An Overnighter

I started writing this from a pallet on the cement floor under a mosquito net in the health outpost in the village of Dolores.  I like to take my iPad with me to the villages because even though we don't have any electricity or Internet access, I have some medical texts on it for quick reference if needed.  We left Punta Gorda in the morning and drove several hours south to see patients in this rural Q'eqchi' Maya village near the Guatemalan border.  At one point I told our driver, Mr. Rudy, that "the roads are not too bad today."  He just laughed a bit and as we were within half an hour or so from the village, I understood why.  There is no bus service to Dolores as even Belizean buses couldn't make those rough dirt roads.  

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When we arrived, we set up the clinic and then ate our packed lunches as the patients started arriving.  There were no huge surprises.  We did see a 3 year old with profound microcephaly, cerebral palsy, and a refractory seizure disorder who is blind and weighs less than 15 pounds.  His mother walked into clinic carrying him slung in a cloth down her back like the Maya carry infants.  He appeared well cared for.  We did not have any phenobarbital with us to refill his prescription and since there is no bus service out of the village (or any nearby village within an hour's walk), we were concerned that we needed to find another way to get his medication.  We were able to arrange for his father to catch a ride out of the village that next morning with the government maintenance crew so that they could get his medication in town.  We were also able to give his mother some help with stretching exercises to try and prevent significant contractures.

One of the medical students entertained the children with photos he took of them.

We ate dinner sitting on a wooden floor of a Maya hut, dipping hot corn tortillas in "caldron" (a Maya chicken soup).  As the sun set, the villagers came to hear our presentation on nutrition and exercise.  Back pain is a huge problem in the villages (as it would be for us if we had to clear our fields with a machete, grind our corn for every meal, wash our clothes on a stone in the river and then sleep in a hammock).  The boys seemed more engaged with our presentation but the girls and the women were mainly spectators.  It is very difficult to engage the Maya women, even when taking a history in clinic, and they were definitely not convinced that they should do stretching exercises or any movement to alleviate their back pain!

With lighting from a drop light plugged into the Land Cruiser, we gave a presentation to the villagers about nutrition and exercise.


The next morning we drove to another village about an hour away, Otoxha.  On the way, the Land Cruiser got a flat tire but fortunately we had two vehicles with us (the first overnight trip we had ever taken two!) and we were able to transfer all of our clinic supplies, medications and charts to the second vehicle.  We sent two people ahead to set things up, left Mr. Rudy to change the tire with one of the medical students and the rest of us walked the remaining mile into the village.  We saw about 30 patients that day and made one home visit before packing up for the long drive back.

We spoke with the government appointed community health worker in Otoxha as well about our ability to offer physical therapy if needed.  The community health workers have very little training and she too was very resistant to the idea of any physical therapy or exercise training as therapy.  So much of what we try to do in medicine is only as effective as the patient believes it will be.  The overnight trip left us realizing we are quite a ways from understanding the Mayas' belief system and culture - something that we have to understand if we are going to be able to use physical therapy modalities in their medical treatments.

Arriving home in the evening, I was happy to see that Bill and the boys had kept up with the dishes as well as had the floors swept.  However, while I was gone we had acquired another housemate.  One of Will's friends is without a home right now and asked to temporarily stay with us.  We have had others live with us before, just never in such a small house with only one bathroom.  We do have an extra mattress and often feed at least 3 extra people at mealtimes now so I think I am doing better with it than I would have done when we first moved here!

Angela

A Banana Republic

For the most part, things do not happen quickly in Belize.  Almost all businesses in Punta Gorda  close at noon and are set to reopen at 2 pm but it can be as late as 3 pm before they do. They often close again promptly at 5 pm or shortly before.   It can be very frustrating to us Americans trying to get things done on the pace we are used to as well.  We have had to work through this a couple of times this past week.  The government had only issued us visas for 30 days and so we have to renew them monthly.  We have applied for long-term visas but they are rarely granted because the monthly fees are a good source of income for the government.  We presented to immigration in Punta Gorda and had our documents checked.  We were then given an invoice and told to go to the courthouse to pay the fees.  After waiting in line with people paying taxes and other government fees, we paid for our visas and then took the receipt back to the immigration building before we could get our passports stamped.

