Chinandega, Nicaragua January 1999

In late October 1998 a massive hurricane named Mitch crawled across Central America leaving death and destruction in its wake. For Nicaragua, this was the worst natural disaster of all time. Estimates of losses are staggering and will continue to add up for years. Immediate deaths were at least 10,000 in Central America. Nicaragua and Honduras were the hardest hit with staggering human and economic losses for these countries. Already mired in poverty, the losses sustained have included the means of food production as the floods ripped the mountains apart and dumped the debris over the campos. Current crops were covered with sand, rocks, animal carcasses, plant fragments, and assorted garbage. In addition to the destruction of current crops, the soil has been either washed away or covered with material which will not support the future needs of the region. An area, which was once a rich garden belt, has been strewn with rocks to resemble the sterile surface of the moon with its huge craters and rocks. Fields of bananas are cut with deep canyons. Sugar cane, which was standing at 8 feet, is washed down or covered completely with silt. Coffee trees were swept down the mountain side carrying with them the opportunity to bring a few precious cordobas into the family coffers.

Water sources were wiped out along with farm equipment; tools, work animals, and supplies needed to maintain existence. Homes were picked up and smashed into bits and splinters on the rocks or covered completely by the mud coming from the mountaintops. Personal items such as clothing, furniture, dishes, and cooking utensils were demolished in the fury of wind, floods, and mudslides. Many people watched in agony as family members were taken away by the forces of nature gone amok. Stories of grisly deaths and heroic rescues abound among the survivors. Failed rescue efforts bring deep sadness in memory. Nightmares continue to haunt the survivors. Diseases and fears of further diseases tear at what strength is left. Adding to the diseases of poverty which have weakened their bodies for years are now the diseases of poor water and food supplies, inadequate medical care, a reluctance to spend what few funds they have for medicine, and lack of knowledge as to the preventive measures which will assist them in recovery.

Shortage of antibiotics and fear of leptospirosis and dengue brought about a call to me from my friends in Nicaragua, Octavio Corea and Carolina Espinosa. Could I arrange to buy and bring a supply of medicines which are now in particular demand and which are not available in Nicaragua? With incredible support from family, friends, and associates in Oklahoma, Minnesota, Texas, and California, several duffels were stuffed with medicines requested and loaded into my car. My airline ticket allowed two bags with limit on each of 70 pounds. The American Airlines check in woman was extremely kind and allowed me to take three duffels each of which weighed close to 120 pounds. Their humanitarian program was kindly extended to assist me in getting those medicines where they were needed. The trip to Managua was uneventful, and I was greeted by Octavio and Carolina who escorted me through customs. They were expecting me at El Jardin de Italia.

At FUNDECI Octavio explained to me that I was needed in Chinandega because of the severe problems in that region. The next day Dr Roberto Granera and Maritza Andino told me some of the problems. Together we decided upon drugs which we would take and even bought some more (anti-parasite medicines are hard to buy in the US). We then loaded a bus and headed for the occidente. Octavio and Carolina had convinced me that this was the most helpful thing I could do. I would stay with Maritza’s family and would work under the leadership of Dr Granera.

As the bus moved along the highway, the storm effects became apparent. There were many detours because of flood damage. There were many areas of new asphalt covering and many trucks and pieces of heavy equipment working on damaged road surface. In a few areas there was still standing water over the old road surface requiring slow and tedious detours through hastily cleared bypass roads. From Leon to Chinandega there were over 25 major bridges which had been swept away. We went down into the canyons over dusty detours competing with other traffic as well as construction equipment for passage. Helpful police were everywhere to give guidance as well as to control traffic flow. The construction crews were a mix of military and civilian workers. The bridges were pretty standard. First, pilings are placed deep in the bottom of the canyon. Then a wall is built leaving a generous opening for future water flow. Then iron shafts (rebar?) are sunk in the pilings and form ribs for the covering. Seeing so many in different stages of development it becomes possible to understand the whole process and to develop faith that the bridges will last. The bridges are quite handsome with red and gray alternated in nice geometric patterns. Native rock and concrete are arranged attractively. The inherent feeling of Nicaraguense for beauty is demonstrated in these new crossings.

