Nicaragua Study Tour Jouranl

January 14-22, 2006

Nicaragua Public Health Service Trip

View the trip photo gallery.

Top row (L to R): Cynthia Fisher, Joanna Lowell, Susan Koo, Teesha Thomas, Jorge Soler, Kerry Burch, Erika Linnander Bottom row (L to R): Jessica Tytel, Therese Menez, Cristina Cardemil, Suzanne Sacher, Katie Richey, Madeline Beal

A team of thirteen Johns Hopkins Bloomberg School of Public Health Master of Public Health students spent January 14-22, 2006, in Nicaragua as part of a public health service trip sponsored by the J.B. Grant International Health Society. Most of their work was focused in the municipality of Siuna and the nearby village of Hormiguero, both of which are located in the remote Northern Atlantic Autonomous Region. The team partnered with Bridges to Community, a U.S.-based non-governmental organization (NGO) that has worked in Siuna and surrounding villages since 1999. Through Bridges, the team also developed contacts with Salud Sin Límites, a Siuna-based branch of Health Unlimited, which is an NGO focused on the health and well-being of adolescents and the training of community health care workers. Typically, organizations working through Bridges engage in construction, agriculture, sanitation or medical projects. The Hopkins students’ venture marked the first time public health was the entire focus of Bridges trip.

Hopkins team members spent six months preparing for the trip, and set three main goals:  (1) pilot a survey for adolescents to determine their knowledge of reproductive health issues; (2) train midwives and rural healthcare workers in sexual and reproductive health, self-esteem building, breastfeeding and pre- and post-natal care; and (3) train adolescent peer educators to conduct classes on reproductive health issues.

The JHSPH students were Christina Cardemil, Cynthia Fisher, Erika Linnander, Joanna Lowell, Suzy Sacher, Teesha Thomas, Therese Menez, Susan Koo, Katie Richey, Madeline Beal, Jorge Soler, Kerry Burch and Jessica Tytel.

Joanna Lowell

Saturday, January 14, 2006
By Joanna Lowell

We departed from Baltimore/Washington International Thurgood Marshall Airport for Managua at 6:30 a.m. Amid the excitement there were a few stress-filled moments-Delta’s passport reading machine broke down and the delay nearly caused half of the group to miss the first leg of the flight. Additionally, a bag containing materials for one set of workshops was lost in transit.

Once in Managua, we were greeted by heat, humidity and Laura Martin, a Bridges representative who arranged the logistics of our visit and who will serve as one of several translators. Following an excellent meal at Cocina de Doña Haydee, a restaurant featuring typical Nicaraguan cuisine, we headed to El Centro Para Comunicación (CPC), a newly-independent offshoot of the Johns Hopkins Center for Communication Programs. At CPC, we met with Oscar Ortíz, the director, who greeted us wearing a Johns Hopkins t-shirt.  He spoke to us about the public health needs of Nicaragua, emphasizing that maternal mortality is an enormous problem in Siuna, the municipality that we will visit tomorrow. Ortiz also presented an overview of CPC’s national “Together We Decide” reproductive health and family planning campaign. A major aspect of this campaign has been the social marketing of Body Guard brand condoms. Through the use of creative television commercials, the campaign has had great success in reaching adolescents and young adults, which are important groups, considering that approximately half of all Nicaraguans are below the age of 25.

Sunday, January 15, 2006
By Joanna Lowell

Today we traveled to Siuna, a remote, impoverished town of about 12,000 people. It is the hub of the eponymous, larger municipality, which consists of 152 rural communities with approximately 68,000 residents. Most people travel between Managua and Siuna by bus, which can take anywhere from 12 to 19 hours depending on how muddy the unpaved section of the road is. We are in the fortunate position of being able to fly to Siuna, which took about one hour. The flight provided excellent views of the Nicaraguan countryside, including Lake Managua, several volcanoes, jungle and many small farms. Although it was somewhat disconcerting to observe both of our pilots reading the newspaper during the flight (the plane had been placed in autopilot), we landed without incident in the rough gravel airstrip in the center of town. There is no official airport here, and our plane rolled to a stop at a spot marked by two orange cones and a fire extinguisher. The plane itself was so small that it required two trips from Nicaragua for all 13 of us to be transported.

