Tapachula Day 24: Wednesday, June 20th, 2018

A day filled with delicious farewell food with all of our colleagues! We spent the morning saying farewell to all the wonderful people at CRISP that offered us so much support during our time here. It was difficult at times to adjust to the culture, the expectations, the weather—but our colleagues remained encouraging and sympathetic. They are without a doubt the largest reason I consider this internship a success.

After a lovely breakfast with the Ecosur and CRISP crew we headed over to the hospital for our final day. As busy as ever, it was filled with new dengue admissions, Guillain-Barré, eclampsia, and HIV among other conditions. Peter and I spent the evening taking histories and physicals and we made our first solo diagnosis: Dengue No Grave.

To cap the day off, we had a lovely dinner with Dra. Romero and a chemist from the hospital. Like I said, it’s the people that have made this trip such a success. The people and the opportunity for such hands-on experience are the reasons I’m considering returning for rotations—there’s so much to be learned and nearly everyone is willing to help you tailor the experience to your needs.

And with that, here is some advice if you’re considering the internship or future travel in Tapachula:

Be willing to chase down every opportunity. This internship tests your comfort levels—its in a different language and culture, and the expectations from medical students are different. Rise to the challenge.
Recognize cultural differences. Our favorite experience was hiking Volcan Tacana to discover a waterfall and spending the afternoon with a lovely woman from the community who made us handmade tortillas and chicken. We never would have discovered this experience if we hadn’t been open to spending the weekend at the home of one our CRISP colleagues—the offer may seem odd to us as Americans, but it was great! On the flip side of cultural differences, machismo is fairly evident—have an idea of how you’ll handle it if/when you encounter it.
Take advantage of your surroundings! San Cristobal is worth a weekend—a charming with amazing local communities and excellent hiking. Palenque is beautiful. The waterfalls Agua Azul and Misol ha are worth the trip. If coffee is your thing, go to a Finca and take a tour! Even if coffee isn’t your thing, it’s worth it. Beware that the majority of travel is by bus and the roads are pretty windy. Also, every bus ride is going to be at least 8 hours. It’s usually worth it!
Eat all the tasty Mexican food! We recommend El Mitote, Pacos Tacos, Café Soconusco, Wings Army, and Hamburgueseria Central (yeah, we know, some of these aren’t Mexican—still tasty!). Try tamales de chipilin! Actually, try all the tamales.
Ask your colleagues for recommendations! Especially Cesar, that man knows everything.

Our Hospital General de Tapachula team!

Our Ecosur and CRISP team!

Look at all this delicious food!

Tapachula Day 23: Tuesday, June 19th, 2018

While Peter spent the morning helping out with the brigadas once again, I spent the morning at home, sick. I can’t believe I made it so far only to be taken down in the final stretch.

With the outbreak, there is growing federal concern in ensuring the process is being handled efficiently and successfully, so we’ve noticed an influx of people from Secretaria de Salud—the federal branch that oversees these efforts. In addition to partnering with the Jurisdiccion to ensure that public health needs are being met, they’re meeting with Dra. Romero and her team today to review the records of all patients admitted with Dengue. With that in mind, Peter and I decided it was better for all if we worked on our research instead of get under foot.

There is no lack of fascinating cases here—from vertical transmission to dengue encephalitis, the potential for research is seemingly unlimited. After a few hours of hard work that was accompanied by the loudest thunder storm either of us had ever experienced, we grabbed dinner and drinks with our newest Touro colleague, Matt Musselman. Welcome to the team, Matt!

Tapachula Day 19: Friday, June 16, 2018

Another day, another puppet show! This time we performed in Ejido Hidalgo, the second of the two test sites for the sterile mosquito release. And maybe I’m biased, but we get better with every showing.

We had a full house! The audience was composed of children ranging from 3-15 years old from the Ejido Hidalgo community and they came ready to learn. Engaged from the very beginning, they were able to answer all the questions about the project at the end (ie. who bites you, Don or Doña Zancudo?) and were eager to meet both the puppets and the actors. This type of successful interaction speaks not just to the education the community is receiving, but the amazing efforts that Ecosur has put into community engagement in the last two years.

With our last puppet show under our belts, we’re off to San Cristobal for the weekend. Hopefully the cooler temperatures will refresh us for next week!

Kat teaches children about Doña Zancudo

Peter makes new friends!

