Programa de Salud 

October – December 2009

 

This quarter we took the first steps of a long journey – the training of a new group of health promoters.  As we prepare for the first course which begins January 25, I feel deeply satisfied with the process thus far.

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The setting

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The health promoters serve an 80 km region surrounding El Naranjo Frontera, a town in the northwest corner of Guatemala, near the Mexican border.  The paved road ends here in Naranjo.  To the north, across the San Pedro River, the land is nominally a protected jungle.  Yet for 15 years, landless subsistence farmers and wealthier cattle ranchers have been allowed to settle the region unimpeded.  The result is almost complete destruction of the rainforest.  Despite the absence of jungle, the political tension has been increasing recently, and there are frequent rumors of forced evacuations.

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Why is the heat being turned up now?  No one is really sure, but theories abound.  Is it to show that Guatemala is stepping up to the plate in the war on drugs?  Is it to capture some yes-we-are-doing-our-part-to-protect-the-rainforest international funding?  Is it because the region is soon to lose its protected status and the multinational companies who will take over want it cleared of people so they can go about their business (mining, hydroelectrics, African palm growing, etc)?  It’s easier, legal even, to remove people by force while the biosphere status is still intact.  Whatever the true reason, the tension is palpable. 

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Last year, the army took control of the ferry, so there is currently no way to cross the San Pedro River with a vehicle after 6 pm at night.  Among other problems created by this move, those living north of Naranjo are now effectively cut off from nighttime access to hospitals.  The current situation is causing the communities within the region to look for even more ways to take care of themselves, which is part of why there has been so much interest in a new health promoter training course.

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Recruitment

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The promoters and I sat down to strategize about how to find the best students to train.  We came up with a list of requirements, each trying to correct or avoid problems we’ve seen with other groups.  Basic literacy skills.  Desire to learn.  Respected by the community.  Willingness to serve voluntarily for a period of ten years.  We put all these in a letter to the mayor and town council of each community, with a copy to the leaders of the church.  We asked the community leaders to meet with their citizens and select their promoter.  And we asked for a response in writing, a letter documenting their support of the chosen individual.

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The response

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The communities rose to the task.

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Particularly in the region north of the river, the communities met and selected their representatives with great care and consideration.  The following letter is typical of the ones we received – carefully hand lettered, signed and sealed, it shows that six of the eight members of the town council are themselves illiterate.  We received 24 such letters.

 

Our job in 2010

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Now it’s our turn to prove that the effort that the communities put forth was worthwhile.  Besides simply preparing and providing the six week-long training courses, I see the following tasks:

• Assure sufficient practical experience for the new promoters in the clinic in Naranjo.

• Facilitate the new promoters’ identity as health providers within their communities by seeing patients with them during community visits.

• Help advanced promoters develop their teaching skills.

• Guide the second promotion of promoters into assuming roles as mentors for this, the third promotion of promoters, while continuing to help them improve their own clinical skills.

• Assist the new group in bonding as a class and feeling a part of the team that runs the Casa de Salud.

The work provides interesting challenges and, if done well, will increase dramatically the quantity and quality of primary health care in the region.  I sure hope we don’t let anyone down!

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Things we could use

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A cast cutting saw, a Doppler for measuring fetal heart rate, and mail of any variety.  The saw and the Doppler need to be in working order, but please don’t anyone go out and buy a new one for us.  I feel certain that someone, somewhere has old equipment available for us.  Ask around! 

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Thank you for your continued support of our work.

 

Wishing you blessings on your new year,

Kate

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Programa de Salud, El Naranjo Frontera

January - March 2010

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First Level Health Promoter Courses

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We started classes in January with a vibrant group of 32 campesinos, all eager to learn whatever they can to provide health care in their villages.  The group represented 20 different communities.  Many students arose at 2 am to travel in to Naranjo and be on time for class on Monday morning.  Since Naranjo itself is a 4 or 5 hour journey from hospital care, one can only imagine the health care vacuum in which the people usually live.  Our goal is to improve access to health services in these most remote regions of Peten.

My team and I feel that requesting letters of support from the village councils helped the students focus and take their task more seriously.  The effect was palpable.  We got right down to business.  During the first week-long course, the promoters studied how to differentiate between infectious and non-infectious diseases.  They began to learn how to take medical histories and learned our rubric of history à exam à diagnoses à treatment and why we won’t let them ask questions which step out of this pattern, like “What medicine is good for cough?”  They learned how and why to take vital signs.  We put these new lessons into practice and took the history of the baby in this photo whose mom was looking for care.  The class asked all the right questions, took vital signs, examined the baby, and diagnosed and treated a ruptured ear drum.  In the end, the mom was pleased with the care she had received and the promoters were delighted with the utility of their newly acquired skills.

