Nicaragua - outreach programs

Hola again from Nicaragua! It's hard to believe another week has gone by here. Our last week entailed another day in the operating room in Rivas, more clinic time and community outreach. We also started doing needs assessments for a future micro-health insurance program and working on a quality improvement project for the clinic.

At the Rivas hospital in the ER

Micro-health Insurance Program

One of the homes in the pilot micro-health insurance program

We are helping one of the FIMRC interns on a project to evaluate community needs and interest in a micro-health insurance program. The program would be opt-in and members would be required to attend one educational talk per month on public health topics. Members would give their permission for spontaneous home-visits where FIMRC would conduct home evaluations to make sure members were following the advice such as covering their latrines, covering all standing clean water, using mosquito nets, etc. For complying with various aspects of the program, members earn points and when they earn enough points they are eligible for gifts to help improve their health in the home such as a gas stove or mosquito nets. 

Cooking over a wood fire in proximity or
within the home is very common in this community

We piloted the home inspection program by visiting the homes of pediatric patients who are repeatedly getting ill to evaluate for possible causes of chronic issues with parasites, respiratory infections, etc. We realized how much information can truly be gleaned about the health of our patients by visiting their environments. It also gave us more insight in to ways to prevent some of the problems that patients struggle with here such as educating about not cooking of wood fires indoors to help patients with respiratory problems. 

Quality Improvement Project

Having worked at the community health post for the last few weeks, we have noticed a few aspects of the clinic that desperately need some improvement.  The most glaring problem is the absolute MOUNTAIN of unorganized charts that piles a large bookshelf.  The health post where we work is the largest in the area-with over 3,000 patients.  And with over 600 new children born per year-the volume of patients is always growing.  

Documentation of health records in Nicaragua is an absolute mess.  When someone is born, the government issues that person one health card with a number on it.  If they lose the card, it's gone forever.  So when someone enters the clinic for a visit-it's really a toss up of if they still have their health card or not.  Because the charts are organized by this issued number-it is impossible to find someone's chart without the number. The doctor then sees the patient without a past medical history and simply writes about the encounter on a piece of paper.  All around the health post, piles of these loose papers sit without knowing which chart they belong to.  In talking to Domingo, the current physician at the health post, he says that it is one of his greatest challenges.  He sees patients who present with new complaints but do not know why they were hospitalized a month ago.  He is continually making decisions without an adequate view of the patient. Then without this documentation, it is very difficult for him to follow up on a patient.

Our goal for the next few weeks is to create a system that the nurses are able to easily use to find patients.  We have made a notecard look-up system where the patient can be looked up alphabetically by first name (everyone has a few last names and prefers to go by a different one). The notecard has name, issued number, and birthdate on it. Then we bought new folders for all of the charts (the old ones were falling apart) and organized them by a brightly labeled patient's number.  This way, if a patient comes in and does not know their number (most patients), they can be looked up by first name, then using their number, their file can be found Hopefully this will then allow Domingo to have a full picture of the patient and also practice better follow-up.

Prenatal Program

This week we embarked on more prenatal home visits with FIMRC’s Nicaraguan prenatal coordinator, Roxana. In a half day we are able to visit about 5-6 women in their homes and within the community they have about 50 pregnant ladies at a time. We set out with our supplies including a scale, blood pressure cuff, stethoscope and binder of information.

Jenny and one of our prenatal patients giving a talk 

Upon arriving at each woman’s home (often by foot), we generally navigate some form of barbed wire fence to enter the property. At almost every home we have then been greeted kindly and someone in the family immediately goes to grab stackable plastic chairs for however many guests there are. We are often set up just outside of the home for our prenatal meetings.

Every visit begins with a quiz that investigates the level of knowledge that the patient has on the topic we will be covering.  The program entails visiting once a month during the pregnancy with a different topic dedicated to each month.  After conducting the pre-quiz, we begin with the educational portion. FIMRC has designed a great handbook for all of the talks so we are able to use the handbook to read and educate the women. After the talk, or Charla, we ask women the same set of questions for our post-test to gauge how effective the program is. Before leaving we always weigh the women and take their blood pressure. Because Roxana is not a doctor, the women still visit the doctor where he checks things like the fetal heart rate and fundal height.

