Margaritas

Helping out the Margaritas fundraising event was one of the last ways that I helped out the non-profit CASA. I published the following article in the local ex-pat weekly newspaper of San Miguel de Allende. My goal was to talk a little about the inadequate attention focused on chronic diseases such as obesity, and juxtapose chronic disease against the hysteria for H1N1. With that focus of attention, encourage people to support CASA by attending the fundraising event that was planned for the following week.

Without further ado...

Health and Perceptions
By Daniel Madrigal
Obesity and the influenza pandemic are two of the most serious health threats in Mexico today. One of these has the whole world on edge waiting to see what will happen next. The other affects 60 percent of the population and is a primary factor in the leading causes of death in the country (diabetes and cardiovascular diseases.) They both have had wide coverage in the media, but lately the importance of obesity has taken a back seat to the H1N1 virus. The influenza pandemic has captivated our attention primarily because nobody really knows how serious the epidemic will be. Some fear that the second year of the flu will be more lethal, as was the case with the Spanish Flu of 1918.

Understandably, public health organizations are devoting energy and resources to ensure that mortality related to the H1N1 virus doen not far surpass the 119 deaths already confirmed (as of July 6). At the same time, the obesity epidemic continues in Mexico with the trends not showing signs of change. National surveys have found six out of ten Mexicans are either overweight or obeses. The statistic has profound implications when considering a study from the Mexican secretary of health, which found that 12.2 percent of deaths in the county have "high body mass index (BMI)" as a primary risk factor. That works out to approximately 57,000 deaths a year, or about 150 deaths a day attributable to high BMIs. With such dramatic figures, one might expect to hear more about the obesity issue rather than the H1N1 virus.

The attention on influenza has produced prevention messages that focus on the use of anti-bacterial gel and facemasks, but what is the solution for the obesity problem? Though a pill doesn't exist for high BMI, the solution is simple: people need to eat healthier and get more exercise. Unfortunately, like many other chronic diseases, the underlying economic, social and political causes are more convoluted. The tangled web of causes complicates the creation of an effective intervention to the simple solution. A comprehensive approach is needed that accounts for all these causes.

In San Miguel de Allende, one organization already is preparing a program to effectively deliver healthy messages about nutrition in the community- CASA (Centro de Adolesceentes de San Miguel de Allende.) Together with community members and health professionals, CASAs experienced theater and radio groups are developing an educational play about nutrition to be performed for local children and youth, and a 12-part radio series to address issues including early good nutrition, breast-feeding, and nutrition and exercise during pregnancy. Increased awareness of how nutrition affects obesity is one component of the comprehensive approach. With the efforts of CASA, more people with understand that dietary choice is as importanas covering your mouth when you cough.

You can help support this work by attending CASA's second annual Margarita Contest on the CASA roof terrace in Colonia Santa Julia. Nearly 30 local restaurants are participating in this enjoyable evening that includes music as well as hors d'oeuvres created by local chef Kristen West.

Tickets are available at La Conexión, La Victoriana and Vía Orgánica as well as the Biblioteca Pública on Sunday 11am- noon. For more information, contact Margo at 154-6060 or cast-interns@hotmail.com

Throughout the writing of this piece, I was very conscious of the inherent contradictions proposed. On the one hand, I suggest greater attention to obesity prevention and at the end I suggest people should go spend some money on a Margarita contest to reach that end. If the "ends" justify the "means" right?

In any case, the event went off spectacularly, and there were was money and awareness raised to the nutrition programs of CASA.

Hors d'ouevre offered by the coordinator of the sexual health education program, Miguel

Mixing among the patron. The "catch" of the fun of the event was to try Margarita's from restaurants around town and judge the best one.

An example of an entry, little taster cups of the margaritas, and then little stickers for the people that voted. This one was of the chocolate variety and was boosted by a spicy little kick.

More mixing and mingling between tastings.

View from the event. The space used was the roof of the CASA building, which happens to have quite the breath taking view.

End of the night, the sun set, and patrons left as CASA employee's busily packed everything away. A few weeks later, word got back from the event coordinator that the event garnered $34,000. For me, the means have been justified.

Intership Notes: Finishing Up

Week 8

Data entry

Also this week, I had the opportunity to speak to the HIV coordintor for the municipal health dept. of SMA. I was able to get another perspective on the HIV services and learn what patients with HIV did in this jurisdiction. A little more difficult for these folks because they have to travel over an hour or more by bus to get to the CAPASITS clinic in Celaya.

Week 9

Data Analysis, umm, but I must say it feels a little disingenuous to call it "analysis" if I don't have a regression or even a p-value anywhere near the report. Nonetheless, data was analyzed and summarized using my second favorite statistical program, STATA.

