AND THE TEMPTATION
“No hay bien sin pero ni mal sin gracia.”
(There's nothing good without a drawback
nor bad without some saving grace.)
--an old Spanish saying
For better and for worse, the Ajoya Clinic has come a long
way since 1965, when it began as a few boxes of medicines
and bandages on the front porch of the casa of blind Ramon,
and its staff was no more than an ex-schoolteacher trying
hard to play medic, assisted by a handful of over-eager village
children. Then, to be sure, we had a strong sense of community
-- sometimes too strong -- for we shared the open porch with
dogs, chickens, pigs, cockroaches, a pile of pumpkins, a corn
crib, a small table at which we ate in shifts; and five cots
which at night were unfolded to sleep eight of the household
Today La Clinica de Ajoya occupies a large old adobe casa
in mid-village. Although once a fine home, when we took it
over in 1970 the place was in ruins. The roof was a sieve,
the walls eroded and collapsing. It had been boarded up for
five years, ever since the ancient widow who owned it died,
and it was infested with bats, rats, fleas, pigeons, spiders
and -- according to rumor -- ghosts.
We cleaned, patched and white-washed the old building as
best we could, and to this day wage a never ending battle
to keep it comparatively sanitary and vermin free. The village
women cooperate by sponsoring a chore lady who daily scrubs,
dusts, disposes of trash and steps on scuttling critters.
But an old adobe house, like a small boy, blithely parries
every attempt at cleanliness. It has too many secret niches.
By day, things appear relatively kempt and under control,
yet at night cucarachas materialize out of the walls to explore
the medicine bottles, rats scamper and skirmish on the eaves,
bats flutter through the patient wards, and an occasional
scorpion steals up a cot leg to cuddle in the warm bedding
of a patient or volunteer. We are still not a high class medical
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
During the past few months, our biggest step forward has
been to equip and get into operation a tolerably functional
clinical lab. Many people have helped donate or scrounge supplies
for it, so that we now have a fair range of equipment including
two fine microscopes, scales, a macro and a micro centrifuge,
and a simple but ingenious incubator for culturing bacteria.
(This last item consists of a styrofoam box through which
runs an exhaust pipe from our small propane refrigerator.
The pipe has a thermostatic shutter valve, so that a constant
temperature can be maintained in the box.) The incubator was
contrived by the husband of a visiting medical technician.
Three technicians have made separate trips to Ajoya to help
set up our lab and train our health workers to use it. During
their short visits the volunteer lab techs have focused on
training Kerry Travers , who has a degree in microbiology
and therefore a head start. Kerry, in turn, has been training
Ramona Alarcon, the granddaughter of the village blacksmith,
(who presented me with a white rooster when I first opened
the dispensary in Ajoya 10 years ago). Ramona, after six months
apprenticeship, is now able on her own to do many basic tests;
to prepare, stain and examine slides of urine, feces, blood
and wound exudates, to seed culture plates, and to identify
common forms of bacteria and intestinal parasites. Our new
lab service has greatly increased our diagnostic capabilities.
Hats off to Ramona, to Kerry, and to our visiting medical
* * *
All in all, the Clinic of Ajoya is not only far better situated
than it was a few years back, but the type of medicine we
manage to practice -- while still relatively primitive by
U.S. criteria -- has become increasingly advanced. Our village
apprentices, have gained more experience, our American volunteers
are better trained, our range of equipment is more extensive
and our laboratory facilities are enormously improved. In
short, one might say we practice ‘better’ medicine.
But, is it really better medicine?
Yes and no. In terms of the widely accepted standards of
Western Medicine, definitely yes. In terms of realistically
getting at the root of the health problems in the mountain
villages we intend to serve, perhaps no.
As we all know, Western Medicine has tended to pay far more
homage to Panacea, the Goddess of Healing, than to Hygeia,
the Goddess of Health. It has poured a vast amount of money,
training, research and prestige into the treatment of illness,
yet a proportionately trifling amount into its prevention
which logically and pragmatically should come first, The reason
is simple: it is the sick who holler loudest. And of the sick,
those who can pay most are often the most readily heard.
Over the past 40 years or so, the Science of Healing has
made extraordinary advances. The discovery of antibiotics,
the introduction of transfusions and transplants, the proliferation
of devices for testing, monitoring, measuring and you name
it, have taken the sting out of many illness and prolonged
life for many who can afford it. Yet the fact remains: on
this Earth today, there are numerically more persons lacking
even rudimentary health care than ever before in human history.
