Primary Health Care and the Temptation of Excellence

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 Ramón, 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 Clínica 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. (The house was well over three-hundred years old. ed.)

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 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 such 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 Alarcón, the grand-daughter 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!

Inching Toward ‘Excellence’, or How Real-Life Complicated the Original Ajoya Clinic Mission

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 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 illnesses 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 the very excellence, as well as exclusiveness, of today’s Medicine, with its increasingly high standards, elaborate technology and exhaustive training, has pushed its cost and availability far beyond the reach of the common man, and perhaps beyond reason.

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.

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 first. The original intention at the Ajoya Clinic was to provide primary care only and to concentrate our major efforts on broad-scale campaigns of preventive 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 well 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 end 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 clamour 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 present 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, Tepíc and the Tarahumara territory of Chihuahua and nearly all are indigent. Some we can help, some we can not; 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?

Simplifying the Ajoya Clinic, in Theory At Least

“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 “trés sophistique.” He thinks we should limit our services to those which villagers can learn to handle for themselves and can duplicate in other villages 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 de-worming 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 once in a while 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 the 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!”

David’s Hypothesis: Promote Primary Health Through Education

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 had 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 promotors” from isolated villages.

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

The Ajoya School of Boondock Medicine

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 “promotor” and his 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 keeled over backwards, 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 rest rancho, my saddlebags over my shoulder, my hands badly blistered; yet I hurt most for the loss of my valiant companion. I managed to borrow another one for the continuation of my journey.

Our Students

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 has completed only the 4th grade herself, she has 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 “promotora 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 a 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.” Suac que Voluptas.

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 of 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 Madre, 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 but and accused him of having given shelter to Tino Nevarez. (Tino Nevárez 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 wiley and elusive thief, the baffled soldiers tried to starve him out of hiding by brutalizing anyone suspected of lodging or feeding him. In this tray, 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 knick-knacks from the distant-coastal cities, transporting them on burroback 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.

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 chilly January night when his grandmother took off of him his 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 almost without a limp, but 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 our 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.

Roberto has a real knack with animals and his ambition is to someday become a veterinary paramedic, If any of you readers might be able to help make arrangements for him to apprentice with a large-animal veterinarian in the U.S. or México, please try. Roberto has spent several months in California visiting with one of our former volunteers and speaks some English. He is 22.

Our Staff, Teaching Approach, and Principles

Our teaching staff for the new training program was every bit as motley as our coterie of trainees. The brunt of the teaching eras 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 Martín Reyes, our chief village medic.

Miguel Angel Alvarrez, our youngest village dentist, trained some of the promotores 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 slow to do simple urinalysis and other basic tests.

As a textbook for the course we used Donde No Hay Doctor (Where There Is No 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 aspects of supportive care and preventive medicine. 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.

We stressed the importance of uncertainty, of never saying ‘I know,’ but only ‘I suspect’.

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 his chief satisfaction should come from giving, not taking. Above all, we tried to impress on the trainees that the health worker should be kind. He should try to put himself in his patient’s sandals, regard him first as a person, and take interest in his life, family, back ground, joys and fears. Finally the medic should admit openly his 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 the medic must feel his way with each patient.

Mencho’s Practical Genius

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 brillant 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 México, or for that matter in America or the whole Earth'.”

Mencho blinked at me, “What in Heaven’s name do you mean?”

“Tell me,” I said, “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 And The Spoon: How Martín Saved a Baby with Little More than Patience

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 fellow campesinos, can handle certain health problems more effectively than the medical professional who, for all his technical skill and good will, remains a stranger.

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

“No,” I said. “How?”

(Martín, for those of you who don’t know him, is our chief 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 (See here and here) and three in San Ignacio, and later helped arrange for him to study for a part of two years as a “contaminant” (unoffical student) in a unique practical medical training program conducted by Dr. Carlos Biro in Netzahuacoyotl—the huge slum metropolis outside of México City. Today, Martín 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 was vomiting for three days running. 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 to 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 he 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 prep 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 had 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 of 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 Martín, who had come in with another patient a few minutes before. On hearing what had happened, Martín 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 Martín showed up again. His eyes were all red and he was looking weary. ‘Is the baby dead yet?'” I asked him.

“‘Not at all.’ Martín 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.

“Martín shook his head. ‘No, I spoon fed him water.'”

“‘But didn’t he just vomit it up?'” I asked him.

“‘Oh yes,’ Martín 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, “Voilá! So there you have it.”

“The baby survived?” I asked.

“Yes” said Mark. “Thanks to Martín 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’s taught me a lot.”