Home for the Holidays

It is hard to believe that we have been in Belize for over 6 months now.  I told my father when we last spoke that it finally seems like we are settled.  Instead of seeing the many differences of people and way of life here, I have begun to notice the similarities.  There are many more things that feel familiar.  Quinn finished his first semester in his Belizean school including exam week and received the highest marks in his grade.  He has made some friends, learned to play marbles and is enjoying playing baseball with the guys.  Caelan is comfortable spending his days at the clinic with us, doing his homeschooling on the Internet.  He is often a big help around the house.  Will has been practicing his guitar everyday - sometimes for hours at a time - and is making real music now.  Both Will and Caelan have gone along on an overnight trip to a couple of the remote villages.

Path leading to the river in the village of San Vicente

I really wanted to make our home feel a bit like Christmas and was initially at a loss as to how to do it.  There is definitely not the commercialization and Christmas trappings here and I wasn't even able to find any red cloth.  Then one of the shops in town got in a small, plastic Christmas tree and some light strands.  We were able to set it up on our dining room table and decorate it a bit.  Caelan, Quinn and I made an old-fashioned paper chain of red and white paper.  It has been so nice to have it and has added a bit of the holiday cheer to our home.  Everyone has also been looking forward to Barbara and Bill's visit (Bill's parents) for Christmas.

It does seem that as we have gotten closer to Christmas, we have been a bit homesick for the States.  Celia (our nurse) and Chad, Natalie (our pharmacist) and family left last week for the states until the New Year.  It was hard seeing everyone leave. Before they left, we were visiting and they were talking about what they were looking forward to: different types of foods, carpeting, no bugs or bug bites, clean environments and not feeling dirty all of the time.... I think we were definitely wishing we were going up for a visit as well.  But then I realized, there are lots of things we miss but we don't NEED anything.



On a funny note, "superstitions" are abounding in our house.  The only hot water in our house is by an electrical shower head that heats the water as it goes through it.  For some reason, recently we have been without power a lot in the mornings which means cold showers. There have been several instances that the electricity has come on just after Bill has finished his cold shower.  Quinn has thought it hilarious that Bill has had to take cold showers and has gone into the bathroom with a battery-powered fan aimed at him in the shower as a joke. This past Sunday the power was again out.  After a couple of hours, Quinn started begging Bill to take a cold shower so that the electricity would come back on.  After awhile we suggested to Quinn that he be the one to take the cold shower and see if it made a difference. Quinn finally thought it might be worth it and after hearing sqeaks and squeals from the cold shower, Quinn emerged.  As he stood there dripping wet and laughing, the power came on.  Then Quinn was convinced, "Somebody has to sacrifice themselves for the family."   Caelan's dry, intellectual approach was that it was "not only a coincidence but an unfortunate event."



We wish you all, our family and friends, a wonderful Christmas and a Happy New Year!

                                          For to us a child is born,

to us a child is given,

And he will be called

Wonderful Counselor,

Mighty God,

Everlasting Father,

Prince of Peace

A Women's World

Most people are aware that my interest is in Women's Health but it has been more challenging to me here than anywhere I have ever been before.  The Maya women have me stumped!  As a physician I am trained to observe.  I will admit that I am not usually that observant of peoples' physical traits but when I walk into an exam room, it is data collection time.  What does the patient look like?  How are they dressed?  How old are they?  How do they interact and respond to me and to my recommendations?  

For starters, there are very little facial expressions.  I can usually judge if someone understands what I am saying by their face but here most faces are blank even when they are engaging in conversation with you.  I have watched them talk amongst themselves with more animation but with the "white doctor," it is a blank face.

Next, it is difficult to examine them.  They are very open about breastfeeding and will do it publicly without any covering until the child is about 2 years old, on the street, in church, etc., but the moment you want to examine their abdomen, they are pulling their clothes over themselves and hesitant.  It is very difficult to convince them to have a Pap smear or a pelvic exam even if they are symptomatic.  Many times they will simply refuse.

That said, I have great empathy for the Maya women.  From my industrialized country perspective, they live a very difficult life.  They marry young and have many children.  For some reason, it is very common for them to have 10 children.  Although we bring options for family planning with us, there is still some stigma associated with it.  We often see patients in open areas with very little privacy from the other villagers which makes it more difficult for the women to discuss these things.  The women often really want these services but are afraid of what the other villagers (or her husband) might think.

