In Alajuelita we have spent the first few weeks getting to know the population. We have been exposed the living conditions, experienced the typical food, and chronicled the entire clinic population with a special emphasis on those with chronic diseases. Here, many people believe that their chronic illness can be cured with a simple medication. And many of the medications given for chronic diseases are shared amongst the entire family regardless of whether each individual actually suffers from the disease. This has led us to focus our project on ways to improve their understanding of chronic diseases. The project specifically targets some of the most common illnesses: asthma, diabetes, hypertension, and obesity. Because the majority of the population lacks insurance, the people have very minimal access to healthcare, particularly medications. Our free clinic serves to provide services to these individuals, however the amount of available medications is never sufficient. This makes treating diabetes and hypertension very challenging as some of the simple solutions in the United States such as insulin, or meds for hypertension impossible. Thus we have had to focus our efforts elsewhere and begin with education.
Serena with Diego, diabetes man.
This is also true when it comes to treating asthma. During our pediatric rotation in the US, we grew very accustomed to treating asthma. When a child came in with pre-existing asthma, we assessed how well it was controlled by asking about certain symptoms, like waking up at night coughing, frequency of rescue inhaler use, and the amount that asthma is interfering with daily life. Once that was assessed, we made recommendations to either continue the same regime or add more medications. Medications almost always included a control medication that was to be taken everyday and a rescue inhaler for emergencies. Here, I have seen only a handful of patients with inhalers. The rest of the population cannot afford the inhaler or the medication for the inhaler. As a result, teaching parents and children about correct inhaler use is almost obsolete except for the few that have them. In addition, in the US, we use an asthma action plan. This plan outlines what to do if a child is having certain symptoms ranging from none to an asthma attack that requires immediate medical attention. However, our population neither has the medication nor the education necessary to follow such a protocol. Indeed, children come to the clinic for unnecessary visits due to this lack of education. Our goal is to use our brochures and posters to give this education and enact the plan to prevent unnecessary visits and time away from school. Finally, in the US, prevention is focused on making sure no one in the home smokes around the child, both in the home and car. Here, however, asthma triggers are everywhere. Since most children live in slums, floors are commonly dirt and cockroaches are abundant. Dist from dirt roads hangs in the air constantly. Therefore, we've had to think outside the box and recommend ways to keep dust down, such as wetting floors, hanging damp bedsheets around the child's bed at night, and sweeping floors multiple times a day. Even with education and interventions, controlling asthma in this environment is difficult.
Our asthma posters!
We have begun developing educational “charlas” (interactive lectures) to help patients understand these common illnesses. This hopefully will alleviate the minimal time the doctor has to run through basic guidelines for management while simultaneously focusing on patient understanding. Furthermore it is unrealistic to simply say “eat healthy” here. Much of the food includes heavy doses of vegetable oil and salt. So while a healthy diet is a component for hypertension, diabetes, and obesity we have again had to reframe our mindset and step into the patient’s perspective to develop reasonable guidelines. We had the opportunity to go to a local soup kitchen last week and give 2 charlas, 1 on brushing teeth and the other on hand washing. The kids were so interactive and excited! However, we learned that in order to give these charlas, repetition and participation is key. Instead of just holding up a poster and reading it, we played games and formed everything in a question to get the kids to participate and hear the information in various forms. Serena held her own workshop on using bead necklaces for natural family planning that went very well too! We are definitely keeping wgat we learned from these experiences in mind while we form our scripts for future volunteers!
One of our main goals is to make these efforts sustainable, so that future volunteers who are not as medically mindful can relay this message as well. Our interactive seminars all include a concise script easy to read for volunteers and in basic language for the patients. More importantly, our aim is to empower patients in the population who are willing to share their own experiences. We recognize that lecturing repetitively is rarely useful. Thus, we hope to identify certain patients in the population with personal experiences of these diseases, as well as ask them to lead certain workshops involving demonstrations of exercises because we know this will be a much more powerful motivator.
We have been so lucky to work with Dr. Natalia who not only teaches us about the social and cultural context within which we are working, but also allows us autonomy to interview the patients and do physical exams. We've had so much fun working with her, and have learned a lot!
Physical exam!
Jen training our new secretary.
Serena interviewing a clinic patient.
On another note, we've been very fortunate to be able to enjoy the beautiful landscape of Costa Rica. A couple of weekends ago we went to Volcan Arenal with another volunteer, Luke. Last weekend, we went to Monteverde, a city in the mountains, and hiked through a cloud forest. Here are some photos!
Beautiful waterfall at volcan arenal.
Crossing a stream in the cloud forest!
Fashion forward boots for the muddy cloud forest
Her majesty volcan arenal 
The sun is setting on our trip here, but we've all learned so much. We are excited to wrap up our project in the coming days and hopefully make understanding, preventing, and treating chronic illnesses a little easier both for the clinic and its patients. Until then, Pura Vida!
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