School is Out and Rainy Season is Here

It is a bit hard to believe that we have passed our 1 year mark here in Belize!  Quinn's last day at school was last Thursday.  He did very well, receiving the highest marks in his class (his teacher said it was double-checked as a lot of Belizean parents do not like the white kid having that honor, particularly when the principal's son is in his class.)  We are proud of how well he adjusted and does despite being teased often and called "White Cheese."

I finished my first year on the P.T.A.  The fact that I was elected is a funny story in itself (I did not understand what they were talking about in Creole at the time and was more than surprised when they called me to the front to give my acceptance speech!).  It has been a very good learning experience for me.  I was asked to participate in the graduation this week of the Standard 6 students (equivalent to our 8th grade).  As I sat there during the ceremony, it was striking to me how difficult it is for a Belizean child to receive an education in comparison to one from the U.S. and how this graduation is more consistent with how we view high school graduation.  Although education is provided through the Standard 6 grade, each student is responsible to pay school fees and have a uniform and basic supplies. The fees are not high - about $20 U.S. per student -  but this can be a huge amount for a family with 6 or 7 school aged children out in a village.  High school is on a merit basis and due to the costs, is unobtainable for a lot of Belizean kids.  According to a recent report, primary school enrollment is 90.3% of eligible students while high school enrollment is only 44.1% of eligible students.  Unfortunately, the drop-out rate in high school is quite high with only 51.3% of the 44.1% enrolled graduating.  Many young people that I have spoken to here (including our clinic employees) would love to obtain a full education, including university, but are unable because of the costs involved.

Quinn's teacher at a school gathering
(we were truly blessed to have her for Quinn this year)

Quinn doing science 

We are looking forward to our upcoming break in the U.S. in August and starting to think about how to approach this next year.  We are still struggling with the bureaucracy and protocols dictated by the Ministry of Health.  It is difficult to not only practice medicine with the limited resources we have but then it can become incredibly frustrating to be restricted by politics.  We have started working with the Ministry of Health on a concerted project to address the severe malnutrition of the children in the most remote villages by deworming them, providing vitamins, nutritional education, and soy protein supplements.  Our treks into remote villages have been hampered a few times already this rainy season by flooding.  The water often rises quickly and fortunately often regresses quickly but it does make certain roads impassable for hours at a time.

Rainy season flooding of Blue Creek

The bridge in Blue Creek allows access to many of the other villages

The narrow cement bridge going into the village of Aguacate was about 4 feet under water today.  Even with a snorkel on our Land Cruiser, we dared not try it.

We are currently in the process of looking for nurses and pharmacist volunteers to serve with us for at least a year.  Natalie, our pharmacist, finishes her promised year here in September and will be moving back to the U.S.  Celia (our RN) has been here since March 2012. She has agreed to stay until mid-December but would then like to move back to the U.S.  She helps us in clinic but is mainly responsible for the numerous home-bound patients that we have in the Punta Gorda area.  It looks like we might have a nurse lined up from Australia to join us in December but we have not found another pharmacist.  If anyone knows a pharmacist who is interested in volunteering with us for 6-12 months or longer, send them our way!

Disease

Providing medical care in southern Belize, we definitely see medical illnesses that we don't usually see in the U.S.  Varicella (chickenpox) is one of them.  We have seen sporadic cases in children since we have been here but there has been an outbreak recently, particularly in the distant villages.  They do not immunize children for varicella here and we have seen cases in all ages.  One of our Belizean staff members, Victor, was even out for a couple of weeks due to the virus.  Fortunately, even though we have seen infants and older adults with it, we have not seen any complicated cases.

There is a lot of suffering here that you rarely see in the U.S.  We are so used to expecting that all of our symptoms will be controlled.  There is no anesthesia available like epidurals for childbirth.  There is very little access to narcotics here and so Tylenol and Ibuprofen are the mainstay for pain control.  These work fine most of the time; however, for conditions like advanced arthritis, cancer and post-operative pain, it hardly seems adequate.  We purchased some tramadol (Ultram) from the U.S. and had students bring it down.  This has helped multiple people but there are times you feel like you cannot truly help relieve their suffering.  There are multiple patients with severe osteoarthritis of the knees who in the U.S. would have had a joint replacement, no questions asked, but that is not an option here.  Right now we have a patient who has advanced breast cancer with bone metastasis and we are concerned that we will soon not be able to control her pain.

