Last Week at Santa Rosa!

Reflections, Stories, and Things I've Learned

This is last week volunteering at the Santa Rosa Health Center and I am sad! I have had an amazing experience and will definitely miss spending time with all of the wonderful people I have gotten to know. As I think back and reflect on the last eight weeks, I am amazed when I think about how much I have learned. 

For example...

My Spanish vocabulary has grown immensely. I have become comfortable giving commands formally and informally to the patients as they come in and have learned a handful of new words and phrases, such as... 

Perímetro cefálico – Cephalic perimeter (head circumference)

Presión arterial – blood pressure

Bien pegado – “stand up straight”

Archivar – to file 

Odontología - dentistry

 Quítese la casaca, por favor - Please take off your jacket

Tome el asiento - Take the seat

Voy a tomar su presión - I'm going to take your blood pressure

Espere afuera - Wait outside

¿Para quién es la atención? - Who is the attention for?

Sácale de su ropa – Take off his/her clothes

...and so much more!

 I feel like my ability to converse naturally and quickly with the patients who come in has improved significantly. I am able to answer questions that the patients may have instead of just referring them to a more fluent Spanish speaker. 

In addition to improving my Spanish vocabulary and speaking ability, I also have developed and honed a variety of new skills that pertain to working in a health center. 

*I know how to weigh and measure patients when they are called to the triage area and recently I have learned how to take blood pressure as well. 

*I have also learned how to correctly weigh and measure the babies in the healthy child control area. Measuring the babies accurately is quite the chore as it is very difficult to get them to be perfectly straight and flat but I feel like I have definitely improved. 

*I also know how to do a psychomotor evaluation for babies of various ages. 

*On a handful of occasions, I have performed a curación del ombligo, or cleaning of the navel and umbilical cord, that is required for all the newborns who come into the clinic. (The very first time I had to clean the bellybutton of a baby, it was comical! That day, there was a mountain of babies who needed to be seen by the doctors and we were all incredibly busy. A mother brought in her newborn baby and I sent her to buy the sterilized gloves that were necessary for the doctor to clean the bellybutton. When the mother returned, I asked the doctor, who was busy with her head buried in the piles and piles of paperwork that must be completed for each patient, if she would clean the bellybutton. Without looking up from her work, she asked me "Do you know how to do it?" At that point I had only watched a few times while she cleaned a bellybutton and so I appropriately replied "No, I do not." She looked up from her work for just a moment, looked me in the eye, and sternly said "Learn."  She put her head back down and proceeded to fill out forms.  I found this comical because she never bothered to teach me how to do it; she only told me to "learn." Of course, I pulled on the gloves and used the tiny gauze squares with a squirt of alcohol to remove the crusties and goobers and clean out the navel. Since that day, I have cleaned several other bellybuttons, each time with more confidence that I know what I am doing.) 

*I have become acquainted with the somewhat confusing filing system and can pull a long list of files in no time at all. 

*I also can fill out new files and paperwork when new patients or newborn babies come into the clinic. 

I'm sure that this list does not even include all of the simple tasks that I have become accustomed to doing at the health center on a regular basis. Even though I have loved learning how to do these things and doing them, there are other lessons of deeper importance that I have learned during my time at the health center.

There are people who come to the health center seeking help despite incredibly difficult circumstances. While there is free (or nearly free) insurance for most patients, the simple task of arriving at the health center can be a great feat for some of the patients. There are some people who have to walk great distances up and down  incredibly steep hills on rugged dirt roads in the beating sun or in pouring rain. In order to get confirm an "appointment" with the doctor (although, I would never use the word appointment to describe what happens in the health center), it is necessary to arrive at the clinic very early in the morning. The first patients who receive attention often have waited outside the doors of the health center since 5am in the morning. The patients have to wait in a very long line in order to place their name on the list to receive medical attention. After placing their names on the list, they have to wait until they are called by the nurses in traige and then wait more for the doctors to call them back to the treatment rooms. They often wait for hours and hours in the waiting area, which consists of a few rows of benches lined up on a mound of dirt and gravel underneath a patchy tin roof in front of the health center. There are people waiting outside in the down pouring rain or in the dry heat of the sun from early in the morning until the center closes for the day.

