SUBSCRIBE We'll keep you up to date on Partners In Health's work bringing hope and health care to some of the world's poorest Cecilia Gálvez became a nurse to support her community in Chiapas but is now facing extreme challenges as violence escalates in the region Cecilia Gálvez has been a nurse with Compañeros En Salud as Partners In Health is known locally in Mexico Although she’s overcome many challenges in her career leading to her becoming a nurse supervisor in 2020 this year has brought unique distress as Chiapas has become a stronghold for organized crime a small community in the Frailesca region of Chiapas Gálvez witnessed firsthand how challenging it was for her family and friends to access health care given the remoteness of her community and cost of transportation—among other challenges Unable to allow this injustice to continue she decided she wanted to be a nurse and support her community the Mexican Ministry of Health built a clinic in Gálvez’s community and Compañeros En Salud began working in the community as well Compañeros En Salud has worked in the state of Chiapas since 2011 in partnership with the Ministry of Health Gálvez began her work with Compañeros En Salud as an acompañante make home visits to chronically ill people she began attending nursing school four hours away on the weekends she never lost sight of her original inspiration—which continues to keep her going to this day “My family and my community are the driving force to keep going because [access to health care] is what I want for them,” Gálvez shares working as a community nurse in the region where she was once a patient mentoring nursing and medical interns doing their required year of social service at rural clinics this year has pulled her home community into a state of conflict—impacting her family An increase in organized crime activity and instability in Chiapas have added extreme obstacles to the work of Compañeros En Salud This year is also an election year in Mexico which has added to the complexity of the situation has been one of the worst-hit by these challenges As rival groups continue to fight for control of the region Gálvez and Compañeros En Salud refuse to abandon their community and patients The work continues despite widespread worry “It has been difficult to work under this situation of insecurity because it is discouraging,” Gálvez says knowing that at any moment your life could be taken away from you but you don’t know if you’ll return," she continues I used to focus only on the problems with the health clinic team and the community I have to devote energy to monitoring my surroundings for a possible attack.”   she remains committed to making life better for her patients as their nurse and neighbor “[I would like to] improve the community’s access to health care services also change the way they think about health risks and [encourage them] to leave their comfort zone to improve habits and Gálvez has been working on how to take care of herself during this time as well has helped her manage the stress caused by ongoing violence and instability “Going for walks and eating healthy has helped me feel better,” Gálvez shares having a support network of family and friends means I can feel more collective support and also take quality time for myself.” Gálvez knows the value of protecting your health and that of your community she continues to show up every day for her patients and colleagues at Compañeros En Salud.  Learn More a movement began that would change global health forever Bending the Arc is the story of Partners In Health's origins Stay informed about Partners In Health's work to provide high quality health care to those who need it most Partners In Health (PIH) is a 501(c)(3)nonprofit corporation Partners In Health, Suite 300,800 Boylston Street, Boston, MA. 021991-857-880-5100 • info@pih.org PIH® is a registered trademark of Partners In Health.© 2009-2024 Partners In Health.All Rights Reserved Please send donations to: Partners In Health Conservation International team up to support coffee farms Coffee-growing regions around the world are struggling to maintain the quality and supply of coffee in the face of aging trees Sanjayan — CEO of Conservation International Conservation International and Starbucks have partnered to promote coffee production that is sustainable transparent and good for people and the planet impacted by new seedlings – equivalent to 38,103 football fields *Calculated assuming an average of 3,330 coffee trees per hectare This project involves a network of 19 nurseries and 27 suppliers Climate-tolerant coffee trees are a critical part of the sector's effort to help farmers adapt to climate change Conservation International has worked with Starbucks to put in place the following safeguards: Help support Conservation International as we aid farmers around the world PIH-Supported Birthing Center In Chiapas Continues To Save Lives a rural city in the Sierra Madre region of Chiapas she found out she was pregnant for the first time—a moment she and her husband had dreamed of for years The pregnancy went smoothly for the first seven months because she wanted her daughter to be born with her family there Macías felt her baby not moving as it normally did and massaged her stomach to see if anything would stimulate her baby She rushed to Casa Materna, the birthing center in Jaltenango supported by Compañeros En Salud, as Partners In Health is known in Mexico. Compañeros En Salud has worked in Mexico since 2011 providing medical care and social support to thousands of patients in the rural coffee-growing communities of the Sierra Madre region of Chiapas Casa Materna has provided dignified care to pregnant women with the support of professional