A Concrete Floor Should Be a Human Right

A concrete floor should be a human right.

Our last day of clinic our team divided into two teams and went on home visits.  Dr. Richard’s team traveled to see two home-bound adult patients in the morning.  My team went to see a newborn infant.  I have done house calls before as a physician, but only in Guatemala.  As a physician I understand the unique gift these are both to the family but also to the physician.  We are not compartmentalizations of a person.  We are whole persons, and our home, how we live, is an essential element of what makes us who we are.  

The students, our community leader and guide, Roland (our Guatemalan brother and coordinator), my translator and I embarked in the bed of a pick-up truck.  We parked along the side of the road and discovered our path to the house was straight up a steep mountain.  Part of the way there were stairs made with used tires to assist the people up this intimidating climb.  These are the events that since my foot injury 4 years ago have proved to be my biggest challenge when in Guatemala.  As soon as I saw that climb I knew my foot was going to be on fire the rest of the day.  A small price to pay for the experience that awaited us.

When we arrived outside the home of our little infant patient a few sparsely-clad toddlers were pouring out of the door of the tin structure that was their home.  I was a little startled initially because I knew these little kids.  I had seen them earlier in the week in clinic.  They came with their grandmother to clinic - 6 of them.  Grandma spoke Q’eqchi -a Mayan dialect.  So even my very capable interpreter had a hard time piecing all of the pieces together.  What we could glean from the grandma in clinic earlier in the week that the kids ranged in age from 9 years to 23 months.  The youngest two were both born at term but only 6 months apart.  So, without being able to pull out the whole story from the grandma because of our communication limitations we presumed that they just must have had two different moms. The kids in clinic were patient, well behaved and clean, relatively.  It takes a long time to take a complete history on 6 children, so that family was in the small, hot peds exam room with us for a long time that day.  There was hardly any crying.  A few times the two 2 year olds squabbled a bit, but otherwise they were quiet and attentive.  The 9-year-old is bilingual, speaking Spanish and Q’eqchi, because he attends school at Cuidad de la Esperanza.  He was as helpful as the grandma in giving us the details we needed to take care of the kids. None of the 6 were still on a normal growth percentile.  They were all chronically malnourished and will all be stunted.  It is unlikely any will reach 5 feet as an adult height.  They drink unfiltered water.  The 8-year-old boy’s face was covered in a healing abrasion from road rash.  Three weeks earlier he was on a bicycle with his dad when they crashed.  His dad broke his arm and has been unable to work the last three weeks.  Wilmer, the 8-year-old, had a concussion but his road rash was healing nicely.  He is lucky he wasn’t more seriously injured.  

Seeing the home these 6 kids inhabit with their parents helps to connect lots of pieces of the puzzle.  They are among the extremely poor of Guatemala.  Guatemala has the poor, and the extremely poor.  Seeing the kids in clinic and now seeing them in their home it was evident they had all been cleaned up for their clinic visit - I have seen this many times in Guatemala.  At their home the youngest was dressing in a shirt, nothing else.  He was naked waist down, which he was unbothered by.  Incidentally, as we were about the leave at the end of the visit he was playing out in front of the house and unintentionally gave us all a full moon - it was a good anatomy lesson!

When we entered the home what I noticed first is that there is no floor.  The structure is built on the earth.  The earth has been packed down hard, but there is no protection from when it rains, so on those days it is mud.  Just put your mind around that for a minute.  During the rainy season it is like having a river in your home.  The size of the two room dwelling was approximately 20 feet by 10 feet.  One room is the “kitchen” - an open wood fire stove is what they cook on every day.  The other room is where they sleep and exist every day.  There were two cots with no mattresses for the 7 people to sleep on each night.  There were hundreds of flies and it was dark.  

