Nicaragua- Last days

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3/17/09
Today we woke up early and traveled to a very poor area where we set up a clinic for the day in a school. After we vaccinated the children, they were allowed to leave school early so we could convert their classrooms into clinic rooms. There were three rooms in the school so three stations were set up: one for vaccinating and giving antiparasite medication, one for the doctors to diagnose patients, and one for women’s health exams (pap smears).

Nicaragua has an interesting medical school system. They attend medical school immediately after high school for 6 years. The last year is a year of service, and these medical students are the doctors that mainly serve the poor in Nicaragua. The way they run their clinic consists of people standing in a long line and the doctor sitting at a desk. The doctor calls down the next person in line and writes down their name, age, and place of residence. They listen to the patient’s complaint and sometimes perform a brief physical. The physicals consist of a blood pressure reading, or listening to a patient’s lungs, or pounding on their kidneys to assess costovertebral angle tenderness. The doctor writes down a diagnosis and then prescribes about 6 medications: aspirin, antiparasite, ibuprofen, and maybe something else. Their method of diagnosis was very simple: if a person complained of back pain and had costovertebral angle tenderness, they had a urinary tract infection. Essentially, the doctors see a huge number of people but don’t do much documentation or physical examination. Also, these doctors see a large number of people for minor problems. Health care is public, and many people visit the doctor for prescriptions for over the counter medications. This way they get the medicine for free and don’t have to pay for it at a grocery store or pharmacy.

3/18/09
We went to La Palmeira today. La Palmeira is the name of a health outpost that was established through a community donation. A community donated a building to the San Marcos Clinic in order for the nurses to provide healthcare at this location twice a month. The building is about the size of a dorm room with two small rooms connected to one larger room. There are cement floors, cement walls, and no doorways. The nurses created makeshift doors with a sheet and a piece of plywood. The large room contained a station for vaccinations and well baby checkup and a pharmaceutical station for distribution of medications from a nurse. The area without stations had lines of people waiting. In the other two rooms, a doctor was in one room seeing people for various ailments, and Carmen Delia was in the other room performing gynecologic exams. The UNMC medical students were giving vaccines and helping with well baby checkups, shadowing the doctor, or performing the pap smears. The clinic was busy later in the day. Carmen Delia explained to us that the reason people showed up later was because most of them were bathing before they came to the health outpost and they had to walk a long distance in order to get their water. Hence, it took quite a bit of time to get the water, take it back to their houses, and bathe.

Another fact: the average age at which women had sex for the first time was about 15, but the average age of the women in the community yesterday was about 13.

The majority of the pap smears were abnormal due to STDs or yeast infections, and according to the nurses, the majority of men were not faithful to their wives. Many men had jobs outside of the community along the coast, and they alternated between living on the coast and visiting their homes during vacations. These men were frequently not faithful to their wives at home. The wives didn’t really have the choice to not have sex with their husband when he was home, and this affected how the nurses counseled them. Instead of asking them to use condoms or abstain from sex, nurses told patients to keep good hygiene and treated STDs by giving the patient two sets of medication: one for her and one for her husband. The majority of people at the clinics were women or children, and the men we did see were either young adolescents or elderly.

3/19/09
Today we drove to Leon and toured UNMC’s sister University and a medical school. Afterwards we went to a seafood restaurant. This was fun because you chose the fish you wanted to eat from a cooler, and they served the fish to you with its eyes and everything! After eating we toured the state hospital where the conditions were horrible. The hospital wasn’t clean or well maintained. There were pieces of ceiling missing with wire hanging down, most of the floor tiles were cracked, tiles on the walls were falling off, and there was trash on the floor. Patients were placed in the hallways in their beds because the hospital did not have enough rooms for them. These bed frames were falling apart and the mattresses did not have sheets on them. It was depressing to see a diabetic patient with his leg cut off at the knee, sitting on a thin plastic mattress labeled “diabetes ward.” On one wall, there was a message painted by the doctors on strike- they wanted better wages and funding. Down the hallway, a different message was painted by the doctors who didn’t agree with the strike. Doctors in Nicaragua make $250/month and nurses make $125/month. This is a pretty good salary for Nicaragua. The hospital was very eye-opening. A hospital in the United States would never look like that, no matter what area of town it was located.

