Step out of your comfort zone, and into the experience of a lifetime... by Joshua Monk

Catching The Dead Eye - March 10th, 2017

We flew out of Philadelphia International at 0500 this morning so naturally I waited until I arrived home from a late dinner the night before to begin packing. With a 0200 arrival to the airport, and pending drive across the state, I decided to forgo any sleep the night before our travel. Most of our travel day I was dead tired, sleeping for almost the entirety of both flights. However upon arriving to Guatemala city, all of the new excitement and wonder that accompanies the arrival to a new exotic locale quickly pushed my lethargy aside. Upon exiting the airport, we met Guadalupe or just "Lupe" who would be our guide for the next nine days. Lupe is a kind and knowledgeable woman who quickly dispelled the myth that Guatemala is a poor country. She informed us that some parts of the country such as the capitol are actually quite well-off, and that there is mainly an unequal distribution, with a majority of the wealth being concentrated in these areas. She also went on to discuss the rampant lack of funds for medical care pertaining not only to patients but also providers and hospitals. We learned that medical equipment required by patients needed to be purchased by patients and their families for the hospital to use. It was made clear that you do not want to get sick or injured in Guatemala. We slowly moved out of the city in a kaleidoscope of brightly colored buildings and cars. After a much longer bus ride than I bargained for, we arrived in Panajachel at dying light. We walked the town and ate a beautiful and delicious meal. After returning to the room where myself, Rich, and Parth were staying, Rich and I grabbed a couple of brews and enjoyed them on the front porch of our accommodation before retiring for the night. How will we be received by the indigenous people that we are here to help? Will they be welcoming? Will they be wary?

Top Left: Our accommodations while in Panajachel; Top Middle: Outside seating at our restaurant; Top Right: Our delicious (and spicy) meal; Bottom: Welcome to Hotel Rancho Grande
The Day Of Café - March 11th, 2017

We started the day with a delicious breakfast. We were served panqueques that were much more like large biscuits that we have in America. It was at this moment that I decided to call Biscuits, the cat that hung out at the hotel by the name of Panqueque from then on. The weather was beautiful and made our walk through town down to the docks and subsequent boat ride across Lake Atitlán all the more enjoyable. Before we crossed the lake, I purchased a pair of the finest fake Ray Bans from a local vendor which broke as soon as I tried to put them on. I was so excited by the fact that the named price was so cheap, I completely forgot to bargain. I feel like this may be the beginning of a trend. The passage across the lake was really pleasant and allowed me much time to talk to my new friend JT. Upon crossing the lake, we arrived in the colorful and steep town of San Juan La Laguna and were shepherded through the tight streets to Cooperative la Voz a coffee production. We learned about the history of the cooperative and the good that came about for the community with its inception. Benjamin was our guide and showed us the entire process of production from the plant to the warm delicious cup of coffee. One of the things that I found interesting was the fact that they not only allowed, but utilized other flora and fauna in an attempt to retain some of the biodiversity in the area which Benjamin said ultimately improved the quality of the beans. After our tour, we were able to taste some of the coffee which had been freshly roasted and ground. I'm not sure, but I would like to think that it was the best coffee I had ever drank. It was certainly the freshest. We left la Voz, bags heavy with coffee destined for home, and meandered back to the docks from where we would return to Panajachel and eventually our hotel. We returned to the same restaurant from last night and I was introduced to Quezalteca the Guatemalan Liquor. After enjoying a few libations, we returned to the hotel for a short brief. A couple of us went out exploring after and found a cool bar with a loft that we could all fit in. After a couple of beers and many laughs, we returned to the hotel for a good night's sleep. The people at La Voz seem to have a great sense of community. Why have we lost ours here in the U.S.?

