A Third of the Village Children

On Monday in the second week, I was advised that I have now assessed over a quarter of the children in the village. By the end of the second week I will have assessed about a third of the children in this rural fishing community. 

I have seen several of the children a second time, either for follow up, for a new problem, or in one case for an allergic reaction to a medication I prescribed. The faces of these children are now familiar, although their names are still a blur. The children are starting to wave at me when I am in town.  

I know the mothers better, because I have seen two, three, and even four children from the same mother on different days. Some of the mothers are therefore "regulars." The returning mothers are a good sign that I am doing ok. 

With the next two-week visit at the end of March, I will likely pass the half the children mark. I kept good notes, which will make every follow-up easier. 

Free Stuff

We brought small, colourful toys for the children, and the toys are popular. For apprehensive toddlers, the toys are a bridge to a happier examination.

Denai Webb and her classmates at the Before and After School Care Program at Alexander Ferguson Elementary School in Calgary, Alberta, Canada supplied the toys. Thank you Denai!

Little girl with toy and knit doll.

Dental care is a huge issue in the children. Almost every child has cavities and some have cavities in most of the lower teeth, and some in most of the lower and the upper teeth! Clarissa Waxmann with Sierra Dental, and her daughter Zoe, arranged for toothbrushes and dental floss for the older children. We found small tubes of toothpaste to complete this gift. Thank you Sierra Dental!

Nutrition is important everywhere, and many parents express concerns about the difficulties to achieve the correct balance of foods for their child. Courtesy of Health Partners International (HPI) Canada, we purchased a two-month supply of chewable multivitamins for every toddler and older child. HPI also donated some terrific knit dolls for the children, which the little girls really enjoy. Thank you HPI Canada!

Some pharmaceutical companies in Canada provide paediatricians with samples of the common fever medications (Tylenol, Tempra, Motrin). We collected these samples over the last six months and have enough to supply every family with enough medication to control the temperature for one febrile illness. Thank you to the manufacturers of these medications.

Irena Burns, a local pharmaceutical representative with Impres Pharma Inc. was especially helpful. She dropped off samples of Pediatric Electrolytes, an oral rehydration solution. Thank you Irena. 

Evil Eye - Mal de Ojo

During the first week I assessed at least one infant a day and almost every one had on a bracelet with several beads. Some had a bracelet on each hand. The beads in the photo above were the most common, but other beads were used as well. 

After I noticed this trend I inquired if the beads had any significance. I was advised that the beads are a talisman to ward off Mal de Ojo, the Evil Eye.

The concept of the Evil Eye is common to many cultures. When I worked in the Middle East there were mothers who spoke of this.

The person who casts the Evil Eye is considered to have powers to injure another person merely by looking at that person. An envious look at a good looking baby is enough to qualify, and according to folk lore, the look is enough to cause illness. The talisman is protection against this possibility. 

Pigging Out in Nicaragua

After working in the clinic, I took my gear to the Toyota Truck, which I park beside the clinic in a shady spot. Clearly this mother pig favoured the shady spot as well. Her six piglets were actively feeding. 

Fortunately the mother pig vocalized her presence before I started the car and drove off. The truck was on a bit of an incline down towards the pigs, so I put the parking brake on, started the engine, waited until the mother stood up, which upset the piglets, and then I backed away very slowly.

Meeting the Needs of the Community

Looking back at the first week, I am wondering if I met the needs of the families who came to the clinic. 

Only about 20% of the children were "sick" with a common paediatric problem. I saw otitis media (ear infection), bronchitis, urinary tract infection, bacterial gastroenteritis, parasitic gastroenteritis, impetigo, tinea corporis (ringworm), and facial abrasions. For these families, I likely met their needs.  

The other 80% all had numerous "complaints," but my sense was that these were mostly "well-child" visits for a routine check up. For these children, I am not sure that I met the needs of their family. I just do not know!

The "complaints" often did not make sense to me. 

Assessing a child for a problem is a kind of detective mystery. The clues are the symptoms and the physical examination findings. 

I was taught that the history (symptoms) is all important. I recollect a professor in first year medical school who taught us that by the time we started the examination we should know the diagnosis in about 75% of patients. Today, many physicians rely on laboratory and diagnostic imaging for a diagnosis and the history is often neglected. I am "old school" and still believe that the history "rules." In my clinic in Calgary, I have a microscope, a uroflowmeter, and an ultrasound. However, the history is still my main tool to sort out a problem, and I am able to predict the microscope, uroflow, and ultrasound findings based on the history with a high degree of confidence.

For the 80% of children with "complaints," the symptoms and my physical examination findings did not "add up" to an understandable problem. The clues did not make sense.

As the week evolved, when the clues did not make sense, I started to go back over the questions to confirm that the "complaints" really existed, and to my amazement and concern, I found that on repeat questioning, that many mothers admitted that the complaint was not really present.

My interpreter is excellent and this was not the reason for the confusion. Mothers everywhere can misunderstand, but the prevalence of misunderstanding is too high in Gigante for this to be the reason. Another possibility was that the symptoms were not temporally related, but I clarified this with precise questions. After ruling out the common and routine causes of this sort of confusion, I was left with a disquieting possibility. Perhaps the mothers told a story that was not true? 

Why would a mother do this? 

I asked the more experienced volunteers in the community and they responded that this was likely and that the reason is "cultural."  

"Perhaps the mothers thought that they needed an excuse to see you," some responded. 

"Perhaps the mothers thought you would be more likely to prescribe a medication if there were more complaints," others responded. 

I learned that some of the complaints were "surrogate" complaints. The child was the emissary for another family member (father) who actually had the symptom (headache, chest pain), and the mother presumed that if I prescribed something for the child, that the father could use the medication!

Medications are highly desired solutions to common problems that do not deserve any medication. Over treatment is a major problem in Nicaragua, and while this might be a "cultural" solution for Nicaraguan physicians, this has never been my solution to a problem.

Given all these "cultural" differences in perspective, I am left wondering whether I met the needs of many of the families. I did not offer medications without a reason and I refused to offer medications for a child that would be used in the father. Instead I relied on the provision of information in the hope that knowledge has power. 

This is the modern way, the Canadian way, and certainly my way, but this might not have been their way. If not, then I likely didn't meet the needs of some of the families, and as such, I need to learn how to meet their needs and still offer good medicine.