A social-worker's job
never ends

My time on the Galapagos has come to an end...

Nancy the nurse struggles to heal her computer



self-portrait

 
It was a great time for learning, and hopefully for helping.



the happy worm train
needs some love



My last weekend on the islands involved a trip to San Cristobol...


cats nappin




happy volunteers on San Cristobol




hungry sea lion,
tired mom

 And swimming with sea-lions, possibly the nature highlight of my experiences!



Aren't these flippers cool?!





Tijeritas - where sea lions play

Adios, Galapagos!  

…waiting for the boat to take me to San Cristobol, where the sea-lions apparently outnumber the humans.  These playful, inquisitive and extremely relaxed mammals may just be my favorites in the Galapagos.  I’ve had two close but brief encounters with them, once diving and once snorkeling, and I’m hoping to for another chance.  But I don’t want to get too close to any territorial males! 

Speaking of which, I have to talk about Tortuga bay again.  I just got out there once this week, lamentably, but it was a beautiful day, and although we had a record crowd in my experience (about 20 surfistas and body-boarders) everybody in the lineup was happy to share the waves, or wait for the next one.  This courtesy is unusual in my experience, and very pleasant.  As a body-surfer (no board, often no fins) I always try to get out of everybody’s way, but it’s nice when people are also trying to watch out for you. 

Of course, it doesn’t hurt when you’re their doctor; one of the surfers in the lineup paddled over to say hello and let me know that the stitches I had put in his head a few weeks earlier had helped him heal up nicely. 

Work was a little slow this week; I’m mostly training the nurse in the clinic, Nancy, on how to use the patient tracking chart we’ve developed in Excel.  I’m also learning a lot about pirated software and viruses!  We’ve had several new patients who have come in to check their blood sugar for the first time in months.  Not surprisingly, their levels were well above the normal range.  I’m hoping that Galapagos ICE and Municipal clinic can continue to help all of these patients and manage their illnesses effectively.  The management plan (an 8 page rough draft of my Independent Scholarly Project which must be submitted for graduation) is what we’ve been using and I’m just trying to help make sure that it’s a practical tool for the clinic.   Vamos a ver (we’ll see!).

With a majority of the volunteers on Isabela island this past week, I’ve been teaching exercise and nutrition classes in the evenings.  The first exercise class on Tuesday was a little bit like the Golden Girls meets reality t.v. , but it was a lot of fun. 

 


an apartment with great ambiance



nice place to relax



Ecuavolley = awe-inspiring




?



Well, it's not Valdez

Otherwise, I’m just thinking about what I am going to do with my bike and my guitar and how much peanut butter I will need to get me through until I leave next week.  I miss Carolyn, I miss my friends, I miss being able to drink the tap water and taking internet access for granted.  It seems like a long time since I arrived here.  I’m sitting at the same restaurant where I came when I first landed, and thinking about how my ideas of this place, about medicine and business, and about us humans have been formed, challenged, changed, and shaped again in these past weeks.  It’s been a terrific experience.

Money Talks

Ah, what a refreshing morning.  Well, not really, considering the sun was blazing at 8am and the humidity is approaching 100%, but it was nice to get a little work done around the apartment, tidying up.  I managed to get my beard clipper working (a couple sharp whacks and a little olive oil for the rust) and trimmed this mangy thing hanging off my chin.  The better to not look the part of a conquistador.

Took out the recyclables (they turn the glass into paving bricks for the roads, which is pretty cool), oiled my chain on the bike (again, olive oil), and then headed out on the eternal search for internet connectivity. 

Carolyn and I have had an amazingly difficult time to connect.  We’ve tried Skype (the best), gmail chat, cell phones, and I’ve even tried shouting across the oceans a few times but to little effect, although I did feel better.  The frustrating part is getting charged for really poor connections. 

But that’s just how it goes when you’re traveling. 

My real challenge, as previously complained about, is trying to provide for continuity of care for the patients I have seen in the clinic, to whom I was promising “we will be here in the long-term”.  A few weeks ago, I changed tack and began encouraging patients to take our recommendations to local doctors and establish long-term care with them.  Although that didn’t feel very good, especially considering that our clinic and the emergency room are the only places on the island to receive care gratis. 

