Thursday, May 21, 2015

Look, Listen and Learn: Learning Lessons from Dad

The team carrying record bags and the vaccine cooler
We walked to a ridge on the side of the
volcano, where there was a welcome breeze
"It's not about the numbers, but the person."

The list of visits for the day included the names of 74 children.  Of the 891 persons living in the neighborhood, 74 were under 5 years of age, and their vaccination records needed to be checked.  In communities with health promoters, the vaccination rate is 100%.  Each family receives 8 visits per year, for vaccinations, holistic education, and water monitoring. Keeping track of water storage and disposal is critical in the fight against dengue and chikungunya.

Vaccination records are kept by the promoters in plastic-covered notebooks.  These log books are meticulously scrutinized by the clinic directors, and by the bosses of the clinic directors.  Each child or adult keeps his or her personal book of vaccination and medical records at home.  Children have green books.  Pregnant women have their own special books.  The information in the patient books is cross-checked to be sure that it matches the information in the clinic notebooks.

"It's not about the numbers, but the person."

Elias said that.  He has been a health promoter since 1982.  We walked under umbrellas to fend off the sting of the hot sun.  "Rattle, rattle, rattle," we shook the gate or "knock, knock, knock" we rapped against the metal door.  "Hi, we're here from the Unidad de Salud!  Bring your tarjeta (vaccination record," the nurse sang out.  Sometimes we were invited inside.  Sometimes, vaccination books were poked at us through holes in barbed wire fences.  "There was trash and smelly water EVERYWHERE," I recorded in my journal.

Elias talking with a young mom about hygiene
As we went from home to home, Elias poked his nose into the pilas (water storage basins) and containers, looking for mosquito larvae.  "A few little tilapia will eat those larvae right up."  Tilapia seemed to be the preferred method of pest control here, as opposed to the permethrin sachets which are also commonly used.  Every now and then, Elias would sidle up behind the nurse and female promoter to listen more closely.  "Have you had your annual pap smear?" he would occasionally interject, following up with a little speech about how important it is for women to have annual gynecological exams.  He was very comfortable in his role:  The Team Dad.

Literally, Elias is the Team Dad.  His daughter became a health promoter in 2008, and works right along side her father.  Watching the two of them working together was quite a treat.  He watched his daughter with pride sparkling in his eyes.  She nurtured the relationships which he had grown over the years.    We met families who lived in a wide set of circumstances.  Our route came to its end in a neighborhood which had a wide street and homes made of concrete block.  The morning shift of school let out, and a big group of kids ran down the road to greet us.  "Hello!"  "Good afternoon, how are you?"  Children are always eager to try out their English on a couple of native speakers.  We walked up to the school to visit an adult technical training program for aspiring beauticians.  If we return, they will want to cut and dye our hair!

Beauty School Class
Practically melting from the long walk in the sun, we decided to wait inside a little cafe for the pick-up to come and get us.  The cafe consisted of a few picnic tables under an awning outside of someone's home.  Pupusas were frying on the griddle, but it was too hot to think about eating.  We talked about the morning's visits, marveling that out of all 74 children, only one needed a vaccination in order to be up-to-date.  The conversation became a little more serious as we spoke about struggles with violence in the neighborhood.  Elias was the dad, the protector:  of course it was best to sit inside while waiting for the pick-up. Sometimes we are oblivious to the care which is being given us. The hostess brought out ice cold orange soda for our little group.  She refused payment, just delighted to give us this small gift in gratitude for our visit and for the work of the health team.

Vaccination delivered.
We returned to the clinic, and said our good-byes, and we were all just a little bit sad.  Our week working with the Unidad de Salud in Nejapa was amazing.  We learned so much in just one short week and gained incredible respect for the community-based work of healthcare professionals who bring basic care and education to the people who are most in need.  The openness of the Unidad de Salud to team up with the Salvadoran Lutheran church is a huge blessing and an opportunity to bring improved access to quality healthcare to people who live in poverty.








