Tuesday, October 31, 2006

¡Feliz Dia de los Muertos!
(Happy Day of the Dead)

Day of the dead is celebrated across norther Latin America after our Halloween. People take time to remember those who are no long with us, and there are a whole host of other activities that vary region to region. In Atitlán it is quite a big deal, as well.

I'd like to ask our readers to take a moment to remember those who were lost that fateful night in October today. Below is a beautiful piece by Kathy Searle about the ceremony that took place on the one year anniversary of the mudslide.

“Despertando con esperanza en memoria de los ausentes”
(“Awakening with hope in memory of the departed”)
Caminata by candlelight: Santiago Atitlán mourns its dead

Thursday, October 5, 2006 –
Commemoration ceremonies on the first anniversary of the tragedy wrought by Tropical Storm Stan one year ago, when torrential rains and mudslides caused the death of over two hundred people, including whole families, and left over four thousand homeless in this town of about 36 thousand.

Four a.m., by the soccer field, and no moon. It felt cold. A few handfuls of people huddled together in doorways, or perched on the wall of the sports ground. We were the early birds, apparently, at the designated starting point for the caminata, or procession.

Dr. Juan Chumil drove by and pulled over, on his way from the adjacent town of San Lucas Tolimán, where he lives. Juan is the Director of the Public Health Center, and it is thanks in large part to his effective leadership and coordination within the health sector that Santiago experienced none of the outbreaks of serious epidemics (such as cholera and typhoid) which so often occur in the aftermath of a natural disaster. An experienced networker and versatile, hands-on leader, and also a strong supporter of the Hospitalito, Dr. Chumil lives up to his name, which mean “star” in Kaq’chikel.

“Aren’t you up awfully early, Doctor?” I asked. “No. I could not miss this caminata,” he replied. “I have to be here, out of respect for what happened here, and for the dead.”

Next to arrive on the scene was Francisco Coché, President of the Cantón Panabaj Association and newly appointed by the Town Council as Reconstruction Coordinator. Francisco carried a large bouquet of white flowers and a large church taper, as did many others who came with him. His quiet self-assurance commanded attention, and the crowd formed two lines on either side of the road upon his soft-spoken request in Tz’utijil and Spanish. Hand-held banners were unfurled. Placards appeared with the names and photos of schoolchildren who lost their lives in Panabaj. A municipal truck sported more signs, with the names and ages of other victims. The preponderance of small children and the elderly was striking.

Suddenly things picked up their pace. The Bomberos Voluntarios, Santiago’s volunteer firefighters, decorated for their valiant performance during the rescue operations, when they saved many lives at great risk to their own, arrived in two ambulances and took up their positions at the head and the rear of the of the procession, and marchers lit their candles. The caminata began.

As we moved forward, the ambulances sounded their sirens in short bursts, low and eerily mournful in the pre-dawn gloom. Sleepy neighbors appeared at their doorsteps, peered down from balconies, and lined the street as the procession passed. The early buses heading out of town pulled to the side of the road respectfully to let us by. The damp wind off the Lake penetrated our wraps, but it felt right to be walking together.

As the caminata approached the last corner before the town square, it was joined by the Mayor and Council members as well as other marchers. These included community members (adults and children, indigenous and ladinos alike), members of the local expat population, representatives of national and international NGOs working in the area: anyone who wanted to express their solidarity and share the grief of the many bereaved families of Santiago. By the time the line of walkers left the park, it was several hundred strong.

Climbing up the hill en route to the cemetery, I stopped and looked back. The caminata made an impressive sight, with its banners and candles bobbing along in the darkness.

Dawn was breaking by time we reached the cemetery gates, where we paused for speeches in Tz’utujil and Spanish by local and state dignitaries. The national press was present, and full coverage would appear in next day’s newspapers. The tragedy in Panabaj has come to epitomize the suffering of the entire country in the wake of Stan.

