Adios amigos!

As my last day here in San Miguel comes to an end, I wanted to reflect on my experiences here in a final blog post.  It's been a little while since I've talked about our project here so I'll update you on what we've been doing these final weeks.  We wrapped up the data collection of our project about two weeks ago, and we've been using these last weeks to set up for next year.  Because Proyecto Puentes de Salud is an annual trip of first year medical students, we want to make sure that we've got things in place for next year's group.  This task is all the more important because we are the first group to come to this site in San Miguel.  The other PPS group has been going to Juventino Rosas (a neighboring town) for 5 years now, and things are very well established there.

To accomplish this, we wanted to create connections and continuity in a few of the communities we've visited.  Over the summer we have been to 13 different rural communities surrounding San Miguel, and at each one we were asked if we would return.  Unfortunately, we had to tell them "no" or "yo no sé" (I don't know).  Next year, we want the group to go to around 4 communities for a week at a time.  So we spent these past 2 weeks returning to 3 communities where we felt a good connection with the people there (we didn't have time for 4).  Once we were there, we interviewed the people, asking them what health needs were most common in the community, and trying to find out how we could most help them next year.  We were at a disadvantage this year being the first group going to this site, and we could only guess what the health needs of the communities were.  All summer we had been popping in and out of communities with our own agenda.  This time around though, we were there to listen and form partnerships with the communities.  Those two weeks spending time in the communities listening to the people were some of my favorites here in San Miguel

Now, all summer long we had transportation provided for us from DIF (the government program), but this time we were on our own, which lead to some adventuring.  Sometimes getting to these communities wasn't too difficult while other times we had no idea where we were.  The first community we revisited was called Los Tovares.  Essentially, it was a community of an entire family named Tovar.  The first time we were here, the mothers had really made an impression on us.  They were wonderful and involved, and they were largely the reason we came back.  We had such great luck on our first attempt to see a community-- all it took was a 20 minute bus ride and a 20 minute walk.  The next time around, we weren't so lucky.

We next set out to visit a community called El Lindero where we had a great experience with the primary school teacher.  This is where we had done the PE class I wrote about in a previous blog.

Anyways, so we knew it would be a good walk from the highway from what we remembered of the drive there, but we had a problem.  There were 2 El Linderos on the map, and we didn't know which was which.  So we made a guess and took a bus that way, and the bus driver let us off where he said was "cerquita" to El Lindero.  He pointed in the direction we should walk, and so we started walking.  After an hour of walking without anything around us, we came across a person and asked if we were close.  The man sort of chuckled and told us we were muy lejos (very far).  Turns out we were a few hours away.  Awesome.  As we started to head back to the highway, Will decided to explore a bit and had a close run-in with some aggressive dogs.  Don't worry the dogs didn't get him-- but the cactus did.  In his attempt to escape the dogs, he ran straight into a cactus and had some spines lodged in his hand, shoulder, and leg.  Ouch.  After a brief period of time thinking that cacti might be poisonous, we figured out they weren't after asking three different people and enduring three chuckles at Will's expense.  Oh well.  Live and learn.  Day 1 of finding El Lindero was unsuccessful and so was day 2.  On day 3, we finally found it with a 25 minute bus ride and a 45 minute walk where crossing a river was involved.

But that walk was nothing compared to the 2 hour walk we took to get to our last community Los Juarez.  This poor little town is located right next to a larger town and they seem to get forgotten a lot according to the people there.  Everyone seems to think they're part of the larger town when they're not, and for that reason they don't receive many services there.  We're very happy to be able to provide them with some services next year.  All this adventuring we did to get to the communities was frustrating at times for us when it didn't work out, but this is the way that the people in the communities live.  They're isolated, and they have to put in a lot of effort to get around.  In a way, I hope it showed our dedication to serving these communities.  The people seemed impressed that we were willing to walk that long to see them in their "rancho pequeño."  


Common needs that came up in our discussions with the communities that we hope to address next year:

1. Pap smears-- many women have never gotten them either because of the expense or the trouble it takes to get to a health clinic
2.  Vision checks-- glasses are so expensive for them but we're hoping to work with organizations to provide affordable glasses
3.  Depression support groups-- the other PPS group in Juventino Rosas has had some success with this for the women there, and we hope to help people in San Miguel with this too.  It's increasingly more common with the number of men now in the United States.
4.  First aid classes-- due to the isolation of the communities, this could be incredibly useful

Hopefully, we'll be able to help with at least one or all of these things.  We discussed our ideas for next year with our advisor Dr. Q. over beers and tequila at our final meeting with him this week.  He was a great mentor to have in Mexico for our project and has been so crucial to our success here.