And every day the number of such persons is growing.
Ever since the days of Hippocrates, the sworn intention of
the Medical Profession has been to serve the people; not just
those who can afford it, but those whose need is greatest.
Yet today's Medicine's very excellence and exclusiveness,
with increasingly high standards, elaborate technology and
exhaustive training, have pushed cost and availability far
beyond the reach of the common people, and perhaps beyond
It is time that the Medical World went less in the direction
of ‘excellence’, which can only be for the few,
and strove more toward ‘adequacy’ for the many.
This requires lowering our standards; or, more accurately,
lowering our standards for technology and training, and raising
our standards for foresight, magnanimity and common sense.
This won't be easy. I can testify from my personal attempts.
Clearly, the chief concern of a primary care center should
not be sickness, but health. Our original intention at the
Ajoya Clinic was to provide primary care only and to concentrate
our major efforts on broad-scale campaigns of preventative
measures and public health, for we realize that only in this
way will we ever make any significant or lasting inroad on
the overall health of the community.
By no means have we neglected preventive measures completely.
As those who have been following our activities will know,
we have plunged into programs of vaccination, family planning,
pure water systems, experimental crops, food cooperatives,
corn banks, health education, medical self-help (including
my villager's medical handbook, Donde No Hay Doctor as well
as conservation of game, fish, timber, beauty, etc.
But for all these sundry programs in community health and
preventive medicine, the trend at the Ajoya Clinic has been
to become increasingly embroiled in the curative side of medicine.
The temptation of excellence has been too strong for us to
resist. It is only natural that one likes to provide the ‘best’
medicine to those who clamor for and appreciate it the most,
namely the sick. And so we have brought in X-ray and E.K.G.
machines, centrifuges and microscopes, built an operating
room, expanded our clinical library, picked the brains of
visiting doctors, and done everything in our admittedly limited
power to upgrade the scope and quality of our diagnostic and
curative services. In short, we have come a long way from
the primary care center we once set out to be.
“But, what's wrong with taking better care of the sick?”
you may ask. What is wrong is that we have put ourselves on
the map. In Sinaloa and beyond, we have gained a certain ‘fame’
for being able to cure difficult and heretofore incurable
ailments. This fame is, of course, unwarranted; the fact being
that in 90% of our more awe-inspiring successes, the difficulty
which has made the illness in effect ‘incurable’
has been economic. Our medicines work wonders simply because
for once, they are within the reach of the people. Yet, however
undeserved our success, the word is out. More and more patients
flood in from farther and farther away. Some have already
sought medical help elsewhere, and come in with obscure or
recalcitrant maladies which we are often at our wits' end
to figure out. Patients come from the slums of Mazatlán
and from as far away as Hermosillo, Tepic and the arahumara
territory of Chihuahua. Nearly all are indigent. Some we can
help, some we cannot; some we refer to doctors we know in
the coastal cities who are conscientious and may even give
them a break; and a few -- especially children with correctable
deformities -- we bring to California for treatment at Stanford,
the Shriners Hospital for Crippled Children, or elsewhere.
True, all this fills a great -- in fact, an endless -- need,
but not the need we set out to fill. This kind of stop-gap,
helter-skelter, cure service is all right for a start; it
helps limit the suffering of an ever-lengthening queue of
sick individuals; but it makes no headway, gains no ground.
On the contrary, the continual flood of ‘outside’
patients has put a tremendous drain on the time and energy
we would like to be putting into long-range community health
and preventive measures in the mountain villages we came to
serve. We have tricked ourselves into plugging so many leaks
with our fingers, we don't have enough free hands left to
build a better dike. Contrary to our stated intentions, we
have focused on sickness, not health.
We have tried to resolve this dilemma in several ways, none
fully successful. We have even made feeble efforts at refusing
service to ‘outsiders’, especially those who come
from areas where there are doctors or health centers. But
we find that many patients have made long journeys, often
at great sacrifice, because they are too poor to get the medical
help they need elsewhere. They arrive with their hopes high
and their pockets empty. In theory one can turn such persons
away. Not in fact.
Soooo, what do we do?
"Simplify!" is the proposal of Mark Lallemont,
a young doctor from Paris who spent three months helping at
our clinics last summer.
