First snufflings of swine flu

The clinic I am working at has been shut until Thursday, because of worries about swine flu!

It just goes to prove that even the remotest communities are privy to the press in this globalised world of ours.

Whether or not there is a real risk to the schoolchildren of catching the disease we are unsure - I´m not convinced not going to school will work as a preventative measure anyway, considering that many of the families here, especially in the poorer communities in the foothills I am working in, live tightly packed with up to ten people in a one-roomed house, all breathing in the same smoke-filled air.

Hopefully we will be fully functioning again by the end of the week, at least for the walk-in patients. Their immediate needs of treatment for common infections in this area are far greater than an incipient risk of swine flu, although I can see that in such communities one person contracting the illness could lead to a complete local epidemic, which would have great cost to the villagers as it is harvest time for many of their crops.

But as with all things out of human control, all we can do is be as prepared as possible and just ´wait and see´.

Lago de Atitlan

I woke up at the same time as the resident rooftop cockerel in order to start my first weekend trip, to Lago de Atitlan, a vast, beautiful lake in the highlands created by the collapse of a volcanic cone (a caldera - http://en.wikipedia.org/wiki/Caldera).

I decided in an adventurous spirit to undertake the short journey by chicken bus, brightly painted old schoolbuses used as public transport. Little did I know that arriving at the bus terminal in
Xela, that it would actually consist of buses queued up
along various congested roads surrounding a monstrous maze of a
market with throngs of people hurrying in the early morning mist to buy their weeks´shopping or to cram onto one of the many impatiently waiting buses. Horns blaring through the crowds signalled buses about to leave, and after three misdirections and sitting on an unmoving bus for twenty minutes, I finally made it onto the right one. Why I thought the station would consist of orderly rows of clearly labelled vehicles and politely queuing passengers I have no idea! I also soon learned that if a bus was labelled ´Panajachel´ it was probably going to Antigua and one labelled ´direct´ wasn´t likely to be going anywhere at all...

The journey itself was an incredible experience. Not only did I get to see the vast highland mountains I had arrived blindly via roll past under clear blue skies, all of my other senses were alerted too. It turned out to be more of a rollercoaster than a bus ride, people jostling for front row seats as we hurtled at breakneck speed around sharp bends cut into the hills, the rickety bus leaning into the corners with its load of baskets, sacks and animals precipitously balanced on the roof above us. The young boys working as conductors hung precariously out of the open door, yelling our destination to pedestrians as the bus slowed almost to a stop with just enough time for new passengers to get one foot on board before we were off again (regardless of whether they were tottering old men with canes, or mothers with babies bundled tight against their chests). Often we´d set off before the boys had returned from stowing cargo on the roof, and their legs would swing acrobatically into the door with only their ruffled hair to show. At first I felt sorry for them, working hard in such a dangerous job and at a young age, but I came to realise they were proud, running a tight ship, their strong muscular backs ruling the bus highway.

I was made most aware of my senses by the unabashed, direct stares of young children, looking questioningly and expectantly at me from between the seats in front. Their charcoal black eyes seemed to invade my thoughts, conveying both intrusion and intrigue as to the world I came from. I got the feeling that they were innocently airing the thoughts of the adults, who smiled graciously and answered my stumbled inquiries as to where we were, otherwise ignoring me.

Eventually the lake came into view between the crowded heads, not receiving a second glance from others going about their days but an internal gasp from me. Its vastness is indescribable and mesmerising, drawing your eyes as far as they can see.

To travel between the various lakeside villages you do so by lancha, ferries that bounce across the impenetrably deep choppy waters, spraying you unsubtlely with its surface. All around the shores are dotted isolated hamlets, farmers tilling the soil by hand for their crops of avocados, coffee and bananas. I stayed in San Pedro de Laguna, described as a party town but actually having much more substance to it than that. Yes, it had bohemian candlelit bars lining the main streets and ugly concrete hotel blocks popping up between the single-roomed ramshackle houses of the inhabitants, but somehow the revelling tourists buying tat from stalls and sounds and smells of families cooking around open fires in their simple abodes nestle comfortably side by side. It is almost as if the foreigners are ignored in order to bring some revenue into the town. But I could not ignore the locals, dressed in their textured dresses and chatting animatedly in shop doors, and made a point of straying from the main strip to see more of the real town - though I ended up hopelessly lost in the myriad of homes piled on top of each other, tiny smallholdings and scruffy dogs separating who owned what.

