My name is Michelle Alyssa Tran, and I am an undergraduate student at Rice University in Houston, Texas. I am studying biochemistry and cell biology and minoring in poverty, justice and human capabilities. I will be attending medical school in New York City after I graduate, and hope to pursue a career dedicated to gynecologic cancer and helping women in disadvantaged settings receive the best quality care and treatment possible.

In the summer of 2016, I received funding from the Rice Loewenstern Fellowship to serve and study abroad through an healthcare internship with the Foundation for Sustainable Development (FSD) in Masaya, Nicaragua. For nine weeks, I lived with a host family and worked in the Centro de Salud Monimbó, a public health center in the southern district of Masaya that offers free health services to residents of low socioeconomic background.

While there, I started up a girl’s leadership club called Chicas Poderosas in a local secondary school to help create educated peer health advocates who are motivated to help their communities improve their health. Through interactive bi-weekly sessions, I worked directly with a group of 35 adolescents to cover themes of sexual and reproductive health, domestic violence, and environmental health. I then supported the girls’ efforts to spearhead their own community outreach efforts, some of which included developing a school poster campaign addressing false myths about contraceptives and teaching primary school students about the public health effects of littering. Leadership was selected within the group as well as from staff at health center to ensure the continuity of the club beyond my internship.

I also formed a teenage pregnancy support group at a neighborhood health post to offer a workshop series on infant care (breastfeeding, bathing, burping, etc.), diet during pregnancy, and postpartum care. I was able to reach out to over 15 different mothers and develop a social support network amongst the participants and the attending doctor and nurse. At the midpoint of my experience, I received a $600+ grant from FSD to financially support the continuity of both my initiatives.

During the rest of my time, I shadowed and assisted doctors and nurses at the main health center as well as aided and accompanied them in their outreach to rural and urban health posts.

All in all, my time in Masaya, Nicaragua was an incredible learning experience that I will never forget. Please feel free to browse through my blog and read about some of my stories and reflections. Please also feel free to check out the Wikipedia article that I created upon returning to the states, which is on Healthcare in Nicaragua. Thanks for visiting, and please feel free to reach me at michellet987@gmail.com if you have any questions.

As I write this post, I am currently on a plane headed back to Houston, TX.

My heart feels like it is being wrenched in a million different directions right now as I reflect on the rich experiences and wonderful connections I developed with the people of Masaya, Nicaragua over the past nine weeks and think about all of the things about Nicaragua that I will terribly miss. I have been having difficulty controlling my water works since last night, after giving a last hug to my host grandmother, Doña Amparo, before my early morning departure today.

The last few days have been filled with despedidas (good-bye parties), excessive amounts of smoothies and nacatamals, and too many farewell hugs. I am terrible at saying good-byes, but farewell get-togethers are important to me because I desire a sense of conclusion.

On Wednesday, I treated two of the pregnant adolescent patients who had the best attendance at my workshops at the Roberto Clemente health post to smoothies at my favorite place in the Parque Central. Nory (in the center) is expecting her baby in the next month while Jessica (on the right) is expecting hers in December (a Christmas present)!

On Thursday, I planned to lead my very, very last Chicas Poderosas session on myths about sex and use of contraceptives, but since school got dismissed early that day, around half of the girls already had unfortunately already left by the time I arrived. However, as always, the same group of girls lingered around after school, waiting for me, so I still decided to run the session. In addition to these girls, a few of their male friends (who participated in the environmental health presentation for the primary students) also joined. It turned out to be an absolutely wonderful, eye-opening session – for both the students and me- and it deserves its own blog post in the future. At the end of the meeting, after exchanging email, Whatsapp and Facebook information, the students begged me to come back the next day for a more proper good-bye with everyone. Thus, on Friday, I returned another time!

On Friday, the room was packed with more girls than chairs. Since the club’s inception six weeks ago, some new additions were made because of friends asking friends to come along, and the club expanded. In addition to reviewing the information that I had discussed with the smaller group the day before (I had the girls who were there on Thursday to help me present.), I gave them final evaluation forms to fill out so they could reflect on their individual experiences participating in the club as well as provide feedback with ideas about how to improve the club. I stayed at the school long after the Friday session ended to help out a fellow intern with conducting parent interviews for her health research on contraceptive knowledge. I spent a great deal of time posing for pictures photos with them on our cell phones and chatting with several of them one-on-one and in small groups. They all told me that I had to come back during a future vacation and to never ever forget them.

Brenda, Sara, Rebeca, Morelia, and Miguel stayed behind to chat longer, and I got the opportunity to introduce them to some of my fellow interns who showed up to help out with the parent interviews. Listening to them rant on and on about all they have learned and done over the past six weeks to my friends made me very proud. They told them that they would not get boyfriends or have sexual relations until they are old and mature enough to handle the responsibility. They told me they did not want to end up like Ana and Pablo (a fictional teenage pair that had an accidental, unwanted pregnancy in a scenario that I had them act out in an early session). Not wanting to say goodbye to them just yet, I invited them to spend the following afternoon in the Parque Central for a small despedida with their friend group. They excitedly agreed and made plans amongst their group.

