Sex, Drugs, and Public Health

January 16, 2018

Cuba, Número Tres

Filed under: Uncategorized — cbmosher @ 7:02 am


De Soto, a fluffed-out peacock, struts onto the Malecón. Potential mates drive by, chrome gleaming and whitewalls spinning, flaring their erogenous zones with colors both bold and pastel.

IMG_2216 copy


The Gulf splashes against the seawall, but not, at the moment, onto the street. A diorama flows by as if De Soto were a slow camera. Tour Guide Lady chats, mixing English and Spanish.


Invisible Observer: “Is this your full-time job?”


“No,” she interrupts her diorama comments. “I work at a hospital. I’m a dermatologist. Now over here you see – ”


“Wait. If you’re a physician, why do you guide tours?”


“I want for that the world sees,” she smiles, “how beautiful are the people of Cuba. Also, I need the money.”


From Vedado we cruise past Central Havana – the most color-less and run-down section of the city. Paralleling the sea, we curve slowly to the right where centuries-old fortresses guard the harbor’s entrance.



Close your eyes. See the Conquistadores in Peru surrounded by hundreds of magnificent gold sculptures. See them melt these into bricks. See them load the bricks onto their ships (well, honestly, the Conquistadores don’t do the work. The local residents such as the Inca’s people do the hard work because they love the Spanish so much that – z-z-z-t! Wrong record.)


See these gold-laden ships make their last stop here in Havana before crossing the ocean to feed the rapacious Siglo de Oro of Spain. See the English, Dutch and French pirates drooling over the gold.






“Here we have Havana Vieja,” Tour Guide Lady-Doctor announces. De Soto disgorges us onto the street. We walk. Our phones take pictures. Quickly we discover that “Old Havana” is two places: first, it is el número uno tourist trap. Also, it’s a sclerotic but dignified City of Ghosts.


First, the Tourist thing because it is the more distracting and you have to get beyond it: cheap cigars hawked in the street; three-peso “Che” coins for only $5 (worth 12 cents at the bank); Hemingway’s bar #1; cigar-smoking ladies in colonial dress available for photos and tips; The Best Mojito in Cuba! ; hawkers for restaurants; Hemingway’s bar #2; music (don’t need to hear “Guantanamera” again); The Best Mojito in World!



City of Ghosts:

           Within a couple of decades of Columbus claiming Cuba for Spain, this satellite Madrid began to grow. With the help of indigenous residents (who proved to be of “weak constitution” for slavery, and were therefore banished early to extinction) and of imported Africans, they used local materials to build streets of wood – – –



And buildings of fossil- bearing stone.




Here, gold played out quickly. They established sugar plantations on the backs of slaves.


473 miles to the east, Spain set up a second capital at Santiago. African slaves in this “oriente” region worked themselves to death growing tobacco, sugar and coffee which were sold by Spaniards and Criollos (those born in Cuba with white skin). Thus were created the two wealthy classes of Cuba: Spanish loyalist land-and-slave owners in the west (Havana) and Criollo land-and-slave owners predominantly in the oriente east. Also was born the far more populous Poor class that worked the flat valleys.




Remember this geography. It will haunt Cuba over four centuries.


Cuba’s Tea Party:

So, while feisty white-skinned English speakers started a revolution in “The Colonies” 90 miles north, feisty white-skinned Spanish speakers on the island revolted against Spain’s Tobacco Levy. Common cause trade between the two colonies began, and grew both economies. Sugar, coffee, slaves.


By 1841 there were 1.5 million African slaves in Cuba. On a subsequent visit to the sugar fields, a Cuban woman showed us around a long-deserted mansion and plantation. “Only men were kept here,” she synopsized her own ancestry. “Their life expectancy was 25 years. Women were kept on breeding farms somewhere else.”


She also gave us a dramatic insight into post-Revolution Cuba. But that’s for later.


Two things Latin America has in abundance are statues of long-dead people and various public streets and parks named for long-dead people. Ghosts whose faces you can see and names you can hear.


Ghost # 1:



This is Céspedes. “Father of the Country.” He owned a plantation in the east. Got tired of the Spaniards telling him (and other Criollos) what to do. Of course, he told his slaves what to do, but that was different.

He was different. In the same decade that the U.S. proclaimed the Emancipation of its slaves, Céspedes freed his own slaves and started a revolution. Somewhat successful for a while. Got himself installed as president of the country. Spain didn’t recognize him, but it recognized his son, Oscar. They captured Oscar.