We were taken to the URACAAN campus. URACAAN is a 10-year-old public university where most of us will spend the week. URACAAN students are currently on break, and  the campus is almost deserted. Our accommodations were not that different from that of an average Siuna family. We all slept on cots in a single small room that normally functions as a classroom. Because of concerns about malaria, we slept under bed nets, however, we did have access to two luxuries: flush toilets and showers.

In the late afternoon, we toured the Carlos Centeno Health Center, the largest medical complex in the region. As it is Sunday, the outpatient clinic of the facility is closed, but there were 19 patients being treated in the inpatient ward, including nine for tuberculosis and two infants who were born this morning. We received a tour of the Center from a physician, who was quick to point out that the Center is not a hospital; rather it serves as a primary care center and lacks the capacity to carry out any but the most routine of surgeries. The center also is in great need of medical supplies, equipment and physicians with specialized training. Moreover, the one ambulance the Center owns rarely is operational because of the lack of funds for gasoline. We learned that Siuna has the highest rates of maternal mortality in the country and struggles with many infectious diseases, such as malaria, tuberculosis, respiratory infections and diarrhea. Remarkably, however, no one in Siuna has yet tested positive for HIV. The doctor speculated that this bit of good news has more to do with the difficulty of traveling to and from Siuna (infrastructure, including roads, is poor in this part of the country) than any propensity of the people to avoid engaging in risky practices. In fact, the lack of knowledge about HIV, particularly for those living in the campo, is of major concern to health officials.

Monday, January 16, 2006
By Joanna Lowell

This morning we headed to the Siuna office of Salud Sin Límites (SSL), the NGO with whom we will work this week. After introductions, we received an overview of the work SSL carries out in Siuna, including training midwives to recognize high-risk pregnancies, holding community workshops in preventive medicine, teaching youth about sexual and reproductive health and holding numerous other environmental projects. By late morning, we had broken into three groups to discuss the activities that each Hopkins team had planned for the week: the first will hold workshops on sexual health, reproduction and self-esteem for adolescents in Siuna; the second organized workshops on maternal and neonatal care, breast feeding and family planning for community health care workers in the farming village of Hormiguero; the third prepared a survey on adolescent sexual and reproductive health, which they will fine-tune with the help of SSL staff with the hope that it can be piloted in Siuna by the end of the week.

Following lunch, we traveled in the back of pickup trucks on the bumpy dirt road to Hormiguero. Although only five members of our group will be working in Hormiguero, we were all curious to visit it. Situated in the countryside about 45 minutes outside of Siuna, Hormiguero is extremely poor. Most people travel by foot and a lucky few on horseback. We did not observe a single car outside of our own. The village is dominated by a makeshift baseball field, a tribute to the popularity of the sport in Nicaragua.  Hormiguero’s fame, however, stems from the fact that it possesses the best health post in the rural community of Siuna. Indeed, in a village largely without electricity or running water, it was impressive to see that the well-maintained health post had both of these luxuries. A poster on the wall illustrated the walking time required to reach each of the villages served by the health post: times ranged from 30 minutes to 12 hours.

Cristina Cardemil

Tuesday, January 17, 2006
By Cristina Cardemil

Today was our first chance to delve into the reproductive health workshops we planned back at the Bloomberg School of Public Health. We designed these workshops to be participatory, educational and interactive, which worked quite well as we found our first group of peer educators (20 participants, ranging from 8 to 18 years old) to be very excited and enthusiastic about learning. Suzy and I conducted the first half of our workshops, "Anatomy and Physiology and Sexually Transmitted Infections," in Spanish. In the afternoon Jessica and Kerry taught in English, using a translator, and presented "Pregnancy, Contraception and Values." Although we had some initial concerns about how the translated portion of our workshops would turn out, we were able to engage the adolescents in a discussion. They already had received some education in reproductive health, but asked many questions about sexually transmitted infections, contraceptives and pregnancy. The students especially enjoyed the role-playing activities, such as pretending to be a new couple addressing sexual health in their relationship. We had such a great interaction with the students that several of them stayed after and asked us if they could come back later in the week. Although we were unprepared for this, we consulted with the Salud Sin Límites staff and decided that we would prepare more material for another workshop on Friday. We left quite energized and ready to take on the rest of the week.

