The Work Beyond the Work

“The sign of man’s familiarity with God is that God places him in the garden. There he lives ‘to till and keep it.’ Work is not yet a burden, but rather the collaboration of man and woman with God in perfecting the visible creation.” 

- Catechism of the Catholic Church, Paragraph 378

In my short time here in Peru I have begun to pick up some new vocabulary. It is not uncommon to hear the words chamba and chambear multiple times throughout the day as people refer to the impending work dauntingly lying ahead or the accomplished work gratefully set behind them. Rumor has it that the word chamba has its roots in the tongues of Mexican immigrants who sought work in the “chambers” of commerce throughout the United States during the 1940s. If this is true, the word, like its pioneers, has also migrated its way into a foreign land- a beautiful and amazing testament to the human interconnectedness that transcends manmade borders and designations. 

Unlike the interesting, and maybe folkloric, roots of the word chamba, the ubiquitous Spanish word for “work,” trabajar, has painful historical roots in its Latin origin. It stems from the word, tripalium, which refers to the three sticks used as a form of punishment for slaves in ancient times. Over time, the word “work” soon became the linguistic label for any activity associated with physical pain and suffering. In this expressive reality one also finds the significance of the word “labor” as a general term for work and also the extremely painful experience of childbirth. The words “work” and “labor” seem to have taken on an unpleasant tone over time. Indeed, amidst the towering stack of paperwork or the overflowing deluge of e-mails, the line of dissatisfied, impatient customers or the waiting room full of ill and suffering patients, the long hours sitting at a desk or the bone-breaking hours of heavy lifting, it can be easy to see our work as an unjust burden, a source of suffering, a form of punishment. But we do not have to look far to know that the work of human hands was not meant to be seen this way from the beginning. 

Indeed, the real origin of our work lies in the truth, beauty, and goodness of a garden- a garden where invisible, though constantly real, scientific organic processes give way to visible, though momentarily imperceptible, blooming of fruits and flowers which we ourselves do not create. We tend to the garden with the use of nimble hands and hydrating water together with the participation of nourishing soil and photosynthesized sunlight, all of which we also do not create ourselves. In the end, our work in the garden is not merely a product of our own doing but our participation in, and collaboration with, the work of something much greater than ourselves.

The garden challenges us. We can choose to work the garden or merely work in the garden. We can choose to help the garden thrive or let it wither. We can choose to use the garden’s fruits and flowers for the garden’s common good or merely reap its yield for our own benefit. In the garden we are reminded that our work is not a burden but rather a free and willing participation in a work greater than that found in the humbling limitations of our own faculties- the “work beyond the work.”

The labor of the past few weeks has been trying. With staffing shortages, the arrival of hundreds of school-age students for the start of the school year, a broken X-ray machine, complicated and often care-limiting bureaucratic restrictions, several extremely ill children, hot and humid afternoons, and multi-day stretches without internet, it can be easy to become defeated by the difficulties of the day’s work. Thankfully as a physician, the eyes of the suffering human person staring back at me are a constant reminder that the work never ends with me, a constant motivator to continue tilling and keeping the garden even when conditions may appear dark, dry, and devoid of necessary nutrients.

***

Morning rounds begin and the hospital is the fullest it’s been in the past two months. In Bed 1 rests an incompletely vaccinated 3 year-old boy who stepped on a nail five days ago. My mind immediately worries about the possibility of tetanus while his mom worries that he can no longer walk. His delay to care is a combination of living in a remote community, lack of money for boat transportation to the hospital, a well-meaning effort by his parents to care for the wound with herbal remedies, and a lack of understanding of what constitutes a medical emergency. With three antibiotics his infection continues to progress and his parents refuse transfer to the city for further care- the addition of a fourth antibiotic, a final effort, finally calms the infection. We all breathe a sigh of relief as he leaves the hospital a week later.

In Bed 2 lies a nine-year-old girl who came to us with prolonged fevers and swelling of the lymph nodes of her body. A quick blood test and a detailed look under the microscope reveal acute leukemia, an aggressive blood cancer. The team works diligently to refer her to the city for a consult with the oncologist. For our team in the middle of the rainforest, acute leukemia is a medical emergency. However, emergency referral to the city hospital is denied because she is otherwise clinically stable. We worry the delay in care will prevail over the reserve of her body. Days later she begins the journey by boat to the city and one week later we receive news that she has arrived at the pediatric cancer hospital in Lima- we are hopeful for her healing and grateful that she has survived the long trip thus far.

