San Cristóbal de las Casas

Tourism in Mexico is down, including San Cris. Usually, North Americans vacation at the Mexican beaches and don't realize the beauty of the pias adentro, country inside.  More than 60% of Mexico is 5000 feet above sea level and there are numerous old colonial cities throughout.

San Cris epitomizes all the charm of Mexican colonial cities. It is over 7000 feet above sea level, has historical landmarks, and el centro is a tourist mecca with shops and restaurants and tour agencies. The downfall is it's not so easy to get to.  Coming from the US you have to fly into Mexico City, then to Tuxtla Gutierrez, then take a taxi or bus 1.5 hours up into the Highlands.  From Tucson, I'd be thrilled if I could get here in 12 hours, however it is usually an average 15-hour day of travel.

Despite the 3 plane rides and taxiing here, its worth the visit.  The climate is cool in the evening and early morning, the sun is brilliant and strong during the day and right now we are getting afternoon showers. The flora and fauna are a mix of pine forest, similar to the Pacific Northwest, with desert cacti and agave plants. The local Mayan wear their traditional and fashionable textiles daily and you can learn to recognize which outlying village they are from by the clothes they wear.

Zinacantecas.

El Centro has colonial structures including elaborate churches from the 16th century.  Even older Mayan ruins; Toniná is 2 and a half hours away and if you want a full day excursion you can go to Palenque, one of the most impressive ruins in Maya Mundo. To learn about the local Mayan textiles and culture, Don Sergio's tour is a must, however, he will only give it if he has a larger group and there is also a nice Textile Museum adjacent to Santo Domingo church. (If you do go to Don Sergio's tour, please donate generously - reading this blog will inspire you.)

Toniná.

Atop of Toniná.

Lastly, Bela's Bed and Breakfast is the most charming place to stay in San Cris. For me, this is my San Cris home. The rooms are decorated with local artesanía textiles and crafts and I get to feast my eyes on a beautiful garden and planted succulents when walking downstairs to the salon for breakfast al gusto that always includes fresh squeezed orange juice. Last year Bela added a room with a loft that has a king bed on the bottom floor and 2 twin beds in the loft, perfect for a family with 2 children. The beds are so comfy and the location is perfect: in the el centro zone and one block from the Santo Domingo Church and market.

If you are looking to get off the beaten 'gringo path', but not too far astray, San Cristobal de las Casas is definitely worth the visit.

Posted by Patricia Ferrer.

Summer Trip 2015

Colleague and friend Jennifer Eldred, FNP has joined me this trip to help Don Sergio. We arrived on Sunday, 3 hours later than planned due to a cancelled flight and bad weather in Mexico City. Thankfully, we arrived safely at Bela’s at 1030pm. As always, she and her staff welcome us as family.

Monday morning we did our patient home visits that extended out to Teopisca, which is a 35-minute drive out of the city. We saw several patients from the area with various conditions: venous stasis ulcer, diabetic foot ulcer, slow healing leg wound on a diabetic, and 3 year old with a hot water burn on the top of the foot and a young man with an impressive lip dermatitis.

After a long day, we started at the museo/clinic at 430 and stayed until 8pm. There was standing room only. The number of foot ulcers continues to increase and, it appears, education about basic diabetes care is continuously lacking.

 

Exhausted from the day, Jennifer and I made it home at 830pm. We showered and crashed.

Thank you to Dr. Henry Beckmeyer at Michigan State University and his resourceful students. Your 4 valuable boxes of medical supplies are much needed and will be put to good use. 

El Regalo de Iker (The Gift of Iker)

January 15, 2015 Thursday

Jueves 15 de Enero

Bela's garden. Jardin de Bela.

Many people ask what will happen when Don Sergio is not able to provide wound and burn care to the people he’s been serving all these years. DS usually answers, ‘I don't know’ or ‘it will just stop’. It makes sense to train someone who can continue, but who would be likely to give of themself as DS does? People have wanted to help but the follow-through has been iffy and in the past, has compromised his trust.

