Who's Benefitting?

A few weeks ago we were given the amazing opportunity to go to Nicaragua and help set up a clinic to treat people with otherwise very limited access to medical care. We worked in groups of 2 or 3 students with a translator to record patient history and take vital signs. We then presented our findings to the doctors who determined the diagnosis and prescribed medicines. During only a few short days I learned more about common medical issues in the area and about how to take blood pressure and pulse or examine a patient than I ever expected to. This was, by far, the most hands-on experience I've ever had with medicine. It was exhilarating, challenging, and fun. And yet, I'm not sure I'm totally comfortable with it. We are not trained physicians or nurses or even medical students. Most of us had never taken blood pressure before or been taught patient privacy protocols. We had one day of orientation to learn all the things we were expected to do and then we were released into the clinic. We were supervised in the sense that there were doctors present, and the patients were informed that we were only volunteers before we began any exam, but I'm not sure if these measures were sufficient.

The patients were grateful to have the opportunity to go to a clinic, and we were grateful to have the opportunity to view the work of a doctor first-hand. Some could argue it's a win-win situation, but is that what we want? When it comes to treating sick people, is it okay for everyone to benefit a little or should nothing less than patients solely benefitting be acceptable? In the United States there are strict rules about patient privacy and what students can and cannot do, and these rules exist for a good reason—we are untrained.

The patients were treated while we learned. They were given medicine while we were given the opportunity to play doctor for a week. I can only hope that the patients feel that they got something out of this experience, because I know my classmates and I did. If this program is designed to benefit the community and truly needs volunteers to help, then I can only support it. But how much did we really help and how much were we in the way? Were we important or did they just need the money we paid for the trip to support the clinic and allow the doctors to do their jobs? At the end of the day this experience left me with a lot of questions. I loved my experience and I am grateful to have been given such a unique opportunity. But I have to ask: who do these clinics really benefit?

Rachel Krcmar

Doctors in Training

One of my favorite experiences in OTS Program was working for the Vida organization in Nicaragua. Two weeks ago, we all arrived in Nicaragua to volunteer with Vida, a non-profit organization that provides free basic medical service to impoverished, rural communities. Looking back on it, I realize I had no idea what I was getting into. In the past I have volunteered at hospitals before; however, I have never been able to have as hands-on of an experience as I had working for Vida. As volunteers we did not only observe, but rather took medical histories, interviewed patients, took vital signs, and provided basic health education to patients. I also, did not realize the large impact that can be made with so few resources. With only two doctors, five interpreters, and us, the volunteers, we were able to see over 150 patients during the four clinic days.

The first day of work I was anxious, wondering if I would be able to take the blood pressure correctly and ask the right questions. I was also wondering how a group of young, American students would be perceived. But then the patients began coming in, opening up about their health concerns and histories, and I realized my nerves had disappeared as I spoke openly and frankly with the people about their health. I was able to learn about how Nicaraguan life and culture may impact health and common diseases and ailments in Nicaragua.

Overall the community was extremely accepting and grateful for the work Vida was doing. As I continued working throughout the week, I discovered my passion for directly interacting with patients and working on the frontlines within a community, and the experience confirmed my desire to pursue medicine as a career. By the end of the week, I understood we were affecting not only the individual patients, but influencing an entire community through the spread of knowledge and hope.

Symone Stephens

Experiencing Nicaraguan Culture

We not only had the opportunity to explore Costa Rica, but we also spent a week in Nicaragua. Although it was for a short time, I felt as if I was able to gain a small perspective of the Nicaraguan culture. First, let’s talk about the people! The communities set up are like none I had ever seen before. The houses were half inside and half outside, the doors were always open, everyone knew everyone on the street, the elderly would sit in their rocking chairs outside and watch the adolescents, and there was always some activity going on outside the houses. It felt so authentic and as if it came out a movie back in the 50’s. In the United States, and even in Costa Rica, barrios like this are not common to find. I really felt as if the community was one big family, and they were just as welcoming to us as well. The families were very accommodating and really cared for us for the little time we spent with them. For example, when I felt sick one night, my host family went out of their way to make sure I had everything I needed, and they even called the coordinator to make sure there was not anything else they could do. This type of kindness is deeply embedded in their culture.

