Reports from Nicaragua

Week three in Managua! Much more activity to report – Lindsay and I spent Friday night in Grenada with the translators from our Mulukuku adventure, and we ended up at a restaurant with FSLN ballads from the Sandinista-Contra war performed live. Good rousing stuff. We also got to visit 6,000 year old footprints in Managua and the oldest cathedral in Central America in Léon, across the way from a Sandinista war museum staffed by former rebel soldiers. It was incredible to see the museum’s images of Léon, a center of Sandinista activity, with shelled out buildings, tanks, and makeshift barricades little more than twenty years ago. Especially given the current situation in Honduras, it was sobering to imagine streets Lindsay and I were walking on patrolled by la Guardia National, or to picture buildings we passed manned by snipers not that long ago. Realizing how recently Nicaragua emerged from a devastating civil war puts the country’s poverty and development in a very specific light, and emphasizes again the crucial role of political alliances. The reason the women’s cooperative in Mulukuku has been able to scale down their clinic work, for example, is because they are staunchly Sandinista and the current government, led by president Daniel Ortega, is too. The communities near Mulukuku are benefiting from the political affiliation of the women’s cooperative – because the women support the government, the government has brought health care services, limited but desperately needed, to the area. It will be interesting to see what happens in Mulukuku if the FSLN doesn’t retain power in the next election. Given the drastic changes associated with each transition of political power in Nicaragua, ASODENIC’s Christian emphasis and lack of political affiliation seems to be a sound policy.

Back to work: Monday morning saw us off to Tipitapa, a reasonably large pueblo 30-40 minutes outside of Managua. From the ASODENIC agency in Tipitapa, we traveled another 40 minutes or so down unpaved roads to San Roque, a rural community with two bancos de confianza (groups of women in the same microfinance pool). Our first stop was at a cooperative of sorts – one woman in the banco de confianza has turned her home into a panaderia, and the other women in the group come over and make tortillas, sweet bread, rolls, cheese, and cream to sell in Managua daily. It was an impressive example of of the micro-enterprise facilitated by ASODENIC.

We presented a capatación on Breast Cancer screening and detection to the women, and to say I was taken aback by the reception is a gigantic understatement. Our lesson covered what cancer is, how it progresses, how it manifests in the breasts, risk factors for developing it, how to do a self-exam for breast cancer, and the importance of mammograms. Though the women seemed to be familiar with the self-exam and mammograms, the Q&A session shocked me. One woman yesterday told us that she had lumps in her left breast that hurt to touch, and wanted to know if she should see a doctor. Another women said she had dark secretions from her nipple and general pain in her breasts, and that her doctor told her that nothing was wrong. Hearing their questions and stories made me mad at the world, honestly. It feels so obvious to me that dark secretions or localized breast pain would be a cause to visit the doctor immediately, but I grew up with American health care and personal experiences with breast cancer. Also, for the women that do go to the doctor, there’s a chance that the medical professional could decree that dark secretions are nothing to worry about. It was hard for me to tell these women that sometimes a second opinion is a good idea, because doctors are such a trusted profession, yet at the same time, these women’s lives are at stake. One of the ASODENIC health promoters said that most women in the area go to a free health clinic first, rather than the clinic ASODENIC contracts with, and that the quality of care is just not up to snuff. Economically, it makes sense: why pay, even at a deeply discounted rate, when you can receive care for free? In terms of justice, however, it’s not right. The lack of education and awareness re: breast cancer detection is a huge factor, of course, but it makes me want to holler (Marvin Gaye reference) that even a little money – it cost me $4.50 to see the doctor for my tonsilitis – is such a huge barrier to quality care. It’s far easier to educate and inform women than it is to readjust the national infrastructure for health care delivery…and promoting factually accurate, culturally acceptable health information is no small feat. I’ve been simmering since yesterday morning.

After we finished our breast cancer presentation, an ASODENIC health promoter asked if there were other subjects the women might like to see covered. They responded with menopause and cervical cancer. As it turns out, Lindsay and I have a capatación on cervical cancer, so we presented an abbreviated version of the information, emphasizing the importance of yearly pap exams. Again, the women were familiar with the material conceptually, but had little personal experience with cervical cancer screening. One woman explained that although she had a cousin and a mother die from cervical cancer, she had never had a pap exam because she was embarrassed. It made me sad and angry to hear  stories like that. One the one hand, it’s really great that Lindsay and I can share this information on a personal level with the women who so dearly need it, but on the other hand, we’re only here for six weeks and at most, 200 women will hear these lessons. The women we are able to speak with and connect with are wonderful – animated, appreciative, and supportive even though we’re young and norteamericana, for the most part. But what about the thousands upon thousands of Nicaraguan women that ASODENIC doesn’t meet face-to-face? And what happens when we return to Texas – there’s not a sustainable health promotion system in place through the government, and ASODENIC is still searching for a full-time health promoter. It’s frustrating to feel like our capataciones are a one-and-done deal. Beyond Traditional Borders very much emphasizes sustainable interventions and innovations in global health, and I wish Lindsay and I were able to do more.

Putting our role this summer in a  more positive light, Lindsay and I do have the privilege of implementing ASODENIC’s health education materials for the first time, and we have the opportunity to make suggestions or modifications based on our experiences on the ground. We also have ambitions to create  outlines for other capataciones not covered yet by ASODENIC – nutrition came up as an idea yesterday. And, if nothing else, we will have spent 8 weeks in a country very different from the USA, one not many Americans travel to with great frequency, and will have gained a perspective on Central American health care service and delivery that not many of our peers can claim.