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An important part of the first course is to begin to use the reference book Where There Is No Doctor.  Those of us who have been surrounded by books our entire lives take for granted the skills required to effectively use a reference book.  The promoters, half of whom never got past 3rd grade, have never used an index or a table of contents to look something up.  Most do not know how to alphabetize, so that’s where we start.  First, we have them put the alphabet in order, using large letters on the wall.  Then, they alphabetize themselves, reviewing names of new friends in the process.  Next, they work on alphabetizing words, and finally, they make their way through a worksheet designed to help them learn to use the book’s index.  Those who continue on in the courses will receive their own copy of Where There Is No Doctor, a book they treasure nearly as much as their bible.

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The second week-long course dealt with diseases affecting the gastrointestinal system.  We worked on anatomy and physical exam and the diagnosis and treatment of disorders such as diarrhea, dysentery, parasites, gastric reflux, ulcer, hepatitis, gall stones, hemorrhoids, and appendicitis.  Their homework is to treat three children for intestinal worms and record the result.  They also took home one treatment for dysentery and anyone who finds a case will treat and report back to the class.  It’s a bold move to dispense medicines to students this early in their training, but the conditions in which we live have convinced me that it’s the right thing to do.

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It would be impossible for me to do all this work myself.  Mario, who has been a promoter for 8 years and helped me train the last group 4 years ago, and Isabel and Victor, the two promoters who rose to the top of the last group, are running the classes with me.  We make a great team.

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Community Visits

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Visiting the promoters in their villages to provide health care side-by-side with them is critical to the success of this work.  In addition to giving them practical experience – which they also get by working shifts in the Naranjo clinic – these visits establish the new promoters as sources of health care in their communities.  Victor has taken these visits on with a passion and is doing a simply amazing job.  In this photo, he and Jose are beginning the trek to one of the outlying communities.  Jose is carrying the medicine suitcase. 

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I haven’t been able to do many community visits recently, even though I do enjoy them and I know in my heart how important they are.  Victor is not fazed by the lack of my accompaniment.  Rather, he told me he thinks it will be easier for the community to accept the new promoters after they’ve already received care from the Naranjo promoters – having a US trained doctor around would just confuse the matter!

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Administration and Clinic Work

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The clinic in Naranjo is open three days a week.  It is staffed with 3 or 4 trained promoters, and now there are two students present on most days, as well.  We see 30 to 50 patients a day.  After the patients have all been attended to, usually by 2 or 3 in the afternoon, we sit down as a team and have lunch.  Then, we all pitch in to clean the clinic and leave it ready for the next day. 

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My role in the clinic is that of a teacher, not a direct care provider.  The learning curve is steep right now for everyone.  The trained promoters are finding themselves in the role of coaches of the students.  This challenges everyone to think more critically and cleanly.  I see improvements in the quality of care being given. 

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Lately, I’ve been focusing attention on administrative systems, like the inventory and medicine ordering process.  Keeping in mind that none of the promoters knows how to use a computer and math is difficult for most, I’m trying to devise a system they can use so that they can keep themselves supplied with the medicines they need.  I’m also studying up on meeting facilitation so I can teach them some skills which will serve them when they no longer have outside help.

 

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Programa de Salud, El Naranjo Frontera

April – June  2010

 

Isabel came to me at the beginning of what looked to be a busy clinic.  “I think she has meningitis,” she said.  I stepped away from my patient, a 5-year-old with severe pneumonia, to take a look.  Rigid neck, incessant cry, fever, refusal to nurse – Isabel was right.  Together, we found and read the handout “The Very Sick Child,” which Julie and Susan had prepared for a course several years ago.  We discussed which antibiotic to use and in what dose, and Isabel did the rest.  Her follow-up was impeccable, and the baby recovered quickly with daily intramuscular antibiotics. 

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I’ve known Isabel for almost 5 years.  She started as my student and later became my friend.  Since we took on the project of training a new group of promoters, she has become my valued coworker.   

