eppinger 6

As I am nearing the end of my time in Guatemala, I have been wrapping up all of the projects I have been working on here. Cody Bowers has been writing about the Oral Rehydration Solution (ORS) project, so I will let him update about that in a different blog. The project that has been taking most of my time here is the creation and implementation of protocol for the screening and treatment of malnutrition.

After participating in care of children at the clinic, and talking with the clinic staff it was apparent that the solution to the inadequate treatment of these children would need to be multi-disciplinary, to address the problem from multiple angles. The clinic's previous protocol was to do exams, give vitamins, and educate the patients. These are all important things to do for the treatment of malnutrition, but the guidelines were so vague that they were rarely being implemented fully. After looking over the current research and discussing ideas with the directors at the clinic I developed a detailed treatment plan, and set out to identify available resources.

In speaking with patients, it became clear that there was a huge deficit in nutritional knowledge. Most people didn't know the difference between protein and carbohydrates. In order to fulfill the clinic's need for an educational plan, I designed one that could be made into a handout and used as a guideline for discussions in the clinic. I made up a food pyramid that was specific to the needs I saw at the clinic, and I included information about each food group, the functions of the nutrients, effects if deficient, examples of the foods in the group, and daily requirements. The other side of the food pyramid handout has information on malnutrition and hygiene, as well as a table to keep track of the child's weight. The clinic now has a sheet for each malnourished child's chart, and a master spreadsheet to keep track of the patients with malnutrition. The educational materials are now stored in each exam room, and a color laminated copy of the pyramid is on the wall in each room.

Another part of the project involved researching ways to get vitamins to these children. Due to supply issues, the clinic was only getting occasional bottles of B vitamins, but no multi-vitamins, and no iron for anemic children. I checked all of the local pharmacies and found an inexpensive multi-vitamin that we are looking into purchasing for the clinic. At the very least, we can write a prescription for the vitamin, and families can purchase it for $1.60 a bottle. Even if we have to wait on more donations or funding, it was important just to know what the local supply was. Previously, no one at the clinic knew what multi-vitamin was affordable, or even how to dose it. This information is very product-specific, and the foreign volunteers really struggled with it. The same thing was done to research an appetite stimulant.

Last Friday the whole clinic came together for a meeting. One of the most important parts of initiating a change like this is having the support of the people who will be doing the work. I was lucky to have support from the entire clinic. They realized the huge need for a specific treatment program, but didn't have the time or resources to create one on their own. Once everything was complete, we held a training session, where the medical students, volunteers, and medical director (head doctor) all took part in learning about how to institute this treatment protocol.

A major part of the training session was reminding people how to help motivate families to return for follow-up, and to have parents take a part in this process. It's easy for people to think there's an element of neglect involved when the parents do not bring their children in for follow-up, but I think it is much more complex. We have to win the trust of the families, and show them that the child's health is a collaborative process. We don't want to take all of the control, nor do we want to be left out when we are needed. There seems to be a stigma here about malnutrition, and many mothers are anxious to see the child's weight, and know if he is at a healthy weight. Any interventions we have to resolve malnutrition seem to be very well received.

In my last few days at the clinic I will be able to help make sure that the new malnutrition treatment program gets going smoothly. It has been exciting already to see families walking away with their educational information. Education is one of the best tools for health promotion, and I look forward to seeing it put to use in a variety of ways here.

by Jenny Eaton Dyer, Ph.D.

This week, CIFA released the long awaited strategic framework report entitled:

"Many Faiths, Common Action: Increasing the Impact of the Faith Sector on Health and Development."

This report was presented on November 23rd the at a meeting with high level United States Government representatives at the White House. Following a welcome from Reverend Joshua DuBois, and remarks by representatives from the Departments of State, Health and Human Services, USAID, and the White House Office of Faith Based and Neighborhood Partnerships. Bishop Dinis Sengulane of Mozambique, Ruth Messinger of American Jewish World Service, Abed Ayoub of Islamic Relief and Bill O'Keefe of Catholic Relief Services speaking on behalf of GIFHD Task Force presented specific asks of the USG, including requests for a high level Working Group for ongoing consultation with the faith sector in policy planning, support for the creation of multireligious collaborating mechanisms at the country level, and support for tools and research supporting congregation mobilization for health and development at the local level in developing countries.