Mucha gente pregunta ¿qué pasará cuando Don Sergio no es capaz de proporcionar atención y cuidado a las heridas y quemaduras a la gente ha estado sirviendo a todos estos años. DS generalmente responde, 'No sé' o "sólo se detendrá". Tiene sentido entrenar a alguien que puede continuar, pero ¿quién sería capaz de dar de sí mismos como DS? Personas han querido ayudar pero el seguimiento ha sido incierto en el pasado, y ha comprometido su confianza.

 

In this seventh year of my working with DS, I have been the consistent medical help that returns again and again…. as far as I can tell.  Thankfully, that has changed.

En este séptimo año de mi trabajo con DS, he sido la constante ayuda médica que vuelve una y otra vez... en cuanto lo que pueda ver. Afortunadamente, esto ha cambiado.

Iker works while DS looks on. Iker esta trabajando
mientras DS mirando.

Iker, from the Basque region of Spain, said when he arrived at his posada last year, he briefly met someone who told him of Don Sergio. Iker went on DS’s tour and then came back later to see if he could help. DS told him, “only look, don’t touch”. Iker, a well-trained RN with a lot of experience with serious wounds, saw DS getting busy so he stepped in and got to work. He has been in San Cris for almost a year and helps DS most evenings at the museo.

Iker, de la región Vasca de España, dijo que cuando llegó a su posada el año pasado, brevemente conoció a alguien que le habló de Don Sergio. Iker se fue de gira con DS y llegó más tarde para ver si podía ayudar. DS le dijo: "sólo mira, no toques". Iker, un enfermero registrado con mucha experiencia al trato de heridas graves, vio a DS ocupado por lo que intervino y se puso a trabajar. Él lleva casi un año en San Cris y ayuda DS por la noche en el museo.

The gift of Iker is trust.  El regalo de Iker es la confianza.

His working with DS consistently has built trust.  Shortly after his arrival, Cesar and Alfonso, two Coletos jovenes (young people born in San Cris) showed up wanting to learn and help DS as well. They both plan on attending medical school and are eager to play a part in some type of patient care exposure. Of course, it is my hope, these Coletos will continue to help and possibly return after all their medical training.

Su trabajo con DS consistentemente ha construido confianza. Poco después de su llegada, Cesar y Alfonso, dos jovenes Coletos (jóvenes nacidos en San Cris) aparecieron y quisieron aprender y ayudar a DS también. Ambos planean asistir a la escuela médica y están dispuestos a participar en algún tipo de exposición al cuidado del paciente. Por supuesto, es mi esperanza, que estos Coletos continuarán ayudando y posiblemente volver después de todo su entrenamiento médico.

From my observation, it was Iker’s presence that made this easy for DS to train and trust them. Iker’s natural energy is sweet, loving, compassionate, and fun and he has a grounded presence everyone is attracted to.  Los jovenes look up to Iker and DS and I can’t imagine better role models.  Now Edith (another premedical Coleta) is helping and its obvious DS appreciates and enjoys their help.

De mis observaciones, fue la presencia de Iker que hicieron esto fácil para DS entrenar y confiar en ellos. La energía natural de Iker es dulce, amoroso, compasivo y divertido y tiene una presencia que todo el mundo se siente atraído. Los jovenes admiran a Iker y DS y yo no puedo imaginar mejores modelos a seguir. Ahora está ayudando Edith (otro pre-medicina Coleta) y es obvio que DS aprecia y disfruta de su ayuda.

Foreigners that come from countries with good medical resources are changed when we spend time in parts of the world where there are great disparities. Once you see things a certain way, you can never close your eyes to them.  This change creates an irreversible desire that moves you to do what you can in your world to make it better in theirs.

