Tuesday, December 4, 2012

El Salvador Day 5

Our Last Day in El Salvador

Today we began our last day together in El Salvador. As we climbed into the van I found myself feeling a bit sad, as we have made such wonderful friendships in such a short period of time. We traveled to a local clinic not too far from our bed and breakfast, in San Miguelito. I am always in awe when we walk into these clinics because there are always mothers and babies who have walked a long way, and have sat patiently waiting for hours. Our PINCC group quickly separates into our delegated areas and get to work. Our Spanish speakers begin their interviews with patients, the Doctors meet up with the local medical staff and my co-worker and I begin our data entry on the computer. In addition, you can always find one of our staff sitting quietly with a patient while they await their procedures. Although we planned to leave early today, the reality was there were far too many patients to be seen for that to happen. The Doctors diagnosed and performed procedures that had lifesaving benefits. It is always a wonderful feeling! After our week of work it was time to recognize the doctors and trainees at their formal graduation ceremony. The head director of the Metropolitan Region was there to speak and honor these Doctors. The national anthem of El Salvador was played, certificates were received and a warm heartfelt feeling of gratitude was experienced by all. They were kind enough to have appetizers and soft drinks for us afterward. We proceeded on to Santa Techa a new upcoming part of El Salvador. We strolled through a beautiful corridor of many Artisans while music played and sweet aromas filled the air. We dined at a favorite little paposa restaurant and had some nice conversation and drinks with the head director and her lovely family. 

Our night culminated back at our hotel Tazumal where PINCC had their closing meeting. They thanked us graciously and recognized us all with official PINCC certificates for our service. It was a most rewarding week. One that will be remembered by us for a very long time. 
Cherie Ackman
Fontana, WI

El Salvador Day 4

At the Clinic

Today we worked at the clinic in San Jacinto, about 45 minutes outside of San Salvador. The doctors saw about 45 women.  Once again, I was given the opportunity to do interviews.   Nearly half of the women I interviewed had experienced some form of sexual abuse.  They never included those experiences when they gave the number of their sex partners.  There were psychologists on hand to counsel these women. 

The younger women had fewer children, and many used a form of birth control.  In this way, they were more modern, and apparently better educated, than the women of Comasagua whom we met last week.   Two of the older women were reluctant to sign their names at the bottom of the form.  With some encouragement, they managed to print the letters of their first name, with the concentration and careful strokes of a first grader.

There were more children today, a number of them school age.  They waited uncomplaining for long stretches.  Each child had one small toy to keep them amused, and they played quietly without disturbing any of the adults.

We gave a cosmetic bag filled with sample size shampoos and lotions to the cook and cleaning lady of the hotel.   We received effusive thanks.   At a visit to the park, we were entertained by a lively soccer game of girls vs. boys.  The girls played in their white school uniform dresses, barefoot except for their white socks.  They were great players and highly competitive.  At the park we also met a charming young couple who chatted with us, delighted for an opportunity to practice their English.   The Salvadoreans are warm and welcoming.  So far, there have been no signs of any of the violence of which we have heard.   

Patricia Spross

El Salvador Day 3

Our Second Clinical Day with PINCC

Today was our second clinical day with PINCC, in a location they have yet to have the opportunity to work. We traveled to Soyapango, a distance outside of San Salvador, to work in another clinic that strongly served women´s and community health and was an urgent care facility at night, thus giving 24 hour care. The teams of teachers and students are getting more cohesive and the day overall was smoother and more productive. We didn't let a little earthquake slow us down, as we felt only a small shake compared to what Mexico and Guatemala experienced in the late morning. Some of us even saw El Salvador's national bird, the torogos, outside a window where it sat on a tree limb for the length of two different patient visits.

In all we saw 65 women today. For some this was their first screening although they were in their mid 60s. Some patients had been sexually abused before the age of 10. After their screening, many received the good news of "adequate and negative" (meaning cancer-free), and left with the self-confidence to take a step toward taking better care of themselves, and ultimately their families.

I know that all of us on this trip are happy to be here to lend PINCC a hand with their amazing work and yet also equally grateful for our own health care options back home. Peace!

Ruthann Marquis, Portland OR

El Salvador Day 2B

Reflections of our first day at the clinic

Today is Wednesday and I woke with a migraine.   So I stayed home to sleep in my dark room until it passed.  Waking in the early afternoon, I take this time to reflect on my first day at the clinic.  Nearly 60 women were treated in an energetic setting of Salvadorean doctors whom PINCC has trained to teach the screening procedure (maestras).  Also present were about 15 to 20 doctors and nurses being trained by the maestras to perform the vinegar procedure.   Clinic support staff, PINCC MD´s, PINCC/DFW volunteers, patients, and their small children added to the mosaic.  Carol coordinated the PINCC team, watching, listening, directing, to make sure that the goal of training the maestras to become trainers themselves was met.  In a previous life, Carol may have been a battlefield general, perhaps Joan of Arc…

Once more, what struck me most about our day were the women.  I was delighted to have the opportunity to conduct PINCC´s medical screening interviews for 5 women before the exams took place.  Sitting with each woman for 15 minutes, interviewers were obliged to ask the usual questions, name, address, etc.   These were followed by a series of probing questions on sexual history.  Affirmative responses to any question on sex abuse steered these women to a session with a psychologist that same day.  The crowds made it difficult to find a private spot for the interviews, but in tropical El Salvador, every building has a large patio or courtyard where a quiet conversation can take place.  

The screenings required a fair bit of Spanish, and it was a challenge.  Yet, each woman was patient and kind, and we both persisted until all the questions were answered.   The faces of the women were serious as they revealed a history of abuse, or anxiety over an abnormal PAP result.  Two women spoke of financial dependency on their husbands, which prevented them from leaving.  This reaffirmed that the micro businesses we saw last week can truly give a woman hope and an opportunity to free herself from abuse. 

All of the patients with whom I spoke were grateful for the high quality medical care they have received for years from this PINCC-supported clinic.  Some of the women awaiting a procedure to remove abnormal cells were frightened to tears.   When asked whether they had come to the clinic every year for screening, all responded affirmatively.  It was wonderful to be able to honestly assure a tearful woman that the doctors would most likely be able to resolve the problem that day with a minor procedure.   PINCC, with donations from organizations like DFW, has supported these women in obtaining consistent, high quality care to prevent cervical cancer. 