On Saturday, five of them showed up (three couldn’t go because their parents would not let them). Since they all live in different locations throughout Monimbo, the southern district of Masaya, they had left their houses at 1 PM to walk/take the bus to meet each other and then come meet me. All in all, it was a two-hour trip for them to come out to the park to meet me! I had no idea it would take them that long, and their act of doing so was a gift I will never forget. It was the first time I had seen them out of their school uniforms, and they all looked gorgeous wearing beautiful, colorful clothing and fancy bags. I treated them to Oreos and smoothies and we laughed and joked about experiences we shared together in Chicas Poderosas. They told me how sad they would be to have me gone with a nurse leader in my place – it just wouldn’t be the same. We walked around the park and then watched a cultural show, which was a sort of pageant competition for young girls that involved traditional dance and speech about cultural traditions. Held in the large Instituto Central, it was a very exciting event, packed full with a lively audience. We took an excessive amount of pictures to capture our last get-together (well, not hopefully not last… they made me promise to come back which I fully intend to one day once I can afford it).

In addition to my despedidas with my students, I also had the opportunity to go see the Masaya Volcano (a surreal, unforgettable experience) and enjoy a farewell dinner with karaoke with my fellow FSD interns. My host family also prepared me traditional, heavy dishes of baho and nacatamals.

On Saturday night, after hugging Doña Amparo and starting to cry, I went to bed with my emotions all knotted up and out of my control. As I looked around my room, which was all packed up and ready to be moved out of, my mind instantly flitted back to nine weeks ago, when I first arrived. I remembered that first sense of panic I felt nine weeks ago when I first brought my luggage in and got a chance to sit down on my bed. I remember questioning myself about what I got myself into… doubting whether I could actually survive the next nine weeks on my own… whether I would be lonely out of my mind, whether I would be able to communicate, whether my project would have any success or whether I would enjoy myself at all… All of these feelings felt so foreign and distant that it seemed like years ago when I first arrived, even though it was just back in May.

I couldn’t sleep at all last night. My emotions were in haywire while my mind overflowed with replays of various unforgettable experiences that I had… I couldn’t stop thinking about every single thing I would miss… everything from the vivid colors of the streets that I have gotten myself accustomed to, the laughter and singing of my host family that I would wake up to every morning, and my students screaming my name when they saw me at the entrance of the school to the pure feeling of excitement of living in the center of the city would bring every time I set foot outside of my door. I had gotten so accustomed to living my daily routine in Nicaragua – from eating traditional food every meal and saluting familiar faces and local friends that I have made throughout the streets to simply all of the smells and sounds in the bustling streets that I had grown to love.

I departed the quiet house at 4:30 AM this morning to reach my flight on time. Doña Ritana woke up at 4 AM to see me off. We both couldn’t stop crying after hugging each other. I still can’t think about seeing Doña Ritana break out into tears without crying. Throughout the whole car ride to Managua/ throughout this plane ride, tears have been uncontrollably falling.

These nine weeks have flown by way too fast, but I am incredibly thankful for all of the  experiences and relationships I have been privileged to develop. They will stay with me forever.

My Nicaraguan Loewenstern summer experience will always hold a very special place in my heart.

A couple of weeks ago, my supervisor, Maria, a trained forensic psychologist in Nicaragua, told me a chilling story of a case she had in the past.

Maria saw two young children of a homicide victim who were scarred from an incident they could never erase from their minds: the first-hand murder of their mother by their father. Their father had seen their mother giving a glass of water to a visiting male stranger, and without caring to know the context, proceeded to brutally slaughter their mother by wrapping her in barbed wire. The children were present while the whole event took place in front of their eyes.

Maria told me this story to help me better understand Nicaragua’s domestic violence problem, which is severe. One out of three Nicaraguan women have reported domestic abuse, making Nicaragua have the second highest rate of domestic violence in Latin America (after Guatemala).

Though in 1996, MINSA declared domestic violence a public health problem, it has done little to address the issue, which remains unfunded and often undiscussed. The problem has not gotten any better since then. Unfortunately widespread poverty and lack of hope continue to feed into this endless cycle of domestic abuse.

Yesterday’s Chicas Poderosa’s session was focused on violence within romantic partnerships and within families. To start off the session we discussed different types of domestic violence – physical, emotional, economical, and sexual- and how to recognize alert signals and identify violent and manipulative partners. We then discussed how to prevent and confront violence in their own romantic relationships. When Maria arrived at the end of the session, she helped me by leading them in an activity (pictured below) that demonstrated the unhealthy power dynamic that exists in violent relationships and then subsequently presenting on what they could do to change this culture of intrafamiliar violence that exists within their communities.

