Note: This article, originally printed
in "Newsletter from the Sierra Madre"
# 10, April, 1975, has become a classic of health care literature.
The story tells the events leading up to the tragic death
of a distressed village woman in Mexico. It shows the importance
of coltural sensitivity and of taking the conerns of the
ailing person seriously. This tragedy helped a lot of us
involved with Project Piaxtla in Mexico to rethink our approach
to primary health care, and to become not only better health
workers but also more humble and compassionate human beings.
WHAT WE LEARNED
From Newsletter from the Sierra Madre # 10
"Men are cruel, but man is kind.'
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
“....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
* * *
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
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
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
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
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
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
“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
“For an awful lot of folks”, I said, “that's
“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
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
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
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
“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
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!”
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
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
“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
“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
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
* * *
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
* * *
“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”,
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
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
“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
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
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
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.
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?”
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
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.”
“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.”
“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,
The overall value of our medical efforts in a village health
program, is at best debatable. The value of ... human kindness
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
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
“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
“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 first all I thought
I heard was a faint fluttery sound, like a small moth trapped
in a kerosene lamp. But almost at once I picked up the rhythmic
‘lud dub’ of a regular, fast heart. I looked up
and saw that Dr. John had joined the group.
“What's the problem?” he said.
“Have a listen”, I said. “I think at first
I heard a flutter.”
He listened, frowning, then shook his head. “Same as
ever -- a steady fast heartbeat. A lot slower than it was
at its worst, thank heavens.”
“She said she's dying”, explained Robby. “Complains
of increased chest pain.”
“When did this begin?” asked Dr. John.
“When we said it was time for her to go, of course”,
said Dr. Mike.
“Just what I thought”, said Dr. John. “Well”,
he added abruptly, “We made a decision this morning.
Are we going to keep it or not?”
I looked at Maria again, more closely. “Doesn't she
look more cyanotic than she was? I ventured. Everyone examined
“Looks about the same as she always has”, said
Dr. Mike skeptically.
“But look at her lips and nailbeds”, I insisted.
I could have sworn they were bluer.
“It's probably just the afternoon light. It's terrible
in here”, suggested Robby.
“Let's play it safe”, decided Dr. John, “And
do another E.K.G. just to be sure.”
For the last time, we wired her up to the magic leads. This
time I did not stand around the machine with the others, but
squatted by the edge of the examining couch, carefully watching
Maria. She looked at me, then suddenly reached out and caught
hold of my hand, like a drowning person lurching at a bit
of floating jetsam.
“No, Maria! Don't move!” snapped Dr. John. I
quickly withdrew my hand, knowing that the contact between
Maria and myself would upset the values of the machine.
“Great!” cried Robby, bending over the hieroglyphic
verdict scribbled across the long scroll. She’s even
better than the last time. Her heart’s slowed down to
-- let me see -- 112!”
“No sign of any new problems?”
“Not a sign of any here!”
“Well then”, said Dr. Mike, “Let's hurry
up and get her out of here.”
“Air!” gasped Maria.
I took a deep breath. “What do you fellows say we keep
her here another day or so?” I suggested hesitantly.
They turned and looked down at me as if I were a child. “Trouble
with you, David, you're too soft. You let Maria’s dramatics
turn your head.”
'It's just what she wants. She's got all of us wrapped around
her little finger.'
Dr. John cleared his throat, and the younger doctors grew
silent. “I thought we reached a decision his morning,
all together, that Maria was to leave this afternoon. It was
established that this would be best for Maria and best for
the clinic. Maria now says she feels worse. This is just as
we might have predicted, considering her past performance
every time she’s been asked to move or to cooperate
with us. Unless we can put our finger on something specific
which demonstrates that she is in fact in worse condition,
I vote we abide by our earlier decision and move her out at
“David!” called Maria in a weak voice. “I
“What do you say?” asked Dr. John emphatically.
I looked down at my empty hands. I didn't have a reason.
I had a feeling. But you can't wire an E.K.G. machine to a
feeling. I thought of giving up and saying, “All right,
take her away.” But there was something inexplicable
inside me, like the voice of a child freshly wakened...