Unlike many of our visiting doctors, who are either frustrated
or charmed (or both) by the relative primitiveness of the
Ajoya Clinic, Mark insists that the level of medicine we practice
is ‘très sophistiqué’. He thinks
we should limit our services to those which villagers can
learn to handle for themselves and can duplicate in other
villagers up the line. He is adamant that we focus on stopping
sickness before it starts.
But sophistication, like crab grass, is easier to come by
than get rid of “How”, I asked Mark, “do
you suggest we ‘simplify’?”
“First of all”, replied the French doctor, “throw
away some of your fancy equipment -- the E.K.G. machine, for
“But it's a useful tool!” I protested. “What
do we do when we've got a patient with a baffling heart problem?”
“Admit you're baffled”, replied Mark. “Be
kind, be supportive, and let Mother Nature or the Great Reaper
determine the course. They will anyway, regardless of whether
you monitor the poor guy's heartbeat. If you have an E.K.G.
machine you're automatically relegated to tinkering with outdated
hearts when what you want to be doing is digging latrines,
improving crops and deworming kiddies.”
“Any other suggestions?” I asked.
“Yes”, said the French doctor. “Get rid
of 9/10 of your medicines. The fewer kinds of medicines you
have, the more people you'll reach with them and the easier
you can teach the people to use them correctly. You can make
do with 10 or 12 basic drugs. This, of course, means you'll
be treating mostly the commoner ailments. But that's fine.
If you limit yourself to primary care you'll have more time
to devote to hygiene, nutrition, birth control, vaccination
and all the other things which in the long run make for less
sickness all the way around.”
“That sounds great”, I agreed. “But when
someone suffers from a not-so-common illness we could readily
treat, it'd seem a shame not to lend a hand, just because
we'd thrown away the specific medicine he needs. Suppose,
for instance, a leper comes in, as happens now and then. Do
we tell him, “Sorry, not today.”?”
“Leprosy's hard to cure anyway”, said Mark. “It
“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?”
“If they can afford it. And if they'll go”, I
said. “But we can get the sulfones they need much cheaper
“Hmmm”, conceded Mark. “In that case perhaps
you should include a sulfone on your list of basic drugs.”
“We've already included it”, I assured him, “along
with a whole drove of other medicines which make a big difference
in this or that patient's life. That's why 'things just ain't
simple...Believe me, Mark, our line of reasoning is pretty
much the same. I'd love to put most of my time into preventing
sickness instead of treating it. But theory's one thing and
life's another. And when a patient who's deathly ill comes
to you because he believes you'll do your damnedest to help
him, by Jesus you do your damnedest to help him, all your
theories about preventive medicine and keeping things simple
“True!” said Mark. “And that's precisely
why you should have only 12 basic drugs and get rid of some
of your fancy equipment; so you won't be seduced away from
the work which in the long run will help people most.”
“Thirteen basic drugs”, I corrected him. “You
just added a sulfone, remember?”
Mark laughed. “Okay! Okay! I get your point!”
and added with a sigh, “Things just ain't simple ...
but Mon Dieu, they should be!”
* * *
Since the above discussion with Mark last September, we have
tried in a number of ways to move increasingly in the direction
of primary care and preventive medicine. Yet we have more
or less resigned ourselves to the fact that the Ajoya Clinic
is, ipso facto, a treatment center. Rather than try to change
this state of affairs, we have determined to use it in every
way possible to promote preventive measures and better overall
To this end, we have set about turning the Ajoya Clinic into
a school. To some extent, of course, it has long been one.
For ten years we have been training local village youths,
on an apprenticeship basis, to function as medics and dentics,
both in the Ajoya Clinic and in our medical outposts (now
four). We have also training programs, both in Ajoya and California,
for our young American volunteers, who range from pre-med
students to high school and college dropouts. In fact, the
continuity of medical and dental care in our health centers
is provided by the work force made up of these conscientious
young amateurs and apprentices, both Mexican and Gringo. The
primary role of visiting doctors and dentists, when we are
fortunate enough to have them, has not been so much to practice
their respective skills, but to teach. We have long felt it
is the doctor's responsibility to assist the auxiliary, not
vice versa, and that it is the auxiliary's job to assist --
and teach -- the patient.
Our latest effort, then, has been to expand our teaching
program in the direction of primary care and public health.
One of our most important adjuncts at the Ajoya Clinic has
been to train ‘health promoters’ from isolated
A village health center should first and foremost be a school.