This was an especially difficult lesson for me to teach. I try to make all of my sessions interactive, by asking girls questions and having them raise their hands and participate, but the girls were particularly resistant to answering questions I presented to them about domestic violence. When I asked them if they thought domestic violence was a problem here, it took them a while for them to respond. After a couple of brave girls admitted that they have seen cases of domestic violence here, the rest of the class got the courage to speak up and agree that they thought it was a problem in their community, and that it was important to make changes in this area.

I realize that this is a very a sensitive topic, and I am very proud of the girls for participating in the charla. After the last few sessions that I have, girls are coming up to me afterwards to let me know that they think that the themes of my charlas are “bonita” and are grateful that I am bringing attention to issues that are recognized as important but often pushed under the rug. I hope that these sessions will start conversations amongst the girls and their social networks to ignite some change or some re-evaluation of their perception of how they can address the domestic violence problem in their community.

 

Every Nicaraguan here who I have talked to about my service has been encouraging. With girls dropping out of school and leaving the labor force and with more mouths to feed, they recognize that teenage pregnancy results in many serious economic and emotional strains on families. Many who I have talked to have also recognized the more nation-wide problems that teenage pregnancy presents in terms of its limitation of the growth of the nation’s economy. Most can talk on and on about how teenage pregnancy is a definite problem in Nicaragua. They can bring up their friend’s daughter that got pregnant at fifteen or their neighbor’s son who impregnated a sixteen year old and talk for hours about how this affected the lives of their families. But when it comes to offering solutions to the problem, it’s not always clear what should be done.

The issue of high rates of teenage pregnancies in Nicaragua is definitely multifactorial. Nicaraguan machismo, lack of contraceptive knowledge, and religious beliefs contribute to 28% of Nicaraguan women giving birth before the age of 18 years. Because there are so many sociocultural forces at play, it truly is difficult to approach this issue with any one clear-cut answer. However, what I have learned over my time here, is that sexual health education here is extremely lacking.

Two of my fellow interns at Foundation for Sustainable Development are currently conducting research at the Centro de Salud Monimbo, the same health center I am serving at. They are interviewing pregnant teenager patients (12-19 years old) to better gauge their understanding of pregnancy and contraceptive methods. Unfortunately, they have been finding that knowledge in this area is extremely lacking and that false community myths are all too common in these girls who are coming. Patients come in believing that taking the day-after pill one time will cause them to be sterile for the rest of their lives. Some think that they can’t get period during their period and depend solely on the unreliable calendar method for birth control.

Last week during my workshop on birth control, I found this widespread lack of knowledge to be true amongst my club of secondary school girls (13-16 years old). Though the girls were naturally embarrassed about this topic, they were intently paying attention throughout the entire duration of my presentation. Out of the thirty girls there, only two had attended any educational session on contraception in the past. I tried to make the session as interactive as possible to make sure the girls absorbed the information. I passed out condoms to the girls, and demonstrated how to properly open the packet and use a condom, using a glue bottle as my model. I kept the session full of back-and-forth Q&A. I observed that when I presented them questions such as if it is better to wear one or two condoms during sexual intercourse, the girls did not know the answers. (The answer is that a single condom is better; two or more can cause friction that can increase the likelihood that they will break and fail at their original purpose.) This experience strengthened my feelings that education about sexual health here is definitely lacking and is likely a strong contributor to why the rate of teenage pregnancy is so high in Nicaragua.

Unfortunately there are many barriers impeding widespread advances in contraceptive education in Nicaragua. Because of adamant religious beliefs, there is no push to teach sexual health in schools. This leaves public health centers and women’s health organizations left to find their own funding to send representatives out to teach students. The initiatives that these organizations spearhead are often very admirable, but sadly are unable to reach many students due to irregularity because of a lack of established widespread model and accountability structure.

I have seen the incredible success of Nicaragua’s community and family health model (Modelo de Salud Familiar y Comunitario – MOSFAC) at work while shadowing doctors at the various rural and urban posts throughout the neighborhoods. These doctors go knocking door-to-door to make sure that no chronically ill patient is left undiagnosed and untreated. This is credited to the dedication of the doctors at the Centro de Salud and MINSA, Nicaragua’s health ministry.

In my personal opinion, a nation-wide model integrating sexual health education into secondary school curriculum would have great success and perhaps make a dent in lowering the national rates of teenage pregnancy. However, implementing a program this wide-spread on a topic that is controversial and touchy for people of certain beliefs would be an extreme challenge.

On Tuesday’s, I work with adolescents aged 13 – 18 years old in a secondary school. Before and after our sessions, the girls are always laughing with friends, flirting with boys, playfully teasing me, and just generally enjoying their teenage years.

On Wednesday’s, I work with girls that are their same age, who are living in a whole other world. They are pregnant with either their first or second children. Most are out of school and do not receive the support that school social networks offer. They walk to my sessions alone, or sometimes with a young baby on one shoulder.

Since I am working with both groups at the same time, the contrast between the groups is not something I can ignore.