The play took place in the Ejidal building

Two community members check out Doña Zancudo

These kids were SO patient while we waited for the rest of the audience to arrive

Tapachula Day 18: Thursday, June 14, 2018

After a morning spent researching Dengue for possible case reports, we met with Dr. Romero at Hospital General de Tapachula, ready to put our new knowledge to use. As we rounded on patients with Dengue Con Signos de Alarma and Dengue Grave, we palpated livers, examined skin for exanthema and petechiae, and assessed for pleural effusion and other fluid accumulation.

As the only treatments are paracetamol (acetaminophen) and liquids, the most important things we have to offer are education and reassurance. This is yet another opportunity to reinforce the importance of taking preventive measures at home: cleaning tanques, removing trash, etc. But reassurance is just as important: a majority of our patients are between the ages of 5 and 14 and parents are understandably concerned.

The toll this disease is taking on Chiapas is immense. In our limited time in the hospital, we’ve encountered over 50 patients with Dengue—and this doesn’t include the patients who have cases of Dengue No Grave that are mild enough to be dealt with at home. Each patient we see represents lost hours of work productivity for parents, long nights spent next to hospital beds, and countless hours of worry. And the worrying is well founded. Though the medical team here does a fantastic job of managing the disease, we have already seen one death from Dengue in our brief time in the hospital.

But our efforts, along with those of everyone else at Hospital General de Tapachula, continue and we hope to help many more.

Tapachula Day 17: Wednesday, June 13, 2018

We returned to the Jurisdiccion Sanitaria in the morning to assist with the day’s brigadas. We set out to the 21 de Marzo community, where we canvassed door-to-door assessing prevention methods and looking for possible Dengue patients.

In theory the preventive methods are simple: ensure that there are no sources of clean water for mosquitoes larvae. But in practice, it takes considerable effort. Tanques where clean water is stored for washing dishes must have insecticide in them. And with the daily tropical down-pour, anything can become a receptacle if left uncovered outside. The largest problem, however, is that it takes complete community support. If you do all of the outlined steps, but your neighbor doesn’t, chances are the resulting mosquitoes aren’t going to respect your efforts.

With that in mind, ensuring everyone in the community understands the importance of prevention was our goal of the day. We split into teams and walked house-to-house interviewing residents about recent symptoms that correspond to Dengue, assessing their preventive techniques, and addressing any concerns. Working in these communities is a slow game—many families weren’t at home and others weren’t eager to open their homes for inspection. The majority of homes we visited were following the public health guidelines, but it’s not stopping the spread of Dengue—we found a case of probable Dengue in an 8-month-old girl. Taking a sample (no easy feat in the field) and encouraging the family to take her to the nearest hospital were all we could offer.

After finishing up in the community, we flagged down a truck for a ride back to the city and headed over to Hospital General de Tapachula. Faced with an ever-increasing list of Dengue patients, Dr. Romero provided a crash course on the disease. After familiarizing us with Mexico’s classification of Dengue No Grave, Dengue con Signos de Alarma, and Dengue Grave, she gave us an overview of the symptoms that land patients on her registry. These signs and symptoms include a high fever, hepatomegaly, fluid accumulation, persistent vomiting, abdominal pain, myalgias, and retro-ocular pain.

With this background, we’re ready to see patients!

A view of the river running through the community 21 de Marzo

Our Jurisdiccion brigada team piled into a pickup on the ride back to town.

Tapachula Day 16: Tuesday, June 12, 2018

It’s the day we’ve been waiting for! Not only did we work alongside Dr. Daenna Romero in Hospital General de Tapachula, but today we also unveiled “Patas Rayadas Enamorados” in Rio Florido.

Why is this so important? Rio Florido is one of two test populations for release of transgenic mosquitoes. And it’s next to impossible for this project to be successful without community support. In our last meeting with representatives from the local communities there were many questions raised about the safety of the radiation used on the mosquitoes, the impact they could have on human fertility, and the presence of so many foreigners (we definitely got some stares when that question was asked). It’s clear that continued education is necessary and involving the kids in fun activities is a great way to ensure the community is engaged.

We performed at the local primary school and kids of all ages we were welcome to join. And they loved it! Although a bit shy, they were excited to learn all about Don and Doña Zancudo. With a newfound understanding of the benefits of mosquito release, we’re hopeful that attitudes toward the upcoming release are changing.

With the success of the morning’s puppet show, we were pretty sure that nothing would top it, but we were wrong! We arrived at Hospital General de Tapachula just in time to begin rounding on patients with Dra. Romero. With an increased number of patients due to the outbreak, she had 37 patients on her service—20 of which were admitted for Dengue Con Signos de Alarma. Over the next 6 hours, we visited each patient—assessing for updates or changes, which provided incredible insight into the progression of the disease and to the additional problems that Chiapas faces; we assisted patients with HIV, morbilidad maternal, Tuberculosis, and more.

