PRIMARY HEALTH CARE

AND THE TEMPTATION OF EXCELLENCE:

David Werner

From Newsletter from the Sierra Madre #10

“No hay bien sin pero ni mal sin gracia.”
(There's nothing good without a drawback
nor bad without some saving grace.)
--an old Spanish saying

For better and for worse, the Ajoya Clinic has come a long way since 1965, when it began as a few boxes of medicines and bandages on the front porch of the casa of blind Ramon, and its staff was no more than an ex-schoolteacher trying hard to play medic, assisted by a handful of over-eager village children. Then, to be sure, we had a strong sense of community -- sometimes too strong -- for we shared the open porch with dogs, chickens, pigs, cockroaches, a pile of pumpkins, a corn crib, a small table at which we ate in shifts; and five cots which at night were unfolded to sleep eight of the household and myself.

Today La Clinica de Ajoya occupies a large old adobe casa in mid-village. Although once a fine home, when we took it over in 1970 the place was in ruins. The roof was a sieve, the walls eroded and collapsing. It had been boarded up for five years, ever since the ancient widow who owned it died, and it was infested with bats, rats, fleas, pigeons, spiders and -- according to rumor -- ghosts.

We cleaned, patched and white-washed the old building as best we could, and to this day wage a never ending battle to keep it comparatively sanitary and vermin free. The village women cooperate by sponsoring a chore lady who daily scrubs, dusts, disposes of trash and steps on scuttling critters. But an old adobe house, like a small boy, blithely parries every attempt at cleanliness. It has too many secret niches. By day, things appear relatively kempt and under control, yet at night cucarachas materialize out of the walls to explore the medicine bottles, rats scamper and skirmish on the eaves, bats flutter through the patient wards, and an occasional scorpion steals up a cot leg to cuddle in the warm bedding of a patient or volunteer. We are still not a high class medical facility.

Little by little, however, we have made ‘improvements’. Over the years we have poured cement floors in the patient wards, fixed up an X-ray darkroom (which is not quite dark), built a workshop, put in a septic system, a flush toilet (which doesn't always flush) and a cold shower. Last year we finished construction of an almost modern operating room complete with scrub room, fitfully running water, filtered air system and surgical lights powered by our increasingly cantankerous 5 kw generator.

During the past few months, our biggest step forward has been to equip and get into operation a tolerably functional clinical lab. Many people have helped donate or scrounge supplies for it, so that we now have a fair range of equipment including two fine microscopes, scales, a macro and a micro centrifuge, and a simple but ingenious incubator for culturing bacteria. (This last item consists of a styrofoam box through which runs an exhaust pipe from our small propane refrigerator. The pipe has a thermostatic shutter valve, so that a constant temperature can be maintained in the box.) The incubator was contrived by the husband of a visiting medical technician. Three technicians have made separate trips to Ajoya to help set up our lab and train our health workers to use it. During their short visits the volunteer lab techs have focused on training Kerry Travers , who has a degree in microbiology and therefore a head start. Kerry, in turn, has been training Ramona Alarcon, the granddaughter of the village blacksmith, (who presented me with a white rooster when I first opened the dispensary in Ajoya 10 years ago). Ramona, after six months apprenticeship, is now able on her own to do many basic tests; to prepare, stain and examine slides of urine, feces, blood and wound exudates, to seed culture plates, and to identify common forms of bacteria and intestinal parasites. Our new lab service has greatly increased our diagnostic capabilities. Hats off to Ramona, to Kerry, and to our visiting medical technicians!

* * *

All in all, the Clinic of Ajoya is not only far better situated than it was a few years back, but the type of medicine we manage to practice -- while still relatively primitive by U.S. criteria -- has become increasingly advanced. Our village apprentices, have gained more experience, our American volunteers are better trained, our range of equipment is more extensive and our laboratory facilities are enormously improved. In short, one might say we practice ‘better’ medicine.

But, is it really better medicine?

Yes and no. In terms of the widely accepted standards of Western Medicine, definitely yes. In terms of realistically getting at the root of the health problems in the mountain villages we intend to serve, perhaps no.

As we all know, Western Medicine has tended to pay far more homage to Panacea, the Goddess of Healing, than to Hygeia, the Goddess of Health. It has poured a vast amount of money, training, research and prestige into the treatment of illness, yet a proportionately trifling amount into its prevention which logically and pragmatically should come first, The reason is simple: it is the sick who holler loudest. And of the sick, those who can pay most are often the most readily heard.

Over the past 40 years or so, the Science of Healing has made extraordinary advances. The discovery of antibiotics, the introduction of transfusions and transplants, the proliferation of devices for testing, monitoring, measuring and you name it, have taken the sting out of many illness and prolonged life for many who can afford it. Yet the fact remains: on this Earth today, there are numerically more persons lacking even rudimentary health care than ever before in human history. And every day the number of such persons is growing.

Ever since the days of Hippocrates, the sworn intention of the Medical Profession has been to serve the people; not just those who can afford it, but those whose need is greatest. Yet today's Medicine's very excellence and exclusiveness, with increasingly high standards, elaborate technology and exhaustive training, have pushed cost and availability far beyond the reach of the common people, and perhaps beyond reason.

It is time that the Medical World went less in the direction of ‘excellence’, which can only be for the few, and strove more toward ‘adequacy’ for the many. This requires lowering our standards; or, more accurately, lowering our standards for technology and training, and raising our standards for foresight, magnanimity and common sense. This won't be easy. I can testify from my personal attempts.

Clearly, the chief concern of a primary care center should not be sickness, but health. Our original intention at the Ajoya Clinic was to provide primary care only and to concentrate our major efforts on broad-scale campaigns of preventative measures and public health, for we realize that only in this way will we ever make any significant or lasting inroad on the overall health of the community.

By no means have we neglected preventive measures completely. As those who have been following our activities will know, we have plunged into programs of vaccination, family planning, pure water systems, experimental crops, food cooperatives, corn banks, health education, medical self-help (including my villager's medical handbook, Donde No Hay Doctor as well as conservation of game, fish, timber, beauty, etc.

But for all these sundry programs in community health and preventive medicine, the trend at the Ajoya Clinic has been to become increasingly embroiled in the curative side of medicine. The temptation of excellence has been too strong for us to resist. It is only natural that one likes to provide the ‘best’ medicine to those who clamor for and appreciate it the most, namely the sick. And so we have brought in X-ray and E.K.G. machines, centrifuges and microscopes, built an operating room, expanded our clinical library, picked the brains of visiting doctors, and done everything in our admittedly limited power to upgrade the scope and quality of our diagnostic and curative services. In short, we have come a long way from the primary care center we once set out to be.

“But, what's wrong with taking better care of the sick?” you may ask. What is wrong is that we have put ourselves on the map. In Sinaloa and beyond, we have gained a certain ‘fame’ for being able to cure difficult and heretofore incurable ailments. This fame is, of course, unwarranted; the fact being that in 90% of our more awe-inspiring successes, the difficulty which has made the illness in effect ‘incurable’ has been economic. Our medicines work wonders simply because for once, they are within the reach of the people. Yet, however undeserved our success, the word is out. More and more patients flood in from farther and farther away. Some have already sought medical help elsewhere, and come in with obscure or recalcitrant maladies which we are often at our wits' end to figure out. Patients come from the slums of Mazatlán and from as far away as Hermosillo, Tepic and the arahumara territory of Chihuahua. Nearly all are indigent. Some we can help, some we cannot; some we refer to doctors we know in the coastal cities who are conscientious and may even give them a break; and a few -- especially children with correctable deformities -- we bring to California for treatment at Stanford, the Shriners Hospital for Crippled Children, or elsewhere.

True, all this fills a great -- in fact, an endless -- need, but not the need we set out to fill. This kind of stop-gap, helter-skelter, cure service is all right for a start; it helps limit the suffering of an ever-lengthening queue of sick individuals; but it makes no headway, gains no ground. On the contrary, the continual flood of ‘outside’ patients has put a tremendous drain on the time and energy we would like to be putting into long-range community health and preventive measures in the mountain villages we came to serve. We have tricked ourselves into plugging so many leaks with our fingers, we don't have enough free hands left to build a better dike. Contrary to our stated intentions, we have focused on sickness, not health.

We have tried to resolve this dilemma in several ways, none fully successful. We have even made feeble efforts at refusing service to ‘outsiders’, especially those who come from areas where there are doctors or health centers. But we find that many patients have made long journeys, often at great sacrifice, because they are too poor to get the medical help they need elsewhere. They arrive with their hopes high and their pockets empty. In theory one can turn such persons away. Not in fact.

Soooo, what do we do?

"Simplify!" is the proposal of Mark Lallemont, a young doctor from Paris who spent three months helping at our clinics last summer.

Unlike many of our visiting doctors, who are either frustrated or charmed (or both) by the relative primitiveness of the Ajoya Clinic, Mark insists that the level of medicine we practice is ‘très sophistiqué’. He thinks we should limit our services to those which villagers can learn to handle for themselves and can duplicate in other villagers up the line. He is adamant that we focus on stopping sickness before it starts.