I am older than many of the pregnant patients in my group, but they carry heavy, real responsibilities that I have never experienced, responsibilities I cannot even begin comprehend.

Take Jessica for example. She’s fifteen years old, and seven months pregnant with her first child – a boy. She’s attended all three of my workshops and has been on time each time, maintaining a perfect attendance record that beats the rest of the club’s participants. Each time she brings her notebook and pen that I gave out on the first day and attempts to take copious notes. She no longer attends school, and from the written evaluations she has turned in, this is obvious.

Since we both live close by, after our last session, we walked part of the way home together. Under the strong sun, my heavy backpack and long pants were suffocating me, and I was sweating up a storm. But I did not dare complain while Jessica walked beside me in her skinny jeans with her bulging belly.

During our conversation, I learned that she has already moved out of her home and is living with her partner’s family. She’s only one year than my younger sister. Yet, she no longer lives with her parents, and is already independent, ready to raise her own family on her own.

We talked a bit about what we were up to that afternoon. I told her that I was going to a meeting with the director of the health center that afternoon, and then to dinner and a volcano excursion with the other interns in my program at night. She told me she was about to take a long nap. Her petite body was tired after the long walk to the center, and she almost wasn’t able to make it out that morning. After her nap, she would clean her house a bit, prepare dinner for her household, rest, and then start the day over again.

I have less than 10 days left here in Masaya, and I can’t seem to wrap my head around the little time left I have.

Before leaving for my trip, I was given envelopes with essay prompts to open up at different times all throughout my internship. Now with only one week left, I have a small stack of prompts that I have not directly addressed in my blog posts. At some point over the past 8 weeks, life here just caught up to me and I was overwhelmed by the feeling of too many things to write about.

However, before I leave the country, I hope to document some of the feelings and experiences I have had here while they are fresh in my mind. Be on the look-out for future posts.

After a wonderful week’s stay in Nicaragua, my family departed last night back to Los Angeles. I thoroughly enjoyed the quality time I was able to spend with my family and was happy that I could show them around the area. I had not seen my sister or father for seven months, which was longest period I have spent away from them in my life. During that time, my sister actually outgrew me!

While my family was here, I enjoyed a brief vacation away from my host family, staying with them in peaceful eco-lodge in Catarina, Masaya that overlooked the Laguna de Apoyo. My family spoiled me with the opportunity to enjoy hot showers, a brief reprieve from mosquito attacks, and the ability to avoid walking the dusty streets by cruising in an air-conditioned, new rental car. Seeing the area from a tourists’ lens was honestly quite strange after six weeks immersed under much different conditions and watching my family’s reactions to what they saw around them gave me some new perspective into my experiences over the past six weeks.

While they were here, I introduced them to my host family. They brought a whole duffel bag of assorted gifts for them, and in return my family treated them to a Nicaraguan-flavored “chow mein” dinner. Unfortunately my family knows little Spanish, so conversation was limited; however, my father, extroverted and unabashed as always, pulled out his Google translator app on his Nexus phone and was somehow able to engage them in conversation the whole time (with a bit of my translating help). My family was overall impressed with how much my Spanish language abilities had improved and admitted to me that they had thought that my pre-trip Spanish accent was no bueno.

I also had the opportunity to show my family what I have been up to over the past seven weeks. They accompanied me to my Monday health workshop for the pregnant teenagers at the Roberto Clemente health post. I was lucky to have my mom there to help me prepare because the theme was “Caring for your Infant: Breastfeeding, Bathing, and More”, and I did not have much prior first-hand experience with this.

Afterwards, I got to show them around Malecón Park, downtown Masaya, and the main healthcare clinic.

They also helped out with my Thursday Chicas Poderosas meeting with the secondary school girls. The day’s theme was birth control methods, and I was forever grateful my parents were there because the girls were infinitely much better behaved. The girls were naturally embarrassed at the topics I covered, so my sister led the girls in an arts and crafts project afterwards. They embellished hair ties with bows and flowers.

I am so happy I could share a slice of my experiences with them and wish they could have stayed for longer!

I am officially two-thirds done with my internship here in Nicaragua, and I can hardly believe it. Looking forward and realizing I only have a few weeks I have left is off-putting because it feels as if I have just started and have so much left that I want to learn and do. However, at the same time, looking back at all of the rich experiences I have had thus far makes me feel as if I have been here much, much longer than six mere weeks.

My schedule here has definitely gotten busier over the past six weeks, and I love it. Once I started my girls’ leadership club in the secondary school and pregnant teenager support group in a local health post, I have always had something to do. Outside of actually leading the sessions, I am often running around town to gather supplies from stores and various houses around the neighborhood that sell homemade refreshments like plantain chips and natural juices. I also dedicate some time out of each day to plan my upcoming sessions by creating educational games, making PowerPoints, informational brochures, evaluation sheets, and more. Sometimes I schedule meetings with health center employees to discuss logistics, and when I have a relatively free half-day, I go into the health center to shadow physicians and nurses in clinic and in surrounding rural health posts. Every Friday, I attend an educational workshop held by Foundations for Sustainable Development, the third-party organization that connected me with my organization. These workshops have covered a wide range of topics ranging from domestic violence, the economy, and the health care system in Nicaragua.

