COVID-19: Oddity of a Shared Experience While Living Continents Apart from My Paraguayan Friends

Reposting a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original post here.

In early March, I had a Zoom call with the other community health Peace Corps volunteers I served with in Paraguay from 2014-2016. One of my colleagues still lives in Paraguay and he shared his impression of the Paraguayan response to COVID-19 compared to that of the US this spring: “Here [Paraguay] everything is locked down. Police will stop you if you’re on the street to ask why you’re out. People are getting restless because, as you know, here many people don’t eat if they don’t work. But Paraguay is taking this seriously. It’s mind-blowing to hear what’s happening in the United States. It’s hard to believe the news of people protesting masks and attending large gatherings during these times.”

At the time of that comment, the US was still widely debating the validity of masks and COVID-19 cases and deaths were still increasing. Vermont, where I live, was among the US states that chose a more aggressive public health approach with the hope of containing viral spread. For much of the spring and summer most business in Vermont were closed, including gyms and many restaurants. There was no curfew, however school was cancelled or switched to completely online and wearing masks in public places was mandated. The almost complete shutdown only lasted a few months. In late summer, many businesses in Vermont started to open again. Now, schools are back in session (many school districts have a hybrid of online and in-person classes). As a second-year medical student, I have in-person classes twice a week and online classes three days a week. I am required to get a weekly COVID-19 test and report any new symptoms and contacts daily.

The short shutdown and recent opening of Vermont is in stark contrast with the experiences of my Paraguayan friends during these past 6 months. I’ve remained in contact with friends in the Paraguayan community where I worked when I lived there during my Peace Corps service.

This fall, just as in the spring, my friends in Paraguay are mostly restricted to their homes. When my friends and I spoke in early summer, they said that only a few members of their extended family were still allowed to go to work. One friend shared her perspective on Paraguay’s infrastructure, “Our hospitals can’t take care of people if they get sick,” she said. “We are worried.”

In early September, I got a voice message from one of the Paraguayan women who is like a mother to me. She was on the verge of tears. She is the primary caretake of her 90-year-old mother. In my friend’s message she told me that she is scared that her mother will die of COVID-19. My friend does not have a car. The nearest hospital is 2 hours by bus. I don’t know if the buses are running right now.

I’ve returned to Paraguay twice since leaving, once for a friend’s wedding and once to meet a friend’s son before he turned one. I was planning to visit again this year because two of the children I taught when I worked there will turn 15. In Paraguay, 15 is considered an important birthday and some families have a large, wedding-like birthday party to celebrate. The two children turning 15 are like younger siblings to me and I wanted to see them during their special year.

In late September, realizing that I probably won’t travel anywhere outside of the US soon, I made a traditional Paraguayan drink called cocido. It is a warm beverage made from steeped yerba mate (similar to tea) and burnt sugar. It’s a perfect study beverage for fall and it reminds me of my Paraguayan friends and our times together. I shared a video of making cocido with my Paraguay friends. One of them mentioned that I should make chipa, a traditional Paraguayan biscuit that is often eaten with cocido. “I miss chipa!” I said over text. “I haven’t made it because it’s better in Paraguay. I’ve been waiting to visit again so I can have it there.”

My Paraguayan friend responded, “You should make chipa. Don’t wait to come to Paraguay. You’re not going to be able to come for a long time. Things are not well. Lots of people are getting sick here now. We don’t know what is going to happen with this virus.”

My friend’s comment was in stark contrast to any previous conversation we’d had about me visiting Paraguay. My Paraguayan friends remind me often that I am always welcome in their homes. Before COVID-19, every time we talked they asked when I was returning to Paraguay. Now my friends seem too far away to visit. Yet, despite the feeling that travel to Paraguay is morally forbidden during these times, there is something novel about sharing the same public health crisis in my home country as friends abroad. It is not often that the primary public health concern in the United States is the same as that in Paraguay. It is the first time since I’ve left Paraguay that I feel my life is still intertwined with the lives of my friends in Paraguay. It’s not reassuring, but it is interesting to consider how interconnected our global community is despite the borders, oceans, and mountains that separate us.

People Get Sick – Some Rise and Some Fall When Faced With That Reality

As the COVID19 pandemic continues, it’s brought out the different sides of people directly and indirectly in my life. I continue to be impressed by the many folks who fearfully, yet generously, show up to work at the grocery stores, the hospitals, and the other businesses of service that we can’t live without and can’t be run remotely. I am equally surprised by those who had the opportunity to help and instead fled. Fear is powerful. It makes those who consider themselves generous selfish.