Left: One of the many colorful storefronts lining the streets of Panajachel; Right: The Panajachelean docks on Lake Atitlán
Drying coffee beans in the sun at just one of the many stages of production at La Voz
Zipidy-Do-Da - March 12th, 2017

Another start to another day. After eating some panqueques and saying goodbye to our friend Panqueque the cat, we loaded up into the bus and headed to the Atitlán nature preserve to go zip lining at Cables X-tremos. We had to hike up to the zip lines, but it was worth it as we were rewarded with beautiful vistas of the lake. Along the way, JT and I became friendly with our guides Baldo and Ceasar and before long, the four of us were passing jokes around in our non-native languages. After zip lining, we loaded back onto the bus (which was being driven by Walter the Magnificent) and headed for Chichicastenango. When we arrived, we ate lunch as a group and of course sampled some Guatemalan moonshine distilled from corn. Lupe insisted that Michael and I "sample" it several more times, and by the time we set out to the market streets, I was feeling adequately warm and fuzzy. I eventually broke off from the rest of the group and found myself in a photo shop run by a man named Victor. I remarked at the many pictures that he had around his shop and we began to discuss some of the history of the town. He then showed me some old pictures from the 70's. One that really stood out was of a group of men recycling old tires to make sandals from them. I thought that this showed the great resourcefulness that can be exhibited by people when they are faced with challenges, a trait which I'm sure the Guatemalan people are very familiar with. After talking with Victor, I roamed around and found a few trinkets to buy (I forgot haggle here too) and then we hopped onto the bus bound for Quetzaltenango. We arrived in the city well after dark and went to AMA house for dinner and introductions. AMA and its headquarters are great. I found that once we were inside of the gate, we were safe and part of the family. Afterwards, we arrived to our hotel where I was to room with Rich and we quickly passed out after a long day of travel. There was a central building in the market where all of the produce was being sold. How often do the vendors bring in new produce? How do they deliver it as the streets are so tight?

Top Left: The view from zip lining; Right: The colorful and crowded market at Chichicastenango; Bottom Left: Men making shoes from tires circa 1974
Building Stoves And A Future - March 13th, 2017

Today started with a trip to AMA for breakfast. After a quick and delicious meal, we hopped on the bus, being piloted by our hero Walter and began our trip to Los Maroquines. After only a few minutes into the trip I realized that I had made a fatal error by not using the restroom before leaving AMA. My bladder moved past the stage of discomfort into feeling like it was going to explode as we bounced along the progressively worse roads that we encountered along the way into the countryside. My first experience when arriving to the village that we were going to work with was desperately searching for a place to relieve myself. I was lead down a hill and told to use what looked like a small child's fort. This "restroom" was made out of sticks and tired looking tarps that were riddled with holes. It was absolutely filthy and honestly mortifying. After some clever maneuvering, I was finally able to take care of business and emerged from the tiny lavatory feeling relieved, accomplished, and just a little bit violated. I rejoined the group and enjoyed our welcoming ceremony which was graciously performed by the women of the village. After introducing ourselves, we watched as the Dons or the AMA masons instructed us how to construct a cinderblock stove. Next we met our families to which our stove-building groups would be assigned. Alessia, Lauren, and myself were assigned to Christia-Maria's house. After meeting her and seeing where we would be woking for the next two days, we grabbed a quick lunch (provided by AMA) and got to work. We had a rough start as the ground was not level, but eventually were able to lay the foundation but the day ended much to early. We traveled back to the hotel and from there to AMA for another great meal. Then back to the hotel to call it a night. I noticed that some of the villagers had smart phones. Where do they charge them as there doesn't appear to be any electricity in the village?

Left: The Dons show us how its done with a mock stove build in the village center; Right: The rolling, rural landscape of Los Maroquines
Burn Baby Burn - March 14th, 2017

