January 7th, 2005


The first thing you remember...

There is no "at" sign on this bedevilled English keyboard running Spanish keysets, and the keys stick wicked bad. Forgive me, O Best Beloved. I have not the patience for an epistle.
Though somehow LJ, bless it, has forced me into an English keyset. The keys still stick.

It is hot here, hot and swelteringly so, though the air moves cleanly and I can bear the heat better than ever I could at home. It is a bit surprising, how well I bear the heat, like the unexpected succulence of fish and vegetables for lunch. Today was a day for surprises. This cafe down the road from our hotel is one of them. The trip to the top of a clambering volcanic hill yielded another. In the shadow of the statue of Sandino's silhouette, there is a cabin overlooking the lagoon in the crater. Running from the cabin to another cabin to a third cabin to the shores of the lagoon some several hundred feet below is a wire cable that, for a mere $10 US or 190 cordobas, one can strap oneself to and zip across the lagoon. I have rarely been so exhilarated. Not terrified at all, once shown the sturdy webbing of the harness. Well, only a little.
The hospital itself was another surprise. We toured the neurosurgery ward without regard for HIPPA or any other privacy policy; we brought stuffed animals for the children. Eight beds to a room; the ICU has air conditioners in the windows and a few mobile monitors of the kind we normally see in the ER. "Stay close to me," the translator insists, after the second or third time I provide him with a vocabulary word he would otherwise lack. I don't mind; he is a lovely long-haired creature of a boy, college-aged, perhaps. I stay close and fill in. I ask permission and am granted, take one picture - a girl, in trach tube and bathing suit top, charming and beautiful, with her new bear coin purse. She is all smiles. In the next bed, another of our group explains to a boy of perhaps ten how to use an etch-a-sketch.
The paediatric wing has been recently repainted, within four years. It is the newest-looking section of the hospital. The rest of it is bare, dingy, peeling paint and ancient linoleum floors. It has the bare and forgotten look of old staircases in the poorest hospitals I have ever seen in the States. It is the country's "reference hospital" - a teaching center, as far as I can tell, a concentration of specialists and unmatched ability - for neurosurgery, gastroenterology, ENT, nephrology, and urology. Perhaps others. This is a major medical center, like our university hospitals. Patients are bedded six and eight to a room, windows open to circulate air through stifling hallways. Only the ICU rooms and the pediatric wing have air conditioning. They are clean, yes, as far as I see; I am sure the doctors are competent enough. One neurosurgery trainee stops to chat. He carries a thick English textbook I have seen before.
I think of my patients at home, complaining, irritated, demanding more comfort and private rooms and better food and snacks from home and I watch the grave and solemn faces of the patients here in this public hospital, this last line of specialists for the country of Nicaragua. I wonder, as I have so often before, whether a surfeit of luxury has made of us infants our entire lives. They are not here in this hospital for comfort, though the walls around them are sturdier than those of their homes. They are not in the hospital for gourmet luncheons and pain medications on command. Care is free. Medications are not. They are in the hospital in desperation, hoping to get well.
The chart in the room where we meet with the hospital's director shows the top three causes of mortality. In no particular order, they are renal insufficiency, diabetes, and intracranial trauma. "There are a lot of car accidents," she explains. I listen. There is no reference hospital for cardiology. A specialist physician here makes perhaps 5,000 cordobas a month; a general doctor 2,000. At sixteen cordobas to the dollar, that's about $150 a month. Enough to live on, here in a country where 80% of the population makes less than two dollars a day. At the private hospitals, where the wealthy go for their care, they make more.

We leave, sobered, some of us. We think of our expensive and shining children's hospitals with their two cribs to a room, four patients to a nurse, TV and Starlight Foundation X-boxes, and mentally we must pause and compare them to the room with two beds and six cribs and eight women, each holding a hydrocephalic child in loving arms, taking the stuffed toys we bring and coaxing pleased reactions from their babies, oversized heads lolling against faded cotton blouses. This is the neurosurgery center for the country. They are in the best of hands. I remind myself of this, and I wonder and I grasp for understanding, but find none.

Tomorrow I leave by schoolbus. I anticipate twelve hours to the health post. I have been promised my own translator and my own patients. I am terrified in my heart, but at the same time I am exhilarated, empowered, excited. I cannot wait.
I will write, O Best Beloved, write down the things I see and the things I do. I will watch and write and take pictures and store it all away in my heart of hearts because I am so very blessed to be here a second time and if there is one thing I do not want to do, it is miss a single lesson that the next weeks will teach me. And when I am done, I will carry it back to you, because if there is only one way to learn something forever, it is to teach it to another. And I have come to know that in telling you, I have drawn a stylus of silver and moonlight across the ready slate of my soul.

I am ready.
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