kids, worms, and pills

28/09/09

A month or so ago I had a pretty cool opportunity that I´ve been meaning to write about, but just haven´t had the time – I´ve been on the road a lot lately, most recently for a week in Lima helping compile all the Wat/San volunteer “Tri-Annual Reports” (really not that fun), and also meeting with the new volunteers from Perú 14, who just arrived a couple weeks ago in Lima for their three months of training. This is right where my group was – a year ago. Hard to believe. There are something like 58 of them, the biggest group to come to Perú yet, and they include the first group of Wat/San volunteers after mine, which is very exciting for those of us who have made it this far (WatSan1 is down to 11 from our original 15). I´ll be heading back to Lima again in late October to take them through some of the water-specific work I´ve been involved in at site, which should be fun for me, and hopefully useful for them.

But now I´ve got some time, so I wanted to write about something else: the medical campaign I got to help out with last month down in Chulucanas, the artisan capital of the North, which lies about an hour outside of Piura city. In a random series of international connections, my fellow Alto Piura Wat/San-er Patrick and I were asked by an Catholic Sister from Australia to come down to her now-home of Chulucanas to help out as translators for American doctors and residents from Johns Hopkins, who would be here for a weeklong free pediatric health campaign for select Chulucanas families. It was organized by the Chulucanas Diocese; basically each parish in the district received a certain number of fichas, or tickets, to be distributed to the neediest of its families, who then came to the “Pastoral Center” in the city (seemingly by the boatload!) on their designated day, to be seen by the docs. It was an interesting experience, for a lot of reasons.

First and foremost, it was nothing less than eye-opening to see all these patients and learn about the health problems of the children of Chulucanas which, I think it can be safely assumed, probably affect poor families all over Perú and the rest of the developing world. During the course of each day we probably saw between 15 and 30 families, whose kids were suffering everything from the common cold to epilepsy to weird skin rashes to heart murmurs to club feet, among many others.

The cold was the most common of all: after a couple hours on that first day, the doctor I was working with and I would have to try hard not to roll our eyes when a mother came in and said her child had a headache, runny nose, and dry cough. I´d say about half of the patients we saw all week had nothing more than the common cold, and were generally baffled when we had nothing to give them but the vitamins that the campaign was donating to every kid who came through. (You can´t blame them for being paranoid though, especially with the recent hysteria over H1N1). Anyway, after a few attempts I realized that it really wasn´t worth trying to explain that in the medical culture of the United States, we don´t prescribe antibiotics or shots for viral infections (unlike here, where a doctor´s first reaction to pretty much anything is often some form of injection). So we just told them that it was very unlikely to be the swine flu, and to drink lots of fluids until it ran its course. The vitamins often saved the day, actually – at least we were able to give them something to take home. And often we´d wind up giving them two or three extra packets, for the kid´s brothers or sisters or cousins or grandma or…you get the idea.

A close second to the common cold was dehydration. To the countless children who came in complaining of headaches, lack of appetite, and fatigue, the first question I repeated time and time again was, “So, how much water are we drinking every day?” After a couple of these, I could predict, almost word-for-word, that Mom would interject with something reassuring like, “Oh, lots of water, he drinks lots of water.” Same with the next response, which I would hear upon pressing a little further:

“OK, so when you say a lot…how many cups, more or less?”
“Oh, at least two, maybe three.”

It would have been amusing, had it not been so sad that these mothers (many as young as my little sister, a high-school junior) simply had no idea how much water their kids needed (up to 10 glasses a day, particularly in a desert climate like that of Chulucanas). Unfortunately, a lot of times, for cultural reasons more than anything, water isn´t even an option; in the desert towns around Piura kids often grow up drinking nothing but chicha, a mildly alcoholic drink made from fermented corn. This all being a great learning opportunity for the young doctors, occasionally another doctor would poke his or her head in and tell the one I was assigned to that there was a special case he should come see. Toward the end of the third day I accompanied them to see a severely dehydrated 2-month old. I´ve never seen such a frail-looking human being – she was so tiny, and you could pull her skin away from her bones like it was silly putty (an obvious indicator for dehydration, I learned). On one hand, it was reassuring to see these critical cases receiving the care they so urgently needed. But at the same time you couldn´t help but wonder how many millions more there were out there who weren´t getting the basic nutrition and treatment that all kids need, even when they grow up in the industrialized world under the best of conditions.

