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The Children of el Mercado Oriental
Eleven Yale nurses. One week. Eighty-six children who are too poor even for public school. Can Americans make a difference abroad?
September/October 2007
by Cathy Shufro

Cathy Shufro teaches writing at Yale. She and photographer Joshi Radin traveled to Managua in May for the Yale Alumni Magazine. (The magazine, which is not part of Yale University, paid for their trip.) The names of the children and their parents have been changed to protect their privacy.

The Moon travel guide to Nicaragua describes Managua’s Oriental Market as “a confusing maze of legal and illegal commerce.” In its 30 square blocks, merchants in makeshift stalls offer everything from sacks of rice to sunglasses to sexual services. Although the book promises visitors to Nicaragua “all manner of adventures,” it warns against the market: “Someone gets robbed here every seven minutes, and travelers should avoid it.”

Eleven-year-old José Tomás Cruz lives a few blocks from the Oriental Market, and he goes there every morning for his job unloading banana trucks. His mother works there, too, peddling coffee and sandwiches on foot. José Tomás shares a room with his mother, his two younger brothers, and three other relatives. His stepfather has been gone for two years; when he attacked José Tomás’s mother with a machete, she finally kicked him out. After that, the family didn’t have enough food for a while, and they would go two days at a time without eating. Things are better now that José Tomás has work.

In the afternoons, he goes to school. An earnest boy with black hair and a cowlick, he’s a serious student. He would like to become a lawyer, because lawyers “fight to set prisoners free.” He learned about lawyers from watching TV, which he is allowed to watch only on Sundays. When I ask why, he seems to find the question ludicrous. “I’m in school,” he says.

He and his brothers are too poor to attend the public school; although tuition is free, they would need school uniforms and black lace-up shoes. Instead, the boys attend a little independent school in the Oriental Market neighborhood. At the Centro Educativo el Esfuerzo—roughly translated, the Hard Work School—the students may wear flip-flops.

Visitors from the United States have arrived at the school this week in mid-May, and classes are cancelled. The visitors are nurses from Yale who will give the 86 students medical checkups.

For the children, the occasion is festive. Most had their only routine health examinations as newborns, and they’re curious, if a bit shy. They like trying on the colorful cardboard glasses that cover one eye for the vision test. They stand tall against the big cardboard dinosaur yardstick, and they touch their toes so the nurses can check their spines for curvature. After their physicals—ears, nose, throat, breathing, heart, belly—each receives a pencil, some stickers, and a small bar of soap.

The examinations are already under way when José Tomás and his brothers enter the school gate with their mother. The children wait their turns in the schoolyard, sitting at child-sized desks under the broiling sun.

For the nurses inside the cinder-block school building—seven Yale students, three nursing school faculty, and one alumna—examining so many children is hard work. They must plow through the long list of questions for health histories, do hands-on exams, and record the results, all in Spanish. A typical checkup takes an hour. In four days, the nurses hope to assess the health of every student, create medical charts for the school, and refer the sickest children to specialists.

“It’s hard to know what’s going to happen,” said School of Nursing student Julie Murray on the eve of the first day. “Are only half the kids going to show? Will we have everything we need?” The seven students have completed two out of three years of training to become advanced-practice nurses specializing in pediatrics or family practice. Most have only recently received their RN licenses, and they’ve never done so many physicals at once.

Nurses in scrubs are dispersed among the school’s three classrooms, parting hair to search for lice, tapping knees to test reflexes, marking heights and weights on growth charts. The nurses who know Spanish speak directly to the children and their parents. Others call on three circulating interpreters as they take histories: which immunizations has the child received? Any chronic health problems? Any worries today? How many rooms in the house? How many people? Any animals? Does the household have running water? A flush toilet? Does anyone smoke? Use drugs? The nursing professors move from room to room, answering questions and observing.

The temperature in the courtyard is above 100 degrees, and the classrooms under the corrugated steel roof are hotter. The children wait quietly. The school has no toys or books to occupy them. When it’s José Tomás’s turn, nursing student Kaberi Mozumder introduces herself in Spanish to his mother, Jahoska Rodríguez Cruz, and invites her to sit at a desk. Nicaraguan Eric Su helps interpret as Mozumder asks about José Tomás, ten-year-old Eliezer, and seven-year-old Edmundo. All three boys had pneumonia as newborns, says their mother. She is 26, a petite woman in a flowered skirt, sparkly black V-neck, and blue flip-flops. The family lives in one room and cooks over a wood fire. Breakfast is corn drink and rice and beans with cheese. Dinner is enchiladas, either cheese or beef. For lunch, the children drink fruit juice.

