Springtime Rambling

My goodness how quickly time passes. It’s hard to believe that the last time I wrote was in the dead of a cold, dark winter—the hallmark of New England. I won’t bore you with the reasons why there was no time to write for so long, except to say that I know a great deal more about equilibrium, acid-base reactions, electromagnetism, circuits, batteries, optics, quantum mechanics, and special relativity than I did in February. Science.

Spring arrived in Vermont with the timidity of a mouse crossing a barren stretch—one step forward, three steps back. But, the soft, new leaves are starting to unroll; the grass needs to be cut, the flower gardens need weeding, and the fruit trees fill the air with soft scents. It’s the lilacs more than the tulips and daffodils that make me think the warm weather will stay a while.

The winter was long and cold. I dared not count the gray days that melted into rainy days between frost and flowers. It goes without saying that spring is a time of new beginnings and the return of the sun.

How I missed the sun! When I went on a walk today rays of golden light danced on the path between the yellow-new, pink fresh leaves. The spirals of young ferns lined the walkway and the damp mix of old leaves and new growth saturated the air. I paused on a bridge over where the river meets the lake. There in the flooded marsh lands a fish swam almost lazily in circles. It was over a foot long. A fin lined its back waving back and forth like a ruffle along its spine as it waved its tail. What a bold fish to be out in the open in eagle, kingfisher, and heron territory!

I’m sure you guessed, but the sun makes me think of Paraguay. I completed my one-year anniversary of my return to the States in April. This is my first full spring in Vermont in many years. And the humming of the frogs, bugs, and birds make me think that this coming year will not only be as productive as the last, but more hopeful.

It is a new beginning because I’m taking my learning out of the classroom. Not so long ago I started running as an EMT. I’m still quite a newbie, but I’ve learned that every patient is a puzzle, and that solving each puzzle is more thrilling than anything else I’ve yet encountered. To realize what I can do to help someone by looking at a few measures—for example breathing, pulse, and blood pressure—is far more interesting than piecing together the clues of a physics exam question.

I’ve been thinking these days about how much I’ve learned since last spring. This time last year, I could not have told you what a healthy blood pressure was or if 5 was basic or acidic on the pH scale. Today I know those things and a great deal more. But, for some reason, Plato’s Socrates and his comment about what makes one wise has been on my mind as I take my spring walks, a translation of which reads:

“I am wiser than this man, for neither of us appears to know anything great and good; but he fancies he knows something, although he knows nothing; whereas I, as I do not know anything, so I do not fancy I do. In this trifling particular, then, I appear to be wiser than he, because I do not fancy I know what I do not know.”

The more I learn about the human body and illness the more I realize how much I don’t know. And what I’ve come to see, now that the frost has cleared, is that the doctorhood quest will not end when I pass my last board exam. It’s a quest for knowledge and better understanding that will only end when I stop practicing medicine. And despite the weight of learning so much for so long, the length and breadth of my journey does not seem daunting. I know that even if there are stretches like a Vermont winter as I make my way, they will always be followed by spring. After spring comes summer. And summer is full of life.

Photo Credit: my father

 

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Pulling Up the Bootstraps

I’ve been trying to wrap my mind around the anxiety, anger, and sadness I’ve felt since the 45th president of the US took office. It blows my mind how quick he began attacking:

  • Women: protection against discrimination, protection against violence, access to health care, freedom of choice
  • Everyone who needs health care and isn’t floating in money (aka most people): affordable health insurance, access to health care, security for those most in need of care
  • Immigrants: melting pot
  • Native Americans: protection of their land, respect of their culture
  • Americans living abroad: ambassadors, protection of foreign service officers abroad and American expatriates
  • The media: transparency, truth
  • Science: climate change (um, like come on…must we really repeat the “Earth is round” history?)…

…the list grows with each passing hour.

I went to the Women’s March in Montpelier on January 21. It was inspiring to see so many people energized to fight for human rights. But, I wondered, “Are we too late? Where were we between August and November 2016?”

The answer came in a common phrase:

When it is dark enough, you can see the stars.

America has never been perfect. We were founded by people who were fleeing oppression, who in turn stole land from the people already here. We won independence proclaiming high ideals, but enslaved millions of people, conquered others, and fought dirty wars with our southern neighbors and across the globe. We ended up a world power, but we still fell short of our ideals—all people in this country do not have equal access to life, liberty, and the pursuit of happiness.

