Archive for the 'Notes from Honduras' category

Notes from Honduras V

Feb 12 2009 Published by under Medical Musings, Notes from Honduras

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip. Part IV is here.
Leaving
Our final evening in Juticalpa saw the reunion of the medical teams that had been sent to the outlying countryside. Our friend Jeremy returned essentially unscathed but with a few stories from the hinterlands. His group was lodged in a small house in a distant village. They bathed with buckets of river water from a basin outside the house, ate as their hosts did, and without electricity, fell into the rhythms of local life. Unfortunately for Jeremy, these rhythms included a two-step to the toilet. His illness thankfully lasted in its severest form for only a day. On one occasion a pick up truck raced up the gravel path to his host's house and two men, guns in their belts, insisted on seeing the gringo doctor who gave their sister a medicine that caused a rash. A local doctor also staying in the house convinced them to turn around and go home.
After washing up, we all assembled for an evening at a local restaurant, and a number of people went later to the local disco, really just a patio along the highway. We were informed that ever since the check-your-gun-at-the-door policy was implemented there had been very little violence. I chose to turn in early.
We had to be on the road at six a.m. to get to Teguz in time to meet the next incoming group. We had only one truck, but we were not burdened by the duffels full of medicine we had brought on our arrival. Six of us piled into the truck bed with our bags, at we headed into the mountains. At this early hour, clouds still clung to the mountains, and we huddled down in the back of the truck to keep warm as we rose into the pine forests.
On our arrival to Teguz we had several hours before our flight to explore the city. Our guide was Ulysses, a young Nicaraguan-Honduran doctor. Both of his parents were also doctors in the city. We stopped briefly at their apartment, a decaying cinder block building on a narrow street. The apartment was well-kept and cozy, and reminded us that our resident's salary back home was probably not so bad. Our morning included a visit to a souvenir shop and lunch at McDonald's. We stepped into the hamburger joint from the hot, crowded street and were greeted by a gust of cool air, and a security guard with a large gun. He smilingly let us pass, and we ate our Big Macs unmolested. Our fellow diners were clearly of the local professional class, with cell phones, pagers, and clean shoes.
At the pace we were going, it was hard to stop and think about the trip we had just ended. As we settled into our seats on the plane, a business man next to me informed me that the only flight worse than the landing in Teguz is the departure, with the plane rising abruptly as the short runway turns into a ravine. As I sat and pondered this, the pilot announced over the loudspeaker that he had met some people in the parking lot who had worked with a group of doctors from Chicago, and they had asked him to say goodbye for them. A warm feeling settled over me, and as I closed my eyes, I felt the plane roll toward the ravine, and jump into the air.
Final Notes
It's been ten years since I went to Honduras, an event which has marked me deeply. It was a difficult time in my life---I was a new intern, I had a sick family member--and I'm sure part of me was looking for escape and adventure (not that the hospital wasn't adventure enough!). I've only read through this a few times, always adding some editing, and I'm not as disappointed with it as I thought I'd be. It's both more and less naive than I'd hoped. Though I'm hardly old, there is something about being young and succumbing to dreams of adventure mixed with altruism. How much good did we really do down there?
We saw many patients with hypertension, but what was the sense in treating them with the one pill we had available? We could only give them a week's supply. I drained an abscess near the eye of a young girl, which I hope made a difference in her life. One man stumbled in after lunch, grabbed our bucket and vomited. I asked if he we a drinker, and the villagers replied, "No, he is a Christian," something which is not exactly contradictory back home. It tuned out he had been spreading pesticide, and forgot to wash his hands before lunch. We had to bribe a man with a pickup truck to take him to the city. I don't know if he survived.
We gave out vitamins like candy, and M and M's like vitamins. What I hope we did bring was a sense that these isolated villagers hadn't been forgotten in the disaster, and perhaps we helped them hang on while the country was rebuilt.
Or maybe not, but I hope that our compassionate motives did the people there even a fraction of the good it did for me. Perhaps some day, when I'm not struggling to raise a family, I'll get back to the Village of the Vultures. Maybe some of the old folks will share their stories of the great floods, and maybe one or two will even remember a few well-meaning Americans who spent a week with them.