Also present was the team of forensic anthropologists slated to begin exhumations in November: a grim reminder that the 76 bodies buried in the cemetery were just those which were recovered immediately following the mudslides. It is estimated that some 132 cadavers remain buried in Panabaj in the area surrounding the original Hospitalito facilities, waiting to be excavated and identified by these experts. There have been many delays in getting official authorization to initiate the exhumations, but the affected families badly need to recover the remains of the victims and bury them if they are ever to get closure on their bereavement. The Hospitalito Atitlán has agreed to loan Module III, the new kitchen-laundry-storeroom facility within a day or two of being occupied when the mudslide occurred, to serve as a temporary morgue for the forensic team.

Last year at this time, the mud and rain had made it impossible to do more then bury the victims in adjacent graves near the cemetery’s entrance. Mourners placed flowers and candles on the crosses marking their families and friends, and the sound of sobbing lamentations filled the air.

After some time, the procession regrouped and continued its trek along the back roads to the site of the mudslide in Panabaj, to honor the victims who remain under ground there. By this point, full daylight was upon us, and the Mayor reiterated his speeches from the back of the municipal truck which served as an impromptu stage, inviting his listeners to attend the various events scheduled throughout the day as part of the commemoration activities.

The caminata ended as individuals dispersed to leave flowers and candles at the various improvised altars which have sprung up around the mudflats which now cover the floodplain on which the bustling neighborhood of Panabaj was once located, its humble homes interspersed among numerous coffee groves and cornfields. Now, all was cold, dusty and barren.

Monday, October 30, 2006

To follow the excellent letter by Ken regarding the board of director’s thoughts on sustainability, I would like to provide more information onthe charges at Hospitalito Atitlán. Below I list the base charges for a sample of the most common services provided. If a patient is not able to pay they are referred to the social worker for evaluation and she makes the decision as to what percentage of the bill the patient will be able to pay.

We know that there are many people in Santiago Atitlán and the surrounding area without recourses. There are men who are the sole providers for a family of six or more, and who earn the equivalent of $4.00 per day. There are also successful business owners, merchants, and hotel owners. People who own vehicles and pay $3.25 agallon for fuel.

In the past, those of the Atiteco middle class traveled to private hospitals for elective surgery.One must also keep in mind the cost of travel to the National Hospitalin Sololá, where it is said that care is provided for free, but in reality never is. With the rising cost of gasoline, the price of crossing the lake on the public boats has risen to Q10 per person, one way. When a family member is ill, it's customary for many family members travel to see the physician togather. Also, the faster boats charge Q15 per person, one way. It's also expensive to take the bus from the dock up to Sololá.

We know that H.A. will never be sustainable based soley on patient charges, but we do feel that those who have the resources to pay for services should be asked to do so. Thanks to all of you who are helping to make this possible.


Consultation...................Q10 ..................$1.33
Emergency....................Q25 ……............$3.35
Normal delivery.............Q300 ….............$40.00
Complicated delivery......Q1200…............$160.00

Wednesday, October 25, 2006

Hospitalito Atitlán Patient Charges

The subject of patient charges has always been a hot topic at the Hospitalito Atitlán. A year ago administration and physicians decided to offer a sliding scale of fees. The discount from full fees is based on measurable criteria—number of persons living in the home, total income, type of housing, water access, cooking arrangements, and number of children under the age of 13 who were not in school but were working. A social worker interviews patients and assigns points based on these criteria. A patient’s points determine a reasonable amount of payment.

On my site visit in August, I talked about patient charges with local residents of Santiago Atitlán, the volunteer physicians, and K’aslimaal—the governing board of the Hospitalito. Perspectives differ widely.

I asked several T’zutujil friends, acquaintances, and strangers about the reputation of the Hospitalito. One family had taken their daughter to the Hospitalito for the birth of their granddaughter. At first they told me that the delivery was too expensive…Muy Caro! In discussing her hospital stay, it became clear that she had had a complicated caesarean birth. At the end of the conversation, grandmother admitted that only excellent care could have given them a healthy mother and baby.

