Boston University Medical Campus
International Health Program

Costa Rica

This summer I went to Costa Rica for three weeks and
attended a medical Spanish immersion program at the Rancho
de Español in La Guacima, a small suburb northwest of San Jose. At
Rancho, I took Spanish classes in the morning in which I reviewed grammar
and vocabulary. In the afternoons I either returned to school for classes
that specifically taught medical terminology or I went to the local clinic
to observe.

The doctor that I shadowed was great and really allowed
me to practice my Spanish skills. Typically she would interview the patient
while I listened and observed; when she was finished, I would get a chance
to ask my own questions. She also let me take my own vital signs on the
patients after she had taken her own. The clinic was small with only one
doctor and one room. She was essentially a family medicine doctor – her
patients ranged from newborns to the elderly; she also did prenatal care
for pregnant women. I would say the most common illnesses I saw were very
similar to what is seen here in family medicine clinics: colds, diabetes,
high blood pressure, and high cholesterol. It was interesting to see how
patients were treated; usually they were given similar drugs that we use
here but in generic form. The most unique cases I saw were those patients
that had contracted dengue fever (transmitted via mosquitoes).

I truly had a great experience there because I was able
to practice the Spanish I was learning with real patients. I was received
very well by the patients. I most definitely recommend this program to
other students interested in learning Spanish.

Guatemala (1)

1. Testing of Local Water/Efficacy of Ceramic
   Filters There was some disbelief that the local water was clean/filtered,
   therefore my objective was to look into how it was managed, how often
   it was to be maintained, and what were the possible causes. Also, I
   was required to learn how their water filtration and disinfection system
   worked. I designed a study to take snapshot viewings of certain days
   and test the water from four different locations within the town. In
   addition, part of this study was to assess the usefulness of the Ecofiltro
   (a ceramic filter used to filter water at individual homes). Our results
   found that the chlorine levels were always 0.0 mg/L when they should
   be 0.5 mg/L and that neither the Ecofiltros nor the tap water was free
   from bacteria. This project was not a pre-established project; it was
   one that I developed with Dr. Sinkinson.
2. Patient Follow Up My other project
   was following up on patients who had been to our clinic. Often, patients
   would not follow their medications as prescribed for various reasons.
   Therefore, I was sent out with an interpreter 1-2 days after the patient
   came to the clinic to ask questions. This project was one of my favorites
   because I was able to go to into the patient’s houses, see how they
   lived, and see the dynamics of their family life.

Most weekends I did some traveling with other students working
with Dr. Sinkinson. I journeyed to the northern part of the country in to
the region of Peten and Tikal, and there were also trips to the Caribbean
(Livingston) and Pacific coasts (Monterrico). Recommendations: I would have
a detailed outline and project description before heading down to the clinic.
There is a lot of down time, and Dr. Sinkinson is not always available to
answer your questions. Therefore, get as much planning finished before you
get down there. An intermediate level of Spanish is required, and the more
fluent the better. There is no one to interpret for you!

Guatemala (2)

My summer in Guatemala was spent doing a combination
of activities that expanded my knowledge of Spanish and traditional medical
practice within the indigenous population of the Guatemalan highlands.
I participated in Pop
Wuj’s Health Services & Medical Care Program that has four parts:
(1) language instruction; (2) home stay; (3) a supplemental curriculum;
and (4) clinical placement.

I began one-on-one Spanish classes the first week of
the program; each class was four hours. The time was divided into general
Spanish grammar and medical vocabulary and common phrases that would be
used in the medical setting. Also during the first week, I attended conferences
held at the school that addressed different themes of medical practice
in Guatemala such as the Mayan belief system which influences the practice
of both traditional and western medicine. I also traveled (along with
a group of other medical students and one doctor from the U.S.) to a highland
village dislocated due to a recent hurricane to hold a clinic in their
schoolhouse. The medical students had the opportunity to practice Spanish
by conducting patient interviews.

After the first week, I was assigned to shadow a midwife
in a small town outside of Xela. The midwife delivered babies, conducted
prenatal visits as well as basically ran a family practice clinic. Exams
were conducted without any equipment besides a stethoscope. The midwife
was able to use a simple abdominal exam to diagnosis illnesses ranging
from parasites to urinary tract infections to gastritis. One of the things
that surprised me about working with the midwife is that she actually
prescribed a lot more western medication than traditional medicine. Almost
all her patients received an injection for some type of pain along with
other medications. The patients who most often were prescribed a type
of traditional herbal medicine were pregnant women so that the medication
wouldn’t harm the baby.

