Archive for Liveblogging from Chiapas
For the last 13 years, the Zapatista movement of the indigenous people of Chiapas has attained global recognition as a preeminent people’s movement for open and representative government, basic human rights and respect for the Earth and all its people. While many know the story, few have experienced first-hand their daily struggle to survive in extreme poverty all the while maintaining their fight for land, respect, food, and the freedom to live by their culture.
Shipra and I were invited by Dr. Juan Manuel, a local physician we have close contact with, and Mere, a “promator” (community health worker), to travel to a Zapatista community in the hills of Chiapas. This, in short, is what we did:
- Meet Juan Manuel and Mere in front of Hospital San Carlos at 8am.
- Travel by “collectivo” (shared van) from Altamirano through valleys and cloud forest to Ocosingo
- Traverse bustling market, carniceria, and shops in Ocosingo
- Eat tamales and atole (milk and corn drink) for breakfast
- Leave Ocosingo by “combi” (covered truck), and speak at length with Juan Manuel about Mexican history and history of the Zapatista movement
- Pass military checkpoint, no hassle
- Arrive at Municipio Autónoma Olga Isabel, a large Zapatista enclave
- Met many Tzetzal “coordinadoras”, indigenous women from many pueblos in the area who lead and organize around the movement. They lead the Zapatista “communidades en resistencia” (communities in resistance). They speak Tzetzal, an indigenous dialect, and little Spanish, making introductions difficult.
- With Mere, ride “combi” up bumpy dirt road to trail head and hike uphill through jungle and pine forests. Dodge a black snake. Stunning valley views.
- Arrive at Campanawiitz, a small indigenous village of several wood, tin-roofed, dirt-floored huts.
- Mere and Solomon, local promator, administer vaccinations in Solomon’s home as Shipra and I entertain the children with hand puppets and silly faces. Children and adults curious of us. Farm animals abound – chicks, dogs, a pig. Small black and white TV, decorations with tricolores (Mexico’s red, white, and green) and with health education posters made by Solomon. Solomon’s wife cooks lunch in adjacent hut, the air thick with the fire’s smoke.
- Lunch with Mere and Solomon of homemade corn tortillas, rice and black beans.
- Shipra and I examine Solomon’s sister pregnant at 38 weeks (baby’s heart sounds perfect, head down) and father suffering from osteoarthritis, we think.
- Hike back to dirt road along a ridge with valley views, through corn and bean fields and several cows grazing.
- Ride combi filled with lumber back to Olga Isabel where we speak with several Swiss human rights workers invited there to witness the Zapatista struggle as observers. We watch a DVD on the Zapatista movement. It begins to rain.
- Take short combi ride through the night to Chilón, a nearby town, where we sleep at the gorgeous home of Nely, a “partera” (midwife) and friend of Juan Manuel.
- Eat heuvos rancheros and Juan Manuel sees a patient as Shipra and I explore the fantastic hilltop views of Chilón.
- Return to Olga Isabel. Juan Manuel sees patients at Clínica Autónoma Municipal, Shipra helps the women bake bread, I chat with the men and shoot basketball. It is a warm, sunny day.
- Two more combi rides: one from Olga Isabel to Ocosingo (2 military stops this time, no issues) and then from Ocosingo to Altamirano and home.
- Happily home and grateful for the incredible experience, we eat, shower (after 2 days), and go to sleep.
As hard as it is to tear my thoughts away from the fantastic cultural journey I’m on, I think I owe it to myself to discuss the reason I am/we are here: to provide medical care to the people of Altamirano, Chiapas.
The pathology and variety of disease seen out here in rural Mexico is not as surprising as is the ability to practice modern, mainstream medicine, of course with limitations, in a place where one’d expect very very little of anything. I am grateful to the Sisters of Hospital San Carlos and those generous folk, physician or otherwise, who’ve come before me and helped bring this, and my experience in it, into reality. I marvel at diagnosing and treating relatively common ailments at least as I’ve been working in the pediatric ward here: bronquiolitis, neumonia, trauma, abscesos y celulitis, recien nacidos eutroficos y hipotroficos (full term and premie newborn babies). In a place where I expected close to nothing, I’ve found so much. Mexico is a land of plenty and of wealth, but of various sorts you might not anticipate.