Women wait with their children to be seen in the village of San Jose

A Maya "washing machine" - stones set in the river for washing

Their daily work is not easy.  They have to carry their laundry to the river where they wash their clothes on rocks while their children play in the water.  They then carry these buckets of wet clothes home and hang them to dry.  They have to haul drinking water for their family from the village wells.  Most villages now have a communal corn mill powered by a generator but they still must take the corn to the mill before every meal to grind it and then make tortillas over an open fire in the hut.  They sew their family's clothes on a pedal sewing achine or weave cloth by hand on a loom.  Most of this is done while carrying their babies and even toddlers in slings from their heads.  Many go from looking very young when they are first married to looking 20 years older than their age within a decade.  They suffer from chronic headaches and backaches from the heavy work.  Many develop COPD (chronic obstructive pulmonary disease otherwise known as emphysema) and have carbon monoxide headaches from cooking over open fires without ventilation in their thatch-roofed huts.  There are a couple of organizations that have worked to provide well-ventilated cooking stoves for the Maya people in Guatemala however, the Maya of Belize have not been accepting of these.  They also develop significant degenerative joint disease, especially in their knees and shoulders.

So we give them a lot of Tylenol or Ibuprofen.  We treat their lung disease symptoms with inhalers and we inject many joints with steroids for comfort.  We have only seen a handful of cases of depression in these women even though we have asked and looked for it.  We just have to continue to educate them, encourage them to have regular pap smears and pelvic exams and otherwise to try and be there to care for them.

Duffle Bag Medicine

"Duffle Bag Medicine" is a term that became popular after an article was published in JAMA (Journal of American Medical Association) in 2006 with this title.  The article describes a typical medical mission trip to rural Guatemala and describes what often happens when good-intentioned people go to third world countries in an effort to provide medical care.  We have seen this here in Belize as well.  A group comes down from the U.S. with bags full of vitamins, medicines and medical supplies.  They set up clinics in rural villages to see as many people as possible for a week and then leave to go back home.  On first look, this is seen as a great thing and those providers who come down and sweat it out in the jungle seeing lots of patients often feel really good about what they are doing but there can be huge problems associated with this approach.  First, these groups have no continuity of care and often operate without any knowledge of the patient's medical history.  The short-term work is not integrated into the local health infrastructure and so after the group is gone and the 30 days of dispensed medications have been taken, the patients are right back where they started.  These medications are sometimes not even available in the area and so even if sought, the treatment is not sustainable.  Second, public health and preventive health measures are usually not a part of the goals of the transient clinics.  All together, the result of these mission clinics do nothing to improve the overall health of a people and can even be harmful.

Here in the Toledo district of Belize, we at Hillside have attempted not to approach the delivery of healthcare in this way but to complement the present Belizean healthcare system and provide true primary care.  This past week Bill and I were able to sit down for a few hours with one of the Belizean doctors from a local government clinic, Dra. Peitra Arana, and her clinic administrator as well as Joyce, our clinic administrator.  Dra. Arana started about the same time we did in the Toledo district after finishing her training in Guatemala and although she initially seemed very reserved with me, we have been slowly building a relationship.  The big breakthrough came when she had a family of 9 from an outlying village who were infested with worms.  She had tried the traditional medication that the government clinics provide, abendazole, with no success.  She mentioned these cases to me one day at the government clinic when we did our regular morning stop to pick up charts for one of the villages.  We had recently acquired a large bottle of Ivermectin which I was able to share with her for this family.  Although she has few resources, she is passionate about her patients and was willing to try and speak out about the issues confronting us at the medical conference in Belize City.  

Barranco - our only Garifuna village

We sat down with them to make a strategy for this next year.  The geographical distances and lack of transportation in the Toledo district is huge.  The government physicians have no way to get out into the villages consistently to provide care and so have staffed more centrally located clinics while we have provided the mobile clinics into the villages in addition to our own centrally located clinic in Punta Gorda.  Even with these arrangements, we are able to only cover a bit over half of the villages and then only once every 3-4 weeks per village. There are a handful of villages which do not have roads into them and we rely on them to walk 1-2 hours out of the jungle to one of the other villages where we are holding clinic.  The question is, is that adequate?  Shy of recruiting many more volunteer physicians who could live in each village, is there another way to approach the needs?  Can we really call it primary care medicine instead of "duffle bag medicine" if we are only in a village once a month?  Yet we do keep medical records on all of our patients and have continuity from month to month with each of our villages.     

