Bienvenidos otro vez a Santa Clotilde Centro de Salud

I only have two days left in Santa Clotilde, and I thought I would send one last letter before I leave.  Padre Jack zipped off to run some errands in Lima last week while I stayed here to guard the proverbial fort, leaving me as the sole remaining English speaker this side of the Rio Napo.  Put another way:  I´ve just completed a 216-hour game of charades.  To everyone´s relief Jack returned Tuesday afternoon, enthusiastic and energetic as ever, and positively triumphant after the glory of this past weekend´s action in the NFL playoffs.  Yesterday morning in the daily staff meeting he managed to combine his two greatest passions – priesthood and football – with a five minute parable in which God paints his house green and gold.  I´m not sure that the Peruvians understood all of the nuances but the overall message was clear:  God is a Green Bay Packers fan.
Although I didn´t relish the idea of Jack´s departure when it was first proposed, in hindsight it turned out to be a great opportunity.  Jack´s absence allowed me to play a more central role in the hospital than I otherwise would have, and with increased responsibility came the advantage of more direct interaction with my amazing Peruvian counterparts.  You´ve already met the likes of Victor Hugo and Nelly in a previous email; now I have the opportunity to introduce you to the rest.
I´ll begin with Dr. Alex, who graduated from Peru´s prestigious Cayetana Heredia medical school in Lima.   He applied to work in Santa Clotilde with a cover letter that read:  “At Cayetana Heredia we learned medicine on the poor in order to practice on the rich.  It is time to do the opposite”.  That caught Jack´s attention.  Three years later Dr. Alex is still quietly hard at work in Santa Clotilde, now happily married to a Lima-born nurse (Janina) who gamely left the big city to come here and join him in the jungle.  Beside them stands Dr. Fernando, another graduate of Lima, who has been in Santa Clotilde for nine months.  Just this week Fernando was accepted into the Oblates (priesthood) and, sadly for Santa Clotilde, in February he is being shipped to Bolivia for a year of elite jedi-level theological training.  Rounding out the medical team is the newly arrived and newly graduated Dr. Angelica – Lima born, Cuban trained, latin dancer extraordinaire.
Between the four of us we share coverage of a 20 bed inpatient department, a busy outpatient center, and a maternity program.  Santa Clotilde serves as the referral center for all of the isolated nursing outposts up and down the Rio Napo, and accepts and treats all comers.  The needs are great, the resources limited, but surprisingly the quality of medicine is never compromised.   I am impressed by the diligence and caring of the nursing staff, the attention that each patient receives, and the refusal to ever deny treatment regardless of circumstance.  Morning rounds here play out like those of the Intensive Care Units of large hospitals back home, each bedside stop accompanied by a detailed nursing report, animated debate, careful clinical planning, and plenty of teaching for the half dozen or so nursing students who are placed here by the schools in Iquitos and circle around Padre Jack like small planets in orbit.
It is here, on morning rounds, that my Spanish really gets to shine.  By convention each bedside discussion begins with a clinical introduction by the physician on-call the night before.  This is when I proudly step forward, chart in hand, and address the dubious crowd as follows: 
“Pregnant lady... arrive at 4am... push push push... push more... much pushing... makes this (pointing to baby)... healthy... then push more... 20 minutes... placenta come... I find tear... tear small... fix good...  everyone happy... I go to sleep... I breastfeed well... no, mistake, HE baby breastfeed well... today vaccinate”.
Or: 
“My friend Nixon... 8 years old... snake bites foot last night... sick and bleedy... medicine and fluids... now okay and eat breakfast... delicious”. 
Those are the easy ones.  The more complicated patients – undifferentiated fever, kidney failure, odd rashes and unusual diagnoses – those take considerably more effort.  Sometimes the necessary hand gestures become so overwhelming that I have to set the chart aside to liberate my freedom of expression, re-enacting the mosquito bite that gave the patient dengue and then trying, and failing, to explain all the minutia of the clinical progression with pantomime.  In the end I collapse exhausted, frustrated, and sputtering in an exasperated explosion of English, French and Spanish, the appalled crowd keeping a wide berth from my flailing arms.  At this point Janina the lead nurse intervenes, bends over to pick up the chart, and carries on professionally as if nothing unusual has happened.  I recover in time to successfully mime the acquisition of syphilis for the patient in bed 6.
