Packard researcher's other classroom in Guatemala

Exposure to Third-World poverty offers students valuable lessons and unexpected insights.

BY ADITI RISBUD

For some Bay Area doctors, a getaway from the daily grind means a trip to the Napa vineyards or the Tahoe slopes. Paul Wise escapes to a small town in the highlands of southwestern Guatemala to work in a health clinic.

It is a pilgrimage that Wise, MD, MPH, a researcher at Lucile Packard Children's Hospital and the School of Medicine, has made every few months for the past 30 years. In the time he has spent in San Lucas Toliman, he has worked with others to help support the creation of a network of local villagers who receive special training to provide basic health care. And since joining the faculty in 2004 as a professor of pediatrics, he has invited students from the School of Medicine to accompany him on his trips, believing that it offers vital lessons to future physicians, not to mention health care for those who desperately need it.

At the foot of fog-draped volcanic mountains on the southern side of Lake Atitlan, San Lucas Toliman is a community of indigenous Mayan people. The town's 15,000 residents, who are mostly farm workers, rely solely on income from coffee crops. They typically earn less than $1,000 per person a year. Stemming from this poverty is a range of preventable diseases: one-quarter of the town's children suffer from malnutrition, and diarrhea, dysentery and parasitic diseases are also prevalent. Additionally, the incidence of tuberculosis is 25 times greater than in the United States.

"Twenty-four hours ago you were in the Stanford Shopping Center," Wise recalled telling students last summer, shortly after they arrived in the remote region. "How do you make sense of what you are seeing now?"

The six students—five from Stanford and one from UC-San Francisco—got ready for the expedition by studying relevant diseases and honing their Spanish skills. Still, there was no preparation for what they saw once there while working long hours in clinics, or consultas, as part of a rural health program run by the town parish. At the end of the day, students would gather for evening reflection sessions led by Wise to discuss what they saw and challenges they faced.

"There were definitely times when we were detoxing," said Tress Goodwin, a second-year medical student. "The amount of poverty, it can be overwhelming if you can't talk about it."

The students, like the local doctors and health-care promoters, often had to ride in the back of pickup trucks along dusty, unpaved roads to the town's outlying regions to set up makeshift clinics. "Hanging on for dear life" is how Goodwin remembered some of the commutes. Lines to see the "American doctor" were filled with women and children and formed early in the morning before they began seeing patients.

The idea of bringing students to this remote town in Guatemala can be traced to Wise's freshman year at Cornell, when the campus was in turmoil with protests against the Vietnam War. He wanted to learn firsthand about the plight of people in developing nations and made his first visit to Guatemala as an orderly in a children's hospital.

"The most striking condition was malnutrition," said Wise, who last year assumed the Richard E. Behrman Professorship of Child Health and Society. "Most of these children were small, skeletal figures with swollen bellies and thin, off-color hair."

Moved by the abject poverty he saw during his time in Guatemala, Wise returned to Cornell and became a Latin American studies major, taking "just enough pre-med courses to get into medical school," he said. While studying and training to become a physician—and even after he had joined the faculty at Harvard medical school—he kept going back to Guatemala. By 2001, he had realized that young doctors-to-be would benefit from working in the town and organized the first trip to San Lucas Toliman for students as part of a clerkship program that he has since relaunched at Stanford.

Wise said that he seeks to teach students to use the skills they are learning in the United States to cater directly to what the community most needs, making sure to give the best possible treatment available.

So Goodwin and Bryan Maxwell, a third-year medical student, found themselves one day handing out toothbrushes to children who never had owned one before—and then taking steps to strengthen the enamel of their teeth.

"We were giving fluoride treatments for kids, which doesn't take any skill, but that's what they needed," said Maxwell.

"Their teeth were rotten," remarked Goodwin. "It's a major health issue."

Maxwell added, "A lot of people come down from the United States to Latin America and their mentality is, 'I'm well-trained, I should be well-used down here so what I want out of my experience is that I should be really busy every minute seeing really interesting cases.'" But, he added, the lesson that he and other students learn in Guatemala is to adapt to the local health-care system that Wise and others have worked for years to develop.

And the students learned how difficult it is to provide basic services in an impoverished place. During a late night shift at the clinic, Goodwin and Maxwell faced an unexpected situation with a young expectant mother.

"It was her first child, and she didn't know if she was in labor," said Goodwin.

A nurse was about to perform a pelvic exam when the electricity suddenly went out, leaving the clinic in complete darkness. Maxwell then remembered a hiking headlamp in his backpack. The nurse put it on, and was able to finish the exam. The patient wasn't in labor, but "she was so excited about the headlamp," said Goodwin. "It was perfect—worlds colliding, but in a good way."

A difficulty the students often encountered was helping patients keep up with their medications. By drawing pictures—a rising sun to represent morning, for example—students were able to send patients home with reminders.

"Everybody is speaking a second language," said Maxwell. "You are trying to figure out how to communicate. I think this experience would serve anyone who wanted to practice in California: If you are trying to be a competent physician, you need to speak Spanish."

Goodwin and Maxwell said they would return to San Lucas Toliman at the next available opportunity. Although the students paid for their own trips over the summer, they said the experience was invaluable.

Wise, who has already been back to Guatemala once since his visit last summer with the students, said he plans to return there with fellow Stanford faculty in the upcoming months. The goal will be to enhance the structure of the program for students, while checking in on his patients.

"The younger patients will greet me with 'Hola, doctor,'" said Wise, of the family doctor-type relationships he has cultivated in the last few years. "For the ones who knew me before med school, it's always 'Hola, Pablo.'"

Aditi Risbud was a science-writing intern in the Office of Communication & Public Affairs at the School of Medicine.

Note: This is a reprint of a story that first appeared 1/26/06.