit the Health Post located there. We all pile into the back of a red Toyota truck and head to the countryside, something we would not consider doing without seatbelts back in the States. When we arrive at the health post, there are numerous patients waiting outside on benches for treatment. There is a massive mango tree next to an equally sizable tamarind tree out front providing ample shade from the hot sun.

The health post is divided into six rooms. In the first room, patients can receive routine dental cleanings, extractions and infection care on Tuesdays, Thursdays, and Fridays. The Dental specialist explains that she does not have the most sophisticated equipment and needs a better dental lamp, but it is enough to provide needed services here. The second room is designated for Women’s Health.

There are speculums for PAPs that are sent out to the health center in La Mantica for sterilization, as there is no autoclave here. They prepare the slides at the post, but are read by pathology in Leon at Heodra hospital. Most of the important information about pregnant women is on the walls. There is a map indicating how many pregnant women are in each sector that the Post serves. Another chart documents patient name, MR number, expected delivery date, etc…

This is the theme at the post, all important information is on the walls. The third room is the doctor’s office where consultations and documentation occurs. Medical records are arranged by date of birth in vanilla folders much like we are used to seeing at home. They even have sophisticated forms to document medical visits that are generated and distributed by the Ministry of Health. If you looked at one of these forms at home, you would think it came from one of our clinics!  Although this community lacks most of the resources we take for granted, they take pride in the level of health care that they provide.

Day 6 (Feb. 21): El Sauce (pronounced El Sowce)

This was the earliest morning for us in Nicaragua, not including our departure from Logan. We left the hostel at 6 am, traveling on a local bus for two hours to reach El Sauce. On the bus we observed one example of how poverty impacts local Nicaraguans. A boy, about nine years old, was selling tomatoes and onions to help provide for his family instead of attending school.  Food for thought when you look down at the foods that color your plate and whose hands they passed through to get to yours.

The hospital here opened in the last year in response to the need for more sophisticated services in this region. Prior to this past year, the nearest hospital was Heodra in Leon. Despite having the capability to perform surgery, there is no night staff for after-hours surgery.  Night trauma would require the injured individual to travel for one and a half hours for treatment. The hospital is also grossly understaffed with 51 openings in all medical specialties, nursing, technicians and social services.

El Sauce is not a small, rural community either. A point of comparison would be living in Worcester, but having to travel twice as far as Boston for care. Imagine if you were an eclemptic woman requiring a c-section and what your chances are for survival in that situation. That is the reality here.

Despite such limited resources, a growing theme on this visit is how effectively the Nicaraguans utilize these resources, and the knowledge they have. They attempt to fill in the gaps by drawing on the community and their organization skills. Maternal care here is superb. They know every last detail about the patient and family.  If an expecting mother misses an appointment, someone visits her in the community to ensure that she is in good health.  Knowing about this program for mothers was very uplifting and deepened my respect for the health care system in Nicaragua.

Days 4 and 5 (Feb. 19-20): Weekend Touring

After an interesting few days learning about health care in Leon, we headed Southeast to Masaya and Granada for the weekend.  Although we would have loved to have Julio take us along on this part of our trip, we got the next best thing, his son Cesar! Unlike his father, Cesar is just getting his feet wet in the tourism industry.  He is also sweet, but very shy and has not yet learned English, a task his father has imparted on us. 

Visiting Masaya National Park and staring down into a vast, smoking crater was a long-awaited experience, despite the strong smell of sulfur in the air.  I was a little nervous knowing that this particular volcano last erupted in 2003. Signs displayed throughout the park instructed visitors to take cover if rocks, lava or other debris were ejected from the crater.  I just crossed my fingers because that did not seem like a terribly realistic measure.

Granada has a more carefree air to it than Leon.  If I could compare it to a place I had been in the States, it would be New Orleans.  There are many more tourists and restaurants that cater to Americans.  We take a Lagoon tour to see some private islands that are occupied by some of Nicaragua’s elite citizens and even some Americans.  The cost for your own private island in this stunning paradise: less than half a million USD.  To me, it is not a very good representation of social justice.  Of course I am dreaming about having my own island at the same time, but to possess one of the most beautiful natural resources of Nicaragua and place my own barbed wire fence around it does not seem to be very fair in the grand scheme of things!

Day 3 (Feb. 18): Prosthetics and Wheelchairs

From the 1970's to the 1990's, many innocent civilians were injured and lost limbs due to land mines. In a country with few resources, two groups formed to give hope to these amputees.

In the morning, we visited the Pollus Center, which through funding from the Red Cross manufactures one prosthetic a month.  In addition to land mine victims, the center now provides prostheses for individuals who have had illnesses, like diabetes, resulting in limb loss.  They have a thorough selection process for candidates including evaluation of psychological barriers to help ensure resources are invested on individuals more likely to have success with a prosthetic. The Center offers payment plans and sliding scale fees to those with economic hardship.  The Pollus Center was fascinating, but could not compare to the effect the wheelchair factory had on us.

