Uphill

online at dartmed.dartmouth.edu—Dartmouth Medicine 27Winter 200926 Dartmouth Medicine—online at dartmed.dartmouth.edu Winter 2009

enjamin Jastrzembski is searching thestreets and shops of Bonanza, a gold-min-ing town in northeastern Nicaragua, for the

perfect piece of scrap metal. He spots a stainlesssteel bowl on a blanket laid out in front of a smallshop. “That might work,” he muses as he pays forthe bowl.Jastrzembski, a 2008 graduate of Dartmouth Col-

lege, sometimes wonders what local residents thinkhe’s up to when they see him carrying around potsor pans or random bits of metal. Sometimes even hewonders what, exactly, he’s doing. But then he’ll bereminded of the difference that a few dollars’ worthof materials can make in this impoverished ruralcommunity.In Bonanza, as well as many other towns in this

part of Nicaragua, thousands of people make theirliving from small-scale, or artisanal, mining. Thework is difficult, to say the least. Miners use picksand shovels, and sometimes dynamite, to extractore from the hillsides above the town. Then they load the ore into bags and bring it to

local processors, where the ore is ground into acoarse mixture. That mixture is combined withmercury, which binds to gold, creating a mercury-gold amalgam that is much easier to collect thantiny flakes of gold alone. The miners take thatamalgam and heat it—often over an open flame ora blowtorch—releasing the mercury as vapor andleaving behind the gold.Sometimes, Jastrzembski says, the process is car-

Toxic pollution from

small-scale gold-mining.

Indiscriminate use of an

antibiotic that can lead to

hearing loss. Scarce or

nonexistent health-care

resources. Those are a few

of the problems that are

drawing more and more

people with Dartmouth

ties down to Nicaragua.

Amos Esty is the managing editor of Dartmouth Medicine.Thanks to financial support from Dartmouth’s Dickey Center forInternational Understanding, he was able to travel to Nicaraguain July 2009 to do on-site reporting and photography for this arti-cle (he took all the photos, unless they are credited otherwise).

Bonanza, Nicaragua, is scenic but remoteand impoverished. Most residents areinvolved in some way with artisanal gold-mining—difficult and dangerous work.

B

An

BattleBy Amos Esty

For a with more photos ofNicaragua, plus several short videos, see dartmed. dartmouth.edu/w09/we08.

WEB EXTRA

online at dartmed.dartmouth.edu—Dartmouth Medicine 29Winter 2009

income of only about $1,000, Nicaragua is one ofthe poorest nations in the Western Hemisphere.And Bonanza is isolated geographically, so anyitems not locally made are expensive. It’s about a12-hour bus ride over bumpy roads from Managua,the nation’s capital. It’s possible to fly to the more-populated Pacific coast, but at almost $150, a planeticket is out of reach for nearly all local residents. Jastrzembski’s work as an ad-hoc mining engi-

neer was an outcome of his 10-month stay inNicaragua on a Fulbright grant. From the fall of2008, just after his graduation from Dartmouth,through the summer of 2009, Jastrzembski lived inSiuna, a mining town just south of Bonanza. Hespent the year interviewing artisanal miners andlearning how the process works. Along the way, heidentified the need for retorts.By the time Jastrzembski applied for the Ful-

bright, during his senior year, he was already quitefamiliar with northeastern Nicaragua. He had madehis first trip to the region in 2005, when he was asophomore, as a member of a service trip led everyyear by Dartmouth’s Tucker Foundation. The par-ticipants—including undergraduates, medical stu-dents, and faculty members from both the MedicalSchool and the College—travel to the rural regionto provide medical services, run public-healthworkshops, and organize various other projects.Jastrzembski returned on the Tucker Foundation

trip each of the next two years, serving as the stu-dent director of the program during his senior year.In 2007, he was awarded the Dean of the CollegeAward for Service for his commitment to Siuna—which included, among other projects, organizingan exchange that brought six Nicaraguan universi-ty students to Dartmouth for two weeks.

