Sayidat

Sayidat and I in Uganda in 2010 when I met her

Sayidat is heading into her final semester of nursing school. She is studying hard and doing very well, I am so proud of her! I need to send her $600 for tuition and room/board sometime this month, if anyone wants to contribute, it would be very much appreciated. I am so grateful to all of you who have contributed over the last few years -- what an amazing thing to have enabled her to finish nursing school together!

If you feel like contributing, you can send me money by paypal to kendradey@gmail.com or by check to my address (which is in the email version if you are on the update list, if not, write to me by email and I'll give it to you).

New Beginnings

March 15th was match day and across the country medical students opened envelopes at exactly the same time saying where we have been sent for residency. Its an intense process, as all of the other scenarios, possibilities, and opportunities vanish out of the realm of possibility in one instant. Couples and families suddenly contemplate separations or cross-country moves, or experience the relief that all those worst case scenarios that a moment ago were possible, now will not come to pass.

 

my match letter

I matched at Contra Costa Family Medicine Residency, an amazing program based in a county hospital about an hour outside of San Francisco. I'll be working hard, probably harder than I would have at most family medicine programs, but I'll be training in an environment where family doctors literally run the hospital, and I will learn to work in the Emergency Room, deliver babies, do cesarean sections, and take care of hospitalized patients and patients in the intensive care unit. And it is an amazing group of really caring, inspiring people that I will be working with. I couldn't be happier.
 

To add to the good news, Mozzi and I have decided to take advantage of this close proximity and live together in Oakland.


Mozzi and I on the beach in San Francisco as we contemplate the move across the Bay

The keys to our new place!

We actually just signed the lease (on my birthday) for a really cozy apartment surrounded by an incredible amount of flowers in the walkway and the backyard. We are both incredibly excited about our new place and this next step in our lives. Less exciting is the reality that I will, for the first time in my life, have to commute to work. Those of you who have known me since high school know that I've always vowed I'd never own a car, preferring to navigate Madison snow and San Francisco traffic on my bike. I'll be buying a car (as a small part of me dies inside) and driving about 30 minutes each way to work. I know this is actually a pretty normal or even short commute by American standards, but it is still taking a lot for me to process and come to terms with it. But I am really happy and excited about all that lies ahead. So many new beginnings!
 

Pupusas and Harry Potter in Cuba

 

 

The river valley of La Estancia

After the marathon of clinical rotations of third year and the endless lineup of tests, applications, and interviews that dominated the first half of fourth year, the freedom of these last few months has been incredible. No tests, no grades, no pressure, just time to do anything we can convince the school to give us elective credit for. For me, this was my chance to go back to Latin America and recharge the other half of my soul. I spent the month of February in El Salvador, living and working in a rural community called Estancia in Morazán province (in the Eastern half of El Salvador, near the border with Honduras). I went through an organization called Doctors for Global Health, who partners with a local community organization called Campesinos para el Desarollo Humano (Farmers for Human Development).



Dr. Juan Carlos Martinez and I

The doctor I was working with in the clinic is named Juan Carlos. He grew up in Estancia, and as he tells the story, one of his high school teachers said to him "you are smart, you should apply to this scholarship to study medicine in Cuba." He applied, got the scholarship, and went off to Cuba at 17 to the same school where I studied, the Latin American School of Medicine (ELAM). He graduated three years ago and has been working as the doctor in his community ever since. It is such an amazing, classic story of ELAM, and after spending so much time with students just like Juan Carlos from communities across Latin America, it was incredibly moving to work alongside him and imagine the future that my friends will have and what amazing work they will be doing for their home countries and communities.




Meggie with our drawings of vaginal infections

During my month in Estancia, I worked in the clinic with Juan Carlos and a couple other medical students, taking care of anyone who came in the door for any reason - parents worried about a one month old baby with diarrhea, children with cuts and scrapes and rashes, adults with joint pains, asthma, or high blood pressure, and eighty year old great grandmas who had walked two hours in 100 degree heat to get some Tylenol for their back pain. The clinic is well stocked with the most common medications, so we could give most patients everything they needed right on the spot. If not, we wrote them prescriptions to an outside pharmacy and if needed, filled the prescription for them and had them come back to pick it up. We also did a lot of house visits, when someone had fallen or was too sick to navigate the mountainous terrain in the hot sun, we would pack a little bag and hike off to their house and do a clinic visit right there. And finally, I also did quite a bit of health promotions, working with another medical student and the local health promoters to give outreach sessions about women's health and cervical cancer. 

