Mornai - An Experience

Adrija Rahman

It was the year 1993. I have just finished my house-staff-ship in a tertiary hospital in Kolkata and was desperately looking for a job. I was newly married and my husband Shantanu was my batch mate; so, we were in the same boat. Fortunately, we got a job in Mornai, a remote tea estate in Assam in Kokrajhar district. Without much thought, both of us landed up there.

It was a 20-bedded hospital with an out-patient department (OPD), from where we were catering a population of 10,000 people. Apart from us, we only had another homeopathic doctor in our team. 

Locals were mostly Santhali and Mundari and the garden was owned by the Lutheran Evangelical Church.In the beginning, they were quite skeptical about us (by nature, they had the tendency to resist anything new). Moreover, we were facing extreme difficulty to understand their language.With our limited knowledge and unlimited enthusiasm,we started our job. Gradually those tea garden workers started accepting us and after some initial hiccups we also settled down in that isolated island!

Next year, I gave birth to my only son. For delivery, reluctantly I had to come down to Kolkata fearing about any complication.The nearest secondary care was in Dhubri, which was 6-7 hours drive from the garden. 

I returned to my job when my son was 40 days old.Soon we realized that for his immunization we should take him to Coochbehar, a 4-5 hours drive on an undulated village road.Moreover, the scorching heat in the month of June was unbearable.

I and Shantanu discussed an alternative, whether we could get the immunization done in the garden.Till then, there was no facility for immunization, as the tea garden workers were against any kind of injection to their children. 

How much we tried, we failed to convince them. We started our correspondence with the local health bodies and government officials.Also,initiated some dialogues with the union leaders.The solution was to get our son immunized first and show the local workers that “doctor Sahab’s son” had received the immunization.

Finally, the day came.My son got immunized. He was the first to receive the shot in the immunization camp. 

After that, there was a procession.The union leader led the procession,carrying “the example” on his back,showcasing him to the local workers.The message was conveyed that if the doctor was ready to give the injection to his son,it was important for the others to do the same.Then there was a big queue in the camp and that was the beginning of the immunization in that garden.

The roller coaster of my life took me from one extreme to the other. After practising evidence-based, guideline-driven medicine in one of the poshest practice in the UK, it was hard to swallow the harsh reality of a remote tea garden.

But at this juncture of my life, I can still visualize two young doctors putting their heart and soul to improve the life of a few backward poor tea-garden workers.

Rural agony to smile

 

 Dr. Pawan KB Agrawal

       

We all are bound to experience pain at least once in our lifetime in one form or the other. The severity of pain is subjected to individual experience and determination to tolerate. At times the pain bound us to kneel in front of someone whom we expect to be powerful enough in a hope that we will be relieved. 

Being a doctor, determined to face the rural challenges to bloom a light of happiness in those desperate faces with excruciating pain coming across such helpless yet hopeful patients is a routine.We do grade pain but often we are not able to address the individual experiences adequately.Nevertheless we always thrive amidst our limited resources and destitution of our fellow patients to help them sustain through their difficult times and at times these turmoil carve a beautiful story to inspire courage and hope in a doctor patient relationship. 

A week back I had this patient 32 years in one of the emergency beds during morning rounds.Two hours earlier I was informed by my colleague medical officer about receiving him in agonising pain in his abdomen which started from his scrotum the previous day.The pain had started the earlier morning.Since there were no vehicles to carry him and he could not walk for three hours with the pain, helpless he prevailed throughout the afternoon alongside his ignorant wife and three small children not knowing what was awaiting him. 

Rather than taking him to a religious healer, they preferred him receiving care in a hospital. A wise and often rare scenario in most of our deprived areas where these religious healers are the only prospects.

With the dusk, some of his relatives finally fetched a jeep and a ride of two hours along the bumpy gravelled roads and finally landed him in our emergency ward. Whatever be the reason pain must not happen. This is what we often emphasize to our fellow medical service providers. 

He received some pain killers while he was being examined and investigated. We established the diagnosis of right obstructed inguinal hernia and explained the patient & his relatives that he needs to be operated as soon as possible in order to save the part of his intestine that had come out as hernia and had been stubborn not to go back.

We could not be sure though if the part of his intestine needed to be cut and repaired. As a general practitioner, a generalist, we are regularly operating hernia that goes in spontaneously but a situation like this where a part of the intestine might need to be cut put us in dilemma given limited instruments, anaesthetic expertise and post operative care. 