n the summer of 2008, shortly before startinghis Fulbright Fellowship, Jastrzembski metJames Saunders, M.D., a DMS otolaryngolo-

gist who, like Jastrzembski, has a longtime interestin Nicaragua. In 1999, Saunders helped found anonprofit organization that provides hearing-relat-ed health services in the rural town of Jinotega innorthwestern Nicaragua. When Saunders heardabout Jastrzembski’s upcoming trip, he wondered ifthe two might be able to collaborate.With help from other members of the Dart-

mouth community, Saunders and Jastrzembski be-gan to plan a research project to investigate the ef-fects of mercury on hearing loss among artisanalminers in Bonanza. Margaret Karagas, Ph.D., aDMS professor of community and family medicinewho specializes in studying toxic metals, helped de-sign the project. Several years ago, Karagas and Car-ol Folt, Ph.D., a professor of biological sciences at

Dartmouth as well as dean of the faculty and actingprovost, advised another Dartmouth student, JoelWickre ’03, who was doing a study of mercury ex-posure in Siuna. The current project, Karagas says,“is sort of the natural follow-up.”The most dangerous form of mercury is methyl -

mercury, which is created when elemental mercuryis released into the environment and taken up bybacteria or by animal species low on the food chain.As methylmercury makes its way up the food chain,it becomes increasingly concentrated—and increas-ingly dangerous. In many countries, including the U.S., the main

source of methylmercury exposure is through theconsumption of fish. But Bonanza residents, eventhough they eat little fish, may suffer from the ef-fects of chronic exposure to low levels of elementalmercury in the environment. Karagas explains thatit’s hard to know exactly what the effects of such ex-posures might be. “There are lots of questions we donot have answers to, especially at low levels,” shesays. “That’s why we’re doing the research.”

With help from others

at Dartmouth, DMS

otolaryngologist

James Saunders and

Jastrzembski began

to plan a research

project to investigate

the effects of mercury

on hearing loss among

artisanal miners.

Winter 2009

ried out in the presence of children or pregnantwomen—two populations particularly vulnerableto the neurotoxic effects of mercury (which is bothcheap and readily available in Nicaragua, unlike inthe U.S., where it is highly regulated). Once, Jas-trzembski even saw a man burning amalgam in-doors, over a kitchen stove.Roughly a quarter of the world’s gold production

comes from artisanal mining. Mercury is almost al-ways used by artisanal miners to help recover thegold, and most of that mercury ends up in the en-vironment. By one estimate, for every ounce of goldproduced by artisanal mining, two to five ounces ofmercury are released. In Nicaragua, that adds up to a lot of mercury

contamination. The country is the leading gold-producing nation in Central America, with morethan 500,000 ounces—over 15 tons—producedeach year. It’s hard to know exactly how much ofthat comes from artisanal mining (rather than fromindustrial mining, which typically does not involvethe use of mercury), but it’s a significant portion.That explains Jastrzembski’s growing collection

of scrap metal. He hopes to build a device called aretort that can be used during the heating of theamalgam to trap the mercury vapor, preventing it

from making its way into the environment and thelungs of local residents. “It’s unrealistic to ask peo-ple to not do artisanal mining,” he says, “and itmight even be unrealistic to ask people not to usemercury. The most important thing I think we cando is encourage the use of retorts.”The difficulty is in finding usable materials that

are locally available and cheap—conditions thatare essential but hard to meet. With a per capita

28 Dartmouth Medicine—online at dartmed.dartmouth.edu

By the time Ben

Jastrzembski applied

for the Fulbright,

during his senior year

at Dartmouth, he was

already quite familiar

with northeastern

Nicaragua. He had

made his first trip to

the region in 2005.

Artisanal gold mining starts with extraction of the oreby hand, below. Then the ore is hauled down from thehills to be crushed. Above, Jastrzembski (left) asks twolocal miners for feedback on a retort he’s built, whilethey run their crusher—a machine known as a molino.

Despite its dangers, mining is oftena family business. At left is such afamily, and above is their crushingmachine, an arastra, which uses adifferent technology than a molino.

