Cathy’s Blog

Final thought

In my final notes from La Moskitia, I find it difficult to summarize my experiences in a concise way. Most folks who ask about my time at Clinica Morava want to know about the bugs, the weather, and the food. My accounts of medical conundrums and sorrowful outcomes are not welcome topics, at least not for casual conversation. For me there is a cornucopia of memories. They are words spoken, faces pictured, or smells and feelings remembered and are frequently part of my day. They come and go like the rain in Ahuas. They are persistant, soft or torrential, and part of who I am now.

So what are some of the simple and special memories of my time in Ahuas anad Cauquira? The carpet of red flower petals from the Royal Poinciana tree at my front door, the discovery of bite size snicker bars at the local store, getting totally drenched at the soccer game on Saturday, walking bare foot through wet brown ooze to get to the beach, boys playing “marbles” with colored soda bottle tops, rainwater showers intitally so cold and ultimately so refreshing, muggy church services with women singing and spinning their panuelos to cool aff and always lots of rain and sweat. Oh and not to forget the many bugs, flock of parrots, and meals of rice and beans.

I continue to wonder about the patients who never returned for care, patients who left us no better than when they arrived,  patients whose futures are surely shortened because they live in poverty. But I also have memories of a smiling boy returning home on crutches. I remembering a body-vibrating handshake from a grateful husband upon the recovery of his wife.  Actually many, many more patients left our care better off than when they arrived, thankful for what we could do. I remember soft footsteps and murmers of the nurse passing my window before dawn to deliver medications. And then there is the man who wandered through the hospital grounds every day with a bridle and lead rope, and no horse. How can I help but smile!

Of course there are many other memories but now it is my turn to leave and say tainke, tainke pali to the people who shared their time, concerns, needs, laughter, friendship, and wisdom. I have gifts to send and a plan in mind for my next visit to the La Moskitia.

Cauquira

The sandy beach where I am standing stretches from the horizon on my right to the horizon on my left. Before me is the Atlantic Ocean.  The waves are small and freguent. I can see a few birds very far in the distance. The light breeze is cooling and behind me I can see the fronds of the tallest palms lifting in the air. Although there are no boats I the 5 or 6 miles I can see, I know there is  fishing activity in the ocean at Cauquira having seen some boats on the beach during my flight here. However, it is the inland waterways and lagoons that are the livelihood of the area. Cauquira is the largest of a string of villages on the narrow spit of land between the Atlantic Ocean the the 20 mile long Caratasca Lagoon. I stand here, on the beach at Cauquira, alone, very near the easternmost point of La Moskitia of Honduras. I once again am moved by the geographic isolation that the people of this area live and survive in.

I am working in a clinic in Cauquira which is a satellite service of Clinica Morava in Ahuas. This clinic provides outpatient services to the area population of about five thousand. Services are available 24 hours a day by Dr Obelio, a cuban trained Honduran native physician. Together he and I see about 15 patients a day in the clinic and may have 1 or 2 patients in observation rooms. The services here are severely limited. There is no oxygen, guaze, IV saline solution, and we ran out of malaria medicine today. The clinic is in need of repair and electricity is availabe by generator just a few hours a day. Still the patients come with old and new injuries, worsening chronic illness, and infections hoping to get some help. We saw a woman today who walked in from her farm three hours away with no shoes on.  Her family brought her in after 4 days of diarrhea and vomiting. She was dehydrated and had a very high fever. We provided some IV solution with glucose and and sent the family in search of malaria medicine. We mixed up some oral rehydration solution for herto start taking in small amounts once we had the vomiting under control. With the help of medicines for vomiting and excellent nursing care she recovered. We hope that a family member can return for her malaria medication when recieve our next shipment.

