Reflections from Nicaragua

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Masaya Volcano

Greetings from Charlottesville this time,

 Now that I am back in the States. I have chance to reflect on my time spent abroad and what I learned not only about Nicaragua and their health/waste systems but also about myself too. The town of Siuna is such an interesting town with a unique history in the mountains of central Nicaragua and I really appreciate the opportunity to go off the beaten path that tourists usually take and see how many Nicaraguan live.

As I discovered earlier in Siuna, things can be quite hectic there with many obstacles popping up. I had been have trouble finding the garbage truck there since it did not follow the same schedule that I had been given. So two days before I left, I went into the city hall with my translator, Eva, and somehow, thanks to her miraculous ability we happened to get an appointment with the hospital administrator who oversaw the garbage trucks schedules and routes. After speaking with him about following the truck, he told me simply come to the city hall at 6 and follow the truck on the entire route. Finally, after so much waiting I was going to be able to collect what I needed and on the last day I was there! So I had a driver who would follow the truck around town on its route and my job was to geocode the location of every stop so that I could find its route and distance traveled. I also had to mark down how much time was spent at these stops so we could get a more accurate picture of how the garbage truck operates on its schedule. It was quite an experience. Following a large blue garbage truck around town the small streets trying to avoid taxis, horses, dogs, and motorbikes was quite a sight. There even was a fender bender between the truck and a taxi. No one was injured but there was a fair amount of raised voices in the street!! All in all it was quite fun thrill ride in its own way.

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Following the garbage truck

One of my favorite moments from this trip was actually from following the truck and just sitting in the passenger seat listening to Reggae with the driver. He could barely speak english and I am completely new to spanish but we both love some Bob Marley. The driver even managed to make some recommendations for me through lots of hand gestures and broken English. 

On my way out of Siuna I had the opportunity to thank many of the people who helped me in my project. And I realized even though it was a solo project, the successful parts I was able to accomplish would not have happened had it not been for these many people who took their time to help a foreigner out. And as my little 12 seat plane took off from the gravel airstrip past the local baseball diamond (Baseball is just as popular as soccer in Siuna), it dawned on me how much the little town had grown on me in a mere two week stay.

Just to give you an idea about the state of Nicaragua’s roads: the flight from Siuna to Nicaragua’s capital, Managua, is less than an hour. But the drive by bus takes about 10 hours! And that is with no rain. One of the people working for the non-profit which helped coordinate my trip told me a trip took him 2 days because the rains washed many of the roads along the way. Thank goodness I was on the flight! On my way into Nicaragua I got the chance to see the historic downtown of Managua.

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The old Managua cathedral

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On my way out I was determined to see some of the area outside of Managua. I ask the NGO group in Managua what were some of the best places to see and they called a trusted cab driver who drove me around to 4 different sites within about 50 km of Managua. I got to visit the Masaya Volcano, the locally famous Masaya market, Catarina, and Granada. 

Nicaragua has 72 volcano’s I got to visit one active and one which caved in. To be honest the active one was a little anti-climatic. You can drive up to it but once you get there and peer inside all you see is a mix of water vapor, carbon dioxide, and sulfur dioxide,The caved in volcano on the other hand gives you some fantastic views of the entire area from the large Lake Managua to massive Lake Nicaragua. The Masaya market was inside of an old colonial building and was quite a maze but I found some good souvenirs and I got to see a local parade. Catarina is on cliff next to Apoyo Lagoon, a beautiful clean lagoon used to be a crater and filled up with water. It has great views of Lake Nicaragua and the active Mumbacho volcano in the distance. And finally we had some time left to drive through Granada, the old capital before Managua, and see lots of colonial architecture.

 

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Caved in crater at Masaya. Mombachu volcano is in the distance.

 

 

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Rushed picture in Granada

 

While all these views were terrific, once again one of my favorite moments was driving around in the late afternoon sun while listening to the taxi driver’s favorite Beatles tracks. Sometime’s it just the little things that really make an impression.

Its been fun!!

Serge

 

 

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Molding New Realities

With the papermaking workshop now over and having returned to the US, I have had some time and distance to reflect on what I experienced. Ghana, and the Ashanti region in particular, is a place filled with life, culture, creativity and opportunity.

Market area in downtown Kumasi.

Market area in downtown Kumasi.

