Just Like Someone Without Mental Illness Only More So

by Mark Vonnegut, M. D.

  The pharmacy, the optometry equipment, and lots of the other equipment we had set up wasn’t very portable, and who was to say the school principal and teachers and community would want to let us come and go as we pleased if we weren’t taking care of patients?

  “Could we wear shorts in the bush?” I asked Max.

  We offered the school two thousand dollars cash to let us take care of people for free. No go.

  Max said that if we had to charge, maybe we should make it more like five dollars a head and see if we could come away with some real money. No one laughed.

  So if we didn’t open and run the clinic as advertised, what would we do? Visit Mayan ruins and fish for the twenty-pound largemouth bass I had heard existed in a remote lake? Maybe just chill at the beach resort? I would have been more than a little disappointed to have come all that way, set up my little area, and then not be able to see how it worked. We should have offered them ten thousand dollars and found ways to take most of it back like third-party insurers do.

  A little after midnight, Gavin Archibald, our fearless leader, got up and said that we couldn’t and wouldn’t shortchange the Honduran people. We would have one of our translators at the desk monitoring the teachers collecting the money, making sure no one was turned away. We were professionals and certainly weren’t going to refuse to treat thousands of people over a lousy forty cents per patient seen.

  At breakfast it was announced that anyone who wanted to could be taught how to pull teeth and that the four-teeth-per-patient limit was silly. There is a fancy word for twisting and rocking back and forth while you pull that sounds like the fancy word for burping.

  A hospital in Rhode Island had donated two thousand sets of blue disposable paper scrubs, enough for each of us to have a fresh set every day. A battalion of white people in dazzlingly bright blue scrubs descended from the blue-and-white bus and took their places in the school clinic, watched by Hondurans who had paid their fee and were waiting patiently. There were adolescents on bikes with assault rifles strapped on their backs in lieu of police.

  On the first day of our clinic the nurse practitioners and I saw 187 patients. Nearly 100 more were given vouchers assuring them of a good place in line for the next day. There was as little or less wrong with most of the patients I was seeing than was usual back home. Most of them were well-nourished, bright, healthy children who didn’t eat what their mothers thought they should or who coughed, usually without fever or waking up or any other symptom. Two children in the first hour were for second opinions on hernias. In both cases Sandor Martinez was right: the umbilical hernia would get better by itself; the inguinal hernia would not.

  Once people pay, even if it’s only forty cents, the expectations and entitlement follow as night follows day. The people controlling the gate had no incentive to not ram as many people as they could through the one-week-only-see-the-Yankee-doctors moneymaker.

  I had three twelve-year-old girls from the local Catholic school translating. They sometimes did it by committee and would argue among themselves about what it was that the patient or I was trying to say. “Bones ache,” “Baby no eat,” and “Cough” were the most common chief complaints.

  The first “Baby no eat” I saw was a beefy thirty-pound two-year-old with wrist rolls, chipmunk cheeks, and a Buddha belly. “Baby eats,” I said. “Maybe the neighbors are feeding the baby or the baby gets up and raids the refrigerator when the mother is sleeping.” The translators looked back and forth nervously.

  Of the babies and children complaining of cough, almost none of them coughed. I never figured out what “Bones ache” meant, but I weighed and measured everyone and asked about whether or not they ate or coughed and if the bones ached more during the day or at night and showed them where their child was on the growth chart, and everyone seemed happy.

  One of my first patients was brought up to the front of the line by our triage nurses right after he had a grand mal seizure. He was back to himself by the time I saw him. He was a strong, handsome, nonverbal boy who had had six to eight seizures a day for many years. His mother was a small, shy, pretty woman who looked like a teenager herself. It wasn’t the seizures she was worried about but the fact that for months he had been holding his penis and screaming while smashing the wall with his other hand whenever he had to pee. She couldn’t look at me for more than a millisecond. It was just as well that I didn’t speak Spanish so we didn’t have to say penis back and forth.

  There was no discharge; the penis looked fine. It could have been a bladder infection. I had brought a couple hundred urine dipsticks from my office that could tell me in minutes if there was blood or protein or sugar or white cells in the urine.

  “Just a small amount of urine in the cup,” I explained to my translators, who passed it on.

  He seemed to understand what he was supposed to do and put a small amount of urine in the cup and a much larger amount in a giant arc on my cardboard partition while he screamed and punched the wall.

  His urinary stream was excellent. The urine in the cup was normal. I had brought the full weight of medical science to bear on his simple problem and had come up empty. I didn’t have the faintest idea why he held his penis and screamed when he peed.

  I tried to explain that he could have a lot fewer seizures a day with medication and wrote out a note to Sandor Martinez. The boy’s mother was politely trying to seem interested. I gave one of our tennis balls to her son, who nodded appreciatively and rubbed his cheek with it.

  The boy with the seizures and over half the other children I saw had scars on their shoulders from smallpox vaccinations. I’m sure there’s been no smallpox in Honduras for many, many years. If you’re a pharmaceutical company, nothing goes to waste.

