Month: August 2019

The Last Outreach

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This week I went to the municipality called Guajiquiro in the La Paz Department. As my final outreach with the clinic, I found it fitting to be one of my favorites. The community is located 3000 feet up in the remote mountainside. Along the way, we passed horseback riders, school children, and women carrying large containers of produce on their head. Many of the houses had their gardens, varying in size and crops. While talking with patients I learned that their houses typically don’t have electricity, plumbing, or a floor. After arriving at our host family I quickly noticed that I was considerably taller than the community. The ceilings, bathrooms, and beds were all “just a little too small”. It was slightly charming to feel like Will Ferrell in Elf.

Our outreach took place in a half-constructed church. The pews were wooden planks propped up on adobe bricks, the ground was dirt, and the door was a combination of sticks to keep cattle out of the building. We saw around 60-80 patients throughout the morning, many walking several miles to be there. Some patients rode horses and others carpooled in the back of trucks. Watching patients slowly trickle in made me think about the sustainability of rural health services. The western view of medicine has created a supply and demand system. In order for a full-time clinic to be established, it must be profitable. If not supplied by private funds, it needs to seek other sources (government, donations, international). For countries in economic crisis, such as Honduras, there must be a radical change in the system which we adhere too or additional sources of funding must be found. The inhabitants of Guajiquiro have little disposable income. While shadowing a cataracts patient consultation, his first concern was money. It felt good to reassure him that his surgery would be covered by the Zoe Health Clinic. Without our ability to absorb his costs, I wonder if they would ever receive treatment. Furthermore, at what cost can a non-profit continue to provide temporary health services? Also, what is the end goal of rural health? How much how rural health should be mobile and how much should be permanent? As I think more about these, I feel a natural interest in city planning growing. Hopefully, I will be able to explore these ideas in the upcoming year.

I woke up to the lovely sound of roosters at 5 A.M. As I tried to drift back to sleep they would continue to call like two competitive people tying to have the last word in a conversation. Breakfast, lunch and dinner were simple meals, all prepared from scratch. I woke to tortillas, eggs, and beans. For lunch, we ate tortillas and bean soup. To end our day we were offered rice, beans, avocado, and a small portion of chicken. Knowing that there are no nearby supermarkets, the chicken must have come from their own personal farm, both heartwarming and disheartening.

We stayed with the hosting church’s pastor and her family. On the property, I met a 5-year-old named Brian. We played soccer together on the slanted grass field in front of their house. The goalposts were made from sticks and the field was littered with piles of cow and horse scat. We took turns shooting on each other and chasing the ball after one of us scored. His desire to play with me made my whole week. I am inspired by children. In all situations, they have a love for nonsensical ideas and perseverance to withstand most challenges. If we aren’t trying to make our world better for them, who are we trying to better?

Coming back from this trip we stopped at a coffee/banana farm. We harvested three bunches of bananas and I tried raw coffee beans (it did not taste good). Similarly, I tried dragonfruit for the first time. I am most grateful for the escape from the city. After living here for a little under two months, it is easy to forget other lifestyles. As I am routinely reminded by my supervisor Alex Flores, “Keep life simple.”

 

Early Trends and Graphs

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I have completed over 100 interviews in 7 weeks! During this process, I learned the best way to obtain consent, conduct my questionnaire, and record data. Along the way I faced several challenges that developed into future research questions. One of the most difficult parts of my study was recruiting patients to participate in my study.

 

My typical methodology would start with the identification of potential participants. While at the main clinic of Tegucigalpa, this was both easy and challenging due to the large quantity of patients and publicity of our conversation. Prior to seeing the clinic, I wanted to conduct my questionnaires in a private area. I quickly realized that it is unrealistic for these interview to take place in a private/secluded area because the patients were waiting for their names to be called on 1 of two loudspeakers. If they weren’t attentive while their name is called, they may lose their position in line. All throughout the morning, the two main waiting areas are typically filled to capacity and slowly open up as the day goes on. This makes it more difficult to conduct an interview conducive to the patients privacy. As a result, I typically wait to start my interviews until I notice patients sitting on the outskirts of the room.

 

After my introduction, I faced problems with illiteracy and participation. As noted in the data by low education levels, many patients sign with their fingerprint on official documents. This type of signature has proven to be more popular outside the nation’s capital, as I found it harder to finish the consent process. Having not prepared for this, I would start asking nearby patients/staff until I found someone who could write. With their help, I could finalize the consent form and start the interview. Other times, I would be met with silence and the gaze of nearby strangers. I wish I had kept a log of rejections and patients who did not want to participate in the study. It felt like it depended on whether the patients were having a good or bad day. While this felt uncomfortable, I grew into this position of vulnerability. Respecting their decision as it is inevitable that people would say no.

 

In the past few weeks, I have been learning how to use python to conduct basic analyses. Here are some graphs I generated from my preliminary data (pre-review). All of these graphs are generate from a sample size of N=103, with a few incomplete sets included. I expect to clean the data after my last day with the clinic.

