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A Note from ISHI President, Dr. Ziad Sifri
The 20-member team that made up ISHI’s first mission has just returned to the United States in good health and spirits, with a feeling of accomplishment and the knowledge that they helped many people in need. With the support of Partner For Surgery (PFS), our local collaborator, and the Centro de Salud Bárbara in San Juan Sacatepequez, Guatemala, we performed 55 surgeries over four days in the clinic’s excellent ORs.

Our journey has come to an end and we would like to thank each and every volunteer, collaborator, friend, family member, and donor who made this mission possible,  supporting us with good wishes, patience, and financial or material contributions. This wouldn’t have happened without you!

This blog will continue to be updated with photos and relevant material, so please check back periodically, subscribe to the ISHI RSS feed, or send us your contact information so we can e-mail you whenever there is new material.

Thank you!

Ziad Sifri, MD

Co-Founder/President
International Surgical Health Initiative (ISHI)

Sunday, November 1, 2009
For the first time in 9 nights, we slept in our own beds (except for Charlie Khoury, who hopefully had a safe journey home to Canada today, and Chia-Chi Wang, who had to overnight on a friend’s couch before heading home to Upstate New York). In the States, we changed the clocks last night for daylight savings time. We woke up to clocks that read an hour earlier, an hour closer to Guatemala time. There seemed a certain rightness to that, at least for me, because all day, and I imagine for a long time to come, I am caught in that hour, that space between Guatemala and life.

This report from the field was to have been filed on Friday, after photographer Vishnu Hoff and I returned from the “take home”—the day we accompanied two patients and their family members back to their homes. I was spent by the time we returned, making our way to Guatemala City and meeting up with the others who had finished surgeries a day early. By evening, the group had a final dinner together and we left Guatemala Saturday morning.

But I would like to say something now about that five hour trip into the northern region of San Pedro Carcha. I would like to put the period – or really, more like the question mark – at the end of the sentence that was the mission behind the mission for me. I hope reading this, you will glimpse some sense of what I saw when I looked into the Mayans’ eyes.

All week, I spent a lot of time with the patients. All week, I dogged them, thinking about future stories, possibilities. Questions. Audio equipment. Camera. Most of the week, I tried—through Spanish and Mayan interpreters—to get the Mayans to speak, to find the right key to open the lock. Often, I heard the same replies of gratitude, no matter the question. All week, I hoped the reserve would yield, the controlled expressions would give way. Even as I type this, I am shaking my head and smiling at my own ignorance.

By mid-week, my conversations with the Mayans had less to do with shaping the right questions for some report than they did with managing my own conversations. I used my audio equipment and camera instead of interpreters. I would gesture my way through some Spanglish and record what they had to say. Then I began slipping my headphones onto their heads and giving them the audio recorder. Crazy incredible—those first moments of watching them holding the machine in the palms of their hands, eyeing it with a certain skepticism, and then intently listening to themselves.

Saying Goodbye
By Thursday morning, Vishnu and I were headed to the mountains to complete the circle of the patients’ journeys. By Thursday, I had no thoughts of holding interviews in the van or during breaks from the excursion on the two-lane highway. Quietly, they sat in the van. Quietly, they sat while the Anglos (me, Vishnu, and Partners For Surgery representatives who arranged the trip) yammered on asking questions and sharing personal stories (hyperbole, but you’ve got to wonder what the Mayans were thinking).

We drove through cloud forests. Areas of black tarp unnaturally appeared, making manicured sections of the untouched hillside of endless trees that is Guatemala. Under the tarps, ferns—the typical ones seen in floral pieces—were being cultivated for harvest and export to the U.S. The ride was long and winding. Exhausting. The van was in desperate need of shocks and cushioned seats. Jostling with each bump or curve, we all looked like a bunch of bobbing heads. And still, quietly, they sat. Patiently, they sat, including our patients, one of whom was recovering from hernia surgery; the other, gall bladder surgery.

When we reached the first patient’s home, we had to leave the van behind, walking on a stony dirt path that had its own climb and curves. I don’t remember how long we walked, but at the time, it felt endless, her journey home, her graceful endurance. When we arrived, her husband came outside. He did not greet her. When I asked if he was happy to see his wife, he said that he had opposed the surgery. Then eventually, he decided she could go, which is why he sent their 15-year-old daughter with her. He didn’t answer my question about whether he thought his wife was courageous. The family served us coffee and we sat in a semi-circle, taking a few sips before leaving to take home the other patient, who waited with her husband in the van. The interpreters offered my apologies for not being able to speak her language and my gratitude at her endless patience for my questions, my machines. She indulged me with another photo and thanked us again. Walking back toward the van, I fell behind the others. Holding the recorder to my mouth, I could hardly speak.