The morning view from my bedroom window was one you would pay hundreds of pounds for in another land, a ´luxury´ panorama, the sombre sun sparkling on sheer glassy water - the one thing that reminded me where I was was the woman on the rooftop directly below scrubbing clothes in an old tin pot and stoking the fire under a huge vat of beans. I sat reading all morning, such a luxury to think about nothing but enjoying the peaceful views in front of me and creating the images from the book in my mind. Although I had a glimpse of what it must be like to admit your profession to anyone - the Romanian girl in the next room came out to ask me my opinion on why he had a swollen neck gland and what drugs she should buy from the pharmacy. I´m realising that medicine is not something you ever take a holiday from in any country.

A failed attempt to find Maximon, a cigar-smoking rum-drinking deity in the town of Santiago. He moves homes every so often, meaning you have to ask where he is currently residing (Ok, I foolishly followed a young boy who said if I paid him he would take me there, being led along deserted streets in the schorching afternoon heat before coming to my senses and asking two wise looking old gentleman who said Maximon was 4km away and the boy was taking me to a fake - I got rather angry with the precocious boy actually, it felt like the little set-up he and his friends had going on was sniggering in the face of all the honest, good-hearted souls I have met previously). I returned to Panajachel, (the main town on the lake) to find a way back to Xela. But something about this place has captured me, with its mix of picture-perfect scenery tempered by the human detritus created by locals living off the land and holiday-makers filling the silent mountains with clunking of glasses; it seems like our way of saying ´cheers´to the world for providing such a beautiful place to relax.

This feverish happiness and the cooling breeze off the refreshing water should be drunk in with some temperance however: it is here that hundreds of people were buried alive in their sleep by the monstrous mudslides created by Hurricane Stan in 2005. http://www.atitlan.net/video/hurricane-stan.htm

I finally left early on Monday morning, catching my final glimpes of Atitlan as we ascended up the mountainside. I may have cheated by ordering a private shuttle (nothing to do with being lazy, just making sure I got back to work on time...)

Preventative medicine at it´s rawest - I saw this tacked to the wall of a crumbling building on my walk home today. Don´t think I´ll be taking up their offer though...

Primeros Pasos

Before arriving at Primeros Pasos for the first time, I am not embarrassed to admit I was petrified. Of simple questions such as how I was going to find the place, of worries that my (very) basic Spanish would prevent me from being remotely useful, and that pit-of-the stomach nervousnes we all fel when we are about to embark on the unknown.

My fears were quelled instanteneously, were made a mockery of, as soon as I leapt off the cog-grinding old yellow schoolbus that had bumped its way through ruts and potholes in the road up to the clinic in the foothills of the Paljunoj valley. I was greeted by open grins from children chasing about in the waiting area, and warmly greeted by the other volunters. A ´guided tour´of the clinic made me realise how much can be achieved in such a small space with very litle equipment or technology. There is a reception area (a desk and rusting filing cupboard in the entranceway, with an old computer that switches off smugly with the frequent power cuts), three consulting rooms consisting of a concrete floor, black plastic couch from the 1970s and scatttered instruments, a lab which is a bench with a lone microscope and much-used slides (mostly for watching giardia and various ova and cysts stare back at you with glee from faecal samples), a pharmacy with donated boxes of brightly coloured pills lining the shelves and a classroom with homemade posters and stories for teaching the schoolchildren about health and hygiene.

I was amazed at the trust proferred to me simply for having the title ´medical student´. Along with Guatemalan medical students, we take histories and examine the children and walk-in patients that walk to the clinic from their villages in the hillside, before testing samples, making a diagnosis and dishing out medication. Whilst most of the problems are simple, a respiratory infection from cooking over open fires in the home, gastroenteritis from various tropical (and not-so-tropical) bacteria and protozoa, and aches and pains from hard toil on the fertile land, the ignorant trust these people place in my diagnoses and treatments frightens me. I know if some foreign student turned up in my town and told me I was suffering from X and should take this medicine (probably only just in date), I would point-blank refuse until all reasoning had been fully explained to me. Thus is the benefit of an education, of the freedom (or trappings?) to be able to choose.