“I can’t give you any good reasons”, I
said awkwardly. “I just have a strong feeling that Maria
is on the edge of a crisis.”
“David!” called Maria again, in the same haunted
voice. I gestured to her that I was busy.
The doctors stared at me in silence. Finally Dr. John said,
“We must respect your judgement. However, if Maria is
to stay here, I think that for her good as well as ours we
should change our system of caring for her. We’ve been
suffocating her with attention. She doesn’t need three
doctors, five medics and four nursemaids. I think we should
appoint one person only to care for her, apart from her father
and the boy.”
Dr. Mike shook his head. “I agree with you 100%, but
darned if its gonna be me.”
“Well then who shall it be?” asked Dr. John,
looking from one to the other of us and mostly, I thought,
at me. I thought of the mountain of other work I had to do,
and said nothing.
“I'll be glad to do it”, said a voice from behind
us. We turned to look at Martin, who had come onto the porch
a few minutes before, and had been silently listening.
Everyone was relieved. “Good!” said Dr. John.
“But remember, Martin, it’s essential that we
wean Maria from the excessive attention she’s getting.
You'll want to follow a strict regimen with her. Take her
vital signs at regular intervals, see she gets her medicines,
and that’s about it.”
“But whatever you do”, added Dr. Robby, “Don't
fuss over her and make much of her complaints. It only precipitates
her coughing and hysterics and generally makes things worse.”
“David!” called Maria. “Help me!”
“I know that”, agreed Martin, and to show us
that he did, added, “We’ve spoiled her enough.”
“Then why don't you start now by walking her back to
her ward”, suggested the doctors. “It’s
high time we got on with something else.”
“Air!” gasped Maria.
“Walking her?” asked Martin dubiously.
“Certainly. And remember, you've got to be firm. Don't
let her talk you out of it.”
“Help me”, cried Maria in a weak voice.
We all nodded our agreement, even old Juan, though we had
been speaking in English and he could not have understood.
“I can’t ... breath ... any longer”, gasped
Benjamín, standing alone now beside his mother at
the head of the couch, fanned faithfully with his tattered
“Weren't you planning to conduct a class this afternoon?”
asked Dr. John, turning to Robby.
“I’d thought of presenting something on extreme
medical emergencies”, said the young surgeon.
“I tell you...”, whimpered Maria between gasps,
“I ... am ... dying.”
Dr. John turned to me for confirmation. “What do you
say we get the class started at once?
Martin can get Maria back to her room, and the fewer of us
who hang around kibitzing, the better.”
“Marvelous.” adjoined Ann, the lab tech whom
we had rescued out of the mud the night before. “On
with the class.”
“Sounds fine to me”, I said.
The rain had stopped and the sky was dappled with high harmless
clouds. The day was waning, so we decided to hold class in
the patio, where the afternoon light was better. Carrying
out benches and chairs, we put them in a circle. Twelve or
so of us assembled -- Mexicans and Americans, doctors, medics,
and lab techs. We all sat down except Robby. As he began the
class, over his shoulder, in the shadows of the porch, I could
see the dark shapes of Martin and old Juan trying to lift
Maria to her feet. As they did so, their voices became louder
and harsher. My mind strayed from the lecture.
First, Martin’s voice, “Come on, Maria. We can’t
Then old Juan, his voice trembling with anger, “I said
get to your feet, girl. Now do it.”
“In a life threatening situation”, proceeded Robby,
“it is imperative that one be able to recognized at
“I can't .... go on another .... step...” Maria
stood, supported by Martín and her father, at the top
of the stairs leading down from the porch into the patio.
Her breath was a succession of rapid, exhausted grunts.
Martín and her father half carried Maria down the
steps and began to guide her, stumbling, across the patio.
Benjamin, his tattered sombrero in his hand, remained at the
top of the steps, small and alone, watching uncomprehendingly.
When the strange triad reached the center of the patio, just
ten feet from our study circle, Maria was caught by a paroxysm
of coughing. The next moment she slumped to her knees in the
The lecturer continued, “The first thing you must be
sure to do is check...”
“Come on, Maria”, shouted Martin. “Up with
“Stand up, child”, commanded her father.
They hoisted her to her feet, only to have her sink again
to her knees.