My first patient was Jose Maria, a charming 3½ year-old boy. He had been admitted 5 days prior to my arrival with a hugely swollen, red and painful right pinna, the conch shell-shaped, floppy outer portion of the ear. He had been seen at an outside clinic and received antibiotics to no avail. What could have certainly been a simple outer ear or skin infection had developed into a serious infection of his ear cartilage – perichondritis (pericondritis en Espanol – See, Spanish no es tan dificil!). This condition can be very challenging to treat given the nature of the tissue itself: cartilage has very little blood flowing through it, and blood carries, among other precious things, antibiotics. If you’ve ever had your ear or nose pierced, you’d notice how while it may hurt like all heck, it bleeds very little (Big ol’ nerve endings, teeny lil’ blood vessels). That said, perichondritis requires up to 2 weeks of intravenous antibiotic, one that can eradicate, among other more common skin bacteria, a nasty little bugger called Pseudomonas, a common organism in this condition. Jose was started on an anti-Pseudomonal medication – Ceftazidime – plus another called Gentamicin for its synergistic effects with other antibiotics. Here, in a rural Mexican hospital, Jose was receiving exactly the treatment regimen he’d be receiving in any American hospital. Fascinating.
As with many things here, though, aside from maybe thunderstorms and black beans and rice, resources are limited. As one might expect, powerful, specialized antibiotics such as Ceftazidime are in short supply. Thus, after 7 days of treatment, Jose Maria consumed into his tiny vessels the entire hospital supply of the ear-saving serum. We continued the other antibiotic and since he made such great clinical improvement throughout his stay, we let him go home early to enjoy his family and his new and improved ear.
Jose Maria on the mend
Jose’s improvement and cheery mood leant for a more treasured and therapeutic plan: the bond of doctor and patient. Jose is a sweet, smiling young boy as you can see. I lucked out as I got to him as he was feeling better so I reaped the dividends of another’s poking and prodding. We joked, played, shared coloring time and he and his family were kind enough to sit for these pictures.
Ready for home
Originally uploaded by daprovocateur
Funny, aside from a few technological gaps in his care, of important but not of critical value, I could imagine the same scenario playing out in the States.
This is my first journal entry and first blog post from Chiapas, Mexico. Today is September 4, 2007. These thoughts were written en route from Los Angeles to Mexico City, the first leg of my journey but were realized today when we arrived in Altamirano, site of Hospital San Carlos and our home for the next 2 weeks. More to come. Enjoy!
You’ve seen her image before: a dark round face. a stout but solid frame. Her body cocooned by colors of all kinds: a patchwork of red and gold stripes, bright green and blue hues, beads and other shiny accents. You may recognize her from the cover of a magazine, maybe National Geographic, or your favorite cable travel channel, but never would you ever expect her to enter your world, to see her and her many children in tow strolling your sidewalk or perusing the aisle of your local grocery. Never in a million years.
Now, flip the image.
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8/29/06 I am getting tired of eggs for breakfast and have gotten a box of bran flakes in town. My teammates make (gentle) fun of me. Consulta externa. Giardia, otitis media, gingivitis, allergic rhinitis, probable fibroids. On the inpatient service, a 33-year-old man with a heart the size of a large cantaloupe. PMI visible where you would normally look for the spleen. Another woman with multiple liver masses.
8/30/06 In clinic, lots of abdominal pain, fibroids, neurocysticercosis, prenatal care. What to do with a positive brucella antibody from an outside lab? Who ordered it? The woman is well, without complaints.
9/2/06 Post-call. I’ve learned a new word: keraunographic markings. The characteristic pattern lightning leaves on skin. A seventeen-year-old girl was struck by lightning. I’ve never dealt with this before. Quick consultation with the books: the girl’s story matches nearly word for word. Loss of consciousness, transient swelling of the legs. Her hair is burned where she was struck. Terrified. Her seventy-year-old grandmother, who weighs marginally more than a healthy nine-year-old American child, is speechless, and I am grateful she was not struck herself. I don’t think she would have survived.
Later that night, an 18-year-old girl I’m convinced has congenital hypothyroidism comes in, hugely distended. A plain film reveals loops of colon 12 centimeters in diameter. At 11:30 pm, I call the surgeon, an insomniac who had finally fallen asleep, and feel guilty for waking him. I’m wondering: ascaris? Volvulus? Adhesions? The next day, he operates, and it’s a megacolon of unknown etiology. I marvel at the care her father gives her. She cannot communicate, first walked at the age of 13, and only on her good days. He holds her, carries her, whispers encouragement. He sleeps at her bedside, on the floor, like many family members at Hosp. San Carlos.