* * *
THE AJOYA SCHOOL QF BOONDOCK MEDICINE
On his first quiz Mencho scored only 19%, but it didn't upset
him much. For Mencho, at 57, has remained as innocent of percentiles
as schooling. Until this last December, when he joined our
new training program for village ‘promoters of health’,
he had never been to school a day in his life. Yet in his
youth he had somehow taught himself to read and write.
Mencho is from Jocuixtita, a long-defunct mining village
crouched far back in the ‘barrancas’ or wild ravine
country of the Sierra Madres 30 kilometers by muleback from
our central clinic of Ajoya. From age six until his early
forties, Mencho worked as a farmer, sowing with a planting
stick small clearings hacked out of the jutting Mountainside
above his village. At age 42, Mencho's life abruptly changed,
One stormy evening after he had returned home from weeding
his high fields, a band of ‘Federales’ burst into
his adobe hut and accused him of having given shelter to Tino
Nevarez. (Tino Nevarez is the hero of many a folk song and
legend today because he was a sort of Billy the Kid or Robin
Hood of the Sierra Madre, who reputedly stole from the rich
and gave to the poor. In the huge manhunt for the wily and
elusive thief, the baffled soldiers tried to starve him out
of hiding by brutalizing anyone suspected of lodging or feeding
him. In this way, according to legend, they killed more than
100 innocent persons). When Mencho denied having hosted the
celebrated bandit, the soldiers threw him onto the earth floor
and jabbed him so hard with their rifles, they permanently
injured his spine. Unable from that day forward to work his
steep cornfields, Mencho looked for other means of supporting
his wife and hungry children. He began to shuttle ‘wonder
drugs’ and knickknacks from the distant coastal cities,
transporting them on burro-back to peddle in the villages
of the barrancas. It was only natural that he prescribe and
administer the medicines he brought, and in time he became
highly regarded as the local medicine man. For know-how, he
depended on the Good Lord and Good Luck, applying with a less-than-sterile
syringe and blunt needle either penicillin, liver extract,
or both for virtually every malady. He had no training and
no resource material. In fact, the first book of medicine
he ever laid hands on was a copy of my villagers’ medical
handbook, Donde No Hay Doctor, which I gave him a year ago.
For Mencho, the handbook was the doorway into a new and challenging
world. When, last Fall he learned that at the Ajoya Clinic
we were offering a two month training program for village
paramedics, he jumped at the chance.
* * *
The purpose of our new training program for ‘Promotores
de Salud’ is to disperse primary health care over a
wider area. Thus we give settlements beyond reach of our immediate
services the chance to select persons from their own communities
for study at our central clinic. On returning to their villages,
they are able to set up health stations and serve their fellow
campesinos by providing simple treatment, vaccinations, programs
for better hygiene and diet, health education and family planning.
To encourage reciprocal responsibility between ‘promoter’
and village, each village is asked to come up with half of
a modest scholarship or living allowance for their trainee
while in Ajoya. Our Project provides the other half.
* * *
In late November, two weeks before the training program was
to begin, I set out on a dash excursion of more than 200 km
on muleback through the remote barrancas of Sinaloa and Durango,
to do final recruiting for the course and announce the starting
date. As it happened, this expedition nearly cost me my life,
and did cost that of my personal mule, La Coloradita. Climbing
a narrow, treacherous stretch of trail into the high sierra,
my mule's hind hooves unexpectedly slipped on the decaying
granite and she fell on her belly, half off the trail. For
a brief moment she teetered on the brink, her hind quarters
dangling in space. In that moment I was able to carefully
but quickly dismount. I scrambled up ahead of the wide-eyed
mule, and pulling hard on her halter rope, tried to help her
back onto the trail. She made a courageous lunge, and slipped
again. The rope burned through my hands as she kneeled over
backward, pawing at the air, and plummeted 200 feet to her
death. After salvaging what there was to salvage (the saddle
was smashed to smithereens) I hiked back to the nearest rancho,
my saddlebags over my shoulders, my hands badly blistered;
yet I hurt most for the loss of my valiant companion. I managed
to borrow another mule for the continuation of my journey.
* * *
The training program began on December 10th as scheduled.
The 12 students made up a heterogeneous but rambunctious crew.
They ranged from 14 to 57 years old and had from zero to eight
years of schooling. The average age was 23; the average education,
3rd grade. Mencho was the oldest and had the least schooling.
