Sandra Jeanine Ortellado
The night before my visit to the Hospital de Clínicas in San Lorenzo, Paraguay, I sat in my aunt’s house, warding off mosquitoes with an electric fly swatter and taking refuge from a flash thunderstorm. With humidity and electricity in the air, mosquitos passed through an electric web and lit up in a purple firework. Leafing through pages and pages of family photos, microbiology textbooks, and Guaraní to Spanish and Spanish to English dictionaries, I could feel the potent elements of family, culture, history, and medicine interacting to build up a frictional electricity of its own. Meanwhile, hot moisture rose and cool rain fell in a thunderstorm cell outside my window, the energy in the atmosphere amplifying the sound of mosquitoes buzzing in my ear.
I don’t know exactly what those mosquitoes were buzzing in my ear, but after countless swollen bites—and subsequent allergic reactions—I know that whatever the message, it was important and urgent enough not to ignore.
I had come to Paraguay to understand something about the interacting elements of heritage, culture, and clinical and professional applications of medicine and biology. Previously I had only a vague, disconnected sense of basic biological concepts and my identity as a student and person of Latin-American descent. Volunteering with Health4TheWorld has been a part of my effort to enrich my knowledge and passion for health sciences by connecting them in context of the cultural and economic disparities that shape health outcomes around the world. As the daughter of an immigrant family, studying in a prestigious university and striving to create something meaningful out of my privilege and rich cultural heritage, I felt like I needed to see the lightning strike first-hand before I could communicate about it to others with the powerful resonance of thunder.
“One patient told me how much she loved the idea of something that could help not only patients but also their loved ones, with information available at their fingertips.”
So I went to the hospital the next morning and saw what I saw in several other hospitals, schools, and laboratories across the country. I saw that this hospital had been shaped by the community that built it and the people it served. I saw patients and doctors and researchers and professors whose connection to each other ran deeper than their resources. Where limited funds alone threatened advancement, resourcefulness and collaboration fueled growth and progress. Outside each ward, untamed flora grew abundantly from pure determination out of cracks in the middle of streets and sidewalks, in chaotic harmony with an urban jungle.
On several occasions, researchers showed me ingeniously crafted makeshift equipment for bacterial culture, plans for funds and equipment-to-come, and even told me stories of how collaboration with researchers and organizations in other countries yielded new technology and procedures for solving problems created by lack of resources.
When I met Dr. Alan Flores and his wife, who treat stroke patients in the Hospital de Clínicas, we soon discovered that they were former students of my aunt and her husband, who teach microbiology around the country. They introduced me to their patients and showed me around the hospital while they explained some of the unique obstacles they face in treating stroke. Limited funds prevent them from distributing enough stroke medication to treat all their patients over extended periods of time. Doctors at the hospital must apply for approval from the Universidad Nacional de Asunción that funds the hospital in order to receive more medication. For government-funded hospitals, getting essential stroke treatment medications like ACE inhibitors, blood thinners, antihypertensive drugs, alteplase and statins is even more challenging, since limited government funds are allocated towards healthcare. In fact, only 9.8 percent of Paraguay’s GDP is spent on healthcare, compared to 17.4 percent of U.S. GDP. However, these medications can be indispensable tools in treatment to relax blood vessels, prevent blood clots, and lower blood pressure and harmful cholesterol production.
According to the World Health Organization, stroke is one of the top ten causes of death in Paraguay, the second highest as of 2012. Cardiovascular diseases and diabetes carry the highest of burden of disease–severe hypertension is very common in Paraguayans over 60 years old. As Dr. Flores explained to me during my visit, Paraguay has a very high incidence of stroke in people over 60. A large proportion of people live in rural areas with no access to public or private medical care, so reaching these patients is a challenge. Additionally, private health insurance in Paraguay is limited, so that the poor population often cannot afford the fee-for-service cost of private healthcare. All of these are contributing factors to Paraguay’s small elderly population; as of 2013 only 8 percent of Paraguay’s population is over 60 years old, compared to 20 percent in the United States.
Of course, preventative and supportive care can be equally important in treatment of stroke. Exercising and quitting smoking can reduce the risk of a first or recurrent stroke (AHA). Rehabilitation and physical therapy can improve mobility and aid recovery from stroke paralysis. Speech and occupational therapy can improve the daily lives of patients (NSA).
This is was the motivation for the Health4TheWorld Stroke App that I showed some of Dr. Flores’s patients. With the app, H4TW aims to reach populations that have limited access to healthcare with information on how to care for oneself and loved ones after a stroke, as well as tools for patients to communicate and exercises for rehabilitation.
The app, which is currently available in Swahili, Spanish, French and Nepali, provides a “Help me speak” section with buttons that verbalize a need, desire, or thought that a patient wants to communicate. It also has an “Exercise” section with animated visualizations of rehabilitative strengthening and stretching exercises, with the option to practice them in an immersive 360 simulated out-of-hospital environment, like the market or the beach. The “Learn” section provides information on spotting a stroke and caring for family, and a “Reminders” section allows patients to set alarms for completing exercises, taking medications, or other tasks essential for recovery and treatment.
The patients I met were excited by the prospect of accessible treatment in the easy-to-use form of an app, not only for themselves, but especially for others. One patient told me how much she loved the idea of something that could help not only patients but also their loved ones, with information available at their fingertips. Another patient told me about how difficult it was for people in the rural interior of the country to get access to healthcare, since the nearest hospital is often too far away. Of course, the app is still working on incorporating the indigenous Guaraní language, one of the official languages of Paraguay. It’s commonly spoken in the rural interior of the country and is especially popular in a colloquial form mixed with Spanish, called Jopará, which is used by 90% of the population in Asunción area. Nevertheless, feedback from patients will be instrumental in providing Paraguayan ingenuity, resourcefulness, and cooperation for making progress.
I have been reading a lot of Latin American poetry since my trip to Paraguay and making connections between the words I read and the people I met. Paraguayan poet Manuel Ortiz Guerrero provides an appropriate metaphor for the ever-overcoming spirit of the Paraguayan people in a poem about the way that water in a meek stream flows innocently and eternally between rocks and obstacles. It reminds me that with a little flexibility and ingenuity, anything is possible. Sometimes multiple obstacles can create a new path, like the crack between two rocks through which water steadfastly flows.
And where streams converge in larger, more precarious bodies of water to tackle issues in global health, I like to think of Pablo Neruda’s description of a ship on the sea:
of wondrous collaborations
between fires and stokers,
navigators and stars,
men’s arms and flags in congregation,
shared loves and destinies
Hopefully H4TW’s collaborations with doctors and patients around the world will result in a similarly wondrous end product of shared destinies.
Neruda may be Chilean, not Paraguayan, but in the name of collaboration, we’ll share flags, too.
“The patients I met were excited by the prospect of accessible treatment in the easy-to-use form of an app, not only for themselves, but especially for others.”