The Amazon Ulcer

Photo of the panorama view

Written by Danuta Ramos Duarte

Translated into english by Carolline Paggi Montemezzo
Reviewed by Andressa Cavalcante Paz e Silva

 Posted by Bianca Cadore Morás

(Portuguese below)

A little more than a month working with the indigenous health in the Kayapo territory I can say that I already lived a lot. Here, everyday is like a week and the work is continuous and exhausting. In the last day I had the immeasurable opportunity to meet a folk, his culture and his comprehensions of body-health-sickness. I'm learning too much from Kayapo's people and it's really sad to me that the first picture of their territory that I share on social media is this one.

Today I needed to take a sixteen year-old pregnant girl, by helicopter to the town, because of the imminent maternal-fetal death risk. When the plane was taking of, the panorama view revealing itself was like a wound open into the earth. A bleeding ulcer, a death threat, endorsed by the most disastrous government in fighting the COVID-19 worldwide. The Earth moans and cries everyday because men's greed.

Narubia Werreria usually says that everybody have indigenous blood, or in the veins or in hands. 

This government is swimming in blood. 

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About the author:

Danuta Ramos Duarte, born in the riverside of Araguaia in a little town of Tocantins state called Araguatins. She studied in a public school, graduated in medicine at a public university, Universidade Federal de Tocantins. Danuta is a person in love with people, nature and also with people’s natures. Granddaughter of a babaçu coconut cracker and an ecologist of Bico do Papagaio, daughter of a teacher, a feminist that dares to love another woman. A resident in Family and Community Medicine for SES-SC, a member of GT Rural from Brazilian Society of Family and Community Medicine (SBMFC).

Original text in Portuguese:

Foto do garimpo

Escrito por Danuta Ramos Duarte

Traduzido para o inglês por Carolline Paggi Montemezzo
Revisado por Andressa Cavalcante Paz e Silva
Postado por Bianca Cadore Morás

(Em inglês acima)

Há pouco mais de um mês trabalhando com saúde indígena no território Kayapo e posso dizer que já vivi muita coisa. Aqui cada dia vale uma semana e o trabalho é contínuo e exaustivo. Nos últimos dias tive a imensurável oportunidade de conhecer outro povo, sua cultura e sua compreensão de corpo-saúde-adoecimento. Estou aprendendo muito com os Kayapó e me entristece que essa seja a primeira foto do seu território que compartilho nas redes. 

Hoje precisei levar uma jovem gestante, de apenas 16 anos, de helicóptero para a cidade, pois o risco de vida materno-fetal era iminente. Ao levantar voo, o garimpo se revela como essa ferida aberta na Terra. Uma úlcera sangrante, uma ameaça de morte, chancelada pelo governo mais desastroso no combate à COVID-19 mundialmente. A Terra geme e chora todos os dias pela ganância dos homens. 

Narubia Werreria costuma dizer que todos temos sangue indígena, ou nas veias ou nas mãos. 

Este governo está nadando em sangue.

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Sobre a autora:

Danuta Ramos Duarte, nascida na beira do Araguaia numa pequena cidade do Tocantins (Araguatins). Estudou em escola pública, formada em medicina pela Universidade Federal do Tocantins, apaixonada por gente e pela natureza e pelas naturezas das gentes. Neta de quebradeira de coco babaçu e do ambientalista do Bico do Papagaio, filha de professora, feminista e que ousa amar uma mulher. Residente em Medicina de Família e Comunidade pela SES-SC, membro do GT rural da SBMFC.

Family Medicine that is not in the books

Photo of a mask hanging in front of a rainy day, taken by the author

Written by Karine Kersting Puls

Translated into english by Bianca Niemezewski Silveira

 Posted and edited by Bianca Cadore Morás

(Portuguese below)

The residency ended. Finally, the idealized life of a family physician was about to begin, but it wasn't just anyone. It was not in any specialty. It was not at anywhere. It was the one as a physician, family physician, family and community physician in a rural city. And the dream began. And the plans started. Staff meeting. Planning.  Agenda management. Knowing the territory. Knowing people. Bonds. Touch. Take care. Two weeks: that was the time. Two weeks for such a virus to emerge and catch dreams, plans, expectations, curiosities, take everything on the way and change the route. Change the known. To change.  Pandemic. Individual protection equipment. Do not touch. Do not hug. It is no longer allowed to share the mate. Do not shake hands. Examine what is necessary. Do what is necessary. Do not leave if not necessary. Pandemic. Fear. Confusion.  Standstill. Action.Make the contingency plan. Isolation. Take the test. And that idealization became reality - not the idealized reality, but the true one. And the real world has shown that reinvention is daily. Family and community physican. She learned that being a family and community physician goes beyond books. It goes beyond the residency. It goes beyond idealization. She learned that a family and community doctor is a reinvention, flexibilization, a daily action in the balance between doing and not doing.  She learned so young that in order to be a family and community physician, a pandemic must be orchestrated in the midst of a non-idealized rural community.