Thursday January 7. San Lucas

Started fairly early to Dr Roberto Granera's clinic in Chinandega. The mayor loaded us in his pickup and headed for the hills. We arrived at San Lucas at 9:00 and went right to work. We treated 200 people who had a range of diseases more common in areas of poverty. I saw many children with upper respiratory infections including several with bad tonsillitis. There were 2 people whom I saw with hypertension. Many had degenerative arthritis. Naturally, there were numerous back pains. The illnesses related to Mitch were horrible skin infections and urinary tract infections. I saw one child that might have had malaria but the symptoms were not strong enough to treat. There is no water in San Lucas. There is no transportation of a public nature so the community is incommunicado. We were the first medical presence since Mitch tore the area asunder.

On the road going to San Lucas, we crossed several rivers where the damage was striking. There was one community adjacent to a wide plain. Through this plain the flood waters had channeled a deep gorge. All along this gorge and on the delta below the gorge were huge stacks of driftwood. Some were 40-50 feet long and 16-18" in diameter. This community was caught up in the flood and scattered over the plain below. Perhaps the most striking show of power was a huge log, which had impaled a house and pulled the house several hundred feet from its origin. The house was wrapped around the log in the fashion of a closed umbrella. I have no idea how many people died at this site.

We passed La Casita on the way. At a distance it looked like one of the frozen rivers down the Tetons with the glacial moraine spread out below. Unfortunately this is not a ski slope and the glacier is mud -caked dry now. Many people are still buried beneath this slide, and the destruction is beyond description.

Friday, January 8, La Higuera

Today was a representation of existing poverty and hideous effects of Hurricane Mitch. Today I held a six-year-old girl in my lap after she eyed me and flirted with me for over an hour. She laughed and teased me between patients. As I observed out of the corner of my eye, she would move alternately closer and farther away. Her eyes were sparkling and her dimples were charming as she looked at me and giggled as only little girls can. While I was checking a new patient, she would be very still. When that patient left, she would flirt again. Then she stood very close to my chair for several minutes and sort of leaned into my arm. Soon she gathered a friend of 5 and teased together. A stethoscope has always held youngsters in awe and today was no exception. I let her listen to her friend’s heart then to her own. They sort of snuggled then into my arm for a warm hug. After she sat in my lap, I heard her story. Two months ago she was washed out of her house into a tree where she clung for 4 days. Her 5-year-old friend was also washed out and was rescued by the villagers several hours later. Her parents were killed in the flood.

Clinic today was set up on top of a road. The house nearest the clinic had 4 feet of mud in it. I could not stand erect while inside. The clinic was held in the shade of a carport-like edifice where trucks once parked when not being used. Now I had to lower my head to walk into the clinic. In spite of the mud it worked well. We set up a long table with me at one end and Dr. Roberto Granera at the other. Patients would wait at the middle and move either direction as a chair emptied.

From a medical perspective today was more challenging. There continued to be many women with urinary tract infections by history. There was one child with severe malaria and another with moderate malaria. I was amazed that I could pick them out but the symptoms were characteristic of Plasmodium vivax. The most fascinating patient today had nothing to do with Mitch and everything to do with poverty. She was 15 years old with a 5-year-old height. She is a first grader who is about even with her 6-year-old peers. She had all the markers of Congenital Hypothyroidism. After serious negotiation we loaded her in our pick up and took her into Chinandega where laboratory tests allowed us to start levothyroxine slowly with the hope of some benefit even though poverty prevented diagnosis for too long.

Saturday January 9 - La Villa

Today was unbelievably busy. We saw over 400 patients. I logged 156 but several came up after we shut down. We ran out of many medications, so were forced to improvise. What is wrong with putting 4 mgm chlorpheniramine into mango juice for an infant to relieve cold symptoms? Instead of amoxicillin suspension, just break the cap and mix it with zapote. Double blind studies were not possible today.

Today was not post-flood problems but pure unadulterated poverty at its worst. We took over two classrooms of a school and went to work. There was no first come first serve system in place here. Numbers were put in a basket and drawn. The people with large numbers were able to return to their house and reduce standing time. The line was still 300 feet long most of the time. I saw more purulent material today than any time in my life. Two children had pneumonia and were treated on site until they stabilized. Acetaminophen elixir and penicillin improved their outlook magnificently.

