Christian's Pop Wuj Medical Program Experience, Part 3 of 4

Christian Ngo was a 4th year medical student at the State University of New York, Downstate Medical Center when he participated in the Pop Wuj Medical Spanish Program in the spring of 2014. He is now a first year internal medicine resident in Dallas at UT Southwestern.  Thank you Christian for sharing your insights with the Pop Wuj blog!

The Gendered Experience of Health
As I mentioned earlier, machismo culture is very prevalent throughout Guatemala. This culture of machismo affected the way in which both men and women interacted with the health care system. A majority of the visitors to the clinic were women and children. Many of these women were well aware of the chronic conditions that they had – GERD, amebiasis, diabetes, hypertension, and hyperlipidemia. A majority of these women had come to the clinic because they had either run out of the medications that had been prescribed to them previously or they had a minor acute illness for which they wanted to be seen by a doctor.

This was in stark contrast to the few men who I treated in the clinic. They would typically come in after several days of chest pain or a severe acute change in their health status. A good number of the men who presented to the clinic were in hypertensive urgency or had serum glucose levels in the unreadable range by finger stick glucometer. In my short time with the clinic, the majority of the cases which had to be referred directly to the hospital were men.

In reflecting on why this happened, I realized that this was not far off from my own experiences with health care in the United States. In my outpatient rotations, many of the men whom I treated only presented after strong coaxing from their spouses or after they had had a frightening symptom. On the other hand, women were more likely to present for routine care. It is clear that there need to be efforts to improve the way health care professionals engage men in the maintenance of their health both at a local and at a global level.

Another interesting aspect of working in Xela was the intersectionality of gender, language, and age. For many of the geriatric female patients who came from outlying areas of Xela, Spanish was a second or third language. These patients spoke only Mam, K’iche’, or other Mayan language. In these situations, husbands or sons would typically act as translators for the patients as there were no translators who worked at the clinic.[1]  This represented another significant barrier to treatment and left me wondering if the patient fully understood what was being explained to them.

In addition to barriers in spoken language, I also encountered a high rate of illiteracy, particularly amongst older women and women who we saw on mobile clinics. This presented problems when dispensing medications and giving instructions on how to take medications. In these situations, I would indicate the ways to take the medication and how many to take pictographically. In addition, I would be sure to ask if there was someone in the patient’s home who was literate and able to help them with their medications. However, when I first started at the clinic, I did not know to ask if the patient was able to read. It was only after another student mentioned that one of his patients was illiterate did I make this a standard part of my patient encounter. This experience has made me wonder how well our patients in the United States understand how to take their medications and if literacy might be an issue that we as medical providers are unaware of.

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[1] Pop Wuj provides translators during mobile clinics in the more isolated, rural areas, however not in the Xela clinic where the patient population speaks Spanish.

Christian's Pop Wuj Medical Program Experience, Part 2 of 4

Christian Ngo was a 4th year medical student at the State University of New York, Downstate Medical Center when he participated in the Pop Wuj Medical Spanish Program in the spring of 2014. He is now a first year internal medicine resident in Dallas at UT Southwestern.  Thank you Christian for sharing your insights with the Pop Wuj blog!

Framing My Experience
One of the first things that struck me when I arrived in Guatemala was how similar it was to the Philippines. I have been to the Philippines many times and been involved in a global health project there as well. The social structure of the two countries was extremely similar. The strong family structures that I saw in Guatemala were the same ones that I remembered from the Philippines. There was also a strong culture of machismo amongst both the indigenous and non-indigenous populations. This machismo had several interesting implications which I will discuss later. Furthermore, the socioeconomic situation of Guatemala is very similar to that of the Philippines insofar as a large proportion of the population works as international laborers and support their families in Guatemala through money remittances. Rapid development and its effect on the environmental health of the population was also another theme from the Philippines that I saw echoed in my experiences in Guatemala. In particular, the export of old discarded machinery from the developed world to Guatemala was very prevalent.

