One Terrific week with Ines

As some of you know, Ines and I had a week long vacation together around Chiapas. I think her blog (click “Mein Fraulein” on the right column) summarizes the trip very well although I thought I would just add some pictures. My favorite part was the Chiflon waterfalls where we had no expectations because it is not in the guidebook and found ourselves at the top after an hour´s hike dripping wet and surrounded by rainbows.

Who´d a´thought i´d get the white horse! This was taken after our ride to the indigenous town of Chamula and before we realized we could not walk. See, her horse was biting every other horse the whole time. It fit her personality well though!

Chiflon. Note that rainbows don´t come out in Sepia mode. We had individually climbed to the higher deck where the water raced around us.


If Ines were Mayan this would translate to a lazy Friday on her back porch. The clouds were not friendly and 10 minutes later we were caught in a bad rainstorm on the opposite end of the ruins without a plantain leave to be found for shelter.

Agua Azul (blue water), literally Agua brown this time of year but it was a nice walk in a trip infiltrated by water in one form or another.

Goodbye Altamirano

I had originally planned to stay at the Hospital San Carlos until I flew home for Christmas but as my work continued, the politics changed. When I had first come, I was told by the coordinating doctor that I should start in consult rooms with another doctor until my Spanish improved. As the first week progressed, I changed my role from observing the patient visit to doing the physical exams only, and then to interviewing the patient as well. The other doctors were very patient with me and gave me room to work with the patients as we alternated interacting with our patients. Finally, by the second week, I started the hardest part: writing the patient histories in the chart. So many words were new and that was a completely different education. For example, I did not know that “Costo-verterbral angle (CVA) tenderness” is “Giordano positivo” or that our “pitting edema” is “Segnas de Goethe.” Nevertheless, I learned a lot and by the end of week 2 was confident enough in my patient visit to start seeing patients on my own. This continued until about week 6 when I was called in by the oldest nun and scolded for not giving a patient with a viral throat infection some medicine. I tried to explain that it is viral and we don’t give medicine for that and that I did tell the patient to take tea with honey for her cough but that was hardly good enough. It seems the sisters are very keen on giving out some medication, even if it is only vitamins. This, I refused to do because the patients have to pay for their medicine. I suppose she spoke with Sor Maite, the head of the hospital because the next day, I was called up to her office and told I was not allowed to practice solo anymore – that I was a student and therefore not responsible for my patients legally. Although the idea of a lawyer coming to Altamirano is as funny as a liposuction clinic starting shop there, she had a point about legal responsibility. Unfortunately, she did not trust any of her own doctors enough to let me continue seeing patients on my own and presenting them to that doctor for their signature. In my mind and in the mind of the United States medical system, once a licensed doctor signs a patient history he/she is legally responsible for that patient. But that is not the mind of Hospital San Carlos. Dismayed and not sure if I could continue – for if I weren’t going to be on my own then I was not being helpful and I am past the level of training where being in general consult with another doctor is the least bit useful to me – I walked down the stairs of her office and followed, feeling like a puppy dog, into another doctor’s consult room.

me, intubating one of the cleft lip kids

That day, however, the coordinating doctor told me I could start on my own again with his signature on the charts. That continued through part of that week until an American Family Practice resident came down from California. He had wanted to observe consults so I invited him in with me, thinking I could use his “medical doctor” signature on my patient charts. We saw one patient and then I was called out and invited to a special meeting between one of the doctors with whom I was not close and Sor Maite. Sor Maite, with a very worried expression, repeated that I was not to be solo. Then the other doctor, aligning herself heavily with the Sor, diminutive the American doctor and told me that working with the new resident was unacceptable because they did not know his credentials. Thinking it unlikely that a plumber or hair stylist would make his way down to hospital San Carlos in Chiapas and then pose as doctor, I dismissed this error as an honest mistake. I didn’t know he was a hair stylist!

Then the other doctor accused me of using an incorrect dosage of an antibiotic. That really hurt me because the thought of doing that is really scary. I had looked up the dosage and I was pretty certain that I hadn’t but Sor Maite, who has no medical training became even more worried about my practice there. Now, forced to stay in the room with someone else, I felt like was wasting my time staying at San Carlos when I could have been helping teach the health promoters and seeing patients in Amatan. Still not ready to leave though, I decided to start working outside of the hospital in the community and had a couple very educational experiences as I have previously posted.

