Mobile Clinics: Daycare #8

We seemed to get a little lost walking to daycare #8.

But when we finally got there, we found a bunch of smiling kids.

We saw a few more babies here than in other places. Both of these were kids I saw (above and below).

As you can imagine, with so many kids in one place, it's not all work. We play some games and hang out with them while we're setting up.

We got a warm goodbye from these kids. The whole group trotted out to the front to see us off!

As we were trekking out, we got a good look at some of the houses in this area. When you see these it's easy to see how so many of their illnesses are related to the environments, because of lack of clean air, clean water, and good sanitation systems.

Mobile Clinics: Daycare #7

After just a few days away from mobile clinics, we quickly got back into the swing of things. Yesterday we were at the clinic in Tierra Colorada, as usual. We waited for the girl from Monday who had the heart problems, but she never showed. I heard that she went to the clinic today, so tomorrow I will have to get the update.

The walk wasn't far, and we saw some familiar faces. This is the place where the teacher has brought the students to the clinic.

The kids were lined up waiting, and playing when we got there.

We found some interesting stuff, though hopefully nothing was too severe. Cody found a boy with an unusual murmur, who had to be sent for some tests. I saw a girl with a chronic ear infection that was draining smelly green-ish goo.

Some of the kids we see in these clinics are actually babies whose moms work in the clinics, or extra people who get invited in. The mom didn't want to be in this photo, but she stuck her son on my lap to pose for the picture.

Daycare #6

Daycare #6 was pretty much in the center of town for this area. It was brand new, and just opened a few weeks ago. Even the walls still smelled like paint! Many of the kids were healthier, but the teachers didn't know them as well so the histories were even shorter. We unpacked our giant bags of medicine, and set out to weight and examine all the kids.

I saw two pretty healthy, though underweight, kids. The first child I sent away with her bar of soap, toothbrush, health form, and albendazole, because all I could see was a little runny nose. Half-way through my visit with the second child, the teacher came up to me and told me I forgot to give her her cough syrup. Well, her lungs were clear, and she had a dry cough. What was I gonna do? There seems to be a strong belief here that symptoms can be treated, and people are willing to try anything. I told the teacher that I didn't have any medicine that would work, because she didn't have pneumonia, and the cough medicine was only for productive coughs. She looked at me like I was crazy, but accepted my answer. I really wonder what she was thinking, though. Maybe it's easier to give cough medicine for kids who don't need it, just to make the parents and teachers happier. Because what happens when we really need them to come in (like for heart problems!) and they don't...
Each kid at the schools get these little bags of medicine and goodies. And at the daycares, this is invariably where the plastic bag goes. I've almost stopped trying to take it out of their mouths!

Daycare #5

I've come up with a theory (okay, okay, hundreds of other people have had this theory before, but I'm jumping on the bandwagon...). The more rural the place, the more health problems we are seeing. I'm sure when you get into the extremes of urban areas you see these things, too, but in general from the daycares and schools we have been to this seems to be pretty true.

The water supply is different in the rural areas. People get their water from big basins in common areas, and carry it back to the house in jugs and big containers in wheelbarrows, hands, or on top of their heads.

Today we went to two new daycares, and I got to see this theory in action. As we got off the bus, we saw a water area like the one above. Once we got closer to daycare #5, the water area looked like this. Daycare #6 was located pretty close to the first water area.

Once again, we were walking along a beautiful country road. The volcanoes and mountains loomed above the valley. Dust was going crazy every time someone drove by. And cows stared at us as we walked.

We even caught sight of a man spraying his fields with pesticides. No boots, no protective gear. Just the spray.

When we got to the daycare, we were greeted by a few overly-excited kids, who shouted friendly "buenos dias" good morning greetings to us. The rest of the kids were lined up waiting for us.

As for the theory, we saw some pneumonia, impetigo, malnutrition, coughs, and what was probably a heart defect. My first patient was a 5 year old girl who was a little small for her age (just on the border of what we'd diagnose as Grade 1 malnutrition). She didn't want to talk to me, so I just went on with my exam, and figured I'd have to find out for myself if there was anything going on. First thing I did was I had her stand in front of me (as I sat in my little toddler-sized chair) and I put my stethoscope to her chest. WOW! It was a grade V/VI murmur. It made all the other murmurs I've ever heard seem like a joke! It was so loud I couldn't hear her lungs well. It radiated to her back and both axillae. There was a strong thrill, strongest on the right side. The murmur was audible everywhere, but strongest at the aortic and pulmonic points. It didn't take me long to go get some help. I went and talked to the clinic's doctor who by chance was with us, and we noticed that she had strong peripheral pulses but had some clubbing and peripheral cyanosis. Her liver edge was palpable about 4 cm from her ribs. We got a little bit of history from the teacher, and it seems that she had fainted once. I'm not sure what else was in her medical history because her parents weren't around to answer.

