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.

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.

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

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

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

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.

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.

There are many reasons to be vegetarian I suppose, but the most interesting I heard was from some British travelers who work with animal welfare. They travel around to different countries, on their own trek around the world but engage with the local culture in the form of protection for animals. They told a great story about being in India and finding a street dog that just needed to be put to sleep to end its suffering. They looked everywhere for someone who would do that and were eventually told to go to the gypsies. So they did, and a gypsy maestro cocked a gun and shot that poor little dog and then everyone ran away (perhaps to avoid being chased by the dog’s spirit). Thus they are vegan; no wool, no leather, no meat, no dairy… There is something about being in countries where animals live and die in such close proximity to humans. They wander the street just like I do and when I see the suffering that street animals can endure, it definitely brings about a feeling of responsibility toward my consumption of meat. Markets here are full of live chickens hung upside down waiting for slaughter. Everywhere sort of smells like flesh. That is enough to give me a lot of thought about the human capacity for cruelty toward living things.

Every community we go to and ask when it was settled, they say, 30 years ago. Its amazing to be meeting people that I am reading about and to talk to them about how the last 30 years have been for them. To say that they are organized would be an understatement. Over the last 30 years, with no electricity, running water, money and absolutely no representation in the government of a country where they are born and bred, they have created structures that support their physical, mental, social, political and economic lives. The community we went to yesterday only got electricity last year (that is in 2007).

I went with 4 colleagues. We drove for 7 hours through some of the most fertile and gorgeous landscape I have ever seen. All cloud forests and jungle. Lots of communities passed along the way, some Zapatista (and therefore autonomous) and some not. We don’t work with the autonomous communities since we are funded by government money, but they are ok with having us work in their areas as it helps people. The Zapatista communities can be identified by the fantastic paintings on the cooperative tienda (shop) that is usually at the entrance to the community and boasts phrases like - “we are united” and has pictorials of peasants in black ski masks. Also the red star (the logo of the Zapatista movement).

We got there yesterday evening - and laid out our supplies. We have to carry all our own supplies (food, water, flashlights, sleeping gear etc. etc.). We were there to train their health promotores (promotores de salud) about TB - how to recognize the symptoms, collect sputum samples, get them to a health facility, communicate results back to the patient and begin/complete treatment if necessary. It sounds simple but a mammoth task when you consider the fact that the road ends in one community and one can still walk for days into the jungle to reach many more. These promotores (all of whom are volunteers) don’t have it easy at all!

We laid out the rations - rice, beans, oil, onions, tomatoes, salt and sugar to be cooked in the next 3 days. We supply, the women from the community cook. We bring enough for us and the promotores. Handed that off, and made our beds (sleeping bags laid out on hard wood floor). Then we ate some bread and jam between ourselves and were off to sleep by 8p. Someone in the next room decided to play guitar for a while and sing. Nice. Woke up several times to dogs and roosters. Felt pretty happy and well rested in the morning.

7a - ready to go after brushing teeth and changing clothes.

7:30a - no hot water to make coffee or tea

8a - some signs of a fire in the kitchen. No one turning up for the training. O no wait, one guy shows up.

8:30a - finally breakfast is ready. Rice, beans, coffee.

9a - No one has showed up for the training. The health committee coordinator is very upset.

9:30a - A heated discussion about what went wrong, why no one showed up when we planned these dates at the beginning of January.

10a - We leave.

Another 5 hour drive back to the next town. Met with the president of the promotores’ association who had personally issued a notice for the training and gotten agreement from all. He is embarassed and we reschedule for a month from now. Have his personal assurance that everyone will show.

On the way back, we gave a ride to one of the campesinos (farmer) who had managed to show. In the car, I was trying to practice my Spanish with him and this is our little conversation (all in Spanish, yippee):

Me: Where do you live?

Campesino: In San Francisco.

Me: Is it far?

Campesino: A bit further ahead.

Me: Did you walk here last night?

Campesino: Yes, but it only takes 30 minutes if you walk along the river. Where do you live?

Me: I live in New York but I am here to learn Spanish and work for a few months.

Campesino: And will you learn Tzeltal too?

Me: Yes, maybe Tzeltal but not Spanish! (everyone laughs)

We pass some cowboys (the real ones!) on the street. The horses and cows are afraid of the car so we have to stop and wait until they pass.

Me: In Sri Lanka, if you drive through the jungle, you see elephants on the side of the road.

Campesino: (looking a little worried)

Me: They have wild elephants that are afraid of the car so you have to wait until they go back into the jungle before you pass. It can take 2-3 hours sometimes.

Campesino: Do they eat elephant meat there?

Me: No. They may use them for work.

Campesino: Oh, like a horse!

Me: Yes like a horse but now they mostly live on the reserves.

Silence for 20 minutes.

Campesino: Do you know giraffes? Well, do they use them for work?

Me: No, they are only for looking at.

Campesino: We don’t have any elephants or giraffes here. But I know that in some places people eat horse meat.

So that was really interesting to observe. We had a good time wondering how the Pope would feel about a church with eggs and chickens! Where soda pop was holy water. Since it was almost mardi gras, they also had a carnival - lots of men playing music and walking around in a very ritualistic way - not wild but definitely different. I didn’t take any pictures - considered too rude - since its not really a tourist event so I had to keep my camera under wraps. But it was a nice day and then we ate some rice and beans and came back home.