Alisa Mae Schultz Tonozzi's Page

-women cooking with open pit cook stove

-a typical house in El Fortin that was built with the help of Casa de la Mujer

May 21nd 2008~
Today we arrived in Granada, Nicaragua, our study location. The study participants live in the barrio El Fortin. After getting over the excitement of living in this beautiful town for the next 5 weeks, we traveled to El Fortin for a demonstration of the stoves organized by the not-for-profit organization Casa de la Mujer who have been helping us. At this time we also met the volunteer women who live here and will be helping us. These women are recruiting women for the study. There was a short presentation with information about the study, introductions of who we are, and information about the stoves. There were about 70 women at this demonstration and you could tell they all understood the importance of a new stove and the valuable investment for their families. After the presentation we helped make tortillas and an authentic drink called atoll. Everyone was very nice, enthusiastic, and welcoming. The children were enjoying the abundant tortillas and sugary atoll, while the women had a chance to become comfortable with us. This welcome participation is valuable to our success and insures sustainability of the study. Our success in this area is due to the help of Casa de la Mujer, an organization that trains women in job skills to obtain economic sustainability and through their help the women hold deep respect and trust for this organization. This organization also helped build homes for the families of El Fortin. A new home is pictured above and is made of concrete helping to move these families out of shacks they call home.
May 22nd 2008~
Today we did our first installation of equipment in our first participant’s homes. Our first two participants were our volunteers, Dona Maria and Dona Maria Teresa. Gathering data is set into two main days of collecting information: set up and take down. During set up equipment is zeroed and ready to install into the kitchens of participants. We are introduced to the participants by the volunteers. We are then welcomed into the home. At this time the study is explained to the women, consent is given, and the equipment is installed. The measurement time for the equipment is 48 hours and at the end of this period take down begins. During take down the kitchen is assessed by taking measurements and observations of the materials that comprise the kitchen. The relation of the kitchen to the home and sleeping counters is also assessed and noted. Also, at this time an extensive questionnaire is administered to the primary participant that does the most cooking and who wore the personal CO device to determine exposure. Secondary participants and participants children are also administered questionnaires. Health endpoints including exhaled CO, pulse oximetry, spirometry, blood pressure, blood samples to measure inflammatory markers, height, weight, hip to waist measurement, and peak flow volume. All assessments will give baseline data and in the following years will be measured to assess improvement of health from cleaner burning stoves.
May 23rd~
Today everyone practiced health assessments on each other. It was also the first time many of us have every preformed the blood test. My mom, Dr. Linda Schultz, who has volunteered to help us and has been a valuable help on the medical side of things, let me practice on her. I was so nervous both because I was being critiqued by a pediatrician and because she is my mom. Well, it went well although she did not bleed very well. With Maggie’s encouragement, we all are ready to enter take down day tomorrow. I guess tonight can be considered team bonding by drawing each others blood.
May 24th 2008~
Today was our first take down day. We did this all as one team and we were more proficient than I expected. Everything took us almost 2 hours and as time goes on we will become faster at this process. Pricking people’s fingers for blood was not as difficult as I expected but I was nervous when it had to be done on a participant for the first time. It was valuable to have the volunteers as participants because after we were done assessing them, we set up more equipment and they were able to explain everything to the participants. I feel this is valuable because the volunteers were able to explain exactly what happened to them, how it felt, and definitely insured trust in the participants.
May 25th 2008~
Today we had a day off and traveled to the volcano Mombacho. It was a 30 minute “chicken” bus ride out of Granada. We then walked to the forest service entrance (Mombacho is protected and is declared a natural reserve), from here we took an old Mercedes war vehicle turned tour bus to the top of the volcano. Definitely a steep climb! While driving up you pass through the different layers of forest comprising the mountain. The bottom, where we started and includes Granada, is the deciduous tropical dry forest, semi-deciduous tropical dry forest, tropical cloud forest, dwarf forest, rainforest. These different types of forests have distinct lines distinguishing them from the next. This was very evident on the drive up and on the hike we took around the top of the volcano around a crater. At the top we were orientated on the composition, history and wildlife of the volcano. Tom almost passed out because there were jars of snakes on display showing which types are around the area. Most of the poisonous snakes are lower in the dry forests and it is too cold for them in the rainforest. We then hiked a loop around the crater discovering many interesting tropical plants, butterflies and an excellent view of Granada and Lake Nicaragua. I was told by a worker to go out back and visit a spot were they are trying to repopulate frogs from the area. We saw thousands of frog eggs and in my desperation to find a tree frog, found one sleeping on a leaf. We got to hold it and it jumped on my face which really made me jump. The rainforest has always been a place of extreme interest to me when I was a child and frogs were my favorite animal. It was very exciting to be able to finally visit a place of such curiosity. I used to have a shirt when I was little with a tree frog on it and it said, “Future Conversationalist.” How fitting considering I am working toward a degree in Environmental Health.
On the way back to the bus we got caught in a torrential down pour. I have never seen rain like that in my life..
May 26th – 27th, 2008
We have now split into two teams and everyone did well getting things organized and completed in the field. We became faster at take down and performing health assessments. I found that demonstrating the procedure and then doing it along with them helped the children do exactly what they needed to do. This helped by giving someone to follow instead of trying to explain it to them in a language that some of us barely know. The nose pieces used to do the respiratory tests became helpful because the participants, especially the children think they are very funny and laugh every time we put them on them. One girl was really terrified when it came to prick her finger so I put the nose clip on and she laughed and forgot we were even doing it. I wish I had a clown nose and could have pulled a Patch Adams.
May 28th 2008~
Today was our first long day composed of take down and set up in one day. All in all it was successful. We have started to notice that participants are becoming interested in the equipment. Matt found one of the particle monitors battery hatch open and a monitor from my team gave readings that indicated the battery may have shorted due to rainy weather. A participant also asked about the numbers she observed on the CO monitor. We will now be taping the monitors to deter interest in the equipment and potential bias.
Today was also my birthday, so much celebrating was in need. We all went to pizza together and my mom surprised me with a birthday cake after we returned. It was a very nice day and I enjoyed spending it with mi amigos. I will always remember this birthday as it is my first in a foreign country. Best birthday presents ever: spending time with friends, my mom and getting to talk to my sister on the phone!
May 29th 2008~
Today we could not go to work. We are in the middle of a tropical storm that started yesterday afternoon and has been named tropical storm Alma. El Fortin is not drivable in this type of weather. The streets are flooding with sewage water due to the terrible drainage and sewage infrastructure common in developing countries. There are diapers floating down the street along with who knows what else. We have been keeping track of environmental health nightmares as we go and a section will be included below. On a normal day there is sewage that trickles down the side of the street and is mostly opaque do to the detergents and pesticides that are poured on the street for disposal. We are all glad that we are immunized for Hep A and carry around bars of soap to wash our legs when we get to the next destination after venturing through the streets.



