Clinic- Laraí

1 Feb 2013

Laraí, a soft-spoken elderly woman with silver hair, waited for us in the patient room as we stepped outside get gloves.  Drew and I were seeing patients together that day, a rare treat for medical students in the clinic – where you get to bounce ideas off a partner without the stress that comes with working with a superior.

It was Laraí’s third time in our clinic in two months.  She had poorly-controlled diabetes (her blood glucose that day was over 200) and well-controlled blood pressure.  We thought all we’d do that day was increase her metformin.  But then she began to tell us that she’d been feeling out of sorts.

No tengo ganas de comer.”  I don’t feel like eating.  “I’m tired.  Food makes me nauseated.  I just feel unwell all the time.”

Looking back at records from her previous visits, Laraí had lost weight.  Ten pounds over two months.

And then she said, “And the mark on my arm isn’t getting any better.”

She held up the back of her left forearm to show a large lesion, dark purple with whitish flecks around the edges.

My first thought was fungus, which is relatively common here.  But this looked unlike any fungus I’d ever seen.  Then another look at her chart showed that Laraí had already been treated for fungus.

Le pica?” I asked.  Does it itch?

“No, but it hurts.  And sometimes it bleeds.”

That’s when Drew and I stepped out to get gloves, so we could take a closer look.

Shutting the door behind him, he said, “I think it might be melanoma.”

Melanoma is the deadliest form of skin cancer.  If caught early it is usually curable by surgical excision.  If not, it has a remarkable ability to metastasize.

Something clicked.  Drew’s statement released the same thought from the back of my head.  Oh dear, I said with my eyes.

We came back, ready with gloves, a ruler, and the ABCDE mnemonic for melanoma.

2013-02-01 Clinic- LaraíAsymmetry – with a concave surface on one side and a convex on the other, the lesion was definitely asymmetric.

Borders, irregular – Yes, they were.

Colors, multiple – It carried at least three colors: purple, red, and white.

Diameter, greater than 6mm – 40mm easy.

Evolution, or change over time – The patient said that it had been growing for at least a year.

We examined Laraí’s heart and lungs, and especially her abdomen.  With her lack of appetite and weight loss, we were worried about metastases to that area.  Everything was normal.  Her belly was not tender when we pushed on it, we couldn’t feel any masses, and her liver and spleen appeared normal.

Yet with the lesion’s growth over a year, which seemed fairly rapid, and Larai’s symptoms and weight loss, Drew and I remained almost certain that she had metastases.

We went outside to speak with the Guatemalan staff about what to do.  As with many of our patients with problems beyond our capabilities, we were to instruct her to go to the public hospital.  She would have to line up before 7am to get an appointment with an internal medicine doctor, who would then hopefully refer her to one of their dermatologists.

The level of education in the US on skin cancer is high.  If I had told a US patient that she likely had melanoma, possibly advanced, she probably would have been freaking out.  But Laraí sat there being her soft-spoken self.  She nodded occasionally, but her blank look cast doubt as to whether she fully understood the gravity of what we were trying to tell her.  I worried that she might not follow through with the public hospital.

I had never been more frustrated with not being tied in to the system.  Therein lies a big problem with being an outside, non-profit health clinic in Guatemala.  (Although it’s unlikely that the government Puestos de Salud could have done much better.)  I wanted so badly to be able to set up an appointment with the dermatologist myself.  So that Laraí wouldn’t have to wake up early, travel to only wait in line, then possibly get discouraged and leave.

But it might not have mattered anyway.  Our clinic coordinator, who is much more familiar with the system than I, told me that the hospital doctors would probably “leave it”.  Because private providers in Guatemala City (read: expensive and far away) are the only ones equipped to give the treatment that Laraí needs.  And because she’s “of age”.

 

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Selection

2013-01-26 Selection

9 Jan 2013

My eyes glance over a familiar gas station through the window of the car, an old land rover that has lost its shock absorbers.  I am accompanying Carmen, the director of Pop Wuj’s social outreach projects, as she does a home visit in Llanos del Pinal.  It is January and it is time for Pop Wuj to select a new group of families for our stove project.