But sophistication, like crab grass, is easier to come by than get rid of “How”, I asked Mark, “do you suggest we ‘simplify’?”

“First of all”, replied the French doctor, “throw away some of your fancy equipment -- the E.K.G. machine, for instance.”

“But it's a useful tool!” I protested. “What do we do when we've got a patient with a baffling heart problem?”

“Admit you're baffled”, replied Mark. “Be kind, be supportive, and let Mother Nature or the Great Reaper determine the course. They will anyway, regardless of whether you monitor the poor guy's heartbeat. If you have an E.K.G. machine you're automatically relegated to tinkering with outdated hearts when what you want to be doing is digging latrines, improving crops and deworming kiddies.”

“Any other suggestions?” I asked.

“Yes”, said the French doctor. “Get rid of 9/10 of your medicines. The fewer kinds of medicines you have, the more people you'll reach with them and the easier you can teach the people to use them correctly. You can make do with 10 or 12 basic drugs. This, of course, means you'll be treating mostly the commoner ailments. But that's fine. If you limit yourself to primary care you'll have more time to devote to hygiene, nutrition, birth control, vaccination and all the other things which in the long run make for less sickness all the way around.”

“That sounds great”, I agreed. “But when someone suffers from a not-so-common illness we could readily treat, it'd seem a shame not to lend a hand, just because we'd thrown away the specific medicine he needs. Suppose, for instance, a leper comes in, as happens now and then. Do we tell him, “Sorry, not today.”?”

“Leprosy's hard to cure anyway”, said Mark. “It takes years.”

“But we've cured it!” I pointed out. “Remember, it's a dreaded, slowly progressive, disfiguring and crippling affliction with a huge social stigma. It's a disease you want to help somebody with if you can.”

“Can't you send such patients to the city for medicine?” suggested Mark.

“If they can afford it. And if they'll go”, I said. “But we can get the sulfones they need much cheaper ourselves.”

“Hmmm”, conceded Mark. “In that case perhaps you should include a sulfone on your list of basic drugs.”

“We've already included it”, I assured him, “along with a whole drove of other medicines which make a big difference in this or that patient's life. That's why 'things just ain't simple...Believe me, Mark, our line of reasoning is pretty much the same. I'd love to put most of my time into preventing sickness instead of treating it. But theory's one thing and life's another. And when a patient who's deathly ill comes to you because he believes you'll do your damnedest to help him, by Jesus you do your damnedest to help him, all your theories about preventive medicine and keeping things simple be hanged!”

“True!” said Mark. “And that's precisely why you should have only 12 basic drugs and get rid of some of your fancy equipment; so you won't be seduced away from the work which in the long run will help people most.”

“Thirteen basic drugs”, I corrected him. “You just added a sulfone, remember?”

Mark laughed. “Okay! Okay! I get your point!” and added with a sigh, “Things just ain't simple ... but Mon Dieu, they should be!”

* * *

Since the above discussion with Mark last September, we have tried in a number of ways to move increasingly in the direction of primary care and preventive medicine. Yet we have more or less resigned ourselves to the fact that the Ajoya Clinic is, ipso facto, a treatment center. Rather than try to change this state of affairs, we have determined to use it in every way possible to promote preventive measures and better overall health.

To this end, we have set about turning the Ajoya Clinic into a school. To some extent, of course, it has long been one. For ten years we have been training local village youths, on an apprenticeship basis, to function as medics and dentics, both in the Ajoya Clinic and in our medical outposts (now four). We have also training programs, both in Ajoya and California, for our young American volunteers, who range from pre-med students to high school and college dropouts. In fact, the continuity of medical and dental care in our health centers is provided by the work force made up of these conscientious young amateurs and apprentices, both Mexican and Gringo. The primary role of visiting doctors and dentists, when we are fortunate enough to have them, has not been so much to practice their respective skills, but to teach. We have long felt it is the doctor's responsibility to assist the auxiliary, not vice versa, and that it is the auxiliary's job to assist -- and teach -- the patient.

Our latest effort, then, has been to expand our teaching program in the direction of primary care and public health. One of our most important adjuncts at the Ajoya Clinic has been to train ‘health promoters’ from isolated villages.

A village health center should first and foremost be a school.

* * *

THE AJOYA SCHOOL QF BOONDOCK MEDICINE

On his first quiz Mencho scored only 19%, but it didn't upset him much. For Mencho, at 57, has remained as innocent of percentiles as schooling. Until this last December, when he joined our new training program for village ‘promoters of health’, he had never been to school a day in his life. Yet in his youth he had somehow taught himself to read and write.

Mencho is from Jocuixtita, a long-defunct mining village crouched far back in the ‘barrancas’ or wild ravine country of the Sierra Madres 30 kilometers by muleback from our central clinic of Ajoya. From age six until his early forties, Mencho worked as a farmer, sowing with a planting stick small clearings hacked out of the jutting Mountainside above his village. At age 42, Mencho's life abruptly changed, One stormy evening after he had returned home from weeding his high fields, a band of ‘Federales’ burst into his adobe hut and accused him of having given shelter to Tino Nevarez. (Tino Nevarez is the hero of many a folk song and legend today because he was a sort of Billy the Kid or Robin Hood of the Sierra Madre, who reputedly stole from the rich and gave to the poor. In the huge manhunt for the wily and elusive thief, the baffled soldiers tried to starve him out of hiding by brutalizing anyone suspected of lodging or feeding him. In this way, according to legend, they killed more than 100 innocent persons). When Mencho denied having hosted the celebrated bandit, the soldiers threw him onto the earth floor and jabbed him so hard with their rifles, they permanently injured his spine. Unable from that day forward to work his steep cornfields, Mencho looked for other means of supporting his wife and hungry children. He began to shuttle ‘wonder drugs’ and knickknacks from the distant coastal cities, transporting them on burro-back to peddle in the villages of the barrancas. It was only natural that he prescribe and administer the medicines he brought, and in time he became highly regarded as the local medicine man. For know-how, he depended on the Good Lord and Good Luck, applying with a less-than-sterile syringe and blunt needle either penicillin, liver extract, or both for virtually every malady. He had no training and no resource material. In fact, the first book of medicine he ever laid hands on was a copy of my villagers’ medical handbook, Donde No Hay Doctor, which I gave him a year ago. For Mencho, the handbook was the doorway into a new and challenging world. When, last Fall he learned that at the Ajoya Clinic we were offering a two month training program for village paramedics, he jumped at the chance.

* * *

The purpose of our new training program for ‘Promotores de Salud’ is to disperse primary health care over a wider area. Thus we give settlements beyond reach of our immediate services the chance to select persons from their own communities for study at our central clinic. On returning to their villages, they are able to set up health stations and serve their fellow campesinos by providing simple treatment, vaccinations, programs for better hygiene and diet, health education and family planning. To encourage reciprocal responsibility between ‘promoter’ and village, each village is asked to come up with half of a modest scholarship or living allowance for their trainee while in Ajoya. Our Project provides the other half.

* * *

In late November, two weeks before the training program was to begin, I set out on a dash excursion of more than 200 km on muleback through the remote barrancas of Sinaloa and Durango, to do final recruiting for the course and announce the starting date. As it happened, this expedition nearly cost me my life, and did cost that of my personal mule, La Coloradita. Climbing a narrow, treacherous stretch of trail into the high sierra, my mule's hind hooves unexpectedly slipped on the decaying granite and she fell on her belly, half off the trail. For a brief moment she teetered on the brink, her hind quarters dangling in space. In that moment I was able to carefully but quickly dismount. I scrambled up ahead of the wide-eyed mule, and pulling hard on her halter rope, tried to help her back onto the trail. She made a courageous lunge, and slipped again. The rope burned through my hands as she kneeled over backward, pawing at the air, and plummeted 200 feet to her death. After salvaging what there was to salvage (the saddle was smashed to smithereens) I hiked back to the nearest rancho, my saddlebags over my shoulders, my hands badly blistered; yet I hurt most for the loss of my valiant companion. I managed to borrow another mule for the continuation of my journey.

* * *

The training program began on December 10th as scheduled. The 12 students made up a heterogeneous but rambunctious crew. They ranged from 14 to 57 years old and had from zero to eight years of schooling. The average age was 23; the average education, 3rd grade. Mencho was the oldest and had the least schooling. The youngest was Nando, a 14-year-old lad on crutches who, having come to Ajoya from a distant rancho for treatment of chronic osteomyelitis, had decided to stay for the course. One of our best students was Leandra, a jovial 33-year-old-mother of six. Although she had completed only the 4th grade herself, she had been serving her remote village (Caballo de Arriba, 60 km by mule trail from Ajoya) as both schoolmarm and folk healer. Perfect qualifications for a village ‘promotor de salud’.