For the first time I saw severe malnutrition with babies gaunt and hollow eyed in spite of being breast-fed. I saw babies and adults eating dirt because there is no money for fruit and vegetables. It is hard to decide a course of therapy when malnutrition is the real monster. One mother held a baby of three in her arms and to her breast. The child had horrible teeth and was pale and limp. By clinical estimate she was severely anemic. I tried to explain that the baby needed food other than the breast milk, but there is no money for food, so iron deficiency is worsening.

The school in which we held clinic is interesting. There are 745 students enrolled. They either go in the morning session (360) or afternoon session (385). I talked with the principal at length. He cried when he talked of how hard it was to conduct classes amid this much poverty. He is paid $92 each month. He speaks passable English, so we hit it off. Another teacher approached me at the end of the day. He said how much he appreciated our efforts but seemed fairly hopeless for the future.

There was little I could say...

 Sunday January 10 - Rancheria

More poverty. We set up shop in a barn, which had been converted to a garage, which had been scrubbed down for our clinic. We ended up seeing 465 patients today. I logged 130. The illnesses today were of two main kinds. The most frequent was a child of almost any age with cough and a snotty nose. Parasites were almost universal. There were still women with urinary tract infections but not so frequent as before. This community had water, which they chlorinated for safety.

An interesting side bar for today. The Alcaldia of Chinandega is kind of like the mayor combined with a county commissioner. He has been a major part of our brigade including using his personal pick-up for transportation and running errands as we request. Really, he is the most "serving" politician I have ever met. I tested my Spanish by asking him about the election process. Chinandega has a population of 130,000. There are 100,000 eligible to vote. In his race, there were 75,000 votes cast. How is that for a turnout? Almost every eligible voter (Chinandega plus surrounding towns) registered and 75% turned out to make democracy work. We also talked about drug addiction. He sponsors an aggressive organization to manage the problem. But his primary thrust has been to get water to the poor people. I gather that progress is happening, but statistics are almost impossible.

Our brigade writes everything in duplicate. One page of the log goes to the Alcaldia and one to FUNDECI, our sponsoring organization. Follow-up will be done on every patient whom we identify. I diagnosed septic arthritis on one woman and the Alcaldia loaded her in his pick-up to take to the hospital for definitive care. She will be followed closely and should have a shot at recovery. Because she also had a hot finger, I made presumptive guess of Staphylococcus - I hope to find out.

Monday January 11 - La Florida

The time clock moves back many years. The many people who were made homeless by the hurricane have gathered what little they salvaged and moved to a settlement camp called La Florida. Steinbeck has described these camps around Salinas, Modesto, and Monterey. Woody Guthrie wrote about the dust and the poverty in his songs of despair and hope. Today I was there. Hundreds of refugees were offered new homes. The homes are standard and use the exact same architectural plans seen throughout Oklahoma as horse stalls, pig pens, and chicken pens. They are lined neatly in rows with the tall end of the building facing the street. The building has four posts, the back two exactly 2 feet shorter than the front two. Four 2x4x12's support 6 pieces of sheet iron or corrugated galvanized iron. The opening then is covered with 3 walls of black plastic leaving the front open. The front allows opportunity for creativity in completion. There is always a cross and usually a flower of sort. One door and sometimes one window complete the deal. There are not shoes in La Florida. At least I saw none. I guess we should be glad there were no ingrown toenails to treat, but there were plenty of new skin things in the bare feet. I seriously doubt our medicines made any impact. Parasites were universal. I saw only 98 people today, because we had planned to hold another clinic in the afternoon. We ran out of most medicines and shut down at 2:00 PM.

The camp is interesting in its development, planning, and the management. It seemed all of the big cities in Nicaragua own the land where they are and a fairly wide swath around the town. So when these homeless appeared, they went first to the schools and churches. The city of Chinandega has now developed a potable water supply in the form of a huge tank near La Florida. The city pays for the housing material and for the workers to build the structures. While we held clinic today they assembled 8-10 of these units and moved people into them. Water and electricity will be added. Construction of a school has already begun. The naked children will have clothes, and the shoeless will have new shoes. La Florida already has a mayor. She came by today to give thanks for our concern and assistance.

