By Fred W. Baker IIIAmerican Forces Press Service
July 24, 2009 - It's just after 9 a.m. in this hot, humid town, and Navy Capt. Colleen Gallagher already looks tired. She is in the throes of running a medical site manned by health care providers from the Navy hospital ship, the USNS Comfort. While the ship circles just off the coast about 12 miles away, hundreds of local residents pack the streets around the town's medical clinic, hoping to be seen by one of the ship's doctors.
The scene could pass for a street fair. Vendors work the crowd selling cold drinks, snacks and fruit. Skinny, stray dogs slip through people's legs, looking for a dropped treat. Babies cling to their mothers, some crying, others breastfeeding. Bigger children kick an empty plastic soda bottle back and forth across the cobblestone.
Umbrellas blossom over the crowd as the tropical sun breaks through the overcast morning, and a local disc jockey blasts a mix of current hip-hop hits and Latin American music.
Sitting on a wooden bench outside of her operations center, which is little more than a small corner room of the clinic with a couple of computers and wires strung everywhere, Gallagher said she hopes a journalist will not take her picture.
"It's been a long trip -- very rewarding, but very exhausting. Kind of a surreal experience," she said.
Gallagher and the Comfort crew have for the past four months served on the front lines of the United States' "soft power" efforts. The ship has charted the course for aligning the U.S. military with humanitarian groups, foreign militaries and political bureaucracies at home and abroad in a synchronized effort to provide health care to some of the Western Hemisphere's poorest countries.
The ship's surgeons have seen some patients on board, but most are treated on shore at sites such as this one. The physicians, dentists, nurses and others are flown to the sites by helicopter, or shuttled on small boats. They are housed overnight in small towns and villages, sleeping several to a room in hotels that sometimes have hot water, but always have tasty local food.
The health care providers rotate to and from the ship, switching out with other staff, spending a few days at a time ashore. They work long hours – up to 16 hours a day – for 10 or 11 days straight, until they leave each country. They get their rest at sea as they head toward their next destination.
Gallagher, a Navy nurse, has led sites in each of the seven countries where the Comfort stopped. She will close this site, the final stop of the mission dubbed Continuing Promise 2009.
The staff has only one more day here. And there are still hundreds waiting for care. It's emotionally difficult for the providers to turn people away, Gallagher said. During this mission, the Comfort filtered more than 100,000 people through its ship and medical sites, but almost always not everyone who came could be seen.
The mission runs, in reality, as a military operation, and the demands of logistics mostly govern the hours the site remains open.
"There's always going to be more walking up to be seen, and we have to shut down at a certain time," Gallagher said. Still, this sometimes grates at the will of the doctors, nurses and volunteers who come with a passion for caring for the poor.
Nicaraguan military troops hold the throng at bay as volunteers work to screen them one by one and route them through the clinic. For those who make it past the guards and the yellow caution tape, this may be the first and last time they are treated by a doctor.
To prevent what officials termed "compassion fatigue," the providers must focus, Gallagher said. "Focus on the one in front of you and the next one you're going to see, and you can't worry about the hundred that may be out there that won't get in today," she said.
The Comfort's commanding officer, Navy Capt. James Ware, said some crew struggle emotionally at the start of the mission. "Initially, you have to learn to understand that the people that you're dealing with truly have much less than you have," he said. "I think most providers were able to overcome the focus on every patient and realize that they can't do everything for everybody every time."
Navy Cmdr. (Dr.) John Fortunato is a reservist and a civilian pediatric gastroenterologist. Normally, he sees about 40 children a week, he said. In his month aboard the Comfort, he averaged about 90 a day.
Because he is a specialist, Fortunato typically sees patients who already have been seen by several doctors and undergone expensive testing. On this trip, he saw his patients from "scratch," without the inches-thick folders of test results and medical reports.
The trip allowed him, though, to hone his diagnostic skills, Fortunato said, forcing him to use his hands and his brains, rather than relying on technology. But that worked against him when he pressed against the belly of a boy who likely had a large tumor growing inside. Without those expensive tests, there was no way to know if the tumor was operable. There was little he could do beyond emphasizing the seriousness of the tumor to the parents and hoping they seek treatment.
"It is hard for us ... to not be able to do everything that is physically available, even though it's not readily available," Fortunato said. "We live in a society where we don't like to lose. We don't like to say it can't be done because we can't get the resources to you."
Most serious cases are referred to the local health ministries for follow-up care. Because care is limited, and because the patients have little money, the reality of them receiving that care is iffy.
But in this boy's case, Fortunato did not settle for a paperwork referral. He summoned a health ministry official to the site, personally briefing the case in the hopes of getting a hospital bed and care for the child.
"It's hard for us ... to say 'Well, you have a tumor – next patient,'" he said. "We really wanted to make sure we got this kid tied into ... the Ministry of Health and the local hospital."
Still, Fortunato said, he wished he could have done more. "You want to fix them. That's the way we're trained," he said. "You don't accept [sending] them to someone else."
Not all of Fortunato's cases were as grim. Most were typical colds, headaches, stomach pain. The patients were sent away with prescriptions for pain relievers and directions to drink more water.
For most parents, just having a doctor say their child is OK is reassuring. They think something dreadful is going to happen, but the exam eases their minds, Fortunato said.
One 15-year-old girl came through his line, complaining of stomach pain. She was coughing up blood, the girl said. Her parents were frightened, thinking the worst. Because it fell within his specialty, Fortunato arranged to perform an endoscopy, which involves running a scope from her mouth to her stomach to look for the cause of the pain and bleeding.
As luck would have it, there was an endoscopy nurse aboard the ship who could assist, and officials agreed to allow him to perform the procedure in their surgical ward.
The parents lived two hours away from the ship, though, and had to pay to get there. They sold a pig, bought bus tickets for about $23, and soon were aboard the Comfort.
Fortunato performed the procedure and found only mild inflammation in the stomach, much to the parents' and the child's relief. A huge celebration was planned – they wanted Fortunato to come to their house for a feast. He had to decline, but that didn't dampen their spirits.
"The father said he wanted to go into medicine after that and help Nicaragua," Fortunato said, adding that he, like many others on the trip, found the experience "eye-opening."
Fortunato said he learned to be more patient on this trip. He used to whine about his staff double-booking a patient at 4 p.m. on Fridays, he said.
"I think it kind of puts it in perspective in a lot of ways," he said. "We don't know how lucky we have it."
The ship's commanding officer said Fortunato's experience is typical. While most are tired at the end of the mission, they are not discouraged, Ware said. In fact, they are proud of their work, hopeful that their efforts made a difference. No one steps off the ship the same as they came on.
"I think it makes people stronger," Ware said. "I think makes them more compassionate, and I think it makes them appreciate what they really have."
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