I hear from physicians what, to no one else, they tell. Their secrets. Their fantasies. Their failures. Their sick little ideas.

Case # 69

“I was sent,” he snarls, this doctor. He is not a physician, I learn, but a surgeon. In this country, they license them the same. “Physician AND Surgeon” says the license. It’s confusing. But I digress.

“Ordered to come here,” he spews. “For the Public Health. Three sessions. So let’s get it over with, and you write to the Authorities that I came, and we’ll be done. Understand?”

“You are,” I say calmly toward his face, so flushed and hot I see steam rising from his sweat, “accustomed to giving orders, no?”

“Damn right. I’m a – ”

“Sit down, please,” I interrupt him. “On the couch. In this office, the orders I give.”

“It all started,” he begins, eventually, after a few more exchanges where, to him I make clear who is boss, “in the hospital. Late. Midnight, I think. I’d just finished an emergency torsion of the testicle, and was in the cafeteria, getting coffee from the machine. You know, for the drive home.

“The place was deserted. Except for this one guy. He was pushing an I.V. pole, his ass flapping in the breeze.”

“Asses can flap?” I blurt.

“The gown,” his eyes rise up and roll like exasperation. “The gown flaps. Don’t interrupt me. So, just as he’s passing me, he collapses. I look around for a doctor. An anesthesiologist. Even just an Intern. Hell, I’d have taken an E R nurse – if she was cute. But no one. The place was like a morgue with dispensing machines. This guy drools some saliva on the floor and his I.V. line pulls over the pole.

“Shit ! I think. Now I’ve gotta see if I remember any of that CPR crap. You know, this is not like on the table in the O.R.”

“No,” I say to fill the brief silence. “It is not like that. Continue.”

“So, he’s not breathing. No pulse. It’s – what do you guys call it? Cardiac arrest. So I can’t do CPR alone there until the 7 A.M. shift comes in, can I?”

“You said you don’t know CPR, did you not?”

“Well, there was that problem, too. So anyway. No way to call someone. Hours until someone might stumble by. So I get this brainstorm.”

Oh, oh, I think.

“Brilliant idea. Which makes sense ‘cause I’m a brilliant surgeon, you know.”

“Continue,” I say during the silence he creates, waiting, I assume, for applause.

“Anyway, I slice open his chest, reach in, massage his heart and, Boom! He wakes up!”

“Good,” I say. “You save his life.”

“Not yet. Every time I take my hand out, it stops again and his brain goes back to sleep. I need help, but there’s no one around. So, here’s the really brilliant part – - – .”

Another silence.

“Continue,” is all I say.

“And do you think he appreciates my brilliance? That I saved his life? No. After he recovers, he goes and gets a lawyer and sues me for mental torture or some such. Reports me to the licensing Board. So here I am.”

“Tell me,” I say, into the silence, “tell me your greater story of this brilliant idea.”

“I squeeze his heart until he wakes up again, then I take his right hand, put it down into his chest, around his heart, and I tell him to squeeze. Once a second. I tell him I’m going to get the E.R. doctor. And I warn him not to stop squeezing, or he’ll black out and die.”

“What did he say?” I ask.

“Say? He said what I told him to say. He said ‘thank you, Doctor’.”

“You’re going to be a doctor, too. Just like the first Dr. Mosher and like your father.” A lot of times, they’d just hobble away after saying that, not even interested in hearing my rebuttal.

Problem was, I had to decide what I was going to “become,” since college was looming and they kind of required at least a vague idea.

“Dad,” I asked my father one night over a dinner grown cold waiting for him to return from delivering yet another inconveniently timed baby. “What does Uncle Jim do?”

“Jim? He’s an engineer.”

I was halfway into my first semester when it occurred to me that I should have asked a couple more questions. To at least, you know, get some idea what engineers do. Because that Calculus stuff was incomprehensible. At least it was when delivered in the thick German accent of our world-famous professor of whom the university was so proud.

World-famous for something, maybe. Not teaching, unfortunately.

At the end of that first year, I was an engineering student with “C” s in math and no summer job.

“I can get you in at the hospital,” my father offered. “They need an Orderly. To help the nurses.”

It was either that – which kind of seemed like a compromise of my anti – Doctor position – or back to stacking two-by-fours at the lumberyard. After a brief internal debate, I decided I’d learned all I’d ever need to know about two-by-fours the previous summer.