After Breakfast at AMA, we bounced our way back to Los Maroquines with our mission for the day being to complete the construction of our stoves. We arrived and quickly set to work while a spirit of competition began to settle in between the different groups. The family living at our house was very eager to offer up any help. We set them busy soaking the bricks and blocks in water while the rest were tasked with the creation of the cement. In the end, even with Don Jose's help, we didn't complete our stove before our rival group. After a long, hard day of stove building, we still were not even close to a complete stove, but the rest required the skill of the masons which we simply did not have. We packed up and left for Hotel Loma Real, where we washed up and headed to AMA for another fantastic dinner. Tonight we had a guest come speak with us. Daniel Mathul is a professor at one of the local colleges in Quetzaltenango. He teaches all about the Mayan civilization and the Mayan cosmovision. This refers to the way that the Mayan see the world and space and all living things. He explained all of the different positions in the Mayan priesthood and their different specialties pertaining to health, the spirit, and the calendar. He then proceeded to challenge not only our western, modern education, but also modern medicine. It was at this point that I began really losing interest. He went on to discuss a ceremony in which he took part of where there is a tourniquet placed on your arm and your vein is pierced with sharpened obsidian. He was then bled for several minutes while a prayer took place to the gods. It was only after he explained the ritual that he explained that its purpose was to ward of hypertension and prevent strokes. "Of course its going to ward off high blood pressure!" I thought to myself, "If you bleed someone out for 8 to 10 minutes, I doubt that there would be enough blood left in their body to maintain a hypertensive state! And low blood pressure reduces the chance of stroke." I was pretty perturbed by the end of the lecture as in my mind, there was a perfectly logical explanation for this "sorcery". Next Daniel brought us to the courtyard at AMA where he explained and began a traditional Mayan fire ceremony. Now I am not religious person but I do believe in a spirit or a soul or something beyond our blood and guts. This being said, and with the bothersome lecture fresh on my mind, I was prepared to tolerate the fire ceremony and perhaps find it entertaining. I cannot put the experience that followed into words, but mid way through the ceremony something happened, and by the conclusion, I felt changed. There was an earnest, purposeful tone to Daniel's voice that I found very endearing. The deliberate, all encompassing symbolism felt natural and complete. And the openness and personal freedom encouraged from the ceremony and Daniel neither felt compulsory nor rigid. After the ceremony I felt a strong connection to myself, my fellow classmates, everyone there, and all of the people of Los Maroquines. I even felt a connection with the land. Again its hard to explain, but this was one of the most spiritually enlightening moments of my life which I still feel to this day. How did the ancient Maya know that bleeding someone would lower their chance of stroke and other medical ailments?

A typical property in Los Maroquines: a house, covered stalls to store produce, basic pens for livestock, and fields of mostly corn. This family is fortunate enough to have a vehicle, most families are not.
My Fair Ladies - March 15th, 2017

After a quick and delicious breakfast at AMA, we headed to Los Maroquines for what was my most anticipated part of the trip, the health assessment and promotion/education fair. My father was a trauma surgeon. He was always very busy, but devoted any free time that he had to his family. He was my hero. He had always wanted to join Doctor's without borders and travel to most remote parts of our country and world in order to be able to offer help to those who needed it most. As I grew up, he imbued this sense of service to others and I eventually wanted to go into medicine and do eventually do Doctor's without borders with him. Unfortunately, when I was 15 he suddenly passed away, making my dream to work along side him impossible. As my life unfolded I never lost my desire to help those less fortunate than I. I ended up on the nursing path instead of medicine and still want to travel abroad to places where people have nothing. At least I always thought that I did. This trip was my chance to confirm my convictions. We arrived to the village and quickly set to work setting up our respective screening stations. Some of us gathered information and past medical histories, then there was height and weight for BMIs, blood pressures, blood glucoses, and vision screening. I was at the blood pressure station. I was kind of nervous, not knowing what to expect and not having taken a manual pressure in a while. My apprehension was quickly extinguished though when villager after grateful villager came through my station. The indigenous midwives were present too so I got to have the pleasure of teaching them how to take blood pressures. I was able to use a teaching stethoscope so that we could both listen. It was a very rewarding experience. After we had gathered all of the health information that we could and compiled health profiles, we took individuals who had elevated and borderline values and engaged them in our teaching program. This was very challenging as the villagers mostly speak Mam, their Mayan language and required English to Spanish and then Spanish to Mam translation. In the end, we felt good about how much information that we could impart but wished that we could do more. In the afternoon a traditional bone setter came to the village and lectured us on traditional healing methods using local plants and medicinal massages. Later they offered traditional healing to the class. It seemed dirty and pretty bizarre, so I declined. My other classmates who did partake said it was "interesting". As soon as we left for the day, I was filled with regret for not having taken part. I decided that I would be more adventurous in the future and say yes more. How effective is this traditional medicine when compared to modern medicine?

