Mid trip update

A particularly tough case of earwax removal during outreach clinic in Pajomel. The word is out that we are very good at it and we've had plenty of people show up!

Things are carrying along at a mad pace here. After my last stay of seven months, it’s hard to believe what an absurdly short time ten weeks is.

Most of the clinic’s work remains considerably affected by Agatha. Of course the resulting evacuations, drinking water shortages, and homelessness have meant were seeing more patients than ever. The Guatemalan Ministry of Public Health’s bankruptcy several months ago hasn’t helped either—in that time, none of their staff has been paid, nor medications purchased, and we’re trying to pick up the slack.

The saving grace has been how well the clinic operated in my absence, and now in my extreme occupation. The efficiency and innovation that our local staff Nohemi and German have put into managing the pharmacy and restocking outreach clinic supplies is unbelievably encouraging. I am thrilled that such vital activities are no longer dependant on the fickle presence of volunteers at the clinic.

Paulina´s ulcer today, almost totally healed (the part that's still left is on the inside)

What the ulcer looked like when I left last November. It had already improved significantly. It was no longer infected and you can see the new tissue coming in (pink as opposed to red or brown).

Paulina´s ulcer when we first started treating it, after initial debridement. The white is pus.

She is really about as tall as yoda. This is not CGI!

Paulina always crosses herself before taking any medication

Of course I’m still looking out for my favorite old patients. Dona Paulina’s improvements in particular have been unbelievable, and I’ve devoted myself to the (unlikely) cause of completely closing her ulcer by my departure. So far that’s meant four visits a week and plenty of protein. I’d become worried that she had scabies, so last month I bought her a new mattress and took all her blankets and clothes to be washed. It turned out she had a huge ants’ nest inside her old sleeping pallet, eggs and all. No wonder she itched so badly! Sometimes I am absolutely floored by the things people endure here. But she’s up and walking about and raising chickens and absolutely radiant.

Although I could devote myself full-time to the clinic, I’ve making as much time as I can to keeping my individual project on track. Over the past few month I’ve transitioned to spending about half of my time living in the hill town of Chuitzanchaj, giving consultations when I’m able and doing my best trying to assimilate.

Progress has been steady on converting the truck for ambulance service, both legally and physically. I’ve convened weekly meetings with the members of the cocodes (village council members) from each of the communities. The decorum and deliberation (in Kaqchikel of course) that accompany every decision has been quite the introduction to diplomacy. And that is to say nothing of the underlying family politics, rivalries, and interests across three hamlets with perhaps a dozen last-names.

Still, we’ve successfully elected a legal representative in whose name to sign the truck over, chosen apprentice drivers and more experienced townsfolk to train them, and starting informing all involved parties of our intentions through formal letters. They are preparing to petition the mayor to cover gasoline and maintenance costs, the hospital to grant us radio communication and passage at the ER, and the ministry of public health to allow us to conduct outreach clinics in the town. Meanwhile, I am still trying to convince the cocodes themselves to allow Mayan Medical Aid to use the ambulance to transport our staff up for outreach clinics, while lobbying hard against any other uses of the truck in my absence.

In the meantime, I’ve been putting a good deal of money into fortifying the suspension, replacing worn break pads and broken windows, and the myriad other improvements. I put down the deposit on our massive oxygen tank on a past trip to the city and this weekend will be spent reconstructing the truck bed with a cot, benches, and storage space.

At times it makes me deeply long for last year when just seeing patients all day was a job well done. But despite the unexpected delays and costs, it has been a deeply affirming process, and a hell of an adventure as well. It is pretty cool to feel how well she handles driving in the area. The roads are truly in very bad shape, especially with the storm and continued rain. There are some places where the road is literally a rut across a mudslide hanging over a hundred-foot waterfall, often at the headwaters of a new chasm torn into the lake shore. But so far we haven’t come across anything she can’t handle, even shuttling eight cocodes home in the cab after a reunion. And there’s plenty of serious motivation as well—like seeing the eight orphaned kids whose mother died in labor last fall playing in the street.