The group was addressed by Dr. Nils Daulaire, USDHSS; Ms. Gayle Smith, NSC; and Dr. Rajiv Shah, USAID. It was clear they were taking the Strategic Framework for Action Report very seriously. Ms. Smith commended the value of the faith sector approach as a strategy for increased public sector engagement with the faith community, and Dr. Shah called for a roundtable to advise on the implementation of the recommendations at USAID. 

Senator Frist currently sits on the board of directors of CIFA, and Jenny Eaton Dyer, Ph.D. sits on the steering committee and task force for the Global Initiative for Faith, Health and Development.

eppinger los vahos

One of the interesting things about being in Xela is the high volume of foreigners living and working here. Xela is rather well known for its Spanish language schools, which draw people from around the world. In addition to the linguistic draw, Guatemala is filled with NGOs, and there seems to be an especially high concentration in this area.

The clinic where Cody and I are working has something of a partnership with a local group of hiking guides called Quetzaltrekkers. This group of outdoor-friendly hikers throws fundraising parties and divides the proceeds between the Primeros Pasos clinic and a school for children who otherwise would have no access to education. In return, medical volunteers from the clinic give classes on wilderness medicine.

A few weeks ago when Cody an I were asked to teach this class, we were a little bit caught off guard, because neither of us had had any specific educational training on the topic. But after a few hours of research, we were able to focus in on some important topics (fractures and sprains, concussions, and allergic reactions). The class went so well that we were invited back for a second one, and given specific topics to cover.

The opportunity to work with a different population (hiking guides who will be in charge of the safety and wellbeing of groups of people venturing out into the nearby wilderness) has been exciting. Our latest class was on medications to use while hiking, and some information about common illnesses. It has been interesting to work with this group because we can easily see how important it is for them to have this information. We are working on a lot of emergency management, and safety.

Xela, Guatemala

bowers pump

Primeros Pasos is a clinic that charges $0.62 cents for a pediatric consultation and $3.75 for an adult to see a provider. Any medicine in the pharmacy is free with the cost of admission and some remedial laboratory work is included in the nominal fee as well. The clinic is constantly receiving miscellaneous grants and substantial financial support from Inter-American Health Alliance (IAHA) to pay the salaries of the few employees that run the place and then volunteers take care of the rest. Lauren and I noticed two issues at the clinic that we felt we could address to cut costs and improve patient care. She moved directly into improving malnutrition treatment protocol and wrote an entire study that is waiting approval. We also have found that the clinic is frequently without oral rehydration salts (ORS) used as treatment for people, but especially children, with diarrhea. Lauren and I were frustrated by the absence of ORS packets in the pharmacy, which led us to create a project to expand care at Primeros Pasos. Finding the perfect recipe for ORS and buying 100 pound bags of salt and sugar is our immediate goal.

Severe diarrhea causes extensive loses of fluid and electrolytes and a child's body does not have the reserves to compensate for missing essentials. Before ORS (known as suero in Spanish) was instituted, intravenous fluids were used to correct diarrheal dehydration and millions of children were dying because they didn't have access to technical medical care. Now we can remedy the situation with salt, sugar and clean water. Rehydrate.org quotes that ORS therapy saves 1 million lives a year, costs about 10 cents per liter of solution and can prevent about 90% of diarrheal deaths in children. The initial recipe for ORS included 8 teaspoons of simple sugar, 1/2 teaspoon of table salt and one liter of pure water. Through many research studies and trial and error efforts, the recipe has been refined and enhanced to optimize diarrheal treatment for the vulnerable, yet resilient bodies of children. There are websites suggesting that vitamin C and zinc can be used to diminish the length and severity of diarrhea by up to 25%. Other sources have been adding artificial flavorings and additives to make ORS more palatable, but in our search for the best recipe we have chosen to abide by the most trusted and overarching source of pediatric medical care. The World Health Organization and UNICEF have combined to create a 123 page manual about oral rehydration therapy and this is now our guiding light. The WHO and UNICEF offer a simple recipe of 2.6 grams of salt, 1.5 grams of potassium chloride, 2.9 grams of trisodium citrate dihydrate and 13.5 grams of glucose. Four ingredients with life saving potential, all of which are usually available at any nearby grocery store.

