Boston medical brigade - where doctors are scarce
Where Doctors are Scarce
"My daughter Cindy is anaemic - so she eats soil now and then." Although medical students Ryan and Claudia from Boston have plenty of clinical experience, this is a first. Cindy's mother, Janeth, is thirty but looks a good fifteen years older. She is painfully thin and prematurely aged by the relentless sun. Ten-year-old Cindy, on the other hand, looks no older than eight. She smiles shyly, overawed like many country children here by the presence of people from outside her village. Ryan tells Janeth she has to stop her daughter eating dirt at all costs. If she is anaemic - as she appears to be - one reason may be parasites. To boost her iron levels, she needs to eat plenty of beans and, if possible, green leafy vegetables and meat whenever possible.
We are in the health centre at Puertas Azules in the mountains of Miraflor, a beautiful but very poor area north-east of Estelí. The mothers and children attending today's clinic are from isolated farming communities. They live in shacks made of rough-hewn planks, with dirt floors, often sharing the space with chickens, dogs and other domestic animals. Estelí is a good two hours away by boneshaking bus (there are two a day), and my guess is that for many of today's patients it must seem almost as remote as New York. The mothers are mostly young, thin and softly spoken, the children abashed but wide-eyed at the prospect of the lollipops the doctors are offering to sweeten their medical examinations.
Ryan and Claudia are part of a medical delegation headed by paediatrician Dr Peter Loewinthan, which has been providing free consultations and medicine to poor children and their mothers in north-west Nicaragua. They have already spent one week in Estelí and a second in Matagalpa Department, and are now seeing patients in the Estelí region again. Yesterday the team treated 60 youngsters in a two-roomed preschool on the outskirts of the city. Today it's remote Miraflor; in a couple of days they will go on to Santa Cruz, a rural settlement just off the Panamerican Highway.
The settings vary, but the problems are similar. All the children are from poor families, and many have not seen a doctor for some time. Typical complaints are respiratory ailments, rashes, fungal infections and poor appetite. The reasons? Poor nutrition and exposure to dust (unavoidable in the long dry season), fleas, lice and ticks, and intestinal parasites. No-one owns a vacuum cleaner here. The water supply is often contaminated, and children who have not had worms or amoebal infections are the exception rather than the rule.
Each day the doctors screen for parasites, offer the mothers condoms to prevent STDs and hand out toothbrushes and toothpaste. Many youngsters have bad teeth, not surprisingly when some mothers try to "improve" their babies' diet by sweetening the milk (or often water) in their bottle. Now and then something more puzzling turns up. In Santa Cruz, ten-year-old José's father is afraid that the red pustule on his son's cheek may be leishmaniasis, known locally as "lepra de montaña" ("mountain leprosy"). Peter examines it closely, asks Claudia and Ryan for a second opinion, and finally e-mails photos to a paediatric dermatologist in Boston. He promises financial help if specialist follow-up is needed. The anxious father thanks Peter with quiet gratitude and pats his son's shoulder reassuringly.
Sixteen-year-old Diajaira comes in with her baby, who has white patches and rashes on her arms. Diajaira herself, a timid shadow of a girl, suffers from dry, itchy skin and dermographitis. "I put alcohol on my skin every day to get rid of the allergy," she says. Maybe this is the root of the problem! She is advised to stop this straight away, wash her sheets in hot water (a luxury here), beat her mattress to get rid of dust and fleas, and use skin moisturiser. Diajaira has had asthma attacks in the past - not surprisingly given that she and her daughter probably share the family home with a variety of animals. If she can manage to follow the doctors' advice on hygiene, a whole range of problems should clear up quite quickly.
By the end of their stint, the team have seen hundreds of patients. They are proud of what they have achieved and committed to following it up. Peter, who has been volunteering in Nicaragua for one month a year over the last decade, is hoping to expand the healthcare programme further. He is already looking forward to returning next year to these isolated rural settlements and deprived neighbourhoods where doctors are scarce.
(All patients' names have been changed).
Fiona Graham