Alumni Essay - John T. Lynn III, MD '78

Map of El Salvador

Summer in Salvador

 - John T. Lynn III, M.D.

A Keck alumnus reflects on his experience working in a rural hospital in El   Salvador in 1975.

I came to University of Southern California School of Medicine from University of Virginia in 1974.  The schools and their environs were very different, and I loved the change.  The evening before the fall semester began, my class had a wine and cheese party; then a group of us went to El Tepeyec for stomach-size burritos.   Each week, guided by faculty physicians, we talked with patients on the wards of LA County + USC Hospital.  One evening a few classmates and I watched third-year medical students deliver babies at the Women’s Hospital. Intoxicated with life at this warm and welcoming medical school and the barrio beyond, I dreamed about practicing medicine in Latin America.

The summer after my first year at USC I had the opportunity to work in a rural hospital in El Salvador.  I asked my favorite professor for advice.  We all loved Dr. Fred Elliot, our professor of Community Medicine. Although he suffered from the ravages of diabetes, his spirit transcended the challenges of his life.  With a cane in one hand and a microphone in the other, he would wander from the podium, and from the subject of the lecture, and would tell stories about his years as a family doctor in a tough Canadian lumber town, where he earned the trust of the citizens by operating, successfully, on the mayor’s dog.

“So you’re 22 years old and you just pick up and go to a country you know nothing about.  Amazing!” he said, looking at me with dry, reddish eyes and tapping his cane on the floor.  I interpreted this as his blessing mixed with a tinge of envy.

The Salvadoran doctor who helped arrange my externship picked me up at the airport in San Salvador, the lovely capital city at the base of Quetzatepec volcano.  After listening to my broken college Spanish, he turned me over to his children, and the kids and I watched cartoons and played games. 

A couple of days later, when the kids could comprehend my words, their father drove me to La Union, a pueblo on the southern tip of the country.  The crisp mountain air of San Salvador gave way to the sultry coastal lowlands. Mongrel dogs chased our car, and skeletal cattle sulked in the parched fields.

At the plaza in La Union, a group of men surrounded our car each holding a ringed notebook filled with pictures of local inns.  The hospital was expecting me the next day.  Randomly I picked an inn.  My friend wished me good luck and drove away.

The inn was a small farm with horse stalls converted to guest rooms.  Exhausted, I set my backpack on the dirt floor and climbed into the hammock.  Overhead I heard the pitter patter of what sounded like mice.  I opened my eyes and saw a large rat balancing on the rope that anchored the hammock to a beam in the ceiling.  Afraid to move, imagining that the rat might fall into my lap, the rat and I stared at each other until the roosters crowed.

That morning I met the director of the Centro de Salud, and he escorted me to a dormitory on the second floor of the hospital.  There were four beds:  two for the interns who were serving their ano social to repay the government for their medical education, and another for a journeyman doctor. 

The director was a rotund, voluble man with thick black hair that crowded his forehead.  Because he had a private practice in town, I rarely saw him except for the night he took me to a bar.  We drank a few beers, and I laughed dutifully at all of his jokes.  His sentences rolled along like one long incomprehensible word.  Finally, I excused myself and stumbled back to the hospital in the black night.

I remember the interns fondly.  Carrito “little car” was a petite, dark young man with a barrel chest and thin legs.  Always energetic and upbeat he had a confident manner rarely given to doubt or introspection.  Mario was pale with a permanent 5 o’clock shadow.  The son of a university professor, Mario was contemplative, but when he made a decision, it was definite and final.  Carrito and Mario had been classmates at the medical school in San Salvador.  The two city boys reluctantly found themselves assigned to this distant, provincial hospital.  Mario emanated an air of superiority that Carrito was able to shrug off, so they got along well.

Every morning someone would knock on our door at 6 o’clock.  Under a trickle from a rusty showerhead we rinsed off yesterday’s sweat while a radio blasted music and promoted the Miss Universe contest to be held in San Salvador that summer.