Monday, May 11, 2015

Look, Listen and Learn: A Little Farther Up the Volcano Road

 We hiked back up the rocky trail to the highway, back to our vehicle.  We drove a bit further up the road to our next location.  Not too far off of the highway, we found the 3-year-old girl who was the next one to be weighed and measured by the health promoter.  Before we could attend to the little one, the child’s mother and her sister began to tell us of their own health issues.  One of the young women complained of extreme stomach pain and had a leg injury.  We could tell that she was very swollen around the middle, and the dressing on the leg looked pretty scary.  Promoter Yani was very patient, listened, gave the sisters the speech about HIV and the need for yearly pelvic exams, and helped the sister with the injury to make an appointment at the hospital for the next day.  Yani looked around the large yard and identified a few plants which the family could harvest to improve their nutrition.  Overall though, there were not many fruits or vegetables in sight, though there were various herbs and greens.  The small corn field seemed to belong to someone else and maybe as the caretakers, they were allowed to keep some of the corn.

It was time to examine the little one.  The first order of business was to dump the urine out of the girl’s plastic sandals and to take off her wet panties.  Yani hung her spring scale in a tree, lifted the little girl and placed her into the sling.  She read the weight, scooped her out, gave her a hug, and set her back down to play before recording information in her medical log.  All the while, Yani spoke to the sisters, “It’s important that your daughter learn to use the latrine.  When she has an accident, you need to bathe her.  Wash her bloomers and when you hang them up to dry, be sure to hang them right-side-out so flies do not land on the inside and leave germs which can contaminate her vagina.”  Yani spoke kindly, but in a way that let the sisters know she was serious.

We shared hugs and playful moments with the little girl.  We left worrying that the sister with the swollen belly and leg injury would not keep her appointment at the hospital.

We walked to the highway and went a little further down the road to visit a family with a preschool girl and a 5-year old boy.  The boy was a little gentleman, chasing the two diligent guard dogs to a safe distance and then sitting calmly on the porch in his 5-year-old-sized chair.  His sister was afraid that she would get a shot.  This is one of Yani’s challenges – convincing children that she is more than just the “vaccination lady.”  After the children were weighed and determined to be healthy, we learned about the family kitchen.  The mom and her sister talked about the great amount of time the generations of women in the household spend cooking and telling stories in the kitchen.  Deb and I could feel the love centered within the family kitchen, and thought about how in our own homes, generations of women gather together to cook, share recipes and wash the dishes. 



 

 We visited a family compound which housed more than 25 people, sons and daughters, grandsons and granddaughters with the Grandma and Grandpa heading up the household.  Little ones were weighed and measured while older children got ready for school or watched us with shy smiles.  Moms did laundry – there was laundry hanging everywhere – all washed with collected water.  Water totes, cisterns and barrels were tucked into every corner amidst squash plants and herbs.  The system was designed to catch every bit of rainwater via a system of roofs, troughs and gutters.  The only source of water for this family, as for most of the families who live on the side of the volcano, is the rain.

We walked below a large and low trellis, home to cucumbers and lorroco, and ducked our way into a little patch of sun and into the next home.  A pink bike was parked in the sun, next to a crouched old man.  “Is he OK?” we gently asked Yani.  “He’s just cold,” she replied.  As in every home, we were treated like dignitaries.  Benches were cleared so we could sit.  The grandmother and two young mothers sat and chatted with us.  The grandfather crouched, his feet flat on the ground, his arms clasped around his knees, his head down – he did not move.  The six-year old boy turned the bicycle upside down in the yard.  He turned the pedals and checked the chain.  The babies were weighed, the mothers were counselled, the grandmother chopped onions, and I was mesmerized by the boy with the bicycle.  He went over to a white tool bucket and took out a small tool or two.  Pretty soon he had the bicycle chain off and then on again, had tightened a couple of screws and was riding in tiny circles next to the grandpa.  When it was time to leave, the grandmother presented Deb and I with two big bags full of bananas which they had grown themselves.  We graciously accepted the gift, hugged the adults, kissed the babies, congratulated the bicycle repairman on his excellent work, and bid farewell to the grandfather. 

We made one final stop in a home with another new mom and an adorable baby girl.  The home was located in a small family compound and the family had sufficient resources to purchase a few more fancy items for the baby.  A male relative who had been drinking stood outside and Yani closed the door.  Yani gets her amazing energy by being with her children.  She hugged and cuddled the last little baby girl for a good long time, resting up before heading over to Yani’s satellite office. 