After a 10- or 15-minute ride, we walked about maybe an eighth of a mile or longer to reach Maria’s house. Her husband, who had accompanied her, walked alongside, sometimes reaching for her arm. We were greeted by her barking dogs which, thankfully, were behind a fence. The chickens ran freely. Maria’s grandchildren were waiting and both she and her husband seemed so happy to see them. A daughter had been called home to prepare a meal for us. It’s a cultural custom that guests are served and the family eats afterward. We were served cups of hot chocolate, a delicious broth soup with chicken legs and wings, and freshly baked tortillas. Maria sat on the bed in the room while we sat at the table, eating. It never grew comfortable, eating without the family. Everything we ate was made from things grown or raised on their property.

None of this report from the field is meant to feel complete or reflect all of what we experienced. I know description of their homes are missing. But, for now, I cannot write about that. In part because what is here, I hope, speaks to who these families are and the women who sustain them. In part because it is still so private.

Maybe it’s enough to say that the Mayans, and particularly the Mayan women, have knit themselves to me. Maybe it’s enough to know that when my 84-year-old mother asked, “Hard lives, Mare?,” I wept from that place of silent pain, like gall stones and 10-year-old hernias.

Wednesday, Oct. 28, 2009
9 AM: Driving to the health clinic this morning, the second van got delayed because of traffic and then a truck accident. The normal 15-minute ride lasted close to an hour. We took many alternate routes. Here’s what it looked like: women cooking outside; chickens in wooden cages; heartbreakingly adorable and lonely looking dogs; children standing outside, in doorways, always watching; the front doors of homes positioned literally a step away from the road; garbage; dirt roads; mud from recent rains; road bumps; narrow passes; garbage; graffiti; lots of Coca-Cola signs; a beautiful tennis court; a heavy woman asleep by the side of the road; a man drinking a cup of coffee, leaning up against a chipped yellow wall; people carrying loads on their heads or their backs; what seems like endless garbage lining the roads; the unyielding green of Guatemala; it all keeps going; the Mayans always keep going.

Walking through the gated entrance of Centro de Salud Barbara, the health clinic, felt familiar, even after only 4 days. Even with guards standing outside the gate. Even with only a few words of greeting to offer in Spanish. Why? Because I had grown familiar to the people who sat waiting on the brick benches built around flowerbeds. Because I knew their faces, their smiles, where they usually sat, waiting. Because they knew my many bags carrying equipment, a laptop, my life. Because I knew their eyes, some of their individual stories, which in many ways, were universal.

Once inside the room, which we have made our own—unpacking equipment, debating the merits of instant coffee, eating banana bread and chips—Charlie and Zeina made some offerings for the blog. Charlie said he likes to pay attention to graffiti because it gives him a sense of what’s going on. “Literally, it’s the writing on the wall,” he said. “Unfortunately, I can’t understand all of it.”

Then a debate broke out between Charlie, Zeina, and Leonard, a surgical resident who wandered in for a snack. The abridged version: Charlie said it made total sense to him that the people living in these villages had cell phones. The others wondered when you have no running water in your homes or electricity, food for your family, how can you afford a cell phone? How did it rise to being a priority?

“I know I can’t get water to my house,” Charlie said. But, he said, holding up the disposable cell he bought on the trip, this can be survival.

“Why would I buy a cell phone when I don’t have running water?” Is there any kind of right answer?

10 AM:
Pretty quickly, 5 of us went on a field trip to the local market, about 10 minutes away. It was crazy wild. Exuberant. A firework of textures and smells: fruits we’ve never seen. A combination of colors from buildings to textiles to produce that together make a Jackson Pollock of life. In some ways the square is more authentic than the Antigua version. It espouses local life. We were never the vendors’ clients. In Antigua, a tourist is endlessly hustled. Here, it seemed we were more intruding on their party. “I don’t fit there. I’m like ski equipment on a California beach,” Charlie said. Usually, we go and the locals are the spectacle. There, we were.

12:00 noon:
By noon, I was in scrubs in the operating room. Ziad, along with the relatively silent Kevin Clarke, walked me through an inguinal hernia operation so I could record it. Then, we all ate lunch.

