Winnebago and Omaha Indian Reservation Service Trip

Monday 3/17/08

We left for Big Mama’s at 7:30 PM and arrived around 9PM at her house. Big Mama was at her daughter, Tiara’s, track meet so we waited for her to arrive before going to bed. Big Mama left out some snacks and so we ate and talked while we waited. Big Mama and Tiara arrived around 10PM, we introduced ourselves and learned about Tiara’s victory. She had won first place at her track meet so we all celebrated and talked for a while and then went to bed.

Tuesday 3/18/08

This was our first day of clinic at the Carl T. Curtis center for the Omaha in Macy, NE. Our first contact was, Deb, a diabetic educator. She took us on a tour of the clinic and we also learned about the different types of Indian health services. For example, there are tribal clinics which are funded by PL-93-638, a public law that is titled the Indian Self-Determination and Education Assistance Act which allows tribal governments to take over administration of social services from the federal government. This law gives the tribes more freedom with their government monies and allows the tribe to direct the funds towards the individual needs of its members. The Omaha tribal clinic is under this protocol. In contrast, the Winnebago Treaty hospital is a combination of both the PL 93-638 and the Indian Health Service. The Indian Health Service is operated and funded by the federal government and does not consider the tribes individual deficiencies or problems when allocating monies.

After our introduction to the clinic, we were split into our shadowing groups. Grayson was shadowing a nurse practitioner, Abby was shadowing a clinical nurse, Jenna was in the nursing home, Cate shadowed a physician assistant and Jessica shadowed a nurse practitioner. Lisa shadowed the public health nurse and Jason shadowed Dr. Anwar Ahmed, the medical director of the clinic. It was baby wellness day, so we got to give lots of immunization shots.

To our surprise, we had an emergency visit from a young man who had been beaten with a golf club and had several lacerations to his hand, legs, and back. Some of the wounds needed suturing. Jason gave the young man a IM injection of meperidine for the pain while Kelly, a nurse practitioner, sutured his wounds.

There was also sad news that day, Winona, the CEO of the clinic was released from her duties, the new tribal council had decided that she should step down. Jason, who had come to the Omaha clinic last year during spring break remembered Winona to be an extremely intelligent and forward thinking individual. He had expressed his surprise at the tribal council’s decision and believed that Winona would be greatly missed at the clinic. Several clinicians and nurses seem to agree, although it was much too busy for anyone to discuss this openly.

That night, after clinic, we went to the Winnebago Casino for dinner with Big Mama, Tiara and Big Mama’s nephew Bo. We had a fantastic time, dinner was great, thanks to Bo, the recommendation to have the cheeseburger was greatly appreciated.

After dinner, we all sat around, telling funny stories about college and silly things we did growing up. We had a great time.

Wednesday 3/19/08

We got to clinic in the AM, all of us were excited because we got to meet Joslyn, who was a nurse and directed the dialysis center for the Omaha tribal members. We learned all about dialysis, they have about 20 patients, who have dialysis on Monday, Wednesday and Friday. The Omaha, because of its PL-93-638 status fund and maintain their own dialysis center, which is not a easy task. Joslyn showed us what has to be done on a routine basis from upkeep of dialysis machines, water quality and preparation, as well as patient counseling and transportation concerns. It was absolutely amazing.

Later in the afternoon we had clinic and left for Big Mama’s. We had a great dinner, Brats and hot dogs, chips, potato salad and ice cream. We sat around and asked Big Mama about the Indian culture and society, we learned a lot and asked a lot of questions, mostly we got to know Big Mama and Tiara, both are AWESOME!

Thursday 3/20/08

This was an exciting time, we met Dr. Shaheb, an anthropologist and endocrinologist, who goes around the world to work with indigenous tribes, to educate them about diet and diabetes. He gave a presentation and it was fantastic, we learned about the American diet, which has a lot of preservatives, is high calorie and dense, can feed a lot of people cheaply but is terrible for our health. We learned why poor people are at risk for being overweight, more so then the average American. We learned about observing individual cultures in relation to health risk or disease, not everyone is the same, and a simple BMI does not have a simple meaning for health when considering a person’s culture or heritage. It was awesome!

That evening we started to prepare the fire for the sweat lodge. Thanks to Tiara and Grayson, it was a burning inferno. It did not take long for the grandfather rocks to turn red and be ready for use during the sweat. Big Mama was an awesome host and the sweat was relaxing and purifying.

While eating dinner, we watched a dance show on TV so it stimulated Tiara to teach Grayson and Lisa how to dance….I must say Lisa was a LOT more graceful then Grayson, in fact, Grayson almost TKO’d Lisa, nice one G.