Over the next few months volunteers will build safe stoves to replace open fires in the houses of carefully chosen families.  Carefully chosen because families must be, or at least appear to be, poor enough to merit our help.  We do a home visit to inspect houses.  If a house looks nicely built – with more than one floor, several rooms, or nice appliances – then we assume that the family ought to have enough resources to construct/buy their own stove.  If the family already has a stove they are, usually, automatically rejected.  Sometimes Carmen will make an exception for a family with a small gas stove – if they obviously only use it when they need to cook something quickly, and if it’s apparent from their house and circumstances that they are hurting for money.

The first home we pull up to is a cluster of three adobe constructions arranged as three sides of a square.  A sheet-metal gate forms the fourth side.  Ofelia lets us in by pulling back a section of sheet-metal that acts as the door in their gate.  She is the matriarch.  Our contact in the family is usually the matriarch.

Carmen introduces us and why we are here.  She is careful to explain who we are and even more careful to explain what we are not. “We’re a social cooperative funded by our Spanish school, all of which is run by Guatemalans.  We are not the government, a foreign or international organization, or a church.”  At each visit Carmen makes sure this is clear.  The government isn’t always trusted.  There are religious quarrels in Guatemala between Catholics and Evangelicals.  And she doesn’t want the families to see our American volunteers and assume that the organization has a lot of money.

Ofelia seems excited to see us.  Her whole family, including children who are probably grandkids and six chickens, come out into the small courtyard.  From here I see that the three constructions of the cluster are each a single room.  One is a bedroom, another a family room or a second bedroom, the last the kitchen.

We ask to see where Ofelia cooks, wanting to examine the space in which building will occur.  The roof of the room is especially important.  All holes should be patched so rain doesn’t damage the new stove.

The first item we see is a large gas stove.  I stop walking and look at Carmen.  My breath is held.  I know that in theory a rejection is coming, but I do not know how to deliver it.  She turns to Ofelia and gently asks, “You already have a stove?”

Si, pero es caro.”  Yes, but [gas] is expensive.  “We were hoping for a wood-burning stove so we can collect firewood instead.”

“I see.  But I’m afraid we won’t be able to build you a stove.  We are a small organization with limited resources; we’re looking for those in the most need of our help.  For this project this is families that cook over open fires, because of the specific problems fires cause.  I’m afraid what your stove shows us is that you have enough means to solve these problems on your own.”

“Oh, but it’s not my stove.  It’s my daughter’s.  She’s lending it to me.”

This pulls my gaze from the ground towards Ofelia.  I believe her.  And the thrown together rooms with dirt floors and corrugated metal roofs show me they are far from a well-resourced family.  I know that I would make an exception.  But maybe I’m too much of a sap.

Carmen stays firm.  She echoes what she said a moment ago and adds, “I appreciate that you didn’t hide the stove from me.  Some families have tried that.”

The family is gracious as we leave.  The children are lined up shoulder-to-shoulder and follow me with their eyes.  Carmen thanks them for receiving us.  I secretly hope that we do not find enough families in this village (we build stoves in groups of ten) so that we can come back and give Ofelia some good news.

“Saying ‘no’ rarely happens, usually our filters before the home visit are good, but it is difficult.  And we have to be careful with exceptions.  If others catch wind of an exception, there could be trouble,” Carmen tells me while unlocking the land rover.  I learn that other organizations are doing stove building work in Guatemala, each with their set of (similar) requirements.

We drive for a few minutes to another home in Llanos that looks strikingly similar to the last one.  Luz de María is our contact here.  The door is opened by a middle-aged woman with teeth missing, wrinkles around her mouth, and braids on either side with purple thread laced through them.  She says that she is Luz and shows us into her small courtyard.

Sitting on the floor half in shade is a visibly old woman.  Her hair is arranged like Luz’s sans the purple thread.  All-but-two of her teeth are missing.  Luz introduces her as her mother Raisa, instructing us to yell because she’s hard of hearing.  I shout, “Hola! Soy Nicki!”  Raisa takes my outstretched hand and nods vigorously.  I’m not entirely sure if she understood what I said.

We are shown into the kitchen.  It is bare except for a small portable table upon which utensils are strewn-about.  On the ground the earth is scorched where the fire usually sits.  There is no sign of a gas stove.

