Friday, December 26, 2014

Look, Listen and Learn: Back to Where it All Began

There are many times when we look back at moments shared or things accomplished with our sister church in El Salvador that we just shake our heads and marvel.  The connections made and friendships built during our very first little Mission of Healing in our sister church community is one of those moments.  We had never been to our sister church community before, we knew nothing about the neighboring community, Distrito, nor the little clinic there, but the wisdom of the locals to cultivate relationships between their neighbor nurses and their new US friends has born a lot of fruit over the past 15 years.

On Friday, after a couple of days out in the countryside dodging cows and learning about rural, door-to-door medicine, we traveled back to where it all began:  the little clinic in Distrito Italia.  We were pretty excited to go there - to see if maybe some of the original staff was still there, to see how the clinic has changed since our last visit there several years ago, and to connect with the medical staff who regularly interact with folks from our sister church community.

The director of the Unidad de Salud (health clinic) was eager to meet with us, but was busy conducting an autopsy when we arrived, so we waited for a bit.  Curiously, a motorcycle was parked next to a set of stairs-to-nowhere in the middle of this strange little waiting area.  Modern art?  Physical therapy zone?  We couldn't decide.  Pretty soon the autopsy was complete and the director led us into a very nice, large, air-conditioned conference room.  We talked about the retirements of some of our friends, and others who were working in different clinics.  We were super happy to see the head nurse, an old friend.  We made good plans for working together.

Despite the fancy meeting room, it was pretty clear that this Unidad has some pretty big challenges.  They have no phone lines (apparently local thieves made off with the cable - more than once) so the doctor and head nurse give out their own cell numbers to manage emergencies.  Most communication, setting up appointments, etc. must be done in person.  As local gang boundaries shift from one community to another, the staff is flexible with accepting patients who technically should be visiting another nearby clinic for their care.  Because this area has been designated as "urban" there is no ECO or team of health promoters to travel to the homes to provide care.  This is a very big challenge, because although the communities surrounding Distrito are only a bus ride away from the city of Apopa, the families live on tiny plots and survive by living in large family groups and pooling together resources from farming rented land, working as day laborers, raising a few chickens and selling items in the market.  Poor sanitary conditions, low water quality and insufficient control of mosquito habitat greatly impact the quality of health in these poor communities.

We toured the facility.  The pharmacy was small, but seemed to have the basics.  The exam rooms were clean and most had been remodeled.  We were surprised to find a large physical therapy room with a few pieces of old yet functional equipment.  We were very surprised to meet the psychologist and two members of the art therapy team.  In a region where poverty and violence touch every family, this art therapy team is a true blessing!  We were absolutely impressed with the enthusiasm and creativity of this team, and with their availability to go out and do workshops in different communities.  We know from our years of work with the Mission of Healing that this type of healing resource in a community can do much more to heal the spirits of the people than a little zipper bag of ibuprofen.

We spent quite a long time talking with the director and all of the staff members and imagining ways in which we could work together in the future.  As the church works to develop its team of health promoters, there will surely be opportunities for the church and the Unidad to complement one another.
Physical therapy room
Gasoline for the mosquito fumigation machines

Fumigating for mosquitoes

Exam room
Art Therapy

Clinic director in the dental treatment area

Sunday, December 14, 2014

Look, Listen and Learn: Super Doctora

A calm bit of road which allowed for a photo
Another early morning and another long ride out to San Pedro Puxtla.  Upon our arrival we were excited to learn that this day was a truck day!  On truck day, the team has access to the government pick-up truck in order to deliver heavy boxes of medications and supplies to remote sites where once per month the team runs a medical clinic.  The ride to this month's remote site was "in the opposite direction of the ECO base, in an area that scares us because the gangs have come there and sometimes threaten the health workers."  It was sad for us to hear that gang activity had come to this remote location and hard to understand what possible economic value gang members could find in terrorizing these incredibly poor farmers.  We bumped along the road without incident, bracing ourselves so that our heads would not hit the ceiling of the cab.  We could not stop laughing because the bumps were incredible!  We asked if the truck had a name, and since it did not, we all agreed to name it Caballo (horse).

Delivery accomplished, we traveled down the same dirt and rock road we had walked the preceding day and arrived at the ECO clinic.  We spent the morning observing all of the operations of the clinic, noting that most of the patients where women who were expecting babies, had recently delivered babies or are raising babies.  Nutrition is a huge issue among these rural families who survive on what they can grow and store.  Many mothers receive powdered milk from a government program.

Dog vaccines are free - provided
by nurses.  The sign below says
"Don't threaten your kids with
Family Planning Information
The clinic itself does not have electricity, so the refrigerator which the government sent for vaccine storage is still in its box.  The team (doctor, 2 nurses, 3 health promoters and a utility guy who cleans and runs the pharmacy) has to run some fund-raising activities in the town in order to pay for an electrical hook-up.  La Doctora has a great educational style, and the makeshift walls between treatment areas are covered in educational posters.  The government actually requires information to be posted about nutrition, dengue/chik, HIV/STD's, and a variety of vaccines.  There was a very helpful bulletin board about family planning, however, at this clinic like so many others, the medications or devices are not available.  It seemed to us that the government simply cannot keep up with the demand nor the expense, and it reinforced our efforts to at least bring a suitcase full of condoms for the Mission of Healing.

The team treated us to a delicious lunch which was made in the community and brought to the clinic:  carne asada (stewed beef), chirmol (fresh tomato, onion & cilantro), rice and avacado.  We shared a lot of laughter around that table.  Re-energized for the afternoon, we loaded up on water and hopped into the truck for a ride out to a patient who lives quite a distance from the ECO clinic.  The story of our Super Health Promoters on that afternoon is recorded in another Blog Post.