Of all the economic and social stresses that poor Salvadorean women experience, their health can be an area where they enjoy some peace of mind.   It has been extraordinary to see first hand that our donations have helped make this happen.

Patricia Spross

El Salvador Day 2A

First Day in Action!

Our first day in action with PINCC sped by! Severe traffic delayed our

start which added to the frenzy. We worked at a Pro Vida clinic in Nejapa,
where women had already been screened for the services offered today.
There was an entire courtyard of women waiting when we arrived! Work
stations were established, rooms were stocked, paperwork was stacked and
patients were seen.

The role of PINCC on this trip is to monitor the nurses and doctors that
are serving as teachers to the students who are learning the procedures
and guide them in assuming their full roles as educators. That means that
many sets of eyes are looking at that patient while in a most delicate
position. Yet always the needs of the patients are prioritized. There is
someone ever-ready to hold someone's hand. There is both uncertainty and
fear in the eyes of many of the women awaiting treatment and all efforts
are made to help them relax and know that those procedures are taking care
of an issue that could otherwise turn into a more serious condition.

In all 54 women were seen today and thankfully that means 54 women have a
chance at a better and healthier life. PINCC in action!

Ruthann Marquis, Portland OR

El Salvador Day 1

Training Day

An early start to our first day with the PINCC team included a hearty breakfast at 6:30 and filling two vans that headed out of San Salvador to the town of Nejapa.  There we joined 33 doctors and nurses for a day of training.  The nurses and some of the doctors (this week known as students) learned about the disease process of cervical cancer and the visual inspection procedure with acetic acid (AKA common kitchen vinegar) known as VIA.  This is the low cost, very transportable, visual screening that PINCC takes on the road to low-resource countries.

The remaining doctors and nurses spent the day learning to be trainers or maestras to the students.  They will be the extra set of eyes and voice of wisdom that will guide the students in their learning experience this week. Many of the physicians have already been certified in the VIA screening technique, as well as some in the two areas of treatment.  True to PINCC´s vision of developing a self-sustaining program, these participants are an example of the trained becoming the trainers.  Remember the proverb about giving a man a fish to feed his immediate hunger versus teaching him how to fish?  This is exactly what PINCC is doing!

Knowing that the training that is happening now is going to contribute to the health and wellness of the women being screened gives me the chills!  Since cervical cancer is so preventable what is being done has such great importance!

Seeing the enthusiasm of the participants today and hearing their thoughtful questions (okay...through some help with interpretation!) made me proud to be here to support PINCC.  Watching their gentle and compassionate bedside manner as they acted out the various scenarios convinced me that their patients will be in good hands!

Tomorrow we´ll get to see all of this hard work put into action.  Stay tuned!  

Ruthann Marquis, Portland OR

Wednesday, November 14, 2012

Tuesday, November 13, 2012

In Puno the city in the sky

We arrived in Puno over the weekend and began working on Monday. Puno is a small city and overlooks Lake Titicaca. The weather is perfect sunny, 60-70s and crispy at night. 

On Monday we met close to 40 midwives called "obstetriz" and a few doctors who wanted to participate in the PINCC  VIA (visual inspection of the cervix) training. We were all overwhelmed to say the least. How were we going to possibly train all these highly motivated and interested students. We started with a didactic and sadly only saw a few patients.

Today Tuesday we got a system down. We have 6 US providers and 2 Peruvian providers who can train/teach the students. We buddied up 6 students per provider for the full day. That way we created a sort of buddy system and the provider could really get to know their group of students. It worked well and we saw 40 patients.

Our group of volunteers are really sweet. Carol our fearless leader has unbelievable patience and is an amazing leader. Linda is a family nurse practitioner from the Boston area who has done work in Guatamala and works part time at a Harvard affiliated public health clinic in Jamaca Plains. Virginia is an ob/gyn who was a solo practitioner in Monterey, California for 30+ years, closed her practice recently and now works part time for the Salinas Department of Public Health. Carol who goes by "Carolina" here is a recently retired public health nurse from San Francisco and is on her 5th trip with PINCC. Tara is in her final year of residency at Kaiser Oakland in ob/gyn. She was in El Salvador with Carol last week and was in Nicaragua on a PINCC trip in 2011. Jamie is a PA originally from Utah who lives and works in NYC, loves to travel and this is her first PINCC trip. Suzanne is a family practice doc who practices at Clinica de la Raza in Concord and this is her first PINCC trip. Eve is an ob/gyn from Kaiser Oakland and this is her 2nd PINCC trip.
Juana is our local midwife, was trained by PINCC a few years ago in Lima and is helping to get us started in Puno. Enrique is a local ob/gyn from Lima who was also trained by PINCC and is working to get things going in Puno as well.
We have an amazing group and we're working hard to get things going. The altitude is incredible 12,000 feet and when you walk up a small hill you get winded. The food is great here. Trout is fresh from the lake and the vegetables are awesome.

Wanted to get something started on the blog. the next entry will be mostly photos.

Sunday, November 11, 2012

Final Screening / Training in Mysore

We concluded our fifth four day camp at JSS Hospital in Mysore on Friday afternoon, November 9. It was a very busy camp, with 242 women screened and numbers of medical students, faculty, guests from Biocon and Rotary coming to observe. We were up to the challenges however, as we had an incredible team of four volunteers -- Dr. Debra Levinsky, Dr. Ginger Ruddy, Dr. Marie Johantgen, and Lauren Sokolik, FNP. While Lauren and I did most of the out front work, Rhoda and the doctors kept the screening tables "turning over" throughout the four days. One vo;unteer had too return home suddenly on the morning our camp was to start, due to a death in the family -- an event that made us all very sad!

The reason for this fifth camp was to solidify a LEEP referral center at JS hospital, to further our contribution to the course work for Gynecology students, to foster planning for a large scaling up of the PINCC protocols over the coming years, and to continue to build on the collaborations that we have been establishing across Mysore.

On the first evening, we were treated to a second meeting with the Swamiji of JSS who continues to be committed to our program. We started out with him, along with two research pharmacists from Penn State, and then went for "prasadum" (gift snacks) in his special dining room. We (just PINCC) were called back for a further few minutes after the light dinner. Auspiciously enough, he and Marie Johantgen were on the same flight out of Bangalore Friday night!