In the courtyard we begin the interview.  I ask questions while Carmen writes notes and interrupts when necessary.  Luz has six children but only the youngest, unmarried and in his early 20s, still lives in the house.  However one other son lives in the house just to the north, one daughter in the house to the east.  The rest have not gone far; they all live in the same village.  All the sons went far enough in school to learn to read and write.  Two of the daughters did not.

Luz responds in the negative when we ask if she has a job.  But after careful prodding – Are you otherwise productive?  Do you work in the fields?  Wash clothes?  Sew?  Sell vegetables in the market? – she tells us that she has irregular work going to houses and doing other people’s laundry.  Here a “job” means steady, secure employment.  Luz’s husband and youngest find work in the fields when they can, other people’s fields.

We learn that, thank goodness, no one in the family has been burned by their open fire.  But the smoke does bother Luz.  It makes her eyes water and sometimes, she thinks, it causes her to cough.

Carmen makes some notes about the construction of the house.  After giving Luz more information about the stove project, including what the family is expected to contribute towards building materials (no more than USD $8), the interview is over.

On the way out I stop to ask Raisa if I can take her picture.  At 92 she is well into what is called la tercera edad, the third age, yet she is hard at work sorting corn kernels.  I’ve seen many like her in Guatemala.  Worn old bodies planting and harvesting in the sun, carrying heavy packages of goods to sell, leading a pack of sheep up a mountainside to where trees still stand and shelter grass on which animals can graze.  I am impressed, and I want to record the moment.

 

For more information about safe stoves that replace open fires, see: https://naranetacrossing.wordpress.com/2012/10/26/clinic-sin-respirar/

 

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How is Suceli

29 Nov 2012

2013-01-22 How is Suceli-2In September I wrote about a mother and daughter.  The first time I met them Sara and Suceli were on their way to UNICAR, a cardiac hospital in Guatemala City.  Four-year-old Suceli was to have an operation for a congenital heart condition.  Since then the two have stopped by Pop Wuj with relative frequency; Sara has occasional meetings with the director of our social outreach projects.  They remembered me from our first introduction and would often look for me to say hi.

In our further encounters I learned that Sara is a madre soltera.  Single mother.  Suceli’s father abandoned them while Sara was pregnant.  They are not, however, without support.  They live with Sara’s parents, four brothers, four sisters, and two grandmothers.  It was her brother who donated blood for Suceli’s operation.  Sara finds work sewing clothes to contribute to the family income.  Suceli is her only child.

In the summer of 2012 Sara took Suceli to a mobile clinic that Pop Wuj had scheduled near their town of Paraje Xek’axtun.  She was concerned; her daughter seemed to tire more easily than she should.  Dr. Wilder examined Suceli.  He noted a heart murmur that he thought warranted further workup.  Suceli was keyed in to our chronic patient program then referred to UNICAR.

Through UNICAR Suceli received all her care for her heart condition up through the surgery.  They evaluated her, did studies and imaging, made the diagnosis and recommendations.  The following September UNICAR doctors performed her surgery.  A few weeks later she came to Pop Wuj Clinic to have her stitches removed.

Since then it has been, shall we say, difficult to get in touch with UNICAR.  We still do not know what Suceli’s final diagnosis was nor what surgery was ultimately completed.  Wilder sent them a letter requesting her records, or at least the principal information, which went unanswered.

The fact that we don’t know the details of Suceli’s care is embarrassing.  As regards the health care projects Pop Wuj is accountable to Timmy Global Health, an organization based out of Indianapolis that partners with the clinic and generously supports the chronic patients. 2013-01-22 How is Suceli-1

But an unsettling lack of information is not all we have to report back to Timmy.  “Ya no se queja del corazón”.  Now Suceli doesn’t complain about her heart, reveals Sara.  “She also eats more than before.”  Sara tells me Suceli no longer tires easily.  One fine day I find them on the roof of Pop Wuj where the four-year-old explorer is skipping around and marveling at the view.

For more backstory see: https://naranetacrossing.wordpress.com/2012/09/17/suceli-and-sara/

 

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Clinic- Silvano

14 Dec 2012

An old man was making his way towards me, pushing his walker in front of him.  There was a scale in his path that I quickly moved aside.  He came into the room, sat down, and handed me his chart.