May 30th 2008~
Today was a take down day and a really long day at that because we missed take down on Thursday due to Hurricane Alma. So today we did 4 take downs and it took about 6 hours. This doesn’t seem long considering the fact that most people work 8 hour days, but due to the climate down here it is extremely draining. We did survive and this day is inspiration to add more participants per day.
In our questionnaire we ask participants what they use to start their fires in their stoves. The most common answer we have received is “PLASTICO”! One time Tom and I were assessing exposure and we noticed that a woman was cooking with plastic. Look for a picture below. And we are worried about exposure from plastic water bottles…it is a whole other story down here.
After this day we went out to lunch at a rotisserie chicken place. It was a much needed celebration and we were all starving. My mom and I ate a whole chicken.

May 31st to June 1st 2008~
Today was going to be a day off, but because we missed Thursday we decided to make it a long week and set up houses for take down on Monday. Today was also the first day our team has had to deny someone from participating in our study. They cooked mostly with an electric stove and had a 3 stone fire in a completely open kitchen space (not enclosed).
Some of us undergrads decided to travel to San Juan del Sur after work. We took a chicken bus from Granada to Nandimae to Rivas and finally to San Juan del Sur. This took about 5 hours and traveled on old school buses in extreme heat. Now we can all say we have traveled like locals and can take a taxi. After all, most of us have saved some carbon credits by riding our bikes to school everyday. I think we deserve the luxury of a taxi. By the way San Juan del Sur (SJD) is a beach town known for its surfing. We met a girl on the bus who told us that the beach in SJD is really polluted because of the hurricane and high use. She recommended we travel north to a beach my mom wanted to go to. We took a taxi through the forest and ended up at a secluded, clean beach. We stayed in an inn that cost $8 per person, and thoroughly enjoyed the beach. We arrived just in time for the sunset. It was spectacular! The next day was spent in the waves boogie boarding and being tumbled around by the big surf. Our taxi drivers from the night before picked us up and took us back to Granada. My mom made them stop at a fruit stand on the side of the road on the way back (in the middle of know where) and bought 2 papayas, mangos, 6 avocadoes, and a banana for $5!