So many people suffer with disease that presents at an advanced stage.  We just lost an employee who we watched suffer for weeks before he died, James.  He presented with pain in the right side of his chest.  Initially it seemed musculoskeletal but he had lost 10 lbs.  As soon as the x-ray machine was functioning again in Punta Gorda, we sent him for a chest x-ray.  It was shocking to see that his whole upper part of his right lung was obliterated by tuberculosis and it was spreading into his ribs.  He was started on medication for TB but despite tramadol, his pain was severe.  He continued to lose weight and had frequent fevers and night sweats.  We were really helpless to do more to alleviate his suffering.  

When James finally died, we attended his wake in the front yard of his sisters's house.  The events surrounding his death were an interesting cultural experience.  His body was displayed in a simple wooden coffin the men of the village made for him the morning of his death. They used fans to try and keep his body from getting too hot as family and friends gathered round the clock for a few days prior to his funeral.  There was eating, drinking and remembering.  Bill was asked to read a letter sent to the family from the founder of Hillside, as she had a special relationship with him as the first Belizean employed by Hillside Clinic.  We had been concerned about the family's perception of our care for him but towards the end of the service, the family asked for all of the Hillside staff to be called up to the front and receive a special blessing.

James' Wake the night before his funeral

James' coffin was taken in one Hillside's trucks for the trip from the church to the cemetery

Hillside staff at the cemetery

Dry Season

It is the dry season right now and it is hot and dry.  The vegetation is turning brown and covered in dust, especially by the road sides.  We have not had water in our rain water collection system in weeks and so we have been buying and hauling drinking water from a business in town.  

There have been lots of fires around the area as well.  It seems that many are started intentionally to try and keep the jungle growth back since this is the only time of the year when it is dry enough to burn.  It is not unusual to see a fire burning along the road unmanned.  It definitely poses a risk to the villages and some wooden shacks and houses with the thatched roof around Punta Gorda.  Last week a fire got out of hand in the village of Eldridgeville, not far from our clinic, and the villagers had to work very hard to save 3 of the wooden, thatched roof houses.

Most of the villages are situated by a river and have at least one good well but the village of Dolores is isolated from any sizable rivers and does not have a good well.  The villagers use rain water and a local spring which is piped into the village when it is flowing for their water supply.  During the dry season, the rain water tanks are dry and they often struggle as the spring dries up.  I took my team out to Dolores to see patients on Wednesday and instead of spending the night as planned after our clinic day, we had to move on to Otoxha because there was no water.  Before we left the village, I wanted to see this spring that was so important as it is something we talk about but I had never hiked out to it.  We walked to the other end of the village and then on a path up a hill into the jungle.  There was a small creek coming from a very small pool of water surrounded by rocks.  The water was barely flowing but there was a woman trying to fill her water bucket from it.  As we walked back towards the village, I realized again how important access to water is and how thankful I am for "pipe water" which flows when you turn a handle.

Muddy Creek in Dolores

Spring barely flowing in Dolores

Hand pump at the well in Otoxha after my morning bath

Asa

Not every day is interesting here in Belize but today was definitely one that was.  I went out on mobile clinic to the Mopan Maya village of San Jose which is over an hour and a half away from our main clinic.   I always like going to San Jose because even though it is one of our busier clinics, the drive there and the village itself is beautiful.  We set up our clinic in the health outpost building there and saw our regular patients.  

At 1:00 pm, I was getting ready to send part of my team up to the school to do our dental program and fluoride varnish application on grades Infant 1 and 2 when someone came running down from the school.  They asked for a doctor to come quickly as a boy had fallen and hurt his leg.  I have a young doctor who just arrived this past weekend from the U.K., Stephanie Jordan, on my team and she offered to go.  It was not long before she sent someone to come and get me to help.  By the time I got up to the school, they had carried Asa, 8 years old, into one of the classrooms and a lot of the village had already arrived.  There were actually so many villagers at the school and crowding into the classroom initially, I could not get in to see him.  Just about everyone in the village had come to see what was happening.  

After the principal cleared the way for me to get in, it was obvious that he had broken his left femur.  Dr. Jordan's comment to me was that she had clinically thought it that it was fractured but wondered how an eight year old boy who is small by our standards, could have fractured his femur after just falling in the schoolyard?  It was a good question but this is the second femur fracture that I have seen since I have been here in an eight year old boy who simply fell at school.  (I have a theory that the children in this area are subject to more significant fractures due to their nutritional deficiencies.)  Regardless, it was something that we could help with.

Fortunately his leg was still neurovascularly intact but it was grossly displaced.  By this time, he also looked to be in shock.  I climbed up on top of the Land Cruiser to get some needed supplies and we sent someone for a board.  One of the villagers returned fairly quickly with a board from the side of their house.  We were able to start an IV and get fluids going, give him a dose of Tylenol and then work at immobilizing him on the board.  Using the white sheet we use for privacy when we do pelvic exams in the villages as well as some triangular bandages and tape, we were able to immobilize and stabilize his leg and him to the board.