midwives and first-year clinicians hired and supported by Compañeros En Salud based at the community hospital in Jaltenango has helped more than 1,000 women give birth respectful care for maternal health patients in a region where obstetric violence in hospitals is common she was cared for by Estefania Monterrosas a nurse who has worked with Compañeros En Salud since 2020 and explained that there was nothing wrong with her: the baby was just sleeping Monterrosas also told her about Casa Materna’s humanized birthing model where women can choose their birthing positions Macías decided she wanted to give birth there He did not want to miss such an important moment "I didn't know if it was the false contractions (Braxton Hicks) or if my baby was already going to be born," she says Her mother immediately took her to the Casa Materna but we didn't know if he would make it to see the birth of our daughter." the obstetric nursing team at Casa Materna helped her do exercises with birthing balls and provided massages and a hot water bath with herbs to reduce the pain as she was supported by her mother and a team of nurses "I was impressed with the treatment at Casa Materna," says Macías you don't want to go to hospitals for fear of mistreatment Obstetric violence is a reality that many women experience in Mexico That mistreatment includes health workers in Mexico's hospitals ignoring and dismissing the concerns of mothers leading to trauma and mistrust in the health system women in labor have also been subjected to illegal including forced sterilization through tubal ligation or IUD These procedures are carried out by doctors operating on the racist classist belief that poor people shouldn't have too many children These doctors are rarely ever prosecuted; the victims are almost always women living in poverty Compañeros En Salud seeks to upend these norms and provide humanized care at every step of the process helping mothers give birth in the way most suited to their needs As she held her daughter for the first time surrounded by her family and Compañeros En Salud staff "I didn't know how to thank them for what they had done for me,” she says Patients walking into Jaltenango Hospital are now greeted by a nurse in a face shield and surgical mask and flanked with bottles of disinfectant and hand sanitizer Then she directs them to a waiting area—green or red—based on whether their symptoms match with those of COVID-19 Life has changed in this region of Chiapas has worked in this southern Mexican state since 2011 The work focuses on strengthening local health systems “Support is very important for places like Chiapas,” said Dr. Diana Sánchez, a newly minted physician in PIH’s pasante program “It’s one of the most vulnerable places in Mexico.” From PIH-supported Jaltenango Hospital to rural health clinics COVID-19 is changing day-to-day health care in Chiapas PIH is responding with compassionate care—the same ethos that has driven its work in the area for nearly a decade While COVID-19 cases remained relatively low for several months the number of confirmed cases began to rise at the end of May at least 49 people had tested positive in the areas surrounding the communities where PIH works suspect there are many more cases to be found so they’re coordinating a massive response which is spearheading PIH’s COVID-19 response in Chiapas a gynecologist whose past experience includes emergency response with Médecins Sans Frontières the COVID-19 response requires two critical components: education and resources Her five-person team educates the public about the importance of handwashing and where to go for help if they believe they’ve contracted the virus They also develop and lead trainings for health care workers on how to use personal protective equipment (PPE) and help patients with symptoms of COVID-19 But education is only one part of the COVID-19 response; resources also are critical Hospitals and clinics must have triage areas Saldivar works with local and national authorities to mobilize resources and send them to PIH sites Most of the PPE so far has come from private donations Saldivar and her team have been scrambling to secure more PPE so hospitals and clinics have the resources they need to fight the pandemic Jaltenango Hospital had just one confirmed case The hospital has only been able to test a handful of people for COVID-19 a hospital must have at least 10 suspicious cases Jaltenango Hospital has not seen enough such cases to acquire the tests it needs—in part because many patients are scared of setting foot in a hospital “There are probably more cases than the one we have confirmed,” González said and therefore acquired more tests from the government Despite Jaltenango’s low case count so far González and staff know that an influx could happen virtually at any moment They’ve worked hard to ensure that the hospital has protocols and procedures at the ready set up at the hospital’s entrance and staffed with nurses The space is divided into three sections—a “green” area for patients with no respiratory symptoms a “yellow” area for patients with one respiratory symptom and a “red” area for patients with more than one respiratory symptom Nurses identify suspected cases based on COVID-19 symptoms and refer the patients to a health center next to the hospital where they receive public health guidance the hospital’s one confirmed case was told to go home and isolate the hospital plans to provide in-patient care Rural Chiapas residents with COVID-19 symptom are more likely to visit a health center or local clinic first and not a hospital Even as hospitals scramble for resources and draft response plans these smaller facilities are also preparing for COVID-19—and are already feeling its