I

online at dartmed.dartmouth.edu—Dartmouth Medicine 31Winter 2009

levels among the miners. The testing is now underway in the DMS Trace Elements Lab, and the re-sults will show whether the mercury used in mininghas made its way into the miners’ bodies.Eventually, the Dartmouth team hopes these

samples and the results of the hearing tests will helpthem determine how widespread hearing loss isamong miners in Bonanza, and whether exposure tomercury might be a contributing factor.This project is just one of many that Saunders is

working on, in an effort to unravel the causes ofhearing loss in Nicaragua—and to do something tohelp those with impaired hearing. He made his firsttrip to Nicaragua in 1998 on a medical mission or-ganized by a woman who attended his church. Atthe time, he lived in Oklahoma City and was on thefaculty at the University of Oklahoma. He and theother volunteers on that trip spent time in severaltowns, but Saunders found himself particularly tak-en by Jinotega, a city of about 50,000 that sits in themountains north of Managua. Unlike in much ofNicaragua, temperatures in Jinotega remain rela-tively mild, often climbing only into the 70s duringthe day and cooling down into the 50s at night.The lush green hills surrounding the town made adeep impression on Saunders. “It’s one of the mostbeautiful places I’ve ever been,” he says.

fter that trip, Saunders began talking withfellow volunteer Mark Falk about estab-lishing a permanent project in Jinotega.

They returned to the area the next year and spenta week there. Saunders brought an audiometer withhim to measure hearing loss in the patients hewould see.“I was expecting to see a lot of ear infections—

and there are a lot of ear infections—but what I wassurprised by was how many kids had hearing loss[but] didn’t really have ear infections,” he says. Thefinding concerned and intrigued Saunders andlaunched him on a quest to figure out the causes ofsuch widespread hearing loss. To start with, he and Falk set up a nonprofit

called Mayflower Medical Outreach to provide oto-laryngology clinics in Jinotega. In the years since,the organization has stretched the scope of its orig-inal mission in order to tackle problems underlyingthe need for hearing-related health services. “Wewent in thinking we were going to treat ear infec-tions, so we got the things we needed . . . to treatear infections,” Saunders says. “Then we realized,‘Gosh, there’s a lot of hearing loss here, so we needhearing aids.’ . . . Then we realized, ‘Well, wait aminute, these kids with hearing aids, we’re sendingthem home with hearing aids and they’ve got noeducational support, so we need to look at the

school. What do we need to do to support theschools?’” Over time, he says, “you just keep gettingdeeper and deeper into the problem.”Every summer, the organization brings a number

of volunteers to Nicaragua. In July 2009, 26 volun-teers joined the trip, including surgeons, medicalstudents, and nurses, plus a number of nonmedicalvolunteers. Together, they provide services thatwould otherwise be totally inaccessible to manyNicaraguans.The 2009 trip illustrates how deeply Saunders

has become involved in Nicaragua. On the day theMayflower team flies into Managua, a Saturday,Saunders spends part of the afternoon talking toDaysi Enriquez, M.D., a Nicaraguan otolaryngolo-gist who has worked with Mayflower for severalyears, about how to divide up the volunteers amongthe various projects.Most spend the week in Jinotega, providing

hearing aids, performing surgeries, or finishing uprenovating and painting a boarding school that ishome to a number of deaf children. Some head forChinandega, a town west of Jinotega, to performsurgeries. And a few of the volunteers stay in Man-agua for the first few days, working in a temporaryaudiology clinic and performing surgeries.While Saunders escorts the group that heads for

Jinotega on Saturday evening, the volunteers stay-ing in Managua set up shop at the city’s Lenin Fon-seca Hospital. The team—which includes physi-cians, a medical student, a nurse, and a techni-cian—spends several days operating on patientswith the help of Nicaraguan nurses and physicians.One volunteer, David Molter, M.D., is a veteran of

David Molter (left), a surgeon atWashington University who hasjoined several of Saunders’s trips,operates here with assistance froma Nicaraguan surgery resident.

Winter 2009

Mercury is known to be a powerful neurotoxin,and in a study of artisanal gold mining in Venezuela,the United Nations found that about a quarter ofminers and their family members in one rural re-gion exhibited signs of neurological damage frommercury exposure. Such damage often takes theform of impaired cognitive function, includingproblems with vision, memory, and muscle coordi-nation. And although the effects of mercury onhearing loss in humans remain undetermined, astudy in monkeys found that animals exposed inutero to methylmercury exhibited more hearing lossas they aged than did unexposed monkeys.To examine the possible effects of mercury on

miners’ hearing, Jastrzembski returned to Bonanzain October. On this trip, he brought with him acomputer program developed several years ago byJay Buckey, M.D., a DMS professor of medicine anda former astronaut. Jastrzembski used the program,which was designed to assess astronauts’ hearingduring space expeditions, to test the hearing of min-ers in and around Bonanza.