As you can imagine, I absolutely loved the work, and really got a sense of what it would be like to be a rural community doctor. You can bet I'll be coming back!  

Sunrise from the top of Pelon, a mountain near la Estancia

On the top of Pelon


 

After my too short month in Estancia, I bused back to San Salvador and flew to Havana. I hadn't been back to Cuba since 2nd year of med school, and now all my friends were 4th years and in their clinical years at hospitals across the country. I hung out for a week with the US folks that I started the program with four years ago, and had such an amazing time. I cannot even express how warm a welcome I receive each time I go, how we fall back into such comfortable friendships it is like I never left. We did a lot of cooking -- homemade pizzas, hummus made by smashing garbanzo beans by hand with a cup, curries and Iranian stew. Each day was a glorious combination of familiar and new experiences. Some things never change, like when I went to buy vegetables at cuatro caminos and one of the vendors, a friend from four years, recognized me and walked across the market to give me a hug and some ginger tea. Other things were new - more formal signs and official food vendors, novel fashion (the union jack is the latest fashion and is blazened across shoes, pants, t-shirts man-purses, any clothing surface you could imagine) and new musical hits.

My amazing ELAM friends!



Sunrise over Cayo Coco

I also got to travel more in Cuba than I ever had before. I took a 7 hour bus ride from Havana to Ciego de Avila, which is around the middle of the island and spent a couple of nights with my friends from Mexico who are studying there. Ciego is a great little town with very few cars, almost everyone has a bicycle and uses it as exclusive transportation, although there are some horse drawn carriages around for hire when you find yourself without a bike. Especially at night, the bicycles totally rule the road and riding and it was so idyllic to ride around the town plaza, park, and pond, right in the middle of the road with only other bicycles to avoid! The next morning after I got there, we got up at 3:30 in the morning to catch a ride out to Cayo Coco, a couple hours away, and got there just as the sun was rising over the ocean! There were some significant mosquitos so we submerged ourselves in the still-cool water, but gradual the sun came out and began to warm the fine white sand and light up the crystal clear aquamarine water. It was heavenly! These are the sorts of places that tourists come to Cuba for, although they probably don't pack spaghetti and mayonnaise for lunch like we did to avoid buying expensive food in the restaurants and hotels along the beach.

With my friends Maritza and Rocio on Cayo Coco




A pupusa topped with curtido and salsa

After Ciego, I went back to the other side of the country: Pinar del Rio, where two of my best friends from El Salvador are now in their 4th year. I had actually been able to visit each of their families for a night while I was in El Salvador, taking tons of pictures and collecting letters and gifts from their family members. It was a real treat to be able to bring these treasures to my friends, as well as spend a wonderful weekend in Pinar. The highlight was definitely making Pupusas -- a typical Salvadoran food that is essentially a stuffed corn tortilla. I brought Maseca (dried corn flour) from El Salvador, since it is impossible to find in Cuba, and we had a blast making bean and cheese pupusas along with the smooth tomato salsa, and 'curtido' (shredded cabbage and carrot with vinegar and oregano) to top them. They came out incredibly well, just like in El Salvador.

While we were cooking, in one of those moments of global interconnectedness, the Harry Potter and the Prisoner of Azkaban came on Cuban TV, shown like all the Sunday movies in Cuba straight through with no commercials. We half watched it as we cooked, everyone intrigued by the British English and whether I could actually understand it. I was left marveling at how different a place and time and moment I was in compared to the first time I saw that movie at home in Wisconsin during high school. And yet it is all part of the same world, and the worlds within it are connected in the most mundane and profound ways. 