Teesha Thomas

Wednesday, January 18, 2006
By Teesha Thomas and Joanna Lowell

Hormiguero is the community where Susan, Therese, Katie, Madeline and Teesha worked during the week along with Kenia, Heynar and Lygia, our Nicaraguan translators and coworkers. Today the Maternal/Newborn workshop was presented to 31 people, plus the community members and children who poked their heads in through the windows. The participants included midwives and health leaders from the surrounding communities, some of whom walked up to 12 hours to attend the workshops. Based on how responsive the participants were to the more interactive activities on Tuesday, we decided to put our acting skills to the test with more skits and scenarios. As we went through the topics of postpartum (including hemorrhage, infection, nutrition and postpartum depression) and infant care, we were impressed by what the participants already knew and surprised by what they did not know. For example, they were familiar with the medication “Amoxicillin,” but were not aware of the symptoms of dehydration in a baby. We also discussed the use of herbal remedies for postpartum care, and the belief of some Nicaraguans that only ‘light’ foods such as tortillas and cheese should be consumed for 40 days after a woman gives birth, a practice that puts the mother at risk for anemia and other complications. Postpartum blues and depression were new concepts for many members. It was gratifying to see their eyes light up with new information or to hear participants say to each other, “Esto es bueno saber,” which means, "This is good to know.” The participants also shared their experiences of working with new mothers. The information was enlightening to all of us. It takes a combination of bravery and skills to be the only source of health care for miles. And despite some frustrations, they truly want to help their communities and improve their own knowledge base.

For the survey team, today marked a major breakthrough. Erika, Cindy, Jorge and Joanna spent the last two days painstakingly going over the survey question by question with SSL staff members Feliciano, Fatima and Yajaira. The immediate goals were to trim the survey down to something that can be administered in 30 minutes or less and to adapt the terminology so that the questions will be understood by the target population of adolescents and young adults, aged 13 to 25, who live in rural and urban areas of the municipality of Siuna. Today, we achieved both goals. Moreover, we were asked by Feliciano, Fatima and Yajaira to accompany them as they initiated the pilot phase of the project. We set off in pairs and began knocking on doors in a neighborhood nearby the SSL office. Given the survey’s length, the sensitive topics covered and our own presence as outside observers, we were impressed that not a single person turned down any SSL staff member’s request for an interview. It was really exciting to observe how the interviewees responded to questions. Some were very well-informed; others had major misconceptions about topics such as how HIV is transmitted. The interviewers did a great job not reacting to any of the responses, no matter how surprising. We plan to continue the piloting phase of the survey tomorrow.

Therese Menez

Thursday, January 19, 2006
By Therese Menez

The workshop presented to the community leaders in Hormiguero today centered on contraception, family planning and sexually transmitted infections. Though the workshop topics were identical to those presented on Tuesday, the audience was different and the dynamics unique as well. What we naïvely thought on Tuesday were lengthy explanations of common practices in the village, we learned yesterday were elaborate stories that in essence were told to solidify the points we were trying to make. It was a learning experience for us, not only on the health practices of Nicaraguans, but on the cultural importance of storytelling to get a point across.
 
In the workshop we were able to demonstrate different methods of contraception using a kit from the Johns Hopkins Center for Communication Programs. We explained IUD and Nuva ring insertion, and correct condom placement using a wooden penis model. We learned that the most popular method of contraception in Nicaragua is the hormonal injection Depo-Provera. We were told that this was a preferred form of contraception for women in the villages simply because they could more readily prevent pregnancy without the knowledge of their partner. For me, it was also gratifying to know that we shared new information regarding HIV and AIDS.  Among some 60 participants in all the workshops, only 15 had heard about HIV, and their questions made it clear that more work needs to be done to educate people about the virus. Currently, HIV prevalence in Nicaragua is 0.2 percent, the lowest in Central America, but Atlantic coastal towns are increasingly seeing higher rates.