The two ingredients that are rather abnormal for a grocery store are the trisodium citrate and potassium chloride, but thankfully there is research suggesting that baking soda can be substituted for the trisodium compound. Trisodium serves as a buffer for the acidosis of severe diarrhea and thus baking soda can serve the same purpose. Potassium being the second issue was not a worry because in the United States we prescribe large quantities of potassium chloride to patients on diuretic therapy and potassium chloride can also be bought as a salt substitute in most stores. Furthermore, I can walk into any pharmacy in Xela and buy almost any medicine I desire, except of course potassium chloride. I felt very few qualms about finding a source of potassium, but I should have realized that the recipe wouldn't be so easy to complete. Potassium chloride seems to be non-existent in Guatemala after a long and thorough search throughout the medical and scientific community.

We started this project with the idea of having four ingredients locally available and we would then have an suero recipe working at the clinic within a week, but the obstacles to our creative alternatives are becoming all too common. These barriers we have found are very frustrating because it is yet another reflection of the restricted resources in comparison to what is at our medically oriented finger tips at home. We have visited a half dozen pharmacies, called local laboratories, considered having volunteers bring prescription potassium from the states, but all proved to be without potassium chloride or expensive, unsustainable and hapless. Lacking a reliable source of potassium chloride has forced us to be inventive in our search for this electrolyte and our team has been delving through research studies as we attempt to compensate for the missing ingredient. Due to the importance of potassium, we want to include as much of it as possible even if we cannot add the 1.5 grams stated in the WHO/UNICEF recipe.

There is a unadulterated, unprocessed sugar in Guatemala called panela or piloncillo and it is apparently loaded with potassium and could be perfectly useful, if we only knew how much potassium there is in every gram. Panela is a locally grown, produced and useful ingredient for the ORS suero recipe, which would keep cost down, make the recipe useful for other clinics in the area and be a culturally sound contribution to the medical efforts in Xela. And knowing that the original life-saving recipe lacked any form of potassium, we are confident that the increased amount found in panela will be very beneficial as long as we keep the osmolarity balanced. Along with the potassium in panela, we can also include potassium iodized salt as another minimal, but useful source of the vital electrolyte.

We still need to standardize and exact the recipe, but thankfully we have a Phd trained chemist back in Nashville to calculate the exact osmolarity (number of solutes per liter of water) to ensure that the amount of additives we are using will be perfectly therapeutic and beneficial for patients with diarrhea. The osmolarity must be kept below 245 per liter of pure water to avoid dehydrating the body further and the chemist will be able to give us the weighted measurements for a safe recipe including sugar, salt, panela and baking soda. We shall continue to seek the answers to our long list of questions and we hope that this research experiment will soon produce necessary results to cut costs and increase the availability of oral rehydration therapy at the Primeros Pasos clinic in Palajunoj Valley, Guatemala. 

by Senator Bill Frist, M.D.

I write to you today a little more optimistic than my last post on the developing disaster in Haiti. I will be keeping on top of the situation there and encourage you to stop by to read updates on my personal website, BillFrist.com. This weekend, I urgently emailed around the medical community, searching for desperately needed supplies for Haiti's ongoing cholera outbreak. From starting with nothing Saturday morning, we now will have a massive bulk shipment of Ringers Lactate and IV sets arrive this week in Haiti, be distributed that afternoon to 8 facilities by evening. Impressive response on short notice.

I also just got word from USAID that they now are also sending more Ringers Lactate. Yesterday morning I was told there were 200,000 in Haiti in storage and 400,000 in pipeline. When I said my people alone on the ground were using 75,000 per month there was a long pause. Now people seem to be getting the picture.

The Clinton Bush Haiti Fund, where I sit on the board, has recently announced an emergency $100,000 grant to the African Methodist Episcopal Church Service and Development Agency (AME-SADA). This wonderful organization is the only organization providing health care to the 350,000 residents of Archaie and Cabaret in the Artibonite region of Haiti. These funds will be used exclusively to fight the cholera outbreak, and USAID's Office of Foreign Disaster Assistance is matching our grant with in-kind, instead of monetary, support.

However this is only the start. As I said last week, estimates vary, but it is almost certain that 200,000 to 800,000 Haitians will be infected with cholera. The death toll has risen over the weekend to 1,250 and the outbreak finally appears to have fully hit the capital, Port-au-Prince, with a reported 15% to 20% increase in cases every day. The successes above are crucial in beginning the wave of support that Haiti and the NGOs on the ground critically need, but they are only the start of the solution. For now, think about donating to one of the charities below (or to one that I haven't listed!) and always remember to spread the word.

