Stories from the Field
2014 HSVMA-RAVS Annual Trip to Nicaragua

We are happy to have veterinarians in the field sharing stories from HSVMA's Rural Area Veterinary Services and Equitarian Initiative clinics in Nicaragua.

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January 6 - 9, 2014

By Dr. Jennie Lane

When Dr. Dave Turoff used the metaphor that that "now only getting hit by a meteorite" would prevent our getting to El Bote, he tempted the universe a little too much and we had a meteorite shower. As we set out on phase 1 of the HSVMA-RAVS sponsored January 2014 Nicaragua working equine veterinary trip, in typical fashion we encountered many roadblocks. The troubles started in customs where it was an arduous, frustrating and maddening experience trying to get boxes of supplies and the dentistry equipment despite the appropriate permits. (More to follow about this process in another blog entry). The troubles continued with some long waits and a long detour to avoid a road made impassable by rains and mud. The ultimate meteorites however, was another truck stuck in the road in the mud, preventing traffic from passing in the downhill direction and a blown rear (fortunately) tire. However with a talented bus driver, wise driving, patience, snack bars, peanuts and a SUPER bus that we are lucky to use due to the generosity of Dr. Eric Davis from R-Vets, we arrived in El Cua around 8PM on Sunday evening.

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We are a large group this year, with an entourage of over 25 individuals representing a number of countries and backgrounds. Veterinarians from the United States include: Dave Turoff, Tom Parker, Shelley Lenz, Raul Casas-Dolz, and Jennie Lane. Greg Murphy joins us from Australia. We are also joined by Fernando Lopez-Ponce, a Nicaraguan veterinarian from San Juan Del Sur and Yvette Pichinte, a veterinarian from El Salvador. Nine veterinary students from Honduras also join us, as well as Claudio Mayorga, a Nicaraguan veterinary student who was on the original trip to El Bote 7 years ago, as well as 2 veterinary students that are classmates of Claudio’s. Ricardo Alvarez, an animal science undergraduate student from Costa Rica, and Randy Gomez, also an animal science student from Guatemala are also with our group. Farrier Chris Hadel rounds out the trip. (When we return to Granada after 3 working days in El Bote the trip roster will change a little bit.)

Needless to say, we are a very large group. Many times large groups can be difficult to coordinate travel and accommodations for, fortunately due to the familiarity with the work sites, lodging options, local contacts and a big bus for transporting us (and all of our stuff) our group travels very well with each other.

The entourage loaded up the bus early Monday morning and set off on the last leg of the journey to El Bote. We changed out the bus for four-wheel drive vehicles about an hour from El Bote, and slipped and slid our way into town, only having to get out and literally dig the truck with our supplies out of the mud once.

Since we were behind schedule workday 1 started around mid-day. We were able to get the registration, dentistry, surgery and farrier stations going rather quickly however, as the Honduran students were already somewhat familiar with the flow of registration, and the most of the team of veterinarians have worked on multiple trips in the past. The surgery team had ample time to spend teaching about anesthesia and castration technique with the one castration presented to them on day 1.

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Day 2 saw about 150 horses. The castration team performed quite a few castrations including two field cryptorchid surgeries, led by Dr. Shelley Lenz. These were valuable learning experiences for the students. Due to the large number of students all students were split up into groups, some paired with surgery, others with anesthesia, the farrier, dentist and registration. Dr. Jennie Lane is also working on a research project investigating the association between working equine health and human health in rural communities for her Master in Public Health degree. She is collecting survey information from owners in the community on socioeconomic standard of living markers, human health and animal health, and pairing this information with animal health scores and child height-weight scores. Data collection for this project started on day one, but the survey team started to develop their method on day two. Most owners are very helpful and eager to participate in the project when invited after registration. One interesting piece of information thus far is that many of the owners in El Bote (all but one owner for all 3 days was male) never attended any school, even primary school. Many of these owners were in their early-mid 30’s, which correlates with the war. Farrier Chris saw some interesting feet; in particular one mule had an abscess that covered the majority of one sole. Day two ended with a delicious feast of fresh pork, purchased from a local owner and butchered that afternoon for the team. The students made spicy, delicious pork skewers and Claudio amazed us all with his cooking skills of a savory, garlicky pork stew.