We tried to refer the girl to the hospital, but the teacher told us that her parents wouldn't take her, even though we explained that it was important. The teacher, sadly, said something like "her mother wouldn't care if she died." So we wrote her a note to go to the clinic tomorrow, and we'll do more tests and try to get them into the hospital from there if need be. I'm working at the clinic tomorrow, and I really hope they make it in to see us!

As we said goodbye, not only did we get heartfelt thanks from the teacher, but we had a little follower who ran out after us. :)

Thermal Steam Baths - Los Vahos

Los Vahos is a place about 3 km outside of Xela, where people can go into private steam bath rooms. The nearby volcano produces the steam, and they have it coming out of vents in tiny little rooms, with a ton of eucalyptus branches. Each steam room also has a larger dressing room area with some wooden benches/beds. The cost for us 5 adults to enter was about $12. But we did have to hike up 45 minutes of steep mountain-hill.

As much as I struggled for breath on the steep parts, I will say that the view was gorgeous. We could see the city of Xela, and the farmland and houses nearby. Some of the farms were actually growing flowers, which made the view even more picturesque.

By the time we left, we hitched a ride (for a small fee) with another family traveling down. The car was an old SUV, whose lights kept turning on and off, which was terrifying on the neglected dirt road at night time. I closed my eyes more than once!

Mayan Day of Thanks and New Year

The sacred Mayan calendar consists of a 260 day cycle. Two days ago was the day of thanks, where they honor a wide variety of things, everything from the wind and earth to ancestors, and fertility. Today is the Mayan new year, so other ceremonies were held all around. Most Mayan ceremonies don't allow outsiders to join, but one of the Spanish schools in town offered a ceremony for outsiders. There were a half-dozen Mayans participating, including a local Mayan priest. Because it was for outsiders, we were free to gawk, ask silly questions, have a translator, and take pictures. I would have never dared if it hadn't been in an environment like this! I got the impression that it was pretty dumbed-down for us, but there was still some really interesting content.

There was a surprising amount of focus on fertility. The ceremony mentioned corn, and harvests, as well as women being sources of fertility. There were moments to give thanks for all of those things. The sacred holding of fertility made me wonder if the families who have so many children actually do so out of more than just lack of access to birth control measures.

The ceremony consisted of symbolically placing things into the fire at specific times, as prayers of thanks for each thing were offered. There was a discussion of the concept of the four corners of the earth meaning more than just inside those corners, but also what was outside. That same concept of inside-and-outside of corners was also shifted onto our bodies and ourselves.

As beautiful as the ideas were, I still couldn't quite get past the idea that the ceremony was being put on for our sakes. But I appreciated the opportunity to see what we otherwise wouldn't have been allowed to see.

According to the World Food Program (WFP), over 70% of people in Guatemala live in poverty. The country has the 4th highest rate of malnutrition, and the highest rate of malnutrition in Latin America. The WFP says that 49.3% of children are undernourished. Most of these children live in the rural areas. I can definitely vouch for having seen something of a geographically-based health disparity here.

The United States once went through a period of time having malnourished children and adults as well. In 1946 the school lunch program was started to prevent and treat childhood malnutrition, after it was discovered that many young men were ineligible for combat when drafted in World War II. Several measures have been put into place, and have virtually eliminated the issues of under-nutrition in the US. These days, aside from a few rare cases, most of the malnutrition we see in the US is actually obesity. That may sound shocking to those of you who imagine a starving child when you hear the word (hey, I do it, too), but the technical definition of malnutrition is actually an imbalance of nutrients and demand, which is pretty all-inclusive.

Now that we resolved the issues of under-nutrition in the US, we have moved to an age of obesity. Childhood obesity is on the rise in the US, and has even been called an epidemic. Some blame it on the fast food, packaged food, and soft drinks that have taken over children’s lives. Others claim it has to do with that leftover attitude from the ages of under-nutrition, thinking that a fat child is a healthy child. I’ve seen some of this in the Southern grandmas wanting their grandkids to be really chubby and healthy.

Guatemala is a country of contrasts. The city and the country, the coast and the highlands, the capital and everywhere else… There are those undernourished kids who make up almost half of the country’s children, but there’s also a small, and presumably growing population of children who are overweight, reaching towards obesity.

I sat down at lunch with my host family today and saw all of these factors coming into play. The family I have been living with is somewhat non-traditional, they are three grandmothers, and one of their teenage grandsons. Today one of the sons was over for lunch with his two sons. They were pushing the 2-year old to eat, even though he had already had a substantial snack. When he didn’t want to eat his soup, they started in on saying that he was too small, they had to bring him to the doctor’s, and he needed to be eating better. Meanwhile, they gave him a total of about 16 ounces of Coke, which he drank in its entirety (after saying something about it being good to calm his nerves)! They actually seemed to have some awareness of the bad-ness of Coke, because they commented that the teenager should drink water instead (why, I don’t know…). This nutritional concern went even further. They threatened the little boy that he’d have to go to the doctor’s and get shots (though somehow they made ME the bad guy here) if he didn’t eat. They talked about other cousins who didn’t have much money, and didn’t eat very well, though they all thought they knew how to better supplement the kids’ diets. When I walked by later I saw the two boys eating giant coated Oreos, with the open package in front of them. And the kicker, these are two chubby boys. I’d say the 2-year old is normal healthy (which is pretty chubby at this age), and the 8-year old is overweight…

But as strange as all of this may sound, it is clear that it comes out of genuine concern for the children. There is something of a backlash against under-nutrition in the communities of people who can afford more than just the minimum of food. It makes me wonder. How long until we are seeing an obesity epidemic here, too? We are already seeing sky-high levels of Type 2 diabetes and obesity in places like Mexico and India. It’s a paradox.