Checking blood pressure at prenatal visit

Going on the home visits has been a great way to educate the women in the community. Some of the topics include: nutrition during pregnancy, fetal development, taking care of newborns and complications such as preterm labor and pre-eclampsia. To be enrolled in the program, all women agree to deliver at the hospital. This has helped reduce the rates of maternal and fetal mortality in the community because the nearest hospital is about 1.5 hours away so when complications would arise in the past, it was not uncommon for women to pass away en route to the hospital. Women in this rural community tend to have many children and to start at a young age. The educational program seems to be especially useful for the young mothers in their teens.

Las Salinas, one of our communities

Diabetic Home Visits

The diabetic home visit program is newer to FIMRC and is less formal than the prenatal program as of now. FIMRC’s diabetic coordinator (also Nicaraguan and from the community) is named Esmalda. For these visits, we check in on the homes of known diabetics in the community and measure their blood glucose (almost no one in the community has their own glucometer) and to check their blood pressure. We were often greeted kindly on these visits as well although sometimes with more hesitation because they knew our visit would entail a finger prick.

 

Girls hanging laundry at one of the home visits

In one morning of home visits, we traveled the dirt roads of Las Salinas to about 10 different homes of diabetics in the community. We inquired about what the patient’s had eaten so far in the day and most of them responded “solo café y pan”. Esmalda let us known that they tend to load their coffee up with ample sugar and whole grain bread is not easily found in the homes in these communities. Most of the patients had glucose readings over 300! We were happy when we finally found one in the 170s but had multiple readings in the 500s. As medical students, we were concerned about these numbers and asked the patients how they were feeling- if they were nauseous, had headaches, etc. Most of them responded that they felt normal; we advised these patients to visit the Health Post to see the doctor. While Esmalda was impressed by the high numbers, she also did not seem surprised.

This coming week the community is hosting a medical brigade with doctors, PA's, nurses and a dentist from Texas. They are all fluent in Spanish and have been to the community before. Each day we will be traveling to different remote areas with them to set up free clinics. It should be a fun week!

Peru Update- Clapham

Day 13 (1/23/14- Thurs):

Today and the past two mornings from 7-12 am, I've went to a private clinic called Clinica Cayetano Herideria. It is called a clinic but it also has multiple ORs and also two inpatient floors (one for OB patients and one general floor). It also has multiple floors of sub specialty ambulatory clinics, as well as a 4 bed Emergency Room. Although it is in situated in a very dusty area of town, the building is distinctly taller than the surrounding structures and has an exterior of marble and emerald tinted glass. Inside is also pretty swanky. Mostly private rooms with private bathrooms on the general floor, I think there's 12 rooms on the general floor and 10 are private and 2 have two beds. OB floors is all private rooms, maybe 6. All the rooms have leather couches and flat screens on the wall. In the basement is every form of imaging apparatus that I know about, including a Siemens brand CT machine that from what I can tell by appearance only is the same model that Hurley has.

I've been following attendings who manage both inpatient floors as well as the ER visits. Most of the general medicine inpatients are not critically ill, most have either pneumonia or are surgery patients (a post-appy patient, a transurethral bladder tumor removal patient,and multiple ortho patients). The first two days I was there I followed an attending named Dr. Poma, who is in his 2nd year out of medical school. He doesn't speak English so it's been difficult to understand everything that's going on about of the time, but also no doubt is good practice to have medical themed convos in Spanish. It has been similar to my experience following a resident in the states, he gave me lots of mini lectures that were complete with drawings and tables and he pimps me about differential diagnoses from time to time, so I've actually feel like I'm expending a lot of mental energy to follow him around all morning. He was great to be with and, like I'm discovering is typical of Peruvians, is very generous. By the second morning he was inviting me and the rest of my group to dinners with him and excursions to the jungle with him. These kind of invitations at first were awkward because obviously we barely know these ppl but I am realizing that 1) everybody down here invites everybody they meet to things all the time and 2) that about 50% of the time ppl don't actually follow through with their invitations.

Then today I was sent with another doctor, named Dr. Vacilio, who was a bit older. Like in the states, different attendings have different personalities, so it was a different experience. He was less interested in teaching me, but also we had a lot more patients than the last few days so were pretty busy. He was pretty friendly and explained things in good detail to patients, but definitely was more "machisto" than Dr. Poma and other younger docs. I think this stereotype of Latin men is fortunately fading with my generation.  He would flirt hard and pinch and poke EVERY nurse as we went to the different floors, and then in front of a big group told me that when he was in medical school he would always date two women at one once. By American standards it was entirely over-the-top unprofessional, but nobody here really did anything more than roll their eyes and most just laughed at his jokes.