The similarities between Guatemala and the Philippines raised the question in my mind of whether this development experience was one shared amongst all developing countries or whether these similarities arose from the common experience of Spanish colonialism – or perhaps colonialism in general. Certainly, I can see the strong influence of Spanish culture in the development of machismo within both of these countries. However, I feel like my rotation in Guatemala raised more questions about the ways in which these systems and circumstances which are intricately intertwined with the health status of the population arose and what social and political forces have created such similar environments.

In the Clinic
Having worked in the developing world before, I am acutely aware of the imbalance between what is gained by a student from an abroad experience and what is gained by the community. Providing appropriate care is extremely dependent on an intimate knowledge of not only the endemic pathology within an area but also the cultural context and social norms that allow for patients to feel comfortable enough to engage the provider as a partner in their care. This problem is only exacerbated in situations where there is a language barrier between the patient and the provider. These barriers to optimal care arise not only in the international setting but when practicing locally where physicians are being asked to take care of an increasingly linguistically and culturally diverse population.

The Pop Wuj program addresses these problems by providing both targeted language instruction and a series of lectures on cultural issues that commonly arise in the clinic. In doing so, I believe that both students and patients had a better experience once they met in the clinic.

Christian with Pop Wuj staff doctors, Dr. Carmen Rosa and Dr. Sammy

 
As a student in the mobile and main clinic, I performed three different main tasks. The first of these was to triage patients. I would take patients vitals and identify what the main reason for coming to the clinic was. In addition to vitals, if I believed a patient needed a point-of-care laboratory drawn (e.g. urinalysis or finger stick blood glucose), I would also obtain these tests so that the results would be available to the teams working in the clinic rooms.

The second main task was performing clinic encounters with patients who had been previously triaged. In teams of two students, I would review patient’s charts, interview patients, perform physical exams and develop a plan to be presented to the Guatemalan physician. After presenting the patient, the Guatemalan physician would review my plan and offer any changes she thought to be necessary. Then, we would see the patient together and I would explain the plan to the patient, instruct the patient on referrals, and provide any lifestyle counseling that was necessary.

The third main task in the clinic was working in the pharmacy. This involved mixing solutions and counting pills to be distributed to patients. In addition, when giving the medications to the patients, I would explain the manner in which the medication was to be taken and any side effects and alarm signs that are associated with the prescriptions.

In addition to the roles that I took on at clinics, I also participated in an educational session at one of the nutrition screenings. Students rotated between doing growth checks and providing the educational talk on that day. I, along with a few other students, spoke with the mothers attending the screening about family planning methods, the availability of both barrier contraception and hormonal contraception at various health clinics including our own, and the benefits of birth spacing.

Christian's Pop Wuj Medical Program Experience, Part 1 of 4

Christian Ngo was a 4th year medical student at the State University of New York, Downstate Medical Center when he participated in the Pop Wuj Medical Spanish Program in the spring of 2014. He is now a first year internal medicine resident in Dallas at UT Southwestern.  Thank you Christian for sharing your insights with the Pop Wuj blog!

Contextualizing the Pop Wuj Clinic
I traveled to Quetzaltenango, Guatemala and participated in the medical program of Pop Wuj clinic for six weeks. Guatemala has a population of approximately 15 million people. The population of Guatemala is extremely diverse with 25 different ethnic subgroups typically recognized as comprising the native Guatemalan population. Twenty-two of these ethnic subgroups are considered to be culturally Mayan. The other ethnic subgroups are the Garifuna, a population along the Caribbean coast of Guatemala descended from West African and Central African groups, the Xinka, a non-Mayan indigenous Guatemalan group, and the mestizo, descendants of the Spanish and Mayan people. Quetzaltenango is the second largest city in Guatemala with a population of approximately 225,000. The population is largely indigenous with the most common linguistic minorities being Mam and K’iche’. The city is situated in the highlands of Guatemala with an elevation of greater than 7,000 feet above sea level. This high elevation significantly affects the kinds of vectors that are able to survive in the area and, as such, certain diseases which are traditionally thought to be endemic to Central America -- dengue fever and malaria being two prime examples -- are quite rare in Quetzaltenango.