This has made me realize how much I take for granted at home in the United States. When I need to go to the doctor, I call, make an appointment, and show up at that specific time. I have often complained as I've sat comfortably in the padded chairs in the quiet, air-conditioned waiting room if I've had to wait for even just a few minutes for the doctor or nurse to call my name. I can't imagine that I would ever go to the doctor if I had to arrive at 5am and then sit and wait for five hours or more, possibly in the pouring rain, just to be seen by a medic for a few minutes. The people here make a much bigger sacrifice in order to receive medical attention. They are much more patient and typically everyone waits courteously outside for their name to be called. 

In addition to this, it is very clear that the Santa Rosa district of Cusco is a very poor part of town. I have seen traditionally dressed women come in wearing the typical sandal-type shoes with extremely dirty feet. When they remove their sandals, mud and dirt often have formed an outline where the straps had been. Sometimes the people have a distinct body odor scent, as if they haven't bathed in several days. I have noticed some patients wearing the same clothes on multiple different days when they have come in. When I explored the Santa Rosa district with the obstetricians for a few days a while ago, we wandered up and down many, many streets of mud brick adobe homes. The streets were dirt and mud, bumpy and jagged with holes, bumps, and channels where the water would run. The dwellings were constructed entirely from the adobe bricks composed of mud and straw. Dogs, cats, chickens, and sheep lived right alongside these people around their humble homes. I'm sure some of them had electricity of some sort, but I would be very surprised if these people have televisions, computers, or internet in their homes. 

Something as simple as personal hygiene is definitely something I have taken for granted as well. It is so easy to be accustomed to having luxuries such as a warm shower and clean clothes on a regular basis that I forget to be thankful for even these simple things. In the United States, we are overwhelmed and bombarded with the desire to always buy new things, new clothes, and new toys to the point that we feel a sense of entitlement to these things. I don't believe it is a bad thing to buy new clothes or to take a shower everyday, but I do think that is it very important to maintain a humble attitude of appreciation for the luxurious lifestyles that we have been blessed with. I'm sure that there are many people around the world who live in much worse conditions that even those that I have seen during my time here. 

Despite seeing many sad situations, my time at the public health center has been filled with positive memories. There is one young mother who I have seen in the center multiple times. Her baby had been born shortly before I arrived. He was very small and very malnourished. I remember watching the young mom wipe tears from her eyes as the doctor lectured her about the state of her newborn baby during his first or second checkup. Just yesterday I saw the same mother bring her two-month-old baby into the clinic; he now is a chubby young little guy with thick legs and round cheeks. His weight and height were right where they needed to be for a baby of his age. 

It is so wonderful to reflect on such a positive outcome to this story. If the young mother (who is 15 years old, by the way... I checked her file) had not chosen to bring her baby boy in for his regular controls, she may have not known that he was severely malnourished. In the worse possible outcome, the baby could have died from malnutrition if he did not receive more attention. Fortunately, the mother had access to care and chose to put forth the effort to bring her child into the clinic once a week or sometimes even more frequently than that. 

I have been incredibly blessed to have had such a wonderful experience at the Santa Rosa Centro de Salud and am very sad that my time there has come to an end. Tomorrow, Thursday, the 13th of March, will be my last official day. Although it would be easy to go to the health center with a heavy heart tomorrow, sad that it will be the last few hours I will spend there, I would rather go with a positive spirit, thankful for the wonderful experiences I have had and the relationships I have formed with such amazing people. It will be hard to say goodbye, no doubt, but I can be joyful knowing that I have been able to make a difference at the health center I love so much.

The Latino Patient – The Clinical Encounter

GREET: Characterizing the Latino Patient

After covering relevant cultural values and the belief systems of the Latino population and addressing variations in the beliefs due to generational differences, The Latino Patient moves on to present a culturally competent care model for Latinos. It begins by offering the acronym “GREET” as a way to characterize Latino patients. By gathering relevant background information about each individual, healthcare providers can increase their understanding of the personal and cultural history of each patient. Expressing an interest in the patient’s personal background can also increase the amount of respect that is perceived by the patient. The GREET acronym is as follows:

G = Generation

R = Reason for Immigrating to the US

E = Extended or Nuclear Family

E = Ethnic Behavior

T = Time Living in the US

Generation

It is important to determine whether the patient is an immigrant or a second-, third-, or fourth-generation Latino. The degree of acculturation varies with each generation and each brings to the table its own set of unique characteristics. The later generations are much more similar to the mainstream culture than recent immigrants

Reason for Immigrating to the US

Knowing a patient’s individual reason for immigrating to the United States can give the healthcare provider insight into the social, political, and economic stressors that may affect the mental and physical health of the patient.

