A stocky man with thick red hair and a red beard, wearing a blue-and-white batik shirt over his trousers, and leather sandals, Fogarty appears from one corridor with his arm around a shy, part-Indian girl, whom he guides through the mob. This is “Clinic Day” for the Interplast team, which flew in last night. Before the operations begin, the surgeons have to see the children, carefully examine their problems, and conduct a difficult triage. The sad truth is that someone with a defect requiring all day to do will have to be turned away, since a greater number of people could be helped in the same time. Eye surgery is also out, as well as anything else that could lead to massive complications. The hospital doesn’t have the equipment, the cardiac facilities, or the supplies of blood and other necessities for a crisis, so they must choose reasonably healthy children, with defects operable under severely limited conditions. Although the team members have many reasons for making the trip, some purely altruistic, some more self-concerned, learning to make do with the minimum—indeed, discovering what that minimum is—is probably one of them. They will also have a chance to take part in tough, challenging operations they may only have read about; to do medicine the way it was done in the days before high technology; to improvise with few supplies and much cunning; to solve problems that, left untreated for too long, have become nightmarish and almost unsolvable, except through high-wire acts of virtuoso surgery; to learn techniques from others faced with the same rigors. That it will stir them deeply, and may prompt them to inspect their feelings about medicine, is also part of the draw. In a sense, it is a way to renew their vows.
In Room 9, surgeons Ruth Carr and Dean Sorensen sit behind two wooden desks, waiting for their first patients. Ruth is trim and petite with shoulder-length blond hair, wearing a denim skirt and a green shirt with a small pink polo player on the chest. She practices in Santa Monica and has a twenty-month-old son. This is her second Interplast trip. On her desk, a brown plastic pot of tongue depressors stands next to a purse-size flashlight—her only examination instruments. Across the room, behind the second desk, sits Sorensen, a tall, athletic, sandy-haired man, wearing a starched white coat over tan pants and a green shirt. Ruth speaks Spanish, but we also have in the room a teenage girl from the local international high school, who acts as an interpreter. Schoolmates of hers circulate throughout the other clinic rooms, translating, carrying Coca-Colas and files, and running errands.
A young mother enters, cradling a two-month-old girl named Isabel in her arms. Dean seats them on a stool beside his desk. Dressed in a blue shift, with a simple black cross on a black thread around her neck, the mother sits with the baby pressed snug against her shoulder, and arranges the baby’s bright red blouse, red socks, and diapers held by yellow-capped safety pins. Isabel’s hair is a small cyclone of dark brown. The mother rocks her as she cries.
“Why is the child here today?” Dean asks through the interpreter.
The mother turns her baby’s face toward us, so we can see the completely cleft mouth and exposed nasal passages. It is a savagely disfiguring birth defect, in which the mouth appears to be split in two and turned partly inside out. Otherwise, she is a stunning little girl, with loam-brown eyes and mocha skin. Because her cleft is so wide, she won’t be able to touch her tongue to the roof of her mouth to speak during the crucial language-learning years. Many of the children Interplast sees today will have equally severe clefts, a birth defect that strikes one in every 600 people. Because the United States has so large a population (260 million), and birth defects are operated on right away, people with clefts aren’t as visible as they are in Honduras, whose population is only 4 million, and where inbreeding and malnutrition may be contributing factors. Dean peers into Isabel’s mouth, using a flashlight and a tongue depressor, questions the mother about the child’s general health, then takes her photograph, and at last jots down her name on a master sheet. She is an ideal candidate for surgery.
Dean explains to the mother that the girl requires two operations, a cosmetic one to make the mouth look normal, and a practical one to fix the palate. He reassures her that the operations will be free, that she can stay with her child, that she will need only to spend a couple of days right now, but that she will have to return in six months for the second operation. They can do only one part of the procedure at a time, and it is far more urgent that the child’s mouth look normal and be flexible. At the moment, Isabel is incapable of smiling, and that makes her helpless, vulnerable, and unarmed. Her life will be simpler if she can speak normally, but it would be a dreadful nightmare if she couldn’t smile.