“I’m struggling to give them more food,” says Rodríguez Cruz. Sometimes José Tomás’s boss gives him food and he brings it home. “I feel bad that he’s providing for me,” she says.

Her parents could not afford to send her to school, and she spent her childhood on the streets, selling candy and corn drinks. When her tray was empty, she would sneak through the fence around the Heroes and Martyrs School. She learned to read by peering through an open classroom window. When I ask what she would do if she were better educated, she covers her face and quietly begins to cry. Then she whispers, “Computers.”

She’s grateful that her sons are “going forward” by attending school. “I’m doing my best to give them opportunities I didn’t have so they can take advantage of the fact that I’m alive and with them,” she says.

Nursing student Janel Drugge examines José Tomás. He tells her that headaches in the afternoons distract him from his studies. She advises him to drink more water and eat a healthy snack. She diagnoses his itchy rash as scabies, caused by mites that burrow in the skin. Sara Thurman examines Eliezer and finds that he has scabies, too. Eliezer says he often has stomachaches.

Thurman is examining Edmundo, the youngest, when he warns her that he’s about to throw up. His mother watches as he scurries out to the courtyard toilet stall. When Edmundo is anxious, she explains, he makes himself vomit. He used to vomit to keep his father from hitting him. He’s very thin and has been fragile from the start, she says, born at seven months after a particularly brutal assault by her husband. Ironically, after his father moved out, Edmundo’s anxiety intensified. He often cries at school. Sometimes he can’t sit still, and the teachers send him home.

“He says ‘I really love to study and go to school, but I miss my dad,’” explains Rodríguez Cruz. “In school, when they draw the family, he draws his brothers and Mom and Dad in the house.”

Mozumder tells Professor Patricia Ryan-Krause that Edmundo and Eliezer need to see a psychiatrist or psychologist. Would that be possible? The question reflects the nurses’ biggest worry: will their work here have any lasting effect?

Foreigners don’t do much good when they show up, “dump medicine,” and head home, says Rev. Douglas Orbaker. In his job as a delegation coordinator for CEPAD, a Protestant social-service group, Orbaker has seen a lot of well-meaning visitors come and go. He is more optimistic about the Yale nurses’ project. CEPAD provides bunkrooms, meals, and guides for visiting religious and humanitarian groups at its fenced-in compound a few miles southwest of the Oriental Market; the nurses are staying here.

The trip’s organizers—School of Nursing professor Pat Jackson Allen and administrator Susan Barringer—are trying to avoid the “dump medicine” syndrome, although they have set a tightly limited schedule to fit their budget and time constraints. As Yale internationalizes, and sends more and more students abroad for service projects, many more faculty and administrators will face such conundrums. Jackson Allen and Barringer’s approach is a commitment to sending students each year for five years. (For this trip, the nursing school paid half the transportation and lodging costs for students and 80 percent for faculty.) They have also set a goal of persuading local health care providers to take over, and maintain, responsibility for the children.

The success of that local connection will most likely hinge on a doctor they’ve contacted through Orbaker. He is pediatrician and neonatologist José Félix Sánchez, chief of medical services at the national children’s hospital in Managua. The day before the nurses began work at the little school, Sánchez met with them in the city and promised to visit la escuelita himself in the coming week to consult and to find specialists for children with serious problems.

In some parts of Nicaragua, says Sánchez, “health care is totally insufficient.” He’s one of many Nicaraguan doctors who do volunteer work in their free time, filling some of the gaps in a country where half the population lives below the poverty line and underemployment is the norm. Groups like the Yale nurses can share some of that work. “Our policy,” he says, “is to join forces with whatever group will be able to help us.”

By opening its gate to the nurses, the school is allowing them to experience what it’s like to work without the equipment and referral system they take for granted in the United States. They’ve learned about health care in poor countries in their classes, says Jackson Allen, “but to go down there and actually see it and feel it and smell it and have the opportunity to do the patient exams on these children is just a great educational experience.”