Now, with our new agreement with the municipal clinic and the enthusiastic team there, I am again telling patients that we will be there for them.  Nancy, the nurse, Jessica, the new general doctor, and Sandra, the gynecologist have been very accommodating to our presence and receptive to our management plan.  With some simple suggestions, I think the medicine will take care of itself.  What I worry about is the will to provide patients with encouragement and support.  It can be a daunting job.  Patients don’t follow instructions (mostly because they didn’t understand, and often because they can’t read).  They don’t follow-up.  They can’t afford medications but are too embarrassed to admit it.  They shop around for different doctors and confuse advice and medications.  None of the patients that I have seen have much confidence in the local doctors, and unfortunately, the feeling is mutual.     

The health professions were built on a foundation of dedication to service, but today many healthcare professionals are more concerned about earning money.  Which is legitimate, I mean, who isn’t?  That suffering home-schooled hermit thing worked for Yoda, but I'm guessing his dental plan didn't cover whitening and obviously there was no decent parking in his neighborhood. 

Healthcare providers should not have daily worries about their income or their crippling debt.  And they shouldn't be able to make millions of dollars annually, either.  Let's keep those business tycoons out of medical schools!  Healthcare providers should be able to focus on patients’ problems.  And society, patients and all those potential patients out there should provide a reasonable measure of financial and job security in exchange for expecting selfless, uncompromised service.  



Las Cascadas
My Barrio's namesake
and the first time I've seen it wet thanks
to all the recent rains



Of course, the same should apply to elected officials, public service employees, and heaven forbid, teachers.  But we get what we demand.  In a society obsessed with material wealth, how can we expect altruism to spontaneously appear?   I have had the privilege to be present with many people facing the last days of their lives, and those experiences have provided a new perspective on things.  I’ve never seen a commercial on T.V. selling what these people talk about.  Family, friends, lost love, love found anew, companionship, relationships.  Unfortunately, many of us realize too late the importance of these forces in our lives.  Money may talk, but it has an extremely limited vocabulary.     

Time Flies

A Big week for me (read: lots of meetings, and not much work getting done!) First with my boss, then with the municipal government that runs our clinic, and finally with the Galapaguenan doctors and nurse that really run our clinic!  The end result: we finally got a mandate to transfer care of our patients to the clinic, but now we have a relatively short period to affect training.  As they say frequently here in the islands, “vamos a ver” (we’ll see).  It’s second only to “manana” in popularity. 

Thursday was cool because we officially gave the bulk of the donations I brought down (thanks again to Steve Kemler and Conversion Partners, LLC!) to the municipal government.  The mayor was there and  was very excited about the condoms, joking on camera that he hoped they would be small enough to fit, then named my boss’s husband as one of the men he was worried about!  She stuttered back that she was trying to get pregnant and didn’t need them no matter what size they were.  Then the mayor began grabbing handfuls of condoms and giving them out to all in attendance.  Well, I’ll take public health in any form possible!

Otherwise, things been rainy and wet.  I’ve gotten out to Tortuga bay several afternoons (my salvation) and have been making the most of the tasty and cheap local fish and beer.  And, in a bonus edition of construction techniques here in Whoville, I’ve included a few favorite  ‘Home Improvement’ photos.  Enjoy.



Yes, my apartment has a pool
(but there’s no lifeguard!)





I’m not sure, but this could be

a rarely witnessed rooftop mating ritual




This is my gas supply… right over the kitchen



I couldn’t think of a better location
for a random 4” plastic elbow fitting
than right there at the bottom of the stairs.



This is what is sitting on my roof




Just imagine your own captions for these next ones…

This is a gem; roof drain pouring on electrical wires…

                                                                   And then splashing in the middle of the road

More beauty from Tortuga Bay



Not sure what the windmill is for;

there is hardly ever a breeze here!




