Thank you Health Partners International of Canada

Last Friday I was networking online, trying to find medical supplies to take to Nicaragua, and I discovered Health Partners International of  Canada. 


HPI Canada was established as a not-for-profit relief and development organization in 1990. During 2010, HPI Canada provided over a million treatments in 75 countries. 

HPI Canada prepares a container of common medications and supplies that are useful for medical trips to countries where physicians and medications are in short supply. The generic container is not focused on paediatric care and is therefore not useful for my purposes, but there was a form for "Special Physician Requests." Supplied medications are donated by pharmaceutical companies who partner with HPI Canada. Physicians are requested to donate a modest percent of the wholesale cost. Definitely a win-win solution all around! 

Paperwork, I thought. Probably take forever. Rather than just fill out a form and send the information into cyberspace, I phoned and was put through to Ms. Martha Florez, Manager of Physician Programs for HPI Canada. Ms. Florez was incredibly helpful. She acknowledged that approving a special request in time for my trip in three weeks was a long shot, but she advised that if I got the paperwork to her, she would do her best.  

I spent the next three hours working on the paper. The time consuming part was estimating medication needs for the trip. I had the data about expected diseases (see my November 29, 2011 blog) but I needed to determine how many bottles of the pediatric formulation of each medication would be needed. I looked up each formulation online, calculated dosages based on the age (weight) of the children I will see, prepared a spreadsheet, inserted my data from previous visits, and estimated the number of children I would see. I'm sure a less compulsive person would just have made a good estimate, but I decided that the time invested would help insure any HPI Canada resources would be utilized. I've seen bags, closets, and even store rooms of expired medications around the world and this is a preventable and sad waste of resources. I do not want to become part of the problem. I need to be part of the solution. 


I was working through this methodically when Ms. Florez phoned to advise that she had talked to individuals at her end and that she needed the documents by about 2 PM. HPI Canada is headquartered in Quebec with a time zone two hours ahead of Alberta and the clock was ticking. I managed to send the completed application, my medical documents, and the important list of medications just in time.  

Yesterday Ms. Florez phoned with the terrific news that she had expedited my application and obtained some of the medications on short notice.  

Thank You Health Partners International Canada and Thank You Ms. Martha Florez.  Wow!

Intestinal Parasites and Solar Water Disinfection (SODIS)

Intestinal parasites in Nicaragua are endemic and the water is the most common source. 


In one recent study, 53% of tested wells contained amoeboflagellates.  A study of 480 apparently healthy individuals in Leon reported that Entamoeba histolytica or Entamoeba dispar was present in 12% of stool specimens. A 2001 survey found that 13.1% of children under 5 years of age suffered from diarrhea as a result of unpotable water.


While in Limon I will find out if there is support for community programs to disinfect the well water.  If this can be arranged, perhaps the problem might not recur after treatment for abdominal parasites.  


Solar water disinfection, SODIS is a method to disinfect water that works and that is commonly employed in poor rural areas around the world. 


SODIS can be used to disinfect water using sunlight and plastic polyethylene terephthalate (PET) bottles.  The World Health Organization (WHO) recommends SODIS.

The PET recycling mark is widely recognized and confirms the suitability of a plastic bottle for SODIS. 


Large 2 litre colourless, transparent PET water or pop bottles are needed. The labels are removed and the bottles are washed. Older scratched bottles should not be used. The bottles are filled three quarters full with well water, shaken for 20 seconds with the cap on, then filled completely and recapped. Very cloudy water should be filtered prior to exposure to the sunlight.  The filled bottles should be exposed to the sun for 6 hours and will heat faster and to higher temperatures if placed on a piece of corrugated metal that is sloped and faces the sun.

Perhaps I should stockpile 2 litre PET bottles and small sheets of corrugated metal and give these out with instructions every time I prescribe an anti-parasitic medication.  

Using Data to Plan Trip Four

During past trips I kept an electronic copy of the written summary of patient visits. I typed out a short summary with the name, age, gender, symptoms, physical exam, assessment, and recommendations.  I used Google Translate to convert the text to Spanish, and the printed version was placed in the clinic chart and a copy was given to the mother. Until I got into the routine I did not save every patient, and when the clinic was hectic, I forgot to save some patients, but I managed to save all but one or two a day, so my records are pretty good.  

I reconverted the files one by one to English, and then made a spreadsheet of age, presenting complaints, diagnoses, and medications prescribed.  

The children ranged from 1 month to 11 years of age and I saw 12 to 24 children a day.

The graph below shows the most common diagnoses and the percent of patients with these diagnoses. 