Health Coach Training in Uganda

I have uploaded a couple of pictures here: http://picasaweb.google.com/kendradey/Uganda#

Check out this video I made about VHT Trainings in Uganda:



Since I arrived in Uganda a month ago I have been wondering how such a dry place could have such richly green vegetation. By the end of my half-hour walk into the office each morning my clothes, skin, face, and mouth would be coated with dust kicked up by the trucks. We remarked how the weather was perfect -- hot but not too hot during the day and cool but not too cool at night, and an occasional sprinkle one or twice a week at the most, not enough to even wet your clothes. I could not understand how a place that seemed so dry could sustain a sort of jungle vegetation not so different from the rain-forests of Ecuador.

The paradox was resolved three days ago when we were walking home from the office for lunch and the skies opened up in a downpour, turning the dusty dirt road to wet clay and mud. This event has repeated itself at least once a day since then, and brings the days activities to a halt each time. It is on such a rainy morning that I take advantage of some remaining battery power in my laptop to write this.

The program that I am working with here is a remarkable one -- a local NGO called Volset is partnering with a US NGO called OmniMed and the local government to train "village health teams" with one community health worker for every 20-30 families. After a week's worth of training, these "VHTs" go back to their villages and start visiting the homes of their neighbors to collect information about the health status of their communities (how many families have latrines, handwashing places, plate drying racks, how many children are immunized, how many cases of malaria there are, etc). They collect this information to give to the local health centers but also work to educate their neighbors and encourage them to fill in the gaps in order to prevent disease and promote health. It is interesting to be a part of a program in this stage of "scaling up" and interesting to see the tradeoffs of training more and more VHTs versus ensuring good support for the ones who already have been trained.

Most of our time here involves working directly with the VHTs -- training them and following-up with those who have already been trained. And these VHTs are amazing, inspiring people, who do all this work with absolutely no reward except the knowledge that they are making a difference in their communities. They are all proud to tell us about how they are seeing their neighbors boiling water, building latrines, taking children for vaccinations. But it is not easy work. How do you insist that an old woman with several young grand children to take care of dig a latrine? How do you tell your neighbors to go to a Health Center when they are sick when more times than not a person will go to a health center, wait through a long line to see a doctor, be told that they have malaria, or TB, but the health center will have run out of medications so they will have to go to a private pharmacy to buy them. The result of this, of course, is that people begin to go directly to the private pharmacy, where they buy medication based on a self-diagnosis or the diagnosis of a nurse who runs the private "clinic" and save all the time and transport cost that a visit to a health center entails.

Which brings me to the bigger picture -- how can a country like Uganda, with all of this foreign aid, a stable government with strong US support not have medicine in their government health centers? People talk about how most of the money stays in the government for internal workings / kick-backs, which I am sure is a big part of the problem, but there is also a greater context. Most obviously and importantly is the legacy of colonialism which shapes so much of the way people think and the way things work. Then there is the fact that the Ugandan government spends so much money on security (sound familiar?) -- both for defense forces within Uganda and the troops they have sent to other countries like the Congo, Rwanda, Burundi, and Somalia. I actually wound up talking about all of this late at night by candlelight with one of the VHTs in his house. Under a roof made of papyrus and sheet plastic, this man listens to the BBC on a radio powered radio and gets a Kenyan newspaper once a week to stay up on what is going on in the world. He explained that the reason that Uganda has been intervening militarily in other countries is that the United States is using Uganda.

Crazy as it seems, I actually have less than 3 weeks left in Uganda. It is always a sad moment to realize that my time is drawing to a close and that I will be leaving behind all the friends I have made here. I do want to stay in touch and involved to the extent that I can, and one thing I've decided to do is find sponsors for one of the amazing young women I have met here, an 18 year old named Saida, to go to nursing school. I'll be going to Kampala with Saida tomorrow to visit nursing schools and find out all the details, but I think it is going to come out to about $100 a month for tuition, room and board for the three years of nursing school here. A substantial amount of money, sure, but it will transform her life and give her the skills to make a real difference in her community. Let me know if you or someone you know might be interested in contributing.

