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| Supervising Health Promoters as they diagnose a 2 year old girl with malaria. She survived. |
Teaching
Advanced antibiotics to a 6th grader?
Have you ever had a child, a close relative
or friend who had severe pneumonia? The fevers, the gasping for a shallow breath
of air, the unremitting cough can take a life in a matter of days. Now imagine
that you have this pneumonia while living in a community like Pueblo Antioquia, where your closest community is a 5 ½ hour
dangerous ride down a rapid river on a raft that will probably break apart en route.
And that brings you to a place where you take another hour boat ride (if your boat is lucky enough to have a motor
it is only an hour) to the community of Unión Embera Katío where there is no store and no pharmacy. If you are fortunate the health promoter is there and he can hopefully appropriately diagnose and treat
you. If you have an unusual form of pneumonia, or if Heberto, the health promoter
isn´t there, then it is another 5-7 hours in a boat with a motor to Ríosucio where you will be given attention if you are
affiliated to one of the for-profit, HMO style organizations (EPS in their Spanish acronym) in town. These organizations haul in the equivalent of $100 US dollars a month in “capitation” from
the government to cover the health needs of those under the auspices of these health businesses. However, the attention given (if any) will probably not include a referral to a hospital, which is another
3 ½ hours away in a speedboat, across the Bay of Urabá in the next department (similar to the next state.) So, for those who have made their way this far, they probably find themselves up a creek without a paddle.
The EPS system in Colombia, is a part
of the international attempt to privatize health care, using the U.S. system as a model.
What lawmakers in Colombia choose to ignore are the 47,000,000 people in the U.S. who have no health insurance due
precisely to this type of privatization. Even the Colombian Social Security health
system went bankrupt this month as the government withdraws funding from health centers and government supported health care
to a subsidy of private industry whose “care” is negligent at best and criminal at worst (several of the medical
providers in our area have fled after being charged with letting patients die because they would neither refer nor treat the
patient under their care.)
The law which changed Colombia´s health
system in the deadly direction it is headed is known as Ley 100 (Law #100, as Colombian laws are known by their numbering
system.) This law eliminated the role of village health promoters in curative
care. If there were a system in Colombia that found another way to provide sufficient
health care to the country this would be understandable, but that is not the case. In
the lower Atrato, none of the communities we work in provide basic vaccines, medical attention, or even a band-aid or aspirin
or ibuprofen. When we first began this program there was no one in this region
of over 60 villages who could take a temperature with a thermometer. So, the
need is here and as I constantly to the health promoters, “If this is the health care system you have after over 500
years of colonization, how much longer do you want to wait until you train people in your own community?”
So, our first year promoters learn about
the basics of the respiratory system. They learn to count breaths per minute,
listen for unusual “adventitious” sounds like wheezes or rhales in the lungs.
They learn to percuss the chest and seek other vital signs and do a sufficient physical exam to decide whether this
is a case of pneumonia or not. Then comes the challenge of deciding whether to
use and antibiotic, calculating this to be a bacterial and not viral pneumonia. And
then one needs to decide, which the best antibiotic is. The old standby of penicillin
still works in many cases here. Then we have the broader spectrum amoxicillin
and it´s cousin ampicillin. Most of our promoters with a 3rd to 6th
grade education can learn this within the first year of courses.
But what happens if the patient is an
infant? The bacteria are very different in the first weeks of life. By the third year of training and practice we are now at the stage where I am teaching the subtleties of
the organisms that can cause pneumonia in the first days of life, and then in the first weeks.