Following two wonderful weekend days of touring local palaces, tomb, battle sites, temples and gardens, we went on Monday morning to help Inaugurate PHRII's (our main Mysore partner) new larger women's clinic. Then we went for meetings with the medical college principal to talk further about curriculum, and also about how to scale up these screening and prevention services.

On Tuesday, the three remaining team members, Dr. Rhoda, Lauren and I, go to Bangalore for a Wednesday morning site-visit with the Biocon Foundation clinic doctors. We have rising doubts that it we can create a screening program in Biocon, but will give it a great effort.

On Wednesday evening the three of us head for Puttaparthi for a 6 day (1 day for Lauren) "time-out" at our Ashram. Then we will do further site visits in Hyderabadand the Indo-American Cancer Hospital and in Siliguri at the Sunitha Cancer Society


John Adams
Sustainable Living in the Mother Lode
209 728 9432
415 385 8388 (Mobile)

Wednesday, November 7, 2012

India report by Rhoda Nussbaum, MD

We had a great and auspicious first day of camp.  We saw 56 women, many returns from the last camp or between camps, did 4 LEEP and 2 cryo and many other biopsies.  Dr. Suma will be certified to do LEEP by tomorrow or the 3rd day and AP Chandrasekar has deported another OBG professor to learn LEEP, Dr. Somia.

Tonight we had a visit with Swamiji arranged by Dr Suma who's in-laws are very close to Swami ji.  We thanked him for his support and described our goals of screening 75% of eligible women by 2020.  He talked about brining training to other parts of Karnataka.

The Vice Chancellor was also at the visit with Swami and we talked a bit about our proposal.  So in the last few days we have met all the important decision makers at JSS expect the principal  land we expect that will happen later this week.

The woman who represents the wives club of Rotary stopped by and two men from Rotary as well.  We will try to get a few of our  California Rotary friends connected with these Mysore clubs and see if we can get buddy support from US and India Rotary for cervical cancer prevention.

So it was a good day.  We are exhausted and satisfied.

India November 2012

 We met with Drs. Vijaya, Bhavana,Reshma, Poornima and our team at PHRII.  Dr. V had evolved her thinking over night and seemed to accept our strong recommendation that "See and Treat" was the only choice in this environment.

We brainstormed any barriers to carrying out See and Treat  in a village.  Drs. Bhavana and Reshma are so astute and have the ability to think about the larger system.  They pointed out that a women who had received biopsy or cryo and had some complaint thereafter would go to the PHC.  If the DHO and PHC staff were unaware that PHRII was doing Cx CA See and Treat  prevention and a women showed up at the PHC, that might cause a problem.  They strongly recommended that we talk to the  DHO and get his permission

The second barrier identified was getting consent for procedures from the women.  It was suggested that women be counseled during the awareness program that Biopsy and Cryo would be recommended if a precancerous lesion was found.  They could bring their husbands to screening  or call them if needed but by setting the expectation that these simple procedures might happen for at least ⅓ of the women screened, issues of refusing treatment because the husband hadn't consented should be minimalized.

 We went to see the DHO this evening.  He is aware and gives his acceptance that biopsies and cryo will be done in the villages.  A process for letting the local PHC staff understand what was done and why and  what post procedure side effects are expected will need to be worked out.

My eyelids are drooping as I write this email so I will say goodnight and will continue to let you know what is transpiring each day  so that a sustainable prevention program will be well on its way and that a program for how to scale up is being worked on.

Friday, August 24, 2012

PINCC's Work in Kibera Aug 20-24, 2012

We just completed a most successful week's work in Kibera, Nairobi,
Kenya. Each day brought many patients, volunteers, Kenyan lunches,
and exciting work to screen women for cervical cancer.

The team was absolutely TERRIFIC. Congenial, to say the least. Two
women (mother and daughter) who worked in both Uganda and Endebess
joined our team for the first two days, then left for safari in
Tanzania. We were also joined by two local Kenyan volunteers, one of
whom had just recently returned to Kenya from having lived in the U.S.
for 16 years. She was accompanied by her aunt who is on vacation from
a government job teaching cosmetology. Both Nimo and Joyce were
incredibly helpful and delightful. And filled with information about
Kenyan life, marriage, Kenyan customs, and food.

We saw over 100 patients this week. For me, it was difficult at times
trying to understand responses from Kenyan women. They seemed very
quiet while waiting, sometimes for hours unfortunately, and never
complaining. Not quite like in the U.S.! I was impressed with the
amount of family planning practiced and the number of women taking
antiviral drugs for HIV + status. Of course, there were those who
didn't want to get pregnant and were not using any family planning.
Many women had 3 or less children and most lived in Kibera. Walking
into Kibera every morning was less crowded than leaving each afternoon
- lots of children wandering about saying, "How are you?" Kibera
seemed to come "alive" each afternoon.

The Kenyan clinical & administrative staff working in Kibera was
terrific. There were approx 8 trainees, and they worked vdiligently
and were very eager to learn and take direction from both the nurse
practitioners and Dr. Kay performing internal exams, PAP smears, &
colposcopies. Several were given certificates to carry on; some
needed more training but we are hopeful they will again return in
January when PINCC returns for another visit.

While this is not my first trip to Kenya, it was clearly one of the
best. I am taking away thoughts about how life exists in a very
impoverished area of the country. For me, I feel I have given my
administrative skills to a project that is very valuable to women's
health. The healthier a Kenyan woman can be, the more empowered she
will become in controlling her life and that of her family.

This has been a remarkable trip and I am planning to meet Linda and
Julie, mother and daughter, in Zanzibar next week. I also feel I have
made new friends whom I will definitely keep up with once back in the
U.S. PINCC volunteers seem to have so much in common with a purpose
of giving to those who don't have as much as we have in the U.S.

We should never forget that the greater population of the world is
impoverished and lacking health care.

Randy Weiss

Tuesday, August 21, 2012

Pics from Kenya

Previous pictures are from Gombe, Uganda and these are from Endebess
Hospital in Kenya

home at last

Unfortunately, we had almost no internet access in Kitale so I was
unable to update everyone on our progress there. The good news is now
that I'm home, I finally show everyone some photos!

