The town is small. The municipality is large. The small government clinic attends to the needs of people who do not have healthcare. These are people who work in the informal economy and much of the care is centered around pregnancy, birth, the care of young children and of old women. A few men come in for check-ups and vaccines. This community north of San Salvador includes a broad range of living conditions, and the care area is huge.
Today we accompanied the chief doctor, the head nurse and a health promoter as they did a home visit to investigate the death of a 2 year old boy who reportedly died of malnutrition. We were told to prepare to walk a long distance. We were told to carry water. We were told that the child died because the family did not care for him properly. There were many things which were not told. The reality of this dead child's short life and the lives of others in the home leaked out secret by secret, breaking our hearts bit by bit.
A little boy was the first to greet us. He is six years old, very small with stick thin legs and arms. He wore a "necklace" which was an old waistband from a pair of men's underwear. The health promoter pointed out his little stool where he could sit with us on the veranda in front of the adobe house. The grandma moved the stool to the other side of the veranda, away from us.
The doctor took a stapled pack of papers out of her metal clipboard case - the baby's medical chart. On the back of the last page, she began to take notes: the exact age of the deceased (2 years, 2 months and some days), the circumstances of his birth, the history of illness, the comings and goings of the family members. The baby's mom is 19 years old. The grandma cares for the six year old. His mom and dad were both murdered. The grandfather works. There is no food. The goats gave milk, but now they don't. There are plants all around, but there is no food. We saw a sack of grain in the house, but there is no food.
The health promoter and nurse had been to the home many times in an effort to educate the family and care for the boys. As the doctor asked questions of the grandmother, the nurse opened her big red bag and pulled out an apple. She gave it the little guy; then out came some packages of vanilla cookies and some grapes. He held it all in a little bag, and would not eat anything despite much urging.
A field of low growth and a family of goats stood between us and a less-sturdy home made from corrugated tin. As we talked, a young woman quietly emerged from the tin house and walked toward us. She wore a faded yellow Sponge Bob shirt, and a tattered maroon skirt which was decorated with a few dirty stickers. She sat on a concrete block behind my friend. We rearranged the plastic chairs a little so that she was in the circle. In a few moments, she was standing behind my friend, hiding.
"How old are you?" the doctor asked the grandma. She did not know. "What year were you born?" The grandma paused and said, "I cannot say. My man has the papers and it is for him to say."
"What happened on the day the baby died?"
"He was tired from breathing. He was making a noise. I put him on the bed. I left to do something. When I came back, he was dead," the grandma recalled.
"So, you left him to do something and then he was dead?"
"He died in his mother's arms."
It wasn't clear who was caring for him when he died. It was clear that the mom, hiding behind my friend, was choking down her emotions. The doctor asked questions about the nurse's visits and the promoter's visits. The investigation concluded, and the team focused on talking to the two women about nutrition for the 6-year old. I walked over and crouched near the little boy. He was enjoying the company of the dogs and ducks who wandered about the patio. "He can eat duck soup, or fruit from the garden or a little bit of flour" I walked over and crouched down next to his seat.
"Are the ducks your friends? Like the dogs? What do the ducks say? Quack, quack..." I made funny duck sounds. The little guy smiled. I quacked and woofed and he giggled a little. I pulled a grape from his bag and encouraged him to try it. The doctor had finished her questions and she came over, pulled a cookie from its wrapper. He took a tiny bite. The 19-year old never said a word. She smiled a little, all of her front teeth were gone and her back teeth were rotted black. I slipped over to her corner and whispered in her ear, "Do you have someone to talk to? A pastor or priest?" She nodded. "You can talk to the health promoter or the nurse, whomever you trust. You have the right to live your life."
We walked a distance away from the house, and I turned and motioned to the sad mother whose baby had died from malnutrition. She paused and waved a little bit, posed with a slight smile, and I took a photo of her standing half-hidden behind the pila (concrete sink). I turned and walked down the mud path past the latrine with no walls, to the barbed wire gate, and down the muddy rock trail to the road.
The health promoter needed to visit additional homes. She headed up the hill, carrying the vaccine box and waving good-bye.
The rest of our team turned and headed back to a main road. We walked quietly for a bit. "I was there for the vigil," the nurse shared. "There was no light, no candle and not one flower on the caja (coffin or box). The family did not even have one cup of coffee for the guests. I went and bought some things for a proper vigil."
"The father is a big man, very dark Sometimes I would come and there would be a huge quantity of dogs viciously barking. They were there when the man was there. He controls everything. No one can talk except him. The boy would not eat anything unless the grandma said it was OK.
The grandmother had told us that she and her husband slept apart. "He's too hot," she complained. We laughed awkwardly at the time. We walked back toward the main road. The nurse spoke quietly: "The husband is in a sexual relationship with his own daughter. We think he is with the three daughters, the one out with him now is beautiful so he takes her. This one is not so beautiful, but he is with her when he is at home. The baby was his child. There was another baby that died when it was six months old. Neither that one nor this one had a proper funeral. I was there. No flowers, no candles, no coffin. The body was put in a cardboard box, like an animal. He buried the box in the yard. No cemetery. Like an animal."
We were all worried about the little boy who would not eat even a grape without permission. The nurse said the grandma would eat that food. The boy has no one to care for him because his parents were murdered. His mother was pregnant and very large when she was killed. We asked if it the deaths were related to gang violence. The nurse said it may have been that, or some kind of internal justice. The baby she was carrying was probably the grandfather's.
The more that was revealed about this family's horrific existence, the more we struggled to figure out how this could be. Where were the police? Where is the protection for the daughters, and the little boy? "We could make a denunciation," said the doctor, "but we have no evidence, only suspicions. The threats will then come to us and we will lose our lives."
Later in the day we sat in on a big group meeting at the civil defense/youth center. The doctor spoke about the morning's investigation. The police will probably try to investigate, but they will have to be careful not to cause trouble for the medical team.
In the meantime, a little boy and a family of women live under the oppression of the grandfather, We carry with us the tragedy of this family and ask, how can this be?