Here’s the deal, Spain said (probably with that annoying lisp). Renounth your prethidency and your thon retunth to you. Famously, mythically, Céspedes is reputed to have said “I do not have just one son. All Cubans are my children.”

At this point in the story you hear a fusillade of executioners’ rifles.



Invisible Ghosts:

There are no statues of slaves. Shocker.

There were to be many slave rebellions, however, in addition to the repeated attempts at revolution against the European colonizer (Spain) by Criollo patriots.



Ghost # 2:

Replica of the statue of Jose Marti arrives in Havana


Name is Martí. This guy lived for a while in the U.S. – Cuba’s major trading partner. Somewhere between Cuba and the U.S. he caught independence fever in 1892 and formed the Cuban Revolutionary party.

Martí’s rebels brought Revolutionary War from the oriente (see the geographical pattern?) right into Havana. Spain was pissed. And militarily stronger. It launched a “War of Extermination” and drove the rebels back to the east. But Martí’s writings inspired many, right down to the 1950’s.



Ghost # 3:



Battleship Maine. No photos; it sunk. U.S. excuse for intervention into the Cuban War for Independence. America destroyed the Spanish fleet and got control of Cuba. Also, took ownership of Puerto Rico, the Philippines, and Guam.



Skipping details, next comes a period of U.S. military occupation, a new Cuban constitution with an amendment demanded by the U.S. allowing us to intervene in Cuban affairs at will, a series of corrupt presidents, large sugar companies displacing Cuban farmers, and another uprising by Blacks and Mulattos.


The pattern of a handful of rich dudes and millions of poor, continues into the twentieth century.


Ghost # 4:

Remember Vedado? It grew during the Boom Era of sumptuous homes built along the Malecón in the 1920’s by U.S. capitalists (they controlled 70% of Cuba’s sugar and much of its infrastructure), by corrupt Cuban politicians, and by colorful gangsters like Meyer Lansky who built hotels, casinos and prostitution rings.




Here’s a Cuban description of those halcyon days, translated by someone with a poetic eye but a tenuous grasp of English: for thousands nine hundreds were built great villas, amazing and rich palaces – – – and new population nuclei formed thus fashionable. Very beaten to the sea it receives from this all his light and magic. Along the Malecón you enjoy near the sea how the sun is lost in the water after the horizon – – – the progressive light dimming.


The 20’s, 30’s and 40’s were lots of fun for American tourists. Wonder if Jay Gatsby still haunts the opulent halls of the gangster-era Hotel Nacional?


The 1920’s also brings the birth of the University Student Movement. Restless, naïve kids fighting injustice. Oh, oh.


Ghost # 5:



Fulgencio Batista. Military dictator who undermined an uprising by soldiers, students, and workers. And who took over, by military coup, the government in the wealthy post-WW II era. Supported by the U.S. which was, as usual, protecting its financial interests.


Out of these University student movements comes, in 1953, a young lawyer. Name is Fidel, of whom we’ll hear more –

               Hey! What’s this?



His wife and daughter wait as Carburetor Man does a re-build on the street. He and wife are perfectly happy to allow a photo. Their teenager daughter sits in the back seat displaying an age-appropriate sulk.



During the entire morning we’ve seen no police and no signs of street-living Homeless.

I. O. turns to Tour Guide / Dermatologist: “Does the government keep the Homeless off the streets in tourist zones?” he inquires, thinking Santa Barbara or Miami.


She stops walking Havana Vieja to explain in English for us. “In the evenings, comes through Social Workers. Anyone they discover with no dinner or bed they offer a place to sleep and a few pesos for ration-card food. To those people with mental illness, they offer care. If they refuse, at least they get food.”


“So, they can get medical care?”


“Everyone can get medical care. No cost.”


I. O. has heard about this for years. But how is the quality? “Please, I would like to see a clinic, a Centro de Salúd. I would like to speak with physicians, if it is allowed.”


“Of course,” our Dermatologist smiles. “I will arrange it.”


We finish the day, back in Vedado, enjoying how the sun, all his light and magic, is lost in the water, after the horizon, the progressive light dimming.