At this moment Ramona, arriving later for the class, hurried
into the patio. She stopped in her tracks at what she saw,
and cried, “My God, Martin, what are you trying to do
to her? Poor Socorro! Can't you see she has shit all over
My eyes lowered to the yellow much on Maria’s legs.
This, for sure, was no act. I jumped to my feet and ran toward
her. The others followed.
Her breathing at first was irregular; short series of rapid,
strident gasps, separated by long ominous silences, as if
she were holding her breath. To our relief, the intervals
gradually grew shorter, until her breathing was again more
or less as it had been before. Weakly, she lifted her head,
looked searchingly about and gasped. “Air.” Her
father took off his sombrero and fanned her despondently.
Maria’s gown and legs were smeared with yellow diarrhea.
The newly arrived lab tech hurriedly brought a damp rag, and
dropping to her knees, scrubbed off a bit of excrement which
had soiled Martin’s pants cuff.
Suddenly our callowness hit me like a club. Here was Maria,
whom I had known as a proud and beautiful woman, reduced to
kneeling in her own excrement while a pack of gaping onlookers
milled about her, like flies around offal. I recalled how,
only a few days before, she had made Benjamín empty
the contents of her bedpan, embarrassed should we see it.
“Hey”, I urged, “Why don't all of us menfolk
get out of the way, and let the womenfolk help clean her up.”
I began walking to the porch.
“Talk about a male chauvinist pig”, chided the
new lab tech.
I pivoted and blurted out, “If I thought it would be
less humiliating for Maria, I would clean her up with my own
shirt. Can't we just for once think of her.” My anger
was out of proportion, and left the poor lab tech bewildered.
We menfolk had just reached the porch when one of the women
cried, “My God! I think she's stopped breathing.”
Swiftly, the medical team jumped into action. Dr. Robby ran
up with a plank and he and Dr. Mike rolled Maria onto it.
Dr. John began heart massage while Robby, holding her nose,
blew into her lungs after each five compressions of the chest.
“Adrenalin!” cried Dr. John, “and a three
inch 20 gauge needle!” When they were brought (the latter
took some tracking down), Dr. John counted down the right
number of ribs and thrust in the long needle. It bent. “Another
three inch needle”, he demanded. This proved harder
to find. Our volunteers tore open boxes looking for one, for
it is something we rarely use. “Hurry up with that needle!”
shouted Dr. John. Not finding the needle in the operating
room, I ran back through the patio, across the porch and into
the dispensary, where I remembered having seen a spinal anesthesia
kit in one of the drawers. Locating it, I ripped it open,
snatched up the needle, and ran back. In the doorway to the
porch I nearly collided with Benjamín, who stood clutching
the wooden door frame, sobbing hysterically.
As I ran down the steps, I thought to myself, “Another
child would have been simply baffled by the immediacy and
confusion of death, but not Benjamín, he knows the
scent.” And across my mind flashed once again the image
of his small form bounding along in the back of the Power
Wagon beside the stiffened body of his father last Christmas
As Dr. John thrust the needle into Maria’s silent heart,
I placed my hand on her damp forehead and whispered, so low
that only she might hear me. “Come back, Maria. Please
come back.” But she was gone.
Each of us, I am sure, knew it (the dogs inside our hearts
had begun to howl); yet none of us had the courage to face
up to it. The loss was too great, the implications too threatening.
So it was that our team continued to work on the body, thumping
at its silent heart and breathing into its vacant cage, for
a full ten minutes after its pupils had dilated and its skin
had turned to wax. Throughout our pointless heroics, Maria's
blank, unwavering eyes fixed challenging upon us, as if to
say, YOU WHO KNOW SO MUCH AND ARE SO SURE, WHO NOW IS THE
Benjamín, who had nothing to hide from -- nor behind
-- howled from the doorway as uncontrollably as a kicked puppy.
Finally ... we, too, admitted defeat. We carried Maria’s
body onto the porch, where a couple of elderly village women
dressed in black, who had materialized on the spot as mysteriously
as genies, began to bathe and change her. They dressed her
in a white gown which Ramona brought from her home across
the street. Meanwhile, Benjamín continued to sob inconsolably.
