Day Twelve: Si Dios Quiere...

The Dominicans living here in the mountains have a standard response whenever I tell them, "I'll see you later." There is always a momentary pause--after which there is a smile, a half-hearted shrug, and then the famous words: "Si Dios Quiere" (if God wants). At first, I found myself puzzled by their response. But upon further thought, I came to understand it. After all, they had probably been visited by many volunteers in the past, many of whom had made empty promises to return. It was perhaps only logical that they had left it in God's hands whether or not they would ever see us again.

Ana and I wrapped up our last clinic session and spent the afternoon finalizing our needs assessment report of Dina's family. In the midst of it all, we were able to fit in one final basketball session. I am amazed by the progress we made in the past 5 days. The respect that the girls have for Ana is almost palpable, and in some ways, I think her basketball clinic had more of a positive impact on their health than anything "medical" we could have done. There's nothing like taking up a sport to encourage healthy habits and build self-esteem. Here's a final picture of the team:



Our parting from Dina and Ramon was a sad one. It was late in the afternoon when we were finally able to get up the hill, and Ana and I were scrambling to catch the last gua gua off the mountain. We said that we would visit them again before leaving for the U.S., and of course, they responded to our promise by saying, "Si Dios quiere." In any case, we did manage to take a family photo of them, which we plan to send to them in a picture frame by next week:



And of course, before leaving the mountain we called "home" for the past week, Ana and I couldn't resist visiting Maribel Dulce again and buying one of her famous empanadas for the road:



Ana and I would stand at the side of the road for a long time before catching the last gua gua that would bring us back to our Santiago apartment. We licked away the last of the grease from our empanadas as we waited, watching the locals mill around the small village store. It was hard to believe that soon, we would be amidst the crazy hustle and bustle of city streets, where the sounds of car horns and sirens would replace the sounds of insects buzzing and roosters crowing. And hence, our time in the mountains had come to an end

Day Ten: House Call

Wow--today was certainly action-packed! After another breakfast of toasted bread and chocolate milk, Ana and I literally set out to conquer the world. Our morning started out on the wrong foot, however. Yesterday, we bought Maribel Dulce five oranges and a pineapple as a thank you gift. This morning, we awoke to find that she had cut up four of the oranges in halves for us to eat with breakfast. Turns out that she had one orange last night (which, according to her, was extremely good), but then discovered that it hurt her teeth tremendously to chew the pulp.

So much for our thank you gift...

In any case, this morning, we were told to help out with home visits in the morning since the whole medical team from Brown was going to be there. Ana and I got there early and spent time chatting with Diego about Dorka and her family. Soon enough, Michael, Heather, and Cindy arrived in short order. We filled a bag with all sorts of medicines and set off to visit the people living in a remote village called Los Pajones. We hiked for about 15 minutes before coming to our first destination.

Our first home visit was quite sad--a 72-year old woman who looked at least 20 years older than her stated age. She had a history of high blood pressure, stroke, and diabetes, and, according to the niece, she had been feeling extremely lousy for a long time. When we saw her, she was in prominent atrial fibrillation, and there were crackles in both lungs. We were told by Diego that the woman was dying, and that everyone was fairly certain that she was on her way out. And with 4+ pitting edema in her legs, and overly-distended bladder, and signs of congestive heart failure, she couldn't have been that comfortable at all.

So what did we do? Other than tinker with her blood pressure meds, start her on a beta-blocker to control her heart rate, and discuss the feasibility of starting her on a diuretic--we did absolutely nothing. I'm really starting to get the sense that symptomatic control is the best one can hope for out here...

The next house visit was not much better. We took care of a couple who had some minor ailments: controlled hypertension and back pain. Their father, however, was also not in good shape. When we saw him, he was lying on a thin matress on a pile of old blankets. His body was fixed in a contracted position, and it was physically impossible to break him away from this fetal position, even to examine him. And it was heart breaking to do so. He had evidence of a pronounced facial droop and asymmetrical muscle strenth. But by far the most disturbing sight were his pressure wounds. Bound to his bed for many months, he was starting to get nasty bed sores on his bony prominences. And there were many of those sores on his body. Michael and I tried getting a blood pressure, but could only manage to get a systolic number due to the fact that he wouldn't relax his arm enough for us to check it properly. We noted, as we were busy moving him around, that the man smelled absolutely horrible. Indeed, we realized that this was because he had been sitting in his own feces and urine for quite some time. The couple taking care of him knew how important it is to change positions frequently, but both of them were too busy with handling their own issues for them to give him very much attention.