At the end of our day, we made the long drive back to San Salvador, stopping for about an hour at La Doctora's house, where we were served delicious homemade pie and hot chocolate.  It was a huge honor for us to share in our friend's work, her friendships, her family, and her struggles.  We have often marveled at the stories she told about her work and the sacrifices she makes in order to have a job.  Now, having walked alongside her for a few days in her own work setting, we are even more convinced that she, like so many healthcare providers in El Salvador, is a Super Doctora!

Tuesday, November 25, 2014

Look, Listen and Learn: Trekking Out West

We couldn't possibly turn down an invitation to learn about the work of our young doctor friend.  After all, we have known her since she was in the university, and she has been helping us with the Missions of Healing for 6 or 7 years.  So, on Day #2 we loaded up our backpacks with water and set off bright and early for San Pedro Puxtla.  We had directions.  We had a map.  We still got lost.  We stopped many times for directions, and thanks to a really kind guy in the street who, in the rain, sketched out a map for us in his own notebook, we eventually found our destination.

Our friend (la Doctora) is the coordinator for an ECOS (Equipo Comunitario de Salud) Familiar:  a community-based family health team.  (Usually the Salvadorans just call it an ECO.)  The creation of ECOS throughout the rural areas of El Salvador has been a key strategy within the healthcare reforms that began in 2009.  Each ECO consists of a physician coordinator and support staff such as licensed nurses, technical nurses, health promoters and a driver/pharmacy person.  La Doctora's ECO is one of the first created in the country.  It is one of two ECOS based out of the Unidad de Salud or health department clinic in San Pedro Puxtla.  Each
ECO has it's remote clinic site and is responsible for the care in a large rural zone.

To get to La Doctora's little clinic, we had to walk about 3.1 miles on a rocky road - and it was HOT!  We walked off of the main road to "go see an awesome view" on our way to visit one of the doctor's patients - a little boy who was sick, and so very thin.  Malnutrition is a major issue for families in this rural area - one of the poorest zones in El Salvador.  Along the walk we saw beautiful flowers, latrines that were not beautiful, and as promised, an awesome view.  We could actually see ships on the ocean far, far in the distance.  We could also imagine that during a storm, the path would become a muddy, slippery mess.

When we got back to the main road we had only to walk for a few minutes when a pick-up came by.  We hopped in back and had an easy ride to the clinic.  The building was given to the ECO by the local mayor.  Before it had this building, the team used homes with large yards or porches.  On certain days of the month, the team still runs clinics out of homes in some of the more remote areas.  The ECO building has no electricity, so vaccines need to be picked up each day at the Unidad.  La Doctora and her team are in the midst of planning fund-raising events to raise money to put in the electrical hook-up.

The plan for the day was to go out and check homes for mosquito larvae.  A case of chikungunya had been suspected (only 1 in 10 suspected cases is actually tested due to lack of funding), so all the homes within 100 meters had to be checked.    We were with the nurse and la Doctora, while the promoters were out checking other homes.  One home was quite fancy, with a beautiful garden and a menagerie.  Most of the homes were very basic, made of adobe or stick-and-mud construction.

Before we knew it, it was lunch time.  We ate at a neighbor's home - the woman is a very good cook and the team often pays her to make their lunch.  After lunch we visited a few more homes, and then it was time to make the long walk back to town.  Luckily we got a ride!

The work day ends at 3:00 PM, when the ECO team reports back to the Unidad.  While the health promoters live within the communities where they work (and this is KEY to their effectiveness), the doctors and nurses typically travel long distances to get to their jobs.  The scarcity of jobs has created a very inefficient system in which none of the medical professionals seem to work near to their homes, and transfers take years to complete.  Despite the hardship of traveling five hours per day on the bus, la Doctora and others like her are extremely dedicated to their patients, and to their team members.

Thursday, November 20, 2014

Look, Listen and Learn: All in a Day's Work

Exterior of the Unidad de Salud
One full day.  What would we learn by spending just one full day at the Unidad de Salud in Guazapa?  It was our first observation day, so we did not know what to expect and we had no reference frame from which to make comparisons.  We were a little nervous - we did not want to be intrusive!

In the morning, these chairs are filled
with waiting patients
The local Lutheran pastors had made the appropriate arrangements for our visit and the director of the Unidad greeted us warmly.  He is new in his position, but already seemed to be a little familiar with the work of the Lutheran Church pastors and health promoters within the church.  Deb, the nurse practitioner, and I introduced ourselves as representatives of the Salvadoran Lutheran Church and its accompanying sister churches from our synod of the ELCA. (Evangelical Lutheran Church in America).  We explained our purpose:  to look, listen and learn, with the hope that we can more fully align the protocols used during the annual Mission of Healing and multiply the positive impacts of the mission by identifying ways in which the church can support sustainable care plans throughout the year.

The conversation with the director was incredibly helpful.  We explained that one day of the mission in the coming year is designated for the communities around Guazapa.  The local pastors coordinate transportation for families to travel to the Mission of Healing site - a large open-air property which belongs to the church near Nejapa.  Right out of the box the director was eager to have staff members from the Guazapa Unidad accompany the people.  They could work alongside the US team and other Salvadoran volunteers.  They could see patients identified with chronic diseases and make the plans for follow-up care.  He offered a dentist, someone to do pap smears - it was incredible!

We talked a lot about medications.  We are strongly committed to purchasing as many medications as possible in El Salvador.  We certainly have had challenges bringing medications into the country (despite following all of the customs rules), and if we can support local production of quality medications, we want to do that.  With the implementation of healthcare reforms, medication prices have come down and availability has greatly increased.

At this point, one of the pastors in our meeting said, "But the medications from the US are so much better quality than those in El Salvador."  We hear this all the time - people do not trust the quality of their locally produced medications.  The director jumped right onto this point:  "You are a man of faith, right?  You know that people need to believe in their medications.  Faith plus medicine.  There is competition now, the medications are of a good quality and people need to believe that.  As leaders, we need to model that belief for the people."

