Day five of Ciriboya UNAH nurse/med student brigade

[Note- I am back from the brigade, and only now catching up on these posts. I fell behind due to a combination of a nasty cold, no electricity, and two days in the field spent designing, printing and collecting signatures for brigade diplomas to satisfy the Honduran official paper & stamp fetish. More to come!]

Every night I planned to get up early and finally learn how to make flour tortillas, and every morning I woke up feeling sick. Mirna's spotless kitchen is really a thing of wonder. Aside from the amazing food she manages to create out of totally mundane ingredients there, it's got an order to it—with the dozens of pots and pans each hanging from their perfect spot—that I admire deeply. These are the students eating breakfast before a long day of fieldwork.

When they set out to do the door-to-door family health history interviews that the hospital requested, I went to run errands. Mirna needed some more ingredients, and the car needed more gas (at L.120—six dollars— a gallon, it's no bargain either). On the way back I made a detour to visit a friend I'd met the previous month at a funeral in the Moskitia. When I got there she received me with a big hug. And then she said, "I'm making casabe! Take pictures." It was more of an order than I request. It was clear I wasn't the first anthropologist to come to town.

The casabe-making process is fascinating (in Garífuna it's called ereva). There's no water involved. It was an impressive process, in part because of the smoke involved. I started crying within a minute of being in the kitchen, and my friend stays in there for a good part of the day. She takes the shredded yucca flour, spreads it around evenly on the comal, then packs it down with an implement not shown here so that the yucca flour sticks to itself and forms the crisp bread, then flips it, then cuts it into four equal pieces. I took the pictures expected of me, and fully enjoyed the process, despite my tears.

As I was hanging out with the family, a fishing boat came in. One after another after another man walked by carrying huge fish. Others ran past them in the other direction to get more.

My friend's sister told me they'd cost L.100 each. I thought about our endless meals of chicken and jumped at the chance. I asked her if they'd take dollars. I'd run out of lempiras but happened to have 20 bucks in my wallet. Of course, she said. She told me to give it to her and she'd go, because they'd rip me off. Sure enough, about ten minutes later she came back with a sack of 5 massive fish. Everyone wanted me to take their picture with them:

When we were done with the photo shoot I stuffed the fish back in the bag.

Then they asked me if I liked coconut water, which to me seemed like a silly question. Does anyone in the hot sun not like fresh coconut water? It was a bit of a challenge to get the coconuts down. First one of the girls climbed up:

...but almost at the top, she slid down, which looked painful. But it wasn't the sliding down part that she was complaining about as she frantically slapped at her legs and arms. "Ants!" she shouted, out of breath. "Too many ants!"

Another boy started up, and while he was climbing I took a picture of my friend's granddaughter holding her brilliant homemade slingshot: a sawed-off soda bottle top with a balloon affixed to the opening.

The boy made it to the coconuts, which was no small feat

...and they brought down enough for all of us, even the kids. The soft coconut meat inside, once you've finished drinking the water (and there's a surprising amount of that) is the best. Nothing to do with what we think of as coconut in the U.S.

Another adorable grandson was on the brink of taking his first steps. Everyone sang and clapped and cheered him on, led by his older sister (on the left of the photo).

Meanwhile, the students were out in the communities doing family health history interviews for the hospital, and Dr. Marilyn shared her pictures with me. Here UNAH bus driver Marco Tulio poses with singer-songwriter-med student Franco, and some of the boys they met.

Another genius home-made toy, this one a coco-boat.


The rivers are pretty clean. People wash clothes and bathe in them.

Part of the students' task in doing family health histories was also to assess living conditions of each family for the hospital's records. Pigs are not necessarily an impediment to good hygiene (depending on how they are housed), but they are cute and a good waste-disposal system.

View of a kitchen in one of the houses surveyed.

The students, in addition to carrying out interviewed, checked on anyone who was sick or about whom the family had a health-related concern.

Those students who forgot to wear their rubber boots had to be carried piggy-back over some sections of the road.

Luckily, the students and Dr. Marilyn are good about remembering group photos, something I always forget.