I had the chance to speak with Dr. Meza (state HIV coordinator), it turns out that the health insurance system in México is way complicated. There are several different systems, like PEMEX, SEDENA, IMSS, IMSTEE, who each have their own networks. It's like if each gov't dept had its own veterans style health insurance system. PEMEX is the one for the Mexican owned petroleum company (I wish we had one of those!). SEDENA I believe if for the military, and IMSS and IMSTEE are for other groups of people defined by their occupation. He was commenting about the complications that arise from these fragmented systems.

Also, I learned more useful information about why CAPASITS Celaya had a hard time participating. Apparently, they are still under the management of the general hospital, so that is who they needed approval from to collaborate with us. As I have mentioned in past posts, the Celaya General Hospital has been less than helpful with the HIV related projects.

Week 10

In the last week, I wrapped all my tables and graphs into a report to be turned in the state health dept. All written in Spanish with some necessary grammar help from Juan and María. With the report I was careful to describe "issues" and recommendations with sensitivity, and in a way that they could perhaps be incorporated. One of the big problems that we noticed was that the budget the HIV programs operated on weren't enough to cover everything that we would've liked to have seen. With that in mind, I tried to aim the recommendations to the most pertinent issues such as providers not having the materials to follow universal precautions or the majority of participants not knowing what CAPASITS (HIV clinic) is.

Zihua

After a the workshops I took the weekend off to go to Zihuatanejo to check out the beach, and what the coast of Guerrero has to offer.

Municipal Beach in Zihua

Maritime Anthropological Museum

The Hostel del Viajero, where I slept. A super find thanks to Lonely Planet, there is a spectacular garden inside, and the keeper of the place, Mali, is just as personable and fantastic as LP says.

Soccer game just across the street from the hostel. About two seconds away from a gol.

When I took this picture, I hadn't done anything. Darn inquisitive children.

This is what the center of Zihua looks like.

Pancakes! A guilt pleasure to be sure, but one that could not be resisted.

Pelicans chasing chum.

Quack.

Looking out over the Zihua Bay

I'm on a boat!

No, not a scene from Spaceballs II, these guys were the beach patrol in Zihua. Although these two look all fuzzy and nice, their colleagues with automatic guns were much more menancing. That whole narco-trafico issue is pretty serious in the state of Guerrero.

Tata! Tienes tocayo!

Melodious multi-tasking.

Barra de Potosí. A beachside town about an hour south of Zihua, made up of several beach front hotels and restaurants. The restaurants are said to have spec-tacular seafood, perhaps next time. The restaurants did have hammocks and agua de coco... mmm.

Internship Notes: The Workshops

Weeks 7 & 8

After the first half of the summer spent preparing for the workshops, we were finally able to start the workshops. The workshops on HIV discrimination and stigma were conducted in the city of Celaya about an hour drive from SMA. They were done here because there is larger population and an HIV clinic (CAPASITS), so the presentation might be able to help some people. We had thought our participants would come equally from the General Hospital of Celaya and the local health dept., but we did not have the support of neither the General Hospital nor CAPASITS. Fortunately, the local health dept. of Celaya were extraordinairely helpful, and they provided all the participants and support that we needed.

The drive into Celaya from San Miguel de Allende.

To begin, we had three main goals with the workshop. Hopefully, we thought, they would be realistic, and something that could be delivered by the end of the day. 1) Create consciousness about stigma and discrimination against HIV/AIDS. 2) Expand knowledge about the rights of people living with HIV. 3) Identify strategies to reduce discrimination and stigma in the medical setting. With that, we were off...

The workshop was a 5-hour event conducted at a hotel in Celaya, a very nice set-up supported by the Guanajuato Health department. Starting at 9am people started filtering in, signing-in, mingling, all of the necesities of any decent mandated training. The day started with the surveys that I had them fill-out, this was my part of the project the stats that we could count up later if you will. The survey asked about general demographics, as well as some questions pertaining to perceptions, knowledge, and behavior concerning people with HIV.

The first day they had us in the hotel bar, a little cramped but fine nonetheless


The second through fifth workshops were done in the hotels actual conference rooms...

We had various anti-discrimination type posters up in the room of the workshop, creating an ambience of compassion, or something. This one says: "When you discriminate... you look VEEERY BAD"

Then into the workshop... starting off, all participants have a little paper that designate them a role to play. The role's are of those people who CENSIDA has termed key populations (poblaciones claves) as well as "general population." Throughout the workshop, Juan and María would ask them to embody the role, and think from the given perspective. From there, on into the "meat."

The first part was section guided by Juan on stigma, talking about historically stigmatized groups, and the etymology of the word (Ancient Greeks) and how they problem presents itself in México. Juan talks about four elements of stigma which include negative evaluation, rejection, isolation, and jokes. By telling stories of his own experiences he is able to explain how examples of stigma arise in their everyday life, sometimes without them being aware.