Last week we noticed a large increase in the number of patients coming in for services. Apparently there had been an influx of cash from drug activity in the area. I suppose if I seeded to hide my comings and goings, this isolated area with access to inland waterways and the sparsely populated mountainous areas of Gracias A Dios  might seem ideal. Cauquira does have a busy legal commerce centered around the cargo services here.  Once a week a vessel arriving from La Ceiba arrives at the lagoon dock, moving goods and products. There is also a very active water taxi service taking people to and from Puerto Lempira, the capitol city of Gracias A Dios. The transit  is a thirty minute fast and wet boat ride across the Caratasca Lagoon. I will leave tomorrow at 5 AM on one of those boats. I take with me the aspirations of Dr Obelio to improve the clinic and expand services here.

bittersweet goodbye to Ahuas

At five AM this morning I realized further attempts to get some sleep were futile. I am leaving Ahuas today for Cauquira, a small town near the entrance to Caratasca Lagoon. I am uncertain about the conditions in which I will be living while there. This area is even more poor than Ahaus. My anxiety is high and I had difficulty keeping myself from leaving with a group bound the states.  Taking risks is necessary, or so I have been told, to explore the limits of our capacities. Taking risks is something the people of the Mokisita do everyday. They truly risk their safety, their livelihoods, the safetly and health of their children, just to survive. I have been reflecting on the patients I have seen and cared for while in Ahuas. One child was brought in by boat after three weeks of fever and changes in conciousness. The family had delayed care because of the cost and risk of travel. She never recovered and was sent home after a week at the hospital, the family unable to access higher levels of care. There are many similar stories I could relate. After some moments of panic and tearfull goodbyes to friends in Ahuas, I am off to Cauquira for two weeks. How could I do anything less?

Internet access in Cauquira will be unpredicable so I added plenty of minutes to my cell phone. The resident physician is a Cuban trained general practitioner serving a one year service contract there. The clinic is primarily for outpatient services and uncomplicated obstetrical care. I understand the budget there is very small and they are lacking in some basic supplies, like guaze, splinting plaster, hand sanitizer and lab reagents. Dr Obelio Alvarez is a skilled and competent  provider who I worked with when I first arrived in Ahuas.  I hope the lighter schedule will allow for some free time to do some surf fishing while there. My friend Geoff would expect me to at least throw a line in the water.

taking a break from work

When George Goff asked me to accompany him on a flight today, I did not hesitate to accept. He was taking a young mother, her newborn, and her mother back home to Wampusirpi, about 15 miles south of Abuas on the Rio Patuca. Traveling at about 1500 feet above the ground I was able to appreciate the vastness of the Moskitia. Everything is green. All shades and textures of  green that one can imagine.  I catch glimpses of the Rio Patuca, the highway of the Moskitia. This flight is truly valet service to and from the hospital. This trip would have been 3 hours by boat.

We landed at the airport, identifiable by a sign on a open shack that said,”Welcome to Wampusirpi”. Our passengers were greeted by family and friends. The baby recieved lots of kisses and was passed around for everyone to admire. Ten minutes later we were alone on the airstrip ready to take off for Ahuas.

Ashley, a nursing assitant volunteer, and I took a day off last week to horseback ride through the same area. Our guide was Epifanio from Paptalaya. He picked us up at the clinic with 3 horses, each one about the size of a medium sized donkey. For you equine folks, about 10 hands. They were very skinny and, to my surprize, pretty energetic. We trotted most of the way on this 5 hour trip. From Epifanio we learned about the flora and fauna of the area. Ahuas was named after the large groves of pine trees in the area. There are papaya trees, mango trees, and mohagany trees to name just a few. The national mammal is the white tailed deer.

Ashley was a trouper as this was her first horseback ride ever. She is 5 ‘ 7″ tall and her feet were not t0o far from the ground. I think that fact helped her feel less fear about the possiblity of falling off. We were both sore at the end of the day. Epifanio seemed to have no ill effects. He is 74 years old and has a prosthetic lower right leg.

About once a week I take the time to walk to the local store to recharge my cell phone and buy things like baby powder for my toes, bleach for my towels, gatorade for my health and, pringles and snicker bars for treats. Although not allways available, I have found my best luck in finding them by arriving at the store before school is out.