We have struggled with finding the best way in which to provide care for chronically ill patients.  Initially we did not treat them (heart-breaking for patients with blood sugar and blood pressure levels off the charts).  Then, we tried leaving a year's worth of medication with the Lutheran Clinic, but follow-up and transportation were big issues.  We told the director that by developing stronger ties with the local Unidades, our hope is to incorporate local doctors into the Mission of Healing so that right on the spot they can make the follow-up plans.  Throughout the year, local pastors can provide encouragement and support to their people who need to follow a regimen of care.

We learned about dengue and chikungunya, and the protocols for treating these diseases for children, adults, pregnant women and the elderly.  The director provided us with a wealth of useful information.  In the midst of my notes about malnutrition and the Barcelona Study, I found this memorable quote from the director:  "People need to eat foods that are REAL."  We were feeling good synergy with the director.  With it's fifteen year history, the Mission of Healing provides a place of education and encouragement, a place where medicine and faith work together, a place where patients feel loved and listened to and cared for by their church and by doctors.  We hope to be moving forward in a good way that incorporates more local healers and encourages continued care and education throughout the year.

After the meeting, Deb and I were invited to observe one of the physicians.  The doctor introduced us to each patient, asking if it was OK for us to observe.  He was very attentive, from listening to the stories of an older woman with pain everywhere to carefully reassuring a new mom with her 5-day-old baby.  During his free moments between patients, he showed us all of the different paperwork he has and gave us bits of information about his practice:

  • He sees 6 patients per hour - that is what is allowed by the government
  • He has 20 active cases of tuberculosis - and his patients come 3 times a week for treatment
  • Upper respiratory illnesses and dermatitis are the most common diagnoses
  • Malnutrition is terrible and anemia is high
  • The number of patients with high cholesterol is increasing
  • The number of cases of renal insufficiency is increasing rapidly - especially in males age 22 to 25.  It is most frequent among men over age 50 who worked in the cane fields.
  • Diarrhea from roto-virus is common due to flies and lack of hand-washing
  • Violence is a big problem with the people because "they are violent inside"
Emergency Room
One ambulance - 3 patients
In the midst of an exam of a woman with a stomach issue, the doctor received word that there was an emergency.  He motioned for us to follow, and we wound our way to the front of the clinic where the emergency room is located.  There was a man who had suffered a stroke lying on a narrow exam table and receiving IV fluids.  The emergency was a 9-year-old boy who had fallen out of a tree and suffered a broken arm.  There was a little chaos because the boy only had his 17-year-old sister with him and she wanted to go back to school.  They moved the man to a wheelchair and took him out to the waiting ambulance.  There was already a woman seated inside:  she was in the beginning stages of labor.  The boy's mother arrived and they started to load him into the ambulance, but then his dad arrived too and said he could take the boy in a friend's pick-up.  That made space in the ambulance for the older woman with the body pain.  It is routine to wait until there are 2 or 3 patients ready to go to the hospital before the ambulance leaves.  There is only one Unidad ambulance for the entire area of Guazapa north to El Paisnal.  There is no EMT - just a driver - so usually a nurse rides along if possible.

We concluded our observation time, ate lunch in little place down the street, and returned to take a tour of the pharmacy and the lab.  The pharmacy was small, but air-conditioned, which we discovered is the norm for the Unidades de Salud in the north.  This is really important for preserving the shelf life of medications in the heat and humidity.  Because the Guazapa Unidad does not have any specialty doctors, they cannot stock specialty medications (for example, their only gynecological medication was over-the-counter cream).  Still, we were pleased to see many common medications in stock, and we took note of things that are needed.  After we visited a variety of pharmacies, we were better able to evaluate the availability of medications at each location.  The lab deserves it's own special story...stay tuned for that one!

We looked.  We listened.  In just one day, we learned so much!  The eagerness and willingness of the staff to share their routines, their knowledge, their frustrations, their hopes and their enthusiasm for new connections was amazing.  

Monday, November 17, 2014

Look, Listen and Learn: Unidad de Salud

We came to look, to listen and to learn.  The two of us, a nurse practitioner and a church worker, did not come to see patients, did not come to bring medications, did not come to fix anything.  We came to look, to listen and to learn.

For nearly fifteen years our synod of the ELCA (Evangelical Lutheran Church in America) has accompanied the Salvadoran Lutheran Church in a ministry we call "Missions of Healing."  The Mission of Healing was born at a time in which the people in our sister church community and throughout poor communities in El Salvador did not have access to attentive check-ups or basic medications.  Public clinics hosted long lines of patients who would wait as long as 8 hours for a 1-minute consultation with a doctor and a visit to an empty pharmacy.  Education, especially about sexually transmitted diseases, was sorely needed.

The first mission of healing team had seven US members. We broke off from a synod delegation to spend four days in our sister church community.  Four team members worked with the teacher in the school and ran a Vacation Bible School event.  The medical check-ups took place in the tiny, ramshackle church.  The altar was the exam table.  The nurse practitioner examined hundreds of moms and babies and some men.  Her husband managed the few medicines we brought along.  A bilingual nurse from the US translated.  Nurses from a nearby town's Unidad de Salud  weighed and measured people and provided vaccinations.  The mission was grounded in a special worship service and the celebration of baptisms.

The Mission of Healing has grown and changed as the needs of the people have changed.  Fifteen years after its founding, the Holistic Mission of Healing (Misión de Sanación Integral) currently provides a healing experience for people in more than 30 Lutheran Church communities.  The people are bused to two different sites during two weeks of work. Spiritual healing through prayer and massage and educational charlas (chats or discussions) are a main focus.  Salvadoran doctors volunteer alongside US doctors.  Most medications are available and purchased in El Salvador.  The eclectic, healing team consists of about 60 healers (each week) from the US and from El Salvador, always with the accompaniment of the Unidad de Salud.  

What is the Unidad de Salud?  Healthcare in El Salvador is delivered via a tiered system.  Private hospitals and clinics are available for those who have plenty of financial resources.  Workers in the formal economy and their families have seguro or insurance which gives them access to a system of clinics and hospitals.  Medications (if available) are provided without additional cost.  The Unidad de Salud or Health Ministry provides free healthcare for everyone else - about 50% of the population. Anyone can go to the local Unidad clinic for care, and if the patient is insured, the Unidad is compensated.

