el dia extraordinario, part II--beware. A Very Long Post.

So, for those of you who have been so kindly following along with our family saga, you may have noticed that about two weeks ago the blog entries sort of stopped. Abruptly. There was a reason for this, and I apologize for not having warned you in advance, as some folks, it seems, became alarmed, thinking some terrible calamity had befallen us. (It had.....but that's not the reason the blogs stopped. More on Hand, Foot, and Mouth Disease later.) In fact we were merely traveling, and without internet, for the last week of our trip, so hence no blogging.

The even more astute of you will also note that today's post occurs some days after our well-publicized return date of April 10th. Not to worry, we did make it back on schedule. But despite the fact that the adventures are over, the downloading of them is not; we plan to just keep adding to this thing until everything that needs to be told is told.

One of the things that needs big-time telling occurred over two weeks ago, during the latter half of the dia extraordinario. Part of the reason I have not been able to bring myself to tell it was the sheer mind-blowing nature of it all..... It has taken a bit to process. On the surface, it was a patient encounter--ordinary enough, right? I am a doctor, after all, or have at least been playing one for over a decade. But while the encounter did stir up many things for me, it was the surrounding context that really blew me away. Allow me to explain.

As I have mentioned elsewhere, Juliana was kind enough to set up a Spanish tutor for Greg and me during our weekday afternoons. Our tutor was a lovely woman, the daughter of a doctor/public health servant and his fashionable and kind wife, herself an owner of a cute papeleria. One day, about a week into our studies, my tutor asked if I would be willing to speak with her mother about a "friend" who had been bedridden for some time, lived on the outskirts of Tapachula, and was in constant, chronic pain. She apparently had been under care of doctors in the past but had recently been unable to travel to free clinics--the only clinics she could afford, as she was unable to work in her condition--because the clinics themselves were too far away and required an ambulance ride which, of course, she also could not afford. I agreed to see her, and the trip was planned in a tentative way for "after the weekend."

A few days later, I, Juliana, my Spanish tutor's sister and their mother were shuttling through Tapachula, "the pearl of Soconusco," to the northeast side of town. The air-conditioned ride felt strangely unnecessary after two weeks of cabbing it through the sweltering Tapachula heat, windows down. We arrived after about twenty minutes in a neighborhood not unlike the one we were living in at Infonavit Las Vegas: narrow, dirt or stone-slab streets populated with smallish but brightly painted cement structures, corrugated metal roofs on the tops of some, and smallish, yappy dogs on others. It was about 5pm, and the late afternoon light created a nice ambiance as we left the minivan and made our way into a narrow cul-de-sac where children were playing, across a stretch of dirt, to a bridge.

The bridge reminded me of something out of Shrek. About 60 feet in length, it was suspended over a 100-foot deep gorge by thick cords of flexible metal. The bridge itself was made up of wooden planks, several with 2-inch gaps or more between them,



and as we made our way across it, the bridge swayed dangerously. A group of kids on bikes waited on the other side for us to pass before risking their own trip across. I was grateful for this, as I was sure their additional jostles would create just the right amount of resonance to send us all flying into the lush and well-littered gorge below.



The road after that was all unpaved. We walked for about 10 more minutes, past small cement shops selling the usual sundries and homes in varying states of being constructed, or of falling over. One house seemed propped up by the stumps of sawed-off trees, sprouting leafy green fronds in between hammered-on wooden slats and metal sheets. Despite the obvious poverty here, there was the usual spectrum of pride of ownership, and some homes, like this one, were quite charming and clearly housed a gardener:




The home we were visiting was one of the better-tended ones. From the outside it had the appearance of being several boxy, wooden sheds of different heights tied together by various sheets of corrugated metal roofing, and despite the absence of any real separation of "inside" and "outside," the setting looked tidy and its inhabitants, well-cared for. We were greeted by the woman who had agreed to let our patient, who I will call "MC," and her daughter stay there after the accident which had left them without an income. This woman was pleasant and expressed her gratitude that we had come. She led us down some cement steps, through several dark rooms separated by sheets of cloth, to the bed where MC lay. Chickens and kittens welcomed us in as we became accustomed to the dim light.



When my eyes had adjusted I saw a woman of about 40 lying naked under a sheet on a queen sized bed, surrounded with various items that looked like they slept with her permanently: a comb, a mirror, a small box of tissues, the remote control. A large, colorful cardboard cut-out of Santa Claus dangled above her bed from a piece of red twine. She spoke rapidly in Spanish and flashed a huge smile of recognition at the mother and sister of my tutor. She did not possess at all the demeanor I expected her to. Tie me to a bed for almost a year and I would surely sink so deeply into the sheets as to be un-findable. But not MC. She was vivacious, talkative, bubbly, and interested to hear how the family had been over the past year.