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About the author:

Karine Kersting Puls is a family doctor in the interior of Rio Grande do Sul (Brazil), member of Rural Seeds and WONCA Working Party on Rural Practice.

Original text in Portuguese:

MFC que não está nos livros

Foto de uma máscara em frente a um dia chuvoso, tirada pela autora

Escrito por Karine Kersting Puls
Traduzido para o inglês por Bianca Niemezewski Silveira
Postado e editado por Bianca Cadore Morás

(Em inglês acima)

Terminou a residência. Finalmente a tão idealizada vida de médica ia começar, mas não era qualquer uma. Não era em qualquer especialidade. Não era em qualquer lugar. Era aquela como médica, médica de família e comunidade, médica de família e comunidade em uma cidade rural. E o sonho começou. E os planos começaram. Reunião de equipe. Planejamentos. Gestão da agenda. Conhece o território. Conhece as pessoas. Faz vínculo. Toca. Cuida. Duas semanas: esse foi o tempo. Duas semanas para um tal de vírus surgir e pegar os sonhos, os planejamentos, as expectativas, as curiosidades, pegar tudo que tinha pelo caminho e mudar o trajeto. Mudar o conhecido. Mudar. Pandemia. EPIs. Não toca. Não abraça. Não compartilha mais o chimarrão. Não aperta a mão. Examina o necessário. Faz o necessário. Não sai se não for necessário. Pandemia. Medo. Confusão. Paralisação. Ação. Faz o plano de contingência. Coloca em isolamento. Faz o teste. E aquela idealização se tornou realidade - não a realidade idealizada, mas a de verdade. E o mundo real mostrou que a reinvenção é diária. Médica de família e comunidade. Aprendeu que ser médica de família e comunidade vai além dos livros. Vai além da residência. Vai além da idealização. Aprendeu que médica de família e comunidade é uma reinvenção, uma flexibilização, uma ação diária no equilíbrio entre o fazer e o não fazer. Aprendeu tão jovem que para ser médica de família e comunidade tem que se orquestrar uma pandemia em meio a uma comunidade rural não idealizada.

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Sobre a autora:

Karine Kersting Puls é médica de família e comunidade no interior do Rio Grande do Sul (Brasil), membro da Rural Seeds e do conselho do WONCA Working Party on Rural Practice.

On social isolation in a Brazilian rural community

Photo of the author at the health support center of Coelhos

The place’s abandonment held me strongly.
And kept my eye throughout all life.

Everything I knew after was full of abandonment.

There wasn’t in the place a way of running off.

We were inventing ourselves through

the path of new words.

We were a piece of an insect on the floor.

That’s why our delight was unseeing the world.

(Manoel de Barros, Free Translation)

Written by Mariel Hespanhol Torres

Translated into english by Cibelih Hespanhol Torres

 Posted and edited by Bianca Cadore Morás

Reviewed by Mayara Floss

(Portuguese below)

I am lucky to be a Family Medicine resident in Amarantina. People say it received this name because it made some Portuguese remember his homeland, Amarante. They also say it is a district of Ouro Preto, a Brazilian historic city, but whoever was born in Amarantina frequently expresses his objection: “Ouro Preto is only about climbing up-and-down the hills! For God’s sake! And what about the cold…?” etc. etc. An Amarantinense sees himself as an Amaratinense – not Ouropretano.  

Amarantina, just like Amarante, has a landscape way more appropriate to vegetable farming than it’s stony neighbors. Because of that, it has grown in both size and economic importance after Ouro Preto's great hunger, in the 18th century. More recently, the inhabitants have increased in order to sustain the mining operations in Itabirito, the closest city. Agriculture is not the main labor activity anymore, and the old village has become a district with more residents than the small towns in danger of extinction in Minas Gerais. However, the ways of life, the local culture and the distance from the big centers with their variety of services characterize the rurality of Amarantina. Each day I learn a little more about the consequences of being rural for the health of its population. 

In times of COVID-19, one particular remark made me think about the vulnerability of populations living in the countryside, such as Indigenous People, Quilombolas and Local Communities. The deeper we go in the rural communities, attending in supporting units or visiting the families, the more we get the sensation that this new disease is only one more bad news coming from the capital. In the countryside we have leishmaniasis, Chagas, dor nas juntas (popular expression for arthralgia), stomach burn, sugar in the blood, and the most diverse diagnosis given by benzedeiras and raizeiros, the communities’ healers… But Coronavirus? This one has not yet been included in many people’s vocabulary. And not just because of its novelty. Using WhatsApp as a Telemedicine tool has shown us that the countryside is not a synonym of lateness – but this is a subject for another story. 

