bare minimum

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It has to happen one day, to anyone here. It was my turn 4 weeks ago, on the second day I was rounding on the pediatric ward. I had taken on the intensive care unit, a sideward to the pediatric department. It only resembles ICUs in the north in that it harbors very ill patients. The care is not really much more intensive than in other wards and definitely not more technologically enhanced. Mostly, children are suffering from severe malaria, pneumonia or meningitis, and many make an astounding recovery.

The third boy I was seeing that morning had a positive malaria test and had been admitted the day before with the usual medications and hydration. He looked very sick, was comatose, and breathing rapidly. He’s intravenous drip was dry and had probably been dry for a while. I have come to appreciate a phenomena much like the picture books that have three dimensional fold fold-out illustrations when you turn the page – when I examine a patient it sometimes feel like slowly turning a page in a medical text book. Signs and symptoms I have read about years ago suddenly manifest themselves in reality.

This boy had a Cheyne-Stokes breathing pattern, an irregular respiratory rhythm that promises a bad outcome. I realized that I was seeing the complications of malaria that kill children here. Further investigation completed the picture: he was febrile, tachycardic, dehydrated, hypoglycemic and probably in cardiac failure. The canula in his vein was clogged up, so I could not give him fluids or glucose. I struggled to find another vein on his cold extremities, one of the clinical officers tried to find one on his scalp, I considered his jugular vein – invisible – his femoral vein, a bone screw….. The intervals between breaths were growing, he started gasping and I knew that I could not keep this boy alive. I looked for confirmation to the nurse and thought that I read agreement in her eyes when she verbally obviously did not disagreed with me. Within minutes the boy stopped breathing, I put my stethoscope to his chest, thinking of a friend who had told me only the week before how desperately I would be trying to hear a beat, feeling my own heart in my throat. Silence. I completed the ritual, shone a light in his dilated pupils and saw no contraction. I turned around to the mother hovering behind me and before my hand touched her shoulder she broke out in the wale of mourning, announcing death in my stead. Thunder crashed over our heads and the lights went out for a split second – his name was Wonderful.

I put some photos online – not here since David has bad bandwidth in Africa. Link:

Photos on Flickr

If you watch it as a slideshow, be sure to click on the (i) in the photo to turn on the feature that shows the descriptions.

Yesterday was my birthday! Thanks to all the lovely people who wrote to wish me from Amsterdam, Maastricht, Durham, Detroit, Philadelphia, New York, India, Sri Lanka, Bahrain and Berlin… I spent the day doing something pretty magical. First a road trip… with 9 people from the posada to a nearby waterfall where we swam in ice cold water, stood in a rainbow, looked at a giant waterfall for over an hour, ate guacamole and chips, swam some more, gave ourselves spa treatments with mud, lounged on trees branched over the water, acted like wild cats, ate grilled chicken from the market, sang songs and got green coconuts. Then a nice long car ride back to town with the sunset. A nice long hot shower for me and back to the posada for más fiesta.

The owner of the posada sold it recently and yesterday was his last day so he had himself a party and turned it into a joint birthday part for me too. I donated 2 bottles of Jose Cuervo for which I was rewarded with a gorgeous chocolate cake, a big crowd singing happy birthday and eventually a stick with which to break my very first and very own piñata, dressed up like a Zapatista of course. Can’t post pics here due to the slow bandwidth D has in Africa but will post them soon somewhere. I did get that beast. The candy inside was some of the most vile I have ever tasted. As I told all the kiddies last night – every birthday since I turned 30 keeps getting better and better.

vocabulary: owner = dueño; party = fiesta; waterfall = la cascada; cat = el gato; to swim = nadar

is a good place. That’s what’s been happening the last few days. I have been meeting more and more people, getting a rhythm and just enjoying being here since its still a while before I go and things aren’t only just new anymore. For one, I don’t get lost anymore while walking around. For two, I have met some really fun people that I like a lot and for three, there is nothing else to do but hang out since work has been really slow and no exciting trips are planned. How I managed to come here during two of the slowest months of this otherwise packed project is beyond me. Things are so slow at work that people actually take naps during the middle of the day. I have given up on scolding them because they always find a way around it by inventing new ways of not working. I guess I am getting used to the pace of life here so I don’t mind it as much and just decided to ask about things actually getting done instead of demanding that 8 hours be spent sitting behind the desk. That does not seem to hold any weight here.

