Just Like Someone Without Mental Illness Only More So

by Mark Vonnegut, M. D.

  The first truth is that none of the thoughts going by are worth drinking over.

  Alcoholism and mental illness aren’t very different and I had both. When I believed that I was well because I worked hard and made good choices … when I believed I was well because I deserved it … I was living in a shoe box. My worries were my enemies, and my best tool was my ability to hold my breath. I was, in fact, a good doctor, and that seemed important, but the importance kept pleading for itself in a way it shouldn’t have had to do.

  Amazingly, during or shortly after that last break, something broke through the thick plate-glass barrier between myself and the rest of the world. I didn’t have to stop and think anymore about what a good father or a good friend or good husband would do.

  At the end of my drinking I had a baby-poop-brown underpowered Subaru that I picked out in the dark when my underpowered baby-poop-brown VW died. The three cars I’ve had since have been a sleek black Honda Prelude with four-wheel drive, a red pickup truck, and a red Mini Cooper S with racing stripes and the extra thirty-seven horsepower.

  Sometimes when we’re stopped at lights, other drivers look at me, and I look back at them like “Who are you looking at?” before I realize it’s my car.

  When I could hear music again I noticed Coltrane, Monk, Professor Longhair, Billy Strayhorn, Stevie Ray Vaughan, Aaron Copland, and some others like I had never heard them before. They too seemed to be trying to tell the truth to save their own lives, and I was intensely grateful.

  Pelotas

  (Photo by Mark Vonnegut)

  *Ockham’s razor is useful when choosing between two theories that have the same predictions and the available data cannot distinguish between them. The razor directs us to go with the simplest of the theories. William of Ockham in the fourteenth century: “Pluralitas non est ponenda sine neccesitate,” which translates as “Entities should not be multiplied unnecessarily.”

  chapter 11

  Honduras

  The real root of all evil is how hard it is to do good.

  Two and a half years after my last psychotic break, my wife and I were on our fourth marriage counselor. I had moved most of my clothes to the basement and slept there. We didn’t talk about it. She said things were fine.

  An emergency-room doc friend named Max mentioned that he was going on a medical/dental mission to Honduras. I asked if I could come along. I’d have to chip in eight hundred dollars for my travel expenses and go to three or four organizational meetings on the Cape.

  Max was a tall, handsome extrovert whom I had known from MGH, but we became friends when we met again in AA meetings when I was first trying to get sober.

  I know you, he seemed to yell as he lunged across the room. He was much too big and much too loud. I had kind of hoped that an anonymous program meant that nobody knew anybody. He asked me how I was doing, and I said I knew I was doing great because I had a ton of alcohol in the house and wasn’t even a little tempted to drink it. Max came home with me and poured my half bottles of this and half bottles of that down the sink so that if I slipped, it would have to be on vanilla extract or mouthwash or rubbing alcohol like everyone else. Thanks, Max.

  At the organizational meetings, we were told over and over that the people of Honduras would be very grateful. Most of them would have never seen a doctor before. We would not be dealing with worried well people. There would be lots of previously undiagnosed disease and chances to make dramatic saves. Back home the patients were so thoroughly picked over there were more chances to mess up than to do good. Helping people was easier if they hadn’t already been seen by a million doctors. There would be no forms to fill out and no malpractice worries. We had more than three thousand slightly used tennis balls to hand out, donated by tennis clubs on the Cape.

  Dentists could line people up and pull their rotten teeth and make them better without a single word being exchanged. Plastic-surgery teams could come down to Honduras and fix cleft lips by the dozen without necessarily getting to know their patients or even having to speak Spanish. Optometrists were going to do vision exams and match up people with discarded donated glasses. Pediatrics doesn’t involve a lot of one-hit good deeds, like repairing a cleft lip or pulling an abscessed tooth. It wasn’t clear to me that much of what I could do lent itself to people lining up with their kids for one-time encounters. I’m a better doctor when I’m seeing fewer patients an hour and when I speak the same language they do and when I’m going to see them again. But we did have all those tennis balls to hand out.

  Treating sickness as a business opportunity has just about killed the joy of healing, the very reason most doctors and nurses wanted to go into it in the first place. Part of what was so attractive about the Honduran trip was that none of us would be making a dime on it; our care was to be free to the patients. We would be tending to the sick because they were sick and for no other reason. The problem with trying to comply with quality-improvement initiatives and worrying about lawsuits and coding guidelines and all the other stuff we have to do is that doing the right thing for the patient gets buried in all the muck. It’s like trying to be an Olympic high jumper with ankle weights. The Honduras trip would be free of all that other stuff. There would be nothing for us to do but the right thing.

  At our last organizational meeting, just before we left, it was announced that we would be staying in a coastal resort, Hotel Villas Telamar, rather than being put up by native Hondurans and sleeping in hammocks. The first two trips had been strictly dental, with less than half as many people involved. Because this was a much bigger expedition, finding enough natives to put us all up in hammocks had turned into a logistical nightmare. Villas Telamar was an all-inclusive beach resort, formerly owned by United Fruit and used as a resort and housing for its executives and their families. They gave us a really good deal. I still wasn’t the world’s greatest sleeper and was frankly relieved by the prospect of a bed in a hotel instead of a hammock in a hut.