Another man I queried about the reputation of the Hospitalito told me he had heard it was expensive. He added a new twist—“Listen, people in Santiago Atitlán are not used to paying foreign doctors. For years, groups of doctors have come to Santiago Atitlán for short visits to provide medical care….this was always free.” A woman weaver told me her neighbor had gone to the Hospitalito and she was charged what seemed a fair amount.

Given Santiago Atitlán’s overwhelming health problems, why isn’t everyone taking advantage of the western medical expertise available at the Hospitalito? Cost is clearly the major factor but not the only one. There is a long tradition of local practitioners and practices available for health problems. When people break a bone they go to a T’zutujil Bonesetter. Lay mid-wives with varying levels of expertise offer prenatal care and delivery. These mid-wives may be reluctant to refer their patients to another healthcare provider. Entering a hospital by many is seen as giving up hope as they are convinced that only those who are dying are admitted. Often people with health problems bypass all providers and visit the Mayan God Maximon to pray for a cure. Many factors determine if, where, and from whom a sick T’zutujil decides to seek health care. K’aslimaal and the Hospitalito need to build relationships with traditional providers and persuade the community that western medicine can provide benefits that all can afford.

Remember the man who said the T’zutujil expect foreign physicians to provide free care? To some extent the foreign physicians have the same expectation. They generously donate their expertise and their time and want to provide care for the neediest people in Santiago Atitlan. They fear that “high” fees keep the poor from seeking care except in emergency situations. They suspect that the financial evaluation system is not working efficiently and that some patients may be charged beyond their means, lending credibility to the rumors that care is expensive at the Hospitalito Atitlán. They are frustrated by the lack of the technology and medicines they were trained to use.

The members of K’aslimaal and the local doctors have a different view on charging patients. Where the foreign physicians see mainly poverty, the locals see all of their townspeople as having some resources to care for themselves. For the short- term, K’aslimaal believes patients need to take responsibility for their own health care. This responsibility includes paying for care at the Hospitalito. If a patient can only afford one quetzal for hernia surgery, they should pay that one quetzal. Paying for services—paying the hospitalito—helps make it THEIR hospital. Patient families can volunteer to work a number of days doing construction or maintenance work at the facility in lieu of money payment. The local providers feel that paying for service is critical to changing local attitudes towards health care.

K’aslimaal and the indigenous providers also believe that local support—especially local financial support—is necessary to ensure the Hospitalito is a permanent part of Santiago Atitlán. The original Hospitalito in Panabaj was run by a U.S. non-profit. When the Massacre de Santiago Atitlán occurred in 1991, the Americans decided it was too dangerous to stay and closed the Hospitalito, leaving the town without emergency or inpatient care for the duration of the civil war. The locals felt abandoned. Many T’zutujil died and many more suffered from lack of medical care during the fifteen years that the facility sat empty.

When local leaders began discussing reopening the Hospitalito, they felt that local support and local control would be crucial for long-term sustainability. With the temporary hospital operating and as plans move ahead for the permanent Hospitalito, K’aslimaal wants to control its future by relying as much as possible on local resources. Patient charges are a part of those local resources that can help the T’zutujil sustain their own Hospitalito. We are currently discussing the feasibility of a pre-paid healthcare plan that would both reduce the financial barrier to care, encourage early and less costly care and provide a predictable stream of income for the Hospitalito. Policyholders would include, schools, businesses, churches, finca owners and individuals.

The tensions between medical providers and medical administrators are found everywhere. Providers want to give the best care they can today. Administrators want a hospital that will be financially viable as long as people need health care. Building a hospital, while providing care increases these tensions. Decisions on how to use limited resources are painful. Does one purchase construction materials or medicines? How do physicians feel when they lose a patient for lack of that medicine?