On the days when I am not post-call I am considerably more dignified.  On those occasions I stand confidently at the foot of the bed – head and shoulders taller than all of my surprisingly short Peruvian counterparts – and listen to the clinical history intently, almost as if I understand Spanish.  When the mood feels right, I quietly nod my head.  Sometimes Alex engages the group in lengthy bedside clinical lectures, which to my non-Spanish ears sound identical to the voice of the teacher in Charlie Brown.   Suddenly he will stun me by turning in genuine interest and asking, “and is this your experience in Canada as well?”  Fortunately I know enough about Alex to predict that he is usually right, and so I concur.  Always concur.  On those rare occasions when concurring has clearly proved to be an inappropriate response (what drug did you use for this when you worked in Africa?  “Yes!!”) then Fernando will step forward and gamely attempt a translation into English.  Unfortunately, unbeknownst to Fernando, to the best of my knowledge he does not speak any English.
After rounds we scatter in different directions.  Angelica is happiest when doing obstetrics and quickly perches herself in the maternity consult office.  I prefer to sift through the wild and wacky unwashed masses in our unfiltered, un-triaged outpatient department.  One of Alex or Fernando will join me there or stamp out fires and fix up the inpatients, and the other runs off to the local high school where they each volunteer a couple of days a week to teach math or science.  Jack doggedly tries to see patients wherever he can, but given his vast experience and kindly demeanor he has become everybody´s problem solver and can´t seem to take a step in any direction without being interrupted with a question or a crisis in progress.
In the middle of all this is the central “topico” (resuscitation and procedures room), where we all meet up at the right time, in the right numbers, whenever things get scary or interesting.  I consider it the heart of the hospital, and it´s the place that I like the best.  The shelves are overflowing with jars of fluids, stacks of dressing materials, ancient half-used medicines, and antiquated cast-away equipment from all parts near and far, and the end result is a hodge-podge of a procedure room that looks like it was designed by Dr. Seuss.  In the middle of the all this chaos is a lone hospital bed, above which someone has installed a surgical light from the 1920´s.  It harnesses all the power of a modern day nuclear power plant and converts it efficiently into a flickering light as bright as a candle.  
On a shelf off to the side, heroically competing for space amongst all this clutter and yet somehow, magically, always visible from any part of the room, is the principle reason why I am here:  a framed photo of a smiling Dr. Kerry Telford.  Kerry was a mentor to me when I completed part of my international health residency at a refugee clinic in Vancouver, and she used to volunteer in Santa Clotilde on a regular basis.  In late 2009 Kerry and her baby daughter were killed in an airplane accident.  For all of us who were inspired and touched by Kerry – and it is a tremendous tribute to her that we are so very many – continuing this work in Santa Clotilde has become a small part of her enormous legacy.  Everywhere that I go in the village, mentioning Kerry´s name is an instant ticket to shared memories and friendship.  To display her peaceful photo so modestly, in such a chaotic part of the hospital, seems to me the perfect tribute.
Through the window of the topico one looks out on the central courtyard, a small grassy space that is crisscrossed by staff and patient and tropical bird alike several hundred times a day.  It is here that one can sit and take measure of the inner workings of the hospital.  There is always activity out in the courtyard, and when appreciating the tidy landscaping, scrubbed walls, and general hustle and bustle, one could easily be fooled to think that Santa Clotilde employs a team of a hundred unionized maintenance workers.  In fact, as best as I can tell, the cleaning and laundry team consists of just one person, Yolanda, and all of the maintenance needs are met by the hardy duo of Orlando and the unfortunately named Nacho.  He makes me hungry.  The rest of the maintenance work here—indeed the bulk of it – is done by an ever-changing team of relentless volunteers.  Padre Jack had mentioned once that “for those who cannot afford the care, there are always little ways to contribute,” but I didn´t appreciate exactly what that meant until I carried my morning cup of hot milk to the courtyard one day and had a closer look around.  That man bent over cutting the grass with a machete... doesn´t he look like the father of the baby with meningitis?  And the lady scrubbing the walls – that has to be the mother of the boy who vomited up five live worms.   Won´t forget that face anytime soon.  Outside the kitchen washing up the breakfast trays – could that be the older brother of the boy with the nasty burn?  And the girl with the broken arm who is sweeping the corridor, isn´t that the... wait a second.  That´s the girl with the broken arm!  What is she doing sweeping the corridor!!