Finally, I made a deal with Lorraine, the older Ob/Gyn from Massachusetts, who had felt very isolated in Altamirano and had asked me to stay until she left, that if I were going to stay, she had to take me under her wing, let me assist on all of her surgeries and teach me. She agreed and I had a very good final week as an Ob/Gyn apprentice. To her credit, she had confirmed that the dosage of the antibiotic I used had been perfectly acceptable and in fact was the dosage she used all the time. She even told Sor Maite that much but after that point, there was no going back for me. Hospital San Carlos is a beautiful hospital that does many terrific things for the indigenous people.

The sisters who run it are very caring people but they are not without their faults and with my independence and normal problems with hierarchy and authorities it would not have been prudent to stay. That is why I am now in San Cristobal, having seen Lorraine off today and waiting to go with my group to the disaster zone of Hurricane Stan to work in a clinic down there. In order for me to stay in Chiapas, I need to feel either useful, helpful, or like I am learning something. Without a combination of those three, I would be wasting my time and feel like I am on a vacation when I do not wish to be on a vacation.

As a side note, Lorraine was nice enough to give me her digital camera for my remaining 3 weeks here so pictures will follow – although I am not sure if internet will be available near Tapachula. Until Next time, Ryan

Thanksgiving and First failed Experiments in Aviation

Today was Thanskgiving; they translate it as El Dia de Gracias but they don’t celebrate it and I’m pretty sure Cortez never shared a meal of brotherhood and understanding with the Aztecs. Then again, neither did the Pilgrims exactly – exchanging influenza for syphilis over cornbread is not what I call a satisfying postre. Anyway, it is my favorite holiday of the year – a non-religious, family-oriented celebration of the fall. Personally, I think it should happen in the beginning of October and outdoors but as I have not been requested for hire as an independent consultant for Hallmark yet, it remains traditionally on a Thursday and in late November. As there it stays, Thanksgiving has become an important marker for what has now become more than a month of Christmas. Although Christmas started on the 25th, a variety of interest groups have been proselytizing and baptizing the previous days from “the 12 days of” to the “2 weeks before” until “the month of…” They seem to be blocked in their concept for the Christmas year by Thanksgiving though and it looks like it will end there unless Easter creeps forward. Anyway, I was never very good with dates and have always depended on my family to remind me when Thanksgiving will be every year. When this year, someone told me it was going to be on a Thursday again, I asked another American doctor, Linea, what we will be doing to celebrate. I remember 12 years ago and in Belarus being invited by the U.S. Embassy to have an official state sponsored turkey dinner, so naturally I imagined being called in by the town council of Altamirano, Chiapas for a special celebration. Instead, Linea said she had planned on making a pie and had indeed already bought all the Plantains she needed. That’s when the poor idea of making our family’s apple pie entered my head. So after a myomectomy and the delivery of an ovarian cyst the size of a small watermelon, I walked down the central street to find apples.

In the one market that had apples, the owner tried to sell me a type called red delicious but I would sooner make an apple pie with fig roots than with red delicious and I think my father would agree. They are soft and watery and sweet apples, really. They are the simple man’s apple. People who enjoy red delicious tend to also own golden labs, enjoy watching golf and drink Budweiser beer. They also eat Chinese food with a fork in case you are still confused. The other option, however, was another red apple. Smaller and bruised, they looked like they had already been thanked for giving by a angry gang of worms, perhaps pawed over by the wild dogs and then used to fill a flat tire on the way to the market. It was a very political decision but I decided to go with the battle-wounded that resembled a cachectic form of what stood out in my childhood memory of a perfect apple for a pie.

Next I had to find orange juice for the crust. I walked to the largest market in town only to find that although I could easily buy peach or guayaba juice in cans, they had no orange juice. Of course I could have squeezed my own but I did not want to spend my entire afternoon making juice as well – which is bound to be nearly as sour as lemons anyway. What they did have was Ju-Mex – a Sunny D-lite/Tang like drink with “real orange flavor.” Seeing as I had already accepted the leprous apples, I bought the orange flavor and went to Juan Manuel’s kitchen to “experiment.”

Assembling the crust proved to be the hardest part. Aside from the OJ imposter, I was faced with no measuring cup, no real bowl, and butter instead of the Crisco that the recipe requires. Linea said I should use 2/3 of the amount of Crisco in butter and I was going to use the full ¾ cup so I decided to split the difference. Because it was cold, the butter had to be melted on the stove and then I mashed it with a fork but I could not get it to mash right and was left with whole chunks of butter buried in flour. So I added more butter. Then more Ju-Mex.