When I first arrived, things seemed to be in order but I guess this pretense of an orderly office couldn’t be kept up for 2 entire months. At first, there were the long lunches – time spent cooking together and then eating and cleaning up together. Something like 2 hours during the peak working hours spent in the kitchen. It was difficult to say something because I was being invited to eat along with everyone and didn’t want to be unappreciative but I did finally say that it had to stop. So this was ok for a short while and people ate snacks instead of complete meals in the middle of the day. Then all of a sudden, almost the entire office started leaving at 4. After a few days, I asked why this was the case and was told its because they did not take their lunch hour anymore so they could leave early! I kid you not. I actually would walk in on people in the kitchen trying to stuff food into their face while standing up so that it wouldn’t count as their “lunch break”. Ridiculous. So I put a stop to this as well and suggested that the best thing to do was bring food from home and heat it up in the new microwave we bought for everyone. This is working out ok. There are still lingering conversations at lunch, and no one does their dishes anymore since it seems to take up work time so the kitchen is a mess. People just don’t bother to clean up after themselves in general. I am constantly surprised by the amount of effort that is exerted into not doing something.

It seems to be no one’s job to clean the office except for a lady that comes way too little. Yet when I say we will pay for someone to clean and cook lunch perhaps on a regular basis, I am met with blank stares. One woman leaves her retainer lying around her desk, the printer, the fax machine, the kitchen counter and the microwave. Another guy brings food that his fiance prepares for him but instead of putting it in the fridge, he keeps it in his desk drawer. Other times, unidentifiable beverages in plastic baggies sit around for days and I think there was a bowl of refried beans that sat in the kitchen for at least a week. I have never been to a country office that was this lax and frankly this nasty. Its hard telling people your own age to clean up especially when you happen to be the visitor!

vocabulary: patient = patiente; dirty = sicio/sucia; to lunch = almuerzar; to waste time = perder

I guess I got so transfixed by asking hippies about diarrhea that I forgot to write for a while. Yesterday we had a full moon here and a full lunar eclipse. The last time that happened was actually on my last birthday in Amsterdam in March when we all gathered to celebrate and watch the clouds slowly creep over the smoky crescent right when the eclipse was supposed to complete. But luckily this time, there was no forecast of cloud cover and the eclipse happened at primetime Mexico. Gringos in town had been really excited about the eclipse for days, as you can imagine. It is already auspicious to be celebrating full moons especially when traveling much less a lunar eclipse to double your pleasure. People in town constantly ask me what time it is because unlike all other tourists, I wear a watch because I got places to be. A couple of days ago I went to see a documentary on Zapatistas at a local independent cinema with some folks from the posada and one hippie looked at the schedule and asked, “its february?” Time and month people may not know but everyone seems fully aware of the lunar cycles and its effects on my toenails.

For the eclipse, we packed 2 vans full of people, dreadlocks, beers, guitars, drums, dogs… i think there were dogs, music, harmonicas, windpipes, enthusiasm, firewood, hot chocolate and 1 Japanese girl and off we went, over the roads, and up the hills and down the pastures and into the darkness, searching for the perfect spot. Actually we weren’t searching at all because the drivers knew where we were going. To the farmland of some local communities that live up on the hill and once we got out of the vans, we were greeted by seemingly ferocious dogs and rifle wielding men that all turned out to be super sweet. The men likely thought we were crazy to be watching the eclipse out in the cold in the dark, considering you could watch it inside on TV. Such is the constant contrast between gringos and Mexicans. Why go natural when you can have it canned?

