Estufas

Honduras is an exceptionally beautiful country: green covers literally everything! The scenery comes in stark contrast to the conditions some of our patients were living in. Bare dirt floors, flimsy wooden slats for walls, and aluminum for roofs in some of the poorer villages were not uncommon. Before ENLACE, most families cooked with wood burning stoves in their homes, causing respiratory illness and leading to emergency room visits for asthma attacks.

With ENLACE and Don Israel’s design, many of these families now have clean-burning stoves. We had the privilege to install 2 of these stoves which require significantly less wood, and pipe the smoke out of the house. Requiring a simple concrete frame, a clay tube, and dirt dug from the owner’s yard, these simple stoves have dramatically reduced the rate of respiratory illness in the communities where they have been installed.  Earnestly asking about each component of the stove, I fell in to Don Israel’s joke when he told me the water we added at the end was the most important part. Eager to understand the construction, I asked why. He smiles and says ‘because it feels the best on your hands” as he massages the water into the dirt to make hard clay. Just another day’s work!

Emily Fisher

Community Medicine and Global Health Fellow

Regresso

I have been lucky enough to have traveled to many different countries for work and vacation. This trip, however, marks the first time I get to go back to the same place twice. The last time I was here, I had by 6month old daughter in tow and it’s not until this trip that I realized how much that had given me tunnel vision. I missed my daughter dearly this time, but I noticed the beautiful surroundings a little more clearly, interacted with the local team more closely.

Being my second time, I could really settle in to familiar surroundings. Improved Spanish helped a lot tambien! At first, the poverty is all you can see. But this time, I was more able to appreciate the incredible welcome, the care with which Don Israel(our host dad for all intents and purposes) shepherded us up and down the mountains, the kindness with which he treated all the villagers, and a surprisingly wicked sense of humor. The smiling faces of the children ecstatic to receive a calcomania(sticker), and the crazy good footwork of the kids who schooled me at futbol were and added bonus!  I look forward to a third visit to this amazing country and the continuing shift in perspective that each trip brings.

Emily Fisher
Community Medicine and Global Health Fellow

A Home Within the Chest

A 63 year old male presents to a rural Honduran clinic with symptomatic end-stage aortic stenosis. If he is a candidate, a valve replacement may be the only thing to save his life. We wish & want this for him, but in truth know little of his life. I have thought much about him since I returned home & below imagine the world in which he may live.

Mechanical thunder rumbles up the hillside.

Trucks carry foreign doctors to our village.

Dust billows & lifts upwards, mingling with dirt & pollen

I upturn in tending to my crops.

An ache has grown within my gums,

a seed dropped by birds in a field it shouldn’t be.

It must be a bad tooth. I hear the foreign doctors

can wrest it like a weed from my mouth.

So I begin the journey towards our clinic-church,

pace myself to avoid exertion, but grow quickly air-starved,

So I must stop to rediscover the wind within my lungs.

This is time- Crops, birds, farmers, & foreign doctors all age-

& this has been my year of aging.

Air washes in & out my chest like well-worn burlap

leaking grain- so it goes with old things like me.

The foreign doctors beg to differ.

I try to show the rotten tooth, but they point at my heaving chest,

skin sagging from thinning bones,

& wonder at ways to turn back time. With a stethoscope

they listen to the drum of my heart,

then listen again,

bright eyes narrowed in concentration (the dust of age

has not yet dulled their glimmer). They speak in hushed tones,

nodding, considering, & finally tell me that my heart

is a home. It has four rooms. Blood moves in-turn

through these rooms & the doorways of my heart,

until it exits to spread like water

across the fields & hills of my body.

But my home has grown old.

Rust has come to the hinges

& blood struggles to open its doorways.

It can barely tend the gardens just outside.

What I need, they tell me, is a new doorway.

Fresh hinges no longer stiffened by age.

They call this an aortic valve & without it,

fear the land of my body may fall into its final rest.

The new doorway will take this year’s harvest

& many more to buy. They ask if I have family.