The mayor of Chinandega promised me that when I returned next year, there would be a good clinic to work in as I see these same people. Today I worked in the most beautiful clinic I have ever seen. Beautiful mango trees provided shelter from the sun and a cool breeze from the Pacific provided the air conditioning. Lunch was served al fresco. Tree ripened bananas and lush zapote offset the tartness of fresh oranges. The most amazing thing was that they apologized for such a poor presentation.

School starts in February.

Manana is Posoltega.

Tuesday January 12 - Posoltega

Floods are not new for a boy from Oklahoma. But a disaster of this magnitude is always rare and always hard to stomach. The Volcano Casita was dead many years ago. As time went by the crater became full of water. There was a military encampment there permanently. Local TV stations built the antenna gardens near by. The view was magnificent so schools were built on the mountain and farmers built their homes on the mountainside right up to the volcano's edge. The air is cool and fresh. The Pacific Ocean can be seen in the distance. Bananas flourished on the slopes. All was well until Mitch dumped rain for four solid days. Now death is measured in mega quantities. There is a banana orchard growing right to the edge of a cliff but there was no cliff until over half of the orchard crumbled away to float down the hills with the men and women who had planted it. Huge trees are barren and sun washed, but little paint marks point out where human bodies were snagged on the way down the hill. There is a mass grave representing over 200 adults and children who were brought to death in this area. There is an area where 800 bodies were cremated as the entire community was washed away. I walked among the grisly reminders where concrete walls remained. There are three huge canyons, which once were fields or gentle swells. One canyon is 300 feet deep. There is one slab of rock, which has been measured to be bigger than an acre. It is about 50,000 square feet. It probably represented one wall of the volcano crater, which had simply slipped away.

There were rotting, drying carcasses of cattle, horses and pigs among the detritus. The earth is now parched and cracked as the water has leached down and evaporated up. To walk over this area is quite reminiscent of an empty lakebed. There are huge boulders whose rounded surfaces demonstrate that they have spent a long time under water. There were some rocks which had holes like coral reefs.

Final count is that over 1400 people from this tiny municipality were killed in one ghastly week. People who were involved in rescue efforts tell of bodies bobbing up and down in the muddy mess. Many near rescues were thwarted by a huge rock crushing the victims as it tumbled down hill in the mud. Trees were swimming by with bodies and live people alike captured in the twisted roots and branches. Depression and Post Traumatic Stress Disorder are rampant among the survivors. They like to talk about what they saw and heard - almost as if that will make the pain go away. The Alcaldia of Posoltega had 4 sons. Three died in the flood. Most families have close relatives who were closely involved. With half of the community being killed in this disaster, no one has been totally spared.

Outside the nearest municipality are news of refugee houses. These are temporary. There is already a plan to construct a new city or community in Chinandega. The refugee camps have potable water but the shacks are very temporary. Pasteboard is the common wall substance. These houses are built on a different design than La Florida. Here there is a center roof rafter with 6 poles in the ground. The middle 2 poles are higher to create a doubly sloping roof. At a distance I could not tell if these were saplings or large bamboo poles, but they would not pass the "Three Little Pigs" test for soundness. They are, however, in neat rows.

Our clinic today was not much. A team of Cuban doctors had done an excellent job of disaster recovery. Most of the skin looked healthy. There were some colds and urinary tract infections but few parasites. Post Traumatic Stress Disorder with insomnia and panic attacks were very prevalent. I listened and offered solidarity, but it will take years to become reasonably whole.

One good note today. The lab test came back from the 15-year old girl confirming thyroid disease. Celebration was enthusiastic as she started her medication.

Wednesday January 13 - Mina del Limon

Dust, dust everywhere and no relief in sight. Why did I think it was dusty in Oklahoma? The dust is powder and seeps into the pores to create grime requiring three passes with soap and water to clear. Everyone wore masks like in cowboy roundup days. The ubiquitous handkerchief is always handy. With a baseball cap pulled down to the eyes and a handkerchief over the nose and neck, everyone looked alike. I have seen pictures of banditos looking like this. I thought they were hiding. Now I know they were riding through the dust. Wet wipes are wonderful.

The Minas del Limon are the source of the largest part of Nicaragua's gold. There are 5 mines here in kind of a star shaped pattern over several miles. The quality of gold is high and apparently in good supply. One man was demonstrating to me how the gold was removed. Apparently, they dig down then move laterally. I also asked who owned the gold and was told that Nicaragua did. The people who live and work in this community are among the poorest in Nicaragua. They are physically beautiful and smile often. The eyes are beautiful and sparkling. But they have no water.