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Notes from Honduras IV

Feb 11 2009 Published by under Medical Musings, Notes from Honduras

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip. Part III is here.
After Hours
We returned each night over the route we came, waving to our patients along the way, occasionally stopping to say hello or take a picture of the cloud-shrouded mountains. Our first stop was always the bodega, to drop off our gear and resupply for the next day's work. Afterward, we retreated behind the gate of the Obispado. First usually came a vigorous shower. There was no water at the clinic, so hand washing consisted of rubbing alcohol over our hands after each patient. It was always satisfying to watch the dirt fall to the shower floor and swirl into the drain (probably to return soon from the spigot). The water was always refreshingly cold. After changing, we usually gathered in the lounge to have a beer, compare notes, read up on diseases that we had never heard of but had likely seen, and await dinner. After dinner we would often gather on the balcony over the town square and watch the festivities. The week was both the local regional fair, and the Feast of the Immaculate Conception. All night long, city sounds and roosters assured us a certain level of sleep deprivation.
The first night I spent in Honduras was typical of those to follow. I fell asleep quite deeply. At about two a.m. I was awakened by a rude clanking, presumably someone moving tin trash cans on the street below. It soon became apparent that these harsh tones broke into my room every fifteen minutes, mas o menos. My somnolent mind finally decided that this must be the sound of the bells in the clock tower of the church. When I politely inquired about this the next morning I was told that local legend proclaims the bell to be none other than that of Christopher Columbus, who visited the shores of Honduras after his first trip to this hemisphere. A more cynical doctor informed me that the bell sounds just like every other bell in Central America. Columbus had apparently brought many such heavy bells inland across the great isthmus.
After adjusting to the sound of the bells (mostly by the insertion of foam plugs in my ears) I began to sleep soundly again. Suddenly an explosion woke me, my heart pounding. It was quickly followed by several more. My first thought was that the men we saw all over towns with guns in their belts were firing into the air. A glance out the window revealed it to be fireworks launched from the hands of young men in the square. As they died down and I began to drift back to sleep, a trumpet's call pierced the air, followed by the brass chorus of the mariachi. I gave up my sleep and sat on the balcony to watch, ducking from the occasional errant rocket. I later read in a national newspaper that fireworks injuries were a major cause of traumatic amputation in the capital.
A Side Trip
On one particularly efficient day, we ended our work a bit early and made a trip to the city of Catacamas. We had been wanting to go, but it is important not to travel after dark, as driving in Honduras is in the best of circumstances a lesson in fear. Our destination was the Escuela Los Sembradores, a religious community founded by a couple from Iowa and known for its mahogany carvings. On the way we of course had to cross a river. To our left as we approached the river were sheer mountains through which the river had cut a narrow canyon; to our right, the path of destruction the river left when the rain flowed off the mountains. Standing in the wreckage were campesinos with their machetes and axes harvesting firewood from the massive uprooted trees. After a few minutes of driving through the flood-path, we arrived at the bridge. This one had collapsed into the middle of the river, and the local people in their usual resourceful way used the initial collapsed segment as a ramp onto the new gravel-fill span. We waited for a few brightly colored trucks to pass, then crossed, rejoining the main highway.
After passing through town we turned onto a dirt road, unremarkable except for its bone-jarring ruggedness. Up ahead we saw a crowd of birds, some on fence posts, some fighting, and as we approached it was clear from their greasy-black wings and bald heads that they were vultures. As we approached, some of the more timid birds drew back, revealing the corpse of a chestnut brown horse. A thin dog rooted through the open belly of the animal, tearing at entrails. The birds concentrated their efforts on the head. They looked up at us irreverently as we passed and went back to their meal. We passed three similar scenes before the turnoff. Turning in, the road smoothed and the fields became well-tended. Up ahead we could see a close-cropped soccer field, a small Spanish colonial style church, and some buildings with very well kept lawns. We were met, most improbably by an elderly woman who spoke in flat, Midwestern vowels, and offered to open the showroom so that we could purchase our souvenirs. This we did, and at criminally low Honduran prices.
On the trip back, we stopped at a roadside stand run by some friends of Flavio, our driver and guide. We were convinced that Flavio was acquainted with everyone in Olancho, as we rarely drove more than a mile before he slowed to exchange a greeting with passers-by. At the roadside stand, a family crushed sugar cane and served the juice, kept cold by a cooler set in ice. The liquid was murky green, eerily reminiscent of the wheat grass juice sold in American health food stores. They handed us plastic bags full of the fluid, and a straw. To drink it was pure heaven after a hot day of work and travel.
Next: Leaving

