The presentation

The group left El Sauce on Saturday morning (July 17).  It was a strange feeling to be moving out of the place we had called home for almost a month.  We said teary goodbyes to Perla, the UNAN nursing preceptor who had been with us for almost two weeks.  We hugged and said goodbye to the Hotel Blanco staff, and told them we would return on Wednesday to give the presentation in their dining area.  Some members of the group jumped on a bus and headed to Granada for a couple of days.  The rest of us headed back to Leon to work on the presentation and to go volcano-boarding on Cerro Negro. We worked on the presentation Sunday, Monday, and Tuesday, and had a practice run-through with the whole group on Tuesday night. We agreed to have four presenters, and the group gave the presenters feedback on their Spanish presentation skills.  I went to bed excited and nervous for the next day's events.

The next morning was not the smoothest of mornings.  I accidentally overslept. One of the presenters woke up sick and was not able to come. I ended up taking on her portion, which I reviewed in the van on the way there. We scrambled into the van with only one laptop, and as it turned out, it was not the laptop with the presentation on it. The driver did not know we were supposed to pick up Dr. Peña.  Luckily, we figured that out before we wasted too much time.  When we picked up Dr. Peña, I informed the driver that we needed to go back to the hostel to get the other computer.  Somehow along the way he forgot that we needed to do that and we were almost all the way out of Leon by the time I realized what was going on.  Fifteen minutes later, we were finally on our way to El Sauce with all necessary people and tools in the van. Phew!

We arrived at Hotel Blanco and hour before the presentation was to begin.  We were informed that due to a city-wide power outage, there was no electricity anywhere in the town except for those places that had generators.  I thought to myself - OK, so we're going to do a presentation with no projector and no fans......uh oh.  Luckily for us, Hotel Blanco had a generator and they said that they would provide power for our presentation.  Phew! (again)

The presentation was scheduled for 10AM and much to my surprise some people actually arrived at 10.  Paola, from the health center, invited nurses and doctors from the clinic, the vector-control workers, and local  health department staff.  Our guides showed up proudly sporting their UNC garb that we gave them at the 'fiesta de despedida'.  About 20 people attended and the presentation began at 10:15. Dr. Peña opened with a brief introduction and a few words about the continuing collaboration between UNC, UNAN, and the health center in El Sauce. We presented preliminary statistics on the demographic information of the survey population, perinatal care, STI prevention methods and knowledge, diarrhea, social networks, and unintentional childhood injury.  We presented the information mainly in bullet points and tables, but we were also able to include maps of the spatial distribution of the data.  I thought the presentation went really well, and I was very proud of our group for pulling something together so quickly and for being able to competently present our findings in Spanish in front of a large group.

Attendees had the opportunity to ask questions and make comments at the end of the presentation.  The health center is collecting some of the data we collected as well, and it was interesting to talk about the differences in what they have found and what we found.  For example, we found that about 75% of women had had a Pap smear, but Paola thought that number was too low.  We promised to do further analysis to see if there are certain areas where the uptake of Pap tests is particularly low.  This information will help the health center target its outreach programs to the health issues of specific communities. The attendees were also interested in the process and software we used to create the maps of health data.  Data mapping technology would be useful for monitoring outbreaks of vector-borne diseases in the El Sauce municipality. Dr. Peña explained that it was a matter of linking GPS points to data in Excel using a specific kind of software, and he said that UNAN/CIDS would help the health center work on their mapping activities. Another attendee (a nurse) suggested that we add questions about HIV testing to the survey for next year.

We received all positive feedback and the health center staff told us that they were grateful for our work. We promised to send them a full write-up of our findings after we have a chance to thoroughly review and validate the data.

I took one last trip to the health center to take pictures of the health posters they have on many of the walls. I said my final goodbyes to Paola and Dra. Velazquez who told me that they look forward to working with the UNC-UNAN partnership in the future.

Paola and Dra. Velazquez

That's me, presenting

Elena presenting

Anisha presenting

Question and answer session

Dr. Peña - opening remarks

Inauguration

On the same Thursday we met with Dr. Pena we also went to the inauguration of a new hospital in El Sauce. The event was scheduled for 3PM 'Nicaragua time' (or maybe 4, depending on who you ask). As we have been told many times since starting work in Nicaragua, there is regular time and then there is Nicaragua time, which can mean that the person or thing you are waiting for may be 15 minutes to an hour late, or may just never show up. Life in Nicaragua is not about being in a hurry or constantly checking your watch; it is about taking the time to engage with others, it is about patience, and it is, in some cases, about survival.  Mothers arrive at the health clinic expecting to wait for hours for care, and we have spent enough time in Nicaragua to know not to show up at 3PM for this event.