We introduced ourselves to the parents, since we had not met them in clinic and said our hellos to the children we already knew.  Dad, who is thin as a rail and probably around 4’10” had his right arm in a cast.  He was very proud to finally have a girl.  Then we embarked on learning about our little patient.  Monse was on triage that day.  She is a sophomore nursing student.  She took vital signs, weighed and measured the baby and plotted her on the growth curve.  I can guarantee none of her sophomore nursing student classmates have every done that before.  Nurse Kristen supervised each step.  Kristen went to Guatemala with me years ago when she was a nursing student at Xavier and now she is part of the medical team.  She is a pediatric float nurse at Cincinnati Children’s Hospital.  Having her on this trip puts me at great ease.  I know if a really sick kid comes in, with her help, we will be just fine.  After we had collected this initial data on the baby, I sat down to talk with the parents to learn more information.  She was born at 36 weeks gestation, in a hospital, had an uneventful nursery course and was discharged in two days.  She weighed 6 pounds at birth and at 5 weeks of age was over 8 pounds.  She was gaining weight fine.   She was clean, alert, and very calm.  The students all got to see a full newborn exam as I talked through the highlights.  We finished up the exam and were able to tell mom how wonderfully healthy she was.  We gave mom one of our baby kits that we fundraise for and put together for the infants in the community.  We talked through each item and how to use them.  She got to see how to use a thermometer to take a temperature. She learned about how breastfed babies need vitamin D to protect their bones,. We told her how to use the nasal saline and nasal aspirator to clear her nose when she gets colds.  We showed her how to use the infant nail clippers.  Gave her some cloth and disposable diapers and wipes and bibs.  We gave mom prenatal vitamins.  

We also gave them two pacifiers.  Mom had never seen or used one -she didn’t know how to put it in the infant’s mouth.  A few years ago I started to notice a common theme among the infants here.  So many don’t grow well in the first two years of life.  Their primary calories are breast milk.  But the way the babies are nursed are not ideal for milk production or infant weight gain.  Basically the babies graze all day.  Mom’s use the breast as a pacifier all day long.  Every infant squawk or cry and mom will put the baby on the breast.  So they nurse for 3-5 minutes every 20 minutes.  Breast milk is a supply and demand system, so when you nurse like that and don’t completely empty the breast the body over time just starts making less milk.  Also, the hind milk, where all the fat calories are, does not let down until about 10 minutes into a nursing session.  So these babies who graze all day are not getting the hind milk.  So we explained all of this to mom (like we did with many other mom’s in clinic all week), and told her to use the pacifier to help hold the baby off during feedings.  Babies like to do a lot of non-nutritive sucking at this age.  So trying to change breastfeeding patterns from grazing to a sit down 20 minute feeding every 2-3 hours will make a huge change in how a baby grows.  

Guatemala has an estimated 50% rate of chronic malnutrition in infants (one of the highest, if not the highest in the world), leading to stunting and many other health problems.  Just making small changes like better nursing patterns can change this.  If a child is not on the height curve at their second birthday, they will never be on the height curve.  

The young parents were grateful for the visit and in Q’eqchi that was translated to Spanish and then English they said they have never had a doctor visit their home and spend such time talking to them.  I told them I was looking forward to watching their young family grow up over the next few years as I return.  We asked if we could take a photo together, which they gladly did.  We walked outside ready to start the journey down the mountain when the dad came out with their family phone and said his wife wanted a photo with all of us on their phone.  So we joined again as one new international family to smile for the camera.  We were all freshly jovial off the full moon by the little toddler just moments before that second photo.  We went on our way.  Roland told me as we were settling back into clinic that the two children that are not their biological children are two toddlers who were abandoned and this young couple is raising them as their own.  Seven kids in one room, dirt floor, unfiltered water.  How can health flourish in that setting.  I asked Roland to make sure that family gets one of the water filters we purchased.  He has already made that happen, because it is the right thing to do.  They deserve a chance.  They deserve clean water, they deserve a concrete floor.  They deserve so, so much more.  

Dr. Lauri Pramuk