Latest and greatest in El Salvador

2009 in Review, el Resbaladero

With all good intentions and warm thoughts, I meant to send this last fall; then I hoped to include you in my Thanksgiving blessings; after that I hoped to sneak my greetings in with the rest of your Christmas mail, but now, at last, a very Happy New Year to you!!

How does one summarize an entire year in a few paragraphs?  Impossible, but let me at least give an overview of some of the outstanding memories in a random assortment of categories.

Most memorable patient: The winner of this category… it’s a hard choice.  I guess I’ll settle on Manuel L, since I have long enjoyed and admired him and some interactions this year have made me admire him and care for him even more.

I have known Manuel as the skinny aging guy from nearby rural Venecia who walks the hour to his clinic appointments despite his atrial fibrillation and heart failure.  When I walk into the room, he removes his hat from his head and he bows gently before shaking my hand.  The visits are pretty standard:  Yes, he is taking his meds regularly and he’s doing really well with the meds and he appreciates our help with his medical needs so much, and (hesitantly, just as I’m ready to walk out the door):  would we have any milk supplements?  He just never has money to buy any milk, and he thinks that better nutrition might help his heart.  And his response of profound thanks is the same whether I have milk or not.

I came to know Manuel a bit better through my attempt to get him to see a cardiologist in consultation.   The conversation went something like this:

Dra:  clearing her throat slightly:  “Manuel, we have just received this wonderful offer from a cardiologist who is willing to examine you and do a special exam on your heart for a greatly reduced cost.”

Manuel:  (Very gentle, polite smile) “Oh, no, doctora, I like my care here with you just fine.  I think I’ll just stay here and keep taking the medicines from you.  I really feel good when I take your medicines.”

Dra:  “Oh, don’t misunderstand me.  We love having you as our patient.  I only want a cardiologist to give his advice on your medications and— you’ve needed an echocardiogram for years and years but I’ve never said anything because I knew you wouldn’t be able to afford it.”

M:  “But I have to borrow or beg for the money for my monthly visits to the clinic here.  I can’t pay for the visit to the cardiologist.

The conversation continues and at last, after I assure him that I want him to go even if he can contribute nothing toward costs, I elicit a hesitant promise from Manuel to show up on Tuesday morning when transportation will be provided to have him go see a cardiologist in San Salvador.  (San Salvador?!  Manuel almost never goes to Santa Ana, 10 miles from our village.  He has never, not in all his 68 years, been to the capitol of the country, a whole 50 miles away!)

On the appointed consultation morning,  clinic staff and carefully-selected patients are all nervous and uncertain.  The patients gather at the clinic to await their transportation and a few of them decide to go next door to eat an outdoor breakfast of our famous Salvadoran pupusas (tortillas stuffed with beans or cheese).  All of the patients leave to find food, except for Manuel.  He’s the skinniest one in the bunch and I know he hasn’t had breakfast and won’t be able to buy lunch.  I don’t want to embarrass him, however, so I run down to our neighbors, slip the cook a bit of money, and explain that Manuel needs food but won’t ask for it because he can’t pay the 50 cents for 2 pupusas.

When I traipse back up to the clinic to explain to him that Niña Mélida has breakfast waiting for him, he smiles his quiet embarrassed smile and is ready to explain again how unable he is to pay for it.  I nod, smile in return, explain, and gently nudge him down the hill to his breakfast.

My efforts to get Manuel to see the cardiologist are rewarded with diagnostic information:  unfortunately, he has infiltrative cardiomyopathy (a rare disease) and so all our efforts to keep him healthy will be challenged by a progressive disease.   In the meantime, Manuel will continue plodding up and down steep hills to keep his appointments, gracing us with his polite warmth, and asking for milk.

Greatest infamy:  It was 9 pm and the day had been long.  My phone, strictly off-limits to patients, rang.   It was one of my staff wondering if I could come to pronounce her uncle dead.

I sighed.  Our people are simply paranoid about burying a loved one who might only appear dead.  And our mortuary-less rural area has burial customs that leave plenty of opportunity for paranoia and self-doubts.  When family consensus determines that a person has died at home, someone sets out to buy the casket while others wash and dress the body for burial.  Since no embalming is available, caskets are made with a glass pane in the lid, allowing visitors to pay last respects to the body while [generally] containing the smells of decay.