At this point we come up with a list of nicknames of the "key populations." For men who have sex with men, sex workers, transgender, injection drug users, and people living with HIV. You can imagine the longlists we compiled from all five workshops, the creativity humans have in name calling is impressive. Names that we have heard a lot in the day-to-day, that are often derogatory, yet we hear nonetheless. This part tended to be a lighter, people shouting out these"bad words," semi-hesitant, awkard, interspersed with nervous laughter. The participants, know as we do, that the words are disrespectful in nature, yet that does not seem to affect their presence. After this exercise, we had one of those"reflection moments," especially for those that drew a card that had one of those key populations.

Juan doing his thing, keepin' the crowd moving

Once stigma has been covered, María moves in to talk about how that stigma can become discrimination. Stigma being the thought, discrimination being the physical manisfestation of that thought. We start going over ways people discriminate in the medical setting; isolation, different treatment, longer wait, etc. Also, she covers a bit about internalized stigma, and when people feel deserving of different treatment, it can start to fulfill expectations, creating a nasty cycle that perpetuates the problem.

María and the Internalized E-Stigma

At this point, a lot of talk from Juan and María, but we wanted to share the voice of real people who had gone through this. We had wanted HIV patients from Celaya to come speak, but as the cooperation with CAPASITS had been so poor, that wasn't happening. Instead, we showed a video made by a Latino HIV support group in the Bay Area called "A todos nos afecta," (It affects us all). The video was a general overview of a lot of HIV related themes, but there were some poignant parts that would really highlight what the workshop was trying to focus on. Folks with HIV shared experiences of being discriminated against, or looking down upon for who they were. The voices complemented the power point presentations on the general themes of stigma and discrimination.

"A Todo Nos Afecta" Video

After the video, the participants were provided a hearty breakfast from the hotel. Thank you state health department. During the break, Juan, María and I had a chance to talk and interact a little bit more with the participants. For example; we learned that one lady had been to a similar type training five years ago... one that included speakers who were HIV+. Another lady, told us that she had done a similar study on stigma and discrimination in the General Hospital of Celaya for her thesis. Interesting pieces that added to our understanding of the situation with the HIV + patient in Celaya.

Hearty breakfast.

Following the break, Juan would jump into the universal precautions section of the training. One of the valid concerns people have is to be protected while they perform their work. The point here was to explain that universal precautions are UNIVERSAL, for everybody, so you can't pick and choose how you are going to be protecting yourself depending on the patient. That of course, is different treatment a primary source of discrimination. Some participants have seen providers appearing like "astronauts"  with all the gear that they have on. The moral here, protect yourself with all patients, not just the ones who present as a "key population."

The penultimate block of the workshop was where María covered the rights of people living with HIV. We presented various cases of ethical issues, and asked the participants to decide on which side of the issue they agreed upon. María would then talk about the issue in the context of the laws of Mexico, and what were the legals rights of the people in these situations. 

Presenting the ethical issue. 

María used three issues: 1) Should a principal have the right to fire a teach who identifies as homosexual. 2) Should a boss/supervisor have the right to demand a HIV test from all employees. 3) Should a doctor have the right to tell an HIV+ women who is pregnant to terminate her pregnancy. Once the issue was presented we asked those in favor to stand on the right side of the room, those against to stand on the left side of the room. Then she would have them debate, and have them try to explain their rational.

Separating the room

After the first day, we realized that people who attend the workshop may have already dranken the kool-aid, and were on board with the message of compassion. To create some debate, we had all the "key population" folk stand on the easy side, and all the others, those of the "general population" stand on the devil's advocate side. That way, we could some what re-inact moral debate's that occur outside everyday. The devil's advocates were good, it wasn't hard to see that the arguments they used were familiar to everybody in the room.

Devil's advocates.

María explaining laws and the legal piece after one of the debates.

For the final exercise, we had them get together in their tables and think about one of the "key population" folk at their table. We had them think of how their work environments would present to this person, and brainstorm of ideas that could reduce discrimination. Basically, what can be done to improve this persons experience at where they work.

Group presenting their future recommendations.

Another group presenting.

And that was a wrap. We gave them the second half of my survey, as the groups finished presenting and let them leave once they finished.

This of course, has been a brief overview of how the workshops went, each one was unique and had a different feel to it. The overview would be incomplete without explaining the role's of key supporting characters. 

Ray- AV guy. Ray was with us throughout the workshops working the power point and video and just making sure the whole electronic situation was under control.

Dra. Ligia Padilla- The public health director of the local health jurisdiction. I am not exaggerating when I say it couldn't have happened without her help. She was enthusiastic, and supportive every step of our journey. If, or when I come back to Mexico, it is people like her that I want to be working with. 