Número Cuatro – Sex, Drugs and Public Health in Cuba

Filed under: Uncategorized — cbmosher @ 7:00 am

Imagine a knock at your door. You open it to find the smiling faces of your nurse and doctor. Time for your annual check-up. You sit in your living room. Questions (AKA medical history), physical exam, BP, inspection of your house for hazards, evaluation of your exercise regimine, vaccinations. This happens at no cost to you – just like all medical care.

Because it is one of your rights as a citizen.

Says so right in your country’s constitution.

If you need more, you may go to your neighborhood Health Center (some more artistically appointed than others).


If your doctor-nurse team can’t handle the problem, you will be referred to a Polyclinic where specialists serve multiple neighborhood clinics. And for surgeries, transplants, cancer care, etc., to a hospital. If a case of Dengue has been found in your neighborhood, the local Health Department will come to your house and eradicate mosquitoes.


If you were a Cuban citizen, you would (based on our conversations with people) not only appreciate your health care, but be knowledgable and proud about its details including:

  • Cuba has developed a vaccine against lung cancer

  • in the 1980’s, they created the world’s first vaccine against a very nasty form of bacterial meningitis (Meningococcal B). I recall an outbreak of this disease in Oregon in 1993. The U.S. didn’t have a vaccine for Meningococcal B at the time and was too stubborn to ask Cuba for some of theirs.

  • The Cuban childhood vaccination program is one of the best in the world.

  • Cuba currently exports physicians and medical technology to 68 countries.

  • Cuba’s life expectancy and Infant Mortality rates are equal to or better than in the U.S. while spending one tenth as much per person.

How did this happen? We picked the brains of several physicians while there: the dermatologist who was our tour guide (see Numero Tres); an Ob-Gyn who took us to the Oriente and the southern coast; the Family Doctor at a neighborhood clinic; a Tuberculosis and Public Health expert at a Polyclinic; an orthopedic surgeon; and a painter-artist who was also a psychiatrist.

But this little kid can get us started.

The Oriente again:


Remember the East? Rural, legacy of slavery, cradle of revolutions since 1868? The farmers of this area were illiterate, therefore poorly educated, and so poverty-stricken that children like this were common before the Revolution of 1959: their bellies swollen with parasites, malnutrition and vitamin deficiency. There were 500 childhood deaths a year from tetanus, measles, pertussis and 300 cases of polio.

Revolutions to change government are relatively common (the U.S. in 1775; Russia 1917; Vietnam 1946 thru 1975; Nicaragua 1979). But a revolution that changes Health Care – that’s rare. It tells us what Fidel was really up to. And it’s a fascinating part of this most interesting Socio-Political experiment of the second half of the 20th century.

We saw a quote by Fidel in a museum which I’ll have to paraphrase:

                        How can a farmer who works (in sugar plantations) just four months a year, whose children are crippled by rickets and who has no access to physicians or education be a productive citizen?


Thus, when the Revolution drove out Batista’s dictatorship, one of Fidel’s first orders was to send an army of teachers into the rural zones and city neighborhoods to eradicate illiteracy. Multiple sources document that, within a year, literacy in Cuba had gone from 60 % to 96 %.

This woman of the Oriente told me that her father, a poor farmer, was illiterate and had five children. Since the Revolution, her father can now read and all five kids have attended university. She became a veterinarian.

However, back in the cities where most physicians practiced traditional fee-for-service Medicine (like we have still in the U.S.) and were therefore of the wealthy class (as in the U.S.), there was a major exodus. The Medical School in Havana lost 138 of its 161 professors. And Miami became, as a friend says, “a Latin American city which is conveniently close to the U.S.”

Those rebellious / naïve university students again:

Medical students held raucous meetings, proposed ideas, took votes. Ultimately, they approached the Revolution’s Ministry of Health which, as a result, created over 300 new positions for doctors in rural Cuba.

They created Medical Schools in rural towns, not just Havana. There are currently 25 Med Schools among the country’s 15 provinces. Traditional Medical Education is two years of theory followed by slow introduction of clinical practice. In Cuba they reversed it, locating Med Schools in Polyclinics and having new students begin their education by seeing patients.

After six years of Medical education, new Cuban physicians all do Family Medicine for three years. If they want to specialize, they can do so after this Family Med rotation. Each M.D. is teamed with a nurse and assigned 125 to 150 families to care for. People like our swollen-bellied girl now had health care brought right to their homes, both treatment of illness and prevention including immunization.