I also discovered another part of their culture; the food. Working in the clinics with the rural community gave me true insight to the Nicaraguan food. The majority of health problems that existed stemmed from the traditional food. For example, most everything eaten is fried, contains enormous amounts of salt, and the consumption of fruits and vegetables is scarce. Mix this combination together and you end up with a population that has a high rate of obesity, hypertension, and gastrointestinal issues. Therefore, as no surprise, the majority of our patients had one or multiple of these conditions. While this food may be traditional, it is a public health issue that needs to be addressed in these communities.

Finally, we experienced a little of the musical culture with salsa and merengue classes. After a one hour class, we mastered (more or less) the steps and felt like professionals (or so we thought)! However, after watching some children dance folklore correctly a couple nights after, we quickly realized we had a ways to go. It was beautiful to watch the children dance these traditional songs in the traditional clothing. The bright colors and elegant movements made for an enjoyable night.

I loved experiencing the Nicaragua culture for a week, and I hope to have the opportunity to explore more in the future.

Morgan Drew

The Pressure was on!

These past three weeks have been full of memorable experiences. First, we visited Nicaragua for a week to volunteer with VIDA, who provide free clinics for people in poor underserved communities. Then we visited Palo Verde National Park and went back to Costa Rican Language Academy (CRLA) to finish out our last week of intensive Spanish classes in San Jose. After 3 weeks at CRLA I learned what four years of Spanish in the US could not teach me, how to communicate.

Our first day with VIDA we learned about the Nicaraguan cultures and norms in the morning, and then we learned how to take vitals and make diagnoses based on the symptoms patients may present in the afternoon. I knew how to take temperature, heart rate, and etc., but I had a little trouble taking blood pressure. After practicing the day before, it was time for me to put everything I learned to the test. We drove into these rural communities, where we had our clinic in classroom like settings with only chairs.

When it was time to see our first patient I was so nervous because I was the first one on vitals in my groups and I didn’t want to screw it up. My group members proceeded with the medical history of the patient, asking her what brought her here to the clinic that day and what symptoms she presented. Of course the patient’s reason for coming to the clinic was because she was having problems with her blood pressure. The pressure was on, because I knew it really important for me to get an accurate measurement because the doctor was going to double check her pressure since that was the problem she presented. I measure her blood pressure first and got 130/100. When the doctor measured it she got 130/ 90. At I was nervous because one of my numbers was off by 10, but the doctor informed me that my measurement was good because sometime the blood pressure changes 10 units or so when it’s taken at different times. I was really proud of myself and my group was proud of me as well. Practice paid off because by the end of the clinic I became really good at taking vitals.

I learned so much from this experience. At first I didn’t see how we were really helping these people by only giving them medication. However, in the bigger scheme of things we cared and we did our best with the resources we had to help the people and the people were so grateful. It was such a great honor to be able to help others in needs. This experience reassured me of how much I want a career in the medicine and/or global health field. This experience showed me that a small group of caring people can make huge difference in the lives of people in need.

Le'Shauna Y. Phinazee

Sugarcane Contemplation

What is it like to start work at 5a.m., to endure the heat of the tropical sun, to rest and drink water only at midday, and to end each day having earned only about eight dollars? Most of us will never know, but for sugarcane workers this experience is all too familiar. When our group went to visit a sugarcane field near Palo Verde Biological Station we saw these men, steadily swinging machetes, their arms covered in the black soot left by the burning of the last crop’s residue. As I watched them work I thought of what we had learned about Mesoamerican Nephropathy, an epidemic of cases of chronic kidney disease (CKD) occurring in the Mesoamerican region. This CKDu (the “u” denoting the unknown cause of the disease) has a high mortality rate and mostly affects male manual workers, especially those that work in sugarcane fields (Torres et al. 2010, Peraza et al. 2012).

