Providence St. Joseph's Global Health Training Team returns to Chicaman, Guatemala March 2019

Providence St. Joseph's Global Health Training Team returns to Chicaman, Guatemala March 2019

Back in Chicaman, Quiche, Guatemala 3.0. March 18-23^rd 2019

Our Training Team in the Chicaman Main Square and New Sign

Bienvenidos y Buenos Dias Otra Vez!  This is my third annual trip to this community of Chicaman with Providence St Joseph’s Global Health helping Medical Teams International to provide instruction to clinical staff who work for the Ministry of Health in this area. We will again be using the World Health Organizations Curriculum that is designed to help give front line clinicians the knowledge and tools to reduce maternal and infant mortality in the communities where they provide care. The course is named Integrated Attention of Pregnancy and the Child and goes by the acronym in Spanish of AIEPI (Atención Integrada a las Enfermedades Prevalentes de la Infancia), and IMCI (Infant, Maternal and Child Integration) in English. Our team’s (Module 1) curriculum focuses on the values of health care as a human right, maternity care and risk stratification and care of the newborn and child up to 2 months. The course was established in 1996 by the WHO and funded by Unicef and was provided regularly by Guatemala’s Ministry of Health until 7 years ago when funding was no longer provided

Team one gets on the bus

Pilote Horacio

This year I was privileged to be the team leader of 5 that included the following amazing clinicians: Jeniffer Hughes R.N. (from Providence Holy Cross in Southern California), Laura Bartlett WHNP (From Swedish Seattle), Domenica Rice CNM (from Swedish in Seattle) and Laura Krinsky MD (3^rd year resident in the Cherry Hill Swedish Family Medicine Program). We have been working together creating the lesson plans and having phone meetings for the past few months, and with the exception of Domenica and I (who attended the Popular Education training in January in Olympia), we all met together for the first time in person in Guatemala City, this past Saturday March 16^th. On Sunday March 17^th our medical training team of 5 boarded the microbus with 13 other Providence Swedish St. Joseph service team members. Their project was to build water and sanitation projects with the Medical Teams International Staff of Gladys Juc, Romeo Lem and Gladys Ramirez RN. The 10-hour bus ride in a 24 seat Microbus to Chicaman, in the central highlands of Guatemala was “piloted” by our driver Horacio (Medical Teams International) safely and skillfully on roads that would be considered barely passable in the US despite an unwelcome flat tire midway through the trek.

The March 2019 AEIPI Training Module 1 Participants and Trainers, Chicaman, Guatemala

However, because our team was so busy each and every day and into the late evening, rather than a daily blog like we have done on previous trips, we decided for this blog to be one episode of compiled individual reflections from my amazing team members with a few photos added in. Enjoy! Disfruta!

Robert Gobbo MD (AKA Roberta)

Residency Director, Providence Family Medicine, Hood River, Oregon.

Jeniffer Hughes RN, BSN Providence Holy Cross Medical Center, Mission Hills, California

Jennifer Cortado Hughes RN at the
Delivery Room
Uspantan Hospital 

Coming back to Guatemala after so many years brings back so many beautiful memories from my childhood. Seeing the city in the daylight and the distinct smell reminded me of when I used to visit the city with my grandma. The nature in this country is unique, as we drove through the Bosque Nuboso on our drive to Chicaman, I was awestruck. I have not seen anything like it in my life. Although I was born in Guatemala, my parents brought me to the States when I was ten years old. Since then I have only been back 3 times and not for long periods of time, therefore, I don’t know much of its history, the demographics or visited any of its many beautiful places. I have been excited to about this trip since I applied and was granted an interview. To finally arrived in Chicaman and meet the participants filled my heart with joy, excitement, nervousness, and motivated me to want to do my best.

Day 1 of training was great! It was exciting to hear from the participants and learn about the services that they provide in their communities and varied of experiences. Seeing their eagerness to learn, their enthusiasm and willingness to participate was very encouraging and rewarding. They ask great questions, make observations and comments that promote discussion, and they all are very smart and knowledgeable. They are able to apply the

Participants and the Hot Cabbage

material and adapt it to the situations they encounter in their community. It was interesting for me to learn about the structure of the health care system here in Guatemala. I was very impressed by how broad their role as professional nurses and ancillary nurses is because of the insufficient personnel and low or lack of resources available. Nonetheless, their driving force is wanting to better themselves and be equipped to serve their communities and enhance the health of the people. Which reminds me of my mom leaving for the States, sacrificing seeing my brother and I grow up and working long hours to support us so that we could have a better future. Seeing the conditions in which the people here in Chicaman is heartbreaking and is a reminder of how blessed I am and I owe it to God and my mother. If it wouldn’t have been for her, I could have had children a very young age like many of the women her in Guatemala and probably wouldn’t have had the means to seek an education. It also puts into perspective how it doesn’t take much to be happy. The people here may not have much but they look content and don’t complain. Their faith and trust in God is exemplary despite their living conditions, it does not waiver.