Another challenge poking us was his referral, a journey of 10 hours by jeep depending on a driver to the nearest higher hospital in Dhangadi,far western Nepal in case the patient party agreed. 

We explained and discussed the scenario with the patient party, scrutinised every option in details. It would have been best if we could refer him in an ambulance with a paramedic to Dhangadi. But it was yet far from happening. 

The turmoil of helplessness,poverty and health care resources in each of us endured the entire night and settled in the afternoon as we, doctors and patient party eventually concluded to put the situation on faith and proceed with surgery in our hospital. 

The patient party agreed that if surgery goes wrong or he dies,they would not raise any claim.A life was on our hands then.How could we not do our best and help him survive was a challenge. 

He was rushed into the operation room almost forty hours later.Together with another generalist Dr. Bikash who is also my mentor since I started working with Possible in Accham two months back.

We put him under spinal anaesthesia and took every precaution available at our disposal. As we explored, the faith or whatever we name it served us with a hope that the part of intestine might survive.It was almost on the verge to die, had we opened him few hours later or had referred him.The anxiety diminished with a sigh of relief. 

After he was shifted to the ward, we prohibited him to eat and had him keep on intravenous fluids.After two days we started with liquids and had him have usual diet on fourth day. He was then walking happily without pain and discharged on seventh day after we are pretty sure that the complication would not happen. 

Sometimes we do end up with a climax where a family turns upside down with an unexpected helpless death of the beloved on a hospital bed.But to our faith & the conviction of his fellow relatives,this time a life in despair was restored with balance and smile for his new journey back home with his small family.

Fresia - Story of a Mapuche Women

   

Imagene: La ruca (Vivienda Mapuche)

Dr.Rossana Betancur Escobar 

         (Original Story in Spanish. Translated into English by Mayara Floss) 

         My name is Fresia. I am a woman, Mapuche, 68 years old.I belong to a rural community towards the coast of Chile. My ancestors are of origin is Lafquenche*. I live with my daughter Rosa.She is the youngest of my children.I had 4 children. The others men went out to try their luck to Santiago ...There they formed a family. A year ago they returned with their wives and grandchildren to a house next to mine.

      A year and a half ago my health declined.I did not feel very well.I was without courage, nor the strength to go and sell my vegetables to the people or feed my animals.

                                     ... Same time my partner left ... 

      Rosa started to worry. She took me to the Machi** and said it would be good if we go go to the doctor but before we did a ceremony to heal my spirit she wanted to go elsewhere.

       We went to Carahue***. How strange was everything ... I do not remember much that they told to me.I only had many examinations.One of them was very unpleasant - a tube by the mouth.Before the examination I did not want to eat.After the examination I was worse and vomited.

        We went back to the house but my daughter was quiet.Next time we stayed an hour in Temuco with other doctors.They examined me & told that I have a cancer in the esophagus ...The only thing I noticed was the young lady in front of me put her hand near my heart ... that place was hurting me for so long.

        My daughter left me in a chair. Waited to be comfortable and said  "Mommy, I have to talk to the doctor" ...
   
         After a while she came back by my side ... I do not know why, but I felt that she had cried. But I did not want to ask her. “They  can not operate because you are very thin ...”. “Well, dear, I told you ... it will be a long wait”.

       We were in the micro bus to return to our house with my eyes fixed at the window ...
 I remembered how my children were born,I attended my sick mother,left her house to follow my partner,told my children that they will study because I was not going to stay for sowing... and now I realise that they are my seed.

      That night  was the most beautiful one.My partner came in my dream.He said: "Fresia do not follow me,you have to go back to the doctors,take good medicine and get fat.Children still need you .. Every time you need me, I'll be by your side ...". This gave me strength to fight back.

      Here we went again ... to Temuco. I'm going to take chemotherapy.They say it's for the tumour to shrink. But before they have to put a hose outside of my throat  so I can feed.

     The return to home was different today... I feel happy ... I look in to mirror and found that I have recovered.Who I am ... I AM FRESIA ... AND I AM HERE.

* The Lafquenches or Lafkenches is the name given to those Mapuches who inhabit coastal areas of the region of La Araucanía at the province of Valdivia in the Southern Zone of Chile.

**Machi: Local folk healer

*** Carahue: A city and commune in southern Chile. It is located 56 km west of Temuco on the northern bank of the Imperial River. 