The hospital is perched on a bit of a hill and, if not for the tangle of trees and huts that block the panorama, it would otherwise afford a pretty nice view of the town and river.  The town itself is surprisingly well developed, or at least more so than I would have expected based on my previous experiences working in Africa.  The streets – never wider than 4-6 feet, for there are no cars here – are neatly built of concrete with gutters on either side for the copious rainfall.  The main streets have lights, at least between the hours of 6pm and 11pm, and here and there tangles of power lines penetrate grass roofs to light up a stereo or a television.  There is even a city sewage system, albeit completely non-functional, and two standard water towers, which are always empty.  The surest sign of progress is the presence here and there of random public garbage cans – something I have never seen before in travels through the developing world.  Presumably these garbage cans are dumped directly into the river when full, but their mere presence adds a soft touch of hospitality to the town.  Add in a central park, a thriving downtown with 6 or 8 general stores, and an unusual fascination with building impromptu outdoor volleyball courts, and Santa Clotilde is a genuinely pleasant place to go for a stroll.
Sometimes I go for these strolls just to stretch my legs, but most times I am driven to abandon the hospital in my perpetual quest for food.  The ladies in the hospital kitchen are always kind enough to give me bread and a hot beverage when they see me lurking in the doorway in the mornings, and lunch, which is taken around 3 pm, is something of a feast.  Nevertheless this is the full extent of food on offer and those long hours between 4pm and bedtime can sometimes leave me feeling a little wanting.  It is for this reason that the randomness of the afternoon strolls can prove so useful.  If, for example, I think that I might cook an egg for dinner, then rest assured that the egg store will most certainly be out of eggs, but in my randomness I might chance upon the girl who sells fried banana strips from a basket she carries on her head, and these will serve just as well.  If on the other hand I happen to crave fried banana strips, then I guarantee that the banana girl will never be found, but possibly, in my search for an egg, I will walk past a house with a papaya for sale in the front yard.  Failing that, in my walks along the riverfront there is an old man who has taken a liking to me and regularly greets me with offers of food, which I gladly accept for the low price of providing him company and watching him whittle wood.  He will ask, “would you like an orange?”, and indeed I would, so I sit down beside him.  He will then shout to his hard-of-hearing wife who trots dutifully out to the yard holding bananas.  Or maybe bread, or a coconut... pretty much anything except for what he has specifically called for.  There are no restaurants in Santa Clotilde – at least not in the easily recognizable and predictable sense of the word – and so if all these avenues fail than my last and only trick, which I am not necessarily proud of, is to head to the charity boarding school and eat with the orphans. 
In truth they are not, technically speaking, orphans.  But I do eat their food.  They are simply children whose parents live far, far away.  For one month every year Padre Edgar – one of Padre Jack´s Peruvian counterparts – runs a charitable boarding school for children who come (for free) from the remote and isolated surrounding villages.  In their one month of intensive schooling the children learn standard school fare, mingle with children from towns and places that they might otherwise never get to see, and are taught about their native Qeechwa culture, environmentalism, and citizenship.  As a raucously full boarding school – with kids stacked like lumbar sometimes 4 or 5 high in impossibly cramped bunkbeds – it is half school and half summer camp, with group activities and organized chaos scheduled for every minute of every day.  It´s a very interesting place to hang out when I need to get away from the hospital and indeed, when I first heard about it, it seemed like as good a place as any to offload the Frisbee that I brought with me from Canada.  Within five minutes of tentatively poking my head through the door for the very first time, Padre Edgar whisked me downstairs to the classroom / dining mess and put me in line for an omelette with the rest of the kids.  Like a stray animal who stumbles across food left out on the porch one night, I would return time and time again.  
As the month draws to a finish the school will close for the year this coming Monday, and last night I was invited to attend the end-of-school assembly.  The idea was simple enough:  the kids, divided into groups of 4 or 5, were each assigned one of a set of “valors” (core values) and they were to artistically present – in whatever ridiculous fashion struck them – how they would incorporate this value into their community upon return to their villages.  A “valor” might be something like “solidarity”, or “respect”, or one of 10 other options whose Spanish equivalent was meaningless to me.  The point here is that it offered a very high probability of not only an omelette, but maybe even candy too, and I quickly accepted.