Another difference that I thought I'd mention is how medical care and medicine is paid for here.  Cayetano is a private clinic and it was very often that the issue of payment came up from a patient. Multiple times I observed a patient in the ER only complete a part of the work-up and take their prescriptions, lab orders, radiograph orders or results and leave to take these to another site to get care. An interesting example is a patient came to the ER with a head wound that he got the day before at his job in the mine a few hours from Huancayo (between Lima and huancayo is a large mining industry). The patient had a bandage over about a 4 inch wound in the middle of his forehead. In the ER, Dr. Vacilio looked at the wound and wrote him a prescription for lidocaine, a syringe, suture, a needle, and antibiotics. Then his sister that was with him ran across the campus to the pharmacy and bought all the things that were needed for Dr. Vacilio to suture the wound. Then he sutured the wound. Also, none of the ortho tools and implants for elective surgery are kept in house, but are ordered when a patient comes in that needs those things. For example, a man with a work injury that broke 3 metacarpals and one of his wrist bones was admitted and given a soft cast and pain meds for two days while the pins that were needed to surgically reduce the fractures were ordered. Another patient who was a seamstress was injured on the job by a needle breaking and lodging in her thumb was admitted in the afternoon even though her surgery couldn't be done til the next day. I tried to talk to Dr. Poma and Vacilio about why these patients were admitted when they couldn't have surgery that day, but unfortunately I never really understood a firm answer they gave.

Despite several differences, I am constantly struck by similarities. A twenty-something came in with back pain and was accompanied by his mom, who asked a TON of questions...which is exactly what my mom would do if I went to the ER.

More things have happened but I will have to write tmr.

Day 19 (1-29-14):

We've done a few things since my last update. Mostly my hospital experience has been at the same Clinica Cayetano that I've been at for these past two weeks. I've been going in from 7am - 1 pm and then going home for lunch. Then in the afternoon we have been doing different campaigns or going to an orphanage. The Cayetano clinic folks continue to be very welcoming. A woman who I believe to be some sort of HR director invited me to go with them the past two mornings on an excursion to the Judicial Office of Huancayo. This office, which I was told has 200ish employees, made a contract with Cayetano to come and do a bunch of health screening stuff on site, including physical exams, vital signs talking, EKGs for persons older than 50 years, a blood draw, and a vision exam station. I felt really priveledged to be invited since this wasn't really arranged by FIMRC. When we first got to the building and went to the basement area where the stations were set up there was a lot of court employees crowding the area and Initially the flow of people through the stations was really disorganized with people not getting the right paper work for that station and people skipping around the stations and not following the flow, which made for confusion and people having to wait around because others went out of turn. I jumped in with the doc who was doing physical exams, but I only stayed with him for about 30 mins because he was ignoring me and not involving me in the interview or exam. So I left that station and found a nurse I recognized from the Clinica and asked if I could help her with EKGs. And I'm pretty happy I did because she taught me how to place all the EKG leads and work the printer, and after a few patients I was running the EKG station. This was a good experience because I was able to talk to each patient that came in and enjoyed the conversations we had. I did that from 9-1 probably. Then today I went back for day 2 of Cayetano clinic at the court, but there were fewer patients and I spent most of the morning talking to one nurse about Peru in general, the Peruvian medical education system, public health issues in Peru, and the Peruvian health care system. It was a really great convo because I learned a lot. For example, she told me that there are not very many heart disease patients or diabetes or kidney failure patients in Peru and also that very few Peruvians smoke tobacco. From what I've observed in the hospital and in the streets, I believe her. She also told me about the people in huancayo having a high incidence of volvulus because the low atmospheric pressure causing lots of gas expansion in the gut. No idea if that's right, but I enjoyed the convo. Then she explained To me how the public hospitals Carmen and Carrion were for people who didn't work, or worked for small shops or manual labor jobs. And that Peruvian who worked for a bigger company Were automatically enrolled in the government insurance available in Peru, called EsSalud (in English, This is Health). These individuals had auto-payroll deductions and were able to go to any of the EsSalud hospitals in the country, hospitals which exclusively treated EsSalud patients. However, while EsSalud is better than no insurance (ie the public hospitals), but still isn't great (long waits, etc). Therefore, chains of private clinics and inpatient and even operative services have developed (like Clinica Cayetano), for which people pay out of pocket for quicker attention and more luxurious environments. I'm not sure if you can buy extra insurances that cover expenses of those clinics.