The youngest was Nando, a 14-year-old lad on crutches who,
having come to Ajoya from a distant rancho for treatment of
chronic osteomyelitis, had decided to stay for the course.
One of our best students was Leandra, a jovial 33-year-old-mother
of six. Although she had completed only the 4th grade herself,
she had been serving her remote village (Caballo de Arriba,
60 km by mule trail from Ajoya) as both schoolmarm and folk
healer. Perfect qualifications for a village ‘promotor
One of our most earthy and energetic students regretfully
dropped out after only two weeks. This was Doña Goya,
a stout-hearted middle-aged midwife from Carrisal, an hour’s
walk from Ajoya. It turned out that her young husband –
who is as unreasonable when drunk as he is irrational when
sober, which is rarely – opposed her taking part in
the course and beat her as often as he learned she had attended.
Stoically Doña Goya endured the beatings, arriving
each day with new bruises; but when her man took to mistreating
her 11-year-old son by previous union (one day he hung the
boy briefly by the neck), she stopped coming. When we asked
her why she didn’t simply leave her insufferable consort,
whom she supports, she answered laconically, “he’ll
kill me … and besides, I like him.” Sua cique
Another of our trainees was Roberto, a youth from Campanillas,
about 16 km northwest of Ajoya. Like Nando, Roberto first
came to us as a patient. Four years ago he was carried into
Ajoya on a stretcher, severely emaciated and totally crippled
by juvenile rheumatoid arthritis. Previously he had been taken
for treatment to the coastal cities, where the last doctor
to see him had told his grandparents that if he didn’t
get better with the final course of medicine, his case was
hopeless. To this day Roberto vividly remembers the chill
January night when his grandmother took off of him the one
blanket to put it over the other children, since ‘he
was going to die anyway’. As the wasted boy huddled
shivering in the darkness, he made up his mind that if he
survived that one night he would somehow manage to get better…
At the Ajoya Clinic, with the help of courage and corticosteroids,
Roberto in fact began to improve. When he was able to use
crutches, we began to give him jobs around the clinic. Today,
although some of the joints in his hands and feet are irreversibly
fused, Roberto not only walks without a limp, but also does
a good job pulling teeth. For the last three years he has
worked with us as an apprentice dentic and as keeper of the
clinic mules. He joined out new training program with the
idea of serving his native village as a ‘promotor de
salud’, and already makes calls there. His first love,
however is for animals.
Our teaching staff for the new training program was every
bit as motley as our coterie of trainees. The brunt of the
teaching was done by Mike Travers and myself, both of us former
high school teachers of sorts. A couple of other American
volunteers also presented some classes and so did Martin Reyes,
our chief village medic. Miguel Angel Alvarez, our youngest
village dentist, trained some of our promoters how to pull
teeth and tutored others, like Mencho, in simple math. Ramona
Alarcón, our village apprentice lab tech, taught the
trainees how to measure the hemoglobin content of the blood
and how to do simple urinalysis and other basic tests.
As the textbook for the course, we used Donde No Hay Doctor.
One objective we had was to help the students learn to use
the book effectively. Emphasis was put not on memorization,
but on how to look things up. We also stressed the ‘importance
of uncertainty’, of never saying “I know”,
but only “I suspect”, for in folk medicine, like
politics, there is a dangerous tendency to come up with answers
before questions. In our class discussions we covered the
pros and cons of folk remedies, as well as the proper use
and misuse of modern medicines popularly used as cure-alls.
In general, we tried to de-emphasize the use of medicines,
especially injectables, and to focus on supportive care and
preventive medicines. We encouraged the promotores to use
every occasion of sickness or injury as a chance to teach
the patient and his family the preventive measures necessary
to avoid the return or spread of the particular ailment.
To bring home the fact that a good medic must first be a
good teacher, we not only encouraged the trainees to teach
each other, but arranged for them to give classes to the Ajoya
school children on topics of personal hygiene, how to avoid
intestinal worms, etc. In addition, our future ‘promotores’
helped the school children set up public garbage pits, and
led them three afternoons a week in pandemonious clean-up
brigades, the outcome of which has been to make Ajoya a far
more attractive and slightly more sanitary village.