Aside from language and the physical surrounding, this particular school performance was not unlike any other assembly of 8 to 12 year olds that I have ever seen.  That is to say:  at two and a half hours long, the assembly was about 2 hours and 25 minutes longer than it needed to be.  What kept it interesting however was that I was invited to join the judge´s panel as a last minute addition, somewhat like a B-list celebrity judge on a low budget version of Peru´s Got Talent.  And by “invited” I mean “ordered”.  Lest I be inclined to mistake the gravity of the task ahead of me, one of my co-panelists, Dr. Fernando, quickly called an impromptu pre-assembly judge´s conference to discuss how the groups should be graded.  I volunteered that maybe we could just watch the assembly and then chat for 30 seconds to pick the winning group, but that of course was voted down as shamefully unprofessional.  Instead a 30 point grading scale was carefully devised and debated, including 10 points each for “creatividad”, which I generally understood, “presentacion”, which I felt like I could guess at, and “applicacion”, which baffled me completely and left me constantly dropping my pencil so that I could bend over and cheat from my neighbour´s scorecard.  It certainly didn´t help that I don´t speak Spanish, or Qeechwa, or have a refined palette for the artistic nuances of native Peruvian dancing.  In the end I created my own 30 point score based on “generousity”, which was directly weighted to the quantity of booze each group donated to the judge´s panel.  The local homebrew in Santa Clotilda is a fermented yucca product called maceta.   It happened to feature prominently as a prop in most satirical reproductions of life in the home villages and, since apparently no one had second thoughts about allowing 8 year olds to use the real thing in their presentations, there was plenty leftover at the end of each skit to be offered as sacrifice to the thirsty looking judges.  Three skits and three drinks later I found myself laughing hysterically at amateur shadow puppets, and weeping with passion over the majestic beauty of crayon drawings of forest animals.  At the end of the assembly I wanted to stand up and slur “you´re all winners to me!!”, but Fernando, consummate professional that he is, kept the panel focused and on track.  We reverted back to the points system for our final decision.
When I am not working in the hospital, or begging for food, or stealing from orphans, there is one other activity which has kept me busy:  soccer.  Yes, tick South America off the list, I have now played football on four continents and counting.  In Vietnam soccer was played in the sand, with barefoot ninjas bedazzling me with tiny feet and fancy footwork.  In Ethiopia it was a game of heat and endurance, with no role for boundaries and wide open plains where kicking the ball laterally could lead at any moment to an impromptu marathon.  Central Africa, land of conflict, was defined by formal rules and official referees, and of course made most memorable for the always ridiculous substitute-player sideline shoe-transfer.  What would be the defining characteristic of football in Peru?
If I had to choose but three words to describe the Peruvian approach to football, I think I would use:  “complicated financial transactions”. 
It wasn´t until week three that Julio, the hospital pharmacist, finally invited me to play in a community football match and – naïve rookie that I am – I foolishly left my wallet at home.  This led to an especially awkward moment at the beginning of the match when I suddenly realized that not only were players being assigned to different sides, but money was being centrally collected.  Perhaps sensing my confusion – or spotting my empty pockets – Fernando stepped forward, paid an unspecified amount, gestured in my direction, said something in very fast Spanish and bam – before I could ask any questions – the game had begun.
I should backtrack here to point out that the game was being played at a nearby schoolyard, on an outdoor basketball court.  Yes, a concrete basketball court.  I did at one point ask why we weren´t playing on any of a number of grassy soccer fields scattered around town and I was told, quite simply, “snakes”.  That seemed like a reasonable explanation.  Nevertheless, when you cram 12 adult men and a soccer ball onto a concrete basketball court, what you end up with is something that is not altogether soccer-like in appearance.  The ball spends a lot of time in the air, and there is an awful lot of good natured but necessarily violent hand to hand combat, and the end result is several mild concussions from repeated headers and a variety of black eyes from flying elbows.  It´s also a wicked amount of fun.
The game was timed to two fast and furious twenty-minute halves, at the end of which was an equally fast and furious transaction of cash.  We lost 5 to 3 and – disappointed equally by both the outcome and the brevity – I was on my way to try and settle with Fernando when it became clear to me that we were gearing up to play another game.  Cue the complicated and boisterous financial transactions yet again, and this time I took advantage of the delay to race home and grab some cash.  Returning with money in hand, I went to Julio and hesitantly held out an open palm of coins, hoping that he could settle whatever debt might be outstanding.  He routed through the stash thoughtfully, picked out two five-Sole pieces, engaged himself in the serious business of yet more complicated financial transactions with players on the other team, and then returned and gave me... a 10-Sole bill.