Samaritan's Purse

Doctors without Borders

Save the Children


by Senator Bill Frist, M.D.

As the cholera outbreak continues to ravage through Haiti, killing hundreds and inciting terror and riots throughout the country, I'm afraid I may have more bad news. It has come to my attention today that the cholera outbreak is being vastly underreported and underestimated. My sources on the ground in Haiti have estimated that the current epidemic is up to 400% worse than the official numbers reflect. Considering that the official numbers already state a toll of 1,110 dead and another 18,000 sick, the scope of this savage outbreak is shocking.

Furthermore, it seems that nearly all the organizations on the ground were caught by surprise by this sudden outbreak and are grossly undersupplied. Simply put, eradicating the cholera outbreak requires resources beyond Haiti's capacity. Ringers Lactate fluid (required for intravenous rehydration) remains incredibly scarce within the country. The UN also refuses to provide any cholera treatment supplies to any NGO, instead dedicating all its supplies to the Haitian government. Medications from the Haitian Ministry of Health are also currently not forthcoming. Certain organizations are simply waiting for the disease to strike the capital, Port-au-Prince, before acting. A group I frequently work with, Samaritan's Purse, is receiving reports of high mortality in remote areas with no assistance reaching them. The U.S. government claims that materials are in place to respond to this developing disaster, but this does not seem to be the case and I worry that false confidence may cost lives.

The spread of cholera now seems past controlling, and using Pan American Health Organization calculations (in the MOST optimistic, with an attack rate of 2% scenario) around 200,000 people will require IV fluid. As around 75% of all cases require hospitalization, each patient uses 8 liters per day for three days, the conservative estimate for IV fluid needed stands at 3.6 million units. Unfortunately, some experts believe that the attack rate will rise above 2% due to lingering sanitation and hygiene conditions caused by the devastating earthquake combined with a Haitian population with no exposure to cholera and immature resistance.

With much of the country living in squalid post-earthquake conditions, we should expect an attack rate of up to 5-8%, according to the Refugee Health Manual. At this rate, we can expect as many as 500,000 to 800,000 cases of cholera. Due to the intense overcrowding, these cases might not be spread out over six months, but rip through the population in six weeks. Roads in Haiti, already devastated by the earthquake and again recently by Hurricane Tomas, continue to keep sick people from seeking and receiving proper aid, meaning that more advanced treatments are needed to halt the disease.

Save the Children, which has been in Haiti for over 30 years and currently operates in 17 large urban camps, is desperately struggling to fight back the disease. They are scrambling to set up new treatment centers around the country as current ones, such as their facility in Port-au-Prince now operates 24 hours a day and still cannot do enough. On the preventive side, Save the Children has distributed 10,000 hygiene kits, 19,000 bars of soap, and chlorinated water to schools and camps. These actions are important and have saved thousands of lives, but in a country of 10 million people, they are simply not enough to hold back the tide.

Similarly my friends at Samaritan's Purse, who remain a major national player in Haiti, report that even with their huge public awareness WASH program, 400 treatment beds, and over 300 staff dedicated solely to cholera, they were completely unprepared for this outbreak. I find it hard to believe that many organizations were prepared for this and I simply cannot imagine that any hidden capacity exists.

This issue needs immediate global attention. Many organizations on the ground do not have the resources to quickly buy, deliver, and administer necessary cholera medications, like Ringers Lactate. Even if they can afford these costs, it is only the beginning of the current logistical nightmare. The airport in Cap-Haitien has been shut down and there are roadblocks between Cap-Haitien and Port-au-Prince, effectively isolating the entire North of the country. If supplies do make it to Haiti, customs holds these shipments 3 to 10 days and the backlog of supplies, not just at Port-au-Prince but around the country is staggering and costing lives every day. NGO's are unable to receive and distribute supplies and are resorting to covert and illegal means in some cases to secure these life-saving medicines. Civil unrest around the country, caused by the belief that the UN Peacekeepers are connected to the outbreak, are further hampering the delivery of supplies that eventually do get through the ports.