The flood swept down from the mountains and left a mess. Not many people here lost their life, but orchards, gardens, and crops were swept away. In this place of beautiful fields are clumps of debris snagged around tree trunks. This debris is a mix of sugar cane, cattle feed, and young saplings, which were ripped out of the ground. We crossed several low water bridges with creek water above and below. I could see minnows and turtles swimming playfully in the water. Only the banks showed signs of destruction with watermarks 15-20 feet higher than the existing creek. Huge trees had all of the soil washed out of their roots so they either died in place or simply slumped over and died leaving the root structure upturned for close study. The real tragedy here is that fertile farmland has been covered with a layer of powder containing none of the organic matter necessary to sustain life. Clearing up the debris will be a full time job for a long time.

Clinic today was interesting. I saw only 102 patients but the variety was more interesting. There were many women in their eighties who were still quite active. Our brigade was the first medical care since Mitch, so we saw a lot of parasites and urinary tract infections. Depression is still a prominent feature of their existence. I saw two people whom I believe to have Rheumatoid Arthritis, but the proof is absent. There is a surprising paucity of hypertension and diabetes.

The total for our seven days is 2057 patients treated. I do not have precise figures on amount of medicines dispensed, but I am sure the final note is staggering. There will be more interesting data after all of this is put together. I hope to return and continue the efforts started this week. Tomorrow I meet with Father Miguel.

Thursday January 14 - Esteli

After Father Miguel's conversation, the drive to Esteli was tiring and filled with strange sensations. Flood damage is heavy. Many fields have logs and assorted debris on top of what was once useful land. There are still many areas where water is backed up and other cut-off lakes where people are swimming and having fun. Some of the cut-off lakes are beautiful and may endure as permanent lakes. There are many houses half under water around these lakes. I remember during my teen years how I loved to fish in the cut-off lakes north of New Boston and Texarkana. Those farmlands were also destroyed for farming cotton then planted with Pine trees to become one of the most productive dollar crops ever.

Esteli actually looks better to me than it did year before last. At that time it was dirty and poverty stricken. The streets were not passable due to huge rocks and ditches. The taxis would only take you close to your destination. Now the streets are graded. There are new homes everywhere. The streets are much cleaner. There has been a lot of paint applied to the houses. The attitude of the people seems more positive.

Albertina's house had a river sweep through it taking doors as it went and leaving mud behind. The outside bathroom facility was swept away. Her house as aligned by accident in such a way that the water didn't swirl around and destroy. It simply swept through the entry foyer and down the hall through the kitchen and back outside. So the house remained. She now has new furniture, new doors, and new paint. I did not see a new bathroom facility but I also did not ask. Her husband has stopped traveling due to diabetes and has opened a welding shop where he fabricates beautiful iron grillwork to cover entries, doors, and windows. Family income has increased. Bianca is still a lovable 7-year-old girl. So the world goes on and disaster sometimes turns out better than we might suppose.

Friday January 15 - Esteli

Four epidemiologists from the U.S. entertained me today. They have been studying the people involved by Mitch and have been taking voluminous data for computer entry. They said they would send me a copy. There were 2 young women, one young man, and one man older than I. His personal story is pretty exciting. He decided after medical school to do epidemiology, and that decision has led him throughout the world. He has done some exciting things in some of the really scary epidemics and has also enjoyed traveling all over the world. They were all fun, enthusiastic, dedicated, and very hard workers. They seemed to enjoy what I had learned. Several things emerged from our combined experience. There is an increase of common problems including upper respiratory infections, urinary tract infections, and rheumatic complaints. They have seen no malaria, very little diarrhea, no dengue, no cholera, and no leptospirosis. There does seem to be an unusual conjunctivitis at high frequency. There are a lot of skin infections. Since parasitosis is endemic, it is hard to judge whether the frequency is up or not. Post Traumatic Stress Disorder is of high frequency now. The epidemiologists were quite impressive. They were clearly brilliant people at work trying to sift through mountains of conflicting information. Solid data are indeed rare, so opinion holds sway in many areas.

