Sole of the Matter

Shoes.  I love shoes but I have come to truly appreciate shoes since being here.  They are not as much a fashion statement as they are a protective item and tool for the environment.  Instead of my favorite shoes being based on shape, color or heel height, my favorite shoes here are ones that are stable, breathe well and can be rinsed off in the river when really muddy and still worn the next morning.  The shoes available here are not well-made and mainly rubber flip-flop and "crocs" styles that are not very durable.  One of the most frequent requests from our clinic staff when one of the volunteers are going to the States, is a pair of tennis shoes.

Girls in the village of Corazon

In the U.S. we are so used to wearing shoes that we don't think about what it would be like to not wear shoes on a daily basis.  The government list shoes as part of the school uniform but children are not allowed to be turned away from school because they do not have them. Out in the villages shoes are definitely not a rule.  The men put on their rubber boots to go work in the fields but many of the women and children go barefoot around the village.  It is actually much more difficult to walk through the mud in cheap rubber flip-flops than barefooted.  We encourage people to wear shoes not only to protect their feet but to decrease the chance of getting intestinal worms (not all worms are contracted by eating affected food, some burrow into the soles of the feet to then migrate).  The chickens and pigs roam freely through the village and there was a study in the Toledo district that showed that at any given time, sixty-six percent of the population is infected with worms.

School children in the village of Santa Teresa

I have definitely thought about shoes since I have been here but as I did home visits with our physical therapist, Annette, I realized how they can truly make a difference.  Santos Norales is a 28 year old man who had a significant brain injury (with unclear details) after working in the heat.  He had a subsequent craniotomy and still has part of skull embedded in his abdominal wall.  He now has memory problems and spastic hemiparesis.  At this time he spends most of his time in bed and has become very depressed.  Annette has been working with him to increase his ambulation but it requires a very stiff AFO (ankle-foot orthotic) on his left ankle, and a lot of help.  He needs a supportive pair of shoes with easy entry and closure so that he and his family can get them on him with the AFO.  The only pair of shoes that his family has found for him here that might give him some support are sandals that are too small (his toes hang through at the end and he and his family are not able to get them on with the AFO).  Something so easily obtained in the U.S. but unavailable here would allow him to get out of his room, out to the front of the house and enjoy life more.

Malnutrition and Worms

We have seen our share of malnutrition in children since we have been here but it is often a subtle form of it - children just below the 3rd percentile of the growth chart, a shallow growth curve or just small stature.  This is nothing like what we have been dealing with in the past couple of weeks.  There is an orphanage in our area started by a Belizean and his American wife as a ministry here.  They established a non-profit group in Colorado and have worked hard to develop an awesome property here with a learning center and playground. They have also struggled with all of the bureaucracy and whims of the Belizean government.  We have seen the children from the orphanage at our house as well as in our clinic - including the time that they all came down with Coxsackie virus (Hand, Foot & Mouth Disease).

Jennifer Choco checking in a patient to be seen in the village of Laguna

A couple of weeks ago they had nine children dropped off in one day.  One of their staff came to find us while we were having lunch with the medical students and asked us to come over as soon as possible.  They were concerned about the five youngest who were all siblings ranging in age from 7 years to 13 months.  Their father is in prison and their mother is unable to care for them and so she asked the orphanage to take them.

They were in the process of bathing the three older boys after they had shaved their heads since they were all infested with lice.  The youngest two are 13 month old twins - a boy and a girl.  We noticed right away that the boy in particular is extremely malnourished.  I struggled with wanting to send you all photos but decided not to because of the privacy concerns.  His growth chart will have to speak for itself.  He was unable to hold his own weight on his legs and had no tone so that he flopped back as he was picked up.  His twin is much more of a fighter and would scrap for any bit of food but he has become an expert at self-soothing by sucking on his own fist.  

We treated them all with a dose of medicine for worms, with a course of antibiotics for the twin boy and started them on small amounts of formula with the concern for refeeding syndrome.  (There is an interesting article just published in the New England Journal of Medicine about using antibiotics combined with refeeding for better outcomes.)

The roundworm from the twin sister

It has been really nice to see them improve gradually.  Four days later he had a low-grade fever but no signs of infection.  He was very irritable and fussy but we thought that he probably finally had enough energy to fuss with hunger.  Two days later they brought them into the clinic because the 13 month twin sister had coughed up/spit up a large roundworm which was still alive so we treated them all with a longer course of worm medication.  Although he has a long way to go, his tone is much better and he actually smiled at me.  He was able to hold his weight for a couple of seconds on his own legs and is trying to reach for things now.  We have all seen the photos of children starving in Africa but it is amazing to me that there is such malnutrition here in this hemisphere, in a country which has some of the fanciest resorts in the world.