Friday 3/21/08

As we did not want to leave, but we were all tired and ready to get back to our families and loved ones. We said our good byes…and thanked Big Mama and Tiara for allowing us to stay and for their love and friendship…WE LOVE YOU!

First days in Jamaica.

When we signed up to spend our spring break working in an underserved clinic in Jamaica we were all aware that we would be asked to do some jobs we weren’t normally used to doing. But when we arrived at the airport at 4:30 for our flight and the airline was understaffed, we weren’t expecting to help load our own luggage! It was good for a laugh and an excellent way to start off the trip.

After four hours on a plane and another hour on a bus we arrived at our dorm and unloaded our luggage. After taking a short break we then went to set up the clinic in preparation for our first day seeing patients. It was a good thing we spent that first night doing inventory because our trip leaders had to make a trip to the pharmacy to make sure we had enough drugs and supplies for the rest of the week.

The next morning we pushed our way through the line of patients waiting outside ready to be seen, and at 8:00 am we opened the doors eager to start the week. Each person had their vitals and chief complaint taken before seeing one of the student providers. When I took my first patient on the first day I didn’t quite know what to expect, but the Jamaican woman I saw was so friendly and grateful for anything we could do for her it put me at ease. After a few probing questions, she pulled back her hair and revealed a 1.5 cm keloid. After discussing her problem with one of our sponsoring physicians, we scheduled her to remove it the next morning.

Having never done a procedure like this before, I was a little nervous but with a little encouragement and a lot of patience from both the Dr Mathews and the patience the keloid was removed and she was stitched up. It was so amazing to be able to do the procedure for her, because it was obvious that she was embarrassed to have that large scar on her head. I only wish I would have been able to remove the stitches and see how well she healed up.

Trapper Jim

by Chantal N. Afuh, M2

Jim Eichman, a trapper for the United States Department of Agriculture has participated in his trade for most of his life but has been working for the government since 1985. Jim is responsible for protecting the livestock of ranchers in Webb County from predators at no cost. In the event that the animal responsible for the death is unknown, Jim is able to analyze the carcass for teeth marks and other wounds to determine the culprit.

In addition to “pest control”, Jim plays a large role in public health. The rabies epizootic in the region threatened the health of dogs and cats as well as the humans they were in contact with. Jim is involved with surveillance and determining the prevalence of rabies, lime disease, and the plague in Webb County coyotes. Jim provides fresh blood samples to the state health department to test for lime disease and plague, and provides the agency with the heads of the animals for rabies testing.

Jim went into great detail about the federally mandated documentation that accompanies his work. Providing a special permit, he is even able to eliminate federally protected animals that threaten human safety. We were impressed with his expertise and passion for his work.

Dos Familias de las Colonias and the Market Basket

by Chantal N. Afuh, M2

I have not witnessed the caliber of poverty as that of Laredo and Nuevo Laredo before. The substandard housing, lack of running water and sewage, proximity of people to animals and also the presence of hazardous structures in homes and yards were things I did not expect to see in the United States. As wealthy as our nation is, I find it incomprehensible and indefensible that even the poorest of our society lack these essential needs.

Access to care is an issue in many communities around the world. Barriers may include cost, lack of insurance, lack of transportation, legal status, and many more. Our community does not offer the best transportation, but most individuals who need the services are able to use them. It is difficult to imagine that many colonia dwellers who do not have their own transportation must depend on what appears to be an ill organized, inconvenient transportation service, if they can even afford it at all. Health maintenance is reliant on regular visits and cannot be attained when healthcare interactions are inconsistent. Without a practitioner being aware of the patient’s situation, a patient may be viewed as noncompliant and not concerned about their health status and preservation. This could possibly lead to the discontinuation of the patient’s services. It is important for a physician to listen to his/her patients and understand what factors impact their continuity of care.

The information provided regarding colonias in our assigned readings and lectures angered and frustrated me. I found the injustice of the landowners’ exploitation of peoples in need atrocious. Additionally, the lack of legislative and civil action against the growing abuse demonstrated that these afflicted people were not valued. Until I visited the two colonias and met Ana and Martina’s families and heard their stories, I did not have a true understanding of the human impact this condition has created.

Nutrition is an integral part of health and wellness. As a student who receives financial aid and who knows my parents can and will assist me when needed, I put little thought into the cost of what I place in my market basket. During our experience, we were challenged to purchase a month’s worth of food for a family of 7 with only 50 U.S. dollars. We were able to purchase a large amount of provisions that we felt met the nutrient needs for only $50.28. Though we appeared victorious, we knew that the amount was inadequate for feeding this family for an entire month. I now have a greater appreciation of the struggle many families face when attempting to prioritize the items they must purchase.