Perhaps because I was only there for a relatively short amount of time, I felt a certain sense of optimism among people but also uncertainty. People seem to have a strong sense of identity and take pride in their culture, welcoming those from outside to share. There is a sense that things are on the move and a high value is placed on education. However, there is also a degree of instability. When I arrived, cars were lined up for hours due to a national fuel shortage. The exchange rate was the equivalent of about one US dollar to three Ghanaian Cedis. Over the course of five weeks, the Ghanaian Cedi depreciated so much that one dollar would buy almost four Ghanaian Cedis. Prices changed from one day to the next and businesses had to maneuver accordingly, ordering and pricing goods and services in a constant state of flux. Ebola had become engrained in the national consciousness as news of increasing death tolls entered from neighboring countries. Miraculously, it had not yet entered Ghana.

Open-air studio where workshop took place.

Open-air studio where workshop took place.

As the papermaking workshop unfolded in this context, questions of global health in relation to the project sometimes seemed far afield. However, a dedicated group of about 10 people showed up regularly, eager to learn a new technique and see how something rampant in the surrounding environment could be transformed into something beautiful and useful. For a week, we beat raw fibers from the inside of the bark of the Paper Mulberry tree, made vats of pulp from both the Paper Mulberry and textile scraps, pulled molds to make sheets of paper, and flattened them to dry.

Emmanuel, one of the children of the family I was staying with, and me pounding Paper Mulberry fibers.

Emmanuel, one of the children of the family I was staying with, and me pounding Paper Mulberry fibers.

Kwame pulling sheets of paper from vat.

Kwame pulling sheets of paper from vat.

Gloria pulling molds from vat of recycled textile fibers to create paper.

Gloria pulling molds from vat of recycled textile fibers to create paper.

A simple drying mechanism we set up for the workshop.

A simple drying mechanism we set up for the workshop.

Dr. Amenuke's daughter and son.

Dr. Amenuke’s daughter and son.

More than the papermaking itself, the project was a way for people to come together, step away from their daily routines and let their imaginations run wild. Participants came from a variety of backgrounds. Dr. Dorothy Amenuke and Mr. Kwabena Poku are fine arts professors at the local university, KNUST and Dorothy would bring her two children with her every day. Former MFA students, Frederick Bamfo and Geoffrey Akpene Biekro, also attended. Kwabena Akrasi and James Kweku Duffy are communications students and Kwame Donkor is studying engineering at KNUST. Bernard Coleman was a young man who just finished a year of national service after receiving a degree in horticulture and had traveled from the Volta region to join the group. Niels Staats had emigrated from the UK and was starting an arts non-profit and residency program in Kumasi. Even Gloria, the young woman who helped with the children and housekeeping for the family I was staying with, was able to join after I learned she was interested in textile design. All of us came together daily at the home of Caterina Niklaus and Smart Sippah who provided us with a space in which to work as well as an inspiring model for how to create a living space that heavily incorporates and celebrates the diversity of the natural environment.

Geoffrey Akpene Biekro, aka "Captain," pounding Paper Mulberry fibers.

Geoffrey Akpene Biekro, aka “Captain,” pounding Paper Mulberry fibers.

Kumasi, Ghana

Kwabena Akrasi presses excess water from newly made sheets of paper.

Caterina and Smart's home where the workshop took place.

Caterina and Smart’s home where the workshop took place.

Caterina's attention to detail was prevalent throughout her home.

Caterina’s attention to detail was prevalent throughout her home.

Smart Sippah sharing his plant knowledge with group.

Smart Sippah sharing his plant knowledge with group.

Over the course of the week, Dr. Amenuke and Mr. Poku talked about ways to incorporate new techniques and media into their curriculum. Kwabena and James began to formulate ideas for how to grow a business that would both generate income and responsibly produce a Ghanaian-made product in short supply. Kwame explained some of the mechanics behind the basic machines we were using. Niels imagined artists who might be drawn to a residency in Ghana specifically to build upon their papermaking practice in a local context. Though Mary Hark took a very hands-off approach, providing participants with the basic knowledge regarding the materials and process, she laid the ground for participant-led exchange, collaboration, and generation of new ideas.

Mary demonstrating how Papyrus could be another local plant used to make strong paper.

Mary demonstrating how Papyrus could be another local plant used to make strong paper.

Paper Mulberry branches from which raw fibers were harvested.

Paper Mulberry branches from which raw fibers were harvested.

Kumasi, Ghana

Fried plantains.

Diagrams showing spread of Paper Mulberry.

Diagrams showing spread of Paper Mulberry.