Holy Week



This is going to be a rant

Some things here are just little annoyances; homesickness it’s sometimes called.  A scarcity of fresh vegetables.  Mosquitoes that bite through your socks and shirt and ants surrounding the honey jar like Aztecs at a virginal sacrifice.  Too much traffic for this little port town; I can’t ride my bike anywhere in peace.  Screens with giant holes.  Poor internet connectivity and not being able to talk to my baby a million miles away.  Heavy rains for most of the past 10 days and wet floors & walls, lakes in the roads and mud everywhere.  I better get used to the wetness; hopefully in Seattle we can find a house that doesn’t leak!

Another Saturday market clinic

But that’s not the rant.  What’s really frustrating these days is the fact that I only have 3 weeks left here in paradise and I don’t feel that our clinic is ready to continue to provide consistent, long-term care to our diabetic and hypertensive patients.  The politics and the economics are metaphorically killing me, and quite literally killing our patients.  

Egos.  Avarice.  Conflicts of interest.  (here comes the rant).  I don’t necessarily believe that healthcare is a right, like freedom or air, because unlike those examples, healthcare costs money.  In Ecuador, unfortunately, the single most important determinate of the quality and amount of healthcare one receives is how much one can pay.  This policy has deletrious effects on the overall health of the nation and its people.   I do believe that people have a right to receive healthcare if a given society can afford it.  And basic, preventative medicine is within the budget of most countries, certainly including Ecuador.  Sadly, patients often have little or no protection from the inevitable conflict between health and profit in a system that rewards physicians, drug companies, hospitals, therapists, etc., only when patients are sick and procedures are being performed, instead of rewarding them for keeping patients healthy and keeping overall costs down.  If your physician is also a salesman, beware!  It’s not healthcare, it’s healthanomics!

Think about it; how much is that cancer worth, or your old, overused gallbladder?  And a failing heart?  Or, best of all, your poor body image and precarious self-confidence (implants, liposuction, lifts & tucks, teeth whitening, etc)?  In the U.S. and in Ecuador, all these ailments are worth a hell of a lot more than keeping you healthy with a prescription of oatmeal and 2 miles of roadwork a day.     



Warning: This product is contra-indicated in

Glaucoma and in sane, healthy lifestyles.   



Speaking of roadwork, I just got back from a little jog out to my favorite beach in the world, Tortuga Bay, and possibly the most irreverently blissful bodysurfing I have ever experienced.  Then I stalked a little reef-shark in the shallows as the sun fell through the evening.  And now a full moon is rising over a breezy tropical night.  Aaaahh, Galapagos.  If only…

temporary gringo

A new doctor is in town, a surgeon from Korea, and after our usual hectic clinic at the Market on Saturday morning, we were asked to take a look at a man who had received 40 stitches in the face after a drunken brawl with a broken bottle.  Apparently the swelling had subsided but his wound was leaking fluid that looked like saliva.  Perhaps the duct from his parotid (salivary) gland to his mouth had been cut.  First the wife took us to the recycling center where the patient was working.  Then we all piled in the taxi truck (me in back) and went back down to the hospital where he could be examined properly.  Kim (the surgeon) removed a few stitches and put in a penrose drain to help relieve the pressure and confirmed what the local doctors had already told the patient; that he had to get to the continent for a specialist to repair the damage. 

For the coming weeks, I will be working with Kim to help translate and hopefully to learn a little medicine (I have been largely unsupervised during my time here, something that has left me feeling unsettled).  My major goal in the few weeks that remain is to develop a plan for our  diabetic/hypertensive clinic to continue identifying uncontrolled/poorly controlled cases and providing care.  To that end, I may have to skip the planned medical brigade trip to the island of Isabela.  Thankfully, however, I’ve already visited and so it won’t be a complete loss!  This way I’ll get an extra week of clinic to coordinate continuity of care with the local healthcare providers. 

Last Thursday night, I was interviewed by the local T.V. station for world health day, to speak about how local people could help to improve their health.  It was a little rough, but I think I got the message across that the most important thing is education and trying to change our habits little by little, to gradually arrive at a more healthy lifestyle.  I also tried to stress the importance of taking care of ourselves so we could take care of our families and teach the little ones good, healthy habits while they are young.  Of course, this all takes time, patience, and consistency to implement, and a brief volunteer position can only hope to build on resources and attitudes already in place.  One thing that has been easy to identify here is the tremendous need for medical skills and public health resources.  