Finally, on a lighter note, I have acquired a Nicaraguan alias. For as many people that call me Katy, at least as many if not more refer to me as ‘La Chela’. Nicknames are a salient aspect of Latin American culture, and it is not uncommon to meet someone and have them introduced by two different names – their given name and their apodo. ‘Chela’ is a generic name for someone with light coloring, often used interchangeably with gringa or norteamericano or yanqui. One would think that Lindsay and I, both as white Americans, would each be a ‘chela’, but that’s not the case at all. The translators at Mulukuku, all the children at the clinics with the UTMB medical delegation, women in ASODENIC bancos de confianza, our taxi driver, and a random pair of old men on a street corner while Lindsay and I were in a cab refer to me as ‘Chela’ at first sight. I feel like I must be wearing a nametag for so many different people to bestow me the same name individually, and with such frequency. Sometimes it’s even accompanied by pointing. The only hypothesis Lindsay and I can come up with is that because I have lighter hair than she does, I am more Chela than she. Regardless, it’s entertaining to have a Nicaraguan nickname and I’m actively trying to work out a way to bring it back state-side.

In the interlude between this post and the next update on the adventures of Lindsay and la Chela in Nicaragua, feel free to check out our facebook pics on each of our profiles. There are some great photos that can illustrate what we’re up to much better than blog text. Hasta luego!

Things are going a bit better in Managua than they were last week. We now have a good idea of what we’ll be doing the rest of the time with ASODENIC, and neither of us is sick! Katy and I have spent most of last week and this week preparing the preventive health capataciones (trainings/lessons) for ASODENIC’s clients. Our primary job will be to present these capataciones to the various bancos de confianza and grupos solidarios both in Managua and further out.

ASODENIC is a microfinance organization helping the poorest people of Managua and other surrounding pueblos. This organization strongly emphasizes Christian values and the idea of client transformation—socially, economically, and spiritually. Clients, or poor Nicaraguans (mainly women) who have a small business, create bancos de confianza of 25-30 people who live in the same geographic area. ASODENIC provides loans to the clients, who are then expected to pay back this loan according to a pre-set schedule. The bancos de confianza meet once a week with representatives of ASODENIC, and a capatación (lesson) is usually provided byASODENIC for the women. Topics can vary from business management to Bible study, but ASODENIC has recently decided to emphasize preventive health issues.

ASODENIC had lessons already made for cervical cancer, breast cancer, acute respiratory diseases, and acute diarrheal diseases when we arrived. A group of BIOE 260 students from Rice had rewritten several of these lessons to better cover these subjects, but ASODENIC has been hesitant to listen to these suggestions because many of the lessons are in English and do not follow exactly the format of their capataciones. Katy and I are doing our best to translate and rewrite the BIOE 260 lessons because we believe that these lessons will help to improve the ones that ASODENIC currently has.

Katy and I were able to lead our first capatación this past Tuesday at the Ciudad Jardín sucursal (branch), which is a short walk down the street. We presented our lesson on cervical cancer to 4 grupos solidarios, which consisted of 14 women and 1 man who were from areas around Ciudad Jardín. While the clients started out quiet and unwilling to talk, they were laughing and having fun and engaging in the topic by midway through. It was great to start our capatación career with an energetic group of people from the middle of Managua, because as we learned from our capatación in a more rural area today, the women in rural areas are much more timid and less willing to volunteer responses. While we did not crash and burn today, there was significantly less interaction. The women appeared to be interested and enjoying themselves; they just didn’t want to talk!

Katy and I will spend the rest of today and parts of next week rewriting the capatación on diarrheal diseases. Next week will largely be a traveling week, and we will be giving 2-4 capataciones per day on cervical cancer and breast cancer. This weekend, we’re planning to stay in Managua on Saturday to continue our exploration of the city and then travel to León on Sunday to enjoy a tourist town and to see another city in Nicaragua.

After my first week in Managua, I’ve given myself lots of room for improvement. I had tonsilitis, a fever, infected ant bites,  a rash from my antibiotic, and as part of my recovery from tonsilitis I had to eschew air conditioning for 48 hours because the particles were irritating my throat. Suffice it to say I am very glad to have that all behind me now. It was about 90 in my bedroom for a couple nights there, and I was pretty cranky and unpleasant as a result.

I will refer interested parties to Lindsay’s post on our time in Mulukuku, but I will say that I very much enjoyed the change of pace for a fortnight. We traveled 8 hours from Managua (the last two of those were on unpaved roads) to the Maria Luisa Ortiz Women’s Cooperative where we joined a team of 31 doctors and medical students, occupational therapists and students, dentists and dental students, and other volunteers from the University of Texas Medical Branch. For 9 days, we hopped in a cattle truck every morning and drove an hour to deliver healthcare to rural populations in makeshift clinics. We saw over 1800 patients in less than two weeks!

The OB/GYN backpack, my senior design project that we brought to Mulukuku, was delivered without a hitch as well. I didn’t get to present it to the women of the clinic until the morning we left, but the portable stirrup attachment was used every day at one of the clinic sites to rave reviews. The Cooperative envisions using the OB/GYN backpack with teams of health promotors traveling to remote villages, and I asked the director to please let me know if there’s a training session while I’m still in Nicaragua.  I would love the chance to return to Mulukuku and help facilitate an instruction lesson for the backpack. We’ll see what happens.

Though we’re still learning about Managua, it was exciting to return to air conditioning and running water. Lindsay and I will be volunteering with ASODENIC, a microfinance organization headquartered here in Managua for the next 5 weeks. Thus far, it looks like our role will be to travel to different women’s groups and their weekly meetings to introduce health-related topics for discussion. We’ve been practicing presenting Cervical Cancer and Breast Cancer information sessions (in Spanish!) this week, and eventually I think we are to be responsible for Diarrheal Diseases and Respiratory Illnesses as well. More updates to come as we get a better comprehension of the rest of our summer….

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.

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