“A son,” I tell them, but wonder if he should pay

when his house holds a wife & daughter,

with homes inside their chests filled

with vibrant blood, newly oiled hinges,

& dreams of a world where their daughter doesn’t work

our family fields, but cultivates the furrows of her mind.

The foreign doctors may know much of medicine,

but understand little of farming, the churn of seasons,

& the dreams which whisper

through the rooms of my granddaughter’s heart.

Ethan Sellers, PGY-III

KP Napa-Solano Family & Community Medicine

Reflecciones

We've been back in the US for 3 days now and I'm already experiencing some serious Honduras withdrawals! I'm not sure what I miss more..the wonderful group of residents/attendings/family members that began to feel like family, the 6:30am runs in Las Lajas (this is maybe more of a love/hate relationship), getting to use and improve my Spanish, prescribing more mebendazole than I'd ever imagined possible or meeting and learning about the culture of the beautiful people of Honduras.


It was an action-packed, exhausting, eye-opening and extremely rewarding week. In my reflections of the trip over the past few days I have come to realize several things. First, I am extremely grateful that our residency program allows all its residents to experience a global health trip should they choose. Not only this, but what a unique opportunity it is to get to experience and practice global health alongside some of our amazing attendings. I've also been thinking a lot about how exciting the partnership our residency/global health fellowship has with ENLACE is. As we continue to bring groups down to Honduras, each trip improves upon the last. I am hopeful that we continue to be able to create more sustainable ways to help the people of El Diviso and Palmichal Carmen and beyond.


I couldn't be more grateful for our time in Honduras. The trip has lit a fire within me to keep global health as a part of the practice going forward. I hope to return to Taulabe soon! Until then..chequeleque panqueque :)


Kelsey Goodwin
Family Medicine Resident, PGY-3

Food for thought

7/16/18

Gealina Dun

Family Medicine Resident

Class of 2019, PGY-3

We’re back!!

It’s crazy to look back and think of how quickly the week went by and how much we were able to accomplish. Each day was memorable for something different.

Tuesday - We went back to El Diviso and did more work at the school, teaching first aid kits, setting up a tablet touch pad for the school so they can play games and learn English, and building a stove. Total, we saw nearly 100 patients in the community.

Wednesday - First day in Palmichal Carmen! It’s a very different community - it seems slightly more affluent, which you can see because the houses seem more durable and the patients are older. There are more chronic diseases like hypertension and diabetes which we didn’t see as much of in El Diviso.

Thursday - Kelsey and Ethan removed a large lipoma in Doctora Floripe’s clinic! This meant a few of us stayed behind and weren’t as helpful when it came to clinic in town… but it still went well! We managed to see nearly 40 patients despite the late start and again do first aid training, teach about tablet use, and install a stove. We also handed out shoes to the local kids. There was a very long line and the kids were so excited to get new shoes!

Friday - We spent the day at Las Lajas elementary school right down the street from the clinic. There were a lot of kids and I spent the morning helping the team check Hemoglobins of any new children and ones who had been anemic the previous year. We checked over 30 kids and found a lot of anemia! Those who were anemic received multivitamins with iron and the hope is that they will improve in the coming year!

Then we said goodbye to our fantastic team and hosts and packed our bags before heading to Tela beach for rest and debriefing. There, we continued to enjoy each other’s company and the warm Caribbean waters! We celebrated Christina’s birthday as thanks to our fearless leader for organizing our wonderful trip.

So those were the logistics and facts on the trip. Some of the things that stood out are more complicated than what I can say in a summary paragraph.