While I was doing this, our driver Mr. Rudy had to drive to the top of another hill, climb on top of the Land Cruiser for a cell signal and call our clinic for a back-up vehicle.  The district only has one working ambulance right now and they don't send it out to the villages as they need to keep it available for transfers to the referral hospitals in Dangriga or Belize City.  Since the bus that runs three times a week out of the village to Punta Gorda did not leave until the following morning, we were his only way out for care at that point.  We loaded him and his father in the back of our Land Cruiser as well as half of our team. The other half stayed to be picked up by another driver.  

We drove him to the hospital in Punta Gorda and were able to help transfer him to the x-ray room and then into the emergency room.  It was so nice to have the availability of an x-ray as we have been without it until just last month.  The x-ray confirmed our clinical diagnosis - a spiral left femur fracture with overriding and rotation.  The Belizean doctor in the emergency room began to arrange for his transfer up to Belize City (7 hours by ambulance) for care.

While it was not a good day for Asa, it was an interesting day for me and my team and left us with a positive feeling that we were able to facilitate medical care for Asa here in Belize.

Brush, Brush, Brush Your Teeth

For those of you who collected and donated toothbrushes and toothpaste for us, thank you!  I want to show you what we are doing with them.  We have been working on distributing these to the children of the Toledo district.  We do this through our dental education and fluoride treatment program.  For most children, this is the only toothbrush they get for the year as well as any dental care.  We go into the schools and starting with the youngest grades, give them a toothbrush and teach them to brush their teeth.  They do this all together while we sing the song, " Brush, Brush, Brush Your Teeth Each and Everyday."

In the youngest grades, Infant 1 and 2, we then apply fluoride varnish to their teeth.  A lot of the children get really excited about getting the toothbrush.  One boy came up to me last week and asked me if it was ok if he hid his toothbrush at home.  He was worried that his mother or older brothers would take it from him because they did not have any toothbrush either.  I will never forget my first overnight trip into a distant village last year.  Three boys approached me and asked me for toothbrushes and "Colgate."  Most American kids I know would be looking for the sticker or treat, not a toothbrush and toothpaste.

Dental needs continue to be one of the most pressing problems in southern Belize.  There is still only one Belizean Ministry of Health dentist serving the entire Toledo district.  He is only able to provide extractions unless a patient can afford to pay for more, which is uncommon.  Hillside has not traditionally provided dental services but we have been brainstorming and recruiting to try and meet this need.  We have had some interest recently from a dentist who is interesting in volunteering with us for ten to twelve months starting this August but is still working on the finances of it.

So keep the toothbrushes, toothpaste and fluoride varnish coming.  We can use each and every one and they do make a difference.

Easter in Antigua

We had a great Easter break in Antigua, Guatemala.  It was a time for the family, a break from the heat, an adventure and one of the most contemplative Easter weeks I have ever experienced.

As is the Belizean tradition, we had an early morning breakfast with the clinic staff on Holy Thursday before leaving.  They served their traditional hot cross buns and coffee.  It is traditionally a time of prayer and togetherness before the Easter events begin.  After breakfast, we left the clinic with Chad and Natalie in charge and caught an open boat across the Bay of Honduras to Puerto Barrios, Guatemala with Celia (our nurse), Meagan (our public health intern), Annette (our physical therapist) and one of Annette's friends who is with us as a student. From there we went by bus the six and a half hours to Guatemala City.  The shuttles and buses were all shut down by the time we arrived so we took a taxi to Antigua.  Even though the travel was long, it was good to be back in civilization.  

Staff breakfast at the clinic

Antigua is a small city 25 miles southwest of Guatemala City.  It was the capital of the Spanish colony of Guatemala and then the country of Guatemala from 1543 until 1776 and is considered to have the best preserved colonial architecture in Central and South America.  It sits at over 5000 feet in elevation providing for cooler days and nights.  We loved the sunny days in the high 70s which cooled off beautifully to high 50s at night.  After the heat index in Punta Gorda being in the 110s the week before, it was awesome! 

Caelan with Celia and Meagan

Volcano de Agua behind Hermano San Pedro hospital and church

The city's population swells by 100,000 people for Lent and Holy Week.  As we arrived Thursday night, there were multiple processions winding their way through the streets and hundreds of people at each intersection to see them.  Large groups of people dressed in black processed through the streets carrying floats that told the Easter story from Jesus' entry into Jerusalem to his crucifixion.  The floats were elaborately painted and decorated and each was usually accompanied by a band playing somber music or by slow rhythmic drums.  Even though there were hundreds of people, there was a quiet, somber spirit that allowed for contemplation of each part of the Easter story (except when the street vendors would occasionally get noisy with their bells!).

