Wednesday, March 20, 2013

Day 11: Buen Viaje

When I first left Nicaragua after living there for nearly two months, I felt a degree of relief to be returning to my native culture and loved ones. Before I left for this trip, I expected to feel something similar at its conclusion. I even joked about eating some sort of meat-based American meal when I returned.

But instead of this sense of relief, I found myself not wanting to leave. I had grown re-accustomed to the language, people, and culture in a way that I had not anticipated just 11 days before. I think my host family and their generosity, patience, and spirit was a large part of my becoming attached to the people, so I want to conclude by thanking them and everyone who helped us along the way, including Dr. Olga Valdman, Coordinator of the Global Health Track. Thank you for reading.

Days 9 and 10: CIDS and El Tololar

Upon returning to Leon, we participated in training at the Centro de Investigacion en Demografia y Salud or Center for Investigation of Demography and Health (CIDS), a robust public health enterprise of UNAN. CIDS researchers have visited many homes within Leon and use GIS mapping to create pictures of public health within the city and municipality. We learned how to collect and store points using a GPS, and how to create a map of the points we collected.

After this training, we traveled to El Tololar, a rural community about 45 minutes outside of Leon. Agriculture, especially peanut farming, is the main source of employment in the town, resulting in a very dusty environment. We stopped at the Puesto de Salud to meet Dra. Arrutia, the town doctor. She showed us around the clinic, including their pharmacy and dentist’s office.

From there, we proceeded to our home stays for the evening. While Elliot stayed with his family from last year, the rest of us stayed with Adilze Rivas. We learned of Adilze through Tyler Sinclair, a Peace Corps volunteer who had lived with her during his time in Nicaragua. Adilze is the principal of the town’s school, and was extremely helpful with our work for CIDS.

After I explained the project to her, she took us out walking a couple of kilometers to various homes to ask people a set of health related questions for CIDS’ public health maps. When we returned home, Adilze showed us the fantastic drip irrigation system that Tyler helped her set up through the nonprofit Tololamos. With the system, she and her family grow enough vegetables for them to eat and sell a small portion of.

The next day we returned to the clinic and shadowed Dr. Arrutia during the morning while she saw patients. She was a very enthusiastic teacher who quizzed us about each patient strictly in Spanish.

In the latter half of the morning, we met Adilze at the school for a tour. She showed us the classrooms, library, and computer lab with 20 computers. In a single day of knowing her, Adilze’s caring nature really shone through; not to mention that she made the best arroz con pollo I’ve ever eaten.

In the afternoon, we returned to Leon for more CIDS training on GIS mapping. I created a map of the area in El Tololar near Adilze’s house (see below).

After that, we packed and enjoyed dinner with our host families one last time. By the time I left, I felt like a part of the Villalobos family because they reminded me so much of my own family in Massachusetts. We sadly said our goodbyes, but will look forward to future years of travel in Nicaragua.

That night, Cesar drove us back to Managua for an early morning flight.

Days 7 and 8: Tour of Leon and the Beach

On Saturday morning, Lt. Julio Cesar Pineda led a tour of Leon to teach us about the city and Nicaraguan history. Our tour started in front of a mural depicting Nicaraguan history from the time of indigenous peoples through Augusto Sandino and finally the modern era. Julio spoke briefly about his experiences fighting in the revolution and movingly brought the mural to life.

From there, we proceeded into the Cathedral, a UNESCO World Heritage Site, and possibly the landmark most commonly associated with Leon, a city of 16 churches. The architecture was nothing short of awe-inspiring. After spending time in the Cathedral, we climbed a number of narrow stairways and emerged onto the roof of the great structure. From this vantage point, we could see volcanoes surrounding Leon in each of the four cardinal directions.

We then visited the house of Ruben Dario, Leon and Nicaragua’s most famous poet. We learned about his life and work, as well as his untimely death from cirrhosis. After that, we visited the art museum and saw works by Picasso, Monet, and many Nicaraguan artists.

In the afternoon, we made our way to the beach in Poneloya for some much-needed rest and relaxation after a busy week. After our trip, we met up with Elliot Schaeffer, MD, PGY-3, one the of the UMass Fitchburg Family Medicine residents.

Noah and his host brother, Ivan


HEODRA stands for the “Hospital Escuela Oscar Danilo Rosales Arg├╝ello,” the main teaching hospital associated with UNAN. Our tour of HEODRA was led by Karen, a Nicaraguan intern who had done two rotations in the U.S. at UMass. We saw virtually every floor and unit, including pathology, in the busy, cavernous hospital, and spent most of our time shadowing an orthopedist. We watched as he changed dressings, examined wounds, and took down casts and splints. Conveniently, each patient has their X-rays at their bedside, allowing us to analyze a great deal of imaging in a relatively short time. Later that day, after our final Spanish class, we said good-bye to our Spanish teachers.  