I believe that the fear of being infected by SARS-CoV-2 is lacking in the same proportion that the personal protective equipment, public services, access roads and citizens’ rights also lack. Through an individual perception of risk, always illogical and subjective, the barriers of access seem to be barriers of protection. If the public policies are not present, why should the virus be? Therefore, rural communities do not take precautionary measures, so estimated by urban population. The paradox of such a situation is exposing a population already so neglected – not to mention, of course, the health professionals whose scholarship does not immunize them against human irrationalities. 

I hope the arrival of COVID-19 in Brazilian countryside will remind us that, even considering how essential biomedical science is at this moment, the health-disease process is still socially determined. Taking the experience from Amarantina, may we learn that, where social and political isolation were already a rule, a false sensation of safeness can be shared between users and professionals of health services. Self-awareness, cultural competence and advocacy will be as important as the measures indicated in official protocols.

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About the author:

Mariel Hespanhol Torres was raised in the bush and learned to like the little things on the ground. People belonging to abandonment move her: as much as the superb little things (paraphrasing Manoel de Barros). She is currently a resident of Family Medicine at UFOP in Amarantina, a district from Ouro Preto/MG.

Original text in Portuguese:

Sobre o isolamento social em uma comunidade rural

Foto da autora na Unidade de apoio de Coelhos

O abandono do lugar me abraçou de com força.

E atingiu meu olhar para toda a vida.

Tudo que conheci depois veio carregado

de abandono.

Não havia no lugar nenhum caminho de fugir.

A gente se inventava de caminhos com

as novas palavras.

A gente era um pedaço de

formiga no chão.

Por isso o nosso gosto era só de

desver o mundo.

(Manoel de Barros)

Escrito por Mariel Hespanhol Torres

Traduzido para o inglês por Cibelih Hespanhol Torres
Editado e postado por Bianca Cadore Morás

Revisado por Mayara Floss

(Em inglês acima)

Tenho a sorte de ser residente de Medicina de Família e Comunidade em Amarantina. Dizem que ela recebeu esse nome porque lembrou a algum português sua terra natal, Amarante. Dizem também que é um distrito de Ouro Preto, mas quem é de lá faz questão de expressar sua oposição: "Ouro Preto é só sobe-e-desce, Deus me livre! E que frio! etc. etc.". Um amarantinense se sente amarantinese, não ouropretano.

Amarantina, assim como Amarante, tem uma paisagem bem mais convidativa ao cultivo de hortaliças do que seus vizinhos de pedra. Por conta disso, cresceu em tamanho e importância econômica após a grande fome de Ouro Preto, no século XVIII. Mais recentemente, a população residente tem aumentado para sustentar a mineração em Itabirito, o município mais próximo. A agricultura já não é a principal atividade laboral e o antigo povoado se tornou um distrito com mais habitantes do que as pequenas cidades mineiras ameaçadas de extinção. No entanto, os modos de vida, a cultura local e a distância dos grandes centros com sua variedade de serviços caracterizam a ruralidade de Amarantina. A cada dia aprendo mais sobre as implicações disso para a saúde de sua população.

Nesses tempos de COVID-19, uma observação em especial me faz pensar sobre a vulnerabilidade dos povos do campo, da floresta e das águas. Quanto mais "fundo" vamos no rural, seja para atender nas unidades de apoio ou para fazer visitas domiciliares nos sítios e povoados, maior é a sensação de que essa doença nova é só mais uma notícia estranha e lamentável que vem da capital. Na roça tem mosquito palha, barbeiro, dor nas juntas, impinge, queimação, açúcar no sangue, os mais diversos diagnósticos de benzedeiras e raizeiros... Mas coronavírus? Este ainda não entrou no vocabulário de muita gente. E não é simplesmente por ser novidade. O Whatsapp como ferramenta de Telemedicina tem nos mostrado que o rural não é sinônimo de atraso – mas isso é assunto para outro relato.

Acredito que falta o receio de contaminação pelo SARS-CoV-2 na mesma proporção que faltam os Equipamentos de Proteção Individual, os serviços, as estradas, os direitos de cidadania. Na percepção individual de risco, ilógica e subjetiva, as barreiras de acesso parecem ser também barreiras de proteção. Se o Estado não chega, por que o vírus haveria de chegar? Assim, não são tomadas as medidas de precaução pelas quais as populações urbanas zelam tanto. O paradoxo de tal viés é tornar ainda mais suscetível uma população que já se vê negligenciada. E ele também contamina a nós, profissionais de saúde, cuja escolaridade não nos torna imunes às irracionalidades humanas.

