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

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.

A New Village Schedule

We started 2013 with a new schedule for visiting the remote villages and so far, so good.  We have given every village a daily schedule of where we are instead of just the dates that we will be in their village.  It appears that we have been able to reach more people, particularly in San Jose where we are going every other Tuesday instead of monthly, as some have travelled from surrounding villages when they know we are there.   We gave up going to Conejo, Midway and Crique Sarco in trade for going every Monday to Santa Ana in hopes that people from more villages would have access on that day.  Bill has been leading the team to Santa Ana weekly and it seems to be working.  The first week they saw 15 patients, the second week 18 patients and then 24 patients last Monday as the villagers know that we are there.  

Map of the Toledo District that Bill developed based on village catchment areas

We have continued to see a consistently good number in our main clinic, often close to 30 patients a day.  We only have morning clinic hours there since in the afternoons we see home-bound patients, visit schools to do education or another community outreach project. So, depending on your team of students, 30 patients can seem like a huge number.

Bill crossing a flooded river on the way to the village of San Benito Poite

I am encouraged that our women services is meeting a need in Belize.  We still struggle to convince women to have pap smears but I am getting referrals from Belizean doctors for consults and colposcopies on patients.  Recently I had a self-referral from Belize City for a colposopy.  As I spoke with her by phone, I asked how she had heard about us.  She told me that she is a nurse in Belize City and she heard that we are doing this procedure in Toledo.  She told me that there is only one person in Belize City offering these exams and patients have to pay out of pocket.  The cost of her bus ticket to Punta Gorda was much less so she was willing to make the trip down to to have it done.  We are now struggling to provide birth control to all of the women who are requesting it.  The Ministry of Health has traditionally provided us with some birth control pills and injectable contraceptives but with their budget tight, they have not had a regular supply of many medications.  If anyone has any ideas on how to obtain birth control pills or injectable contraceptives at little to no cost (our available budget), we would love to hear it.

Bill has been rooting for the Belizean football team which has made it out of the first round in the Central American Cup.  They actually tied with Guatemala (an embarrassment for Guatemala!) and beat Nicaragua.  They play Honduras on Friday evening.  There are 3 guys on the team from Punta Gorda and Will has played with them in the local football league.  Mr. Rudy doesn't have a TV so he has been over to watch the games with us.  Since they made it out of the first round, they qualify to go to the U.S. this summer to play in the Gold Cup.  Big news for Belize!!!

Morning in Aguacate

We have a doctor with us this month whose hobby is photography, Jon Rodrigues.  The photos I have included were taken by him.

Happy New Year!

We have a running joke amongst the Americans volunteers down here about what people in the States think we are doing in Belize vs. what we are really doing.  Belize is usually thought of as a tropical paradise with a high amount of tourism, particularly in the northern part of Belize.  This holiday season we have had a chance to experience that other side of Belize.

We really enjoyed having Bill's parents here and showing them where we live and our favorite spots.  They were able to attend our clinic's Christmas party and meet all of the Belizean staff.  A couple of days before Christmas, we rented a boat and went out to the Cayes (islands off-shore, out by the reef).  We haven't had the opportunity to do this since we have been here and it changes your perspective of where we live.  As you head out about 12 miles towards the reef, the water begins to clear and the scenery is beautiful.  The guys caught some fish on the way and when we got to Moho Caye, we had grilled fish cooked over a fire - absolutely delicious!

When it came time for them to go back to the U.S., we drove up to Belize City and had lunch on the Belize River before they flew out.  We then went into Belize City and caught a water taxi over to Ambergris Caye.  As we waited for the water taxi with a group of Americans, we realized that we were no longer Belizean volunteers but tourists for the next few days.  We did have the chance to meet a couple from California who are both physicians - a pediatrician and an anesthesiologist.  We of course told them of our work and tried to recruit short-term volunteers.

Sunrise on Ambergris Caye

Ambergris Caye was wonderful!  We definitely felt that we were on vacation.  It is a beautiful tropical island with white sand beaches and crystal turquoise waters.  We did a lot of nothing around the pool, beach and climate-controlled room.  Bill, Will and Caelan went out snorkeling a few times, including at Hol Chan and Shark Alley.  We also got our fill of American food - cheeseburgers, cinnamon rolls and pizza.  

It was interesting to see the differences in language and culture on the northern Cayes compared to the southern Toledo district.  The street language is primarily Spanish and Creole and then English where we do not have to speak Spanish frequently in the south even though we are sitting right next to Guatemala.  Their accents and English are easier for me to understand than in the south.  It might be that we are used to hearing English with a Spanish accent but not used to hearing English with a heavy Creole accent.

We came back by water taxi and then bus to Punta Gorda.  Once we hit the bus station in Belize City, we knew that we were back to the Belize that we were accustomed to.  We noticed right away that the buses don't go slow.  We were also serenaded with Caribbean and Spanish music for the duration of the ride through speakers that worked very well.  Crossing the Maya Mountains was like riding an old-fashioned wooden roller coaster - slowly going up the hills and then as you reach the top, plummeting down the other side at break-neck speeds, curves and single-lane bridges included.  While we have travelled up to Belize City several times in our own car, it was a markedly different experience.  The boys will have another story to tell their children.

All in all, throughout our holiday break, we have had a relaxing change of pace and definitely added to our experience of living in Belize.

Happy New Year!

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.