INTERNATIONAL MEDICINE

At Home in Guatemala

By Julie Kiser, MD

I work in a three-room clinic in Las Cruces, a small town in northern Guatemala. We have dirt roads and draw our water from a well, and we usually have electricity.

A few weeks ago, a 17-year-old mother came to our front porch with her two small children. The 10-month-old had rotavirus and was dehydrated, so I brought water, sugar and salt from our kitchen, and together the mother and I made one liter of oral rehydration drink.

The mother said the 3-year-old, a girl, had an earache. I examined both kids: temperature, pulse, respiration, ears, lungs, belly. The girl had a fever and a tender liver. From the clinic I got microscope slides, cloroquine and primaquine. Back on the porch, I stuck the girl’s finger and made a thick and thin smear to read in the afternoon. As the mother held her daughter, we pushed in the first dose of three days of bitter cloroquine. Then I wrote the record of the visit on two green cards, one for each child, and gave them to the mother. She paid me a few coins, which I returned to our pharmacy fund.

During the mother’s visit, I was nurse, pharmacist, lab tech, records clerk, doctor, accountant and mom’s helper. We were outside in the fresh air. The only copy of the medical chart went home with the patient, who will bring it when she returns.

Dr. Kate Feibusch and I have lived in Guatemala with our daughter, Mira Moore, since December 2000. We live in the northern state of Petén. Kate and I graduated from the Santa Rosa Family Practice Residency in 1999 and 1997, respectively. The residency sent us off with an excellent education and an ethic of service. When Sonoma Medicine asked us to write about our lives here, I saw a way of sending gratitude to our teachers and our circle of Santa Rosa friends.

Although we love seeing patients, direct patient care is not our only job here; we also administer a project that supports rural health workers. Last week, for example, I rode with Mira in the back of a pickup truck over dusty roads for three hours, carrying a box of medicines and a mosquito net. My destination was the Unión Maya Itzá, a community established in 1996 by refugees who returned at the end of Guatemala’s civil war. They and their children now farm near the Usumacinta River, Guatemala’s western border with Mexico.

We stayed in the community for two days with a rural health worker named Angelina, a 34-year-old mother of three. She has seen about 70 patients a week for the last five years. She receives emergencies at all hours, including births and wounds requiring suturing. When necessary, she keeps patients overnight in her home.

During my stay, Angelina and I consulted on her difficult cases, including a neighbor with psychosis who takes chlorpromazine. The day I arrived, I visited a man with high fever and vomiting, possibly caused by leptospirosis. I repaired Angelina’s sphygmometer and restocked her chest of medicines. I had brought a dermatology book with me; we reviewed the appearance of tinea corporis, tinea pedis and kerion. We set a date for my coworkers to apply fluoride to school kids’ teeth. I also talked with Angelina and her husband about building an annex, in order to move the medical consult out of their living room. Angelina taught Mira and me more words in Q’eqchi’, one of 20 Mayan languages spoken in Guatemala. Angelina, like many indigenous Guatemalans, is bilingual. She speaks Spanish and Q’eqchi’ (pronounced *EK-chee, where * is a click in the back of the throat).

Our main job is to visit volunteer medical workers called “health promoters” and teach them in formal classes. From January to March this year, for example, I presented three five-day courses. The first course, in Spanish, covered musculoskeletal medicine, including back pain and common knee and shoulder problems. The second course was a Q’eqchi’ version of the first course, presented to five women and 15 men. The same group received my third course a month later, on diagnosis and treatment of skin problems.

The courses are designed for peasant farmers who come to study six times a year, leaving their homes and fields for a week each time. Angelina graduated from our project’s three-year curriculum in 2000. Like most of the participants, she never finished elementary school.

We approach all our teaching with a method called Popular Education, which includes many active learning techniques. In the musculoskeletal course, for example, we refer to a life-size skeleton and have students color a sketch of the brachial plexus, including surrounding bones, muscles, and vessels. We purchase a cow’s leg at a butcher shop and dissect the knee. Every day the group does therapeutic exercises, which they then teach to patients. Echoing the Harvard model, we pass out clinical cases on Monday, one per student; by Friday, the course covers diagnosis, treatment and prognosis of each case.