Some other things I've learned this summer:

1.  The Mexican people are overwhelmingly welcoming
Very often people will come up to us and talk to us because they know we're American, and their favorite question to ask is "What do you like most about Mexico?"  I always answer "the people."  It may sound corny, but it's so incredibly true.  The people here are amazing.  They love that we're here, they want us to enjoy their country, they want to help in any way they can, and they want to be our friends.  I've had a great experience with the people of Mexico.

2.  I like gynecology
After shadowing Dr. F. a few times at Hospital CASA, I've become more interested in gynecology as a specialty.  Not necessarily the obstetrics side of it, but the endocrinology, microbiology, and reproductive care combined into a primary care profession really appeals to me.  I like the focused aspect of the long-term care.  This is the first time that I've really felt interested in one specialty in particular.  BUT we'll see how things go!

3.  Cacti are not poisonous
See above story.

4.  You have to make mistakes to learn
For me, this is the most important aspect of learning a foreign language.  You can learn the words, know the vocabulary, but until you can really string a sentence together-- you don't know the language.  Pushing through your stumbling and stuttering can really put you outside of your comfort zone, but it's the only way you'll learn.  You have to make the mistakes.  I find that it's a progression from speaking incorrectly to speaking incorrectly at times to speaking incorrectly at times but recognizing those mistakes to speaking nearly correctly.  So I've stumbled and stuttered my way through many conversations, but I've also learned a ton!

5.  I now know where the Mexican immigrants have come from
In North Carolina, we have a huge population of Mexican immigrants, a large portion of whom are from this area of Mexico.  I've already written about the many communities we've been to where there are hardly any men around because they're all in the United States.  One of my goals coming here to Mexico this summer was to get a good understanding of the Mexican people who will be part of my patient population in North Carolina.  I knew the language, but I didn't know the country or culture.  Now I've gotten a taste of their culture and their people.  I've seen the communities where they may have lived, and I've talked to the women that could be their wives.  I'm not saying that I know everything there is to know-- far from it-- but I've at least gotten a start.

6.  Health is the most important wealth you can have
This is a concept that's been instilled in me a lot growing up.  My mom has always told me that as long as you have your health, you have everything, and nothing could be more true than that bit of wisdom.  Visiting these isolated communities and talking to the people about their experiences with illness and how they get their healthcare, I'm so grateful to live somewhere with easy access to good health services.  Apart from the time investment to travel to get health services, the people in these communities go to clinics where there hasn't been a doctor for months and there's only one nurse, and to get an appointment you have to go in person to the clinic just to get an appointment three months from now.  These are the daily challenges they face to be healthy.  So I am grateful for the privileges I have in the United States and hopeful that our group can make a tiny difference in the lives of these people if only for a few days a year.

So that's my last blog post.  I hope you all have enjoyed reading about my experiences here in Mexico.  I've had a great time writing this blog and hearing from all of you!  See you all soon!

Sierra Gorda Mountains

Word of the day: lodo

Translation: mud

For our last weekend here in Mexico, Jamie, Will, and I decided to take a trip to the Sierra Gorda mountains in the neighboring state of Queretaro.  Sierra Gorda is an ecological reserve with amazing biodiversity and changing landscape about every 15 kilometers.  The sites were absolutely breathtaking.  To get there, we rented a car and drove the 4-ish hours through winding mountain roads to the little town of Pinal de Amoles.  That little Chevy Chevy put in a lot of good work for us this weekend-- a car so epic it needed two names.

As we ventured further into the mountains, winding up and down the peaks, we were treated to beautiful views (and a dash of motion sickness for whoever was lucky enough to sit in the backseat).  When we finally arrived in Pinal de Amoles, we rented a little cabin with a kitchen for the weekend.

On Friday afternoon, we squeezed in a quick hike along the Rio Escanela before it got dark.  We took the turn off the main highway and snaked down a rocky road for a few kilometers to the valley where the river ran.  From here, a local guide-- 15 year-old Gustavo-- took us on our hike along the river.  With Gustavo at the lead, we followed the river etched in between the mountains.

 A few times we had to hop the stones to avoid stepping in the water, which of course happened to me anyways.  We wanted to make it to a cave called Puente de Dios, but the ebbing daylight would not permit us.  Despite that, it was still a perfect start to the weekend.  After the hike, we headed back to our cabin to cook up some food, drink some beers, and go to sleep before our big day on Saturday (although at the time, we didn't know how big of a day it was going to be).

