• History of World Service -
  (Department of Ophthalmology)
• Thomas Stamm, MD World Service Endowment
• Foreign Ophthalmology Missions Day
• American Academy of Ophthalmology Humanitarian Awards
• FOCUS - Vital Ophthalmic Services in an Area of Extreme Need
• Community Service

Hello all, Guatemala Synopsis, February 2007

My first real impression of Guatemala was the car ride from the airport in Flores to the residence in San Benito. Apparently the only traffic law in Guatemala appears to be that one has to break all laws at all times. To make the driving even more perilous, pigs, dogs, cows, chicken, horses, mules and goats were all over the place, sometimes wallowing suicidally in the middle of the street. Some roads were under construction, evidence of the upcoming election. Huge machines dug deep trenches in the dirt roads, followed by men sorting the rocks that turned up and by some criteria discarding large ones at the roadside. A steam roller would compact the road only to have the huge machines repeat their havoc and the flock of workmen continue their onerous task. This process continued for the two weeks I spent in San Benito along the same two mile stretch of road without signs of imminent paving. When we lost internet service in the first week, it took three days to restore service not from technical difficulty, rather motivational inertia. The driver hired to bring patients from an outlying village told us at 6:30am that he was on his way and never showed up. Lunch hour spanned from about 11:30am to 2:30pm, the longest hour of my life.

I include these vignettes to illustrate the differences in nearly all elements of daily life and interpersonal expectations. As an American one is used to working 60+ hours per week, especially during residency. One takes for granted excellent service when it is contracted for. But the values of hard work and reliability appear to have less priority in rural Guatemala. People that can be relied on to keep their word are difficult to find and worth their weight in gold. Fortunately Linda Novak has found many of these people to make things happen in the Peten area. The mission benefited greatly from these connections, but we still had difficulties.

My first week started with a two day jornada in Dolores, a village about 85 kilometers from San Benito. We were hosted by the Dominican malnutrition hospital which, as you can imagine, has very ample and good food. We saw about 40-45 patients over two days and gave out many glasses, sunglasses, artificial tears and glaucoma drops. Six patients were surgical candidates and transportation was arranged to bring them to the Hospital Shalom in San Benito for surgery on Wednesday. When we called the driver on Wednesday morning he told us he was on his way. Then we heard from the staff at the malnutrition hospital that nobody had come to get the two patients that came for surgery. So they were put on a bus and arrived at 10:30am for 8:00am surgery. We did their pterygium surgery and arranged for them to take a bus back to Dolores.

Out of the six people scheduled for surgery only two came. This is a testament to several factors that impede access to care in rural Guatemala; money, transportation and fear. We had taken care of the first two issues by charging minimal fee for surgery and providing transportation, however eye surgery is not routine as it is in the US. The surgical techniques are not as refined, and as a result more bad outcomes occur. Patients hear about situations where a friend or relative was blinded by surgical complication and as a result avoid surgery. The Peten program is like a new practice opening its doors in many ways. Locals are still finding out about us by word of mouth and the jornadas. If people continue to have good experiences with Loyola doctors and know that they will be able to rely on them arriving during a certain part of the year, more will trust and more will come. Good surgical results will help allay some of the fear of eye surgery.

On Thursday we operated on patients from Santa Rita who were screened for surgery the week before I arrived. Four out of eight people scheduled were brought for surgery. One man had come all the way from Mexico to have an extremely dense cataract removed. After the two pterygium surgeries were completed, we called for this man and were told that he had left. Apparently he had second thoughts and headed back to Mexico, still blinded by his cataract. We did an extracapsular cataract surgery on the last patient and called it a day.

The surgeries are done at Hospital Shalom that has converted its ER to an OR while the true OR facilities are being completed. The facility was very good for surgery and well stocked. Many of the donated surgical supplies I brought were superfluous as they have been accumulating over time with few surgeries done at Hospital Shalom. Once a larger volume of surgeries is done, I am sure that we will need to replenish them. Having each resident that does the Guatemala trip put together a list of needed items while in Guatemala will help guide future residents to bring the necessary items. Another consideration for future trips will be to make the surgical setup mobile, to be able to take the OR to the jornada thus eliminating unreliable patient transportation as a limiting factor. This is by no means as easy as it would seem and will require logistical planning and possibly capital investment in reliable transportation.

After providing eye care at Hospital Shalom’s wheelchair jornada on Saturday, the medical students and I spent Sunday and Monday at the Mayan ruins in Tikal. It is really awe-inspiring to see what the Mayans were able to accomplish with the limited (by our standards) scientific and technological resources.

Week two was spent seeing patients at the Dominican Dispensario eye clinic in San Benito, following up on post-ops and seeing patients in a local nursing home that was recently opened. During our follow-up on post-ops in Santa Rita, I cemented my Spanish skills by helping a wife pick out a pair of sunglasses for her husband. I must say that even though rural Guatemalans may not have many material possessions, their appearance is very important. If someone tells a very nearsighted person who is blind without glasses that their glasses don’t look good, they will not wear the glasses.

On Thursday and Friday of the second week Linda Novak and I attended a conference in Guatemala City hosted by Rudy Gutierrez. The topics were mainly refractive and phacoemulsification cataract surgery, an interesting choice since most surgeons who attended don’t do refractive surgery and are still doing extracapsular cataract surgery. Nonetheless, I did get a chance to meet some of the ophthalmology residents and practice my Spanish comprehension. Linda Novak knew and approached many of the ophthalmologists who attended the meeting regarding epidemiological research. The idea would be to collect ICD-9 diagnostic information from ophthalmologists via an interactive online website.

Unfortunately the conference prevented me from giving lectures and teaching. I think that there is a significant need to work with our ophthalmology resident colleagues in Guatemala. From discussions with them, I discovered that much of their clinical and surgical training is on their self-guided and by no means as standardized across residency programs as in the US. On future trips, inviting the residents to join us in eye jornadas in Chichicastenango and Coban would provide an opportunity not only to give lectures but also to exchange surgical techniques. We don’t have much experience with many of the procedures that they are comfortable doing, like pterygium and extracapsular surgery. We may be able help the Guatemalans learn other techniques like phaco and glaucoma surgery. The potential partnership extends beyond our travel to Guatemala. Many residents may be interested in coming to the US to learn, to make connections for possible clinical fellowships in the US, and to have a good time.

I was invited to spend my last weekend in Antigua at Rudy Gutierrez’s house. I didn’t see much of Rudy, but Antigua was a wonderful end to my travels with a symphony concert in the main square on Saturday night (complete with military band, marimbas, and the 1812 Overture) and a Lent pilgrimage on Sunday morning.

Guatemala is a beautiful country with spectacular variation in geography and a great need for eye care in the rural areas. I think Guatemala is very important in the future of Central American ophthalmology as many of the future doctors are currently training in Guatemala. We can have a positive impact on the quality of their training and raise expectations for quality of care in Guatemala by working with the ophthalmology residents in the formative time of their careers.

Joseph Doe, MD, spent several weeks in Guatemala performing surgeries, running clinics and teaching the Guatemalan residents. Joe was the fourth resident to participate in the second year program.