Arrived

Little Blue Heron Surfside

This morning I did manage to confirm that the rental car was not available. I actually spoke to a Hertz employee who turned up at the hotel. No car for me.
So, I took a taxi, a 2.5 hour taxi, to Limon, and around noon, I arrived. Whew. Seemed like longer but really only 3 days compared to the usual 1.5.   


The next problem is how to get back and forth to the clinic. Well, Matt, an especially helpful person who manages the casa where I stay, has offered to lend me his motorcycle. Ok by me. I enjoyed my motorcycle days as a young man. I even raced motorcycles for a season. So, the motorcycle works for me. 

Matt's Honda

I unpacked and placed all the medications and supplies in one bag. I had mixed them all up with my clothes and equipment because there was a last minute snafu with the permit for customs. This time the meds were co-mingled and I chose the correct time to put the bags on the conveyer belt that takes the bags through the scanner. I was watching the scanner operator and he was periodically pre-occupied with a young woman. I put the bags on during one of his pre-occupied moments. Hey no problema! So, now the meds are ready to take the clinic.  


All in all, the sky is clear, the sun is shining, the bags and medications all arrived intact, and tomorrow is another day.  

Peace, Goodwill, and Complicated Travel

A trip to Nicaragua would not seem right unless something went wrong with the outgoing travel. Major glitches in the past include luggage that did not arrive, and officious customs officials who confiscated supplies.


The problem started on the 23rd when my flight from Calgary to Houston didn't happen. The pilot advised that the repair crews swapped out multiple computers and the plane was repeatedly powered up and down,
but all to no avail. The fuel tank, definitely full of fuel, did not say full. Safety is important and rules are meant to be followed in the interest of public safety. So, after several hours on the tarmac, without any hope of making my connecting flight to Managua, I re-booked for the next day. Sounds simple, but that was not my karma.


Christmas travel is generally complicated. Everybody is traveling. Seats are in short supply. Patience is thin. Even so, I did manage a flight to Houston on the 24th, but there was simply no possibility of a connection to Managua the same day. So, last night I enjoyed the Houston Marriott. Nice hotel with a revolving restaurant at the top.


The good news is that I am now in Nicaragua, with my luggage, and the supplies were not confiscated.


The bad news is that I arrived two days late, and I am still in Managua.


The 4 Wheel Drive Toyota Land Cruiser that I rented with Hertz was not waiting for me. I had phoned to make sure they would hold my car, and I had offered and was happy to pay for the two missed-use days before I arrived. I arranged a very early morning flight from Houston so that I could pick up the vehicle and drive the same day to Limon, the nearest community to the clinic. Not only was the car not waiting for me, but the Hertz booth at the airport was not even open. A confirmation number is worthless when there is no one to discuss this with. All the other car rental agencies were open. Of course none had vehicles.


So, I took a taxi to the Hotel Intercontinental. I had been scheduled to stay there on the 23rd, and ended up paying for the room because by the time the airplane computer thing ended, I had passed the cancel-before deadline. Not that I hoped that the hotel would offer me a free room. That doesn't happen. But, I did want to check the Hertz counter at the Hotel and I hoped to enlist the concierge in my quest for a car.


The Hertz counter at the hotel was also closed, of course.


I checked in. The Hotel Intercontinental is definitely the best hotel in Managua. I'm lucky there was accommodation. In fact, the availability of the room lifted my spirits and I thought, surely fortune is now smiling on me.


I enlisted the help of the concierge and thanked him with a large monetary encouragement. He phoned the person who was on local-Hertz-Christmas-duty, and this person apparently agreed to contact the Manager, or more likely, to try and contact the Manager on Christmas Day. They are to call back. Hmm.


The rainy season ended in Nicaragua a month ago, but you could have fooled me. The palm trees are swaying very briskly, the sky is grey, and there is rain falling. But, I am on the Hotel veranda, which is very dry, and somehow I know that tomorrow will be sunny.

"Into every life, some rain must fall."

That's Longfellow quoted by a Shortfellow.

"Wake Up"

The lyrics of the song, "Wake Up," 

by Arcade Fire, 

certainly my favorite group from the last decade, 

should be read by my generation.  

Win Butler, the lead singer songwriter, 

alternates between sadness and screaming, 

in this anthem for his generation.


Somethin' filled up

my heart with nothin'

someone told me not to cry.

But now that I'm older

my heart's colder,

and I can see that it's a lie.

Children wake up,

hold your mistake up,

before they turn the summer into dust.

If the children don't grow up,

our bodies get bigger but our hearts get torn up.

We're just a million little god's causin' rain storms 

turnin' every thing to rust. 

I guess we'll just have to adjust.

With my lightin' bolds a glowin'

I can see where I am goin' to be

when the reaper he reaches and touches my hand.

With my lightnin' bolts a glowin'

I can see where I am goin'

With my lightnin' bolts a glowin'

I can see where I am goin'

You better look out below.


The song is not merely about children waking up, 

but also about the need for their parents 

and their grandparents (my generation) to wake up.


Change waits on nothing, 

and change now happens on a logarithmic scale.

This song helped me realize 

that my eyes have not stayed wide open 

to the changes in the world around me.


The Internet is woven into the lives of 

the youth in Nicaragua, 

and they must be restless.


