Friday, October 6, 2017

Running the mesas, the deserts, the mountains

Since moving to the Hopi Reservation last fall, I feel a sense of coming full circle on my path to running.

I hated running as a child, and only came to it as an adult, around 10 years ago on Pine Ridge Reservation in South Dakota when I started running simply because I felt cooped up from physical inactivity. So I started running on the gorgeous rolling plains of South Dakota. It took several weeks for me to build up the ability to run a mile or two, and then, for the first time, it actually felt good and I was hooked.

Rolling grassland of Pine Ridge reservation. I learned to run on this gravel road.  
Since then, I've kept running a part of my life, at least in some way, and it has become a sanctuary to get outside, to move, to clear my thoughts, to feel my heart pounding and my lungs burning. I've received some puzzled glances from local communities as I ran on the beaches of a Garifuna village in Honduras and the dirt paths of the Rainforest in Peru.

And then, one year ago, I moved to the Hopi Reservation in Northern Arizona, and incidentally found myself in a place where not only do I not receive any puzzled glances when I run, but where I am completely amazed and humbled by the running tradition and culture of the Hopi people.

The Hopi have a long tradition of running, and maintain that tradition to this day, through ceremony, sports, and everyday life. In 1912, a Hopi runner named Louis Tewanima won a silver medal in 10,000 meter race, setting a US record that would stand for 52 years. There is now an annual 5K and 10k race in his honor, which I had the honor of participating in earlier this month. http://www.tewanimafootrace.org/about.html

At this, and many other races I have attended, Hopi people of all skill levels and all ages, from elementary school children to grandmothers and grandfathers, come out to run together, and cheer eachother on: "nahongvita" or 'stay strong'. There are running trails all over the reservation, looping around all the villages, up and down the mesas. The Hopi Wellness Center runs an annual "100 mile Club" which encourages participants to run or walk a total of 100 miles over the course of the summer.
Running trails behind the Wellness Center
In one other impressive example of the ongoing culture of running, the Hopi High School boy's cross country team has won the state championship in their division for the last 27 years in a row. Here's a New York Times Article and an ESPN SC featured video about the team and its legacy if you are interested.

It has been truly amazing to be a runner and be surrounded by such a deep, rich, running culture.


This fall, I've joined an eight-member team of mostly Hopi staff members of the hospital for a 2-day trail relay run in November 3-4 at McDowell Mountain Regional Park outside of Phoenix. We'll each be doing three legs spanning day and night for a total of 15.4 miles each or 123 miles total. It'll be a fun time and a good challenge for all of us, but we are also doing it as a fundraiser for the Unite to End Violence Native Women's Empowerment, a small grass-roots organization that organizes a run on the 25th of every month to raise awareness about domestic violence and works to support survivors.

Example care package for survivors of domestic violence
We're collecting donations to Unite to End Violence via this gofundme page if anyone would like to contribute.

Saturday, July 29, 2017

a new understanding of water

“How could a place defined by the absence of water be defined by the presence of it?” --Craig Childs, the Secret Knowledge of water.

When I chose to move to Arizona, I gave little thought to fact that I was moving to the desert or how radically different this would be to any other climate in which I have lived. In the last nine months, I have become so much more aware of water: when and how I drink it, when and how and how much falls from the sky, how it defines the landscape and living creature’s relationship to it. I'm including a few quotes from a book "The Secret Knowledge of Water" by Craig Childs which express much more eloquently than I could some essential concepts around water in the desert. 

Each time I go into town for groceries, I also load up the back of my car with empty gallon water jugs, which I fill with tapwater in Flagstaff and bring back. This is a choice I make because the water that comes out of my tap comes from local groundwater that naturally contains arsenic, at slightly above EPA recommended levels. I then watch the water jugs empty themselves, about one per day, for my cooking and drinking water, until I get a chance to replenish them.

And this is only at home – when I go hiking or backpacking in this area, planning water sources is much more critically important. In the desert, there are a few types water sources: springs, streams/rivers, and potholes: natural depression in rock which fill with water and, depending on the size, remain filled for a matter of days or up to weeks to months if they are large enough. 

