I'm looking forward to seeing some of you in April. I know this is something that you've heard before, but please know that your support is life-giving, hope-giving and life-saving. Many of you have supported us from the beginning of our health work, for 15 years. You may be asking, “What?, she's still asking for money? Why can't they get their act together and be self-supporting?” The answer is simple: the poor we serve have no money and no way to make money. The government, whose job it is to provide basic health care, is too poor, also. So, we go on begging from our friends. 
 

Why is it important to keep the clinic alive? Friends tell me that the world is going to hell and I believe them. George Bush again, the terrorist Negroponte becoming the head spy, CAFTA looming, threatening more hunger, and landlessness, Iraq, U.S. plans to bring "Democracy" to more countries rich in natural resources and hope (Cuba, Venezuela). My childhood faith told me that if we do good, and follow the rules of our faith, our lives and the world would be okay. Our child's faith doesn't work anymore, does it? When this evil plan to rule the world by violence and make the most amount of money possible for the transnationals collapses, as it must, what will we be left with? I believe that we will be left with models of work. Of poor people who, with the help of their friends, have organized to meet their most basic needs. I believe that the Maria Luisa Ortiz Cooperative is such a model and, therefore, deserves your continuing support. I'm giving it all that I've got with the years left to me.

Please enjoy an article in this newsletter written by one of our visiting doctors. The group of progressive health workers, Doctors for Global Health (DGH), sent volunteer gynecologist, Dr. Linda Price, and anesthesiologist, Dr. Dan Price to inaugurate the operating room by performing 25 surgical sterilizations and one hysterectomy. Many of the women sterilized had more than 10 children and were not candidates for other birth control methods. Also, please learn from our visiting public health specialist, Sue Howe, about Mulukuku’s new official status as a municipio. She also writes about the pap smear study we conducted. We have been accepted to present our findings with Dr. Janice Smith at the International Health Medical Education Consortium in San Francisco at the beginning of the tour.

Dr. Saul Contreras, Director of APS (Atencion Primary en Salud) continues the monthly three-day classes in early recognition and attention of disease for 28 community health workers. Each health worker now has a supply of 20 basic pharmaceuticals and plant medicines with which to work. These workers join a growing network throughout the country. APS addresses the lack of access to health services that the majority of the rural poor suffer. Added to this training the health workers received a two-day monthly course in Human Rights Recognition and Intervention in Violence from the University of the Atlantic Coast. Each health worker preformed a diagnostic study of violence in her/his community.

Thank you, dear friends for being with us. Your life, resources and good hearts are precious and absolutely necessary for the survival of this endangered earth and all it's rocks, plants and creatures including the women and children of Mulukuku.

Women 7,225
Men 881
Adolescents 1,390
Children 1,822
Dental 113
(62 children under age 5 received
2 prophylactic treatments)

Total 11,431

Protection of Intra-familial Violence Program:

Consultations for women and children 17,144
Legal Office Actions:
Criminal Cases: 194
Civil Cases: 243

Women and children in Refuge 30

Pre Natal Care 1st visit 418
subsequent visits 693

Family Planning 1st visit 489
subsequent visits 1,014
Pap exams 1st visit 852
subsequent visits 725
Transfers for further health care 376
Cases of malaria 1,014

Alice Nadelman, of Teaneck, New Jersey celebrated her 60th birthday by encouraging her friends to donate to the clinic in Mulukuku. What a tribute to the wisdom we gain over the years! Joan Lewis did the same in Warsaw, Missouri. Thanks, gals!

Susan Studebaker donated her time to write an $18,000 grant for the tuberculosis screening and treatment project, and it was funded by the Potts Memorial Foundation in November! Those with the stamina for grant writing are near and dear to our hearts.

Two memorial donations were received this month, one from Sherrill Hogen who writes: “My great-nephew, Mason Ritton, age 4 years and 4 months died on November 17, 2004 of complications caused by failure of his body to continue to support a transplant of his small bowel and liver which he received at 17 months. He received the best treatment money can buy plus the great love of his parents and baby sister. I choose to remember him by donating to your clinic where your great love will stretch these dollars to help many children who have not been as lucky as Mason, in hopes they will survive. Thank you for your dedication and courage. May the coming year bring you many blessings.”

Linda Lucas also made a donation in honor of Phyllis Stigall “who was a great champion of women’s rights and empowerment. She died this week at age 87. We will miss her. Keep up your good work.”

Thanks to all for sharing your love and kindness through gifts of healing and dignity.

Our kids, Maya & Zoe, were excited to go to Nicaragua (as they had been when we went to El Salvador for the prior 2 years for 3-4 weeks each time). They were now 6 & 8 years old -- veterans of sleeping on airplanes, standing in long lines at the airports, and eating beans & rice 3 times a day.

My husband, Dan, and I are doctors who work at the county hospital in Oakland California and have volunteered for Doctors for Global Health (DGH) for 3 years. Our kids end up being a great ice-breaker and most local people seem pleased that they are learning Spanish.

We met Dorothy Granada at the DGH conference in July 2003 and were caught by her charisma and vision. She made a plea for doctors who perform women's surgeries and we responded. I am an ob/ gyn and Dan is an emergency medicine doctor. We could only go in November of the following year but we did do it.

With the assistance of Dorothy, Grethel, and the staff at the Women's Cooperative Clinic we performed 26 mini-lap tubal sterilizations and one vaginal hysterectomy with bladder suspension (that patient had 12 vaginal deliveries- ouch!). We used the BRAND NEW operating room!

We used anesthetics which do not decrease a patient's drive to breathe so we did not need to assist breathing on any patient (midazolam, morphine, kefzol and ketamine for you medicos out there).