Over the course of years, the combination of literacy for all, free education up thru university (or trade schools based on students’ interests and abilities) and Med Schoools located close to the entire population, here’s Cuba’s situation with physicians now:

            Cuba – one M.D. for every 200 people

            U.S. – one for every 390

Is the quality of the medical education good, or are these Cubans just Russian doctors with Spanish accents? Our conversations with Cuban physicians revealed a knowledge base equal to ours. A report in a Canadian medical journal stated “Cuban medical education parallels Canada’s.”

Cuba attracts students from other countries (including the U.S.) to its ELAM school for Medical Education. Cuba hosts international symposia and meetings in various specialties, and Cuban doctors travel abroad for post-graduate training.

Where Cuban physicians fall short – and they are fully aware of it – is in lack of advanced technologies and very expensive drugs. Here are two orthopedic surgeons:

On the left is Dr. Robot, a member of our group who pioneered computer-aided robotic hip replacement surgery. The man in the middle is a Cuban doc who generously gave us some of his time off and revealed a good knowledge of basic orthopedics, but had no access to such advanced technology. Dr. Robot will try to help in that regard.


Recall that the free-wheeling capitalist days along the Malecón, with U.S. gangsters, music, and casinos, included a booming prostitution industry. The resultant health ramifications included V.D. and unwanted pregnancy.

Changes to the system of Reproductive Health Care since the Revolution include free access to birth control in the neighborhoods where people live, a home for unwed pregnant women which we saw in Havana, legalized abortion, comprehensive free (and compulsory) pre-natal care. The following is a synopsis of Cuba’s approach to the nastiest V D in our times.

Three years before the first case of HIV infection hit the island, they forestalled it by banning the import of blood products, destroying all blood products on hand, and screening Cubans who returned from abroad. Cuba is first country in the world to have eliminated maternal-newborn transmission. They have also eliminated transmission by blood products and IV drugs. The island has the lowest HIV rate in all the Caribbean and one of the lowest rates in the world at 0.07%.



The U.S. embargo (“el Bloqueo”) which tightened its stranglehold over the Cuban economy in escalating stages, made it nearly impossible for Cubans to obtain insulin vaccines, antibiotics, or anti-cancer drugs from the U.S.

1958 – arms embargo

1961 – prohibits aid to Cuba

1962 – prohibits aid to any country that aids Cuba

1963 – freezes all Cuban assets

1996 – penalizes foreign companies doing business with Cuba

So Cuba created its own pharmaceutical industry including research facilities and factories of vaccines and medications. They sent researchers to Germany, Finland, France, Japan, and the USSR to gain the needed skills and expertise. Some of Cuba’s more notable developments are sought after by other countries and institutions (including some in the U.S.). Examples:

Cima-Vax is a vaccine against Epidermal Growth Factor, created at Cuba’s Center of Molecular Immunology (CIM). Some cancers, including non-small cell lung cancer require EGF to grow. So the Cuba-created vaccine induces antibodies against EGF, starving the n-s-c lung cancer of this needed molecule. Cuba has been using it to treat this form of cancer, with reported success. It holds so much promise that it is now being tested in Japan, the European Union and Serbia. Most notably, a major cancer center in the U.S., Roswell Park, has – in spite of the Bloqueo – obtained it for study. We await results.

Nimotuzumab is an antibody of human-mouse origin developed at CIM, which binds with receptors of EGF and is used as an immunotherapy agent to fight certain cancers. Cuba has granted licenses for it to Europe, South Korea, Japan, India, China, Peru, Brazil, Pakistan, Argentina, Mexico and several African nations. The U.S. treats it as an “orphan drug” (for use in one disease only – in this case, a form of brain cancer).

Meningococcal B Vaccine. In the 1980’s, there was an outbreak of a virulent form of meningitis in Cuba, devastating children and teenagers. There was no vaccine against Men-B in the world at the time – too technically difficult to create. Cuba, however, succeeded in developing a vaccine in 1987, conducted trials, then vaccinated every Cuban under age 15 by 1989. The vaccine was so successful, that Brazil, Argentina, and Colombia began using it. It has been proven safe and effective in randomized, double-blind studies.