Then close evaluation has to occur. Can this promoter really use a combination
of injectable ampicillin and gentamycin in the first weeks of life? Will they
then be tempted to use them in other circumstances? Many of the medical students,
or recent medical graduates here use injectable gentamycin as though it were a harmless placebo instead of a broad based grenade
of an antibiotic that can cause permanent deafness. We do NOT want our health
promoters heading down that road! And with so many cases of Chlamydia in women,
how can we not expect to have many cases of Chlamydial pneumonia in the first weeks of life that may need azithromycin or
another similar antibiotic? The decision of what to train, and what not to train,
in primary care at this level is a challenge that becomes much more apparent when I am in a community, days away from decent
advanced health care. The family cannot afford to send the father who must work
to keep the economy for the other children going. If she leaves, the mother will
not be cooking or caring for the other children, and she may not have basic Spanish to communicate if she is from and Indigenous
village. Due to such poor care in these communities and the few remaining health
centers, few people have faith in the medical system, and prefer to take the risk of staying in the village, even if the only
available remedies are herbal plants, with little effectiveness against the aggressive bacteria that can kill an infant, child,
or even adult in days.
Today´s challenge on this first day
of our course on “Advanced Essential Medications” is Pneumonia in the Child under 6 months of age… What to teach a 6th grader…
and how…
The puzzles are in place, the water
melon with ping-pong balls, the sample antibiotics in their vials, the pages of “Where There is No Doctor” marked
and ready, the copies of new medication on the table. Looks like I´m ready. I know that in the communities the patients are…
A reflection on achieving 50 years of life…
As
a thin film of sweat covers my entire body, I decide to go down to our little out-house sized bathing room where I pour relatively
cool water in bowls over my head. I know this is only a temporary solution, but
it cools me enough to keep my mind thinking a bit straighter. In over three years
I have yet been able convince myself to join our 1 ½ year old, Gregory in his raucous splashing in the river. It is difficult to ignore the sights of the dozens of floating out-houses, the cleaning of the fish, washing
of the clothes and dishes, brushing of teeth, bailing out of the muck from the bottom of the boats, the rinsing off of motorcycles
that make up the newly emerging taxi service.
I
think that even the small amounts of water that reach my mouth bring to mind the subjects of my 17 courses a year where I
teach the promoters to meticulously learn the life-cycles of the microscopic life that shares this life giving water. Ascaris, oxiuros, uncinaria,
strongyloides, H. nana, Entamoeba hystolytica, Giardia lamblia, Shigella, Salmoella typhi.
The relationship between living organisms
is frequently defined through three manifestations:
- Symbiosis which encompasses commensalism ("eating at the same table", wherein two organisms co-exist in the same space, and one organism benefits while neither
harming nor helping the other),
- through mutualism (wherein both species benefit from the interaction)
- to parasitism, wherein one organism, usually physically smaller of
the two (the parasite) benefits and the other (the host) is harmed.
The
names of parasites and destructive organisms have taken so many lives in my years in regions such as this lower Atrato River. My heart still races every time a semi-conscious infant is brought by a desperate,
or too often resigned parent or half thrown over the shoulder of a eight or nine year old sibling. The infant with the skin that stays pouched up as I pinch it to get an initial sense of the tissue drying
that has occurred with the dehydration. The whites of the eyes roll up, weakness
having invaded even the orbital muscles of the eye. It there is a cry it is a
high pitched weak one. We are able to save most of even these children, but the
damage from the combination of dehydration and malnutrition is usually long term. The
combination of so many factors come into play; 13 year-old mothers, lack of potable water systems, lack of any sewage system,
lack of even a basic health promoter in their village, lack of vaccination against the most common viral cause of diarrhea,
too many armed groups limiting travel and transport to economic centers and drain the number of work age males. I could continue for pages on individual, family, societal, economic, political, social, spiritual reasons
for why these children end up this way. Many of families have already exhausted
the few resources they have had up to this point. The traditional healer could
not heal this disease, the medical doctor was too expensive or didn´t bother to do even the most perfunctory exam or listen
to the medical history. The pharmacy, always ready to sell the needed medications
(with or without prescription) was too expensive as well.