They gave me white pajamas to wear. I bought some white shoes. The nurses taught me how to fetch ice for the oxygen tents, how to tuck sheets under a mattress, how to catheterize men, and how to shave men’s pubic hair in preparation for tomorrow’s surgery without performing inadvertent surgery with the razor.

The other Orderlies taught me how to hide from the nurses.

“Shouldn’t we be doing something?” I asked the other Orderlies as we smoked around the Utility Room bathtub.

“Sh-h! The nurses will hear you and find us. This is just a summer job for you, but for us, it’s lifetime employment. Don’t ruin it for everyone by working hard.”

Nancy wore white, too, like the rest of us. After all, she was a nurse. But she sure didn’t wear her white like everyone else. Skin tight. I was mesmerized by her uniform when she walked. It allowed me to accurately visualize the human body’s individual muscle movements. Especially the gluteus muscle ( I’d learned that term from reading the patients’ charts. I was becoming more interested in this Medicine stuff than I wanted to be). The muscles of her legs I didn’t need much imagination for, since her uniform stopped about mid thigh, and when she sat –

“Chuck !” called the old crusty Boss Nurse. “Are you real busy right now?”

Gosh, I hope my staring wasn’t obvious.

“We need something from Central Supply.”

“Sure.” I was always happier to work than sit around the tub, whispering and smoking.

“Go on down and tell them we need a left handed Fallopian Tube.”

“Okay. What’s it for? Is it a catheter?”

“Sure,” she smirked. I think I saw the other nurses behind her turn their faces away. “A catheter. Hurry.”

So down into the bowels of the old brick hospital I went. I called from the door for the lady who ran Central Supply.

“Whatcha need?” she pushed from the corner of her tobacco-stained mouth. Her ash-colored face, devoid of any make-up, revealed decades of boredom and complete apathy for her job.

“Left handed Fallopian Tube,” I chirped. At seventeen, jaded older folks had no effect on my moods.

Her eyes rolled. Her head drooped. She exhaled chronic exasperation. “You go tell those sluts on Three West to stop wasting my time!” and she disappeared among the labyrinthine shelves of her personal cave.

Now my mood was effected. How could I go back up there empty handed? Having failed in my mission? I never wanted to do that. But no amount of calling, whistling, or yelling would bring back the Central Supply lady.

“There’s a problem,” I stammered in my best attempt to sound professional while awash in the shame of failure.

Boss Nurse fluttered her sparse, un – mascaraed lashes. “Oh?”

The other nurses all turned their faces away again. All except Nancy. She wore a sympathetic half smile like someone watching a puppy. That’s not all she wore – or almost wore – but I tried hard to concentrate on the job at hand.

“So what’s the problem?” Boss Nurse prodded. One of the nurses behind her snickered, and I got suspicious.

“They’re out,” I said. “On back order.”

And the floodgates burst. Everyone, even I, laughed one of those long spasms of laughing that leaves your rectus abdominis muscles sore.

I wasn’t about to ask them what a Fallopian Tube was – I’d consult my parents’ encyclopedia at home, later. But I was curious about one new medical term.

“By the way,” I broke thru the waning laughter, wiping my eyes. “What’s a slut?”

The hospital is built of adobe and plaster, and it has no heat. So the nurse gives your wife a blanket. Chunks of plaster have fallen from the walls, revealing coarse adobe beneath, where mice and spiders live. There is a hole in the ceiling over your wife’s bed. The hospital has no incubator for babies; bare light bulbs illuminate the delivery room.

The only doctor is out of town.

That’s the scenario which ran thru my mind as we inspected a 40-year-old “Puesto Sanitario” (Health Post) in a farming village in the Bolivian mountains. The villagers had asked Mano a Mano to build a new Health Center for them.

In the mountains of Bolivia, the chances that a woman will not survive childbirth are one in every 200 births. In the U.S., most people have never heard of a maternal death. But, in Bolivia, the chances of this catastrophe are thirty times what it is in the U.S. The main differences explaining this are the availability of heath care, and of a clean, equipped health facility.

When I was a medical student, I spent 3 months working in a small, rural hospital in Bolivia. I subsequently went on to a career in Preventive Medicine and private practice, including two years in South America and many years in the U.S. Then in November we returned to Bolivia and spent a week in Cochabamba with the people of Mano a Mano to watch their approach to improving people’s health, and to see if we could help.