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Notes from Honduras III

Feb 10 2009 Published by under Medical Musings, Notes from Honduras

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip. Part II is here.
Zopilotepe; the Clinic
We loaded our supplies and our tired but excited selves into a jeep and headed out to the highway. Shortly after leaving town we turned down an unremarkable dirt road that threaded through bean and corn fields. The rough-hewn wooden fences were covered with purple and pink morning glories. As we wound down the road our elevation dropped slowly and we were gradually surrounded by more and more red mud, uprooted trees, tractors, and other wreckage that indicated we were nearing a river. After about a mile of wasteland the river appeared, with red, fast-running waters and a gravely shore. Trucks lined the river as some people bathed and others sifted gravel, selling it for repairing roads and bridges, and using the discarded sand to make cinder blocks to rebuild houses.
We crossed the narrow span of the recently-built bridge and a young man stood collecting tolls at the other end. We refused to pay the five limpira toll until a few days later when the young men laughingly offered to destroy our tires with machetes if we continued our deadbeat ways. In a country where everyone carries a gun, we felt we got off easy.
The next river we crossed was shallow enough to drive through. We shared the crossing with cattle and young men drinking and cooling off in the waters. Several large grain trucks were stuck in the mud on either side, but our jeep climbed the bank easily. The road began next to wind though villages of rough shacks with pigs, roosters, and banana trees in their yards. People came out and stared as we drove by. Passing ox-carts and young boys with machetes heading out to the fields on horseback, we came to our last river crossing, five logs thrown across a ravine with gravel fill in the interstices. Each day the bridge looked just a little bit smaller.
After turning down a few more small dirt roads, we came across a few houses along the road surrounded by fields, and a white concrete building with crowds of people milling around the yard, some having set up food stalls, mothers combing children's hair, dogs and chickens wandering between legs. People moved aside (slowly) as we pulled up and unloaded our gear into the local health clinic. The building had three rooms; a large anteroom and two small clinic rooms. It also had a bathroom whose toilet was flushed by pouring in a bucket of river water at the end of the day. No running water was available, and the water that was available was quite unreliable. I am still not sure if we had electricity.
We had no idea what to expect, but from the look of the crowd already gathered, it was clear that we would be busy. Fifty percent of the Honduran population is under fifteen years old, so it was no surprise to us that many of our future patients standing in the yard were children. We had been trained very well to treat adult patients in the US. Without a thought, any of us at home would order a CT scan for a dizzy elderly woman, or an EKG for a grandfather with chest pain. Here our patients were mostly kids, and our laboratory was our hands and our stethoscopes. It took about an hour for us to organize into a system that worked. Interestingly, all the groups that went out ended up organizing along very similar lines. Kim Marie became our pharmacist. Meghan was nurse and translator, Ty the physician in the main exam room/pharmacy. I set up a second consultation/exam room in the next room with my interpreter. Magda spoke perfect Spanish. My English was more than adequate. Unfortunately neither of us was bilingual. In between patients, however, we conjugated verbs and compared adjectives until we developed a system of communicating rather effectively.
Most of the people came in for unremarkable problems: headaches, backaches, diarrhea, heartburn. Unfortunately, the closest pharmacy was in Juticalpa, until recently unreachable, and in the best of times about a four hour ride by ox-cart, two hours on horseback. We dispensed a lot of Tylenol and aspirin.
Many patients came in complaining of parasites. It took us quite a while to learn how to best approach the problem. At first I took detailed histories, inquiring how their food was prepared, if they owned livestock, used clean water, without getting closer to actually diagnosing a problem. Finally, a mother came in complaining that her child had worms around his anus. I put him up on the table, pulled down his shorts, and sure enough, there was the little white Enterobius worm squirming away. I began to itch. From then on I took their word for it. It was just a matter of learning the village lingo (which we probably got wrong) and finding out whether they had the little white worms (bichas) or the long reddish worms (lumbrices; Ascarias).