*This category does not apply to second-, third-, or fourth-generation Latinos.

Extended or Nuclear Family

By gathering information about the living circumstances of the patient, the healthcare provider can have an increased understanding of the social support network that the patient may or may not have. Typically, in the Latino culture extended or nuclear family members live in close proximity to each other. This can present problems for immigrants if they are unaccustomed to living far from family.

Ethnic Behavior

It is useful to gather information about the patient’s personal preferences in regard to food, music, holidays, and recreational activities. This is important because habits such as consumption of alcohol at parties or celebrations can have significant health implications.

Time Living in the US

As variation in acculturation is seen from generation to generation, similar variation is seen as the time spent living in the United States increases. Patients who have recently immigrated will cling more tightly to traditional Latino cultural values, while second-generation Latinos who have lived their entire lives in the US will be more similar to the mainstream culture.

The Clinical Encounter

There are a few important points to keep in mind during the initial part of the clinical encounter with a Latino patient. While the healthcare provider may be accustomed to interacting with a diverse clientele, it may be a new, and sometimes scary, experience for the Latino patient. Cultural and language barriers can be equally, if not more, intimidating for the patient, who is making an effort to seek medical attention in a health system that may be entirely different from the system in the country of origin. With this in mind, there are a number of crucially important factors that should be taken into consideration during the initial interaction with the patient.

Eye Contact

As a sign of respect, making eye contact with the patient is critical; however, it is important to be careful with gender differences. Maintaining eye contact for an extended period of time with a person of the opposite gender may be perceived as an attraction towards that individual.

Facial Expression

A simple smile and friendly facial expression can work wonders in setting the tone for the entire clinical encounter. The combination of a smile and eye contact can make the patient feel accepted and welcome in the office. A stern face can send the message that the health care provider is unhappy with the language or cultural barrier.

Gestures and Touch

Gestures such as standing up when the patient enters the room and gesturing towards a chair while greeting a patient can send a welcoming message. It also shows respect for the patient. A warm, firm handshake upon greeting the patient can also contribute to the feelings of respect perceived by the patient.

Voice Intonation

Healthcare providers will be best-received if they talk in a friendly voice that is neither too loud nor too quiet. A loud, abrupt voice may give the impression that the healthcare provider is ill-tempered, impolite, or upset with the patient. A quiet voice may imply a lack of personality.

Titles

The use of titles is very important in the eyes of Latinos and conveys respect for the patient. By using titles such as Señor (Mr.), Señora (Mrs.), and Señorita (Miss) before the last name of the patient, the healthcare provider can show respect for the patient and gain respect in his or her eyes.

The Latino Patient – Effective Communication

Delivering Health Messages Successfully

While conveying health messages to Latinos can be difficult at times, by taking the cultural values into account, a health professional can increase the effectiveness of the communication. In order to initiate change in a behavior of a Latino patient and to help maintain the change, it is important to consider four different factors: familism, friends, faith, and fatalism.

Familism

While the Latino culture is not individualistic, telling a patient to change a habit in order to improve personal health may not be a sufficient reason to invoke change. As the culture is more family oriented, implying that changing a habit may be beneficial for the family is much more likely to result in a change in the behavior.

For example, to encourage a smoker to quit smoking, one might say that changing the habit will allow the patient to…

• ×          Live a longer life and have the pleasure of knowing his or her grandchildren
• ×          Set a good example for children
• ×          Protect family members from suffering or harm caused by secondhand smoke
• ×          Save money for a family vacation

Friends

Similar to the idea of familism, Latinos highly value their social relationships and connections. The opinions and advice given by close friends are held in high regard and have strong influence over the actions of many Latinos. Again, encouraging a habit change in order to achieve a personal goal is not likely to produce a change. On the other hand, referencing issues related to friends and relationships may have a greater impact on the patient.