In the afternoon we visited the cigar factory and had a long session with the manager (maybe owner, I don't know). It was interesting to watch them at work. When we first went in to the shop, the smell was not fresh. It is hard to describe, but somewhat like an old barn. One of the fascinating things was to watch at work what many of us think is not a good system. After a few minutes, a young woman spotted me and got permission to say hello. This was interesting for the gawkers. She was an old friend from previous visits. We did end up getting nice samples, but I did not accept because of my addiction.

The people (mostly young women) who work there seem to like the work. The company hires 1000 and is pretty paternalistic with them. I don't know what they are paid now, but it isn't much. Fidelia told me they are expected to make 400 cigars each day. She is just learning, so she only makes 200 a day.

There is strong competition for the jobs and an arduous training period during which time they are paid but may be asked to leave at any moment. Even after the probation period, their hold on the job is tenuous. But they like it, and the company is civic minded. There is no union, but there is a worker's group with a representative who is a mature and well liked woman.

Following this tour I met with a family which included Abertina Urbina and many of her relatives. Two years ago I met most of them. The focus of this visit was to console the matriarch. She recently lost a son aged 37 from heart disease and a grandson shortly thereafter. Her grief was severe. She cried most of the time I was there. Then there was a procession of relatives very few of whose names I recall. It is a close and warm family with ties throughout Esteli. Tania became married in December. Much of the family is in Miami, so problems abound. Many of them are without green cards. I don't know much about that either.

After the family "grieving" meeting, we returned to Managua for a mini-fiesta at FUNDECI. This was a Witness for Peace Celebration. I acquired numerous T-shirts to distribute among my close friends. I also accepted literature.

Saturday January 16 FUNDECI

Today Octavio called for me to take me to an interview. A Norwegian reporter wanted to talk to me about my impressions gleaned during the last 10 days. He was friendly and thorough, taking voluminous notes. The first hour he interviewed psychologists and social workers that only spoke Spanish. I followed most of what they said. Basically, they focussed on Post Traumatic Stress Disorder. There was a Cuban doctor there who had spent a lot of time in Posoltega. (See my notes from last day.) He shared his ideas and talked of preventive actions. It was clear that there are some problems. Apparently, many of the donated drugs, food, and clothing have not been distributed. They talked of docks full of goods, which have not yet been sent to the areas of need. There as a lot of talk about how the government people are diverting these goods for their own benefit. I have absolutely no knowledge about any of this, but I could readily perceive the political posturing on both sides even with my poor knowledge of Spanish. I tried to concentrate on things I understood rather than get into water over my head.

Then I had a private interview with the reporter for another hour. He was very bright and told me he worked for the largest paper in Norway. He shared many of my ideas and talked about how the U.S. had made such a mess of the Contra thing and was now making a huge mess of the Clinton scandal. He is deeply concerned about the effects of the Religious Right in the U.S., because he thinks it will cause trouble throughout the world. He obviously likes Clinton very much and gives him credit for a good outcome in Bosnia, Ireland, and the Middle East. He believes the Sandinistas have the right to approach to managing Central America but that Daniel Ortega should move aside so that fresh faces can be more successful.

Summary:

What a visit! I really enjoyed this two weeks more than any other. I feel lost because I have had no contact with the news or with my E-Mail. I likely have a full day of just answering E-Mail at work much less at home. But I have enjoyed my time away. Will I be able to return to work? When I left home, I was apprehensive about this time. Now it is over.

I found in Chinandega a new world. The sense of community is astounding. Organization of effort is well under way. I could not discern how much of this was initiated by the Mitch disaster, but it is real. The Alcaldia said it well when he described the election process and how all parties seemed to agree this is a better way. But the light that shines hope on Chinandega in Maritza. She is a bundle of hope, charm, and energy. She has four daughters two of whom are in the university. They are dedicated to study but do all of the housework so she can be about reforming and rebuilding the community. She is an agronomist who once worked for the state. Now she is a social worker-nurse who looks after the people. She is about 5 feet tall and 100 pounds, but she is 3" taller than her mother. Her smile is 4 inches across and lights up the whole room. She is so organized that I shudder to think of my own random life.

