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.

Summer Institute on Migration and Health

Week 5

This was the week of the much anticipated “Summer Institute on Migration and Health” in Puebla, Mexico. Juan, Maria, and I took a break from the SMA life and went down south on Sunday, a journey which involved a few buses and many hours. To avoid a tiresome play-by-play of the conference, I will give a general overview of the conference and there are pictures down below for those that don't like to read blogs.

The main cathedral of Puebla

The conference, the Summer Institute on Migration and Health, is a collaborative effort supported by a few organizations that have a vested interest in the health of migrants. The first, and what I believe to be the guiding force is the Health Initiative of the Americas, a research/ program development group out of UC Berkeley, the second IME, Institution of Mexicans of the Exterior, which had the financial backing of successful migrants, and BUAP, the local university in Puebla that hosted us. From what I gathered, the primary goal of the conference is to improve migrant health by bringing together researchers, program directors, program staff, and students who are involved with migrant health and give an introduction to the most salient issues.

The conference consisted of presentations, workshops, and gatherings to facilitate networking. These components of the week were sandwiched between formalities and ritual, which I am beginning to understand as a necessary part of any get-together here in Mexico.The informational presentations were very helpful in getting more information of issues focusing on migrant health. The presentations touched a little on everything, from migrant rights, to juxtaposing the US and Mexican health systems, to the mental health of migrants. As any conference, some speakers were more dynamic than others, but all were contributing to this bigger picture of migrant health.

Topics that stood out were the mental health presentation by a Spanish psychologist who talked about a “Ulysses Syndrome.” Basically, a collection of symptoms that is common to migrants, who are often mis-diagnosed with such illnesses as depression. Another interesting speaker was a Dr. Schenker out of UC Davis who is interest in occupational health hazards migrants are frequently exposed to. My research interest was piqued by his talk.

In addition to the presentations, there were workshops which mainly focused on the programs that address migrant health. I went to one on HIV where we got to hear from with Jorge Zepeda of the SF AIDS Foundation. The workshop, was especially effective because a migrant with HIV who had navigated both US and Mexican health systems was present to share his experiences. The second workshop I attended was on a Mexican program called "Vete Sano, Regresa Sano" (Leave Healthy, Come Back Healthy). The program tries to inform and educate migrants before they head off to the USA so that they can know a little more about what to expect on their journey. A fantastic idea, but from the providers present, it sounds like the program is underfunded and could benefit from some organization.

Along with expanding our knowledge of migrant health issues, we were also there to network, to possibly provoke future collaborations with other participants. I know Xochitl (director of Health Initiative of the Americas) was especially excited about this because of plans of bi-national research she intended to fund. The networking was encouraged and supported by frequent cocktails and field trips out to see the sights in Puebla. The whole conference had a comfortable, homey, vibe which eased conversation with fellow participants. I was able to connect with many folk who work with migrants, and I think it would be fair to say that many of us students the left inspired and excited for the next step.

I am not sure what these next steps are, but I now know the people I need to be talking to.

Now for some more pictures...

Licensiado Mario, director of IME. He likes to talk about how great Puebla is/was/will be. I enjoyed his Poblano pride, and hearing about his cherished city.

The UC contingent: top row: Diego, Alisun, Shruti, Anisha, and Leslie. bottom row: Maggie, Rachel, Priscilla, Naya, Maria-Elena, and Me

Our informal guides who work with Licensiado Mario, Adal in white shirt and Roberto in green. Adal is a suprisingly adept breakdancer; Roberto enjoys all music, but prefers Reggaeton.

Tour of the catedral

Organ of the catedral

Meditation to fight the post-lunch coma

Michael Flynn, he works for the CDC and gave a presentation on the health system for migrants in the US. Mr. Flynn proves that you don't have to sell your soul nor live in Atlanta to work for the CDC. Comforting.

Networking

Bi-national photo : Diana, Maria-Elena, Priscilla, and Sagradio. Diana and Sagradio are graduate students from Sonora. One of the future goals are bi-national partnerships, however, these were the two students from Mexico. A start nonetheless...

Networking and Dancing

Snack time for students

It's a gordita!

The participants of the summer institute hearing from the clinic staff, as part of the field trip

Birthing table with a observation area for students (not us, nursing students and such)

Tonanzintla, a church that blended indigenous and missionary mythology. As the guide said: from the outside you cannot imagine what the church holds inside.

So, alongside Jesus, there were two thieves. One repented, and one did not, the penitent got a straight cross. There two thieves are tiny to demonstrate how much more important Jesus is.

Crazy ornate

200+ faces in the dome. The faces are of children, because in the tradition of the the indigenous peoples living there at the time of the construction of the church, in the afterlife one becomes a child once again. The missionaries decided to incorporate those traditions into their spiel so that their message would be more palatable to the locals.

Xochitl addressing the group at the field trip luncheon

Mole Poblano... this has been the best dish I have had in Mexico

Relaxing with some golfito back at the hotel

Closing ceremony at the Puebla City Hall

Mario and Xochitl

Credit where is credit is due. Many of these photos come from my colleagues. Big thanks to Shruti, Diego, Anisha, Nura, Morgan, Naya, Maggie, and Ana Paula for the excellent photos.