June 2nd 2008~
Today we did 2 take downs and 2 set ups. All went very smoothly. Pricking people’s fingers is becoming less nerve racking and we are all getting better with practice. I find that the best way to do things (beside the finger poke) is to demonstrate. Today I had a women do peak flow without any exclamation marks (this is a good thing) and even spirometry. I am very proud of this because I am not fluent enough to really explain what to do but what I could explain worked along with my demonstration and doing the tests along with her. Our team has become a well oiled machine and take down days are becoming much quicker.
Today Dr. Jay Smith arrived from back east. He has participated in similar studies in Peru and was connected with us through Trees, Water, and People. He will be helping us with spirometry and trying to coach participants through this test. If any of you reading this have done this, you know it is very draining. You must blow with all of your force into a cardboard tube with a fancy computerized device attached for 6 seconds. Some of us on the team can’t even do it. By the end of the day (after doing one demonstration of piko-1, 6 piko-1 tries with participants, 4 exhaled CO demonstrations, and spirometry with participants) I am completely drained and light headed from being out of breath. All of these tests require some sort of holding your breath and/or exhaling “mas fuerte!”
In El Fortin the roads are very poor and every day it rains the roads become worse. We arrived here at the beginning of the rainy season and experienced a nice, somewhat smooth dirt road. Now we four-wheel to get to El Fortin. Sometimes our driver Jeri must create concrete patches of rocks in order for areas to be drivable. There is one drainage area that passes through the middle of El Fortin. When it rains it pours, and this area becomes impassable and water levels reach about 5 feet. This problem has inspired “Puente Mateo” (Matt’s Bridge). Matt is going to design this bridge (he is a civil engineer), we will get it approved and built somehow, all that is certain is that it is going to happen someday soon. There are so many little things that we would love to do for El Fortin. They are such wonderful people.
June 3rd 2008~
Today was just a set up day. Short and sweet! After some of us went to the market (always an adventure admiring practices that would give a health inspector a heart attack), did a little souvenir shopping and celebrated my mom’s birthday. It was a very nice day to mellow out and escape from the hot weather.
I don’t think I have mentioned this before, but one of our participant’s children is now Tom’s new girlfriend and my adopted daughter, Isabella. When were taking down equipment she watched us the whole time and Judy named her our supervisor. We dressed her up in latex gloves and the stethoscope; she then listened to our hearts and her own. We made her and her friend balloons out of our gloves (a very popular thing here with the kids). Maybe someday she will become a doctor. After all she is my adopted daughter and the pressure is on to go to college.
June 4th 2008~
A black cloud hung over our group. We only needed to take down two homes and set up two. In this process we ended up going to two wrong houses, then a primary participant was not home and we had to come back, one was disqualified, and one participant decided she didn’t want a stove. The participant that was disqualified had a stove that was not enclosed. This day was really long and it didn’t help that I was waiting for T-Rae (my sister) to come today. Our first participant today was very nervous and you could sense that she was scared. We had to have the men in our group leave because this seemed to be the cause of her worry. What I think has been our most valuable tool so far in working with our participants is a big smile and a sense of light heartedness to gain their trust.