  His mother asked if she had to go back outside and get into line and pay her lempira all over again to be seen herself. I took her across the building to introduce her directly to Max with my translators. Max was under the impression that he spoke Spanish and started doing so at the small, shy woman, who shrugged and looked hurt and confused. Max is big and energetic in any language.

  “Speak English, Max. Use the translators. Your Spanish scares people.”

  Our baby-blue paper scrubs didn’t hold up well in the heat and humidity. By noon they were falling apart. Bellies and underwear were flashing. Someone was dispatched to go back to the compound to get more. Cloth shorts would have had advantages. Our money belt was plainly visible wrapped around Max’s glistening belly.

  “Be careful, Max. I think they can see our valuables.”

  While I was over on the adult side, someone asked me if I’d help hold down a twelve-year-old boy while they were draining an abscess, so I grabbed a leg and helped out, wondering if the kids with something wrong with them were ending up being seen on the adult side and I was the “baby no eat–bones ache–cough” specialist. They got about five cubic centimeters of pus out of a not-very-swollen lymph node. Wouldn’t antibiotics and hot compresses be just as likely to work? What did we know about abscesses in the tropics and the risks of making a surgical incision in someone you might or might not see again? What if we slipped and nicked a big vessel or nerve? We put a draining wick in, gave his mother a prescription for Keflex, and told them in Spanish to come back at the end of the week. What if we had run across this kid on the last day of the clinic? Would we still have gone after that node?

  In my regular job, many of the children I see for ear-infection follow-up couldn’t possibly have had ear infections. The eardrum has no thickening, no redness, no fluid. There’s nothing but a thin, translucent, perfectly normal eardrum. The antibiotics these children were put on couldn’t possibly have worked so quickly. Doctors and patients and parents are so eager for the resolution a diagnosis of ear infection brings that phantoms appear and are welcomed. The doctor finds something wrong, thus doing his job. The parents’ decision to seek medical attention is validated. The visit is over. Everyone gets to move on.

  Now, in Honduras,
where I was expecting a stream of severely ill children, I’m suddenly in the same position as the ER doctors back home. I’ll never see these people again. A few hours into the first day I see a bulging, bright red eardrum and feel warm all over. The little girl probably had ear infections before and had gotten over them on her own. She would have ear infections again and get over them without a doctor or antibiotics, but I was a happy guy.

  “Ear infection,” I said to my translator, who passed it on like a great gift to the parent who had brought the child and stood in line for hours.

  “Amoxicillin,” I said generously as I wrote out the prescription for the parent to take to the pharmacy.

  “Should be better in forty-eight hours,” I added expansively.

  I now know and suspected then that antibiotics have very little effect on ear infections, but it takes longer to explain that than to give out prescriptions.

  After seeing another two hundred or so patients on day two, I was a dishrag, dazed and barely able to walk. I wedged myself into a window seat on the bus and waited for it to take me back to the compound. I had promised myself that I was going to swim at least a little every day. There were three doughnut-ring formations of coral twenty yards from the beach. Each ring was about thirty feet across and contained its own little world. There were lots of bright-colored fish riding the swells in and out of the giant doughnuts. There was also a menacing barracuda about seven inches long. I just wanted to fit in and tried sliding in and out of the coral doughnuts with the fish. My legs got cut up pretty badly.

  When Max asked what had happened and I tried to explain about being playful, he said it was lucky I didn’t attract any playful sharks.

  Every day the lines got longer. The charter buses from La Cieba east along the coast started to arrive. Ten of me couldn’t have put much of a dent in those lines.

  After four days of breathlessly trying to keep up, I met Freddy Ruiz, a small, quiet man who picked his way carefully through the chaos and asked if I was Mark and if I took care of children. I said I was, and he asked if I would come to his orphanage.

  My team was more than happy to get rid of me. After three days of martyrdom to a nonstop onslaught I was probably painful to have around. It didn’t matter what or how much any of us did. In many ways the nurse practitioners would do fine and maybe a little better than me.

  Almost everyone else on the mission had already taken tours of this or that or a beach day or been shopping for native crafts.

  There was something very likable and reassuring about Freddy, but my attitude after being held hostage and made to practice pediatrics in a concrete coop for three days was not good. Why didn’t this guy Freddy just pile his kids into a truck and have them wait in the forty-cent one-lempira line like everyone else?

  Freddy’s orphanage was only about thirty minutes away, but I felt better and better with every mile put between me and Escuela JFK. Halfway there it became clear that Freddy thought I was a dentist.

  “No, Freddy, I fix just about everything except teeth.”

  I was invited to see the orphanage anyway: twelve houses with about five to six children and a set of foster parents in each sprinkled over about ten acres of citrus groves. The biggest building was a school with paper and books and art all over the place. There was a giant vegetable garden and a barn with cows and goats and a chicken coop.

  It was owned by the Catholic Church, but Freddy was quick to point out, “You don’t have to have Catholicism to be a child here.”

  Since Freddy had taken over, the children at the orphanage were no longer available for adoption. They had only been able to place two or three of the younger children a year anyway, and the rest of the kids and staff just sat around feeling like unwanted failures. Now all the kids went to high school and beyond. They all had jobs and tutors. The comparison with the kids I was seeing back at our clinic, where less than 10 percent were going on to high school, was stark. One thing a Honduran child might consider to get ahead would be to lose his parents and find a way to get into Freddy’s orphanage.