effects The health center where Sánchez works used to see dozens of patients each day a first-year doctor completing her social service year with PIH says that much of the Jaltenango Health Center’s usual programming has been put on pause The center has moved to limit appointments for patients with chronic illnesses She estimates the center now sees only 25 percent of the patients it used to Not all PIH programs in Chiapas have seen such drastic changes; some have simply been modified with nurses and midwives following public health guidance to prevent the spread of COVID-19 as they conduct prenatal appointments and assist with labor and delivery community health workers still make house calls in the rural communities where PIH works The need for strong health systems could not be more urgent especially for Chiapas’ most rural communities “There are sometimes four to six people sleeping in one bedroom,” she said “The idea of quarantine or social distancing is pretty much non-existent.” While PIH-supported clinics are equipped with PPE and triage areas people in Chiapas’ most remote areas—not supported by PIH—still don’t have access to a health facility equipped to handle COVID-19 She also worries about patients who have comorbidities such as diabetes or hypertension “We are really worried about vulnerable populations,” Saldivar said “I’m afraid of the virus really getting into the community A lot of our population are really vulnerable for other diseases So this pandemic is really challenging for patients.” a stream of misinformation surrounds COVID-19 Not everyone believes the pandemic is a real threat Some think it’s a political conspiracy; others turn to religion as an explanation for the disease and Health care workers must walk a fine line between listening to community members’ concerns while also educating them about the facts of COVID-19 and correcting misinformation PIH is fighting to mobilize resources and accompany patients each step of the way “It hasn’t been easy and we hope everyone gets quality health care,” said González “Hopefully this will help us build better health systems and we will be able to know where we can improve.” The center opened in partnership with Mexican Ministry of Health to address high rates of maternal mortality Partners in Health opened a new maternal health center in one of the deadliest places to give birth in Chiapas will provide dignified care for mothers and newborns in the rural community of Siltepec serving a population of up to 32,000 people The new center follows the model of PIH’s first Casa Materna in Jaltenango new and expectant mothers in Siltepec had to take long and costly trips to other cities to access such care or give birth at home with assistance from a traditional midwife "The [new] Casa Materna provides a safe space for quality care for mothers and their babies," says Estefanía Monterrosas clinical supervisor at the Casa Materna in Jaltenango "We come to strengthen the health system in Siltepec and to complement it with our skills and knowledge." The first Casa Materna was opened in 2016 in Jaltenango a central city in the rural Sierra Madre region of Chiapas established the maternal health center in collaboration with the Mexican Ministry of Health and the community hospital Hospital Básico Comunitario Ángel Albino Corzo the center provided care for 1,490 women and supported the delivery of 292 babies Compañeros En Salud has worked in Chiapas since 2011 providing health care at 10 rural clinics and at the community hospital and Casa Materna in Jaltenango—work that has now expanded to Siltepec is known as obstetric violence and can have lasting effects on women’s physical These issues make Casa Materna’s model of “respectful childbirth,” first practiced at the center in Jaltenango and now at the new center in Siltepec "We want to rethink and rebuild the way births are attended in Chiapas so that women recognize that their body is theirs and that they can have control over the care they receive," says Monterrosas The respectful childbirth model centers the needs of patients by recognizing their autonomy and empowering them to make decisions at the time of delivery These decisions include birthing positions preferences about set up within the labor room It is also led by midwives and nurses—not doctors. The United Nations found that models of care that include midwives help prevent two-thirds of maternal and neonatal deaths midwives regularly facilitate consultations  "The role of nursing is also something fundamental since we have the first contact with the patients and we build relationships of trust with them making them feel safe," says Julieta Gonzalez The Casa Materna de Siltepec will have a labor room This design will allow patients to have privacy during consultations and childbirth helping them feel protected and avoiding putting them in vulnerable situations ”Our ultimate goal at Casa Materna is to provide a safe space and quality care for dignified births through collaborative work and respect for pregnant women,” says Monterrosas Partners In Health responds to pandemic in Chiapas with compassionate care Armando Torres is a 67-year-old father of four who has dedicated most of his life to working on coffee crops as do most people in the Sierra Madre region of Chiapas Torres greets everyone he encounters with a big smile and is known for his warm personality he thought it was just an intestinal infection caused by something he might have eaten But it didn’t feel normal or like any of the usual side effects of his diabetes he started coughing and became exhausted after doing simple activities he felt his legs shaking as he attempted to get up from his chair until I woke up later that night in the