Tortillas Nutritivas

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:

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Recipe #1: Dominga adds crushed peanuts to the corn tortilla masa (dough).

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The peanut masa is ready to be made into tortillas.

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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.

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A sesame tortilla, ready to be cooked on the "comal" (griddle).

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Moms gather in a neighbor's open-air kitchen to "tortillar" ("to make tortillas").

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Tortillas on the comal.

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Before the tortillas are served, Vicente and Dominga give a talk on how to prevent malnutrition. (Visual aids courtesy of yours truly).

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It is important for moms to give their children de-worming medication every six months after their second birthday. Parasites and worms are one common cause of malnutrition.

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Often moms think that if their child takes a vitamin pill, it will stimulate their appetite and cure their malnutricion. What many don't realize is that if their children eat a variety of fruits and vegetables, they will get all of their necessary vitamins and minerals and won't have to spend money buying vitamin pills.

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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.

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One mom looks on expectantly... will her child like the peanut tortilla?

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Moms and kids, enjoying their tortillas nutritivas.

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In this photo, a baby, trying to snatch his brother's tortilla... Mikey likes it!

Shampoo

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:

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Ladies from San Martín, pulling leaves off of branches of "escobillo," (I'm not sure there is an English language equivalent), a plant with medicinal properties that, once the plant is boiled in water and added to the shampoo mixture, help keep hair from coming out when you brush or comb your hair.

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Escobillo leaves, ready to be boiled.

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"Sabila," (aloe vera) is added to the shampoo because it helps treat and prevent "caspa" (dandruff).

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Sabila is a cactus-like plant, which needs to be peeled of its outer skin, revealing the gelatinous inner layer.

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Kate and I, watching Dominga and Magaly (one of the health promoters from San Martín) peel the sabila.

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Cutting out the gelatin.

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Sabila, all peeled and ready to go in the blender.

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Blended sabila.

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Dominga adds the "shampoo base," from Lafimarq, a pharmaceutical and laboratory supply company in Guatemala city.
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Next, Dominga adds two caps-full of rose fragrance, as well as a green dye, also from the same supply company.

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The final ingredient is table salt, which helps to thicken the consistency of the shampoo mixture (shampoo base, sabila, escobillo, and water).

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Vicente looks on as Rita (left), another health promoter from San Martín, and a lady from the neighborhood mix the shampoo with their hands.

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Ladies crowd around the tub to watch the shampoo take shape.

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Once the shampoo is made, Vicente begins his talk on how to prevent diarrhea, with the help of promoter Magaly.

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Once the talk is over, the ladies thank Vicente, and wait patiently to fill their plastic bottles with shampoo before heading home.

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Rita makes sure everybody gets an equal share of the shampoo.

Medioambiente

This past Tuesday and Wednesday, we participated in a health promoter training course entitled, "Medioambiente," or "Environment." We started with a review of the topic of last month's training, "Pregnancy and Prenatal Care"; these reviews are an important part of ensuring that health promoters in training continue to renew their knowledge base and recognize their strengths and weaknesses.

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The first day of Medioambiente training consisted mainly of discussions led by Vicente and Dominga on water systems and sanitation in the rural communities around San Lucas, and resultant disease burden. In nearly all the communities we serve, there is an elected committee overseeing water and sanitation. Sometimes parish health promoters are on these committees, sometimes not. In either case, the objective of the first day of training was to provide them with an understanding on the basis of which they could play an advisory role for their community's water committee.

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The second day, Kate and I talked about water-related infectious diseases seen in the communities, such as dengue (breakbone fever), malaria, onchocerciasis (river blindness), infectious diarrhea and intestinal parasites. The Centro de Salud (government health center) has vertical programs in vector-borne diseases, but their active case finding, prophylaxis, diagnosis and treatment are plagued by poor coverage, lack of resources (they don't do thick smears to diagnose malaria?!), and inflexible protocols that don't respond to individuals or communities. Similarly, the local government-funded NGO, APNACH, is responsible for management of diarrhea and intestinal parasites in the communities, but their health workers are only paid to work 3-4 hours a day, and their community formularies are stocked erratically (a community can go 4-6 weeks, or more, without oral rehydration solution or deworming medication). Teaching the parish health promoters to identify and begin first response to these problems, it is hoped that they will be able to fill in some of the gaps left by an ailing public health system.

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Here are some photos that Elena took during the two-day training:

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Kate, teaching the symptoms of Malaria: fever, chills, and headache, among other things.

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Kate must have said something hysterically funny, because Vicente is cracking up in this picture!

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Day One: The health promoters from each community were invited to bring water samples from their community water source(s) to test them for contamination. Here, Delma and Micaela measure out 20ml of water that they brought from their community, Totolya'.

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Dominga rips open the packet of test powder, to pour into Domitila's water sample. Domitila's community, Xejuyu', does not have potable water running to each house. Instead, they have made an agreement with the finquero of Sto. Tomas to bring water from a spring on the finca's land.