Imperfect America has always strived to be better. We eliminated slavery, we changed legislation to give all citizens the right to vote, we’ve made net improvements in the rights of all minorities and women in this country, we’ve made progress protecting the rights of the LGBTQIA community; we’ve achieved many other wonderful things. But what we’ve done is not enough.

After much contemplation, I am certain that we are not too late. Perhaps Trump’s election was a necessary evil. It made me fall to dark places. And in the dark, I saw so clearly what had been easy to ignore in the gloom of modern America. In recent times, I and many people like me have been lethargic. We plodded along accepting what is even though it is not good enough.

The 2017 inauguration woke me. I saw the stars. And I’ve joined the struggle to improve this Nation. Regretfully, like a large mass starting from rest, I’m off to a slow start. I’m still not entirely sure what my role is and will be, but I know I have one.

On one hand, I’m already doing good work. I’m forging along on the Doctorhood Quest because my vision of delivering primary care services to underserved populations only becomes more vivid as the days pass. I will not let a man with disregard for the life and wellbeing of others allow millions of people to be cut off from the health care services they need and deserve. Also, in my current professional life, I help ensure that homeless young adults and at risk youth have the resources they need to build their own success. On the other hand, I know that I must do more than just study and work.

I have some ideas for action. Small stepping stones. I do not know where exactly I’ll end up or how my rejuvenated commitment to improving my country will unfold. All I know is that America has never chosen the easy path, but we are brave. I’m brave. It’s time to pull up those bootstraps, not just to elevate myself, but also as many as will come with me.

I’m proud that the momentum of the Women’s March has, thus far, translated into sustained action to fight for human rights. Let us stay together and be strong. Let us not leave anyone behind or push anyone who is part of us down. Let us continue to not only talk, but also do. As Margret Mead put it:

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.

So my question, what are you going to do?

You’re not fat, so why do you exercise?

Paraguayans in my site love to comment on my weight periodically…you know just in case I’m not aware of the current state of my own body. And as much as they like to say I’ve gained or lost weight, I’ve stayed about the same since I got here. Well, until recently. I turn 26 this I year and I decided that because I’m now closer to 30 than 20 I should stop putting off my body goals. In July, I started to take steps to lose weight by my birthday in October. At the same time, a friend asked me to run a 10 km race with her for fun. The race brought back my running bug, which I lost sometime in 2012. The point being two fold. First, I’ve started controlling what I eat and how much. Second, rather than just exercising in my house—which I did consistently for most of my service—I started running. Now, everyone in my community can see me exercising.

I think most people know the basic math of weight: if you eat fewer calories than you burn you lose weight, if you eat the number of calories you burn you maintain your weight, and if you eat more calories than you burn you gain weight. Depending on what you are doing weight gain can be muscle or fat. That said, I think many people in Paraguay and the US overestimate the power of exercise in this equation. If you want to lose weight the most effective way to do it is to watch what you eat. Why? Because it is hard to do enough exercise to burn more calories than you consume if you are eating many high-calorie foods.

We are now in late August. I am a little skinner, and Paraguayans like to tell me so, and they attribute it to my exercise. Well, actually, first they say it is because I am in love. A common Paraguayan wives’ tale is that you lose weight when you’re in love (I always thought it was the opposite…). But, after I assure them that I am still single they turn to the exercise excuse. While I was visiting a señora the other day she asked, “You’re not fat, so why do you exercise?” The question struck me. I do link exercise and body image, but for me the connection is muscle tone rather than jiggle or skin-and-bones not exactly weight. And, I exercise more because I feel like crap if I don’t, not because I’m worried about muscle tone. The señora’s question made me think about exercise theoretically, and why so many people don’t do it.

Obviously, it takes effort and time to exercise, but after considering those things I think there is a greater force preventing people from being motivated to exercise. And I think that force relates to how society talks about exercise. Many people, in Paraguay and the US, regulate physical activity to the castigation of the overweight and the amusement of a special elite class of “fit” people. Just as my señora friend’s question suggested, exercise is considered by many to have the single purpose of helping one lose weight. I see this belief as dangerous.

If I had been quicker on my feet I would have explained the following to my señora friend: You don’t have to be fat to exercise. You don’t have to be special. Nor do you have to do a specific type of exercise; all exercise is not equal but most ways of exercising are better than not exercising. Exercising helps your heart, your bones, your brain…everything.