9/6/06 We fell, one by one, to the “venganza de Moctezuma.” The case of traveller’s diarrhea that hit Mark made its rounds through half the team. We blamed fruit, water, our own underchallenged immune systems. A few doses of Cipro later, we were back on our feet.
The two weeks passed quickly. From the distant vantage point of our supremely overweight nation, it’s hard to believe that people can be so malnourished, that their illnesses can be so ignored.
Well, after a day of travellers diarrhea, I´m more or less back on my feet, so I thought I´d try to send a blog. We´ve now been in Altamirano, Chiapas, Mexico for 1 week, and we have another week to go. Following is a description of some of the cases that I´ve seen with some reflections interspersed.
23 year old lady with 6 months cough, white sputum, and severe weight loss. Previously she weighed 50kg, and on admission she weighs 27kg. It´s not uncommon to see ¨healthy” people with weights of 35-45 kg. And most of the people we see (especially women-I suspect girls don´t get the same nutrition as boys here) are short. Anyway, this lady had tons of bugs on her AFB (they call it “BAAR” here) and a chest xray with a whole bunch of cavitary lesions. I´m generally relieved when people are diagnosed with TB because it´s treatable, and we can test and treat families as well to control the disease. “Up to Date” describes TB as a “social disease” related to cramped living conditions, lack of air circulation in homes, etc. and I think that´s a valuable way to think about it.
18 yo G1 at 38 6/7 wks presenting with 1 day of vaginal bleeding, some fevers/chills the day before presentation. Heretofore an uneventful pregnancy and her fundal height is 35cm (which is much better than most gravida patients at this stage here) and estimated fetal weight of about 3kg (again ¨healthy¨ for Altamirano). Unfortunately, I was unable to doppler fetal heart tones, and I didn´t see any spontaneous movement or cardiac activity on ultrasound on an otherwise well formed fetus. I had a nun who does ultrasound here confirm my findings, and we admitted her for labor and delivery of IUFD. She was already 100% effaced and about 7cm dilated-when I ruptured her membranes, dark black fluid was obtained. Unfortunately, i missed the delivery because I was vomitting in the bathroom, but I´m told it was a normal looking baby aside from being in demise. I´m wondering why she had such a sudden turn for the worse. She denied itchiness, so I don´t think she had cholestasis of pregnancy. Gilbert suggested antiphospholipid syndrome. Unfortunately, they don´t have resources here to do detailed lab workup for these kinds of things, so it seems unlikely we´ll have a definitive diagnosis. This is the third IUFD (intrauterine fetal demise) that I´ve seen here, and it seems like the families usually want the baby and placenta to bury it and maybe have it baptised as well. There was one IUFD at 22 weeks where the fetus looked considerably younger than that and the grandma was sad that we couldn´t tell the sex of the baby.
34 yo man with several months complaining about dyspnea, dizziness, and palpitations. On exam you could appreciate regurgitant murmurs over the pulmonary valve, at the right sternal border (b/c of cardiomegaly) and at the apex and axilla. He also had frequent premature contractions and an old EKG with Atrial flutter. Most remarkable on exam was a visible PMI 8cm below the nipple. It looked like his heart was occupying territory normally reserved for the spleen. On an old xray you can see diffuse cardiomegaly, and make out enlargement of all cardiac chambers. Despite serologies negative for Chagas disease, we think it most likely this young man has Chagas cardiomyopathy. Again, he´s not getting the detailed workup that we would do in Los Angeles. The nuns weren´t keen on us checking his iron level for hemochromatosis because that´s a sendout lab here and costs the hospital. And there´s certainly no echocardiograms here.
18 mo old with failure to thrive weighing 7kg (less than my daughter who´s kind of tiny and 3 months younger) with large ankles and wrists bilaterally (kind of looks like a puppy) and 1 large axillary node, several palpable inguinal nodes. They´re going to try to refer him to Tuxtla Gutierrez, or some other tertiary center where he can be worked up for genetic disorder or rheumatologic disorder. (after ruling out TB).