There are definitely no easy answers.  No decisions have been made as of yet but will need to be soon.  With 70% of our monthly in-country budget going to vehicles and gas to get us out to the people, it is something that needs to be contemplated.  There are not as many chronic patients out in the farthest villages but that is most likely because they have not been diagnosed.   I feel that we are doing the best with our current restraints and lack of resources while Bill has been brainstorming about staffing outlying clinics more consistently that are placed central to several of the farthest villages.  Transportation remains one of the biggest hurdles to care.  Would we be able to provide transportation to our patients with chronic illnesses like diabetes and hypertension to leave the village for their care?  If we were consistently in a particular place, would we make those diagnosis of chronic illnesses better and be able to treat?

The Forgotten District

This past week Bill and I went up to Belize City to attend the Belize Medical and Dental Association International Congress.  It was two days of medical education lectures for physicians practicing in Belize as well as Guatemala and the Quintana Roo area of Mexico.  It was nice to see the advances being made in medical care in Belize and there were some very well presented lectures in English as well as in Spanish.  The care in Belize City is still decades behind that of the U.S. in many ways but there are some good, very intelligent physicians working hard to make a difference.

We had the opportunity to meet an American doctor and her husband who are running another mission clinic in the northern part of Belize.  Although the north is far more developed, has a very different culture being so close to Mexico and has much more access to care, it was great to spend some time together.  Even though they are from Indiana, there was great camaraderie and a good exchange of ideas.  Their clinic is better outfitted than ours and they gave us some stateside contacts that might be helpful for us.  We live a bit more rustic and quite a bit more isolated than they do but she is jealous of my clothes dryer!  (Something I requested of Hillside before we came.). They have 3 girls - the oldest is Caelan's age and the youngest is Quinn's age and the boys enjoyed visiting with them over dinner.  

What was striking from the conference was the number of foreign physicians practicing in Belize - particularly Cuban and Guatemalan.  Belize does not have a medical school and has traditionally relied on the goodwill of Cuba to provide primary care physicians and more recently to train Belizean physicians.  It creates huge barriers in communication as the official language in Belize is English and the street language is Creole and unfortunately the Cuban physicians speak very little English.

The other striking thing was, like we experienced in rural U.S., the distribution of healthcare is not equitable.  The southern Toledo district covers an area of 1795 square miles and a population of over 30,500 but with only a handful of primary care physicians (including Bill and I).  Many of these people have very little or no access to the healthcare centered around Belize City.  Unfortunately, the people responsible for the healthcare decisions in the Ministry of Health do not seem to understand the access problems faced by those in the Toledo district.  For one of our patients in the village of Dolores to access care, they have to walk about 1 hour to the village of Otoxha where they can catch the Monday, Wednesday, Friday or Saturday bus at 4:30 am for a 2+ hour bus ride to Punta Gorda.  They have no access out of the village to care on Tuesday, Thursday or Sundays.  As I have mentioned before, if they need an x-ray, they have to take another bus about 2 1/2 - 3 hours north to Dangriga.  All the specialty care is centered around Belize City and Belmopan, 6 - 8 hours by bus north of Punta Gorda.  We have given many people bus fares for the trip north but they still have to come up with a place to stay as well as food to eat.  We have known these things for quite a while but our time at the conference in Belize City solidified our concerns - the Toledo district is really "the Forgotten District."

Thanksgiving in Belize

The Thanksgiving Day holiday celebrated with pilgrims, turkey, stuffing and cranberry sauce is a unique holiday to the U.S. however, people all over the world celebrate the harvest season.  At the beginning of November, the Harvest Thanksgiving is celebrated here in Belize.  The children practiced in school for their parts in the program and places are decorated with stalks of sugar cane, citrus fruits and dried ears of corn.

The corn has been harvested here in the villages and this a major staple in their diets.  When you are in the villages you can hear the corn mills before every meal as they grind the corn for masa to make their tortillas.  The citrus is also coming ripe - the market is now full of grapefruits, oranges and limes.  The Stann Creek District north of the Toledo district is home to many citrus orchards and there are trees scattered around our area as well.  

Quinn, his teacher and some other people in the community helped educate us on our part in the Harvest celebration.  Traditionally people bring a small part of their crops as a gift to the church in brightly decorated containers.  The church then distributes it to the poor or sells it to bring in some money.  Living in town with no fruit bearing trees, we did not have any "crops" to bring so our basket was filled with homemade banana muffins and cookies.  We decorated our basket with flowers from around our house to make what I call our Belizean cornucopia.