I can’t remember what I told that señora, but I see a greater opportunity, based on her question, for public health wonks. Maybe we should focus less on telling people to exercise and focus more on changing how people talk about physical activity. After all, exercise is for everyone not as a punishment or as a chore but because our bodies need to move to work correctly. Exercise should not be thought of as extra. It should be lumped in with things like vitamins, necessary and required.

When $%#@ Goes Down, God Has Spoken

Not so long ago, a woman in my community died. I don’t know all the details of the story. I only heard a witnesses account, and I only understood what I gleaned from the conversation. But, it’s too good of an example of health access and religion in Paraguay to let it pass untold.

The woman had diabetes and that’s what killed her. Diabetes, high blood pressure, and obesity are common health problems in Paraguay. There may be genetic component (I’m not sure) but it has a lot to do with the diet and life style. Food is saturated in oil and fat and most meals are nothing more than a medley of carbohydrates with a chuck of fatty meat at the center. For many, life is centered around sitting, and dirt bikes have made is so many people don’t even need to walk to go to the corner store or their neighbor’s house.

I don’t entirely understand what happened. The doomed lady at first felt very ill and had to lie down. She sent her younger child out of the room so the child didn’t have to see her that way. The person telling me the story, started calling around to ask if anyone with a car could help take the sick woman to the hospital.

In Paraguay, ambulances aren’t the norm. There are ambulances, especially connected to private hospitals. Public hospitals also have them, but those ambulances don’t cover the hospital’s whole territory—I’m still murky on how that works. The closest public hospital to my site is a half hour bus ride away, but they can’t help with everything. The closest major public emergency center is about two hours away by bus. Basically, in an emergency, you need a ride. Cars aren’t super common. More people have dirt bikes, but a two-hour ride on a dirt bike is not really the best idea understanding the dangerous traffic conditions of the route. Not to mention, holding on to a dirt bike when you’re sick must be hard.

So, the lady trying to find a ride for the ill woman called several people—the old go-to’s, people with cars known to give rides, the taxis. No one could help. When she returned to the ill lady, the woman was dead and her skin colored with blood leached out underneath.

The woman telling this story, was actually telling the woman I was visiting that afternoon. And the woman I was visiting responded to the story by saying something like, “When you need help and there is no one, it’s your time.” The three of us nodded in agreement to that comment; it made perfect sense.

Each person has his or her own system of beliefs. But, in Paraguay belief in the Christian God helps explains a lot of things. Life isn’t always fair. There is suffering. There is joy. God helps relieve feelings of injustice and despair by providing one reason for why things are the way they are.

Soda

Soda is a bubbly drink that comes in many flavors and contains a pile of sugar. Sugar-free sodas replace the mountain of sugar with synthetic sweetener (even if you can stand the flavor of fake sugar, I suggest looking up the latest research on the effects of that before switching to zero-calorie drinks). Some sodas taste pretty darn good. Many people like carbonated drinks.

In Paraguay, soda with sugar is common (sugar-free sodas are less common here, so I’m not going to talk about them). Bus venders sell soda by the bottle and by the glass. A neat thing about soda here is you can by 2-liter glass bottles, which you then return to the place where you bought them. Actually, soda in glass bottles is very common in Paraguay…the only part of soda culture that I adore.

I’d be lying if I said that soda is drunk in moderation in my community. People guzzle down glass after glass of Coke, Niko, Piri, Fanta, Pepsi…I didn’t know there were so many brands of soda. It’s common for a family to down a 2-liter bottle after lunch (the biggest meal of the day). Like in the US, soda is served at parties and is a common “refresher” to go along with a snack or to drink while sitting with friends and family. The only thing that slows people down is that soda is usually drank with a common glass—so either one glass (or several glasses) is passed around to everyone or people take turns drinking a full glass, but only use one or two glasses for everyone.

The complaints about the health effects of soda are the same no matter where you are. Summary: Soda has too much sugar. The sugar rots your teeth, is generally bad for your body, and can make you gain weight in an unhealthy way. But, I find the knowledge of that to be lagging in Paraguay. I hear frequently from mothers and other caretakers of children that kids should not eat candy because it’s bad for their teeth. I hear people note often that sweets and carbohydrates make you gain weight. Very few people say anything about soda. Kids are infrequently denied a second, or third, glass of soda while they might be denied another cookie.

How did soda escape scrutiny?

