Why Tijuana for sick man? Better doctors, better service, better price.

Seven neighbors tapped at my gate

Deep-Fried Quesadillas

Everything was just out of reach as I lay on my left side in a bed at Tijuana's newest and most modern hospital. I had to sit up or lie down only on my left side because of a stinking wound the size of a pack of cigarettes on my lower right back. The pain was exquisite -- a merciless, unrelenting pain that kept me awake at night, that made it difficult to move, that sent the muscles in my buttocks into periodic spasm.

It was now late August of 2007, and for the third time in a month, I was tethered to an IV line pumping three different powerful antibiotics into my veins. The hospital room was top- of-the-line, designed with patient comfort in mind: individual climate control, cable television, local- and long-distance calling at the touch of a finger, high-speed Internet access so I could connect my laptop, a reading lamp, an in-room programmable safe, and a spacious private bathroom. Twice a day custodians swept, mopped the floor, emptied the garbage, and left new towels and little hotel-sized bars of soap.

What looked like hardwood flooring was really just a laminate floor covering; on two sides, large squares on the walls stood out in relief, giving them a sculpted look; an abstract Southwestern print in shades of orange, red clay, and dirt brown hung on the west-facing wall, the northern exposure featured high windows the width of the wall, and if I opened the eggshell-colored aluminum blinds, I could see the "Torre de los Médicos" (Doctors' Office Tower), a ten-story, terra-cotta structure suggestive of older Mexican architecture but with modern lines.

When the hospital opened in December 2005, at a cost of $70 million, many Tijuana doctors moved their practices to the tower. The hospital is situated on Avenida Paseo de los Héroes, a tree-lined boulevard in Tijuana's Rio Zone, directly across the street from a T.G.I. Friday's restaurant. Two blocks away is a Sam's Club and the immensely popular Ocean City Chinese Buffet. A few blocks up a hill on Boulevard Salinas are other American franchises: McDonald's, Burger King, Carl's Jr., Smart & Final, Bob's Big Boy. In the last ten years, such franchises have sprung up from one end of the city to the other -- Office Depots, Costco warehouse stores, Ace Hardware, Home Depot, Kentucky Fried Chicken -- although a few, like Wendy's and Jack in the Box, folded after a few years.

Despite all this free trade, Tijuana maintains its Mexican identity. Some of the tastiest food in the city comes from thousands of mom-and-pop businesses, and so it is in El Mirador, a few miles from the beach. My neighbor Beatriz operates a little restaurant from the patio of her home on weekends. Beatriz, who lives with her twin sister, a son, a daughter, and a tenant who rents a room from her, sells pozole, menudo, and other traditional Mexican fare. My favorite -- now off-limits by doctor's order -- is a distinctive version of quesadillas, made with corn tortillas filled with cheese, onions, lettuce, and tomato, then deep-fried. An order of three costs $2. During the day, a food cart selling tacos a vapor (steamed tacos) sits in front of Beatriz's home; at nightfall, until about midnight, another family sets up a portable taco stand, and the aroma of tacos de carne asada fills the neighborhood. Up and down Boulevard El Mirador are variations on the theme: more taco stands; food carts featuring hot corn on the cob; a fellow who stands outside a neighborhood grocery from 8:00-midnight most days, selling homemade tamales from two big aluminum pots; a neighbor lady who irons clothes at her shop for 50 cents an item, next door to a dentist's office run by her daughter. Another neighbor's son runs a charbroiled hamburger stand from 3:00-11:00 p.m. in front of the family home, where his widowed father, Don Raúl, rents out three added-on apartments. Two blocks away, a lady who looks to be in her 60s runs a nighttime hotdog stand. And deadly dogs they are, fatty Rosarito-brand hot dogs, wrapped in bacon and grilled, served with mayonnaise, mustard, grilled onions, catsup, and, unless the customer specifies otherwise, hot, diced serrano chiles. Somehow, word reached her of my diet, and she refuses to sell them to me.

I often see the hot-dog vendor early mornings walking to daily Mass at the neighborhood parish, San Juan Bautista. Every June, on the feast of the saint's nativity, the parish holds a parade down the boulevard, and every Christmas there is a parish fair. On Friday afternoons, a shop that sells student supplies also sells out-of-date breads, bagels, and sweets purchased from supermarkets in the U.S. All the proceeds go to the parish. On weekends, many neighbors sell used clothing, furniture, and appliances in front of their homes. When I first moved here, I furnished my home from those yard sales. The refurbished refrigerator and washing machine I purchased from one such sale are still going strong after five years. Almost every day, a pickup truck parks on a corner a block away, and from the back of the truck you can buy fresh whole watermelons, strawberries, oranges, pears, and sometimes peaches and mangos. Plumbers, electricians, carpenters, and painters park their trucks along the boulevard, some with hand-lettered signs offering their services.

My Golden Cage

Three stories below my hospital room was a well-maintained garden with lush green foliage and blooming red and orange flowers; in front of the office tower was a patio with aluminum tables and chairs -- but it was rarely used. After I learned that the pump controlling my IV had a battery that lasted for up to three hours, allowing me to disconnect it from the wall plug and wheel it around the room, I made frequent visits to the window. When my cardiologist, Dr. Mario Zúñiga, stopped by to check up on me, I asked, "Why doesn't anyone use the garden? Why can't I be given access?" "Because," said the doctor, "you are connected to an IV line." "Yes," I said, "but there are sometimes hours between the administrations of medicine. Why can't the nurses cork the line during the intermissions, allowing me to move about more freely? After all, they do this briefly each morning so I can shower." Zúñiga sighed in exasperation. "Okay," he said. "You can use the garden for 15 minutes in the morning and 15 minutes in the afternoon. I'll note it in your chart."