Speaking of the enchanting neighbor island of Isabela, a few of us went over for a quick weekend trip and had a great experience.  We camped at a beautiful little property called Campo Duro in the highlands, with dinner and breakfast provided (from chicken and fruit raised right on the property), and then had an enjoyable (and wet!) tour of the cauldron and the various cinder cones from the recent (the latest within 3 years) lava flows.  Later in the day we had another poor visibility snorkel session, but, we did see turtles, sharks, penguins, sea lions, rays, flamingoes, and marine iguanas.  Our last morning was spent lounging in the hammocks at Campo Duro and later at the beautiful beaches in the main Puerto while we waited for our afternoon boat back to Santa Cruz.  



a close-knit family




Sea-Lion Territory



Sea-Lions know how to relax



...and play



Volcano pix

In a shocking development, we realized we had been booked for a return on the Albany, which had been out of action since last week when she and her crew single-handedly ruined our trip to Floreana after their engine broke down.  Our only other option seemed to be waiting in port until the next morning.  So reluctantly we climbed onboard, stowing our gear within easy reach in case we had to ditch the boat. 

On the way out of the harbor, the captain was zig-zagging around coral banks like a fish fleeing a predator.  I asked him why they hadn’t marked the channel, and he said, “This is a short-cut, I can save 25 minutes this way.”  Two minutes after those words, as we passed the last and gnarliest-looking reef, the boat scraped bottom with a sickening sound (one I know well after my years of trial and error sailing!).  After a concerned silence, the captain fired up the engines, then declared, “Todo bien.” 

And miraculously, everything did work out.  Of course, the boat on which we thought we had been booked passed us mid-channel and was well out of sight (and safely home) an hour before us, but at least we made it.  Well, sort of… when the engines quit outside the harbor just like they had on the previous trip, they restarted without too much trouble and we limped into port.  Part of the reason I am bailing on the planned trip to Isabela is that I don’t want to end up on that damn boat again! 

The rains have been heavy here, and my new apartment has flooded as water comes through the windows and from the unfinished floor above, leaking into the walls.  I caught my neighbor outside and asked her if her apartment was flooding, too.  “Yes,” she replied, with the kind of sarcastic incredulousness that made adding “duh, it’s raining” unnecessary.  Since this incident, I’ve been polling volunteers and locals alike, and it seems like approximately 50% of households do leak when it’s raining.  Other than the foreign volunteers, nobody seems too disturbed about stepping into a lake covering the kitchen or bedroom.  Thankfully, my traveler’s instincts told me to keep my stuff off the floor, and nothing got wet other than furniture. 

Anothering interesting philosophical exchange occurred tonight at the local track, where I was trying to get a little work-out in as the sun set on our exercise group.  Running past a man with a large mongrel off his leash, I was not too surprised when the dog started barking at me and coming toward me aggressively.  Public safety is not high on the priority list for Galapaguenos.

As the dog came closer, growling with teeth bared, I placed a kick just across the hairs on his head that backed him off rather nicely, although I was a little disappointed that I hadn't made contact.  Completely stopped on the track now, facing the owner, I was expecting a bit of remorse from the owner and a perhaps a reprimand for the dog.  Instead, it was I who the owner accosted, "Don't kick my dog!" he fairly shouted at me.  My poor Spanish language skills usually deprive me of a quick comeback, and so I stood there, slack-jawed and awed by the double-barreled attack.  "If you hadn't tried to kick him he wouldn't have tried to bite you" he continued.

"This is a public place!" I finally managed, "that dog tried to bite me!".

"If you hadn't tried to defend yourself he wouldn't have attacked" the man repeated the same perverse logic.  I wanted to explain that this was not an issue of the chicken versus the egg; the sequence was 1) his dog attacked me; 2) I kicked at him to defend myself.  Further, I would have liked to briefly elucidate my belief that his dog should be under control in a public place, that I should be able to run past him without the slightest concern that he might bite me, and finally, I really hoped to explain my urge to kick his *#&%!ing dog the very next chance I got. 