Belizean Cornucopia

The boys of Quinn's class presenting their gifts and telling what they are thankful for

 Girls in Quinn's class doing a Liturgical dance to Give Thanks With a Grateful Heart

Give thanks with a grateful heart

Give thanks to the Holy One

Give thanks because he has given 

Jesus Christ his son

And now let the weak say I am strong

Let the poor say I am rich

Because of what the Lord has done for us

Give thanks

- written by Henry Smith

The "Christmas Breeze" Is Coming

One of the best things that has happened over the past couple of weeks is that the weather has cooled a bit.  The temperature during the days is still in the 80s with a heat index in the low to mid 90s but it is much better than a heat index of 115-118 degrees everyday!  It is also cooling down at night to the mid to upper 60s which makes for great sleep.  You will still sweat during the day, particularly if you are in the sun, but overall it is a welcome relief.  Everyday now I find myself thankful for the wonderful temperature and the lack of the oppressive heat.  I actually have appreciated my surroundings a bit more and understand why some people like to vacation in Belize.

Now that school is in full swing, we have begun planning our health education and community outreach for the year.  This past week I met with all of the principals of the 7 schools in the Punta Gorda area (not the villages) as well as with the head of the Ministry of Education's Health and Family Life Education agency to find out how we can help provide health education to the school children in the Toledo district.  It will start this next week with the small school in Cattle Landing (on the outskirts of P.G.).  They have less than 30 students but many are infested with lice.  We have asked that all the parents come to the school in the afternoon so that we can educate both parents and children.   We plan on treating all of the individual students at that time.

Bill and I met with Dr. Solomon, the local Ministry of Health dentist, last week.  Dental needs often seem to outweigh medical needs in the Toledo district.  Hillside does not have a dentist but has tried to facilitate some dental care.  Dr. Solomon was very anxious to have Hillside help in providing dental care, particularly in the villages.  Last year a private donor provided enough fluoride for us to treat all the young children in the villages once.  Our goal is to do that again this year and this time include the children in the Punta Gorda area.  Hillside had applied for a grant from the American Academy of Pediatrics to fund the fluoride but we just found out that it was rejected so we will need to look for other sources of fluoride.  Dr. Solomon did give us clearance to use the dental chair that is in the San Antonio clinic as well as the mobile dental unit when we go out to the villages if we have a visiting volunteer dentist.

We have an eye doctor in town this month.  He is a volunteer from Australia working with Belize Council for the Visually Impaired (BCVI).  They are a non-profit group that provides free eye exams as well as treatment for a nominal fee.  They try to have an optometrist here in Punta Gorda for a few days each month and an ophthalmologist a couple times a year who can do cataract surgery and other procedures.  When they are not in town, we have to send people to Dangriga (a 2 1/2 - 3 hour bus ride away) so it is nice having an eye doctor for a consistent time, even if it is brief.

Rio Blanco

Hillside Staff

The work that we are doing now in southern Belize is possible because of the Hillside Health Care International.  Everyday, one of us has a team who sees patients in our main clinic in Eldridgeville, outside of Punta Gorda and the other one takes another team into one of the remote villages to set up clinic there.  We have 6 - 8 medical students, 3 pharmacy students and occasionally a couple of physical therapy students that rotate with us for 4 weeks at a time and are the extra hands in the work.  We also occasionally have short-term providers like physicians, physician assistants and nurse practitioners who volunteer anywhere from a week or more.  (Although as it heads into winter in the U.S., we have had a lot of inquiries from people who would like to volunteer during January or February!).   We also have a  physical therapist, pharmacist and nurse from the U.S. who are volunteering here for 1 year each.  Our nurse works with us (Bill has mainly taken this role) to care for our 50 - 60 homebound patients around the Punta Gorda area.  Our pharmacist helps me keep our pharmacy running smoothly.  She and I are working right now on a system to keep our pharmacy stocked with a very basic formulary from donated medications and ones that we can buy inexpensively from other organizations that provide medications at lower costs to mission clinics.

None of this would be possible without our Belizean support staff who are with us day after day.  Because the organization is small but we are covering a huge geographical area as well as large patient base, many of them are crossed trained to check blood pressures, draw blood, translate for Q'eqchi' or Mopan Maya and act as a liaison for us in the Maya villages.  They work with us in our main clinic but at least 2 accompany us everyday on mobile clinics into the villages - even the handful of clinics we do every month that require an overnight trip, sleeping on the floor without electricity or running water.  Wages are not high in Belize when compared to the U.S. but jobs in the Toledo district are scarce and they all seem very thankful to work for Hillside.  One of the goals of Hillside is not only to provide a few jobs for the local people but to provide training as well so that they become qualified to provide excellent healthcare to their fellow Belizeans.  Hillside is currently paying for Alva and Alfia to take an online pharmacy tech course from the U.S. (it is not available in Belize) so that they will be certified.  Floracita has recently completed hands-on training with our physical therapist and is now doing restorative therapy work with our homebound patients.  Jennie is in nursing school on a scholarship from Hillside with the understanding that when she finishes her degree, she will come back and work at Hillside for at least a few years.  Victor did well on his high school exit exams and has expressed that he would like to be a physician.  We have started talks with him about Hillside providing a scholarship for his university coursework which is required to apply for medical school (there are very few Belizean doctors but the government does pay for them to be trained in Cuba if they qualify).