Alas, no warning signs about rigor mortis are attached to the coffins.  I don’t know how often I have been called to the homes of a person who is logically quite deceased, having been contained in an air-tight coffin for more than 24 hours, when some on-looker notices some movement inside the coffin and rumors start flying about the still-living person lying in that enclosed box.  (Grief does not specialize in logic).  And then the doctor gets a call.

On this particular night the biggest challenge was not to decide if the patient had died, for he most certainly had.  The biggest challenge was waiting to examine him while the family rustled about trying to find something with which to tie the jaw shut.  They finally decided upon a white curtain.  The second challenge was to draw upon my local cultural skills to know how to best mingle with the crowd outside.  It’s not a mourning crowd; the air is more of a celebratory late night neighborhood gathering.  But to guess which of the crowd are longing to be comforted and which are merely distant neighbors; ah, this is a challenge.  And to decide exactly when my duties as physician and neighbor have ended, this, too is challenging.

So, what is the infamy of this?  Just this simple little secret:  I have been called to see far more patients already laid in the coffin than I have been resuscitate patients on their death beds (the faith and logic of rural Salvaodorans:  no use calling doctors when they’re about to die, because when it’s God’s time for them to go, we don’t want to stop Him.) Come to think of it,  I have also delivered many more placentas than I have infants here.  (Community midwives and family members are appropriately cautious of applying traction on the umbilical cord, and so I get to do that for them periodically.)  It seems that most of these slightly eerie situations seem to  occur in dark adobe-walled, dirt-floored dwellings, with a dog or two sneaking in behind me.

Most beneficial delay.  It was 7 a.m. and we had been sitting on the Delta runway in Wichita for 20 minutes.  I had just had a pleasant several days in Kansas and now I was heading back to an important meeting as soon as my plane landed in El Salvador and then to full days at the clinic.  But, a mechanical defect on the plane caused our delay on the runway, which led to a rescheduled flight to Houston which eventually brought me into San Salvador much later than planned. As I called San Salvador to update the mission of my status and fought my frustration at having caused an important meeting to be canceled,  I reminded myself that sometimes what seems to be ‘misfortune’ to us may be seen as ‘fortune’ by the Omniscient.

It was on the delayed flight from Houston that I sat in the same row with a talkative woman who could speak English as fast as she could Spanish and within minutes we had made connections.  She was married to a physician, a Salvadoran who had practiced in Wichita during my training years.  He was at this time president of the Salvadoran-American Medical Society [SAMS] and was flying down to initiate their annual conference the next day (it was the first time I had even heard of SAMS).

He offered to pay for any interested staff at our clinic so we could attend the conference.   The conference was helpful in many ways:  getting in touch with some of the medical educators in El Salvador, learning technical medical terms in Spanish, and being introduced to the entire group of conference attendees, and meeting physicians.  We had lunch with a cardiologist who wished to help his own people and offered us his full scope of services at a minimal cost to our clinic and its patients.  Unfortunately, philanthropic thoughts come easier than philanthropic deeds, and the results haven’t been quite as generous as the offer, but we have still been blessed to be able to obtain echocardiograms for ten of our sickest patients.

Most educational home visit: Several weeks ago I started questioning the honesty and compliance of an adult patient with seizures.  I guessed that he and his mother (who always accompanies him to clinic visits) weren’t wealthy, but had they really missed their last appointment due to not possessing the $2.00 for the bus fare?  And why was Santos’ gait so unstable and his words so stammering after his last series of seizures?  Had he really been out of his meds only since his prescription—filled at our clinic—ran out? Was there a possibility that someone was reselling these medications on the street and that he wasn’t even benefiting from them?  I decided that his health had deteriorated enough and that there were enough unanswered questions about their socioeconomic status that a home visit was meri.