Pothole water in the Grand Canyon
Spring in the Grand Canyon
All of these but the largest of rivers and potholes are seasonal, and can be found completely dry in the summertime, making careful research, planning, and budgeting of water essential. I recently went on an overnight backpacking trip in the Grand Canyon where none of these water sources would be available, so we each carried 11-12 liters of water (around 25 lbs). That is a heavy load!

Colorado River at the bottom of the Grand Canyon -- always has water, but hope it to be clear like this not muddy after a rain!
Much more dramatic than my own personal relationship with water, is the way in which water defines the natural environment here. Surely the natural springs on the mesas at Hopi played a role in their settlement here over one thousand years ago. In some of the villages, you can still see the natural potholes dug deeper by ancestral Hopi to store water on top of the mesas. And to this day, the Hopi perform ceremonies and dances to bring the rain their crops need to survive and thrive. When the rains come, they seem to be another entity altogether from the rain I am used to anywhere else. The open landscape allows you to see for miles in any direction, and see storm clouds dumping rain and lightning in a patchwork of places with some areas left bone-dry in between.

It's raining on the buttes in the distance, but not on the road i'm walking


Which brings me to the flipside of water in the desert: its momentary abrupt abundance and resulting floods. In the space of a few minutes, flash floods can turn a dry rock channel into a living, seething, roaring river with water and rock defining one another: “the shape of the canyon is the shape of moving water, and the shape of water, like the canyon, will amend to the slightest bias. While resisting and accommodating each other, water and canyon both become patterns of the same intelligence.” --Craig Childs, the Secret Knowledge of Water.

Dark Canyon in Utah, carved by water
Closer to home is the sandier version of canyons: the numerous ‘washes’ that meander across the Hopi and Navajo reservations. They appear as dry creek bottoms, lined with cottonwood trees, and fill with water only for short bursts of time, but enough to define their physical paths and resulting ecosystem. Paved roads have bridges with signs marking the wash as if it were stream or river (which is sometimes); unpaved roads simply go through the washes, sometimes heralded by a “do not enter when flooded” sign.  Families that live off of some of these dirt roads not infrequently find themselves trapped, unable to venture out from their homes to town, work, or appointments at the health center due to mud or a flood.

Mud cracks as it dries the day after a rain

To say that the desert has no water is a tantalizing misstatement. It is believable. But to look over this raven land and know the truth – that there is immeasurable water tucked and hidden and cared for by bowls of rock, by sudden storms, by artwork chiseled hundreds and thousands of years ago – is by far a greater pleasure and mystery than to think of it as dry and senseless as wadded newspaper. It is not only drought that makes this a desert; it is all the water that cannot be seen.” --Craig Childs, the Secret Knowledge of Water. 


Tuesday, January 17, 2017

New year and new life on the Hopi Reservation

It is hard to believe it has been more than three months now that I moved out here and started work as a family doctor on the Hopi Reservation. I haven't written before now partially because I have been busy and partially because I have been struggling with how much I feel is appropriate to write publicly about my experiences here. The Hopi people are very open and welcoming to non-native guests such as myself in the community, but also clearly and understandably request respect for their privacy. There are many signs throughout the reservation requesting no photographs, audio recordings, or notebooks.

So I'm going to focus on my own experiences and share photos of the natural environment, but will not be sharing any (even de-identified) patient stories or recount any of my experiences with Hopi cultural dances or ceremonies. If you are Hopi and are reading this and would prefer I remove any part of it, please let me know and I'll be happy to do so.

My goal in these posts is to update friends and family about my life as well as to share some of the experience of working here with others who might consider coming to work at Hopi or a similar IHS site. This first one is a general overview and as such may be a little on the long and dry side but there is so much to say to give you a picture of my life.
A double rainbow behind first mesa, taken from my backyard
I continue to truly love both work and life, more than I could have possibly imagined when I made the decision to come. On my interview, I fell in love with the mesas, the desert, the sky, and the people. And while I knew that I was signing up to work at one of the more remote sites, with a much smaller medical staff than any of the others and therefore potentially much less support and mentorship, I followed my heart to come here because I felt the experience at Hopi would be most in line with what I was looking for with IHS -- cross-cultural medicine and meaningful connection with a compelling and underserved community.