Our guide, a man who had once worked in sugarcane fields, told us these men avoided resting and drinking to appear more manly and that they did this taxing physical labor every single day from December to April. Rather than being paid by the hour, as is the case for other sugarcane workers, the workers in this field were paid by the amount of cane they could cut. This, along with the previously mentioned attitudes toward resting, deters workers from giving their bodies the breaks they need to remain healthy. We had learned this two days before in class where our professor had said that the US Occupational Safety and Health Administration recommends 45 minutes of rest for every 15 minutes of labor in these conditions. It was clear that these men did not and could not afford to follow these recommendations. They mainly come from other provinces and Nicaragua because they need the work in order to support their families. Yet, for the little they earn there is a great cost to their health.

While standing in the oppressive heat for only about thirty minutes I wondered how these men went through this physical strain every day. I thought of their risk of Mesoamerican Nephropathy and for the briefest of moments I wished machines could take over their hard labor. I shook off the idea, knowing that putting these people out of the only work they could find was no solution at all. I thought about how their situation needs the service of local public health organizations, worker rights organizations and researchers. Local public health organizations could campaign to help with the stigmas around rest and re-hydration. Workers rights organizations could work to demand fair hourly pay so that breaks are not taken at the expense of wages. Researchers may further investigate hypotheses regarding the cause of the disease, including possible factors such as pesticide usage, heat stress and chronic dehydration, the use of non-steroidal anti-inflammatory drugs and arsenic (Landau 2014).

I realized I find this research inspiring and that I may like to work with agricultural workers in the future, either in public health or public health research. Before this experience I found it difficult to imagine working conditions such as this or a mysterious illness so specific to certain populations. Now, I find myself imagining the ways we might begin to help.

Literature Cited

Landau, E. 2014. Mysterious kidney disease plagues Central America. CNN.
http://edition.cnn.com/2014/06/11/health/kidney-disease-ckdu/

Peraza, S., Wesseling, C., Aragón, A., Leiva, R., García-Trabanino, R.A., Torres, C., Jakobsson, K., Elinder, C.G., Hogstedt, C. 2012. Decreased kidney function among agricultural workers in El Salvador. American Journal of Kidney Diseases 59(4): 531-540

Torres, C., Aragón, A., González, M., López, I., Jakobsson, K., Elinder, C.G., Lundberg, I., Wesseling, C. 2010. Decreased kidney function of unknown cause in Nicaragua: a community based survey. American Journal of Kidney Diseases 55(3): 485-496

Erica Rayack

Mosquito Misfits

Palo Verde, located near the Cañas region of Costa Rica, was our third most awaited biological station visit. Out of all the stations we visited, it had the most different climate and forest. Located in the Palo Verde National Park, Palo Verde has a dry and humid temperate forest within its wetlands. The station prizes its gracious chef, mango trees, and the bountiful monkeys and iguanas roaming casually around the station. Arriving with our only male professors, drivers, and teaching assistant, our group of 13 girls were suddenly faced with an intense dry heat, and of course…mosquitoes.

Unlike the more humid and pleasant climates of Costa Rica, Palo Verde was the hottest place we had ever been to within our 4-month trip. Despite it being the dry season, Palo Verde frequently experiences the rise and fall of the river, and subsequently, also the wetlands. We learned that when the water rises, it brings with it the mosquitoes. For about 4 of the 7 days we were in the station, the water had risen in the wetlands and in came the beasts. I had never seen this quantity of mosquitoes in my life, even in India, where they are most hated! I was mostly surprised that there could be this amount even in the dry season. Of course each night we had to tuck ourselves into our mosquito nets, and we even had to rush our toilet time because the bathrooms were just swarming with mosquitoes. My classmates even brought mosquito nets to class. By the end of each lecture, there was always a shocking mosquito graveyard. By the end of our week at Palo Verde, our bodies were covered with swollen mosquito bites!

