Quiet Places

 Our jeep moved cautiously along the muddy trail under the tall forest canopy. Despite the jungle cover, the roads become quite wet and the soil turns to glue that is almost liquid as you slide on it and then remarkably solid when the vehicle arrives at its resting place.  As we slithered, the monkeys followed above and commented on our progress.  Abruptly, the road turned, trees disappeared and we entered the small village that was our goal. There was a fire pit at the near end of a central clearing and some small fields at the other for growing vegetables, sugar cane, manioc and whatever products could be gleaned from the fertile but fickle soil. As we came to a halt, the Mayor of the place appeared to welcome us and the school bell began to ring. The “Accion Civica” team was here to provide the episodic medical clinic, consultations about agriculture and spread the gospel of democracy. This was the sixties and Fidel was spreading his own gospel throughout Latin America. Crude dictators were springing up as enthusiastic disciples. We were the counterreformation.

 I enjoyed these trips to places where people lived beyond the end of the road, despite the sobering knowledge that medicine was simply the lever to open the door for a political message. Medicine held such a high place in my life that it concerned me to see it used as bait. Nevertheless, we did some good and practiced clinical medicine of a type close to the original sense of that term where the five senses served as diagnostic kit and laboratory. Our portable medical box held only basic medical and surgical tools, along with antimicrobials, antihelminthics, antiseptics, antidiarrheals, and topical antibiotic ointment. We were anti most things. Another box contained a (sun)light monocular microscope and Gram and acid-fast staining solutions. We had all we needed. Hyperaldosteronism and apathetic hyperthyroidism were not considerations here.

 The schoolmaster’s bell brought people from the various huts and farms and out of the jungle. They were mostly children, herded by their mothers so the Doctor could look into eyes and ears and at rashes, non-healing sores, and sore throats; listen to coughs and chests; and poke bloated abdomens. Rashes and sores were cleaned and treated. Blood smears were made and quotidian fevers quieted. Pulmonary rales were managed with antibiotics or antihelminthics, as indicated. 

 The children ran around inside and outside the school that was the temporary clinic, shouting excitedly. This visit made the day special and provided the unexpected benefit of closing the school. Some of the men began to build a fire and a large pot was placed on it. They filled it with water and the women brought vegetables and roots for the stew that was to be our payment. Several reluctant chickens came to the party as well. The Mayor made a speech and everyone applauded. The men discussed the issues of the time and the women shouted at their children. One of us suggested gently that the stew be boiled first and then simmered. 

 As people passed into the clinic and out the other end of the porch, the day evolved into a fiesta. The scene always seemed to me to be the twentieth century equivalent of a medieval medicine show but I enjoyed it, since, unlike those shows, we actually did some good. Malarial fevers went away, diarrhea was halted, bacterial infections disappeared, worms were purged, and preventive medicine was explained. Leaflets were given out to teach about parasitic diseases, water-borne diseases, tuberculosis, nutrition and hygiene. We generally left a village at the end of the day with a feeling of fulfillment and not a small amount of self-congratulation. The fact that all these evils would return in about a month was not discussed. Medical change required fundamental economic and political progress and that was not to be. So, we convinced ourselves that short-term medical progress was truly social progress. Kurt Vonnegut had it right: “…and so it goes.” It was intellectually rewarding, from a clinical point of view, and viscerally satisfying, from a human perspective, and a more formative time in my own career than I knew. It was medicine as I had dreamed it.

 This day, at the noon stew break, the schoolteacher approached me about a woman who needed my assistance but could not come to the clinic. Would I go and visit her? The stew was never truly flavorful but I still would have preferred it to a walk somewhere to see a person who did not want to come in. I was to pay handsomely for that unworthy thought. Nevertheless, I agreed and the schoolteacher indicated a narrow path that led into the jungle and said the walk would be about twenty minutes and her home would be the first hut that I would encounter. I took my small kit and started out.

 Jungle is green above and brown below and all is dim and wet. It swallows sound. Despite the abundance of birds, insects and animals, relatively little is heard. It is visually rewarding: Bird-of-Paradise flowers grow wild, as do orchids, and wonderful parasitic plants. The smell is fecund and the sight and sense of decay and the tenacity of life are pervasive - from the rotting vegetation giving birth to new growth to the parasitic plants in the trees. The wetness makes more of an impression than do the monkeys that follow you through the trees or the bright-plumaged birds that call. The skin is alive with the humidity and hypersensitive to the touch of cloth or leaf. The miracle that makes possible all the varied life in this part of the earth drips down your arms. The quietness aids the mind in its perusal of the surroundings but the information is processed in a primitive manner. One is confronted with the apparent contradiction of the transience of life and the timelessness of the place.  But the real message is the appalling indifference of an enduring system that provides abundant life that goes on to die, apparently casually, to become new life and has done so for eons and will continue long after you have not. One does not take himself too seriously here.