 

The Respiratory System

 

The course we gave this quarter is an ambitious one.  We cover anatomy, physiology, and pathology of the respiratory system, including how to diagnose and treat colds, bronchitis, pneumonia, asthma, sinusitis, strep throat, outer and middle ear infections, whooping cough, tuberculosis, and allergies.  We teach what antibiotics are, how they work, how to pick the appropriate antibiotic, how to administer antibiotics orally and via injection, and how to identify and treat anaphylactic shock.  Students learn how to clean wax out of ears and extract foreign objects from noses.  (They practice the former on each other.)  This course marks the first half year of study.  Anyone who has continued to this point receives the equipment necessary to do physical exams -- a stethoscope, otoscope, and thermometer – and their own copy of Where There Is No Doctor and Medicinas Esenciales.

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Despite the full schedule, the teaching team and I decided it was a valuable use of time to spend the first hour of class having the new promoters share their experiences with each other.  They started out with a good-natured competition about who had been most successful at deparasitizing children in their communities.  The “winner” had counted 35 worms  -- the large, round Ascaris worms – from one child following administration of the medicine that they took home after the last course.  Two promoters had successfully treated dysentery with the antibiotic we provided.  One promoter had inappropriately given the antibiotic, mistakenly thinking that it was another worm treatment.  Then followed a terrifically meaty discussion which touched on a myriad of issues important to promoters – what do when someone asks you to do something you have learned is wrong (inject vitamins, for example), how to respond to criticism from the community, what to do when someone refuses to pay, and on and on.

 

Community Visits

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The visits continue with no help from me except the occasional phone consult.  To date, the advanced promoters have visited 17 communities, providing badly needed health care and supporting the new promoter.  My counsel to Victor and the rest has been to maintain a pace that will continue to get the job done without burning them out, since there is no one to replace them.

 

“Well, ya gotta start sometime.”

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I can still hear the voice of my attending pediatrician as he pushed me into a room to see a patient on my own for the first time.  It was 1993 and I had had 6 years of university education to prepare me for that moment.  Now, I find myself in the role of the attending physician.  The difference is that my students have had 3 weeks of training.  It’s tremendously rewarding these days in the clinic to push student after student into a room with a patient and have them discover that they, too, have many of the skills they need to see patients.  They interview the patients, take vital signs, do a physical exam, and then emerge, as I did so many years ago, to consult with a more advanced provider.  Together, we decide upon the diagnosis and treatment plan.  Empowered, the student promoter counts out whatever medicine the patient needs and re-enters the room to dispense the medicines and educate the patient about his disease.  My heart swells every time a new promoter blossoms.

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Medicines

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This quarter I spent many hours updating the price list, a task which had not been done thoroughly since 2003.  A few prices rose, but just as many dropped, reflecting the true cost of generic medicines on the world market.  For example, the cost of three 500 mg Azithromycin tablets (marketed as a “Z-pack” in the US) is $0.30.  Six tablets of Trimethoprim-Sulfamethoxazole (“Bactrim” in the US) to treat a urinary tract infection cost $0.17.  These are prices which the majority of our patients can and do pay.  We maintain an “Emergency Fund” to subsidize medicines for those who have greater need.  Prices in the local pharmacies – and of course in the US – are substantially higher.

 

I also spent time this quarter revamping our inventory and medicine ordering system.  I devised a new form which, I hope, will make it easier for promoters to carry out this critical task.  José, a poised father of seven with three years of formal schooling, is stepping forward as the one to take responsibility for ordering medicines.  In July, he will take an inventory and place a medicine order which will carry us into 2011.  The medicines are likely to cost over $10,000, an enormous sum to these health workers who, when they are not attending to patients, till their fields as subsistence farmers.

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Christine’s visit

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My good friend and project supporter Christine Smith, OD visited us this quarter and took us out of the Peten heat.  We traveled up to the highlands to provide eye exams and reading glasses for a cooperative of weavers with long-standing ties to Concern America.   

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Programa de Salud, El Naranjo Frontera

July - September 2010

 

The highlights of this quarter for me were the courses.  In contrast to the first three courses, which have been designed and perfected by Susan over the years, these we had to develop on our own.  The first, The Urinary Tract and Prenatal Care, was put together from material typically taught in the second year of training.  The second, Essential Medicines, is a course that’s been given for years, but the outline was washed away in the Las Cruces flood two years ago, so we had to reinvent the wheel.

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The Urinary Tract and Prenatal Care, Course #4

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The most important skill we taught during this course was how to read the 10 different tests on the urine dip stick.  As always, we make the teaching as hands-on as possible.  Solutions of salt water show the color changes that the dip sticks make with increased urinary concentration.  Egg white mimics protein in the urine.  Coca Cola shows, you guessed it, sugar.  Mashed up hot dogs release nitrites, the same substance found in some bacterial infections.  It delights me when I hear rural Guatemalan farmers appropriately using terms like leukocytes and ketones.  At the end of this course, we gave each of them 3 dip sticks and 10 Bactrim pills.  Their job was to do the right thing and tell us about it during course #5.