During this whole time I was reminded that my mom used to make clay for my brother and I on rainy days from flour and water and salt. With that thought, I was acutely aware that whereas I had wanted to make dough, I may have been assembling clay instead. Well I mixed everything and it still did not work. So since you cannot subtract in the kitchen, I kept adding until I could finally assemble a ball of dough. Then, worried that the next time I saw it may have turned into a solid sphere (I imagined myself having to explain ‘instead of a pie I made a globe of the world to show you all where I live!’) I wrapped it and put it in the refrigerator to let it think about what it had done.

About that time, Lorraine, our American Ob/Gyn came to help me peel and cut and excise the ulcers from said apples. To my surprise, Odile, the Swiss doctor had shown up the day before with a jar of wheat germ. This wheat germ, an inferior distant cousin to our wheat germ, however, was tasteless and so small and powder-like that if you breathe at it the wrong way, you could scatter it into the wind and make someone sneeze in Guatemala. But since I was making the best of it, I decided to use it anyway, and in fact use twice as much. Even if the apple pie tasted like a box of Kleenex, it was at least going to contain all the right ingredients.

Next, I called the dough out of the fridge and rolled it on the table using an empty jar of jam for my rolling pin. The dough had the distinct resemblance to a stretchable eraser, but subject to enough abuse, it was able to get it into a large enough size for the pie pan. I hurried to transplant it and let it stick to the pie pan before it snapped back into a ball of dough and perhaps rolled itself back into the refrigerator to hide.

Pie completed, I placed it in the oven, lit several matches, and set the oven on level “5” for “hotter than 4.”
When finished, it looked pretty, and people enjoyed it after I had carefully explained to the other doctors in my Spanish that Thanksgiving is the time of the year when the Pilgrims and pumpkins got together and ate the Indians. But in reality, it tasted like apples in a cardboard box. No one noticed, though, and no one tried to top their pie with beans and salsa which was a sure compliment to the chef that they enjoyed the flavor --- or at least the change from the beans and salsa they had piled on top of the beans and salsa that was our dinner.

Making things more authentic for the Thanksgiving experience, the electrical company shut off the power for the entire town at 2pm because the municipal had not paid their bill so we sat ate our dinner by candlelight. There we sat, three people from the United States with the modern versions of native Mexicans, passing apple pie pieces and beans and salsa (though not together) – it was so metaphorically perfect, I may have had tears in my eyes – if you could only see them in the dark!


Yesterday, what started as a simple lantern made of paper by a nurse developed into an intensive origami training program in Lorraine’s room until I would not stop before a hot air balloon was generated. We mastered the paper balloon over our lunch break and I quickly decided to expand to a larger piece of newspaper. Then I taped a plastic cup to it with dental floss below the opening and placed it aside, proud of my accomplishment. Frightened by my concept of filling the cup with gasoline, Lorraine kept the balloon well hidden until tonight when, bored and sitting in the candlelight, I decided it was time to take it to the air. The gasoline stores closed, I filled the cup with tissues and headed outside, my aviation glasses and silk scarf in place. Lorraine followed for the momentous occasion as my “co-pilot,” I said – “chaperone,” she said. After several takes, I finally succeeded in burning the entire balloon, plastic cup and then reluctantly, the tissues. Well, that happened to the Hindenberg too but that doesn’t mean it wasn’t great. A car passed us as we watched my dream of escape turn into a small fiery flare in the dark street. Although I will next be heading to the disaster zone of Hurricane Stan, near Tapachula (where the floods are that had been on the news in the U.S.) and she will be heading to her home in Massachusetts, we both have two days left here in Altamirano and we are both ready to leave. “If the car stops,” I said to her, “tell them we got lost in Texas and our car broke down but we were on our way back to New York and could they give us a ride as far as the border.”

This morning I woke up without electricity, without hot water and without cold water. It is 48 degrees inside during the night and this week my new digital camera was stolen. I don’t know what the pilgrims were thinking, but I would not mind going back to the United States for a few days. At this point it is three more weeks until my break. Currently, however, I am looking forward to that warm Tapachula sun about which so many popular American folk songs have been written. Happy Thanksgiving!!