The first figure demonstrates a strong relationship between cataracts and hypertension. In a quick chi-squared test, I found that patients are significantly more likely to be diagnosed with cataracts and hypertension. This established co-morbidity helps provide my data with validity, as they align with published academic literature.

 

The second figure demonstrates the total number of patients diagnosed with cataracts, hypertension, or diabetes. I was surprised to find a relatively small number of diabetics and high rates of hypertension. I think the number of diabetics may be low because people are not being tested for this disease. On the other side, I think the high number of hypertensive patients may be due to environmental factors (access to healthy food and physical exercise) or genetic factors. The closeness in prevalence of hypertension and cataracts helps solidify that relationship in the patients of the ZOE Health Center.

 

The third figure works to demonstrate that there is a relationship between diabetes and cataracts. Despite the low prevalence rate of Diabetes, there were three times the prevalence rate of diabetes in patients with cataracts.

 

The fourth figure distinguishes the amount of individuals affected by one, two, and three conditions. While over half of the participants have any pair of two conditions (cataracts & hypertension, cataracts & diabetes, diabetes & hypertension), dramatically less have all three conditions.

 

There are more ideas embedded within the data I hope to uncover in the upcoming weeks. For example, when interviewing women I found a large portion were unmarried. This social trend may be connected to larger questions about family planning, help-seeking behavior, and population. In addition, I found that over half had no idea about the co-morbidity between diabetes and cataracts. Whether due to low education rates or lack of public health resources, there is an absence of health knowledge.

This quick report will serve as a placeholder, until I can decide which trends I hope to address in my analysis.

Our Innate Fragile State

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While in Choluteca, we drove by sugar cane farms. Their rows felt nearly endless. The larger fields had plants that looked to be 6-7 feet high and created an impassable thicket. When I first saw these fields, I couldn’t figure out what they were. After asking my co-workers I thought of coursework from lectures and readings about the history of Central and Latin America. Earlier in the year, I had read the books Open Veins of Latin America by Eduardo Galeano and The Shock Doctrine by Naomi Klein. Both of these books focus on understanding the regional history and complex veil that has surrounded Central and Latin American development. During the colonization of these countries, sugar cane plantations started appearing anywhere it could grow. This resource was an integral part to the exploitation of both the land and local people. These plantations, tempted by greed, failed to rotate their crops. As a result, the consecutive harvests removed essential nutrients from the soil. Following this period farmers struggled to diversify their farms as they relied on commercial farming inputs (fertilizer, insecticide, and weed killers). It was humbling to drive by families in adobe houses, knowing that history has barely changed.

While living abroad for more than 1 month, it is almost certain that you will get sick. Thankfully I had nothing dangerous or life-debilitating illness; however, it took me 2 days to recover. For this reason, I am doing a combined update between week 5 and 6. At the end of week 5, I had 3 blood tests and visited 2 doctors. I was diagnosed with Travelers Disease, otherwise known as Montezuma’s Revenge (it’s a much better name, as gringos tend to be the one contracting this disease). The first doctor I saw told me I could have anything ranging from Dengue, Chikungunya, Zika, to influenza. This was difficult to hear, as my initial reaction was to deny anything more serious than the flu. In addition to that I have received e-mails and read articles about the latest Dengue outbreak in Honduras.

A day later my diagnosis was confirmed. I was prescribed drug which helped cure the effects within hours. Knowing that my disease could be nearly anything, I feel ecstatic to come out unscathed.

These weeks I visited the departments Choluteca and Colón. While in Choluteca, we entered several different communities with the organization FunDeSur. Our outreaches were set up in public health offices whose walls were decorated with homemade posters describing family planning, high blood pressure, Zika, and basic epidemiological efforts. There were posters of the neighbourhoods, mapping which houses contained diabetics, hypertensive patients, and kids. In our other outreach locations (churches), I haven’t seen any other form of public health information. 

From witnessing the lack of education, I know increased efforts to connect individuals to this information can help reduce the rate of preventable diseases. There are many barriers to these ideas as many patients cannot read or write. These efforts would have to be replayable on mobile devices or delivered in person. Whichever intervention is chosen, I know it will come at a cost these offices cannot afford. Sustainable health care delivery is difficult in communities that are not profitable. The delivery of these services should be reframed for their potential impact on the communities productivity and welfare. These communities are living without an accessible source of potable water. A majority of the people in these communities purchase 16-ounce pouches of water. Being their only clean source, they are reliant on these items. Furthermore, many of these people are living without electricity; thus, no automatic tools, refrigerator, stove, or television.

The clock is starting to wind down as I only have 2 more weeks with the Zoe Health Clinic. It saddens me to leave this beautiful country. Two of the most common questions I get are:

 

“Do you like Honduras?”

“Yes I love the people, food, and nature”

My response is very much to their surprise. Without delay they ask:

“When are you coming back here?”

“Whenever I can get the money.”

 

During my first month, I was scared. Scared of the danger portrayed in the news. Scared of the language barrier. Scared of unknown foods. In this time I have grown out from my comfort zone. While the learning curve is steep I have grown to understand the transformation process. Locals here are not any different from I and I from them. We all sleep, rise, work, and repeat. In some sense, the connection we build with each other is all we can claim as our own.