Beginning in 2008, the national government in El Salvador began to implement a series of healthcare reforms to improve the accessibility and quality of healthcare for the uninsured population.  During recent Missions of Healing, caregivers have noticed the positive effects of the reforms.  As coordinators of the missions, the nurse practitioner and the church worker wanted to learn more.  The two of us received an invitation from the Unidad de Salud in Nejapa to come for an extended time to observe and participate in the daily work of the doctors, nurses and health promoters.  In October 2014, the two of us spent three weeks in the northern zone of El Salvador, with the amazing and caring staff of several Unidades de Salud.  In each location, we introduced ourselves and explained that we were there to look, to listen and to learn.  We were warmly welcomed by each Unidad director and given complete access to observe all aspects of care...and we have some amazing stories to share.

This is the introduction to a series of posts about our three weeks with the Unidad de Salud in the northern micro-region.  My friend and I want to express our deepest gratitude to SIBASI Norte and all of the staff members who shared their time and insights with us.  We believe that the strong connections between the church and the health ministry will be mutually beneficial to the patients and those who care for them.

Thursday, November 6, 2014

Off the Beaten Path: Mike Mike

Sometimes it happens.  Plans fall through, transportation becomes a challenge, walking is not an option, so even if it is not your plan A for the day, you end up hanging out at Metrocentro.

If you live in San Salvador or visit San Salvador, you know about Metrocentro.  It's a mall.  It's gi-normous.  It's a bus-hub. You go there to window shop.  You go there to meet up with people.  If you are part of a delegation, you go there to run errands at the Dollar Store or Super, or you walk in circles trying to find the food court.

One day, recently, a friend and I found ourselves with plans that just could not get organized and there we were, with several hours to spend at Metrocentro.  We decided to embrace the experience, walking and walking, eating and eating, shopping and shopping.  This was hard-core, delegation-leader research:  figuring out which food courts have the best seating, which fru-fru coffee drinks are the tastiest, which places have fee wifi, and where to buy the cutest gifts for grandchildren.  We actually did learn some useful information and when we need to run to the mall with a group for food or stuff, we will actually be able to navigate without getting lost (hopefully).  One of our best finds came near the end of our Metrocentro adventure - Mike Mike.

We went in because we both love purses.  We did not NEED purses, but we saw no harm in looking.  I picked up a bag - good price, well-made, made in El Salvador.  I asked how long the store had been in business and the guy at the counter said 49 years.  I asked if everything was made in El Salvador and he said yes.  Huh, how is it that in all my Salvadoran adventures I had never learned about Mike Mike.

I bought a lunch box.  Seriously, I love this lunch box.  It is the best lunch box I have ever used.  It cost me $14.95 and I paid $6 for an adorable beach bag (perfect for a computer) as a "premio" for spending more than $10 on my first item.  The staff was super-friendly and kind, answering all my questions and allowing me to take photos.

There are Mike Mike stores located all over El Salvador.  They are on Facebook and have a web site.  The prices on the site are definitely higher than in the store, so if you are ever stuck for a day at Metrocentro...check it out!

Saturday, November 1, 2014

The Horse-Rider of the Night

Photo taken in the Cultural House in Dulce Nombre de Maria, Chalatenango
If you search the internet for Caballero de la Noche (literally "Cowboy of the Night"), you will find an endless list of references to Batman.  However, throughout the countryside and small hamlets of El Salvador, a question asked about the Caballero de la Noche brings forth tales of fear and the devil...

The Horse-Rider of the Night is a being which causes panic and fear.  Of course, if the Devil appeared to us as himself, we would die of fright because of his monstrous image.  But as you know, the Devil is a clever devil, and to appear as an ugly animal would be absurd.  So he appears in the most attractive way possible.

It is said that a long time ago, some land-owners suddenly disappeared, and then some reappeared as dead horsemen with insides made of nothing but straw.  How did this happen?  It is said that whenever bad luck surrounded men or for reasons of life they despaired, they would call upon the devil in search of help.  Without wait, suddenly a thick swirl would form and a rider appeared, very elegantly perched on a powerful horse.  With gleaming stirrups and a grand cape, his business was to buy souls.  It pleased him that there were those who would invoke his name and accept offers of money, women, luck, a future for their children and riches in exchange for their souls.  The Horse-Rider would give seven years to his customers, during which they could enjoy all that he had offered them.  After the seven years, he would return to claim that which he had bought.

Tuesday, October 28, 2014

The Squeaky Cart

In honor of is the story of La Carreta Chillona
This photo was taken in the Cultural House in Dulce de Nombre de Maria, Chalatenango
Throughout El Salvador, the midnight sound of squeaky wheels rolling down pavement or cobbles or pathways of a town brings fear to those who hear it.  The cart passes by at the time when everyone should be asleep, so that none would be exposed to the company of cadavers traveling by cart on their funeral route.  Some believe the cart is filled with the bodies of those who have dared to look upon it as the cart passed by.

Historians believe that versions of this tale were spread throughout the Americas by Spanish rulers, who wanted to discourage the local people from venturing out after dark to conspire against them.  The story was used as a threat to anyone who was caught in the street.

In the hills near San Vicente, the people tell a particularly gruesome version of this tale...

One evening, the haunted cart appeared to a very gossipy woman.  The cart appeared to be moving, but no oxen were pulling it.  Human skulls with grotesque, grimacing faces were stuck onto the tops of sharpened poles on the sides of the cart.  The cargo consisted of a grand pile of naked, decapitated bodies, with arms and legs writhing like the tentacles of a thousand octopi.  In place of their heads, the body-carriers had bunches of grass. They danced around lashing the bodies with a big black whip, making a horrid sound like bullets, and all the while calling out the names of the people of the town who were known liars, cheats and hypocrites. The gossipy woman could not contain her curiosity when she heard the sound of the haunted cart.  She went outside to look at it, and her horror was so great, that she woke up dead*, lying in a pool of her own curious, gossipy, revolting blood.  And the sound of the squeaky wheels of the haunted cart has never been heard crossing the cobblestones of the town since that night.