While working as Health Officer, I watched closely as an outbreak of the same disease erupted in Oregon beginning in 1993. The outbreak lasted four years. In 1999 the U S obtained the Cuban vaccine but only to send it to Belgium for testing. Not til 2013 did Europe develop a vaccine against Men-B. Later in 2013, there was another outbreak, this time at Princeton University. The U.S. imported the European vaccine for emergency use.


How can a poor country afford all this?

It is precisely because Cuba is poor that it has shifted the focus of Health Care from diagnosing and treating disease to preventing it. They still provide the diagnosing and treating, but prevention is much cheaper.

The U.S., overwhelmingly focuses on treating illness, and spends 17.6% of its GDP on “Health Care” annually. About $10,000 a person.

Post-Revolution Cuba, while it treats disease also, focuses intensely on Prevention, spending 11% of its GDP. About $ 800 a person.

In Public Health, we measure success of a Health Care system by statistical data on the population as a whole, such as Life Expectancy:

            Cuba (before the Revolution) – 56

            Cuba (today) – 79

            U.S. (today) – 78.8

And Infant Mortality:

            Cuba (before) – 41.8 per 1000 Live Births

            Cuba today –   4.4

            U.S. today – 5.8

            The U.S. figure, worse than Taiwan or Poland, varies greatly by demographic group. E.g. in King County (Seattle) the Infant Mortality rate is 3.9 for the entire population, but for African-Americans, it’s 7.1 (about the same as Kuwait or Russia).



Vaccine-preventable diseases:

            Years ago, in a hospital in rural Bolivia, I saw a seven year-old boy lying alone in a dark room. “We leave the lights off,” the doctor whispered, “because any stimulation causes muscle contractions.” And at that, the boy’s entire body went into spasm. His back arched so violently, I thought his head would touch his heels. Every muscle in his body was as tight as we experience with a leg cramp at night.

            This was Tetanus.

            Recall that, pre-Revolution, 500 kids died of tetanus or measles or whooping cough each year. Tetanus has nearly disappeared (incidence less than 0.1 per 100,000) The other two diseases are now extinct in Cuba. As are polio, rubella, mumps, and diphtheria. Cuba’s childhood vaccination rate is 95%, one of the highest in the world.

            Better yet, Cuba produces its own vaccine (necessary because of the Bloqueo) which guarantees a stable supply. A situation Canada lamented that it did not have as recently as 2004. As Health Officer, I recall more than one season when our vaccine supply was compromised because the Pharmaceutical manufacturer had either a contamination in the factory, or was diverting vaccine to higher paying customers. For one period of several months, physicians had to send their private patients to Health Departments for tetanus shots.

            Hepatitis B is a crippling disease which often kills with cancer or failure of the liver. It can be transmitted to newborns from the infected mother. In 1991, Cuba recorded 2300 new cases. They developed a vaccine at their Genetic Engineering and Biotechnology Center. By 2003, the number of new cases nation-wide was 90.


As a result of all this, Cuba’s population is living as long as in the U.S. and dying of similar diseases: heart disease, cancer, stroke, emphysema. But Cuba also has one of the best rates of Blood Pressure control in the world and is aggressively attacking smoking. Cigs can no longer be obtained using ration cards and carry this warning:


“Every cigarette is one day lost from your life.”

Another measure of the success of prevention: over the period 1980 to 2000, there was a decrease in hospitalization and in hospital out-patient visits with a parallel increase in primary care visits in the neighborhoods.

How much do Cuban doctors make? Not much. Just got a raise to $60. A month. Also, as mentioned earlier, access to equipment or expensive drugs (psychiatric drugs in particular, per our conversations) limits their effectiveness in the treatment-of-disease part of health care delivery. Cuban physicians asked us for such simple tools as face sheids (to protect surgeons from fluid splash) and goniometers to measure the range of motion of joints. Physicians do have access to computers to do research and education, but it’s dial-up and limited in time.

Our Dermatologist with Face Shield

Capitalizing on their success:


Shocker – Cuba’s health care system actually produces revenue. Their ingenuity and vision created such successful work-arounds to the Bloqueo that Cuba now exports physicians and medical technology. 37,000 Health Care workers serve abroad in 68 countries. I’ve seen them in Bolivia, Haiti, Ecuador. They work under international contracts and generate revenue for Cuba. In the case of Venezuela, Cuba gets oil. And Cuban doctors get paid more when they serve abroad.

Leading sources of revenue.

            Before 1959 Revolution: Sugar

            Now:   Physicians serving abroad.