One of our most earthy and energetic students regretfully dropped out after only two weeks. This was Doña Goya, a stout-hearted middle-aged midwife from Carrisal, an hour’s walk from Ajoya. It turned out that her young husband – who is as unreasonable when drunk as he is irrational when sober, which is rarely – opposed her taking part in the course and beat her as often as he learned she had attended. Stoically Doña Goya endured the beatings, arriving each day with new bruises; but when her man took to mistreating her 11-year-old son by previous union (one day he hung the boy briefly by the neck), she stopped coming. When we asked her why she didn’t simply leave her insufferable consort, whom she supports, she answered laconically, “he’ll kill me … and besides, I like him.” Sua cique voluptas.

Another of our trainees was Roberto, a youth from Campanillas, about 16 km northwest of Ajoya. Like Nando, Roberto first came to us as a patient. Four years ago he was carried into Ajoya on a stretcher, severely emaciated and totally crippled by juvenile rheumatoid arthritis. Previously he had been taken for treatment to the coastal cities, where the last doctor to see him had told his grandparents that if he didn’t get better with the final course of medicine, his case was hopeless. To this day Roberto vividly remembers the chill January night when his grandmother took off of him the one blanket to put it over the other children, since ‘he was going to die anyway’. As the wasted boy huddled shivering in the darkness, he made up his mind that if he survived that one night he would somehow manage to get better… At the Ajoya Clinic, with the help of courage and corticosteroids, Roberto in fact began to improve. When he was able to use crutches, we began to give him jobs around the clinic. Today, although some of the joints in his hands and feet are irreversibly fused, Roberto not only walks without a limp, but also does a good job pulling teeth. For the last three years he has worked with us as an apprentice dentic and as keeper of the clinic mules. He joined out new training program with the idea of serving his native village as a ‘promotor de salud’, and already makes calls there. His first love, however is for animals.

Our teaching staff for the new training program was every bit as motley as our coterie of trainees. The brunt of the teaching was done by Mike Travers and myself, both of us former high school teachers of sorts. A couple of other American volunteers also presented some classes and so did Martin Reyes, our chief village medic. Miguel Angel Alvarez, our youngest village dentist, trained some of our promoters how to pull teeth and tutored others, like Mencho, in simple math. Ramona Alarcón, our village apprentice lab tech, taught the trainees how to measure the hemoglobin content of the blood and how to do simple urinalysis and other basic tests.

As the textbook for the course, we used Donde No Hay Doctor. One objective we had was to help the students learn to use the book effectively. Emphasis was put not on memorization, but on how to look things up. We also stressed the ‘importance of uncertainty’, of never saying “I know”, but only “I suspect”, for in folk medicine, like politics, there is a dangerous tendency to come up with answers before questions. In our class discussions we covered the pros and cons of folk remedies, as well as the proper use and misuse of modern medicines popularly used as cure-alls. In general, we tried to de-emphasize the use of medicines, especially injectables, and to focus on supportive care and preventive medicines. We encouraged the promotores to use every occasion of sickness or injury as a chance to teach the patient and his family the preventive measures necessary to avoid the return or spread of the particular ailment.

To bring home the fact that a good medic must first be a good teacher, we not only encouraged the trainees to teach each other, but arranged for them to give classes to the Ajoya school children on topics of personal hygiene, how to avoid intestinal worms, etc. In addition, our future ‘promotores’ helped the school children set up public garbage pits, and led them three afternoons a week in pandemonious clean-up brigades, the outcome of which has been to make Ajoya a far more attractive and slightly more sanitary village.

One concept we tried hardest to get across -- largely, I hope, by example -- is that medicine and health care should primarily be seen not as a business, but a service. The village medic is of course entitled to modest remuneration, but one's chief satisfaction should come from giving, not taking. Above all, we tried to impress on the trainees that the health worker should be kind. We should try to put ourselves in the patient's sandals. We should look first at the person, and take interest in the person's life, family, background, joys and fears. Finally, the medic should admit openly his or her limitations, and “Do no harm!”

The brunt of the students' training took place not in the ‘classroom’ (actually an old attic over the bakery and blacksmith shop) but in the clinic, where from the first day they began to soak and dress wounds, practice suturing on fetal pigs, provide simple nursing care, and sit in on patient consultations. In the second week, the trainees began to consult and examine patients under the supervision of our more experienced paramedics Thus each consultation became a learning/teaching opportunity for paramedic, trainee and patient.

In these three-way learning sessions, conducted as of necessity in the simplest possible language, it was interesting to note how many patients, far from taking offense at having their problems used for teaching, expressed appreciation at being included. Several patients who had formerly sought medical help elsewhere commented with relief that this was the first time they came away with an inkling as to what their malady was all about. Even when an illness is grave or incurable, we have found that most patients find it less frightening to be given some insight into their problem than to be left completely in the dark. Of course, medics must feel their way with each patient.

* * *

On the final quiz of the course, Mencho scored 64%, still -. like Einstein -- at the bottom of his class. Fortunately, we'd had the chance from the very beginning to appreciate Mencho in the practical as well as the academic setting. If in the classroom he proved the dunce, in the clinic we soon realized he was special. He has a certain ‘touch’ with patients which I believe, comes less from being brilliant than from being humble. He is above no one, approaching each patient as a peer and equal. Being himself rustic and a farmer, his interest in the daily lives of his patients is not ‘professional’ but real, and campesinos -- like patients anywhere -- are quick to sense the difference. He gains their confidence and cooperation because they feel he cares. Patients often ‘open up’ to Mencho who won't to other medics or visiting doctors. He has a way of gently drawing out the true problems which hide behind the apparent ones. Above all, Mencho is unhurried. No patient is too dull, nor problem too trivial not to claim his warmest sympathy and undivided attention. As a result, whether or not Mencho is able to do anything medically for a given patient, the patient almost invariably comes away feeling better. And that's what the art of medicine is all about. (The science, of course, is another matter.)

Still and all, Mencho had great difficulty with some of the classroom work, especially the math. One afternoon he stayed behind to get special help on calculating doses of medicine according to patient weight. After much repetition he was still perplexed. At one point he shook his head wistfully and said, “Why waste your time on me, David? It's pointless putting new shoes on a worthless old mule.”

“Mencho!” I asked him sharply, “Do you know what you're worth?”
“About so much”, he replied, grinning sheepishly.
“Look here”, I cried, “You're worth more to your own people than all the doctors in Mexico, or for that matter in America or the whole Earth!”

Mencho blinked at me, “How many doctors are there in your neck of the barrancas, up there around Jocuixtita?”

“Why you know there aren't any”, he replied mildly, “It's too remote. The people are too poor.”
“That's exactly what I mean”, I said.
"I still don't follow you”, said Mencho with an embarrassed smile, “but if you don't mind, let's get back to those doses. I reckon I've just about got the hang of them.”

THE NEEDLE, THE SPOON

I would like to relate to you now an event which Mark, the young French doctor, experienced in the Ajoya Clinic, and subsequently related to me. Of all his arguments for a simpler approach to medicine, this episode, I think, is the most convincing. Not uncommonly, visiting doctors or medical students have felt stymied medically because they have been at a loss culturally. For example, the patient may simply not permit a pelvic or rectal exam which might be important for diagnosis, or may interrupt a critical course of treatment because of some taboo, or switch to an old folk remedy. As Mark makes clear, there are times when the village-born paramedic, who knows only too well the strengths and foibles of his or her neighbors, can handle certain health problems more effectively than the medical professional who, despite all technical skill and good will, remains a stranger.

“Have I ever told you about how Martin saved the life of a baby after I had failed?” Mark asked me.

“No”, I said “How?”

(Martin, for those of you who don't know him, is our village medic. Now 24, he first began helping at the Ajoya Clinic when he was 14. We sponsored him through secondary school, including two years in California and three in San Ignacio, and later helped arrange for him to study for a part of two years as a ‘contaminant’ (unofficial student) in a unique practical medical training program conducted by Dr. Carlos Biro in Netzhualcoyotl, the huge slum metropolis outside of Mexico City. Today, Martin is the mainstay and ‘coordinator’ of our Ajoya Clinic. Although at one time he had his heart set on becoming a doctor, he is now strongly dedicated to his less impressive but more progressive role as a pioneer in village paramedicine.)