Last week the president of Hillside's board and our Stateside director came down for the week to see how things were running now that we have taken over as the medical directors.  It is nice to report that they thought things are running as smoothly as they can in a third-world country with limited resources!  At the end of the week, they provided us with a rare treat of lunch out with all the staff and spending a couple of hours together away from clinic duties.  Hopefully these photos will allow you to better envision our team here in Belize.

Hillside Staff (left to right)
Top Row:   Victor (clinic intake and translator), Everett (head of maintenance), Annette (physical therapist volunteer)

Back Row:   Randy (night watchman), Rudy (driver and community liaison), Celia (nurse volunteer), Amelia (housekeeper), Leslie (clinic intake and driver), Bill, Angela, Alva (pharmacy supervisor and tech)
Front Row:   Joyce (clinic administrator), Polly (administrative assistant), Alfia (clinic intake, supervisor and translator), Floracita (physical therapy tech), Carmelita (clinic intake and translator), Jennie (clinic intake, translator and nursing student)
Not pictured:  Natalie (pharmacist volunteer) (she is the Caucasian woman in blue scrubs at the far end of the table in the first photo)

~Yes, Bill does joke that he came to Belize so that he would not feel so short~

First Times

One of the adventures of travel is the ability to experience things outside of your comfort zone. There can be many first-time experiences as you discover your new surroundings.  Some firsts are anticipated or even expected while some catch you by surprise.  Some first experiences are lost in the sheer monotony of the repeated experience.  I really don't remember the first time I realized that an ant was crawling up my arm as it is an everyday, frequent experience in this new environment.  While there are far fewer first-time experiences these days, I have had a few notable ones recently.

While seeing patients in a remote village, I performed my first full pelvic exam on a woman while she was lying in a hammock in a dark Maya hut using a headlamp for light:
When out in the villages, we often see patients in an open room or out under an open thatched roof.  If we cannot find a private area for an exam, we will climb into the back of the Land Cruiser and use the back bench seats while covering the windows with sheets.  During my encounter with this woman, I realized that I really needed to do a pelvic exam to rule out some concerning things based on her symptoms.  She refused to be examined in the Land Cruiser and said that she would only let me examine her in her own home.  So a medical student and I set out  to follow her across the village.  We eventually came to her thatched roof hut.  It was a typical Maya hut with no electricity, no windows and with hammocks strung from post to post that function as both couches, chairs and beds.  She was much more comfortable in her own hammock and home and although technically challenging, she allowed me to do an adequate exam.  Definitely a first for me.

In the remote villages, transportation is an important factor in our delivery of healthcare and sometimes I am amazed by the people's ability to get around despite the lack of vehicles or decent roads.  Seeing a wheelbarrow ambulance was definitely a first for me:

While out in another remote village, a woman came to the clinic where we were seeing patients and asked me to come and see her mother-in-law because she was too sick to walk.  Again, a medical student and I gathered up some medical equipment and walked across the village to a Maya hut.  When we arrived, many of the family had gathered around an elderly woman lying on a wooden platform bed.  She had been hospitalized in Punta Gorda several weeks earlier with abdominal pain but they did not know what was causing it so they sent her home and told her to come back into town when a radiologist came down from Belize City (once a month) with an ultrasound.  That appointment was still several days away when her abdominal pain began increasing and she developed a fever.  The family debated taking her into Punta Gorda but knew we were coming the next day and so decided to wait for us to evaluate her.  On exam, she had a temperature of 102 with a low blood pressure, high pulse and what we call an acute abdomen - tender with guarding as well as rebound tenderness.  She definitely needed surgery.  I was also able to feel a large, firm mass in the right lower quadrant of her belly.  We needed to get her to a surgeon right away. 