I enjoyed the program at Pop
Wuj because in addition to the Spanish classes and the exposure to
medicine, I was also able to participate in some of the volunteer and
recreational activities that the school organized. An example is a tour
of a coffee factory and hike to a lake that the school arranged for the
students. The school also coordinates stove building projects, a daycare
center, and a scholarship program for children to attend school; Pop Wuj
students had the opportunity to engage in these programs. These activities
provided me with the opportunity to learn more about the educational system
and how people lived in the surrounding villages. I was satisfied with
Pop Wuj because the program allowed me to explore many aspects of the
culture and social structure of Guatemala.

Guatemala (3)

I found myself in Santa Cruz La Laguna, a small Mayan
village on Lago Atitlan in Guatemala, during the summer of 2005. The doctor
in the village clinic was researching child health and malnutrition, and
my main task was to weigh and measure all of the children and enter the
data I collected into the computer. I chose this project because I am
interested in both Native American health and culture and pediatrics.

In addition to working on the research project, I was
able to shadow the doctor and get a true sense of rural medicine in a
developing country. This experience helped me to discover the type of
doctor that I hope to become and further proved to me how rewarding practicing
medicine can be. Here are two stories from my journal that I think best
reflect my experience in Santa Cruz:

• "A Day at the Clinic" When we returned
  to the clinic after lunch, there was a four-day-old baby waiting to
  be seen. The nurse had not known what to do and was very relieved to
  see us come back. The baby was jaundiced and had a large bump on his
  head. It was a hematoma that was probably caused by a traumatic birth.
  The father was so filled with joy when the doctor told him that the
  bump would go away on its own and that the baby was healthy. After they
  left, the doctor explained how unique the case we had just seen was.
  It is very rare that a baby so young is brought to the clinic, and it
  was even more unique that a father brought the baby in, for infants
  are usually at their mothers’ breasts constantly. The doctor explained
  that the mother most likely did not come in because she may have been
  worried that her son’s disfiguration was her fault. Moreover, this case
  was a huge breakthrough because it showed how much trust that doctor
  has earned from the community.
• "My Thoughts on My Way back to the States"
  I think I am going to miss Guatemala more than I can understand now.
  The friendliness and warm smiles of the people, meeting and bonding
  with other travelers, feeling lit up from the energy of the children,
  getting stuck in the rain, watching clouds drift and lava flow on Pacaya
  (volcano), seeing temple peaks protrude from the rainforest at Tikal,
  disinfecting avocado trees at Earth Lodge (an avocado farm), the people
  that became my family at the youth hostel…I didn’t realize it while
  it was happening, but looking back, I have learned so much. I certainly
  have a better understanding of medicine in an impoverished, indigenous
  community. But I have an even better understanding of how people connect.

Guatemala (4)

As part of the Ohiyesa
Summer Language Proficiency Program we spent four weeks in Antigua,
Guatemala with 12 other medical students advancing our Spanish-speaking
skills and learning about the Guatemalan health care system and medical
issues pertaining to the Guatemalan way of life. Our schedule was as follows:

• Mornings (8:30-11:30 a.m.) were spent learning medical
  Spanish as a group, listening to a talk on some aspect of Guatemalan
  health care, or visiting different clinics.
• Afternoons (2:00-6:00 p.m.) we were at school learning
  Spanish one-on-one with a native Guatemalan, learning according to our
  respective levels.
• Evenings (6 p.m.+) we were free to study, go out on
  the town, or catch up on sleep.
• Weekends were spent visiting Lake Atitlan and Mayan
  ruins or volunteering in a clinic. Being that we were first- and second-year
  students, our help in the clinics was limited to what we could do as
  lay people without medical training.

Student #1 (Summer 2000):
The major reason I enjoyed the Ohiyesa Program was because of the structured
exposure to Guatemalan health issues that I would not have seen on my
own. Through this exposure, I was able to solidify my desire to someday
return to the country as a medical student or doctor. This program is
great for anyone considering practicing medicine internationally in the
future and would like a structured program to give them an idea of what
it would entail to practice abroad. Because there isn’t much time for
exploring on your own, I wouldn’t recommend this program for anyone who
enjoys the freedom of exploring and traveling as an individual. I had
no previous Spanish and in one month, was able to lay a general foundation
for future Spanish learning. However, because the group we traveled with
consisted of all English speakers and because Antigua is a city full of
tourists, I didn’t spend as much time speaking Spanish and therefore learning
as much as I anticipated. I think I would have learned more if I had gone
there with a foundation and then solidified that foundation through conversational
practice with my teacher.