In Bed 3 a two-year-old boy is cradled by his mother. He arrived with an emaciated body and thin, fragile, discolored hair. The outline of his ribs and the undulation of his hollow intestines are visible just under the surface of his skin. A few measurements, calculations, and tests confirm a moderately malnourished child with a burden of parasitic worms. His equally thin parents explain they do not have enough money for food which is evident in the voracity with which he cleans every hospital plate, bowl, and cup. One week later and almost two pounds heavier, life returns to his face.

In Bed 4 I see a 7 year-old girl who is unresponsive- we are anxiously awaiting the arrival of the water plane that will take her to the city for a chance at continued life. She has not passed a bowel movement for two weeks, and while her intestines lie dormant the other organs of her body begin a final sprint to keep her body going. A couple days later as I pass the bed in which she lay, we are informed she has died, the cause- a ruptured abscess of her appendix obstructing her colon. My heart aches for her family, and I begin to wonder if I could have done anything differently.

Bed 5 houses a man under a mosquito net who is suffering from the painful and dehydrating effects of the mosquito-borne dengue virus. Meanwhile, a team from the hospital goes house-to-house in the community in an effort to eliminate the harboring reservoirs of these blood-thirsty arthropods. Thankfully he does not show any signs of significant complications from the disease. I am reminded to keep lathering on the mosquito repellent day after day.

The mosquito net of Bed 6 shelters a 12 year-old girl with anemia and an enlarged spleen. Her body fights malaria, a disease spread by a closely related sister mosquito of that which has infected the man next door. Though their ailments are different, the blue nets draped over their beds remind them of a shared culprit. A few days later, an inverse healing process makes itself known: her spleen begins to decrease in size while her iron stores slowly rise.

Under the covers of bed 7 sleeps a woman awaiting a blood transfusion. She has been bleeding from a mass in her cervix, likely cancer. She comes from a remote community and has not had access to routine cervical cancer screening. With a heavy heart, I watch her leave the hospital as she refuses further evaluation and management. Though I am happy she has received pain relief from the natural herbs and remedies of the local curandero, I fear that the treatment of her cervical mass is beyond any of our capabilities.

The patient in Bed 8 is seen behind a transparent, plastic wall. Through the impermeable barrier I see the smile of an emaciated young man with a new diagnosis of HIV and a type of pneumonia that only affects those with this immune system-suppressing disease. Though this wall serves its purpose as we rule out the possibility of highly contagious tuberculosis, when he leaves the hospital he will suffer from the invisible walls of stigma put up by those in the community. I am reminded of the men, women, and children with HIV I have met here who have been reluctant to share their diagnosis with their doctor.

Bed 9 is found behind closed doors and is occupied by a woman who quietly suffers from a first trimester miscarriage. Just down the hallway beds 10 and 11 are shared by two mothers who have just given birth to their healthy, crying newborns. The somber silence seems unjustly overcome by the festive fussing.

Bed 12 safeguards a child bitten by a venomous snake. She has received the necessary vials of anti-venom and after a few days is now able to walk on her leg again. Only two weeks before, a young girl bitten by a snake arrived at our ER with severe hemorrhage and developing compartment syndrome (increasing pressure from swelling that can cut off blood circulation and nerve conduction). She, too, is walking again.

In Bed 13 lies a middle-aged woman who is paralyzed after falling from a tree many years ago. The constant pressure of lying on her back without moving has eaten away at her underside, revealing bones and muscles that are not meant to be exposed. We struggle to understand how this woman was neglected for all this time. Meanwhile, I remember the 17 year-old boy who used to lie across from her bed; he also fell from a tree, sustaining a spine fracture resulting in paralysis of his legs. In a severe depression, it took him over 2 months to find the will to take his wheelchair outside to see the sunlight. On his last day in the hospital, I found him outside with a smile on his face playing with one of the younger patients. He was beginning to “move” again.

***

On March 25th our hospital celebrated the feast day of The Annunciation, a day in which the Church remembers the free and willing participation of a humble and trusting woman in God’s loving plan for mankind. In fitting recognition of both man’s and woman’s participation in the creation of human life, Saint John Paul II designated this same day as the International Day for the Unborn Child which, not coincidentally, occurs 9 months before Christmas. On that day here in Santa Clotilde, the perpetual sacrifice of the Mass culminated in a community walk for the protection of the vulnerable, unborn child as well as for the fight against tuberculosis (celebrated on March 24th), a disease that continues to plague the most vulnerable in our world. 

With this special awareness, I am reminded that the human person is the most beloved garden of all, a burgeoning life deserving of the most caring hands, the most life-giving water, the most nourishing bread, and the most transforming light. I am reminded that just as the garden challenges us, so too does our most vulnerable brother and sister. We can choose to tend to our sister or merely pass our brother by. We can choose to help our sister thrive or let our brother wither. We can choose to help our sister seek her common good or use our brother for our own benefit. We can view our sisters and brothers as a burden or we can freely and willingly participate in their flourishing. In the end, it is not the handiwork of the individual gardener but the “work beyond the work” that bears much fruit.