My next adventure is in the planning stage, a trip by boat on the Rio Patuca for fishing and a visit to a cattle ranch owned by the maintence man at the clinic, Sabio. One of the nurses asked me today if I was here on vacation. I replied that I supposed it was a working vacation. We both laughed. I suspect she was privately questioning my sanity.

getting along

It is a warm and muggy evening. We just finished dinner and I am listening to singing coming from the hospital. An elderly man who sufferred a stroke has had family and friends singing to him daily for the last 3 days. Sometimes a few, sometimes a dozen or more folks sit with him and sing for a couple of hours. It is lovely to hear the acappella, 5 part harmony songs and hymns.

Tonight we discussed the differences in health care and support that the elderly experience here compared to the United States. The family response to the health care needs of its members, as I have witnessed here, is health care assurance. It is cheap and available to anyone. For the elderly I suspect it may afford them some sense of peace knowing that they will be cared for. By comparison the elderly in the United States need to plan ahead for the expense of meeting their health care and personal needs in their latest years. Think of the years of work, the dollars paid to us that go towards the planning and purchasing of the things we may need in our later years.

Families here in Ahuas often include cousins, brothers and sisters through marriage, grandchildren, and children that have attached them to one or another adults for reasons known only to them. There are a lot of children here. The exact figure I am not sure of but I believe that 60% of the population is under 18 years of age. Even at the doctors house there are surprise guests that just arrive for meals for several days in a row. Atfer lunch today I ran to the house to get something and there was a family  eating and talking around the table, none of whom I had seen before. No one else seemed to know exactly why they were here. I am sometimes, well actually often, confused about which adult I should discuss a childs health issues with. Often it will be an different adult or older child inquiring after test results at next days clinic. They look curiously at me, wondering if I might have a memory problem I suppose, when I ask about whose results there inquiring.

Add to this open doors , literally, in the houses, hospital corridors, and bathrooms and it seems chaotic here. Listening for fetal heart tones is futile.Communication is a challenge but smiles and handshakes go a long way to establishing mutual trust. Jokes help a lot too. Many at my expense I am sure.

reality of life and health in Ahuas

I have been in Ahuas now for a month. The confusion and tension created by entering a new culture seems to be well behind me. I can appreciate the syntax of the moskitio language and understand a few words now. Thankfully many, but not all folks here speak spanish. For those of you interested in some of the  health issues of the patients we serve I offer the following information and observations.

As I have related in prior entries, the remoteness of La Moskitia and its relative under- development places enormous burdens on the people in accessing care. Today I saw a couple and their 2 month old child that traveled 7 hours by boat to see us. It is not unheard of for pople to travel a day or more in seeking health care. While traveling they generally have little or no food and rely on remote relatives and friends along the way to support them. Travel by motor , or boat, is most common.

Most local people eat lots of rice and beans, some of which is grown locally. Fish is a common source of protien, as well as chicken and beef. Frescas, or soda pop is easier to find than bottled water. The diet is low in calories, lacking in vitamin A, calcium and iron. The government has a program to supply vitamin A to children every 6 months for the first 5 years of like, but they often run out.

About 25%, or 1 in 4 children do not live past the age of 5. Death for these younsters comes in the form of malaria, dehydration from diarrheal desease, sepsis, and pneumonia. For mothers, access to definitive care during perinatal emergencies is the key to survival, but not readily available. The Millenium Goals for this nation contain provisions for the building of new maternal and child centers to provide this type of care as well as increasing the level of care in existing centers. Most women will have 6 or 7 children and 10 or so pregnancies. Early pregnancies in girls under 16 is not uncommon.

One of my first patients was a 58 year old women who complained of heavy vaginal bleeding off and on for several years. Her hematocrit was 17% when she was admitted. The normal range is 36% to 50%. Anemia is a risk factor for pregnancy and birth complications, and injury.

People work hard here. They garden, clear land, butcher animals for food, build their houses by , and carry water with their own two hands. Trauma to these precious tools is all too common. Last night we worked  a long while to close a laceration to the arm of a 68 year old female that lacerated a tendon. She was using a machete.

In the end, we can provide surgery, close wounds, offers vitamins, talk about how to build sanitary latrines, but in a community where there is no opportunity to work, travel is ardous, and goverment programs struggle to serve the many needs, our imact seems inconsequential.