I’ve seen a lot of construction projects in South America over the years. Often, soon after a new school or Health Center is built and dedicated, it begins to fall into disrepair because no one maintains it. But Mano a Mano does more than just build a Health Center: they involve the community and local government in the process so that the Center becomes a valued community asset.

Mano a Mano insists that the requesting community donate volunteer labor and a percentage of the cost of the project, and that the Municipality commit to maintenance of the Center and to recruiting a physician. Thus, our Mano a Mano contributions go further, and the locals are invested in their Health Center. That’s why so many Mano a Mano projects continue to serve the community long after the dedication ceremony.

The hard-working men, women, and children of rural Bolivian communities lucky enough to have a Mano-a-Mano Health Center enjoy healthier lives. And Bolivian women who bring new life into those communities have cleaner, safer places to give birth. This gives them a much better chance to survive the experience and become mothers, rather than tragic statistics.

So, I chastised myself, Ghandi would have taken the blow and not responded. I admire him because he was little and frail and non-violent before his tormentors. I emulate him: a better man than I, but I’ll bet he was never stuck in a Department store in a predicament like mine.

I was tired and hungry and had to go to the bathroom. Actually, I had been struggling against my inner body’s desire to empty itself for more than half the day – an unforeseen conflict between the urgencies of Public Health and commitment to my Action – when, like some malevolent Santa Claus, this agent of the Millionaire State broke from his ranks. He hid his identity behind a cowardly layer of black: right down to leather gloves (paid for by us taxpayers) which so completely covered him that I couldn’t even guess his ethnicity. His face, like all the others lined up menacingly before me, was hidden within a black helmet and opaque shield. As if he had stolen a one-way mirror from the set of some mid-day cop show to cover up his identity.

He came straight at me, club in right hand, pepper spray in the left. What do YOU want for Christmas, little boy? No one in the Movement had thrown anything other than words, so I wasn’t expecting this. And with all the cell phones filming my Action (a very creative and brilliant Action, I must say) I figured You-tube phobia would keep the cops civilized.

But no. He swung. I twisted and ducked. Whack. Right across my shoulder blades. The blow threw me against one of those white synthetic Department store beards they trot out to dress up their mannequins and employees every Shopping Season. You know, to make you think it’s the North Pole, even in Miami.

I expected the small crowd to howl and boo at such Gestapo tactics, but beyond the pain, I heard a cheer. Perhaps someone from the crowd is rising to my defense? I hoped. The cop towered over me – big, brave cop: menacing this skinny dissident who was chained in place and couldn’t run – and began to scream at me from behind his mask. His voice was distorted by the echo within his helmet and face shield:

“Go home – - – get a job – - – take a bath – - -“

My innards spasmed at the last words, awakened by visions of the inside of a bathroom. That just increased my suffering on behalf of Free Speech and the struggle against Crippling Consumerism.

Ghandi, I reminded myself. He must have endured worse. Be strong.

“No one wants you here – - – “ the Darth Vader voice echoed, “ – - – unlock yourself and get out!”

He raised his club again. I cringed forward, away from the coming blow, but Santa pushed me back, right into its pathway. The wooden stick sliced thru the Department store air, thick with nauseating perfumes.

Whoosh.

Whack.

The stick hit me in the mid back and set my kidneys to vibrating and my intestines to spasming. Santa, animated now by the bully-cop, pushed against me. Against my bladder.

“You Son of a Bitch!” I yelled at both of them. “This is a non-violent Action, you idiots! Free Speech. Don’t attack me. Attack the corporate millionaires who are fleecing you for Christmas!”

And immediately I felt chagrined at my outburst.

“Last chance,” Darth Vader warbled within his camouflage. “Unlock yourself and leave Santa alone.” He raised his stick. And aimed the can of spray.

Bright lights appeared. I looked toward them. TV cameras within the crowd. Four hours earlier, I’d actually been hoping they’d show up, but now things were piling up. First, Department Store Security, then this SWAT team, and now my own body beating on me from the inside.

And inexplicably, the crowd had turned against me. I was fighting for their Freedom. The Freedom of Buy Nothing Day. Freedom from the brainwashing of non-stop Consumerism. Freedom to tell millionaires that you won’t be feeding them any more of your hard-earned cash. But the crowd was cheering the cop.

I struggled to endure it in silence. Like my hero.

Then, from deep within this gloom of pain, I heard someone shout a word that cheered me enuf to raise my head and smile for the cameras.