As much as I complained about the mosquitos, I began to understand how they truly contributed to the biodiversity of the wetland environment. Without them, there would be no frogs, iguanas, or monkeys that could eat them. No frogs or iguanas, leads to the absence of birds. The entire ecosystem falls apart without these blood-sucking misfits! We, as humans, have truly impacted the environment with our presence and infrastructure. Mosquitoes were constantly attracted to light, and they knew exactly where to find us. With this human impact, there is no way we can stop these mosquitoes. I asked one of the Palo Verde rangers about the quantity of mosquitoes during the wet season; he mentioned that we only experienced 2% of what he usually encounters. I couldn’t believe how nonchalant the workers at the park seemed, and how they just accepted their bites. They knew how important mosquitos were to the dry forest biosphere, and there was nothing they could do about. I admire there attitude and their research at the station.

I know now that when I see the next mosquito, I will think twice about killing it!

Meghna Purkayastha

Mí VIDA en Nicaragua

The week we spent in Nicaragua has definitely been one of the highlights of this trip so far. Working with Vida, an organization devoted to bringing health clinics to rural communities in Honduras, Costa Rica, and Nicaragua, was such a rewarding and enriching experience. Throughout our stay in Nicaragua we were all placed in homestays. My host mo was named Jeanine and she as the sweetest, happiest, and hospitable lady—the epitome of Nicaraguan culture.

Three of our days in Nicaragua were spent doing clinics in rural communities. During these clinics we were split into groups of two or three people with one translator. All members of the group would each take turns being responsible for filling out the patient’s medical history chart, asking appropriate questions about the reason for the patient’s visit, and then taking vital signs. Once all three task were completed, one of the two doctors leading the clinics was then called over so that we could present the patients’ medical history and current symptoms. After presenting each case, the doctors would always give us the opportunity to diagnose the patient. Whether our diagnosis were correct or not, the doctors were always extremely encouraging and more than willing to spend time explaining and teaching us things that we did not know.

I loved how hands-on this experience at the clinics was and how much it challenged me to really critically asses each patient symptoms and try to come up with a diagnosis for each patient based on my previous knowledge and experiences. I really loved seeing the way that the doctors interacted with each patients, they were very patient, endearing and so compassionate. I learned a lot from the way they deduced what the patient had, how they prescribed medication, and how to create treatment plans form the patients to follow. Because it was so evident how passionate the doctors were about their jobs and also about teaching us what they knew, I was newly affirmed that I am definitely in the right field and have been motivated to continue pursuing my career of being a Physician Assistant with more drive than ever before.

Karina Handal

Medical Clinic in Nicaragua

Two weeks ago while in Nicaragua we participated in a volunteer based medical clinic run by the Vida organization. The day before we were to start working, we had an orientation day in which we learned how to take vital signs and reviewed diseases and illnesses we would most likely see. The first day of the clinic was in a very small, rural town by the name of Papayal. Our clinic environment was a small community room. We set up five circles of plastic chairs, each circle included two or three of us: one person to scribe, another to interview, and another to take vital signs. Each circle also had a translator who translated anything we said in English into Spanish for the patient and vice versa. Each circle would work with one patient or family at a time and two doctors rotated through our groups to make the final diagnosis and subscribe any needed medications for patients as well as educate them about their illness or disease. We appreciated the doctors because before making a prognosis they would as us what we thought and why. This was a great learning experience for us.

It was very obvious that Papayal was a very poor neighborhood. Many of the mothers with small children were still in their teens. The first case my group saw was an 18 year old mother with two toddlers. After doing the extensive medical history questionnaire we asked her why she came to the clinic and she told us she just wanted some vitamins for her and her children. Many of the children were prescribed vitamins. In another case, a mother brought in her 12 year old daughter and 4 year old son. Both children had had recurring diarrhea and lack of appetite. The doctor concurred that they both were infected with Giardia, a parasite. In these communites most children take a de-worming medicine every six months. The clinics were very successful and we were able to treat all persons who came seeking medical attention. It was an extremely rewarding experience and because of it I absolutely plan on volunteering in a medical environment in the future.

This experience has been one of my favorites so far this semester. It solidified my desire to become a doctor. It was a great feeling to be part of a team of individuals providing healthcare to people that otherwise wouldn't have it. In addition, I felt very appreciated for my efforts and enjoyed being able to talk to patients about day to day life while we were waiting for the doctor. I hope for another experience like this soon in life. `

Hailey Alexander

Nuestro Tiempo en Nicaragua

Our time in Nicaragua was one of the most enriching and exciting of our experiences on our semester long OTS program. Not only were we able to have hands-on experience in the clinic setting, we were also able to live and experience for ourselves what life in the country was like with our host families. I had some of the most fun and most difficult moments of my semester while there in Nicaragua and it deepened my passion for studying medicine.