For example, to encourage an alcoholic to attend AA meetings, one might say that joining AA will allow the patient to…

• ×          Help friends who struggle with the same problem
• ×          Be accepted by friends
• ×          Influence and be influenced by others in the social group

Faith

Religious faith and faith in the health care provider are both very important. Many Latinos believe strongly in the power of God to heal and direct the outcome of all circumstances. When an illness is experienced, Latinos may visit shrines and offer prayers, candles, or other offerings to God or saints with hopes that they will cure the illness. Faith can also be placed in a trustworthy health care provider with whom the patient has had past experience and successful outcomes. This faith can help encourage a patient to begin or maintain a healthy lifestyle change.  As a health care provider, alluding to a patient’s faith in God can be beneficial in encouraging the change.

Fatalism

Fatalism is the concept that all events are predestined and that all humans are subject to an unavoidable fate over which we have no control. This can present a real challenge for health care providers, especially if the patient believes that there is nothing that he or she can do to change the situation.

To encourage a patient to make efforts to overcome an illness, one might say…

• ×          “God may be testing your faith and want to see you make efforts to improve”
• ×          “There may be other missions in life that God has planned for you and overcoming this obstacle might be important in achieving the others”
• ×          “God or the saints may be impressed with your perseverance and unwillingness to give up."

The Latino Patient – Health Attitudes, Beliefs, and Practices

¡Abrígate Bien!

One of the many historical attitudes towards health that is held by many Latinos is known as the Hot and Cold Theory. This theory claims that the body has four different fluids of different textures and temperatures:

Blood- hot and wet

Yellow Bile- hot and dry

Phlegm- cold and wet

Black Bile- cold and dry

In this pattern of thinking, a balance in the body among the four types is seen when a person is healthy. A sick person experiences an imbalance among the fluids. According to this theory, temperature plays a big role in the health state of individuals. For example, to lower the temperature of the body, a person may be offered a cool drink. On the other hand, drinking warm liquids and consuming warm foods such as tea or soup is thought to help an individual with a cold.

 I have seen practices similar to this in the belief patterns of nearly every Peruvian person I have met. They all seem to 100% believe the wives' tale that if you are cold, you will catch a cold. It is almost humorous how frequently I am told to “Abrígate Bien,” or “Dress warm.” The temperature here is not exceptionally cold on most days. Usually the temperature ranges somewhere from 55 to 75 degrees, but the people here usually dress as if they were living in the arctic! In the clinic, many of the nurses and ladies wear multiple layers of clothing, including warm jackets and scarves, for the entire day. On multiple different occasions, I have been working in the health center in just my short sleeved shirt and constantly am asked if I am cold. I usually proceed to explain that it is much, much colder where I am from and so I don’t feel so cold here. In addition to this, a few people have sternly told me that I need to dress warm or I am going to get sick and then the whole clinic will be sick. Since then, I have worn at least a long sleeved shirt on most occasions.

The need to dress warm especially applies to the babies who are brought into the health center. When they come in, I always tell the mothers to undress the baby so that we can properly record the weight and height. The undressing process usually is quite lengthy as the babies are typically wrapped in two or three blankets and clothed in several layers of jackets, sweaters, and shirts, complete with socks, gloves, and hats. Sometimes the babies are actually damp with what I presume to be sweat by the time all the layers are removed.

I find it really interesting that even the educated professionals working in the public health center find it so important to dress warm all the time. One time the head nurse working with the babies got mad at a mom for leaving her baby undressed and exposed to the cold for too long. She lectured the mother about how her baby was going to get sick. The same nurse has lectured me about the same thing on a few occasions as well. 

The Latino Patient – Cultural Values

Cultural Values of Latinos

Acculturation increases as individuals remain in a country for a longer period of time and as the generations proceed. The initial immigrants that come to a country will retain many of their core values and traditions from their home country but their children and the children of their children will become more and more representative of the mainstream society. For Latinos in the United States, there are a few basic values that seem to be retained regardless of the amount of time spent in the country or the generation level. While the culture in the United States tends to be very individualistic, the Latino culture is group- and family-oriented. American culture is often focused on personal achievement; Latinos strive for harmonious relationships and cooperation. In the US, respect is often awarded to those who have achieved success, but for Latinos, respect is given due to age, gender, or hierarchy.

In addition to these three values that are constant across generation and acculturation levels, there are several other general values shared by all in the Latino culture that do vary slightly as individuals acclimate to the mainstream culture.