Into El Campo

In the past couple of weeks, I have had two opportunities to go into the Zapatista communities (‘partes de la resistencia’ as Aurora, Gregorio’s wife fervently calls them). The first time was with Gregorio, an older Mexican doctor who speaks with a well annunciated deep voice. He and his wife, Aurora, had lived in Guatemala for years and had only returned in the last 4 years to work with the Zapatistas. Gregorio oversees the medical clinics in three of the Zapatista municipals while Juan Manuel oversees another three. That day we going to one town to help the health promoters (promotores) give vaccinations. We left at 7 am in Gregorio’s double bench pick-up because we had to get the vaccines from Ocosingo. As much as the Zapatistas try to stay separate from the Mexican government, they still take their health supplies from them. Historically, this should be of no surprise. For example, the only official relationship the stolid Soviet Union had with Europe after the First World War was through their health department’s infectious disease offices as well.

Ocosingo is 30 minutes from Altamirano, but the journey took us longer because every time they saw someone walking or looking for a ride, we would stop and offer that person or that person’s entire family to climb in. We went from 3 people to 4…7…10…12 people before long. Before long, however, but definitely after the need to exhale had passed, the vaccines, in picnic coolers with ice packs, were loaded in back and we had left the paved road for a dirt one and had arrived in a small town of spread out houses, grass fields, and the small clinic which in most of these Zapatista towns is always the exact size of a hotdog and french-fry stand at a baseball game. One of the Promotores brought out the megaphone and announced that, although we already had half a dozen kids in our truck, vaccines were being done for the remainder of the town’s children. Mothers with 2-4 kids ambled in through the grass fence and lined up to hand us their vaccination cards. Aurora had left to do consults somewhere else (she practices homeopathic medicine). Gregorio had wanted the promotores to do all of the vaccinating because we were there to help them, so I helped him do the registrations.

They receive the same vaccinations we do and use the Sabin Polio vaccine. (Recall that after a huge medical feud and a long hatred between Salk and Sabin, we now have two forms of polio vaccines, Salk’s dead polio and Sabin’s live inactivated. In the states we used Salk intramuscular shot because there is always the fear that some of the live, inactivated may not be fully inactivated and every once in a while someone with the vaccine comes down with polio (1 in 2.5 million). But then again, Salk’s form does not create quite the same immune reaction and there is the possibility that it does not last as long as Sabin’s. Not to mention which, Salk´s is an injection versus Sabin´s oral drops. Needless to say, Salk and Sabin hated each other and we have two vaccines.)
About 30 kids received some vaccine or another in their butts or arms or mouths according to what our records and their papers said they needed. Afterwards, the three of us did a few consults and ate a quick beans and tortilla lunch.

Consults without labs is interesting. Clearly not everyone needs lab tests. There are certain ailments for example, for which there is no great lab test. Surely for gastritis or acid reflux, we could do an H.Pylori test and an endoscopic exam with biopsy of the stomach lining, but not even in the states do we go that far. I diagnosed a urinary tract infection and an umbilical herniation, neither of which really need lab tests but knowing that we cannot do them anyway, feels like working on a high wire without a net below. Since the clinic did not have enough medicines, Aurora opened up her treasure chest of homeopathic liquids and poured 3-4 drops of something over a few pellets of electrolyte salts. I thought we should say a quick prayer as well to double our chances of cure but I did not say as much. There are many strange forms of medicine out there that work in more than just the 33% of the population who enjoys the effects of sugar water (placebo effect) than we understand.

After we cleared out of that town, we came to another, smaller village where there were no roads and hiked in, taking turns carrying the ice box and homeopathic treasure chest. Fifteen minutes into the hike, after one creek and two hills we arrived at a picnic table and set up shop once again, after Aurora made sure everyone was parte de la resistencia. After vaccines, we did a few more consults – including one child with Scabies who received more electrolyte pellets and mysterious liquids. They served us another lunch, which consisted of chicken-based soup and lemonade and watched us as we ate it. It was probably more food than they ever eat in one setting and although the woman who served us had dipped her very dirty fingers in every glass and we did not know where the water came from in the lemonade, and I was sure I was going to be sick we ate it all. And I did not get sick.

Kids Find Out They Are About to Receive Shots!