Most afternoons Yani returns to her home community and has office hours in the small clinic there.  The community is just a tiny hamlet with one rocky dirt path, just barely navigable by vehicle.  The community school is just up the hill from the clinic, so as Deb and I sat on the porch, we were able to greet the school kids as the shifts change at midday (little kids go in the morning and big kids in the afternoon).  Yani snuck off behind the clinic to her house to cook us some lunch, so Deb and I poked around the clinic a bit.  We were pretty impressed with the amount of educational material she had, as well as basic medications, an exam table, scale, wall posters and the mandatory wall map of her promoter-zone.  Pretty soon Yani appeared with two plates full of fresh, scrambled eggs, beans, tortillas and crema.   We could not contain our admiration for Yani’s work nor our humble gratitude for her generosity.  She showed us her log books and the way in which she records each patient’s information.  She updates her records every afternoon and is often interrupted by people coming by for advice on a health issue, a check-up or to pick up some condoms.  Yani runs educational workshops for the community, and treats emergency cases until an ambulance arrives.  She is trusted by everyone in her care-zone and beloved in her community.  After lunch, she walked us to her own home, and gave us a tour of her garden.  Cutting bananas from her own tree, she presented us with a gift of fruit.  This is how we said good-bye.

Yani and her patients taught us about life on the side of the volcano.  They taught us about survival in remote places, dependence on family and community, and the vital place health promoters have in in the lives of families which have extremely limited access to healthcare facilities. 


Wednesday, May 6, 2015

Look, Listen and Learn: Up Volcano Road

We drove up the volcano road, past the familiar turn-off to Parque el Boqueron, to the neighborhoods on the side of the volcano.  To get to these small communities, we parked on the highway and trekked our way in.  Promotora Yani was our guide, we walked from one home to the next, following barely visible paths of mud and rock.  Yani's goal for the day was to weigh and measure all of the children ages 5 and younger.  

Baby being weighed using a spring scale
Our first stop for the day was at the home of a 12-year old boy with a shoulder injury.  He had a sling and had been to the clinic for care.  The injury was the result of an accident.  The father had  been riding his bike, either picking up or taking the kids to school, and the bike crashed into the boy.  It seemed a pick-up truck was somehow involved.  Dad had a fractured finger, which he had "fixed" himself.  Yani checked each of the children over, weighing the little ones, and prescribing acetaminophen and anti-parasite medication for the boy with the hurt shoulder.  As Yani worked, we observed family members emerging from hidden spaces and soon realized that as in many homes, this was a family of several generations working and living tightly together.  The family was very friendly and happy for our visit.


The size of this hill was really much larger in person...
check out the ladder used to climb to the top of it
Our second hike of the day took us deep into the woods, where we had to climb our way to a little community of a few homes perched precariously on the rocky mountainside.  We smelled smoke, and crept down a steep rocky "staircase" which led us to an enormous mound of smoldering wood.  The fire at the center of the hill has probably been burning for years.  The man and the woman both looked older than their ages, and I imagine that they tend the fire day in and day out.  A couple of children climbed onto the pile, picking out the precious charcoal, which is sold to sustain the family.  Los carboneros (charcoal makers) survive by carrying on this ancient profession for those who live on the side of the volcano.  

We greeted the fire-tenders, and continued our walk along a muddy ridge above another house.  A quiet woman stood next to the wood pile - wood to be burned to make more charcoal.  We noticed a fantastic collection of plants growing along the side of her house.  Perhaps these are plants the family has gathered from the forest to sell at the market.  Yani thought maybe the woman gathered them so she could have a beautiful garden.

We arrived at our destination a little further down the path - a tiny home made of mud, sticks and tin.  Mom and Dad were tending a baby who looked to be about 6 months old, the patient on Yani's list for this household.  The family consists of 2 parents and 9 children who share the 1-room home.  We stood outside, and a few of the children tentatively peeked out from the open doorway to see who had arrived on their front porch.  A make-shift table held a large, fire-blackened aluminum bowl full of weak coffee.  We had arrived at breakfast-time.  Some of the children emerged to claim their small cups of coffee and little breads.  We enjoyed talking with the family, especially the dad, who marveled as we did at the great menagerie of exotic birds singing and fluttering in the tree-tops on the hillside below the house.  

I asked the children if it was OK to take their picture, and they agreed.  Some of them ducked behind the beds.  It was the first time foreigners had come to their home.  It was the first time for them to have a picture taken.  One of the girls who was about 13 had already left school to go to work to help support the family.  She and her dad both work in agriculture, spraying insecticide on farm fields.


Part of the rocky path to the Carbonero's home
A small stool on the front porch of the home
with 9 children
Dad and the happy baby
Children having their first picture taken