Sunday, May 18, 2014

Spring Summary 2014

Beautiful mural in local San Cris restaurant.
There is so much work to be done in global health. In this region, Don Sergio is the only local safety net for wound and burn care.  It  is not a long term solution to the problem.  It is not sustainable and he knows it even though he's been working 6 days a week to give help to those who need it for more than 40 years.

Don Sergio is now 73 and although his energy level is good, he's not going to live forever.  There is no system in place to provide for wound and burn care in the future. 

In Mexico there has been little emphasis on prevention of diabetes.  Don Sergio sees more and more foot ulcers, amputations and other related type 2 diabetic complications.  It can be overwhelming and limited resources contribute to poor outcomes (see previous post).

Colorful mural painted on a home in Colonia Mexicanos.

My last day working with Don Sergio we saw an insulin dependent T2DM (type 2 diabetes mellitus) patient with a partial left foot amputation complication. The 71 year old wheelchair-bound man had an above the knee amputation of his right leg done a few years ago secondary to diabetes. His left foot, now is malodorous, there is pus, and the top and bottom of his foot are held together by large deep non-absorbable sutures (take these out and his foot will flop open like a book). Clearly an infection and the top of his foot is becoming dusky purplish (impending necrosis). His mental faculties are sharp but he complains of diminishing eyesight.  He discontinued his insulin as he felt it made his eyesight worse.  This is a common misconception for the people Sergio serves.  They believe insulin makes you go blind. Stopping his insulin only made his foot problem worse.
We see some serious and critical wounds so its nice to find beauty and peace in a local park.
 Lack of diabetic education is a huge problem. Prevention is the key but for those who already have diabetes they need to know how to control it.  Awareness of symptoms and proper healthcare follow-up are crucial.

It is very frustrating to me, having worked with the patients in Chiapas to never see  public health/education campaigns directly targeted to prevent diabetes on a national level.  The major advertising continues to be for soft drinks which are pervasive and easily obtained in the most remote villages.

In so many words, Don Sergio has expressed the need for a facility to provide medical care for these patients, i.e. access to care, as the work for wound care is piling up. With Dr. Mateo working with him earlier this year, maybe the idea of a proper wound care and burn center has appealed to him.  But a clinic would be more practical to begin with. Although, this is not the complete answer, it is part of the solution and other basic systems (e.g. education) can expand from there.

The local medical community is very aware of Don Sergio being a safety net and the director the hospital has asked Don Sergio to give a talk to the local physicians on causes of burns within the Mayan communities. Burns and minor skin injuries is how Don Sergio first fell into the wound care business.  Right now the burns are secondary to the diabetic ulcers.  When he speaks at the hospital it will be his opportunity to show the extent of the problem and his need for help. 
L>R: Don Sergio, Carolina, Iker, Cesar and Alfonso.  Sergio's el equipo.

I will not be there during his talk as I've returned to Tucson, but Erick will be there and will help him with a PowerPoint presentation. It seems Don Sergio has attracted a few international professionals that have taken an interest in supporting and helping. Don Sergio's connection and trust from the Mayan communities, international support, and a connection with the local medical community may one day yield that be continued.
Double rainbow viewed from our West Tucson neighborhood. Captured by professional photographer (and neighbor) Bob Torrez.

Posted by Patricia Ferrer.

Sunday, May 11, 2014

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.

Sunday, May 4, 2014

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.