Katy and I are back safe and sound in Managua after Round 2 of our internship: two and a half weeks in a rural region of Nicaragua called Mulukuku. This was a drastically different experience from our time in Antigua for a number of reasons. Most notable was the change in our environment: we went from one of the most affluent cities in one of the most successful countries in Central America to a very rural and underdeveloped region of the second poorest country in the Western hemisphere. Fortunately, we had a much broader team with which to share this experience. While we worked with two wonderful organizations in Antigua which consisted of small groups of very dedicated people, we had the opportunity to work with a huge team of UTMB medical students, doctors, occupational therapists, and dentists in Mulukuku.
Our team lived at the Maria Luisa Ortiz Women’s Cooperative, which was founded by an American woman, Dorothy Granada, who is very dedicated to human rights and women’s rights (http://www.mulukuku.org/). This cooperative had been providing the only health care to the Mulukuku region until recently. Because of recent political changes in Nicaragua, the activities of the Ministry of Health (MINSA) have been drastically altered. While there used to be no MINSA doctors in Mulukuku, there are now 14. The original purpose of UTMB’s trip to Mulukuku, which began in the mid 1990s, was to work with the cooperative to provide health care to the people of Mulukuku. That plan had to be altered this year, as there was not as strong a need for health care in Mulukuku. Instead, we travelled 70 minutes every day to the pueblos of Santa Rita and La Bodega for two weeks. Some of my favorite memories are from riding in the back of our “cow truck” on loose wooden benches and unpaved roads, covered by a rain tarp and unable to see anything around us.
Katy and I went into Mulukuku intending to implement Katy’s OB/GYN Lab in a Backpack and incorporate it into the work of the cooperative, to disseminate instructions for the neonatal hot cots, and to help the UTMB team in any way we could on a daily basis. Most of our time was spent at the clinics in Santa Rita and La Bodega. Katy created a position for herself at La Bodega as the “gatekeeper”: we had noticed very early on the first day that stray dogs, chickens, children, and patients tended to wander in and out of exam rooms at will, and that the doctors were having trouble communicating which patients needed to go where. Katy organized all the patients and their files and kept operations running smoothly. I spent most of my time at Santa Rita helping in the pharmacy—we were a bit short-staffed in that area, and it was the place where I could make the greatest impact. I greatly enjoyed learning about all the drugs, the difficulties in acquiring medications, how to improvise a back-up plan when the correct medications aren’t available, and interacting with the patients in order to relay administration instructions. I had a number of flashbacks to my BTB internship in Botswana, where I was working to implement pediatric HIV/AIDS dosing guides. Most times it is crucial that a medication be taken correctly in order for it to be effective, but not much time is spent making sure that these patients understand what they’re being given. A huge number of antibiotics were prescribed, but I often questioned the sagacity of this course of action; several patients were unable to repeat back to me their administration instructions, while others simply had too many medications to keep straight.
Katy and I were happy to find that the neonatal hot cot given to the Cooperative last year is functional and being used on a weekly or biweekly basis. The midwives and nurses have been using it correctly and have not had any problems with it. I was disappointed to find that there was little potential for the incubator in the rest of the region. We heard from several women on the staff and in the town that the Cooperative was one of the few birthing centers in the region. There was one 2.5 hours away in Rio Blanco, but most women just had their children in their homes. Many of these women have 7 or 8 children and do not feel that it’s necessary to receive medical attention beyond a midwife or family members. Katy and I set up a meeting with MINSA doctors to discuss MINSA’s potential use of our incubators, but they echoed what the women at the clinic told us: there was simply nowhere to use them.
On a happier note, we were glad to find out that the rumors we’d heard about the justa stove being used incorrectly were largely incorrect. Two members of BTB travelled to Mulukuku last summer and built this justa stove in order to decrease the amount of smoke that typically pervades a rural Nicaraguan kitchen. We had heard that the women at the Cooperative were using the stove but removing the plancha, a critical component in keeping the smoke contained. After a brief meeting with several of the staff members who did the cooking, we found that the staff members were using the stove correctly, but that the women who were patients at the Cooperative did not know how to use the stove and were instead removing parts so that they could cook over an open flame. One of the staff members agreed to speak with the patients who were staying there and to teach future patients how to correctly use the stove.
I’m excited to be working in Managua now—it will be interesting to get both urban and rural perspectives of this country.