The program is as well suited for use in ruralNicaragua as in outer space. It runs on a laptop andrequires only a small probe fitted with speakers plusa microphone. The program includes three differ-

ent tests: one that measures the functioning of theinner ear; a second that gets an overall assessmentof hearing; and a third that gauges the brain’s abil-ity to process sound. Using the three tests, Buckeysays, provides a fairly comprehensive picture of aperson’s hearing. On this recent trip, Jastrzembski also took fin-

gernail samples that will be used to test mercury

30 Dartmouth Medicine—online at dartmed.dartmouth.edu

The Dartmouth team

hopes the fingernail

samples and the

results of the hearing

tests will help them

determine how

widespread hearing

loss is among miners

in Bonanza, and

whether exposure to

mercury might be a

contributing factor.

In July 2009,

26 volunteers joined

the trip, including

surgeons, medical

students, and nurses,

plus a number of

nonmedical volunteers.

Together, they provide

services that would

otherwise be totally

inaccessible to

many Nicaraguans.

Above, James Saunders (left) chats with a colleaguebetween cases at DHMC, shortly after his return fromNicaragua. Below, Jay Buckey demonstrates a laptop-based program that he helped to develop and that hasbeen used to test the hearing of Nicaraguan miners.

JON GILBERT FOX

A

online at dartmed.dartmouth.edu—Dartmouth Medicine 33Winter 2009

she and another Mayflower volunteer, Debra Fried,Au.D., an audiologist from New York City, doublethe number of practicing audiologists in the entirecountry.One of Gudlewski’s first patients is a nine-year-

old girl who is blind in addition to suffering fromchronic ear infections that are causing hearing loss.When Gudlewski begins the examination, the girlstarts to scream. Her mother explains that a localprovider had tried to fit the girl for a hearing aid,but the process had been intensely painful; obvi-ously, the girl remembers the earlier encounter.The problem, Gudlewski later explains, was

probably with the use of the material used to makea mold for a hearing aid. In order to make a moldof a patient’s ear, Gudlewski uses a material thatlooks like Silly Putty. It is inserted into the ear,where it hardens to the exact shape of that individ-ual’s ear canal. “When you’re doing an ear mold im-pression, you want to make sure that it doesn’t stickto the eardrum because that is painful,” Gudlewskisays. “So you put in what’s called an otoblock. Thatmakes sure the material doesn’t get to the eardrum.”She thinks what probably happened to the girl isthat some of the material seeped around the oto-block and hardened against her eardrum. When theimpression was pulled out, it stuck to her eardrum,causing intense pain.This year, Gudlewski says, the Mayflower team

is equipped with materials that allow her to makeinstant hearing aids. Previously, she would havetaken an impression, which would be brought backto the U.S., where the hearing aid would actuallybe made. But then the hearing aid had to be sentback to Nicaragua, requiring the patient to returnto the clinic to pick it up. In the past, Gudlew skisays, some patients have not shown up to get theirhearing aids. Using the instant materials allows herto ensure that people get the help they need.Before long, Gudlewski has an instant hearing

aid ready for the young girl. When she’s done, sheasks the mother to bring her daughter back later inthe week so that Gudlewski can make sure the hear-ing aid is set properly.By Wednesday, when they return for the check-

up, the girl’s mood is dramatically improved.Gudlewski has her sit in the sound booth for a hear-ing test. When she is sure she has heard a signal, thegirl shoots her arm into the air. When she is lesssure, she lifts it slowly and waves her hand. Eitherway, she smiles as she responds.When the test is over, Gudlewski gives the girl

a lollipop. “Thank you,” the girl says in English.Her mother thanks Gudlewski repeatedly, hug-ging her before they depart. “Hasta pronto,” the girlsays as she goes out the door. “See you soon.”