Espero que a chegada do COVID-19 nas zonas rurais do Brasil faça lembrar a todos que, por mais fundamental que seja a ciência biomédica neste momento, o processo saúde-doença segue sendo socialmente determinado. Que possamos aprender com o causo dos amarantinenses que, onde o isolamento social e político já era regra, uma falsa sensação de segurança frente a problemas globais pode surgir em usuários e trabalhadores da saúde. Autoconhecimento, competência cultural e advocacy serão tão importantes quanto as medidas que constam nos protocolos oficiais.

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Sobre a autora:

Mariel Hespanhol Torres foi criada no mato e aprendeu a gostar das coisinhas do chão. Pessoas pertencidas de abandono a comovem: tanto quanto as soberbas coisas ínfimas (parafraseando Manoel de Barros). Atualmente é residente de Medicina de Família e Comunidade pela UFOP em Amarantina, distrito de Ouro Preto/MG.

Rural telehealth against the coronavirus

Photo with the Araucaria trees in Santa Terezinha

Written by Danuta Ramos Duarte

Translated into english, posted and edited by Bianca Cadore Morás

Reviewed by Mayara Floss

(Portuguese below)

Being a doctor in a small town, in the middle of Santa Catarina state in Brazil, with a population of nine thousand people, imposes some challenges. But my small town has a secret name: Santa Terezinha. To get here from the coast we have to cross narrow streets amid Brazil’s Atlantic rainforest, trees called araucarias and small plantings.

The road is rough, full of hills and valleys, with rivers crossing the forest to become waterfalls. Little unpaved roads connect the districts, holding an area of approximately 450 miles.

The people who live here sustain themselves basically with farming, as the plantation of tobacco, corn and soybean are the most frequent crops. They are rural workers, little farmers descended from European migrants who took refuge here during the World War II, finding in Brazil a home beside the nazi horror. They’re polish-descendants (self-titled “polacos”), ucranians and germans who carry strong family traditions: the boundaries between public and private is lost among social relations.

At the chimarrão (mate tea) reunions in the evening, they gossip about the lives of everyone in the community with great detail – a scene capable of provoking an unpleasant sense of invasion of privacy but at the same time a growing feeling of belonging and reception among them.

To care the population, we have three Primary Healthcare Unities with healthcare teams, and other three supporting stations in more distant locations.

A lot of people living in remote areas don’t even have access to phone lines, having trouble coming to our basic care unities because of the miles between us. In realities like this, the telehealth is an essential tool to reach the people that can’t easily come for health facilities.

Fortunately, the internet and the radio are modern resources already consolidated in most homes, are helping us to reduce the distances.

So, as an educational health strategy, we are using Whatsapp and the community radio line to inform people about the coronavirus and the changing on rural basic care units working routine, since we’re attending only priority groups, emergencies and respiratory syndromes. The town provided an official telephone number as an open communication channel with the community. Besides that, the community health agents – who live in the neighborhood – spread the official information in their area of coverage, since they already have Whatsapp groups with the people they visit.

Instead of what we might think, most of Brazilians, as well as the people from Santa Terezinha, live in rural areas and traditionally put great confidence in the word of doctors and public authorities.

We use this confidence to reinforce the need of social isolation to withhold the pandemic of coronavirus which is getting close to us, many times we are going against what the federal government is, irresponsibly, preaching in their recent statements.

Educating the population, promoting autonomy and critical thinking, really saves lives.

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About the author:

Danuta Ramos Duarte, born in the riverside of Araguaia in a little town of Tocantins state called Araguatins. She studied in a public school, graduated in medicine at a public university, Universidade Federal de Tocantins. Danuta is a person in love with people, nature and also with people’s natures. Granddaughter of a babaçu coconut cracker and an ecologist of Bico do Papagaio, daughter of a teacher, a feminist that dares to love another woman. A resident in Family and Community Medicine for SES-SC, a member of GT Rural from Brazilian Society of Family and Community Medicine (SBMFC).

Original text in Portuguese:

Telemedicina rural contra o coronavírus

Foto com as araucárias de Santa Terezinha

Escrito por Danuta Ramos Duarte

Traduzido para o inglês, editado e postado por Bianca Cadore Morás

Revisado por Mayara Floss

(Em inglês acima)

Ser uma médica num pequeno município, no interior de Santa Catarina, de 9 mil habitantes, impõe seus desafios. Mas minha pequena cidade tem nome sagrado: Santa Terezinha. Para chegar do litoral até aqui passamos por estradas estreitas ladeadas por mata atlântica, araucárias e pequenas plantações.