It turns out that the concept of 'Nicaragua time' also carries over to completing projects, such as the new hospital. The inauguration event occurred on July 16th, the official opening date for 14 hospitals and 24 Child Development Centers throughout Nicaragua. Though the hospital structure, wiring, and much of the plumbing is finished, there is still plenty of work to be done and the true opening date has slid to mid-August.  The head Epidemiologist of the El Sauce health center said that the new hospital does have an X-ray room, although they have no X-ray machine, and they have space set aside for ultrasounds and laboratory work, although they lack a sonogram machine and some key lab equipment. It has capacity for 30 beds, and is much larger than the El Sauce health center. I truly hope that this initiative brings in adequate resources and doctors to utilize this space to its full potential. You can read more about this initiative here in Spanish and here in English.

Prepared for a delayed commencement, we lazily strolled over to the event, which did not actually start until 5:30. The majority of attendees was dressed in red and black - the colors of the Sandinista National Liberation Front (FSLN) - and at times it seemed more like a political rally than a celebration. The FSLN is the current party in power, the president of which (Daniel Ortega) is said to be responsible for the initiative to open these new centers. The FSLN is named after Augusto Cesar Sandino, a national hero, who led the Nicaraguan resistance against the United States occupation of Nicaragua in the 1930s. The small child sitting in front of me wore a shirt that said "Hay hombres que tienen la Revolucion en la boca, y viven de ella...Pero hay quienes la llevan en la sangre y mueren por Ella", which roughly translates to 'There are men who have the Revolution in their mouths and live for it, but there are those who carry it in their blood, and die for it'.  Amidst cheers of 'Viva Daniel!' we watched young women dance in traditional costume and style and listened to a band play songs praising the FSLN, the revolution and Daniel Ortega. Unfortunately, we had to leave early for dinner, but we were grateful to have been invited to the celebration.

Wrapping up our last week in El Sauce

Our last week in El Sauce involved visiting the only remaining community - San Jose.  A large village of 60+ houses, it took us two days to complete.  We felt a great sense of accomplishment as we headed home that second day. We invited the guides to attend a farewell dinner on Thursday evening and they accepted.

Thursday morning we met with Dr. Peña.  We discussed plans for a final presentation in El Sauce the following week.  There was still some data entry to be done, but we planned to finish it by Saturday, thanks to the hard work of Cathy and Jess, our two main data-entry people.  We explained that the data would still need to be reviewed for any errors, and that would have to wait until we returned to the US.  But we agreed that we would be able to present some preliminary statistics as part of the presentation.

We also discussed our intent to donate more medical supplies to El Sauce, using the money we had made selling Selva Negra coffee in the spring.  Though money was tight due to our move to El Sauce, we as a group felt very strongly about providing something tangible to the healthworkers in El Sauce.  We had already distributed some medical supplies donated by MedWorld and UNC doctors and nurses.  But we wanted to use the Selva Negra funds for an urgent need identified by the health center.  Dra. Velasquez and Paola (two of our local project stakeholders) told us that the 'Casa Materna' currently does not have a lamp for obstetric examination.  Pregnant women who live far from the health center arrive at the Casa Materna around the time of predicted delivery date, and wait to deliver there.  Also, women with pregnancy complications stay at the Casa Materna so that they can be monitored.  Casa Materna is associated with the health center but it is a separate building. Dra. Velazquez and Paola also requested that we purchase more strips for urine testing.  Blood tests are often not possible due to the lack of laboratory equipment, and so urine tests are much more commonplace. We gave Alex, the UNAN -UNC coordinator $300 to purchase these items and planned to present them to the director of medical services at the health center after the presentation.

Thursday evening was a blast. Several of the guides joined us for dinner.  The owners of Hotel Blanco surprised us by bringing in a band especially for us - they played typical Nicaraguan music as well as some cumbia and dance songs.  We sang and danced until the late late hour of 9PM, when everyone was tuckered out from the long day.  We were very grateful to the staff of Hotel Blanco for giving us such a lovely send-off.

The group at our 'cena de despedirse'

The band!

Some pics from the field

Surveying in Montoya

Our truck! Able to cross rivers and carry 15 people!

 

Rachel and Josie conducting a survey 

 

The new hospital being built just outside the center of town

 

This is where we slept for three weeks in El Sauce

 

El Sauce on a clear morning

    

Piloting the survey in the Centro de Salud, El Sauce

Trabajando...

(The church in El Sauce)

We encountered a few hiccups the first week which I did not think to write about because I was so excited to start working on the project. The hiccups mainly had to do with lack of communication and miscommunication.


We showed up the first day for work without lunches for the guides who would be introducing us to the families all day long. No one told us explicitly that they we were expected to bring lunch for them. They were hungry by the end of the day and finally accepted our offer to share our PB&J sandwiches, though they were totally confused about why we would put peanut butter, jelly and bread together. We felt so bad about the fact that they were hungry, and we made sure we had proper lunches for them the next day.


