What I Learned From My Time in Nicaragua
When I heard about Natural Doctors International (NDI), I knew it was an organization I had to get involved with.
As I par roused the NDI website and flipped through pictures of their clinic on Isla de Ometepe, Nicaragua, something occurred to me. I only had access to naturopathic and integrative medical care because I was able to pay for it and only because I was desperate to feel better after my bout with Lyme disease.
Something about this idea, that the medicine I was studying would be reserved only for patients who could pay out of pocket for it, really bothered me. NDI was my opportunity to witness the reverse— free primary naturopathic medical care for people with limited access to any other form of health care.
For eight months, I and seven other naturopathic medical students organized fundraisers and solicited donations from nutraceutical companies for our ten-day trip to Ometepe. We were eager to gain clinical experience and simultaneously help a severely underserved community.
It didn’t really hit me until I was attempting to argue in broken Spanish at the Nicaraguan border for the safe passage of our donated supplements that I was finally there. I remember feeling a twinge of nervous ambivalence. I had no idea what to expect and no idea if I was actually prepared mentally or emotionally for what was to come in the next ten days. After all, our first year of medical school had just finished a week ago and I felt like I hardly had time to catch my breath.
We spent our first two nights in a little hotel in Managua, the country’s capitol and largest city. It had been a while since I had been in a foreign country and even longer since I had been in a third world country. Despite the beauty in its people, culture, and landscape, the poverty in Managua was glaringly obvious. I found out after I had already arrived that Nicaragua is the second poorest country in the western hemisphere.
On the morning of our departure to Ometepe, four students from the naturopathic medical school in Puerto Rico joined us at our hotel. I was suddenly feeling a little bit more relaxed about our language barrier as I listened to them speak Spanish fluently. I also felt somewhat discouraged that my five years of high school Spanish gave me no discernable advantage in a Spanish speaking country, other than knowing how to ask someone’s name or how to find the bathroom.
It was another long travel day to our final destination, the little island in the center of the giant Lake Nicaragua. My nervousness morphed into excitement as the ferry approached the island. The two peaks of the volcanoes that are the islands namesake were barely visible through the fog and the island seemed so mysterious to me.
In the short fifteen-minute van ride from the ferry dock to the town of Los Angeles, Ometepe, I tried to take in as much visual information as I could to get my bearings. My gaze was locked on the expansive farmland, the passing islanders, their herds of farm animals, and the colorful concrete houses with tin roofs lining the single paved road.
We were welcomed under “el rancho” the large gazebo like structure that would be our meeting place and sanctuary for the next ten days. Dr. Dawson Farr, ND, the medical director of NDI, spent that first day with us reviewing the physical exam skills we would be responsible for conducting and what to expect of working along side him in the clinic.
We learned that first day that NDI is the oldest naturopathic global health organization and only permanent medical clinic offering free naturopathic integrative health care to an underserved community. It was founded in 2005 by Tabatha Parker, ND, and has since serviced over 25,000 patients while generating around 500,000 US dollars worth of medicine and supplement donations.
NDI is not a medical tourism group and this was strongly emphasized. It is NDI’s philosophy that in order to provide true and lasting health care, it is important to integrate into the community and to understand and work within the local government’s rules and regulations. Along these same lines, NDI believes that the motivation for change is likely to come from respected members of the community, and empowerment at the community level is what propagates change.
As a part of their community integration, NDI employs local women to host the medical volunteers. So after our debriefing at el Rancho we were introduced to our homestay moms and we settled into our temporary homes. I will never forget the warmth and kindness we were received with, despite my insecurities of what these people might think of us.
Would they resent us for smelling too strongly of mosquito repellant and carrying too much baggage? Do they think its weird that we only drink water out of a special filter that is installed specifically for NDI volunteers? Will they be offended by our 5th grade level Spanish speaking skills? These were all legitimate concerns of mine before I met the smiles of our house mom, Rubina, her daughter, and young grand daughters.
Despite NDI’s permanent fixture on the Island, we were told that the islanders always know when a medical volunteer brigade is in town. To the people of Ometepe, a brigade visit means that there is a new batch of donated supplements and extra hands for physical exams. On my first day on shift at the clinic, I was overwhelmed by the crowded waiting room, filled with patients from all over the island that had been waiting there as early as four in the morning to get an appointment.
In the four days at the clinic the student volunteers split time between shadowing the attending ND’s, the staff psychologist, Lilliam, and preforming physical exams in the waiting room. The following themes became glaringly obvious.
Chronic disease plagues the majority of the patients and the underlying cause is poverty
Naturopathic medicine aims to find and treat the root cause of disease. But as Tabatha Parker recently pointed out, “The underlying cause of disease on Ometepe is poverty.” So how do you go about treating the root cause of disease when your patients do not have the means to change their circumstances?