“Liberate!” someone yelled. They said something else, but a rumble in the crowd drowned it out.

The cop backed away.

Redemption, I thought.

“Liberate Santa!” someone in the crowd echoed.

Wait. Liberate who?

“Liberate Santa!” several voices cheered. “Liberate Santa!” and it took on a chant like some damned football game.

That’s when my inner body’s failsafe mechanisms failed. It was a weird yin / yang feeling. Viscerally, it felt good. A relief. Psychologically, it was a defeat.

“Liberate Santa! Liberate Santa!”

I dug into my pocket, pulled out the key, and opened the lock. The chain binding me tightly around Santa’s waist fell to the red carpet. Santa stood up before I could, dumping me from his lap onto the Department Store floor.

The TV cameras moved in. Hovered over me. Whirred as they drank in my disgrace.

I got to my feet, moving carefully to avoid further embarrassment. The crowd was already disbanding.

The cop who had attacked me unsnapped his chinstrap, and pulled off his helmet. He was a blonde woman, thirty-ish. Attractive, actually.

“Sorry I had to hit you,” she said. “That was actually a very ingenious move – the chain and all. You probably caught Santa by surprise.”

“Yeah. Him and all his corporate masters,” I replied, a little bit proud again.

“But I had to do it. I have kids, you know. Two of them. Had to do it for the kids.”

“Sure. The kids.”

“You smell funny. Are you O K ?”

“It’s nothing a bath and change of clothes won’t fix.” I scrambled to change the subject. “What do your kids want for Christmas?”

“Oh,” she got animated. “Jason wants a Modern Warfare 3 for his X Box, and little Jessica, she likes the classics.”

“ ‘Classics’ ?”

“You know. Barbie. And her stuff.”

“All made in China,” I said, backing away a little so she didn’t have to smell me so acutely. “By child labor, probably.”

“China? I’d hoped to buy only things made in the U.S. this Christmas.”

“Good luck with that,” I said. And then I started my exit from the Department Store. I walked slowly, carefully, and tried to stay toward the walls, away from the shoppers. My Action for this day was done. But I agonized that my outburst had damaged the Movement’s greater story.

I wonder if Ghandi ever felt this way?

As I stood above the City, my eyes sweeping the skeleton of granite blocks so carefully carved and placed that 600 years of earthquakes haven’t dislodged them, and simultaneously allowing my eyes to plummet into the cloud-filled valley of the Urubamba river which wraps around the site, or to embrace the jungle-covered mountains that loom like sentinels in the mists protecting the City, my camera dangled, impotent, from my hand. I fought back tears; my throat filled up and spasmed.

I didn’t understand why I reacted like this to a sight so well known, so fully advertised in advance, so frequently photographed (I saw myself as a re-creation of one of the international visitors to Yosemite who insist on taking, each one, their own photos of Half Dome).

It’s taken me many days – two weeks’ worth – to let it percolate around my synapses before I felt I could write it. And I realize that the writing, like 2-D photos, will only diminish it.

But I write anyway. So that implies that experiencing Machu Picchu is probably not just a tourist “off my Bucket List” move, but a very personal experience. Let’s explore that angle.

The Incas built a drinking water system for the city which is still running. A spring is directed into narrow granite aqueducts which spill over a series of “fountains” (more like little mountain waterfalls) under which the inhabitants could position their aryballos to fill them. As I passed one of these, I saw a visitor pause, look around half guiltily, then squat down near the fountain. She carried the excess weight of the middle-aged; her long hair was a careless blend of yellowing brown with lots of grey; her pants were baggy and patterned with at least four different primary colors; her blouse looked like it was bought in New Delhi; her purse was of Peruvian textiles; she wore glasses. Santa Cruz would be my guess for her current home, now that her movement had disbursed since the 1970’s.

She pulled a small vial from her pocket, quickly unscrewed the top, and thrust it beneath the trickling water. It filled within seconds, and she twisted the top on it with such determination that there was absolutely no chance she’d lose a drop before getting it to her home, 5000 miles away.

A man, tall, thin, unremarkably dressed, walked past me and began his descent of an ancient and very steep granite staircase. Slowly, he descended. Carefully. But clearly determined to have his personal experience of the City in the Clouds. Very determined. He was on crutches.