As I was preparing to use my super night vision to locate my friends from the other van, about 5 people dropped to their knees and started chanting ‘OM’. Some other people decided to take the firewood and start building a fire. Others thought drinking beer and listening to reggae on the vans’ radio was the right thing to do while others still just wanted to sit in silence and smoke cigarettes. I found a girlfriend and had a glass of wine with her. This pretty much sums up the kind of people I have been exposed to here in Chiapas.

Once we watched the eclipse complete, we went to the fire and played music, drank hot chocolate, cracked jokes and listened to one Mexican guy go completely gaga over the Japanese girl (big fan of manga). Its great being one of something. One Indian girl means all the hippies like your country and you. One Japanese girl means all the manga freaks think you might as well be Princess Mononoke.

vocabulary: eclipse = el eclipse; new moon = la luna nueva; full moon = la luna llena; Japanese girl = la Japonésa

Sometimes you don’t really need a doctor or some pills or a website tip to heal you. Sometimes, all you need to do is ask a hippie. I’ve been feeling a little ill for the last 3-4 days but was really sick with diarrhea this weekend. So I cut out of my hostel and came back to my office/house to sleep and have easy access to a clean toilet. After feeling a little better, I went back to the hostel last night and people asked where I had been. I told them about nursing my little stomach and diarrhea all weekend. And one hippie said… “O, the diarrhea of the new moon… everyone has been sick this weekend with the diarrhea of the new moon. I know at least 6 other people”. Well, of course! How could it not be related to the moon? Why did I never think of that? In all my helplessness and feeling so alone and sick over the weekend, I forgot that sometimes talking to a good hippie can take away all your troubles.

Someone then made some teas she had bought at the Museum of Mayan Medicine and we all watched a movie and drank our bitter medicine and felt like we were still of this world.

Not surprising, people are very nice here, the proverbial smile is on everyone’s lips, the pace is relaxed, physical contact is friendly and easy and the weather has been marvelous for the past few days. Thyolo Hospital is set in a beautiful part of Malawi, in the rolling hills amidst tea plantations on red earth, scattered houses, mount Mulanji towering 3000 meters high in the distance.

All well, wasn’t it for the fact that it’s a hospital, not the kind of place that can thrive on smiles and beauty. Physically, the hospital is in rather good shape, thanks to the fact that is was  built only four years ago and is equipped by Medicins Sans Frontiers, who run a large AIDS program here. The current president is from this area and rewarded his people with a nicely designed district hospital shortly after he came to power, and he wasn’t skimpy on the (EU) money. Reality bites when it comes to the work being done in this lovely place. Any western doctor gets his or her heart broken at least once a day, no matter how long you’ve been here. People die and suffer unnecessarily, the lofty ideal of Hippocrates’ thou-shalt-not-do-harm is taken lightly.

One part insufficient education, one part demoralization in a slow and difficult system, and one part – forgive me my cultural arrogance – pure and utter disinterest make for appalling patient care. Two young and very dedicated Dutch doctors are employed by the Malawian Ministry of Health as the only full time physicians, working with a large group of clinical officers. Even after a year in this place, they relentlessly press the staff to improve their performance, provide good care, learn and teach. With the ever looming culture clash of the white folks treading on local ground, no matter their intentions, it’s a delicate business. What to say if once again a man shows up at the emergency department with a very painful belly, is seen by a clinical officer in training, is admitted to the ward without a diagnosis, nor a plan, nor a senior clinician being involved, only to be found 36 hours later by a nurse, hours before he dies of a cause that could have been operated on at time of admission?

Is it that life is not worth as much here? Why are people who decide to work as health care workers not dedicated to saving lifes? Still a lot for me to figure out.

Not a good day, today. I should write you again on another day when I come out of the hospital smiling, happy that we could do some good things for a patient, found the right diagnosis. Yesterday, when at the end of the day I went to see the woman who had been admitted with a pneumonia, but then it turned out she didn’t have a pneumonia at all and I could relieve her shortness of breath with a very simple intervention – wonderful, at least for that brief moment things made sense. But even then, one can’t look too far ahead, or one would see that the quick victory of the day will be overshadowed by the unstoppable progression of her advanced AIDS……..

Okay, enough already, I don’t think the lightness of being will be flowing into this keyboard today.