Here’s more food for thought for future groups:

• Dental Care - the residents were assigned “waiting room talks” to try to educate the community while they were waiting to be seen. We talked about things like hand washing, dental care, and sleep hygiene. My topic was dental care and it is a huge need in this community. Dental had a line every day and they saw 20-30 patients a day doing cleanings, tooth extractions, and fillings! When I would ask the patients whether they brushed their teeth, many of the kids would exclaim “YES!” and say that they brushed their teeth three times a day. However, the evidence seems to point otherwise - as there is a significant burden of pediatric caries in the community. Many houses have running water, but their sinks are outside and not potable. You can see this sink has a sock over the faucet because there are so many minerals and particles in the water that gets collected that they use a sock to filter it. Then they fill the bowls with water to wash their hands. To the left of the photo is a shower, and to the right is the toilet, which is basically surrounded by a cardboard wall. It’s definitely not like the USA where we have sinks easily accessible and can brush our teeth anywhere without worrying about catching a stomach bug.
• 

• Nutrition - I spoke about this already, but it still nags at me that there is not a great source of vegetables among these patients. Sodas (frescos) and chips (churros) are a very popular food source that can be found in pupuserias (convenience stores) in these communities. They are fairly cheap - 18 limpira ($0.75) for a soda and 45 limpira ($1.88) for a bag of chips. The diet tends to consist mostly of rice (arroz), beans (frijoles), and chicken even though vegetables are also very reasonably priced. There was talk about building garden towers so people could grow their own vegetables, and it’s an idea that we are still exploring.
• Sustainability - one of the best things about this medical mission trip is that its model aims to be sustainable. We bring care to patients where they are in the communities (kind of like a home visit) but still refer them to Doctora Floripe in Taulabe so they can follow up and continue to get medicines. It’s not free, but at least it’s a place where they can get care on a sliding scale basis. We also build stoves and try to improve the education system which is hopefully improving the environment in which they live. There are still many ways in which we could help - finding or creating jobs so that people can afford better food and nutrition, afford their medications, and addressing the social determinants of health in addition to the acute care we provide.
• Stoves - The fuel efficient stoves help to improve the lives of these people in many ways. It improves air quality by 80% by decreasing the particles in the air and the amount of carbon monoxide, as well as decreasing fuel use to 20-30% of its original. This means that people are spending less time finding wood, buying fuel, and being sick. These families do have electricity, but they don’t have electric or gas stoves because it would cost more money not only to buy them but to maintain them. These concrete stoves are portable and can move with them if they were to ever need a new home.

This is the stove elevated on bricks. The concrete outside is filled with clay to help insulate the heat.

The hole on the bottom edge of the picture is where the chimney is put. There is a hole in the bottom of the tube so that it can be turned and opened or closed. When it is closed, it allows the stove top to heat up faster by preventing air to flow out and therefore there is not as much cool air moving through the stove.

This is the lid or stove top that gets placed on top a layer of ash. The clay is wet and stamped down to seal it, and the ash is put in a layer to also help seal the stove top down. Because the ash is much finer than the dirt/clay, it acts as a better seal to help prevent smoke from getting out underneath. The design of the stove top also allows heat to move to the bottom and around then into the chimney instead of straight down the middle.  

This is the chimney being placed. The air flow above the chimney allows it draw up the smoke and warm air.

Yay fire!

And here if the finished product! That stove top gets pretty hot so the owner can grind her beans and make coffee and tortillas.

Whew! I feel like I threw a lot of information out there. It’s a wonderful trip and I feel like I was able to contribute to the community without taking too much away from the established system, practice and improve my Spanish language skills, and get to know my teammates and colleagues better. I would definitely do it again and recommend it to any resident interested in seeing how to run a community clinic and establish oneself in a community.

Thank you Honduras! Maybe I’ll see you again next year!