More health histories:

A lobster in the path:

And of course, my students took more pictures of themselves with adorable babies (the first pic is with mom).

After a late lunch of the delicious fresh fried fish I'd bought a few hours earlier ($20 worth of fish easily fed almost 40 people), I made the poor exhausted group go over to the hospital for an afternoon of writing and brainstorming. I first told them about how we had been able to fund the brigade—through the generous donations of individuals they'd never met, but who had put their faith in the hospital, in me, and especially in them. I explained why it had been politically important to me that the experience, like the hospital, would be without cost to students. Many of those present, in particular my nursing students, would never have been able to afford the trip, and I did not want it to be an exclusive experience. I then asked them to do a free-writing exercise reflecting on their experiences so far, to share on my blog. They took about half an hour to write, during which time young Omer also was hard at work alongside the students, repeatedly asking for more paper. He presented me this lovely picture of the hospital as his submission:

I have to admit, the free-write was a guided exercise and in no way neutral, despite the fact that (as I mentioned in an earlier post) there was no grade or overt disciplinary mechanism attached to it, and that anonymity was an option. But even so, and despite a familiarity with Honduran dramatic writing genres, I was surprised by the poetic exuberance of the students' comments. "In five years of studying medicine I haven't learned as I have during these few days in Ciriboya" one began. "I know that I alone cannot change the whole world," another wrote, "but by changing myself, I am changing something of the world." He concluded, "I carry Ciriboya, Iriona in my heart." Another concluded, "This has been one of the best experiences of my life, which I wouldn't change for anything. I wasn't sure about it at first, I didn't know if I should come or not, but now I don't want to leave. I have enjoyed Ciriboya so much, and not just for its beautiful beaches, but for the humanity and warmth that is here in Ciriboya."

Most of the short essays, like the above, focused on the personal impact of the experience. Many also reflected on what it means to them to be Honduran with a mixture of nationalist pride (on considering Garifuna culture part of who they are as Hondurans) and shame (on seeing the marginalization of these Honduran communities by the government). Another titled his essay "I am a foreigner in my own land."

Inspired by the model of the First Garífuna Hospital, many students also discussed something that they had repeatedly mentioned in our meetings throughout the week: the deep structural flaws in Honduran healthcare, their relation to antidemocratic politics, and the need to change the "system" as a whole.

One student wrote: "It is inhumane to see how politics affect us so much. I don't like politics, I'm not interested in getting involved in them because politics shouldn't be messing with our health. They spent millions of lempiras in these past elections on publicity, and if that money had been distributed not just in the health sector but to our other needs and rights that we have as human beings we would not have such a poor health system. I will pray to God every day for Ciriboya, I will implore him to make things better in the years to come, and that we can get ahead as a people. It's not just Ciriboya that needs help, it needs a miracle, but it doesn't need politicians, it doesn't need hypocrisy and above all, it doesn't need more deaths."

Here is another essay reflecting on the intersection of politics, healthcare and nursing practice:

I want to thank everyone involved in this project from those of us who are here living it to those who gave their support without thinking twice. This is an important experience in my life and for all of those here, my colleagues and the med students from the UNAH; it has opened up our minds [to think differently] in our professional work. Another important point is that I have known for a long time about the idea of public health and APS [Primary Health Care], with a clear understanding of the model as such. But upon getting to know and applying the model in such a remote community like Ciriboya, abandoned by the politicians of my Honduras, I find myself reflecting deeply on how it is not about waiting for them to systematically change Honduras's health system from above...I as a nurse have an obligation to my country to go to communities like this one and others like it to make changes from the very grassroots of our society. It's about organizing, creating infrastructure and having the will to do the work; to go from a curative to a preventive health [model]; from hospital care to community care. That is why I don't want to stay in a hospital, stagnant and impotent in the city, without even knowing the houses where [my patients'] families live. Today more than before I am ready to get myself muddy doing whatever needs to be done, wherever it needs to be done, in order to give our nations the best of ourselves.