  

                              Supreme Court building in Belize City

We faced a similar situation getting our medical licenses.  Our administrator applies for temporary Belizean medical licenses for all short-term volunteer physicians who come down but we applied for long-term medical licenses due to our positions.  We received official faxes stating that we were approved and were to appear at the National Registry in the Supreme Court building in Belize City to sign for them.  We had a volunteer physician here from Iowa for the week so we were able to leave the clinic with her and drive up to Belize City Friday morning.  When we arrived, the offices were closed for lunch and then when we returned at 1 pm, we were told that the person who we needed to see would not be back until 2 pm.  Shortly after 2 pm, we were able to see Ms. Lopez who informed us that the faxes that we brought were not sufficient but we needed the original signed copy that was with an administrator across town at the Karl Huesner Memorial Hospital.  By this time it was 2:30 pm and they would not accept fees after 3:30 pm.  We caught a cab, as we figured he would get us across town much faster than if we drove, and arrived at the hospital.  We knew the administrator was out of the country but thought his secretary could help us.  We were sent in multiple different directions by several people and saw a lot of the hospital including Labor and Delivery before we were taken to the right administrative offices.  We were able to get the original documents and then head back to the Supreme Court building by cab.  Once there we met with Ms. Lopez again who entered our names in a large bound book.  She then handed us the book to take out to the cashier in the hall to pay our fee.  Once again we waited in a line with other people paying for licenses, taxes and other government fees.  When we brought the large registry book with our receipt back to Ms. Lopez, she had us sign our licenses and gave us a copy.  In Belize they have a saying, "If you have patience, you will lose it; if you don't have patience, you should get some."  We found this saying applied perfectly to our situation.  We were impressed with the amount of time and effort it took simply trying to get our medical licenses after they had been approved!

 Unlike the city, the way of life is much different in the Maya villages we visit.  They work very hard to live without many resources.  The men work in the fields growing the rice, beans and corn for tortillas.  The women grind the corn for each meal and cook it over a fire.  They raise chickens, pigs, some turkeys and ducks to supplement their diet on special occasions.  They wash their clothes on stones by the river and often have to haul their water from the river or a shared well.  They make their own clothes using a manual sewing machine powered by a foot pedal.  They have to gather and carry their firewood as well.  There are no cars in the villages and so transportation is by walking, bicycles or a bus from the village to Punta Gorda 3 times a week on market days.

Thank you for all of your interest in helping the people of southern Belize.  There have been a lot of questions about where to send things.   If you are able to collect any of the needed medications and supplies, please email me when you are ready to mail them and I can send you an address of a medical student or volunteer who is coming down from the U.S. to save on international postage.

Rain and Geckos

 

It is definitely rainy season here.  Every night we have large storms and torrential rains.  The rivers are full and in many places there is standing water.  As we drive out to the villages, the streams that we crossed previously are much larger and sometimes flowing quite briskly.  We had to cancel one mobile clinic this week as the river was too swollen to cross into Blue Creek.  

Bill's team trying to cross into a village by foot with the gear for clinic since the footbridge was flooded.

I thought I was doing well adjusting to the tropics and the amount of pests that accompany it.  I am good at looking for lines of ants and spraying for them everyday.  Caelan and I even went after the army ants last weekend who had decided to nest in our front door and were successful at rooting most of them out.  However, tonight I am not so sure it I am being a good sport.  We have geckos in our house which live up where our walls meet the ceiling as well as behind the kitchen cabinets and I have thought they were cute and helpful in keeping the bug count down in our house.  The guy in the kitchen even likes poking his head out now and then and talking to me.  Several litters must have hatched recently though and over the past couple of days there have been small geckos everywhere in the house.  Tonight as I was doing laundry, one actually dropped down on my neck and I have to say that I no longer think they are cute.  To top it off, I have had 3 large (2 - 2 1/2 inch) cockroaches fly at me in the kitchen this evening.  My goal now is to train Louis to go after any of these if they are within his reach.  He has caught one gecko and one cockroach for me so far!  The geckos can stay high up on the walls, off me and we can again achieve a balance in our ecosystem.

      Gecko baby

We have been enjoying some of the local foods.  It is the start of breadfruit season and I have fried it up for the boys like I remembered having it on San Andres.  They really like it as well.  They do have ketchup here which makes it all the better!  The nutrition conditions here are interesting and as varied as the many cultures that live here together.  In Punta Gorda (the town of 6,000 in which we live) food is not always plentiful but there is not a lot of true malnutrition and actually there is a percentage of obese people in the Guarifana population (African-American).  My guess is it is because they eat so many starchy foods - the fish is scarce since it the bay was over fished and their diet consists of a lot of plantains, rice, beans, some roots and bread fruit (also very starchy).  They also fry a good bit of this food in coconut oil (which is homemade frequently).  We see a large amount of diabetes and hypertension in these people.  The Mayan villages are very different with a large amount of malnutrition in the children.  Fortunately they all breastfeed for 1-2 years but then after that, the kids fall off the growth curve!  There are few vegetables in Belize but the villages have none - existing off of mainly rice, corn (tortillas) and beans that they grow.  It is amazing at how small/short and skinny some of the kids are.  There have been several times that I thought that a child was 3 or 4 years old to find out they were 9 or 10!  We are working with the Belizean Ministry of Health to implement a nutrition supplement called Incaparina (from Mexico) for these kids.  Not sure exactly all the ingredient but at least the kids do like the taste of it and it does seem to help in their growth.  Interestingly enough, there is also a large amount of type 2 diabetes in the villages as well.