Meanwhile, Saunders has spent several days inJinotega, performing surgeries to fix chronic earproblems and continuing to study the underlyingcauses of hearing loss in the region. He has spent alot of time since his first visit a decade ago trying topiece together the mystery of the widespread hear-ing loss he has found there.

everal years ago, Saunders put some numbersbehind what he knew was a significant prob-lem. In a study of schoolchildren in and

around Jinotega, he found that 18% of them exhib-ited significant but previously undiagnosed hearingloss. In the U.S., by comparison, only about 3% ofchildren have hearing loss. And Saunders believesthe prevalence of the problem in Nicaragua may beeven higher than 18%, because children who havesevere to profound hearing loss may not attendschool.He also determined that many of these children

came from families with a history of hearing loss.But in genetic tests, Saunders found that the muta-tions usually responsible for hearing loss in theUnited States were not to blame in Nicaragua. Nota single child had either of two mutations commonin the U.S. among people with hearing loss.During this year’s visit to Jinotega, Saunders met

with members of a local family that he hopes mayhelp tease out other genetic factors. Many of themembers of this family have hearing loss, indicat-ing that there might be a hereditary factor in play.Saunders plans to continue to take genetic samplesfrom family members and have them screened forother genetic mutations that may be responsible.

Gudlewski is all smiles after shehas been able to help this nine-year-old Nicaraguan girl, who isblind as well as hearing-impaired.

Winter 2009

a number of Mayflower trips. He knows Saundersfrom their days as residents together at Duke Uni-versity Medical Center; Saunders asked Molter tojoin Mayflower’s efforts several years ago. A pedi-atric otolaryngologist at Washington University inSt. Louis, Molter spends part of Tuesday afternoonoperating on a woman with a hole in her eardrum.A second-year Nicaraguan resident assists him, asother residents observe. Molter works confidentlyand steadily, explaining to the residents what he’sdoing as he proceeds.With a long list of patients to see, the operating

teams plan to work well into the evening. But at6:30 p.m., as they wait for their instruments to besterilized so they can start the next procedure, aNicaraguan doctor tells Molter that the auto-clave—the sterilization device—isn’t working. Hedoesn’t think the teams will be able to operate againuntil the next day. It’s a frustrating delay for the vis-itors, but one that’s clearly nothing unusual for theNicaraguan doctor.With the surgeries at an end for the day, Molter

visits earlier patients now recovering in the wards.In the cool, almost cold, operating rooms, it’s easyto forget the stifling heat and humidity of Managuain mid-July. The walk to the patient rooms offers a

quick reminder. Six or seven patients, and perhapstwice as many family members, are crowded intoeach room. Fans blow the hot air from one side ofthe room to the other.Molter sits down near one of the day’s first pa-

tients—a teenage girl. Through a translator, he ex-plains to her family that the girl will soon recoverfully. But the girl isn’t listening—clearly she’s al-ready doing well, since she’s talking away on hercell phone.

hile Molter and other volunteers providesurgical solutions to Managuans’ hearingproblems, DHMC audiologist Kerry

Gudlewski, Au.D., puts her diagnostic skills to usein a small 10-foot-by-10-foot office. A quarter ofthe space is taken up by a testing booth. The booth,which in the United States would be soundproofed,here offers only minimal buffering from the ambi-ent noise. And the dim lights on the audiometer,which Gudlewski uses to chart patients’ responses,require her to turn off the overhead lights so shecan read the machine.This is Gudlewski’s second trip to Nicaragua

with Mayflower; her first was in 2008. Nicaragua isbadly in need of audiology services. During this trip,

32 Dartmouth Medicine—online at dartmed.dartmouth.edu

DHMC audiologist Kerry Gudlewski(center) has just fitted this man fora hearing aid using a material that

takes an instant impression, andshe’s now explaining to the patientand his wife how the device works.

In the past, Gudlew ski

says, some patients

have not shown up to

get their hearing aids.

Using the instant

materials allows her

to ensure that people

get the help they need.

Gudlewski has the girl

sit in the sound booth

for a hearing test.

When she is sure she

has heard a signal, the

girl shoots her arm

into the air. When she

is less sure, she lifts it

slowly and waves her

hand. Either way, she

smiles as she responds.