"It was a Sunday morning in the middle of the rainy season”, began the young doctor, "and unbelievably hot. Being Sunday, the Clinic was supposed to be closed except for emergencies. But this young couple showed up with a sick baby, about a year old. They said his name was Filiberto and he'd had diarrhea and vomiting for three days running. Well, it was, in fact, an emergency; the poor infant was dangerously dehydrated. His eyes were sunken and dry, and his skin was all shriveled like an old man's. They said he hadn't peed since the day before. I explained to the parents that the baby needed intravenous solution right away. The father got anxious and said he thought the baby was too weak too resist it. For some reason, his misdirected concern annoyed me. “Resist it!” I hollered, “It's the one chance we've got to pull the baby through!” He said, “Oh.” So we took little Filiberto to a back room and I began to hook up an I.V. The mother and father helped hold him while I tried to get the needle into a vein. I tried every lousy vein in his thin little arms and his scalp, but no luck. You know how hard it is with a baby, and dehydrated at that. Believe me, I was sweating it. And so were his poor parents. They kept begging me to stop hurting him, and just give up. The mother started to cry, which made me all the more nervous. I realized that if I didn't get some fluid into the baby's veins quickly, he was going to die. And for all I knew, his parents would blame me.” The French doctor smiled nervously. “I tell you, I was damn scared! In a big hospital it's different. You don't have the parents as your assistants. You're not put on the spot in the same way; you're more insulated; you've got nurses, consultants, anesthetists and tons of equipment; you can avoid getting so close ... You know what I mean?”

“I decided my only chance of getting into a vein was to do a cutdown.” Mark continued. "I brought in gloves, forceps and a scalpel from the surgery room, and began to prop the child's ankle. Before cutting, I explained carefully what I was about to do and why. But the mother suddenly cried, No! that her baby suffered enough already. I tried to argue with her, insisting that if we didn't get in the needle the child would die. Instead of replying, she snatched up her baby and ran out or the Clinic. The father, before he followed her out, turned to me and said, “Thanks, in any case. I guess we brought him too late.” “Wait!” I protested. “The baby can still be saved!” ...However, they were on their way.”

The young doctor made a frustrated gesture, and went on. “I felt angry and foolish. I thought of getting a court order, or some such, until I remembered where I was. So I went to talk to Martin, who had come in with another patient a few minutes before. On hearing what had happened, Martin ran out of the Clinic to look for the parents and the baby.”

“Well”, Mark gave a long sigh, “it was the next morning before Martin showed up again. His eyes were all red and he was looking weary. “Is the baby dead yet?” I asked him.

"Not at all”, Martin said with a big smile. “He's still got the runs, but he looks a whole lot better. He's not dehydrated now. He's begun to piss and shed tears.”

I couldn't believe my ears. “You did a cutdown?” I asked him.

Martin shook his head. “No, I spoon fed him water.”

"But didn't he just vomit it up?' I asked him.

"Oh, yes”, Martin said sleepily. “But every time he vomited, I gave him more. I gave him one spoonful of water with sugar and salt in it every 3 or 4 minutes all afternoon and all night long.”

"All night long?”

"All night long. I learned a long time ago that when it's a matter of life and death you can't chance leaving it to the parents, no matter how carefully you instruct them. They either give too little or too much. You've got to do it yourself..."

The French doctor paused and spread wide his expressive hands, "Voilà! So there you have it."

“The baby survived?” I asked.

“Yes” said Mark. “Thanks to Martin and his patience and understanding.” He grinned at me. “So your village paramedic has taught me something I never learned in med school. As a matter of fact, he taught me a lot.”

WHAT WE LEARNED FROM MARIA
"Men are cruel, but man is kind.'
-Rabindranath Tagore-

Those of us whom solitude entices to peer into the night skies of our own being, and thereby into Being in general, are often dumfounded by the didactic irony of fate. It is as if ‘blind’ luck and ‘pure’ chance conspired with our human sensibilities to pursue paths as clear yet inexplicable as evolution. Perhaps we are just imagining things, reading into events whatever significance we project upon them, as with inkblots. Be as it may, the chips do fall at times with awesome significance, stopping us short. The sleepless Fates, which once presided over Greek plays, weaving with the portentous shuttle of strophe and antistrophe the thread of the hero's Hubris until at last he snarled in the inextricable web of Nemesis -- even today ring within us a note of fearful recognition. Events in our daily lives time and again fall into momentous patterns, as if trying to teach us something we have long known, yet ignored; as if Fortune herself were half Poet and half Prankster, and our disquiet existence a tragic-comedy deftly designed to put us in our place.

“....And Lord, if too obdurate 1,
Take thou, before that Spirit die,
A piercing pain, a killing sin,
And to my dead heart, run them in.”

-Robert Louis Stevenson-

Medically and technically, we did everything we could for Maria. But it wasn't enough. If we had reached out a little more with our hearts, if we had let our response to her agonizing pleas be a little more visceral, more human, still she might have died, but differently. As it happened, we became so involved, frustrated and at last fatigued by the complexities of her physical problem, that somehow the frightened woman trapped in that sick body was lost in the shuffle, even before her death. As one first notices the loud ticking of a clock only when it stops, so, of a sudden, we wakened to Maria. But a heart cannot be rewound like a clock, although -- heaven knows! -- we tried. And in the warm stillness that followed, we in turn wakened to ourselves, and shuddered.

If Maria had been the victim and we the villains (would it had been as simple as that!) there would be little justification in telling her story. But we, the medics and doctors who attended her, were also, in a sense, victims, half-blinded and swept along by that glittering army which, through years of study and discipline, we have recruited to serve us. If we acted unwisely, reader, forbear. If we were unkind, remember that we endorse kindness wholeheartedly, that each of us had come to this little Mexican clinic voluntarily, with the will to help others. If we were self-complacent and you could condemn us, recall, at least, that you may be in the same boat.

This, then, is the account of how a group of humanitarian medics and doctors, propelled by the intensity of events, trapped in the maze of technological and medical acumen and discouraged by their own ineffectiveness, were marched along by their cumulative strengths and weakness, step by irrevocably step, until -- truer to their decisions than to life -- they sat to one side and watched their patient struggle to her end.

* * *

In retrospect, the stage seemed ominously set for this unhappy play of events (or was it our minds were set?). Even the fact that we called our patient Maria echoes our key flaw. She had been baptized ‘Maria Socorro’, and to her friends she was Socorro. For all our medical skills, we somehow missed the name she went by. An excusable error, yet the irony remains: ‘Socorro!’ is the Spanish cry of ‘Help!’

In this account I shall continue to call her Maria. It is too late to correct our mistake.

Maria, as you may recall from the last newsletter, was the young wife of Marino, one of the two brothers killed at a dance in Guillapa on Christmas Eye a year ago. It was she who, crowded in the back of our power wagon with the corpses, authorities and wide-eyed children, had lifted the edge of the blanket and gaped at the stiffened gaze of her husband until someone ordered her to cover him up again. On reaching Ajoya, Maria had collapsed, moaning and stroking her chest, and had needed to be carried, along with the bodies, through the quick throng of curious, pushing villagers. At the time, I had not thought there was anything physically wrong with Maria, and perhaps there was not, for her collapse had every sign of grief and hysteria. Many other women, likewise, verged on hysteria, a few from genuine grief, but most from sheer contagion. There is something in a Mexican village which thrives on tragedy and comes alive with Death.

Following Marino's death, Maria and her children had taken asylum with her aging father, Juan, at his isolated rancho called ‘El Amargoso’ (The Bitterness), 12 miles upriver from Ajoya. A long time passed before we heard from her again.

On the morning of September 15, three little boys burst into the Ajoya Clinic like startled ravens, shouting that someone was being carried into town on a stretcher. Moments later, a small knot of sweating, tired campesinos maneuvered through the doorway a cumbersome homemade litter. On it lay a handsome, very pale, young woman with dark wild eyes. It was Maria. The men had carried her through the stormy night from El Amargoso, following the precarious ‘high trail’, so as to avoid the treacherous fords of the river.

Old Juan, her father, had come too, and stepped forward to greet us. Wrinkled and resilient as a peach pit, he had perennially sparkling eyes and huge friendly hands. He begged us to do what we could for his daughter who, he explained, had begun to hemorrhage from her “obscure parts” the day before, and had lost “at least two liters” of blood.

Maria was anxious and petulant. It took a lot of coaxing and explaining before she reluctantly submitted to a pelvic exam. The results, however, were unremarkable; no apparent evidence of pregnancy, infection, abortion or tumor. She was, however, very anemic, we supposed from blood loss, and was going into congestive heart failure.

We kept Maria under observation for two days. She lost no more blood, but neither did her clinical picture or her anxiety improve. We felt she needed transfusions as well as a thorough gynecological exam, and recommended taking her to Mazatlán. Old Juan was reluctant, partly because of cost and partly for his native fear of cities and hospitals, but Maria was willing and at last so was he. Risking the weather and bad roads, Martín, our chief village medic, drove them to Mazatlán in the new clinic Jeep, and placed Maria in the care of a first-rate physician, one who has provided treatment or surgery for many of our patients, often at minimal charge.

Barely had Martín made it back from Mazatlán, when a furious ‘chubasco’ (thunder and wind storm) struck the Sierra Madre. During most of the summer the monsoons had been mild, leaving river and roads more or less passable. Now at the end of ‘las aguas’ the Weather poured it on with full force, as if bent on meeting a seasonal quota. Roads turned into rivers, the river into a sea. Corn and squash grew overnight, the jungle burgeoned. The clinic roof leaked.