I’ve seen great efforts of humanity from handmade protective equipment to online hangouts bringing people who haven’t talked in years together. I’ve seen folks put on fitness, meditation, and medical school classes virtually—I’m amazed how much can be done over online video chat it a pinch.

I’ve also seen people lash out at people who are sick but not dying, in anger and fear. It is easy to blame those who are sick for their illness and label them as a threat but, like everything in life, it isn’t that simple. It’s worth remembering that pandemics are not the work of individuals; they are the work of collectives. What is more, viruses and other microbes are perfectly simple and wonderfully complex. Nothing made by humans can be quite as clever as they are, so no need to find human scapegoats to blame for a disease they could not have made.

The idea of not knowing if someone has an illness you can catch is scary. But, that’s the nature of many infectious diseases, not just COVID19. And while many of us born in America do not necessarily think of potentially deadly infectious diseases often, that is a luxury people in different parts of the world do not have. It helps give perspective to remember that millions of people die of infectious diarrhea and malaria, for example, each year. And their plight isn’t one the larger world community has committed to ending. It will go on…perhaps as long as humans exist.   

We are strained by social distancing today. Yet, we carry on because we have a sliver of hope that by limiting our interactions we can end COVID19. We believe that we can limit the number who die or get sick. As we hold on to these ideas, we should also remember that social distancing need not make us less compassionate for others. Protecting ourselves does not require that we compromise kindness. I would hope that we all see this time as an opportunity to discover creative ways to help those who are sick while also protecting those who aren’t yet. The infection count is not a numbers game of distant people we don’t know, it is happening right here, today, and to real people with families and a story. Just remember that those numbers you’re refreshing are humans. Don’t forget that, because if you do you just might become apathetic. We have a pandemic to end. It will take the actions of each of us to be successful. Stay engaged.

Mental Health and the Emergency Department

Checking into the ED for a psychological complaint

When a person comes to the emergency department (ED) with suicidal thoughts or another mental health state that could be a threat to themselves or others (ex. extreme paranoia, homicidal thoughts, mania, etc.) the processes is simple. They change into paper scrubs and their clothes and belongs are locked in a secure closest, returned upon their discharge from the hospital. A hospital staff member sits outside of (or just inside) the person’s ED room conducting constant observation—which includes observing the patient at all times and recording their location and general behavior every 15 minutes. The constant observation is to ensure that the patient does not try to hurt themselves, try to leave, or try to hurt anyone else during their ED stay. Many people who check in for psychological evaluation are not allowed to leave the hospital until their mental condition has been cleared by a psychologist, meaning they are forced to stay in the ED until a doctor says that they will be safe returning to society. Patients suffering from psychological conditions that require more treatment than the ED can provide remain in the ED until a bed in a specialize treatment facility (or in the hospital psychology unit) opens.

One way to define “a national mental health crisis” in the US

When I think of a mental health crisis in the US, I think of all the people stuck in the ED waiting for a psych evaluation and then waiting for a bed in a facility that specializes in psychological treatment. I think of the patients who remain on lockdown in the ED for 100s of hours because if they leave they might knowingly or accidentally hurt themselves or someone else. These patients have no other safe place to wait for an in-patient bed. I think of the people who come to the ED and, even under the watchful eye of our staff, try to kill themselves. I think of the people who end up in restraints, literally tied to a bed, because their condition escalates to the point that they try to escape, attack hospital staff, or harm themselves. To me, the mental health crisis in the US is that we don’t have enough 24-7 services and specialized treatment facilities to keep patients with mental health conditions out of the ED. To me, mental health is just like any other aspect of health. We need to bolster our programs to help prevent acute mental health problems, but we also need adequate mental health treatment programs for those struggling with psychological conditions. The crisis, I think, is a lack of preventative care and readily available treatment, not the existence of diseases.

The ED does welcome mental health patients as we do all patients, but the ED is not equipped to find long-term solutions for any health condition. It is true that the ED can help with acute symptoms, which is all some patients need for a short period of time, but we don’t have a calming environment nor do we have the staff to provide intensive treatment for mental health conditions. We serve as a gatekeeper to specialized treatment and as a place to go when there is nowhere else to go. Just like the ED is not an appropriate place to perform and recover from surgery, it is not the right place for those who need in-depth evaluation or long-term treatment. The ED was designed to keep patients for ideally a few hours or, at most, for part of a day before sending them home or to an in-patient facility. But, what happens with some of our gravely ill psychological patients is that they must stay in the ED for days, even weeks, because there are no openings in specialized facilities.