My work at the Hopi Health Care Center feels similar in a lot of ways to global health experiences I have had (ie Santa Clotilde, Peru for those who have been there). It is a critical access rural hospital with a 24-7 emergency department which receives patients from the tribal EMS system as well as walk-ins, a small 4-bed inpatient unit, a 2-bed labor & delivery unit, an outpatient clinic, behavioral health, physical therapy, lab, pharmacy, radiology with x-ray, CT, and ultrasound (and a mobile MRI van 2x per month), and a private dialysis clinic all housed in the same beautiful one-story building with doors coming off a large common lobby / waiting area filled with natural light and Hopi-inspired architecture.
That same rainbow continued its arc through the sky to end at the Hopi Health Care Center

When I'm on I work in every aspect of the hospital -- covering hospitalized patients and obstetrical patients then seeing patients in clinic and helping out in the emergency department on weekends. Its really beautiful to work in such a small, tight-knit hospital, because it never feels bureaucratic or impersonal -- I almost always know and have a personal relationship with the staff in other departments that I work with regularly, and everyone is willing to pitch in to make things happen for patients. Sometimes that means going out to the parking lot with a social worker and public health nurse to have a family meeting in a patient's car. Sometimes that means a pharmacist getting to do the med rec and suggesting which medications to continue on a hospitalized patient because I got pulled elsewhere before I had time to do it. While there is always more to be done, Hopi is in the process of developing a really wonderful medical home model in clinic. I work closely with a nurse "care coordinator" who makes phone calls and follows up with patients when i'm gone, and I work with the same medical assistant every single day I'm in clinic(!!) which makes everything so much smoother for me and for patients. When I'm not in clinic she is preparing charts, calling patients, ordering labs, processing medication refills, and getting ready for the next day in clinic.

Some days at work can get a bit hectic when i'm pulled in multiple directions at once (which isn't so uncommon in the medical world) and other days are much more smooth. I am grateful every day for the strong training I got in residency at Contra Costa -- we do have very friendly specialists in Tuba City and Flagstaff to help us out and who will take our patients as transfers when they require a service we do not offer at Hopi, but sometimes there is a snowstorm and there is no safe way to transport a patient and we have to turn the Hopi ED into a mini-intensive care unit for 18 hours with patients on breathing machines until the storm clears.

My first backpacking adventure out here in Dark Canyon, Utah

After the intense schedule of residency, I am luxuriating in my schedule here. We work ten hour days for eight days out of every two week pay period. This means sometimes I work four days and have a three-day weekend, and sometimes I work longer stretches (up to 8 days straight) and then have a four, five, or six-day weekend. The result is that I don't need to use vacation days to take frequent five and six day trips, including a roadtrip to california for a friend's wedding in yosemite, multiple trips to see family, and a few backpacking trips. I also really enjoy having time off at home here at Hopi when I go for runs on the trails behind the housing complex, go hiking at some of the nearby canyons and mesas, and participate in some of the community events here at Hopi including lots of organized 5K/10K/half marathon runs when the weather is warm, and when I'm invited, observe some very special dances  or a baby naming ceremony.

This trail run was amazing -- so many people of all ages running together to celebrate the Hopi running tradition

Within the tribal housing complex where I live, there is a great community of hospital staff and other tribal employees. We get together frequently for potlucks, movie nights, or book group, loan eachother tools and supplies, and bring each other groceries from town. I love that I have close friends of all ages who do all kinds of different work.  I've also adopted a grey cat named Blue who previously wandered from house to house through any open door. I shut the door on him a few times at first, but he was persistent and has won me over. He is very playful, a bit rambunctious at times, but very loving and is sleeping on my chest right now as I type this. In addition to keeping me company, he's also been a great way to meet many of my neighbors as he wanders into their homes and most take him in and play with him until I get off work to pick him up!