O terreno é acidentado, cheio de morros e vales, com riachos entremeados na mata, formando cachoeiras. As estradinhas de terra estreitas conectam os distritos, abrangendo uma área de aproximadamente 720 quilômetros quadrados.

O povo que aqui vive se sustenta basicamente da atividade agrícola, sendo a plantação de fumo, milho e soja as culturas mais frequentes. São trabalhadores rurais e pequenos agricultores e agricultoras, descendentes de migrantes da europa, aqui refugiados durante a Segunda Guerra, que encontraram no Brasil um lar ante o horror nazista.

São descentes de poloneses (autodenominados "polacos'), ucranianos e alemães, de tradição fortemente familiar: os limites entre o público e o privado se diluem nas relações sociais.

Nas rodas de chimarrão ao entardecer toda a vida da comunidade é discutida e recontada aos detalhes - cena capaz de provocar uma desagradável sensação de invasão da vida particular, ao passo que faz nascer o sentimento gostoso de acolhimento e pertencimento à comunidade.

Para atender a população, temos 3 postos de saúde com equipe saúde da família, com outros 3 postos de apoio nas áreas mais afastadas da sede.

Muitas pessoas em suas localidades não têm acesso a rede de telefonia e enfrentam dificuldade de acesso aos postos devido às grandes distâncias. Em contextos como este, a telemedicina é ferramenta essencial para alcançarmos as pessoas que não alcançam os serviços de saúde com facilidade.

Felizmente a internet e o rádio são recursos modernos já consolidados em grande parte dos lares dessa gente resistente, nos possibilitando reduzir as distâncias.

Então, como estratégia de educação em saúde, estamos usando o whatsapp e a rádio comunitária para informar as pessoas sobre o coronavírus e as mudanças na rotina das UBS e postos de saúde rurais, já que estamos atendendo apenas grupos prioritários, emergências e síndromes respiratórias. O município forneceu um número de whatsapp oficial como canal aberto de comunicação com a comunidade. Além disso, as agentes comunitárias de saúde, que moram nas localidades, repassam as informações oficiais para as famílias da sua área de abrangência, pois já possuem grupos de whatsapp com as pessoas que atendem.

Ao contrário do que possamos acreditar, a maior parte dos brasileiros, tais como os terezinhenses, vive em zonas rurais e tradicionalmente depositam grande confiança na palavra de médicos e autoridades públicas.

Nos valemos dessa confiança para reforçar a necessidade de isolamento social para impedir que a pandemia chegue até nós, indo, muitas vezes, em contramão do que governo federal tem apregoado irresponsavelmente, nas suas declarações mais recentes.

Educar a população, promovendo autonomia e criticidade, salva vidas.

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Sobre a autora:

Danuta Ramos Duarte, nascida na beira do Araguaia numa pequena cidade do Tocantins (Araguatins). Estudou em escola pública, formada em medicina pela Universidade Federal do Tocantins, apaixonada por gente e pela natureza e pelas naturezas das gentes. Neta de quebradeira de coco babaçu e do ambientalista do Bico do Papagaio, filha de professora, feminista e que ousa amar uma mulher. Residente em Medicina de Família e Comunidade pela SES-SC, membro do GT rural da SBMFC.

Watercolor

Carnaúba dos Dantas - Brazil

Your eyes have

A non-defined color

And, perhaps because of this,

You ​can see the other tones in everything

From the cold gray

Of few shades,

That I coldly plan,

You can identify a small

Sick pink

That motivates my grit

In the green-water lies

That I tell to please you.

You only see the red

Bloody one

That burns me!

You see the invisible notes

With your eyes

Which color, then,

My mother,

Is the soul

That I have mixed

With mine?

__________

Alexandre Dantas is a doctor, teacher and writer. He was born and lived most of his life in one of the driest backlands of Brazil - where he returned 4 years ago, working as a rural doctor. He created the project "A Medicina Rural" on Instagram (@amedicinarural) in order to give visibility to the rural spaces in which he works and voice to the people who live in them.

On my Skin

On my Skin

She opened the door of the health unit almost sensing something that morning. In the Rural Health Unit, about 100 kilometers away from the nearest reference center. A newly appointed doctor....and the farmers of the region saw in those hands a ray of hope. "The doctor listens to us."

Maybe this was the beginning of a cry about the future on her face. When she was in the office with another patient, somebody knocked the door, "Doctor, please come fast". The nurse was already gloved, a woman in great pain, laboir pain. Upon touching down the cervix, it was 5cm dilated. Fetal heartbeat flickering and Ineffective contractions.

Labor without progression was sensed. Oxytocin, orientations, everyone entering the small emergency room. Got everyone out of there to take a deep breath and called the 911.