Student #2 (Summer 2005):
The Spanish teachers know very little English so you are forced to learn
and speak Spanish the entire time. This was the best part of my day. The
downside of Antigua is that while it is a beautiful city, it has also
been discovered by others and has become a popular tourist site so you
can get away with speaking English the whole time you are there. So I
really enjoyed my one-on-one sessions because it was the only time I was
able to learn and practice my Spanish. My friends and I tried to enforce
a Spanish-speaking only rule but it was broken countless times. During
some afternoons we had off and the evenings, we studied, slept, went to
the gym, or explored the city, such as immersing ourselves in the Artesian
Market using our knowledge of numbers in Spanish in a bargaining game.
Weekends were free so we climbed Pacaya (an active volcano), visited the
Mayan ruins in Tikal, and went to Lake Atitlan. The host family you stay
with varies. The family I stayed with also housed many other students
so I felt like I was in a hostel and did not have many opportunities to
speak to my host family and practice my Spanish. However, it was the opposite
for some other people in my group. We had 3 meals/day prepared for us,
excluding Sundays where we were free to try the many restaurants in Antigua.
I had a lot of fun in this program and got a lot out of it as well. I
went to Guatemala without any previous knowledge of Spanish and came out
in a month being able to have a conversation in Spanish and be able to
continue to add on to that skill. I saw a lot of the hardships people
face and the lifestyle in Guatemala that opened my eyes and forever changed
my views of people who live in third world countries. It helped to reinforce
my desire and passion to work abroad as a physician in the future and
provide the much needed medical attention for the poor. It is up to you
to make the most out of what this program offers. I know I did!

Honduras

My time in Honduras was a great experience for acquiring
a few clinical skills, practicing my medical Spanish, and working with
the doctors and patients of El Progresso Hospital. Each day we went to
the hospital with no set structure. We went to whichever clinic was willing
to let us observe. In the ER, one student learned how to insert a catheter.
At the Diabetic Clinic, we learned how to to monitor blood glucose levels
and received a brief introduction to the most commonly used drugs. Some
students were able to observe several surgeries.

Dr. Hall, an internist, allowed us to shadow his outpatient
and inpatient clinics. We practiced taking blood pressures and distinguishing
the various sounds on auscultation such as ronchi and rales. Most of the
inpatients we saw had coronary heart disease. Dr. Hall also shared with
us his work on an asthma project to properly teach patients how to use
inhalers. The doctors, residents, and nurses were extremely open to us
working with them. Even the patients seemed to welcome the extra attention.

Whenever there was any downtime or slump in patient flow,
we headed to the Obstetrics Department where we were almost always guaranteed
action. There we worked Dr. Castillo, Dr. Moya, and several residents
who were doing their “social service” portion of their residency. One
morning, Dr. Castillo quickly and charismatically taught us the basics
of Obstetrics. Even with his broken English, we learned how to calculate
the expected delivery date, measure the fundus height, approximate the
position of the head and spine of the baby, how to listen to the fetal
heart beat, and manually measure the width of the cervix. Before we knew
it, we were assisting in deliveries – always with one of the doctors standing
right beside us. After carefully placing the slippery baby aside, we delivered
and examined the placenta. There was something so exhilarating about a
successful birth that made it clear why the expression for delivering
a child is called, “dar a luz”- giving birth to light.

Sister Terre, our contact, took care of our food, lodging,
and arranged our clinical experience. Sister Terre made certain that we
were safe and well fed. In addition to our time at the El Progresso Hospital,
Sister Terre set up visits with the some of the community organizations
established by the Sisters of Notre Dame. During our free time, we once
visited the Nutrition Center which was established for children with malnutrition
or failure to thrive. Another day, we visited one of their orphanages
and played with the children. One time we rode on the back of a pickup
truck about one hour outside of San Pedro Sula to visit families who lived
in these shacks on top of what seemed to be large mud plateaus. These
families had lost everything to Hurricane Mitch. We assisted Sister Terre
with a questionnaire for a project being conducted by one of the other
sisters. There we also met the local midwife who was so excited to show
us how she assesses her patients that she invited us into her home and
sent for one of her expecting neighbors and demonstrated her skills to
us.