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It rained all night long and day 3 started under very rainy skies, making the working conditions very difficult. The quick purchase of an $8 pair of rain boots made a few doctors much happier with dry feet. The registration team split into 2 groups, as one owner presented 47 horses, the majority of which were literally wild, and had to be lassoed and roped. Both teams moved quickly through registering, examining, vaccinating (tetanus toxoid only) and deworming with Ivermectin. The wild horse team was proud that they were able to treat all the horses that presented safely and patiently, and some students learned some excellent horse handling skills. The castration team withstood the elements and still managed to perform about 10 castrations. One castration surgery that was initially thought to be cryptorchid, and was approached as such was ultimately determined to probably have been only unilaterally castrated in the past, perhaps as a young horse before the other testicle descended. Dr. Tom Parker also explored, flushed and placed a penrose drain in a infected wound involving the carpal extensor tendon sheath of one mare. He also resected and placed a drain in an extensive saddle sore over the withers of one horse. For the most part, most horses in the community were in decent body condition, with some saddle and girth sores, but few severe ones. There is ample grass in the mountains, at least during the rainy season, and despite many of these equines working quite hard for the owners, both as riding animals and packing out coffee and other crops, collectively they were in decent shape. Day 3 ended with a large group rounds session after dinner on the post-operative management of common castration complications and field anesthesia. The students were really eager to participate and many asked insightful questions that indicated they were learning and thinking about what they were seeing during the preceding days.

It is important to begin to more critically evaluate the impact these trips have on communities. Respect for local veterinarians to not undermine their services is paramount. Training the next cadre of local veterinarians is essential to improving the depth and degree of local knowledge and improving the sustainability of veterinary care in the area. Maintaining and reviewing records of animals presented and going beyond the sheer number of animals presented, but their health conditions and attempting to measure the impact of services is important. Hopefully the development of a more comprehensive health score that Dr. Lane is working on will help to provide a metric to evaluate health more critically, provide a baseline for a community, serially track both individual animals and communities over time, and compare different communities with other another, as well as measure the impact of different interventions (ie., short veterinary service trips, local veterinarian interventions and training programs, saddler/harness and farrier service training, training of community animal health workers, etc.) to better determine which types of interventions are the most effective for different communities and populations of both working equines and their people.

trucks passing through river

Equally important is to realize just how difficult and remote the community of El Bote is to reach. All told, it took over 12 hours to both reach and return from there in our bus. While this included multiple stops, vehicle changes, muddy road delays, detours from impassable roads, etc., it is a very important consideration when both planning and working on these trips. When traveling in any developing country, time frames need to be shifted, and the little mantra “no one else is in a hurry” needs to be repeated frequently. Patience and local contacts are essential to getting any work done.

El Bote, was not a glamorous destination. In fact, it was the poorest town some of the people on the trip had ever traveled to, despite the fact that even poorer towns exist in Nicaragua and elsewhere. A conversation with the local doctor taught us that areas in Jinoteca (the district that El Bote is in) have some of the highest maternal mortality rates in the country, many women still deliver babies at home, and that malnutrition is one of the biggest health problems in children under 2. The young doctor works with two other colleagues in a very small clinic that has no diagnostic abilities, no Internet and must share the only satellite phone in town. Sanitation in the community was moderate at best and frequently abysmal, with many latrines about 100 yards or less from the river and very limited hand washing areas. Many of the diverse communities Equitarians travel to are like El Bote; far flung places on the map with less attention paid to social problems. An open but critically thinking mind, with an appreciation and dedication to evaluating our impact in tandem to how we could otherwise affect the communities we work in is essential.

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January 10, 2014

By Dr. David Turoff

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Today was our busiest day so far on this trip, and likely to be the busiest we will have. Set up at the parking lot of the local baseball stadium, our team attended to almost 300 horses, with a variety of fairly serious problems.