Pop Wuj was founded as a teachers cooperative which taught Spanish as a second language. The proceeds from the school are reinvested into several community projects focused on improving the social situations of the local communities around the school. The development projects associated with the school include a safe stove project, a scholarship program, a family support center which provides child care and educational support for children of single, working mothers in Llanos del Pinal, and the clinic in which I worked. The Pop Wuj clinic permanent staff consists of two local Guatemalan physicians and a nurse. The main physical location of the clinic is in Xela. The clinic here has three examination rooms and sees approximately 25 patients three mornings per week. In addition, the clinic is stocked with medications provided by Timmy Global Health. The clinic occurs at this location two days per week. Once weekly, the staff holds a mobile clinic. These mobile clinics are located in more rural areas of Guatemala between half an hour and two hours from the main clinic site. The mobile clinics are typically run out of a family’s home and the resources available at these mobile clinic sites vary greatly, in particular private spaces in which to perform physical exams. Medications and supplies for the mobile clinic are brought with the clinic staff.

In addition to these three clinic days, the medical staff also have one day of the week devoted to a nutrition program. As a part of this program, the staff visits three different sites each month and measures the heights and weights of children between the ages of 6 and 24 months. Children who fall into moderate malnutrition category are provided with Nutributter nutritional supplementation and children in the severe malnutrition category are given Plumpy Nut nutritional supplementation. During these nutrition and development screenings, the clinic also offers educational sessions to the mothers in attendance. The topics of these sessions range from family planning and approaching spouses regarding birth spacing, to hygiene, to incorporating discipline into child rearing.

Staff Meeting at the Family Support Center

It’s been a busy few weeks at the Family Support Center, formerly la Guardería. The school year ends on October 15th and all of the children are working hard to finish homework and study for exams. Last Friday, Pop Wuj headed out to Llano del Pinal to meet with the staff at the Family Support Center and discuss each child – all 40 of them. The main focus of the meeting was to determine if any of the children were at risk of failing their current grade, thereby being forced to repeat the year or go to recuperación during school vacation.

Starting the staff meeting

After a long meeting, we were able to pinpoint which children were struggling and in what areas. Math proved to be the subject that caused the most trouble among students of all ages. Multiplication tables, in particular, are a challenge for a lot of students.

Knowing this, the staff and volunteers plan to be at the Center in full force, devoting individual attention to the students who need it most. We are also working on finding fun ways to teach and learn multiplication tables once and for all through various games and strategies!

Discussing the needs of individual students

While the next two weeks will be a lot of work for everyone, the end of the school year signals the arrival of vacaciones and a long break from the daily school routine. The Family Support Center will be open all day throughout summer vacation, so many fun and educational activities are being planned for the next two months.

As the rainy season slowly fades away, we hope to involve the students in a ton of outdoor activities such as gardening, recycling, soccer tournaments, and hikes! We certainly have a lot to look forward to at the Family Support Center.

Reflections on Healthcare, Guatemala, and Pop Wuj

By John Hann, MD

John was a Pop Wuj Medical Spanish student in May, 2014.  At the time he was finishing his Family Medicine Residency at Ventura County Medical Center in Ventura, CA. Thanks for being a fantastic Pop Wuj student and volunteer -- and for sharing your story and pictures! 

Women walk on the streets while carefully placing their feet in the areas not yet soiled by the stray dogs who rummage through plastic garbage bags that line the streets. Unable to afford niceties of street sweepers, clean engines, or even trash cans, the city instead relies on bright colors, flowers, bustling markets, and the inevitable afternoon downpour to shine through. Even through the thick soup of exhaust belching out from passing buses, the flowing colors of women's clothing can be seen. 

Like many others, Guatemala is a land of contrasts: beauty enveloped by pollution, tranquil people inhabiting cities filled with chaos, and a culture of stamina that belies the chronic disease and pain suffered by many.