Interestingly, we had a number of people come in complaining of enuresis (bed-wetting) and insomnia. My first thought was that it was a response to the stress of disaster. However, I was reading up on worms the next night and found that both are very common symptoms of pinworms (bichas). From then on we treated both problems with our standard Mebendazole de-worming regimen.
Our tools were very simple out of necessity. We knew intellectually that 80 percent of diagnosis should come from the history and physical, but here we were practicing it. In fact, most of out diagnosis was based on history. My hematocrit was a glance at the conjunctivae. At no extra cost, I could simultaneously look at the sclerae to assess the bilirubin. If a woman gave a good history for it, we treated her and her husband for Trichomonas infection without the benefit of a microscope. Urinalysis was replaced by very careful questioning. Thick and thin blood smears for malaria were replaced by "┬┐Tiene malaria?"
Flavio, our driver, was supposed to have been our guide for the first day, just until we learned the way to the clinic. His talent was too useful to give up, so we recruited him to be clinic manager. In addition to registering people and giving them numbers, he would seek out the very sick ones and bring them to the front. We saw between 150-200 patients per day. On the first or second day, he came running in with a eight or nine year old child with a piece of cloth tied around his foot. I took off the soiled cloth, revealing a four inch machete wound, with deep subcutaneous tissue dehiscing through the irregular gash. I cleaned the would and attempted to anesthetize it with lidocaine, but it became apparent that with the materials I had on hand I would not be able to suture it well enough. I stopped the bleeding, dressed it, gave him a tetanus shot, and sent him into the city.
Fungal infections were universal. Tinea versicolor, which causes white patches on the otherwise sun-darkened skin of the campesinos, was the most common, followed closely by tinea pedis (athlete's foot). One grizzled man in a cowboy hat came in complaining of a foot fungus. He removed his shoe revealing a large violet-colored patch covering his toes. My first thought was to turn to my Tropical Medicine text to find out what horrible creeping crud causes the foot to turn purple. Then my interpreter explained to me that this was the folk remedy for tinea; paint the foot with violet dye.
The extent of an illness depended largely on the level of poverty of the patient. Most showed up in their Sunday best, the little girls in beautiful dresses, the boys with clean shirts and hair combed. However some were too poor for even that. A mother brought in her child because of foot fungus. I brushed away the dirt covering her foot and found large open wounds teeming with small flies. I asked her if she had shoes and she stared at the floor shaking her head "no". I gave her soap and antifungal cream, but in my heart I knew that before long, maggots would begin to debride the wound.
Our patients were universally welcoming and kind. One brought me a bag of oranges, which in Honduras should really be called "greens", but their flavor is quite good. Each of the six oranges had been carefully peeled and the tops sliced for easy eating.
A note on food: our host, the bishop, insisted as noted above, on having traditional American food. The cook at the church made us sandwiches of ham and American cheese for lunch every day. Flavio overheard us express the desire to eat some more indigenous food, and made some inquiries. The second morning of clinic a plate arrived on my desk with two thick, potato-filled flautas garnished with fresh cabbage, salsa, and queso fresco. I greedily devoured the warm, crisp tortillas, then moved in on the cabbage. It was as I was taking the last bite of cabbage that I realized that I was eating the same cabbage, in the same village, watered by the same river, and picked by the same hands as the people who came to me complaining of parasitas. I dropped the plate and somewhat irrationally ingested a gram of Mebendazole. This was only the first of my dietary indiscretions. After the first day at the clinic, Flavio ensured that we were supplied with generous portions of (well-cooked) red beans, rice, cheese, and corn tortillas for lunch. We later realized that all the various versions of queso fresco that we had been enjoying were made from unpasteurized milk. After that initial shock I took a real chance and started to brush my teeth with tap water. Fortunately, after 600 patients I am quite familiar with the remedies for the various creeping nasties that may cause me future distress.
While we enjoyed the novelty of beans and rice at lunch, Magda, our translator, made it known through subtle expressions that she missed the ham and cheese sandwiches. It turned out that she eats the same dish every day, three meals a day. It is always prepared the same way, without change in spices, presentation, or ingredients. It seemed only humane after that to leave her to her sandwich while we enjoyed our Honduran lunch.
Next: After Hours...