hospital,” he says “I was in a wheelchair and the doctors were bringing an oxygen concentrator to me Torres’ family had doubts about even taking him to the hospital, as disinformation was spreading in the community and taking advantage of people’s fear of the disease—there were even claims that patients arriving to the hospital would be killed. But one of Torres’ sons knew that many patients had recovered and been discharged from the Respiratory Disease Center in Jaltenango, where Compañeros En Salud Going to the hospital was a decision that may have saved Torres’ life “My father was treated as soon as we got to the hospital,” says Armando Torres Jr Compañeros En Salud’s COVID-19 response comes in addition to the vital health services it continues to provide for patients across its programs which Compañeros En Salud has supported since 2011 patients like Torres not only receive treatment and care for the virus but also support for their mental health and emotional well-being When Torres’ family understood the severity of his condition they considered taking him to a larger hospital about 1.5 hours away from Jaltenango But that would have meant they wouldn’t be able to see him until he was discharged—and only if he recovered they gave us the opportunity to visit my father,” says Armando Torres Jr noticed too: whenever his family was close to him “We provide families with personal protective equipment and allow them to visit the patients so that they won’t feel lonely and to generate a therapeutic alliance,” says Rodríguez “This is something that no other hospital does our patients feel supported by their families and can go home earlier.” Jaltenango Hospital’s visitation policy also helps families feel reassured about where their loved ones are staying and that they are receiving quality medical attention Torres is recovering at home with his family He says that he has learned so much from this experience—as harrowing as it was “I was in the hospital for 18 days,” he says and I didn’t know what was going to happen but I trusted the medical team and thanks to them Community-based mental health services crucial for accountability From 2010 to 2020, substance use increased by 26% across Mexico—but access to treatment has lagged a city in the mountainous Sierra Madre region of Chiapas But treatment for people who use drugs has historically been few and far between Substance use generally doesn’t happen overnight or come out of nowhere It is complex and often linked to people’s trauma it takes much more than abstinence alone to achieve rehabilitation—there are many social and economic factors that influence a person's recovery Since October 2022, Compañeros En Salud, as Partners In Health is known in Mexico has run a mental health project called "Me cuido y nos cuidamos” (Spanish for “I take care of myself and we take care of each other") the project is led by clinical psychologist Azul Marín and mental health community health worker Ervin Morales "Me cuido y nos cuidamos” works with men who are staying at one of the treatment facilities for substance use recovery in Jaltenango and with high school students at the nearby Centro de Estudios Científicos y Técnicos (CECyT) It has two goals: to create a safe space for men to reflect on their substance use and to unpack their understanding of masculinity The program was inspired by the success of Compañeros En Salud’s pilot of “Women’s Circles” in 2022 and wellness for women in the Sierra Madre region Marín and Morales gather reflection circles for men to discuss their feelings and experiences with substance use and their relationship with masculinity Marín and Morales hope to help the participants process their experiences “We have had men who started using substances from the time they were 12 years old…and we believe it has a lot to do with cultural influence on what it means to be a man,” says Marín “It is very much related that to be a real man There is no one reason why people use drugs but substance use can often be related to mental health problems such as depression Instead of prioritizing treatment for people who use drugs’ mental and physical health governments have historically moved to criminalize drug use and imprison people adding to the trauma that marginalized people more policies and programs have emerged that aim to address substance use as a public health issue “Me cuido y nos cuidamos” is one of those programs "There are a lot of men who don't take care of their mental health and because of the social dynamics in which they operate,” says Morales “There is pressure to be a man who has to put up with everything.” Support groups like the reflection circles offer spaces for community and accountability—crucial in helping people on their recovery journeys The recovery model of care emphasizes that treatment is not medicine alone and that human rights are granted to all the young men in the treatment facility have been able to form healthier relationships with themselves and others as they continue on the path to recovery "I questioned a lot where drugs have taken me and I learned about what I was doing wrong,” says Osmin “But what I learned most is that for as many things as I am or what I go through The project has not only had an impact on the men in the group “They are very strong and courageous people and all this also helps to put a name to many processes that even I lived through." "Me cuido y nos cuidamos” will maintain its activities continue to reach out to men seeking recovery from addiction and work to prevent substance use among adolescents offering support and a safe space for men to recover COVID-19 response underscores need for strong public health systems When COVID-19 arrived in Mexico in late February