Cuba is a destination in Health Tourism. Approximately 20,000 people a year come for health care from Latin America, Europe, Canada, a few from the U.S. Health Education is incorporated into all schools. And Alternative Medicine is recognized and integrated into Cuba’s western medicine model.



The Herbalist

To me, this is all a spectacular example of what a government can do for its citizens if it has its priorities straight:



Cuba: Literacy, Education, Health Care

           Just looking out a window, you can see what languishes for lack of resources – streets, building maintenance.

            But we heard almost no complaints about this. When the hurricane storm surge inundated streets and homes, the people came out to do clean-up themselves.

U.S. : Money

              “Success” is measured by income. Almost everyone – including millionaires – believes they don’t have enough.

            “Insurance” is the vehicle for Health Care (for those who can afford it). 27 million are still without this vehicle. Insurance company profits are a major cost of Health Care, which costs double what it does in developed nations like Canada, Sweden, Germany, France, and ten times what it does in Cuba.

            And now Trump is trying to sell us that the economy is “national security” to be “defended” by our U.S. military.

Back in Cuba, that little symbolic Oriente girl with a swollen belly has had her parasites purged, her rickets cured with vitamins, been vaccinated against the traditional childhood killers, been taught to read, has graduated from the university and gets free pre-natal care.







SOURCES: World Health Org, Pan American Health Org., UNICEF, New England Journal of Medicine, World Bank, BBC, Canadian Journal of Infectious Disease, MEDICC (Cuban Health Education Journal), Miami Herald

NEXT: Cigars, Beaches, and the Rolling Stones.

November 4, 2017

Orthopedic Team to Ecuador

Filed under: Uncategorized — cbmosher @ 4:09 am

Here’s how it works. We arrive at the hospital in Cuenca on Sunday to find a large crowd of people hoping to get surgery by the North American orthopedic surgeons. The surgeons screen them (translators needed) and then refer them all to anesthesia, where I work.

We obtain histories, nurses check B P etc. and the anesthesiologists determine whether each kid is safe to go under. Most of these cases are complex and / or risky, so the Gringo surgeons will teach advanced techniques to the Ecuadorian surgeons in the O R.

Case # 1: Jordy – he broke his tibia at age 5 and has undergone four surgeries over the past seven years, but the bone never healed.


He hasn’t walked in seven years. His mother has placed her hopes and faith in the North American surgeons (a bit of a cultural problem, as it can undermine faith in the local docs). On the morning of surgery, the team of five Gringo doctors, two Ecuadorian doctors and I (as translator) stop at his bed. The ortho docs pull out X-rays and discuss them while the patient and anxious Mom watch.


“We shouldn’t be doing this case,” one surgeon shakes his head. “He has congenital psuedoarthrosis – it’ll never heal. What he needs is an amputation.”

The head surgeon begins an intense discussion with the surgeon who proposed this change of plan. Meanwhile, an Ecuadorian doctor tells the mother what has been said. Her mouth falls open in shock. Then tears overflow onto her cheeks. The doctors move on to the next bed.

“Señora,” I hold her hand as I trail the docs, “I’ll be back and explain this to you. Don’t worry.”

Rounds over, while the surgeons change into scrubs, I return to the floor. The mother is in the hall, listening to an intense young Ecuadorian.

Good, I think, some physician is explaining things to her.


I start work with another patient in a room, then hear loud yelling in the hall. Not just once – over and over.

What the hell?

I look out and see the young man gripping Jordy’s mother and yelling for Jesus to come down and heal something. The mother convulses in sobs.

I hurry down to the OR, get the head surgeon and implore him to come up and go over the issue with her. He assigns a different surgeon to go up with me.

Patiently, we explain to both Jordy and his mom that it was likely he had a condition which would prevent his tibia from healing. That the bone would remain in two un-united pieces. That this fifth surgery might fail, too. But it is their decision – they can go for repeat surgery, for amputation and prosthesis, or to go home and live with the crutches. But we stress that, even if it does someday come to amputation, his life with a prosthesis would probably be better than a life on crutches.

Mom is not ready to consider amputation. Surgery goes forward with these results:


In the Recuperación Room, Jordy smiles as soon as he is awake, and doesn’t complain of pain. His mother is grateful and happy.

Upon hearing the story, one of our nurses offers to speak with the Mom.