*"woke up dead" is the way that the people tell the interesting phrase, I think.

Monday, October 27, 2014

Mujeres Emprendadoras: Women Developing Small Businesses

"See you at the fair!"  As we made our way to church early in the morning on Sunday, women from the community made their excuses and made their way to the bus stop.  Church is important, but the opportunity to market themselves and their products took priority.

After worship, we made our way to Tonacatepeque, to the sidewalk in front of the mayor's office.  The fair was small, but the mood was hopeful.  There were not too many people buying things.  We wondered how well the event was promoted to customers.

We wandered from table to table, and we did do a little Christmas shopping - which means our purchases are still top-secret!  I asked if I could take a photo of the woman who sold me a beautifully crocheted a memory for the person who will receive the gift.  This creative business woman also sells natural medicine made from herbs in her garden.

The hand-made items ranged from embroidered cloths and blouses, to knit and crocheted items, to hand-sewn skirts and tops, to beaded jewelry.  Some of the women purchased items such as sandals and hair clips for resale.  Some of the women had brought things from their homes to sell, such as used clothing and toys.  Of course there was food, so we ordered a slice of pizza from the baker.  (Pizza is often sold at bakeries in small towns in El Salvador.)  It was one of the best slices of pizza I have ever eaten!  Since the pizza was so delicious, we decided to buy small loaves of orange bread and banana bread from the same baker.  We were not disappointed!
We were excited to see our friends from the Unidad de Salud (health clinic) participating in the fair.  They were ready to take blood pressures and give vaccines.  It was also a great opportunity to hold up the professions of female healthcare workers in the community.

Each of the entrepreneurs had a turn speaking into a microphone.  Their voices echoed from gigantic speakers across the town square, inviting people to come and see what the women have learned and what they were selling.  We applauded for our friends, and then walked across the street to the town's market.  Men and women entrepreneurs have been selling their wares in this market for years.  About 60% of the booths are dedicated to local fruits and vegetables.  The remaining tables feature everything from underwear to plastic plates.  It's not exactly a tourist stop, but we did find a couple of cute things for grandkids (again, top secret), some undies for a little girl who has none, and some mamones de China (lychee fruit).  The market is damp and dark, under black plastic sheeting or corrugated tin roofing.  It is supposedly going to be relocated and remodeled.  Perhaps the new entrepreneurs are thinking about putting their businesses into the market.

We walked back to the mayor's office.  Soon the music started.  Street music in El Salvador is never quiet and this did not disappoint:  super loud karaoke, sung by the local school's music teacher.  He was pretty talented, and a couple of the grandmas started dancing in front of the sales tables.  They were both much less than 5 feet tall, had great smiles and demonstrated some pretty sweet moves!

We enjoyed the music and dancing for a while, and then headed back to our sister church community.  We felt really proud of our sisters' business efforts.  Hopefully the movement to help women create sustainable small businesses will not end with the fair.

Friday, October 24, 2014

Just Click: San Salvador 2014

Every now and then, I take a ride through San Salvador with my camera at the ready.  I stick it out the window and click...never knowing what images I might capture.  Despite the rainy weather, I managed to collect a few images from October 2014:
Arbol del Fuego - Tree of Fire -- blooming in full force all
across the city and countryside

It's hard to appreciate just how closely we drive next to the buses
when in the center of the city

This photo is not auto-corrected - this is the real color of the sky
on this day...the blue and white of the sky reminded me of
the Salvadoran flag...which, appropriately, is flying next to the
monument to the constitution

The mayor's office in this municipality adjacent to San Salvador
has a huge problem organizing trash pick-up

Along the round-abouts on the north side of the city, people
sell a variety of things, from coconuts to furniture.  During October,
kites are for sale because the winds usually come and it is the
month of the child

Mural along Constitution Blvd

A new twist on an old favorite - green mango with chili!
The mango is put onto a spindle and rotated and cut to create
long spirals of mango (in the bags) - add the magic powders
and sauces and you have one of my favorite treats.  (You
can recreate this in the US with green apples, cumin, lime juice
and chili sauce.)

When the October winds come, so does cold and flu season.
Salvadorans really love their cough medicines...and many people
know how to make them from the plants in their gardens!

On the northern outskirts of the city, Nejapa Power has expanded
its diesel power plant.  This formerly wooded valley was cleared for
sugar cane, and now the cane competes for land space with factories
and housing developments.

Thursday, October 23, 2014

Fighting Chik

Chikungunya.  Most Salvadorans just call it "Chik."

Chik scares people.  "Our bodies have no memory of this disease, so we cannot fight it."  It runs through family members in rapid succession.  Data indicates that the majority of victims are teens and young adults.  Parents are frightened to see their energetic youth suddenly stricken by fever, severe headache, joint pain and a red, itchy rash.  For some, the joint pain is so severe that victims cannot walk or stand, and pain seems to linger in the wrists after the other symptoms have passed.  For some, rehydration with IV fluids is needed.

Clinics are inundated with cases of Chik.  Doctors are seeing four times the number of patients usually seen in a day.  Pregnant women, people with chronic illnesses and high-risk patients are hospitalized.  Treatment consists of taking acetaminophen for the pain and drinking lots and lots of fluids, especially Suero.  For some, complications occur when patients take ibuprofen or other pain reliever and damage is done to the patents' kidneys.  For some, joint pain can be permanent.  For most, the disease lasts a miserable seven days, and then the patient is fully recovered.