While I applaud K’aslimaal’s push for a locally controlled and locally financed health care facility, no hospital sustains itself on patient charges alone. Given the medical needs of a community this poor, it is only realistic to assume that the Hospitalito finances will require subsidies into the future. And given the local poverty, it is reasonable for the foreign physicians to want a working sliding scale payment system.

The current sliding scale payment system was designed to address these issues. It didn’t seem to be working. I asked a group of Harvard medical student volunteers to get some data about charges. They reviewed hundreds of patient charts. They found that the majority of patients were not financially evaluated. There is no policy that all patients need to be evaluated. Indeed, the social worker may have too many responsibilities to evaluate everyone. Apparently the patient or the provider must request a financial assessment. The availability of a sliding scale payment system is not advertised in the Hospitalito. Even when a patient had an evaluation, they were not consistently charged the price their points indicated. Some patient overcharges were documented. Most of the variance from sliding scale charges occurred among low income patients; those with more income were usually charged the correct amount.

As representatives and stewards of donors’ contributions and intentions, Pueblo a Pueblo is concerned about access to hospital care in Santiago Atitlan. The Board of Pueblo a Pueblo cited this study in presenting our concerns to K’aslimaal. We requested that they reexamine the issue of patient charges. Policies need to be developed, documented, and publicized. Implementing these policies will require training and personnel. While we have made suggestions to K’aslimaal, we believe it is up to them to determine the appropriate changes within their cultural context. Pueblo a Pueblo asked that K’aslimaal report their patient charge policy to us. We also asked that they complete a similar study of the utilization of the sliding scale payment system by November 30, 2006. We made it clear that we expect that needy patients will be appropriately charged based on a fair system. We expect the Hospitalito to reduce barriers (financial or otherwise) so that physicians can provide care to increasing numbers of indigent patients. We understand this may require scarce resources that could be used for building the permanent Hospitalito, but that this approach better reflects of the interests of all constituents.

The Board of Pueblo a Pueblo knows that documenting and implementing a sliding scale payment policy will require much time and resources. We feel strongly that the sustainability of the Hospitalito depends on meeting all constituents’ interests. Consistent use of a fair sliding scale will encourage physicians to volunteer as the hospital attracts more needy patients. The reputation of the Hospitalito will improve as patients pay charges that are consistently within their financial capabilities. Donors will continue to support a medical facility that can demonstrate that it is providing care to the entire T’zutujil community. Lastly, K’aslimaal will strengthen its control over the Hospitalito and ensure long-term sustainability by building strong partnerships with volunteer physicians and donors.

In working through these issues, I felt admiration for everyone working for the Hospitalito. I admire K’aslimaal for working hard to support itself by generating local income….by paying their staff with earned income rather than donations. And I respect the physicians desire to provide care to more needy patients. Both these goals are good. I believe the Hospitalito can achieve both these goals by further developing and implementing a working payment system.

Despite the obvious shortcomings of the payment system and its to-date poor implementation, simply raising these issues and presenting the data from the study has created some effect. Tensions seemed a bit relieved as folks began to voice their perspectives. I recently got an email from Lyn Dickey saying that the Social Worker had evaluated a patient family and determined that they should receive a 90% discount for a surgery. That is what they paid. The social worker was ecstatic. Presumably the patient was, too. This anecdotal report was heartening and we look forward to systematic changes and the November report.

Kenneth Wood

Executive Director

Tuesday, October 24, 2006

Thanks to our video producer extraordinaire Nathan Smith, if you missed Dra. Irene's talk last week, you can now watch in on YouTube:

Dr. Irene's speech is live online! The speech is divided into five parts to accommodate Youtube's length and size limitations. Most are approximately nine minutes, and the last two are each about 5 minutes.

Part I
Part II
Part III
Part IV
Part V

Please feel free to distribute to anyone who would like to see it!

Nathaniel W. Smith, Ph.D.
Ware College House Dean

Monday, October 23, 2006

Pueblo a Pueblo is proud to announce it's partnership with Oasis Entertainment!