Conclusion

Using the ED as a long-term home for people suffering from psychological conditions is neither therapeutic for them nor is it a cost-efficient design of the health care system. We need more mental health treatment facilities in the US. We need more programs designed to help those coping with mental health conditions manage their symptoms at home. We need more people going into the psychology fields and social work. In summary, we need to dedicate more resources to mental health in the United States. I think to do that we need to start by acknowledging how many people struggle with mental health and how weak or absent our treatment options currently are for those people. Next, we need to make mental health a budget and policy priority at all levels of government and in private health care systems. Right now, EDs are serving as the catch-all. They are not the solution. While the ED might be the right place for folks in any kind of acute health crisis to go initially, the ED only works if there are specialists and specialized facilities to refer our patients to once we’ve identified the sustained medical care they need. It’s times we prioritize mental health as we have heart health, lung health, and cancer-free health so that no patient is held in the ED because they have no other safe place to go.  

The Do-Good High

Did I tell you I’m an EMT? I’ve been running for about 5 months. Long enough to have learned a thing, maybe two. Let me tell you about the do-good high.

There’s a certain kind of person who becomes an EMT and sticks with it. Hint: It has nothing to do with your age, background, or future.

It boils down to what I call the “do-good high.”

There are EMTs who want patient experience so they can then become nurses and doctors. There are others who like sirens and driving large vehicles with lights. Many EMTs want to give back to the community. Others like the satisfaction of saving lives. Whatever the reason, the thing that makes all EMTs the same is that they get a thrill from doing good.

Whether it’s helping a little old lady after she’s fallen or bringing a person back from the dead through CPR, the folks who stay in emergency medicine are there because they’ve caught the do-good bug. When the alarms go off at 3 a.m., waking you from a dead sleep, and the dispatcher comes over the speaker: “56-year-old male, vomiting and diarrhea…”† I think a normal person would choose to go back to sleep. Not an EMT.

The EMT answers the call. Why? Partly it’s our duty to put on our uniform and leave the station as fast as we can, but there’s also something beyond obligation that makes us go. Even in the grossest of circumstances, like when we pick up that vomiting and pooping man and sit with him during the 30-minute ride to the hospital, we helped turn a bad night for him into a slightly better night.

The feeling you have sitting in the back of an ambulance as the sirens holler and you hustle to your patient is something like that of standing on the start line of a giant race. Your heart goes just a tad bit faster and your mind zips through the possible scenarios that could unfold once you arrive at the scene. Then you reach your patient and a calm descends upon you. There’s a human in distress and what’s ailing them is your puzzle to solve. You might be the one who saves their life. But even if you aren’t called upon to be a hero, you can ease their distress by helping them breathe or reassuring them as you go to the hospital. Seeing your patient’s face relax or their color return after you help elicits an adrenaline rush that starts in your center and spreads out to every corner of your body. It’s a high like that from scoring the winning goal or beating a chess genius at their own game, but it’s better because it lingers. This rush and joy that rapidly overtake you after helping a patient is the “do-good high.” All EMTs get it. It’s what keeps us coming back.

 

†Fictional dispatch that captures the essence of a typical call. HIPAA and other privacy measure prohibit sharing patient information.

The Time We’re Given

My training earlier this week went as well as my travels there. It was a 3-day training where the first day and a half we worked with a contact we brought from our community and the second day and a half was a capacitation for volunteers in my group. I found the time, uninterrupted and focused, with my contact invaluable.

The head nurse at my health post came to the training with me. She, like the other nurses at my health post, is extremely nice and hardworking. I know her pretty well in a professional sense because I’ve spent a lot of time at the health post since coming to my site. Despite feeling welcome at the health post, I’ve been unsure how to start projects with them and I hoped that the training would give me a jumpstart.

The best part of the training was having focused time to talk with my contact about the needs in the community and possible project we could do to help address those needs. I liked having time to talk with her one-on-one outside of the distractions and pressure of our community because it enable us to talk in-depth and about topics we’ve never before been able to discuss.

It was interesting to learn what health needs she sees in the community and to hear about the ideas she has for projects. One topic that was surprising to me was the jail in my site.

In my site there are two large jails, and the national government is planning to build several other jails and make my community the biggest jail town in the country. The members of my community tend to see this as a negative thing. However, my contact sees it as an opportunity. She thinks the community will benefit from all the jobs the jails will bring. She also thinks that the jail has not impacted life here as much as the community claims. As my contact explained, the community uses the jail as a scapegoat so they can avoid addressing problems in the community. An example of this is HIV. A number of people have HIV in the community, but rather than focus on prevention the community tends to blame its presence on the jail and do nothing.