Daniel Ortega, 

a young revolutionary of my generation, 

started a successful revolution 

in a relative communication vacuum.


Arab Spring 
proves what is possible 
with restless revolutionaries
in the digital age.


I do not know whether Ortega 

has the pulse of the Nica youth. 

Are his eyes wide open? If not, 

the poverty and the discrepancy 

between what Nica youth live at home 

and what they see on the Internet, 

might herald spring in Nicaragua.  

Worms in Nicaragua

Intestinal worms are common in Nicaragua. 


Children Without Worms (CWW), an organization dedicated to the worldwide control of worm disease, performed a survey in five Nicaragua communities in 2005, and documented a prevalence rate for worms of 49%!


Worms are soil-transmitted helminths (STH). Eggs are ingested by individuals through food that is not carefully washed or on dirty hands. Larvae penetrate the skin directly. The eggs or larvae develop into adult worms, which produce eggs. Infected individuals contaminate the soil with their feces. Eggs develop in the soil. The cycle continues. 


Once infected the child can develop abdominal pain and distension, intestinal obstruction, iron-deficiency anemia, malnutrition and poor growth, allergic reactions, and lung disease.


CWW in partnership with Johnson & Johnson and local government, targets school-aged children to receive a 500 mg dose of mebendazole and the families to be educated on hygiene.  In Nicaragua the drug is administered by the Ministry of Immunization. 


CWW advocates four key components to break the cycle of worm disease.


1. Water - access to potable water for handwashing and cleaning of foodstuffs. 
2. Sanitation - latrines to keep infected feces away from individuals.
3. Hygiene Education - personal and environmental hygiene (handwashing).
4. Deworming. 


I emailed Ms. Kim Koporc, Director of Children Without Worms. to inquire if there is a way for me to help in the clinic where I will work.  


At the very least, I will prepare my own handout on how to disinfect water and on the need to wash all fruits and vegetables prior to food preparation, and the importance of regular hand washing.  


While in Nicaragua, I will find out if the Ministry of Immunization campaign in 2010 included the clinic region where I work and how often the dosing is administered. Without intervention to prevent re-infestation, the worms will return. I will bring enough 500 mg tablets of mebendazole for every child I see and handouts in Spanish on hygiene and how to prevent re-infestation.   


I've traveled extensively in my life and I only developed a gastrointestinal problem once. While on a family vacation to snorkel in the Cayman Islands, I developed shellfish toxin poisoning after eating at a fancy restaurant, which could just as easily have happened in Calgary. I've never been ill, touch wood, with any of my trips into rougher country. I've visited Haiti once and Nicaragua three times in the last twenty months and stool tests performed on my return from each trip have been negative. I set high standards and my compulsive nature helps. I was very strict about hand washing and all the fruits and vegetables were carefully washed in a dilute bleach solution before use.  

Malaria in Nicaragua

Malaria is present in Nicaragua. The Center for Disease Control reports malaria is present in only 6 of the 17 Departments (sort of provinces). The six reported Departments are located on both the Pacific and Atlantic coasts and in the interior. The absence of reports in the other 9 departments must be a reporting anomaly. Mosquitos do not acknowledge borders.

Malaria in Nicaragua is due to Plasmodium vivax in 95% of cases and P. falciparum in the remaining 5%. This is good news because P. vivax is still chloroquine sensitive and has a good prognosis for full recovery, compared to P. falciparum, which is a much more serious infection. 

The anopheles mosquito transmits malaria. The bite transfers asexual parasite forms into the bloodstream and these parasites undergo a liver and then a red blood cell stage. About a week or two after entering the red blood cells, the blood cells burst and release thousands of parasites and inflammatory chemicals into the blood. The inflammatory chemicals include pyrogens, which cause the fever. The fever in P vivax develops every 48 hours days, which is referred to as tertian malaria. The red blood cell destruction results in anemia.

Children suffer the most severe disease; especially children aged 6 months to 5 years. In parts of the world where malaria is endemic, malaria might cause as many as 10% of all deaths in children. Survivors develop partial immunity.

Older children might present with the classic periodic fever with chills and shivering. However, this is uncommon in young children. After the mosquito bite, younger children are asymptomatic for one or two weeks. The fever is usually continuous and might be very high (40°C) from the first day. The symptoms are non-specific. Children become restless, drowsy, apathetic, and anorexic. Older children might report generalized ache, headache, and nausea. Many children have only flu-like respiratory symptoms, with mild cough and cold. Vomiting is very common. Mild diarrhea is also common, with dark green mucoid stools. Seizures might occur at the onset of the disease. Differentiating a febrile seizure from cerebral malaria is often difficult. The liver might be slightly tender. Splenomegaly takes many days, especially in the first attack in nonimmune children. Children with partial immunity might develop only a low-grade fever, anemia, poor appetite, and malaise. The diagnosis is established when parasites are noted on a thick blood smear, but only 50% of children with malaria have a positive smear, even on repeated examination. P vivax malaria might relapse for up to 3 years.

Since the symptoms are often non-specific, high fever in a susceptible young child requires a high index of suspicion, and in the absence of a recognized cause for the fever, empirical treatment might be necessary.

The treatment of P vivax is a 3-day course of chloroquine, followed by a 14-day course of primaquine. The primaquine is necessary to eliminate the dormant stage of the parasite in the liver.