Here is a clip from a recent Coffee Talk magazine article.

Thursday, October 19, 2006

Last Chance to Hear Dr. Irene -- TONIGHT in DC!

7pm - Friday the 20th

St. Stephen and the Incarnation Episcopal Church

Washington, DC
1525 Newton St NW Washington, DC 20010-3103
Dining Room

Monday, October 16, 2006

Meet Dr. Quiejú in Philidelphia!
Tuesday, October 17th

Tragedy and the road to recovery in
Santiago Atitlán, Guatemala:
the story of Hospitalito Atitlán

Dr. Irene Quiejú Sojuel

3:30 – 4:30pm (reception to follow)
Claire M. Fagan Hall (Nursing Education Building) Auditorium
418 Curie Boulevard, University of Pennsylvania
October 5, 2006 marks the anniversary of
Hurricane Stan, which triggered mudslides that
buried the neighborhood of Panabaj in Santiago
Atitlán, Guatemala, killing hundreds of its
indigenous Tz’utujil Maya residents. Hospitalito
Atitlán, which had just re-opened in April 2005 after
being closed for 15 years due to civil war, was also
destroyed by the mudslide.
The Hospitalito quickly
resumed providing 24-hour medical care in a
temporary facility and performed its first emergency
surgery only 15 days after the mudslide.
Dr. Quiejú Sojuel will discuss her experiences
as the Hospitalito’s medical director, life in
Santiago Atitlán during the civil war and after the
mudslide, and how she realized her dream of
becoming the first female Tz’utujil physician.
sponsored by Guatemala Health Initiative, Women’s Health and Midwifery at Penn, and Pueblo a Pueblo

For information on Hospitalito Atitlán, see www.puebloapueblo.org
For information on Dr. Quiejú’s visit, e-mail byunj@mail.med.upenn.edu


The Hospitalito’s land presentation was very nice. Congratulations to Kaslimaal and the hospitalito for all their hard work.

It was a very nice sunny day. The property was cleaned up, a stage was made, balloons and ribbon decorating it. Lynn had made a display with lots of photographs of the old hospitalito, the current one, and plans of the new one.

Chairs were set in front of the stage and behind them there was a little booth, attended by the local staff from the Hospitalito. They were doing a campaign, “one block for your health”. A high quality block costs five Quetzales.

Members of the staff and volunteers were there. A group of comadronas came, older Atitecas. The Red Cross came with the new Santiago Atitlan ambulance. Cofrades showed up. Diego Esquina, the mayor, was there as well, sitting up next to the stage with the Comite Kaaslimal. At first there seemed to not be a lot of people, but when the event started all these people showed up.

Irene first took the stage and did an introduction, welcoming everyone.

Francisco Sojuel then gave a moving speech.
Before beginning he asked everyone to observe one minute of silence remembering the victims of Stan.

He then talked about four basic phases that the Hospitalito has gone through. The first phase was in the late seventies, when Care was funding the hospitalito out in Panabaj.

The second, when Comite Kaslimaal was founded and started and incredible process; to clean and rehabilitate the Hospitalito.This was fruit of many volunteer groups and local football teams.

The third phase, Francisco said, was Hurricane Stan and the reestablishment of the hospitalito in Tzanchicham.

About five days before the anniversary of the disaster, Francisco began to remember the day Stan happened and he relived this experience with several people from the audience. Francisco talked about how Leah and him went out to the Hospitalito the morning after the mudslide in Panabaj, and how it took them an hour to get out there (a trajectory that normally takes about 15 minutes approximately).

The perseverance of all the doctors and people involved with the hospital is incredible, said Francisco; -“it only took us fifteen days to get the hospital up and running”-.

The fourth phase is the current phase, says Chico. The hospitalito has bought land. The hospitalito has architectural plans. The hospitalito has a future.

Francisco talked about all the people and organizations that have helped. The majority of them are not from this town, but want to help.