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Notes from Honduras II

Feb 09 2009 Published by under Medical Musings, Notes from Honduras

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is part II of my diary from the trip. Part I is here.
To Juticalpa
As we left Teguz, we crossed one more bridge and began to climb into the hills that surround the high valley in which rests the city. Thin dogs wandered along the roadside sniffing at the animal skulls lining the road. Women and children crowded into ravines to wash clothes in the river which was both life and death for the people. We stopped briefly at a bakery for a snack and some Cokes and got on the highway for Juticalpa, and oddly normal act in this profoundly odd environment.
The road is one of the best in the country, and one of the few paved roads outside the main cities. As the road winds into the mountains, the air becomes cooler and fresher. We could see ahead the unusual mountains that dominate the geography of Honduras. It looks much like Napa or Sonoma in northern California. The mountains are low and steep, and crowd together as if vying for space in this small country. Pine trees and clouds cling to the hillsides, which are dotted by mud shacks with red-tiled roofs. Cattle and horses graze lazily. As we enjoyed the scenery, we came abruptly upon a line of rocks across the road indicating a detour. The river had washed away a bridge ahead.
To digress briefly, the most damage from the Hurricane came not from devastating winds or sudden violent storms, but from the long, steady rain that continued for a week as Mitch poured the warm Caribbean water onto the loose soil of the mountains. Water poured down the sides of the mountains and found the beds of the normally tranquil rivers. The rivers rose quite suddenly. The mountain people and campesinos are experts at reading the rivers and moved to high ground as the rain fell. The city dwellers had no such knowledge and died in large numbers as flood waters carried them away in their homes and the mud entombed them. Many of the health problems related to the storm stemmed from contamination of the water, and the isolation of communities by the destruction of bridges. There are very few areas that can be reached without river crossings.
I had long since climbed from the bed of the truck and into the cab with my driver Rolando. He spoke only Spanish, and I only English, but we conversed a reasonable amount. We turned onto the dirt track that served as the detour and crossed the river on a makeshift bridge that had been finished only a few days before. It was very rough, but afterward we rejoined the main paved road to Olancho. About 2 hours later, we rode into Juticalpa as the sun was setting.
Juticalpa is a small city and is the capital of a large cattle and farming region. Like many Latin American cities it has a main square and a large church. We pulled up to the church and Obispado (Bishop's residence) and unloaded our gear. The Obispado is about 50 years old and built in the old Spanish Colonial style, an inner courtyard lined with an esplanade from which one enters the individual rooms. The Obispo himself is an Irish American from Boston, a very congenial and hospitable man. The cooks keep him fed with pretty traditional American meat and potatoes, so we sat down every night to unremarkable fare, although one night we had some traditional smoked ham from Olancho, and another night we had a traditional Honduran chicken soup. We were very well cared for. The rooms off of the courtyard were simple and comfortable, with two cold water showers, one each for the men and the women. There was also a lounge with a well-stocked fridge and liquor cabinet and satellite TV where we could gather and share beer and stories.
There were a remarkable variety of people down there to take part in relief efforts: EMTs, nurses, doctors, most of them very enjoyable people to spend time with. We were all divided into teams and given assignments for the week. My "go" team included Ty, Kim Marie, a nurse from Nashua, and Magda, a young woman from Juticalpa who would serve as our interpreter. Magda was clearly from one of the wealthier families in town; she attended the English School, wore American-style clothes, and lived in a neighborhood with cobbled streets instead of dirt tracks. She lived with about 9 siblings and their families. There was much confusion among our group as to here actual first name; it was unclear whether is was "Magda" or "Mauda". As it turned out, her mother had named her "Magda", but it had been written incorrectly on her birth certificate as "Mauda". Her family could not afford the fee to make the official change.
That evening we went to the bodega where the supplies were stored, pooled our resources, and put together supplies for the next day. Our group would be heading out to the village of Zopilotepe ("Village of the Vulture"), the bridge to which had been rebuilt about three days prior to our arrival. No one had been out there yet, and we did not know what to expect. During our briefing we were informed that we would be serving as public health officials. Normally, Honduran medical students spend a year of service after graduation in the outlying clinics, but this year had seen a very small graduating class, an unfortunate coincidence in this time of need. The Bishop had offered up our services to the health department as fill-ins. It was not well know what the road conditions would be, so we rose quite early the next morning to set out to our assignment.
Next, Zopilotepe; the Clinic