Tuesday, Oct. 26 and 27, 2009
The past two days have been an emotional tornado. Yesterday was Day 1 of surgery and there was a natural veil of tension cloaking the operating rooms. But as a volunteer along to help document the story of the mission, the docs and more importantly, the patients, the truth is the surgical staff tamed the two Operating Rooms pretty quickly. Before the first operations—hernias—were done, I got the OK that I could start observing the action in the OR.

As a way of settling myself, I worked my own equipment—recording audio (many blessings for the Edirol R-09 which slips nicely in and out of scrub pockets) and taking photographs. With audio, the best way to create a sense of place is through ambient sound, which also is a kind of weird fetish of mine. The sounds of the OR machines, metal instruments touching. The soothing kind of mellow jazz music (hear Curtis Mayfield and you’re on the right track) playing in any OR where Kevin Clarke, a surgical oncologist, is operating. The typical exchanges about retracting and instrument counts. Together, it’s almost like a chant, which seems right. The OR is a sacred space. It doesn’t really hit you until you’re standing behind the sterile field surrounding the table, the patient and staff. Intense. Private.

By mid-morning, the OR teams had settled into the new surroundings. The anesthesia machines were humming. People had found their own routines around the operating rooms and were familiar with the set-up. By the end of the day, they had done 15 surgeries. Everybody was in a zen state: the anesthesiologists—Leslie, Sue and Dennis worked alongside Spanish and Mayan translators, offering words of comfort or lighthearted jokes to their patients, most of whom had never had a procedure before, much less an operation. The seasoned OR nursing team—Irene, Mae, Socorro and Pushpa—moved effortlessly within the arena, while Recovery Room nurses Alison, Natalia and Sherine enthusiastically waited for the first post-op patients.

When the OR sounds became white noise even for me, I started to appreciate the visual aspects of the OR through photographs—shout out to Dave Bergeland at The Record in New Jersey: I LOVE THE G-6. MUCHAS GRACIAS for the loan.

Vishnu Hoff is the real photographer documenting the mission. Those of us on the mission lucked out. We were the first to see some of Vishnu’s stunning images of the color of Guatemala and her people.

There were also photos of Pacaya—the active volcano, which most of the group scaled. (Flashback to Saturday: I got about halfway up Pacaya before I reached my anti-namaste meltdown. Still, for those of us who stopped earlier, it was extraordinary. But Leslie said exactly what was in my heart: I wasn’t afraid. I was terrified. Steep from the start. Slippery. Darkness about an hour away, the others pushed on. Word had it there was “good lava.” Nobody exactly knew what that meant, but nonetheless they wanted it. For those who scaled the peak and stepped on lava dunes and roasted marshmallows BECAUSE THEY COULD, it was exhilarating. Many in the group described it as the hardest thing they had ever done. BUT, I learned later, they leaned on each other, encouraging each other, guiding each other down the pass with flashlights, headlamps and Christmas carols.)

In photos from the volcano top, there was a beauty to their faces that made me wish I had been able to out stare the darkness of my fears. (Evenings at Casa Damasco we’ve been relishing slide shows of each other’s work. Tonight we saw a mix of photos by Charlie and Ziad….tomorrow night, I might be the opening act for Kevin’s photos.)

After the intensity of the last two days—29 surgeries—a million bows to the rocking surgical team (Asha Bale, Kevin Clarke, Diego Rieno, Leonard Mason, Chia-chi Wang and Ziad Sifri), multiple languages and food that screams for mas picante—we need Guat-EVER. And we need it now. Thank you Zeina for all the lovely Swiss chocolates. Thank you Charlie for all the clean clothes.

By week’s end, we expect that 54 surgeries will have happened. Interestingly, there’s been a run on gall stones. Docs removed some 200 stones from one woman alone. Another surgery yielded a massive gall stone that someone is coveting for a curio in Brooklyn. (FYI, gall stones may be Vishnu’s weird fetish.)

If music, art, or food are universal languages, let’s not underestimate the power of a good photo shoot. One minute patients and their families—divided only by gender—sat quietly on folding chairs, waiting to be called for examinations. The next, they grew bold and beautiful. Formal. Somewhat shy. Sometimes downright pushy. Sometimes injecting themselves into other people’s pictures. No one went unphotographed. Nobody worried about their souls being kidnapped.