last year The pandemic would not arrive in the southwestern state until March and would remain in the single digits for weeks But doctors knew the worst was coming—it was only a matter of time “It took so long for the pandemic to reach Jaltenango,” says Dr Chacón is based at the community hospital in Jaltenango de la Paz When the virus did arrive, it would leave no community unaffected. In late March, cases jumped from single to double digits, passing the 1,000 mark in May. By June, the surge had begun; Chiapas joined the rest of the country at the maximum “red light” level on the Mexican Ministry of Health’s stoplight map Compañeros En Salud has worked since 2011 in Chiapas, where it has focused on strengthening health systems in Jaltenango and surrounding rural communities That work has included a mentorship program for first-year clinicians COVID-19 put that system to the test—challenging doctors nurses and care delivery teams to think quickly on their feet and improvise when necessary in response to a pandemic that often showed little sign of relenting clinicians delivered critical treatment at all hours of day and night That care has made an impact. Although cases are ticking upwards, as expected following the holidays, clinicians are better prepared. The mortality rate in Chiapas has steadily declined since August. And the state was no longer “red” on the stoplight map clinicians are leveraging their expertise and experience to respond with compassionate care applying lessons learned over the past several months That work has made one thing clear: investing in public health systems is crucial—for the pandemic response and beyond When Selene Chacón finished medical school, she took a leap of faith and decided to do her year of social service, required by the Mexican government for all university graduates, with Compañeros En Salud through its pasante program The program, designed for first-year doctors and nurses where she provided primary care and received training and mentorship from experienced physicians the newly minted doctor decided to continue her work with Compañeros En Salud What followed was a race to respond to a public health emergency that intensified by the day clinicians scrambled for resources that were scarce and struggled to keep up with rapidly evolving public health guidance “There was not much information at the time or guidelines on how to treat patients,” says Dr who supervises the COVID-19 medical team at PIH-supported Angel Albino Corzo Community Hospital “The protocols were based on very new information.” In her new role as infection and control coordinator working with her team to establish a triage system at the hospital and to coordinate the pandemic response across all of Compañeros En Salud’s care delivery sites based in the community hospital’s COVID-19 unit Mexico provides universal health care to citizens but that care can be hard to access in states like Chiapas where the majority of people live in poverty Compañeros En Salud has delivered care to an increasing number of patients over the past several months as resources the team has treated at least 526 suspected and 16 confirmed cases at the community hospital and clinics Compañeros En Salud partnered with Angel Albino Corzo Community Hospital to open the Respiratory Disease Center a 5-bed facility equipped with oxygen concentrators to treat patients with severe COVID-19—care that once would have required a long costly journey to another hospital at least two hours away the center saw its first patients and helped them recover and return home to their families Compañeros En Salud also worked with hospital leadership to introduce a new policy that allows family members to visit their loved ones with personal protective equipment—the only hospital in the area that offers such visitation That decision has been crucial in helping patients recover and fighting the disinformation about the virus that once ran rampant encouraging more people to seek medical care “Patients now have more information and less stigma,” says Rodríguez instead of waiting until they worsen—a sign that gives clinicians hope that communities now have a better understanding of the virus and when to seek care we are already more prepared,” says Chacón “There will still be peaks…people must know that we are still here and we are in this together.” Alejandra Catalina Ramirez was starting to feel big—a completely normal sentiment for a petite woman in her sixth month the 29-year-old had naturally begun showing much earlier than she had with each of her two sons who knew how large this baby would be after three more months for her prenatal appointment in March 2017 and was greeted by three doctors working with Compañeros En Salud Ariwame Jiménez had two visitors that day from the main office in Jaltenango—Dr “Looks like you’ve got two in there!” said Arrieta who noted Ramirez’s size as she welcomed her to the clinic Ramirez lay down on the examining table and lifted her blouse Arrieta methodically moved the wand of an ultrasound machine over the mother’s rounded abdomen The doctor swished her wand into a different position What had started as a joke suddenly became reality: Ramirez was pregnant with twins and The mother beamed and didn’t seem surprised—twins ran in her family She couldn’t wait to return home to share the news with her 28-year-old husband the doctors recommended that Ramirez travel to a more specialized hospital in Huixtla where technicians could perform a more detailed ultrasound she did; what she discovered helped save her and her sons’ lives One-third of women living in Chiapas still give birth at home usually with the assistance of a traditional midwife according to Mexico’s National Institute