Just to clarify- in the last sentence, "nations" is a translation of pueblos which here refers to the idea that different recognized ethnic groups comprise different "peoples" within Honduras.

While the last of the students were finishing up their essays, I noticed a UNAH pickup truck outside. It was a surprising coincidence, to say the least, all the way out in Ciriboya. I went out to see who it was and say hello. To my utter delight, it turned out to be my colleague anthropologist Santiago Ruiz, rector of the UNAH campus in Tela. I had first met him in late 2009 or early 2010 in the basement cafeteria of the U.S. Congress, where the french fries were still called Freedom Fries (remember that proud moment in Federal lawmaking?). He was in Washington with Dr. Luther to speak with the members of the Congressional Black Caucus and others about the impact of the coup (and U.S. support for it) on Garífuna communities and on Hondurans more broadly. At the time Dr. Ruiz lamented the difficulty in finding an academic position in Honduras, and was teaching instead in Puerto Rico, where he had earned his doctorate. I had been happy to hear several months ago that he was not only back in Honduras, but actually in a position of influence. I had been hoping to get the chance to see him again, so running it to him in Ciriboya was a wonderful bit of serendipity. He was enthusiastic about our brigade, and asked to speak to the students later that evening at the Cubans' house, which of course we were all happy about.

When the students and I reconvened after their writing exercise, I had them split up into groups to brainstorm about what concrete actions they were going to do once they returned to Tegucigalpa to carry forward the things they'd been talking about carrying forward in the abstract up until that point. Night fell while they were working, but they went ahead, writing notes and presenting their plans by flashlight. They had great ideas that included media strategies and workshops in a variety of venues to share their experiences and support the struggle for a free, universal healthcare model. They also came up with lists of strategic allies, and thought about potential funders for future brigades who (like in this case) wouldn't require compromise in terms of the brigade's political commitment.

This photo of the report-back is deceptive, thanks to my camera's flash. It was almost completely dark:

From there, we had a quick dinner and went to the Cubans' house so that the med student group leaders could give a training to the rest of the group on the research project that was on the agenda for the next (last) three days of the brigade. They would be collecting blood sample to determine the prevalence of sickle-cell anemia in Ciriboya, which would benefit the community (they argued, and the hospital staff fully agreed) in various ways. First, they would be able to identify people who had sickle-cell anemia and hadn't known about it, which would allow them to treat it earlier, and also, with a better sense of prevalence, the hospital and other local health authorities could begin to devise a better plan for treatment and management of the illness on a population level.

In the below pictures, one student draws another's blood, demonstrating all the steps the student teams would take in each household. By that time most of the students already had band-aids on their arms. They'd been practicing the blood-drawing part on each other all day. The student presenters took very seriously and spent a long time on informed consent before getting to the actual blood drawing, which was a big relief to me. Talk of taking bodily substances from indigenous populations generally causes me to think of Darkness in El Dorado and other anthropological horror stories, and to hyperventilate. But the students had done thorough and rigorous planning for the study, going through all the appropriate university and governmental protocols, and by this time I felt I knew them well enough to trust they would carry out their work with the utmost respect and professionalism.

When they finished, Dr. Ruiz gave a short speech about the importance of the work that these students were doing for the university and for their country, and how this represented a great example of the direction in which he as rector of the Tela campus would like to see the university move.

Dr. Luther had assured me that as long as the community knew that the sickle cell study had the hospital's blessing, community members would eagerly cooperate. As an anthropologist I had my doubts, and so did Dr. Ruiz. He stressed to the students how very very important it was to not pressure people at all, to err on the side of caution, and to not draw blood if they had an inkling of doubt about any given participant's consent. He also worried that many community members would refuse to cooperate, making it hard for students to collect a sufficient sample size. He offered to call various respected people from the community to spread the word and/or accompany the students in the morning, although we agreed it might be a little late for that.

It turns out we anthropologists needn't have worried. Students told me the next day that they had nearly no refusals, that community members were ready with their sleeves rolled up when they arrived at their houses, and that some even chased them down to ask when they were going to draw their blood. Go figure.