Silvano.  76 years old.  With high-blood pressure controlled with three medications, diabetes not-quite controlled with two, venous insufficiency, and a history of a below-the-knee amputation on his right.

According to the chart during the patient’s last visit Hugo, one of our clinic doctors, referred him to a “vein clinic”.  Silvano said that it went fine.

Se puso una máquina de sonido en mi pie.”  They put a sound machine on my foot.  “Then they gave me a pair of long socks, told me that I should walk around when I can and elevate my leg at night, and were very emphatic that I come here regularly for control of my blood pressure and diabetes.”

“So the test that they did on your leg, that went fine?”

“Yes, they said everything was okay.”

They probably did an ankle-brachial index, I thought.

ABI is the ratio of blood pressure in the legs to pressure in the arms.  Lower pressure in the legs is an indication of atherosclerotic disease in the arteries, buildup of cholesterol deposits and plaque causing blockage of vessels.

Listening carefully, the patient’s heart and lungs sounded fine.  His left lower leg was discoloured with mild swelling.  But there were no lesions, his pulses there were strong, and he had good sensation.

Because I was a student, he wanted to show me his amputated leg.  He took off his prosthetic and began unwrapping the ace bandage around the stump.

Por qué necesitó la amputación?”  Why did you need an amputation.

“I had an infection.  It began in my little toe and kept growing.  To stop it they took off my leg.”

When it seems like a patient’s everyday might be difficult, I’m curious about what support they have.  And I ask.

“Who do you live with?  One of your children?”

“I don’t have any children.”

“Do you live alone?”

“Yes.  I do everything for myself.  Cook.  Clean.  Everything.”

Pause.

“Do you have any family?”

“Yes but it’s as if I have none.”

At this point my Spanish slightly faltered, but it sounded like he was estranged from his family because of a religious disagreement.

Silvano began re-wrapping his knee.

I wondered, how do people here do it?  How could Silvano manage on his own?

In the developing world there are few constants, little support that you can depend on, outside of family.  The education system is likely to fail you.  There is no health insurance.  The government or an NGO may or may not have a helpful presence in your area.  But there are, usually, big extended families that live together, work together, often fight with each other, yet help each other.

And most of our patients have family.  Grown children come with parents and translate from their Mayan language into Spanish.  Parents bring all their young children and the doctor sees the whole family at once.  But occasionally a patient wanders in who has no family, lives alone, and endures a scary illness.

When Silvano was ready I told him that I would be increasing the dose of his metformin as his glucose was still too high.  I also emphasized the walking and leg elevation, and discussed the time for his next appointment.

As Silvano left to wait for his meds, I went to find Hugo.  I thought he would want to know how his patient was doing.

Hugo was pleased to hear about how things went with the vein clinic, agreeing that they would have done an ABI.  The only thing he wanted to add to the plan was re-counseling about diet.

“Where is Silvano?” he asked.

“In the waiting room.”

We looked around the waiting room.  He wasn’t there.

Worried, I asked the receptionist if he had left.

“No, he’s outside by the food vendors.  Drinking a glass of atol.”

Atol is a corn drink laced with sugar.

My and Hugo’s heads turned in unison to look out the front door.  Sitting in a chair with his walker folded next to him, Silvano was holding a glass of atol and eating a chuchito covered in thousand island sauce.

Ay, no.”  Hugo shook his head and sigh-smiled at once.  “He should not be doing that.”

Hugo strode forward to talk to Silvano.  I listened carefully to learn the vocabulary.  So I could discuss diet with the next patient who probably wouldn’t listen.

 

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Clinic- Mi Deformidad

5 Dec 2012

On a day when the Pop Wuj mobile clinic was in a Mam-speaking community, Mateo was my last patient.  I opened the door and called his name.

Mateo’s father Fidel walked up first.  He looked to be in his later 40s, stood a little taller than me, with glasses and a friendly smile.