Mobile Clinics: Daycare #4

The schools where we have gone have been hugely different. Sometimes I wonder why these kids are even in school, they look so sick, and other times I wonder how much we're needed there. Primeros Pasos has been widely successful in lowering the rates of malnutrition in the community, though. That is largely due to screening the kids in programs like this, and giving out the doses of Albendazole. Kids with GI infections (like worms, which are killed by Albendazole) are not able to eat and grow as well. But today I must admit that I felt useful. Daycare #3 was pretty healthy, but at Daycare #4, we saw some much more serious stuff.
When we walked into this daycare, things were a little chaotic. There was a little boy laying on a mat on the ground, and others gathered around. The teachers said that he had had a seizure about 15 minutes before we got there. He apparently had fallen from his chair and had a tonic-clinic seizure, lasting just about 5 seconds. We couldn't figure out much about his history, because there was no way to get in touch with his parents, though we knew that he had seized once before.

After we checked him out, and talked to the teachers, we ended up treating him for an ear infection and febrile seizures. We gave him some acetaminophen and Bactrim. We also referred him to the clinic to come talk to us on Monday, for a more careful assessment, to determine if he needs other medications or a referral to a neurologist. A couple of us also spent some time talking to the daycare teacher about safety during a seizure.



But we got on to working with the rest of the kids, while the boy rested and tried to sleep off some of his exhaustion. My first patient was a three-year old girl who had a nasty cough and pneumonia. She hung around me long after I gave her her medicine. She seemed not to be traumatized by the exam process at all, unlike many other 3-year olds.


This is what most of our patients looked like (though this guy certainly was exceptionally cute).


And as usual, the kids were thrilled to be in photos!

Mobile Clinics: Daycare #3

Daycare #3 was interesting. The teachers must have announced to the parents that we were coming, because almost all of the kids had their parents present. It was nice to be able to get a deeper history from the family, instead of just from the teachers. I will say, though, that the teachers seem to be really involved and care for the kids deeply.

This was the view walking to and from the daycare. We lucked out to get a gorgeous, sunny day! This part of Guatemala is up pretty high, about 8000 feet, and this area is up even higher than Xela. It means that when the weather is right, it's like living in the clouds!






The kids were really curious. Whatever we did, they were swarming around, trying to get involved. But they sat still for a picture at the beginning.


Can you see why I was a little worried why I'd get lice the other day? But I wouldn't ever trade it. It was so fun having the kids climb all over and play with me! I actually didn't find lice on a single kid today.




Time to do some assessments. Most kids here were pretty healthy. The only medicines I gave out were expectorants for coughs when the moms really wanted them. Of course we gave albendazole to all the kids to treat for worms, and collected stool samples so all kids could be treated for GI infections if they had them.

I was super-allergic to something in here (cats? dust?), and was sneezing non-stop. I had to take frequent fresh-air breaks, and keep the roll of toilet paper and bottle of hand sanitizer near me at all times. It was kind of embarrassing to see the moms look inquisitively at me when I had a sneezing fit while trying to care for their child...

Mobile Clinic: Daycare #2

This morning we went to two daycares for mobile clinics. This one was the second one we went into. It was closer to the bus stop, or downhill from the other one. The kids were really sweet, and the teachers, too. We had plenty of time there, so I had a great time taking pictures, and playing with the kids. Too good of a time, perhaps, because now my head is doused in vinegar because I found lice on one of the kids, after we'd been playing close together. :) But they were fascinated by the camera, and all wanted to be in pictures. Every time I was taking pictures, one would jump on me, and others would try to run into the shot. It was cute, chaotic, and lots of fun!

Our beautiful walk into the daycare.

The entrance to the daycare. This is actually the building here.

A smiley warm welcome.

This little guy was snacking all by himself.

When we arrived it was snack time. Little kids brought each of us plates of orange slices, same as they were eating. It was the sweetest thing, just like we were guests in their house!

An image of the classroom, and the decorations on the wall, including a portrait of the wife of Guatemala's president. These are two of the med students who went to mobile clinics with us today.

The kitchen and washing facilities for the daycare. Can you imagine trying to prepare food and clean up after 25 kids with this? They have to work really hard!


In this area, moms seem to be allowed to work with their young child tied to their backs. Both of the daycares had teachers who were sporting the baby look, like this woman here. I really have to get them to teach me how to do that!

On our way out, we encountered this guy who stared us down as we walked on the little road out of the daycare.