There is so much to be learned here and we can’t wait to come back tomorrow.

Our DJ and the actor behind “Los Zancuditos” prep before our performance.

Students and families register their cases of Chikungunya, Zika, and Dengue after the show.

Our audience is rapt!

Tapachula, Day 15: Monday, June 11, 2018

Today was yet another perspective of the Dengue outbreak. We spent our morning at the Jurisdiccion Sanitaria, which oversees epidemiological efforts from the level of the municipality.

Every hospital within Tapachula reports cases of infectious and monitored diseases to the Jurisdiccion Sanitaria, which is then able to review the data and generate a plan for preventive efforts. While we received an overview of the operations at the center, we observed people reporting from each neighborhood and hospital—each person brought data via USB for their regional report.

Once the information is compiled, epidemiologists identify regions with a high incidence of Dengue and schedule the week’s brigadas. Jurisdiccion Sanitaria coordinates brigadas for fumigation, education, and resources—each of which has teams that focus on increasing prevention in areas with high rates of Aedes mosquitoes and increased incidence of Dengue.

We also had the opportunity to get further insight into the platform that’s used to track the biggest Mosquito borne illnesses: Chikungunya, Zika, and Dengue. It’s a useful tool to ensure that information about these diseases is readily available throughout the country.

With a growing understanding of the multi-faceted efforts to abate this outbreak, we’re looking forward to Wednesday, when we’ll get to work alongside brigadas to assess preventive efforts.

Tapachula Day 13: Saturday, June 9, 2018

Today marked the first showing of our Patas Rayadas enamorados puppet show and it was wildly successful! In other words, the kids (and adults) learned about disease prevention, including sterile mosquitos, and nobody found it too boring. We’re ready to take this show on the road! We’ll be visiting Ejido Hidalgo and Ejido Rio Florido, the two communities in which the pilot sterile mosquito release is taking place, to share this masterpiece with them next week.

How do you celebrate successful puppet theatre? With delicious street food, of course! We happened upon a local market on the side of the road, complete with vendors offering fresh fruits, agua fresca, quesadillas, and two amazing marimba players. Another successful day in Chiapas!

Our talented crew and wonderful audience.

Tapachula Day 12: Friday, June 8, 2018

Tomorrow is our first showing of the obra de guiñon, so we spent this morning working behind the set of Patas Rayadas Enamorado. We invited ECOSUR staff to enjoy our rehearsal show this afternoon and it underscored the importance of this component of the project. Due to a lack of resources (mainly funding), there are common misconceptions about mosquito prevention, and today’s audience was no exception. Several of the ECOSUR staff were surprised to learn that mosquitoes will lay eggs in any clean water and admitted to closing their doors during insecticide spraying (doors should stay open to allow for maximal dispersion of insecticides) due to concerns of cancer. Workshops and plays, such as Patas Rayadas, help to dispel these misconceptions.

And on a hopeful note, we had the opportunity to connect with Dra. Romero today. We originally met with her last week and were poised to begin assisting at Hospital General de Tapachula, but unfortunately her son became ill with what turned out to be Dengue. We’re happy to hear that he is recovering well and with Dra. Romero’s return late this week, we are excited to work alongside her at the hospital.

Our team of amazing puppeteers: Ann Laura, Peter, Kat, Ariane, and Annike. Missing from this picture is our talented AV manager, Ingo.

Action shot!

Behind the scenes. Yep, those are scripts taped to the back of the set!

Don y Doña Zancudo.

Tapachula Day 10, Wednesday, June 6, 2018

Today was a free day (aka. it was hard for us to find activities), so we enjoyed a lazy morning at Café Soconusco (clima and delicious coffee—we highly recommend it).

We decided to up the ante in the afternoon by heading over to CRISP to practice blood draws. Dr. Clemente was happy to provide the necessary supplies and even offered up his own veins for practice! Now we’re ready for next week.

Starting Monday, we’ll be heading out in brigadas with public health organizations. These teams will target areas with high densities of Dengue cases. The efforts in these areas include additional education regarding prevention, mosquito and larvae sampling, and blood draws of potentially infected individuals.

It’s been fascinating to observe the interplay of organizations as this outbreak develops— each organization has a critical role, especially in prevention.

Peter and our fearless colleague, Dr. Clemente Mosso

Kat’s turn!