Grace Fletcher is a candidate for the MPH in Global Health & MA in Latin American Studies at Vanderbilt University and a former WK nutrition intern. Kate Douglas is an incoming medical student at Washington University in St. Louis and will serve as the nutrition intern for the next year. German (pronounced Hairmon) is the manager of WK’s nutrition program and the coordinator of community clinics in the highlands.
I (Grace) just returned from a three-month stay in Guatemala, working on a monitoring and evaluation project for Wuqu’ Kawoq’s nutrition program. I wanted to share a little bit about what an “average” morning is like with Wuqu’ Kawoq’s above-average nutrition program. Hopefully, it illustrates how the nutrition program works “in the field” and highlights some of the reasons that it is so effective: a compassionate, smart, and hard-working staff; strong collaborations with other organizations working on related issues; comprehensive care with follow-up; and a dedication to meeting patients exactly where they are: in their homes, in their language, in their social, cultural, and familial context.
5:00am: Grace gets up. After several months, she doesn’t even hear the neighbor’s roosters any more.
5:02am: Grace successfully turns on the gas stove using only one match in order to boil water for tea. Grace feels pretty accomplished already. Grace really needs her tea.
5:30am: Grace drinks her tea and talks to her family in the United States. She also reviews some changes for the survey tool she’s developing for the nutrition program.
6:00am: Grace’s roommates Katia—WK’s social media and complex cases coordinator— and Christina—WK’s diabetes education program coordinator—emerge from their rooms and head out for a casual 10km jog to Iximche, the Mayan ruins near Tecpán, where we live. Grace doesn’t do that.
6:30am: The sounds of American Top 40 pop music and vigorous, if slightly off-key, singing indicate that the last roommate, Boris, is taking a shower before one of his numerous early- morning Skype calls with the research team. Boris is a Guatemalan physician coordinating some of WK’s research programs in nutrition and maternal health.
7:30am: After eating breakfast and getting ready for a long day, Grace leaves the intern compound and walks toward Kate’s home-stay house, avoiding motor taxis, chicken buses, small children, women carrying huge loads on their heads, animals, and puddles. Today is Kate’s first day in Guatemala as the incoming nutrition intern and Grace is going to bring her to the office, where they’ll meet up with German, the manager of the nutrition program. German said to be at the office by 8am, so they are shooting for 7:55am because German is obsessively prompt.
7:55am: Grace and Kate arrive at the WK offices. Kate meets some of WK’s incredibly dedicated and competent staff, already hard at work. Yoli, an integral part of the nutrition team who works as an educator, is not there. While she usually works as part of a terrific partnership with German, today she is giving women’s health classes in another community and won’t be joining us.
8:01am: German speeds up to the WK offices on his bicycle. Grace continues their running joke, suggesting that German overslept since he’s arriving so late. German laughs and goes along with the joke. He then informs Grace that he had been to see the carpenter who is building new stadiometers (used for measuring children’s height) for the nutrition program, had stopped by the store to order food supplies for the next day, and had put gas in the car, all before we arrived. Grace stops talking.
8:05am: Grace, Kate, and German load the black SUV with a scale, a stadiometer, computers, a small bag of medicine, cans of infant formula, and the cartons of eggs, bags of beans, bottles of oil, and packets of vitamins we will be distributing to families participating in the nutrition recuperation program.
8:15am: Grace, Kate, and German hit the road, on the way to a K’iche’-speaking community called Chichimuch nearly an hour away. We have an ambitious day planned and high hopes for productivity. In the morning, we’ll be training the women’s committee in Chichimuch to weigh and measure children correctly so that they can help collect the data used to monitor the nutritional status of all children under five in the community. In the afternoon, we’ll be conducting house visits with malnourished children and other patients under WK’s care.
8:20am: Grace, Kate, and German pull onto the Panamerican Highway. Kate hurriedly tightens her seatbelt and hangs on to the overhead handle as we zoom around hairpin curves and dodge packed buses. Grace reminds herself, perhaps for the 400th time, that she’s probably never been closer to death than on this road and so she should probably just relax about airplanes and snakes and all the other things that scare her.