of Statistics and Geography Most local health centers are not equipped for deliveries and the closest public hospital for many Chiapanecans is in Jaltenango a good three-hour drive down rutted dirt roads cut through the Sierra Madre mountains These and other barriers help explain why maternal mortality in the state of Chiapas is among the highest in Mexico with 81 deaths for every 100,000 deliveries compared to 36 in 100,000 nationwide as of 2015 the year of the most recent government data PIH has been partnering with Mexico’s Ministry of Health to educate expectant mothers on the importance of delivering in a hospital while also providing technical and culturally appropriate training to local health care professionals Together they began operating Casa Materna a maternal home next to the Jaltenango hospital expectant mothers receive pre- and postnatal care at the hands of obstetric nurses and first-year doctors all supported and supervised by PIH clinicians At least 21 women have given birth at the home and clinicians have provided 970 consultations since its doors opened in May 2017 Women who live far from the hospital are encouraged to stay on hospital grounds they walk from the hostel to the hospital for immediate access to doctors and nursing staff A pair of ambulances stand nearby to transport mothers to a specialized hospital one and a half hours away in Villaflores should they need an emergency cesarean section these measures meet the needs of most laboring mothers Several weeks after her first visit to Soledad was among the patients the two doctors saw that day She arrived with her new ultrasound images which the doctors pored over with growing concern Ramirez was carrying an excessive amount of amniotic fluid—a risk factor for premature labor They recommended she undergo a procedure that would remove some of the extra fluid The procedure involves a measure of risk—it sometimes causes internal bleeding that can endanger the pregnancy The doctors informed her that she would likely go into labor within two weeks if she and her husband decided against removing the extra fluid she should head to Jaltenango sooner rather than later to be near the hospital Hernandez wasn’t thrilled with either option He had already missed too much work while traveling with his wife for doctors’ appointments outside the community and was thinking about their other sons back home the couple decided to remain in Soledad and try their luck That luck turned sour within days of Ramirez’s last appointment Her water broke when she was 33 weeks along they left their sons in the care of Hernandez’s mother and hailed a taxi to Jaltenango Montaño and a social worker based at the hospital worked their contacts to find a facility that could perform an emergency c-section and provide intensive care for premature infants both of whom—the clinicians assumed—would require incubators Montaño got a green light from a hospital in Tapachula but officials there requested that a doctor and nurse accompany the couple in the ambulance who was supervising another PIH doctor in a neighboring community fielded the call from Montaño: Would she be able to go along for the ride jumped into the back of the awaiting ambulance Hernandez was already in the passenger seat losing amniotic fluid and enduring waves of early labor pains The anxious crew took off for the eight-hour ride south None of them had ever traveled to the Tapachula hospital The boxy vehicle swayed back and forth over the mostly paved roads A mountain range rose between them and their destination navigating switchbacks along narrow two-lane highways her legs straddled behind Ramirez’s gurney to keep it in place She could hear Hernandez vomiting out the passenger window the entire drive the group arrived at the Tapachula hospital and wheeled the laboring mother into the emergency room Nurses assured Arrieta that the family was in good hands The journey had been a harrowing adrenaline rush Arrieta felt drained—and reluctant to let go and return home Ramirez was recovering after her c-section and both boys were alive and hooked to oxygen and feeding tubes They wouldn’t be able to return home until they could breathe on their own and had gained a significant amount of weight but she and her husband had nowhere to stay and needed to be near their sons for regular feedings like many families of the hospital’s in-patients They accepted food and café con leche from a local order of nuns who visited daily They called home regularly to check on their older sons And they tried their best to remain patient as days spun into weeks Ramirez knew exactly how long they had followed this routine: “One month and 10 days.” Finally doctors examined the twins and declared them well enough to return to Soledad the family paid for public transportation for the long ride back home where children in school uniforms and heavily laden donkeys trudged past Ramirez’s red mud-brick home The heat of the day was finally relenting on a late afternoon in November her long black hair wet and tied back into a ponytail She balanced one 5-month-old son on each knee Gabriel and Emanuel wore caps and footie pajamas both so plump they looked like small Stay Puft Marshmallow Men Alexis and Yoiner were in constant orbit around their mother who seemed completely unfazed by their questions and commotion One of the twins began to fuss as feeding time drew near but Emanuel was “more difficult” than his older brother Months had passed since those frantic days in April when she and her husband feared they would lose their twins “It was such a dangerous time,” Ramirez said She thanked PIH for supporting her family through it all The rest of her sentiment—if PIH doctors hadn’t been there—was understood