W

S

online at dartmed.dartmouth.edu—Dartmouth Medicine 35Winter 2009

During the day, the children attend classes at aJinotega public school, wearing the uniform re-quired of all the school’s pupils—white shirts, withblue pants for boys and blue skirts for girls. Theyreturn to the home after school.In July, many of the Mayflower volunteers

worked at the home, painting rooms and finishingwork on a bakery attached to the facility. When itopens, the bakery will provide sustainable fundingfor the home. The work progresses steadily duringthe day while the children are in class. But in thelate afternoon, after they return, work slows as someof the volunteers put down their paintbrushes toplay with the children.Later in the week, Saunders returns to Managua,

where he and Fried, the audiologist from New York,are meeting with officials from a public university.They hope to set up a program that will trainNicaraguans to become audiology technicians.That way, some services that are now available onlywhen Mayflower volunteers are in the country canbe provided year-round.Fried says there is no program in all of Central

America as rigorous as the one they’re planning; itwill be a nine-month course. Their long-term goalis to establish permanent clinics in different parts ofNicaragua so residents will not have to wait forMayflower’s trips to have access to basic audiologyservices. Another long-term goal is to establish anationwide screening program so that children withhearing loss can be identified and helped as early aspossible.Saunders and Fried hope to have the training

program off the ground soon. They already havethree potential students—including two of thenurses who worked with Gudlewski in Managuaduring her visit this year. Fried says it can be daunt-ing to think about setting up such a program in aforeign country, but it’s worth the effort. “Peoplecome here desperate for hearing services,” she says.“You just have to follow through.”Saunders did not expect when he first went to

Nicaragua that his involvement there would be-come so consuming. He reflects on his ever-deeperties to the area several weeks after his return fromthis year’s trip. “It can be overwhelming,” he says.“You hang on to those little bits of progress that youmake. I look at where we are now and compare itto where we were 10 years ago.”Over the course of that decade, Saunders’s inter-

est in Jinotega has grown into a broader engage-ment with global health problems generally. “Thathas been very rewarding for me,” he says. “This hasbecome, I would say, the major focus of my profes-sional life. . . . Everything that I do these days insome way has something to do with global health.”

And after just two trips to Nicaragua, Gudlews-ki is already as enthusiastic as Saunders. “It reallyjust makes me so happy,” she says. “I love doing it.”

n her last day in Jinotega, Gudlewski testsa 10-year-old boy. He has profound hearingloss in his right ear; his left ear is not quite

as bad. Gudlewski explains to his mother that thereis nothing that can be done for his right ear, and themother’s face falls. But, Gudlewski quickly adds, his left ear can be

helped. She takes an impression of his ear canal andsays that a hearing aid will be ready soon. Themother smiles, but nervously, and asks how much itwill cost. It’s free, Gudlewski explains. The moth-er’s face lights up.When Gudlewski is done, she explains that the

mother will be contacted when the hearing aid isready to be picked up. The mother asks if Gudlew -ski will be there to put it on—she wants to bringGudlewski a souvenir to help her rememberNicaragua. Gudlewski smiles. It’s a nice gesture, butit’s clear she won’t need a souvenir to make the tripstick in her mind. “I can’t wait to go back,”Gudlewski says later, after her return to DHMC.“I’d go back next week if I could.”Like Saunders and Gudlewski, Jastrzembski is

certain he’ll get back to Nicaragua, too, even if hedoesn’t yet know in what capacity he’ll do so. “I’veinvested a lot of energy and time in getting to knowthis area,” he says. “It has a lot of interesting as-pects, and it has a lot of need.“I can’t imagine myself not being involved in

this part of Nicaragua for the rest of my life.”

Winter 2009

But Saunders notes that there are other possibleexplanations for hearing loss in Nicaragua. One isthe easy access Nicaraguans have to a class of an-tibiotics called aminoglycosides, which are knownto have ototoxic side effects. Pharmacies in Jinote-ga sell such antibiotics for just a dollar or two—noprescription needed.Then there’s the ubiquitous environmental

noise. Gudlewski says the lack of awareness aboutthe danger of exposure to loud noise in Nicaraguais similar to the situation in the United States 50years ago. She often sees patients in the U.S. intheir 60s or 70s with significant hearing loss be-cause they worked in noisy environments withoutear protection. Now, she says, things have improveddramatically in terms of recognizing the need toavoid constant exposure to loud noise; she hopesthe same will eventually be true in Nicaragua. “Fora lot of these people, prevention is the only treat-ment you can give them,” she says.It’s also possible that the high rate of hearing

loss is the result of some combination of genetics,environmental influences, and the use of ototoxicantibiotics, with each factor exacerbating the oth-ers. Recent research has found that the combina-tion of aminoglycosides and exposure to loud noise

can cause greater hearing damage than either alone.While Saunders continues to try to unravel the

causes of hearing loss in Nicaragua, all of theMayflower volunteers work to ameliorate its effects.Just last year, Mayflower opened a home for deafchildren that now houses about 15 youngsters be-tween the ages of 6 and 13. Jinotega also has a pub-lic school that offers special classes for deaf chil-dren, a service that is not available in the isolatedmountain villages outside the town.