8:45am: German has fielded three phone calls in this short period of driving—one from a patient, with whom he reviews in rapid fire Kaqchikel the doses of the medications she received after a recent appointment; one from Boris, asking about the stadiometers the carpenter is constructing; and one from WK’s complex case manager confirming details about a patient who is going in for chemotherapy in the capital the next morning.
9:15am: Grace, Kate, and German arrive in Chichimuch and park outside of the community center where we will work with the women’s committee. No one is there.
9:16am: Grace, Kate, and German sigh and begin to think of a plan B. Grace eats a snack while German starts making phone calls.
9:20am: German has confirmed by phone that the members of the women’s committee are all attending a church activity and will not be able to meet today. He has also thought of a half dozen other tasks on his long list that we can tackle instead. We start to drive through the community.
9:30am: One of German’s contacts at Mil Milagros, another NGO collaborating with WK in this area that refers participants with health needs to WK, calls him back to refer a newborn from Chichimuch whose mother probably has lactation failure to the nutrition program. Kate adds this child to a list she’s keeping in her notebook for the morning.
10:30am: By now, Grace, Kate, and German have loaded an examination table into the SUV and moved it from one community center to the other, in anticipation of the medical consultations scheduled next week in Chichimuch. We’ve also dropped off medications for an elderly stroke patient near the town center and medications for a mother and her toddler who both have well-controlled seizure disorders due to their participation in WK’s community clinics.
10:45am: We drive through cornfields on our way to visit a child who’s been participating in WK’s nutritional recuperation program for several months and is making progress, although not as fast as we had hoped. Before we get to the house, however, German sees Maritza, the government health center’s outreach nurse, walking along the side of the road. German and Maritza often collaborate, with Maritza informally referring children to WK whom she knows to need help beyond what the health center can provide. Today, Maritza, a woman of many talents, is walking from house to house, vaccinating neighborhood dogs against rabies.
10:50am: German and Maritza catch each other up on patients that they both know and German asks Maritza if she’s aware of any new children who might benefit from a home visit from the nutrition team. Maritza’s face lights up and she tells us all about a 16-month- old child just down the road who she’s been worried about for months, but not been able to help. Maritza hops in the back of the SUV with Kate, temporarily abandoning her canine patients, and we head to Julia’s house.
11:00am: We’re standing in the dirt patio of a two-room, stick-walled, tin-roofed house that tilts crazily toward a deep ravine covered in corn plants. This is where Julia lives with her parents and two preteen sisters. In the doorway, Maritza, Julia’s mother, and Julia’s oldest sister are carrying on a very animated conversation in K’iche’, and Grace catches the words “sick,” “cough,” and “diarrhea.”
11:02am: Grace knows that this is going to be a complicated visit and has another snack. Kate is watching the conversation like it’s a tennis match and trying to soak everything up.
11:05am: Julia’s mother agrees to talk with us about Julia. Grace and German hang the scale from a beam in the kitchen and set up the stadiometer. Julia’s mother carries her over to the kitchen and we get our first good look at her.
11:06am: Grace says a very bad word in English under her breath. Julia at 16 months of age looks smaller than a six-month-old we saw yesterday. Her hair is patchy and straggles over her blurry eyes. Her nose is covered in dried snot and we can hear her breathing from here. She takes one look at us and starts to wail—a fairly typical reaction at the sight of a scale.
11:10am: German and Grace weigh and measure Julia while Kate enters the data into the computer. As they work, German comments that he didn’t know the swear word that Grace used, but he knows it’s a bad one and she should translate it for him. Grace demurs until German threatens to ask Boris and she promises to tell him later.
11:15am: As we look at the computer screen at Julia’s growth chart, Grace says another very bad word in English, Kate looks a little shell-shocked, and German looks as stoic as usual. Julia is one of the more severely malnourished children we’ve seen—her height and weight measurements are over five and four standard deviations below normal for her age, respectively. Her malnutrition plus her obvious acute illness make her a very fragile child in need of lots of support.