* * *

Day after day the rain gushed from a wild, churning sky. On the afternoon of September 23 a waterlogged wayfarer, arriving on foot from the world outside, reported that a couple of Gringos destined for our clinic were stranded in San Ignacio. They had tried to hire portage to Ajoya in a four-wheel-drive jungle buggy, only to get stuck in the first arroyo crossing this side of San Ignacio.

The Gringos, we supposed, would be Mike and Lynne, a young pediatrician and his lab tech wife, who were planning to help for a month at our clinic. (Mike had first taken interest in the project when, last Spring, he had helped care for a severely burned baby boy whom our Ajoya team had flown to a San Francisco Burn Unit.) Roberto offered to fetch the stranded couple with the clinic mules. These took some finding, however, and he was still saddling up the mules when Mike and Lynne, sore but radiant, plodded into Ajoya on borrowed mules.

“How bloomin' far is it, anyhow, from San Ignacio to here?” asked Mike, gingerly dismounting.
“Seventeen miles,” I answered. “Seem longer?”

The Texas-bred pediatrician shook his head slowly and grinned. “Reckon it’s about the longest, bounciest damn 17 miles I ever swam!”

We laughed and welcomed them in.

* * *

The Patron Saint of Ajoya is San Gerónimo. The Día de San Gerónimo was now only a few days away, and the young men of the village had begun to wonder if the rain, would subside in time to truck in the cerveza (beer) for the grand fiesta. As for myself, I crossed my fingers for a deluge. But on the 27th, the weather calmed. On the morning of the 29th, three ex-army ‘commandos’ loaded to the gunnels with beer lumbered into the village plaza. Tents and tables went up. The dance would go on! For two nights.

After dusk the ‘ruta’ arrived, for the first time since the chubasco. This is a backwoods ‘bus’, actually, a 4-wheel drive flat-bed truck with wooden benches and a solid canopy. That evening it carried so many passengers that they spilled over and were hanging onto the roof and sides. One of these passengers was Miguel Angel, our first village dentist.

He had played hooky from the ‘preparatoria’ (a sort of junior college) in Culiacán in order to attend the fiesta. I was frankly delighted to see him.

“You wouldn't believe it!” exclaimed Miguel Angel. “The road is that bad....! And Toño, what a great goat! He made everybody get out and wade across the fords and up all the hills, so the truck wouldn't get stuck. Half the time it got stuck anyway and we all had to push. Hijuela! And the priest -- you know, the one from San Ignacio who gets drunk at every fiesta -- was along too. Moteo and I had to carry him piggyback across the fords. Hijole, my back aches! But instead of thanking us, he’d just get mad and scold. Finally, Moteo got fed up and ‘accidentally’ dropped him in midstream...” Miguel Angel gave a low whistle, “Ever hear a priest curse?”

Everyone laughed uproariously. Miguel Angel, a born entertainer, grinned appreciatively. Then suddenly a shadow crossed his childlike countenance and he turned to me. “Know something, David, Toño is a true beast. When I say he made everybody get out and walk, I mean everybody. Well there was this real sick woman on the ruta. She had a terrible cough and trouble breathing. Toño made her get out like the rest of us, and the more she had to walk, the worse she got. On the steep hills she’d hack and gasp something awful, like somebody drowning. Even back in the truck she couldn't get her breath. I tell you, David, she looked like she was about to drop over. And still at every hill the brute made her walk. A fool would have shown more compassion!”
“Who was she?” I asked, guessing.

“Marino's woman, the one who collapsed in the Power Wagon last Christmas .... I think her name’s Socorro.”

“Maria”, I corrected him. “Doesn't sound like she’s much better.”

* * *

I half expected to see her at the clinic that evening, but she didn’t come. That night, despite intermittent showers, the festivities continued nearly until dawn. In the plaza three different musical combos competed with each other and the thunder. Trumpets blared, clarinets squeaked, drums thudded, lightning flashed and the villagers -- those who could afford to and many who could not -- drank and danced. Staccato joy shots punctuated the merry chaos. As the night wore on, there were the usual scuffles. The only significant injuries, however, were those inflicted by the Municipal Police; they had Come from San Ignacio ‘to maintain law and order’, got drunk and --among other indiscretions -- gunwhipped a campesino who had given them, they said, lip. We stitched up the poor fellow's face at the clinic and he hurried back to the dance. All in all, the fiesta was a booming success.

* * *

Next morning our first patient was Maria. Weak, wide-eyed, gasping for breath, she arrived supported by her father and her 7-year-old son, Benjamín. As they came into the clinic, Maria began coughing and sank, exhausted, on a bench. Although the tropical morning heat was only just beginning, her face glistened with sweat.

“Air!” she gasped between coughs. “Benjamín! Give me air!”

Her small son took off his tattered sombrero and solemnly flapped it in her face. The boy shared his mother’s broad, attractive features, yet his puerile countenance was as imperviously calm as hers was wildly agitated. Into my mind sprung the dark memory of this same waif jammed with his siblings and cousins in our Power Wagon beside their father’s body that fateful Christmas morning. Small wonder he looked strangely grown-up for his age.

“Faster, can’t you!” Maria's gasping voice had the frustrated urgency of the captain of a floundering vessel shouting to his men on the pumps. Benjamin fanned faster.

While Martín helped Maria into the examining room, I questioned old Juan. No, he had not brought a physician’s report from Mazatlán. All he could tell me was that his daughter has been given 2 1/2 liters of blood and a “scraping of the mother” (D & C). With this, she had seemed to get a bit stronger, but her feeling of ‘drowning’ had failed to improve. After ten days she had been released from the hospital, still very ill.

“So I reckoned I’d bring her back to you fellows in Ajoya,” said old Juan. “The trip was kind of rough on her, though. I’d have brought her here to the clinic last night except that she was that bent on watching the fiesta. You see, the silly girl claimed it would be her last and she was not about to miss it. She didn’t either. Damned if she didn’t even down a couple of cervezas! Fool child! Everybody knows cerveza’s the demon for a person with ‘susto’. I warned her it’d do her harm. But she said..... Hesitating, he looked bewilderedly at his wild-eyed daughter.

“Said what?” I encouraged.

The old man frowned. “She said it meant ‘mother’ to her.... But that’s her way. Sullen.
Stubborn as an ass. Too proud to hear what’s good for her. She’s always been that way, even as a tot. But now she's worse, since her ‘susto’.”

“Snare?” I said. (‘Susto’ is a mysterious folk malady, a state of self-consuming, irrational anxiety usually precipitated by a terrifying experience and often considered to be the doings of the Devil.) “Do you mean since Marino was killed?”

“That was the start of it”, said old Juan, “But the crowning touch was just after that, when her father-in-law stole her six cows and the beans.”

“You mean Nasario robbed Maria?!” I exclaimed. I have known Nasario only as a kind and generous old man; I could not imagine him otherwise. Yet I've knocked around enough to know that every person, like every story, has more than two sides.

“But why?” I demanded. (Perhaps I shouldn't have asked, for I was anxious to examine Maria, yet I wanted to hear out her father, and it was important to him that I do so.)

Old Juan's gentle eyes clouded with anger. “Because the old python knew he could get away with it,” he said. “You see, Marino when he was alive had never bothered to get his own branding iron; he’d always used his father’s. So when he was killed, Nasario just up and took the cows, simple as that. What could my daughter do? The cows had the coward’s brand.”

“Nasario did that!” I puzzled.

“That's not all!” Old Juan spat angrily on the clinic floor. “He sent his son, Celso, like a lone coati to rob her whole winter's supply of beans, said they’d been planted on his land, the fox.” The old man’s eyes narrowed. “Do you follow, Don David? They broke her like a sprig of cane. Within eight days the poor girl lost everything; husband, cows, beans! What else is there? All they left her was a handful of hungry children.”

The old man laughed wryly, “And a crotchety old father on his last legs.” He spat defiantly. “But God hear me, while I live, I eat!” The old man put a huge hand on his grandson’s slight shoulder, “And Benjamin here's going on eight. Couple of years and he'll man his own cornfield and plant his own beans. Right, son?”

The boy tilted up his quiet face and answered his grandfather with a fleeting half-smile that would have bolted Leonardo to his easel.

Maria’s case, we knew, would be tough. I was grateful we had Dr. Mike with us, and asked his help. He consented gladly, but when, on examining her, we found Maria had a dangerously fast pulse and a possible pulmonary embolism (blood clot in the lungs) he began quite wisely, to shy from the responsibility.

“I’m only a pediatrician”, he protested. “And besides, she should be in a hospital, not a backwoods clinic. Can't we get her to Mazatlán?”

“We already got her there”, I explained to him. “They discharged her from the hospital two days ago. That's why she’s back with us.”

Dr. Mike’s jaw dropped. “You've got to be kidding. What sort of hospital is that?”

“Busy”, I said. “Understaffed. It's sometimes simpler just to dismiss an indigent patient with an extra difficult or demanding problem. Happens all the time.”

“That's incredible!” said Dr. Mike. “That's barbaric!”