I am very happy with the progress of my projects and all that I am learning from my work. My thirty-three students in the girls’ leadership club called Chicas Poderosas that I started up at a local secondary school in Monimbó never fail to impress me more and more each session. We just finished our fourth after-school session, and thus concluded our first unit on environmental health. This unit started off with me presenting a couple of workshops on health effects of the environment and the girls discussing ways to make change in the way their fellow community members approached treating the environment. After discussion of the challenges they have observed their community face, the girls collectively decided to pursue a community outreach project involving educating the primary school students at their school on the topics they had just covered. They subsequently collaborated in six small groups to develop lesson plans and campaign posters to present to the students. Originally unbeknownst to me, a couple of the groups even brought their posters home to decorate them further with their peers! Watching the groups confidently present half-hour lessons about the public health effects of littering, the dangers of plastic, and how to prevent Chikungya, dengue, and Zika to around twenty primary school students each gave me the proudest feeling. The girls did a wonderful job at engaging the students- going off-script and trying to get them to participate- to the extent that already dismissed primary school students came back inside the classroom to watch!

I am also pleased with the progress of the pregnant adolescent support group that I helped organize in a local urban health post. From the evaluation sheets and the girls’ consistent participation in the sessions’ discussions, I think that they are benefitting from the workshops. At my last session, the women were furiously taking notes on each slide, which made me happy that they were actually interested and invested in learning more about the topic of following a healthy diet and physical activity plan during pregnancy. Beyond their interest in helping themselves, it was also apparent that they were interested in taking what they have learned and sharing it with others to make a difference in their communities. During the last session, the girls and the supervising doctor had long conversations about observations of problems they identified in their community such as seeing pregnant women mount horses and motorcycles and consume alcohol and greasy soups sold in the streets. The doctor and I both emphasized that they could help change what they saw, by spreading what they have learned and addressing myths to the benefit of their community’s health and safety.

While content with the current progression of my projects in respect to the value that the participants are extracting from each session, I still worried about the sustainability of my projects. The health center employees are extremely busy seeing patients and have limited time to take on extra projects. Furthermore, financial strains are all too real and relevant. With the pregnant adolescent support group, I think I have found health workers who have become invested in the success of the project and who might be willing to continue it in the future; however, I am still looking for someone to help lead the girls’ club in the secondary school when I leave. The health center director keeps on pushing back the date of when she plans to send someone with me, and I am getting worried. To balance this with a bit of good news, I was awarded a grant from Foundations for Sustainable Development yesterday after a trying application process! I now have $616 to dedicate to making sure that these programs will last beyond the duration of my internship.

Outside of my project work, I am thrilled with my current level of integration into the community. I have gotten very close to my host family and often have long chats with the grandmother and mother, who have worked with Foundations for Sustainable Development for the last fifteen years. They have provided me a wonderful amount of social and emotional support that has helped me adapt to life here more easily. Before coming here, I set myself a goal of attending at least five community events outside of work events, and I have accomplished this with the help of social networking through my host family. I have attended church mass, birthday parties, Father’s Day and Mother’s Day celebrations, and city-wide religious parades. My goal of befriending more than five of my neighbors here was also accomplished. Because socialization and community involvement are huge parts of my host mother’s life, people are in and out my house all of the time. In general, people in Masaya are quite friendly and open, and it is easy to strike up conversation with anyone. I even have managed to make friends with people who live in the houses along the path that I take to the health center. I am also extremely happy that my Spanish has improved exponentially. I have picked up on a great deal of Nicaraguan slang and am able to interact smoothly with locals. I am actually now able to absorb background conversations and television shows without intentionally concentrating my attention on them, which, for me, signifies a huge leap in my comprehension skills.

I am also extremely grateful for the opportunities I have had to travel outside of my town to visit marvelous lagoons, volcanoes, hot springs, and beaches. Nicaragua’s natural beauty is breathtaking. My family (my father, mother, and sister) are arriving tonight for a week’s stay, and I am excited to show them around and share a slice of my experiences here with them.

Besides these overwhelmingly positive experiences, I am also appreciative for all of the challenges I have confronted and overcome. In the past six weeks, I have unfortunately been sick quite frequently, experiencing strep throat, horrible nausea, diarrhea, and heat syncope. It was when I was in the middle of waiting out a horrible two-day long fever or a horrible bout of vomiting that I felt the most alone and vulnerable. There have been a couple of times on this trip when I felt like my body was being attacked by everything Nicaraguan. During these times I couldn’t even stand leaving my house to walk down the street because of the feeling that the dust from the street – mixed with horse and dog waste, human trash, and polluted urban runoff- was contaminating my eyes, nose and throat. I couldn’t bear to go to the bathroom and pee because of my fear of the inevitable attack of the bathroom mosquitoes on my exposed butt cheeks. I couldn’t sleep right because of the terrible city noise at night and the horribly loud cohetes (celebratory air horn) early in the morning. These times of illness were definitely the most trying parts of my trip, but I am glad that I experienced them because now I feel much more strong and independent.