There are a whole lot of skinny, mangled looking stray dogs guarding different neighborhoods here. It can be scary walking around because they´ll start barking at you intimidatingly. I don´t suppose that the government considers neutering these animals a priority. Many houses have horses hanging out nearby and the locals use them to carry items back and forth. I don´t think hardly anyone has a car here unless they´re driving a taxi. Often, we admit people who arrive in the late afternoon from far away cuz it´s hard for them to get back home in the evening. Many houses have a special tin one-room hut where women cook and you can see dark black smoke emanating from the spaces between the roof and walls. Most COPD (they call it EPOC-enfermedad pulmonaria obstructivo cronico or something like that) here is in older women from years of inhaling fumes from these huts. Because of the recent elections here, there is a lot of political paintings on the sides of buildings. Apparently, businesses sometimes paint the political party they support on the side of their establishment. My spanish isn´t good enough to assess how tense things are right now with the official winner of the elections in question. We´re supposed to find out soon what the courts have decided. A lot of patient´s families wait in the outdoor areas between different wards, and many of the men have bandanas around their necks. I´m told that´s a sign of support for the Zapatistas. One interesting cultural observation is that whereas men are frequently dressed kind of like Americans-shirt w/ buttons, jeans or corduroyish pants, the women are generally dressed in traditional outfits reflecting their particular villages. Most women of child-bearing age have a blanket they´ve tied around their bodies hanging from one shoulder in which they carry a child from infancy to about 3 years of age where the kiddo can nurse on demand. I´m sure my spanish is improving significantly as all our notes and orders are in spanish. Many of the patients don´t speak spanish but rather indigenous langauges, and the nurses have to translate for us. Various noises you hear throughout the day and night-lots of roosters crowing, stray and domesticated dogs barking, the guy selling tortillas or something in the street squeezing a hand held little high pitched horn letting you know about his presence (at 7AM ugh!), the intermittent pitter patter of the heavy rains that happen about four times a day and last from minutes to about a half hour. Most rooves are corrugated tin and that amplifies the noise of the rains.
Except for my encounter with E. Coli, I´m having a great time, learning a lot, and enjoying working with my colleagues from Harbor.
–Mark Bunin Benor, R3 Harbor UCLA family medicine
8-26-06, Saturday evening. Overnight flight to México City, connection to Tuxtla Gutierrez: an airport so new the cement still smelled wet. Rising above the tropical plains to San Cristobal by taxi, the air cooled and we awoke to red tiled rooves and the bright blue and yellow housepaint of the historic city.
In San Cristobal at the Posada de Carmelita (somehow I had imagined a Carmelite convent, but Carmelita is a person), the entrance hall is vividly painted in blue and red, and decorated with great bunches of calla lilies. We freshened up and found lunch at a vegetarian restaurant on the corner. Whole wheat empanadas, oat cakes, and the usual assortment of quesadillas and tamales. An American guitarist-street performer came by and played some standards. The number of tourists and foreign settlers here is impressive in these days of vote recounts. The guitarist left, and some lovelorn cook turned to a recording of ¨si te vas,¨a salsa number that was fine the first twelve times. We left in the middle of cycle thirteen.
After a nap back at the posada, we ventured out again for dinner, after which a walk around town revealed a demonstration in support of ¨la otra campaña,¨ the ongoing struggle in Oaxaca for teachers´wages.
8-28-06 Feast of St. Augustine. Yesterday, Sunday, we caught taxis from San Cristobal to Altamirano, 2 hours away winding through the hills, the location of the Hospital San Carlos where we´ll be working for the next two weeks. On the drive, the taxista was chatty. We traded questions – mine on the crops, the growing season, the rules of the road (driving on the shoulder is encouraged; at a stop you yield to the person on the road indicated with the red arrow; corn has two harvests in the lowlands but only one, July to September, in the highlands)—his on wages in the US, cost of living, education.
Overnight, hard rain, dogs barking, and the noises of a strange place made for less than restful sleep. First shift today – outpatient ´consulta externa´. Leg length discrepancy, acute gastroenteritis with aphthous ulcer, intestinal parasitosis, bronchilitis (admitted), prenatal care.
8-29-06 Today, consulta. Giardia, otitis media, gingivitis, allergic rhinitis, admission for active labor. I´m learning a little tzeltal along the way. So far, I´ve got yes, no, rain, and pain. I have not seen so much malnutrition since starting medicine. Older women here routinely weigh less than 40 kilos. Many families have only posole (a sort of maize porridge) to feed their children. The result – protein-calorie malnutrition, with iron and other deficiencies. One woman I saw for chronic obstructive pulmonary disease (too many years over a smoky wood stove) offered me eight eggs, carefully wrapped in corn husks, and 3 kg of plantains. She weighed 37 kg herself.
Our surgeon has taken out 3 or 4 gallbladders since he arrived. It happens to be his specialty, but he also does tubal ligations, cesarian sections, and hysterectomies, for lack of an OB-Gyn. More to follow.