Her story, when she told it, was devastating. She had been a strong, healthy woman who, almost a year ago now, had fallen from a 2 meter ledge in her rented home that had no banister, landing on her left hip on a concrete floor. Her spine had broken in two places, and her spinal cord been damaged, leaving her with no sensation or motion in the lower half of her body. She had had one surgery, to put her vertebrae back together with metal rods, after which she had been discharged to the rental home she could no longer afford with a 20 year old daughter who became her everything. Her pain was severe, both in her left hip and in her back, where she felt like "something sharp was rubbing under my skin everytime I moved." She spent a month lying flat in bed, where she developed ulcers under both legs and lost, for lack of use, the upper body strength necessary to maneuver herself into a sitting position. There was no physical therapy provided, or even suggested, by the doctor who had done her surgery. She did have one follow up appointment scheduled, "for them to look at my hip, which they never bothered to examine on my first visit," but by that time she required several people to lift her, would have required an ambulance she could not afford to get there, and so of course did not go.....

At this point in the story she asked us all to leave for a moment, stating that she needed her daughter to come change her diaper before she was examined. She was on her period, she said, and did not want to offend anyone, "even though we are all women here," she called after us exhuberantly. During this break I took a self-guided tour through the less sheltered portion of the home, exiting through a crooked door made of planks nailed to sticks. A row of dark, well-used cast iron griddles, lined up neatly and wedged into the fence that surrounded the property, caught my eye, and I wondered what they were doing there. Directly above them in my line of vision, but much closer to me, was a row of three chickens roosting on what appeared to be a tree branch. As my eyes adjusted to what was now brightness, I began to recognize that I was standing in the family's kitchen. The pans suddenly made more sense, so close in proximity to the cooking apparatus--in this case, the open bottom of an oil barrel split length-wise, and topped with a wire grill, on which the remains of wood from an earlier meal had been set to smolder. A wayward white squirt from one of the ruffled birds actually hit the smoking log, causing a little sizzle.




I was reminded of the story of a home visit told by one of my colleagues in residency, where it was discovered that three different types of animal feces were noted to be evident in the home of the patient being called upon, "some wild, and some domestic," and that there was a discussion of public health risks and so on. The two domestic turned out to be a dog and a cat, and I could tell that some of us were on the fence about whether this consituted grounds for alerting the health bureau--I mean, anyone who has raised a puppy or a kitten has discovered the occasional, week-old "accident" under the table in the livingroom. But we had all shuddered at the part about wild animal poop until we made him spell out that they were in fact mouse droppings. I mean, come on. If we're gonna start calling the city about mouse droppings, at least hand everyone a free mouse trap or two before you do it. (And this is the point at which half of you decide never to visit my home again.) In any event, when I saw the injured squirrel in a cage,



and then the sick dog in a box,



the number had indeed reached three (4, if you count the kittens), and this memory flashed into my mind. I do not hesitate to think that this situation would have indeed been a cause for alarm among public health people--both back home and here, in Mexico.

At this point MC was ready for me, and after an exam in which I determined that yes, her legs did not work and yes, she did have leg ulcers that, though tended to carefully and thoroughly by her 20 year old daughter, were not going to get any better until she got out of bed, I began my acupuncture treatment. I decided to address both her chronic back/hip pain and her chronic qi depletion, with an N->N+1 treatment of the Chong Mo/Dai Mo curious meridians. As I put the ear needles in she became extremely anxious and squirrely, so I had her place a few drops of essence of flowers under her tongue before I completed the treatment. She remained anxious and uncomfortable until the electricity was hooked up and the moxa going over her feet, and it was at this point that MC began cooing to me--to all of us--relaxing into it, saying it felt "muy rico," and inviting me to come live with her. ("After all, there's an extra bed, right over there!") I found myself once again amazed at the rapidity with which people here seem to respond to acupuncture, as she stated that her hip pain was progressively leaving her, her nerves relaxing, and that she was starting to feel "something moving" in her legs and feet. We left with her completely relaxed and pain-free, and agreed to come back two days later if schedules permitted.



So what bothered me so much about this afternoon? It wasn't simply the pathetic state in which we found MC. Though her invisibility to the larger health care system was appalling, access to care is a problem in this country, as well, and did not surprise me. The degree of poverty we encountered there was surprising to me, but even so, she was well-taken care of by a loving (if exhausted) daughter, and had been taken in by generous souls. She had a roof over her head, clean sheets to cover her, meals three times a day. The home terrain was less than ideal for a rehabilitation program--even if she could be assisted into a wheelchair and her upper body strength encouraged, which I asked all there to do religiously, learning to navigate a wheelchair on rocky, uneven earth would be extremely difficult. Any trips that she might be able to afford in an ambulance would also have to entail three or four people carrying her on a stretcher for 10 minutes over a rocky dirt road, and then across a foot bridge. And so on.

These features made her story more horrifying than the already devastating fact of the loss of her lower body and elimination functions. But as we walked back at dusk over the perilously swaying foot bridge, I was struggling with something else that I could not yet name.