Although Dr. Melissa had to leave on Thursday night, we were joined by
Dr. Kay on Friday and were able to certify many of our trainees in VIA
at Endebess Hospital and a few in cryo as well.

We then had a very long journey to Nairobi on Saturday and after many
transportation issues, Jaya, Priya, and I made it to the airport in
time for our flights back to the US. I won't go into detail except to
say that we rode in 4 different vehicles for a total of 12 hours.

I finally made it home on Sunday night and went back to work in the
Bronx today. I can't believe how lucky I feel to have an exam table
with stirrups and disposable table paper and drape sheets. I feel so
spoiled and grateful that every exam room has a sink with running
water and electricity. I truly have a different perspective about the
care that I give and also how much waste exists in our health care

But on the bright side, everyone I encountered today who knew where
I'd been and what I'd been doing could not wait to hear about my
experience and was so proud of me and impressed with the work that
PINCC is doing.

I've heard the work in Kibera is going well and hopefully we'll hear
something from the rest of the group soon.

Thanks for reading and enjoy the pics!

Monday, August 13, 2012

Arrived safely in Kenya

After an easy border crossing but a long drive complete with a bit of
pouring rain and a loose fan belt, we arrived in Kenya yesterday. (So
far the bathroom in Busia at the Uganda/Kenya border, which costs 10
Kenyan schillings to use gets our vote for the worst of the trip).
After thanking Mike, our driver, for his fantastic driving skills, we
settled in at The Kitale Club. It's an interesting and pretty place,
set on a golf course. We were happy to be able to sit outside on the
patio and watch the sunset - which we did for a while since it took so
long for our dinner to be ready!

Today was our first day working at Endebess Hospital and we were happy
to set up and get working. We had many trainees with varying levels
of expertise so it will be interesting to see how they progress
throughout the week. Everyone seemed enthusiastic about continuing
their training and was eager to perform lots of exams.

Maria, an MPH student, joined our group here and is working with the
community health workers to educate them and some of the clients about
HPV and cervical cancer.

I'm looking forward to more work tomorrow (and hopefully a shower with
hot water).

Will try to keep writing and updating you on our progress. Sorry no
pictures yet but I am working on it!

Keep reading!

Saturday, August 11, 2012


I did not know exactly what to expect upon arriving in Gombe, Uganda. But the circumstances at Gombe Hospital were even more dire than I anticipated in terms of staffing, equipment and resources. We were shocked when Dr. Haruna, who not only runs the hospital in Gombe but is also the head hospital administrator for the entire district, told us that his budget was cut by 33%. He was also not allowed to hire new staff unless someone retired, even though the hospital was at about 50% in terms of staffing. Oh, and by the way, he came to greet us and deliver this news after completing a c-section for a woman who had placenta previa. The condition had been identified before delivery and the patient had been instructed to stay near the hospital. She and the baby made it out of surgery healthy and another woman's life was saved.

Despite all the challenges, the team of clinicians at Gombe was upbeat and motivated. Nurses, medical students, and anyone who knew we were there was eager to meet us and learn whatever we had to teach them. The patients, although nervous, were very grateful for the services that were provided and at the end of the week, 3 of the clinicians, Sarah, Penninah, and Carol were certified in VIA. Dr. Melissa was absolutely unrelenting in her quest to get the cryo machine to work and after some duct tape and chewing gum (I kid you not), she was successful and able to certify Penninah in cryotherapy.

Our team of PINCC volunteers has really gelled: me, Julie, Dr. Jaya and our fearless medical director, Dr. Melissa are the fabulous clinicians. Then there's our nurse extraordinaire Linda (also Julie's mom) who is willing to teach anyone who will listen. Our support staff members, Shelby (Melissa's daughter) and Priya (Jaya's daughter) are hard workers and mature behind their years. And of course, none of this would even be possible without the always calm and supportive Carol, making sure we have what we need and get where we need to go.
Today we had a day off in Jinja which we spent shopping and then on a sunset cruise on the Nile. We had a bit of rain but overall it was fun and beautiful.

We leave for Kenya tomorrow morning. Can't wait to see what adventure awaits us!

Hope we will be able to post some pictures soon!
Rebecca Donn
Sent from my Android phone with SkitMail. Please excuse my brevity.

Thursday, June 7, 2012

We are enjoying the cool weather of Lima and the lovely facilities of the clinic where we have been working, but are overwhelmed with patients.  100 the first day, and then Carol limited it to 60-- but we still ended up closer to 75 for the next 2 days!  Busy-- and the same trials and tribulations with the trainees and good moments and tough ones-- but there is certainly need, evidenced by the sheer volume of women we are seeing and the numbers we are turning away (40-80 each day).  I gave my lecture to a group of 30-40 last night, and I give many thanks to Sallie for help in translation-- as I worked it into a powerpoint cutting and pasting and adjusting on a bumpy 1+ hr bus ride to the clinic each morning.  OK, off for another day of PINCC adventure.  
From Pam Lotke, MD, OB/GYN, Medical Director in Peru, June 2012

Tuesday, June 5, 2012

The true voyage of discovery consists not in seeking new landscapes, but in looking with new eyes.