Yes, I Can Cook

I think my community lives in fear that I will starve. Part of it is cultural, it’s part of Paraguayan culture to give your guest food and share everything you eat with the people sitting around you. But, the food I’m given goes above and beyond. People ask me what I eat regularly and are often surprised to hear I cooked my own lunch.

I don’t know why they’re surprised. If I was a good Paraguayan woman I’d already know how to cook. I guess it goes to show where I fall on the scale of Paraguayan women. Sometimes I think it’s because I live alone—one can’t simply cook for one can they?

I’m not complaining about Paraguayan generosity. It’s one of the things I love about living in here. Besides, recently I’ve been almost short on money—something about a Peace Corps salary and a run of bad luck. If I’m hard-working and visit people, I almost don’t need to cook or eat at home. I don’t go hungry, that’s for sure.

But, the free food comes with a small cost: I eat the food that my Paraguayan friends and contacts are eating. Which is to say, a lot of meat and bread and yucca and rice. Don’t get me wrong I like barque and yucca as much as the next girl, but even I have limits.

In Paraguay, food isn’t a meal unless it involves chunks of meat. This might be another reason why people don’t think I can cook. I don’t cook meat in my house. When I describe what I eat, they kind of give me this blank expression as though they are waiting to hear what I ate after my rice and vegetable stir fry. Nothing?

I was never a picky eater, and my time in Paraguay has made me less so. I’m an expert at eating things I don’t like, and not showing it. My community members bubble with enthusiasm every time we eat hot dogs or sausages. I just enjoy their happiness and I’m thankful for being invited to share a meal with them. But, I can’t help but think about the diet and what it’s doing to my body. My hair is thinner and duller. I’m sure could do enough exercise to burn all the calories. Is my face breaking out because I’m stressed or because of what I’m eating? No way to know.

I know what I cook is healthier than the standard Paraguayan menu, but I also don’t want to be cut off from something as important as eating with families. It’s a balance between eating what makes me feel good and tastes good and spending time with my Paraguayan friends. My Paraguayan friends always win.

Where Public Health Fits Into the Health Picture

ClimbingParaguay and Health Care

Every country has it’s own way of trying to protect its citizens’ right to health. In Paraguay, there is universal health care. This means that consults and medications are free. Well, at least that’s the idea. Most people have access to doctors and nurses trained in family medicine, but things get complicated when it comes to medications and access to specialists.

Every medical facility in Paraguay doesn’t always get all the medications it needs for its patients. (Paraguay is working to decentralize its medical system with the hope to reduce some of the bureaucracy that might be contributing to these shortages.) As for specialized care, it’s unsustainable for every health clinic to have specialist in all areas, so they are centralized regionally in hospitals and health centers.

These limitations sometimes mean individuals go without the medications or care they need. Public health has a role to play to help relieve strain on the health care system by helping people lead healthier lives in the first place.

Barriers to Medicines and Specialized Care When They Are Not Available in Local Clinics

The main barrier is access. When a local clinic doesn’t have a needed medication patients must either buy it or find a public health facility that has the medication.

For families where money is short or income is unreliable, it means individuals go without their medications—a scary thought in a land where hypertension and diabetes are leading conditions.

Traveling to another medical facility might also be out of the question. It costs money to travel—whether by bus, by dirt bike, or by car. What’s more, it takes time that individuals might not have. For those who work, they can’t be absent from their jobs. And, for those who are looking after a house, there’s food to cook, children to watch, and clothes to wash.

When patients have to travel to a regional facility for care they face the same challenges as accessing medications. It’s not uncommon for local health care providers to use their personal money and vehicles to help people see specialists. But, that is limited because it puts stress on health care providers beyond their normal work and their vehicles may not fit everyone who needs to see a specialist.

There’s no silver bullet for resolving barriers preventing people from the health care they need. But, one thing is for sure; the more we can do to help prevent illness the better off individuals will be. That’s why health education and providing individuals with advice on how to lead healthier lives makes a difference.

Turn On the Public Health

Palms and ParaguayMy latest quandary (excluding all the integration and assimilation challenges I face) is not whether I will have work but rather where to begin. The community clinic and school where I plan to start my work seem open to have me do everything I can do to share information about health. What’s more, my school expressed commitment to teaching life skills and sexual health, my dream topics, along with all the other PC community health focus areas (plus some, like drug prevention).