Chik is spread by the same type of mosquito (called zancudo) which spreads Dengue.  Zancudos are day-biters.  An infected person receives a bite; the zancudo bites another person and shares the virus with that person.   While Chik is scary, Dengue can be deadly.  The ramped-up efforts by health departments, clinics and mayors' offices to fight Chik are efforts which should be (and often are) used to fight Dengue.

The best defense is to eliminate the habitat for zancudo larvae or to eliminate the larvae once they hatch.  Larvae develop in clean water, like the water kept in pilas (the big cement sinks used to store wash water) and barrels for drinking.  Barrels must be kept covered.  Pilas must be scrubbed periodically and outfitted with a little bag of premethrin or be a home for a couple of tilapia which eat the larvae.  Zancudos also like to lay eggs in places where rain water collects, which means every bottle, cup, plastic bag, plant container, or depression in a rock, must be searched for larvae.  In neighborhoods where there is no trash collection, this is an overwhelming task.

After walking all over El Salvador with health promoters on larvae-patrol, my friend and I became obsessed with looking for larvae.  When we visited homes we found ourselves gazing into the pilas, and meandering about the yard flipping cups and containers upside down.  Sometimes we would find a duck on the premises which made our search easier:  ducks eat zancudo larvae.  With this rainy October being especially wet, the task was never-ending.  Old tires are especially popular locations for larvae.  "Bury them and fill them with dirt," is the standard instruction.  At a little celebration which was held for us at an elementary school, we decided to give have a charla (educational talk) about larvae, and we took the kids out on patrol through the school yard.  Sure enough, we found some swimming around in a pool of water in a plant container which had no holes in the bottom.  The teacher was horrified!  The next day she planned to fill all the holes in the big pile of volcanic boulders with dirt so larvae would not hatch in the holes.  Every now and then we would find a yard with a duck.  Since ducks eat zancudo larvae, we did not have to check the cups, bowls or containers on the ground.

When larvae patrol is not successful, and pupa develop into zancudos, officials bring out La Bomba.  Fumigation is a last resort in the minds of health officials.  The chemicals are expensive, cause allergic reactions in many people and are dangerous for people with asthma.  Bomba sprayers usually wear gas masks.  Big cans of gasoline are stored at the health clinics for running the bombas.  The general public asks for fumigation - they like it because it is easier than hunting for larvae and it does kill the zancudos.  To us, the bombas seemed much more scary than Chik.

As news travels around the world about one frightening disease or another, Salvadorans are mindful that the challenges of poor infrastructure and many people living in small spaces make the population susceptible to infections which run wild.  This is the root reason behind the fear and furor surrounding Chik.

My friend and I want to hold up the amazing efforts of the ECOs and Health Promoters (government and church promoters) throughout El Salvador who are working every day to educate families and mitigate the risks to the health of the Salvadoran people.  We also think every family should have a duck and a couple of tilapia.

Friday, October 10, 2014

How can this be?

The town is small.  The municipality is large.  The small government clinic attends to the needs of people who do not have healthcare.  These are people who work in the informal economy and much of the care is centered around pregnancy, birth, the care of young children and of old women.  A few men come in for check-ups and vaccines.  This community north of San Salvador includes a broad range of living conditions, and the care area is huge.

Today we accompanied the chief doctor, the head nurse and a health promoter as they did a home visit to investigate the death of a 2 year old boy who reportedly died of malnutrition.  We were told to prepare to walk a long distance.  We were told to carry water.  We were told that the child died because the family did not care for him properly.  There were many things which were not told.  The reality of this dead child's short life and the lives of others in the home leaked out secret by secret, breaking our hearts bit by bit.

A little boy was the first to greet us.  He is six years old, very small with stick thin legs and arms.  He wore a "necklace" which was an old waistband from a pair of men's underwear.  The health promoter pointed out his little stool where he could sit with us on the veranda in front of the adobe house.  The grandma moved the stool to the other side of the veranda, away from us.

The doctor took a stapled pack of papers out of her metal clipboard case - the baby's medical chart.   On the back of the last page, she began to take notes:  the exact age of the deceased (2 years, 2 months and some days), the circumstances of his birth, the history of illness, the comings and goings of the family members.  The baby's mom is 19 years old.  The grandma cares for the six year old.  His mom and dad were both murdered.  The grandfather works.  There is no food.  The goats gave milk, but now they don't.  There are plants all around, but there is no food.  We saw a sack of grain in the house, but there is no food.

The health promoter and nurse had been to the home many times in an effort to educate the family and care for the boys.   As the doctor asked questions of the grandmother, the nurse opened her big red bag and pulled out an apple.  She gave it the little guy; then out came some packages of vanilla cookies and some grapes.  He held it all in a little bag, and would not eat anything despite much urging.

A field of low growth and a family of goats stood between us and a less-sturdy home made from corrugated tin.  As we talked, a young woman quietly emerged from the tin house and walked toward us.  She wore a faded yellow Sponge Bob shirt, and a tattered maroon skirt which was decorated with a few dirty stickers.  She sat on a concrete block behind my friend.  We rearranged the plastic chairs a little so that she was in the circle.  In a few moments, she was standing behind my friend, hiding.

"How old are you?" the doctor asked the grandma.  She did not know.  "What year were you born?"  The grandma paused and said, "I cannot say.  My man has the papers and it is for him to say."

"What happened on the day the baby died?"

"He was tired from breathing.  He was making a noise.  I put him on the bed.  I left to do something.  When I came back, he was dead," the grandma recalled.

"So, you left him to do something and then he was dead?"

"He died in his mother's arms."

It wasn't clear who was caring for him when he died.  It was clear that the mom, hiding behind my friend, was choking down her emotions.  The doctor asked questions about the nurse's visits and the promoter's visits.  The investigation concluded, and the team focused on talking to the two women about nutrition for the 6-year old.  I walked over and crouched near the little boy.  He was enjoying the company of the dogs and ducks who wandered about the patio.  "He can eat duck soup, or fruit from the garden or a little bit of flour"  I walked over and crouched down next to his seat.