Huh.
No time for questions however as once again the game was underway.   There were heads to collide with and elbows to contend with and, once again, after two fast and furious 20 minute halves we came out on the losing side, 5 to 3.  Yet more complicated financial transactions were taking place all around me while I lingered in confusion, waiting to see if someone would approach to ask for money.   Nobody did.   Then – who cares that the sun was starting to set – it became clear that we were gearing up to play yet again.  Repeat the madness.
This time, having established by careful observation that the going rate appeared to be five Soles, I put a single five-Sole coin in my hand, walked up to Julio with clarity and purpose, and offered the single coin on an outstretched hand.  Surely this could not be misinterpreted.  Julio collected it quickly, engaged in some rather laborious haggling with nearby players and then, after 5 to 10 minutes, returned and handed me... two one-Sole coins.
Huh.
Start the match.  This time we won 4 to 3 and, albeit thoroughly exhausted, I was keen to hang around and see what this would mean for my three-Sole investment.  After a number of yet more complicated financial attractions Julio finally approached me, pointed to Victor Hugo´s younger brother Watson, and said:  “you give him 14 Soles”.
Huh.
So let´s recap.  Losing, and not paying in the first place, apparently costs nothing.  Scoring two goals and getting a black eye in a winning effort nets -5 + 2 – 14 or a total of -17 Soles, which, most interesting of all, I have to pay to Watson.  WATSON IS MY TEAMMATE.
Huh.
I didn´t have enough cash left in my pocket so a group of us straggled back to the hospital – Watson eagerly in tow – where I routed my piggy bank and came out with the 14 Soles required.  I gave this to Watson, who turned and engaged in a complicated financial transaction with Fernando, who turned and engaged in a complicated financial transaction with Julio, who turned and handed me... a 20-Sole bill.
Huh.
Funny game this Peruvian soccer.   I can´t complain about the outcome however, black eye notwithstanding.
Now there are just two days left before I depart for Iquitos.  On Sunday I will be on call for one final time, breaking my streak of 3 consecutive Sundays in church.
Pause here to allow someone to throw a bucket of cold water on my mother.
Yes, in Peru I have turned into something of a church-goer, enamoured as I am with the spectacle of Latin American social gatherings.  Just a few of the unique perks of Peruvian mass that prove attractive to a lapsed catholic such as myself include the offering of wine for EVERYONE with communion, served in the always popular party style of chips-and-dip, and the latin American habit of mixing a little Simon and Garfunkle in with the church music.  Don´t believe me?  Search You Tube for “Padre Nuestro - Sound of Silence” for but one example of the Garfunkalization of the holy word. 
Additionally, and most importantly, church is where I am most likely to encounter my good friend Leo, the world´s craziest Maccaw.  Leo is owned by Padres Jack, Edgar and Roberto, or perhaps vice versa, and as a free roaming Maccaw he has little sense of respect for formality or etiquette.  Halfway through mass last week Leo suddenly swooped into the church, searching for Roberto or Edgar and probably hoping for a peanut.  As the giant blue and yellow bird flew over the congregation zeroing in on the target destination of Padre Roberto´s shoulder, both priests frantically gave the international hand signal for “not now, not now you crazy bird”, confusing Leo and prompting  him to change the flight plan just as he was reaching the altar.  Now resorting to Plan B, Leo decided instead to land on a candle – which unfortunately was lit – and after knocking it over and threatening to burn the church down – all for lack of a peanut – he screamed loudly, dive bombed the crowd, and then swooped majestically to an impromptu perch above the main door of the church.  There he sat with his back to us, nonchalantly scratching his wing and perhaps looking for scorch marks, and trying for all the world to preserve what little dignity he had left.  THIS is what I call entertainment.  If I could get seconds on the chip and dip I would probably stay for an extra hour.
So that´s all from Santa Clotilde.  The going away party is tomorrow afternoon and then, unless I can weasel my way out of it, a night at the local disco to practice my latin American dancing.  Monday Iquitos, Tuesday Lima.  Wednesday its an overnight flight  to Canada and Thursday:  Toronto.  Finally Friday, if all goes well, I´ll back in Salmon Arm.
Looking forward to seeing everyone when I get home!
Rich