The true voyage of discovery consists not in seeking new landscapes,
but in looking with new eyes.
Marcel Proust
Julio, our guide, arrived at 8:00 sharp for our walking tour of Leon.  After a few short blocks, he conscientiously sat us in the shade in front of a large mural that related the history of Nicaragua from its indigenous roots to the current president, Daniel Ortega. Interspersed with our history lesson, Julio encouraged members of our group to read aloud pieces of literature in English, merging sentiment and imagery with fact.  Lezli and I took turns reading A Roosevelt by Rubén Darío, which speaks directly and frankly to the bullying of Latin America by the U.S. government.
The U.S. is potent and great
When you shake there is a great temblor
that passes through the enormous vertebrae of the Andes
With eloquent grace, Julio described the U.S. support of Somoza, the evolution of the Sandanista revolution, and the new hope and unavoidable challenges ahead for his country.  Juio later shared that he had been picked up on suspicion by Somoza's army at the age of 14 and was incarcerated, for no reason, for several months.  He took us to the Martyrs and Heroes Museum where he showed us pictures of those who had died for the sake of their country including his step brother and many friends.  The photos were of children and helped us understand the depth of Julio's participation and his pride in the true story of his country.   " Nicaraguans now have freedom", he said " but they need to think, and care about each other to really change the country and make it better."  He was very careful to communicate that his issues with American policy were not a reflection of his feelings for the American people, and again thanked us, emphatically, for listening to his story and giving of our time and our hearts to help his country. 
Our next stop was the rooftop of the cathedral.  I love how rooftop tours give you a completely different perspective on a place.  Julio pointed out the ring of volcanoes that surrounds León, one of which was belching gray smoke.  Numerous times I had heard how "we're due for another major eruption", and my midwestern heart skipped a beat.  The land I come from offers me stability and support, but the earth here puffs and groans, spews fire, rumbles, shakes, and breaks.  The Masaya volcano was so active this week that the park was closed to the public.  It is always enlightening to look down on the markets, the plazas, and streets.  After a few quick photos of the bell towers and a pair of lovebirds, we were ready for a cool drink at the best hotel in town, El Convento. 
Both the the art center of the Ortiz Gurdián Foundation and the El Convento hotel are funded by BanPro which charges a minimal entry fee, much of which is donated to Mujeres con Cancer, a charity that helps low income women get treatment for breast cancer.  The art collection was superb with pieces by Picasso, Chagall, Miró, and a predominance of amazing Latin American art from Rivera to Tamayo and numerous very talented Nicaraguan artists that were new to me. It is a private collection displayed in a lovely Creole-Civil style home with a rose garden at its center. Nicaragua is a country of poets, artists, and artisans – on our way back to the hotel, we passed an elderly gentlemen that greeted Julio warmly.  He is a local poet that had been honored the night before where he received a stipend from the government to continue his work.  He was impeccably dressed in a dark suit and cane, despite the sweltering heat.  I found it interesting that in a country this poor, there is still support for the arts and their ability to bring beauty into our hearts with simple words, brush strokes, and notes.
After the tour, we stopped for lunch at the beach and then headed for Managua.  On the outskirts of the city we visited another artisan cooperative, Esperanza en Acción, which is run by the niece of a friend of Patricia.  The organization works with 25 groups of artisans (275 individuals) of which 95% are women and come from rural and economically disadvantaged areas.  Through fair trade initiatives, they offer artisans a fair wage ($1.25/hour as compared to the usual $1.00/day) and a worldwide market which they are working hard to expand in the future.  Esperanza en Acción consistently encourages artisans to improve the quality of their work and offers them low interest loans to help improve their standard of living.  Each individual sets the rate for pay back, according to their individual needs and living situation.  I'm honestly not much of a market person - always wondering what percentage of the price actually goes to the vendors and artisans.  These cooperatives are a win-win for everyone, and so much less chaotic.  I also loved having the artists signature on the piece and the peace of mind that came from knowing I was truly making a difference with my purchase. 
After a quick stop at the hotel for a much needed shower, we were off for dinner at El Tercer Ojo - Managua's only fusion restaurant which was conveniently walking distance from our hotel.  Ann from PINCC warmly accepted the invitation to join the group for our final dinner.
In true Patricia fashion, she encouraged each of us to share an insight from the trip.  Gratitude and Generosity were the common themes expressed around the sangria filled table.  We discussed how misunderstood HPV is in our country, how each donation counts, and how rewarding it has been to travel with the intention of service as opposed to pleasure.  We all agreed that the unique combination of the DFW itinerary has been perfect.  It was important to get to know each other beforehand to gel as a group and create an atmosphere of comfort and trust with each other before the intensity of the service work, and equally important to have this down time at the end. 
"I'm sending PINCC some real post it notes and binder clips", said Marcy.  She was on the data entry team and corrected (with a smile) my previous blog entry that the office staff had access to REAL post-it notes.  They had paper clipped numbered pieces of paper to each file to identify cases that kept falling off causing confusion and slowing down the process.  "A little adhesive would have made a big difference!" She's going to send Carol some office supplies from Atlanta for the next PINCC mission.
"I'll never look at my Ob-Gyn visit in quite the same way, " said Dani.  The trust these women put in the medical and support staff was sobering.  There was no privacy, no room for modesty.  A piece of paper toweling placed on the exam table was the only "sterile" surface between patients.  The same hospital gown was used all day.  But these women showed up because they wanted to take care of themselves so they could be around to take care of their children and grandchildren. 
Catherine also spoke to these women's courage.  Many of them thought they had cancer and cried with relief when they heard negativo.  The Nicaraguan staff spent a lot of time repeating instructions and educating patients about the severity of recurring infections and STDs and the importance of treating their partners and using condoms to prevent recontamination.  None of these are easy concepts to understand the first few times you hear them.  The patience of the staff, the volunteers, and the patients was truly impressive.
Arlene spoke to the need to equalize resources at the local level, and pointed out that although the conditions at the hospital in León were shocking to us, it is a FREE hospital where EVERYONE can see a doctor and get a prescription filled. 
Leslie's eyes filled with tears as she once more remembered the warm welcome she had experience when a young mother invited her into their modest dwelling right next to the pottery shop in San Juan de Oriente.  The family picture with Leslie at the center says it all.  Write about it, Leslie.  
An amazing memory. 
Amidst hugs and tears and promises to keep in touch, we finally said our good-byes.  We had challenged Proust's wisdom and succeeded in seeking new landscapes AND looking with new eyes.  Somehow we all knew we were returning to our "real life" changed on some level, yet to be determined.  Keep in touch gals!  I want to see posting on Facebook and will start looking for the photos in the very near future!
On behalf of our group, I would like to thank DFW and PINCC for making this mission possible.  I would also like to formally recognize that amazing job that Patricia Anderson did as leader of the DFW group.  With patience and grace and tenacity, she kept us on schedule and always had time to listen to our stories.  I especially appreciate her sense of adventure and willingness to jump into a horse drawn carriage for a tour in the rain, and her many connections that brought us to cooperatives and clinics where we could experience the results of non-profit and fair trade organizations, first hand. 
Hasta pronto y que todo les vaya bien.
Tina Romenesko

Sunday, June 3, 2012

In A Country This Poor, Every Donation Is Appreciated

In a country this poor, every donation is appreciated


Friday morning.  Our last day with the medical mission.  The load was lighter than expected as a group of 19, that we were hoping would arrive from a distant village, was unfortunately not going to be able to make the trip to the clinic.  The interpreters were sent into the hallways to do patient education and do interviews accessing the level of knowledge patients had about health issues in general, and cervical cancer, specifically.  Shannon was always able to get a smile from the kids and the adults with her bright effervescent personality.  At 19, she is the youngest member of the DFW team, and by far the most energetic!  By around 12:30, we were completely done with patients and were packing up the suitcases that organize the medical supplies, getting them ready for their next stop.  Peru.  Dr. Pam and her kids, and Carol were leaving for Lima the next morning for another PINCC mission. 