After a hearty breakfast of scrambled eggs, sweet bread, mangos, and instant coffee, we set off on our journey to see el Sótano del Barro (translation: mud crater) outside of the mountain town of Jalpan.  Along highway 120, there are 864 turns in the road leading to Jalpan, and oh boy do I believe it.  I've never been on so many windy roads in my life.  Just outside of Jalpan, after nearly missing the sign, we turned off the highway onto yet another bumpy road for 23 kilometers.  Now, that may not sound like too far (~14 miles), but when you're averaging about 25 kilometers an hour weaving in and out, up and down mountains, forging rivers, it takes a while.  23 kilometers later + 3 km past it +3 km back to it, we arrived at Santa María de Cocos, the town with access to el Sótano del Barro.  We soon found out exactly what "access" meant-- 2 hour hike there and then 2 hours back.  Our guide, Marcelo, offered us some mulas if we would rather not do it by foot.  Ok, we thought, we came all this way so we're doing this hike the right way, and not on mules.  Maybe there was slight foreshadowing as to the strenuous nature of this hike implied in the offering of the mulas, but if there was, we definitely missed it.

So off we went in our ignorant bliss, which soon became painful reality when we realized that the hike to el Sótano del Barro was literally up the mountain-- straight up with nary a transverse.  I was huffing and puffing like I'd never exercised in my life.  The worst part was that it was incredibly muddy so every step was 10 times harder than usual as we struggled to get our footing.  It was like climbing stairs for 2 hours.  I started to question why I even like hiking, but then 2 long and grueling hours later I remembered.  The forest began to thin, replaced by piling rocks, and as I climbed over them towards the outlook all I could say was "holy moly" (or a less G-rated version of that).  The view was absolutely breathtaking and indescribable-- which is why I'm including pictures!  But even those don't do it justice.

Living in this giant crater are an endangered species of birds, las guacamayas verdes (Green Macaws), a type of parrot.  We saw them soaring in and out of the crater, diving down into its depths while emitting their characteristic call.  We sat at the lookout for nearly an hour, taking in the beauty of the view.  The hike back was far more enjoyable, minus the layers of mud I had caked on my shoes and legs, which is why the word of the day is lodo (porque había muchísimo). There were incredible views on the way back down the mountain too.  By the time we got home to our cabin, we were exhausted, looked like swamp monsters, but had thoroughly enjoyed our day.

For our final day in the Sierra Gorda mountains, we went on a shorter hike (thank goodness) where you were supposed to see a great view of the mountain ranges.  Unfortunately for us, it was extremely foggy so our view was very limited.  The hike was great though, with these beautiful mossy trees, and a vast open area at the peak.  Even the fog was pretty cool because it was so incredibly thick.  After a fun-filled weekend, we packed up and headed home, stopping to watch the World Cup final in a town on the way.

Some things here are not like the other...

Now that I've been here for over a month, I'd like to comment on some of the differences I've noticed between my life in the United States and life here in San Miguel.  Some are obvious, while others are more subtle.  DISCLAIMER:  These things are not necessarily true for all of Mexico (but some are).

1. Traffic laws
With only two traffic lights in the entire city (someone told me there are 2, but I have yet to see either) and no stop signs at four-way intersection (except in the round-abouts), people tend to drive following a mutually understood law of common courtesy. It's a strange experience at first, seeing people pause at intersections, wave others on, and choose an opportune moment to drive on through.  As my host father Alex would say, the only rule you need to know is "Primero las guapas" (first the pretty girls).  No one seems to get angry at each other.  If there's a misunderstanding about who goes first, the interaction usually ends in a smile, a wave, muchas gracias and buenos dias.  I wonder what Mexicans in the United States think of all the road rage, profanities, honking, and gestures in our country despite the rules of traffic lights, stop signs, and intersections.  Maybe things work better their way.  At least, they seem a lot happier than we do.

2. Dogs, dogs, dogs
There are endless amounts of stray dogs here in Mexico.  Every neighborhood, every street corner, every school, and every doorstep it seems.  It's sad to see so many dogs wandering without homes, begging for food, mangy and feral.  Before I came to Mexico, I wasn't sure why the rabies vaccine was recommended.  Now I see why with so many dogs running around.  Although I have to say, I have yet to encounter an aggressive one.  They're mostly searching for food and wary of people because so many of the children here abuse them.


3. Saying "hello"
When you greet someone here in Mexico, whether it be good morning, good afternoon, or good evening, you always give them a kiss on the cheek.  When I studied abroad in Spain, it was a double kiss, but here just a single kiss suffices.  It seems to usually be the right cheek, but sometimes I forget and get locked into an awkward game of "Which Way Is Your Face/Kiss Heading?"  No worries though.  I usually recover well by charming them with my witty Spanish banter...  In general, I've found it's a friendly and affectionate way to greet someone and to be greeted.  In the U.S. we like to keep people at an arm's length (literally) with a handshake.  Sometimes handshakes even feel too formal.  Then there are those people that just go straight for a hug.  I like the happy medium of the cheek peck.

4. Shorts
So I'm a big fan of shorts.  In fact, I only brought one pair of pants with me to Mexico.  Apparently, it's not too common for women to wear shorts here.  Oops.  Again, no worries.  Jamie and I still wear our shorts pretty much everyday.  One day we were on a walk, and someone starting singing to us, "Caminando por kilometros de concreto..." (Walking over kilometers of concrete).  It had a lovely melody.