We were able to see a few more cases that morning, including a man with aortic stenosis, a woman with possible tuberculosis, and a man with asthma. But overall, I felt these home visits went far more smoothly than the ones we had done previously. Heather is essentially our attending now, and she has adapted incredibly well to her new role as a leader and chief caregiver.

I should mention that these home visits are primarily for patients who live in areas so remote that it is extremely difficult for them to access the clinic. As such, it would usually take us the whole morning to see 5-6 patients, since the houses were so far apart from one another. Walking through the woods and mountainous terrain made me very appreciative of just how strong one has to be to live here.

After our home visits, Ana and I scampered off to Santiago to try and get some toys for Dina and Ramon's children. This turned out to be a far more labor-intensive experience than anticipated. Diego was able to give us a lift into the city in the early afternoon. Ana and I had about two hours to take a cab back to our apartment, eat, go toy shopping at the market, and find our way back to the Gua Gua stop for the last ride up to the mountains. We made it, just in time...only to endure a very long ride up the mountain with a fairly reckless driver (though it seems that reckless is the norm over here). Finally we arrived in the mountains...ten minutes before basketball practice was supposed to begin. Feeling disoriented and quite car sick from the ride, I managed to stumble behind Ana as we trekked up the hill to deliver goods to Dina and Ramon, and then back down again to play some basketball with the girls.

Thankfully, the day had a happy ending. We may not have saved the world, but we did manage to get back to Maribel Dulce's house in one piece...

Day Nine: Poor but Rich

So the good news: I survived the nighttime insect swarm that apparently invaded our beds. And the extremely cold shower that followed my awakening only served to sharpen my awareness of how absolutely different my life is from the people who live here.

Breakfast today was again, simple but delicious. We had 2 pieces of toasted bread each, as well as a generous mug of hot chocolate milk. It felt good to drink something warm this morning, since the temperate had literally dropped 30 degrees overnight.

We eventually left the house to get to clinic around 8:30 a.m. And already there was a long line of people waiting to get in the clinic when we arrived. I was assigned to the role of taking vitals this morning, and it gave me a chance to do a lot of counseling about diet and exercise (a lot of female patients were frustrated with their weight on the scale). Ana saw them in clinic with the doctor, and apparently were more than a fair share of interesting patients. There was one child who was given treatment for worms since his mother saw some in his stool. And it was also "Papanicolau Day," so many women were there to review their results. Out of the approximately seven women who came for their results, two had cervicitis. Fortunately, the Dominican government has a similar sort of reporting system to the United States for sexually-transmitted diseases. Good to know that they are keeping an eye on things, I suppose...

After clinic, Ana and I paid another visit to Dina, the 18-year old mother of three that we met for the first time yesterday afternoon. She was in good spirits when we saw her, and she was very excited to see us. Her husband, Ramon, was there as well. Whereas yesterday, both of them had been reserved and polite when interacting with us, we found them to be extremely talkative and open with us today. Thanks to the good weather, we had a great chance to have a look at the household. As I said before, the whole family lives on a farm up on a very steep hill that looks something like this:

De Medical Adventures in GuaGua Land

The view from the top of the hill is absolutely amazing. The farm itself however, is extremely poor. Dina and Ramon have no share in the land--they were placed there by a landlord who gives them a living space in exchange for taking care of the farm. There is no running water, and the family uses a latrine. Animals seem to have utmost control of the place, running to and fro in the fields as well as in their house. It is a far cry from what they must have been used to in the city. I could only imagine what Dina must be going through, being only 18 years old and with three very young children.

Ramon, however, seems to be very supportive of his wife and family. Unlike other spouses, who seem not to care one bit about what goes on inside the house, he seems to love Dina very much and would do anything to make sure his wife and kids are happy. "I am a lucky man," he told me, when I asked him how he felt about his circumstances. "I am very poor, but I have a wonderful wife, three beautiful children, and good work. And look...the view up here is pretty, and it is quiet and peaceful. So in a way, I am rich."

I was so touched by his words that I couldn't help but smile the whole rest of the time I was there. Dina, who sat next to me, couldn't stop smiling either. I was struck by just how much they seem to love each other, despite the fact that they were so young and virtually stuck on an isolated farm in the middle of nowhere. To me, their situation was tragic. But given their attitude, I left the farm with a glimmer of hope that their story might actually have a happy ending.

