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.

Sunday, June 16, 2013

And the run is over!

Photo of today's race on Golden Gate bridge from SF Gate

Well I did my half marathon today, and I have to say it is amazing what training can do. Two years ago I messed up my knees (my IT bands to be precise) while training and could only swim to train. Race day was the first time I had run in months, and while I finished, I couldn't walk for a few days afterwards.

This time, I managed to keep my IT bands happy and trained pretty well, so I was hopeful this would be a much smoother day, and indeed it was. The route was beautiful, starting at the ferry building, running along the Embarcadero, through the (hilly) Presidio, across the Golden Gate bridge and back, and then through (hilly) neighboorhoods down to Golden Gate Park for the finish. And even though today's race was waaaay hillier than the one I ran 2 years ago, I felt much better the whole time and though I'm sore for sure, I'm walking without a limp already!

Wave 7 with the Bay Bridge in the background
I always thought I ran at a 12-minute mile pace, so I signed up for that wave, but somehow I ended up running at a 10-minute mile pace today, so I spent most of the time weaving in and around people to pass them. And there were a LOT of people running, so it was actually kind of a challenge, but kept things interesting I suppose. It is always fun to run with so many people at once, and see people of all different ages and paces and running styles. Quite a few people struck up conversations with me about my crazy 'toe shoes' that I run in, which is always fun.

At the finish line!

I ended up finishing in 2 hours 12 minutes, which is a 10:07 minute mile pace. I feel pretty proud, although I was barely in the top half of runners, haha, and I didn't do a whole marathon. Maybe someday!

And the real success is the over $3,400 we raised for Clinica Martin Baro!!! Thank you so much to everyone who contributed, I really appreciate it. If anyone still wants to donate, its not too late, you can use this webform.

Thursday, June 6, 2013

Half marathon training, or how I ended up running 7 miles in a mini-skirt

Ten days from now I'm doing my half marathon for Clinica. My start time is 5:30 in the morning so if all goes well I'll be done around 8am and I'll have the whole rest of the day ahead of me. Crazy way to start a day! There are four of us doing the half, and a couple others doing the 5K, and between all of us we're hoping to cover Clinica's rent for the year. We're doing pretty well, having raised $2275 between all of us -- we need another $2000 to meet our goal.

If anyone has been meaning to make a donation, there is still time to do so using this webform.

I wanted to write a post about all the fun, exciting, crazy, and sometimes painful adventures this training process has brought. So here they go:

Brady passed out on the floor after one of our runs
#1: Scrubbing my dog Brady down with dishsoap. While home in Stoughton, WI, I went on a few training runs with my mom's dog Brady, who is a great companion but loves swimming too much for his own good. We can never take him off the lease because everytime we have, he chases rabbits, ducks, and geese for miles before we can track him down again. We were running on a floating pedestrian bridge over a little river when Brady up and jumped over the side, happily swimming alongside the bridge on his lease all the way to the other side. "River" might have been a generous term for the swampy water we were crossing, so when we got home I knew Brady needed a serious scrub down before coming in the house. After a bunch of hose water and some dishsoap, he was good to go.

A Google Streetview shot of Broadway Terrace
#2: Leaping off the road into landscape shrubs. Today I thought it would be fun to investigate Robert Sibley Volcanic Regional Park, only 3 miles away from my house as the crow flies, and the nearest point to me of the epic Bay Area Ridge Trail. Unfortunately, as the roads go, the way from my house to Sibley Park involves going through crazy switchbacks up on a road called Broadway Terrace through a very affluent neighborhood. I did my best to always run on the side with the best visibility and move off to the side anytime I heard a car coming, but a couple of times I ended up flinging myself into the landscape shrubbery in front of a house as a car came around a blind corner. I'm never running on that road again.

Grizzly Peak Boulevard (from Google Street View)
#3: Going over instead of under the Berkeley Hills. To avoid running back on Broadway Terrace today, I took Grizzly Peak Boulevard, which is a well-established bike route and much more pleasant to run on. It also took me directly over Hwy 24 as it enters the Caldecott Tunnel, which I will be traveling through twice a day every day to get to work (and not so infrequently waiting in a long line of cars to enter). Only we were so high above it and the day was so foggy, I didn't even realize we had already passed the tunnels until way too late. I'll have to come back another day to get a bird's eye view of these Tunnels that will be such a part of my life for the next 3 years.

My running route from today
#4: Surprise, going 11 miles! As a result of #2 and #3, my little jaunt to check out the park that is 3 miles away form my house turned into an eleven mile run. I walked bits of it due to steep hills, scary blind corners, and a few side stitches, but I ran the vast majority of it and it makes me much more confident that I will indeed be able to do these 13 miles ten days from now.

#5: Running 7 miles in a mini-skirt. On my last day in Madison, I knew I'd have a few hours downtime in the city so I packed my running stuff -- my "toe shoes" that I run in, sports bra, shirt, waterbottle, even a backpack to put all my other stuff in and have my brother watch it for me. I was all prepared -- except I forgot to take my shorts out of the drier. I wasn't about to let those hours go to waste, so I thought desparately about creative solutions - running in my underwear (its just like a swimsuit bottom, right? no one would care in madison), or in my jeans (not the most comfortable and they'd be super sweaty afterwards, but better than not running). In the end I realized I had a second shirt with me, a plain black tank top, so I put it on like a skirt and went on my run. I'm sure I was getting funny looks, but I got my run in!

#6 Running in Zion National Park at Altitude. I only got to do one run while hanging out with my family in Utah (after the first one I came down with cold) but it was pretty spectacular -- running on a dirt trail along the Virgin River through Zion National Park. Here is a picture of the river and trail from someone else's trip there. So beautiful and solitary, mostly I just startled mule deer out of their slumbers.

And a couple last photos to share, that have nothing to do with running, except that doing this painting has made me see the trees and their trunks, branches, leaves, and how the light hits them so much more intensively when I am out running. They are of the mural of a birch grove my mom and I painted during the six days I was home with her in Stoughton.