Kumasi, Ghana

Smart demonstrating Annatto (Bixa orellana).

When I think about the biggest impact the papermaking project had, I think it would be its ability to bring people together who might not otherwise meet and introduce them to a new way of working that draws on local materials. Though still operating on a very small scale, the papermaking project has the potential to turn into something much larger. It could take on a variety of forms but will have to be done so in a sensitive, responsible manner. It could operate on a workshop basis, attracting an international audience and contributing to the growing tourism industry in Ghana. Its model could be replicated by innovative, enthusiastic people like Kwabena and James and turned into a business that employs a variety of local farmers, artisans and technicians. Its end product could be folded shaped and sculpted into a whole set of finished goods that could be sold nationally to the many hotels popping up around the country. It could be incorporated into the local curriculum as a means to raise awareness about the implication of invasive plant species and the Paper Mulberry in particular. It could also remain as is, providing a base from which visions can grow and participants can think about how to direct their education, skills and efforts in new ways. Or it could be a combination of these. All are valid and possible and offer unique, long-term contributions to global health.

Dr. Amenuke demonstrating creative use of handmade paper process.

Dr. Amenuke demonstrating creative use of handmade paper process.

Though papermaking will not offer a solution for eradicating Ebola or answering to fuel shortages, it can generate a soft wave that gently pushes people to form partnerships and re-imagine their possibilities. Those who I met over the course of my stay in Ghana who have already been involved are living proof. The farmers who gather the raw fibers from the Paper Mulberry appreciate the extra income and assured us of their continued interest in future work. Gloria called me from Ghana the day after I returned to the US to tell me she had told her mom (who is a seamstress) about the experience and was thinking about its relation to her textile design work. The Ashanti are known for their astute sense of business and also for their strong and lively culture and will undoubtedly find ways to morph the project in ways that make it suitable to the environmental and cultural landscapes in which they operate.

Group shot in front of the studio.

Group shot in front of the studio.

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The reality of hospital waste disposal and collection in a rural Nicaraguan town

Hello from from rainy Nicaragua!  

UVa has had several projects over the past few years in the rural municipality of Siuna. There was one a couple of years ago where a group of students built a garbage station at the local hospital to make the disposal of hospital waste safer, easier, and more convenient. My project during my brief two-week stay in Siuna would be to collect data and observe how much waste is generated by the hospital, what kind of waste it is, and how is that waste disposed of. And as I near the end of my stay, I can tell you that nothing is what I expected it to be. In fact almost all of my assumptions about what things were going to be like were proved false.

Siuna is a bustling little town that you can explore in about a day. Being in the large north east province of Nicaragua, the province is self-governed with little oversight by the main Sandinista government which governs the rest of Nicaragua. That said there is a more visible military force here since the town is very close to the border of Honduras where there was resistance activity during the Contra scandal where the U.S. funded Nicaraguan resistance back in the 80’s. While the town is not large the surrounding area is quite expansive with communities as far as 2 hours away still considered part of the municipality. Trash is visibly a large problem in town as there is only garbage truck and lots of trash is either thrown in the streets or creeks and rivers nearby.

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Morning in Siuna

The hospital here was quite surprising as well. It was a collection of about 5 or 6 one story building all brightly painted in blue, green, or pink and lined with palm and coconut trees. These buildings house administration, the visiting/registration center, the sick wards, kitchens, and a couple others I never learned about. There is also a garbage disposal area, and incinerator. What I quickly learned however is that things in Siuna are very unpredictable. My meeting with the hospital administrators was moved back several days once I arrived in Siuna giving me free time to explore the city and the surrounding communities. Next the hospital administrator with whom the project was previously explained had been moved to another position so I had to meet with a new hospital administrator to explain the project again so I could have access to the disposal area. Once I was given permission I quickly found out that much of the trash was not being disposed of correctly. Almost all of the hospital trash including gauzes, bandages, and used medical bags were mixed in with regular waste making it impossible for me to measure how much of each category they were generating. While the more dangerous hospital waste was to be put in the incinerator. I found that vultures had found their way into the incinerator and thrown trash everywhere. Finally, the garbage trucks schedule was just as unpredictable leaving me waiting for half a day before giving up.

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The Siuna Hospital just inside the entrance

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The new garbage station

All these challenges required unique solutions to make sure I can collect as much data as possible in a safe manner. My complete lack of Spanish is another challenge and while I am learning as much as possible I still rely heavily on a translator who is extremely helpful.  Everyday can bring its own unique challenges to overcome and I have learned quite a bit about learning to expect the unexpected. I guess that sort of chaos is just part of the whole learning experience!