When we first entered the country, I was shocked at the drastic differences there are between Nicaragua and Costa Rica. The dryness of the land, evident poverty in the cities, and intense heat all signified we were no longer in the country we had become so accustomed to for the past three months. However, there was still beauty beneath the dust and dirt in the form of beautifully colored homes and an expressive, outgoing people. We were able to experience the amiableness of the people first hand in our homestays. My host mom was a kind, generous woman who loved us like her own daughters. In her home I discovered such a beautiful simplicity of living that transcended unnecessary comforts like hot water and air conditioning. As silly as it sounds, the lack of these things was at first a distraction for me, but once that wore away, I grew to appreciate so much more the love and warmness of the home.

I have traveled to both Mexico and Bolivia for medical missions trips and have helped run free medical clinics many times before. However, in none of these experiences was I able to do as much as I was with Vida Volunteers in Nicaragua. Not only were we able to interview patients ourselves and learn what things to look for, but we were able to make our own proposed diagnosis, and the doctors respected and critiqued our estimations. It made me feel so useful and valued as a student. Although I am not yet a professional, the knowledge I have been taught can still be useful in helping another in need. One of the biggest things I learned through the interviews were how closely linked nutrition is to health. I also had a first hand “taste” of this in my homestay and was able to see the amount of sugars and fats that fill many Nicaraguan diets. Seeing this first hand link between poverty, nutrition and overall health gave me so many new ideas for my future in Medicine.

Overall, my time in Nicaragua not only taught me more about myself and health in a poorer country, but it has driven my passion for pursuing medicine and nutrition with a focus on helping those most in need.

Stephanie Hynes

Gringas in the Central Market

Before resuming our Spanish classes at CRLA in San Jose, we spent a full day learning about global nutrition. It was a very interesting topic, although very sad to think about. There is a large percentage of the world’s population that has to live on less than $2 per day, so even if they have food available to them, they cannot afford it. It was very humbling to think about, and I realized how blessed I am.

But we didn’t just learn about this problem. We got some hands on experience, which was a really fun experience. We split in to four groups and were given one thousand colones (less than $2) to spend in the central market. Then we were told to go and try to buy food for one person for a day. My first thought was that there was no way that was even remotely possible. But I was a good sport and followed my group in to the central market. The first stop was eggs. We got four eggs for 400 colones, which left us with about a dollar left for the rest of our food. We then proceeded to the fruit stand, where we bought a carrot and some potatoes. After this purchase we were left with 120 colones, which is about $0.25.

Finally, we decided to buy cheese with what little we had left to spend. But as we were asking the cheese sellers to cut 120 colones worth of cheese, a lady passed by us and overheard our conversation. When she heard that we only had 120 colones to spend, she turned around with the most concerned face I have ever seen. She thought that was all we had for lunch between the three of us and then started to offer to buy us something to eat. Her concern was so adorable and kind! We had to try and explain in our broken Spanish that it was only for a project and that we actually did have money. She laughed about it, but I think she thought we were a little weird for trying to buy such a small amount of cheese. And the vendors definitely did. But we finally got our cheese and met up with the rest of the group.

I thought that we wouldn’t be anywhere near the 1500 calorie recommendation (which we weren’t), but we weren’t as far off as I thought we would be. We came in around 1000 calories, which I thought was pretty impressive for being so terrible at bartering. But it was an eye opening experience to try and buy food for so little. I am so blessed in my life in the States, and I now see that even more clearly.