Los extranjeros que vienen de países con buenos recursos médicos cambian cuando pasan tiempo en partes del mundo donde hay grandes desigualdades. Una vez que ves las cosas de cierta manera, nunca les podrás cerrar los ojos. Este cambio crea un deseo irreversible que te mueve y al hacerlo querrás hacer todo lo que está en tu mundo para hacer mejor el suyo.

In the near future Iker will be leaving San Cristobal on his bicicleta to unknown Central and South American destinations for an unknown length of time, hoping to promote blood donation and finding ways he can help along the way.  He has no concrete plans; just to live and help on this journey of life.

En el futuro próximo Iker se irá de San Cristóbal en su bicicleta a destinos desconocidos de centro y Sur América por un período de tiempo desconocido, la esperanza de promover la donación de sangre y encontrar maneras que pueda ayudar en el camino. No tiene planes concretos; Sólo para vivir y ayudar en este camino de la vida.

Iker believes there are no coincidences and his time here was meant to be…this I agree.  Iker told me that this may be the last time we see each other, but I don't believe it, nor do I feel that way.… I think our paths will cross again, somewhere, someday.

Iker cree que no existen las coincidencias y su tiempo estaba destinado a ser aqui...estoy de acuerdo. Iker me dijo que esta puede ser la última vez que nos vemos, pero no lo creo, ni me siento así...Creo que nuestros caminos se cruzaran otra vez , en algún lugar, algún día.

L>R: Patricia, Santo Iker, Mexico’s future physicians: César, Edith, Alfonso.

Thank you Iker, we love you! 

 I > D: Patricia, Santo Iker, los futuros médicos de México: César, Edith, Alfonso.

Gracias Iker, te amamos!

There are more photos of Iker in past blog postings over the last year.. Hay más fotos de Iker en publicaciones en esta blog el año pasado.

Posted by Patricia Ferrer.

El Problema es.........

-->May 11, 2014

The same in the United States but at different levels:  lack of nutritional and health education, public health services, reasonable access to healthcare with cultural awareness, and in San Cristobal, adequate resources for healthcare professionals to deliver optimum healthcare.

These statements are my personal observations while working intermittently with Don Sergio over the last 6 years. Seeing the consequences of these deficiencies brings me to these conclusions.

Lack of nutritional education.  

Sweets are hard to find in nature so our bodies have not evolved to handle consuming large amounts of sugar. This early and chronic consumption can result in type 2 diabetes (T2DM) at an early age as the pancreas’ ability to produce insulin wears out in keeping up with elevated blood sugar…hence the term ‘impaired glucose tolerance’, aka IGT. We often see many 30-somethings with out-of-control diabetes and horrific foot ulcers are their first obvious signs of this disease - they are unaware they have diabetes.  Interestingly, these people are not obese, as in the US,  some may carry 2-10 kg too much, but not all.

Typical aborrotes packed with soft drinks.

It is not unusual to see a mother pouring a refresco in her baby or toddler’s drinking bottle, or just letting them drink straight from the soda bottle (I see this in the Hispanic US population too).  The sugar content in these 400ml/~12 oz drinks is about 46 grams. There are 4 grams of sugar in a sugar packet. That means there are 11 packets of sugar in one bottle. When this starts early in life, the taste of water does not ‘taste good’, therefore continued consumption of sugary drinks seem normal. 

It is not unusual to see a 3 year-old child with deciduous (baby) rotten teeth. The acid in the soda breaks down the enamel and the oral bacteria feed off the sugar creating an imbalance of oral flora and therefore damaging the teeth.  I saw this clearly with our 3 y/o boy that was burned with hot liquid on his chest, abdomen, and hand. He had a dark brown nub of one of his front teeth and a few others were beginning to rot. His parents fed him soda to try to distract him during these wound-dressing changes. Pain medication would have been ideal but it is not available.

In some places you have to ask the staff to unlock a door to buy toothpaste, or it's behind the counters in the pharmacy.