I wanted to say all that, and, given enough time, I might have been able to approximate those sentiments in my gringo Spanish, but before I could even start the dog charged me again.  "Look!" I shouted at the owner, as I moved toward the dog with a rush of adrenaline.  Some protective instinct kicked in and the dog backed off.  "This a public place, that dog is dangerous!" I shouted at the man.  People were stopped on the track, watching.  The man was still shouting at me and not the dog, although he did collar the mutt and put his leash on him.  "you're crazy" I said, and trotted away. 

If a person is attacked by a dog and doesn't defend himself, does he still end up with a gaping wound and a nasty infection?  More in the next installment... 

 

Man, where did the week go?

A relaxing ambiance

Last weekend was a couple of adventures.  First was another dive trip with Scuba Iguana, this time to Seymour and the notorious Gordon Rocks, infamous for its ripping current.  I was teamed up with a German woman who had come equipped; dive-knife, computer, under-water camera, not to mention the basics such as wetsuit and inflatable vest.  I, on the other hand, had splurged on a $35 mask, snorkel and fin set, borrowed a 7mm wetsuit (way too hot for these waters), and had no booties or gloves.  I was just thankful that the regulator they gave me didn’t leak and that the depth gauge worked this time!  Despite all her gear and her impressive number of dives (117, I believe she said) she seemed a little nervous, as if just last night she had watched the director’s cut of  “Das Boot”.

Anyway, breathing underwater is such a strange and terrific experience, it’s probably as close as I’ll ever get to being an astronaut on another planet, and it’s very exciting and fun to explore every nook and cranny and be the first to spot things.  At Seymour, the visibility was pretty good at 7 meters or so, and we saw reef sharks, turtles, and lots of other fish.  With so much to see (and hoping to see something really cool like a whale-shark or playful sea-lions) I was ranging out from our little pack of divers (and my dive buddy), but managed to keep them in sight. 

Of course, it helped that our divemaster was tingling his little noisemaker (when he wasn’t dragging it across the coral, along with his spare regulator and his fins) every 7 seconds, sometimes pointing out cool fish, and sometimes (and I’m speculating here) just to be annoying.  Maybe he had just watched “Open Water” and was also a little nervous. 

Anyway, on one of my sorties, I spotted a large manta-ray hidden in the sands between coral castles.  My pack was huddled together 5 meters distant, facing away.  Too bad I didn’t have a little tingling noisemaker.  Finally my dive-buddy looked around and I caught her attention.  “Manta Ray!” I signaled.  “We are buddies!  Get over here!” she signaled back, slamming her fists together with index fingers extended.  My manta sign dissolved into underwater thumb-twiddling, and I said goodbye to my sandy friend and schlepped over to join the pack staring out into the murky blue, waiting for something to appear. 

For the rest of the dive, I stayed close, just a little above and behind my dive buddy.  This is essentially a diver’s blind spot, and yes, I was now the one being annoying.  Whenever she started to cast about nervously, I would slide down and away on either side and come into her view a couple meters away, flash a concerned “Are you okay?” sign, and then  quietly fade away again behind her and out of her sight.  I must admit, watching nervous humans underwater can be as much fun as watching the other reef-life!

To Hildegarde’s credit, she did apologize for “shouting” at me after we got back on the boat, explaining that in her work she is constantly herding students who have wandered off.  And I believe her.   

The following day, in a coup d’etat of vacationing freedom, I joined several of my volunteer companions on a trip to the neighboring island of Floreana.  Half-way across the straight, we lost an engine.  Apparently there was something wrong with the propeller.  We were now at half-power and probably worse than half-speed.  Our under 2 hour crossing became closer to 4 hours, and during the entire debacle, the crew gave not one word of explanation.  Whatever, the day was perfect, cloudy and not too hot, and I was perched on the front of the boat, watching the ocean’s ever-changing face. 

When we finally arrived, we took a chiva (which apparently means “truck without shocks”) toward the top of the island and then hiked a bit to see where the first families who settled the Galapagos had lived, and where pirates and sailors had come for fresh water.  We also saw some tortoises who may have been around when this history was occurring.