For myself, I awoke at 4 A.M. Breakfast at 4:30. Up the bumpy road by bus in the half dark of crepuscular light. The sun was climbing out of the Amazon forest and awakening the sleeping creatures who lived among the bromeliads on the slopes of the mountains which face away from the City. I wanted to be at the Hitching Post of the Sun before it showed its golden face to the ancient walls yet one more day. I hurried over the streets of granite, up staircases that made my heart thrash and my newly broken rib stab me with each breath.

There, atop a granite platform that looked down upon the City’s central plaza, upon the royal residence near the western precipice, and upon the workers’ houses near the eastern agricultural terraces, I stood by the upright stone called Intiwatana. The city below me was half obscured by swirling clouds. Mists snaked up from the Urubamba, hundreds of feet below, flowing past the eastern, northern, and western flanks, and slithered over the vacant City. Clouds obscured the tallest mountain, Huayna Picchu, altho it felt close enuf to touch, and too big to hide.

Above me, clear black nite sky was brightening to dark blue. Birds drifted on invisible currents.

Then He rose. I squinted. He threw His light against the Intiwatana and then against the walls that faced east. Quickly, the mists evaporated before Him. He turned the agricultural terraces from nite black to emerald green. Had the bare walls of granite – the City’s skeleton – still worn plaster and hammered discs of silver and gold, His arrival would have been blinding. But still, up here where the beauty of the clouds and mountains are paid for by the black cold of nite, His warmth brought comfort, brought the growing of food, brought illumination for human eyes.

What they did, centuries ago, it occurred to me, is to take what God had built, and to compliment it with a city which incorporated rocks already there, with the rocks they carved. They oriented their walls with respect to the pathways of the Sun and Moon. They borrowed the mountain’s water by re-directing it, before returning the unused volumes back to the mountain.

No bulldozers flattening the mountaintops. No neon urging people’s attention away from the birds’ songs and the whispers of perfumed air. No air conditioning and heating inside the houses to create an environment that doesn’t exist in God’s realm. And, of course, no cell phones to distract people from virtually everything that exists around them as both Beauty and Danger, and from creatures that will talk to you, if you listen.

Yes, that’s right. Dozens, if not hundreds of people who travelled half the world to come to Machu Picchu and discover its secrets, wandered the granite city, searching for a signal.

We build our own prisons, don’t we? And walk right in.

So maybe my personal experience there was to see a glimpse – just a glimpse – of what is out there, beyond my own comfortable prison.

Campesinos flooding into the capital looking for jobs and foreigners seeking cheap retirement in Paraguay have spawned uncontrolled growth of the city. But I found some goodies.

The Panteon de los Héroes still honors past dictators in crumbling plaster, protected by adolescents in military garb wearing serious faces too young to shave.

And right across the street, the Lido Bar, packed with customers both inside and at tables on the sidewalk, offered us batidos de durazno, grilled chicken, but no mandioca (I can’t believe I actually wanted some). They were all out of the tasteless, stringy root. We had to settle for potatoes.

A couple of blocks away I caught a glimpse of a name painted on a building, the paint so faded it nearly matched the sooty plaster of the wall. But it was legible : “Munich.” Maybe it’s closed, I thought, but I’m gonna get a picture anyway. I know some folks back home who might like to see it.

But it wasn’t closed.

Dinner that nite, on the patio of the Munich, did include mandioca. And beer. And stars glittering thru the vines of the overhead arbor. The cathedral bells gonged our time there, in warm and perfumed nite air.

The Hotel Guarani got a visit from us, but not our business. The visit was to its roof, which offered a good, but precarious view. No railing; demolition underway for remodeling. But we looked down upon the Plaza and the flowering tops of trees: orange and yellow blossoms. Down upon the lazy river that winds past the city, no more urgently than in 1972 (or, I imagine, 1872).

The other Plaza – Uruguaya – was littered with crude tents, smoldering fires, and heaps of stuff resembling garbage.

“Indiginas,” we were told. “From the North. “They want land.”

The next day,we walked thru the Plaza, and found just that. Families living a very dirty and marginal life. They had brought the distant campo right into the downtown. I squatted and asked a nursing mother where they were from.

“Alto Paraná.”
“What group? Aché?”

She shook her head: “Guaraní.”

ABC Color, the local newspaper, ran a very short article buried on page 30. They referred to the occupiers only as “Indiginas.”

Deja vu, indeed.

