The Untitled Riya Game
- Riya Dange
- Mar 16, 2024
- 7 min read
Middle photo by Dr. Asha Mandava.
It’s a beautiful day in the village, and you are a gringo.
–– Tagline for a video game about my life
Worthiness to conduct a pediatric ear exam is judged by staring contest. As you twist the otoscope tip onto the end of the instrument, your patient eyes you suspiciously from across the painted wooden desk. Break eye contact, and you’ve already lost. Flick the otoscope in a mildly threatening manner, and you’d better admit defeat. Lurch too suddenly towards the trepidatious child before you, and you might as well turn in your resignation. Any pediatrician will tell you: kids can sense incompetence from a mile away.
I’ve gone through some variation of this trial by fire over a hundred times so far, during our “away visits” to the schoolhouses in nearby villages. La Clínica Hombro a Hombro (Shoulder-to-Shoulder Clinic) in San José serves seven adjacent municipalities in southern Honduras: San Marcos de la Sierra, Concepción, Colomoncagua, Camasca, San Antonio, and Santa Lucia.
Image from Shoulder-to-Shoulder website, linked above.
Every six months, when the brigade rolls into town, the organization holds a series of pop-up well child clinics at local schools in San José as well as schoolhouses in the surrounding villages. Tributes for the “away visits” are selected on a volunteer basis. I went as often as I could. At 8:00 AM each morning, the “away team” would climb aboard our trusty pick-up truck, laden with plastic water tanks, medical supplies, and pharmaceuticals. We’d brave the lengthy mountainous travail to the town that our brigade director assured us was “just over the next ridge.” By and by, we would reach a schoolhouse: oftentimes a single dusty concrete building erected amidst the wilderness, its walls painted a bright cerulean or parrot green. Inside we’d find rows of rickety wooden desks and lilliputian chairs facing a single white board.
On our arrival, a teacher would wrangle the schoolchildren into a single-file line while we pushed all miniature furniture against a wall. Some schoolhouses, like the one in Cerro Prieto 2 (not to be confused with its sister village Cerro Prieto 1), comprised multiple buildings with a central open patio area, where we’d set up shop.
The pediatric parade stretched from the schoolhouse door, where a teacher helped register the children by name and birthdate, and wound through the Height and Weight, Vision, History and Physical, and Pharmacy stations, culminating in a one-on-one with the BBEG (“Big Bad Evil Guy”): Dentistry. I say this because nobody who has attempted to paint varnish on a schoolchild’s teeth should ever disrespect a dentist again. When gloves were scarce, they would go to the Dentistry station as a priority – lest one of us sustain a multifloral bite wound from a good deed gone awry.
Because I spoke Spanish fluently, I was typically placed at one of the History and Physical stations. Forms in hand, the students would meander over one by one from the front of the line. They’d survey me from the little chair across from mine while I scanned their form for indications for referral. One of these was vision. A child with vision poorer than 20/50 merited referral to the local optometrist – which, depending on the village, might have been in the next town over or a whole day’s pick-up truck ride away. I often thought to myself that the pipeline to follow-up might as well have been a sieve. Still, it was better to flag all concerning visual impairments such that at least a few children might seek further care.
Another “flag-able” indication was short stature. “Stunting,” or height restriction, can be a sign of pediatric undernourishment, along with the obvious: being underweight. Although the entire nation is plagued by inequities in land division and food distribution, the people of southern Honduras are particularly vulnerable (USAID). Frequent droughts during the dry season lend the region its moniker: the “Dry Corridor.” Amidst climate change, environmental degradation, and a bevy of natural disasters, the nutritional cracks in the Dry Corridor have only widened over time (World Food Program). Thus, of the 1.5 million Hondurans experiencing food insecurity, the majority live in the south or west (World Food Program). In children, undernourishment can lead to stunting, delayed development, and death. Nearly a quarter (23%) of Honduran children under age five have stunted growth, placing them squarely in the “to-flag” category (Secretary of Health, Honduras).
