by Brian Kevin
“An old man with some kind of pulmonary symptoms,” Cessar said. “Not far from here.”
“He’s pretty sick,” added the principal. “He smokes and drinks a lot.”
So we followed her directions up a nearby hillside to a ramshackle homestead at the edge of a barren field. At the gate out front, George clapped his hands three times (“the Paraguayan doorbell,” he said), and four ageless women toddled outside to welcome us. We were led to a small livestock shed out back, a brick building sized somewhere between a large chicken coop and a small barn. Inside, an old man lay prone across a foam mattress sitting atop two wooden pallets. As we stepped in, he squinted in the light from the doorway.
The old man looked bad. At first glance, his hands and feet were grotesquely swollen, like latex gloves used as water balloons. He was wearing only a tattered pair of canvas shorts, and his chest rattled as it rose and fell. Even in the darkness of the shed, he looked pallid. George greeted him warmly in Guaraní, and Dr. Laurel crouched with her stethoscope. The old man’s Darth Vader breathing filled the room.
“Strong signs of pulmonary edema,” Laurel said, listening to his chest and gingerly examining his hands and feet.
One of the women brought in a dusty X-ray slide, and Laurel held it up in the weak light of the window.
“Long-standing COPD,” she said eventually, “either emphysema or chronic bronchitis. Let’s give him a bronchodilator.”
Cessar grabbed an inhaler from the travel kit, and he and George tried to explain in Guaraní how to use it. You just put it up to your mouth, Cessar told the old man. First you exhale, then squeeze the trigger while you inhale. The man looked at him like he’d been handed a fish. He held the inhaler a few inches from his mouth and squeezed, and the puff hit harmlessly on his lips and tongue.
“Close,” George said, and he showed one of the women how to use the inhaler instead. She held it up to the old man’s mouth and got him to put his lips around it, but when she pushed down the cartridge, he exhaled hard.
“No, inhala!” she insisted. “Inhala!” Everyone in the shed began making deep-chested inhaling motions, trying to show him, but the man just looked confused. Then George took the inhaler and pantomimed using it.
“Like a cigarette!” he said loudly in Spanish, and a light went on in the old man’s eyes.
“Ah, como un cigarrillo!” he croaked, nodding.
Everyone chuckled at the irony, but that first patient in the shed illustrated for me just what George and the medics were up against. It wasn’t just that these people had no access to medical care. Many of them hadn’t the slightest notion of how even the most rudimentary elements of medical care worked. All the same, that sad old man in the shed seemed to trust George implicitly.
Back at the schoolhouse, the line outside was already a dozen families deep, and it tripled by noon. I pulled up a desk in the corner of the exam room, from which I could watch and listen as I helped split pills, filled little baggies with painkillers, and generally tried to make myself seem useful. Patients sat down one at a time in front of Dr. Laurel, describing their symptoms. George and Cessar translated Guaraní as she took temperatures, measured blood pressures, listened to chest cavities, depressed tongues, inspected rashes, felt ribs, admired ear canals, tested reflexes, examined mucus, and generally poked and prodded her way to exhaustion. Laurel consulted not only Cessar but also George, who’s built up an impressive knowledge of medicine over the years, and both men kept busy testing urine samples, mixing salves, and filling prescriptions as the young doctor requested them.
I sat back and enjoyed the cadence of their banter. In the absence of complex tests and medical equipment, making a diagnosis seemed like a very Socratic process, heavily reliant on Q&A, and I could almost picture the decision tree that Laurel must have followed in her mind. This was probably a lot like how medicine used to be practiced in the United States, I thought, a century ago or more. George had a bedside manner that many veteran MDs should envy, and he joked lightly with patients who came in looking tense.
“Forty-five years old! It can’t be!” he’d exclaim, drawing blushes from campesino women.
“This one’s a heartbreaker!” he would announce, disarming a nervous-looking teenage boy.
“One every ten months, eh?” he joked with a pregnant woman, who came in trailing five wide-eyed kids, all seemingly under seven years old.