It all began when patients who were being interviewed and recorded for documentary purposes also got photographed. Soon, as one person finished telling his or her story, others spontaneously began sitting down. No one feared the audio recorder. And after the photos were taken, the patients began gathering around photographer Vishnu Hoff like moths to a flame. Soon, he was surrounded with calls of “me too” in English and Queq’chi, one of the Mayan languages.

“We had been warned to always request permission before taking any photographs, so I was trying to be respectful of the Mayan tendency to be very shy and reserved,” Hoff said. Pretty much, he said, he focused on the person being interviewed.

“As I was reviewing images on my camera’s screen, I looked over my shoulder and noticed 10 people also trying to view the pictures. A minute later, there were 20. As soon as I approached one of the people in the crowd for a photo, I was suddenly bombarded. Everyone wanted their picture taken,” Hoff said. “It was a wonderful shift in the energy of the room, especially when the mood became playful and it was obvious we had broken a barrier.”

Sunday, October 25, 2009
Maria Teresa Mendoza Rayas sat curious, waiting. Her face is pleasing, plump, soft with a subtle blush. Her eyes darted around the room where others, about 80 or so patients and accompanying family members, waited to be called for surgical evaluations. At 42, Mendoza Rayas didn’t mind the wait for gall stone surgery. It paled compared to the two years that she has been feeling “mucho dolor.”

On the other side of the room, Jose Che Mucu sat with the other men. His angled face showed sincerity blended with shy uncertainty—classically Mayan. At 29, he hasn’t worked as a banana cutter in over a year. Single, he lives with his parents who give him money in order to live while he waits for hernia surgery. Through a Spanish interpreter, he said he was a little anxious about the surgery. His face somewhat softened after someone told him that she had had hernia surgery. He asked, through an interpreter, if he would go back to feeling normal or would he always be aware of the hernia feeling. When he heard he would feel just as before the hernia, he flashed a fleeting smile.

They are two of the people who came on Sunday, many driving from distant villages, to have long-needed surgeries. In the US, these operations—primarily hernia, gall bladder and lypomas—would have been easily disposed of, even in underserved communities. On ISHI’s maiden voyage, the ship which began being carved about 6 months ago, had sailed into port. Even as the patients sat mostly quiet, looking, the ISHI volunteers, including surgeons, anesthesiologists, nurses and non-medical staff, began ramping up. The energy was palpable. Patient files ready. A system in place. In a makeshift triage room, now the doctors waited somewhat anxiously.

“This is why we’re here,” said Diego Rieno, one of the surgical residents meeting with patients to help sort through situations and the surgical priority schedule.

As if on cue, as patients walked into the room, doctors rose.. Hands extended. Conversations began.

In San Juan Sacatepequez, the Guatemalans of Mayan descent who had come said that in their experience surgery was possible, but often at private clinics where the cost was prohibitive. Mendoza Rayas, a homemaker, said her gall stone surgery would cost about $8,000 Quetzals (about $1,000 US). As a single mother of 5 children, she could not afford it. Many others had their own versions of this reality, all with the same outcome.

For Mendoza Rayas and others like Maria Oxom of Carcha who has lived with a hernia for 10 years, ISHI’s timing was perfect. Rayas, who had gone to doctors over the past two years and received injections for the pain, said that her gall stones had been acting up and causing her great discomfort as recently as the day before. She took another injection to manage the pain and traveled 8 hours to get to the mission hospital. She looked forward to later in the week when the surgeons would take care of things.

Oxom said she has pain all the time. Like many Guatemalan women, she stayed home to be mother. She said her hernia prevented her from lifting heavy things. When she works more, it hurts more. She laughed often and particularly when asked if picking up her daughter was difficult. “No,” she said, her lacy peach blouse rising as she leaned forward in laughter. “She’s 23,” she said in Queq’chi, one of the Mayan languages.

The mission, which partnered with Partner For Surgery, a McLean, Virginia based non-profit, provided interpreters who spoke both Spanish and Mayan. Patients and their families were being housed at a dorm-style facility on mission grounds where they could rest and share meals. Transportation for many patients and their family or friends also were arranged by Partner For Surgery.

By the end of the day, 45 patients had been evaluated. The surgery schedule for Monday and Tuesday had been organized. On Monday and Tuesday, about 13 additional patients were also expected.

—Articles for the 2009 Guatemala mission have been contributed by Mary Ann D’Urso.