For an infant, a smile is the real human coin of the realm, as valuable to a Maori girl as it is to a boy from New Jersey. A child needs to be able to engage adults in a broad, open smile that can stop them in their tracks, elicit love, and turn antipathy to goodwill. Smiles are infectious, and rejuvenative. In 1906, French physician Israel Waynbaum offered a theory of how facial expressions affect our moods. Just shaping the mouth into a smile increases the blood flow to the brain and we feel elated, he said. More recently, at the University of Michigan in Ann Arbor, psychologist Robert B. Zajonc has been updating and extending Waynbaum’s findings. It now appears that smiling also changes brain temperature and the release of neurotransmitters. Studies conducted by a psychologist at the University of California at San Francisco suggest that facial expressions conveying disgust, sadness, fear, and anger trigger nerves, which in turn signal brain areas responsible for heart rate and emotion. Although this is still a controversial issue among psychologists, the evidence strongly suggests that changing your facial expression can change your feelings. Norman Cousins, a longtime advocate of riotherapy, argued the usefulness of laughter against a variety of ailments, and told of his own success with watching guffaw-producing films in his fight against cancer. Adults find smiling, happy children more attractive, and attractive children receive more attention from teachers and more encouragement and affection from their parents. Smiling is an essential part of the shy pantomime we call flirting.
But a child also needs a normal mouth to perform that large repertoire of nonverbal signs we make with our faces, revealing moods according to a set pattern that people instinctively understand and expect. There is a code of basic facial expressions which all humans share—happiness, anger, fear, surprise, disgust—which are recognizable to people from different cultures, who speak different languages, who have never met, who seem to have nothing in common. A face is only bone, cartilage, tissue, and skin. And yet when these components work in unison as they were meant to, they create many thousands of subtle expressions. Children who are born blind make the same expressions as those who are sighted. Spontaneous, automatic, the face forms words before the mind can think them. We often rely on facial semaphore to tell us truths too subtle or shameful or awkward or intimate or emotionally charged or nameless to speak. Cancel that language of the smile and glance and you doom a child to a lifetime of emotional formality and effort, you cast it out of normal society.
Isabel leaves, and the parade of children continues: a mother with wide-set eyes brings in a girl who has Apert’s syndrome. Seventeen months old, the baby has twisted feet with six toes fused in pairs on each. Her hands have fused fingers. Ruth and Dean study X rays of the hands, and decide to separate one finger on each so that at least she will be able to grip things. Next comes Nubia: a four-year-old with short, curly hair and unusually long eyelashes, wearing a blue-and-red plaid jumper with a white-collared blouse under it and frilly anklets. She has fingers which surgeons fixed last May. Crying and hiding her face, she allows Ruth to open her hands, where only small white scars remain between her fingers. Ruth inspects them, and nods; they have healed beautifully. Now Jessica arrives: a three-month-old whose hair, just starting to grow, stands up in an unruly quiff. She has a wide cleft palate; one half of the lip vanishes into the nose. Then David: a five-year-old with a badly deformed ear that looks more like a small, dangling doll. After David, José: a nine-year-old wi
th a badly burned leg on which the scars look like small mountain ranges. He had been carrying firecrackers in his pocket and they went off.