Immediately after a decent lunch in the tiny port, we hobbled down the coast for some hurried snorkeling in water that was about as clear as cement.  Knowing that we were getting hosed because of the lost time with the engine breakdown, I yelled up at our guide on the deck, “It’s too sandy; we can’t see anything out here!”  Visibly annoyed, he grabbed his mask and jumped in the water.  After 10 minutes, he yelled over to us from an area we had been told to avoid because of the aggressive male sea lions nearby.  “Sea turtle,” he said, and then headed back to the boat.

Surprisingly, the engine hadn’t been repaired and the boat hadn’t been replaced, and so we trudged across the ocean as the stars filled our view.  One of the crew cornered me and got free English lessons for about 3 hours as I unwittingly helped him flirt with one of the passengers.  At some point, he got up and handed out some oreos.  Still no word about what happened with the engines, when we were going to get in, or how they were going to make it all up to us.  Just writing that last line makes me laugh with cynical mirth! 

Just one good kick...

Finally the lights of Santa Cruz island came into view.  And never got bigger.  It looked like the remaining engine was barely keeping up with an opposing current.  Just as I was seriously contemplating my chances of reaching shore faster by swimming, the crew began shouting at us to move to the back of the boat.  Apparently we were running out of gas, and they wanted to tilt the boat to suck every last drop from the tanks.  Of course, in our desperation, every warm body on the boat hastily complied.  But to no avail.  With a heart-wrenching whine the last engine stilled and in the refreshing silence I could finally hear myself think.  And they weren’t very nice thoughts. 

Thankfully, in short order, a launch came out and picked us up, ferrying us the last half-kilometer into port.  Needless to say, the crew did not receive any tips, and I believe our Swedish volunteers have reported the incident to their consulate.  I will keep you posted as to how we are all compensated. 

A three hour tour, a three hour tour...

And finally, work!  Tuesday was another interesting day at the hospital.  I use the word “interesting” in the sense that things there are so far outside of my previous (and please note: minimal) medical experience it would be futile and counter-productive to explain.  Suffice it to say that I believe that here in the Galapagos we are sometimes using our resources ineffectively and that there is strong political and economic inertia that often stymies improvement.    

One of the young “rurales” (a young doctor completing a required year in rural service) said to me, “welcome to the Galapagos; you are not used to how things work here in the 3^rd world”.  That term again!  I told her that “3^rd world” sounds like an excuse to me, that there are plenty of resources here in the Galapagos to provide good, basic medicine.  We ended up talking for over an hour about the problems we both have witnessed in the Galapagos and how hard it is to improve things when the politics aren’t backing change.  Her passion for helping people was coupled with a defensive attitude toward gringos such as me who come and complain, but I hope she understood that I was trying hard not to be that gringo. 

Which brings me back to ICE and our clinical work.  Today I counted 233 patients to date who have been screened for diabetes, obesity and hypertension, and of those, nearly 50 were in one or more of those categories.  Several of the diabetics and many of the hypertensives had no idea that they were ill.  We have seen improvements with weight-loss, blood-sugar levels, and blood-pressure, mostly with education, exercise and meditation classes, and by providing lots of support.  We have helped some of our patients to take their medicines correctly.  We have encouraged others to get prescriptions from doctors here in Puerto Ayora and are helping them with dosing and management.  And we have provided medications to a few who are too poor to visit the doctor or afford their own medications. 

Emily Pozo tames the legendary
Llanta Lizard

In the coming weeks, a new crop of volunteers will be coming (including a surgeon) and we hope to improve on those gains and continue to help more people with the basics of health-care here in the Galapagos.  This experience is putting all of my skills to the test; Spanish, anthropology, medicine, ethics, and I’m fascinated and challenged every day.  We had a volunteer meeting and talked about starting a garden club, and women’s health education, and providing dental, dermatological, ENT and other special surgeries, more exercise classes, English classes, the list goes on.  Our boss, Emily, takes all of our suggestions with a sigh and tries not to get carried away too far with us.  She has lived here in the Galapagos for 6 years and knows first-hand how hard change can be.  “One thing at a time, chicos,” she cautions, but then she spends 2 hours with me after the volunteer meeting planning another project; a turtle made of used tires that we are going to build on a local elementary school playground.   I am returning to my roots and soon will be able to add “construction” to the list of challenges above.  More to come…