Comadrona at Uspantan Hospital
 Medicinal Herb Garden

The participants had the opportunity to share these days with are also great examples of wanting to make change happen in their communities and knowing that to achieve it, the change must start with themselves. Which means seeking an education and returning to serve their communities and become role models for the youth that surrounds them. The change although slow, it has and continues to happen. The statistics about the mortality rate of the women and infants in the past years was gut wrenching to hear, but at the same time motivating as those numbers have decreased because of the increased education and partnering with the Comadronas in the communities whom are highly trusted by the families. Also, identifying the mothers in the communities that can help educate other mothers on the proper care of themselves when pregnant and their infants and partnering with them to expand the education and be resources has aid reducing the mortality and infant death rate. What was saddening and heartbreaking to hear was that many of the maternal deaths could have been prevented if only the personnel and resources were available. These nurses truly exemplify the caring behaviors and define nursing in every sense of the word, service, compassion, and love for others.

This day was truly eye opening and brings back many memories of my childhood, growing up in a farm with no electricity, no paved roads, yet I was happy. I am very humbled by their kindness and warmth, and more than every grateful for all that God has blessed me with although I am undeserving of it.

Sociodrama (Role Playing) Twin Pregnancy

I am beyond thankful for the opportunity to be part of this trip and be part of these team, Laura Bartlett, Domenica Rice, Laura Krinsky and Dr Gobbo are amazing individuals, who truly seek to help others, are genuine in their sentiment, and not arrogant using their status superior.  I have learned a lot from them and see the as my role models. I love how quickly we bonded, support each other in every way, and I would be honored to share another experience like this one with them!

Domenica Rice CNM Swedish First Hill, Seattle

Reflections from: Tuesday 19 March 2010

Domenica and a Bouquet of Baby Manniquins

Another completely packed 18 hour day! Tamales and goat milk fresh from the goats (who were on a truck by the side of the road) for sale tempting us on the way to breakfast. So impressed with the Guatemalan doctor and nurses we are sharing learning with on this trip. The nurses have 3 years of training and function as primary care providers in rural communities with extremely limited resources in areas that are beautiful, lush, mountainous, rugged, remote, and very, very poor. Auxiliary nurses have 7-10 months of training, and learn a lot on the job. Gladys Ramirez (the lead RN and organizer for MTI trainings), who I would love to be when I grow up, has such a strong vision for how to improve the lives of everyone in her community, and has the wisdom, experience and strength to get it done. MTI is improving quality of life in Guatemala in measurable ways with the training we are facilitating and with building water and sanitation systems in partnership with remote communities.

The Popular Education techniques we learned are keeping everyone engaged while we cover so many different topics around improving maternal and infant health. Jeniffer and

Roberta experience Eclampsia

Laura led the classes on labor and newborn care today and Bob led the dinamicas with a special appearance by “Roberta,” his seizing, abrupting, pregnant alter ego. Small groups to teach a basic version of neonatal resuscitation were so fun. Got to chat a lot more with individuals and hear about their experiences with maternal and neonatal mortality. Many communities do not have basic equipment for neonatal resuscitation, and transport to a higher care level of a woman or baby can take hours, if it is even available. The dedication and caring and creativity these men and women talk about so casually makes me feel such strong emotions it is hard to express them, but I am so grateful to get to meet people in this world so willing to serve these families and make these changes.

Late Night
Lesson Preparations

After class, we took a walk up behind the town with the green jungly mountains as a backdrop all around us. Found a stationery store to make cards for all the participants to present to them tomorrow, and put in some keychains Jeniffer had brought from LA. Then dinner and our hours-long strategy session for the next day. Improvising lesson plans as we go along, depending on what the group responds to best. Adding more skits because our Guatemalan counterparts are so enthusiastically good at them!

I am also so completely impressed with my group. Each person is so kind, warm, and funny and brings a unique quality that I can’t imagine the group being without.

Laura Krinksy M.D. 3^rd Year Resident in the Swedish Cherry Hill Family Medicine Residency.