Author:

Rossana Betancur Escobar is a resident doctor in Family Medicine at U de la Frontera in Chile.She started to write this material as a compilation of life histories of her patients throughout her 9 years of work. This is mainly based on rural health and cultural relevance as Mapuche population predominates in the area which she respect and greatly admire. In 2009, she started working in a Health Unit as a family doctor, at Hernan Henriquez Hospital in Temuco, Chile. The unit was responsible for caring the the patients in their homes whether due to acute pathology or terminal cancer. People come from all over the region and from the city.She continue to attend a large percentage of rural population.She is trying to get the attention of her colleagues in other specialities in a hospital of high complexity to raise awareness about patients being cared at home and with the support of their families. So was born this idea to tell patients life stories and how they have experienced the sick. Today she is  working in a rural health centre inserted in the interior of Mapuche communities and she hope to write more stories.



Spanish version
Fresia

Imagene: La ruca (Vivienda Mapuche)

                   Mi nombre es Fresia. Soy mujer,mapuche,tengo 68 años. Pertenezco a  una comunidad rural, hacia la costa. Mis ancestros son  de origen es lafquenche.Vivo junto a mi hija Rosa.Ella es la menor de de mis hijos.Tuve  4…los demás ,varones,salieron a probar suerte a Santiago…por allá formaron familia.Hace un año volvieron,con sus esposas y  mis nietos,construyeron sus casa junto a la mia.

              Un año y medio atrás,mi salud decayó.No me sentía muy bien, estaba sin valor, ni fuerzas para ir a vender mis verduras al pueblo, o alimentar mis animales.

                                   

                               …Mismo tiempo que mi compañero partió…

                  Rosa se empezó a preocupar.Me llevó donde la machi y ella dijo que sería bueno que fuera al médico ,pero que antes hiciéramos una ceremonia para sanar mi espíritu , que quería irse a otro ladoFuimos a Carahue.Que raro se veía todo…No recuerdo mucho que me dijeron, solo que tenia que hacerme muchos exámenes. Uno de ellos muy desagradable, un tubo por  laboca.De antes ya no quería comer,después del examen hasta vomité.Volvimos a la casa, con mi hija…calladitas.

                 Al tiempo ,le entregaron una hora para Temuco,donde otros doctores.Meexaminaron.Me  dijeron que era un cáncer, en esófago …yo lo único que me fijé era en la señorita al frente mio que se ponía la mano cerca del corazón…ese que me dolia tanto, hace tanto tiempo.

                 Mi hija me dejó en una silla..”espérememamita,tengo que hablar  con el doctor”…Al rato estaba de nuevo  a mi lado…no sé porque sentí que había llorado,pero no le quisé preguntar.”Mamita el doctor dice que no se puede operar, porque está muy flaquita…Bueno hija, le dije…tocará esperar”.

                   Ibamos en la micro de vuelta a nuestra casa, con la mirada pegada a la ventana….recordé cuando nacieron mis hijos…cuando atendí a mi mamita enferma…cuando dejé su casa para seguir a mi compañero….cuando le pedí a mis hijos que estudiaran porque yo no me iba a quedar para semilla…y ahora me doy cuenta que ellos son mi semilla.

                   Noches atrás, fue la mashermosa.Mi hombre, en sueños me vino a visitar…”Fresia no me sigas, tienes que volver a los doctores, tomar buen remedio y engordar.Aun haces mucha falta a los nuestros…Cada vez que tu me necesites, a tu lado estaré”….

                  Aquí vamos de nuevo…a Temuco.Me van a hacer quimioterapia, dicen que es para que el tumor achique.Pero antes tienen que poner una manguera, esta vez por fuera de mi guata, para que pueda alimentarme.

                  El regreso a casa hoy es diferente…me siento contenta..miro y me encuentro…he recuperado quien soy…SOY FRESIA…Y AQUÍ ESTOY.