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There’s nothing like practice to solidify new skills.  After studying theory during the week, we devoted Thursday of the course to prenatal care.  In teams of three, each promoter only attended to one or two patients, but they raved about the utility of the experience.  I devised a new Prenatal Care form to replace the one made for illiterate midwives, which we had all been using for more than a decade.  The new form is designed for literate promoters and addresses issues such as gestational diabetes and HIV.  All the promoter has to do is read the line that says, “If a woman with HIV or AIDS takes medicines during her pregnancy, she can keep her baby from getting infected.  Would you like an HIV test?” Afterwards, the new promoters said that they had been nervous to broach the subject, but that the women didn’t seem to mind.  Of the 15 patients seen, four opted for testing.  One was positive.

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Periodically we hear that our county of La Libertad has the highest HIV rate in the state.  I am convinced that this is what epidemiologists call a testing bias – Concern-trained promoters throughout the county have been courageously testing for HIV for over 10 years.  If someone dies from AIDS in this region, the chances are that they knew their diagnosis.  In other regions, deaths are still chalked up to witchcraft.

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Essential Medicines, Course #5

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Essential medicines are those deemed by the World Health Organization to be safe, economical, and effective.  They are the only medicines we use. 

This course is full of eye-openers for the students, and it’s a lot of fun for us.  My favorite part is teaching the difference between brand names and generic names for medicines.  We teach the concept, and then we send them all out on a treasure hunt to buy a sample of many different brand name medicines.  They are blown away when they reconvene to read the fine print and find out that there are 12 different ways to buy acetaminophen.  One by one they are filled with righteous indignation as they begin to see how the profit-driven pharmaceutical industry has manipulated them with marketing.

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With games, puzzles, and activities, we teach the concepts of expiration dates, placebos, secondary effects, and drug interactions.  We used baggies of M&Ms to learn about adherence to prescribed medication – what happens if you give a patient one medicine every 8 hours and another every 6 hours?  The group brainstormed a great list on ways to improve patient adherence. 

We developed a series of exercises to emphasize the importance of label reading – similar bottles with different medicines, the same medicine in different bottles, and different doses of the same medicine.

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We worked on math a little bit each day, and it was a challenge for everyone.  How many kilograms per pound?  How many milligrams per kilogram?  How many milligrams per milliliter?  How many milliliters per dose?  How many doses per bottle?  And finally, how much should we charge the patient? 

Wednesday, I set aside an hour for the students to share what they had done with the urine dip sticks and the medicine we had given them during the last course.  They told story after heartwarming story of health care given locally, and they refused to stop until everyone had had a turn.  It took two hours. 

My favorite story was from Marleny, one of the top promoters in the group.  She went to visit her neighbor and noticed the two-year-old crying on the bed.  Marleny asked what was wrong, and the mother replied that the girl had been complaining that it hurt to pee since the day before.  Marleny explained her new tests and went back to her house to get them.  Sure enough, the child had a urinary tract infection.  Marleny used her trimethoprim-sulfa to treat the girl.

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“But Marleny,” I protested, “those pills are for grown-ups.  How did you know how much medicine to give her?” 

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“I looked in the book,” Marleny replied with confidence.  “I gave her a quarter of a tablet twice a day for three days.  One and a half tablets.”  The girl was better by the next day. 

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Thursday afternoon we set up the “Museum of Horrors”, with example after example of tricky, inappropriate or downright dangerous medicines sold over the counter in local pharmacies.  Guatemalan consumers have to be smarter than Americans – the government isn’t protecting them.

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Once the students have passed this course, they are eligible to receive their pharmacies and begin seeing patients on their own.  They are itching to apply their newly acquired knowledge to help their neighbors. The next round of community visits will include meetings with community members to report on the promoter’s progress and officially present the pharmacy.

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Striving for improvement

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Inventory – One huge difference between our work and that of the ministry of health is that we maintain a very consistent inventory of the medicines we use.  Patients with infections get antibiotics right away and those with chronic diseases don’t interrupt their treatments.  In July, Jose directed the vast majority of the work to count what we’ve got and order what we need to get us through another year.  Jeanette orders many of these medicines from Europe, so now we start the waiting game and hope we don’t run out of anything before the delays in ordering and shipping the medicines have been resolved. 