Both Sánchez’s participation and the school itself are legacies of the 1979 Sandinista revolution that overthrew the corrupt Somoza regime. The name of Sánchez’s hospital—Hospital Infantil Manuel de Jesús Rivera—is one of the many reminders throughout Managua of that era; it honors a 12-year-old boy killed for serving as a courier for the revolutionaries. The socialist Sandinista government fell in 1990, but the Sandinistas remain active, and their tradition of grassroots organizing survives. Sánchez does his volunteer work as part of a Sandinista-style brigada de salud. The Oriental Market school grew out of a 1996 meeting of neighborhood residents who came together to discuss local needs. Many of them were squatters in the ruins of a district that had been leveled by the Managua earthquake of 1972 and that, 24 years later, still had no school and virtually no social services. “The government wasn’t worried about this area,” says Carlos José Aguilera, 38, one of four teachers at la escuelita.

Those attending the meeting wanted a school, a health clinic, and a woodworking shop, but since they had no money, only a school seemed possible. “We asked ourselves, ‘What do we have? Just human resources,’” recalls Aguilera, then a cobbler. About a dozen volunteers started teaching—120 children in three shifts. Aguilera was one; among the others were two dressmakers, sisters Leonor and Alicia Narváez Najeras, who also still teach here.

For a few years, the teachers found space in churches. After the government built a neighborhood public school, some students enrolled there, but classroom space for the rest was still hard to come by. At one point the teachers even contemplated holding school in a park. In 2001, with funding from two couples in the United States, the school moved into its present home. The American donors pay the teachers—four in all today—salaries equivalent to $40 per month. (The Central Bank of Nicaragua estimates monthly subsistence income for a family at $185.)

The teachers and the Yale nurses found each other through the grapevine. Orbaker and his wife, Penn Garvin, employ Alicia and Leonor’s mother as their housekeeper. When the sisters lamented the lack of health care for their students, Garvin spread the word to friends back home in the United States. The news reached some Yale nursing alumnae, who in turn got in touch with Barringer, associate director of the school’s Center for International Nursing Scholarship and Education. “You’d call that an answer to prayer if you’d thought to pray about it,” jokes Orbaker.

The students have come to Nicaragua partly to experience a different culture—for the “instant perspective” travel provides, says Thurman. Mostly, though, they’re here to try out their skills and serve people in need. Mozumder says, “I feel like everybody deserves to have what I was given—my parents supporting me financially, having a place to live, never having to worry about where my next meal was coming from.” Her family is from India, and she says it’s only by chance that she grew up in affluence and the Oriental Market children grew up in poverty. “I’m not any more special than they are.”

Julie Murray sees the visit as a chance to manifest her Christian faith by helping people: “When they are vulnerable, to connect with them, to show you care about them even when nobody else does. That’s a huge reason I chose nursing, and that’s a huge reason why I chose to go on this trip.”

Murray once took part in an international project that she doubted was helpful. Before entering nursing school, she spent two weeks at a clinic in Vietnam. “I left that trip with a lot of frustration because I felt we showed up for two weeks and left. If I give this man pills for 10 days, is that really helping him? You can either make shallow footprints and cover lots of space or make deep footprints in one place.” Murray hopes that the nursing school’s five-year commitment to la escuelita will leave a deep footprint. Still, she worries. “I don’t know how much impact we can make in one week.”

At least, says nursing student Jenner Greil, the children will benefit from a connection with the local health care system. “Let’s put these kids onto their radar. If that’s the only thing we do, I think we’ve accomplished something.”

Oswaldo and Isabel have had their checkups, but the next day they’re back at school, hand in hand. Six-year-old Oswaldo desperately wants his teeth cleaned. He says so, and then in case the American nurses don’t understand Spanish, he rubs his index finger back and forth across his blackened teeth.

Dentist Alicia Reyes Mendoza has set up a clinic in the courtyard. She created a shady tent by draping red-and-white checked fabric over the school’s swing set, and she has lined up her gleaming picks and probes and her miniature mirrors on a sterile cloth on top of a plastic storage bin. The children lay their heads in her lap as she cleans their teeth and applies banana-flavored fluoride. She hugs them when she’s done. By the end of her four days of volunteer work, Reyes Mendoza will have seen 70 children, from toddlers to teenagers. Only two of them have ever seen a dentist before.