Author:

Rossana Betancur Escobar es  residente segundo año Medicina familiar en la U de la Frontera. "Este material inedito, es el que he empezado a preparar  y que es la recopilacion de las historia de vida de mis pacientes a lo largo de mis 9 años de trabajo. Este se ha dado principalmente en salud rural y con pertinencia cultural,donde predomina en mi zona la poblacion Mapuche,la cual respeto y admiro mucho.A partir del año 2009 comencé a trabajar  en una unidad a cargo de un medico familiar en Hospital Hernan Henriquez de Temuco,Chile, una unidad que atiende pacientes en sus domicilios, ya sea por patologias agudas o cancer terminal.Llegan personas de toda la region y de la ciudad y sigo atendiendo un gran porcentaje de poblacion rural. Buscando una forma de encantar a mis colegas de otras especialidades, en un hospital de alta complejidad,para que deriven pacientes para ser atendidos en su casas y con apoyo de sus familias, es que nace esta forma de contar sus historias de vida y como han vivenciado el enfermar.Hoy me encuentro trabajando en un centro de salud rural, inserto al interior de comunidades mapuches….ahí se comenzará a escribir nuevas historias…."

About a Diabetic gangrenous foot and negligence in its care with dexamethasone injection

 Dr Smruti Mandar Haval 

Dear readers,

You must have used dexa injection for various purpose in your daily OPD. But a wrong unthoughtful injection of same can destroy someone's life. Hence as a primary care physician it is our duty to educate patients and fellow physicians, AYUSH or complementary medicine practitioners about use of various allopathic drugs.

This is story of mrs.X who came to my OPD on one heavy Sunday OPD. She was a known case of diabetes,IHD,HTN and was on irregular treatment due to unawareness of issues related to its complications. She has a trivial trauma from her footwear and gradually she developed sepsis and gangrene.

Initially they took it lightly and went to a non qualified physician who prescribed her few IV antibiotics and gave a dressing. To reduce her pain and other complaints as a routine practise in rural India yet he gave her one shot of dexa. She got relief for some time but did not understand that her sepsis has flared up. They wasted another 2 days and during that she develop dry gangrene with wet gangrene changes.

With someone's advice they went to a surgeon and later underwent debridement and amputation of 3 fingers of one of the foot. One physician was managing this but as they find it difficult to go to him regularly for follow up they gave up and start visit of one more non allopathic physician.

Things were ok but sugars were uncontrolled and she developed few more patched of gangrene over her amputated part of foot. Mean while due to her pain she gave up her food, was on liquid diet/IV fluids and that too relatives were feeding her in lying down position.(?aspiration pneumonia start).

During this phase they read about my news diabetic foot can be saved in newspaper and they came to me .When she came to me she was hypotensive still on hypertensive drugs, no aspirin for her PVD status, patches of gangrene has set in which require amputation, cough with crepitations, foul smelling but without pus wound cachexic lady.

I did try to talk to relatives, ask them to avoid continuous lying down posture, no feed in that position ,movement of limb in bed minimal ambulation etc. Also I told them about improving nutrition via diet and only glucose or RL IV won’t help.

I also did amputation for her gangrene patches and gave her fresh dressing with antibiotics, insulin etc. She was doing ok for 2-3 days post my visit but on day of her follow up she developed ? MI or aspiration pneumonia as she has symptoms of chest tightness, dyspnea and uneasiness. These symptoms can be of hypoglycaemia too with use of insulin therapy and skipped meal by her last night.

They phoned me but as I was out of hospital I ask them to show other doctor. When she reached there she has vomiting and situation deteriorated then he shifted her to other place for further intensive management .After this I have no news about her.

Conclusion

This case raised many questions in my mind like does a stoppage of dexa injection in time could have reduced her sepsis? Is IV fluid therapy is the treatment for patient satisfaction or small meal counseling to relatives works better? Can intensive insulin therapy aggravate her symptoms or any other cause is there for her health deterioration.


I still feel if she would have come to me early and not wasted her time with quacks she would have been in better position today. I am still hoping that she is doing well and is in safe hands now.

______________________


Dr Smruti Mandar Haval (Dr. Smruti Subhash Nikumbh); M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology & Geriatric Med; Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA; Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders & Geriatric Medicine; C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka; Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum

Blog: drsmrutihaval@blogspot.com
drsmrutimhaval.blogspot.com
Area of practice: Sankeshwar, Dist – Belgaum,Karnataka. Epidemiology of your area in brief: It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes, hypertension, asthma, hypothyroidism etc.