Sometimes, it was clear what an advantage it conferred to speak a common language that your patients do not. Often enough, George and Laurel were able to consult frankly on a grim diagnosis that they might not have discussed candidly in front of an English-speaking patient. They reached slow consensus about prescriptions, taking time to ask questions that they might not have if their patient had been able to understand them. Should we give forty milligrams or would eighty be better? Are you sure about Thalitone? Why not Sectral? It also allowed them to take bets on how high a patient’s blood pressure was going to be, then to exclaim (like true Mainers), “Holy shit, that would kill a moose!” when it surpassed even the upper end of their wagering.
Sometimes, though, I wondered if the patients could guess what we were talking about. One young pregnant woman sat down across from Laurel and told her she just wanted a checkup, to see how her baby was doing. A three-year-old boy in a blue sweatsuit clung nervously to her leg. The woman wore a white cotton T-shirt and a blue pleated skirt, and her right eye was clouded with blood. Dr. Laurel felt the woman’s abdomen and moved her stethoscope across her belly. Everything sounds great, she told her, but she wanted to take a look at that eye. While Laurel grabbed an ophthalmoscope and asked the woman to lean forward, Cessar excused himself quietly and stepped out of the classroom.
“That could be an infection,” she said in English, shining her light around the woman’s eye, “or sometimes the blood vessels pop during morning sickness. I should know if she’s puking extra hard.”
Cessar stuck his head in and asked George to come outside. George stepped into the waiting area as Dr. Laurel gently prodded the woman’s eyelid, asking in Spanish whether it hurt. The fluorescent lights buzzed softly in the fixtures overhead. I smiled at the little boy, who grinned back at me shyly, and I dug around in my pocket for some of the candy I’d brought along.
Then Laurel grunted a small “uh-huh” sound.
“What do you think?” I asked.
“Well,” she said matter-of-factly, putting down her scope, “I’m actually going to say that somebody hit her.”
And before I could respond, George walked back into the room.
“Don’t worry about that eye,” he said, disappointment in his voice. “I had a chat with the husband, and it’s not a complication of the pregnancy. That’s from him beating her.”
Laurel nodded and sighed. She handed over a baggie of vitamins and told the woman she could go. The pregnant woman and her son got up silently to leave. I handed the little boy a wrapped piece of candy on his way out, and he stared up at me with eyes that were big, dark, and clear.
The remainder of our days in the campo passed in a similar fashion. I spent my nights in the clinic and walked over to Cessar’s each morning just after dawn, keeping my eyes peeled for the poisonous snakes that George said regularly slithered between the two buildings. We chatted for a while over mate and oatmeal, which George—still iron-stomached from his Peace Corps days—supplemented with stale bread soaked in hot sauce. More than once, I watched him chase his daily malaria pill with a swig of the previous night’s warm beer.
Then it was back into the truck and off to another community where Cessar had scheduled a pop-up clinic. Dr. Laurel saw 100 patients on our first day in the schoolhouse, and on some days that number swelled to 150. We set up in schools, in fields beneath wide-canopied trees, and in the bedrooms of locals who were acquainted with George and Cessar. Most mornings, the line outside the exam room was fifty people deep by ten o’clock, and more often than not, the vibe was somewhat festive, since George
’s annual visits were an anticipated community event. On our busiest day, working out of a private home on a well-kept little farm, a vendor actually showed up selling ice cream out of an insulated cart.
The most common ailments were parasites like giardia, a mostly waterborne bug that causes chronic diarrhea and vomiting, spread by contact with human waste. These are easily treated with antibiotics, but the central problems of uncovered wells and poor hygiene require more long-term solutions. Here too, though, the Andrea Ritz Clinics represent some progress. A clean water system that George and his team built for the Cerrito clinic years ago today consists of almost ten miles of pipe, reaching dozens of nearby farms and families. High blood pressure and heart disease were frequent diagnoses, and more than once we made home visits to deliver insulin to housebound diabetics. Occasionally, we encountered more serious cases—a boy with a skin disorder so severe that his back looked like the hide of an elephant, a few men presenting with early-stage prostate cancer—and Dr. Laurel treated their symptoms while Cessar made appointments at the clinic for further exams and referrals.