I stood back. Already, there were too many well-meaning and
disillusioned adults trying to force their way across the
no man’s land into that lonely naked world of the orphaned
child. Benjamín buried his face into the unyielding
door frame and shook off the hands that sought to comfort
him. Old Juan, standing as silent and rent as a lightning-
struck oak, looked mutely down at his big hands. Dr. John,
who would have felt awkward trying to comfort the boy, said
to me, “Oughtn't we to ask her father if we can do something...”
Interrupting, I blurted stupidly, “We ought to ask
I turned and stumbled into the darkroom, shutting the door
behind me. There I wept as I have not since my childhood.
My weeping, I know, was selfish. It wasn't so much Maria’s
death that wracked me -- her death was perhaps inevitable
-- it was the way she died. In her hour and moment of greatest
need, we had done it so stupidly! So complacently, so blindly!
How could we have let it happen? How could I have let it happen?
Well, it was done.
And the blood on our hands was no longer mortal; it was universal.
No, I wasn’t weeping for Maria, or even for Benjamín.
I was weeping for the death of something inside of me, something
I had believed in: the death of Kindness, the death of Love....
Slowly, as I crouched in the darkness, a new light began
to glimmer from the ashes of despair.
With a start, I realized that Kindness and Love had not died;
rather, they had been rekindled by Maria’s death; they
were in the throes of rebirth. What had died had been something
false and petty and obdurate within us, something which needed
to die, to be wrenched from our breasts so that Love and Kindness
could find more room in our lives. Unwillingly and unwittingly,
Maria had been the martyr to the cause of our knowing ourselves.
To this end, her untimely death could not have been better
timed. I shook my head in baffled and respectful amazement.
Strained voices reached my ear from outside the darkroom,
and I went out. Martin was sitting on the edge of the examining
couch, his moist face pressed into his hands. Dr. Robby and
Dr. Mike were standing beside him. Robby said, “Come
on now, Martin, it’s not your fault.”
“But I was shouting at her, dragging her, like an animal”,
“You were doing what you thought was right”, insisted
Martin shook his head. “No, I wasn't. I knew that wasn't
right. It's never right to be cruel. I can't understand what
came over me.”
“Maybe it’s truer to say”, said Dr. Mike,
turning to address Robby, “that Martin did what we thought
was right. After all, we set the example.”
Robby nodded slowly. “That's true, Martin. It was our
decision to be so strict with her. And to make her walk. Don't
“I know, I know”, said Martin. “But even
so, I should have known better.”
“We all should have known better”, said Robby.
“Don't reckon it’s ever too late to learn”,
said Dr. Mike.
Martin stared at his slender hands, and whispered, “Poor
We carried Maria’s body up the street to the house
where, earlier that same afternoon, we had intended to dispatch
her on foot. She was laid out on a burlap cot, decked with
bougainvillaea and dahlias, and the noisy wake began. I convinced
old Juan to let us take care of Benjamín for the meantime,
as I could see no advantage of having him sit through the
long night with a covey of wailing women; of tears, he had
already shed his share. The journalist took the boy to the
house of Martin's family, but unable to suppress his hysterical
sobbing by the end of two hours, brought him back to the clinic.
It was Martin who was finally able to bridge the gap to the
suffering boy. He simply took Benjamín by the hand
and led him to a cot in the back room, where he lay down beside
the boy and let him weep, not sympathizing, but just there.
When the child was at last empty of tears, they both got up
and went over to the typewriter. Benjamín had never
touched such a strange and many-buttoned thing, and his child’s
curiosity was sparked. Martin taught him how to peck out his
own name and, within a quarter hour, the boy was laughing.
It may have been hard on the typewriter, but it did wonders
for Benjamín .... and for Martin. Although the typewriter
was mine, I did not protest. It was high time a machine came
second to our feelings.
* * *
Maria’s death had a profound effect on all f us. It
stopped us in our tracks, forcing us to stand back and take
a sharp look at ourselves, what we are about and where we
are going. It pricked the bubble of our self-assurance and
left us all, I think, a little more humble. In the couple
of remaining days before the visiting team flew home, we had
many soul-searching discussions.