He talked about Ray and Ron, and the piece of land that they bought for the Hospitalito.
He thanked Ken Wood and PuebloaPueblo for all the work they have done and are doing.

He then pointed out the outline done on the ground with chalk of the Hospitalito’s planned building area. It is truly amazing to stand in the middle of this outline and see the size that the hospitalito will be.

Francisco then asked the mayor and the Municipalidad, whom were present, for all their support in making the entry road wider so that the ambulances could get through.

Juan Tzina got on stage to show the measurements of the land.

Kathy and Irene got up to talk about the statistics at the Hospitalito (how many people had been treated, for what, what age, sex, etc.). This portion surprised me, for the quantity of people treated is incredible if you think that the Hospitalito has only just started working not two years ago.

Diego Esquina got his turn. He was very brief, saying he deeply respects the effort done by Kaslimaal. The effort has borne fruit. He said; -“any organization that uplifts and develops the town in a positive way will always have the support of the Municipalidad”-.

At the end Francisco asked if anyone wanted to say any words.
A man from the audience got up and said he was thrilled to be there. He asked if all the members of the Comite would stand up on the stage and be recognized.

The next activity was the digging of the first ditch. Different atitecos including teachers and coffee beneficio members and members of the community got a shovel with a ribbon around it and they dug into the ground along the chalk outline.
David from the Posada. Betty from the bank. Little atiteco children. The pastor of the Alfa y Omega. Comadronas. Many others.

At the end, the hospitalito handed out donated trees to everyone, to make up for the trees that have and will be cut down to build the hospitalito.

The hospitalito handed out Pine trees because the name of the area where the new hospitalito will be is called Xet’chaj, meaning “Under the Pine Trees.” Everybody left with a little tree under their arms.

-Xelani Luz Foregger Velasquez

Tuesday, October 10, 2006

Come Join us this Friday in New York City!

Monday, October 09, 2006

The tour continues. Here Dr. Quiejú meets with Guatemala's Ambassador to the United States, and our Executive Director Ken Wood at the Embassy last Thursday on the anniversary of Stan.

Sunday, October 08, 2006

For the Heart of Heaven, Heart of the Earth... Consecrating the new land in Xetchaj

by Kathy Searle de Acevedo

Flower petals and incense, chocolate and bread, candles and liquor: offerings to the ancient spirits which have guarded and guided the Mayan peoples since time immemorial. It seems only right to ask their blessing upon the land which will be home to the Hospitalito Atitlán.

At daybreak, we seven make our way to Xetchaj, and climb to a small terrace partway up the rocky mound at the rear of the new property. This small hillock remains untouched, in contrast to the rest of the land, recently cleared of all but the largest trees in preparation for groundbreaking in a few weeks’ time. With us is an ajq’ij, or spiritual guide (literally, “keeper of the days”).

He will lead the ceremony and guide us in offering thanks for this tremendous gift, for this land in a safe location on which to rebuild a hospital that will offer care to all the people of the community. We also wish to ask forgiveness for the removal of numerous trees and plants, including a sizable plantation of coffee loaded with unripe fruit. And finally, we seek guidance and wisdom in the challenging project we are about to undertake.

As the sky lightens, don Juan begins to lay out the altar, following the cardinal points of the universe. To the north, the color white, symbolizing rightness, color of wisdom, color of teeth, color of bones. To the south, yellow, the color of blessing, of life, of the fertility of Mesoamerica’s Pacific coastal plains. To the east, red, color of strength, in honor of the rising sun, which is at this moment making its appearance over the top of Tolimán Volcano. To the west, the color black, the color of night, which follows day, the color of death, which follows life… The symbology is many-fold; these colors also represent the four colors of corn, mainstay of life and raw material for the creation of the first humans beings…

Our guide invites us to help in laying out the ceremonial circle; soon the fragrant smoke begins to fill the air with the aroma of incense, and rises along with don Juan’s invocations. Behind us, the Volcano San Pedro, Ch’utchuj, is bathed with the golden light of early morning, and the birds are pouring forth their medley of greetings to the new day. For the Heart of the Sky and Heart of the Earth, the Creator and Shaper of the Universe…