Simple Joys

Guantes!  Guantes!  Mi, mi, mi!  I can’t imagine kids in the U.S. getting as excited about a single disposable glove, much less buying into the activity of trash pick-up with only the bribery of the opportunity to sing a simple song about putting trash into the trash can.  Yet these kids in Honduras soaked up the activity.  I had children climbing through fences to collect trash on the other side!  They would run to me with handfuls of trash to throw in the bag I was carrying.  They expected no reward in return – I think they just loved the excitement of a new activity, a break from their usual routine.  A single glimpse of their school and you can see that organized arts and crafts activities and other fun games are probably minimal.  There are only two single connected rooms for around 50 children.  There are few books, no computers, and only a single whiteboard with a few scattered old posters on the wall.  The wood on the student desks is fraying – it’s hard to imagine how a child can even write on them.  There is no playground equipment – just an open field.  Occasionally visiting volunteers bring a soccer ball and the kids will pay with it until is completely worn out.  Most kids sadly don’t get to go to school beyond the 6^th grade.  A typical daily routine of a 12 year old becomes washing clothes, preparing food, cleaning and taking care of infant siblings.  Is it any wonder then that these kids soak up the opportunity to wear a glove and run singling and collecting trash?  So you can only imagine their excitement when my mom brought out the arts and crafts and they got to create butterflies out of fun foam and clothespins and airplanes out of popsicle sticks.  I imagine it’s close to a U.S. kid’s excitement about Disneyland.  It’s memories like this that I try and hang onto so I can recall it the next time I am getting stressed about first world problems like my computer not turning on fast enough or what type of new flooring I’m going to put in when I renovate the living room.  I have a lot to learn about stressing less and finding joy in simple things when Honduran kids live in houses with dirt floors and find immense joy in wearing a single latex glove to pick up trash!

- Christina Kinnevey, Community Medicine and Global Health Fellow

Tortillas

Homemade food.  It’s something loved and welcomed among all people and a bridge between cultures.  I thought about that today when we had a mini class to learn how to make tortillas.  Suddenly we had a way to bond with the wonderful women who cook our food everyday.  They seemed excited to share their skill set and we were eager to learn how the delicious, warm flat pieces of bread that we enjoy every morning come into existence.  I realized there was an art to getting just the right amount of dough, forming it into a small ball in the palm of one’s hand and then flattening it out in a perfect circle.  There are two ways to go about the flattening – one way involves a heavy metal contraption that squeezes the dough between two cast iron plates.  That was quite fun and the challenge came in learning how to apply just the right amount of pressure to get the appropriate thickness.  My first attempt looked more like a French crepe, as I got a little over excited with the pressure applied.  The second method of flattening involves a seemingly easy twirling of the dough ball on a flat surface with just the tips of one’s fingers.  The reality of the task’s ease was quite different – my attempt came out looking much more like what I would expect a 3 year old would make if told to squish her Playdoh into a pancake.  Nevertheless, the cooks were patient with us and let us keep trying.  In the end, I don’t think I significantly contributed to the large basket of tortillas that were served at dinner as many of my trial ones ended up being reshaped by the professionals.  But I enjoyed the experience and have a new found appreciation for the work and pride that goes into making quality homemade food to share.   

Christina Kinnevey, Community Medicine and Global Health Fellow

Por fin

I woke up today feeling excited, yet nervous. My first time seeing patients on a global health trip as a physician. It seems like such a long road to arrive here. One of the initial reasons I pursued medicine was to have the ability to care for patients in need on both a local and global level - regardless of zip code, country of origin, ethnicity or language. There have been so many hurdles to jump over to get to today - hours of medical school lectures, endless exams, Step 1, 2 AND 3, surviving intern year of residency, learning to become a senior during 2nd year of residency and now, finally as a 3rd year resident, it’s happening.

The group set out early and we slowly traversed our way along the side of a mountain to a small village near to the top: El Diviso. Upon our arrival to the local church, that also serves as a makeshift clinic, was teeming with patients of all ages awaiting our team. From here things happened quickly - within minutes the tables were set up and before I knew it I had my first patient sitting in front of me. A 70 year old gentleman seeking relief from his low back pain that he sustained from frequently bending over while chopping grass and brush with a machete. Throughout the morning I saw entire families, 3 month old infants, young mothers diagnosing and treating illnesses including migraines, anemia, parasitic and viral infections. Meanwhile, the rest of the church was bustling with patients being seen by other providers, receiving dental care from a local dentist, picking up medications from our makeshift pharmacy and learning about healthy eating and low sodium diet from our patient education team.