This region of Guatemala is predominantly of indigenous populations, a people discriminated against and particularly affected by the ramifications of a recent civil war. Lack of education and basic commodities and little help from government - in fact often the exploitation by politicians - has led to an infant mortality rate in excess of 25%. Much of this can be accounted for mainly by problems of poor nutrition and preventable infectious disease, and lack of access to healthcare - in this region there is one doctor and one nurse for a population of 15000 people.

Hence the work at Primeros Pasos is invaluable to the children in this area. All schools in the 10 communities served by the clinic participate in a health edcucation programme (hygiene and sanitation, nutrition, infectious disease prevention and so on) and receive a yearly check-up. Women in the area are also targeted, by programmes in their own villages that teach them about basic health and hygiene, and empowerment through encouraging the women to become involved and teach others what they have learned themselves. Many studies have shown that improving the education and health of women in rural communities is key to improving the health of the population, and is one of the UN´s Millennium Goals http://www.who.int/mip/2003/other_documents/en/MDG3.pdf And here the key really is primary, preventative healthcare.

However great their plight, all the people I have seen at the clinic are happy and smiling. Whether this is because they do not know the scale of the healthcare problem here, or whether it is because they have learned the hard way to smile in the face of adversity, it is a refreshing change to patients in England who grumble that they had to wait an extra ten minutes to be seen, or that the newest and most expensive treatment they have seen advertised on the internet is not available to them right now.

We can only want what we know about: I am beginning to believe that knowing too much can be a dangerous game, and serves to make us unnecesarily greedy when not tempered by a little realism.

After all this seriousness, I will end by exclaiming as to how joy-filled my days are, roaring through the placid villages in the gas-guzzling schoolbus to be greeted by the friendly faces of the other volunteers (Emily, Katie, Fergus, Chris and Elizabeth to name a few) and the ear-to-ear grins of the children we are seeing - at least until we advance towards them with a threatening stethoscope, or worse, oroscope. I wasnt even deterred on my second day when I stepped off the bus into a knee-deep muddy people, to the glee of the schoolchildren watching´...

Bienvinidos a Quetzaltenango

I arrived in Quetzaltenango, or Xela (pronounced shey-lah), in a gear-crunching, cog-grinding bus travelling on the ´new road´(read: not yet built in most parts) in a torrential downpour, the heavy grey skies pounding the tarmac and steaming up the windows. So my first impression of the place, as I scuttled along deserted ´Avenidas´ late on Sunday afternoon with rainwater pouring into my sandles and soaking my backpack, was not wonderful. I furrowed my brow against the elements in that way us Brits are expert at, and curled up in bed with a cup of tea to try and warm up as soon as I reached a hostel. I lay there dozing, thinking once again ´What on earth am I doing here, why am I not on a hot tropical beach somewhere soaking up the rays?´ That question was to be answered the following day. It was still drizzling, that misty rain that dampens you hair and your soul, everything, even the magenta, turquoise and ochre houses appearing dull and grey. But my mood lifted as I joined other volunteers on the stone steps to catch pur ride up to Primeros Pasos, in the foothills of the surrounding verdant mountains. An old yellow school bus bumped and bounced its way up the dirt tracks, through what appeared to be the city´s dumpsite, up to a simple breezeblock building nestling in a small village. It certainly does not look much from the outside, but within seconds of stepping inside those walls a sense of warmth, and welcome, and people really making a difference up in these lonely villages suffused me. There was such an energy about the place, even though there were not many patients as the schools are closed for holidays. More about Primeros Pasos in the next post.

Xela itself is similar to Antigua in design and architecture, but with much more

grit and reality. Here, the people walking the cobbled streets are people heading to work, or visiting friends, not tourists, and the sparse gringos are here for the long-haul, studying Spanish ($3 per hour of one-to-one tuition...) or volunteering at one of the many trekking, medical or environmental charities around this area in the Northern Highlands. Xela is noisy, busy and polluted yet peaceful, frantic yet calm, a place where new sights and sounds batter your senses like the rain yet move you to feel settled almost instantly.