We outlined a project: Creating a recreational space in the community. Currently there are no parks, and the only real spaces for exercise are soccer fields. We think that creating a park with basic gym equipment—Paraguay has outdoor stationary bikes and walking machines in some of its city parks—would provide women and children a way to exercise more easily. Soccer tends to be a men’s domain and not an accessible form of regular exercise for women. Making a space to exercise might help address some health concerns in the community like high blood pressure, diabetes, and being overweight.

Time will tell whether our idea of creating an exercise space will blossom into a real project. To make the space we must work with two different community commissions and solicit money and/or exercise equipment from the government. Despite the uncertainty of that project, for the first time since coming here, I feel that there are concrete project opportunities for me with the health post starting to materialize.

Coping Strategies: Not for Me This Time

Not long ago the unimaginable happened in my community: a teenager commit suicide. I’m not entirely sure of the circumstances, but he attended the high school where I work and supposedly in his note he claimed having his girlfriend break up with him was one reason he decided to take his life.

When I heard the news I thought naïvely, “I didn’t know suicide happened in Paraguay.” But, apparently it’s not the first attempt by kids in my community and it’s not the first kid in the area who’s succeeded. Yet, if I hadn’t stumbled across the news the day of the memorial I’d never have known. It seems that the topic is unspeakable.

After I heard the news, I decided that I couldn’t proceed without taking the time to address the topic in a small way. I work with all the kids in 7th grade through 12th grade at the school he used to attend. So, I revised my lesson plan for the following week to address the topic of mental health in a round about way. My thought was to at least open the door, and see where the students decided to take the topic.

My lesson started by defining stress and what causes stress, and from there we brainstormed all the problems we can face in our lives using 4 locations: home, school, work, and community. After coming up with a sizable list of problems, we discussed ways to solve those problems. We brainstormed with whom we could talk if we needed help and the qualities of someone in which we could confide. Then, we talked about what we could do if a friend approached us with a problem, and how we could help him or her find help if we didn’t know how to help him or her. Finally, we talked about strategies to reduce stress and why it’s important to think about problems and address them before they pile up.

Most of the classes proceeded like a normal class, except one. In that class we had the opportunity to talk in greater depth about coping strategies, finding someone with whom we can confide, and what it means to be a good friend. We touched on what it means to be in a healthy relationship, and that no one should be obligated to stay in a relationship. As we worked the dynamics of the class transformed from the normal jokes to serious. Some students asked questions, they don’t often ask questions without much urging, and some students seemed like they might be on the edge of tears.

There were some heavy themes that came up. What hit me hardest, however, was that most of the students said they’d never before talked about something like coping strategies. On top of that, one class explained that they couldn’t talk to their parents about their problems because that’s not how parent-child relationships are in this country—according to this one class; peers are the common source of help. Not being able to talk through problems with parents is hard for me fathom in a culture that centers on the family, like Paraguay’s culture does. It’s difficult, being an outsider, to understand something that seems so contradictory. Families, in Paraguay, are the nucleus of everything, so shouldn’t families be the first source of support and information on all topics? Are the needs of individuals being overlook as families focus on the good of the whole? Is there another explanation?

Family Planning and Religion

HouseOne of the topics about which I will teach here is family planning. Before coming to site, I was concerned about the topic because of how polarizing it is in the US. I worried that there would be as much religious rhetoric against contraception and teaching sexual health in Paraguay as there is in the US. Paraguay is a Catholic country and I wondered if some of the same denial of basic health realities was present here as in the US. It is not.

Family planning and sexual health in Paraguay is not a subject cramped by religion. It is awkward and hard to talk about, just like in the US, but not because of religious beliefs. I find it awkward because of the power relationships between men and women here. And, well, because it’s just a hard subject to discuss eloquently.

In Paraguay, birth control pills and condom are free and offered at every public health clinic in the country. To get birth control pills a woman simply needs to go to the health clinic, request them, and present her ID. Sexual education is taught in many schools. I like to think Paraguay is transitioning to a family model that allows women to have the number of children they want when it makes sense for them. Paraguay isn’t there yet, but it’s on its way.

One thing I find particularly interesting about the relative ease of discussing family planning in Paraguay is that abortion is illegal. Period. Having one national set of laws in Paraguay that governs actions related to family planning makes it easier than in the US to know what can be said and can’t be said when teaching.

What Do You Do With Your Trash?

House at the edge of the fieldIf your community didn’t have trash collection services, what would you do with your trash? That’s a questions that most Paraguayans face. Few communities have any organized trash collection, so every family is on their own.

Let’s assume you’re already doing everything you can to produce as little trash as possible.

Would you burn your trash?