Conversely, I was inspired by the stories the two women we were acquainted with shared. Despite the poverty that is their reality, their barriers to healthcare, and the number of other issues they face, both women were triumphant in preserving their dreams for their children and grandchildren. Martina ensures that her children attend school in order to have the opportunity to improve their lives. She is also supportive of her husband who is studying to become a healer. I imagine her family must sacrifice even further to strive for an improved future.

Ana is a strong matriarch who sacrifices much for her family. Even as an older woman Ana has spent four months in North Dakota harvesting potatoes for the past five years. We were able to see the influence she has made on her children, grand, and great-grand children through their interactions and the reverence they give her. The school-age children are in school and Ana’s youngest son also has plans to return to college soon where he will study to teach middle and high school math.

Herbal Medicine 101

by Chantal N. Afuh, M2

As first a generation American, daughter of a father from Cameroon in West Africa and Trinidadian mother, I have encountered holistic medicine and the use of herbal therapeutics. I considered myself relatively knowledgeable regarding “mainstream herbals” such as ginkgo, garlic, niacin, and the various others we learn about in ICE and pharmacology lectures. After our morning experience with medicine man Tony Ramirez I realized my understanding was extremely limited.

Tony Ramirez, or Coyotl Cuica Cuilahuac (“Singing Desert Coyote”) has gained much of his knowledge from his grandmother and other healers. He has written several manuscripts and hopes to preserve the art of herbal healing through his work. He fears that the thousands of years worth of knowledge will be lost if the younger generation does not embrace their culture. He is encouraged that the recognition and increased practice of complementary medicine will work to legitimize traditional medicine.

The Hill of Agave and Peyote was the spiritual epicenter of the ancient tribe that once roamed in the region. Since the grounds were sacred, Tony led us in a ceremony to ask the spirits for permission for our entrance unto their holy ground and for protection from rattlesnakes and other dangers we could encounter. We were instructed to form a circle and were blessed with a prayer and tobacco cleansing before we began our herbal medicine walk.

It was amazing to learn about the many herbs we encountered. What appeared to be shrubs and thorny bushes embodied the richest medicine cabinet imagined. Many conventional medications include unwanted side-effects which may prove to be deleterious. Many of the herbs Tony presented to us had many beneficial “side-effects”. The complexity of these herbs resulted in their simultaneous favorable impact on various organ systems.

The Rio Grande

by Chantal N. Afuh

Nearly 13 million people depend on the 180,000 square mile Rio Grande and Rio Basin. Recently, much attention has been paid to the extensive water and air pollution, poverty, and environmental justice issues plaguing the region in addition to the integral role it plays in U.S.-Mexico trade. Decisions severely impacting the basin are often made by distant policy makers who are unaware of the sensitivity of the issues and are unlikely to present pragmatic solutions to the complex problems.

We had the opportunity to spend the entire day along the banks of the Rio Grande in Laredo in order to assess the water quality. The four sites we visited included the river bank along Pico Road which is upriver of Laredo, Hernandez Ranch which is downriver from the Nuevo Laredo, Mexico waste water treatment plant, the banks along the Webb/Zappata county line, and 30 miles downriver at the San Ygnacio waste water treatment intake.

The river data we collected included pH, temperature, salinity, amount of dissolved oxygen, turbidity, amount of E.coli and other fecal coliforms, and the types of insects found in the water. We found that the river water samples upriver from Laredo were significantly cleaner than the samples obtained from downriver. Although the region has a waste water treatment plant there is a small amount of untreated water that gains access to the drinking water supply.

Four Agencies in One

By Chantal N. Afuh, M2

The U.S. Customs and Border Protection (CBP) was formed March 1, 2003 after the consolidation of the U.S. Customs Service, U.S. Department of Agriculture, Animal and Plant Health Inspection Service, the U.S. Immigration and Naturalization Service and Border Patrol. Officer Rodriquez of the CBP shared that the impetus for creating the unified agency was the terrorist attacks of 9/11. The mission of the agency is to provide a unified front in the protection of the U.S. Thirty-thousand agents trained in diverse duties with different objectives are now working together to share their experience and expertise with one another and to forge a new history of teamwork and achievement.