Mayan cosmovision is not a religion. It is a way of seeing the universe, of seeking to live in harmony and balance with all of creation. Nor is it exclusive, don Juan explains to us; anyone may join the circle around the sacred fire. It is necessary only to approach respectfully, with an open mind and an open heart. The lessons to be gathered from the traditional ceremony can be meditated upon, and applied to practical aspects of our lives. In this case, our guide invites us to reflect carefully upon the importance of involving the people of Santiago more closely in the enterprise of rebuilding and operating the Hospitalito Atitlán. Inclusiveness, connectedness, interaction. Timely counsel indeed, and we take it to heart.

On the day Four B’e, Nawal of the continually unfolding road of existence, Nawal of history and destiny, we consecrate this land to the saq’ b’e, to the right path and to the correct destiny, to the service of the community and to the healing powers of the universe.

Thursday, October 05, 2006

From Santiago Atitlán

This week will be the one year anniversary of the mudslide that buried our hospitalito. Yesterday we had the groundbreaking for the new hospital. The new location is in a zone deemed safe from mudslides, very near our house. It is on the road toward San Lucas, on the opposite side of town from the original hospital. The majority of the land was donated by two Americans, Ray and Ron, friends of Ken Wood. An additional parcel was purchased with additional donations. An architect from the US is donating his services, working with the Comité to build in a modular from which can be expanded later. The Comité is selling “bloques”; cement blocks for 5Q, about 80c a block. One donor has said he will pay for a totally equipped delivery room. Fundraising is underway.

Meanwhile work continues at the temporary hospital. Our in-patient census is up a little. My last call there were 6 patients: 2 women with vaginal deliveries and their babies, a diabetic man with uncontrolled high sugars, a 13 year old with appendicitis. Doesn’t sound like much work, but in addition there are the ER patients. We are currently doing daily dressing changes on a little girl with 2nd degree burns covering the entire front of her R leg, and half the front of her L leg, as well as a number of other time consuming patients. We have recently had a huge turnover of nursing and other staff for a fascinating variety of reasons. The result, however, is that we frequently have very inexperienced nurses working. Why is that a problem? An example: Jack wanted to give 2mg of Decadron to a patient. It came in a vial “8mg/2cc”. Jack thought that he would give a dedicated young nursing student a chance to shine. “How many cc do you need to give to give 2mg?” he asked. The student was totally stumped. Jack, the diplomat, said that is after all why he is a student, to learn stuff like that, and that he should ask the nurse. So they did. She couldn’t figure it out either. So Jack explained that it would be 4mg/1cc and therefore 2mg in 0.5cc. OK, lots of smiles. Jack has been here long enough to ask them to show him the dose before giving it. The nurse happily showed him a syringe with 0.05 cc of Decadron. So after a brief discussion, the patient was given the correct 0.5 cc and all were happy. Time consuming. We are trying to do some math lessons. Basic math lessons.

The good news with the staff changes is that our new director of nurses, Felipa, is very conscientious and pleasant to work with. The new nurses are very motivated, and the student nurses are incredibly motivated and eager. Since many of you know the staff, here are the people who have gone: Luisa, for more money and no night shifts, to PRODESCA (a public health position in Santiago), and for “other reasons” Concepcion the nurse, Diego, the head nurse, Pedro the lab tech, Maria the laundress. Also an update: Selman, Aclax’s son, (thanks to Peyton’s tutoring, Hurrah!), passed his chemistry test. He and Rebecca now only need to pass their reading comprehension tests (which seems to be the hardest to pass) to be accepted to medical school. Rebecca goes down to Guatemala City tomorrow to take it again. Jacinto is taking classes to get an official certificate as a scrub nurse. Felipa is continuing her classes to be a “graduate” (RN level) nurse.