Water system successes

For more information about the project, see www.sachayaku.org
For more photos from this trip, check out my picasa album

I went back to Santa Ana Ecuador for four days this December. There is something incredibly special about this community, and it was so wonderful to see everyone again. I have been involved in this place for almost four years now, and children I met as one-year olds just beginning to talk are now about to start first grade.


This girl, Shirla, is one example. The photo on the right is me with my beloved comadre Elsa.

The community water system is still working. It is not textbook perfect, but they know about the problems and how to solve them, and that means my role is to step back and let Santa Ana handle these challenges for themselves.

One of my days was spent on a follow-up to trip to La Encañada, one year after the Santa Ana water board helped them install family-level rainwater systems in each of 9 family homes.

We found all 9 tanks still working, in good condition, and getting very positive reviews from the community. We tested all of the families' water: some had extremely clean water and some quite contaminated. They all emptied and cleaned their tanks in anticipation of our arrival (little bit of mis-communication there), so we had to test water that they had stored in other containers, so it is hard to know whether the rain water tanks themselves were the source of contamination or the storage containers.


Either way, we know that it is possible to have very clean water with this system, but it likely depends on the maintenance each family provides and if and how they store it in another container.

We also repeated a house to house health survey and found that the reported number of times a child had diarrhea in a year dropped from an average of 6.9 to 1.9 times per year from before our intervention, which is quite promising.

The most exciting part of all is that the new mayor has made water her top priority for the next 5 years. Two communities have asked for Santa Ana's help to apply to her for funding for the tanks, and they have both gotten tanks and are working with Santa Ana's water technical team to do the installations. How amazing is that?

The fact that this work is starting to take a life of its own is the ultimate success. However, on this trip I was also touched by a number of anecdotal stories that help me feel in a smaller more personal way that somehow, with all of this effort, we really are making an impact.

Melida, who is one of the people most active in the Santa Ana water system and outreach to other communities told me that she first got interested her first summer when her son came home from school and told her that their water was contaminated and they needed to boil it. I think that the water quality testing kit, which I just restocked thanks to a generous donation, is one of the most important parts of the work that Santa Ana is doing, because it enables people to have these kinds of "ah-hah" moments when they see for the first time what sources are cleanest and why they need to treat their water.

Another anecdote came from the first operator we trained, Oldemar, told me that in his new job in another part of the country, there was a broken pipe and he fixed it with a patch he made by heating up each end of the PVC pipe and molding them with another pipe. The community was so thankful and called him a water engineer.

Medical School

Sooner or later I figured I should write a blog post about Medical School at UCSF. Hopefully I will put up some more thoughtful and reflective posts at some point in the future.

Last September marked the beginning of a great transition in my life – from the world of water and engineering to the world of health and medicine. It is exciting and at times overwhelming to be entering such a complex world, but I have really been enjoying med school so far. It is hard to capture in a few paragraphs what it means to be studying medicine, but I’ll try to give you at least a rough idea. UCSF is completely pass-fail for the first two years, and the curriculum is based on blocks divided by organ system or major theme. I just finished the 6-week cardiovascular system block in December, for example, and an now a week into the 3-week pulmonary (lung). We have an exam every three weeks or so. Even though the exams aren’t cumulative, it is like studying for the most intense final of undergrad every three weeks. I enjoy the rhythm, because I can focus on thing other than school for two weeks and then put it into high gear for the last week before each exam. The material is interesting and challenging, but it is not very stressful because there are no grades; we only need 70% to pass, and if we don’t pass a test we just take it again. I think it is a brilliant approach, because we can focus on learning as much as we can, and don’t have to play games of selective studying to optimize our test scores.

Since September, I have learned to take patient histories, practiced the routine physical exam, developed a basic understanding of human anatomy over many dozens of hours working with a cadaver in the anatomy lab, and begun the tremendous task of understanding the workings of the human body, how to tell what has gone wrong, and if and how we can intervene to put things right. I loved the cardiovascular block – all the talk of valves and flows and pressure gradients were comfortingly reminiscent of water system engineering.