Burning your trash would get rid of it, which is a plus because it would keep your property neater. But, when you burned plastic it would create a terrible smell and release bad chemicals.

Would you throw out your trash, just on the ground at the edge of your property?

That would avoid releasing bad chemicals in the air like when you burn it. Tossing trash is easy. But, it would make the entire area where you throw your trash ugly, and you might have to clean up trash a lot when animals and wind bring trash into your living space. Depending on what kind of trash you have and where you decide to throw it, it could contaminate water or make animals sick.

Would you bury your trash?

Burying your trash would get it out of sight and avoid releasing bad chemicals into the air. But, you’d have to dig a hole and cover it, and then a dig another one when it got full. That’s more work than burning it or tossing it. Depending on where you decide to dig your trash pit, it might contaminate your water, and it would make that area bad for growing things if you wanted to put a garden there in the future.

Would you divide your trash and treat each type differently?

It would be a lot of work, but you could do something with each kind of trash.

You could burn your paper trash. That would get rid of a lot of it—in Paraguay you can’t flush toilet paper so you have to get rid of used toilet paper somehow.  Because it’s paper it wouldn’t release too many harmful chemicals into the air.

You could make a compost pile or feed your food scraps and other organic waste to animals.

You could collect and reuse glass, metal, and plastic bottles, jars, and containers. In some places in Paraguay you can get money for glass and plastic bottles you bring to recycling, but sometimes those centers are really far away. Sometimes there is someone who goes around buying glass and plastic bottles for recycling.

What about all other plastic waste? It could be buried. With things like plastic wrappers and bags you could use them for other things. You could make trash art or eco-bricks. Plastic is the trickiest.

In places where there are public trashcans and trash collection it’s easy to just toss your trash and never think about it again—especially in areas where litter doesn’t serve as a visual reminder. But, despite what you think, your trash does go somewhere. In Paraguay, often that somewhere is a lot closer to home than a dump at the edge of town.

Drinking: Underage and Driving

DawnDrinking is just as common in Paraguay as it is in the US. The difference? Paraguayan private and public organizations haven’t sunk as many millions of dollars into raising public awareness about alcohol safety. The result? People are getting harmed.

You’ll see 15-year-olds get drunk in front of their parents, with beer their mother bought. You’ll see drunks finish their drink and hop on their motorcycle or in their car. Few people talk about the fact that driving is impaired by alcohol consumption, and fewer wear seat belts (ever) or opt out of riding vehicles operated by people under the influence.

You know there’s a reason why you’re not supposed to start drinking too young: it can affect brain development. As for drunk driving—if you’ve ever been sober while riding in a vehicle operated by someone who’s been drinking you already know it’s terrifying. According to one report, Paraguay has one of the highest motorcycle-related mortality rates in the Americas, with a rate of 2.5 deaths per 100,000 from 1998-2010. And according to another report, one of the highest traffic injury-related mortality rates in the Americas.

I get that people just want to have fun. But, do responsibility and fun have to be mutually exclusive? I think not.  My quandary: How can I help transmit this message in Paraguay? More difficult still: How can I help encourage behavior change to improve drinking safety?

Bad Habits

Paraguayan skyWhy is the knowledge that something is bad for you not enough to make you stop doing it?

I’ve been thinking about this question a lot recently. When I tell Paraguayans that I’m in Paraguay to teach about health they jump right in and tell me how bad the Paraguayan diet is. Paraguayans tell me their food “has a lot of fat” or that the food “is heavy.” They tell me that there are a lot of people who are overweight, have diabetes, or have high blood pressure.

Next, Paraguayans ask if I like their traditional foods like sopa paraguaya, tortillas, and mandioca. They tell me they want to lose weight, but then put three tablespoons of sugar in the milk they are going to drink with bread. They ask, already knowing the answer, if they should eat fewer carbohydrates if they want to lose weight. They explain how they don’t exercise or eat vegetables.

I don’t know if the people I talk to know that different foods have different nutrients or that balancing calorie intake and calorie burn is the center to weight control, but it’s clear they know what they are consuming isn’t the healthiest option.

If they know it’s bad for them, why aren’t they trying to change it?

  • Is it habit?
  • Is it that they don’t know how to cook different foods?
  • Is it taste preference?
  • Is it cost?
  • Is it cultural heritage?
  • Is it a lack of information or understanding about what makes food healthy or unhealthy?
  • Is it something I’m not seeing?

In the past, I wrote about developing public health programs that encourage change by focusing on the out-of-box-experience. But, as I work in Paraguay, it’s daunting. Clearly, a lack of knowledge isn’t the only thing at work here. But what can I do other than provide information?