"The ambulance can only get there in two hours, it is in another displacement." The calculation was not difficult... Two hours to come plus two hours to cover the 100km made 4 long hours. Can we handle it? Will the baby be born before that? We ask for priority, but the whole state needs priority.

Deep breathing, medications, salines, change of position, but still it is only 6cm of dilation in the first hour. The Fetal Heart Beat slowed down. They call the ambulance. "I need it for now." It doesn't arrive.

It did not come, it did not happen, it did not progress and it was not born.

Some colleagues would say, "it is her fault that she chose to work where she has no recourse". But is there a way to have a hospital in the countryside? To have an anesthetist team in the middle of the green of the corn? To have a team with obstetrician? Pediatrician? There, where the soy is planted?

Several will condemn "it is the doctor's fault, who went there," but would the unborn child stop herself being born or would the mother stop going into labor because they were in the countryside? Would the countryside stop existing just because there are no qualified professionals in it?

The baby was not born, the baby did not survive. Everyone hears the fetal heartbeat fade away without recourse, no training, no legislation, no doctor adequately trained for more than 60% of Brazil's population living in rural areas. While the ambulance did not arrive, a sigh, a tear.... A fatality? Could we have avoided this?

From birth to mourning. To err is human, to kill and to die is human too. But a doctor in the rural area without training is inhumane.

Warm regards,
Mayara Floss

Review by: Nisanth Menon
Translated into English by: Bianca Silveira

Posted and Edited by: Ana Júlia Araújo

Link to Portuguese text: http://balsa10.blogspot.com/2018/05/na-minha-pele.html?q=mayara+floss

Mayara Floss is a young doctor working in a rural area: Cunha Porã (SC), Brazil. She Co-creator of project 'Health Education League'.  She is the creator of the Rural Family Medicine Café to provide a forum to discuss Rural Health – a forum for students, young doctors and experienced professors and GPs from all world. She is the student representative of the WONCA Working Party on Rural Practice. She also co-created with Pratyush Kumar the project 'Rural Health Success Stories' and writes a weekly blog of Popular Education, Arts and Health - the Ferry Street of 10.

Ruralices

Amber Wheatley and Mayara Floss

The experimental short movie produced by Mayara Floss and Amber Wheatley called "Ruralices" received the award for best original background at the FISFA - International Short Film & Arts Festival during the 15th WONCA World Rural Health Conference, New Delhi with voice of Amber Wheatley and the music of Lucio Yanel and sonoplasty by Mayara Floss.

"My first job as a junior doctor in South West Wales involves a 1 hr and 15 min journey by bus from my apartment in the city centre to the hospital in Llanelli. My colleaguess often commented on how difficult it must be because the public transport in Wales, particularly the most western you go, is notorious for having problems. Make no mistake this is absolutely true but it also provided me with two unique opportunities; 1) I took the same bus as the people living in the community so I understood all too well the issues of getting to hospital when you relied on public transport and 2) I got to watch the sunrise every morning as I moved from an urban setting to a suburban setting. During my commute I had more time than at any other point in the day to be alone with my thoughts and take it what was going on around me. I also used this time to catch up on reading, writing and social media. Before medical school I wrote songs and poetry in my spare time but medical school seemed to kill all my creativity. I was slowly starting to reclaim it when one day looking at a photo from the Ruralices instagram page, I was overcome with inspiration. Dr Mayara Floss started the Ruralices page to capture and share images of the daily life of a rural doctor. Each of the pictures I knew held a story and that story inspired these poems". - Amber Wheatley

_____________________________________________________

Amber and Mayara are Young Doctors and ambassador of Rural Seeds. They are committed and passionate about rural health, arts and writing. 

Rural Family Doctor

Mayara Floss

Taking care of the patients in the countryside was my way of coming back to rural. I planted tobacco when I was young and today I try to support patients  to stop smoking.

Brazilian South, Jul / 17

Simplicity

Fábio Schwalm

Home visit in the late afternoon
Hi Dona Ana, how is going the hemodialysis
She responds:
Well, at first it was difficult, I had a bad time ... now I'm fine ... I spend the four hours praying
while I pray
And eating?
Better now I can eat more
And how can we help?
She hold a list in her hands:
What is Damascus?

__

Fábio Schwalm is a Brazilian rural family physician. He works in Brazilian South in a city called Barão. He is learning to write and grew in a rural area working in the smoke farm. 

The day that I dealed with death peacefully

 Andressa Cavalcante Paz e Silva

“When the rain falls down / What brings it back? / Opens the resurrected cloud / From white to black / It's a second birth / For dying skin / In my coffin...” 

(My coffin - Jon Foreman)

I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. So, I’m going to tell you a rural success journey story.