The U.S. visitors are amazed by the children’s equanimity. Not one cries or fusses. Even a little girl whose rotten tooth is pulled cooperates silently, a few tears sliding down her cheeks.

When Oswaldo’s teeth have been cleaned, Reyes Mendoza sends him to the courtyard sink to learn the art of brushing. Nurse Mozumder is at the post, pantomiming brushing technique for children who are trying out the new toothbrushes that have been labeled with their names.

Oswaldo’s teeth are worse than most, but many of the children have decay from drinking soda. Mothers often carry small plastic bags of Coke with a piece of a drinking straw attached and squeeze out a sip now and then for their children. When Thurman examines Isabel, she tells her not to drink so much Coke. Isabel, who is four or five (the children are not sure) seems incredulous. She crosses her arms and wrinkles a face framed by brown curls tinged red, perhaps from poor nutrition. “What am I supposed to drink?” she asks.

The inseparable Oswaldo and Isabel come back again the next day, and they invite us to visit. In their muddy yard, rice simmers over a wood fire, and animals mill around: pigs and piglets, a dog, chickens and ducks. A board propped across the bottom of the doorway to the one-room house keeps the animals out. Inside, a poster of the Last Supper hangs on one wall. The children show us their bed, a frame with cardboard over the slats instead of a mattress. The bed fills most of the room; their parents, they explain, sleep on the strip of concrete floor beside it.

When we leave, their mother, holding a diaperless baby on one arm, clings to us with the other, begging for money to fix the leaky roof. I ask her to write down her name, but she pushes the notepad away. She cannot write.

Nursing student Farrell Godbout has a question for the doctors. Two have come to the school today—Sánchez and Eddy López, an epidemiologist from the children’s hospital. Godbout has just examined two-year-old Angélica, who wheezes when she exerts herself and has gone to the hospital twice this year during respiratory crises. López asks for a history. Are there smokers in the house? No, says Godbout. Do they cook over an open fire? No. The doctor rules out esophageal reflux because the girl is too old and says cystic fibrosis is rare among Nicaraguans. If Angélica had recurrent pneumonia, she’d be thin and frail. “That’s not the case here,” says López, laughing as he looks down at the chubby toddler. Angélica should be treated for asthma, he says. He’ll get her an inhaler.

López says he appreciates being consulted. Many foreign volunteer groups don’t even inform the national Ministry of Health when they do medical projects in Nicaragua. “These groups act in a very independent manner,” adds Sánchez, “according to their interests, their politics, their strategy as an organization. This current government accepts the collaborations very happily—”

“—because we need it,” interjects López.

But Sánchez thinks all health care, voluntary or institutional, should reflect national priorities. He mentions the international group that repairs children’s cleft lips and palates in Nicaragua and elsewhere. “For us, heart surgery is more important, or treating kidney problems.”

“There are so many needs,” says López.

Then how important is a single school with only 86 children? Sánchez points out, “The Oriental Market is the center of the most violence and epidemiologically high risk of any place in Nicaragua, because of the population density, the poverty, the drug use, the alcohol.” It seems a good place to begin.

On Thursday, the final day of the project, a few children have been invited to return for appointments with Sánchez. Among them is seven-year-old Josselyn Escobar. Nursing student Cassandra Jones is concerned about a large swollen lymph node beneath Josselyn’s jaw. Sánchez diagnoses bronchitis and prescribes an antibiotic. Jones has already told Josselyn and one of her sisters that they have head lice; she explains that they should use lice shampoo and wash their sheets and hang them in the sun to kill any remaining lice.

Josselyn is here with her sister Sandra, the oldest of the six Escobar children who attend la escuelita. Sandra is 14, stylish in a trim Aéropostale T-shirt and fitted jeans. She has plans: “If I don’t study, I won’t have a better future. I want to become a journalist. I know it’s difficult, but that’s what I want to do.” But her teachers say Sandra misses so much school to help out her parents and ten siblings that she reads at a second-grade level. She’s not alone; UNESCO reports that Nicaraguan children who finish primary school take an average of ten years. A third of the schoolchildren never make it.