Take Care everyone,

Serge

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XDR-TB in Lima, Peru: the human side

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In the hospital, the tuberculosis program head nurse (Raquel) talks to me about the recent admissions for XDR-TB.

Arriving in Lima, 2014

I arrived in Lima not knowing what to expect. Last year, I had spent six months working with extensively drug-resistant tuberculosis (XDR-TB) patients through Socios en Salud, the Peruvian branch of Partners in Health. I had interviewed them about their treatment experience in their homes and in the hospital. Especially with those patients in the hospital, where they stayed on average for six months, I had developed a connection through repeated interactions and a small bi-weekly activity. We did everything from origami to yoga.

This year, I was fortunate enough to be able to return through funds provided by the UVA Center for Global Health. I hope that this post shows the importance of Partner’s in Health (Socios) work in Peru and helps to reflect on the need to develop better treatments for the people who die every day from drug-resistant TB.

 

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Cutting the panetone at one of the birthday celebrations for one of the hospitalized women.

In 2012, the Peruvian Ministry of Health (MINSA) implemented a new treatment scheme for XDR-TB. It had almost universally achieved culture conversion, meaning no tuberculosis in the patients’ lungs. A positive culture indicates that there is live Mycobacterium tuberculosis in the sputum, and is used as the gold standard laboratory measure of a treatments’ efficacy.

But the week before I had left, one of the patients with whom I had spent time passed away, despite negative cultures.

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Outside the house of one of the patients with one of the Socios nurses. I accompanied him to administer treatment a week before the patient passed away.

So, when I stepped into the hospital for the first time the day after I arrived, it was not without tredeptation. Over the next days, I found out about two patients who also had passed away. Despite my expectation, remembering their stories and hopes for a cure as they became culture negative and began to gain weight, the personal nature of the tragedy hit me.

The death of J.

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Patients spent up to six months in the TB ward during treatment and developed friendships. This photo was taken in one patients’ home, mourning the death of J. and the others she had known who passed away.

In June, one of the patients returned to the hospital. Last year, I had helped him get his Peruvian social security number (DNI), delivered a birthday card to his granddaughter and bought him shoes when his broke—

and he had trusted me with his story, the death of his wife while he was incarcerated, his childhood on the streets, the joy he took from (of all things) knitting. After nearly a year hospitalized, he had been discharged.

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J. and other patients working together to knit.

When I found out he had entered through the emergency room, I was on the other side of the city. I resolved to go the next day. But it was too late. He had gone into kidney failure, as a side effect of his TB medications, and the nephrologist wanted to see proof of a recent negative culture to start him on dialysis. In the three-day scramble to find the papers and present it, the dialysis came too late.

He entered a coma and passed away on the fifth day.

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J. won the TB ward’s contest with this drawing. In English: if one thing is sure, it’s that tuberculosis can be cured. We all fight tuberculosis. Get on board.

Common tragedies

As I told the story to a member of the PIH team who has worked all over the world, he told me (not minimizing but factually) that unfortunately stories like this were all too common.

That afternoon, I went to a group therapy session for recovering patients who had DR-TB. As I listened to their struggles with poverty and stigma, many so common to those I had found in my interviews. Not knowing where the next meal is coming from; not knowing who will raise their children if they die. These common tragedies, those that affect the lives of people at the edges of society who are not expected to make it.

People who are expected to remain at the edges, hanging on to not fall off.

This is for them.

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More Reflections on Conducting Laboratory Research in an International Setting

Welcome to the second installment of happenings in Brazil!

          Only a week remains until I leave Fortaleza and head to Rio de Janeiro to spend the last few days of my time in Brazil. As I mentioned in my last blog post, it took some adjustment to feel competent in a working environment as foreign to me as that of the Federal University of Ceará (UFC). To be honest, I was pretty disappointed at first by the setbacks outside of my control that prevented me from taking full ownership of my project and maximizing my experience at the bench, which is what I looked forward to before my arrival. Now, in retrospect, I view my Brazilian experience as a healthy exercise in reorienting my expectations, and I couldn’t be happier with how things have turned out. 