Maybe I should keep the wheelchair factory a secret since some of you reading this may follow in our footsteps as future UMass residents. Then again, maybe you won't feel so confused as to why you are traveling such great lengths simply to visit a factory.  When we arrived, we heard all about the history of this center and how the six factory workers are also wheelchair-bound themselves.  We watch them curiously, eager to hear their stories and then our tour guide said those magic words:  “what would you like to ask them?”

Ernesto had been a carpenter prior to joining the group five years ago. He specializes in children's wheelchairs, customizing each miniature chair to serve its owner in the best way possible. He explains what a joy it is to work for children who experienced what he had been through. (Here's where I tell you to sit down on the floor, look around, and stay there awhile…) Ernesto had spent the first fourteen years of his life on the floor, which is why he takes pride in fabricating hope with his own two hands in a sweaty, dirty factory day in and day out. Roger and Anastasio had similar tales, but you should go there and hear them yourself!

Oh, and let me add that these amazing men each have built three chairs for themselves to serve in different capacities:  a home wheelchair, a work wheelchair and a travel wheelchair. They travel between 7-8 kilometers to work by wheelchair each day and despite extensive flooding during the winter, "we are always here at 8."  I don't know if many people can say that about themselves with a heck of a lot more resources available!

When I left there, I no longer viewed this place as a factory.  These men are not ordinary factory workers, they are artists with passion in theirs eyes, giving hope with their hands.

Day 2 (Feb. 17): Walking Tour of Leon with Lt. Julio Cesar Pineda

History tours and tour guides bring to mind commercialized and exaggerated accounts of history that can often times be boring. I was eager to learn more about the tumultuous history of Nicaragua, but my expectations of a guided tour were actually quite low.  I was definitely in for a surprise.  Julio, from Julio Tours, started our day chatting about different things going on in the Central Market of Leon. He explained that the beautiful, baroque-style cathedral of Leon is recognized as a World Heritage Site and was blessed by the Pope in the 1800’s following its construction.

Soon, we came upon a park with a mural depicting notable moments of Nicaragua's history, the US occupation before the Great Depression, the Sandino guerilla movement, Samoza, Chamorro and so on. I'm not exactly sure when the story transitioned from knowledge about his country to personal accounts, but it quickly became apparent that Julio wasn't a regular civilian who had learned about his country's history in a classroom and then decided to become a tour guide.

Julio had seen the revolution start when he was just a boy, when male gender bought you a gun and a place in the Nicaraguan army. He had gone to prison at fourteen years of age for frivolous reasons and saw his homeland decimated by war. While in the army, he moved through the ranks to lieutenant, serving in both the USSR and Cuba. Following retirement from the military, Julio worked at a variety of positions, made attempts to travel to the US and eventually lost all of his money to a Sandanista congressman before founding Julio Tours.  Meeting him, you would never believe a man of such warmth and natural sweetness had been through so much. I wonder if facing that much hardship would have eventually broken my own spirit.

How lucky most of us are to live relatively sheltered from tragedy. I think back on how I lived through 9/11 and what it would be like if that story occupied more than half my life.  I was so inspired by this city tour that it brings tears to my eyes sitting here now.  Makes you stop and think about who the people around you really are, especially those that aren't so full of light and hope; and if they are your patients, how you may bring some light back into their lives.

Day 1 (Feb. 16): The Arrival

Our morning started with an excited anticipation of our upcoming adventure! Personally, I had never been to Central America and for even those who had, it was a new chapter, a new perspective on our call to serve. I have to admit, this anticipation was accompanied by much yawning, red eyes and that blurred vision you have when trying to leave for the airport at 3am, a small price to pay for what I'm sure will be an unforgettable experience.

That first glimpse of Nicaragua as the plane started its descent was powerful, when all the abstract facts about this wonderful place we discussed over the last two weeks became a reality. Volcanoes and mountains revealing a geological history, modern buildings and cars, isolated homes and shanties telling a different story. It is still hard to imagine that some people of Nicaragua subsist on less than $1.25 US dollars a day. A single pack of gum...your gym membership may be more than one spends in a year! Surely puts things into perspective.

One thing that stands out in places we find so destitute is the people:  the vibrant yellows, oranges, reds and greens tell a different story. There may be more life and happiness than we sometimes find in our sterile world. That's part of he draw, what I want to be a part of, what I'm thinking about as I settle into my temporary home, the tortuga booluda (or the lazy tortoise) with my temporary family. There are star fruits and limes in our courtyard. It's warm and sunny and I'm relaxing with my feet up watching a gecko watching me and thinking about what I will see and who I will meet tomorrow.