Dr. Robby, in one of these discussions, shook his head and
said something like this: “It's hard to believe we could
have been so blind. So callous. And on purpose! ... that's
the frightening part of it. We held at bay our natural urge
to give Maria the compassionate support she begged for and
we could have so easily given, because we were so set in our
opinions about what was best for her and the clinic. At the
end we were actually paying more attention to our decisions
than to Maria!”
Robby frowned self-consciously, “You know, I used to
take pride that in my brief career as a doctor I had never,
to the best of my knowledge, committed any technical errors.
Now, all of a sudden, I realize the biggest errors a doctor
can make aren't technical, but personal. It's so easy in modern
medicine, with its endless maze of techniques, technology
and technicalities, to lose sight of the patient altogether.
We tend to get hung up in the details of illness ... The science
of medicine endangers the art. Believe me, from now on I'm
going to listen a little more closely to what the patient
is trying to tell me, and show a little more genuine feeling.”
Dr. Robby knocked on the edge of the table on which he was
sitting. “At least, I hope so.”
The morning after Maria's death, Dr. Mike approached me where
I stood alone, to tell me how badly he felt about the way
things had been handled at the end. “I know we can’t
undo what’s done”, he said. “But I just
wanted to tell you, David, that I think all three of us M.D.s
are going to be one heck of a lot better doctors for what
happened to Maria. I know I will be.” He extended his
hand. "Well, I just wanted to say thanks."
“Thanks for what?” I asked him, taking his hand.
“I guess thanks for letting Lynne and myself come down.
I'm not sure if you guys wouldn't have done better without
us, but it's given me a whole new outlook on medicine, and
where I'm at...”
Dr. John, being older and wiser than the rest of us, kept
most of his ideas to himself, yet I could tell the event of
Maria’s death affected him deeply, perhaps more deeply
than any of us. Preferring actions to words, he quietly took
up a collection to pay for the simple wood coffin which was
prepared for Maria. This meant a lot to old Juan, for it showed
him that we shared some of his feeling. One post-Maria comment
by Dr. John has stuck with me: “When a patient says,
“I'm dying”, assume he’s right.”
Martin was unable to talk dispassionately of Maria's death
for several days, but one morning, after the doctors had flown
home, he said to me, “I've been thinking, David, if
we'd been alone here in the clinic, I mean with our usual
group of medics and apprentices only. Maria might have died,
but not like she did. Because we're not doctors, I guess we're
not so sure of what we're doing. You know what I mean? We're
forced to rely a little more on our feelings. We would have
had to listen more to Maria and what she said her needs were,
because we wouldn't have had quite so much trust in our own
judgement. I know we aren't as highly skilled, and probably
we wouldn't have practiced as good medicine. But for Maria,
even the best medicine didn't work. Maybe kindness would have....”
“One thing I learned”, continued Martin, “is
that doctors are just people like the rest of us. And you
know something else I've learned?...”
“What?” I asked.
“That I should do what I feel in my heart is right.
I knew I shouldn’t have treated Maria like that.”
“I knew I shouldn't either”, I said. “Martin,
I think we learned the same thing. How did you put it?”
“To do what I feet in my heart is right.'
* * *
As for Benjamín, he must have learned something too,
although I hesitate to think what. I suppose he learned that
the behavior of adults is incomprehensible. But then he knew
that already. In his philosophic way, he seems to be as understanding
of our hardhearted treatment of his mother, as he was of his
mother’s unfair treatment of himself.
One thing that Benjamín has learned since his mother’s
death is that adults, at least in retrospect, can be kind.
Martin has taken him to live with his own family and is like
a father to him, although more gentle. Charlotte, the journalist,
periodically sends him clothing, as well as funds to help
with his living and educational expenses. Dr. Robby has made
possible a cow, so that the youngster can have milk to drink.
Short of a mother and father, what more can a small boy ask?
Old Juan would have answered, “Beans.”
-- 0 --
Note: The above story, "What we learned
from Maria," was the main article from "Newsletter
from the Sierra Madre" # 10, April, 1975. The
articles in the first half of the seminal newsletter can
be found in the paper, "Primary Health Care and the
Temptation of Excellence."