It was eye opening to learn how infrequently this community seeks/receives medical care. There is a significant lack of healthful foods, with minimal vegetables and a high carb/starch diet as these are the more affordable foods. After a nice siesta this afternoon and clase de espanol, our group debriefed the day - brainstorming ways to better care for our patients and streamline our clinic. Now we are sitting around sharing stories and laughs. I’m exhausted, happy, and can’t wait to see what tomorrow may bring..

Kelsey Goodwin, PGY-3

Lessons Learned (Lecciones aprendidas)

Monday July 9, 2018

Today was our first day of clinic today in El Diviso! Kaiser Permanente has been coming to this area for the past few years with the help of Don Israel and Dr. Javier Sevilla. We were joined by multiple community physicians, la Doctora Ester and Doctor Fabricio and Dentista Gabby. We are very lucky to have these community relationships as they have helped us maintain connections with the community so we can hopefully make some lasting changes outside of our single week.

Things I’ve learned so far (among other things):

• Finding vegetables in Honduras is hard. We attempted to talk to patients about healthy eating (comer saludable) which we found to be more difficult than we thought in this community. They often have rice (arroz), tortillas, beans (frijoles), occasionally chicken (pollo) and potatoes (papas) for meals. When asked about vegetables (verduras), they reported it was difficult to get vegetables. They do have access to sodas (frescos) and chips (churros) and it seems that they often prefer these over spending the money on fruits and vegetables. Yet buying vegetables in town may be cheaper than the sodas/juices and chips. It will be an uphill battle to change the culture and emphasize eating more verduras instead of churros.
• There were many young women who are pregnant (embarazada), but there is little to no desire to have a conversation about contraception (contracepción). According to some of our local physicians, sometimes the men/husbands pressure the women not to use contraception. There is not a lot of education regarding the natural rhythm method and general preconception counseling is limited. The women seem very shy and timid about the subject.
• The health care system in Honduras is bottlenecked by residency training. Medical students have 8 years of study after high school, and then they have 2 years of required service - one intern year similar to what we have in the US and then a year or service to the government during which they can be sent to any regional hospital. This means that people are at least 28 years old by the time they are able to practice on their own. After this, they are considered a General Practitioner. Most people want to go to residency, however there are limited spots for <50% of graduates. Many go abroad for residency, but >40% of physicians are listed as unemployed. Some statistics suggest that 40% of Honduras’s health care is provided by volunteer medical brigades like ours. Whether this is helping the system or enabling a broken system, it is hard to say.
• Our most common diagnoses include: Parasite treatment (tratamiento para parasitos, both for active infection and prophylaxis), well child visits (niño saludable), hypertension (hipertensión), dermatitis (skin rash), cold symptoms (gripe), headache (dolor de cabeza), and acute pharyngitis (faingitis aguda), reflux (reflujo).

For those who come in the future, I hope these tidbits help inform you so you arrive less ignorant than I did. The people here are very grateful for our time and care and we are privileged to be given the opportunity to affect these lives!

Gealina Dun

Family Medicine Resident

Class of 2019, PGY-3

Kaiser Permanente Napa Solano Family Medicine Residency

PS. Read Ethan's entry from today - it's a beautiful poem that reflects many of our sentiments I don't have his skill to express!

El Baile

We pile into pick-ups,

weighted down with medications,

to wind our way up verdant mountains

enshrouded in billowing fog.

Overhead, birds circle & dart

like dark tildes through the mist.

La Clínica, the village church on other days,

awaits us at the summit,

as do our patients who crowd & seethe

in anticipation of los Doctores arrival.

They look like a patchwork flag

dancing in the mountain breeze.

We also dance, a spirited salsa-

dipping, weaving, & twirling about the clinic-

touching stethoscopes to chests,

pressing pills into palms.

Our counseling is a chorus

which struggles to keep to the beat.

Exhausted, we wave goodbye

to children chasing our trucks downhill.

The learned doctor and I sit side-by-side,

bumps drum our backs through the truck-bed,

& we philosophize over arroz, aterosclerosis, y envejecimiento.

Overhead, coffee beans hide like so many secrets in deep green shadows.

Ethan Sellers, PGY-III

KP Napa-Solano Family & Community Medicine