Emily Leytham

Diseases Left Behind

Equity in healthcare is a key part of the global health agenda, one that we have approached over and over this semester. Despite great strides in battling disease epidemics, reducing infant mortality and increasing life expectancy, the health needs of certain marginalized groups remain unaddressed. The Tropical zone, including Central America, bears the enormous burden of a class of diseases know as Neglected Tropical Diseases. These diseases are often vector-borne and associated with poverty, lack of clean water, sanitation and/or basic preventative care. So-called “developed” nations have the technology and resources to combat NTDS, but may be blind to the burden of NTDs on the productivity and wellbeing of afflicted nations.

During our time in the agricultural zone surrounding Palo Verde, I learned about Mesoamerican Nephropathy, a neglected Tropical health issue, for the very first time. Thousands of people in Mexico and Central America with no other cause of chronic kidney disease are suffering or dying due to kidney function complications, and doctors don’t know why. I was shocked that I had never heard of this critical health and social justice issue. Chronic Kidney Disease of Unknown Causes (CKDu) primarily affects young male agricultural workers in the lowland pacific side of Mesoamerica. No cause has been identified yet, although chronic dehydration, manual labor under the sun and heavy metal or toxin exposure have been suggested as possible risk factors.

Little funding or research attention has been devoted to solving the puzzle of CKDu, and the incidence and mortality rates keep rising. The Area de Salud that we visited in Guanacaste has organized an investigative committee to find answers and decrease the incidence of CKDu in the community. However, without the attention and resources of major research organizations and drug companies, progress in the fight against CKDu will likely be slow going. Meanwhile, each year more otherwise healthy Costa Ricans will end up hospitalized, hoping for a new kidney and undergoing daily dialysis as their body mysteriously fails them. Many of the afflicted agricultural workers in Costa Rica are migrant workers, who likely have no one to advocate for their unique needs and challenges.

Women, minorities, the disabled, indigenous groups, and those in poverty all face extra challenges when it comes to health care access and attention. Developed world chronic diseases, including cancers and COPD, are the main concern of more privileged populations and thus are the focus of cutting edge medical innovation and discovery. Less research resources are directed toward Neglected Tropical Diseases and conditions specific to marginalized groups. We need to start prioritizing the health of the voiceless, and turn our attention toward sadly overlooked epidemics.

Abigail Mahoney

The Choice

During our time in San Jose this past week we had the opportunity to go to the Central Market as a group. Earlier in the day we had a brief lesson on nutrition where we learned how the history of Costa Rica impacts the common diet of residents of the country. For example, how a typical breakfast of Gallo Pinto or lunch of Casado each have up to a thousand calories in order to historically feed agriculture workers who would use a lot of energy in their daily work. Today the average person in Costa Rica needs only about 1500 calories based on the amount of work they do a day. We also learned how individuals living in poverty live on 2$ a day for all expenses. In order to really see in action how difficult it is for people in poverty to live on this low income and eat well and sufficiently we went to the Central Market.

Once there we broke into groups and with only 1000 colones (2$) we set off to buy as much nutritious food as possible for the most calories and the most food groups. In my group we ran through the colorful and crowded marketplace to find produce. We bounced through colorful and loud stalls where vendors called out their wares of fresh fish, flowers, and tourist crafts. Finally stumbling upon a vegetable stand, we bartered with the salesman about the price of two carrots and a banana. A little disgruntled about our excellent bargaining strategy he told us “Not everyone bargains here, you’re lucky you got me”.

We walked along to find our next food group and found a stall selling cheese. I asked the man to cut me as small a piece as possible. He told me it would be 350 colones. I showed him 200 colones, take it or leave it. We left with the cheese. At our next stall it was Abigail’s turn to do the bartering. She handed him 150 colones and in return was handed a sizable bag of lentils for our grain and protein food group. Left with 500 colones, we decided to get an avocado and sweet potato at the same lentil booth. I felt pretty confident with our purchases and tried to not feel regretful as we found our classmates who were armed with eggs and shrimp.

Back at OTS base we presented each of our purchases. We were told that our entire budget had only bought 1400 calories of food. This was the most calories of any other group, but was still not enough! It was discouraging to see how hard it is to find enough food for an individual, much less a family, but it gave us all a good opportunity to see how food security actually works in the real world. Overall, our excursion to the Central Market was my favorite program activity in San Jose.

Marcela Zegarra-Ballon