As one would expect, there’s always sad news mixed in. Last year Espíritu Santa, a 27-year old mother of five who works for us as an interpreter, attempted suicide by hanging. Her husband is an undocumented worker in the US. To pay for his passage, he owes the first 10,000$ he earns to the coyote who smuggled him in, and their house and plot of land was left as a collateral. For over a year he’s been incommunicado and has yet to send any money. It was assumed he had abandoned his family, and the coyote has threatened to seize the property. Our clinic doctors were able to stage an intervention to postpone any loss, and with employing Espíritu for extra hours and starting her on antidepressants, we’d hoped we’d turned a page on this story.

But beleaguered by continued financial problems, Espíritu left for the US as an illegal last week. Her 15 year-old daughter has been left to care for the other four children. She made the announcement to the clinic staff at the birthday party we put together for her three-year old son. Watching little Esteban play with his new fire truck, completely unaware of the news his mother was breaking, ranks among the most chilling and surreal moments of my life. Our attempts to change her mind fell on deaf ears. For Mayans like Espíritu , who’ve barely left their home village, the concept of the horrors and hardships of such a voyage are impossible to convey. Everyone here knows someone that’s lifted their families out of poverty from remissions. These success stories seem to hold more traction that the abysmal job market, rampant murders and coercions in Mexico, or destruction of many clandestine routes during tropical storms Agatha and Alex.

White thunder crossing a particularly bad stretch of road between Pajomel and Chuitzanchaj

Since then it has become completely washed out by a series of landslides. It is almost impossible to cross by foot, let alone by car.

If there was one point I took away from driving through Mexico, it is how dangerous and backbreaking it would be to cross it as an undocumented worker, to say nothing of entering the USA or finding work. Especially since I just read Roberto Bolaño’s 2666, a novel based around the deaths of hundreds of such unknown women in Cuidad Juarez. And the debt is unconditional. Even if she is immediately deported, or even dies in the journey, the debt will remain unsettled on her or her children. I see absolutely no good coming from this.

In addition, Rony Elvis’ cleft lip repair, performed by HELPS, has not closed up nearly as much as it should of. It was always scheduled to be a two-part surgery, with a cleft palate repair to follow, so we hope we’ll have another opportunity soon to try again.

Last Monday, I was up in Chuitzanchaj when I received a knock on the door of the little house I rent. A concerned neighbor led up the road to a hut. The funeral-like dirge of an entire extended family in prayer emanated from within. Inside, I found a woman in her thirties soaked in sweat, suffering from stabbing abdominal pain. I was almost floored by the sensation of déjà vu.

I don’t know if you remember or if I told you, but last November I found myself in a similar situation that ended very poorly. I had been hiking through Chuitzanchaj, on my last day in Guatemala, when I was called over to an almost identical house. The woman I found within was feverish, had a tender abdomen, and had been suffering from bouts black diarrhea for days. I was alone, had no equipment, and had come on foot. I recommended that her family bring her to the hospital immediately. Impossible, I was told. There were no vehicles in the village to drive her to Sololá. If one had hazarded by, the cost of transporting her along with the family, let alone their lodging outside of the hospital, would cost several weeks’ of wages. In the end, I ended up arranging for a course of anti-amoebics for dysentery hiked up from the clinic.

I learned she died a few days later from a ruptured appendix. That event wracked me with self-doubt and recrimination and crushed any illusions I’d harbored of single-handedly curing any village. But it has remained one of my most powerful motivations as I strived to make the ambulance a reality.

This time, I convened the entire family. A quick conference addressed most of their fears involving the cost or unfamiliarity of the hospital. Within half an hour she had been bundled into the pickup along with her husband and eldest children and we were lurching along in 4WD.

After hours of waiting in the emergency room, a nurse finally arrived with laboratory results in hand. Petrona had pyelonephritis, caused by a UTI than had gone untreated for weeks. She was on IV antibiotics and already improving. It has only been one initial success after month of effort and costs. But the conversation the event has fostered in the villages has me hopeful this is a first sign of many successes to come.