11:20am: German begins to explain our observations to Julia’s mother. He tells her that the first step is to enroll Julia in WK’s nutritional recuperation program. As a part of the program, Julia will receive food and vitamin supplementation in the form of beans, eggs, cooking oil, and vitamin sprinkles as well as growth monitoring every two weeks for the next six months. She’ll receive regular medical checkups and be treated for acute or chronic illnesses. Her mother will participate in intensive nutrition education with Yoli so that she can make the best choices she can for Julia’s diet.
11:25am: Julia’s mother agrees to participate in the program and German begins to administer a short intake survey that covers key points from Julia’s medical history and the social circumstances of the family. Grace also asks about Julia’s diet (intake) and recent bowel movements (outtake). Julia’s mother explains that Julia has been very sick with a racking cough, fever, and diarrhea for almost 10 days, but was slowly getting better. The health center had given her a small amount of medication, which helped a little, but had wanted to send her to the hospital in the departmental capital because of the severity of her illness. Julia’s family refused to go to the hospital because they were afraid that Julia might be taken away from them. Julia’s mother adds that she will only participate in WK’s nutrition program if we promise not to separate her from her daughter.
11:30am: Based on Julia’s mother’s responses to the intake survey, German makes some suggestions for small changes that could be make in Julia’s diet and does a wonderful job of motivating her to make those changes. It’s a short but intense, personalized, and effective nutritional education talk.
11:35am: Grace steps outside to make a phone call to WK’s physicians back in the office at Tecpán, because she’s worried about the combination of Julia’s acute illness and her malnutrition. The physician is concerned about the possibility of pneumonia and asks Grace to go back inside to see if Julia’s skin is sinking underneath her ribs when she breathes and if her breathing is rapid and shallow, which would indicate pneumonia. If Julia has pneumonia, they would want to send Julia to the hospital because it’s highly likely that she would die in her weakened condition. Grace knows that the family will not want to go to the hospital and goes back inside to examine Julia.
11:40am: Just as Grace walks back inside the house, Julia’s father returns from working in his corn field for lunch, casually swinging a machete and looking suspiciously at the strangers in his home. German quickly and calmly explains our presence, our observations of Julia’s health, and our plan to enroll her into the nutrition program. German succeeds in persuading Julia’s father to allow her to come under WK’s care, although he also expresses concern about having her taken away. Julia’s father and mother briefly step out of the kitchen and Grace quickly explains to German the concerns that the physicians had and the potential that we might need to send Julia to the hospital. German immediately grasps the brewing conflict and asks Julia’s mother to come back inside so we can look at Julia’s breathing.
11:45am: Julia’s breathing isn’t quite as labored as we had feared, and German steps outside to talk to the physicians again while Grace and Kate pack up the equipment and make casual chatter at Julia and her mother and sister.
11:50am: German comes back inside to report the decision from the physicians that since Julia’s breathing was not as bad as feared and that her mother had reported that her symptoms were improving with the small amount of medications from the health center, we were not going to try to send her to the hospital. However, the plan is to make sure that she sees a WK physician within the week, to enroll her in the nutrition program, and to ask Maritza to check in on the family and insist that they take her to the hospital and call German immediately if her condition worsens. German gives Julia’s mother his personal cell phone number and tells her to call any time, day or night, because we want to do everything possible to support Julia and her family.
12:00pm: Grace, German, and Kate get back into the SUV. Grace eats another snack and explains some of the nuances of English-language swearing to German. They still have two more home visits with the previously mentioned children—one who is already participating in the nutrition program and the newborn referred for potential lactation failure—before they can head back to the town center for lunch and more home visits in the afternoon. Even though this morning did not go as originally planned, we did some good work.
Update on Julia: A WK physician came with us a week later to see Julia in her house. He did an extensive physical exam, treated her for probable pneumonia, taught Julia’s mother and sister how to administer her medications, and educated them extensively on danger signs for the future. Julia began receiving her food and vitamin supplementation and in-home intensive nutrition education with German and Yoli. The physician also ordered lab work to rule out any underlying conditions that might be contributing to her malnutrition and weakened immune system, which showed slight anemia and subclinical hypothyroidism. Julia is receiving treatment for these conditions and WK will continue to support her and her family.