Last Friday I was on mobile clinic in San Felipe and had an interesting experience.  A woman came to area where we were set up and asked if the doctor could come to the house to see her mother who could not walk.  We take charts with us into the villages so I found hers, grabbed my stethoscope and a blood pressure cuff, left the medical students to see the patients who had gathered and went with Rudy (our driver) to her house.  We drove to the other side of the village, parked and then started our walk to her house.  We had to cross one stream on a 2 x 4 board, walk a ways through ankle-deep mud past other huts and then cross another stream on a footbridge to get to the house.  I have to admit that by this time I was a bit apprehensive about what I was going to find.  The house was made of wood slats and a thatched roof.  Her mother was putting on her shirt as we walked in (the older women as well as children often go shirtless in the villages) and shuffled slowly across the dirt floor on a walker.   Most people sleep in hammocks but the older couple had a simple wooden bed with a threadbare quilt spread neatly across it.  A wheelchair sat in the corner but she was not using it.  Her chart said that she has a history of documented spinal stenosis which was causing her to slowly lose her mobility.  She had had some type of injection (undocumented) in her back in the government hospital which gave her no relief.  Surgery would be the best treatment but is not an option as it is not available.  Once we were there, the daughter asked me to see her father as well.  Both of them are 88 years old, very thin and looked frail but they were clean after their bath in the stream that morning.  The daughter spoke English and was able to translate to Mayan for me.  They sat on the edge of the bed so that I could examine them.  Their blood pressure and pulse was great and their hearts and lungs sounded good as well.  On exam, they both were still surprisingly strong despite significant osteoarthritis in his knees and hips and pain from her spinal stenosis and significant scoliosis.  In fact, in a country where life expectancy is lower than ours, I was very impressed with how well they were doing.  The mother only asked for Tylenol to help with her pain and the father asked for Ibuprofen to take occasionally for his osteoarthritis.  Walking back to our mobile clinic I realized that despite my muddy feet and sandals, it had been a very positive experience to see inside their world and to offer them something small that we daily take for granted in the U.S. but made a difference for them.  It was also hard not to think about their positive outlook of the same diseases that we often see approached completely differently by patients in the U.S. and how despite their surroundings, they maintained a quality of life that is often lost in similar circumstances in the U.S.

A Different Life

Everything is so different here - we are really in another world.  It has begun to sink in that we really live here as well.  Quinn has understandably struggled the most with the changes but mainly with the amount of children constantly at our house, peddling things, needing food or wanting to play.  These children live in absolute poverty without parental guidance (their mothers are prostitutes).  Despite our attempts at having him see them as God's children, he has not done well with them until this weekend.  Bill took a whole truckload of children to the San Antonio falls.  The children had never been to the falls before and were ecstatic.   Quinn was able to swim and play with them on neutral turf instead of constantly worrying about his toys disappearing (we lost a Kindle and iPod before we became astute.  I have had to watch them closely and have them pull toys out of their pockets before heading out the door).  It was an answer to prayer that he was able to finally see them as individuals and enjoy being around them.

 Bill, Caelan and Quinn playing Sequence with Jamelah, Jameka and Michael

We have assumed full management of the clinic now.  Everyday, either Bill or I stay at the clinic here in town and one of us goes on "mobile" where we pack up the clinic Land Cruiser with medicines and medical supplies and drive to a village and see patients there.  Some of the villages are several hours away and most have no electricity or running water.  The roads to get there are quite rough and some spans are barely passable even in a 4-wheel drive.  My favorite so far is San Jose.  It is up in the mountains - a beautiful Q'eqchi' Maya village of wooden slat houses with thatched roofs.  There are chickens and pigs everywhere but it is a clean village.  It seems that everyone's yard is like a storybook with flowering trees and bushes.  Unfortunately, i didn't think to bring my camera but definitely will next visit.  I have seen multiple wild animals (including a gibnut and a coati) as well as large lizards and many beautiful birds.  Last Friday I was in San Marcos.  It is a Mopan Maya village of about 1000 people and it seems like a number of them had conjuctivitis ("pink eye")!  We dispensed more eye drops than I have ever seen before.

There is a lot of COPD (emphysema) in the villages because they all cook on open fires inside their home.  The thatched roofs don't allow enough ventilation and they are exposed to it from birth.  We have an adaptor for the neb machine so that we can plug it into the truck to give nebulized breathing treatments.

It really is surreal at times seeing patients in the village settings - in very basic, dirty, and hot conditions under a metal roof - but it is rewarding at times knowing that we are the only medical providers that they can see each month.  To be quite honest, often they come in with simple complaints just to get some Tylenol or Ibuprofen because they cannot get it in their villages.

 Setting up for clinic in the Maya village of Summer Wood.  The clinic building is only big enough for intake and dispensing medications.  The patients are seen out back under the thatched roof.