This village is so remote that there is not a road that goes into it.  After a almost 2 hour drive, we park the Land Cruiser and have to carry all of our medications and clinic supplies across a river and then a half mile into town.  I told the family that if they were able to get her to our Land Cruiser then we would take her into Punta Gorda to the hospital where she could then be loaded in an ambulance for the 2 1/2 hour drive north to Dangriga where there is a surgeon.  I was not quite sure how they were going to do it but as we were carrying our things out of the village, here they come pushing her in a wheelbarrow.  Her sons pushed her all the way to the river and then carried her across to our Land Cruiser.  We were able to put her in the front seat and take her into the hospital for care.

Another first-time has nothing to do with medicine but is equally notable in my book.  It is my first experience of gourmet food in Belize:

Hopefully no local Belizeans will read this and take offense because there are some fabulous cooks around here and rice and beans from them is definitely better than rice and beans from an average cook.  Also, while I love the hot, corn tortillas they make on an open fire in the villages, I have missed a variety of foods and complex flavors.  It can be very depressing trying to buy groceries or plan meals as the largest grocery store in the whole district is about the size of a convenient store in the U.S.  There are plenty of bananas and pineapples but there are few vegetables and basically produce is only sold at the open air market on Monday, Wednesday, Friday and Saturday mornings.  The boys will often talk about the restaurants they wish we could go to or the familiar foods they are craving.  After the first month, I have not allowed myself to think about food from the U.S. and have worked on learning to make cookies and treats with what we have here and perfecting my Belizean rice and beans.

Then Juan came to visit.  Juan is our chef friend from the U.S. who has been living in Honduras for the past 6 months volunteering at an orphanage.  He has made us wonderful meals in the past and I wrote him several months ago about my cooking quandary and asked his advice.  He caught the ferry from Honduras over to Independence, Belize and then rode a bus into Punta Gorda for a visit this week.  We have really enjoyed showing him some of Belize and I love his reaction to our food situation.  We of course fed him rice and beans his first evening here and then the next day while I was at clinic, he and Will walked into town to shop for food.  Even he was amazed by our limited supply of food choices but took the challenge in stride and made us a wonderful gourmet meal for dinner tonight.  I was able to find a bottle of wine in town to serve in our one wine glass and we had quite the feast:  mac 'n' cheese fritters topped with roasted whole onions covered in coconut curry sauce.  A first for Belize but it was awesome and beats rice and beans any day!!!

Settling In

Things are continuing to move along in Belize and I am sorry for my lack of communication but I have been working at really settling in.  Our things have been unpacked and settled in the house for awhile and I know the clinic and mobile routines but it is the mental adjustment that we really are going to be living here for at least the next 2 years.  It is one thing to spend a few weeks working in a strange place with inconveniences but at some point there comes a realization that you are not going back to the known, the comfortable anytime soon.  Even though I have moved frequently in my life, it has never been easy for me.  This move has also been particularly challenging both mentally and physically.  

It has not helped that Quinn has struggled in his new school.  Fortunately, a new couple arrived from the U.S. a week ago to work with us for the next year.  She is a pharmacist and they have three boys (the youngest is only 7 weeks old!). The older two boys are aged 6 and 4 and Quinn bonded with them immediately.  They enrolled in the same school as Quinn and even though are not in his class, it has given him a bit more confidence and security.   He is also not quite the novelty that he was and the other kids seem to be more accepting of him.  It is still a daily challenge to help him adapt to such different surroundings and culture.

This week I was upstairs in the kitchenette at the clinic and noticed something taped on the cabinet that I had not seen before.  It is simply written but seemed very applicable to me:

When the space is cramped,

and the shower is cold,

and my sunburn really stings,

When my stress is high and my patience low,

and I'm sick of rice and beans.

When mosquitoes sting and sand fleas bite,

and I spend the night a-itchin'.

When the sight of bugs and the threat of lice

is enough to set me twitchin'.

When the mud's waist deep,

and the power goes out,

and the water's just a drip,

and I wonder why I ever thought

I'd enjoy this sort of trip.

When several women share the shower;

wash undies in the sink,

And an internet that's often down

Is my only Stateside link.

When I want to scream, and I want to cry,

and I'm ready to complain.

I'll remember that in all these things,

I'm to praise His Holy Name.

I will set aside my petty needs;

and pray for a servant's soul.

And a mind that doesn't dwell on me

will be my greatest goal.

And when it's done, I'll see I changed,

but only through His grace.

For when I served the "least of these,"

I saw God's holy face!

- By Jackie Schmidt (founder of Hillside)

In the Maya village of Jalacte

Makeshift Medicine

Ok. Yes, I am still somewhat addicted to Diet Coke.  It is a bit more expensive and more difficult to get here and we are trying to live frugally but I still like to drink one in the morning if we have one.  And now I have justification....