Blue and I watching the sunrise through my window and enjoying breakfast before work
Where do I buy groceries? many people ask. There are a few general stores on the Hopi Reservation with basics to get me through, but then every 1-2 weeks I make the 2-hour drive to Flagstaff, a small but beautiful mountain and university town. "Flag" as it is known in the area has everything I need in a city -- multiple natural food stores, a farmers market in the summer, an amazing public library, numerous outdoor gear stores, several thrift stores, a craft store, a used book store, and a pretty good selection of ethnic restaurants. And the San Francisco Peaks lay just to the north of Flag, giving beautiful mountain views, great places to hike, and attracting a lot of down-to-earth outdoorsy sorts of people. And then the Grand Canyon is just an hour an half north of Flag. I'll close with some pictures from hikes I've taken there. I had previously visited the canyon as most tourists do -- driving along the rim and looking down into a giant hole -- and just felt overwhelmed by it.  But since moving here, I've gotten to hike down and around and through the canyon and realized what an incredibly complex, intricate, and truly gorgeous maze of a canyon network is here as a regional park for me to explore.

At the top Battleship, a peak within the Grand Canyon

A cottonwood grove seen while winter backpacking in the Grand Canyon
Sorry once again for the length of this post -- I've never been very good at brevity and even less when attempting an overall portrait of my life out here, so different from my former life in the SF Bay Area. Hopefully I'll get some shorter, snazzier posts up sometime soon.

Thursday, September 22, 2016

second mesa sky

It hasn’t been so long since my last update, but I wanted to share a few things:

After six months of house-hopping in California and three months of travelling, I am a migrant no longer. I just moved into my first ever home of my own, a two-bedroom duplex just behind the Health Center where I will be working on the Hopi Reservation in Northern Arizona. The home is truly beautiful, and the housing complex, like the Health Center and everything else around here, is surrounded by a breathtaking expanse of desert, mesas, and sky that extend in every direction as far as the eye can see. Every time I step outside my door or look out my window, I feel so grateful to be alive and present in this extraordinary place. I don’t start work until October 3rd, and I have enjoyed being able to take my time driving around trying to find all the utilities and offices and stores that I will need for life around here in a place where there are no addresses, few street signs, and everything is in a trailer that often has no sign in front of it to identify it as the Water Office, for example. 
My home with a beautiful tree giving great shade

The dirt road behind the complex where I went running this morning

The other thing to share is that I was finally able to go back and visit Santa Ana, Ecuador, the community where I have been doing water work for the last 10 years although had not visited since 2012. There is now a paved road, a health center, and an “infocenter” which is like a public internet cafe with incredibly slow internet. The community water system still isn’t working, but most families still have the rainwater systems eight or nine or ten years later, which is remarkable. And many families actually asked me for chlorine dropper bottles for water treatment, in contrast to the summer I first went when no one wanted any kind of “chemical” in their water. 
Rainwater tanks on the large covered community area in Santa Ana

With all this ‘development’, the people are still very passionate about preserving their natural environment, maintaining their language and culture, and working to provide an education and opportunities for their children. It has been fascinating to witness the progression of one community’s effort through all the challenges, contradictions, and complexity, to enact that mythological entity of ‘sustainable development’. In Santa Clotilde, Peru, I was told that many patients had come to the hospital since I left asking for tests for parasites because they heard the water was contaminated, and I helped the environmental health office prepare a grant proposal to install a treatment system at the hospital.

It was gratifying to feel that even after prioritizing medical education over these water projects for so long, that my work over the years has had some positive impacts and that I continue to have a very close connection to these places and the people that mean so much to me as they grow and change. And man do they change. For example, I met Sacha as a 7-year old in the family I lived in the first summer in Santa Ana, at which time she was frequently helping to look after her younger 2 year old twin sisters as well as guide me around the community. Now Sacha is 17 and was elected the “Nusta Warmi” or “Princess” of her community, which means that she is supposed to work with her community’s local government to raise money and provide support for children in Santa Ana. I’ve made a gofundme page to try to help her raise money for school supplies for the primary school children. If you would like to make a donation, she and I would be very grateful: www.gofundme.com/santaana


Sacha with her "Nusta Warmi" sash

Saturday, September 17, 2016

phases of change

See the following blog post: Phases of Change: a D-lab Incubator and Community Health, which I wrote as a reflection of water and health work in Latin America over the last 10 years.