One of the many Good Friday processions

Many people put down elaborate "alfombras" or "carpets" of pine needle, flowers, flower petals or dyed sawdust for the procession to pass over.  Some of the designs were quite beautiful, taking hours to complete.

On Saturday we hiked up one of the four volcanos that surrounds Antigua, Volcano Pacaya.  Listed as a "leisurely hike" in the online guidebook, we were excited to do it.  To our surprise, there was nothing "leisurely" about the climb but we did finally made it up to the top. The boys were able to roast marshmallows over the steam vents and the view was spectacular.  Quinn was very proud of himself that he conquered two fears: climbing a volcano and standing near the edge for a photo.

(I passed my cardiac stress test!)

Sunday was a happy day in Antigua.  There were trucks with loudspeakers going slowly through the streets broadcasting, "Cristo Vive, Cristo Vive" (Christ lives).  The processions that wound through the streets were made of flag-waving, dancing crowds singing songs of the resurrection and carrying a float to tell the story.  I got to see one of these processions from the upstairs floor balcony of the bakery where Quinn and I were having brunch with Meagan.  The bakers had made beautiful loves of sweet bread shaped as animals, crosses and other designs.  They laid these out on a large bed of pine needles in the middle of the street and decorated it with colorful blown eggs shells.  As the procession came toward them, they knelt and offered them to God.  Then they gathered up the bread, placed them in plastic bags and placed them on the float and gave them to the priest.  It was the most personal interaction I saw with a procession passing over an alfombra and was very meaningful.

One of the Easter morning processions

Monday was a long travel day back home: taking a shuttle to Guatemala City, a bus from Guatemala City to Puerto Barrios and then the water taxi over to Punta Gorda.  The trip was well worth the travel time and I highly recommended spending Easter in Antigua.

Volcanos Fuego and Acatenago as seen from Volcano Pacaya

Scabies and Lice

After months of planning, we started the implementation of our scabies and lice eradication plan.  Both scabies and head lice are endemic in the villages here and we have not been able to obtain enough permethrin to treat them on a daily basis.  It seems that as soon as we get the problem under control in one village, it crops up or explodes in another one.  Several months ago, we started to try and think outside of the box on another approach and came across a couple of studies that were carried out by the World Health Organization.  These  infestations were approached by treating the village as a whole in order to eradicate the problem.  The numbers looked pretty good - 80+% reduction at nine months - and so we thought that we would give it a try.   It obviously requires the cooperation of the villagers and a lot of planning and logistics in order to treat a whole village at one time.

A public health intern from Baylor University, Meagan Young, is here with us for a few months and has helped me outline our protocol as well as helped with contacting the alcaldes (mayors) and the community health workers in the villages.  She and I also met with officials in the Public Health Department and the Ministry of Health to discuss our plan and seek their approval.  San Marcos is one of the closer villages and when both the Alcalde, Mr. Sho, and Community Health Worker, Mr. Carlos Mes, were excited about our proposal, we decided to have it be our pilot village.  The village leaders thought that Sunday would be the best day as the men would not be out in the fields working but in the village with their families.

So we gathered all of our students and volunteers with us right now, divided everyone into four teams and drove out to San Marcos early Sunday morning.  Each team had a village member with them as we went door to door and treated all six hundred plus villagers.  We weighed everyone and treated those fifteen kilograms and larger with oral Ivermectin at the time and then gave them a dose to repeat in seven days.  All of the children less than fifteen kilograms were treated topically with 5% Permethrin with instructions for mom to wash it off the following morning.  We handed out baggies of laundry detergent and instructed them on washing their bedding and clothes.  We also gave them large trash bags so that they could bag items that were not essential for the next 3 days and leave them in the sun.  Many of them sleep in hammocks and a few have mattresses so we treated all of the sleeping surfaces with a 0.5% Permethrin mixture.

Weighing in

  

Bedding and clothes needed to be treated as well

 

Mr. Sho, the Alcalde, and Meagan Young

Almost all of the villagers seemed receptive and willing to be treated.  It was a long day and I have to admit that when we stopped for lunch, I did not think it would be possible to finish in one day, but we did!  We gave out every last pill of Ivermectin that we brought with us and fortunately the Permethrin spray lasted through all of the hammocks.  We were able to take a census of the village at the same time as well as a count of the number of houses that have functioning outhouses.  This is information that will help Mr. Mes in taking care of his village.  Everyone was hot, grimy and exhausted at the end of the day but left with the feeling that we had done something to make a difference in the village of San Marcos.

My team, Team #4, with our guide the Community Health Worker, Mr. Carlos Mes as we finished our part of the village and the sun is setting