Officer Rodriguez informed the group about the changes that will be instituted as early as June 1, 2009 called the Western Hemisphere Travel Initiative (WHTI). The travel initiative is a way to secure entrance into the U.S. by requiring secure documentation of proof of identity and citizenship. Some aspects of the initiative are already in practice. Effective January 31, 2008, United States and Canadian citizens are no longer able to obtain entrance at the U.S. southern border by relying on oral declaration. Acceptable documents include a U.S. or Canadian passport, Trusted Traveler Cards, U.S. Military Identification with Military Travel Orders, and Native American Tribal Photo Identification Card. For individuals who are unable to produce an approved document, providing both official identification and citizenship documents from the approved list will permit entrance but with possible delay.

In addition to ensuring the lawful entrance of persons into our southern border, the CBP is concerned with the entrance of plants and animals into our country and the willful and unwitting bioterrorism that may accompany it. The STEER participants were able to visit the Laredo Department of Agriculture and speak with Dr. Don Provinger.

Dr. Provinger shared with us the challenges which accompany pest identification. The Laredo department is responsible for inspection of cargo crossing the city’s four international bridges, one rail bridge, and two import lots. His team is comprised of two entomologists, one botanist/plant pathologist, and a few dogs specially trained in pest identification. Insects they are unable to identify are sent to a specialist at the Smithsonian. Contaminated cargo is either incinerated, “deep buried”, or sent back at the owner’s expense. Dr. Provinger discussed the importance of the service in protecting the lives and livelihoods of our U.S. citizens. As a child, he witnessed the severity of Bang ’s disease (brucellosis) first hand. After the destruction of his family’s livestock he decided to commit his life to protecting our nation from the devastation of disease.

STEER

by Chantal N. Afuh, M2

Untreated drinking water endangers the health of the 225,000 people who live in the colonias of Laredo, Texas and Nuevo Laredo, Mexico. Approximately 90% of the homes in these underdeveloped and unincorporated subdivisions lack sewage systems, running water, and waste disposal. The South Texas Environmental Education and Research (STEER) Center, a part of the University of Texas Health Science Center at San Antonio has created a program that permits future and current health practioners the opportunity to work with Laredo’s public health systems to investigate the once forgotten diseases and constant health threats to the public health.

This spring break, Christine Ngaruiya and Chantal Afuh both second year medical students and Rahman Strum a masters student in the College of Public Health became the first UNMC students to participate in STEER. They accompanied the seven public health students from the University of North Texas Health Science Center (UNTHSC) from Fort Worth and had the opportunity to experience life in the United States’ busiest inland port as well as its sister city in Mexico.

Sharing the Green raises $38,000

Second year medical student, Matt Bogard, attempts to reach the flag, held by Bill Dorwart, also a second year medical student. SHARING board members from left: Olamide Alabi, Mark Stavas and Josh Euteneuer. A record haul of about $38,000 was raised during the eighth annual SHARING the Green golf tournament on Sept. 25 at Indian Creek Golf Course. The money raised benefits the student-run SHARING Clinics of UNMC. Despite the cool and windy start, nearly 100 golfers participated in the event, with a number of them winning prizes for best drives and longest putts at various holes throughout the course. Golf was followed by dinner with a presentation on the clinics and a talk by Mark Stavas, SHARING board fundraising chair and the main organizer of the event. SHARING board members were thrilled at the success of the event. The SHARING clinics are a nationally recognized group of three clinics that serve the uninsured and underinsured of Omaha at little or no cost. Founded in 1997, the SHARING Clinics include: SHARING for general health care; RESPECT for STD testing, treatment, and counseling; and GOODLIFE for diabetes care. Students and faculty from a variety of disciplines, including medicine, nursing, physical therapy, and public health work together to provide patients with integrated, multidisciplinary care. This coming year, SHARING will celebrate its tenth anniversary as an operating clinic.

Dr. Fayad on the importance of community outreach

Since UNMC is the only state supported academic medical center in Nebraska, the department of neurological sciences feels an obligation to reach out to neurologists and other physicians and health care workers across the state to get to know their needs and explore areas of education, patient care and research where we can provide support and establish collaborations.

Our neurological grand rounds conferences have been transmitted live to more than 20 hospitals across the state though the telehealth network. They also are streamed live through the Internet. We provide that service free to allow access to neurologists, neurosurgeons and others around the state as a prime source of education on neurological issues.

Our department and faculty are involved in numerous research trials investigating therapies for stroke, dementia, epilepsy and movement disorders. Some of these studies involve exciting therapeutic venues that are medical or interventional and are supported by the National Institutes of Health.

Since our department is only six years old, and has rapidly recruited top-notch faculty, it is important to make neurologists and others aware of what kind of programs and efforts we are developing that can help them in their practice.

Photo: More than 100 people turned out for Dr. Fayad’s presentation at the North Platte Senior Center.