Forty-two hospitals cover the 18 million people that live in Guatemala, a country whose economic sector is said to be dominated by money sent by family members living in the U.S. Twenty-two official native languages are recognized that have all descended from the Mayan empire.  Family members are accustomed to systems that are slow, inefficient, and racist. 

The clinic created at Pop Wuj by Guatemalans with the support from the U.S. is, for some, the only healthcare they receive. The projects started with scholarships and building safe stoves before expanding to provide child care for women living in the impoverished countryside and later healthcare.

Stove building material delivery day

Delivering bricks and other materials for the stove construction

Though established by Guatemalans, the organization (like much of the country) relies on foreign donations and volunteers. In the last decades, U.S./European volunteers’ interest in international development waned as interest in medical volunteering rose. Reading the writing on the walls, Pop Wuj teamed with local doctors and organized a volunteer clinic that eventually grew to what it is today.

Pop Wuj's clinic is not entirely dissimilar to clinics in the States. Spanish-speaking patients, diabetes, hypertension, poverty and, of course, "one last question" as you are leaving the room. As is the trend in the states, medical records are stored electronically on old Linux machines.  Teams of volunteers with varying Spanish skills work with local doctors, one of whom is even the daughter of the founders of the school. 

Lining up for clinic

Getting things done, in some ways, is even easier than in the states: very little regulation exists for medications and labs can be ordered just by paying for them (no doctor's Rx is needed). Not having to worry about insurance companies or copay, billing is non-existent, and deciding which medication to give is as simple as determining which medication is in the stockpile that month. 

Parasites and worn out joints dominate chief complaints, but with joint replacements being the equivalent of 15 years wage, most walk away with Tylenol.  Low administrative overhead from all donations keeps things slim on the organization front, but, as it does in every country in the world, perseverance and flexibility are the "recipe for success."

    

My experience was not limited to the clinic. Building stoves with chimneys for women living in one room, one bed, tin-metal walled, multi-children, smoke-filled homes was especially rewarding. As was being a first responder to the inevitable motorcycle accidents that happen in the anarchic streets...twice. Even my teachers sought assistance with us for their skin infections and wives with hypertension.

Building a safe stove

On the eve of graduation from residency, it is nice to reflect on my training and the blood, sweat and tears I have put into the last three years. Being able to slip from a busy, Spanish-speaking clinic and ER in the states into a busy Spanish-speaking clinic in Guatemala makes me appreciate what the long nights and countless charts have yielded. I look forward to the next adventure and am grateful to those organizations, Family Medicine Education Fund and Pop Wuj, who helped make it happen.

Independence Day: Celebrating Everything But Independence

September 15 is a very important day for not only Guatemalans but all of Central America. On this day last week, it marked 193 years of Guatemala’s and Central America’s independence from the Spanish crown. It is celebrated with parades, high school marching bands, fireworks (more than usual that is), food and much festivity.

In the Family Support Centre it was no different.  Thursday last week leading up to the almost week long celebrations, the Family Support Centre once again turned chaotic with the arrival of this year’s Mini-Feria. And the fact the rain forced everyone inside, only heightened the craziness and fun.

As always there were decorations, food, games, prizes, smiles and laughter. The mothers had all laboured hard over the previous days to supply the kids and each other with a smorgasbord of treats and snacks.

The day started off with the formal national flag ceremony and anthem, which was followed by a very important speech regarding the true independence of Guatemala.

Ilcy, Yesica and Wilson bearing the national and department flags for the National Anthem.

Despite being called Independence Day, it is hard to say that the people of Guatemala and much of Central America, for that matter, were every really made independent: rather that its control and profits was transferred from a small elite in Spain to a smaller elite of Spaniards living in Guatemala. With an economy controlled by corrupt bureaucrats, manipulated and tainted by the west; a vast majority of people without the freedom of self-agency; inaccessibility  to education, health and social services; and an inability to do be who or what they want to, due to a lack of resources: can Guatemalan’s really be called ‘Independent’?  