By midafternoon, all the children begin to blur into one compound child, afflicted with itself, temporarily betrayed by its body. Many would profit from going to the United States for treatment, but Interplast can afford to send only twenty children a year, since it depends entirely on private donations of money, air tickets, and supplies. On principle, it has no government funding (and therefore no political interference), and the air tickets, especially, are expensive. So, instead, an Interplast doctor will often begin reconstructive work—to remove part of a burn scar, say, or do the first part of a cleft mouth-and-palate operation—on a child whom another Interplast doctor will continue operating on six months later. This works out all right for the children, and it unites the surgeons in a powerful invisible chain. For, although the doctors who patrol the world for Interplast seldom meet face-to-face, they often meet in the body of a single child. In May, one doctor will operate on a cleft mouth; in September another will examine his predecessor’s work and go on to do the palate; the following May yet another doctor will pick up the scalpel and perhaps fix a small hole in the roof of the mouth; the following September, another doctor may try to give the nose a longer and more natural philtrum. In this way, a child’s life sentence is rewritten, over many months, by many hands, with sutures. In a U.S. hospital, a cadre of psychologists, surgeons, orthodontists, and pediatricians would probably confer about such children. Here, decisions must be made fast. But on tricky cases, Ruth and Dean sometimes call in Dave Thomas or Dave Fogarty or Luis Bueso (who heads the project in Honduras), or all of them at once, to examine a child stricken with some delicately bizarre abnormality, and discuss what can be done.
Cleft mouths are by far the most frequent deformity. According to the folklore of many countries, the “harelip” is a result of a pregnant mother being frightened by a rabbit. One variation on this is that a mother only has to step over a rabbit’s nest to produce a deformed child, a catastrophe she can undo by ripping her petticoat in a certain way. This was so widespread a belief in Europe that an old Norwegian law actually forbade butchers from hanging up rabbits in public view. It’s hard to say why rabbits were chosen as the spell-carriers. True, a rabbit’s upper lip is cleft, but so is a cat’s—many animals share the trait. Along with cats, rabbits were thought to be witches’ alter egos, a supposedly harmless animal form they took when they wanted to get up to mischief. Throughout the ages, and in many cultures, rabbits have been associated with the moon. One African myth tells how the angry moon split the rabbit’s lip. And in ancient Mexico, a pregnant woman who watched a lunar eclipse supposedly caused her child to have a cleft lip. But it was always the mother’s evil, sin, or contract with the Devil for which the deformed child was a punishment. During the Middle Ages, if a child’s deformity looked in any way animal-like it was concluded that the mother had had sex with the animal, and the deformed child was their offspring. Such children were killed. So, fixing a child’s cleft lip also, in part, repairs the supernatural burdens of a family.
Many of the Interplast children are part European, part Maya Indian. The surgeons are making them “normal” according to contemporary European standards of beauty. But in the days of the Mayas, they would have wished to look quite different. The Mayas, who were a naturally broad-headed people, deliberately deformed the skulls of their children to accentuate that feature, making them look as different as possible from their narrow-headed neighbors. Four or five days after birth, a child would have a flat wooden board tied to the back of its head, and another board tied to its forehead. The two boards, lashed tightly together, prevented the child’s head from expanding normally, and because it was soft and malleable enough to bend easily under pressure, it would grow upward. After a few days, the boards were removed, but the child’s head stayed flattened for the rest of its life. The sculptures one sees on Mayan monuments show profiles with loaf-shaped heads—dramatically receding foreheads that run straight down to the nose. (The Mayans weren’t alone in their passion for skull shaping. Africans, Minoans, Britons, Egyptians, and others changed the shape of their skulls.) Why did the Mayans prefer long, pointed heads? Perhaps because they lived among similarly shaped temples, arching toward the heavens in the geometry of holiness. Because the Mayans also found crossed eyes beautiful, a mother would attach balls of resin and other small objects to a child’s hair, allowing them to dangle between the eyes, attracting the child’s gaze and training the eyes inward. Beards were unfashionable, so Mayan mothers scalded the faces of their male children to prevent facial hair from growing. Men would burn a round patch of skin on top of their heads, to keep that spot bald, but they grew the rest of their hair quite long, braiding it, wrapping it around their heads, and allowing it to fall into a long ponytail behind. Both men and women filed their teeth to jagged points that looked like saw blades. Boys painted their faces and bodies black, but only until they were married, at which point they painted them red, “for the sake of elegance,” as Sylvanus Griswold Motley reports. Adult Mayas often wore tattoos all over their bodies.