When we originally put together a preliminary survey schedule with Dr. Peña and the coordinator from the El Sauce Centro de Salud (Paola), we decided that we would send out four survey teams per day in order to reach as many houses as possible. Our understanding was that we would have four guides and that the schedule would necessarily have to be flexible depending on the rain. We didn´t realize until after a few work mornings full of confusion that there were only 3 guides, that Paola had no control over the number of guides, and that the guides´ first priority is to handle issues related to vector control. Vector control is any work related to the spreading of disease by animals or insects (e.g. mosquitos, rats, etc.). Whenever there is a case of dengue, malaria, or any other vector-borne disease, they are required to investigate and, if necessary, fumigate. We spoke to the head Epidemiologist at the Centro de Salud, who informed us that we would only ever have three men at most to accompany us. Once everyone realized what was going on, we readjusted our plans and the journey has been smooth ever since....except of course for the rivers we have to cross to get to some of these communities, but that´s another story...:-)

Work has been continuing steadily and we have accomplished more than we originally thought we could over the past two weeks. We have visited communities with varying access to health care, education levels, and topography. As of last Thursday, we had visited 247 houses and conducted 143 surveys. We only have a couple of communities left to visit, and I can´t believe how quickly these couple of weeks have gone by.

My favorite thing about this whole experience has been the interaction with the women we interview. The women are always so gracious as they set up the few chairs that they have for us and welcome us into their homes. They are generally very open with us, which makes our work easier, and they are patient when we get tongue-tied in Spanish. We bring crayons and jumpropes with us to each house and sometimes we get to play with (i.e. distract) the kids while interviews are being conducted. Most of the houses we visit have 2 or 3 rooms, corrugated metal or ceramic tile roofs, dirt floors and many children. Some villages have houses close together, while others are more remote with houses a significant walk/hike away. Many are set in beautiful surroundings with cloud-topped mountains and vibrant green fields. As is to be expected during the rainy season, there is a TON of mud. We are well-equipped with tall rubber boots, quick-dry pants and the understanding that we will return home muddy almost every day.

On Friday we went to Montoya, a small village of about 20 houses, set in the lush green hills about 45 minutes outside of El Sauce. We split up in groups and spent the day walking far and wide to reach each house in the area. My group met back up with another group that was accompanied by a woman who was leading them around to the remote houses. The woman told me that she was a ´brigadista´ and that she was passing out flyers at each of the houses for a local health promotion initiative. Brigadistas recieve technical training in order to provide basic health care and medicine to mothers and children remote communities. The main function of brigadistas is to find and treat the most common infectious diseases in their communities, with the broader goal of saving the lives of children under 5. This program allows mothers and children to access basic services such as vaccination, treatment for diarrhea, and family planning methods without having to make the difficult trek to the nearest health post. Brigadistas mainly work from a ´Casa Base´ where locals can go to benefit from their services, but they also do some outreach and educational work in the communities. One of our teams had passed by the brigadista´s house earlier in the day and was told that the eligible woman was not at home. Luckily for us, she was happy to do the interview with me while walking us back the truck at the end of the day - a true field survey. It was a great ending to a long day, and we looked forward to our well-deserved weekend trip to Matagalpa.

Getting our feet wet....literally

Friday was a wonderful day. The first three teams headed out on the adventure that is field work – Destination: La Flor. We were told that it would take at least an hour and a half to get to the health post of Guayabo by vehicle, and from there we would have to walk at least 45 minutes to the community of La Flor. Our driver got us to the health post 45 minutes after we left, after crossing over several small rivers. We began the muddy climb up to the houses in the area, splitting into three teams: one for the lower regions, one for the middle of the mountain, and one that would go all the way to the top. Josie and I volunteered to trek to the top and we were pleasantly rewarded with beautiful vistas and a sense of accomplishment. Most of the families we encountered were willing to participate in the survey, and the household with 10 children even offered us warm fresh bread called ‘semita’– ¡Qué rico! The local health workers who came with us helped to introduce us to the families and intervened when we had trouble communicating in Spanish. The three teams reunited at the health post, and though everyone was worn out from trekking to every house in La Flor, we were energized as we recounted our stories from the day.

While we waited for the truck to pick us up it began to pour, and there were murmurs from our local counterparts about the rivers growing bigger and potentially becoming impassible. The wild ride back proved the tremendous driving skills of our fearless truck-driver. We huddled in the back under a tarp, bouncing over ruts created by the rain, and catching glimpses of the emboldened rivers we had crossed, grateful for our safe passage to the other side. The rain let up as we entered town, and we thought it was over. But it turns out that it starts raining in the mountains and then passes through town, so we caught the rain twice….but at least the second time we were happily showered and eating dinner in the Casa Blanca. We reviewed any survey issues that came up with the group and talked about the schedule for the following week.
The effects of Hurricane Alex came through and turned the streets into rivers that night, and it rained for most of the weekend. Several of us stayed in El Sauce for the weekend, and attended the 6th Annual Youth Talent Competition – young hopeful Sauceños dancing, singing, and reciting poetry for the chance to represent El Sauce in the larger competition in Leon in August. The kids were so cute (!) and we were happy to get a taste of the rich culture of the region.