Maritza has worked with the doctors in Chinandega to organize some health care delivery for the whole area. She is known everywhere. She is Sandinista from toenails to the top hair on her head with a fervent belief in the ability of people to handle things. She honored me without deference. She bossed me around as she saw fit. In the clinic she would run errands, fill out forms, clean up messes, measure pills into containers for individual patients, give shots, and calm the troubled waters if things were out of control. When the clinic bogged down, she came around telling me to speed things up a bit. But when I had a difficult patient who required more time, she was totally supportive. When I needed a break, she made sure I was allowed to be alone with my thoughts to recover.

Maritza's mother is wonderful - I guess meaning she reminds me of my mother. She is built much the same and has a square face like my mother. She makes the best bread I have had since my mother died. Every evening after dinner, she invited me outside to sit in a rocker while she sat on a rock. About every 10 minutes she would say "esta' fresca". She loved the cool evening. She would then pump me about my day. Then she would call all of her neighbors and brag about my prowess in the clinic. Then she would go into the house and force each one of her grandkids to come talk to me. I loved that part. The youth are so full of ideas and dreams. They would tell me about their studies. One evening, I picked up a notebook, which was homework. It was full of stuff I learned in graduate school, including some of the same examples. How small the world!

I broke all the rules about food this trip. Every night I had fresh salad (to die for), rice, beans, chicken, and fruit. I drank a mix of stuff with ice, which came from somewhere. This woman is an incredible cook. About the third day I nosed around and found the kitchen. It is about 50 feet outside the house in a concrete blockhouse. The fire is open. She fuels it with slivers and chunks of wood. As her judgement leads, she adds a bit of wood to the fire and pokes it a bit. The kitchen is across the patio from the house. Around the wall are stacks of flour, corn meal, baking powder, and other delights. When she makes bread she reaches her hand into the sack and comes up with a handful, or a pinch, or a double handful, and puts it into her mixing bowl. She may add more later as her mind tells her. She has no refrigerator, and no thermostats or thermometers. But the output of that kitchen is marvelous. While she cooks the day's food, she washes clothes on a washboard and hangs them to dry on lines strung around the banana trees. Every morning she reminded me to set out my "ropitas". She would wash them and pass them to one of the girls who would iron. When I returned in the evening I had fresh clothing to brighten my spirits. After an ice cold shower, she would serve dinner. Needless to say, there was no weight loss possible this trip.

The hurricane damage was striking in its power and extent. When La Casita opened 1400 people were killed in minutes as if by a giant tidal wave. Altogether some 6000 people in Nicaragua lost their lives. The economic cost will continue to escalate because of homelessness, destroyed livestock, destroyed equipment, and destroyed farmland. The solidarity expressed on an international level has been gratifying and will surely bear fruit. There is more hope now that the international community will develop a workable partnership with the Nicaraguense rather than the patrimonious approach of the past. As with many disasters the poor seem to bear an inordinate share of he personal damage. Living with no margin for safety, the disaster destroys not only existing resources but also the tool with which to build replacements. Thus the camposinos lost current crops but also oxen and ox-carts, plows, cattle, and chickens. What can the international community do to assist in this recovery? How can we as citizens of the United States best help in recovery?

Nicaragua is and has been struggling under an incredible debt load brought on by major disasters in the past including a massive earthquake which leveled downtown Managua in 1972. Before that disaster was forgotten an internal revolution against 50 years of dictatorship continued the economic drainage. The International Monetary Fund provided capital but has required a heavy burden of structural adjustment which hits the poor at an inordinate rate. Just as inflation tears at those with fixed incomes, structural adjustment singles out the young, the old, and the poor to contribute a higher per capita rate of national debt payments. Debt forgiveness and removal of all economic sanctions are necessary to allow the rebuilding of Nicaragua. Nicaragua is second only to Haiti in poverty. To forgive Nicaragua's debt would hardly be noticeable in our budget. It would allow them to utilize funds, which are currently going to pay interest. Utilization of these funds to rebuild infrastructure makes excellent economic sense. Public education and a clean water supply are two items that would allow recovery and strengthen the ability for self-determination. Debt forgiveness is closely akin to offering a drink of water to a starving human. It will not provide adequate nutrition, but it will maintain life while other means for survival are developed. After World War II the Marshall Plan was developed to re-build Europe. We have often "Led the Way" among the international community in assisting poor nations to survive. We are in a position to lead the way again by forgiving Nicaragua's debt to the United States. It makes good economic sense to make Central America healthy and maintain that health with continued shared goals.