Then we went to a beach. It was gorgeous, and the hotel on the beach even had running water. It was nice to be able to flush the toilet! We hung out on the beach and got dinner at the restaurant in the hotel. I had lobster for $13; it was a lot of lobster and it was delicious.

Nicaragua – Managua work days

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Here in Nicaragua, our half of the UNMC students which stayed in Managua spent Monday through Wednesday working in schools and in neighborhoods giving vaccinations.  We worked with the Nicaraguan ministry of health and a pediatrician from Los Chavallitos Clinic, which is a clinic that is funded from donations from Omaha.

Our work days in Managua started out like all others here in Nicaragua.  All of the houses are very open here in the tropics and so as soon as the sun starts to rise around 5:30 or 6:00, the birds start to sing and you can hear them all through the house.  Add to that the cat that lived below our window, and it made for noisy mornings!  Good thing the light sleepers had been warned ahead of time to bring earplugs.  After getting up, a shower is the next thing to do, and if you’ve never been to South or Central America before, then the fact that there is no warm water will surprise you!  Since it’s always at least 90 degrees during the day, there is really no need to take warm showers and the cool water feels good!   Breakfast in the morning always included beans which were accompanied by fruits, rice, and eggs among other things.  After breakfast we slathered on our sunscreen, put on our hats, and headed out to the bus and went to the Los Chavallitos Clinic to pick up our supplies for the day.

Our first stop on our first day was an elementary school.  We saw about 200 kids.  Some of them got the works, including shots, and some of the lucky ones only had to take anti-parasite pills, take some Vitamin A, and get a fluoride treatment.  The school, like all buildings was open to the outside and all the kids lined up outside would ask us with concern if they would be among the unlucky ones.  Most of the kids liked the anti-parasite pills, but a few did not like them and a couple even threw up.  I think this was the only place that anyone threw up, and they were all together in a row, so I wonder if the kids seeing other kids throw up didn’t create some sort of vomiting domino effect!  In the afternoon we went to a house in one of the poorer neighborhoods where parents brought in their kids.  In the neighborhoods we saw more babies and they were always so peaceful before getting their shots in their little legs, which was both sad and cute.  Half of our group in the afternoon stayed outside of the house because there wasn’t enough room for us all to work.  Some boys from the neighborhood started following us around and pretty soon they were challenging us to a soccer match.  I had to unfortunately turn them down, but I did go get Matt, who had played soccer, so that he could show them a few tricks.  One of the boys ended up cutting his toe, which just meant we had one more patient!

On the second day of work, we went to the neighborhoods first and then went to a school in the afternoon.  I enjoyed working in the houses in the neighborhoods because the pace was usually a little bit slower and we had more of a chance to chat with the kids.  One of the girls I treated had a lot of necklaces and bracelets, and so while treating her I complimented her on them and asked her all about them.  She made some of them herself and bought the others at school.  At the end of the visit she ended up giving me one!  During the whole trip, our group of gringos took quite a few pictures, but in that neighborhood we had a first.  One of the residents of the neighborhood came in to take pictures of us!  That afternoon we went to a school and split up into two groups.  After our group finished we had to wait a while until the other group was ready to go and we had to wait in the classroom we had been working in.  The room that we were in had bars on the windows and doors and the kids at the school all crowded around to see us.  Needless to say we felt like animals at a zoo!  One girl that was probably 11 or 12 asked us if she would come in because she wanted to chat with us.  As she talked with us we were all impressed by her mannerisms and maturity.  She spoke so clearly and formally that it was almost as if she were at a job interview.  I think we met the future president of Nicaragua!

On our third day of work we again went to a school in the morning and into the neighborhoods in the afternoon.  When we got to the school that day, the principle told us that a large number of kids didn’t come to class that day because they had heard about the vaccinations.  So we treated the kids that were there, but unfortunately we missed a bunch of kids.  I just picture some present day Nicaraguan versions Tom Sawyer and Huck Finn convincing all of the other kids to play hooky that day from school!  All of the days we gave fluoride treatment and all of the days it was evident that it was needed.  We saw so many kids with cavities and completely rotted out molars which was really sad.  We handed out toothbrushes on our last day.  We also ended each day by sending a few of us to an urgent care clinic at a local health post.  The urgent care clinics had very few resources and most patients were told to come back the next day when the lab was open for tests.  On of the doctors said she didn’t even make enough money to have ever had a car.  She asked us to tell Oprah about her so that she could get her a car!