Tiina insisted that we buy some food for her and her family. A good idea. It would probably be very difficult for the woman to take any money I might give her and shop with it. We brought them a picnic of chicken barbecue, a carton of milk, juice, crackers. A good meal for one day, but they need something else. And that’s in the hands of Paraguay’s government. Again. Still.

Home for our two days in Asúncion was the Gran Hotel del Paraguay. Refurbished, but still the sprawling century- old home of Madame Lynch, with its ten foot high doors, tile floors, hardwood trim, and brass beds. The staff behaved as if it were the 1920’s; the food was good; the pool was big and decorated by the breeze with floating leaves and twigs. The diesel belching cacophony beyond was muffled, and the heat defeated, by gardens of flowers and fruits I’ve never seen before, where a macaw and toucan live.

I warned Tiina that, one of the endearing things about Paraguayans was their innocent recurring irony of trying to be classy and up to date, but planting little surprises there to which they were oblivious. Like the modern glass paneled shower stall in the hotel room wherein the shower head was aimed right at the hinged part of the shower door, so that the floor of the bathroom was flooded by the time you stepped out. Or the large script letters painted on the exterior of the downtown icon proudly proclaiming it the “Hotel Guarani Splendor” but with paint peeling in large sheets from the wall just beneath the letters.

The final deja vu, amid the concrete and glass sprawl of the New Asuncion, was the Paraguayans themselves. Self proclaimed historians who laughed at my jokes told in Spanish and who bubbled about the glories of the country’s multiple wars of wholesale slaughter. The geologist who was born in the Chaco (Filidélfia) and discussed at length the need for a quality education for Paraguay’s future generations and also for birth control. And, finally, the cab driver who pulled over from the random traffic after I’d tried to wave down a cab for half an hour.

“The city has grown since I lived and worked here 40 years ago,” I opened.

“Forty years? Mucho tiempo. Where are you from?”

“The E.E.U.U.”

“No me diga. Before I drove a cab, I used to work for North Americans. The Cuerpo de Paz. You know it?”

“Uh-h. yeah. What did you do?”

“Messenger. And driver. From 1985 to 1992.”

“Well, I worked as the Peace Corps doctor in the 70’s, and bought a car from the driver. His name was Francie.”

“Francie?! I know him! He is a friend.”

I felt the warm flow of Deja vu like a swallow of caña, from my heart all the way up to my smile.

With crepuscular light over Asuncion, he whistles a high / low / high / low pattern which jumps up a half octave after a few repetitions, then down for a few more. It´s so distinctive, it stands out over all the other birds´jabbering into the early morning, even the piercing caw of the caged macaw.

Notice the onomatopeoia in the bird´s name?

They speak two languages here: most Paraguayans speak Spanish, imposed on them by gunpowder and steel from Europe 500 years ago; all of them speak Guarani, the language of the original dwellers of forest and savannah who must have learned from the birds how to communicate.

Now the Spanish here has taken on the melody of Guarani, the melody of the animals. It is smoother than the Quechua infused Spanish of Peru and Bolivia, and certainly softer than the arrogant trills and sibilants of Argentina, the looming big brother who casts his shadow over Paraguay in many ways – most currently, on T.V.

This city has doubled or tripled in size since I lived and worked here long before my hair was grey, bringing plenty of Public Health issues to feed my synopsis to come. But the bird in the garden tree ignores all that and speaks with his original voice – his only voice. The voice that taught some of us to speak.

We could all benefit by listening more to such organic sounds, and a whole lot less to the electrionic sounds that have taken over our world.

We began high in the mountains where the Quechua have lived for centuries, even after the murder of their revered king, the Inca. Explored the bare rock skeleton of their magnificent city in the clouds, long devoid of plaster, gold and silver fixtures, and colorful textiles, but still breathtaking. I stood looking at it, fighting back tears. Elsewhere in the mountains, we walked on stones they laid over 500 years ago; we stepped over the mountain spring water still running in their ancient stone canals; we heard them speak their language, and then speak Spanish with strong Quechua pronunciation.

Sitting at a table on the plaza in Ollantaytambo – which name implies it was a resting place for the Inca runners who carried messages thruout the Empire – we saw a Quechua man in a red poncho bend over one of those open stone canals, dip in a plastic cup, and drink. As would have a runner over 500 years earlier. (Sans plastic).