          Because of the delays in my proposed project, I took advantage of my freedom to expose myself to the laboratory environment of the entire floor of the biomedical research complex of UFC. I met visiting medical students from France, Spain, and Portugal completing their internship programs at UFC; I met “sandwich” PhD students from Colombia working on part of their graduate program; and I met countless Brazilians conducting biomedical research in the building and had the opportunity to shadow and learn about their projects. Although it isn’t common for graduate students at UFC to speak English, it is often expected of them to be able to present their work in English. So, on countless occasions, students would request my assistance to help proofread, make edits, and rehearse their presentation. I was more than happy to be of any help! Also, out of necessity and with the help of bi-weekly, private Portuguese lessons, I’ve really come a long way with my language comprehension and proficiency, which was one of my motivations for coming to Brazil in the first place, so I’m pretty excited about that!

           There are two ongoing projects in lab that I will be presenting for my CGH funded project. Both projects are models of chronic intestinal inflammation in an animal model and are validated protocol that seek to mimic the sub-clinical condition termed “environmental enteropathy,” which is a condition where gut inflammation as a result of malnutrition leads to chronic changes in the body’s metabolic and cognitive function. The first model is a maternal separation study where the mice are separated from the mother after birth in increasing time windows and monitored for 14 days; the second model is a diet-induced malnutrition study where the mice are weaned from the mother at 22 days of life and fed a low-protein diet and monitored for 40 additional days. Both models are compared alongside a control. Changes in intestinal morphometry (villus height/crypto depth ratio), blood biochemistry (total cholesterol, glucose, and C-reactive protein levels), and weight over time will be analyzed to determine how they are affected by chronic malnutrition. I will be working primarily with PhD student Ítalo Figueiredo in Dr. Oriá’s lab throughout the fall as data continues to be collected.

          Outside of work, I’ve had the opportunity to develop friendships with lab people and better understand life as a Cearense (of the state of Ceará). I’ve played pick up soccer, basketball, watched indie Brazilian films, and attended a bi-weekly fitness class on Beira Mar Avenue, an activity that’s becoming increasingly popular with Cearenses. Although I’m as Gringo as they get (note the complexion of my skin), I’ve been doing my best to assimilate with the local people, learn from them, and experience life in a city burdened with economic equality. Unlike any other experience abroad I’ve had yet, I’ve spent time truly getting to know the people (living independent in a big city can really make that necessity), rather than exploring the sights of the country. I can only hope that I can take a small part of Cearense culture, from the endearing way in which people interact to the incredible hospitality that they pay to foreigners in their midst, back home with me in a couple of weeks. I’m going to miss these folks, but thank goodness for mutually beneficial university collaborations, I have an excuse to see many of them in Charlottesville in the years to come.

          I can’t thank the CGH family enough for believing in me, and for making this incredibly opportunity for my career and personal development a reality!

 

Muito obrigado, or “much obliged” as they said in Brazil,

Cam Elward

Friends from lab and the beautiful beach town of Jericoacoara at sunset

Friends from lab and the beautiful beach town of Jericoacoara at sunset

Selfie with some of the transgenic goats engineered to produce human lysozyme in their milk for one of the ongoing projects in lab

Selfie with some of the transgenic goats engineered to produce human lysozyme in their milk for one of the ongoing projects in lab

An old Jesuit church in the mountains of Guaramiranga, Brazil just outside of Fortaleza

An old Jesuit church in the mountains of Guaramiranga, Brazil just outside of Fortaleza

Attempting to wakeboard at a popular cable park inside the city

Attempting to wakeboard at a popular cable park inside the city

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Identifying & Combatting Psychosocial Stigmas Towards Children with Special Needs in Ecuador

Hello everyone! This is my second installment regarding my project in Quito, Ecuador –

I have spent the past six weeks working as a speech therapy intern in a school for children with intellectual disabilities and other special needs. The school where I worked typically serves between 25 and 30 students at one time. Students are divided between three classes based loosely on age, but primarily on their abilities and mastery of material. A speech therapist comes to the school up to three days per week. Students in Ecuador attend school for about 4 hours per day, coming for classes in the mornings.

My project involved administering a questionnaire to the parents of the students at the school where I worked. The questionnaire was about five weeks in the making, between adjusting grammar and wording to fit the colloquialisms of the area and coordinating with staff at the school to determine administration procedures. As I wrote in my first post, “flexibility” has a slightly different meaning in Ecuador, and is perhaps more similar to our “procrastination” in the way that it plays out in everyday life!