June 5th - 10th 2008~
This week the new stoves arrived in El Fortin!! The women are ecstatic and so proud of their new stoves. I am glad that I was able to witness this and I must say their excitement and happiness definitely made me emotional. I think I can speak for the whole group in this excitement! It was a family affair when the first family received their stove. It is not just a women and her stove, it impacts the whole family and it is the whole family that knows exposure to the smoke from the old stoves is bad for every ones health in the home. It is amazing to see how this simple possession that we take for granted daily makes a family so proud, excited and supported by all members of the family. Even the neighbors came over to admire the new stove. The women say that they are wonderful stoves and the hardest part about them is learning to use less wood. They are easier to start and burn at hotter temperatures than their old to make cooking more efficient. We got to witness one in action and a woman cooking tortillas on it with pride. Hopefully with these more efficient stoves, the women can stop using plastic to start them everyday. Even though this is not a part of our exposure assessment, in our hearts we will know the impact of the new stoves is even greater by reducing the exposure from the burning plastic.
One house we went to was an elderly couple. When we arrived the husband was cooking fish in the kitchen and their son and grandchildren were visiting. The son overheard what we were doing (this was a set up day so they got the down low on the whole study) and took us aside. He requested that we come to his house to participate and wanted a new stove for is daughter. She is about 16 years old and does ALL of the cooking for the family. When I say all of the cooking I mean she makes 3 meals a day, 7 days a week, for approximately 8 people each meal. This father insisted that we include her in our study so he can buy her a new stove, worried about her wellbeing.
We have only had two families decide to not participate in the study. One woman said she just didn’t want a new stove and the other her husband decided for her. Machismo!!! This kitchen was black from suit, their newborn baby’s hammock was next to the stove and you could read the disappointment in the women’s face. All of her neighbors were participating and getting new stoves and I’m sure she experiences the same noticeable health impacts from her stove. Not to mention her concern for her babies health. I am not sure if this is what she was actually thinking or just scared from her husbands reaction, but after talking to so many of the women they know that the smoke is really bad for their health and even forgo cooking meals due to the irritation from the smoke. Her husband just stated, “No. I want my wife to cook traditionally.” And that was that. Dona Maria (our volunteer) gave this man the sternest look I have ever seen in my life and walked away.
This last weekend we had off. We all traveled to Isla de Ometepe. This is an island in Lake Nicaragua that has two volcanoes on it, one of which is still active. My mom,
T-Rae, Matt and I went kayaking around part of the island and went to Monkey Island. These islands have monkeys on them that are quite interested in the kayakers that drift by. We did not venture onto the islands though because the monkey’s bite and we were well warned of this from the locals. It was quite the adventure and exciting to see monkey’s outside of a zoo in their natural habitat. The next day sitting at our hotel, a big 4 inch long bug came cruising by. I thought it was just some big bug native to here that was beautiful and didn’t think twice about it. The owner then informed us that this bug is a giant wasp!! This wasp was huge and I never knew they could get this big. It was a dark iridescent blue. Apparently these wasps fight tarantulas and then lay their eggs inside of the tarantula. I think we were all a little bit more cautious when dismissing a simple bug around here as harmless.

Food:
The market is streaming with entrepreneurs trying to sell their fresh goods. Produce is extremely inexpensive. A pineapple costs 15 Cordoba’s which is less than one US dollar. Cheese here is what I like to call squeaky cheese because when you chew it, it squeaks. You can buy 3 kinds of cheese; the really squeaky kind used for frying, a crumbly really salty not so squeaky cheese, and a really, really salty crumbly squeaky cheese. When you buy cheese from the market they cut a piece off and let you sample it. Mind you no washing hands or gloves. Eggs come in cartons, are bought off the street and are not refrigerated. Milk is highly pasteurized and also does not require refrigeration until it is opened. It tastes more like evaporated milk. Garlic is abundant and I have been eating a clove a day to try and keep the mosquitoes away. Not very commonly used in large amounts in the native food though.


Environmental Health Realizations:
One day we were buying groceries at the store across the street from our house and the kids surrounding us (who where begging for food) started yelling at us to cover our noses and mouths. I looked down the street to see a truck spraying pesticides along the homes and sidewalks. We tried to hide, but getting sprayed was inevitable. The pesticide smelled like it was petroleum based and the people, who were cooking and selling food on the side of the street all got sprayed. It didn’t even faze the people and was obviously a daily practice.
• All sewage drains into Lake Nicaragua, which is lined with trash and from the volcano could see brown ring around the edges of the lake
• Diapers thrown on the street, dogs eating them, and flowing down the street when it rains.
• Trash everywhere
• No washing hands when handling food
• Meat is not refrigerated and can be bought off the streets in the market
• Sewage system is composed of it running down the streets mostly and I’m sure the drainage from homes ends up in Lake Nicaragua.

-cooking with plastico!!! women often use plastic to help start their fires

-tree frog on Volcan Mambacho

-exposure monitors hanging in a participants kitchen

-the new stoves have arrived and the beginning of instillation!

-Mateo's new look...

-the 3 interns ready to combat indoor air pollution one participant at a time