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Jose does all this work with a calculator, a pencil, and a razor-sharp mind.  The barriers to using a computer for the task feel insurmountable to both of us, so we’re sticking to paper for now.  This quarter I taught him how to draw a star, as in, “Put a star by that medicine because we’re about to run out of it.” Sometimes even I get surprised by what they don’t know.

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Clinic Responsibilities – The team got together and made a list of the once-in-a-while jobs in the clinic, and everyone picked one.  It might not sound like much, but it’s a relief to know who to turn to when the faucet leaks (Rudy), when the glasses need re-stocking (Eugenia), when the incinerator needs to be scooped out (Maximino), and when the bathroom door comes off its hinges -- again (Alejandro). 

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Raising the floor – Once the rains started, the men’s dorm flooded.  The guys put up with it with humbling tolerance, but they did comment in the course evaluation at the end of the week that it was awkward to have to put on rubber boots before getting out of bed in the morning.  The group decided that the solution was to backfill with four dump trucks full of gravel, lay a new concrete floor, and raise all the windows and doors by 10 inches.  What floored me, so to speak, was that among the group they had the skills to do this.  Health care providers in the States aren’t usually quite so versatile!

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Easy Target

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This was a bad quarter for theft.  I was pick pocketed once in Guatemala City and robbed 4 times at home by someone who figured out which days we are gone in the clinic all day.  Thankfully, this thief has only been interested in music and telephones, not computers or passports.  I finally broke down and am paying a young woman to be here when I’m not.  Her $100 a month salary takes a big chunk out of my stipend, but it seems necessary.  On the plus side, she does the dishes while I’m at work.

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Kate Feibusch

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Programa de Salud, El Naranjo Frontera'

October - December 2010

 

2010 ended with a bang – not just the fireworks traditionally used to celebrate Christmas and New Year’s, but also the culmination of the year’s work training 27 new promoters.

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Pharmacy kits delivered to the communities

 

After 6 week-long training courses, 8 practice days in the clinic, and a couple of community visits, the new promoters have earned their pharmacies.  This quarter we went out to meet with the communities and present the kits.

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It rocks our top-down, first-world medical paradigm, but these new promoters, farmers with minimal schooling, can and have treated patients with pneumonia, asthma, malaria, urinary tract infections, fungal infections, impetigo, cellulitis, intestinal worms, dysentery, gastric ulcers and more.  They take their job seriously and provide competent, conscientious medical care in areas where there has been none.

 

This year, the visits have been done almost exclusively by the advanced promoters.  It’s worked out well.  If I’m nowhere to be seen, then the debate about whether or not “la doctora” will attend to a particular patient just never comes up.  This facilitates community acceptance of the promoters.  One night, though, they called to ask me to go on the next day’s visit.  It wasn’t that they needed my medical expertise – they needed someone to drive the truck.  Of course, I agreed.  But I wasn’t much help when we got a flat tire.

Driving out to this moderately-distant community for the day helped me better appreciate the barriers to care for the people who live there.  When someone from La Bomba arrives at our clinic in Naranjo, they’ve gotten up at 3 am to catch the bus, spent 2 day’s wages, and lost a day of work to get there. 

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Nutrition Course and Graduation

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The final course of the first year is the nutrition course.  We explain the concept of a calorie and investigate how many calories 100 grams of a variety of foods have.  The range is 23 to 900 calories, depending on the food.  Once we have this scale to refer to, we discuss strategies for managing the two extremes of nutritional disorders which we see commonly – malnutrition in toddlers and over-nutrition in adults.  Recognizing the community’s need, we pulled diabetes from the second year curriculum and dealt with it thoroughly during this course.  Other important topics were breast feeding and vitamins.

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A solid year’s work came to a close with the graduation party, complete with speeches, diplomas, t-shirts, and dancing.  Family members traveled large distances to share in the festivities and we all felt proud of what we have accomplished.

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The Season of Light

 

This holiday season we celebrated solstice with the lunar eclipse, Christmas with traditional posadas and fireworks, and all eight days of Hanukah.  Welcoming light into the time of darkness transcends culture and religion.

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Blessings from our family to yours.

Kate 

El Naranjo Frontera, La Libertad, Peten

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The Story of Magdalena

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Magdalena, a midwife/promotora with decades of experience, called me at 5 pm about a girl who had come to her house to deliver her baby.  The baby was fine, the placenta had come out with no problem, but the 16-year-old, now mother of two, would not stop bleeding. 