Skardu

Dr. Sanam Shah

F lives in a small brickhouse along the river stream. She lives with her husband and an adolescent son. On first instance there is something truly enchanting about her surroundings; im distracted by the sky so blue, tugging at me to get away from my city, 2000 km away near the sea. This is Skardu. It is home to three famous mountain ranges namely Himalayas, Hindu Kush and Karakorum and people reside in the foothills despite the natural upheavels and unrests; enough to lure us there in an instance. Lack of engulfing high rise buildings, the city traffic and general urban craziness would make it an ideal place to retire, I thought to myself. But I am moved by something unsettling about her demeanour. She spoke fluent Balti and conveyed phrases with long pauses. I try to connect with her in Urdu, she nods in reply. However, I wait for her son to return with her bag of medicines that she has been taking for a long time.

I take a breather and admire the lovely backdrop. The clouds hang low and I could almost reach up and try to touch one and the surrounding peaks are draped in the early winter snow, glistening under the rising sun. I almost imagine moving up here in the countryside seeing people like F who have been living in this town since a very long time. A nearby river stream fills the silence.

I learnt that there is a big district hospital some distance from this place serving two districts in this town and a bunch of smaller clinics serving this town of approximately 700000-800000. The number of doctors practicing there remains short. The hardest hit are women as they are compelled to see male doctors due to few female doctors serving the area. The doctors themselves are overworked in these challenging circumstances.

So the son finally arrives with a big white plastic bag that I empty on the table before me. To my astonishment there are numerous strips of Levofloxacin that she has been consuming for the last two years that apparently has not made her any better anyways. I look up at her quizically and reconfirm her history that is clearly pointing towards asthma and allergic rhinitis. I dramaticaly ask the family to discard any remaining strips and to avoid using in the future. I write a prescription of anti asthmatics and hand the son with my number in case of any questions and concerns in the future.

This is just one family I chanced to see during my last travels and I begin to think about the other families that make up approximately 800000 population in this town. Its probably just wishful thinking but I pray about having graduate programs in these locations in context of the needs of the local population and someway of retaining health professionals here who often prefer urban centres due to myriad instances like lack of facilities; public-private partnerships that can address the health care challenges and perhaps someday see the establishment of a medical school here!

Five days later when I moved back to work I still thought about her and the numerous challenges meted out by nature both complex and multifactorial. I felt guilty of the urban comforts and started to look at life from perspective of people residing without them on less than 5 dollars a day income. Even after three months of returning, I think about them and their smiling faces and I twinge to return and serve the people and enrich my life with the real stories of life and living in the real world of rural and remote health care. Thats when I think about the neccesity of primary care in developing countries and the need to mobilise a strong workforce of ancilliary health workers besides doctors and nurses. A part of me is there that will cause to return and I would be happy to succumb as long as I can.

__________________________

Sanam Shah - Editor of the Blog Rural Health Success Stories
WONCA South Asia Region

Crying to give happiness

By. Dr. Bikash Gauchan

Mother in law, sister in law and a husband of 23 years old female brought her in the emergency department of Bayalpata Hospital in rural Nepal for labor pain at 9 months of pregnancy. It was very sad to know that she had lost her previous baby at 8 months of pregnancy because of intra uterine fetal demise (IUFD). When we examined her, she was in true labor pain, her cervix was 30 % dilated and membrane got ruptured on the way to hospital. Another bad news was revealed lateron, her baby was in breech presentation. We confirmed with obstetric ultrasound and we explained the difficulty of normal delivery and probable need of c-section delivery. The husband stood up and said, “She would need to work and if we do surgery it would be difficult for her.” Family doctor explained the breech delivery of baby might happen normally and might not lead to any complications. As the membrane was ruptured, the baby has less amniotic fluid. As soon as her husband heard us about the probable need of c-section, he ran away not to be found in the village and not to be contacted by mobile phone. His family members shared with us that he might have gone to India because he could not bear the stress. We waited her labor to progress. We waited till another 8 hours, monitoring her in between. Finally we had to diagnose as a case of Breech presentation with obstructed labor. It was very challenging to get the consent for c-section. Finally, mother in law and sister in law gave consent for c-section. After preparing well for anesthesia and giving medications she was rushed to operation theatre (OR). There was the presence of only one Family Doctor at that time. The only anesthesia assistant was on leave. The family doctor quickly gave spinal anesthesia and requested one of the medical officers to monitor for anesthesia. The family doctor scrubbed, painted and draped the lady. He started the c-section and delivered a baby who was passing meconium and little was found inside baby’s mouth. The circulating nurse and medical officer took care of the baby and the baby finally cried to give happiness to the lady on OR table, family members and whole medical team in rural hospital in Nepal. This story highlights the importance of family doctor in saving the lives of mother and neonates in rural regions. The is significant importance of training family doctors for c-section so as to reduce maternal and neonatal mortality globally.   