For some reason in Mexico (this is in the north and the south) for the poor population, oral hygiene is not advocated. In Tucson, many of our Mexican immigrant patients need emergency dental care due to tooth abscesses, sinus tract development and grotesque caries due to lack of basic dental care and oral hygiene. Poor oral hygiene and early soda consumption appear to be a bad mix.

Lack of health education, aka PREVENTION, ¡por favor!

Diabetes is at ~11 % in Mexico and at ~7% in the US; these stats reflect the number of those actually ‘diagnosed’! There are numerous people with IGT in which 30% of these people will go on to develop T2DM if they are not educated and informed on how to prevent the progression. 

Global T2DM is increasing in mid- to low-income nations but high-income nations have their burden too. If we don’t educate our youth (and all for that matter), we will exhaust an enormous amount of resources.

Diabetes puts in motion the following problems: heart and vascular disease, kidney and eye disease, and neuropathy. This can lead to high blood pressure which increases the risk of stroke; kidney failure resulting the need for dialysis; eye disease leads to blindness. Neuropathy (burning, tingling, numbness of lower legs and feet) results in inability to feel a pebble in a shoe which can lead to a small ulcer, then infected ulcer, then amputation, etc. Complications from diabetic neuropathy is the main reason so many wound care centers have popped up in the US over last 15 years.  Don Sergio tries to fill the local wound care void; hence the 120 + patient visits per week.

Public health promotion.

I have not lived in Mexico long enough to comment with complete understanding of the public health (PH) system. However, Bruce and I were living in Oaxaca for 3 months in 2009 during the ‘Swine Flu Epidemic’ and it appeared the public health system rose to the occasion as did the government. PH vans roamed the neighborhoods knocking on doors asking specific questions about symptoms of illness. Well-publicized professional soccer games in large stadiums cancelled, as were schools and offices to contain the spread. It was quite impressive how Mexico responded. I don't think we in the US would cancel any professional sporting event to contain an infectious disease.

Common cooking stove.

Some people can't afford a stove and wood burning to cook is their only option.

 This being said, in the San Cristóbal region, education on preventing common burns and diabetes seems non-existent. Small children frequently get burned with hot water or oil, the ubiquitous fire crackers use can cause serious damage, and neurocysticercosis can cause epilepsy and those centrally located, non-enclosed fire blocks in the home seem to be a magnet for one experiencing an epileptic seizure. Public service announcements, posters, television blurbs could make a huge impact. The US population can benefit from these public service announcements as well and we have resources to do so, but for some reason don't implement.

Don Sergio finds remnants of feugos artificiales.

Cultural awareness is so important.

This is one place in the world, in the Americas, that still has a heavily populated Mayan/indigenous culture with their own style, beliefs, dress, language and ways. These cultural identities can vary from town to town. It is a pleasure to be able to experience the diversity.  However, with healthcare, there must be a bridge and understanding their culture as to yield the best results when caring for these unique groups.

Resources for the healthcare system.

I often hear the Mexican physicians and nurses go on strike not for money, but for resources to provide better care. These physicians and staff want to help and do their job well, but resources are limited which can result in bad outcomes.

So what is the solution?

Do what we can within our abilities to improve these flaws. It has to come from within a community and we (wherever we are) must have the desire to be part of the solution. However, this is difficult when the infrastructure to support these ideas is not in place.  As with every visit here, I ask Don Sergio, “Why do you do what you do?”. His response this visit is, “I don’t want to be closed in and think about myself, I want to think of others and be part of the help and solution”….”people need help”.

Okay, I’m stepping off my soap-box. To reduce the suffering and needless life/limp/game changing ailments we must invest in education: not just in Mexico but in the US as we are no better. We have our own burden of T2DM and it appears to be taking the globe by storm…..we’ll soon match Mexico’s 11% of diagnosed diabetics if we don’t do something.

Posted by Patricia Ferrer.

The Help

May 4, 2014

Friend and artist Violeta Abitia's color pencil drawing of a resting dog.