"Are the ducks your friends? Like the dogs?  What do the ducks say?  Quack, quack..." I made funny duck sounds.  The little guy smiled.  I quacked and woofed and he giggled a little.  I pulled a grape from his bag and encouraged him to try it.  The doctor had finished her questions and she came over, pulled a cookie from its wrapper.  He took a tiny bite.  The 19-year old never said a word.  She smiled a little, all of her front teeth were gone and her back teeth were rotted black.  I slipped over to her corner and whispered in her ear,  "Do you have someone to talk to?  A pastor or priest?"  She nodded.  "You can talk to the health promoter or the nurse, whomever you trust.  You have the right to live your life."

We walked a distance away from the house, and I turned and motioned to the sad mother whose baby had died from malnutrition.  She paused and waved a little bit, posed with a slight smile, and I took a photo of her standing half-hidden behind the pila (concrete sink).  I turned and walked down the mud path past the latrine with no walls, to the barbed wire gate, and down the muddy rock trail to the road.
The health promoter needed to visit additional homes.  She headed up the hill, carrying the vaccine box and waving good-bye.

The rest of our team turned and headed back to a main road.  We walked quietly for a bit.  "I was there for the vigil," the nurse shared.  "There was no light, no candle and not one flower on the caja (coffin or box).  The family did not even have one cup of coffee for the guests.  I went and bought some things for a proper vigil."

"The father is a big man, very dark  Sometimes I would come and there would be a huge quantity of dogs viciously barking.  They were there when the man was there.  He controls everything.  No one can talk except him.  The boy would not eat anything unless the grandma said it was OK.

The grandmother had told us that she and her husband slept apart.  "He's too hot," she complained.  We laughed awkwardly at the time.  We walked back toward the main road.  The nurse spoke quietly:  "The husband is in a sexual relationship with his own daughter.  We think he is with the three daughters, the one out with him now is beautiful so he takes her.  This one is not so beautiful, but he is with her when he is at home.  The baby was his child.  There was another baby that died when it was six months old.  Neither that one nor this one had a proper funeral.  I was there.  No flowers, no candles, no coffin.  The body was put in a cardboard box, like an animal.  He buried the box in the yard.  No cemetery. Like an animal."

We were all worried about the little boy who would not eat even a grape without permission.  The nurse said the grandma would eat that food.  The boy has no one to care for him because his parents were murdered.  His mother was pregnant and very large when she was killed.  We asked if it the deaths were related to gang violence.  The nurse said it may have been that, or some kind of internal justice.  The baby she was carrying was probably the grandfather's.

The more that was revealed about this family's horrific existence, the more we struggled to figure out how this could be.  Where were the police?  Where is the protection for the daughters, and the little boy?  "We could make a denunciation," said the doctor, "but we have no evidence, only suspicions.  The threats will then come to us and we will lose our lives."

Later in the day we sat in on a big group meeting at the civil defense/youth center.  The doctor spoke about the morning's investigation.  The police will probably try to investigate, but they will have to be careful not to cause trouble for the medical team.

In the meantime, a little boy and a family of women live under the oppression of the grandfather,  We carry with us the tragedy of this family and ask,  how can this be?

Monday, October 6, 2014

Super Health Promoter!

We drove down the second most bumpy road of the day.  It was a long distance from the clinic, too far to walk for a child or for a mom who is weak from illness.  It's no wonder the mom missed her appointment.  The doctor or the health promoters sometimes walk to visit the patient, but with today's access to the health ministry's pickup truck, the team was able to drive.  As we bumped along, my friend and I almost wondered if it would be easier on our bodies to walk than to be jolted side to side, despite the hot sun.

The two of us are shadowing a community-based family health team (called an "ECO").  Healthcare reform was implemented during the Funes administration, and the Salvadoran government continues to work to increase the number of ECO's in rural communities.  This ECO is based in a converted community center and depends on the cooperation and fund-raising capacity of the local mayor's office, community leaders and the medical team in order to be sustainable.  The team is made up of a doctor, a nurse, three health promoters and a utility guy who runs the appointment desk, does the cleaning, dispenses medications from the pharmacy and drives the pick-up.

We arrived at the patient's home in the mid-afternoon.  We hopped out of the truck and were greeted by cows.  Big cows.  "Two months ago, a guy got killed by this bull," the doctor told us.  "Really?" we asked.  She was dramatic.  She did not want to through the cow pen to get to the house.  Suddenly one of the health promoters, a small man with bright blue eyes and a lively spirit, leaped over the barbed wire and ran through the cow yard waving his arms and shouting "yee-ha" like a cowboy.  He ran to the house to see if the cows could be relocated.  The nickname we gave him earlier that day, "Super-Promotor de Salud," was sure to stick after this crazy stunt.

A few minutes later, Super Heath Promoter returned with bad news, the cows could not be moved.  He told us the cows would not do anything to us, so, one by one we ducked through a space in the barbed wire and walked by the cows.  The yard was soft with black dirt and a little bit steamy with fresh manure.  The doctor, my friend and I were welcomed by the patient into her home.  "Come in, sit down," she insisted.  We sat on plastic chairs.  The only light coming into the adobe house was through the open door.  A small table in the corner was covered with a torn red lace cloth and piled high with the family's belongings.  a few things hung from the ceiling.  The doctor and the patient spoke quietly.  Diabetes, hypertension, HIV, dental problems.  The dentist comes once per month.  She would see the dentist on Monday, but did not want to stay for an appointment with the doctor because she wanted to go to her daughter's school for the Day of the Child festivities.  The next clinic day would be Thursday.  "Will I live until Thursday?" asked the woman.  She was serious.  "Come on Wednesday.  I will make a special time for you," said the doctor.

A young face had been peering around the curtain to the back room of the house.  As the doctor and her patient finished talking, the little girl came to sit by her mom.  "Good afternoon," we smiled, "nice to meet you."  We asked if she would like to have her picture taken.  Her mom sent her back to get her shoes.  She stood in the doorway and she smiled for her photo.  No one from far away had ever visited before.  No one had ever taken the little girl's photo.  Maybe the doctor can take a printed copy to the little girl.