Sandra’s father has a college degree, and she says her family was once comfortable. But they lost their house and spent six years camping in a public park. Her father, now a sign painter, built their new house from scratch. Sandra looks happy as she tells us about it: a room for the parents, three rooms for the girls, and two for the boys. There’s a kitchen and living room.

Later, we ask to see the house. In place of the rooms Sandra described, it has one large, bare space. The only furniture is a small table with a portable two-burner gas stove. The floor is concrete, the roof corrugated metal. There are no beds, and no sheets to wash and hang in the sun to kill the lice.

“We’re very poor,” says the mother in a quiet voice. We have embarrassed her. The father sits on the front stoop in a plastic chair, mixing paints for a sign. As we leave, he admires my School of Nursing hat and is happy to keep it.

By Thursday night, at their final meeting in CEPAD’s courtyard, the nurses have evidence that their visit might have some lasting effects. For starters, Sánchez has delivered 15 albuterol inhalers to the school, provided by the Ministry of Health, and the teachers will show students with asthma how to use them. “He’s followed through,” says Jackson Allen. “The government has this stuff and it just hasn’t been getting to these people.”

Sánchez has also promised vaccinations for children who have missed essential shots, as well as medicine for all the students to clear out intestinal parasites. He has made several appointments with specialists, including a psychiatric consultation for Edmundo and a visit with a specialist for a girl with two perforated eardrums. Jackson Allen proposes leaving some of the money the nursing students collected before they left Yale—$1,450 in bake sale revenues and donations—to pay taxi fares, so the children and their parents can get to appointments.

The children not only showed up for their checkups, but they brought along some friends: the nursing students did 91 exams. The nurses are leaving 15,000 pediatric multi-vitamins with the teachers, enough for each child to take vitamins three times weekly for a year. They’ve bought lice shampoo for all the children and left $25 so the teachers can buy a fine-toothed nit comb for each family, to help control the lice.

Sánchez has also promised to enlist a nurse from the local health center to visit the school monthly and check on any children with problems. The dentist will return to pull decayed teeth and fill cavities. And Jackson Allen has started arranging for the return trip in 2008.

Mozumder says the visit has confirmed for her that “I finally have some clinical skills that I feel are useful to someone.” Greil says she learned from working alongside the professors: Ryan-Krause immediately noticed that a child had vision problems, and Mikki Meadows recognized a possible case of bronchiolitis from a single cough. “They always tell us in nursing school that your observation skills are your most vital tool,” says Greil. “You can tell a lot about your patients by looking at them, before you even touch them.”

Greil is already thinking about next year. She wants to add health education to the project by making posters and by asking nurses fluent in Spanish to give talks to the parents on child development, nutrition, immunizations, and contraception. A few weeks later, looking back on the trip from New Haven, Greil says, “I’m going to do whatever I can do to get myself back there.”

Murray knows the satisfaction of coming back. While an undergraduate at Stanford, she saw the same children three summers in a row when she volunteered at a school for disabled children in Peru. “You go one year and they have their baby teeth. Then they don’t have any front teeth at all. They have a ventana, a window. And the next time they have buckteeth. It’s great to be in people’s lives over time.

“I don’t know what will happen. I do believe in relationships. I think this is the beginning of a deep footprint, and I definitely want to come back next year and see that happen again.”

Postscript

Two of the nursing students were hospitalized with typhoid after returning from Nicaragua. Both have recovered.

Penn Garvin has visited the Centro Educativo el Esfuerzo regularly since the nurses left.

The students now line up to brush their teeth at the end of each school day. The girl with a chronic ear infection took antibiotics and the infection cleared up. A boy named Alvaro who screams and cries when he sees male strangers has gone to three psychotherapy sessions arranged by Sánchez and is scheduled for another.

The health ministry has not yet visited the school to give vaccinations or set up a system for providing anti-parasite medication three times a year. The mother of a nearly blind boy failed to take him to an appointment with an ophthalmologist arranged by Sánchez, and Edmundo’s mother declined to take him to a psychiatrist, saying he no longer vomits after meals.

Garvin says the teachers are urging parents to follow up with appointments. But “it takes time to move them in that direction,” she wrote in an e-mail. “They have much on their plates to survive, and doctors have never been part of their own or their children’s experience.”  

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