“For an awful lot of folks”, I said, “that's life.”

“Air!” panted Maria. “Where's Benjamin?”

“In the hall”, said Martin, “I'll ask him to come in.”

Dr. Mike took a deep breath. “O.K.”, he said, “I guess I'm game. Let's keep her here. We'll do everything in our power for her.” He looked doubtfully at Maria. “But I sure wish a specialist in internal medicine would drop by about now.”

“In a week one will”, I said. “Literally! 0n October 8 a medical/dental team from California should be flying down by private plane. The pilot’s an internist, and really sharp.

“Tremendous!” exclaimed Dr. Mike with restored optimism. “Let's get on with it then. Martin, can you and Roberto get an X-ray of her chest. David, does that old E.K.G. machine work? Good. We'll see if we can't get this young lady breathing a little easier.” He gave Maria an encouraging smile. She looked away and started coughing. “Think I'll ask Lynne and Ramona if they can do an acid test on her sputum”, mused Dr. Mike, “Maybe she's got T.B.”

Back in the hall, I spoke again with old Juan. He must have sensed my concern. “Tell me straight, Don David”, he said “because well ... if she doesn't have a chance, I'd just as soon tote her back to El Amargoso straight away.”

I grasped the old man’s dark, sinewy arm. “She’s a strong woman, Don Juan”, I said. “You know we’ll do all we can.”

“I know”, he said with a frowning smile. “Yet something tells me...” Instead of finishing his phrase he looked at me squarely and asked, “Can you Gringos cure susto?”

I thought of all the things I might or might not say, and repeated simply, “We'll do all we can.”

We set up a cot for Maria in a small room open to the patio. As is our custom, her father and son also moved in to help care for her. We provided them with a narrow burn bed and a miniature gurney, which was the best we could do.

* * *

I won't go into all the medical details of Maria's case, lest the reader get bogged down in them -and lose track of the human side. Let it suffice to say that from first to last we were baffled by Maria’s clinical picture. We took X-rays, endless electrocardiograms, analyzed and reanalyzed her blood, urine, excrement and sputum, and kept track of her vital signs and fluid intake/output. Yet the more we learned, the less we really knew. One day we suspected pulmonary embolism, the next ‘wet’ beriberi, the next thyrotoxicosis, the next rheumatic fever, etc. Time and again we mesmerized ourselves into believing we were on the right track. On the third day for example, when we thought Maria’s breathing seemed easier in response to digitalis, Dr. Mike exclaimed cheerfully, “I think we did the right thing to keep Maria. She's gonna get better!” That evening, however, Maria took another turn for the worse, and we recognized in her ephemeral improvement the mirage of our own wishful thinking.

Sick as she was, Maria retained a strong sense of pride. She had the traditional campesina modesty, which made examinations and tests unnerving both for her and for us. Most of all she hated being wired up, open bloused, to the E.K.G. machine. Every time we wanted an E.K.G., Dr. Mike and Martin had to spend 10 to 15 minutes cajoling her to lie quietly and keep from covering her breasts. She would start coughing and beseech us to wait until she caught her breath, which she never did. Although she always made us carry her to the porch for the E.K.G.s, protesting that she was too short-winded to walk, once the tests were over, she would jump up and run back to her cot.

During these tests, Maria’s dread of asphyxiation always seemed to get worse. Fear is, of course, the tinderbox of fury. One morning when Maria was wired up for an E.K.G., the mother of a sick child made the mistake of peeping in through the doorway.

“Chinga to madre!” exploded Maria. Aghast, the mother withdrew. We marveled that someone with so much trouble breathing could muster such an ear-shattering curse.

It was hard for us to tell how much of Maria’s distress was physical, and how much was due to her fear. She had the eyes, the breath, the heartbeat -- and at times the bared teeth -- of a cornered animal fighting against the odds for its life. Her cough, although unproductive of phlegm, had something exaggerated about it, even vocal, as if Maria, while too proud to beg for help directly, was pleading succor through coughing.

Frustrated by the fact that Benjamin fanning her helped so little to ease her distress Maria thanked her small son largely with abuse. One afternoon I heard her gasp, after a fit of coughing, “More air! Come closer, damn it!” Benjamin, who was already almost flicking the sweat drops from her brow, accidentally grazed her with his sombrero.

“Can't you ... be careful ... you son of a slut!” she gasped.

Without a word, and with the same immutable look of concern, the boy kept flapping his tattered sombrero.

Perhaps, I mused, he is so used to her scolding him he takes it for granted. Or, perhaps, with a child’s instinctive wisdom, he takes her cruelty as a proof of love.... Whatever the case, Benjamín needed no defending. Yet my heart went out to him often, as did the hearts of the others in the clinic. With his quiet compassion, the small boy led us all. Would he had led us further!

Maria's respiratory distress seemed to get worse not only when we wanted to move or examine her, but whenever her father or Benjamín left her side or were trying to get a little much needed sleep. Her worst and loudest paroxysms of coughing occurred between 1:00 and 3:00 A.M. Benjamin would dutifully get up and fan her. Martin, Ray (an American paramedic) or I -- often all three -- would also rise, give her appropriate medication, and try to calm her. I found it did a lot of good -- more, in fact, than the medicine -- to sit quietly beside her, speaking softly and reassuringly, encouraging her to relax. First she would be resentful and taciturn, but little by little her breathing would grow easier and sometimes she, too, would begin to talk of her children, Marino and things past. Never of things to come.

One night at the second crowing of the cocks (about 3 A.M.) I was aroused by Maria's vociferous coughing. Between coughs I heard her frantically call, “Benjamin .... wake up .... Hurry!”

I quickly pulled on my boots and waded across the dark patio toward her room.
“Benjamin! ... Wake up!” she gasped, her agitation mounting. “Don't you care if I die?”
I found I was the only one who had wakened, (No matter how tired, I sleep lightly.) Maria had kept us all running too many days and nights. Old Juan’s big chest heaved rhythmically on the burn bed. Ray’s musical snore came drifting from the adjacent room. Benjamín, still sandaled and clad, lay in a fetal question mark upon the small gurney, his tattered sombrero clutched in his small hand, sound asleep.

“Benjamín!” gasped Maria with increased terror, “For the love of God... give me ... air!”

I carefully lifted the sombrero from the small relaxed hand and began fanning Maria. “Let him sleep”, I said softly. “He needs it. Try to be calm, for his sake.”

Maria shook her head in frustrated fury, and staring into the darkness gasped, “More air!” The Flickering of the kerosene lamp accentuated the terrer in her wide, sunken eyes. She looked like a woman possessed. I kept fanning.

“He needs ... I need ... air ... sleep ... can't go on!”

“Maria”, I begged her, “Try to relax. Your body needs less air when it's relaxed. Try to be calm.”

“You don't understand”, gasped Maria. “It's their fault ... Air! ... The beans!” She made an angry gesture, as if trying to push back the darkness.

“Take it easy, Maria”, I said in a reassuring voice. I thought: she's right, I don't understand. “The beans?” I ventured.

“Give me air!” she demanded. I fanned harder. Benjamín stirred in his sleep. I looked down at him and yawned longingly. Somewhere a toad was singing. The night was cooler now, before dawn, yet Maria’s distraught face was sculpted with golden rivulets of sweat. After a long silent spell, she began to speak, spacing her words between air-hungry gasps.

“Morning ... they buried Marino ... afternoon I went back ... our hut... Guillapa getting dark ... alone ... More air! ... going inside ... jumped out of the shadows something ... male ... straight at me Air! ... waving his hands ... I thought it was ... his ghost looked just like ... the darkness...ran past me ... Air! ... out the door ... Give me air! ... in the light it was ... Celso...
Marino’s brother the devil ... Nasario ... sent to rob ... the beans!” She began to cough again, and fishing the sticky mucous out of her mouth with trembling fingers, wiped it on the bed sheet.

“What happened then?” I asked.

“I don't know”, she panted. “My heart ... pounded ... like crazy ... my legs ... More air! ... I fell ... Since then ... Give me air!” I kept on fanning her. She gave a light sigh and shut her eyes.

“Maria”, I said cautiously. “What do you think your illness is?”

She opened her eyes and stared at me as if I were a child. “Susto”, she snappcd. “What else?”
With a pained grunt she turned onto her side with her back toward me. Her breathing, however, seemed to grow a little easier and a few minutes later she apparently fell asleep. I took up the kerosene lamp and examined her carefully. Even in sleep, I noticed her breath was strained and rapid, her face anxious. Cautiously, I took her pulse. It was 150 per minute. Perplexed and wary, I stumbled out into the dark patio and looked skyward.

Not a star.