The values listed below are the most relevant to a clinical encounter in a health care setting.

Collectivism

Latinos tend to enjoy spending time with others as opposed to being alone for personal satisfaction and self-assurance. Workplace or social relationships strengthen all and give the individuals a sense of belonging. Situations are viewed from the perspective of the group instead of that of the individual.

Familism

Latinos highly value family relationships and often maintain close relationships with family members, close and distant alike. Due to the fact that many Latinos consider the family to be “sacred,” many health issues can be addressed most effectively by including some or all family members.

I have witnessed this with my host family. We spend time very regularly with various family members, including the brother of my host mom and her father. Much of the distant family, including various distant cousins, aunts, and uncles, has also come to visit on multiple occasions.

Personalismo

Personalismo refers to the ability to relate to other human beings on a personal level, without regard to the social level or economic class.

My host mom is a prime example of this. My host family is well-off compared to much of the population in Peru but when visitors come to our home, she treats everyone the same, always offering food, tea, or anything else we may have to offer. We have had visitors from the “campos” (fields or country, generally people of a lower economic standing) come to our home, and they are always treated with respect and courtesy.

Respect & Power Distance

People in positions of power deserve respect and obedience. In a health care setting, a doctor is rightfully perceived as being more knowledgeable about health and disease than the patient and thus is respected and obeyed. Additionally, respect and admiration are awarded due to valued qualities a person may possess, such as honesty, integrity, and courage.

Simpatía

The ability to develop a harmonious relationship that expresses a warm and caring attitude is known as simpatía. It is important for a health care provider who is working with Latinos to have a “people-oriented” disposition.

Time Orientation

Managing time appropriately is not of high priority for Latinos. In most Latin America countries, the pace of life is a little slower and more relaxed, with less bureaucratic health care systems. Consequently, when Latinos immigrate to a country like the United States, they may often arrive late for appointments, not out of respect for the doctors, but rather because their culture never taught them to value timeliness.

I have fully experienced the lack of concern for time and timeliness during my time here. On more than one occasion I have had to wait at least 30 minutes for a friend to show up to hang out or have coffee. Coming from a culture where time management is crucial, I absolutely hate to be late and hate to have others waiting on me. It is different to experience an entire culture that doesn’t care so much about being on time or not.

Out of the Ordinary Events of the Week

Eat Well. Stay Healthy.

Something a little out of the ordinary happened on Tuesday this week. When I finished working in triage, I made my way back to the CRED ("Crecimiento y Desarrollo del Niño" aka Child Growth and Development) area to help with weighing, measuring, and evaluating the babies. There was an exceptionally large hoard of ladies crowding the tiny space and I wondered why the nurses weren't telling them to wait outside for their turn, like they usually do. It turned out that there was a "charla," or chat/presentation, for the mothers in the clinic and many of them were told specifically to come in on that day to participate in the chat. 

The first segment of the presentation was a very brief talk about how to prevent stomach cancer. One of the doctors in the clinic gave the presentation and talked about various factors that can increase the likelihood of getting cancer, including things like genetics and lifestyle. She stressed that while we have no control over the genes we inherit, we can choose to live in a healthy way and take control of the factors that we can. 

The doctor covered basic healthy habits that can prevent stomach cancer among various other health problems. She recommended that everyone eat five fruits everyday in addition to vegetables like lettuce and broccoli. She also said that exercise is important in preventing cancer and that everyone should get 30 minutes of exercise daily. While it is not likely that many of the ladies in the health center have time to go for a run or hit the gym every morning, the doctor did say that even just walking a total of 30 minutes everyday can be beneficial and they don't have to be 30 consecutive minutes. I don't doubt that many of the mothers walk at least 30 minutes everyday, if not more, just getting around town and such. The doctor also suggested not drinking alcohol in excess or smoking. Most of the advice given seemed pretty basic and nothing was all that novel for me, but it could have been the first time some of the ladies heard some of these things.

The second part of the presentation was much more hands-on and much more interesting. It was about how to properly feed babies and young children and how to eat as a nursing mother. The nurses brought in food and showed examples of various different types of foods in different forms and quantities to give to babies of varying ages. I helped by making a mashed potato puree mixture with other vegetables and meat. It pretty much was homemade baby food made by mashing all the components of a meal into puree. 