Building on what has been achieved in the past and looking to the future keeps clinics and hospitals like Clinica Morava operating in La Moskitia.

health care for la Moskitia

There are five indigenous cultures in the Moskitia; Rama, Twahka, Miskitio, Pech, and Garifuna. I may have stated before that these cultures may have originated in South America and share some cultural similarities.

Ahuas, and the Clinica Evanglica Morava, sit very near the banks of the Rio Patuca. This very long, un-dammed river originates in the southern highlands of Honduras in the state of Olanchito. It is wide and swift and, I am told, full of fish and shark and crocodile. It is likely that pirahna wait in the shallows for likely morsels. We have had fresh fish a couple of times, provided by neighbors with temporary bounty.

Ahuas is a community widely spread out in the Moskitia. I am not clear about the population, I suspect somwhere around 5000. Nearby communities include Wawina, Brus Laguna, Cropunta, Wampusirpi, Paptalaya, and a few more I can not remember the names of. Paptalaya is the site of the government health center.  I spent 2 days this week visiting and working there with Wilber, the Cuban training physician who is completing his year of service required by all physicians wanting to practice in Honduras.

The government health center provides direct patient services, oversees sanitation and vector control programs, tracks and treats TB and malaria cases. The clinic has 2 lab technicians to do malaria blood smears and acid fast stains for TB. The clinic has a large and active staff of nurses that provide immunizations and home visitation. One nurse on staff makes daily home visits for children needing vaccines that can not come to the clinic. Honduras has a very high national vaccination rate.

Public health physicians are charged with implementing standards of care directed at reducing maternal and neonatal mortality, childhood morbidity and mortality, as well as routine patient care. Medications are available and are free. Obstetrical patients do not have to pay for visits. I found Wilber and his staff competent and committed to the goals of the government of Honduras.

Clinica Morava, which has been in Ahuas for 50 or 60 years is a referral center for the communities and clinics in the surrounding area. Consequently we see complicated patients with advanced illness, trauma, obstetrical complications, and difficult infections. For example, we have a 9 year old girl in the hospital with recurrant multiple abcess we have been unable to treat successfully. We have a diabetic patient brought into the facility in a coma and after 2 weeks is now awake and ambulatory but we have been unable to control his blood sugar without insulin. He will not be able to continue insulin therapy outside of the hospital. Unless we can get him control somewhat on oral medications he will likely not survive many more years. A young 15 year old preganant girl presented with pre-eclampsia which progressed to eclampsia. She had a cesarian section and sufferred a seizure immediately after delivery. She is still here.

The patients here are dedicated to Dr. Rudy and Dr Goff. Conversation often revolves around family and friends. Some intersting cultural notes  are that eye contact during discussions in the exam room is minimal. I am reminded of the Navajo patients I have had in the San Luis Valley who also avoid direct eye contact. I have had several patients delay coming in to the clinic hoping that traditional herbal remedies might cure the problem. One family had a traditional healer come in to the hospital to help their son who had sufferred a snake bite.

I am beginning to hear the rythm of the Moskito language a bit better. Na’kisma? Paine, ma. How are you? Fine, and you?

Its time for bed.

Na’ksa, hello from Ahuas

Na’ksa from Ahuas! Mornings are delightfull here, relativley cool and the sun is out. The jacaranda tree has deposited a new blanket of crimson on my front lawn. I am up about 5 AM everymorning and hospital rounds begin at 7AM following morning devotion, prayer and singing. I rely on Jenaina the nurse to keep us in tune, and she does lovely harmony. Rounds on the patients begin about 7 AM and end when the do.  The clinic doors open at about 9 AM. Today we , Norvelle Goff, Gerard Rudy, and myself, saw 27 patients, finishing at 1PM.

Clinica Morava serves local residents and also is a referral center for patients in the surrounding region, for example we have recieved patients from Brus Laguna for trauma and from the coast for dive trauma. Patients travel hours and days to come to Clinca Morava, usually by foot. When they arrive they need to find a way to eat and a place to stay if they can not get back home the same day, which is often the case.