These hindrances to saving lives must be eliminated. Haiti needs IV fluids sent in massive quantities. Life-saving supplies must be allowed to enter immediately into the country, not sit on pallets for 3 to 10 days out of bureaucratic formality. Organizations on the ground have sophisticated software that allows all the various partners to work together to comprehensively treat the population; we simply do not have enough supplies. The immense backlog of supplies at the ports has strained the entire response grid to the point of collapse and the internal rioting makes it difficult and dangerous to move supplies inside Haiti. The world must help, and must help now.

In addition, the United States needs to seriously and objectively consider a military airlift of supplies into Haiti. While this may appear a drastic measure to some, we cannot sit idle while our neighbor to the south suffers through this nightmare. Our military provided crucial support to those suffering after the Indian Ocean tsunami, Hurricane Katrina, and the earthquake that ravaged Haiti in January, and can do so again in this dire time of need.

Cholera is a disease we can defeat if we work together. Up to 80% of cases can be successfully treated with relatively simple medicines, such as rehydration salts. So join me in telling your friends, writing your congressman, volunteering, or writing a check to one of the many worthy organizations on the ground. We need to spread the alarm, and quickly. This epidemic is larger than previously thought or reported, we are drastically underequipped to deal with it, and it's moving fast.

shnepper kijabe

While it feels as if I just arrived, I can't believe I will be heading back home tomorrow. What a phenomenal experience this has been. This month has not only had a high impact on my education, but has been a unique, once in a lifetime experience. I say once in a lifetime, but I certainly hope this is not the case. I would love and certainly hope that I will be back to visit Kijabe in the future.

Much of our time here has been spent working with the student nurse anesthetists. My co-resident and I have helped conduct their practical exams, have provided intraoperative teaching, and have given them lectures while rotating through the icu. Their education is vitally important, as when they become nurse anesthetists many of them will be in parts of Africa where they are the sole anesthesia provider.

We have also spent a fair amount of time teaching regional anesthesia. One nurse anesthetist has shown an inordinate enthusiasm for nerve blocks, and it has been a joy teaching her. I have provided a picture of the two of us performing a nerve block using ultrasound, something that will surly help patients with postoperative pain relief.

Our experience has also included time rotating through the intensive care unit. While taking call in the ICU, I helped take care of a very sick 8 year old boy. The boy had severe respiratory failure and sepsis, requiring an emergent exploratory laparotomy operation. I helped provide anesthesia during the surgery. Sadly, the boy passed away. His death was devastating, and it is often difficult or impossible to find any silver lining in events like this. But I did take away hope by the passion shown by all those involved in taking care of the child. Our team of anesthetists, nurses, pediatric surgeons, and critical care intensivists did all we could to save this child, but sadly he was just too sick. The deep desire of the people here to help those in need is unparalleled. The passion shown for others is inspiring. Unfortunately, despite being one of the top tier hospitals in all of East Africa, the resources at Kijabe are often limited and lacking. But hopefully with such a strong base of people wanting to make a difference, this will continue to improve. My experience at Kijabe has been touching and incredible. I have been inspired, and I only hope those I've been in contact with have been too. I can't wait to come back.

by Jenny Eaton Dyer, Ph.D.

Senator Frist, M.D. sat down with Jim Thebaut of Running Dry.org, an organization working for access to safe, affordable, and sustainable drinking water for all, to in the video below.

This video will be circulated throughout the House of Representatives to promote awareness and support for the Senator Paul Simon Water for the World Act 2010.

We invite you to watch!


by Living Waters for the World

lww creek

Creek in wet season

Imagine getting up early in the morning, standing in front of the kitchen sink, you turn on the faucet and nothing happens. Has the pump failed again? You slip on your jacket, grab a container and start walking down the hill. It hasn't rained lately you're thinking to yourself and you stop in your tracks – the stream-bed is dry. This is not an excerpt from some prairie novel written about life at the turn of the century; it's reality for many families across Appalachia.

lww crew

Gene, Bill, Bob (LWW volunteers), Tonya, Matt, Angel, Andrew

For one family along the KY/TN border, their water source was a stream-bed down the hill from their house. The county will probably never run a municipal water line down their hollow – there aren't enough families living there for it to be profitable. And even if the county did run a water line, it's hard to pay a water bill when your income is virtually non-existent. It's hard to believe that this story plays out in communities across the US but it does. Luckily, there are people who care and are willing to do something about it.