“About what?” I ask.

“I’m an amputee,” she reveals. “She can see how it hasn’t kept me from a productive and fun life. Let me know.”

As she walks away, I watch her gait closely. Can’t see a limp, a stiffness or anything abnormal.

Jordy’s mother, however, isn’t ready to hear it. She beams optimism and faith. “What can I do for my son to help him?” she asks.

I go over post-op care at home. I feel a responsibility to temper things a little. I remind her that we don’t know how well the tibia will heal, in spite of good alignment. Then I say something I seldom say. It seems appropriate in this case:

Señora, you can pray.”



  • Pentacostal “christianity” has penetrated deeply into traditionally Catholic Latin America.

* Congenital Psuedoarthrosis – if Jordy indeed has it – is pretty rare. About one in every 250,000.


Case # 2 – Too Cute

Filed under: Uncategorized — cbmosher @ 4:05 am

Look closely at her picture.  At her hands.



She came to us with congenitally misplaced digits on both hands and with mild club foot deformities.


The hand surgeon had me translate for the mother.  He said he might not have time to do both hands and feet. With which hand or foot did she want him to begin?


She said she’d noticed the girl drawing and playing with preference for her left hand. So the left hand was most important. As long as she wore shoes, she could walk without crying.


The surgeon did a “tendon and pulley reconstruction” in her hand using a plastic tube, giving her improved finger function.



Case # 3 – The Jesus Family Drama

Filed under: Uncategorized — cbmosher @ 3:59 am

This kid wasn’t on the schedule.


On the morning of the last surgery day, we found the mother standing outside our little office, clutching X-rays. By her dress, it was clear she was Quechua and very likely lived beyond the city. When she spoke, her Spanish was so heavily inflected with the language of the Incas that we had to repeat and re-phrase things.



Her five year-old had a fractured femur, treated with a cast a week prior in her remote town (a four hour ride away). She was concerned that it wouldn’t heal correctly.


The X-ray thru the cast revealed that she was correct. The two halves of the femur overlapped by several inches. If it healed, the leg would be shorter.



I called over the head orthopedist. “We’re full,” he shook his head. “We leave tomorrow.” I handed him the X-rays.


He shook his head again. “This needs to be fixed.”


She wheeled in her five year-old. A strikingly beautiful girl with long black hair. The two of them were taken down to E.R. to be admitted while our surgeon found room on the schedule.


I was assigned to follow up in the E.R. : make sure the kid didn’t eat; check lab work (would transfusions be needed?). Looking at the paperwork in E.R., I found a mistake. Pointed it out to the nurse.


“This says the patient is a boy.”




“But – ”


“He has long hair,” the nurse rolled her eyes. “They’re Indians.” Controlled distain dripped from the last word.


His mother approached me with small, deferential steps. “I don’t know what to do,” tears began to well in her lower lids. “My husband says that the cast is good enough. He says if Jesus is not well after surgery, he’ll divorce me!” she trembled.


Pretty ballsy decision you made, Señora. But a good one.


I reassured her that, without surgery, it was likely her son would have difficulty walking. Without promises, I said it was probable that things would turn out better with the bone held in place while healing.


After surgery, up on the ward, Mom remained anxious. The poor kid was in pain. I gave her liquid analgesics and instructions how to give them.



Then the kid’s father walked in.


The man had the short stature of the Quechua but looked strong – most likely a farmer. He greeted me and Steve, then thanked us for what we’d done. It seemed overdone, compelled by social pressure (an Indigenous, treated in his own country as a second-class citizen, speaking with a couple of North Americans). We made a point of saying – enunciating carefully – that he had made the right decision to seek out surgery. That, because of his decision, it was likely that his son would have a better outcome than with the cast only, making sure not to promise an outcome.


Mom looked more relaxed after that.



Steve demonstrated the importance of keeping the cast dry with correct placement of a urinal. I gave Mom some money to buy more Tylenol and Ibuprofen (she had no cash). We set up an appointment with an Ecuadorian physician. Hoping for the best.



1. Prejudice and social marginalization of Indigenous people in South America

is no less than in the U.S. What’s notable in Andean countries (Ecuador,

Peru, Bolivia) is that this racial discrimination continues even though

Indigenous constitute a much higher percentage of the population (25% /

45% / 55%) than we see here.


  1. Rural health care is grossly inferior to that available in the cities.



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