We were in the village of Na Luum Ca today and had a mother bring in her 2 year old twins.  They were born prematurely and are quite small for their age and both had recently developed respiratory infections.  Mom had walked with them from another village for them to be seen.

Both girls did have viral upper respiratory infections but one was quite tight and wheezing.  We gave her a couple of treatments of nebulized albuterol using the Land Cruiser to power the machine and knew that she would need albuterol treatments over the next couple of days.  We had inhalers with us but we don't really have spacers.  Here is where the Coke bottle came handy.

I do have to confess that it was originally Bill's idea last week that I just worked on perfecting.  A Coke bottle with either end cut off and then foam tape secured with more durable sport tape to make a soft mask and help seal the other end around the inhaler.  It seemed to work.

School Days

School started in Belize this week and so our family has been transitioning back into the school year.   Caelan is starting again back on his online high school studies and we have been trying to help Quinn adjust to his Belizean school.

The Belizean school system is based on the British school system as they were a former British colony but it is definitely affected by the fact that it is a third-world country.  English is the official language in the schools.  Education is provided through "Standard 6" grade which is equivalent to our 8th grade.  Each student is responsible to pay the school fees, 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 costs about $400 U.S. per year.  This makes it unobtainable for a lot of Belizean kids.  Often a village is only able to send one or two children at a time.  We have had one villager come to our house weekly since we arrived selling coconut shell carvings and other handmade items to pay for his son's books for high school this year.  I ran into him in town last week at a hardware store and he showed me the list of books and was excited that he was going to buy the last one that day.

There is not a "public school system" like in the U.S. but most schools are affiliated with a church and the government subsidizes their operating costs.  The only real "government" schools I have seen are in remote villages where churches have not established a school.  The Methodist and Catholic churches seem to have the most schools in the Toledo district.  For the most part, children attend the school closest to their home although in Punta Gorda the Methodist school's fees are the lowest which attracts a lot of families.  All of the schools seem to be short on teachers, space, books and supplies!  Quinn immediately noticed that there are no school playgrounds either.

Both of the schools in Punta Gorda are very large and so we opted to enroll Quinn in the school closest to our clinic in the small village of Forest Home - Forest Home Methodist School.  We purchased fabric for his uniforms and paid a lady in Jacintoville village to sew them. You cannot buy ready made uniforms and it took me a while to find a seamstress since all of them had their hands full with orders.  I thought about doing it myself since I brought my sewing machine but there are no patterns available, they just take the child's measurements and know how to cut and sew them.

Quinn's Classroom

Quinn was very apprehensive and a bit overwhelmed at first but has done remarkably well.  We figured he should be in Standard 1 by age but was placed in Standard 2 due to his previous schooling.  There are 9 children in his grade who still cannot write.  His class of combined Standard 2 and Standard 3 is 34 students and taught by the principal.  She has great English skills and her accent is very understandable although Quinn has struggled to understand her when we are not there since they often speak in the Belizean street language, Creole.  He also has been surprised that there are very few books and no workbooks.  One of the students are called to read from a textbook and the others write the information down.  A lot of their work involves drawing pictures as well as writing paragraphs about the subject. Even though it is so different from his previous school experiences and a big adjustment for him, each day he has done better and we have been so proud of him!

An update on Slim....we were able to buy a plane ticket and get a lawyer from Belize City down here for the continuation of his trial last week.  Apparently all charges were thrown out within minutes.  The lawyer also picked up at least three other clients as people whose cases were also scheduled in court that morning were really happy to have a lawyer in town.

Listening

Sometimes we get so caught up in our daily activities that we forget to listen.  I have really been working on listening....  Yesterday I went on mobile to the village of Crique Sarco.  It is definitely one of the most difficult mobiles that we do.  Not only is the village very remote but there is not a road all the way into the village.  After driving over an hour on very rough road, you have to park by the river and carry all of the supplies and medications for clinic across a footbridge over a river and then about 1/2 mile into the heart of the village where the clinic building is.  This is not an easy 1/2 mile hike but one that is at least ankle-deep (and sometimes much higher) in mud.

Medical students carrying clinic supplies on the hike to the clinic in Crique Sarco

We saw a good number of patients in Crique Sarco including a home visit to see a 8 year old boy who was still healing from a femur fracture.  The day was particularly sunny and hot and so by the time we got everything back across the river in the afternoon, we were ready to go home.  As we started our drive, we passed the house of a premature child.  The baby was born at 32 weeks in Belize City and because there is no real neonatal care, was sent home at 2 days of life to see if she could make it.  We have been stopping by the house every time we are in the village to check on her.