“Our labor here is brief, but the reward is eternal.” 

- St. Clare of Assisi

Motion in the Stillness

One of the most notable differences moving to Santa Clotilde is the absence of lane-marked roads, busy freeways, and four-wheeled cars. In the US it is nearly impossible to live without a car; here in Santa Clotilde, it is entirely impossible to have a car. In the US, 5G networks extend into suburban and rural lands; here in Santa Clotilde, one’s cell phone only occasionally registers a futile one “G" signal. In most of the US electricity currents run twenty-four hours per day; here in Santa Clotilde, it is necessary to plan your phone charging, laundry washing, and blender mixing operations between 8AM and 2PM and 6PM and 11PM (assuming the power doesn’t unexpectedly cut this time short). In the US, fingers of physicians and nurses quickly sweep across keyboards to record pertinent patient details; here in Santa Clotilde, the pressure of the tip of a pen glides over a tinted film sandwiched between an original and a carbon-copied document to chronicle a patient’s story. 

Upon first impression, the town of Santa Clotilde may appear to be a stagnant puddle resting on the outskirts of the rushing river of the “constantly progressing" world. A still pool of water overshadowed by the roaring waterfall cast down by the “developed” global reservoirs extending far beyond its reaches. But first impressions can be deceiving. A deeper dive into the still waters of this isolated Amazonian pueblo reveals the clearer reality of a unique and subtle dynamism. Even stagnant puddles boast an immense kinetic energy present in their invisible molecular bonds and cascade-fed pools a strong, hidden undercurrent capable of sweeping even the strongest swimmer into their depths…

Motion takes a different form here in the daily stillness of the Amazon rainforest. I first become aware of this upon awakening each morning. The cyclical passing of time from night to day is announced by the crescendo crow of overeager roosters and the staccato song of their aerial accomplices. Shortly after, I am spurred into motion with Mass at dawn. From the chapel window of our hospital’s convent I see the steadily arching sun rising from the east and the slightly faster current of the Napo River patiently crawling its way down south to meet the Amazon River. Within the chapel walls I hear our hymns and prayers soaring upward to our Creator while, at the same time, I see and feel His real presence coming downward to meet us in the form of bread and wine. After the morning nourishment of the Holy Mass, I make my way to the hospital with a persistent, though often difficult, intention: to share this sustaining bread I have received with others. Depending on the mercurial mood of the tropics, fog rises up, gratefully consumed by a hungry, bottomless atmosphere, or rain plunges down, received with open arms by a thirsty, porous earth. A quick glance into the horizon reveals patients approaching slowly, but surely, as they climb up the hill to register their appointments. Alongside the patients, hospital staff conspicuously clothed in an array of scrubs and Ministry of Health uniforms set a quicker pace, signaling the forthcoming start to the work day.

The day seems to be picking up speed, but only for a moment. Uninhibited, absent-minded motion is shortly overcome with a single-minded stillness as all staff come together in one large circle. It is here that our multidirectional daily motions are united in a unidirectional trajectory originating in the Sign of the Cross, a brief reflection, the Lord’s Prayer, and a prayer to our Holy Mother.

As the day goes on, I am reminded of the stillness that surrounds me here. It is in this stillness that I discover a beautiful, necessary, and carefully designed paradox: motion in the stillness.

I have been in Peru for just over one month now, enough time to witness this paradox in full force. Sometimes the stillness is more difficult to bear and understand and the motion more difficult to see and appreciate. But one thing I know for sure- God is always active, working even if and when we don’t see it…

A child with a swollen abdomen arrives by boat from a community eleven hours away. The doctor orders a stool exam to check for parasites. Through the lens of the microscope, the lab technician recognizes the dormant egg of a round worm named Ascaris. The diagnosis becomes clear, the culprit of the child’s swollen belly a load of mobile parasitic worms. The lab technician gives us more valuable information. The boy also has a condition in which his kidneys are dumping out protein, causing fluid to shift into his tissues; this better explains the swelling around his eyes and in his legs. After two weeks of daily exams and frequent ultrasound evaluations it’s time for him to leave the hospital. Only this time what is usually our quick friendly exchange of a daily high-five turns into a firm grasp of my hand that doesn’t let go. Motion in the stillness.