But these twentieth-century Honduran children want only to look normal according to our western ideal, set in part by pictures in magazines and on television, and in part by the faces of their families and neighbors. That translates into features with a simple, rounded symmetry.
By 6:00 P.M. the waiting room holds only a few adults, the clinic rooms have grown dimmer. The fans continue mixing the thick, hot air. Tongue depressors lie on the floor. A long crack in the wall of Room 9 meanders like a healing scar. The single fluorescent light casts a glare over the room, in one corner of which sit two empty Coca-Cola bottles. In this room alone, Ruth and Dean have examined eighty patients. “It’s a bottomless well,” Ruth says, leaning wearily against the wall.
Wrung out and sweaty, we gather up our belongings and head across the courtyard and down an alley to the parking lot, where a mustachioed driver waits to ferry us home. We are all lodging with upper-class San Pedro Sula families, at houses walled in and splendid, patroled by men with rifles, and most nights there will be dinner waiting for us and the oasis of an air-conditioned bedroom in which to sleep.
Operations begin the next morning, so I head straight for the “break room,” a tiny place dominated by a large red Coca-Cola refrigerator and dozens of boxes of patients’ charts. In a dim narrow corridor, I slip on a lavender scrub dress, blue-and-white shoe covers, shower cap, and mask. I walk down a long hallway. Swinging doors open onto a small room, glared over by exposed fluorescent lights, where two operating tables stand parallel, about ten feet apart. The blue tile walls give way to green paint at shoulder level, and the olive-green tiled floors look ready for a track meet. Waves of people wearing identical masks and scrubs bustle through the room.
Then the surgeons go into the hallway to wash at two white porcelain sinks, which stand beneath two large barrels of water, methodically soaping and scrubbing their hands, fingernails, and arms up to the elbows. Ten minutes later they return and enter the operating room with their hands held high, as if ready to cast a spell in unison. A nurse holds a glove open. Dave Thomas, a tall, stately surgeon in his late thirties from Salt Lake City, makes a purse of his fingers and slides the hand into the glove. Pursing the other hand, he slides it into the second glove. Then he works the latex down snug around the fingers with small tugging snaps. The three operating rooms are over eighty years old, and one of them has an opaque wall of glass bricks. A few years ago, when the electricity failed during an evening operation, Luis Bueso ran outside and pointed his car’s headlights at the glass wall, and nurses held flashlights above the operating tables. Two tables will be in use simultaneously, something that is strictly forbidden in the United States because of the possibility of cross-contamination. But in Honduras, operating rooms are scarce, and there are no malpractice suits to worry about. The absence of malpractice laws als
o means that I can serve as a circulating nurse, bridging the sterile and nonsterile worlds of the operating room, a privilege impossible for a nonmedical person in the States. In any case, most of today’s operations will be on mouths, and the mouth is full of germs to begin with. In this twin-tabled room, doctors float from one operation to the other, advising and observing, and the experience is doubled, condensed.
A small, part-Indian boy is carried in and laid on the near table. His skin looks waxy in the lamplight, and he sleeps in a blue turban like a miniature prince. A shiny aluminum clamp, holding the wrap closed, dangles over the top of his head like a jewel. An anesthesiologist tapes his eyes closed and an air tube into his mouth. Then she clamps a plastic clothespinlike device onto one of his toes, to measure pulse, blood pressure, and the amount of oxygen in the blood. Nurses arrange shiny, color-coded instruments in the correct order on a “back table,” grouping them according to size and species. Dave Thomas bends his gloved fingers and holds them up as if praying. It is an old habit, not letting his hands drop lest they become contaminated. At last he settles himself on a stool at the head of the operating table, and Dean, sitting down on a stool at one side, gets ready to assist, and I join them.
A Natural History of Love Page 36