We were thanked for our visit.  What a surprise to have guests from so far away.  We picked our way back through the cows and the poop.  We ducked through the barbed wire.  We got back into the truck.  "Will she come for her appointment?"

It's a long way to walk.


Monday, September 1, 2014

The Corn Fiesta

After marching with flags, balloons and a few thousand other Lutherans through the hot, sunny streets of San Salvador; after listening to speeches, admiring community banners, honoring the king and queen of the national youth group, singing a couple of songs and clapping wildly for the youth dancers; after listening to the story of the Subversive Cross; after meandering over to Pizza Hut for a quick lunch and a bit of luscious air conditioning ... we were ready to celebrate corn.

Every year, the Corn Fiesta is celebrated on the afternoon of the Anniversary Celebration for the Salvadoran Lutheran Church.  A few years ago, the planning for the Corn Fiesta was turned over to the youth.  Maybe this is a way in which to make an old tradition seem fun for the younger crowd.  As the afternoon sun baked the pavement, gringos piled out of their little buses and Salvadorans emerged from their community trucks and cars, and headed toward the covered area near the big portrait of Jesus.  People gathered in the circle of plastic resin chairs. There was a little bit of waiting-around-time, an opportunity to meet up with delegations from different parts of the US and Europe.  You never know who you might meet at the Corn Fiesta!  This year:  Bavaria, Washington DC, California, Minnesota, and Wisconsin.

Bishop Gomez traditionally begins the fiesta by recognizing the Mayan ancestors' cultivation of corn and their story of creation in which humans were formed from corn.  Thanks and praise were given to God for the harvest. A drought has destroyed the corn crop in about half of the countryside.  It seems difficult to celebrate when the food situation is so dire for so many, and might explain why several Salvadoran communities were not able to participate in the day's events.

The youth band from Soyapango provided dance music - not your average corn-fiesta-folk-music, but some pretty hard-core rock.  Refreshments were served:  the central moment of the fiesta, when each guest receives a hot ear of corn wrapped in a small white napkin and rich atol de elote (corn milk) served in a styrofoam cup.  As we sat in a patch of shade munching on the corn, someone commented, "This corn is dense.  It really fills you up.  It's a meal."  I think that pretty much describes the role of corn on the Salvadoran table...whether eaten off the cob or as tortillas or tamales, corn is a high-calorie food which fills you up.  Salvadorans are people of the corn.

Most of our group loved the corn milk.  Seriously, these particular Lutheran Church women make the best corn milk I have ever tasted.  It is smooth, not chunky, with real cinnamon and no floating corn silk. My opinion aside, one of our guys just could not drink it, "I just don't like this stuff."

His comment made me think about the previous August.  During that trip, our delegation spent a lot of time visiting families in their homes.  Everywhere we went, as a gesture of hospitality, families offered us plastic chairs in the shade, boiled ears of corn from their milpas, and styrofoam cups full of steaming atol de elote.  We spent a lot of afternoons picking corn silk from our teeth and sweating our way through hot cups of corn milk.  Near the end of the week Pastor Santiago whispered in my ear, "The group is really eating all the corn!  I am surprised.  Are they all OK?" We just had to laugh about the corn and corn milk which was brought out everywhere we went!  We were always so full!   I did write down one comment in my journal from the last day:  "It's just so hard to drink another cup of this stuff you have to chew!"  On the next page is a big stain labeled with the words, "Julia's corn was here."

People created from corn, corn tamales, corn pupusas, corn tortillas, ears of corn, corn milk, corn fiestas...that's a lot of corn!

Like most people in the Americas, I have a relationship with corn.  When I was a kid, there were a couple of weeks every summer during which we ate corn for lunch and corn for dinner, ears of corn drenched in butter and salt.  We purchased bright yellow sweet corn from local farmers - small ears for the kids and big fat ones for Mom and Dad.  Sometimes the corn would be a little tough and my dad would say, "This is field corn."  We chewed our way through it, hoping the next kettle-full would be tender and sweet.  We froze corn for the winter.  Today, the corn at my grocery store is pale yellow and white and every ear looks the same.  I buy corn from small farms.  I think about genetically modified seeds, mono-culture farming, corn production for animal feed, ethanol production and the impact chemical farming practices have on the environment and our health.  I have learned some things about corn production in the Americas.  I need to learn more.

The Mayan ancestors established corn as the source of daily bread, as the stuff of survival for the people of El Salvador. The Corn Fiesta brings honor to this simple grain which provides Salvadorans with calories and full stomachs. At this year's fiesta, after the refreshments, the youth drum corps from the bishop's church played some high-energy music.  Dancers gathered to step and jump to the rhythms.  It was a great testimony to the rich energy which corn provides for the people.

The Corn Fiesta happens on a very full and busy day, both for the Salvadorans and the visiting delegations.  The fiesta provides time to give thanks and celebrate and taste and enjoy.  It is an honor and a blessing to share in the celebration.  I believe it is also a responsibility to reflect upon the experience and upon our own relationships with corn.

During this year's visit, our delegation ate corn with a family at an organic farm where Bishop Gomez provided seeds that had been saved by indigenous people.  The site provides classes for farmers to help them move away from chemical-dependent seeds and practices.  There, we learned about compost and natural insect repellent -- knowledge we can apply in our own gardens in the US.  At this year's fiesta, we ate and drank corn which was grown in a large organic garden, tended by students and adults and which produces food for the meal program at the Lutheran homeless shelter.  This garden is supported in part through Lutheran World Relief.

When we eat corn, when we eat animals which eat corn, when we use products made from corn, it is good to ask ourselves, where did the corn come from?  how was it grown?  how did its production impact the environment?  how did its production impact small farmers and family farmers?  Whether we are connected to the Mayans through ancestry or geography, as Americans we are all people of the corn.