I can see the need for public health education—from five-year olds with rotting front teeth to pregnant teens. It’s exciting to transition from creating health education materials in an office far removed from those I was trying to help to working with my target audiences directly. It’s a wonderful puzzle trying to find resources and find methods to convey information in a way that each audience will find useful.

It’s not going to be easy. I still don’t know how to say everything I want to say in Spanish (or Guarani). I don’t yet have allies in the community I know will help me or know if anyone will show up to whatever activities I do plan. I’m not sure I know enough about all the topics about which I’m supposed to teach.

I’m excited all the same. I have two years to give it my best shot. I hope by the end I’ve given at least a couple of people information they can use to improve their health and that of their loved ones.

I see a lot health presentations, lectures, games, and activities in my future. Don’t worry; I’ll let you know what works for me and what doesn’t.

We Built a Fogone

A fogone is a wood-burning cook stove. It is made out of brinks and mud/cement.

In rural areas of Paraguay some families still cook all their meals over open fires. Oftentimes these fires are under a roof or inside the house. While cooking over an open fire is just fine while you are camping, it can negatively impact health if used for all meals throughout a lifetime.

Negative effects of open-fire cooking as a part of daily life:

  • Back problems caused by having to bend over to cook
  • Increased risk of upper respiratory infections due to breathing smoke
  • Burns, a bigger risk for children playing by fires

A fogone offers an economical solution for families that use wood to cook. Gas is expensive and many traditional Paraguayan foods require a lot of time to cook. Wood is generally inexpensive and can be an environmentally friendly, sustainable option if the wood is harvested correctly.

Building the first couple layers of the fogone.

Building the first couple layers of the fogone.

First two layers of the fogone.

First two layers of the fogone.

Backside of the fogone.

Backside of the fogone.

Frontside of the fogone.

Frontside of the fogone.

Checking out the done fogone - photo courtesy of Kelsey Levering

Checking out the done fogone – photo courtesy of Kelsey Levering

The fogone is done! - photo courtesy of Kelsey Levering

The fogone is done! – photo courtesy of Kelsey Levering

 

 

 

 

 

 

Open Hearts, Heat, and Carbs

Open Hearts 

We fit in the bus!

We fit in the bus!

The people of Paraguay are what make the country wonderful.

For training (about 10 weeks) I’m living with a host family of seven – a father, a mother, two sisters around my age, one sister and one brother about 10 years younger than me, and a much younger sister.

I feel like a long-lost cousin—one that wasn’t born in Paraguay but has always been part of the family. My family makes me feel welcome and included even though I don’t know Guaraní (Spanish has been a great bridge) and I know few of the social norms of Paraguay.

In Paraguay you say “hi” to people when you walk by and it’s not strange to look at people as you pass them. It’s the small town of New England without the icy edge of New Englanders. News travels fast and everyone has countless cousins. The most practiced pastime is sitting with family and friends while chatting and drinking tereré.

It’s Hot

A classroom

A classroom

Paraguay is hot. It’s the kind of hot where doing nothing but sitting and drinking tereré for hours makes a whole lot of sense. It’s the kind of hot where you don’t want to sit on plastic lawn chairs. It’s the kind of hot that a fan can barely tamper. It’s the kind of hot that makes you understand why the Paraguayans are described as tranquilos (calm)—because it’s just to darn hot to be anything else.

Carbs, Meat, and Fat

In the US we blame a (large) portion of our battle with non-communicable diseases, like diabetes and obesity, on processed food. And, while the Paraguayans I’ve met don’t eat many processed foods, I can’t say the average diet here is much healthier – enter the carbohydrates, meat, and fat. Most of the traditional foods in Paraguay are heavy in carbs (especially corn and mandioca) and involve frying or fat is some other way…and red meat. And, much like processed food they are quite delicious (“rico” in Spanish).

One of my trainers did a good job of putting the diet into prespective. The trainer mentioned that many of the foods served Paraguayans well when they were working long, hard days in the fields. But, now that life has changed and things are easier the calories aren’t needed anymore. Things, like food, that have a deep cultural connection evolve a lot slower than society moves into modernity.

Some traditional foods

Mandioca – boiled

Mandioca

 

 

 

 

 

 

 

Sopa Paraguaya – a type of corn bread with cheese

Sopa Paraguaya

 

 

 

 

 

 

 

Tortillas Paraguayas – fried flour, eggs, milk, salt, and veggies

Tortillas Paraguayas