Thus what was celebrated last week at the Family Support Centre was not Independence, but the love for a home land, and the initial steps being undertaken towards the nation’s freedom; achieved through, what the Family Support Centre does best: educating the youth of the Nation.

After this somber reminder of reality, the fun got underway. With their tickets in hand, the kids and moms devoured the delicacies on offer. There was crazy corn, cotton candy, enchiladas, hot dogs, nachos, popcorn and of course the obligatory fresh fruit just to name a few.

Jonathan getting his fill of crazy corn.

With still half swallowed food in their mouths, the kids charged full speed into the games. There was the traditional coin toss; ten pin bowling; the pyramid skittle; the lottery/bingo; bean bag toss; and as with every year the crowd favourite was foosball. Prizes went flying out the door and the festivities continued on until dusk began to set in, calling an end to another fun filled Feria at the Family Support Centre.

Amy and Evelyn sharing secrets.

Tia Leti selling her hot dogs.

Yadira winning prizes in ten pin bowling.

Life as a Pop Wuj Intern

Working as the Projects Coordinator intern at Pop Wuj was an incredible experience. I left Xela about three weeks ago and I am now integrating back into my life in the United States. The job that was my day to day responsibility and preoccupation has already become a memory I will never forget.

"Public" transportation in Llanos

When I first arrived at Pop Wuj I was primarily interested in the Safe Stoves Project for its prevention of respiratory illnesses within rural families that used open fires their homes. It was also the project with which I got started with right away by training during my first weekend there. 

As my work on the job progressed I really gained an appreciation for the physical labor and team ethic that goes into stove building. I took the role of leading stove building groups, gaining not only leadership skills but also the ability to adapt quickly to a leadership position in field of work that was unfamiliar to me.

A finished safe stove

Soon after I became involved in the Family Support Center (FSC) as well. Going into it, I did not know what to think of or expect from my work in the FSC. This is not to say I had any doubts about the project itself—it successfully offers academic help and loving support to 41 Guatemalan children. That’s a given. However, I was nervous about working with so many different children of all ages when I had very little background experience working with children. That fear went away as my time in the project quickly turned into some of my favorite memories made while working with Pop Wuj. 

We did everything from painting tables, playing soccer, and constructing puzzles to working on homework and reading books to just goofing around with newspaper hats and paper planes. Upon arriving I immediately felt welcomed by all of them, and upon leaving I received a flooding of hugs, well wishes, and voiced hopes for my future return to the project.

Sharon with some of the Family Support Center participants

Another facet of my job included assisting with the scholarship meetings in towns near Xela. Carmencita, Amy, Chloe, and I spoke with mothers of Pop Wuj scholarship recipients about how their children were doing in school.  Additionally we talked about the very relevant topic: the illegal immigration of Guatemalan children to the United States. In the meetings we gave presentations about the dangers and consequences of making the journey mojado, (illegally) always opening the room up to discussions about the topic: "What do you like about your hometown?" and "Why do people choose to go North?"  We also spoke with the children and youth of the FSC, this time including colored pencils and crayons for the option of drawing their responses. 

These presentations proved to be some of the most challenging work I did as many mothers and kids alike had misconceptions of what the journey was like--some even believing that the border had been opened for free passage. Our work was to discuss the realities of the dangers that children are exposed during the journey and at the destination in hopes of discouraging them from risking their lives in the attempt.

Other projects I helped coordinate and participate in included the Reforestation Project and the Recycling Project, and I occasionally helped out in the Health Projects such as Nutrition. I helped translate some lectures at Pop Wuj and always attended the Thursday night dinner. Though I was sick during my final dinner at Pop Wuj and had no chance to give a speech, I hope it suffices to leave this blog post here as a final appreciation for the great experiences had, memories made, and friendships forged by this opportunity.

Hasta pronto,

Sharon Broadway

Sharon found Pop Wuj via our partnership with Entremundos.  Pop Wuj offers five distinct internships/long-term volunteer options.  Visit Entremundos to learn more and apply.