  We had two hundred volunteers: nurses, doctors, dentists, optometrists, pharmacists, translators, and all-purpose helpers. There were more than a hundred crates of donated supplies and medicines. We were each paying most of our own travel expenses, with local fund-raising and charities covering the rest. A couple of drug companies were chipping in. We were all giving ten days of our time to help the poorest people of one of the poorest nations in the hemisphere.

  Short time here, long time gone. The reason to try to be good, smart, kind, and on the side of angels is because it’s more fun and because there really aren’t any angels.

  It took us eighteen hours, on three flights and a long bus ride, to get to where we were going: Tela, Honduras. Gavin Archibald, a dentist from Texas who had recently married his office manager, was in charge of the mission. On the longest leg of the flight, from Houston to San Pedro Sula, I fell asleep and dreamed I was back in junior high. I had no clothes on. Everyone else was dressed. I had a baseball glove. No one else had a baseball glove. It wouldn’t be fair to have figuring out dreams be important to mental health.

  There was a physical therapist named Crystal who might have been flirting with me. She gave me a neck rub during the layover in Chicago, and I would have followed her anywhere. Even with my marriage going poorly I hadn’t dared to even so much as flirt with anyone else prior to this.

  By coincidence the prime minister of Honduras was with us on the flight from Houston to San Pedro Sula. He and the dentists from Texas were chatting, sipping drinks, in the front of the cabin like they had gone to Andover together. The prime minister made an impromptu speech to us about how important and significant and needed our mission was and how grateful he was and how grateful the people we helped would be. He mentioned that the Haitians manipulated the data when they claimed to be the poorest country in the hemisphere and that it was in fact Honduras that had the lowest per-capita income and highest infant mortality.

  At the welcome banquet, dessert was a flan loaded with rum. Max, who’d been sober ten yea
rs, was wolfing down the flan till I grabbed his spoon, interrupting the rapid round trips to his mouth.

  “Rum, Max.”

  “What?”

  “The flan is full of rum.”

  “Oh.”

  The resort had swimming pools and a pure white sandy beach with a main building and numerous outlying bungalows. Each bungalow had a refrigerator with distilled water. Before I was fully awake, I brushed my teeth with tap water. We’d been told not to do that.

  “Remember to brush your teeth with the bagged water,” I told Max.

  “Of course,” said Max.

  Max insisted that I turn over all my cash and identification to him. He would keep it safe in a brown khaki bandolier money belt under his fresh blue paper scrubs. I would get to wear the money belt the second half of the week. I had forgotten how much fun it was to have a roommate.

  “I’ll keep a little pocket money,” I said.

  “Sure,” said Max. “Just ask me if you need more.”

  I walked the beach early in the morning and found a dead dog, legs up, bouncing in the surf. It could have happened anywhere.

  On the way to breakfast I saw very well nourished vultures in the trees and nicely dressed laughing kids atop two-hundred-dollar dirt bikes.

  Breakfast was fruit and eggs and bacon with waffles from overflowing platters on a giant buffet table or omelets cooked to order. The Reverend Calvin Peters, an Argentinean who made a living shepherding medical missions like ours, got us each to give him a few hundred dollars, which he would exchange for us for Honduran lempiras so we could have some spending money. He said that he could get us the best deal, since he would be exchanging a large amount. He also posted sign-up sheets for shopping trips he would arrange so we could buy local arts and crafts.

  Peters was a smooth, soft man with thin arms and legs, silky silver brushed hair, and a small round belly that made him look a little bit pregnant or like a python who had swallowed a baby pig. His wife, who joined our trip with him in Houston, was about twenty-five years old and Barbie-doll bouncy.

  We spent most of Sunday setting up the clinic so we could see patients the next morning. The clinic was going to be in a school. A peeling faded wooden sign announced ESCUELA J F KENNEDY. I got a lump in my throat.

  Next to the school were weeds that looked like twelve-foot-high asparagus stalks, bearing individual red and yellow fruits the size of candlepin bowling balls. Subfreezing temperatures and the changing seasons give New England foliage a certain seriousness and discipline. I’ve never looked at an oak or maple tree and thought that there might have been a different way to do things. Here, next to the bright colors of the plants, the school’s gray concrete and gray wood trim made it nearly invisible.

  Mark Twain said, “Coconut palms look like feather dusters that have been hit by lightning.” I wished I’d said it first.

  The school had no plumbing or electricity. There were no windows, just chain-link mesh where windows should have been. For blackboards each room had a square section in the middle of the front wall where the concrete was more smoothed out than the rest of the wall. There was a one-story building and a two-story building, neither very big.

  The dentists took the one-story building because it had a porch; they set up three dental chairs and could work in the open with plenty of air and sunlight. There were five dentists and five dental assistants who manned the three chairs in rotation, twisting, pulling, rocking, chiseling, and leveraging rotten teeth. People waiting to see the optometrists and doctors watched people get their teeth pulled while they stood in line.