* * *

One of our ongoing battles with Maria was trying to keep track of her fluid intake and output. Time and again we asked her not to empty her bed pan, but whenever we weren't looking she made Benjamín sneak it out, for she had diarrhea and was embarrassed to let us see it. Equally difficult, was trying to keep tab on how much Maria drank. Because we suspected pulmonary edema (water on the lungs) contributed to her respiratory distress, we felt it imperative to restrict her fluids. Her thirst was insatiable and she was forever having Benjamín sneak her water from the communal urn. Dr. Mike tried patiently to reason with Maria, explaining to her that drinking less would mean easier breathing. Maria nodded that she understood and would cooperate, but the moment the pediatrician turned to leave she gasped very audibly, “Benjamín, bring me water!”

Dr. Mike stiffened as if slapped, then returned to her bedside and sat down. He looked into her pale, perspiring face and said gently, “Maria, do you want to die?”

Her dark eyes narrowed, and in a tone whetted with ire, she snapped, “Yes!”...

Next we tried to reason with Benjamín. This put the child in a serious double bind: whom to obey. It was, of course, easier to deceive us than disobey his mother. Maria’s breathing continued to get worse and we were at our wits’ end. At last, Martin took Benjamín to one side and had a boy to boy talk with him. They arrived at a peace treaty whereby Benjamín, could continue to ‘sneak’ water to his mother, but would first ‘sneak’ the glass to Martin so that he could limit and measure its contents. Each time the boy brought him the glass, Martin showered him with praise for taking such good care of his mother. Needless to say, the treaty held. Little by little, Maria’s breathing began to improve. And so, temporarily, did her state of mind ... and ours.

Her heart, however, kept beating at frantic double time, and by the end of the first week, we were more baffled than ever. We could scarcely wait for the arrival of the flying doctors.

* * *

On the afternoon of October 8th, at long last, a small Cessna buzzed over the village, dipping its wings in a greeting. Ramona, our apprentice lab tech, ran into the patio and looked up. “It’s them!” she shouted jubilantly. “The Gringo doctors! They’ve come!”

Dr. Mike, Martin and I looked at each other with shared joy and relief. “Thank Heavens!”

Miguel Angel, the younger dentic, had left in advance with the Jeep for San Ignacio to meet the plane. The road was still an obstacle course, although the rains had calmed; it was well after dark by the time the visiting crew arrived. There were two doctors, a dentist, an oral hygienist, a journalist and her husband, a photographer.

The pilot and leader of the group was John, a radiologist, with a long background in internal medicine. Over the past several years Dr. John has been an invaluable help to our village project. He obtained most of our X-ray equipment for us and trained us in its use. He has helped us get patients into a number of hospitals in the Bay Area. He has also assisted in the education of our village apprentices, both personally and financially. And he has flown to our area many times with visiting medical/dental teams. Having worked with him in many situations, I have gained the highest regard for Dr. John both as a doctor and a friend. He is abrupt on the surface and warm underneath.

The other doctor, an intense young surgeon named Robby, was new to our project. We found he had a vast amount of medical know-how at his fingertips, and was a gifted instructor. Taking to heart our motto that “The first task of the visiting doctor is to teach” Dr. Robby held classes and bent over backward to our young volunteers and village apprentices. The dentist and oral hygienist likewise did a splendid job in instructing our apprentice ‘dentics’.

Welcoming in the visiting team, we took them onto the back porch where the air was cooler. Everyone was seated on chairs, gurneys, boxes or the floor. From her open room on the far side of the patio, we could hear Maria’s distraught coughing.

* * *

20
“Sounds like you've got a pretty sick patient back there”, said the journalist, lighting her notebook with a small flashlight.

“That’s Maria, whom I told you about”, said Martin.

Wanting to waste no time, I turned to Dr. Mike. “Why don’t you explain Maria’s case to the other doctors.”

Dr. Mike, as eager as I to share our responsibility for Maria, began to describe her case with all the systematic detail of a ‘grand rounds’. As he talked, Maria’s cough grew louder and more urgent. The journalist whispered something to Martin, and a moment later the two of them softly made their way across the dark patio toward Maria’s room.

The new doctors listened intently to Dr. Mike: the history, the signs and symptoms, the lab reports, and our attempts at diagnosis. When Dr. Mike mentioned pulmonary edema, Dr. John interrupted sharply.

“Her? Pulmonary edema?” His voice had a note of slightly scornful incredulity. “Anybody who can put on a cough like that couldn't possibly have pulmonary edema. You can't blow a horn without wind.”

Dr. Mike laughed sheepishly, and said, “It's mighty good you're here. We needed somebody with more experience...”

I, too, felt foolish, but relieved. Already, without even having seen the patient, Dr. John had shed new light on her case. In simply hearing her cough, he had been able to put his finger on something we had half known all along, but never come to grips with; irrespective of how sick she might or might not be, to some extent at least, Maria was putting us on. To be sure, her physical problem was serious enough, but perhaps we could cope with it better if we didn't let ourselves get entangled in her melodramatics.

And so it was that Dr. John’s first of f -the-cuff judgement of Maria was the germ of a shift in our attitude toward the woman and her illness. From that evening on, we grew more stern with Maria, for we felt that if we catered to her hysterical fears, we would only intensify them. When we had to examine or test Maria, we no longer coaxed her as much or played up to her illness. We no longer waited as patiently for her to catch her breath (which she never did) before taking an X-ray or E.K.G. Dallying, we agreed, would only encourage her theatrics. We must be gentle, but firm.

However, it wasn’t always easy to be both. Sometimes, our firmness became more harsh than gentle. I vividly remember how one night, very late, when everyone in the clinic was trying unsuccessfully to sleep and Maria’s cough sounded deliberately loud, I went to her bedside and said firmly, “You know, Maria, if you didn’t cough so loud, maybe some of the people around here could get a little slcep. Just because you can’t sleep, doesn’t mean nobody else should, now does it.” In the muted glow of the kerosene lamp Maria turned her sweated drawn face toward mine and looked at me briefly with fatigued, haunted eyes. I had never before spoken to her like that. She turned her head away, gave me a couple of muffled coughs, and gasped, “Air, Benjamín!” At once I wanted to take back what I had said, to beg her pardon, to explain that I was cross because .... Instead, I gave her her medicine and stumbled off through the darkness and the mud.

* * *

In spite of our temporary increase in staff at the Ajoya Clinic, we were more swamped with work than ever. Apart from the enormous amount of time we spent on Maria, we found that our patient load had increased by leaps and bounds. People from San Ignacio and surrounding villages had seen the plane land and were coming to consult the ‘flying doctors’. Some were patients who knew Dr. John from his previous visits and had confidence in him. Among these were a mother and son from San Ignacio. Five years ago, the mother, Agustina, had to come to the Ajoya Clinic complaining of a breast lump which had proved to be cancer. Her suspicions verified, she had gone to pieces, terrified by the fear of leaving her children orphans. Deeply touched, Dr. John had gone to great effort to arrange surgery for her in California, as well as to see that she was comfortable during her visit. Two years later, when her eight-year-old son, José Antonio, developed a bone tumor in his arm, Dr. John had helped make similar arrangements for the boy. Both operations had proved successful. Now mother and son had returned for check-ups and to greet their old friend.

Apart from our increased patient load, another thing that slowed us down -- and justifiably -- was the visiting team’s unstinting commitment to teaching. Doctor John feels strongly that visiting doctors’ time is best devoted to training the paramedics who provide the continuity of care, and he had primed his team to this idea in advance. The team did most of its instructing through serving as clinical consultants. In addition, as I have mentioned, Robby conducted a number of excellent classes and seminars.

However, the visiting doctors were unable to devote as much time to teaching as we had planned, largely because of the time and energy they devoted to Maria. Concerning her condition, the number of opinions had increased with the number of doctors, This, of course, meant more tests and more electrocardiograms. For the E.K.G.s, we decided Maria should walk to the porch rather than be carried.

Though she would invariably complain that such walking was too exhausting for her, we felt it was better to be firm.

* * *

At long last we made a major breakthrough, Drs. Robby and John had noticed, by comparing the cardiograms over the last several days, that Maria’s heart rate was always a constant 150 per minute, no more and no less. They speculated that this could be due to ‘paroxysmal atrial tachycardia’ (or PAT, a sort of electrical ‘short circuit’ of the heart in which an unregulated point of discharge stimulates a very rapid but constant rate of contraction). In order to confirm this suspicion, and at the same time, if possible, interrupt the PAT and return Maria’s heart beat to normal, Dr. John injected a vasopressive agent (Aramine) into a vein of her forearm. The rest of us crowded around the E.K.G machine to witness the results. They were dramatic. Within the space of two heart beats (less than a second) her second heart rate dropped from 150 to 60 beats per minute. Maria uttered a gasp of terror and turned grey. On the E.K.G. machine her heartbeat leveled at 80 beats per minute for about two seconds, than flipped back to 150.

“It's a PAT!” cried Robby jubilantly. “What'd I tell you!” He pointed at the squiggly line. “See that sudden drop!”

Maria, trembling and clutching her chest, gave little grunting sighs with each strained breath. Benjamín, a faint frown on his innocent face, fanned his mother furiously with his tattered sombrero.