One concept we tried hardest to get across -- largely, I
hope, by example -- is that medicine and health care should
primarily be seen not as a business, but a service. The village
medic is of course entitled to modest remuneration, but one's
chief satisfaction should come from giving, not taking. Above
all, we tried to impress on the trainees that the health worker
should be kind. We should try to put ourselves in the patient's
sandals. We should look first at the person, and take interest
in the person's life, family, background, joys and fears.
Finally, the medic should admit openly his or her limitations,
and “Do no harm!”
The brunt of the students' training took place not in the
‘classroom’ (actually an old attic over the bakery
and blacksmith shop) but in the clinic, where from the first
day they began to soak and dress wounds, practice suturing
on fetal pigs, provide simple nursing care, and sit in on
patient consultations. In the second week, the trainees began
to consult and examine patients under the supervision of our
more experienced paramedics Thus each consultation became
a learning/teaching opportunity for paramedic, trainee and
In these three-way learning sessions, conducted as of necessity
in the simplest possible language, it was interesting to note
how many patients, far from taking offense at having their
problems used for teaching, expressed appreciation at being
included. Several patients who had formerly sought medical
help elsewhere commented with relief that this was the first
time they came away with an inkling as to what their malady
was all about. Even when an illness is grave or incurable,
we have found that most patients find it less frightening
to be given some insight into their problem than to be left
completely in the dark. Of course, medics must feel their
way with each patient.
* * *
On the final quiz of the course, Mencho scored 64%, still
-. like Einstein -- at the bottom of his class. Fortunately,
we'd had the chance from the very beginning to appreciate
Mencho in the practical as well as the academic setting. If
in the classroom he proved the dunce, in the clinic we soon
realized he was special. He has a certain ‘touch’
with patients which I believe, comes less from being brilliant
than from being humble. He is above no one, approaching each
patient as a peer and equal. Being himself rustic and a farmer,
his interest in the daily lives of his patients is not ‘professional’
but real, and campesinos -- like patients anywhere -- are
quick to sense the difference. He gains their confidence and
cooperation because they feel he cares. Patients often ‘open
up’ to Mencho who won't to other medics or visiting
doctors. He has a way of gently drawing out the true problems
which hide behind the apparent ones. Above all, Mencho is
unhurried. No patient is too dull, nor problem too trivial
not to claim his warmest sympathy and undivided attention.
As a result, whether or not Mencho is able to do anything
medically for a given patient, the patient almost invariably
comes away feeling better. And that's what the art of medicine
is all about. (The science, of course, is another matter.)
Still and all, Mencho had great difficulty with some of the
classroom work, especially the math. One afternoon he stayed
behind to get special help on calculating doses of medicine
according to patient weight. After much repetition he was
still perplexed. At one point he shook his head wistfully
and said, “Why waste your time on me, David? It's pointless
putting new shoes on a worthless old mule.”
“Mencho!” I asked him sharply, “Do you
know what you're worth?”
“About so much”, he replied, grinning sheepishly.
“Look here”, I cried, “You're worth more
to your own people than all the doctors in Mexico, or for
that matter in America or the whole Earth!”
Mencho blinked at me, “How many doctors are there in
your neck of the barrancas, up there around Jocuixtita?”
“Why you know there aren't any”, he replied mildly,
“It's too remote. The people are too poor.”
“That's exactly what I mean”, I said.
"I still don't follow you”, said Mencho with an
embarrassed smile, “but if you don't mind, let's get
back to those doses. I reckon I've just about got the hang
THE NEEDLE, THE SPOON
I would like to relate to you now an event which Mark, the
young French doctor, experienced in the Ajoya Clinic, and
subsequently related to me. Of all his arguments for a simpler
approach to medicine, this episode, I think, is the most convincing.
Not uncommonly, visiting doctors or medical students have
felt stymied medically because they have been at a loss culturally.
For example, the patient may simply not permit a pelvic or
rectal exam which might be important for diagnosis, or may
interrupt a critical course of treatment because of some taboo,
or switch to an old folk remedy. As Mark makes clear, there
are times when the village-born paramedic, who knows only
too well the strengths and foibles of his or her neighbors,
can handle certain health problems more effectively than the
medical professional who, despite all technical skill and
good will, remains a stranger.
“Have I ever told you about how Martin saved the life
of a baby after I had failed?” Mark asked me.
“No”, I said “How?”
