We had a great time during clinics, which were attended by people from the communities of: Pampacche, Providencia, Santa Cruz del Quetzal, Rosario Italia, and Panhux. Also included were our current chronic medical patients. The ASOSAP nurses appreciated the teaching and clinical input by Dr. Beth and Dr. Michael.
The day’s clinic will be in Providencia, an hour and half drive that first climbs another thousand feet and then down 3000’ along the gravel road that is the main thoroughfare for the small Pokomchi Mayan communities that we serve. Everything is covered with a thin coat of dust and we frequently pass groups of men, each with a bandana over his face, spreading piles of dirt into the wide, deep pits of the road. Their effort seems futile. As we descend from the crest, there is spectacular scenery of the deep, narrow river valley. Clouds sit like merengue on pie in other valleys off in the distance. It’s apparent that we’re in a different temperate zone, easily identified by the banana trees and wild red ginger along the side of the road. Here cardamom is a cash crop. The entrance to the village is a marked by the clustering of single room homes. Most are made of horizontal wood slats, brightly painted different colors, now faded; all have rusting, corrugated tin roofs and dirt floors.
The health post in Providencia is made of cement block and painted ocher with red-brown accent. There are three exam rooms, reasonably lit from the side windows, and a spacious waiting area. Although there is no running water inside, there is the luxury of a cement floor. Miguel is ASOSAP’s full time nurse here and the community’s only primary healthcare provider. He is the equivalent of a practical nurse in the U.S.
Today Beth, a pediatrician from Texas, who is along with me, will mentor Alicia, the clinic nurse in Pampacche.They will see the thirty-five patients with acute ailments. Miguel, Conzuelo our head nurse, and I will see those 24 patients in ASOSAP’s chronic medical program. Some of the patients live here in the village; others have traveled, mostly by foot, two to four hours to be seen.The chronic medical program serves this indigenous population that is isolated by distance, poverty and lack of education. The adults here have virtually no other access to the diagnosis and treatment of common, chronic medical problems and hence are subject to all the mostly preventable complications of them. However, once identified, a patient is seen monthly and their medicine is adjusted according to written protocols.They are educated about their illness and given the month’s supply of medicine at no cost to them.
Although our chronic medical program had typically followed adults, Miguel asked me to see Otto Felipe for the first time 18 months ago when he was four. His mother brought him in every 6 weeks for significantly difficult breathing. Going to the hospital in San Cristobal, 1.5 hours away, was not an option; they couldn’t afford the dollar and a half bus ride and so Miguel would see Otto Felipe. He’d be given nebulizer breathing treatments, oral steroids and antibiotics and get better for a few weeks only to return with similar symptoms.
He was not attending school, nor playing with other kids. In fact he did not leave his house regularly. His mother was so on edge all the time, waiting for the next exacerbation, that she became clinically depressed. Often I’d get an email from Conzuelo, asking advice about treating a bad flair up. Typically when I’d see Otto on my semi-annual visits, he’d be sitting in the exam room, leaning forward in the chair, actively working to quiet his audible wheezing, looking up at me hopefully as his mother recounted the time since my last visit. And so 6 months ago, we expanded the chronic medical program to include not only adults with chronic asthma/bronchitis but also children like Otto. I re-wrote the protocol and I started him on inhaled medications, standard treatment in the US, but rarely available here. He is seen monthly in our follow-up clinic where our staff makes certain he’s using the meds properly and gives him another month’s supply. Today things are different; both he and his mother have big smiles on their faces as they walk in confidently. He brings in his lesson notebook to show me that he’s in school every day and getting good grades. And he is playing soccer with the other kids. Miguel hasn’t seen him for an exacerbation in the last half-year.
When 89 year-old Carmen comes in, she reminds me of a hobbit. Walking barefoot with staff, her colorful quipile and skirt seem to accent her prominent ears only slightly less then her long grey hair braided halfway down her back or her big smile missing 4 front teeth. She entered our chronic medical program 6 years ago because of a blood pressure of 200/80 and angina. At that time, the bedside ultrasound I did on her showed a significantly dilated heart. I knew that by any stretch of the imagination she wouldn’t survive 12 months if living in the U.S., let alone here. She was started initially on low doses of medicines and every month, according to the written protocol, it was adjusted. Today, pain free, she walked 20 minutes to see us and stepped into the clinic with a smile that lit up the room.
We started this program with the goal of treating patients with chronic medical problems, with the same expectations there would be for any person in the developed world. What we lack in technology, we make up with regular follow-up by bright, dedicated nurses who are part of the local culture.
There are currently one hundred twenty Pokomchi Mayan patients who participate in ASOSAP’s chronic medical program. I am a part of this initiative and extremely proud of it.