I could also see the effects of this “flexibility” in the number and results of the 19 questionnaires I received back. Many of the families at the school had already withdrawn their children to go on vacations, or had opted to keep them at home during the summer months, decreasing the size of the participant pool. However, 83% of questionnaires were returned at least partially completed. The other component to my project was conducting interviews with the professionals working at the school, including teachers, administrators, and therapists.

I have only scratched the surface of data analysis at this point, aggregating the results from the questionnaires and reading through the responses to the open-ended questionnaire items, and my notes from the interviews. However, some trends that have begun to emerge are: a) the disparity in the amount of aid or support that families receive from the government and from friends and family members, b) the optimism of families with children with disabilities, and their generally positive perceptions of people with disabilities, and c) a lack of education about disabilities as a primary cause for stigmas towards children with special needs in Ecuador.

The information from this study should help clinicians begin to understand how best to serve Spanish-speaking families from Ecuador and other Latin American countries living in the United States.

DSC_2381A view over Quito and the Andes from the peak of volcano Cruz Loma.

 

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Assessing Community Health Workers in Rural Guatemala

Hello again! This is Natasha updating with another blog post. Guatemala is an incredible country where the streets are lined with colorful houses and the markets are filled with all kinds of delicious fruits. Our first four weeks in Guatemala were in Quetzaltenango (Xela). Both Spencer and I took Spanish classes at Celas Maya for 3-4 weeks in order to help us with interviewing CHWs. Spencer took an extra week of Spanish school since he did not have anyone helping him with his interviews, while I worked our in country partner, Miriam, who went with me to site visits. During my first week of data collection in Xela, I went to local Convergenicas de Salud, Centros de Salud, and Puestos de Salud. All three are government run healthcare clinics that are located in most communities in Guatemala.

Celas Maya where me and Spencer took classes

Celas Maya where Natasha and Spencer took classes

I realized that things work a little differently here in Guatemala in that we rarely set up appointments to interview the CHWs. Instead we usually went to the community and asked if there were any CHWs at the health clinic. If there were none, we would usually get pointed in the right direction of where we can find them. People here in Guatemala, no matter how busy they are, are willing to help you, which is really refreshing. In some of the more formal settings of Centros and Puestos de Salud we would have to obtain permission from the director in order to interview CHWs.
I moved to San Lucas to work on my project in some of the smaller communities for the remaining two weeks. I worked with Felipa, another one of our in-country partners, who was a CHW in San Lucas for 6 years and trained as a CHW for 3 years so she is very knowledgeable about CHW. Over the course of two weeks we traveled to Santiago, San Gregorio, San Juan, San Lucas, and San Martin. The biggest problem we encountered was many CHWs work out of their individual homes and not under one structure. It made goal of interviewing them a little harder since they were so spread out. In total though, there are many more CHWs to survey in the Lake area in comparison to Xela, which is a more well-developed city. Felipa also told me that many CHWs, unlike in Xela, work on their own instead of working for a big organization like a Centro de Salud.

San Martin, one of the many communities I interviewed CHWs from

San Martin, one of the many communities Natasha interviewed CHWs from!

In total I was able to interview 35 CHWs and 1 director of a health clinic that utilizes CHWs. I just came back to the States (still in denial that I left the beautiful country of Guatemala) and am starting to analyze my data. In the end I hope to learn the top choices for which programs people were most interested in implementing in their organizations, which topics were most popular among health fairs, and which topics were most common for additional classes.

Natasha with her host abeula in Xela

Natasha with her host abeula in Xela

One of the biggest trends that I was echoed among many CHWs along the lake was the issue of adequate healthcare. There are Centros de Salud in the Lake communities like Santiago that are free and government run but do not have adequate staff to care for the population, little to no medicine, and poor treatment of patients. Most people go here for medical care but are rarely ever treated properly. The alternative option is the Hospital Parroquial, which is a private hospital that treats many of the people around the lake. However, you have to pay to get medical treatment here. This is an issue for many people because they do not have enough money to afford treatment at the private hospital but never get treatment or medicine at the Centro de Salud. Economic barriers are the most common problem people face in and around the lake region. This is a major concern for many as people choose to not seek healthcare because of this issue. All CHWs I interviewed wish there was an alternative or a way that this issue could be resolved. This is one of the many issues that have come up as I begin to analyze my research.

Beautiful Lake Atitlan where Natasha interviewed CHWs for 2 weeks

Beautiful Lake Atitlan where Natasha interviewed CHWs for 2 weeks

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