“We see fewer infectious diseases and chronic problems than we used to,” George told me at one point.
“That’s because we’re having an impact,” Cessar said.
Of course, the medics also encountered the usual maddening comedy routines that I imagine all doctors put up with: rambling hypochondriacs, patients who refuse to give straight answers, parents who are certain that something is wrong with their kids but can’t describe any symptoms. Some of the patients lumped together weird sets of unrelated details. “I get terrible headaches and my nose itches,” complained one sixty-four-year-old abuelita. Others came in with oddly specific complaints. “It hurts when I eat watermelon,” one man kept repeating. “Every time I eat watermelon, my mouth just hurts!”
Other times, it wasn’t clear what role folk knowledge was playing in a patient’s description of his or her symptoms. A graying old man complained of chest pains, but only “when the south wind blows.” On the one hand, this sounds a little superstitious. On the other hand, it might be an allergy or some kind of atmospheric joint pain. I was impressed by how much composure all three medics showed, even to those who had obviously come only for the excitement of being seen. When I was assigned the task of distributing reading glasses, I struggled to show the same patience with the grabby-handed and clearly not all near-sighted crowd that mobbed me once word of “free glasses” got out.
All the same, I was happy whenever I could make myself somewhat useful. Hanging out with heroic Third World doctors can get a man thinking about his relative usefulness in this world. More than once—often while executing my primary task of pouring the tereré—I found myself reflecting on Thompson’s idea that a writer could be “twice as effective” as a Peace Corps volunteer in the field. Standing in the dim corner of a one-room schoolhouse, scribbling uselessly in my notebook while a team of medics treated kids with chronic asthma, I was about ready to call bullshit on Señor Thompson.
Of course, the more dramatic the poverty and hardship, the easier it was to feel ineffectual. The medics and I spent another afternoon in a village called Tacuaro, home to a band of Paraguay’s indigenous Mbyá people. The Mbyá were the first inhabitants of the country’s once great Atlantic forests, and they watched the great majority of their ancestral lands sold off wholesale during the dictatorship. Stroessner spent decades pursuing a kind of reverse land reform, during which he parceled out indigenous lands to commercial ranching, logging, and agriculture interests. Huge tracts were awarded to political cronies, many of whom sold their new plots to Brazilian speculators, absentee landlords who decimated the forests to make room for cattle, cotton, and sugarcane. Today, most of the Mbyá are landless or live on small reservations like the one at Tacuaro—sunburned plots that represent fractions of their former territory. The once wide-ranging hunters and subsistence farmers have struggled to adapt to sedentary lifestyles on these marginal lands, and most Mbyá live in considerable poverty.
Other areas we’d visited had been remote and disadvantaged, no doubt, but at least the people there scraped out a functional agrarian living. A few even seemed to be doing rather well. The Mbyá, by contrast, were destitute. It didn’t take an agronomist to see that the soil in Tacuaro was next to worthless, a brownish clay with scrubby vegetation and none of the tall palms I’d grown accustomed to seeing (though George did say that the Mbyá had cut down and sold many of their valuable trees). The small wooden schoolhouse that George had helped build was being used as a chicken coop, so the medics set up in the shade of the tallest tree we could find, next to the clapboard house of the community’s chief.
Most of the patients that afternoon were children, suffering from the usual infections and parasites but also from malnutrition, and a few had the brittle and blond-streaked hair that indicates nutrient and protein deficiency. As a rule, the kids were playful and unspeakably cute. While the doctors saw patients and dispensed medication, I played with a few of them awaiting their turn. One of them held a piece of yarn with a coati on the end of it. I’d seen several of these small snouted raccoons back in the Pantanal. Thompson actually kept one as a pet during his stay in Rio, a house-broken coati that he claimed to have rescued from an abusive owner in Bolivia. This one skittered around comically on the end of his yarn, scratching at the dirt with fishhook claws. In the wild, a coati can shred a heavy log like a house-cat tearing at newspaper. Here, I thought, was an animal that could raise some hell if it ever got tired of its leash.