As Fidel moved to the side I saw Mateo walking up behind him.  I knew from his chart that he was 16 so I was surprised to see that the top of his head barely reached my chest.  He walked with a slight limp and one shoulder sat higher than the other.  I motioned for him to come in.  He passed me as he entered the room.  Seeing him from behind revealed a large protuberance on the right side of his back.

We all sat down.  I asked Mateo why he had come.  He had a long list of complaints.

No tengo ganas de comer.”  I don’t feel like eating.

“I’m weary.  Caminar me cuestaMe cansa.”  Walking costs me.  Walking tires me.

“Sometimes I find it hard to breathe.”

“I have back pain.”

“I have stomach pain.”

Overwhelmed, I employed a technique you learn in med student 101.  “What bothers you the most, Mateo?”

Tengo una deformidad en mi espalda.”  I have a deformity in my back.  “And one leg is shorter than the other.  When I walk I have a hard time.  I feel tired all the time.”

His father jumped in in and told me that Mateo was born with a bone deformity, a horrible hunchback.  A few years ago the family went to doctors in Guatemala City.  “They did studies, took a lot of pictures.  At the end they told us there was a surgery that could be done, in the US not here.  But they said it could have left him an invalid.  His mother and I decided against it.  At least now he can walk.”

After a pause Fidel continued.  “But now for the past few months he hasn’t been eating well.  He’s also talked of pain in his chest and trouble breathing.  We’re hoping there is something you can do.”

I suspected that Mateo, in the middle of his teenage years where looks are everything, was depressed and not eating.  It was also clear that his deformity was exhausting him, his awkward bone structure tiring him while walking.  And at 16 perhaps his bones were growing in such a way that impinged on his lungs.

When examining Mateo I first wanted to see how he walked.  He stood up and took several steps around the room.  His walk was actually quite functional despite the limp.

Next I had him sit back down and take off his shirt.  I felt my breath still when I saw the skin tented over his distorted bones.  Mateo’s spine was twisted in an exaggerated S-shape.  It looked like his right scapula was overgrown, a pyramid that came to a point just to the right of his spine in his mid-thorax.  A smaller prominence of bone was visible above his right abdomen as well.

When I asked Mateo to indicate where his back and stomach pain were, he pointed to where deformity met normal in both areas.

I listened to his lungs.  They sounded normal.  And they were surprisingly hearable, except directly beneath the top of the hunch.

Pushing down on various areas, I examined his stomach.  The pushing did not bring on additional pain.

Asking Mateo and Fidel to wait, I excused myself to find a doctor.  When I saw Aleema in the hallway I said, “I need a consult.”  In other words, I don’t know what to do – please help me.

Since the family did not want surgery, the other option was to control his pain.  Aleema advised me to prescribe a strong pain killer.  She also told me to screen for depression.  “If he screens positive, give the one thing that we have.”

Fluoxetine. Also known as Prozac.  The only option in our pharmacy.

There are 9 possible symptoms of a major depressive episode.  If you have 5/9 for two weeks you are having an episode and thus have major depressive disorder.  If you have 3/9 for two years you have dysthymic disorder, a sort of mild depression that lasts all the time.

Mateo answered yes to 4/9: feeling depressed, want of energy, changes in appetite, and sleep disturbances.  Given his overall situation, I prescribed the Prozac.  And the strongest painkiller we had.  “I would also like you to follow up with every mobile clinic.”

I went to help in the pharmacy and ended up filling medications for Mateo’s mother and vitamins for his little sister.  The whole family had come to clinic that day.

All four walked up to the pharmacy door when I called.  Mateo took the prescriptions for his family and put them in his bag.  They walked away together, Fidel keeping slightly behind as if watching over everyone.  And Mateo with one arm around his sister’s shoulders, the other holding his mother’s hand.

 

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Isaias

2012-11-30 Isaias

30 Nov 2012

One morning I was tasked with taking Isaías and his mother to a cardiologist’s private clinic.  Isaías is almost 14 years old and has been a long-time student of the Guardería, the family support center.

The Pop Wuj Clinic does biannual well-child checks with the children of the Family Support Center.  In March 2009 when Isaías was 10, one of our doctors at the time noticed that he had a grade II (on a scale of I to VI) systolic heart murmur.