For breakfast we had fried plantain, rice and coffee.  By then patients jammed the waiting room and queued along the walls outside the hospital.  We worked in the clinic for five or six hours or until every patient was seen. 

Most of the patients were children with diarrhea and dehydration.  To reach the hospital, mothers swaddled their babies in ragged blankets and walked barefoot for hours in the night.  The young doctors were conscientious, asking the right questions and examining the patients carefully.  They scolded the mothers for bundling their febrile children (an ancient rural practice that made the dehydration worse).  I looked at these women, their faces cracked by the sun, their feet with deep fissures, and I cringed at the harangues, but as a visiting student there wasn’t much I could say.

In the clinic I rotated my time with the three doctors.  I sat with them in the stuffy examination rooms and stood by them on hospital rounds.  I helped patients on to the exam tables and lifted them from their beds so the doctors could listen to their chests.  I ran errands and drew blood for tests.  It was more like blood letting than phlebotomy.  The needle used to puncture the vein was attached to a bottle, and blood dripped into the bottle.  Yet the patients were always stoic and grateful for their care.

I also watched and assisted with minor surgery.  I shudder to see the word minor in print.  In 1975—maybe it’s different now—the compesinas rarely accepted oral contraceptive pills.  Pressure from their husbands and their priests and the cost of the pills factored into the decision.  We did, however, perform tubal ligations most days.  For anesthesia a nurse soaked cotton gauze with ether and placed the gauze over the patient’s nose and mouth.  If the patient moved or groaned during the operation, more ether was poured.  The young doctors made deft incisions and probed with gloved fingers for the fallopian tubes, which they sutured and cut.

We treated male patients for injuries from farm work or fishing.  Fights with machetes led to gaping flesh wounds and severed limbs.  The doctors tried to stop the bleeding, and the patients who survived were transported by car to larger hospitals.

By mid-afternoon we trudged up the stairs for a siesta.  It was too hot to nap.  The heavy air seemed to press on the land, and the leaves on the trees were still.  We just sat on our beds and perspired. 

Life in the Centro de Salud was not all drudgery. Music was ubiquitous.  The nurses sang and chatted joyfully.  New life entered the world, pink and gurgling.  To show appreciation for their care, fishermen brought fresh fish and shrimp to the hospital, and the cook made delicious bouillabaisse.

In the evenings I often walked the cobblestone streets lined with colorful shops and single level row houses.  Near the naval station where soldiers stood guard in crisp white uniforms, I played basketball on a playground court.  At 5’9” I played center.  I felt like the comedian David Steinberg, also of slight stature, who recounted playing basketball in Japan.  “Get the ball to the big guy,” his teammates would holler.

On a walk I met a woman about my age, and we had a few ice cream dates.  Sweet and soft spoken, she lived with her family in a one-room thatched-roof house.  They slept on hammocks, which were taken down in the morning to make space for living.  Her father worked on a ranch.  Being the oldest child, she quit school early to help raise her siblings.  When I invited her to a dance hosted by a local dignitary, she demurred.  I offered to buy her a dress and shoes for the occasion.  With some embarrassment she admitted that she would not feel welcome at the dance.  My first insight into the caste system of this pueblo by the sea.

Throughout the summer I had intermittent diarrhea and lost 20 pounds.  The interns thought it was funny:  the gringo with turista.  I put on my game face every day, but I felt terribly tired and weak. 

At the hospital the staff always wanted to speak English with me.  Many hoped to immigrate to the United States for a better life.  They wondered why I would leave the USA to be in El Salvador.  Besides my youth and obvious ignorance of medical practice, to them my stay in La Union seemed another sign of my foolishness. 

To practice my Spanish and to escape the penetrating suffering of hospital life, I took a week off to travel.  As my bus passed through San Salvador, hundreds of people were rioting in the street to bring attention to the execution of students who had protested the spending of public funds on the Miss Universe contest. That we had the resources to travel in a Greyhound-like bus must have labeled us as an elite group with ties to the ruling class.  A large group surrounded our bus and pushed on the sides in an attempt to tip the bus.  Rocks crashed through the windows.  We dove to the floor.  The bus driver stomped on the accelerator.

