As my regular readers know, my former partner and longtime friend, Dr. Michael Polifka, now works as a medical missionary in developing countries. From time to time, I post updates from him that I get by e-mail. Here is the first of two posts about his trip to Guatemala this past April and a return in October.
San Cristobal, Alta Verapas, Guatemala
6 April 09
The rainy season is about to begin here in the central mountains. It is wet most of the year with mist that mutes the green of everything. But the sun is bright and the flowering bushes around the aged wood planked homes, the early corn in the fields and the vague outline of the peaks instantly reorients me. I am working with Roberto and Maria two locals who are associate nurses and are the primary care providers in this region of a dozen communities of Pocomchi Maya where roads access less than half of them. Some days we will see patients in the two room rural health center, others we will hike with back packs full of medicine from one to two hours and run the clinic in the community.
On the first day in Providencia, a community of 850 families we see about 50 patients, almost all with chronic medical problems, either not diagnosed or untended for more than five years. In the morning there is a man with symptomatic heart disease, another who has had a stroke, and one with dangerously high blood pressure. Next is a middle aged woman with severe emphysema from cooking fire smoke in her house, followed by a thirty year old in earlier stage of disease, and then a young mother with a 6-year-old, profoundly retarded child and another at home looks to me for a miracle…I obviously have none. The last patient of the morning is a 22 year old with disfiguring oral tumor that has been noticeable for at least a year and is now starting to cause problems swallowing. The afternoon is pretty much the same. I start treatment for those that I can, advise some simple changes at home when appropriate, offer to make a referral for those whose treatment is way beyond what I can do (none accept), and advise that they are doing the best they can already when nothing more can be done. Each patient leaves expressing in one way or another that they are grateful that I came. At the end of the day, walking out on the narrow, tropical flowered lined path, it was crystal clear to me that I was exactly where I should have been at that moment. A week later, haunted by the events that unfold, I would question that.
The second week’s work seems framed by two patients, David and Abeleno.
After Monday’s community clinic in San Sebastian and a pleasant 45 minute hike back to the road, there was plenty of time to visit an old man who was sick in his home. The mist outside of his dirt floored home previewed the eerie scene inside. Without windows the only light inside came through the cracks of the hand hewn wood slats that made up the walls. Smoke wafted in from the adjoining kitchen’s cooking fire. The moaning in the corner bed led me to the patient in the bed in the corner who was shaking with rigors. Abeleno, appearing fully fifteen years older than the 65 years noted on his crumpled ID card, had been increasingly ill for at least a week. Initially he probably had pneumonia but refused to come to the rural health center, now he was obviously septic. After examining him, I advised him and the ten family member audience that even with the most aggressive treatment that I had, he very well might not survive the week. No doubt out of fear, their decision was not unanimous but as the old man agreed to treatment, I gave him a dose of IV fluids and medications. I made arrangements for him to have additional doses of medicines for the next few days and told him that I would return in three days though I well knew he might succumb to his illness.
Upon returning to my room in San Cristobal, Glenda, one of the translators (from Pocomchi to Spanish) brought her two year old son to see me for a second opinion about his condition. David had been frequently ill since his birth and had been recently been put on another antibiotic for ‘tonsillitis.’ David is not particularly small compared to other Mayan children and for his age is remarkably engaging; the kind that smiles as adults irresistibly tussle his thick jet black hair. I sat on a bench in the shade outside my room with and examined him as he sat on my lap; it is immediately clear that he has significant asthmatic bronchitis and was on the wrong treatment. I changed his treatment to three medicines, appropriate for his condition, and asked his mother to bring him back to me in a few days feeling certain that he would likely be profoundly better. The next three days went by as they had the first week.
Thursday morning as Roberto was making his presentation about a patient that we were seeing together at the community clinic in Pamuc, Nicholas, our driver, came in to say that just heard from the town that David had suddenly died that morning. The rest of the day focusing on patients took all of my professional discipline; teaching the nurses was impossible. On the way out of town we stopped to see Abeleno who in spite of my pessimistic but realistic expectation was making a turnaround from his deadly course and was now likely to make a full recovery; but my mind was on the little boy. For the hour drive back down the mountains my mind raced over and over the smallest details of my interaction with him. What had I done, what had I not done, what did I miss….?
That evening at the wake in the family home there were dozens of Maya in traditional dress, weeping, consoling each other, as coffee and bread was brought around. As I was introduced to one then another family member, I couldn’t help feel responsible (my sentiment not theirs) for the child’s death, though intellectually I knew differently, considering the profound limitation of resources here for testing or treatment, things we so take for granted in the U.S. I hugged David’s mother and told her how sorry I was, but I couldn’t imagine the intensity of her grief. Mostly I was dumbfounded as I sat there looking at the small white coffin. Then the sky opened up and rained for an hour, a deluge of tears that I was too numb to express.