  A hasty clinic session was arranged. I was ushered into a clean, nicely set up exam room with an office, where, one at a time, children with charts and coherent problems and histories appeared with a bilingual nurse who knew what medications were available.

  There were two girls with complex congenital heart disease who had never been seen by a cardiologist. Neither was doing well. Both had a chance of being helped if we could get them to Boston or Miami for catheterization. It turned out that wasn’t out of the question and that a note from me would help. I taught them how to make a paste out of aspirin to get rid of warts. I saw about ten kids and started scheming with Freddy and his nurse about getting the useful leftover equipment and medications from the mission to end up in their health center rather than somewhere else.

  I stayed in touch with Freddy for several years afterward. One of the girls with congenital heart disease did well after an operation in Miami. The other had had too much blood going through her lungs for too long and would have a shortened life.

  By the time I got back to the hellhole I had helped to create at Escuela JFK it was late in the day. John, one of the translators, was in my room with a stethoscope around his neck, putting it on one well-looking child after another.

  “All these kids with coughs who don’t look sick, which is most of them, I listen to their chest and then give them 250 milligrams of amoxicillin, which is what the nurse practitioners told me to do. We had to do something. They seem happy with it, especially since they don’t have to stand in the pharmacy line.”

  “If you turn the stethoscope around, the earpieces and your ear canals will line up better and you’ll hear more,” I said.

  More than a few patients were taking whatever medication they got from us and selling it to brokers on the street.

  When we told people we couldn’t see any more patients, mothers pressed their babies and children toward us against the chain-link fence.

  “No pelota.” We’d run out of the tennis balls after day two.

  Friday was mostly spent cleaning up. Two of the doctors from the adult side brought over a beaming twelve-year-old boy whom I didn’t recognize until they showed me the wound and wick from where we had drained the abscess Monday. We took out the gauze wick and covered the wound with antibiotic ointment and a sterile dressing.

  “We did him some good,” said one of the docs. The mother was effusively grateful. I couldn’t help thinking how easily it could have been otherwise.

  About midnight the night before we left, Max and I borrowed a car and went back out to the clinic site. In the moonlight we could see that nothing was left. A battalion of recyclers must have descended and stripped the place bare. All the cardboard, the wiring, even the litter was all gone. It was like we had never been there. Come Monday they would have school and most of the kids would have new, slightly used tennis balls.

  There was a three-hour layover in Houston. Crystal and I got a cab and went shopping at a nearby mall to buy sunglasses and gifts. It was more or less like any other shopping mall. We got coffee and doughnuts and bought Houston Rockets T-shirts, all of which were available at the airport, then made a mad headlong dash to make it back in time for our flight. The flirtation never came close to being anything more, but it scared the hell out of me how much fun it was palling around with a girl.

  The pictures I took in Honduras came out well, and I made up a slide show to go along with a talk I presented at senior rounds. The chief asked if I’d consider giving the talk at grand rounds, which was held in the same amphitheater where I occasionally went to AA meetings on Fridays. Out of the blue the dean of admissions of Harvard Medical School showed up in my office, took me out for lunch, and asked if I’d consider serving on the admissions committee.

  “Yes, yes,” I said. “Yes.”

  Mark goes mainstream.

  If you know how things are going to turn out, why bother?

  (Photo b
y Barb Vonnegut)

  chapter 12

  Not Right for Here

  Normal people do not make particularly good doctors. They’re too good at taking care of themselves to be able to take good care of strangers.

  The Harvard Medical School admissions committee sees a steady line of bright, creative young people who are eager, ready, willing, and able to give of themselves for a chance to be useful. Six thousand apply, eight hundred are invited to be interviewed, and two hundred of those are accepted.

  Once the first forty-two hundred or so have been eliminated, the quality of those left is so high that a perfectly good class could be selected by flipping coins and throwing darts. Many applicants rejected by Harvard go elsewhere and become excellent doctors. Except for one psychopath, there was no one I interviewed who couldn’t have become a good doctor. Beyond the pool of applicants selected for interviews, there are many qualified people who want to be doctors who can’t get into any American medical school and who have to go to Guadalajara or the Caribbean to pursue their dream.

  I seriously doubt that my application would have made the first cut against today’s applicant pool. No candidate whose application I reviewed or heard of had anywhere near as low an undergraduate math-and-science grade-point average as mine. It’s possible the committee members of the day, back then, were distracted by the question of whether or not I was schizophrenic and overlooked my grades.

  Interviewees invariably talked about how much they wanted to contribute to society, help people, push medical science forward. When I asked them what being a doctor was going to do for them, often they looked at me like was a trick question.

  We rate applicants on a scale of 1 to 10, but you quickly learn that a 9.0 is the kiss of death. I mentioned this to one of my fellow committee members, who said, “Yes, and 9.5 is no kiss at all.” If you didn’t have all or mostly 10s, you probably weren’t going to get in.