At the break of dawn the hospital administrator and I set out on a “rapid” boat to evaluate a pregnant woman with bleeding who lives a couple of hours away. When we arrive her bleeding has stopped, but, as Doppler soon communicates to us, so has the heartbeat of her unborn child. The woman accompanies us on the boat ride back to the hospital. Though we are gliding over the water too quickly to make out the various animals swimming in the murky river waters, I feel the stillness that is present in the fruit of her womb. But I need to see it, confirm it with an ultrasound, before we decide the next steps; so, we keep moving. A while later, an ultrasound divulges the secret: the hidden motionlessness of her child’s heart. Motion continues- tears stream down the mother’s face, inadequate words of consolation depart from my mouth, a boat arrives to take her to the city of Iquitos to induce labor where replacement blood is more readily available. In a moment of stillness I recognize God’s guiding hand in it all- the rural health post was getting ready to send her home; had we not been sent that morning, the mother may have suffered from severe infection, bleeding, and possible death. Motion in the stillness.

I am in the outpatient offices when I receive a message that an elderly woman has arrived at the emergency room with severe abdominal pain. I make my way to the ER where the woman is writhing in pain and a gentle touch of her abdomen is met with a rigid jolt. With a sure sign of what health providers call an “acute abdomen” and without any words she tells me to get an X-ray. My US-trained mind secretly wishes for a CT scan, but I know that’s not available here. A quick review of the X-ray by my novice eyes reveals an obstruction of her bowel. We try to arrange transfer to the city for definitive surgical evaluation and management but distance and weather present themselves as a logistical shield to any forward movement. I consult our visiting gastroenterologist from Spain who reviews the still black and white image of her abdomen. Edema, swelling, in the walls of the intestines, he explains, is the X-ray’s way of communicating to us that her bowel is already dead. After a brief moment of hopeless inertia, I soon recognize this encounter as a working blessing in disguise. If it were not for the standstill imposed by inclement weather and transportation limitations as well as the gastroenterologist’s expertise in X-ray interpretation, we likely would have sent the patient out by water plane to Iquitos. In transport, or far away from home, she likely would have died without her family at her bedside, without a spiritual blessing from the priest in her last moments of life. We are able to alleviate her pain and distress with medications, and she passes from this life the next day. Though her body appears lifeless, she lives on in the life of her great-grandchild present at her bedside and with the reconciliation of her soul, she begins her journey along a celestial path. Motion in the stillness.

Just when I think the day can’t get any busier, a mother runs into the emergency room carrying her daughter in her arms. Though I am easily distracted by the abnormally-shaped skull of the infant in front of me, I try to focus my attention on the emergency at hand. The infant suffers from a rare condition called pancraniosynostosis, a result of premature closure of the spaces between her skull bones. The nurse determines the infant has a fever, I quickly recognize the infant is having a seizure, and the mother explains the unresponsive infant has been having abnormal movements for more than thirty minutes. Together we arrive at a diagnosis: complex febrile seizure with status epilepticus. I scramble to determine which anti-seizure medicine and its proper dose to give while the nurse scrambles to place an IV. An injection of anti-seizure and anti-fever medicine into her muscle does nothing. The pediatrician happens to walk by and begins to assist me with additional medication dosing. Only after one hour and three additional doses of anti-seizure medication does her predictable, rhythmic jerking finally come to a relieving halt. Tranquilizing stillness slowly replaces distressing spasm. Only now the stillness brings uncertainty- how will the infant recover from this prolonged cerebral attack? The next morning, the infant is heard joyfully cooing from behind the curtain as her mother gratefully welcomes another day to love her child. Motion in the stillness.

An elderly woman arrives to the emergency room in her wheelchair. She has a history of severe heart failure and an abnormal heart rhythm. As my stethoscope touches he chest the frantic beating of her heart makes me nervous, and I see a similar feeling in her face. She can’t get enough air to speak in a full sentence, but her body gives us enough information to act in full force. We give her some oxygen, try to remove some fluid from her body with medication, and start her on antibiotics for suspected infection. An ultrasound reveals a perpetrator of her heart’s chaotic motion, an unwelcome and dangerous pocket of fluid surrounding her heart. Unfortunately our hospital does not have the medicines to slow her heart down or restore its normal rhythm or the equipment to relieve the fluid around her heart. Her heart continues its solitary race despite the silent protests of its exhausted teammates: her worn out lungs, frugal kidneys, and stiffened blood vessels. I explain to her and her family that we are doing all we can. Her body cooperates just long enough to say, “Thank you, doctor, and God bless you.” With her last words to me, the life-taking motion of her heart moves my heart in a life-giving way. Motion in the stillness.

“The Lord will fight for you, and you have only to be still.” 

- Exodus 14:14

It is common for the power to go out here unexpectedly (like at Mass one evening in the picture above). Fortunately, the light always works its way into the darkness just as His motion works its way into the stillness of our lives.