Dr. Mike, who had doubted that Maria had PAT, was less elated. “I guess you guys are right”, he said. “But she flipped right back into the paroxysmal beat. What have we gained?”

“That often happens”, explained Dr. John. “We’ll put her on Quinidine. If she doesn’t come out of the PAT in a couple of days with that alone, we’ll give her another shot of Aramine and she should convert and stay converted.”

All of us felt encouraged. We had, we supposed, at last tracked down the cause of Maria’s distress, and knew how to treat it. For the next two days, impatient for the Quinidine to take effect, we anxiously monitored her heart beat on the E.K.G.

By the end of the second day, however, there was still no response. Maria’s heart kept on pumping desperately at double time. That evening the thunder growled and it began to rain again.

About ten o’clock that night, a boy arrived on horseback from Carrisal (a small village on the way to San Ignacio) to tell us that a Jeep Wagoncer full of Gringos was bogged down in the mud near ‘la cruz’ (a wooden cross by the side of the road which marks the site where many years ago a young woman had been dragged to death by a mule). I was very tired, but my eagerness for a change of scene got the better of me, and I said I would go to the rescue with our Jeep. Dr. Mike, although as weary as 1, also jumped at the chance. After an hour or so of slithering up the badly washed out track, we came to the mired vehicle. Parking on somewhat more solid ground, we hooked up the winch of our Jeep to the Wagoneer, and wound it in like a floundering catfish. It was after 1:00 A.M. by the time we made it back to the clinic.

The arriving group of Americans was a lab tech (Ann), her husband, a mechanic (Bill) a young friend of theirs, and a new paramedic (Memo). (In case the reader is astounded by the number of Americans we had here at one time, so were we! We never plan to have so many at once, but sometimes it happens. Actually, the two groups overlapped for only three days.)

The next morning Maria was still the same -- rapid breathing, perspiration, fear of suffocation, pulse of 150/minute. We told her we wanted to get another E.K.G. As ever, she protested that she was too out of breath and begged ‘to wait a minute’. Yet this was the day we were to ‘convert her heart’ (bring it back to normal rate) and we were too eager to show her much patience. Dr. Robby and old Juan helped her, protesting, to her feet and ‘walked her’ to the porch. When she was hooked up to the leads, we crowded once again around the E.K.G. machine, eyes riveted on the rapidly jumping needle, while Dr. John prepared to inject her. Maria, recalling with terror the shock of the last such injection, pleaded that we not give it again, but Dr. John assured her it would not harm her, and was necessary if she was to get well. Unconvinced, Maria tried to restrain his hand, and her father in a sharp tone ordered her to behave. At last she submitted, calling with a weak voice, “Air, Benjamín!” The call was now less of a petition than a rite. The small, unfailing boy leaned forward and vigorously flapped his tattered sombrero. Dr. John injected the medicine.

Nothing happened.

Again, we were baffled. Three days before, her heart beat had "converted" -- though temporarily - with Aramine alone. Now, with Quinidine in her system, it was supposed to have converted yet more readily, and to have stayed converted. Instead, no change. The needle on the E.K.G. machine jittered rhythmically at 150/minute, as before.

“Maybe that means it’s not PAT after all”, suggested Dr. Mike.
“It has to be PAT”, insisted Robby, pointing to the stack of electrocardiograms.
Dr. John, concerned but still unflustered by Maria’s failure to ‘convert’, speculated, “We still might be able to block the PAT with Prostimine. Do we have any?” We had. We injected Maria with the appropriate dose and impatiently watched the E.K.G. machine. No response. “It often takes a while”, noted Dr. John, still not discouraged. And sure enough, at about 10 minutes, Maria’s heart rate began to drop. After half an hour, it had dropped to 120 per minute.

Everyone was ecstatic. Everyone, that is, except Maria, who continued to gasp for breath and call to Benjamín for ‘air’. Still, to us she looked better. Her blood pressure, which had been low, was back to normal, her pulse was at long last stronger and slower. Obviously, she was better!

“How do you feel, Maria?” asked Dr. Mike with an encouraging smile.
“Bad.” said Maria.
“But you do feel a little better, don't you?” he persisted.
She coughed and turned her head away. “Benjamín!” she gasped, “Give me air!”
Benjamín, who had trapped a fly on his bare arm by clapping his small hand over it, now held it carefully by the wing and was dreamily watching it twist and buzz.

“Give me air!” cried Maria with renewed anguish. “Or I'll die!”

The boy released the hapless fly, which spun in a drunken spiral to the floor, and snatching up his tattered sombrero, returned to fanning his mother. Old Juan, who stood planted beside his daughter like a wistful cypress, took hold of her long, thin, hand and gently massaged it in his own big ones.

“My poor, lost daughter!” muttered the old man wearily. “But if it's God's will to take her, so be it.”

Dr. Mike gave him an exasperated look, opened his mouth as if he were going to say, “Damn it, can't you see she's getting better!”, thought better of it, humped his wide shoulders and walked away.

“David”, said the journalist, who had spent most of the morning typing in the back room, “If you could spare me just a few minutes of your time...”

* * *

Later that same morning, the three doctors approached me with their recommendation:

“We have talked it over and decided that we’ve done just about all we can do medically for Maria here in this clinic. There is obviously a strong psychological element to her illness which has grown dependent upon and is aggravated by all the medical attention she has been getting here. If she is to get better, she should be elsewhere.

“Furthermore”, they continued, “We doctors came here with the understanding that we were to give priority to the training of paramedics and village apprentices. And just look at us! Ever since we arrived, the major efforts of this entire health center have been poured into one extraordinarily complex case: Maria!”

“In short, we feel that the advantages of moving Maria to a private house far outweigh the disadvantages. For the good of Maria as well as the clinic ... Agreed?”

Their points, I thought, were well taken. “When”, I asked, “do you suggest we move her out?”
“The sooner the better. Now, if possible.”

“Now?”

“Right now. This very morning.”

“But we just started the Prostimine this morning. Her heart rate is still dropping. Oughtn’t we to keep an eye on her for a few more days?”

“If she stays at a house here in town we can check on her as often as we need to.”
I nodded.
“Then you'll tell her father?”
“Yes”, I said. “It’ll take him a while to arrange a place to stay. I'll ask him to be ready by this afternoon. He should bring a couple of men to carry the stretcher.”

“Why a stretcher? As you know, that just reinforces her dependency. Better she walk...”

“Pardon me again”, said the journalist, who had been trying patiently to get a word in edgewise. “Do you mind if I quote from your introduction to the Ajoya Manual, this part right here.” She pointed to the very beginning, which reads:

The overall value of our medical efforts in a village health
program, is at best debatable. The value of ... human kindness is
unquestionable. Let this, then, be our first goal...

“Sure”, I said to the journalist, “Quote it if you like.”

“And wonder if you’d mind looking over what I've written so far...”

“As soon as I talk with old Juan”, I told her.

* * *

Old Juan accepted the news mutely. Yet when I told him we thought Maria would improve more quickly in a private home, his eyes grew moist and he put a friendly hand on my shoulder. I could tell he thought I was lying in order to spare him, and was grateful to me. He was sure we considered his daughter's case fatal, and were sending her out of the clinic to die. I tried to tell him otherwise, but it was hopeless.

* * *

I can't remember everything that happened during the next few hours, except that I was kept so busy that I missed lunch.

About 3:00 P.M. I was returning to the clinic from an errand. Hearing loud voices from the porch, I went there. Dr. Mike, Dr. Robby and old Juan were standing beside the examining couch on which they had propped Maria into a sitting position. The time had apparently come for her discharge. I remained in the doorway.

“That’s a girl, Maria”, said Dr. Robby. “You can make it if you take it easy. It's just a short way down the street.”

“No! ... Please! ... I can't do it! ... Air!” gasped Maria, “I need air!”

Like an injured bird, a tattered sombrero slipped out from between the two doctors and fluttered at Maria's perspiring face.

Next Dr. Mike spoke. His voice was gentle, but stern. “Now pull yourself together, Maria. You're getting better, you know that. Let us help you up.” He pulled gently on her arm.

“No! No! ... Please don't ... make me ... No! ... Not ... just now!” whimpered Maria. “Air!”

Dr. Mike took a deep exasperated breath and turning to Robby, said in English, “Every bloomin’ time we want to move her or treat her, she suddenly gets worse.” In his frustration, he turned back to the patient and said in Spanish, “What is it with you, anyway, Maria?”

“I'm dying”, Maria panted. The tattered sombrero flapped harder.

“David!” Maria cried out suddenly. She must have spotted me in the doorway. This was the first time she had ever called me by my first name, and it struck me as odd. I moved forward. “What is it, Maria?”

“I can't ... get enough ... air!”

There was nothing new about that. I moved closer and looked at her more carefully. The same terror and exhaustion were in her eyes. But something struck me as different, though I was hard pressed to know just what.

“It hurts ... me here”, grunted Maria, putting her hands to her chest.

I put a stethoscope over her heart. At firs