As far as I could tell, the typical diet on Ometepe consists of rice and beans with a side of fresh fruit juice and maybe some plantain fried in vegetable oil. Meat isn’t usually an option because it’s too expensive.
What is even less expensive than the foods listed above is imported packaged foods full of preservatives, refined sugar, and oxidized or trans-fats. Naturally, these foods become staples. Although vegetables could be grown in Ometepe’s favorable climate, families do not have the time or resources to devote to growing these low yield, low calorie foods for their own consumption.
Ometepe is a farming community, devoted to cash crops like tobacco, coffee, rice, beans, plantain and some other fruits. Men spend most of their days doing difficult manual labor in pesticide ridden fields while the women stay at home, take care of the children, cook, and clean.
The consequence of these lifestyle factors is health care comprised of symptom management. Ironically, the non-communicable diseases that came through the clinic are generally considered diseases of abundance. Diabetes, hypertension, heart disease, fatty liver, and gastritis were some of the most common presentations. There was also a high prevalence of anemia and other nutrient deficiencies. A large percentage of patients presented with chronic pain and arthritis from a combination of a labor-intensive lifestyle and poor diet.
While it was empowering to be able to send these patients home with life changing supplements like fish oil for chronic inflammatory diseases or milk thistle for chronic liver diseases, it felt like a Band-Aid to the poverty epidemic.
A (very) high percentage of women on Ometepe are sexually and/or physically abused.
In my opinion, one of the most valuable assets to the NDI clinic is Lilliam Zacarias, the staff psychologist who grew up on Ometepe. She is the only psychologist on the island and provides an incredible resource for the high percentage of women who have been or are being abused.
Both of the cases I observed with Lilliam were cases of sexual abuse. Lilliam described the “Machismo” of the male community on Ometepe and Nicaragua as a whole. The oxford dictionary roughly translates this term into “strong or aggressive masculine pride.” This is a culture that emphasizes male dominance and reinforces sexual and physical violence against women. Thus it is more common than not as a woman in this culture to be taken advantage of or abused.
In observance of this disturbing trend, Lilliam has worked hard to advocate for these women, working with the local police force as a liaison for women seeking justice. Lilliam also works closely with the DIOSA program, a program started by NDI to increase accessibility to gynecological screening procedures like PAP tests for women. The program emphasizes women’s empowerment and provides workshops and outings for DIOSA women to learn about health topics and to be reminded of their value and voice.
Naturopathic medicine does not and should not be reserved for those who can pay for it
Despite the feeling that we were band-aiding patient symptoms and not addressing the underlying poverty on Ometepe, NDI has demonstrated a successful and self sustaining model for increasing health care accessibility in an underserved community. It is a start and giant step in the right direction for rebalancing the distribution of health resources. Naturopathic medicine offers a special kind of health care that is especially helpful for these patients.
Many of the patients came in with empty homeopathic prescriptions and multivitamin supplements from prior brigades, asking for more because they were so helpful. And while we had limited ability to influence diet choices, I will never forget the story of the patient who came in with diabetes, weighing over 200 pounds, and wanting to lose weight. One of the attending NDs prescribed two simple recommendations. Replace rice with beans and eat fruit rather than drinking it. These minor naturopathic interventions can make major differences in the lives of these patients.
NDI is working towards a more sustainable “farm to clinic” supplement model, utilizing locally grown herbal medicines for use in the clinic. Last time I checked, it’s pretty difficult to grow your own NSAIDs or hypertension medications. As this model continues to develop, the clinic will be less reliant on supplement donations and can still offer a robust medicine chest in between medical brigades.
A surprising catalyst for change
I have only had a few months to reflect on my time at the clinic on Ometepe and I’m not sure that I have completely integrated my experiences there with my life at home on my journey to becoming an ND. I have a hard time coping with the fact that there are such inequities in health care across the globe. I still feel a weird mixture of gratitude for the life and opportunities I’ve been given and guilt for spending most of my life ignorant to issues in health care abroad.
In our closing exercises, all of the student volunteers were asked to participate in a ten minute free form writing meditation answering the question “What moved you the most during your time in the NDI clinic?”
Despite my disjointed stream of consciousness during this exercise, the dissonant feelings of gratitude and guilt are very apparent in my response. I wrote mostly about the resilience of our patients and my happy surprise at their openness and faith in the medicine we had to offer. This faith is a true testament to the service NDI has provided and their influence on the community of Isla de Ometepe, Nicaragua. It is my hope that this faith will continue to be a catalyst for the growth of sustainable, accessible naturopathic medical care on a global scale and in other underserved communities.