People
go where they have faith for their health care. If your belief is that there
is a spirit in the world called Jai, as our Embera sisters and brothers believe,
that causes illness and wellness, then one needs to go to the Jaibaná to be healed. Similarly, for those who believe it is an evil spirit, many here go to a priest for
exorcism. Over these last years many people now go to their Health Promoters
because they have seen the results. These people from the same village do not
charge for their curative and preventive health work. They are available day
and night and show the compassion and care that many villagers have rarely experienced in the medical system. We all go to where we have faith… we believe that a virus exists, though the vast majority of the
world has never actually seen a real one. We believe that the medical provider
has our best interest at heart, and if we don´t believe that, we try to change to one who does. We believe that there are remedies, curative and palliative, for the ailments we suffer from. Just as the names of the organisms that can cause so much damage have taken up a good part of my life,
so have these remedies. My vocabulary, as well as the health promoters we work
with are now full of terms like; Oral rehydration, 0.9% Sodium IV, Hartmann´s solution,
Trimethoprim-Sulfamathoxazol, Ampicillin, metronidazol, tinidazol, mebendazol, etc.
My
major interest is in combating these diarrheas and the pneumonias that take millions of lives around the world. My call to this path in the world came in my 20s as I realized how little my college education had prepared
me to save an infant from a basic diarrhea. In the midst of the conflicts of
this world it seems to be a rational and compassionate response to offer a positive source of light and hope through the work
of health promoters in areas of the world where no medical professionals will practice during our lifetimes. Now that I have crossed the threshold into 50 years old, I realize that I have spent well over half my
life working in this way of service and non-violent resistance to the wars that reign in these areas.
While
I pain for the children we work to keep alive, and take great joy when we are successful, there is the other side of this
work that has kept me in places like this isolated jungle region of Colombia, South America.
That is the harder side of reality in this world. Having to put my fingers
into the wounds made by gunfire or machete, seeing how deep the wound goes, where the fragment might be. Checking to see the entry wound leads to an appropriate exit wound, as most bullets in these war areas
are made to either flatten and expand or to spiral, causing as much destruction as possible to nerves, bone, muscle, tendon,
blood vessels. It is a well calculated strategy to wound more than are killed
so as to drain society’s resources in the work of recovery and rehabilitation.
I cannot imagine the pain and suffering being caused on a daily basis, all consciously caused by one human being against
another. Neither can I imagine the daily labors of the numerous people in this
world who work to experiment and perfect the distortion and destruction of the human body and soul. How many lives have been dedicated to knowing what tensile strength of metal will resist a bullet, or amalgam
of a missile to penetrate the same protective barrier? There are the people who
have faith that our last resort must be guns and nuclear weapons, and there are people whose faith is that these are a first
resort. Either way, there is an inordinate idolatry of faith that weapons will
save us.
When
I think of causation and prevention or cure, I cannot help but think of the most obvious causal factor; of those who act in
a similar form as the parasite – a few smaller organisms that wreak so much damage in the larger world today. Their names come all too easily as well; Negroponte, George Bush
(either one), Condoleeza Rice, the Jerry Fallwell and Pat Robertson ilk, Donald Rumsfeld, Gates, Cheney. I recall again the damage these people have obligatorily done to their hosts by their viscous actions of
dismemberment, hangings, decapitations, torture and illegal imprisonment.
We
need to move from a mode of parasitism to mutualism and commensalism, and learn from those who function with no complex brain
or heart. Our faith must be in those who offer vision and community, not in war,
death, disappearance, and torture.
Yet,
in this week of commemorating Martin Luther King Jr.´s life and struggles for Truth, Justice and Peace the names of those
who provide the remedy comes like a cooling breeze as I recall the; Martin Luther King
Jr., Mahatma Gandhi, Kathy Kelly, Dan Berrigan, Phil Berrigan and Liz McAlister, Thich Nhat Hahn, Bishop Oscar
Romero, and so many others. I recall the teachers, health workers, workers
in organic industries, those who do community organizing, feeding of the poor and visiting of the prisoners, those who practice
real listening in mental health, and the millions who oppose war and killing and I have hope that we can bring true change
around. We need to and we need to act fast, because empires are not long lived
creatures… and they harm those around them.
En Paz y Servicio,
Curt
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