A note of why we don’t like to refer our patients. Our administrator, a man of about 30, has had intermittent knee problems. With his last flare, he said he couldn’t stand to put weight on it, that it was locking up in certain positions. Exam by us non-orthopedists was negative other than joint line tenderness. We put him in a splint and said that maybe he would want to have an orthopedist check the knee, since it seems to flare up often. He came back with x-rays, a diagnosis of a “bone fissure” and a regimen of daily injections at home and pills and a follow up appointment in 3 weeks. To us, his x-rays look fine. Any orthopedist want to weigh in on that? (for the non-medical people, in my 36 years of medicine, I have never heard of a bone fissure, nor of daily injections to help heal an injury (other than an infection). But the orthopedist is richer! And that is the private system.

Right now we have 2 emergency doctors here from Philadelphia for a week, AJ Dean and Kathy Beaver. In addition to doing shifts, AJ is doing and teaching ultrasounds and Kathy is doing extra dermatology. Just arrived are 2 residents from University of North Carolina, Chapel Hill: one pediatrics (Lisa DeCamp) and one medicine-pediatrics (Carrie Cox). They are here for a month, and promise to give us tons of teaching, also in addition to doing shifts. They said that they have a black cloud. Everyone laughed. Then, 30+ patients arrived from a pick-up truck accident. Luckily AJ and Kathy were at the hospital and did the triage, sending the vast majority home so, freeing Carrie and Lisa for the more seriously injured. Carrie and Lisa are settling right in. They decided to move from their first room here when the roof leaked on the bed. They actually read the orientation info I sent and brought a flea collar and plastic sheets so now they have sprayed their new rooms and are covering the beds to hopefully avoid the bedbug, or is it fleas, problem at the Milpas. And the beloved dog will get the flea collar. So far Carrie and Lisa are in good spirits, unperturbed by leaks, a deluge of patients, the threat of fleas or bedbugs. I love young doctors!

Last summer the U Penn medical students made a video for us in Tzutuhil on how an asthmatic patient should use an inhaler. I forgot to tell Lisa and Carrie about it. Their cultural encounters the first day included trying to tell the brand new mom why she should not give her newborn a baby bottle filled with tea, as well as how incredibly difficult it is to get a Tzutuhil to use an inhaler correctly. They know where the video is now.

The hospitalito has hired a wonderful young Mayan doctor, Eliseo Cojon, to work full time. In November we plan to hire a second. Both went to medical school in Cuba under Cuba’s program to train third world doctors for free. Both just finished their schooling and so are more or less interns. Although I have only worked with them a tiny bit, I think they are close to the level of US interns. What a great program Cuba has! Great for PR for Cuba, great for health of the third world countries. Very comparable to the US program of…… well, I guess we don’t have one.

I just returned from an entire month of vacationing. First I went to the states and saw my family, then went to Korea with Jack and joined our two youngest kids, toured Korea a couple of days, then India for 2 weeks, then London for 2 days, then returned. It was a great visit with our 2 kids, and a great break.

Showing my ignorance, when I first heard that tortillas were made of corn with lime added, I thought it was lime as in lemon. It is lime as in calcium oxide. Here it is called cal. Yesterday at the groundbreaking, the footprint of the new hospitalito was outlined in cal. The day was beautiful, warm, sunny, a nice breeze, blue sky, bright multicolored streamers hung from the trees, kids playing. The president of our Comité, started the program with a moment of silence for the loss and suffering of October 5, 2005. As usual, my mind wandered. I looked around at the bright day, then the footprint made of cal caught my attention. After the mudslide cal was sprinkled on all the paths leading to and through the area. The lime was described as being there for various reasons. To keep down the smell from the buried bodies, to protect the people walking through. We think it was maybe a symbolic protection from the spirits of the dead more than anything else. Anyway, yesterday the cal was a poignant reminder of the disaster that caused the need for the new building.

Dr. Bernie Page