My story begins with a young girl going to a home medical visiting in a little rural area called Curuá, in Baixo Amazonas, north of Brazil. This girl was attending Medicine classes for four years in a College School in Rio Grande do Sul, a state located on the opposite side of Curuá, south of Brazil. However, this story is not about her. This story is about the day she understood the real meaning of Rest in Peace. This girl is me.

It started out with a “Hi, good morning, mrs. Maria. Have you called out for our visit? Let me see how Mr. Manoel is going.” and them the medical interview continued.

-Thank you for being here, doctor, he is not so well. He can’t speak anymore and It is being pretty difficult for him to walk. Also, he is refusing to eat since the day he had this strong diarrhea.

- Oh, and how was this diarrhea, mrs. Maria? You see if he is suffering of pain? Tell me more about it. - The student asked.

- It was last week. It’s been 5 days since the only episode. Oh and those black stools were so so smelly as I’d never had seen!! And in the last two days he is totally constipated. We tried so hard to give him food… We even tried to lay down some pasty food and in his lips and mouth, but the only thing he wants is water and sleep. We are trying so hard to give him the medications another doctor prescribed us, as well as those nutritional supplements. Now he isn’t suffering of pain, but we are worried about inappetence.

Mr. Manoel, an elderly man aged 77, was clearly dehydrated, hypotensive (80x40mmHg) and in the neurological exam we found out Glasgow 10. When we touched his belly during the abdominal exam, his face showed heavy pain. In our hypothesis we conclude that maybe Mr. Manoel was having an upper digestive hemorrhage. 

Unfortunately (or fortunately), the medical conduct wasn’t totally accepted by the family. First, we suggested moving the patient to Santarém, a place with a hospital, in which he could do exams to confirm the bleeding and treat specifically. Nevertheless, the logistic for all transportation stuff and maintenance of the patient and the family in Santarém was really difficult. 

Actually, even if there were no problems at all, Mr. Manoel’s family had already decided he would die at home. “We can’t send him to Santarém… A couple of weeks ago when he was a little better he said that If we ever try to send him to another place instead of here, he would come to haunt us after his death for sure!” - they said. In summary, the elderly man was medicated with some Oral Rehydration Solution and referred to the doctor of the city, as I was only in an observership. This experience was really different and meaningful for me. The empowerment of that family caught my attention and I started to think about empowering my parents and my relatives to understand the finite of life and to embrace palliative care too. Mr. Manoel get better in the consequent day after drinking the oral rehydratation solution, but after two days he died at the crack of dawn. 

So, I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. I guess Mr. Manoel’s journey through death was peaceful and I guess he will not come back to haunt his family. 

Photo by: Keith Dalmon Ferreira

--

Andressa Paz is a Medicine Student living in the South of Brazil. She loves listening to stories and rural ones are her favorite. She had her first contact with rural and remote Medicine in Kat Kalen - Haiti and then in brazilian Amazon area

Isolation

Caruaru - Mayara Floss @ruralices

Mayara Floss

I need to call Emergency.

There is an emergency in the rural unit.

"But doctor, there's no phone."

Caruaru 02/17

Mayara Floss 

Undergraduate student of medicine at Federal University of Rio Grande (FURG) - Brazil. She Co-creator of project 'Health Education League'.  She is the creator of the Rural Family Medicine Café to provide a forum to discuss Rural Health – a forum for students, young doctors and experienced professors and GPs from all world. She is the student representative of the WONCA Working Party on Rural Practice. She also co-created with Pratyush Kumar the project 'Rural Health Success Stories' and writes a weekly blog of Popular Education, Arts and Health - the Ferry Street of 10.

Neither burden nor feather

André Silva

This post was originally wrote for the Brazilian Blog of General Practice: “Causos Clínicos”

Attention: The following personal essay is based on a real case, but all names are fictitious. Further, all the story elements occurred in different situations. I saw main story with a wire of my life story. In this patchwork some details are older, some newer. But all are thea background of memories and heart.

As a suggestion please listen this soundtrack to read this story, this is the playlist that I listened when I wrote it. They are songs that made me smile, cry and touch as human in my vulnerability. Good reading!

AppleMusic

Spotify

------------------------------------------

 -   You're kidding me! I do not believe in you !! This is absurd !!

I heard the shouts at reception, a woman's voice. All while I was talking to two undergraduate students in their final year of medicine. They were preparing to meet the last person in the morning at that Thursday autumn. It had up a music of Enya which the resident had said that she was fed up of listening it.

I'm going to the front desk, and I come across a lady I had met three weeks ago, Mrs. Matilde. Skinny, black, with hands punished by time and hard work in the fields and at home in their seventies. So slight that it was hard to imagine that she had four children.