Dra. Jose- The HIV coordinator of the local health jurisdiction. She was also present at every workshop, and was helpful and filling in gaps where we couldn't. One of the big surprises that we found was that few people knew what to do in the event of a needle stick, or even what the CAPASITS was. She gave a brief overview of their program, and let the participants know that they could go to the clinic if an accident every occurred.

Ray, Me, Dra. Ligia, María, Dra. Jose and Juan after the last workshop.

Internship Notes: Filling in the gaps

With the help from readers of this here blog, I have come to realize that I have left out a couple key components to my San Miguel de Allende summer. I am going to jump back and start at the beginning of my adventure and how I came to be involved to the state of Guanajuato for the 2009 summer.

As mentioned in the text box to the left, the masters in public health program that I am a part of requires a 480-hour internship. The internship has many requisites, but it is generally accommodating if you have a project you want to work on. Past students had gone abroad and from the beginning of my first semester at Berkeley, I was trying to make that happen myself. I had been interested in working in Latin America, so there were several professors that I wanted to talk to. Around that time, in my initial fact gathering phase, I was put in touch with María Hernández who works at the Center for Public Health Practice. She knew people in México who were doing public health work and were interested in collaborating with a student, which is how I met Juan and María.

María Aguilar and Juan Camacho both had public health careers in Alameda County, and had since retired to the town of San Miguel de Allende in Guanajuato Mexico. Although retired, both are actively involved in public health work; from hand washing campaigns to helping out a local mid-wifery school. They suggested a few possible projects that we could work on over the summer. Of them, the one project on HIV/AIDS stigma and discrimination was the most appropriate given my background. In 2006, there had been an article in the Mexican Journal of Public Health that described discriminating behaviors and stigmatizing attitudes held by some health workers. Juan and María had also received reports in Guanajuato of providers breaching confidentiality and refusing to work with patients who were HIV positive. The problem was clear, that some health professionals were creating uncomfortable environments that could possibly act as barriers to care for people who are HIV positive or at high risk for HIV.

The solution was/is not so clear. The intervention proposed by Juan and María is that we would do a workshop to sensitize providers to the issue. In short, we would make providers aware of what was happening, and hope to draw attention to the differential treatment that we had been reading and hearing about. As for my internship, I would evaluate the project by administering an survey before the workshop, after the workshop, and 3 months later. The survey asks basic demographic info: age, profession, do you work with HIV positive patients, and information about perceptions, knowledge, and behavior concernining HIV and HIV positive patients. The idea was to see a baseline of what providers thought, and then see if the intervention had any effect on them.

We wanted all hospital or clinic personnel who had interactions with patients at any time during their visit. This included the doctors, nurses, lab people, as well as security, custodial staff, and receptionist. The idea being that all of these people create the environment with which a patient find themselves, so to create a safer place it would be necessary to include everybody.

With those initial ideas, Juan, María, and I went about developing the project. During the spring semester at Berkeley, I created the survey for participants to see if there had been any impact by the workshop. At this time María and Juan spoke with health officials in Guanajuato working out the finer details of the implementation of the workshop.

DF

After the summer institute a bunch of students decided to visit Mexico City for a few days before heading back to our respective summer plans. I was able to stay for a only a day, but was able to pack a lot in. I had come with the impression that it was a crowded and polluted city, and left with a different perspective and a need to come return. Next time I come through, I will definitely need to set aside at least 3-4 days.

Here are a few of the places that we were able to visit...

Palacio de Bellas Artes


A Diego Rivera piece in the Palacio


Sitting in front of murals


Flash mob dance in front of the Palacio de Bellas Artes. For those unfamiliar with the flash mob, a group in a crowded public area starts dancing at a pre-planned time. No director, so people of the groups slowly come out of the crowd and start dancing. Within the dance there was a "get out and vote on Sunday July 5th" message (the following day). Go social marketing!

A few of us debating whether to spend 50 pesos to see a view of the city.

The DF group doing a gap model thing. From left to right: Ana Paula, Anisha, Nura, Diego, Maggie, Naya, and some random guy.

Guao, that's some good birthday flan


Picture of the Photographer


Piece outside Anthropology Museum


Bats are always cool


Lake in the Bosque Chapultepec


Diego and Maggie underneath the castle in Bosque Chapultepec which contains the Nacional History Museum


The castle's garden


Me, Maggie, Anisha, and Diego overlooking the Bosque


View of the Bosque Chapultepec from the castle


Ceiling at the entrance to the castle


Skulls at the castle


Mural at the castle


Ride you bike Sundays in DF. On most Sundays they have kiosks where you can borrow a bike for the day (not today, presumably because of the nation wide elections).

Again, big thanks Diego, Anisha, Nura, Ana Paula, Maggie and Naya for sharing their photos.