I think that we all enjoyed our days working and learned a lot.  On one hand, it was sad to see the poor state of health of many people, especially some of the kids, but on the other hand it was fun to get to know some Nicaraguans and do a little bit to try to help.

Martin Goodenberger, M2

Nicaragua- First days

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3/14/09
Today was eventful. Flight schedule: arrived at airport at 4:30 am, flight left at 6 am, landed in Dallas at 8:30, left for Nicaragua at 9:15, and landed in Nicaragua at 12:15 (11:15 am their time). We drove to the Los Chavalitos clinic, unloaded our luggage, and went to a mall for lunch. They had almost the same restaurants as the US: McDonalds, Tip Top (fried chicken), Hardees, Chinese food… Afterwards we went back to the clinic and saw a presentation from MINSA (Nicaragua’s public health department) about vaccines. An OB/GYN also gave us a presentation about common diseases in the country. Then we gave each other shots in front of the nurse from Nicaragua to show her we knew what we were doing. We used water to wipe each other’s arms off because we needed to save the alcohol wipes for the real vaccines. This was definitely different from the United States.
The buildings and weather made me think I was in a California town, but then I noticed all the trash along the side of the road and people standing in the streets selling things. As soon as the car stops, people walk by your window with water bottles, cashews, and even watermelon. I saw graffiti written along the sides of buildings, but it was graffiti in Spanish. Frequently I saw people riding in the beds of trucks. We were driving down the road when a truck drove past us with lots of guys sitting in the bed waving at people. I thought “Oh no,” because they drove right past a policeman, but the policeman just waved back at them.

We went zip-lining late that afternoon. Really fun! We went down three zip-lines around a lake. It was surprisingly not scary, but I was concentrating so hard on moving quickly and keeping my body facing forward that I didn’t notice how far it was to the ground.

3/15/09
We woke up at 8, ate breakfast at 8:30, left at 9 for Mission and shopped the markets. The markets were very cute with murals on some of their walls. I was struck by the number of kids that were working in Nicaragua. There was a boy about 6 years old selling gum at the markets, and the majority of the people selling the water bottles in the streets were kids. After the markets we drove to Granada. We ate lunch at a restaurant on a lake and went on a boat ride. The lake is the second largest in Latin America and has many islands in it. About 3,000 people live on the islands in the lake. A monkey, “Lucy,” jumped on our boat and entertained us a bit. After the boat ride we walked around the city: we walked up to the lookout point at an old fort, we went to Mass in a massive church, and we ate dinner at a nice restaurant. Mass was more relaxed in Nicaragua than in the U.S. People were walking in late halfway through the Mass and large birds and bats were flying around the rafters.

3/16/09
Today we went to a school and gave kids vaccines. We are working with our host Carmen Delia today and for the rest of the week. Carmen Delia is a nurse that works for the clinic in San Marcos, and she is the head of the group of nurses that travel to the communities to provide healthcare. The clinic in San Marcos is so busy that people are encouraged to stay in their communities while the nurses and doctors go to them. It is difficult to walk down the hallways because the clinics’ walls are lined with people waiting to be seen.
The school we went to was well maintained and owned and operated by nuns with the help of numerous donations. Nicaragua had different health standards: we used cotton balls with alcohol poured on top instead of individually wrapped alcohol wipes. We also gave every child an albendazole tablet to combat parasites. We were able to sit in on a class they have once a month for adolescents. A doctor was talking to them about speaking assertively, being able to say no, and respecting other people’s opinions. The doctor asked them what they wanted to discuss in later classes and some of the suggestions were abortion, AIDs, birth control, and malaria. We were surprised at the serious topics the adolescents suggested.