Murmurs are a whooshing sound that a physician hears with a stethoscope. They are created when turbulent blood flow across an area of the heart or blood vessel produces noise.  Pathologic murmurs, the kind you don’t want, are caused by structural problems that interfere with normal flow.  Functional murmurs occur when physiologic conditions, normal conditions of the body, allow for the hearing of blood flow.  This second type is common in children because they have more dynamic circulation and a thinner chest wall.

Isaías’ murmur seemed like a functional flow murmur to the doctor, who wrote in the chart that it should be followed for changes.  The murmur continued as grade II/VI until 2012.

During a well-child check in September one of our current clinic doctors, Wilder, noted that Isaías’ murmur had changed to grade IV/VI.  It had gotten much louder.

He was sent to the university/public hospital clinic to see Dr. Garrías, one of their cardiologists.  After the doctor examined Isaías he said that the patient needed a special test: an echocardiogram.  For some time we’d been hearing that the university’s cardiology equipment needs servicing.  Isaías was thus told to go to Dr. Garrías’s separate private clinic where, as a university patient, he would receive a discounted rate for the echo.

Isaías and his mother Gloria met me promptly at 9am.  Accompanying them on Gloria’s back was 10-month old Daniela, the youngest of Isaías’ five brothers and sisters.  We walked through Xela and arrived at 9:30, quite early as the doctor wasn’t going to be working until 10.

The receptionist took our information and said the discounted rate shouldn’t be a problem.

We sat down and I began to ask Gloria questions about her family for the chronic patient info form. Gloria is 37 and works cleaning houses in Xela while raising five of her six children.  Her eldest is married and has a child of her own.  Her other children are ages 17, 13 (Isaías), 11, 10, and 10 months.  The baby Daniela has a different father from the rest.  Isaías is an attentive older brother and dotes on her.

10am came and went.  Then 10:30.  Then 10:45.

I asked about Isaías’ father.  He “found a different woman” and no longer lives with the family.  However, according to Gloria, he continues to be a source of financial and emotional support for the children.  He lives in the same town and sees them frequently.  As we were waiting Gloria’s cell phone kept ringing because Isaías’ father was anxious to know the results of the echo.

At 11am I lost my patience and asked the receptionist if the doctor was on his way.

“Yes.  He’ll be here in un ratito.”

Un rato or its diminutive un ratito are the worst things to hear when you’re waiting.  “A while” and “a little while” respectively, they could mean anything from a few minutes to A WHILE.

Dr. Garrías arrived at 11:30 and to his credit immediately began to see to Isaías.  However he did not offer an apology for his tardiness, which upset me.  This family had been on a bus for 30 minutes then walked another 30 to see him.  And they could have come from much father.

He finished the echo and instructed us to wait outside.

After a few minutes the receptionist called me to her desk.  She handed me a large brown envelope and told me the cost of the visit.  I was incredulous.

“Doesn’t the doctor want to talk with us?” I asked.

La cosa es que this visit just covers the test.  You should take the results back to the doctor who originally referred you.”

My head almost exploded.  I felt this was the height of discourtesy.  As far as I’ve seen the consulted physician always goes over the results of the test with the patient.  And he’s the cardiologist!  This was a specialty cardiology test.

I wondered if the story would have been different if we were paying full price for the visit.

Isaías, Gloria, Daniela, and I walked back to Pop Wuj.  Luckily Wilder was in attendance at clinic.  I approached him while he was in between patients to give him the echo report.  When I told him that Dr. Garrías did not go over the results with us, he was as disbelieving as I had been.

Wilder took out the report and we looked at it together.

“Mild insufficiency of the tricuspid valve.”  The tricuspid is a gateway between two chambers of the heart, the right atrium and right ventricle.  When the ventricle contracts to squeeze blood into the vessels of the lungs, the tricuspid is supposed to seal shut.  Valvular insufficiency means that the valve does not completely seal.  Backflow of blood occurs, accounting for Isaías’ murmur.

“Mild pulmonary artery hypertension.”  Now that’s confusing.  In the circuit of the heart the pulmonary artery comes after the tricuspid valve.  Backflow of blood should initially cause problems earlier in the circuit, not after.

“How would you account for this, Nicki?”

“Um.  I can’t.”

“Neither can I.”