There are twenty-six families living in the Tacuaro band of Mbyá, and judging from the line that day, they’re averaging a minimum of four kids per family. So it’s likely that the hardscrabble reservation at Tacuaro will sooner or later have to support more than twice its current population, and when that day comes, the available arable land may not be enough. Needless to say, three volunteer medics dispensing antibiotics beneath a lime tree will not be enough either.
We were in and out of the village within a couple of hours. After Dr. Laurel saw her last patient, we took some pictures, then climbed into the truck, heading out along the same red-clay roads we came in on. A troupe of the Mbyá kids chased after us, and I watched as they grew distant in the side-view mirror. Then we turned a corner, and I lost them behind a green wall of sugarcane.
Here and there, George told stories from his Peace Corps days. He was in Chile in 1970, at the end of his volunteer stint, when Salvador Allende became the continent’s first democratically elected Marxist president. Initially, there had been some question as to whether the new leftist government would allow the yanqui volunteers to stick around. An Associated Press article at the time actually quoted a twenty-three-year-old George, who said something remarkably similar to what Thompson had said about the communists back in Tom Martin’s living room.
“No matter where you are, you’ll find people who want to get rid of the Americans,” young George had told the reporter. “But in my work here, I’ve met Communists and Socialists who have nothing against Americans personally. If you do a good job for Chile, they’re all for it.”
In George’s mind, today’s Peace Corps goes a bit heavy on classroom instruction and “raising awareness,” and a bit light on the kind of hands-on, direct service that characterized his days as a volunteer and director.
“There’s just no substitute for that on-the-ground stuff,” he said over mate one morning, gnawing on a hunk of Tabasco-soaked bread. “Environmental education is big now, but the Paraguayans don’t necessarily learn well by being told. They are great copiers, however, and if they see somebody actually executing an idea that works, they’ll want to try it.”
I asked George which philosophical side of the PC he saw “winning out”—the service mission or the diplomatic one.
“Well, in theory,” he said, “they’re supposed to be integrated.” Then he trailed off, hesitated, and threw up his hands. “Look, I don’t know. I’ve been out of
that game for a long time. You should probably talk about that with a few current volunteers.”
As it turned out, I got a chance to do just that. Toward the end of the week, we took the mobile clinic to a village called Oculto, where a PC volunteer happened to be posted. At one time, George recalled, Peace Corps volunteers in the region used to be a lot more numerous (Cerrito itself had one until 2003), but the agency has followed the continent’s changing demographics and shifted much of its focus to urban programs. Greater Oculto, meanwhile, is decidedly not urban. The village is just down the road from Cerrito, and as we drove through a green valley a few miles away, George casually remarked that the area “used to be known for its leprosy.” He said this calmly and without alarm, like you might say, “This area used to be known for its farmers’ market.”
When we pulled up to yet another simple brick schoolhouse, a PC volunteer named Sean Conway was waiting for us. Sean was a year and four months into his two-year stint with the PC, a baby-faced agriculture volunteer who had studied printmaking at Colorado State University. He was a couple days shy of his twenty-fifth birthday and seemed glad to have visitors passing through his little corner of Paraguay. As we unloaded the truck, George asked him a few questions about Oculto. Were the wells covered? What were most families’ latrines like? Sean answered without hesitation, showing a thorough knowledge of the town’s drinking water and hygiene habits, which was maybe in part because he’d battled several months of truly vicious giardia when he’d first arrived.
As the patients started rolling in, Sean led me on a short tour of the village. I got a look at the bountiful garden plot he’d helped to start with some of the schoolkids, and he told me a little about his first few months in the village—how hard it was to adjust, how his relationship with his host family had gone south pretty quickly. Initially, Sean said, he’d been viewed as kind of a means to an end by the woman who’d headed the effort to request a PC volunteer for Oculto. A few years before, in a neighboring town, another volunteer had helped start a women’s cooperative and later worked with its members on some grant-writing skills. One of their grants came through, and a few months later, some NGO or another had awarded the town a few dozen chickens and some free supplies to build coops.