The Nicaraguan staff of doctors and nurses plus Jenny had made plans to take both the PINCC group and DFW out to lunch to culminate our mission.  We sat at the same large table where we'd eaten the night before.  It was inspiring to see how the entire group had gelled.  Spanglish was heard at all levels as we connected as colleagues outside of the confines of the hospital corridors.  There were lots of snapshots and smiles and exchanging of email addresses.  Dr. Pam addressed the group and offered her thanks to each and every one of us for our important role in preventing cervical cancer through education and training medical personnel.  Five certificates of graduation were distributed amid rounds of applause and tears.  The recipients varied from Ob-Gyns, to Family Practice Physicians, to nurses, and one nurse's aid that had only completed an eighth grade level of education.  What is particulary amazing about this screening method is that it can be performed by any trained medical personnel, which makes it much more sustainable in developing countries.  We posed for our group picture in the restaurant garden, and said good-byes for another 15 minutes before finally dispersing the group.  An amazing experience that has filled all of us with a deep sense of gratitude.


That evening we met for dinner in the hotel lobby and shared, again, some of the high and low points of the trip.  I donated my headlamp to Carol - an essential piece of equipment in the VIAA process.  Because of headlamps, clinics don't need to have electricity to do screenings.  She was thrilled, exclaiming that this headlamp would go to Antonia, the nurse's aide that had just received her certification.  We were also leaving our scrubs and various pieces of clothing from running shoes to t-shirts.  "In a country this poor, every donation is appreciated,"  explained Carol. 


A few of us rounded up the evening at Via Via, just around the corner from our hotel, dancing to the rhythm of a local salsa band.  Tomorrow we head for Managua. 

Friday, June 1, 2012

"Quando quiero llorar no lloro, y a veces lloro sin querer¨" - Rubén Darío

Quando quiero llorar no lloro

Y a veces lloro sin querer" 

Before heading for the hospital, Patricia and Carol worked together to assemble the group, in full scrubs, for a photo.  These two groups have melded seamlessly into one over the past 5 days.  In our group meeting, the PINCC volunteers admitted they were skeptical about the  " Dining for Women" volunteers when we came in on Sunday.  They´d already had a full week together and were very close, but the lines have completely blurred now and I can sense a gratitude that flows beautifully both ways between all of us.  Ann and Karen have even expressed an interest in joining a DFW group when they get home.  Another full circle. 

The hospital day typically begins for the PINCC group with a teaching session in one of the meeting rooms, briefing the Nicaraguan doctors and nurses who take written tests, are asked to interpret photos of lesions and suggest treatment plans, and also work on bedside manner and patient etiquette with the U.S. staff.  Carol had asked me to share my son´s experience using breath (pranayama) for his spinal taps when he had cancer 20 years ago.  Ross is now 26 and cancer free.  The techniques are similar to the LaMaze technique used in childbirth and help patients focus on their breath instead of the procedure and discomfort (a.k.a. pain), breathing in through the nostrils and out through the mouth, very slowly and rhythmically.  It is also a great way to connect directly with patients and offer support.  The doctors were very open to the suggestions and appreciated Ross´s story.  I also slipped in a mudra for relaxation: Prajna Prana Kriya.  You curl the index finger into a small ring and place the index fingernail at the base of the thumb on the inside.  It is very effective for reducing anxiety and again, offers another focus that helps the patient remember to relax into the procedure instead of resisting it.

I was agained assigned to Karen´s room (yay!) and the other interpreters headed to the hallways to do patient eduation.  Everyone is getting more comfortable with our role as volunteers and finding new ways to help everyday.

By around 1:30 PM, we had seen our last patient and were given a tour of the hospital, which was very eye opening and sobering.  The hospital was built during the Samoza regime as a private hospital but is now the official teaching hospital for the university.  It does not have air conditioning, except in conference rooms, offices, and a few treatment rooms, has almost no natural sunlight (which naturally kills bacteria)  and is very difficult to clean.  There is an open area in the middle of the building where the generators are housed allowing pigeons access to the hospital corridors on a regular basis.  Patients have to bring their own linens upon admission and it isn´t unusual for two patients to share one bed.  Yes. You read that correctly.  When Carol first started coming down to Nicaragua in the 80s, they were still sharpening and re-using needles.

Our first stop was the basement where the Emergency room is located along with the Pharmacy and Pathology.  I had noticed that our patients were given their specimens to deliver on their own to Pathology with their name scotch taped onto the bottle.  A different level of quality control than we are used to in the States.  The morgue was also in the basement.  When our guide, Carmen, asked if we´d like to see it there was an emphatic No, Gracias from the group.  The "mor-gay" was not going to be a part of the DFW tour.....

Maternity was on the second floor.  We walked into a large room which 8 moms and newborns shared together in the sweltering heat.  We wished them congratulations and asked the names of the babies.  Ernesto, Gonzalo, Maria,...HILLARY.... and KEVIN!  Lesli, our infectious disease control expert, noticed a used catheter sticking halfway out of a garbage can in the middle of the room and tried to steer everyone around it.  The hospital averages 15-20 births a day, and has a small NICU with incubators, respirators, and monitoring equipment.  More serious cases are referred to the Pediatric Specialty hospital in Managua.

We visited Orthopedics, Med-Surg, Infectious Diseases..., but the most heart breaking area for me was Pediatrics, where the mothers were sitting with their sick kids in crowded rooms, with little to do and lots of time to think.  I expressed the compassion of our group to a couple of mothers wishing them good luck from our hearts to theirs and couldn´t help but imagine my time in the hospital when my own children were ill.  The hospital was a refuge for me where I felt safe and supported.  I could barely control the tears as I recognized the fear and pain in these mother´s eyes.  As we left the building, everyone expressed a renewed gratitude for the state of medical care back home.  It´s certainly not perfect, but the standard of care is completely at a different level.