With the challenges I have confronted and overcome so far and the progress I have made on the goals I have made before this trip, I am happy with where I am and excited for where I am going.

Wednesday, June 23, 2016

Today was definitely the most exhausting yet rewarding day of my internship here thus far.

In the morning, I led my second health education workshop or charla for a pregnant adolescent support group I recently started up at a local urban health post for girls aged fifteen to twenty years old. This time I worked with a new set of girls from two different residential regions in Masaya. The topic of the charla was diet and physical activity for pregnant women, and we went over what they should and should not do in order to maintain a healthy lifestyle while pregnant. I was extremely impressed by the level of engagement and interest of the participants this time. The workshop took on an interactive split lecture and discussion-based format, allowing me to present the informative PowerPoint I had previously prepared while still incorporating time for the women to discuss amongst themselves and ask the attending doctor and me several questions.

Though the room was dead silent when we first began, it was buzzing with conversation by the end. After discovering that none of the girls knew each other, I started off the workshop with introductions and an icebreaker game. I gave each girl a pink post-it note with an object or celebrity name to place on her forehead. With the help of verbal hints from the surrounding girls, a great deal of laughter, and many failed attempts, the girls finally each guessed their own word.

With a bit more cheer and energy in the air, I then began presenting my PowerPoint, starting it off by questioning them paying attention to one’s diet during pregnancy is important. I then asked them a couple of more questions to spark discussion, asking if any of them knew the recommended amount of weight they should expect to gain during the course of their pregnancy. No one could answer. After I told them they should expect to gain between 25-35 pounds over the course of their pregnancy – around 1-5 pounds during their first trimester, and about one pound per week during their second and third trimesters –, they were surprised and began started furiously taking notes in the little notebooks I provided them.

The charla covered many sub-topics, discussing what should be included in a well-balanced diet as well as emphasizing the specific vitamins and foods pregnant women need to prevent birth defects, ecclampsia, and delivery complications. The girls shared me what their typical meals – breakfast, lunch, and dinner – include, and we discussed ways slightly modify their way of eating in order to improve the health of themselves and their babies. We also discussed many of the foods and activities they should avoid to keep healthy, and they posed many questions to the doctor and me about things they had heard from family members and friends. One participant asked if it was okay for pregnant women to have a beer from time to time; she said that her family and friends always tell her that one beer would not hurt her. Another asked if it was recommended that they take a nine-hour airplane flight while pregnant. The doctor and I addressed these questions, and many more.

I was extremely pleased with the participation of the doctor all throughout the charla. He shared very valuable information with the girls, providing medical advice that I had not been aware of beforehand, and sharing some of his own experiences working with mothers with birth complications and babies with birth defects resultant from at-risk pregnancies. Since he is part of their community himself, he has observed many risky practices of pregnant women and was familiar with what local myths about pregnancies to address. He discussed how while locals may say eggs and beans are dangerous to eat during pregnancy, they actually are not and carry very important nutrients. He also brought up how it is very common here to see pregnant women riding horses or mounting motorcycles, and subsequently emphasized how both of these practices can be extremely dangerous. Something that I particularly liked was how he emphasized the importance of family planning for future pregnancies, throwing in information about how taking folic acid four months before you become pregnant can greatly reduce the risks of having a baby with birth defects.

All throughout the charla, the doctor interjected with advice and answers to the participants’ questions and was an amazing help. Though the original plan was for the charla to end after one hour, it continued for almost two hours because of the fantastic dynamic between the doctor and the patients. I hope to be able to leave this project in his hands for him to continue after I finish my internship.

I was also very happy with the girls’ interaction throughout the session. It was evident they were interested in learning this information by how they were taking meticulous notes and asking several fantastic questions. I enjoyed listening to them discuss practices they had seen in their community, and street myths about pregnancy diets that they themselves have heard or been told. One thing that both the doctor and I consistently underscored to the girls was how integral it is for them to take what they had learned that morning and spread it amongst their families, friends, neighbors, etc. From the interest and motivation I saw in the girls this morning, I have confidence that this group of girls will take what they learned today and use it in some manner or another to help themselves and others in their community.

The second half of my day consisted of working with the 33 female students in Chicas Poderosas, the new girls’ leadership club in the Modelo Monimbo secondary school that I helped start up a few weeks ago. The girls have been hard at work on an environmental health project. After participating in a week’s worth of my workshops, they have been subsequently discussing ways to make change in their community. They have decided to work on an educational campaign for primary school students to teach them about the dangers of littering and plastic as well as how to prevent the spread of Chikunguya, dengue, and Zika in their homes. We dedicated today to making the posters that they will use to present.