We identified children with abnormal heights and weights by their Z-scores, which (statistics professors, rejoice) quantitatively compare them to the average expected statistics for their age groups. One has to wonder whether these Z-scores are adjusted for demographics and geography. For instance: at five feet tall, I am decidedly below average height by the American standard. During my semester abroad in Denmark, I was considered unfathomably tiny. In India, I’m just about average. My own physique made writing referrals for “short stature” tremendously ironic. Imagine being told you need to see a doctor for growth monitoring by someone who’s basically your height.
On the other hand, being small likely meant I was a lot less scary. And speaking their language had rather the same effect. The brigade volunteers were often referred to as “gringos” – a term which, technically, means “white people,” but was used as a general alias for “Americans.” On slow afternoons, the children of the clinic staff would rush by us during an intense game of tag, chirping, “Hello gringos!”
Being gringos meant we had to work harder to cultivate trust with our patients – and rightfully so. A lofty medical degree and Littman stethoscope mean nothing to a child whose primary concerns are eating, walking to and from school, and learning the vocabulary for “travel by train.” The truth is: the children only did as we asked because their teachers instructed them to. And their teachers only trusted us because the clinic’s founding faculty had painstakingly seeded and maintained relationships with the local community for twenty plus years.
At the History and Physical station, however, trust was also built on an individual basis. You began by inquiring gently about your patients’ concerns. You listened carefully as they pointed out what hurt. You answered their questions patiently, diligently. You explained the exam to them as you moved through the steps: “Ahora, voy a examinar tu cuello” (“Now, I am going to examine your neck”). You asked for permission at appropriate points: “¿Estará bien?” (“Is that okay?”). You reassured them when you brought out the otoscope. You gave them firm, specific directions to face the wall without moving their head. You checked in with them afterwards to make sure they weren’t hurt.
None of this was foolproof. Just breathing was enough to set off some of the more tear-inclined children. Others, however, responded well to patience and kindness. They described their headache symptoms in detail. They showed you their knee scrapes. They asked keen, perceptive questions about why the nodules in their neck swelled when they were ill.
Sometimes, medical problems came to light by more unconventional means. I was kicking a ball around with some kids after one visit when one boy pulled his shirt up to wipe the sweat off his face. I paused. Had anyone noticed that rash on his belly? The neat lines of elevated lesions were characteristic of scabies. I immediately circled back to the brigade team, who by this time had neatly packed up the pick-up truck. An attending came back with me to examine the child and prescribed permethrin cream, which I explained to the boy and his teacher before we left their village.
For many children, especially in the outlying towns, the brigade’s biannual “away visits” are their only opportunities to receive screening for childhood issues, check-ups for illnesses, and any vitamins or medications they need. Consequently, entire families often show up, babies in hand. This brigade, we saw an aggregate of about 700 kids. That’s 700 physicals with 700 ear exams, 700 months’ worth of multivitamins, 700 discarded paper cups from anti-parasite medication ingestion, and 700 data sheets dappled with hand-sweat. I had never seen so many dental caries in my life.
One of the most prevalent issues with the brigade-based model of foreign medical aid is the “dependency hole” created by a dip-in-dip-out approach. Because the Clínica Hombro a Hombro in San José was built by a twenty-year-long collaboration between the University of Pittsburgh and the Shoulder-to-Shoulder organization, our patients are guaranteed year-round follow-up – assuming they can make it to the clinic. The biannual “away visits” are one way to bridge the transportation gap. Even so, there is still a ways to go toward true continuity of care. For instance, prior to this year, the data sheets from all of the away visits – painstakingly completed, meticulously handwritten – were discarded at the close of each brigade. So, if a child dropped an entire standard deviation in weight from one visit to the next, they might not be flagged for follow-up unless they fell to 2 standard deviations below the mean. This time, however, all of the data sheets returned with us to Pittsburgh to be entered into an electronic medical records system by one of our brigade members.
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