  Kids in the courtyard made impressive human pyramids and played soccer with a crumpled paper-and-tape ball. By the end of day one, they would all have tennis balls.

  The optometrists took the upper floor of the two-story building, which normally was the school principal’s office. That left the bottom of the bigger building for the medical team. The adult doctors wanted to see some kids. I didn’t want to see adults.

  There was a chiropractor with an adjustment table who liked kids and others looking on while he cracked necks and spines.

  ——

  I had an Ambu breathing bag with a full set of pediatric masks. I shoved two desks together to make an exam table. I had solutions to clean wounds, antibiotic ointments, sterile gauze and triangular bandages for slings, IV catheters and solutions, a stash of IV antibiotics, and five hundred 3x75-inch index cards. I was going to make out a card for every patient I saw. If I had managed to keep up with the index-card idea, five hundred wouldn’t have been enough.

  An internist who had been on an earlier trip said that virtually all the children would be malnourished and infested with parasites and that we should worm them all, but the kids playing in the school yard looked healthy and well nourished.

  It was late Sunday afternoon by the time we had things set up and ready to go. Patients would start lining up at seven the next morning, and we would start seeing them at about eight. We boarded our sweltering hot chartered bus and waited to be driven back to the resort.

  Tela and the surrounding towns were plastered with posters announcing the clinic. A charter bus company was planning to run buses from La Ceiba, sixty miles east. What we didn’t know, because none of us had seen the posters, was that every patient was expected to make a contribution of one lempira, about forty cents, for each doctor they saw.

  That night we had a meeting in the same room where three weeks earlier the presidents of several Central American countries had worked out a peace plan that was unacceptable to the United States. You had to go up ten steps to reach the podium, reminding me of the Whaleman’s Chapel in New Bedford from Moby-Dick.

  The first speaker was Lorenzo James, a midsized dentist from Texas dressed in battle fatigues with surgical tubing, Kelly and straight clamps, and several sizes of needle holders hanging from his double-punched black leather and steel eyelet belt.

  “How does that surgical equipment stay sterile out in the field?” I asked Max.

  “Without him this trip wouldn’t be possible,” said Max. “He’s the president and founder of the Foundation for Medical and Dental Care for Central America.” President George H. W. Bush had declared Lorenzo James a Point of Light.

  Along with the clinic at Escuela John F. Kennedy there would be a mobile unit that went out into the bush, as they called it, with two Land Rovers. They would set up in remote village squares and take care of whoever needed taking care of, sleeping in the homes of villagers and moving on when they ran out of patients.

  Among the positive attributes of the Honduran people cited by Lorenzo James was their deep gratitude for the help we were bringing, their hospitality, and the fact that they bled less and required less pain medication than patients in the United States. The germs in Honduras were less likely to be antibiotic-resistant, so small doses of penicillin usually did the trick. The children were very brave and rarely cried. James told a joke about malpractice insurance.

  The next speaker was Dr. Sandor Martinez, the chief of service and only surgeon at the local hospital and commissioner of public health for Tela and the surrounding area. It was under his auspices that we would be practicing. He would arrange follow-up care for anything we thought needed follow-up. He mentioned that the local doctors and dentists weren’t thrilled with our presence. It had never occurred to me that there were local doctors.

  “The Hondurans are a very conservative and dignified people. Please don’t wear shorts except in the resort compound. Please don’t pull any more than four teeth from any one patient. You don’t know what happens when you leave. Some of these patients bleed and bleed and we can’t transfuse them.”

  Three teachers from the school, one of whom was pretty, said through translators how grateful they and the whole community were that we were there. They knew they were closing the school for a week for a greater good.

  The last speaker was the school principal. He was a maybe five-foot-tall Mayan who smiled only br
iefly and spoke perfect English. After the bare minimum of pleasantry he said that what the school needed more than anything else was a new fence and that they would be setting up a gate to charge patients one lempira per consultation. The teachers would man the gate.

  All hell broke loose.

  “We’re like a bake sale,” I said to Max.

  Could we make a cash contribution or come back later and put up a fence ourselves? It was important that the care we gave be free, that people not have to pay.

  The principal shook his head. If we were here to do what was good for them, we could start by listening to what it was that they wanted done, and what they wanted was to charge one lempira per consultation and use the money to buy a fence.

  It became clear from the discussion that Calvin Peters had known all along about the fee and that he himself had been paid a fee by the school to recruit our mission. When we got the money he had gathered from us at breakfast it was three days later and at an exchange rate considerably less favorable than that offered by waiters, cabdrivers, and assorted street urchins. Exchanging dollars for lempiras made no sense anyway, as there was not a merchant in Honduras who wouldn’t gladly deal in dollars. The rev was doing nicely for himself.

  Lorenzo James was outraged and urged a boycott of the clinic we had spent all day setting up. We should just run shuttles with the Land Rover and go out into remote villages like he and his crew were planning to do and as the previous two missions had done.

  “They’re a very proud, grateful people. They have no money but bring food and carvings. No one in the bush has ever seen a doctor. Forget the clinic.”