In many ways I feel very much like I felt as a freshman at MIT – my interests piqued by so many issues and questions but with little knowledge or experience to grapple with any of them. I am thrilled that so many of my classmates are also interested in healthcare for the underserved, global health, health disparities, single payer health care, etc, and that our school not only allows but encourages us to invest our time in such issues. As I anticipated when I decided to come back to the US from Cuba for medical school, sometimes I get extraordinarily frustrated with the US health care system, or, as speakers on the topic tend to quip: the US disease treatment industry. I wish I had some sort of hope to offer in this regard, but I am only beginning to understand the depth of the issues. I believe we need some kind of single-payer solution, and am starting to work through the practicalities and subtleties. This Sunday I am going with a number of other students to a training and then Monday we will be meeting with California legislators about the state-level single payer healthcare bill. Then in the Spring, I will take a comparative policy elective which discusses the health care systems of a number of different countries, which may help me flesh out my thoughts a bit more.

I am often asked what kind of medicine I want to go into. I realize that I am only at the beginning stages of this process and my ideas will most likely change and evolve as I go, but right now I plan on doing some kind of primary care. I am interested in figuring out innovative ways to foster health and increase access to health care in marginalized communities. For a while, my debt will require me to do this kind of work in the United States, but after I have paid it off I want to move abroad, maybe to Latin America, maybe to some other part of the world. I have grand visions of being the village doctor someplace, training and supporting local health promoters, mentoring future doctors in the region, and maybe traveling occasionally to learn from others and share any insights I manage to glean. I am beginning to realize how much I love to teach and how teaching could serve to multiply my impact, whether that is by training health promoters or teaching medical students. However, I think I would rather teach in another country besides the US– solutions to global health issues must be born in the global south, in the minds and hearts of people who share a language, culture, and history with the people they want to serve.

My new home in San Francisco

I am completely in love with San Francisco. I knew it was a cool city, but I wasn't prepared for just how amazingly cool.

Check out this map of San Francisco to get you oriented. Downtown San Francisco is where are the crazy tall buildings are (the financial district, Union Square, etc). The Mission is an awesome neighborhood with a really high Latino population, lots of latinamerica feeling stores, markets, and restaurants, plus dollar stores and thrift shops. As you can see, my house is right by UCSF and Golden Gate Park is pretty much my backyard...

Photo from: http://www.bloggingsouls.com/archives/2007_03.html
This is a picture of Strawberry Island, which is in the middle of Stow Lake in Golden Gate Park. I have been running to stow lake in the mornings, across the bridge to the island, around the island and back. It is absolutely gorgeous!

This zoomed in gives you a better idea of my neighborhood. I had no idea how much I lucked out on my room -- the rent is incredibly cheap because the room is very small, but the location cannot be beat.


Plus I have everything I need in my room -- a closet that fits all my stuff, a bed on a loft, and an amazing nook under the loft with a little table and pillows to sit on. You can see more pictures of my room (including my desk, which I now have in my room, unlike my last 3 years at MIT) in my picasa album.

And now, here is a list of some of the things I love so far about living here, in no particular order.

1. Living 3 miles from the ocean -- an easy bike ride through Golden Gate Park.
2. In case I don't feel like biking, living a block away from the MUNI streetcar stop on the line that goes to the ocean and also to downtown San Francisco.
3. My 'commute' to school that consists of walking a block to Irving street, getting in an elevator and going up 8 floors (yes eight) and I am in the student union. Cross the street and I am in the academic buildings.
4. My room, how small and fun it is, and how it won't let me accumulate stuff even if I want to.
5. My house. It is really spacious and full of character, and the other women who live with me are total kindred spirits -- environmentalist, socially conscious, spanish-speaking, etc.
6. The sheer number of ethnic restaurants within walking distance.
7. The friendly people in San Francisco. Multiple complete strangers have offered me coupons in stores -- combined they saved me $25
8. The random breathtaking views of the ocean, or the bay, or just down an insanely steep street I see while walking/biking through San Francisco
9. The street names carved into the sidewalk tiles at street corners, kind of like in Cuba.
10. The quantity of thrift stores and dollar stores within a few blocks of each other in the mission
11. No winter
12. The fact that San Francisco is, if anything, even more hippie and progressive than Boston. wow
13. Fresh produce from farmers markets YEAR ROUND : )