As described in Cultures of the World: El Salvador, El Salvador is slightly larger than Massachusetts and is wedged between Honduras to the north and east, Guatemala to the west, and the Pacific Ocean to the south.  It has about 20 volcanoes; several are still active. The soil, rich in volcanic ash and sediment, and the climate are ideal for growing coffee, and coffee is El Salvador’s largest export.  Beneath the ground three tectonic plates inch towards each other creating earthquake fault lines.  This explosive geographic setting is home to 650 people per square mile, the highest population density on the mainland of the western hemisphere.

In the 16th century, Spain granted large tracts of arable land to 14 families.  This oligarchy of landowners and wealthy businessmen has grown to about 200 families, which—along with the military—have ruled the country for centuries. 

Compesinos work on farms either directly for the landowners or as tenant farmers. Throughout the 19th and 20th centuries compesinos agitated for reforms that would give them parcels of land.  An uprising in 1932 led to the slaughter of 30,000 people by the army.

During my summer in El Salvador friends at the hospital warned me to stay away from the mountains, where guerilla groups were forming. The 1980s were marked by massive earthquakes and by civil war, in which students, workers, priests and nuns demanded a fairer distribution of wealth. A peace accord was reached in 1992.

After a long visit to El Salvador in 1982 to try to understand the chaos and killing, Joan Didion wrote in Salvador:

Whenever I hear someone speak now of one or another solucion for El Salvador, I think of particular Americans who have spent time there, each in his or her own way inexorably altered by the fact of having been in a certain place at a certain time.  Some of these Americans have moved on and others remained in Salvador, but, like survivors of a common natural disaster, they are equally marked by the place.

I returned to school in the fall 20 pounds lighter, and I felt 20 years older, scarcely recognizable to my classmates.  The student health physician found that I had a Giardia infection, the cause of my diarrhea and malabsorption.  A short course of Flagyl cured that.  My Spanish had improved, and that has helped me communicate with patients throughout my career.

In my senior year, during a rotation at Rancho Los Amigos Rehabilitation Hospital, I spotted Dr. Elliot in a wheelchair gazing out a window in the corridor.  One leg was heavily bandaged from an amputation for gangrene, a complication of his diabetes.  He wore a hospital gown.  I approached him, my stethoscope draped from my neck, swaying against my white smock with each step.

After I greeted him, I realized that he was almost blind from diabetic retinopathy.  I put my hand over his and introduced myself.  There was a moment of silence; then he said “Yes, and how was your trip to Central America?”

“Well, it was an experience I’ll never forget.”

“Will you work for WHO or do some other international work after your training is over?”

“I don’t think so.  I’ve gotten very interested in Internal Medicine.  And there’s plenty of suffering here.”

I did a residency in Internal Medicine and a fellowship in Rheumatology.  Twice divorced, I have four healthy children.  Until being sidelined by illness, I practiced medicine in Colorado Springs.  I am grateful for my privileged life and for being able to help many people in my community, but I have lived with some guilt and grief for not being a part of the solucion for that small, crowded land rocked by poverty, disease, war and natural disasters, the country that gave me my start in clinical medicine and that taught me what life was like for billions of people in our world.

As we age, our thoughts return to the paths we have chosen in life.  Youthful dreams change as we face the limits of our ability and stamina.  Now my dream, my hope, is that with the present commitment of the developed nations and foundations to improve the lives of the less fortunate, a new generation of doctors and nurses, those who dream big, will work towards the solucion.  That would be, to use Dr. Elliot’s word, amazing!

Dedicated to the memory of Fredrick Elliot, M.D.

References

Foley, E. Cultures of the World: El Salvador. Marshall Cavendish Corp., 1995.

Kephart, B. Strange Love in Strange Places. WW Norton Co., 2002.

Danner, M. The Massacre at El Mozote:  A Parable of the Cold War. Vintage Books, 1994.

Didion, J. Salvador. Vintage Books, 1983.