In the afternoon we have done a few different things. Twice we have given first aid presentations to the Huancayo Serenazgo, which seem to be like a neighborhood watch type group because they clarified that they aren't police, but they wear camo uniforms and drive around the city in labeled tanks. At first hearing that were supposed to do this, I wasn't excited because I recognize that we aren't really knowledgeable in first aid topics. But we spent a long evening making talks and posters about different first aid topics and it seemed like it would be okay. Then when we arrived at the site for the first session, the 40 some Serenazgo that were present stood in a ine and at attention. This made me feel even more inadequate, because how could we possibly teach these professionals anything? But, and I think to all of our surprise, they were all super engaged, asking questions, discussing their own experiences with rescuing people, and even taking notes during all our lessons. Then after about 2 hours of lessons, we took about 30 minutes of photos at their request and that was it. We did this session 4 times as a group so all the serenazgo were Able to participate.

Finally, we have spent two afternoons at orphanages.  One that was pretty big and had a big play ground. The other that was smaller, with only an indoor play area, and had fewer children and was specifically for children with HIV and a few of their siblings that didn't have HIV. Both experiences were simply running around for 2 hours without a break and entertaining small children that were hanging all over us begging to be spun around or lifted up or pushed on the play equipment.

P.S. Our family is simply amazing. The experience would definitely be worse without them. The señora is a cute grandma that dotes on everyone and we try our best to make her laugh with our jokes. She micromanages us like little kids, but it is with such affection that we don't mind. Like she tells us to tell David that he should sit in the front of the cab after he has climbed in the back, or to tell Danielle to go put socks on because the floor is cold, etc etc. They are a really tight family with all four apartments on their complex being occupied by their brothers and sisters and their spouses and kids.

Health Campaigns and Saturday Fun

We have been fortunate to host campaigns on Hypertension, Dental, and First Aid. We also had a great Saturday visiting historic sites with our wonderful host family.

We held a blood pressure screening at the oldest elementary school in the city. We screened around 150 adults and encouraged participants to visit their regular doctor.

MPH Student Beth working hard on Hypertension Posters

Our 5 booths for the Hypertension clinic

Another event this past week was a fluoridation project for the children in school. Along with a local dental students, we visited classrooms and drizzled fluoride liquid in children's mouths.

Chris applying fluoride to a child

These teeth were some of the better ones seen during the campaign

All in all, the kids were happy!

Our most recent project was teaching first aid skills to city security guards, the "Serenazgo." 

Preparing for First Aid Campaign

We taught the "Serenazgo" which are city's security guards. They are called for minor emergencies or if neighbors are being too loud. After brainstorming with our local coordinator, Natalia, we decided to cover the following topics for these potential first responders:

• CPR (John and Beth)
• Heimlich maneuver on adults and children (Chris and Emily)
• Trauma (Laurie and Danielle)
• Intoxication and Electrocution (Chris)
• Emergency labor and delivery (Phil)

Phil teaching the most important things for emergency labor

We were interested to hear of some emergency deliveries that some of the Serenazgo had encountered. Phil's lecture was helpful to cover the most important things to do and not do during an emergency labor.

Chris giving Phil a life-saving hug demonstration

John and Beth with Peruvian medical student, Freddy, teaching CPR on home-made dummy

Danielle teaching cervical-spine support while simulating car extrication

While some of the Serenazgo had some experience with these topics, many very grateful for the lessons. We were invited to complete further trainings for the police force. The feedback was so positive that local TV footage was taken of Laurie for the Monday news. FIMRC was also featured live on the radio. It was a fun and productive day.

Laurie speaking to TV interviewer

Group photo with the Serenazgo!

This past Saturday, our host family was gracious enough to show us ancient ruins and beautiful areas around Huancayo. 

Margot (left) and Julia (right) are a dynamic daughter/mother hosting pair, featuring their garden

Beautiful Catholic church

Wari Willka ruins - most recent excavation by Danielle Kurin at UC Santa Barbara
(http://www.fertur-travel.com/blog/2013/the-practiced-craft-of-ancient-peruvian-skull-surgery/8156/)

Chris, Laurie, and Phil on top of ridge overlooking Huancayo and nearby mountains

Hasta luego!