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As much as her difficulty writing drives me nuts in the clinic, Magdalena’s clinical sense is solid.  How many times have I looked at a consult card that Magdalena is working on to tell her that such-and-such a question is important, only to find that her history was impeccably complete.  What she lacks is a fluent ability to document information.  In her home, where she attends the majority of her patients, literacy is not so much of an issue.

“Do you want me to come?” I asked.

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 “Por favor,” came the answer. 

 

This is a first for us, so I hustled.

 

I zipped back to the clinic and grabbed what I thought I would need – gloves, gauze, ergotrate to stop the bleeding, a syringe, IV solution and tubing.  Again I wished I had learned how to place IVs.  When it doesn’t matter, I feel bad about poking folks to practice.  When it matters – tonight? – I don’t have the skills I need.

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I got to Magdalena’s house, not much more than a hut in the farthest corner of Naranjo.  The floor is made of dirt.  The room has space for three cots and a table.  The table is stacked with Magdalena’s medical supplies.  Thanks to a generous donation by the late Harvey Toub, a solar-powered fluorescent bulb illuminates the room.  Sacks of cast-off clothing are in the corner.  Magdalena buys them from the Goodwill-equivalent and uses them to absorb the blood from the births she receives.  Then she burns them, along with the sterile gloves and gauze she gets from the clinic. 

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The girl lying in the bed was pasty pale.  A beautiful baby was lying next to her, wrapped in an XXL polo shirt.  The new mother’s heart rate was 120.  She didn’t want to move, trying to avoid provoking another gush of blood.  I donned gloves and evacuated a half liter of clots from her vagina.  Thinking we were out of the woods, I started talking to her about family planning.  The way she cast her eyes downward and didn’t answer sent a message to Magdalena, who translated for me.  It was about the girl’s husband… either he wouldn’t let her, or he didn’t give her the money.  Worst case, he beat her.  We still don’t know.

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Shortly thereafter, the husband showed up.  He was a scruffy guy in his mid twenties, swinging the key to a motorcycle in his hand.  I handed his new daughter to him and began my spiel about family planning.  Two babies in 15 months and a life-threatening bleed – her womb needed a rest.  Mid-spiel, I checked the patient again and realized she was still bleeding briskly.  My message to the husband changed:  Go find a car.  Your wife needs to go to the hospital.  Where we are, four hours from the hospital, that decision has to be made early.  I hoped it was not too late.

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Uterine massage, clot evacuation, ergotamine injection, change the rag, check the placenta to make sure it all came out in one piece, check blood pressure (not too bad, 110/80, but as Susan says, it’s the last to crash), change the rag, call Jeanette and Susan for advice, send Magdalena’s husband through the now-dark town by bicycle to buy pitocin from the pharmacy,  call Sergio to get the number for the nurse in town, try to start an IV, fail, try again, fail again.  The pile of medical waste and bloodied rags grew on the dirt floor beside the cot.  Call the nurse, give oral rehydration, change the rag, inject pitocin, elevate the hips with a pair of men’s size 18 pants, call the prayer circle at Magdalena’s church, change the rag, nurse arrives and starts the IV, give a medicinal plant to stop bleeding, change the rag, change the rag, change the rag.

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At some point I realized the guy wasn’t going to come back with the car.

Tears of frustration fill my eyes as I write this, and yet I don’t want this story to be all about him.  Magdalena and I were battling to save the life of this young mother, and there was no one else pulling.  Relegated to this distant corner of Naranjo, in the most remote region of Peten, in the furthest extreme of Guatemala, I felt an unaccustomed powerlessness, perhaps the powerlessness that is such a part of this girl’s life that she can’t imagine anything different. 

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And at the same time, I saw, felt, breathed Magdalena’s strength.  Profoundly poor in the economic sense, Magdalena has a richness of spirit that awes me.  Perhaps she knows from experience the life lived by this child.  Her midwife training began when she attended her own births, alone, all 10 of them.  The first 5 survived; the last 5 were born breech and suffocated during birth.  Her husband, though he’s mellowed with age, was previously domineering and abusive.  Magdalena attended to this patient as I imagine she attends to them all, with kindness, gentleness, and not a trace of bitterness or anger. She pulls money from her pocket to pay for medicines, rags, and food, seemingly without a thought to reimbursement.  Her inner light radiates brightly and I am honored to bask in its glow.

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The guy came back two days later to pick up his wife and daughter.  Later that week, the team celebrated Magdalena’s 60th birthday.