It is fitting that our last day of work was in Nueva Providencia, the poorest of the communities we serve. A few months ago, we discovered that more than 50 % of our children in Nueva Providencia are severely malnourished (-3 SD weight-for-age vs. mean CDC curves), marking a significantly elevated risk of mortality from intermittent illness. Every month, we have come here and been overwhelmed by the sick, malnourished kids. Ending with a morning in Providencia, then, reminded us of all the work that remains to be done.Dominga gave a talk on the prevention of respiratory problems before we began seeing patients. It was fabulous! I was very, very impressed today. In general, she sometimes loses her train of thought and her audience in Spanish, but in Kaqchikel she is an engaging speaker and educator. The women loved it, chiming in and laughing throughout! It is always very different when the rest of us help with the talks, whether it is me or Vicente, whether in my halting, three-quarters Kaqchikel or Vicente’s oscillating KaqchiSpanish (all Kaqchikel, switching occasionally to lines like: “Si yix se dan cuenta, yix van a ver que hay mucho yab’il awe pa comunidad…”). Something about Dominga’s comfort with Kaqchikel, something about her being a respected Kaqchikel woman from the communities, something about the women’s identification with her make for wonderfully interactive and fruitful preventive health talks.
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Dominga, talking about contagion!
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She spent a long time discussing the importance of breaking the transmission of disease in preventing acute upper respiratory infection, which is often completely absent in people’s understanding of the etiology of gripe (the common cold). When we have tried to explain the concept of contagion to patients, the best response we have gotten has been, “Oh, thanks.” Very rarely has it appeared that patients were listening, understanding or believing what we were saying. But with Dominga on Thursday, things were completely different—the women became really engaged with this concept!
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Dominga, interacting with her audience.
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"Don't let your children play in the rain"
"Don't let your children play in the rain"---
Everyone got a little fixated on the lack of shoes on these children (above), playing marbles outside in the rain. And so the talk got a little side-tracked momentarily as we learned about hookworms, which, honestly, is not much of a problem here. I think things like hookworms come up so frequently because the materials made for health promoters and workers in settings like ours are written generically for the “tropics” or for the Third World, and because visiting physicians and nurses who love to include exotic parasites in their diagnostic thinking (without having explored local epidemiology) unduly influence the health promoters.
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"Avoid dust; sprinkle water."
"Avoid dust; sprinkle water."---
Throw water on the ground to keep the dust from kicking up. This may have something to do with preventing environmental allergies, but almost nothing to do with respiratory infections (as it was presented). Either way, the women seemed to have had enough by this point in the talk. But Dominga plugged away, nonetheless. It is always difficult to know how to keep people’s attention, to know how to present things in a way that will be engaging and fit with people’s cognitive frameworks, thereby turning into pragmatic knowledge.
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Dominga, seeing patients with the assistance of Kate. Once we are gone, Vicente has said that he thinks they should continue with their mini-consulta after nutrition days. I agree.
This past Tuesday, we participated in another one of Vicente and Dominga's preventive health talks and community activities, in San Juan Mirador. This time, the topic was how to prevent skin infections, and the activity was making an anti-alergic "jabon de manzanilla" (chamomile soap). Here are some photos from the day: 
The ladies of San Juan Mirador, taking apart the manzanilla (chamomile) flowers. According to Vicente and Dominga, one of chamomile's medicinal properties is as an anti-allergen.
Dominga, showing Veronica (one of the health promoters from San Juan) the soap to be used in the recipe: odorless, chemical-free, "natural" soap bought in the market.
The chamomile "tea" is added to the soap chips. 
While the soap and chamomile mixture simmers over the fire, Vicente and Dominga take the opportunity to give their talk on preventing skin infections (illustrations by me!).
The proper cleaning of burns and wounds: wash with boiled (disinfected) water and soap.
In order to prevent fungal infections on the feet, it is important to wash and dry your feet well before putting on socks and shoes.
Avoid the infection of "sarna" ("
Dominga pours the soap into the cardboard-box-covered-in-a-plastic-sheet mold.
As part of the health promoters' series of preventive health talks, this past Monday, we spent the morning in San Felipe focusing on the topic of malnutrition and making tortillas. But not just any tortillas... "tortillas nutritivas!" (nutricious tortillas). One of the most common complaints moms have of their often malnourished children is that their kids refuse to eat tortillas. This is the mainstay of the Mayan diet, the one food around which all other foods revolve. So you can understand why a mom would be distressed if her child refused to eat it. The health promoters have come up with a solution to getting kids to eat their tortillas and get more protein in their diet... mixing peanuts, sesame seeds, and sugar into the masa (tortilla dough). Though an expensive solution if cooked for the entire family, it is potentially affordable if moms only make the recipe for their children under age five. Below are some photos of moms learning the new recipes: 
Recipe #1: Dominga adds crushed peanuts to the corn tortilla masa (dough). 
The peanut masa is ready to be made into tortillas. 
Recipe #2: Dominga adds sugar to another batch of corn masa. Once this masa is made into tortillas, sesame seeds will be sprinkled on both sides before they are cooked. 
Moms gather in a neighbor's open-air kitchen to "tortillar" ("to make tortillas"). 
Tortillas on the comal. 
Before the tortillas are served, Vicente and Dominga give a talk on how to prevent malnutrition. (Visual aids courtesy of yours truly).
Avoid spending money on packaged junk foods such as chips and soda. Fruit is a much more nutricious snack, at a fraction of the cost.
This past Thursday, we accompanied Vicente and Dominga to San Martín, one of the rural villages surrounding San Lucas Tolimán. The activity for the day? Making shampoo! "What does this have to do with health?" you ask (we asked ourselves the same question). The obvious perks to this activity were that the shampoo we made was anti-dandruff, and it was free to the women who came to participate. Shampoo here is sold in small packets (similar to what you see sometimes in hotel bathrooms). Because money is tight, families will often buy a packet (25 cents) on the day they need to wash their hair, as opposed to having a bottle around the house, as we are accustomed to. The main reason for this activity, however, is to provide a fun and valuable incentive for women to take a break from their morning activities of washing, cooking, and farm labor, in order to listen to a preventive health talk (see previous blog, "suero oral"). Here are some photos from the day:
Escobillo leaves, ready to be boiled.