Laura teaching
Neonatal Resuscitation

I came to Guatemala with a deep sense of interconnectedness. For decades, my country (the United States of America) was responsible for equipping and training Guatemalan security forces to massacre thousands upon thousands of indigenous civilians. Since getting off of the plane, I have been witnessing the legacy of the genocide against the Mayan people. Guatemala is not just a foreign country, but a land where countless have suffered (and are suffering) for US interests. As I prepared to facilitate a training, I contemplated the history of the US-led School of the Americas teaching students to egregiously violate basic human rights. This is the history of our relationship. There is no making up for this. How can we contribute to mitigating the abuses against indigenous people?

It was an honor to work alongside both Guatemalan and US medical professionals who are developing a different kind of connection – one focused on the health and dignity of rural Guatemalan women and children. Despite a lack of resources, Guatemalan nurses are working tirelessly for their communities. Their brilliance, creativity, and compassion cannot be overstated. Just bearing witness has been a joy. For me, our training helped forge a connection based on empowerment.

We held a yarn ceremony to conclude our training, with the web connecting us to one another as a representation of the time we shared and hopes we hold for the future. One by one, we all stood together and shared a blessing -- from the circle and to the circle. The participants’ words - “Opportunity” “Love” and “Solidarity” - endure.

Dimanica "Soy un Cartero" (I am a Mailman)

By day three, the butterflies in our stomach had dissipated. Instead of excitement and anxiety, the walk to breakfast was filled with bittersweet reflections – acknowledging how far we have come in such a short time while we prepare to say our farewells. Our team was better than ever; we had become a well-oiled machine as we prepped the canastas, wrote objectives, and warmed up the repollo.

Team in Full Costume

Amazingly, despite hours and hours in the same room, the participants’ enthusiasm had not waned. If the preceding days were our actor’s rehearsal, then our last day was their grand debut. They went from playing charades about neonatal warning signs to developing skits about omphalitis to demonstrating lactation counseling to acting out developmental milestones to writing and performing sketches about nutrition and development, all without skipping a beat. There was no awkwardness or embarrassment, only joy and the genuine desire to learn and take the lessons back to the community.

I am astonished by how much material we covered as we simultaneously laughed, bonded, and created lifelong memories to guide our practices and our hearts. I am blown away by the participants’ camaraderie, energy, and commitment to bringing the best and most compassionate care to their communities

Laura Bartlett WHNP. DNP. RN Swedish First Hill Seattle, Washington.

Laura Bartlett outside the Delivery Room
Uspantan Hospital 

Guatemala is a beautiful place. It is comforting to be situated in the foothills and surrounded by mountains and greenery. The people are kind. The colors are vibrant. The community is welcoming.

This week, I am working as a part of a team of physicians, nurses, and midwives to “train the trainers.”  The training team participants (those receiving the training) are composed of nurses (who function with the skills of ARNPs and CNMs) with various experience and one local physician. They come from a number of different communities and healthcare settings. Each person comes with unique insight and an eagerness to work cooperatively with their peers. They will soon be taking this content back to their communities and presenting it to the other health care providers in their work sites. It is evident that these nurses and physicians are leaders in their health care communities.

Participants acting in a role-play "sociodrama"

Each day I am more and more inspired by the health care providers we’ve worked with in the training. Their incredible dedication to the health of their community is awe inspiring. While working in small groups, reinforcing neonatal resuscitation skills, I had the opportunity to learn more about the real life experiences of these nurses.  To hear about their personal experiences with maternal and neonatal mortality was chilling and heartbreaking. Their utmost desire is to provide comprehensive, culturally sensitive care to their patients, but their lack of resources and overwhelming poverty are huge barriers.

Quiche translator
with family

Prenatal Visit

One very memorable experience was being able to visit the local health care sites. Being able to be present in a rural health clinic (“puesto de salud”) was an enlightening experience. As we left the hotel and drive out of Chicaman, we see the local people going about their daily routines, walking to work with machetes in hand. Along the way to San Sebastián, we pass farms along the rolling hillsides and small villages.  The roads are steep. The mountain views are breathtaking. We came across a site with small wooden crosses. We’re told by Vidcar that this is where a terrible bus accident occurred several years ago, killing over 20 people.  It is a 45 minute drive from Chicaman to San Sebastián, but we were in the expert hands of our driver and friend, Vidcar.  He maneuvers the pothole ridden, winding roads like a professional.  We arrived in San Sebastián at 9:00am and saw patients until 2:00pm. I was able to be present for 6 prenatal care visits while Dr. Bob attended to the newborns. In the clinics they don’t have a lot of resources. Nonetheless the care there is thorough, comprehensive, and compassionate. 