I am staying in Casa Argentina, a sprawling building of private rooms with a shared courtyard and kitchen area. My room - $2 per night - has not only a double but a single bed, a crackling old TV, and a balcony view across the rusty tin rooftops of Xela. The mornings are provincial and subdued, the town waking slowly as the sun warms these rooftops, becoming animated as vendors sell their wares in the street and shopkeepers make their money. It feels suspended between a slightly damp grey industrial town in Northern England and a 19th Century imperial

court. The contrast between familiar and extraordinary is rife here, surprising you at every turn. I watched children playing barefoot in the muddy straight right outside a neoclassical building that houses the main bank, a guard armed with a shotgun preventing them breach the entrance. All over town, young girls dressed in traditional woven skirts sit in internet cafes playing online games and movies.

There are so many signs of progression, but an air of something underground holding it back. Guatemala was recently voted the worst democracy in Latin America (some stiff competition there). When I find out what that something preventing the de-marginalisation of Mayans and reduction of poverty is, I will let you know. Something warns me it may be to do with power, and violence, and lawlessness - I read today that 70% of the arable land here is owned by 3% of the population - leaving more than 50% below the poverty line.

Antiguan fire

Guatemala City was exactly as described in all the guides I have read: dirty, dangerous, and dull. In the few short days I have been in the country, I have heard countless frightening tales of that city from other travellers, from stumbling across a dead man in the street to being bribed by police armed to the hilt. So I think I made the right decision to get out of there as quickly as possible, heading to the old colonial capital Antigua.

Antigua is a fairtytale city, brightly painted houses lining cobbled streets along which horse and carts trundle, set in the basin of three volcanoes rising majestically into the slate-coloured sky.
It has an eery feel to it, when you escape the tourists (of which there are many, especially Americans, in the Parque Central) by walking to the edges of town and entering the numerous crumbling pieces of architecture that have designated this city a UNESCO heritage site. In one old convent I found myself completely alone, with stunning views through gateways and plantlife creeping out of cracks in the softened stone. But it did not feel peaceful. Even here there is an ominous air of danger, numerous muggings in the past being dampened by the installment of the ´tourist police´ in 2005: guards armed with shotguns appear on streetcorners, at the bustling market, in church doorways, even guarding deliveries of water to shopkeepers. I did not feel in danger at any time, locals being more friendly than ever, but it certainly gave you a heightened alertness, a look-over-your-shoulder before walking down a street alone. In a way I found this refreshing; at home I take my safety for granted all the time when perhaps I shouldn´t. In the evening I had an intersting debate with some American college students and an Irish teacher over the gun law. Of course, all we concluded was that gun use in a country is largely shaped by its´past experiences, its´stability both economically and politically, and its current culture. Here it is every man for himself, and if the muggers and police have guns, then you want a gun also. It is simply self-protectionism, which all of us are guilty of. It is just a shame that they perceive they have to resort to violence in order to survive. The argument became rather heated, predictably the Americans pro-weapons and us anti-, especially the more of the local ´fire water´and ´pollo´beer was consumed...

To clear my head, the next day I joined a trek up one of the volcanoes, Volcan de Pacaya, (http://www.youtube.com/watch?v=_3h16HOPgXQ) which I had heard was rather active but offered stunning views across to the other mountains in the region. So we set off in the drizzle, which turned to a downpour and eventually bullet-sized drops that hammered the roof of the van. Luckily we rose up through the clouds into a fine mist hugging the emerald slopes, and tumbled out at the base to be proffered walking sticks chopped down by local children. We declined, but soon wished we hadn´t as we began to ascend the steep, slippery path accompanied by shouts of ´taxi taxi´from horsemen. But nothing could pervade thje silence and stillness of our surroundings, suddenly rising up out of dense vegetation to a clearing with indescribable vistas across to another volcano, its peak proudly jutting out of the cotton-wool clouds and spewing out toxic, angry black fumes. We skidded our way down the steepest ´black run´of magma I have ever seen before clambering over recently flowing lava formations, a lonely moon landscape, to reach the still flowing glowing molten lava a little higher up. We toasted marsghmallows in the angry embers, the most successful barbeque I have ever seen. The air filling my heaving lungs was chill, but the ground beneath our vulnerable feet was burning only a foot below, blasting us with hot air that in some places you simply had to get away from, your retinas feeling scarred by the fire and from the incredible views. It was breathtaking and exhilirating, a real show of what danger is. I am much more frightened of mother nature than men with guns.