Wilder took a picture of the report with his iPad.  He then called in Isaías and Gloria.  Gloria only wanted to be reassured that it was nothing serious.  Wilder told them that there was nothing to worry about now, but there could be in the future if we leave Isaías condition alone for too long.

“I’m going to look into things a bit more.  I’ll have Pop Wuj call you when I have more information.”

We bade the family goodbye.  As Wilder closed the door he told me that he was going to show the report to some friends.  Frowning, he said,

“I really wish the cardiologist had talked with you.”

 

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The Land Above

20 Nov 2012

2012-11-20 The Land Above

In mid-October my host brother Pepe approached me with an out-of-the-ordinary request.  He knew of someone who tried to cross the border and had since gone missing.  Pepe was hoping that I might be able to help find him, or find out what happened.

My Guatemalan family knew of Arsenio, the missing, through the woman who helps my host mother keep house.  María travels to Xela two mornings a week to clean, wash dishes, and do laundry.  Sometimes she brings her eight-year-old daughter with her.

In June, four months earlier, María’s husband had left for the north.

At the time my host brother talked to me, María hadn’t heard from Arsenio since July.  The last time he called he was about to cross the border.  Pepe seemed unsure as he related the story, but it’s possible that Arsenio was being transported by drug runners.  And now all they had to go on was that a man recently returned said he had seen Arsenio, that they had been in el cárcel together in Arizona.

Nos puedes ayudar, Nicki?”  Can you help us.  “María is very worried.”

Pepe and I did some internet searching and found a website where you can supposedly look up prison inmates in Arizona. We tried different combinations of Arsenio’s name but didn’t find anything.

“We probably won’t ever know what happened.  He could be dead who knows where.”

After the tenth combination, Pepe sighed and closed his laptop.

“I don’t know what María is going to do,” he continued.  I’m sure they spent a lot of money to send him to the States.  They might have taken out a loan on their house.”

A couple of weeks later I had an idea.  I started planning an email that I was going to send to two friends, a lawyer who has worked with inmates and a community organizer who has worked with immigrants.  And then I overheard my host mom talking to María.  Arsenio had returned.

The conversation did not last long.  María expressed her relief.  My host mom said that she was happy for them.

Arsenio had apparently spent months in prison in Arizona. When I asked my host mom about why he wasn’t able to call from there, she shrugged her shoulders.

Following came a few more questions that she did not know the answer to.

I thought she had an unfortunate lack of curiosity.

I would like to have asked María, learned more of the story.  But I did not know her that well and I felt uncomfortable asking such personal questions.

One of Pop Wuj’s best employees is Angelica.  She began working in the Guardería, the family support center, where her two daughters are students.  Angelica showed that she is awesome and reliable and so was gradually given more and more work: as a stove group leader, at the school.  Before Pop Wuj she worked selling fruit and vegetables on the street of an outdoor market.

Her husband left for the north years ago.  To pay for his passage he mortgaged land that belonged to Angelica’s father.

He has a new family in the States while she is still paying off his loan.  He sends some money, but it is not enough to keep her from working three jobs.  Sometimes he calls to talk to their daughters, promising them gifts that he never sends.  And to verbally abuse Angelica.

The community where the Guardería is situated is called Llanos del Pinal.  The view while riding the bus through Llanos is a lesson in contrasts.  Two-story modern houses with bright new paint stand next to worn grey adobe houses with rust-covered corrugated metal roofs.

I asked Amy, our student and volunteer coordinator, about the discrepancy.

“The families with nice houses have husbands or sons in the US who send money.  The families with adobe houses either do not, or their husbands or sons have stopped sending money home.

How strange it must be.  To have a hard life, but the promise of a better one in a land not far away.  If you can just take a few arduous steps you can get there.

What kind of effect does this have.  On a person.  On a culture.

My friend Anna has lived in Guatemala for more than a year.  Sometimes she is approached by people who are considering crossing the border and want to know, as an American, what she thinks of the idea.

“Don’t do it,” is always her response.

Like me, Anna has heard stories of those who mortgage their homes only to be sent back.  Or of those who die in the desert trying to make the journey.

“It’s just not worth it.”

And yet people continue north.

 

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