I have enjoyed the time here in Guatemala. I have learned priceless lessons in patience, kindness, community, compassion, teamwork, and unity.  This journey has been rewarding in innumerable ways.  I feel blessed to have been chosen to be a part of this team. This experience wouldn’t have possible without our fantastic team leader, Bob, and the amazing women (Jeniffer, Laura, and Domenica) who have inspired me each day.  To say that they are amazing is an understatement.  It has been a true blessing and honor to be lucky enough to work alongside such incredible individuals. They truly have helped me be the best version of myself.

Closing:

Our training team is indebted to the Community Health Workers at the Next Door in Hood River Oregon, who were the inspiration to us and gave us the capacity to organize this course using Popular Education techniques (DINAMICAS “icebreakers but much more”, Role Playing, Sociodramas, Games, Singing and Dancing, Simulations, Brainstorming, Cooperative Learning and Reassessment).

Neonatal Resuscitation Simulation
 Champions League Tournament

The themes of Popular Education are grounded in the values of the Social Justice Movement that started in Latin America. We included a group sing-a-long to the folk song “Casas del Carton” (see lyrics below). I recorded “the NextDoor Singers” led by Joel Pelayo, and explained to our participants that this song was a gift from community health workers (Promotoras del Salud) in my “aldea” or village of Hood River, Oregon to them and have included the lyrics below.

All at Calvary Summit, Chicaman

The nurses and physician who were among the 18 trainees in the 4-day course remained totally engaged, energetic, spirited, compassionate and inspirational. We got to know them like family. The comments from this evenings closing celebration and our evaluations were overwhelmingly appreciative, loving and heartwarming.

Three more teams will be coming this year. The next, in April,  will focus on Child Care from 2 months to 5 years. The two subsequent teams will be providing assistance to these same participants who will then be the teachers as they provide this course to another 80 front line clinicians.

Tomorrow we will boarding the bus back to Antigua for a day of sightseeing this beautiful colonial and picturesque city. We will be coming home late Sunday but will never forget the strong connections we have made with each other, our new professional health care colleagues and many of our old friends we have met on previous journeys. I know we will return, but we leave a piece of our hearts here in Chicaman.

Bob (middle) y Los 4 Angeles - Dominica Rice, Laura Bartlett, Laura Krinsky and Jennifer Hughes.

Blessings/Bendiciones:

The Providence Swedish St. Joseph’s Global Health AEIPI Training Team Module I:

Jeniffer, Domenica, Laura K, Laura B y “Bob”.

Lyrics to Casas Del Carton and Translation:

"Casas De Carton"

Casas de carton Que triste se olle la lluvia En las techos de carton Que triste vive mi gente
En las casas  de carton

Viene bajando el obrero Casi arrastrando sus pasos Por el peso del sufirir  Mira que es mucho sufrir Mira que pesa el sufrir

Arriba deja la mujer preñada Abaja esta la ciudad
V se pierde en su maraña Hoy es lo mismo de ayer Es un mundo sin mañana

Que triste se olle la lluvia En las techos de carton Que triste vive mi gente En las casas de carton

Niños color de mi tierra Con sus mismas cicatrices
Millonarios de lombrices y par eso Que tristes viven las niños
En las casas  de carton

Que triste se olle la lluvia En las techos de carton Que triste vive mi gente En las casas de carton

Usted no lo va a creer Pero hay escuelas de perros
Y les dan educacion
Pa que no muerdan los diarios Pero el patron hace af\os Muchos años que
Esta mordiendo al obrero

Que triste se olle la lluvia En los techos de carton
Que lejos pasa una esperanza En las casas de carton

English Translation

“Cardboard Houses"

Casas de carton How sad the rain smells On cardboard roofs How sad my people live
In cardboard houses

The worker comes down almost dragging his steps By the weight of suffering Look what a lot of suffering Look at the burden of suffering

Above leaves the pregnant woman Below is the city
And is lost in its tangle Today is the same as yesterday It is a world without tomorrow

How sad the rain smells On the cardboard roofs How sad my people live In cardboard houses

Children color of my earth With their same scars
Millionaires of worms and for that That sad children live
In cardboard houses

How sad the rain smells On the cardboard roofs How sad my people live In cardboard houses

You will not believe it But there are dog schools
to give them education
So the newspapers do not bite But the boss has been around for many years
He is biting the worker

How sad the rain smells On cardboard ceilings
How far a hope passes In the cardboard houses

If I had ten million dollars

On Wednesday, we had a chance to meet with a fellow named Salvador Baltizón, a physician working for Project Concern International who is currently tasked with writing a grant. USAID has apparently offered $10-25m in aid to focus on improving health in Huehuetenango and Quiché departments. He essentially posed the question, “what would we do if we had millions of dollars to spend to try and improve the health and well being of the people in western Guatemala”.