I expect to see about a hundred patients during the next trip and based on this data I can predict how many of each diagnoses I will likely see and I will bring enough medications in each class to cover the common problems without dipping into the clinic pharmacy stores.  As well, I will bring my preferred medication for each problem, which obviates the need to choose a second or third line medication from the clinic stores.  

The most common prescribed medication was an anti-pyretic followed by an antibiotic.  

I'm sure that I did not diagnose all the cases of scabies, ringworm, and tinea versicolor. Many children had these skin infestations but the mother often didn't point the rash out as a problem. As well, the clinic did not have supplies of medications for these skin infestations. With the next visit I will bring enough medications to treat these problems.  

I am also sure that I did not diagnose all the cases of abdominal parasites.  A case might be made that any child who drinks well water, that is to say probably every child, likely has an abdominal parasite.  Perhaps I should bring enough to treat every child.  But, if they continue to drink the well water, the parasites will return.  

Over the next month I will prepare a teaching handout in Spanish for the common problems such as fever, cold, ear infection, rehydration with gastro, nutrition, abdominal parasites, scabies, ringworm, tinea, and impetigo. Having the handouts will save me time when I see children with these problems.  

Planning the Fourth Trip in 14 Months

Orange-fronted Parakeets

During the last week of December I will fly to Nicaragua for my fourth visit in fourteen months.   


Illness doesn't take a holiday, and my presence, I hope, will allow clinic staff in Limon to spend more family time during the Christmas festivities. All good.  


Daniel Ortega, the president of Nicaragua, recently re-elected for another five year term, stated that he expected to continue to govern on a path that is "Christian, Socialist, and in Solidarity."  The church figures prominently in his government and in the country generally.  Christmas is an important religious holiday in Nicaragua. The predominantly Catholic population celebrates the birth of Jesus with festivals, pageants, and traditional church activities.  

My goals for this trip are to provide Spanish teaching sheets for the common problems that I will see, to bring along the majority of the medications that I expect to personally use, and to establish a long term relationship with an interpreter. 


On prior visits I kept a computer file on almost all of the children that I assessed.  I prepared the files as a permanent record for the clinic chart and the recommendations portion was given to the mother as a written reminder of the instructions.  I am tabulating these records and in due course I should be able to estimate the medication needs.  


I am hopeful that some of my Calgary colleagues will again donate medical supplies for me to take to Nicaragua, and I will purchase the deficiencies between my estimate and the donations. 


The records will also serve to identify the basic problems for which Spanish teaching sheets need to be prepared.  


Finding an excellent translator is an important project.  I will pay the translator very well by Nicaraguan standards but a modest amount by ours.  An excellent physician translator relationship can make a huge difference with quality of care.  


I expect to post a blog every week or so until I leave and then daily while in Nicaragua so that the friends of Help Nicaragua Children can keep in touch.   

Gigante, "Foot of the Giant"

   Depending on who you talk to, or what you read, the foot of the giant is either this peninsula that forms one arm of the bay, or the foot is the entire bay.  
   When we arrived in Gigante, just before noon, the town was in full Samana Sanata swing. The restaurants and bars were alive with music and people were spilling into the streets with cervezas.  

   One table had three local fellows, a bottle of rum that was almost empty, and they looked like their sobriety was fading fast. Bo Fox reports that the combination of alcohol and breaking waves with undertow is a fatal formula on holiday weekends. 
   Gigante is a fishing village and we learned that the local fisherman are hard workers and hard drinkers. They smoke and drink much more than the average Nicaraguan, perhaps because they earn more. The fish they catch is packed on ice and has a good market in Managua. 

   The population of the town had swollen with the holiday festivities and we were very fortunate to bump into Bo Fox as soon as we drove into Gigante. He was literally the first person we saw. This was fortuitous because we brought along the remainder of the toys that we had brought for the clinic patients.  
   As we walked to a beach restaurant, Bo said hi to at least ten local fellows.  He has only lived in Gigante since January, and by now he seems to know most everyone. What a congenial guy! We enjoyed a soda with Bo and then he had to leave to do a Skype conference with a volunteer for Project Wave of Opportunity, the charity he works for. 
   We walked along the beach and enjoyed lunch in a Gringo cafe at one end of the beach. There were hundreds of families on the beach. Children built sand castles, adolescents played soccer, and parents sat under tarps or umbrellas.  The beach was a sea of smiles.
   Later that evening, back in Limon, we hosted a party for the clinic staff.  Everyone was in Samana Santa holiday mode, and we had a great time. What a great finish to a week of work in Nicaragua!