Clinica Morava has the services of Dr. Rudy and Dr Goff, who both provide full obstetric services. The both are skilled at ultrasonagraphy, caring for women in preterm labor, post term labor, and women with twins. There is a high maternal mortality due to multiparity and co-morbidities like anemia.  Many women choose to deliver with midwives as well.

Clinica Morava has the only hyperbarric pressure chamber in the region and they treat about 1 patient per month with nitrogen toxicity illness due to lobster diving, a lucrative but dangerous undertaking. I have seen 4 patient, all male , with paralysis from dive trauma.

One patient still in the hospital is an 11 year old with snake bite trauma.

On a happy note, we celebrated the birthday of the dentist yesterday with lots of food and strawberry cake to top off festivities.

Night time is hot, muggy, “buggy” and welcome. A tepid shower before bed and calling home ends the day.

hard landing in Ahuas

the 4 AM flight from La Ceiba to Puerto Lempira was right on time. The expanse of the Mokitia is even more that I thought it would be. We traveled for most of the 1 1/2 hour flight over multitextured green forest, deeply wrinkled with mountains and hills, drainages and rivers, farm plots and the rare dwellings. The final flight path came right over the eastern savannah of the Moskitia. Large ribbons of muddy rivers flowing into an expanse of rivulets, lagoons, swamps, and finally Caratasca Lagoon and the landing strip at Puerto Lempira. Jarle Hofstad from Mission Air Group was ready to fly me the final way into Ahaus. A short flight of 30 minutes and we land at Jarle’s house, about 50 yards from the hospital. Jack is the family dog, a lovely but tired looking Labrador.

I meet the dentist, Theodosia, who takes me to my apartment above the surgical suite. I am thinking it is mid-day, but rounds at the hospital have just begun. It’s 9:30 AM. Off to work where I meet Gerard and Norvelle Rudy and the many nurses whose names I am just beginning to remember.

Well, since then I work 7AM to 7PM, eat and fall asleep after calling home. I wake up feeling a bit disoriented, in part due to the mosquito net and likely fatique. I am sure I still have the “deer in the headlights” look at work , the patients are difficult, complicated by the 2 and 3 languages spoken in the exam room or delivery room. Ni’ksa , na’kisma is hello, how are you in Moskito. Now I am going to  “slax”, relax and call home.

what to expect

 I have been in contact with the folks at Clinica Morava and the Missionary Air Group and tomorrow is my final leg of the trip into Ahuas. Here is some information I have gathered about the clinic and hospital. But first, some corrections. The proposed dams on the Rio Patuca are ( I think ) on hold. I have been looking for up to date information about this.

Here is some historical context for Clinica Morava, my destination. The moravian mission group has been in the area for a long time. In 1849, almost 100 years before the clinic in Ahuas, the group was in Bilwaskarma, Nicaragua, from where, in 1946 there was an outreach effort into Honduras to Brus Laguna , Cocobilia and Ahuas.  In 1970’s, a mission aviation group became involved, now known now as Alas de Soccorro(George Goff). In 1980, Nicaraguan and Honduran providers took on the leadership of the Ahuas hospital and clinic, which is the support center for the other clinic services of Octotales, Brus Laguna, and Cocobillia. In 1990 Dr’s. Gerard Rudy and Norvelle Goff began their service in Ahuas. Tomorrow I will meet them both.

In preparation for the last leg of my trip to Ahuas, I needed to get some things in La Ceiba. I made three trips to the MEGAPLEX mall after forgetting several things. This is not unusual for me! By the end of the afternoon I felt pretty comfortable with getting around the central part of La Ceiba. I successfully purchased a cell phone, with the help of a local taxi driver, and have called home to say all is well. Since last being in La Ceiba, the MEGAPLEX mall is at least twice as big. It seems the econmy is growing.The central mercado was bustling and a very nice young lady sold me a pair of tennis shoes and told me how to bet to the ferreteria.

As I have experienced before, the Hondurenos are eager to be of help and very proud of their country. My language skills are improving quickly and everyone I have met so far has been willing to teach me more.

Four o’clock AM is early, so bye for now.