That Friday, it decided to take the step that I’ve been putting off for weeks. It was time to head to the frontier to make the truck officially Guatemalan. I spent Thursday night in Xela, and woke up early to make it to El Carmen by nine. I had been seeking out advice on the importation process for the past two months. Since I had no bill of sale, the taxes I paid would depend entirely on the value the officials put on my vehicle. I was assured that with the physical damage and over 200k, it wouldn’t be much more than $400 or $500. The catch was you couldn’t find out the exact sum until you arrived.

By noon, I was fairly sure I’d made the trip in vain. I had spent hours in the no-man’s-land between Mexico and Guatemala, pleading my case with a half-dozen import agencies. Everywhere I was informed the rules had changed. The mileage and condition of the vehicle were no longer being taken into account. Without a bill of sale, I would be charged a tax of over $1500--more money than I'd paid for the truck in the first place, and almo more than I had in my name. I would have to repeat the fourteen-hour round trip later, if I could even raise that much. Meanwhile, I had a temporary car permit stamped in my passport. This step, designed to dissuade anyone from trying to import a vehicle without paying import taxes, meant I couldn’t leave legally depart Guatemala unless the vehicle left with me. Even if I had a family or medical emergency, I was told I'd be detained at the airport.

In the end, desperation won out. I was able to talk business with a small import office under a disco-slash-brothel. Through means I was assured were perfectly legal, they told me it ought to be possible to produce a bill of sale from a used-car dealership in Texas. The price was still outrageous, but barely within my means. After a taxi ride to several ATMS across Malacatán, I had emptied every account I owned and just reached the revised sum of Q6,100 (nearly $800). I felt sick to my stomach as I pushed through the street vendors, hawkers, and prostitutes with the roll of bills in my pocket. The man in the office whisked the money and my passport out of my hands and into his pocket with a mischievous grin. I wish I could see his eyes through the aviators.

For the next six hours, I waited at a taco stand, watching telenovelas and sweating bullets. I literally had no money left, and had freely given over my passport to a document forger. The sun set. At 7:40, twenty minutes before the border closed for the night, I was told to start up White Thunder and pull into the queue, still dozens of cars long. At 7:59PM, as I pulled up to the turnstile, my facilitator appeared at the window. He slipped me a manila envelope and disappeared. I passed it over, contents unseen, to the customs officials. While the truck's undercarriage was sprayed with insecticide and interior searched by flashlight, I watched as a flurry of stamps and signatures ensued. As the lights turned off and the metal screens came slamming down over the custom agency windows, I was waved back into Guatemala. A heavy drop of rain hit the windshield.

I drove about an hour before stopping to look at the papers. The bill of sale was from M&M motors in El Paso. The signature of our clinic's pediatrician, Dra. Carmen Cerezo, had been forged numerous times. I had spent 11 hours in the seediest place I’ve ever wandered in, a cross between the Cantina scene in Star Wars I and 1968 Hanoi. I had essentially paid for my truck a second time for the right to give it away. And I still had to drive half the night, climbing 10,000 ft in a thunderstorm, to make it back to my hostel in Xela. But, as far as I can tell, the deed has been done and I can now pass the car to the village cocodes, as well as start medical school next month.

Meanwhile, my cherished emergency committee in Tzununá did me proud that same afternoon. A woman thirty-four weeks pregnant, and a half-mile hike up from the shoreline, went into seizures. The members of the emergency committee arrived on scene, identified eclampsia and called for the ambulancha. At this point five women and four men carried her in a stretcher down a massive boulder-filled river bed left in the wake of Agatha, at one point crossing the water-choked ravine via a log. Meanwhile MMA’s nurse practitioner Guadalupe, was on call at the clinic. In what she calls her “mala suerte” (bad luck) but to the patient’s great fortune, it was Guadalupe’s fourth eclampsia within a year. She intercepted the patient on her journey down, and the woman was receiving Magnesium Sulfate intravenously by the time they arrived at the dock. During induced labor at the hospital, she gave birth to a perfectly health baby boy.