Emptiness

 Mayara Floss

“(…) Now one of you says to me, "But Grandpa: does time you are counting as was his boyish life, in the fields And now you start talking about emptiness ..." Then I explain: "It's the fields it is where the emptiness is large. the city is the place where emptiness is small. " In the city we look out and eyes just hit a building, a wall, automobiles. In the city we see short. In the fields, because the emptiness is large, the eyes see far, far away: the fields, the woods, the mountains on the horizon, the sun dies, the moon rises, the stars ... What a beautiful thing to see the white curtain rain is coming ... When emptiness is big world grows. (...)“ – Rubem Alves

I met him in the green cold and welcoming emptiness of Connemara. At night it is possible to see all the stars and in the distance his house near to the mountains is visible. It is necessary to cross a bridge and drive some Kilometres  to get there. When I met him I did not know he was a painter, he came into the Surgery with allot of smiles and jokes and a red nose. He had a obvious cough, sounded chesty and after an examination it was suggested that he take an antibiotic. He declined with a shake of his head saying that it would probably make him  more ill and cause him to be unable to work. His GP and myself a Medical Student gave some medication options but he was kindly sceptical.

While the Doctor spoke on the phone I got a chance to sit behind him and explained with a drawing all about Pneumonia, Bronchitis, emptiness and fullness. He raised his eyebrow and said you have made it very clear, now with your drawing I understand he said.

He accepted a prescription for medication but his GP and I felt that he was unlikely to take the medicine. Before he left the surgery with his prescription the doctor changed a big paper clip for a smaller one and he jokingly chided the doctor for being a penny pincher.

We laughed and I went with him to his car to be greeted by his Labrador, “ I never leave home without her".

The Doctor told me about his patient and friendship and the long life of difficult negotiation with medications. Sometime later we went to visit him which was more a social visit than a House call. The Labrador was on the road waiting for us before we turned in the dirt road. She already knew when the doctor was coming. According to the painter she feels the doctor coming and runs and waits in the ground to welcome him. He recounted how he happened to arrive in that place which he called his spiritual home. Back then may years ago there were only 2 or 3 houses and he described the enchanted emptiness of that rural island.

He was in the process of painting the local landscape, the greenery and lakes outlined with geometrical figures which he painstakingly re altered depending on the view he utilized . His little triangles and squares of paint were repeated thousands of times to get the colour and light exactly right so that he could produce the right green emptiness. His house and structure had evolved over the years based on previous adventures and alliances. Everything there had his personal touch, little pulleys  to close doors, solar panels to provide light, a fireplace strategically constructed in the middle of the house to heat bedrooms behind it and the living room in front. His house spoke his personality and was like a painting of himself. He invited us to sit at a table and sample food including Soup a routine played out often between him and the doctor that I was lucky to be part of on this occasion. Where the doctor sat an envelope with his name which on opening the GP found a chain of paper clips all that had been given by the doctor to the painter in the previous years. We all laughed at his reinforcement of the doctor as a penny pincher. Many people choose to be city dwellers where things are full, less empty, places where there are many things to do a lot of structure for treating diseases and a lot of everything. I learned with a bowl of soup some clips ink and people that emptiness is what could fill myself.

_____________________________

 Mayara Floss is an undergraduate student of medicine Federal University of Rio Grande (Universidade Federal do Rio Grande - FURG) in Brazil. She is the co-creator of project "League of Education in Health" based on the freirean principles and co-empowerment of communities and students (Blog in Brazilian Portuguese: www.lesfurg.blogspot.com ). She was Fellow of the Science Without Borders Program at the National University of Ireland, Galway 2014-2015. She is the creator of SUS Series ( https://www.youtube.com/channel/UC7p_rNpzJmlIQp2xFMMtk_g  ), a video Series about the Brazilian National Health System. She created in 2015 the Rural Family Medicine Café (https://sites.google.com/site/someambassadors/familymedicinecafe ) and she is coordinating the recently created Word Rural Medicine Student Network (WRMSN). She also co-created with the Indian Dr. Pratyush the project "Rural Health Success Stories"  and writes weekly for the Blog of Popular Education, Arts and Health - the Ferry Street of 10 (www.balsa10.blogspot.com - in Brazilian Portuguese ).