While most of the men are at work, everyone that's left lines up for the health fair
Practicing taking blood pressures with Irma, one of the indigenous midwives associated with AMA. Here we are using a split stethoscope which allows both of us to listen to the same thing at the same time.
Don't Cry Because It's Over, Smile Because It Happened - March 16th, 2017

We started today with (you guessed it) another quick breakfast at AMA and headed to Los Maroquines. Today our focus was more education and saying goodbye. I was with Lauren and Alessia and our topic was to discuss contraception with the indigenous midwives. The other nursing group had to discuss sexually transmitted infections. The indigenous people have a very poor biomedical knowledge base. This makes education in subjects such as reproductive health very difficult. If you don't know how a baby is made on a cellular level, it is difficult to explain almost every type of contraception. Our lecture quickly devolved into anatomy and physiology class as opposed to our original topic. Learning still took place, so I was happy about that, and when endeavoring in this type of work, one has to be flexible. After our teaching, we all ate together in the village center with the midwives and villagers. Following lunch, the girls in our group were dorn in traditional Mayan garb and had their hair braided in the traditional way. There was a very nice thank you/ goodbye ceremony. We all received floral arrangements and handwoven napkins. It was very touching, and many of people in our group were overcome with emotion when it was time to finally say goodbye. As sad as it was, I felt good because we left this place better than we found it. After stopping by the hotel to change into swimsuits, we hit a volcanic hot spring that was very relaxing, but a little bit touristy. Afterward, we grabbed some pizza that was surprisingly really good and then went to learn how to Salsa at a local salsa school. Armed with our new moves and grooves, we set out to a salsa bar near the city center to test our moves. When observing other people who have been dancing way longer than us, we realized just how bad we were. It didn't stop us from having fun though and we ended the night on a high note, celebrating all of our hard work. Will AMA ever go back to Los Maroquines? If so how often? Is what we left behind sustainable?

Top Left: Our buddy Rudy; Top Middle: Our finished stove; Right: Some interesting architecture spotter in Quetzaltenango while we roamed the streets looking for pizza; Bottom Left: (Most of) the group stopping for a quick selfie in the volcanic hot springs
Welcome To Paradise - March 17th, 2017

For the very last time we woke up and headed to AMA for breakfast, but this time, all of our gear was packed and loaded onto the busses as we would be leaving Quetzaltenango for good after this meal. We picked up and paid for all of the gifts that we had picked out and said our goodbyes. People were sad once again, but it was once again for a good reason. We loaded onto the bus and chugged back towards the East. We stopped at some Mayan ruins which happened to be some of the youngest from about 1,000 years ago. They were peaceful. I really wanted to sit on the top of one of the temples that had a tree growing on top of it, but there were signs telling us to keep off. As we explored the ruins, we even found a fire ceremony in progress and I was reminded of the one that I had been a part of a few days prior. We then herded ourselves back onto the busses and set out on the final leg of our trip to Antigua. When we arrived, there was a lot of activity. This would be the most crowded area that we had visited. As we wound through the streets, we finally came upon our hotel. It was beautiful. It was a bitter sweet moment unloading the busses because this would be mine and JT's last time with Walter who had become a good friend over the course of the week. I had literally spent several hours with the man trying to converse in Spanish while he told me about his life and family and taught us all the bad curse words and phrases in Guatemala. We gave both Walter and Sergio some gifts to remember us by and sent them on their way. Dr. Pontes had to leave us to as she had an induction to attend the next evening in the U.S. Saying goodbye to her was sad too, but we would see her again soon. We checked into our lavish room and went to dinner as a group walking through town and enjoying the sights. After dinner we set out looking for fun ass we had a free day tomorrow and thus a free night tonight. We eventually found a packed club where Wiz Khalifa randomly showed up. Some of us got a little rowdy when it was time to leave so we decided to call it a night. How can places like Antigua and Los Maroquines exist just a few hours from each other?

Top left: A fine pairing recommended by our new friend Blanca; Top Right: Some of the youngest Mayan ruins (circa 1,000AD) in existence; Middle Right: Colonial ruins in Antigua that have stood up to earth quakes, volcanos, and floods; Bottom Right: A peaceful garden in the courtyard of one of the many hostels scattered throughout Antigua; Bottom Left: Relaxing cobbled streets of Antigua
1. Based on the readings, lectures and observations during the course, please explain your insight into the sociocultural, economic, legal and political factors influencing healthcare delivery and practice in Guatemala.

Guatemala is a nation that is sorely lacking in resources. This was made clear by lecture and the readings. The nation has been under the boot of oppressive government that hasn't done much to ensure the humane treatment of the people let alone providing health services to those who need it most for much of the last century. Economically, health care facilities just don't have the funds to effectively treat patients as we learned with patients and their families needing to provide most of the medical supplies required in their treatment. Guatemala also has a very large percent indigenous population. Health care delivery is by no means modern nor uniform due to the continuing large practice of traditional medicine.