(Martin, for those of you who don't know him, is our village
medic. Now 24, he first began helping at the Ajoya Clinic
when he was 14. We sponsored him through secondary school,
including two years in California and three in San Ignacio,
and later helped arrange for him to study for a part of two
years as a ‘contaminant’ (unofficial student)
in a unique practical medical training program conducted by
Dr. Carlos Biro in Netzhualcoyotl, the huge slum metropolis
outside of Mexico City. Today, Martin is the mainstay and
‘coordinator’ of our Ajoya Clinic. Although at
one time he had his heart set on becoming a doctor, he is
now strongly dedicated to his less impressive but more progressive
role as a pioneer in village paramedicine.)
"It was a Sunday morning in the middle of the rainy
season”, began the young doctor, "and unbelievably
hot. Being Sunday, the Clinic was supposed to be closed except
for emergencies. But this young couple showed up with a sick
baby, about a year old. They said his name was Filiberto and
he'd had diarrhea and vomiting for three days running. Well,
it was, in fact, an emergency; the poor infant was dangerously
dehydrated. His eyes were sunken and dry, and his skin was
all shriveled like an old man's. They said he hadn't peed
since the day before. I explained to the parents that the
baby needed intravenous solution right away. The father got
anxious and said he thought the baby was too weak too resist
it. For some reason, his misdirected concern annoyed me. “Resist
it!” I hollered, “It's the one chance we've got
to pull the baby through!” He said, “Oh.”
So we took little Filiberto to a back room and I began to
hook up an I.V. The mother and father helped hold him while
I tried to get the needle into a vein. I tried every lousy
vein in his thin little arms and his scalp, but no luck. You
know how hard it is with a baby, and dehydrated at that. Believe
me, I was sweating it. And so were his poor parents. They
kept begging me to stop hurting him, and just give up. The
mother started to cry, which made me all the more nervous.
I realized that if I didn't get some fluid into the baby's
veins quickly, he was going to die. And for all I knew, his
parents would blame me.” The French doctor smiled nervously.
“I tell you, I was damn scared! In a big hospital it's
different. You don't have the parents as your assistants.
You're not put on the spot in the same way; you're more insulated;
you've got nurses, consultants, anesthetists and tons of equipment;
you can avoid getting so close ... You know what I mean?”
“I decided my only chance of getting into a vein was
to do a cutdown.” Mark continued. "I brought in
gloves, forceps and a scalpel from the surgery room, and began
to prop the child's ankle. Before cutting, I explained carefully
what I was about to do and why. But the mother suddenly cried,
No! that her baby suffered enough already. I tried to argue
with her, insisting that if we didn't get in the needle the
child would die. Instead of replying, she snatched up her
baby and ran out or the Clinic. The father, before he followed
her out, turned to me and said, “Thanks, in any case.
I guess we brought him too late.” “Wait!”
I protested. “The baby can still be saved!” ...However,
they were on their way.”
The young doctor made a frustrated gesture, and went on.
“I felt angry and foolish. I thought of getting a court
order, or some such, until I remembered where I was. So I
went to talk to Martin, who had come in with another patient
a few minutes before. On hearing what had happened, Martin
ran out of the Clinic to look for the parents and the baby.”
“Well”, Mark gave a long sigh, “it was
the next morning before Martin showed up again. His eyes were
all red and he was looking weary. “Is the baby dead
yet?” I asked him.
"Not at all”, Martin said with a big smile. “He's
still got the runs, but he looks a whole lot better. He's
not dehydrated now. He's begun to piss and shed tears.”
I couldn't believe my ears. “You did a cutdown?”
I asked him.
Martin shook his head. “No, I spoon fed him water.”
"But didn't he just vomit it up?' I asked him.
"Oh, yes”, Martin said sleepily. “But every
time he vomited, I gave him more. I gave him one spoonful
of water with sugar and salt in it every 3 or 4 minutes all
afternoon and all night long.”
"All night long?”
"All night long. I learned a long time ago that when
it's a matter of life and death you can't chance leaving it
to the parents, no matter how carefully you instruct them.
They either give too little or too much. You've got to do
The French doctor paused and spread wide his expressive hands,
"Voilà! So there you have it."
“The baby survived?” I asked.
“Yes” said Mark. “Thanks to Martin and
his patience and understanding.” He grinned at me. “So
your village paramedic has taught me something I never learned
in med school. As a matter of fact, he taught me a lot.”
WHAT WE LEARNED FROM MARIA
"Men are cruel, but man is kind.'
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 answer, “Beans.”