Sipi Falls Update

Hi all!

We traveled to Sipi Falls in Mt. Elgon National Park this weekend, and it was beautiful, so I wanted to share some pictures! 

In other news, we will be rounding with a doc at Bududa District hospital next Tuesday and Wednesday. This should be an interesting experience because he covers the entire hospital. I guess we start the morning in the ER, move on to Labor and Delivery, then on to each of the wards, including Male, Female, and Pediatrics. Oh and of course there are a few surgeries thrown into there in the Operating Theatre between everything. I'm not sure how all of this is even possible for one physician, but we will see.

Happy traveling to the other groups!

Nicaragua- Project Limon

A recap of some highlights from last week in Tola, Nicaragua at Project Limon:

 

Caitie, Jenny and Nicole outside the hospital in Rivas

We have had a lot of fun different opportunities so far between working in the clinic and hospital to many community outreach programs. Some of our outreach experiences have included: 

Community tours

Our community is in the Department (like a state) of Rivas, Nicaragua. The community, Tola, is very rural and is comprised of 5 smaller neighborhoods. We spent an afternoon walking through the communities to get acquainted with where we are and learn more about our surroundings. We visited some of the Tiendas and restaurants but there isn’t much for sale here and the nearest grocery store is about an hour away.  We visited the local cemetery and noticed all of their caskets were cement and above ground. We saw the salt fields where they harvest salt from the ocean. 

Cemetery in Las Salinas, Rivas

There is a bakery, Paradise Bakery, but they don’t have baked goods on hand, its all made to order days in advance. Similarly, many of the “restaurants” are found in the homes of women who are known to be particularly good cooks in the community and open their living rooms for dining at lunchtime. A typical meal always includes beans and rice or gallo pinto (bean and rice mixed) and some sort of meat, especially sea food.

Typical Nicaraguan meal

The Natural Healer

We spent an afternoon visiting a local natural healer. She was in her eighties and grew up with other natural healers in her family. Despite many non-western methods she also prescribes things such as anti-parasite medications when she thinks they are indicated. While we were there she diagnosed us individually with ailments from parasites to slipped vertebral discs.

The natural healer working on Jenny

Diabetic and Prenatal home visits

We divided up and spent a few afternoons visiting patients in their homes for diabetes and prenatal checks. For the diabetic visits we checked every patient’s glucose and blood pressure and spent some time counseling. For the prenatal visits, FIMRC has a program where they visit the home of every pregnant person in the community once a month and go over an educational curriculum about pregnancy and motherhood. We all really enjoyed the opportunity to get out in to the community, meeting different members of the community in their homes. 

Physical therapy and clean-up

Tomeny helping us with the clean-up

Every Friday morning, FIMRC runs a therapy clinic for children with various special needs such as children with developmental delays, learning disabilities, cerebral palsy and more. We work with the children every Friday doing physical therapy and learning games. They always finish with a good game of musical chairs. This week we also helped cleaning up the center inside and out, including weeding with machetes and burning the yard waste (the method of trash removal around here). 

Jenny tending to the fires of our yard clippings

FunLimon Carnival

A local community foundation, FunLimon, put on a carnival Friday evening were we participated by creating a health Jeopardy game for kids to play and gave out prizes from the donations we brought. The game was a big hit (or more so the prizes) and we had a never-ending line of kids. A few other local organizations set up informational booths and there was a bouncehouse, a clown running games and cotton candy. Also, 3 major league baseball players came down to run a baseball camp over the weekend and were signing autographs at the carnival. 

Showing off our handy work - Jeopardy game behind us

Us with most of the FIMRC Nicaragua group

We could go on about all we are experiencing and learning and all the great people in the community we have been getting to know, but that's it for now!

"jumping" picture as we head off for a hike

Week 2 in Uganda!

MONDAY

What a day! We all hopped on Boda bodas in the morning with Michael from the clinic. We drove all around the Bududa loop, the road that connects the trading centers within our Bududa district. We visited two other clinics in the district, as well as the Bududa Regional Hospital. 

I was pleasantly surprised with the clinics, as I have been so far with our own clinic. Things seem well organized and it seems like there is decent access to care. There are pharmacies, maternal care, and immunizations available. Everyone was very friendly and welcoming. I think there has been national and international emphasis on increasing the quality of and access to community clinics, and you can really see the positive outcomes from this in these clinics.