Friday, January 20, 2006
By Cristina Cardemil

Our last working day in Siuna was packed with morning workshops and an afternoon farewell celebration. Our survey team rounded out the morning with Excel training and final editing of the survey, while the adolescent reproductive health group presented new material with a motivated group of students that had returned from earlier in the week. In the adolescent group we addressed communication, abstinence, condom use and self-esteem themes. Since we knew all the students from prior workshops, we were able to move more quickly, build on their past knowledge and challenge them further. We also gave the peer educators leadership roles in some of the activities, as well as ideas about how they could develop their own workshops.

In the afternoon we had a very warm good-bye party with the adolescents and the SSL promoters. Feliciano Olivas, one of the SSL promoters, wrote a song for us entitled “Gracias, Amigo,” (for lyrics, visit www.hopkins-nicaragua.blogspot.com). He sang and played the guitar. He was accompanied by SSL leader Juan Antonio Herrera on piano. The peer educators also prepared a series of theater acts that dealt with each reproductive health theme we had presented to them earlier in the week. Our Hopkins group was quite touched by the warmth and generosity of our Nicaraguan friends. We ended the afternoon with a short skit to thank them, and then danced together to Nicaraguan music. We shared arroz con leche (rice pudding) as a snack, took endless photos and exchanged addresses and contact information. As we were leaving, we had the good fortune of meeting the Technical Coordinator of SSL in Siuna, Dr. Ivania López, who had been out of town but stopped by to meet us before we left. We discussed our plans to follow up with the survey and opened the possibility of future research collaborations between Johns Hopkins and SSL.

That night we continued to say good-bye to Siuna and our SSL friends. We had dinner together with the SSL technicians over a typical meal of arroz, legumbres y plátanos (rice, beans and plantains) and danced the night away. We found that Nicaraguans love to dance and their enthusiasm was contagious.

Sunday, January 22, 2006
By Joanna Lowell

The journey back to Baltimore spanned two days. We spent most of Saturday morning waiting for the plane from Managua to arrive in Siuna, as flight availability varies according to weather conditions. As with our journey to Siuna, two trips were required to transport all of us back to Managua. Once we arrived in the capital city, it felt somewhat jarring to be back in an environment with highways, fast food and cell phones. 

In the afternoon, we visited the Mercado Viejo, an artisan market in Masaya, a town outside of Managua. The market featured items ranging from pottery bowls and hammocks to sandals and coffee. Suffice it to say, no one walked away empty-handed. We also visited El Mirador de Catarina (Catarina Lookout Point) where we saw a spectacular view of the Apoyo lagoon, Mombacho volcano and, in the distance, Granada and Lake Nicaragua. Following a final celebratory dinner at a Mexican restaurant, the evening ended at our hotel, where we gathered with Bridges staff to reflect on our week in Nicaragua.

Sunday morning we took a quick tour of the major sites of Managua. We first visited El Parque Nacional de la Loma de Tiscapa, the former site of General Anastasio Somoza Garcia’s presidential palace and a prison used to torture dissidents during the years of his dictatorship. It is now a park that features views of the Tiscapa Crater Lagoon, Lake Managua and an enormous statue of the silhouette of Augusto Sandino, the leader of the 1927 rebellion against the presence of U.S. Marines in Nicaragua, who was later assassinated by the national guard under the command of Somoza. It is from Sandino that the Nicaraguan revolutionary group, the Sandinistas, derive their name. We also drove by the old cathedral, destroyed by the 1972 earthquake, and the current presidential palace.

The flight home was long. A two-and-a-half hour delay in Atlanta gave our group time to talk over what a great experience we had in Nicaragua. We owe an enormous thank you to our NGO partners, Bridges to Community and Salud Sin Límites, as well as the many Siuna and Hormiguero residents with whom we had a chance to meet and work. We also want to thank J.B. Grant advisors Tim Baker and Rashid Chotani, Shand Green, and the MPH program office for their support that made this trip possible.  ¡Muchas gracias!

Public Affairs media contacts for the Johns Hopkins Bloomberg School of Public Health: Kenna Lowe or Tim Parsons at 410-955-6878 or paffairs@jhsph.edu.