The patient population here is predominantly urban cart and carriage horses, and as elsewhere, these tend to be in generally worse condition than their rural counterparts. Although parasite transmission in the urban environment is less intense, there is also lack of anything for them to eat which is not provided directly by owners. In the countryside, where most horses are either turned loose or tied out when not working, they are able to graze; not so the urban horse. Also, many of these are never fully released from their tack, and spend nearly their entire lives standing, some in full working rigs. Changing this cultural pattern of husbandry is a challenge, and a major goal of our program.

Our roster of team members has changed a bit. Dr Raul Casas had to go back to his practice in Florida, and we were joined by Dr Sara Gomez, from Massachusetts, who with her husband, Doug Cook, are moving to Nicaragua to staff the new clinic at San Pedro, on Ometepe Island (more on this later).

We are fortunate to have with us so many high quality and fairly experienced students (nine from Honduras alone, recruited on the Equitarian Initiative trip to Choluteca, Honduras, in November last year, as well as one from Costa Rica and one from Guatemala, and two Nicaraguans). Last year in Granada we saw about the same number of animals, but with a team of only 12 people, and it was a truly brutal day. This year, the caseload was handled with relative ease and efficiency; even so, 300 animals in a day is a lot.

The stadium parking lot is not an inviting environment in which to do general anesthesia, but fortunately, Dr Tom Parker is skilled at standing castrations, and did 13 of them, which also provided an opportunity for all of the students to learn the technique.

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We also attended to many cases of serious dental pathology, and quite a few musculoskeletal problems, in addition to routine vaccination and deworming.

Tomorrow we depart for the island of Ometepe, where we will work in five different communities, circumnavigating the island as we go, and will probably see around 500 animals. We've hit our stride, though, and the team is functioning in a well-organized and efficient manner, despite the number of people, and this big a caseload will allow all the students to gain hands-on experience unobtainable in any other way. These students are the future of veterinary medicine in an entire multinational region, and in part because of our program and other like it, that future looks increasingly brighter.

In reality, though the work itself is important, it is the students we train and mentor who will have the most durable and sustainable impact on working equid welfare in this extremely disadvantaged part of the world. They are an inspiration to me and to all of us, and it's a gratifying and humbling experience to have the opportunity to work with them.

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January 18th, 2014

By Dr. David Turoff

We haven't been able to post daily blogs here because of time and connectivity constraints, and we've now concluded the working part of the trip, so this will be a sort of retrospective summary.

Before the description of the work days, though, a discussion about what we learned about importation of equipment and supplies into the country is in order. There has always been difficulty getting equipment and supplies into this country. It's a two stage process, involving permits from MAGFOR, the Nicaraguan equivalent of the USDA, and the Customs officials, whose main concern is collecting import tax.

Obtaining the import permits is a difficult process, with requirements that are not consistent from year to year, and subject at times to seemingly arbitrary impediments. One year, for example, Tetanus Antitoxin was rejected as being a prohibited modified live virus product, despite the fact that it not viral nor live, The tax, though, has always previously been simple; based on the aggregate weight of the products to be imported, irrespective of value.

This year, our permits from MAGFOR were in perfect order and that agency gave us just a reasonable inspection, but the Customs agents, for the first time, unexpectedly wanted to charge import tax based on the commercial value of the items, which we were unable to document, and confiscated everything, including equipment which was to be removed from the country at the conclusion of the trip, and not imported at all, really.

After about 24 hours of fruitless and futile debate, we eventually hired a professional Customs broker, and that person was diligent and persistent enough to allow everything ultimately to be imported, after the payment of a reasonable tax. The lesson learned was that the couple of hundred dollars spent on that service was well worth it, and we will be engaging the same agent to handle the entire process from now on in future years.

The entire episode was a good example of the sorts of problems faced routinely in the course of doing equitarian projects in several different countries. Rules and requirements change, often unexpectedly, and a flexible approach to adapting to that change is needed for any program which is committed to ongoing and regular reiteration. In a sense, the logistical problems of these sorts of trips can never really be considered to have been solved; it will likely always be a moving target to some extent.

We're back in Granada now, and doing our inventory and storage and final clean up today, after a very successful and productive five working days on Ometepe Island, where we attended to about 500 patients. More on that in a summary final blog post tomorrow...

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