Now Kate and I are teachers. We remember warmly our teachers at the residency, including Drs. Rick Flinders and Lou Menachof. Like them, we provide health care to the poor. As we are the last stop for many difficult and challenging cases, we must go to the limits of our abilities. The philosophy of the Santa Rosa residency was to prepare for a broad practice, including procedures. We do a lot of minor procedures, including using ketamine anesthesia for kids and trauma. We also repair extensor tendons of the hand. We refer to a local hospital when a patient needs an appendectomy or a cesarean section. Since we have no X-ray or ultrasound, I especially appreciate the physical diagnosis skills from our early training. Much of the musculoskeletal medicine I teach, I learned from Dr. Veronica Vuksich. We do our own blood smears, Gram stains and TB slides, and we use the intensivist skills learned from Dr. James Gude because we receive emergencies from a 100-mile radius. Kate completed a fellowship at the HIV clinic in Santa Rosa, and she is the main coordinator of HIV care in the region.

Mira, Kate and I have lived in Guatemala for almost eight years. Our younger daughter, Toby, was born here. Our days are filled with patient care, visits to health promoters in small towns, and teaching courses. Mira, 14, is as tall as I am. She’s a good student, and she can suture wounds. Five-year-old Toby enjoys the freedom of living in a country town and has many friends. Kate’s vision for community improvement spurred her to build playgrounds and establish school libraries. Anything we can add is welcome.

People live very simply here. A typical house is made of sticks and boards with a roof of palm leaves or tin sheeting. Families sow the land with corn and store sacks of harvested corn in their houses. To make a meal, women rub kernels off the cobs, cook the kernels with lime and then grind them to make corn dough. They pat the dough into tortillas, which they cook over a wood fire and serve with black beans.

We work for the service arm of the Catholic Church, but our financial support comes from a U.S.-based organization called Concern America. Since its establishment in 1972, Concern has worked quietly with refugees and materially poor communities in 15 countries. It is a non-religious nonprofit that makes long-term commitments. Our project has been in Las Cruces for 12 years and employs six Guatemalan health workers whom we consider peers. Julia Martinez, for example, has worked full-time for our project since 1999. She is my age, 46, and she has seven children aged 27 to 12.

At age 13, Julia apprenticed to a doctor who was posted here. She has since delivered thousands of babies and has helped train dozens of midwives. She oversees our women’s health program, which provides gynecological exams and follow-up to 500 women per year, along with prenatal care to about 100 women per year. In 2007, we adopted protocols for direct visualization of the uterine cervix and immediate cryotherapy of acetowhite lesions. This practice is especially appropriate for our third-world conditions, where the expense and logistics of Pap smears are prohibitive.

Guatemala is only 700 miles south of the United States, but its health indices are among the worst in the world. Guatemalan women face 20 times the maternal mortality of American women. The Guatemalan government spends $15 per capita on its public health system, compared to the American expenditure of $2,000 per capita. Trade agreements with the United States favor pharmaceutical companies and restrict the use of generic medicines in public clinics. For these reasons, our project involves itself in local and national politics.

The Guatemalan constitution recognizes the right of citizens to create a public health council in each county. Locally, the members of that council receive information and meeting space from us. In recent years, the council has successfully lobbied for placement of Q’eqchi’ translators in hospitals, expulsion of hospital workers who come to work drunk, and changes in the hospital formulary.

When I speak with friends and family in the United States, they ask how they can help. A monetary donation to Concern America reaches us directly and goes a long way. One hundred dollars can buy:

• Enough generic penicillin to treat 100 patients with staph infections or strep throat.
  
• One visit to see 60 patients in a distant community, including a tank of gas and wages for three health workers.
  
• Expenses for two HIV-positive patients to obtain medicines in the capital.
  
• Half the materials for a new roof for our clinic.
  

Specialist physicians who are willing to give us their cell phone number can be especially helpful. On occasion we get really stuck with a case requiring a specialist, and we need somebody to call. We run into orthopedics, ophthalmology, oncology and surgery cases out here in the sticks, and a friendly, informed American colleague could help us think things through.

To find out more about supporting our work or visiting our clinic in Las Cruces, go to www.concernamerica.org or contact Kate and me directly at kate_julie@yahoo.com.