Saturday, July 2, 2016

From the Rainforest of Peru to the Mesas of Arizona

 Late entry. Originally written June 12, 2016:

It has been almost 3 years since my last blog post -- one of many things in my life that went on hold during Family Medicine Residency. On reflection, residency does seem like a bit of a black hole that has consumed more time and energy than I ever could imagine I had to give, week after week, year after year. On the other hand, it has also given me so much: knowledge and skills, incredible friends and colleagues, and the opportunity to bear witness to so much joy and sorrow in the range of the human experience.

Now those three years are coming to a close and I’m fortunate enough to be spending my last month of residency on an away elective at a hospital in the Amazon Rainforest of Peru. It is absolutely incredible here; it feels like a combination of medical school in Cuba and working in Santa Ana, Ecuador, which have been two of the most incredibly rewarding and life-changing experiences of my life. I am working in a small town called Santa Clotilde on the Napo River in the Amazon Rainforest of Peru. Santa Clotilde is only accessible by boat, by an approximately 7-hour journey by motorboat from Iquitos, the capital of the region which is in turn only accessible by boat or plane. Remote as Santa Clotilde is, it is home to several thousand people and is the district capital and houses the government and the hospital for a vast region of rainforest. I am working as one of five doctors at the local hospital, which has a 20-bed unit for hospitalized patients, one delivery room for vaginal births, one operating room for cesarean sections and other basic surgeries, and an outpatient clinic area with four exam rooms. There is a lab which can run some basic tests (blood counts, some kidney and liver function tests, as well as checking for malaria and intestinal parasites) and an ultrasound machine, but no x-ray. Many of the staff at the hospital are recent graduates from their areas doing their year of “social service” which is required before being able to move on to further study such as residency for physicians. I am living in the same large house they all stay in, which is part of what reminds me of my time at ELAM (medical school in Cuba) – cooking, washing clothes, eating communally with young medical professionals from all different parts of Peru. The ingredients available to buy are rather limited, but we are always discovering new ways to prepare the basic stables (flour, oil, rice, beans, lentils, yucca, platano) and a few fruits and vegetables (tomatoes, onions, carrots, cabbage, beats, peppers) in new and different ways. Today I taught them how to make flour tortillas from scratch and we made tacos which turned out delicious.

The rainforest here is amazing. Yesterday afternoon after we finished seeing patients, one of the local staff members took us on in a ‘peke-peke’ (homemade boat with a small motor for going short distances in the river) up the Napo River to a neighboring community named Wiririma. We swam in a tributary of the Napo River that has an intense black hue to the water due to some kind of mineral. The river was high due to the recent rains, with the bases of many trees swallowed by the black waters. It happened to be Wririma’s anniversary celebration, so after we swam, we went up into the community center to watch the soccer tournament and taste the local homebrewed fermented yucca alcohol Masato. It is an opaque white liquid that tastes a bit like yogurt or kambucha mixed with some fibrous remnants of yucca. Traditionally women would chew the boiled yucca and the saliva would provide the enzymes necessary to produce the sugars for fermentation to produce alcohol. In this region, people have generally switched over to alternative methods such as adding sugar cane juice to facilitate fermentation. It is fascinating to see the blending of tradition and modernity in Santa Clotilde and the surrounding communities. In general, the influence of modernity seems to predominate more in this area than in Santa Ana, Ecuador, the community in which I previously had worked for years on water treatment. Even though all of these communities here in Peru are accessible only by river and Santa Ana has road access, fewer people speak their native languages here (although some do speak kichwa and I’ve gotten to use a bit of what I remember from Santa Ana), there is less traditional music and dance, and more integration of modern expectations of hygiene and lifestyle. But people still maintain an incredible knowledge and intimacy with the natural environment, from the chakras where they still grow a lot of their own food, to the rivers that provide fish and transportation, and the tributaries where people wash clothes and swim. Although some seem to live more of a "city" lifestyle, there are limits in that there is only electricity here from 6pm-11pm because it is generated here, the paved roads only go so far within the city, and it is impossible to escape the mosquitos and the diseases they carry, especially malaria. Most people around here have had malaria at least one, if not many times in their lives, and we see and treat it every day in the hospital and clinic.