 Since New York Times video by Janet Jarman and article by Elisabeth malkin last year and more internet exposure more people have become interested in what Don Sergio does and want to work with him. Many locals have known about Don Sergio but the internet makes it easier to learn about his work and a way to contact him: his official website Yok Chij. In addition, the documentary done by Consuelo Alba and John Speyer, El Andalón, gives a very good overview of his 50 year history of being in the Highlands of Chiapas.



Our new friend, Erick, has decided to move to San Cristóbal for the next 3 months. Sergio will have the benefit of having constant help most of the summer.  Erick had to return to Galveston to move things out of his apartment before month's end and wanted to visit family and friends in Connecticut while in the US. He will return after I leave.

L to R: Sean, Wilhelmina, Kirsten, me, Eric. Oscar took the photo.

The Graff family from Salt Lake City, who lived here for a year 2012-2013, returned for a 2-week vacation prior to my arrival. I was lucky to catch them the last night before their departure back to the US. Sean, an RN and the father, worked with Don Sergio every Monday while here and drove him to see all the patients. They continue to advocate financial and medical material support.

As for local help, Carolina continues to work with Don Sergio 2 nights per week and a local friend has brought another young lady to see if she can work with Don Sergio. It seems as the flow of soft waves lap on the beach, help comes and goes, but always comes back.

Carolina and Iker.

Another interesting fellow has also shown up to help Don Sergio. Iker, a nurse from Spain's Basque country, and his girlfriend of 10 years, have been traveling the world for three years and have landed here for a few months.  In their desire to learn more about the places they visit, they volunteer their time. This exposes them to things the tourists does not see and enriches their life and knowledge. Iker, comes to work with Don Sergio 4-5 times a week mostly in the evening clinics. He has helped tremendously as we've been so busy.

Sergio and Iker.

Lastly, in those lulls of retreating waves, friends of Don Sergio continue to support and help from afar on many levels. This support helps allow Don Sergio to purchase supplies and sustain himself and family.

It's no surprise the draw of working with Don Sergio has on an individual. He attracts loving and kind people, those that give of themselves, those that watch his work from afar and want to support him.

For me, my gain is immeasurable: I work along side a living saint while working with the local people from various areas, meet like-minded locals and foreigners, see and learn medicine in a different setting than in the US. The experience is one of the richest one can have in a lifetime.

Posted by Patricia Ferrer.

Dr. Mateo's Experience

February 12, 2014

Tucson wound care physician Scott "Mateo" Bolhack has returned from his first 'working vacation' in Chiapas.  I asked for his comments and observations of his experience....I believe this may be a bit different from his private practice in the US.

There are no appointments.

The patients come in and wait on the bench patiently.

No one complains if they are waiting and no one complains how long they may have to wait.

No one says that they are in pain. No one complains of pain.  They thank you with a kiss -- your right cheek to right cheek or handshake – always.

They are given their leftover supplies and they return the next day with the supplies for you to use.

They hold the flashlight for you.

Sometimes, the waiting families and patients who are waiting to see you hold a flashlight also.

Don Sergio's Tenejapa black saints placed behind the green waiting benches.

There are no barriers to care: no insurance, no phone calls, no confirming coverage, no appointments to make, appointments to cancel.

This is Sergio's office. You ask him for for 'permiso' to take care of a patient or he directs you to do so, so that the patient knows that he has approved.

  

The kind man with neuropathy/heal wound due to an electrical injury 20 years ago comes in. He was offered an amputation by the local doctors. Don Sergio says no [amputation] ”not necessary".

I have now worked on this man's foot every day since I have been here and every night his family comes with him. He waits patiently to be seen.

Much better;"mucho mejor" I tell him.

He comes with his wife, who wears a traditional dress. His boy, age 4, looks directly over my shoulder each evening. So small in stature, he looks like a two-year-old.

He never cries, he never winces, stares intently analyzing what I am doing. He is my little inspector.

