What does it mean to be a Heston Intern in Nicaragua? Sixty-six days ago, I do not believe I could have easily answered the question, if at all. Now, on the last day in Nicaragua, I believe I finally have some wisdom to impart on my behalf.As a foreigner in a strange land, the journey is often not the destination, but the journey. The destination, ostensibly, is the airport from which we will leave tomorrow yet the journey lies behind us and within us. As I can only speak for myself in this blog, I can easily admit that the growth I have experienced has been immense beyond measure. The struggle now becomes one of self-expression. I want to share all I have learned so that the awe I feel at my own perceptual transformation may be best understood. I feel, however, that I could never explain all that I have observed and all that I have learned without using clichés or other overused phrases. Regardless, Nicaragua was—in a word—momentous. So, perhaps a few quips will illustrate the growth better than a dense paragraph: The food is great and often times adventurous, if not predictable, but the water can be a gamble. Life’s daily expenses were once unbelievably cheap, but, as I have steadily acclimated to the way of life they now seem normal; so much so, in fact, that an $8.00night hotel is far too expensive for me when compared to my $2.00night hostel in Santa Rosa. The majority of the people are incredibly friendly and always caring. Even though small cultural differences can sometimes prove uncomfortable, learning from them and growing therein is perhaps the greatest lesson that I have taken away from the experience. My host family was always concerned for my safety, my emotional stability, my physical stability (after all, they enlisted me in a race and expected me to win), and overall were the core foundation of my little life here. The sprawling vistas—lands crinkled with volcanic mountain chains, cut into gushing swaths by rivers, and decorated with year-round greenery—can scarcely suffice comparison. The stars at night are brighter and more majestic than I have seen anywhere in the United States, thanks to limited light-pollution and rolling blackouts. The “rainy season” began forcefully when we arrived, but has since sputtered out to nothing; the headline of yesterday’s paper was: “Drought Threatens Nicaragua”. A Heston Intern or any citizen of a more developed corner of the world must learn, above all, to adapt to the unexpected. Nicaragua, as a functional component beneath a broader Central American culture, is full of surprises, adversity, letdowns, and then sudden and glorious moments of triumph. Internet performance is one facet of life that comes to mind and reminds me how life here requires patience—not helped in the least by the Nicaraguan hour, which is usually a half-hour later than what it should be. Adopting cultural nuances, as I did here, is the quickest expedient to making the most of an experience. For three days, I had the privilege of working in the rural mountain community of Santa Rosa del Penón where I was immediately impressed by the precision with which the doctors manage the clinical healthcare setting. Having just constructed a new laboratory the past year, the health clinic in Santa Rosa is able to perform the basic services of healthcare by testing bodily fluids to help diagnose infirmities. Helping the doctor there, I learned how his repertoire consisted of a simple centrifuge machine, a glucose-meter, and a microscope and with these he is able to creatively adapt standard medical practices to accommodate for the simplicity of clinical care. Perhaps even more impressive, however, is the accuracy with which the doctors can diagnose patients without the validation of more complicated screenings and tests, as are performed in the hospital in Leon. For two immediate examples of this, I shall draw upon my first ten minutes of work on Monday. Doctor Martinez, whom I shadowed first, was examining a pair of six-year-old twins who both exhibited the same symptoms of respiratory illness: runny nose, fever, and, of course, a violent cough that launched diseased saliva with each expectoration toward the doctor who did not seem in any way preoccupied about his own health. With a brief physical examination of their throats and an auscultation of the patients’ lungs, he was able to determine that the infection afflicting both children was a matter of the upper respiratory system rather than the lower system; a belief that a phlegm test later confirmed. The second doctor, Dr. Reyes, grabbed me from my idle seat some two minutes later to pull me into the observation room where there sat a small boy with his hair parted to expose a raised heap of skin. There, the doctor briefly prodded and poked with his fingers and then snapped on a set of powdery gloves, gripped a fine razor blade, and sliced into the quivering lump on the child’s head. With great force, he then squeezed the skin for a minute, working from different angles and with different pressures; in the bloody conclusion, a fat larva squirted from its fleshy home and nearly jumped right into the doctor’s mouth. Fortunately, we found it later on the floor and squished it. The center in Santa Rosa is not just impressive for its well-kept premises and equipment, as logistically the size makes this more feasible than in Leon, but it is also impressive for its maintenance of personnel. During night-shifts, the doctors sleep in unoccupied patient beds and they invited me to spend the night working and evaluating patients and of course I was not going to say no to a sleepover. As an additional measure of self-evaluation, every week the staff congregates for a staff meeting to improve services rendered to