I have been very impressed by the Centro de Salud Santa Clotilde where I work both in the care it provides and the integration in the community. The inpatient area is an open ward meaning all the beds are in the same two rooms except for an isolation room and two rooms for moms and babies. I often seen the patients hanging out with each other within the ward or in the courtyard. Although there are only 5 doctors, there are so many other staff members here: laboratory staff, maintenance staff, nurses, nursing techs, pharmacists, midwives, administrative staff, public health staff, and they do an incredible job with very little resources to care for a large number of patients each day (approximately 30-50 outpatients and 10-20 inpatients). In addition to seeing patients in clinic and taking call every fifth day, I have also brought water testing equipment and am teaching the public health team how to use it to assess water safety and encourage treatment (generally boiling or chlorination) as I have done previously in Ecuador and Uganda.

Working here feels like a merging of many threads in my life – public health and medicine, water and health, living and learning in another language and culture. It has been 10 years now since I first traveled to Santa Ana. I am not sure what it says about me that I still love this work just as much and have the same goals and dreams as I did 10 years ago. Maybe I was a precocious 19 year-old. Or maybe I am stunted in my ability to grow and evolve. Or maybe it is simply that I have come to the end of an 11-year educational process of university, medical school, and residency, and am just now finally be able to start to do the work that I have always intended to do from the beginning.

Sometimes I really do wish I could just move here to Santa Clotilde and work full time after I graduate in a few weeks, but I still have too much debt from medical school to make that a reasonable option. Instead, I have chosen a rather parallel job within the United States for after I graduate: working for the Indian Health Service at the Hopi Health Care Center on the Hopi reservation in Northern Arizona. I start in October and will be working in the outpatient clinic, as well as in the emergency room, on the 4-bed inpatient ward, and the tiny labor and delivery ward for low risk vaginal deliveries (women who are high risk or might need a cesarean section for any reason deliver at Tuba City instead which is 45 minutes away), along with three other physicians and a handful of nurse practitioners and physician's assistants that run the small critical access rural hospital. There is a laboratory and radiology department on site with x-ray, CT scanner, and ultrasound capabilities and an MRI that comes in a trailer twice a month. The Hopi reservation is both incredibly remote and stunningly beautiful albeit in a slightly austere way. It is in the high desert of Northern Arizona with few trees and little water, but incredible mesas with endless trails for hiking and running. The Hopi are a pueblo people and have lived continuously in some of their communities at the top of their mesas for almost 1,000 years. Their traditional culture, including language, religion and farming practices are still very much alive and the Hopi have a reputation for being very open and welcoming to medical staff, often extending invitations to ceremonies and dinners. I am very much looking forward to this opportunity for a cross-cultural experience as well as the opportunity to apply the skills and knowledge I have gained over these last 7 years in a place where they are very much needed.

Sunday, June 30, 2013

container garden!

Just wanted to share some pictures of my awesome container garden that I planted just over 2 weeks ago. It is doing really well despite the fact that it is in a narrow alley and doesn't get very many hours of sun. I guess the fact that it is direct midday sun and that it is so nice and hot here in oakland in the summer is making up for it somehow.

Here I am standing  with my newly planted herb garden


My little carrots that sprouted a few days after planting them

Zucchini, morning glories, tomatoes, and herbs

Beans on top and argula/spinach on the sides

The avacado plant I sprouted in the last weeks with a baby spider plant
Baby arugula coming up!

In the middle - the big brother avacado tree I sprouted many months ago

It is so much fun to come home every day and water my plants and see what is new -- it really does change every day!

Also, I wanted to share that I hired a really awesome woman to help me get the right supplies and plant things the right way. Her name is Asha and she works with another really awesome guy named Spira to run a business called Rhizome Urban Gardens. If you are in the bay area and want some help starting a garden or want to hire gardeners to plant and maintain it for you, I highly recommend them.