There were all sorts of different types of food: rice, quinoa, lentils, potatoes, carrots, squash, chicken, and chicken liver. I found it really interesting that the nurse stressed multiple times how important it is that the babies and nursing mothers eat liver at least 2 or 3 times a week. She said that anemia is a big problem and liver is high in iron. I personally am not a huge fan of the idea but do admit that I have eaten liver a time or two while I've been here. I don't particularly care for it, but it's not horrible either. 

I think the talks were very beneficial and it definitely added some spice to my day. I think that preventative and educational talks are really important as I've mentioned before that I think the majority of the problems experienced by infants and children come from a lack of knowledge. I'll be interested to see if this is a  somewhat regular occurrence or a one time deal. 

Strike!

Today and yesterday in the health center, the doctors were on strike. There still were a few doctors who accepted patients with emergencies or who needed immediate care but there were significantly fewer patients than normal. They only accepted a total of 15 patients yesterday when normally there are double or triple that seen by the medics alone. Today no patients were seen by the medics, but a few patients were still seen by the obstetricians and in the child grow and development area. 

The posters on the door to the health clinic said:

Paro Medico - Por la Reforma de Salud

Más insumos para pacientes

Mejor infraestructura

Más medicamentos por tu SIS

No a la privatización de Salud

 Which translates to:

Medical Strike - For Health Reform

More resources for patients

Better infrastructure

More medicine for your SIS (Integral Health Insurance)

No Privatization of Health

 Today I found out that the strike was not limited to the Santa Rosa health center but was nation wide. I believe unfair pay and salaries were part of the issue that the doctors were protesting, but I am not 100% sure about the exact reasons behind the strike. It made for a slow couple of days in the clinic because of the significant reduction in patients. I hope that Monday of next week isn't too crazy with all the overflow of people who would have been seen today. 

The Latino Patient - Defining the Latino Patient

Who are "Latino Patients" in the United States?

In 2002, when this book was written, there were 35.3 million Latinos living in the United States. In order to provide healthcare appropriately to this population, there are three main challenges that providers must overcome: language, diversity, and culture. Adequately overcoming the barriers in communication involves having some proficiency in the Spanish language in addition to understanding the diversity in the Latino group and its culture. 

Here are a few of the many facts mentioned in The Latino Patient about the Latinos living in the United States:

• The terms Latino and Hispanic can be used interchangeably, both referring to people of Spanish decent (from Spain) and people whose native language is Spanish.
• People from different Spanish-speaking countries in Latin America have distinctive accents and speech patterns. 
• For example, Mexicans use many idioms, Central Americans tend to speak very quickly, and South Americans have melodic intonations and an more educated vocabulary.
• There are 22 different countries to which Latinos can trace their origins.
• The majority of Latinos are Catholics, which can influence their attitude towards health and disease.
• For example, some may believe that an illness or ailment is a consequence of disfavor in the eyes of God.
• U.S. Latinos are a young population, which a median age of 25.9 compared to 35 years as the median age of the general population
• The life expectancy is 79 years for the Latino population while that of the general population is 75 years.
• The major health problems of Latinos in the United States are similar to those of the general population, including diabetes, tuberculosis, and HIV infection, among others.

There are a few interesting theories that may explain the low mortality rates seen in the Latino population. One of these is known as the healthy migrant effect, which suggests that the people who immigrate are those who are physically able to go and healthier than those who remain behind. Additionally, the salmon bias effect states that many Latinos return to their home countries after a temporary stay in the United States, wishing to return home when they grow old or become seriously ill. 

In addition to language differences, which is an obviously barrier, there are many factors that affect the decision of Latinos to seek healthcare and treatment. While nearly two thirds of the Latino population has health insurance coverage, a third still remains uncovered. This increases the difficulty in accessing healthcare for many Latinos. Many resort to seeking care in emergency rooms, which obviously can provide care for temporary problems but lack the ability to offer follow up or preventative services. Acculturation, the changes that must be made to adapt to a new culture, also presents Latinos with unique challenges. This includes learning to live in a culture that is loaded with rules and regulations. Practices such as taking a number, waiting in line, filling out forms, and so on, can be great hassles for Latinos who are unfamiliar with such habits.