patients. The meeting I attended included a rather Socratic discussion from all members of the staff, from cleaning personnel to the director of the hospital itself, Doctor Luna, all seemed conducted in an egalitarian manner such that it seems that staff cohesiveness is what ensures the success of rapid and effective treatment of patients. Given that Santa Rosa services eight separate districts; as the local health headquarters, it handily shuffles its sparse quantity of doctors between clinics and house-to-house consultations—Doctor Martinez has lost twenty-five pounds over the course of four months all because of the daily hikes he must make to far-flung communities hidden in the mountains. They all joke that the doctors in the air-conditioned United States have no idea what it means to be a real doctor. Overall, the maintenance of the whole operation is very impressive. For my final day of work, I worked for 16-straight hours to understand the daily challenges that doctors face when working two-shifts. By 12:00am, the end of my shift, I could appreciate the dangers of practicing medicine in such a state—this, however, is a reality for much of the emergency room staff, among others. The evaluation and rotation system in the hospital seeks to eliminate such dangers. Continual reevaluation of patients by a group of doctors every hour seems to reduce the incidence of medical error. It would be naïve to think that a twenty-one-year-old kid from the quiet suburbia of Pittsburgh would reasonably be able to investigate a health care system in the western hemisphere’s second poorest country and genuinely propose a panacea or even a remedy to patch the country’s issues with social services. What I can definitively say I have come away with, however, is a revered sense of perspective such that I can appreciate the difficulties of managing healthcare within an environment vastly different from the United States. As the hours lurched toward the madrugada—the middle of the night—on Monday night with the flow of patients refusing to abate, Doctor Lopez turned to me and said: “I hope in your country you never have free health care, because look what happens!” Inasmuch as this is a sore subject in the United States with the November elections approaching, I thought the doctor’s statement was an interesting statement at face value. A statement indeed made all the more interesting by the fact that, under the current president, Daniel Ortega, the Nicaraguan healthcare system has steadily improved since his most recent inauguration in 2011; there are still problems, nevertheless, where the politics of the state interfere with the professional realm of the hospital. Doctor Lau, my boss for the summer, is a supporter of the PLC, the opposition party to Daniel Ortega. Because of the extension of political power in healthcare, Doctor Lau is not paid nearly as well as his Sandinista-supporting compatriots. After I bade them all a farewell at the hospital on Friday and had goodbye parties at the PGL office and at the house, my little life began to fall away all around me as I slowly realized that I have indeed reached the end of the experience. After all of this, I know what Nicaragua has meant to me and I have told all with whom I have come into contact: “Although I am leaving, I am not forgetting.” Now, instead of counting days, I am counting hours—hours until the hotel serves free breakfast! Just kidding, but I am looking forward to that too before the return trip. Overall, I think it would be a lie to say the time flew by because, by nature, time is inherently metronomic; when we attach feeling and assign emotional value to time is when its circadian precision seems to fast-forward. Now, nearing the end of the experience, I certainly look back upon the successes achieved, the friends made, the difficulties overcome, the language barrier diminished, the embarrassments encountered, the cultural differences understood and I suddenly realize that among this whirlwind of an experience I have had what a brochure would call a “once in a lifetime experience.” But seriously, when am I ever going to return to Nicaragua’s level two Oscar Danilio Rosales Hospital and work like a fake specialist in internal medicine? A pessimist would say never, an optimist would say soon, and a realist would say what I say—“I have no idea.” Although I try not to break the hearts of the wonderful people I have met here by telling them “the future is uncertain, I might be back, God-willing”, the sad reality is that what I tell them is not just rhetoric, it is the truth. Indeed, I have been very privileged with my stay here as it has shown me more about the world and about myself, within a worldly context, than I would have ever thought was possible. I know this reflection of measurable growth is typified and often compulsory, given circumstances similar to mine. I swear, however, to those of you who are not my supervisors/administrators that I write this with the conviction of sincerity to fully highlight, beyond a shade of doubt, that living in a foreign country for two months has wrought changes, however subtle, that will forever affect not just how I view healthcare but how I view life and its privileges, its successes and difficulties, and how making the most of opportunities, in spite of perceived difficulty or unwillingness, is the indisputable path to personal growth. Without the fiscal and visionary support of the distinguished Mr. Heston, the experience would certainly not be the same or might not even exist at all. For this, I am indebted to Mr. Heston for his part in funding and cultivating a program that has figured so significantly into my life. Por fin: Nicaragua’s Heston-ers are U.S. bound! YOHO -C.J.D.