or some of the children who live at thehome, their hearing loss is so severe that itwould be impossible for them to attend

school otherwise. For others, it gives them a placewhere they are more accepted than they wereamong their families. Sara Wernicke, a Mayflower volunteer who

knows sign language and works with the children,says that some were abused or abandoned by theirfamilies before being brought to the home. Whenthey first arrive, many of the children have little orno ability to communicate. But given a chance tobe around other children with hearing loss and toattend school, they start to pick up sign languageand other communication skills very quickly.

34 Dartmouth Medicine—online at dartmed.dartmouth.edu

Above is a street scene in Jinotega;the trip that Saunders’s team madethere this year fell right in the middle of the region’s rainy season.

This is one of the special-needsclassrooms in the Jinotega publicschools; note the sign language

alphabet. The girl on the left livesat the new home for deaf children.

Some of the deaf

children were abused

or abandoned by their

families before being

brought to the home.

When they arrive,

many have little or no

ability to communicate

but they pick up sign

language very quickly.

Saunders did not

expect when he first

went to Nicaragua

that his involvement

there would become so

consuming. “It can be

overwhelming,” he

says. But, he adds,

it “has been very

rewarding for me.”F

O

58 Dartmouth Medicine—online at dartmed.dartmouth.edu Winter 2009

was someone fighting to stand on his own, tohelp his caregivers bring him back to goodhealth. I have come to believe that this realme is something like the soul. It is what re-mains when an illness suddenly strips awaygood health and personal history. But it’s in-visible to those treating the illness unlessthey look carefully, and it’s often obscuredeven from the patient himself.

There were moments in the hospitalwhen I recognized only a faint flicker of thissoul, so how could I expect the doctors andnurses to see it? Nonetheless, no matter howwasted a patient is, there remains an essen-tial self he desperately needs to hang onto.And if he is to recover in a timely and effec-tive way, he needs to believe that others seethat essential self, too.

I now think that looking for this is key tohealing the very sick. It will never supplantmedicine’s therapeutic arsenal. I could nothave survived without the brilliant, aggres-sive care I received. I know I was lucky tohave so many important pieces in placewhen I fell ill. That cannot be the case forevery patient.

At one point near the end of my thirdweek in the hospital, internist Ed Merrensexplained to me, “When you came to thehospital, we took control of your body. Now,we are going to give it back to you.”

Only by relinquishing myself to the ex-perts was I able to survive. But once I did sur-vive, I needed to be seen and understood soI could begin to really recover.

M y recovery has been nearly total.There was a little permanent damage

to my lungs, so I have to be careful if I get achest cold. But through running and weight-lifting, I have regained the body I lost duringall those weeks in bed. In the fall of 2008,Dr. Walter O’Donnell, the Mass General pul-monologist who has monitored my return tohealth, looked up with a warm smile fromthe results of a breathing test I’d taken anhour earlier and said, “We just don’t see re-sults like this.”

Even so, I don’t run many races these days.But I did mark my recovery by doing the gru-eling Mount Washington Road Race againthe next year, in June 2007. The 7.6-milecourse has been called “sadistic” for its verti-cal rise of nearly 5,000 feet. I finished furtherback than I ever had. But it may have beenthe most satisfying race I’ve ever run.

The Longest Run

continued from page 49whole hospital. “Write about this,” he said.

So what is there to say? I felt frustrated bythe occasional misunderstanding of—and,rarer, disregard of—the real me. But my doc-tors and nurses were focused on treating myillness. When they interacted with me, theyaimed their words, understandably, some-where between the delusional me and the ra-tional me—never quite connecting with thereal me.

But how could they? Even I couldn’t seemyself as I truly was. At one point, for ex-ample, I believed I would be discharged atthe end of my third week in the hospital andwould be able to run a few light miles thatweekend. In fact, it was four months later, inDecember, before that was possible.

I n the time that has passed since my ill-ness, now years rather than months, I

have come to understand that my essentialself, the real me, began to emerge the minuteI awoke from my coma. Beneath the delu-sions, the dreams, the infirmity, the stubble,