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Notes from Honduras I

Feb 08 2009 Published by under Medical Musings, Notes from Honduras

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip.
Beginning
The idea to go to Honduras came about in a way that may or may not be unusual. I have no way to judge, never having done it before. I had of course heard of the disaster of Hurricane Mitch. As I listened every day on the radio, I thought about all of the potential deaths that could be avoided by simple medical care. One day on NPR they were interviewing the Episcopal Bishop in Honduras. He was asked what he tells the faithful about what happened. Paraphrasing, "It is OK to be angry with God," he replied, then tearfully, "I am angry with God, but I know that things must come out for the best. It must. The people suffer so much, so many have been lost. I am so angry with God, but I know we can move on and continue life and faith."
I am not a man of faith, but to hear a man of such deep faith in so much pain, to hear him try to explain to the faithful why they must repeat the trial of Job, this affected me very deeply. The idea came to me the same way as the idea to go to medical school. It was something I wanted to do and I would make it happen.
As it turns out, it is not easy to put together something like this. Support is not the problem. Everyone wants to support missions such as this. But to take raw enthusiasm and puzzle out how to create something useful, this is the challenge. I called the Honduran consulate, the major aid organizations, finally my rabbi. Among other things, he gave me the name of a Vincentian friar at DePaul with connections to some of the Catholic aid organizations. He in turn gave me the name of Dr. Don Mehan of the Catholic Medical Association. Dr. Mehan runs a surgical program in Honduras but had converted his infrastructure for medical disaster relief. With an infrastructure already in place, I knew I had the number for the right person. Rabbi Gordon informed me that funding was unlikely to be a problem, so I recruited a team and we went.
To Honduras
My team assembled itself. Ty G. and Jeremy S., residents in Internal Medicine at Northwestern, and Kim Marie M., an all-around nurse from Marengo, IL, who had heard about the trip from her sister, a member of my congregation. We met at O'Hare's international check-in at 4 am on December 6. The flight was uneventful until the landing. Kim Marie, who had been to Honduras before, described in detail the landing we would experience in Tegucigalpa ("Teguz"). Her memory was very accurate. Approaching the airport the plane descended sharply, banked steeply with the wingtip visible barely 80 feet above the ground. We slipped between the mountains sideways and dropped immediately to the runway, braking violently. Despite her warning, I walked out of the plane and into the heat already covered in a cold sweat.
We stepped out of the plane onto the tarmac and walked into the shack that serves as the arrival area in Teguz. The air was mild, dry, and clear with a nice view of the small mountains that we had just slipped though. We were met at the airport by Monsignor Muldoon, the bright-faced and boisterous Bishop of Olancho, and his crew from the Caritas organization. They whisked us and a group from Boston through customs and immigration and loaded us into pickup trucks for the ride to Juticalpa, capital of Olancho, the largest department in Honduras. The younger of us were instructed to ride in the back of the trucks with our supplies so that in the crowded, poor streets of this partially devastated city we would not have anything stolen.
We were driven down to the river district to view the extent of destruction in this 300 year old mining town. The city's crowded streets looked reasonably normal until we approached the river. Beginning about a half a kilometer before the river is the mud. It had been about a month since the Hurricane and the mud had hardened into the same local cement that we would see children making into cinder blocks a few days later. Pompeii must have looked somewhat like this, had anyone survived to see it. Buildings and cars, and probably people, were entombed in the hard, red cement. In some places, cars and houses formed grotesque chimeras, permanently joined in unnatural-looking ways. Uprooted trees rested against half destroyed buildings. I was impressed by the destruction, but this could also have passed for any decaying warehouse district in the US. In the nearly deserted flood path, the human element was missing.
We crossed the river and rode up to a bluff above it to get a better look at the extent of the horror. From our vantage point the Bishop showed us the kilometer-wide swath the river had cut through the city at two in the morning. Buildings were sheared in half, cars piled against anything harder than them. It must have been terrifying. I pictured families crowded into small apartments, awakened by the roar of mud, having heard rumors passed from door to door about the rising river, not believing that this time it would mean their lives.
Descending into the city again, we passed down toward the river, the crowds growing as we neared one of the few remaining intact bridges. At its base was an ancient church whose foundation was severely eroded, with a car rudely molded to its medieval-appearing walls. And here, the human element. People were crossing the bridge slowly on foot and by car, tired-looking young women with baskets of food on their heads, young men with machetes carrying torn pieces of metal for salvage. As we inched onto the remaining causeway, the river slowly passed under us, its red surface visibly teeming with insects. Many pedestrians held cloths over their faces. My first rather unfortunate instinct was to inhale deeply. The smell of sewage and death was overwhelming. My camping and travel experience had taught me that a bandana is always useful, so I took one from my back pocket and brought it to my nose and mouth, inhaling the sweet scent of laundry detergent, wondering if the pedestrians saw me as a weak gringo arriving to document, perhaps exploit, their misfortune. On the other side of the river the water line was visible on the shops and homes, and the power lines were caked with detritus of the flood, but shopkeepers set out carts before ruined store fronts and the business of daily life continued.
Next: to Juticalpa...

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