I was proud to see the girls working so hard on their posters- discussing ideas amongst themselves, sketching drafts in their notebooks, excitedly scavenging around outside for a few pieces of trash to place on their poster for demonstration pieces, and looking in their school workbooks for related images to cut-out. It was wonderful to see how the members within each group divided up tasks and worked together to create really wonderful posters.

 

 

 

 

 

What truly made my day was when one group brought up a draft of their poster that they had been working on as a team outside of school, in their free time! I brought out the posters for the girls last week during our Tuesday workshop, but unfortunately we were not able to get to work on them until today. I thought I collected back all of the posters, but I must have missed one. Unbeknownst to me, a few girls took this poster with them, and worked on sketching these beautifully detailed to illustrate what actions people should take in their daily lives to avoid getting mosquito-transmitted diseases like dengue, Chikunguya, and Zika. The final product was lovely and made me very proud.

With the passing of every session, I am more and more impressed to see how these girls and the patients I saw in the morning are exercising leadership over their projects and the material they are learning and demonstrating genuine motivation and interest in helping their community. These girls are my inspiration, and the reason why I absolutely love my work here!

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“When you walk in, you’ll be awe-struck,” Dr. R claimed while excitedly waving around her hands. “The floors are sparkling clean. Each patient has a private fan and access to two full bathrooms, a kitchen always stocked with fresh fruits, new television sets, and even a lovely vegetable garden in the patio. There’s a well-trained nurse roaming the building 24/7, checking in on the patients every hour while they relax; it’s a paradise for pregnant women!”

In rapid-fire Spanish, Dr. R described the services of Casa Materna, a nearby health center for at-risk pregnant women. We were enjoying our lunch break out “en terreno” in the dirt yard of a family who had voluntarily lent out their house to allow us to use it as a health post to conduct patient consultations outside of the main Centro de Salud Monimbo. Earlier that morning, we set up a small picnic table, lined up a few plastic lawn chairs, and laid out our small cooler of vaccinations and a box of medical supplies and began seeing patients seconds after we arrived. Wave after wave of patients came, and Dr. R did not get a break until lunchtime. After watching how these sick patients had to travel by foot in hot weather to wait in long lines at the health post and at the main health center, I was convinced by Dr. R’s pitch of Casa Materna. What at-risk pregnant mom would turn down FREE 24-hour air conditioning and private, constant medical attention to address her needs?

Flash forward less than 24 hours.

I’m in the main health center, sitting across from a very pregnant woman, only two years younger than me – 17 years old. She is explaining her precarious medical situation to Dr. M, the primary care doctor I am shadowing. We’re all sweating in the small, cramped room with no A.C.

She’s 35 weeks into her pregnancy and is complaining of serious chest pain and shortness of breath that has been bothering her over the past week. She says she has diarrhea and is pre-eclamptic. I take her blood pressure and confirm- her systolic is 170, higher than it should be, a sign of pre-eclampsia, a dangerous condition for pregnant women. Dr. M. asks her if she has been taking her blood pressure medicine, and she confirms that she’s taking it. How often? Every hour. She did not realize the medication is only supposed to be taken every 12 hours.

By now Dr. M is worried. She tells her that she needs to go to the hospital right away. At the word “hospital”, the girl cringes. Dr. M also refers her to stay at the Casa Materna, the “paradise center” for at-risk pregnant women that Dr. R had just described to me the day before, to wait out the next few weeks before her pregnancy, and to my complete surprise, she responds with a flat-out, “no”.

She tells us that someone – she won’t tell us who – gave her the advice not to go. She had heard from his person that all of the women at Casa Materna are forced to water the garden, clean the bathroom, and mop the floors, and she doesn’t want to be to be over-exerted while pregnant and clean up after others for no pay. Dr. M calls someone she knows who helps direct the Casa Materna and puts her on speaker-phone to help clear up the false rumor. The lady on the phone says that mother’s who aren’t physically capable of helping out with chores are definitely not forced to do anything. But the girl’s still unconvinced.

With nothing else for us to try or say and with 5 more pregnant patients waiting impatiently outside, all Dr. M could do was prescribe her more hypertension medicine and vitamins and send her off to the hospital, hoping that she will go quickly and that she will receive the advanced immediate care needed and follow-up care with her family in her home so that she can safely deliver a health baby.

The day before, Dr. R mentioned to me that Casa Materna was self-run and sustainable, with patients helping upkeep the center to keep them active during their pregnancy. It sounded like a fantastic program to me. However, apparently a past patient or perhaps a friend or acquaintance of a patient or who knows what spread a bad rumor that convinced the girl that it was a horrible place.

Casa Materna is a wonderful humanitarian project that has been backed by Americans and Nicaraguans alike and to-date has helped so many women. Unfortunately it’s hard to change the way patients think or combat rumors like these. People will more often than not listen to their friends and family over licensed medical professionals – sometimes blatantly refusing to change their behavior in front of the doctor or pretending to agree to make lifestyle changes in front of the doctor but then going home and not doing anything differently at all.