Last evening, I held this hand and walked him over to the supply room. I handed him a soccer ball that was as large as his entire torso. Before his parents could instruct, he says open "muchas gracias".

Nadia, my special interpreter told me that the wife asked if I eat homemade tamales. More handshakes; the patient will return on Monday for further care. -->

 

Iglesia de Guadalupe.

 This is a city filled with cultural humor.

 

It is a city of neon Guadalupe Saints, Negro Jesus Christos, and water trucks that announce themselves by playing Burt Bacharach's "Raindrops Keep Falling on my Head" (in a city where very little English is spoken). 

It is the same city in which the mannequins displaying woman jeans are turned so that you can see the buttocks.  

The Chamulas, a native Mayan population punish their prisoners sometimes by making them spiritual leaders in the community.

Chamula community leaders, photo taken 2009.

Our only accessible pain meds, although you can buy Tramadol OTC.

And so for the elderly gentleman who fractured his femur was sent home without a brace, he cannot be treated with any opiate pain medications. So that in the country drug wars and drug lords, it is very difficult to order any opiate medications for any patient in pain.

Written by Scott Bolhack, MD, posted by Patricia Ferrer, PA-C.

Conditions of Care: August 2013 Trip Summary

For Don Sergio's make shift wound care clinic the conditions we work in are not the cleanest. He does the best he can with what he has and its all the locals have.

His stocked travel bag is always by his side.

The chairs we use are tiny, Don Sergio always looks up to the patient, never downward.

For house calls he adequately stocks his travel bag with what he needs for the daily rounds.  For the museo/clinic he keeps this bag at his side, on the floor and uses small chairs for a foot rest for dressing changes and the burn patients sit in an larger chair.

The 'dispensary' room.

There is no privacy as those waiting are sitting on one of two benches behind him. HIPPA patient privacy rules don't apply. He does have a dispensary/supply room with poor lighting which is where I usually work. Thanks to Clínica Amistad in Tucson, they donated a wall mount oto/ophthalmoscopy that I use for focused lighting when necessary as well as it's functional purpose.

As for supplies, here's how it works:
 - people from France and the US with access to medical supplies ship them to him. The supplies he receives differ depending on what people have access to.
 - from the US, I ship donated and purchased supplies to San Cristobal from Nogales, Sonora via Correo Mexico. (I drive across the border, have aduana's search through the items and give their stamp of approval.)  If anyone would like to donate supplies to Sergio it would be best to send them to me in Tucson. Contact me by email if you are interested.
 - if patients can afford it, they will bring in their own supplies which Don Sergio will use.
 - visitors who are aware of Don Sergio's work will have collected supplies and bring them down as well.
 - donated money allows Don Sergio to buy medications, creams and supplies locally.

Many people ask "what does Don Sergio need?".  From my observation:
 - Funding: although this is a small operation it is costly and time consuming as Don Sergio sees about 100 patient visits per week.
 - A constant stock of medical supplies (gauze, gauze wraps, wound dressings, medicated ointments, etc - see Yok Chij website Support page).

These conditions are not easy for a US-trained healthcare provider to work in. One has to keep an open mind and adjust to the patient's culture, mindset and expectations. This is challenging and satisfying when results are obtained and a positive difference is made; its disheartening when resources are so limited there is nothing that can be done.

This visit completes my 8th trip working with Don Sergio over the last 5 years and it is so gratifying to assist this septuagenarian provide needed medical services that are otherwise not available.  Don Sergio is unstoppable even after his auto accident in Febuary 2013 that caused him to lose all his upper teeth (his face hit the dashboard). An avid supporter of Don Sergio has given him the money to have him fitted for dentures, I hope he uses this for himself and not others.

Don Sergio lost some mobility in both wrists and hands in his auto accident as well. A physical therapist from Monterrey Mexico had been on his small tour the night before and came by to work on him.  He does accept help from others.

I plan to return January 2014.
Post by P. Ferrer, PA-C