I would have saved myself a fair amount of effort (but lost a great education) if I had taken their words at face value.  Four of us from the clinic arranged to meet them at their home in Santa Ana.  In my mind, this was going to be the easiest home health visit ever:  take the bus, get off in Santa Ana, walk a few side-walked city blocks, evaluate the neighborhood and the home, reemphasize the risk of medication non-compliance and status epilepticus and ride the bus home again.

Wrong.  Really wrong.  The address was Santa Ana, but the instructions were for  outskirts of the city which I had never heard of.  After wandering around the dusty and unpaved side streets for a while, we met a bustling young woman on an errand.  We asked her for directions; she stopped, thought, and deciding that our errand was more important than hers,  took us to the path that she believed might go past the soccer field and eventually end at the patient’s house.

Arriving at the soccer field, directions were again uncertain, so we asked the players for assistance. They interrupted their game and huddled together to try to get us to our Santos’ home. We were all glad to see the sweaty woman come panting up the path announcing that she had been told to expect us and to take us to the home.

You remember the few city blocks we were supposed to walk to get to the patient?  Well, these “city blocks” curved down a steep ravine, across a creek, up a  hill so dusty that I took off my sandals for better traction, past neighbors who now smelled adventure from visiting ‘dignitaries’ (well, had any blue eyes ever seen this area before?  Indeed, had 4 professionals ever gone that far off the main road into their neighborhood? )

We wound past adobe homes and bare front lawns until we met the excited, welcoming grins of Santos and Fidelina (Santos’ mother, who accompanies him wherever he goes in case of seizure or other problems). Their property consisted of a steep hillside;  a few meters of ground had been excavated to create a level patch for their home.  I glanced around the outside of the home to make several surprising observations.  There was no pila, that concrete water storage tank/kitchen sink without which no Salvadoran family survives well.  There was no latrine.  There was no kitchen.  Indeed, the only thing these two people (as well as another adult son who lived with them) owned for a home was a tin shelter, 6 feet by 9 feet in size.  The sole opening into the hut was the front door.  They invited us into the single room that comprised their home and welcomed us to sit on their cots, used for both beds and seating.  Three cots were so tightly sardined into that space that we crawled over each others’ laps to find a seat on the cots not accessible at the entrance. Clothes were stored on cardboard scraps inside the front door to protect them from the packed dirt beneath our feet.  Not only were the walls tin, but the roof was tin also, and the shelter without windows.  We were sweating and it was only 9:30 a.m.  This, then, was the extent of their possessions:  3 cots, the clothes we saw on the floor, and a single room in which to sleep in.  How in the world do they appear with ironed clothing at each clinic visit?

Within a few more minutes of chatting, my questions were answered.  Now that Santos was back on his medications and in his home environment, he stammered less and his gait had normalized.  The mother and son had a close and affectionate relationship and were merely lacking funds for food, transportation, and medications.  They were kept from starvation by the occasional donations of an international agency which would drop off food items at the community center,  (but, how does one gain nutrition from raw beans, uncooked rice, and a gallon of vegetable oil without pots or a stove?)

It seemed like a case of absolute poverty and I noted quietly that we needed to find some way to waive their clinic fees without injuring their pride.  Leaving  Santos and Fidelina’s home, we commented on the several coleus plants she had potted in old tin cans.  She stepped to the largest one, picked it up to give it to us as a gift, then decided against that.  “I’ll walk with you to the bus stop and carry the plant so it won’t be so heavy”.  I left marveling at the spirit of these people, who, despite complete lack of financial resources, have friendship, generosity, and smiles in such abundance that they have enough to share.

Greatest highlight:  Surely parents and siblings are treasures beyond words.  So, when I received an e-mail from my dad telling me that  my siblings were gathering at my parents’ place for Christmas, and that if I could make time to join them, my air fare would be paid, I deliberated only a few seconds before replying with a delighted,  “Of course!”.

And thus it is, that the greatest highlight is just around the corner as I write this.  It will be the first year our whole family is together for Christmas in the past 18 years.  And we all believe that we have found a large pot of gold at the end of the rainbow called 2009.

God’s very best to you in the 2010!  Thank you especially for your ongoing friendship  and prayers and for your generous financial support to our work even when finances are tight.

Jana Nisly