In Guatemala, Health and Safety does not exist. As humans, we must learn to trust our instincts and look out for our own wellbeing, whether it be standing on an active volcano, on a busy foreign street, or simply going about our everyday business.

A Guatemalan Welcome

Leaving Heathrow at ridiculous o´clock in the morning on Thursday with my stethoscope in my bag, I sleepily contemplated what I was flying off to Guatemala to achieve. I am excited and intrigued to be exploring a new country and learning about a new culture, but I couldn´t escape the medical side of things either. The Panamerican newspaper I attempted to read on the flight had an expose on the growing problem of C.diff in Honduras and Costa Rica. The Costa Rican couple next to me were intrigued that I´d chosen to work in Central America, and pleaded with me to return one day and fix Dengue Fever in their country, a little researched and poorly treated disease because it doesn´t make enough money for the pharmaceutical companies and none of the indigenous people can afford the drugs anyway. It scared me, the way they looked at me with pleading, hopeful eyes. They truly believed that one person, just an average medic from England, held the power to improve the health situation in their country. That brought home to me how healthcare has changed so much at home in the UK, with the reduction of paternalism and contantly increasing choice available to the patient. Out here, they cannot afford the luxury of choice, they cannot afford any form of treatment at all, and so someone, anyone, coming to provide such treatment becomes instantly respected and needed. In all honestly it was a gratifying feeling, to realise that we can do things in this life which are useful and appreciated, but at the same time a feeling of guilt and fear combined to form an irrepressible feeling in the pit of my stomach, a feeling of the unfairness of it all.

But instantly on arriving in Guatemala, the feeling shifted. The Guatemalans are a happy, friendly people who will go out of their way to help you or just to be nice. At the airport, a man lent me his phone for free and a young boy led me to exactly where I needed to go with no expectation of a tip, simply a ´gracias´. I was introduced to Guatemalan food by my hostel owner, who cooked me a fresh meal from scratch at 9pm, and made me feel so welcome, playing with her baby son and chatting around the long kitchen table until I could not keep my heavy eyelids open any more.

The locals seem to go about their days on ´Guatemalan time´, a term I was introduced to by an American I met who had been travelling here for three months, and explained that the sweltering days can seem to stretch on for infinity when you are moving at their relaxed pace. They wander the streets, wearing traditional brightly coloured embroidered dresses, with wares to sell balanced precipitously on their glossly black plaits. Many of these are young children, especially girls, boredom shown in their frowning expressions as they ambivalently swat away flies in the stifling heat.

At the hostel, the owners were explaining to us why indigenous Guatemalans will not go to school. They said an education here will not benefit you unless your skin is white. They cannot afford to put children through school if there are no longterm prospects for them.

My skin is very white. And I feel so very privileged here, privileged not only at home, in the opportunities I have had in life so far, of studying medicine in a beautiful University town, but in being able to come here and learn and grow as both a person and a medic.

Incidentally, the first thing I saw on arriving at the airport was a huge sign requesting that all passengers ensure they did not have any symptoms of cough, sore throat or fever. And so it begins...

After months of hard graft in my penultimate year studying medicine, spending days practising sticking needles into people and evenings with my nose in a pathology textbook, we are to be rewarded with a ten week medical elective. Whilst it will be a much-looked forward to break and is an excellent opportunity for travel to far-away climes, I will be putting my new-found skills to use by working for two medical charities providing free healthcare to indigenous children in Guatemala and Mexico (www.primerospasos.org; www.oaxacastreetchildrengrassroots.org).

You can follow my (mis)adventures here, and hopefully learn a little about the social and cultural aspects of these two intriguing countries along with me. And I promise swine flu virus cannot be transmitted via the web (if I have learned anything from my studies this year!).