Then, moving south, Cochabamba: an old town of Spanish buaildings which are slowly being consumed by algae and dissolved by rain. Everywhere, you see both races – the Euorpean faces of Bolivians who run businesses and create the local art scene, and the Quechua, still wearing sandals and traditional textiles, speaking their language until forced to speak Spanish. Their faces are still bronze, muscular and proud.

Both groups call themselves “Bolivians” but – - -

Now, here in Santa Cruz, its hard to feel that we are still in Bolivia. The second language here is Guarani; Quechua ponchos and colorful dress are rare. When I was here 40 years asgo, it was a sleepy Spanish farm town. Ox drawn carts on main street. Main street made of mud. Now, the city sprawls like a large Fresno or a small but growing L.A. Million dollar mansions and flashy sports cars rule, and the hot humid air makes you take off your poncho, but also spurs the trees to flower. Flowers so bizarre and colorful, nothing we have ever seen is like them. Even locals cant name them for us.

Yesterday we were assaulted by macaws and a toucan, looking for food. Butterflies everywhere.

So we have moved from the South America that existed before the Spaniards came, to streets where the two races intermingle, and now we watch as California – style agribusiness and cocaine dollars pave the formerly muddy streets and raze the sleepy haciendas to re-create Miami.

Leaving today for Paraguay, country of Jesuit missions, aboriginal forest people, and millions of memories.

Where there is only one doctor assigned and he is sometimes absent.

Upon these briefly trained people falls the responsibility of being sometimes the only medical professional for miles around, and for every medical need.

With these folks I walked thru an investigation of a disease outbreak, hidden within the routine patients they see every day. Cholera lurks in the northern section of town, and the first three cases show up, among the routine sore throats, tuberculosis, and pneumonia. I planted nine envelopes at desks in the classroom, and, as the nurses in those seats open them and read aloud the description of each of the 9 cases, I urge them to begin to suspect an emerging outbreak. With the Power Point, we re-arrange the data, and the pattern emerges. I praise their detective work and warn them to be vigalent. Epidemiology 101.

Next, I discussed (at Dr. Zegarras request) the Social Determinants of Health. I urged them to think beyond their clinic walls, to see how the source of water, how getting prenatal care, how drinking (“chicha” is a favorits alcohol here) and driving result in Bolivias high mortality statistics. In short, I urged them to also do Public Health.

But what they seemed most interested in was to hear the Gringo doctor sing a song from this “California” place. They asked for it. They got “Folsom Prison.” Bush and Cheney would replace waterboarding with my singing, if they could, but it sure broke the ice. I hope they rememmber the Public Health lessons more than my croaking.

Their only health facility was an old adobe structure, crumbling back into the earth from which its bricks had been formed, decades before. It was dark and cold inside. Flashlite and parka. The waiting chairs were bare metal. A wire of 220 volts hung menacingly from the shower head in the (frankly disgusting) bathroom. But it was the “Sala de Partos” that was most telling.

Women were put into the rusted metal beds covered with tattered blankets, to labor their children into the world of Cotani Bajo. Paint peeled from the walls. In the middle of the stark room loomed a metal delivery table. No bassinet. No incubator. In the ceiling over one of the two beds was a gaping hole above where a mothers head would be.

Bolivia has an Infant mortality rate more than ten times that of California.

Its Maternal mortality rate is over 300 deaths per 10,000 live births, twenty times that of the U.S,

The townspeople, who came out to greet us in the cold dawn at 9000 feet, had requested that Mano a Mano help them build a new Health Center. They had a site, a plan to provide electricity and running water, and were already building a plaza of carefully laid stones. Altho crude, I could see in their rock work the visual echos of the work of their ancestors – the Classical Incas.

We shook hands with all the coca chewing men, walked around the grazing cows and sheep, and drove on to our next stop, the trucks heater blasting.

Later, in another town, we stopped to inspect an operating Mano a Mano Health Center. The doctor was busy with patients, all smiles, working in his well-lit, clean, brick and tile building. The dentist showed off his new Brazilian dental chair, hydralics and compressed air and integral plumbing. He had just bought colorful toothbrushes for the local school kids. For contrast, I looked into the Sala de Partos. Clean, well lit, an incubator waiting, clean bed, sterile equipment. A cheerful room.

Since the new Health Centers construction, Infant and Maternal mortality stats have begun to fall.

When Cotani Bajo gets its new Health Center, it will be Mano a Manos 125 th over the past 15 years.