After a long day - a few of us headed to the Museo de Rubén Darío.  Darío is Nicaragua´s most famous poet and he is from León!  The museum is the house where he lived for most of his childhood and is also where he died.  Doctor Sara´s husband and mother-in-law run the museum so she had encouraged me to seek him out and get a personal tour, which we did!  He proudly explained each item in the museum in great detail, from his funerary mask to his writing table.  Darío was sitting on this very curb, writing poetry, at age 6 and is credited with changing the way metaphor is used in the Spanish language.  He was influenced by Poe, Emerson, and Whitman, and spent quite a bit of his life in Spain, Paris, and New York.  We learned about his many lovers and tried translating some poetry that was preserved in the original written form. They also house a small library that is available to university students studying Spanish literature.

As we wound our way back to the hotel, Patricia shared that she had nearly dropped into a pot hole on one of  her errands.  Pot hole doesn´t accurately describe the state of the streets here.  There are huge holes in the sidewalk that come up at a moments notice, so you have to look down with every step.  AND, the drivers totally have the right of way.  If you try to cross in front of them they beep at you, impatiently.  So walking around is a full on sensory experience!

Carol had arranged dinner at an open air restaurant - where we all sat at a huge table and shared stories, old and new.  Dr. Pam´s and Dr. Ilana´s kids rain between rain drops and played games at the end of the table as we waited for dinner.  The kids have been a wonderful addition to the group.  A true breath of fresh air with all their energy and enthusiams.  Two of Carol´s friends also joined us - sisters that have been helping with the intakes in the morning to get patients into treatment rooms more efficiently.  One is a nurse and the other, a biologist.  Fascinating, dedicated women from León.

I´d like to close this blog entry with part of a poem by Rubén Darío that speaks to the emotions that each of us have experienced in our own unique ways here in Nicaragua.  Tears connect our hearts in compassionate caring and often appear when we least expect them.  Thanks for the permission, Rubén.  To tears.

Quando quiero llorar no lloro

Y a veces lloro sin querer" 

"When I want to cry, I don´t cry

and sometimes without wanting to, I cry"

Felicidades a Mamá

Felicidades a Mamá 

(Gracias a dios - I just learned how to do accents on this Spanish keyboard!)

There was definitely an energy of celebration in the air as we headed toward that hospital in the morning.  Mother´s Day in Nicaragua is a national and obligatory holiday.  Imagine that!  Only the restaurants and stores are open and everyone is shopping for mom!  As we passed the market, I saw a large table completely filled with mother´s day cakes, a yellow cake with bright white frosting and lots of red frosting roses with Felicidades a Mamá written across the top.  I bet there were 50 of them, monitored by two young boys, towels in hand, swatting at the ubiquitous flies that were trying to land on these masterpieces.  

Because of the holiday, we expected our patient load to be much smaller, in fact the entire clinic was on skeleton staff except for the PINCC group.  Carol couldn´t justify an entire day off in a 5 day training so she and Jenny had  encouraged patients to come and get their cervixes examed for mother´s day - giving themselves the gift of health.  

The PINCC translator, Sallie, was needed to translate a document for Dr. Pam, so I was upgraded to translator for Karen, the Nurse Practitioner from Spokane, in a treatment room.  We saw 6 patients with various needs and there were also 3 Nicaraguan doctors in a very small room with two fans, duct taped to the walls.  It was my first view from the other side of the table.  I felt the pressure of accuracy as I was interpreting the results of tests and treatment plans.  I dropped out of my logical / grammatical mind and into some numinous space that seems to be able to speak medical Spanish!  Karen is a wonderful teacher and briefed me between patients so I could understand the terms I was translating!  I learned so much first hand and was able to experience the conditions these doctors and nurses work in.  We are definitely not in KANSAS anymore.  Everyone is very professional, but the rat poison on the floor, use of one hospital gown for the entire day, and placing a piece of paper towel on the exam table to provide a clean surface for each new patient are just a few examples of the limited resources they are working with on a daily basis.  Our exam table didn´t even have stirrups for the woman´s feet.  She had to hold herself in the compromising position necessary for examination, sometimes placing her foot on the doctor´s knee while they performed the inspection.  More than once, I found myself leaning over a patient, coaching her to breathe, and holding her ankle at the same time to stabilize her foot on the table as she had a procedure.

We brought our donations today - which filled one entire side of the corridor.  Gloves.  Hospital gowns.  Scrubs.  Shannon is a pre-med student and also works at a clinic, so she had an entire extra suitcase filled with an amazing variety of medical supplies that she had lugged with her from South Carolina.  Each of the Nicaraguan medical staff filled a bag with medical goodies.  It was a rare treat for all of them and much appreciated.  Just about everyone in the DFW group brought something, from toothbrushes to ibuprofen and specific supplies. 

Carol had predicted that it would be a half day - due to the holiday and around noon there was only one patient still watiing to be seen for a procedure.  Carol asked her to wait while we had our private Mother´s day celebration so everyone else could go home.  Jenny had purchased flowers for each of the mother´s in our group ( a Nicaraguan tradition) and our last patient was thrilled to be the first to receive a rose while sitting in the hallway in her hospital gown with the group!  The smile on her face spoke volumes!  Jenny had also brought in a Mother´s Day Cake.  just like those we had seen in the market on the way to the hospital that morning, which we all shared.  I´m sure this was one gynecological exam this last patient will never forget! 

The DFW group headed for the beach around 2:30 PM, but I opted to stay back and write and do yoga.  So.  One of them will have to do the beach update!  I know they were able to take nice walks, had access to a lagoon perfect for swimming, and fresh seafood for dinner.  That sounds pretty good.