My thoughts and emotions were swirling during the minivan ride back to my tutor's house, where Juliana and I had been invited for "refrescas." They lived less than 2 miles from what I later learned was called "la perla del norte," or The Pearl of the North...the name of the area of town in which MC lived. Yet the houses here ran along well paved roads which afforded nice views over the city of Tapachula. It was difficult to tell where the homes started and ended, as they were all surrounded by large, blandly painted walls that were taller than me, and often studded with small iron spikes at the top. At one such fortress the minivan stopped, and a large garage door slid sideways and we were admitted into..... such a retreat! Large, mature plants hung on all sides, and a small, scalloped walkway led to an ornately constructed dwelling that was painted a calming shade of sea blue. The large, glossy wooden doors opened to reveal my tutor's mother, who had gone in ahead, and she greeted us warmly and offered us use of the lavatory (which ended up being the nicest place I peed in all of Mexico, including, though I hadn't experienced it yet, the bathroom in our fancy resort in Cancun). The house was open and airy, and had accents of Chinese art throughout, in addition to the usual religious paintings and decor--though I noticed that even these seemed much more expensive and elaborate than in other places I had visited in Tapachula.

We sat on the porch surrounded by comfort and sipping "jamaica," which was refreshing and delightful and completely surreal after the two hours we had just spent at MC's. As we enjoyed our drinks in the light breeze the mood was somber, contemplative. The sister said suddenly, "She used to be so strong....her legs were so thick!...she used to be able to carry a table--that table there," (and here she pointed), "all the way across this deck to that house, by herself." "That table?" I asked. Oh, yes. As it turns out, MC used to WORK FOR this family....well, not this family, really, the uncle's family, next door...before her accident. Suddenly it all made sense. The sense of duty that drove this kind, upper class woman to seek out a volunteer doctor's opinion, and to trek out to the Pearl of the North. The look of recognition and delight on MC's face when mother and daughter appeared in her room. The strangely familiar way that the my tutor's sister had admonished MC for not getting out of bed more often, firm but loving. This family, this home, had kind of been her home....but that had all changed the day she slipped and fell off a concrete ledge without a banister.

The tutor's mother asked what I thought of "the case" of MC, and sudddenly I knew exactly what I thought. I thought it was tragic. I thought it was shameful. I thought it was ridiculous that here I was, in the home of one of two doctors who knew this woman well--whose families had benefitted from her strength, her energy, her hard work and her cheerful disposition--and who had not managed to help her get even basic follow up care after a surgery that had not brought her relief, or physical therapy, or even her records from the hospital so she might be better informed of her prognosis. I thought it was absurd that I was contemplating her pathetic tale from the comfort of a place that she had once been a part of, while she was lying in a dark room with chicken poop on the floor and no space to learn how to use a wheelchair. Above all, I thought it was crazy that the only professional advice available to her was that of a random, volunteer family doc from America who had no way of providing the kind of continuity and follow up that her "case" deserved.

But I didn't know how to say that in a way that would be helpful and not indicting to this clearly well-meaning family (let alone how to say it in Spanish). So what I said instead was this: "I find it very, very sad. And hard to believe that there is no one here, in Tapachula, to help her." The mother leaned forward and whispered, emphatically, "Yes, that's exactly it. It IS difficult to believe." Her daughter began to explain that in Mexico there is not the same culture of volunteerism as exists in the United States, that people here "only look out for themselves and their family." I had heard this before, when talking to locals about the shelter, but I still found that hard to swallow. You mean in this country, were the intellectuals were never punished or "sent down" anywhere, where there exists a wealthy leisure class, there is NO ONE interested in serving others than themselves? In this town, on the border, which sees so much suffering of displaced and mutilated migrants, and even had a college devoted to the southern "frontera"... weren't there even a handful of undergrads there interested in a little service-learning? No, the answer was. And in fact, that college really only specializes in frontier agriculture.....

But the disconnect was powerful. I was living with Dona Olga and family, a collection of Tapachultecos who seemed to live ONLY to serve others. In addition to portraits of Saints and Mother Theresa as a young girl, the walls of their home were scattered with small, unobtrusively placed plaques and certificates documenting the gradual recognition--first locally, then by the president of Mexico, and soon to be joined by an award the Dalai Lama will present to Dona Olga and Don Jordan later this month--of this family's dedication to human rights and social justice. Dona Olga was a simple, humble woman. She did not attend school, and never learned to read or write. Neither she nor her husband came from wealth or the leisure class. Yet she had been a force capable of changing the way her town handles ailing migrants. Was that the prerequisite here, then? Having suffered enough to know the pain of others? When I talked to cab drivers or people I met in shops about what I was doing in Tapachula, they had all, to a one, heard of Dona Olga's work, and all expressed their appreciation for what the shelter does for the dispossessed migrants. But when I shared this with Doris, one of the administrators of the shelter, she laughed and said, "Oh, they SAY that, but what are they doing to help?" I did not have an answer. I still don't.



Dona Olga with Angelito, the 18 month child she took in who had been abandoned at birth.