Clinic building in Crique Sarco

As we passed the house I thought that we really did not have to stop.  She was well over 2 months of age now and had been doing ok.  We had jumped in the river to cool ourselves off before starting the drive back and were wet, still hot and really just wanting to get back.  Then I listened and something told me we really needed to stop.  Mr. Rudy humored me and went back to the house.  We were relieved to hear that the infant was thriving, was 12 pounds now and was actually in another village visiting her grandparents.  We were getting ready to get back into the Land Cruiser when a man asked us to see the baby's cousin.  They brought a toddler out of the house and she had a large fluctuant abscess on her left face and neck.  We got down our equipment and were able open it up and drain it.  We were getting her antibiotics as well as Tylenol out of the rooftop carrier when they asked us to also take a look at her older brother.  He too had a fluctuant abscess on his thigh which needed drainage so we did that as well.  We were able to give him a course of antibiotics and talk with the family about bathing and wound care.  It was very clear by this time why we were to stop at this house as they had not sought medical care for these two large infections.

Guatemalan weekend

    Last week as we were setting up for clinic in the Mopan Maya village of San Jose, the medical students and I were discussing languages.  This month we have four from Germany working with us and I have been impressed with their English skills.  They had worried about their medical English but have studied English in school since kindergarten and are exposed to it through our TV shows that are exported there.  We discussed the prevalence of Spanish in the U.S. and that I was actually missing speaking Spanish as I had been doing it almost daily in my previous practice.  Well in walked our first patient and I got to speak Spanish.  He was from El Salvador but had relocated to this Maya village in Belize along the Guatemalan border because of the violence in his previous home.  He was farming corn, beans and rice like the other villagers but had not learned to speak Mopan Maya or English.  The encounter went well as we discussed his back pain and other issues and it was fun to do it in Spanish.

Looking across the ocean in front of our house to Guatemala and Honduras

Then the opportunity came to really use my Spanish.  Since Bill had a birthday on Sunday, we took a weekend trip as a family across the Bay of Honduras to Livingston, Guatemala to celebrate.  Getting everyone on the same page about the trip and making the arrangements was challenging including reserving a place to stay and negotiating for a water taxi across the bay but once we pulled away from the dock in Punta Gorda, it was a nice feeling.  We have really been needing a break.  The 45 minute boat ride in the 21-foot boat was bumpier than a log ride at Six Flags and Will who was sitting towards the front got just as wet but it was nice to be in open water heading for the mountains we see in the distance across the bay daily.  As we were coming up to the town, Caelan leaned over towards me and noted how developed everything was.  Now if we were to plop someone from the U.S. down in Livingston, Guatemala, their first impression would be that it is a quaint town in a third world country; however, we had just come from southern Belize that has less infrastructure and amenities and so it really does look developed.  Livingston sits on the Bay of Honduras at the delta of the (river) Rio Dulce.  After we got our passports stamped in the immigration office up the steep hill from the dock, we continued up the hill to the market area.  We had dinner in a restaurant and then had real ice cream cones from another place for dessert.  We stayed in a small hotel built on a dock that juts out into the bay.   

The water taxi that took us to Guatemala

Coming into Livingston, Guatemala

Docks on the Rio Dulce side of Livingston

Saturday afternoon we hired another boat to take us down the coastline where we then hiked into the jungle to see the "Siete Altares" (Seven Alters).  This is a series of waterfalls into cascading pools made from volcanic magma flow.  The boys found a place to jump from and we all enjoyed the cool water. 

Siete Altares

We enjoyed walking around Livingston, and doing shopping in the little stores.  The streets were cleaner, even the dogs looked much healthier with much less mange!    I was on a search for a mixing bowl since I am presently using a bedpan to mix any batter when baking but was not able to find one in Guatemala either - every bowl has a fairly flat bottom.  I guess it makes sense since so much of the time they carry it on their heads and it would be difficult to carry a rounded bowl like we are used to using.  We were also looking for soccer cleats and goalie gloves for Will who is playing on a local soccer team.  No one had larger than a size 43 (U.S. 9.5) or medium gloves and Will wears a size 11.5 or 12 and would use at least large or extra-large gloves.  It is indicative of the average size of the Belizean or Guatemalan guy.

A neighborhood "laundromat" in Livingston

The Maya in Guatemala carry their babies just like the Maya in Belize - in a cloth hung from their head down their backs (or hung from a fence while waiting for a ride).