-          Doctor, why are you doing this to me? - She said almost in tears.

As she screamed, a short film went through my head: the diagnosis of HIV for more than month and she denying it. The case discussion with the nurse and the difficulty to make her understand. And those cold data on paper: 14000 and few viruses per mL of blood, 350 leukocytes type CD4, numbers that leave no doubt, but Matilde only increased her anguish.

I almost as a reflex, call her to the office, the same that had Enya as background music.

-          Doctor, I couldn’t have AIDS, I am with no man for over 30 years since I husband had died, I did not take blood... what will I become? How much life do I have?

       I ended up stopping the music. I thought it was worse, because it was possible to hear the strained breaths of both students, Bruna, Pamela, and my own.

-          Mrs. Matilde, let's talk calmly. I'm here to clarify all your doubts.

-          Doctor, I'm not with a man for over thirty years, my life was taking care of four children, and just now I met my first granddaughter. Look, you need to wash the chair where I sat, so people will not be contaminated when sit here! – She was sobbing, already standing.

"Hard to believe that today there are still people who think that HIV is transmitted like this." - I thought in my smallness. "I need to act fast, accurately and undressing of my prejudices and my fears."

I turn on the music again. I ask Mrs. Matilde to sit and breathe deeply with me. The students in the corner observing were seedlings.

-          Mrs. Matilde, the main point now is not where this virus came from. What matters is that today we have treatment and we will always be here to care you.

-          But doctor, people will not be able to get closer to me and ...

-          Mrs. Matilde, please give me your hands.

-          But but...

-          Mrs. Matilde, give me your hands. Let's go. - I speak with her more firmly.

I welcome those skinny little hands, and look at that old lady with a scarf on the head.

-          You see? We don’t get HIV like this? Can you see thaat you don’t need to be afraid? You still could play with your grandoughter.. You just need to slow down. You will be able to take the medicine and live quite yet.

-          Doctor, you have the age of my grandson. Aren’t you lying to me, right? I'll even be able to continue to come here, sit in this chair and be cared by everyone here at the Health Basic Unit?

-          For sure, Mrs. Matilde.

-               And I can get my granddaughter on my lap?

-               Of course.

-               And could I hug anyone?

-               You can even hug me, Mrs. Matilde.

Them, the lady opens her arms and wraps me in a hug, weeping. "Thank you," she said. And a new film goes through my head, my poor childhood, the youngest of eight children, the causes and conditions that led me to medicine, family medicine, for living the distance of five thousand kilometers of the city where I was born and raised. The miss of my mother, that great friend the lives over thirty years with HIV, that another friend who has been diagnosed recently, the fragility and richness of this phenomenon called life. And drops a tear inside my being, while I hug that little person.

-          Doctor, so I'm going, much more peaceful. I do not want to take you time. I can come tomorrow with my daughter for you to explain to her how it will work from here on?  The exams... medicines...

-          Please Mrs. Matilde. We will be waiting for you.

  And Mrs. Matilde leaves the surgery, light as a feather. I observe Bruna and Pamela thrilled.

-          Professor, how beautiful was this! But we have a question: a doctor at the hospital told us once that we should never hug patients, neither in private practice, because "gives a lot of freedom" for the patient to ask for more and more things, and it becomes a burden. Do this mean that we can hug?

"I need to be careful with the words," I think as I remember the zeal I learned to have when I do ikebana, those Japanese floral arrangements.

-          But even ICU doctors say that touch helps, what about us, family physicians, doctors of people, of lives, stories and emotions? Hug is therapeutic for patients and for us. And I imagine you have had a good example just now.

-          Undoubtedly teacher. We will bring it to life. Thank you - tell the students at the same time.

So I say goodbye to the students and I'm thinking about it at the office. The clock mark midday, lunch time. I look at the picture of “Lord”, my dog that died few months after 14 years of affection, and I am there, absorbed in my thoughts, in my longing, in my tears, in a vacuum. Moreover, remember Master Dogen, an ancient Japanese Zen master, who said that our practice in life should be "no gain". I think it is. Only family doctor, of people, of lives, stories, emotions. Without any gain or burden, nor feather.

Several months later, after comings and goings of Mrs. Matilde she is "very well". When I was doing another ikebana before dinner during a retreat as I finished the floral arrangement, I remembered Mrs. Matilde and what it means life: a breath, a flower that blooms and withers, a force, the bird flight that leaves no trace, a moment. And ikebana was like this picture. I am grateful to you, Mrs. Matilde. And I found myself not burden nor feather.

_________

André Silva is a Family physician in Brazil and works in a Rururban area located at Porto Alegre within rural characteristics with local creation of animals but the influence of urban problems like drug dealing.