When we were vaccinating a second grade class, the nurse asked the children how old they were (we only wanted to vaccinate children older than ten years), and most children didn’t know how old they were or their birth dates. The nurse gave them the assignment to ask their parents when they were born. Which seemed crazy…these children must not have birthday parties either.

Down by the River

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Wow, I am a morning person, but 4am comes really early. Somehow we managed to be on the road in our tourist bus by 5am. We headed north of San Jose, out of the city. Los Chiles was where we had to meet a boat. On our way we stopped and saw lots of iguanas. At Los Chiles we technically exited Costa Rica, went through immigration, then got on a boat. The boat was interesting…long, two seats on one side, one on the other. It required weight balance and shifting of some people before we got going. Everyone pulled their cameras out as we were told we would see monkeys. Little did we know that the Nicaraguan border was only a few miles up the river. Waiting for us there were a few Nicaraguan soldiers. Of course everyone was still taking pictures, which didn’t make the military men (boys) very happy. When we stopped so they could inspect our boat, one of the men came on the boat and made all of us (most likely for a good laugh) put on our life jackets!!! Lesson learned.

Next we were off to San Carlos, which sits at the corner of Lake Nicaragua, Rio Frio and Rio San Juan. We had to go through Nicaraguan immigration and then we had lunch. After lunch we returned to the boat and continued on to El Castillo. It was a beautiful 2 hour boat ride. It was so nice to pull in to El Castillo and get settled. We would stay for 3 nights and 2 days at Hotel Victoria.

We all went off to explore after we got settled. We went to see the fort the town is named after. This is where we discovered that no one in Nicaragua has change. (ASIDE: Two reasons for this—1) We were in small towns and we were tourists; 2) we learned that Nicaragua just doesn’t have much currency.) The lady taking money and one of our trip members conversed in Spanish while about 19 students stood by confused at why we couldn’t just pay our $2 to explore the fort. It all worked out in the end, and the view of the river and the surrounding region was awesome.

At our meeting that evening we learned we would be “hiking” to El Gavilan community the next day to do home visits. Then the day after that we would hold a clinic for the same community.

Flying and then some (March 14th and 15th)

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Our first day consisted of pure travel. Arriving at the airport at 430 am is not exactly my favorite thing to do. Everyone in our group made it on time and we flew to Phoenix on US Airways. I am happy they decided it was worthless to charge for beverages (including water) on their flights.

After we arrived in Phoenix we left security and parked our selves in an area with tables and chairs. We read, slept, did crossword puzzles and even played “paper basketball.” I don’t think the custodians were too happy with our group after 5 hours of lounging and bonding.

I was so happy when we got on our second flight. It was another 5 hours…yikes. My favorite part about the flight was meeting the woman in our row from Canada. She was also traveling for a mission. She had only been out of Canada a couple of times and it was to the States. This was also the longest plane trip of her life. I was happy to share it with her. She had been organizing a project for 3 years and had always sent off care packages. This time she actually got to see the children who received the packages and deliver them in person. The group from Canada was traveling to the “Earthquake Zone” in Costa Rica.

When we arrived in San Jose, Costa Rica we were met by our trip leader Marta. She is a group leader for ISL (International Service Learning). This group organized our trip. We stayed in their “Casa Concordia” for our first two nights. They had a cook that made some of our meals. We slept in bunks, which reminded me of being at camp when I was in 5th grade. The windows were open through the night and some people had trouble sleeping with dogs barking and other unfamiliar sounds startling them.

Many of us awoke by daylight—530 am. Really not too early (630am) at home, but considering we had traveled the previous day (all day), I was wishing my sleep would’ve lasted longer. Some of us decided to take a walk early in the morning. There was a nice park around the block as well as a bakery that some in the group tried.

In the morning we had class on medical spanish and tropical diseases.

In the afternoon we explored San Jose’s City Center. Since it was Sunday many families were out and about. Some of the highlights of the city center were the National Cathedral, the National Theater and the post office. For dinner we went to an area called El Pueblo. It seemed like an American Tourist Trap. We ate at a seafood restaurant. We were informed that we would be leaving the next day at 5am!!! It would be a long day of travel to our next destination: El Castillo, Nicaragua.