Nicaragua

This summer I participated in a public health research
project in Nicaragua. The Brookline-Quezalguaque
Sister City Project, in its long-term collaboration with Quezalguaque,
a small municipality in western Nicaragua, had noticed an alarmingly high
rate of chronic renal insufficiency in the area. This observation was
not unique; the disease is known to have high prevalence throughout the
pacific rim of Central America. The cause or causes of such high rates
are unknown.

Beginning last November, I assisted in planning the project,
which developed into a field study involving 300 households in a representative
sample of the municipality of Quezalguaque. The project was supported
by researchers at the National Autonomous
University of Nicaragua (UNAN, in Spanish lettering), the Nicaraguan
Health Ministry, the municipality government and the local health center.

In mid-June, four other volunteers (who each had public
health training) and I flew to Nicaragua. For the first few days we adjusted
to the homes in which we were staying and to the culture and local conditions.
Although many of the rural areas we would later visit were extremely poor,
life in the town where we stayed was relatively comfortable given Nicaragua’s
status as the third-poorest country in this hemisphere. My house, which
was also a restaurant and bar, featured a flush toilet and some of the
town’s best cooking. Less pleasant were the loud music, bucket baths,
and bar patrons. But the family was extremely kind and accommodating.

Upon arriving, we five were helped by a couple of professionals
from Brookline to coordinate with local organizations, obtain project
approvals and train the local workers. After a week and a half, they returned
to the United States and the project began in earnest. There were four
two-member field teams, each with an American and a Nicaraguan member.
In the study we took the following data: name, age, weight, height, a
GPS reading, creatinine (to measure kidney function), glucose, blood pressure,
a urine dipstick reading and a survey concerning occupational history
and personal habits. To save time and effort, for about two-thirds of
the 773 participants we only took name, age, weight, height and GPS. Our
preliminary results, which are pending verification of the hand-held creatinine
devices and the data-entry, show roughly 90 participants with moderate
to severe renal impairment (~12%).

My responsibilities in the project were numerous. I volunteered
to create and manage the Microsoft Access database we used to enter the
data and as a result, I managed and participated heavily in the data entry.
Additionally, my Spanish being slightly stronger than the rest of the
team, I acted as a go-between with a number of local organizations, including
the municipality government, the health center, the local staff of the
Brookline-Quezalguaque program and the researchers at the National University.
I also acted as the field coordinator for the project. I had a heavy hand
in decision-making concerning sampling and other protocols, coordination
of supplies and scheduling. Moreover, the majority of days I spent 6-8
hours working in the field. In short, my schedule was grueling, largely
for reasons beyond my control. In exchange, I received a tremendous amount
of practical experience in coordination of a field study in a third-world
setting, experience both hard to come by and valuable. And although the
results are yet to be analyzed and a quick glance at the data seems not
to indicate a clear answer to the epidemic of renal disease, the study
was largely successful. We managed to visit our target of 300 households
in four and a half weeks, had a participation rate among individuals of
roughly 85% in the 92% of participating households and gave a fairly clean
demonstration that classic risk factors of high blood pressure and diabetes
are not the sole causes of the disease. Much remains to be done with the
project. As I managed the data during the trip, I will have to lend a
hand to the analysis team here in the States. As a recent companion and
friend of many Nicaraguans in the region, I feel some personal responsibility
in following through with the study and lending a hand where appropriate.
Eventually, the whole team would very much like to see a paper published
with hopes of drawing the eye of organizations with more resources and
expertise in hopes that they will carry out larger and more comprehensive
studies.

In summary, this project was formative for me. The public
health experience, especially the leadership element, taught me more than
I could have expected to learn in such a short time. Using Spanish in
official settings (presentations and discussions with professionals and
researchers) was also extremely valuable. There was just as much to be
learned in the projects’ hardships, with long days, longer weeks, a few
bouts of sickness and the emotional toll of seeing an unexplained and
fatal disease devastate an already challenged population (CRI is the region’s
leading cause of death). Most importantly, it was the care and effort
we were able to provide to that community that I value highest. Accept
my deep and sincere thanks for making the experience possible.