This was one striking situation over my past week and a half working in the Centro de Salud that I wanted to share.  It just goes to show how extremely hard it is to change people’s daily health practices. To get people to change their ideas about what they think works is difficult. We failed at influencing the teenage girl to decide against staying at home and waiting out a dangerous pregnancy in a rural area where there are not nearby available midwives or medical services in the middle of the night if something unwanted were to (God forbid) happen. From her point of view, living in a strange place with negative reviews  where she would have to perform work for strangers for a few weeks just to deliver her baby was not worth it.. even with the bribes of free modern medical attention and a free stay in a nice facility.

Making strides in maternal health is definitely a tough business.

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Over the last week and a half, I have learned from many patient cases like these. I have met inspiring health professionals doing wonderful work for their communities with limited supplies and time and have been extremely impressed by the community-based healthcare delivery model that the Centro de Salud operates by. My time here has been filled with unexpected twists and turns, and I have learned and absorbed more than I ever thought I could from these adventures.

On the first day of work, I was placed into the gynecology exam room where I watched Nurse M performing Pap smears and rapid 1-minute vinegar tests on women to screen them for cervical cancer. I acted as her assistant as she used a low-cost cyroprobe to burn off some pre-cancerous lesions on a women’s cervix. It only takes 11 minutes in total for her to administer a simple procedure that can save a woman’s life.

Nurse M. told me she has been doing this work for a very long time. She has helped save many early-stage patients, but has also diagnosed many who had come in too late. She showed me her personal record spreadsheet of patients from the past three months that she had tested, dragging her finger down the list of names and diagnoses.

“This one came in with stage three lesions. And this one, this one, this one..”. Nurse M. pointed to name after name down the list. It was terrible and all too real. The people with these advanced lesions were generally people who had never come in for a PAP smear in their entire lives beforehand. When I asked her the reasons why these patients chose not to come in, she told me that it’s due to a range of personal decisions and preferences. I personally think that with the right education and campaigning, more women might come in for regular gynecological exams.

Cervical cancer is a highly preventable cancer, easy to screen for with pre-cancerous legions that are cheap and easy to treat. However, if caught late, it’s hard to cure. Death by cervical cancer is a horrible painful one, and it happens far too often in Nicaragua, which boasts the highest morbidity rate from cervical cancer in the world.

On our second cyroprobe patient of my first day, right before Nurse Margarita was about to burn off the lesion, she let me look into a magnifying colposcopy machine to see the pre-cancerous lesion more closely. While peering into the dark depths of the stranger’s vagina, I became dizzy and suddenly blacked out.

“Michelle, Michelle..? Estás bien?”  I heard a tinny Nurse M. call out my name and felt her take my arm and walk me out into the hallway where another doctor helped me sit on the bench. The next thing I remembered is vomiting in the hallway and then getting attached to an IV. While still a bit dizzy and dazed, I was questioned in Spanish, to which I had difficulty responding to.

Apparently I had fainted from the stifling heat (and also the stagnant smell of the biological liquids and cleaning chemicals, I think) from staying too long in the cramped exam area with no air circulation.

Rough first day, but I gained a whole level of new respect for Nurse M. and the other doctors who were able to work tirelessly in these conditions every day. I was thoroughly embarrassed, but the staff was very nice and understanding, having worked with foreign interns unaccustomed to the heat in the past.

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In addition to becoming integrated into the health center by shadowing physicians and going out to patient consultations, I have also been starting to lay the groundwork for my development project, which is looking like it will be two-fold, involving (1) implementing a sexual ed education outreach program by creating a girl’s leadership club in a rural school (2) creating a pregnant teenager support group with workshops on maternal and infant health.

I have been trying to get a better sense of existing needs and resources. I talked to doctors and walked around the city to speak with outside organizations such as the Centro de Mujeres Masaya and Ixchen. I received some nice donations from them –  condoms, power points, brochures and posters.

Yesterday, I visited the Roberto Clemente Mental Health Clinic in Malecón where I plan to start up the pregnant teenager support group. There I went through stacks of patient files and identified the names and phone numbers of all the female patients under 20 who are pregnant. I will be calling them soon to recruit them to come out.

Outside of my project work I have gotten the chance to get very close to my host family and their friends and explore the area a bit more.

On Mother’s Day, I got to dance with all the women in the family and laugh over old family memories. During a visit to a family friend’s ranch, I learned how to pick the juiciest jocote fruit. Last weekend I gave swimming lessons to my 3-year-old host cousin and snuck into a $7 entry fee Laguna resort with my host mom to go kayaking and swimming for free. While it was pouring rain and dark outside, I spent quality time exchanging stories with my host grandma in her room.

I am very lucky and grateful to have received so much love and acceptance from my host family, other family friends and neighbors, and fellow staff at work. I hope to be able to give back.

Signing out to get back to my house before it gets dark. Thanks for reading!

Michelle