Common to almost all the patients, regardless of their other symptoms, was anemia. I´d say about 3 out of every 4 kids we saw were anemic, meaning (as I learned) that their hemoglobin count was low because of a lack of iron in their blood. In the worst cases the kids had eerily bright white eyeballs and pale-looking skin, which are two signs of severe anemia. Apparently, a hemoglobin count below 11.5 is considered anemic – mine is something like 14.2. Some of these kids´ blood tests showed numbers as low as 8. It´s caused by lack of iron in the diet, which comes from protein-rich foods such as beef, fish, beans, and nuts. Which makes total sense, given the predominant role of 1) potatoes, and 2) rice in the Peruvian diet. We handed out iron pills like they were candy, and advised the mothers to try to include more protein-rich foods in their children´s diets: a recommendation that sadly, doctor, translator, and patient alike were painfully aware would be essentially impossible to fulfill, given the economic situation that most of the families were coming from.

Anemia is also exacerbated by intestinal parasites, which suck nutrients from the lining of the intestines, therefore preventing their absorption into the body. Poor Peruvians are essentially an endemic population for pinworms and other bichos, and indeed many mothers reported the telltale symptom of small, rice-size worms in their children´s stools. Fortunately such worms are easily wiped-out with a single, 400mg. dose of Albendazole, but as with the diet issue, it wasn´t the immediate cure but rather the long-term environmental conditions that were worrisome. I realized that to truly eradicate these problems, what they needed was a Peace Corps volunteer in the community for a couple years, teaching proper hygiene techniques and helping implement basic sanitation infrastructure. A free pill or two wasn´t gonna do it.

To that end, it was really interesting, if a little depressing, to think about the philosophical differences between the theory of sustainable development and that of medical practice. As development workers (and the Peace Corps stresses this even more than other NGOs and aid agencies), we´re trained to investigate the root causes of these problems, and then to look first within the community to see what internal resources we can use to solve them. This model emphasizes sustainability in development. Within the Peace Corps, asking for outside funding for a project, for example, is promoted only as a last resort. This is because it can encourage what in Perú we call asistencialismo, or the “gift-expecting” syndrome, where poor populations become conditioned to expect free gifts from NGOs, in the form of say, sanitary latrines or other quality-of-life-improving installations. As a result, the recipients tend to value them less and take care of them less than they would, had they had an integral role in the funding, planning and execution of the project. We see failed projects like this all the time, like the cocinas mejoradas (“improved kitchens”) project in Chalaco, built by a Spanish NGO a few years back.

Contrast that with the stereotypical (and this is, in fact, a very generalized example) medical approach of slapping a band-aid on the problem and sending the patient on his way to make room for the next one; in a sense, it´s about as opposite as two strategies could be. I absolutely don´t mean to criticize or belittle the work that doctors do in developing countries, particularly when they travel thousands of miles and give up their time to put on free clinics. And it´s certainly not to say that Peace Corps or other volunteers always succeed in the process I described above. The point is just that for me, the experience highlighted what often manifest themselves as two very different approaches to the same issue, that is, improving the lives of the world´s poorest people.

One the bright side, throughout the week I learned a ton about health-related topics that I´ve always wondered about, but never urgently enough to say, Wikipedia them. Among them: pregnancy, babies, breast-feeding, ear infections, general nutrition, worms, how the heart works, and what exactly doctors look for when they shine that light back and forth in your eyes (it´s more complicated that you might think). I also picked up some particularly jarring news for a WatSan volunteer who preaches chlorine water treatment as gospel – turns out chlorine kills viruses and most bacteria, but many parasites can survive it. Somehow I had missed that piece (or more likely, it was never mentioned) during our training; I just thought chlorine was the magical all-germ killer. So that kinda flipped my whole WatSan world upside-down for a couple days, not to mention made me question the efficacy of the ceramic filter I´ve been using to “treat” my drinking water and that of my host family (I mean, those things can´t possibly block every single parasite that comes along, right?) I´ve since looked into it, and although that does seem to be the consensus, it appears that there isn´t any real, feasible alternative at the moment. Global health experts continue to recommend chlorine treatment for all drinking water, plus boiling it before consumption, particularly in at-risk areas with poor sanitation and hygiene (ie, most of Perú and the developing world).

So, always nice to clear up a question that, however briefly, poses an existential threat to your day job. But even though we have treated water in Chalaco, I´ve started myself on a tri-annual Albendazole self-medication regimen, just to periodically clear out anything that slips through the cracks. Last week my dog and I each took 400mg. (he´s had pinworms pretty much since birth). Nothing weird came out of me…yet. Wish I could say the same for him.