Grethel and the clinic staff had hand-picked the patients as being the poorest of the poor - those who could not really feed the children they already had and for whom more children would mean no chance ever of a better life. It was so nice to receive tearful hugs of appreciation the next morning from the patients. Several invited me to their houses for coffee (unfortunately that meant a 3 hour walk one way and I didn't have the time or the leg muscles that they did).

On our first day of clinic, a baby came in and died. The grief and unfairness of an easily treated condition was heavy. The mom had done the right things but the lousy doctor down the road that she saw only the afternoon before had not even examined the baby. The baby had died of malaria which in Mulukuku still responds well to medications.

Later that week a 7 year old boy was carried for 4 hours into clinic by his 98 pound mother. He had been bitten by a poisonous snake. The mother was concerned that the dry moss placed on the snake bite by the herbalist was not working. There was only 1 vial of the correct medication left at the clinic. The boy was in terrible pain and fear but after a sedative and the vial of anti-venom he began to recover ever-so-slowly. Two days later when both the boy and his mom were smiling it brought tears to my eyes.

While we were performing surgeries, our kids played on a farm with Grethel's grandkids. They got to go swimming, drink coconut milk, go for horseback rides (and "ponyback" rides), watch baby pigs drink from the mama pigs, chase chickens and check out 4 tiny bats that slept during the day high up on a wall. Our kids still rave about a special kind of fruit drink called Calala juice. They got to see a baby be born, see the boy with the snake bite get treated & improve, and they saw the recovered patients being thankful.

On a Sunday afternoon we got a special escort of 5 friendly 7-10 year old boys to go to the river. It was warm, the rain was warm and those boys really took care of our girls. While we were all playing rock the canoe over, laugh & get back in, I realized this lovely hand-carved wooden canoe was of course made of the local wood -- mahagony! We were playing in a very valuable canoe!

To end with I'd just like to say that all those unbelievable stories about Dorothy's love & courage are really true. And, she is part of that community -- not a rich intermediary. Like my kids said, "She is famous but doesn't even act like it!"

Linda Price MD, Berkeley

Volunteer surgeon Dr. Linda Price and her daughter enjoy the morning light; this “quiet” scene is accompanied by roosters!

Successful Cervical Cancer Prevention in Mulukuku
By Susan Howe, MPH, San Diego

In 2003 the Maria Luisa Ortiz Clinic (MLO Clinic) participated in a new cervical cancer-screening program involving the coordinated efforts of three organizations. Nicaragua’s Ministry of Health (MINSA) donated 2500 free vouchers for Pap screening and follow-up treatment if needed through the Ginecobono program sponsored by the Instituto CentroAmericano de la Salud (ICAS), a non-governmental health research organization. The MLO Clinic coordinated outreach, education, screening, tracking and follow-up of patients. ICAS coordinated quality controlled cytology and diagnostic work-up with LEEP treatment, if needed, and MINSA provided follow-up for those patients requiring more extensive cancer treatment.

An evaluation of the first year of the program (2003) showed that it was remarkably effective. Coming from over 79 remote communities throughout the North Atlantic Autonomous Region, a total of 2132 women received Pap screening. 68% of the women were 25 and older and 32% under 25. The proportion of abnormal screens requiring diagnostic follow up was 3.7 % for women over 25 and 0.04% for women under 25, which is more than four times what would be typical in the USA. The proportion of women with abnormal results who received diagnostic work-up and treatment if needed was 91% for women over 25 and 100% for women under 25. The majority of the women were detected in the early stages of disease when simple one-day outpatient treatment can prevent invasive cancer. The ratio of pre-invasive disease to invasive disease was almost two to one.

The success of this program demonstrates the quality of service that the MLO Clinic is providing. The MLO Clinic was able to reach the women of the RAAN at highest risk for cancer, with quality cytology screening and high rates of diagnostic follow-up, showing that cervical cancer screening can succeed in remote, low-resource settings when coordinated efforts are made to remove barriers and ensure quality.

The 2500 vouchers have now been used, and the MLO Clinic is looking for funding or other methods to continue their successful program. A voucher for Pap screening through the Ginecobono program costs $12 (USA Dollars) but this fee covers the cost of diagnostic work-up and treatment if the woman should need it.

Clinic Director Dorothy Granada, Public Health Specialist Susan Howe of San Diego, and Dr. Janice Smith of Galveston will present these findings at the International Health Medical Education Consortium (IHMEC) conference in San Francisco on March 31.

Mulukuku Wins the Right to its Own Municipality

Mulukuku and the surrounding villages in the western section of Nicaragua’s North Atlantic Autonomous Region (RAAN) scored a victory in October when they won the right to organize and represent themselves as their own district (municpality or municipio).

Both the clinic and the legal office run by the Maria Luisa Ortiz Cooperative serve the poor, underserved and neglected region on the west edge of the RAAN. Located between Rio Blanco to the west and Siuna to the Northeast, these communities have been caught in a political no-man’s land, unable to organize their local services or elect delegates to represent their local interests. This victory will help them move forward.

An important factor in winning this victory was the development of a network of community representatives (Brigadistas). Throughout 2004 these Brigadistas came into Mulukuku each month for a week of medical and legal training so that they could diagnose and treat the most common illnesses, help settle disputes and resolve family issues in their communities, where there are no doctors or lawyers.

In July these Brigadists came to Managua as a large group and pleaded their case for re-districting before a committee of the National Assembly. Demonstrating their training, they were well organized, spoke eloquently and presented a strong case for re-districting. There have been other large, well attended meetings held throughout the Mulukuku region as well.

This is an important victory and will pave the way for more organization and better services for the area. It will also enable the clinic and the legal office to better coordinate and follow-up on needs in these outlying communities. - Susan Howe, MPH, San Diego