Let there be light!

In Spanish, a phrase meaning "to give birth" is dar la luz-- literally "give the light."  I love these little peculiar phrases in Spanish because it always makes it easier to remember when they're such strange translations! Although, I'm sure a non-English speaker would find telling someone to "break a leg" for good luck just as peculiar.  Anyways, I digress.  This week I shadowed the ginocológo, Dr. F, again.  


3:30 pm
I arrived at Hospital CASA, and we saw our first patient.  A woman with abdominal discomfort, absence of menstruation for 4 months, and the distress that it was impossible for her to be pregnant because her husband had been out of the country for 2 years!  Baby Jesus?  Nope.  An ovarian cyst-- un quiste ovárico.  Immediately, my mind started racing through possible differential diagnoses-- one in particular being Polycystic Ovary Syndrome, a very common disorder affecting 5-10% of women of reproductive age (believed to be the most common endocrine disorder). Diagnostic criteria for this disorder must include any 2 of the following "Rotterdam criteria"

1. Anovulation (absence of ovulation)
2. Irregular menstruation
3. Hyperandrogenism (increase in male hormones)
4. Multiple ovarian cysts
5. Insulin resistance

Many patients are also overweight as this patient was (~50% of PCOS patients are obese).  So far we know #2 is true and #4 could be true although we only located one ovarian cyst.  To be sure of the diagnosis, further testing was necessary so Dr. F. referred this woman to an endocrinologist to evaluate hormonal levels and likely evaluate for hyperandrogenism, anovulation, and insulin resistance.  

I hope you're still reading this blog post after I went off on that nerd tangent with you.  This appointment took about 10 or 15 minutes.

3:45 pm

Our first patient leaves, and Dr. F. and I walk down the hall to see a patient in labor who had come in not long before we saw our first patient-- let's say a little after 3 pm.  The patient was a 29 year-old woman named Guadalupe (name changed) accompanied by her mother who waited outside the room.  This was her second child, and she was breathing heavily as she worked through the pain of labor.  Dr. F. handed me the fetal heart monitor and showed me how to position it over the uterus to detect the baby's heartbeat racing away over 100 beats per minute.  Meanwhile, Dr. F. was inspecting Guadalupe's cervix to see how she was coming along.  The pediatra (no translation necessary I hope?) came in and introduced himself to the woman because he would work with her and inspect the baby once it was born.  Before he walked out of the room, he made sure she was comfortable and pulled the covers up over her knees. I found myself thinking, "Huh, I guess this will probably take a little while." Wrong.  

4:05pm

It's hard to exactly describe what happened next because it happened so fast so excuse me if I'm being too detailed (by now I've surely lost my older sister as a reader).  Guadalupe made a noise, and I thought that maybe she had an urgent need to use the bathroom because she had expressed interest in it earlier.  Wrong again.  Dr. F. pulled back the sheet, and there was a baby laying there.  One second nothing, the next a baby.  Needless to say, my jaw dropped.  This is only the second birth I've seen, and it was the complete opposite of the first one.  To start with, I was in the United States speaking English and so was everyone else.  There was lots of coaching, lots of pushing, lots of doctors and nurses, lots of heart monitors and machines.  This time, it was just me, Dr. F., Guadalupe, and a pain medication IV.  Oh yeah, and Jennifer, the new baby, she showed up pretty quickly.

This shadowing experience made me reflect on the differences between healthcare practices in the United States and healthcare practices here in Mexico.  I walk into CASA.  It's a beautiful, open building with a central indoor fountain and garden, emanating peace and tranquility to the patients.  The rooms are arranged around it in a square.  Enter, Dr. F.  Hair slicked back with gel, button-down shirt and slacks, a white coat.  A symbol of authority and respect but also social status.  All his patients regard him with the utmost reverence and thankfulness.  Now, let's go to his office, which is also his examination room.  A simple room with a patient table for ultrasounds and general examinations on one side.  On the other side, his desk where he can speak with the patients and a bathroom for the patients to change into gowns when necessary.  The lighting is poor, there's no sink for hand washing, no ultrasound technician, no nurses station for taking vitals.  Everything is compressed into this room with the doctor.  In a way, it's more personal.  The patient spends all his/her time with the doctor.  Dr. F. is even the one to go to the waiting room to call the patients back to his office for their appointment.  He's 100% available to them.  They have his cell phone number, which he's told them to use if they have any doubts or questions.  On the other hand, I'm only in the first year of my medical training, and I've been told countless times the importance of washing your hands before and after every patient, when to use gloves, the importance of cleaning equipment in between patients.  Those things don't seem to be practiced as stringently here.  I'm not sure the reasons for this, whether it be out of lack of resources, knowledge or just plain not doing it.