In other news, Ana led her first basketball workshop for the girls in the village. She had originally thought of the idea when remembering the youth basketball clinics she taught at for her local youth group. Anyway, it was received with a good deal of excitement here in El Llano. It is amusing to me to think of the little improvisations we've had to make while being in this town, however. We ended up holding today's session in a small, enclosed concrete area with no basketball net. Ana is determined to find a real basketball net tomorrow. We shall see...

Dinner was a huge heap of fried cheese and batatas. It was really good, but had the side effect of making both Ana and I bloated and sleepy. Will write more tomorrow...

Day Eight: Life in the Mountains

So the immersion adventure begins. During last week's excursion up to Pequnos Pasitos, it was decided that we would go up to the mountains two at a time to stay in one of the rural villages for a week and to perhaps implement some small public health intervention. Ana and I volunteered to be the first two guinea pigs for the experience, and so we woke up at 5:30 a.m. to prepare for what will probably be the absolute highlight of this trip.

We packed hurriedly and with a frenetic sense of urgency--despite the fact that we had spent so much time packing the night before. Because of our communal laundry habits (and the fact that we don't have a dryer), we had laid out a huge collection of clothes to dry the night before our trip without realizing that we had to factor in "drying time." What resulted was a collection of half-dried clothes that we were forced to pack in our backpacks, which only got wet again when we sauntered out into the rain.

When we arrived at Pequeno Pasitos via Gua Gua, we were immediately put to work. Ana and I were asked to take vital signs and to switch off with one another so we could each have individual time to work with the doctor. The doctor was great to work with, since she always took time to explain things and didn't seem to patronize the patients. Plus, she spoke to us only in Spanish, which was an added bonus since it forced us to stretch our language skills.

Clinic was interesting, not so much because of the patients, but because one of the medical staff suddenly got sick. Marta, one of the cleaning ladies, was struck by a sudden episode of dizziness, nausea, and vomiting. With prodding, she eventually went home to rest. No one thought anything else of it until she sent someone to the clinic to pay Marta a house visit and take her blood pressure. I turned out to be the lucky person, since no one else was available to do so.

Marta's house, like many others in the village, was a tightly-constructed hut made of wood and covered by a metal roof. Her room was small but tidy, comprising nothing more than her bed and a few possessions displayed on a number of make-shift shelves. When I saw Marta, she was sitting up in bed and seemed relatively chatty despite her ill appearance. But as I examined her, it was clear that her body said otherwise. Her blood pressure was moderately elevated, but what concerned me most was the fact that her heart rate was barely in the 50s. I hurried back to the clinic, eager to tell the doctor that she should at the very least have an EKG done and some labs drawn. But before I could say anything, I was told that none of that was possible at the clinic. They did not own an EKG, and it seemed that Marta would have to make the 40 minute trip to Santiago in order to have any sort of lab test done.

After clinic, we had a wonderful lunch of rice, black beans, and broccoli. Diego, the clinic director, took us to fulfill our promise to Fatima (a patient whom we saw during our previous visit), which included dropping off a lab slip so she could have her TSH rechecked. We then journeyed to El Llano, a small village within the clinic's catchment area, up an incredibly big hill to do a home visit with an 18-year old mother of 3 very young kids. She and her husband were once inhabitants in Santiago, but they decided to move out to El Llano when her husband was promised a more lucrative job on an isolated farm. It instantly became apparent to me that they had made some pretty steep sacrifices. They young mother really wanted to have a career as a singer, while the father's main wish was to return back to Santiago to take care of his sick mother. Instead, they chose to leave the city and live in a remote shack in the middle of nowhere, with no running water and no help to bring up three young kids. It was indeed a way of life they hadn't known previously.

We finally met our house "mom" that afternoon. Her name sounds almost too good to be true: Maribel Dulce. And indeed, it is a name that suits her well, given her incredibly sweet nature. Her home, small as it is, is wonderful. It is certainly more "cush" than Ana and I were expecting, especially since there seems to be running water and a semi-workable toilet.

Dinner here was pretty simple, but very tasty: eggs and mashed potatoes. When I asked Maria what she had put in the eggs, she smiled real big and said in a proud voice, "milk, butter, and Parmesan cheese." Ana and I simply looked at each other and smiled. Given our lactose intolerance, this was certainly going to be an interesting week...

And tonight, we're sleeping in beds in a house that is partly open to the elements. It's been raining here the entire day, and the dampness in the room is palpable. What a drastic change from the living conditions in Santiago. Just sitting in bed, writing this blog entry with a flashlight, I now see that we are surrounded by all sorts of flies, mosquitoes, and other random tiny insects. Here's hoping that we don't get eaten alive tonight...