Unfortunately, I did not have the same reaction to the regional hospital. The hospital is large. There are many wards: male, female, maternity, pediatric, operating theatre and an ER. For the entire hospital there are three doctors, but usually only one doctor in a given day. The wards are very simple; there are no private rooms, but instead one large room. There are not enough mattresses or IV poles, but they do seem to make sure they have the medications necessary for the patients. I was impressed with the staff I met there, but they just don't have the resources they really need to provide the care they want to. 

This was a powerful day for me, and eye-opening to the medical system in Uganda. I hope to keep having such powerful experiences!

Putting sunscreen on for the day:

TUESDAY

Today was another day in the clinic for me in the morning, and then I traveled back to the hospital with another volunteer, another Michael, to arrange shadowing for us. It was another Boda Boda ride through this gorgeous country, and I loved it!  We came back to the clinic, and the afternoon was spent teaching community health workers how to take vital signs, so they could do that on their outreach trips to different villages. It felt like a really productive day.

Two other med students, Androuw and Carolina, made their way to the hospital in the afternoon as well, and attended a surgery, an inguinal hernia repair. They said it was a good experience to see the similarities and differences between surgery in the US and here in Uganda.

WEDNESDAY

Another adventurous day! We took bodas to the village with the school for orphans I visited last week, Bushika. The building is constructed out of mud, and they are building another room for the fourth grade class. We spent the morning digging out the land for dirt for mud. We worked with one of the teachers, Hosaya, who explained that things like learning how to dig are an "informal education," which, especially in Bududa, can be as important as any "formal education" you would get at school. Within a couple hours we were all pretty good with our hoes!

The afternoon we spent in the clinic, and observed a group called Marie Stopes, who  travel around clinic to clinic to provide women's health services. They did many IUD and

 Implanon placements, but the most amazing was the tree tubal libations we observed. This is a surgery that in the US is done under general anesthesia in an operating room in a hospital. We watched them do these surgeries in an open air pavilion under local anesthesia... This means patients are awake for the whole procedure, and get up off the table and walk away immediately after it was done. It was completely amazing! 

THURSDAY

Today I spent the whole day working with Kristen, a PA that has been here for three months. We saw kids all day, and it was a great day. Some of the other medical students traveled to the other clinic where Marie Stopes traveled for the day to observe more procedures, while others worked taking vitals, in the lab, and seeing adults. Overall a great day!

FRIDAY

Today we will be touring the hospitals in Mbale, the biggest city close to us. I am curious to see how this hospital will compare to the regional one. 

This weekend we are traveling to the Sipi Waterfalls in Mt Elgon National Park, and we are looking forward to the arrival of a professor and OB/Gyn from MSU who will be working with us for the next two weeks!

Packing into the van: 

Monika and the LMU Uganda team

Welcome to Restauración

Restauracion is a small town of approximately 7,000. It is located in the Northwestern region of Dajabon, a border province of the Dominican Republic with Haiti. Our 1^st day involved traveling back towards Santiago to the town of Mao to see the director of public health for the region. We had been told that we needed his blessing for me to be able to work clinically. Luckily, within a few minutes of seeing the director and speaking to him, he gave his permission, and I was officially set to go. We drove back to Restauracion, for me to get an introduction to the hospital, and the FIMRC organization. 

Starting Tuesday, 1/14, I began my work at the clinic. Although it was labeled as a municipal hospital, and did have 3 small wards for inpatients, the Hospital in Restauracion mostly functioned as a primary care center. There was capacity for IV rehydration and antibiotics, as well as an OB/GYN room for births and exams. However, any complications or procedures requiring specialists needed to be sent up to Dajabon, the Regional Seat. The hospital was staffed 24/7 with 1 physician (there was a rotation of 3 that worked 24 hour shifts every 3^rd day. One attending physician and 2 medical interns doing their required year of service. 

As this is dry season, my patients presented with mostly run-of-the-mill complaints, colds, flu, UTIs, the occasional Hypertensive urgency, but consistent with a family practice in the US. I was told of episodes of Dengue, occasional malaria, and the epidemic of Cholera that they had faced here months back.

I spent the rest of the 1^st week getting used to the town and meeting the generous and welcoming inhabitants.