 The hut was a surprise in a sudden, small clearing, and of the usual type: it was raised on poles, out of respect for the heavy rains of the wet season, and had a palm thatch roof and a single, open floor with a small sleeping room. It was quiet here too, but quietness of another type; this was not sound smothered but sound absent. Had I not seen the figure standing in the doorway, I would have thought it uninhabited. She was a short, brown woman with the lines of time on a relatively young face. Her feet were callused from harsh use and the loose dress had been washed in rainwater often enough that the floral pattern had withered. The terrible thing was her eyes. In the centers of the surrounding wrinkles were two shining, brown windows through which her soul spoke and the message was of hope and gratitude that I had come. Everything now would be all right. I was too naïve not to have been immediately afraid. 

 Her story was delivered in a low voice that was insistent and rapid. I stopped her and explained that my Spanish was still a bit weak and she would have to tell me more slowly. In answer she led me silently to the back of the hut where her husband lay on the floor. One look and I wanted to be almost anywhere else in the world. He had a dense right-sided hemiplegia. She turned to me nervously, smiled slightly and waited for the magic to begin. He looked at me as well, out of a drooping face. This was not a neurological game of description of a lesion, nor was it the passing out of nostrums to support the policies of governments. It was a primal human encounter as immediate as the jungle that surrounded the scene: the shaman was here to exorcise the demon that had destroyed this family, and she waited expectantly for the dancing to begin.

 I let her talk and describe the story I already knew and slowly gathered my composure. Then, after the rite of the history, I began the ceremony. The stethoscope was laid on, the reflex hammer applied, and probing done. Strength was tested, motion judged, and bed sores searched for. I talked a bit to him and her as this went on so that the appearance of incantation was met as well. He was neat and clean; this woman had cared for him well. Then the service was over and the moment of truth filled the place. 

 She had anticipation in her face as I began to explain what had happened to the man she loved and lived with and worked alongside of on the patch of a garden they had coaxed from the forest. We spent time on the blood supply and how it moved; then more time on why it no longer worked. Her eyes grew dimmer as their doors began to close. But they brightened again as she asked how much longer this would last. So I took her hand and explained some more while the life went out of her soul and the body slumped as we sat together on the floor. And I felt the shame and inadequacy of failure that my tools and knowledge were useless, as were the diplomas and various awards I had garnered. Now she understood, more quickly than I, that he would die out in this place where people rarely came; that her small farm would not be worked again. I had changed her from a wife allied with her husband wringing a living from the reluctant earth into a nurse who would now live on the charity of others. And I knew bitter humiliation because I had brought this knowledge to her without the hope that could make it bearable. My current emotional support would fade very soon in the face of the reality of living here. 

 So we sat a while together saying nothing and then I let go of her hand and made an excuse about returning to my work where I was doing amazing things and went out the front and down the steps and back into the jungle from which I had appeared and life back there simply went on standing mutely still. The looming, indifferent jungle crouched and lowered around the clearing as it made plans to take it back. I still could see the woman sitting by her husband, looking out of her home with her back to me. What was she pondering: regretting that she had sent for me at all since she had the hope of ignorance before I came; planning a way out of the situation; perhaps completely despondent in the face of the reality? Or, perhaps she was asking some existential questions that ultimately are forced upon us all.

 I did not know those answers and disappeared myself back into the green mansion where the umbrella ants with their leaf hats walked the jungle floor into dirt to make the path I followed for a while. I thought about her and of the oddness of an existence that brought pain and confusion into lives of subsistence sustained by constant work yet which were complete until this enormity invaded their home.  The jungle was very quiet; as quiet as the man who lay back there on the floor; as quiet as the devastated woman who sat beside him. I walked, defeated, in my own cocoon of silence created not so much by the surroundings as by senses that seemed to have recoiled from the incident and isolated me as a defense against the monstrous unfairness of what I had witnessed. Confusion roiled inside, as I contemplated a long education and a life that had served me well and yet served these people so badly.  I had come squarely against a fact of life, a biological event, a social misfortune, a moral horror and was able to do no more than explain the event and offer well-intentioned support. My good intent, the craving of a young physician to make a bad situation better, had been nudged aside by life. Then, partway back to the village I paused abruptly in the path, hearing a question that came from far inside, “What will you learn from this?” At that point I think I stopped being a Doctor and began to be a physician.