2. Based on the readings, lectures and observations, what are some of Guatemala’s health policy implications on issues of health equity and social justice?

Guatemala, simply put, is a developing nation. Everything in the country contributes to health inequality and social injustice. There is a corrupt, self-serving government that helps the rich stay rich at the expense of the weak. There are stigmas against the indigenous population that can be traced back to the conquest of Central America by the Spaniards in the 16th century. This stigma continues to effect the indigenous and perpetuates their social isolation from the rest of modern Guatemalan society. The very land and insufficient infrastructure that accompanies it also contribute to the problem of the limited healthcare available to the people not making it far out of urban centers to rural regions and their people and vice versa.

3. What similarities and differences do you see when comparing Guatemalan culture to your country of birth?

Guatemalan culture is not so different from that of ours here in the United States. I was born here, so I don't know any different, but here are universal values that translate freely between our cultures and I would presume many other cultures from around the world. We both value family, hard work, and freedom. It's hard to know for certain, but I would say that there is a greater emphasis on family in Guatemala as family is an essential commodity that is heavily relied upon for not only social capital but economic as well. The people are poor and they must work hard. In many cases they work to provide for themselves and their families, barely scraping by. This is not a concept that is very alien to many American families. Guatemalan culture is different that of America in some ways too though. In Guatemala the culture is highly homogenous. There is not as rich of a history of immigration into Guatemala form different nations around the world. There is however a much larger indigenous population in Guatemala, but that population as it is in America is largely marginalized and subject to the whim of its' respective government.

4. What was the greatest barrier/challenge related to this experience? How did you attempt to overcome the barrier/challenge?

The greatest challenge for me personally was dealing with the considerable level of ignorance exhibited by the villagers of Los Maroquines. I don't mean it in a harsh or condescending manner, but the truth of the situation for these people are largely illiterate, have little to no formal schooling, and speak almost entirely their native Mam language. This means that everything that is taught must be done by mouth, and that no literature could be prepared and left with the villagers as reference. This meant that teaching had to be thorough, simple, and repetitive in order to promote retention. The fact that most villagers spoke only Mam, and that most of our class spoke only Enlish, required that what was being said be translated twice with every exchange. This severely slowed our communication, not to mention some of what was said was lost in translation... Twice. In order to best communicate given the circumstances what was taught was kept short and simple, avoiding complex necessary language. Finally, the villager's overall lack of biomedical knowledge made it difficult to explain why their health problems were significant. For me, I understand concepts better if I have a basic underlying understanding for what is happening. Understanding what a pancreas is and what insulin does helped my understand diabetes. Understanding what protein, fats, and carbohydrates were helped me understand the diabetic diet and glycemic index. This requires background knowledge that simply couldn't be taught in the time available. We had to keep knowledge shared simple, and the directions for what and how to eat direct. All in all it was the biggest challenge that we as a group faced and one that while I'm not sure we entirely overcame, we addressed as best we could with the allotted and time and resources.

5. What did you learn about yourself as you interacted with the team and the Guatemalan people?

When I signed up for this class, I didn't know a soul on the roster. On the other hand, when I attended my first pre-departure class, I realized that many people who were on this trip did know each other. I found this intimidating as I would be the outsider working my way into the group. Once the trip began however, I found that I was able to connect with my classmates quite easily and before long felt like old friends with absolutely everyone. I met and learned a little about everyone on this trip and found some common ground upon which stand at the very least. I have been considering travel nursing for some time, but have been apprehensive considering the very similar social challenges posed to these temps who must become part of a professional team in a relatively short amount of time. I now feel confident that I would be able to do this and will definitely keep travel nursing in my future plans. As far as my dealings with the Guatemalans, they have done nothing but confirm my conviction to travel to strange places and work with strange people, while doing good deeds. This entire experience has truly been a distinct privilege. I was lucky enough to experience something genuinely new to me and found that I fully embraced the opportunity. I had the chance to help people who needed it and appreciated it in my own small way, and found it to be one of the most rewarding things that I have ever done with my life. Now I know, without a shadow of a doubt, that I will one day answer the call to distant shores and lands where different looking people who speak different tongues need medical help. I will do so freely, with pleasure, and a whole heart. And I will know that I will be working alongside my father in one way or another.

Adios Guatemala

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