I shared dinner with Ann and Sallie from PINCC.  We had to make a reservation and put down 200 Córdobas because of the mother´s day rush.  We got there at 7 and the place was half empty but as we prepared to leave at 8:30, things were really getting going.  We shared a delicious margarita and as he brought out agua con gas and a big glass of ice I asked if the ice was made with agua purificado.  No - was the answer.  Hmmmm.....  My margarita was on the rocks......  Rocks are ice.......  We all said a little prayer, and drank warm seltzer water with dinner.  Carol had explained to us the first day that the water pipes and sewer pipes run side by side in Nicaragua and are open so microbes can easily pass from one pipe to the other  That description had firmly instilled the fear of Monteczumas revenge in all of us.  We reasoned that the tequila had probably kiilled any errant bugs that might upset our intestinal tracts.  

We headed for bed as soon as we got back to the hotel.  Two mother´s days for me this year.  Monteczuma wouldn´t dare take revenge on a mother on her second mother´s day.  Right?

Wednesday, May 30, 2012

Happy Nicaraguan Mother´s Day

Wednesday, May 30th, 2012. Mother's Day here in Nicaragua and a big deal it is! We walk along our route to the hospital where we begin our third day here. The Dining for Women group has been here for a whopping 4days (!) and they are already super seasoned and they have the routine down pat.  It's truly impressive! -  I think that sometimes they underestimate the amount of support they offer but it is truly noticeable and obvious. It's funny how one doesn't have to speak the same language to communicate compassion and support!
I don't know how many patients we saw today, it felt like a lot and the team I was with was a well oiled machine, Ismara the RN and Cecelia the general physician - It is such an honor to work with such dedicated professionals.
One patient sticks out in my mind, (at this particular moment, many more are in the back of my mind). This patient came from quite a distance, (had to leave her house at 5 in the a.m. and arrived at 7a.m.) and as she entered the exam room I saw here make the sign of the cross. Quietly, subtly, and I realized how nervous she was and how TRUSTING she was. Again, what an honor! We ended up finding a lesion and providing her cryotherapy and she left the clinic at about 4p.m. She did well, and her grace was beautiful. A gift. And, a gift to be part of that - to be part of the team that is PINCC that could serve this woman! Happy Mothers Day! Anne Daly 

Healing Hands

There is healing in the laying on of hands;
in the letting go of fear, in asking for help,
in silence, celebration, prayer. 

(Danna Faulds, Yoga teacher and poet)

The chairs were two deep in the hallways when we arrived at the hospital for our second day of the mission.  By 11:00, we had interviewed 30 patients and were well into seeing them in the treatment rooms.  There are usually 4 treatment rooms running at one time - each one lead by one of the four medical professionals on our trip.  Pam, Ilana, Ann, and Karen.  Our mission is to teach the Nicaraguan staff and ideally graduate them to teaching their own staffs in outlying hospitals how to perform the cervical screenings and remove pre-cancerous lesions on their own. Most of the clinics don´t have the equipment needed to remove the lesions, either by freezing them (cryotherapy) or excising them with a live wire (LEEP).  Training is one issue and funding equipment to do so is another.

I again began the day doing intakes and found that I was much more comfortable with the vocabulary and questions.  The true challenge came when one of the patients told me yes, she had been abused by her husband, that he had been killed, and she had lost a son to suicide.  The previous day all answers were emphatically negative.  We paused.  I took a big breath, held her hand, and told her how sorry I was for her pain and loss, making a note for her to see the psychologist before leaving.  This woman´s story wasn´t unique - along with poverty comes violence, loss, and struggle.  We finished the interview and I handed her a sheet in Spanish that explained a little about female anatomy and the treatments we were offering that day at the clinic.  When I walked into the data entry area, I burst into tears.  I wasn´t expecting it.  I couldn´t stop crying.  But of course, eventually, I did.  Feelings here are very close to the surface, it seems.

This woman had  waited over 4 hours in the hallway to be seen.  I was able to intercept her afterward and escorted her to Jenny - the director here in Nicaragua - to set up a psyc consult for Thursday.  I pray that she shows up and gets some professional emotional support.  Her screening showed no abnormal cells.  Finalmente.  Un poco de buena suerte.  She gave me a big hug and the traditional kiss on the cheek.  I asked for another and hugged her again as we said goodbye.  Tears in both of our eyes.

In the afternoon, I adopted another new role.  Hand holder.  This role is very important and not language dependent.  Each of the DFW volunteers can share a story of connecting with one of these patients as she received a LEEP or Cryo.  Wiping away tears.  Squeezing hands.  Sharing pictures of home on their iPhone.  Talking about our kids.  Coaching the patient to find their breath and exhale...... This job of hand holder is not to be minimized.   One patient pantomimed to the volunteer that she could feel her heart in her hand, supporting her and holding her fear. Compassion crosses all barriers of language, when we are open to truly and vulnerably connecting.

Imagine getting on a bus at 3:00 a.m., arriving at a big hospital by 7:00 (the time they are told to arrive) , and sitting in a sweltering hallway for 2 hours before the medical staff even arrives.  My last patient on Tuesday was seen at 3:00 p.m.  She had to catch the 4:30 bus back to her pueblo and probably hadn´t had anything to eat except for the couple of cookies I encouraged her to eat along with the glass of water that washed down her ibuprofeno. We handed out sodas and crackers.  Many volunteers shared parts of their lunch with women that had been waiting for hours.  There was no protocol except to follow your heart.  Some volunteers even brought toys and crayons for waiting children.

When we got back to the hotel, we were all exhausted, but felt good about the work we had done for DFW and PINCC, and for the connections with these very brave Nicaraguan women.

Nicaraguan dancers arrived around 6 and we were treated with 3 traditional dance performances by local young people.  They were amazing and full of celebration and  laughter - just what we needed after the long day.  We then ambled down the street to Carol´s favorite family owned restaurant for soup and postre de tres leches.  The soup was delicious, served in giant bowls with giant spoons that looked more like spoonRESTS than soup spoons.  We encoutered numerous new root vegetables and potatoes in the broth which was made with a huge variety of ingredients including sour orange.  Yum.

After dinner some of us found our way to the rooftop again and were treated with double fireworks.  Arriba (to the east) was an amazing display of lightning that traversed the sky like words written in cursive (a direct quote from Marie Cruz).  Abajo we heard the boom and crackle of  fuegos artificiales or fireworks.  I thought they might be coming from down on the beach, a preveiw for tomorrow´s national holiday.  NICARAGUAN MOTHERS DAY!