lww water system

LWW Standard UV Disinfection Clean Water System

In this instance, the family's water source had dried up after a long dry spell and it was the attentiveness of a grade school classmate that something wasn't right that brought the family to the attention of Living Waters for the World. Now, thanks to a grant from the Hope through Healing Hands Foundation and Brad Paisley's H2O World Water Tour, and additional contribution and volunteer labor from Rivermont Presbyterian Church in Chatanooga, the family now has a sustainable supply of water that is safe to consume.

eppinger house

In a country so plagued by poverty, one would hope that the contrast between wealth and destitution would rile up people's desire for justice. But following conversations with my Guatemalan peers in the clinic, it has become apparent that the silent apathy has also become just as prevalent as the poverty that screams for our attention. Despite the undeniable contrasts, many people seem to view poverty as benign and even acceptable. Those who choose to acknowledge poverty here do not always know how to or take action against it.

It is not just apathy within the local community that can be so dangerous, but apathy within the global community as well. Apathy can be defined as a lack of drive to do or change things. In Guatemala it can be seen by the lack of involvement in social change with everything from education reform to recycling, and the overall contentment with the status quo. Admittedly, Guatemala's recent brutal political history probably contributes greatly to this condition, but passive resignation is essentially a form of active acceptance. There is general agreement that apathy is a sort of coping mechanism for those who experience frequent and poignant suffering and this form of psychological protection is very commonly utilized in Guatemala.

As I said, apathy here in Guatemala is alarmingly widespread. Some people have begun to recognize the gravity of this situation and have been campaigning for a change in the national attitude. Yesterday I saw a billboard defining patriotism as fighting for the wellbeing of the country. In the past I have even seen television commercials carrying the same inspirational message.

Despite these small efforts towards raising awareness of our power as global or local citizens, I have heard numerous people openly express their acceptance of their perceived powerlessness in the situation. Unfortunately, the struggles here seem to accumulate at least as fast as any efforts to relieve the suffering. Guatemala is a country with extremely low levels of education, literacy and health. Guatemala has the highest level of malnutrition in Latin America, and the fourth highest in the entire world. Healthcare is unattainable to many people due to many elements of access, and almost no one receives adequate primary care by the standards expected in the United States.

As an international volunteer working in a clinic in Guatemala, I do my best to pay attention to how my actions affect my environment. Naturally, I want my work here to be effective, and to help elicit positive change. I have heard my Guatemalan peers express strong support for the work being done by NGOs in Guatemala. This kind of acceptance of foreign aid is a good sign in a place where people are somewhat quick to resign themselves to a bad situation out of habit.

Although it may be easy to imagine that my job here is to work in the clinic and see patients as needed, I believe that I should be doing much more. It is my personal belief that people should use all of their available resources (knowledge, skills, etc.) for the greater good. My motivation for getting into the medical field was to be able to have concrete skills to offer and to be an effective agent of change. What makes apathy so dangerous is that it undermines the ambition and knowledge people could embrace to achieve change for the better.

A famous medical doctor known not only for his contributions to physiology, but also for his foundation of the idea of social medicine, Rudolf Vichrow, has been quoted as having said: Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution.... The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.

Although this statement was made over a century ago, the sentiment resonates with me and how I view my role and obligation in alleviating the cycle of poverty and its associated suffering. I interpret Vichrow's use of the word physician as being applicable to all medical professionals. Through our education and training we are given the tools to help people, and practice our science of "human beings," not only as a means to earn an income, but also to do justice to the science itself. If apathy gets the best of us, and we are unable to motivate ourselves to use the resources within ourselves, we cannot fulfill our duty and lives are left unimproved.

By using whatever resources we have access to, and working with the underprivileged, and advocating for their needs, we can indeed establish positive change in the global community. By recognizing this, we can begin to tackle some of the major obstacles, including the epidemic of apathy. Through the use of educational programs, casual conversations, passionate debate and positive examples of successful NGOs, we can appeal to the sense of hope within people and take our first steps towards achieving these goals.

As medical professionals, one of our most important resources is our understanding of the human body and the body's interaction with the surrounding environment and I feel we have an obligation to work with our patients in the clinic, but also advocate for the rights in the larger community. These skills and advocacy are our personal resources for establishing positive change, and that is what the medical profession is all about. The support of Hope Through Healing Hands, sending people and resources out into the world as well as instituting change can be an essential catalyst in alleviating some of the healthcare and social discrepancies globally and specifically in Guatemala.

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