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Day Two: After 24 hours, Benita, from Totolya', was surprised to discover that her community's water results came out black = contaminated. Per Micaela, another promoter from Totolya', nobody in Totolya' or Porvenir, which share a water supply, is doing anything to purify their water. The health promoters from Totolya', after discussing this result with Vicente and Dominga, decided to get additional tests at different points in the community's water supply to determine the source of contamination. They intend to take these results to the community leadership so that plans can be made to clean up the water.

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Ingrid, from Xejuyu', holding her result (yellow)--no coliforms!

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Vicente (who lives in Quixayá), was so proud of his community's result!

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The results are in: 4 out of the 7 water sources tested were found to be contaminated with coliforms (that is, poop). For those promoters whose water is contaminated, they are charged with the task of presenting these results to their COCODE (community leadership council).

--- Dominga, being silly... This past month leading up to the Medioambiente training, we have had several discussions about how to get the 2nd year health promoters more interested and about how to provide opportunities for non-threatening self-assessment. Dominga really shone, coming up with several excellent ideas to break up the monotony, promote interactive learning, and incorporate assessments into fun activities.

--- "Medioambiente" was the last training we will participate in, since we're leaving in less than three weeks. This is one final group photo of us and the 2nd-year students in the health promoter program. They thanked us for our support and presence in their work and capacity-building, and we thanked them for their acceptance of us and for the opportunity to help and learn from them. We said that we respected their committment to their communities, and we wished them the best in their continuing studies and engagement in the health of their people.

Frisbee!

In her last mail package to us, my mom sent a frisbee, which we used for the first time this past Saturday. What a big hit!!! All the kids in our neighborhood came out to play, and we had a great time throwing the frisbee around all afternoon. Here are some photos I took of Shom and the kids:

Shom, with Rosbin (our host-brother, in black), Juan, Lucia, and Jessica.

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Rosbin, winding up for a big throw.

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Lucia having some fun, while Rosbin waits impatiently for his turn.

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Running after the frisbee.

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Rosbin, waiting for a good catch.

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...take that!

Xkojb’a ke la Boston!

During our time here in Guatemala, I have been forced to reflect quite a bit on how to respond to our experiences here. When we arrived, I had thought that all I needed to do was apply my existing skills in medicine and public health and my linguistic capacity in Spanish, and I would be able to do good work.

In encountering the limits of my abilities in medicine and public health, my perspective on my remaining training has changed significantly. Before, I thought of the years of training before me as a series of prerequisites; now, I have become aware of the clinical opportunities I need to seek out if I am to become a competent physician to impoverished populations in complex healthcare landscapes like the one we have encountered here. Honestly, in light of our experiences, I feel that 3 years of residency training is not enough—I need to gain an internist’s knowledge of medicine, a pediatrician’s knowledge of children’s health, a psychologist’s aptitude for psychiatric elements of illness, and an obstetrician’s experience and surgical dexterity. This makes the prospect of choosing a specialty for residency more complicated. In any case, this past year will make me a more deliberate learner as I continue in my clinical training.

Another unexpected realization of this year is the narrow scope of the training and education I have pursued thus far. Issues of cultural and socioeconomic justice have only been touched upon in passing in my medical and public health education. While I have a natural predilection to trying to contextualize my experiences in broader perspectives of political economy and history, I have neglected this as a focal practice in my life, partly because I have been overwhelmed by the pace of medical school and partly because this is not something that is emphasized as important for medical students, at least not in my experience at my school. I have experienced a growing awareness of the necessity of anthropologic perspectives and ethnographic practice through my engagement here in Guatemala. I have had inklings of this awareness over the past three years, and I somehow knew that at some point I would probably pursue studies in medical anthropology—to the point that when I started thinking concretely about applying to programs this past fall, I already knew where to look and which schools to consider. In December and January, with the encouragement of Elena, friends and mentors, I submitted applications to a number of schools that offer Master’s programs in anthropology for healthcare professionals.

Of the programs to which I was accepted, I decided that Harvard University’s MA in Social Anthropology with a focus in Medical Anthropology was best suited to my needs. The program offers a broad introduction to anthropological theory and the opportunity for in-depth study of a variety of topics of utmost importance to a student of the health and lives of the global poor. In addition, the institutional partners participating in the Program in Medical Anthropology at Harvard (e.g. Partners in Health and the Dept of Social Medicine and Health Inequalities) are exciting to me as a physician-in-training who hopes to couple critically engaged scholarship and social justice work to clinical medicine.

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So I am taking another leave of absence from the MD/MPH program at Northwestern, and Elena and I are making preparations to move to the Boston area this summer. We are looking forward to this next step in our journey, and Elena has already begun to look for jobs in Boston’s non-profit sector. Once we have an apartment, we would love visitors!