Days 4 and 5: El Sauce

We headed out for El Sauce (pronounced “el sow-say”) early in the morning accompanied by two sixth-year medical students from UNAN named Alma and Cynthia. Along the way, we stopped at a centro de salud (health center) and a puesto de salud (health outpost) to learn about the different scope and scale of clinics in Nicaragua. Centros are often larger and better equipped, with some basic lab testing available as well as the occasional specialist. Puestos are typically more rural with little to no on-site lab testing, and require referrals to other centers for any necessary specialist care.

In El Sauce, we toured the recently constructed secondary hospital and learned about a number of community health programs run out of the hospital. The hospital had 30 inpatient beds, an operating room, emergency department, primary care, maternity care, lab services, and X-ray. A number of programs operated in the hospital, including one for ensuring healthy growth and development of children. Despite the specialized services, the hospital did not perform emergency surgeries or handle high risk OB, both of which patients had to travel 1.5-2 hours to Leon for.

We spent the afternoon in the emergency department, shadowing a pediatrician who also saw adults. The ED was initially relatively quiet, and then became very busy, as patients arrived with chief complaints ranging from syncope to fall from a horse to contractions.

The next morning, we participated in rounding on inpatients, which lasted all of an astonishing 20 minutes--this is something the U.S. health care system could learn from Nicaragua! Rounds involved attending physicians from every service at the hospital, including pediatrics, anesthesia, surgery, medicine, etc., an interesting model for incorporating a variety of medical perspectives.

At the conclusion of rounds, all the doctors met for a few minutes to discuss the impending changes brought by the ICD-10, a challenge all around the world, I then realized. We proceeded to the primary care pediatric and internal medicine clinics, where we shadowed doctors as they saw patients.

In my mind, one of the biggest lessons that Nicaraguan health care holds for the U.S. is how much more effectively they practice public health in Nicaragua. Even specialists tabulate each of their visits for the day on a special ledger with room for the chief complaint. With pediatric diarrhea, for example, they record the severity, or whether oral versus IV rehydration was given, for instance. They also record whether the patient is being seen for the first time for the complaint or in follow-up, and so on.

That evening, we returned to Leon and headed out for some work-life balance/cultural competency with our host families for salsa dancing.

Day 3: Visiting the Polus Center

In the morning, we met Santiago Castell├│n, director of the Polus Center, a nonprofit that operates a number of different projects in Nicaragua. Our first stop with Santiago was Caminando Unidos (Walking United), a workshop where adult and pediatric prosthetics are fabricated. Initially, because of the Revolution and Contra War, the center created prosthetics mostly for people who had lost limbs as a result of war.

Now, however, diabetes and motor vehicle accidents are the most common reasons for patients to need their prostheses. We toured the molding, casting, and finishing areas, and spoke with workers, many of whom used prosthetics made by the center.

We then proceeded to a private workshop that constructs wheelchairs. The ingenuity on display in each of the wheelchairs we saw was simply striking. From the image of a chair with wheels that most people probably have in their minds, to a hand-powered racing chair, to all sizes of pediatric chairs, the center truly seemed able to craft nearly any design to fit the physical needs of its clients.

Late in the morning, we visited Santiago’s office, where we found a collection of Red Sox memorabilia that would rival even that of the most ardent Boston fan. That afternoon, we had Spanish classes at Dariana.

Day 2: UNAN, Spanish, and Home Stays

After a restful sleep, we met Brunilda and headed to the Universidad Nacional Autonoma de Nicaragua (UNAN) School of Medicine, for an orientation of their medical school curriculum. Medical school in Nicaragua consists of six years, which begins directly out of their equivalent of high school. Their curriculum bears a striking resemblance to the integrated one that UMass Medical School recently transitioned to.

During the pre-clinical years, the anatomy, physiology, pathology, pharmacology, etc. of a given system are taught simultaneously rather than in discrete courses. The clinical years consist of rotations much like those at most American medical schools, but additionally feature a six-week block devoted to primary care and community health.

That afternoon, we made our way to Dariana Spanish School for three hours of one-on-one Spanish lessons. Instead of starting by memorizing nouns or conjugating verbs, my teacher, Denis, and I began simply by talking and getting to know each other. I found out that he was not only a Spanish teacher, but also a published poet. In addition, he had two children, both of whom were doctors who had studied at UNAN.

From Dariana, I walked just a few blocks to meet the family I would be living with for the next nine days. The moment I arrived, the Villalobos were warm and invited me in to sit and talk in the living room with their large family. There was Sr. Villalobos, a retired math teacher in the local high school and the patriarch of the family. His wife, Sra. Villalobos made a mean bean soup and is the president of a local telethon for children with Down syndrome.

Ivan, their son and my host-brother, is a professor of Religious Studies and Ethics at the Technical University in Leon. Ofelia, Ivan’s sister, is a dentist who has learned a good deal of English from American TV and movies. Dinner that first night felt just like dinner with family, only speaking Spanish instead of English and with more gallo pinto.