The question is not a simple as it seems. Huehuetenango alone is a region with nine different languages (including Spanish), two hospitals (Huehue and Barillas 6 hours away), 2 CAIMIs (health centers that can do cesareans when staffing is present), several CAPs (like Santa Eulalia and Jacaltenango - mini health centers that can do vaginal deliveries) and dozens of Puestos de Salud (Health Outposts that can do very basic medical care). There is about one physician per 10,000 people and poverty can be overwhelming. The makeshift road network connecting cities and remote villages is sketchy at best. 

Popti speaking comadronas in Jacaltenango

We did not see only barriers to improving health. Cell phone service is not bad (even in remote villages), and internet with wireless access is becoming more available. There is a hospital in the Quiché department with a similarly modeled “Casa Materna” that actually inside the hospital and patients can deliver without needing to leave the Casa. There are often visiting medical teams offering periodic opportunities for medical and surgical treatment. 

Our vision, along with Casa Materna, has always been to make pregnancy and birth safer, and to empower midwives and women with choosing when and where and how to have their births when possible. To that end, we allowed ourselves a little dreaming. A dream of having contraception readily available (which it mostly is). A dream of local midwives with a standardized training in managing birth emergencies and readily equipped to initiate treatment when needed. A dream of readily available electronic communication for remote communities in order to be able to consult as needed. And for women with higher risk pregnancies, a dream of delivering inside of Casa Materna, with a midwife speaking her own language with the support and respect of the hospital medical team when intervention is needed.

Carly, the "muñeca pero en viva" (real life doll)

Dr. Baltizón brought us to think, almost like a child at Christmas time, what if we had enough resources to take a step forward in the vision of Casa Materna that every woman should have the opportunity of a safe pregnancy and birth within her cultural norms.

Chojzunil, a small remote town outside of Santa Eulalia

Nos Vemos

One of my favorite Spanish expressions, “nos vemos” literally means “we will see each other (again)” as opposed to “adios” which does not express a hope of a future meeting. On Friday morning, we met with the most of the PCI staff in Huehuetenango to have a breakfast and to say goodbye. One of the customs when you have a “reunión (meeting) is to have speeches with affectionate language, and this day was no exception. Bal Maria (PCI director in Huehue) spoke about her appreciation for the work we do in partnering with them. Our sense is that our partnership with PCI and Casa Materna continues to build and strengthen.

The staff of PCI prepared and served the meal which was excellent. We said goodbye to Bal Maria, our drivers (Danilo, Juan Carlos, Josue, Henry, & Roni), our nurse partners José & Yasmín, Dra. Susan, Dali, Vilma, and staff too numerous to count. And of course there was lots of photos, hugs, tears, and thanks. 

Breakfast at PCI Headquarters

We boarded the Los Halcones (Falcons) bus for the seven hour trip back to the capital where we arrived at our hotel and met up with Abesaida (our normal host in Huehue who was undergoing treatment in the capital.) We also met Arnoldo, Paty, Abesaida’s brother William and his wife, Paty’s friend Miku, and Natalia, a graduate from Landívar University, currently working as a hospitalist.

Jemie, Chris, Kristen, Karin, Miku, Arnoldo, Pablito, Carly, Suzy, Abesaida, Brenda, Paty, Conchis, and William

We spent a quiet night at Hotel Ciudad Vieja and had a second round of hugs and tears. We expressed our hopes for the future with the simple expression “nos vemos”.

Pablito celebrating his second birthday

My Dinner with Manuel

Thursday was a day of “Féria de Salud” (Health Fair) at Casa Materna. We divided up strategically: Chris working with Dra. Susan, Brenda working with Carly on ultrasounds, and Jemie & Kristen doing consults. Jemie had a patient with a congenital vascular growth in her thumb. We are currently trying to connect her with a team of traveling surgeons who can treat her in Huehuetenango.

8yo girl with a vascular malformation of the thumb

Brenda with one of Manuel's new kittens

That night we visited Manuel Saenz, a genteel Guatemalan man who is a wonderful host and entertainer. Not only did he share his newborn cats and give us a tour of his new home, but also showed us a slideshow of his recent trip to Asia, including Taiwan, Vietnam, Cambodia, and Thailand.

Interior of Manuel's home

Manuel sharing photos from his asian trip