Another two weeks passed before I went back to the community, this time with Juan Manuel, a Mexican doctor from Aculpulco who served down in El Salvador for years before moving up here to help the Zapatistas about 10 years ago. A tall man with a straight mustache, deep eyes like a bull (one eye that does not work), and a quick smile, Juan Manuel enjoys lecturing on the difficulties of the people. Although he is the first one to say he is not a Zapatista, he helps their health promoters fight for what they believe in. We left on a rainy morning and headed into by collective up to Ocosingo and then waited for a car to take us to 1 de Enero, the community in which he was going to stay for three days to teach Promotores from different parts of the same Municipal.

Like many Zapatista towns, the buildings are covered with colorful murals of Commandante Marcos and Che Guevera and colorful landscapes. In the small clinic, we were met by 10 young men and 3 women with smiles and handshakes. After we shake everyone’s hands Juan introduces me and they all clap. It felt good to be there and we started right in on talking about the importance of Vitamin A for children. Tzeltal is their native language and Juan Manuel tries to speak it to the extent of his knowledge which is quite impressive (and gives me the freedom to leave the room and explore the town because I don’t understand a word they are saying). When the children saw me taking pictures, they ran up to me. I had one follower initially, but they quickly grew and before long I had an entire class of at least 25 kids around me. They were fascinated by the camera and made a game out of hiding from its view. They would surround me and when I went to press the button hide behind trees and buildings. That was, at least, until one of the teachers came out and yelled at them for leaving his classroom without persmission.

At night we had a discussion about organic coffee production, which the head promotore, Juan, has just started doing. The coffee bean season has just begun all over Chiapas and as an important source of income it is a major topic of discussion. One person can pick nearly 25 kilograms of coffee beans in one day. The organic crops in collectives pay better than the non-organic ones.

All the health promotores have second jobs to support their families. They work as health workers out of interest and out of their own passion. They have a deep desire for what they do, but their capability is hindered by their lack of education, inability often to do multiplication for drug doses and no formal health education. What they have is what people like Juan Manuel can offer them and what they can read from Where There Is No Doctor, their textbook. They know plant medicine very well, however, and use that whenever they can as a supplement to or instead of manufactured medicines for pain or to treat symptoms of an infection.

The Outback Medical bible

When the night wore through and the candles were already low, we put tables and benches together to make beds. I had my sleeping bag and pad but still slept poorly owing to the flickering candlelight, the relentless mosquitoes and ants. At one point I woke up and my lower lip had a knot in it from my biting it I think. In the morning, when we got up at 6am, my right eye was swollen nearly shut. I presumed I was stung by something and I cursed myself for probably looking so feo on the day before my Ines arrives. Fortunately, by midday it was entirely gone. We had started classes at 6:30 am and I stayed until 9:30. Then I said my goodbye’s, thanked Juan Manuel for the experience and headed out to the edge of the community to wait for a truck to ride into Ocosingo.

In the truck I met a young man who said he worked for Mexico’s only gas company. He leaned forward and told me “I carry cocaine.” I did not know if he expected me to buy some or just that he had to tell someone. I told him it was very dangerous and I suggested he not use it. He agreed that he does not use it, he only takes it from the Chiapas border – where it arrives from Colombia – to Ocosingo where someone else takes it up Baja California to the United States. I asked him how much it pays and he said two dollars. I do not know if that is per kilo or per delivery. So I told him it’s not worth swallowing and he agreed saying that he just wears it around his waist. He asked me if I pass through Ocosingo occasionally. I said I did and he promised to look for me. You can try, I thought, hoping I never see him again!

I am now in San Cristobal, staying in one of the regular 10 dollar hotels while I wait for Ines. Tomorrow afternoon my luxurious vacation begins. Nice hotels and food are not something that either of us needs, but I think it will be worth it.

I leave you with an image from the day after the Day of the Dead, November 2, a very special day here during which family members visit their deceased relatives in the cemetary and leave them flowers, foods, and things they liked when they were alive.

Next post on ´Problems with Authority -- la cuenta de mi vida!´ And why I am leaving for Amatan at the end of this month.... For now, 8 days with Ines and all the treats my family sent down with her --- thanks Mathew, Mom, and Dad!

New Post coming!!

Sorry it's been so long for anyone who has been sitting at their computer, waiting for a new blogpost, not eating or sleeping, and now is drooling and smells funny. I will post a new entry on Friday afternoon, I promise!!

Thank you for all your comments, it is a really good feeling to know even if you don't smell funny, that you are interested in either my life or in rats (like the one i couldn't get out of my bathroom this morning) or cockroaches (like the one that dove out of my tang powder into my water last week) or chiapan life.

Ryan