The nurses attending me were scandalized. Never before had a doctor specifically ordered that a patient be allowed access to the garden. Normally, all patients were confined to the floor, with a security guard posted at every exit to prevent patients from fleeing the hospital without paying. To ensure that I did not run off during my daily outings, I was required to wear two white, collarless flowing hospital gowns -- one facing front, one covering my rear -- and flip-flops. And I had to check in and out at the nurses' station. I looked like a morbidly obese ghost or a Ku Klux Klansman whose sartorial political statement had gone awry. In short, I was a ridiculous figure. One afternoon I overstayed my allotted 15 minutes, and a nurse was dispatched to retrieve me. "If you run off, I'm the one who will get into trouble," she scolded. Another morning, a walkie-talkie-equipped security guard carrying a clipboard to note unusual events asked me my name and room number. He noted these in his report, also recording the time and location, obviously worried that he might have trouble on his hands. The guard then called the nurses' station to check up on me. Once he received assurances from the head nurse that it was "part of the patient's treatment," he gave me a little salute and wished me a quick recovery.

When I was not off on one of my brief tastes of freedom, I spent hours sitting on the side of my bed, chatting with the nurses, who had come to work in Tijuana from all over Mexico. Bertha, a chubby, short woman whose curves strained the seams of her uniform, told me that she was from Veracruz, at the opposite end and opposite coast of the country. Bertha's smile revealed a missing tooth, but she didn't seem troubled by it. She was perhaps the most chatty of the nurses, volunteering that she had three children, one awaiting a kidney transplant that she was saving up to pay for, which is why, she said, she worked two jobs. Her husband, to whom she has been married for 21 years, worked as a carpenter, but even with three incomes, life was a struggle. "Two of my sons are in high school, and you know that costs money," she said. Although Mexican law guarantees free public education, the law is rarely observed. Parents are asked to pay for tuition, books, the mandatory uniforms that are a feature from kindergarten through prep school, and for the upkeep of the school building and grounds. Still, Bertha was always smiling, happy because, she said, Tijuana has jobs -- plenty of them, for anyone willing to work. Hospital Angeles, part of a nationwide chain of hospitals owned by the same company that operates the five-star Camino Real resort hotel chain from its corporate headquarters in Mexico City, pays her 3000 pesos every two weeks, about $280 at the current rate of exchange, or $140 a week. A one-night stay at Hospital Angeles, billed at $277, nearly pays her salary for two weeks

Osvaldo was a young male nurse, maybe 28 years old, from Sinaloa, a state along Mexico's central coast best known for the resort city of Mazatlán -- and for its marijuana crop, drug-trafficking, and narco-corridos, a kind of folk music glorifying the life of drug smugglers. Osvaldo had come to Tijuana for the same reason as Bertha -- to work. He wore too much cologne and was fastidious about his uniform. It was precisely pressed and fit him as if tailor-made, which, with his close-cropped haircut, gave him a vaguely military look. For some reason, all the male nurses wore white pants and lime-colored smocks, while the women wore white skirts and light-blue blouses. Nurses' aides wore a navy-blue uniform. "I wish I were home," Osvaldo told me. "But there is no work there, and even if you can find work, it does not pay anywhere near what they pay here in Tijuana. There is a lot more opportunity here, more than anywhere else in Mexico." Osvaldo often used late-night visits to my room to review messages on his cellular phone. He seemed to get a lot of calls.

Denorah, an older nurse's aide, probably in her early 60s, was the friendliest of all those who attended me. Just below the windows that faced the garden was a narrow sofa with foam cushions covered in a rough, faintly blue fabric. In other rooms, family members of patients used the sofa to sleep on so they could remain at the side of their hospitalized loved one. I had no loved ones geographically close enough to take advantage of the sofa and suspected the nurses had taken note of that and tried to fill in as best they could. Besides, I had discouraged friends in Tijuana from visiting -- it was an affront to my pride for anyone to see me in such a pathetic and helpless state. Denorah would sit on the sofa and talk to me for 30 minutes every day. She had short, straight black hair and hard, angular Indian features that defined a mournful face suggesting she had long led a tough life. She would hold my hand, caress my head, and tell me, "Pobrecito. Everything is going to be okay." Sometimes she patted me in much the same way you might pat a dog -- but I enjoyed the attention, was comforted by it. Denorah was from Oaxaca, a southern Mexican state that in recent months has been torn apart by political unrest -- massive demonstrations, strikes by teachers and government employees, riots over rising tortilla prices, shootouts between the government and radical leftists. She worried about her family back home, she said, hinting that she sided with the leftists: "In the U.S., you have rights. In Oaxaca, no. You never know what is going to happen to you. People think Tijuana is bad, but it is nothing compared to Oaxaca. The rich stay rich and the poor suffer, and suffer more." But, said Denorah, she had her hands full now in Tijuana, where she, her husband, and her family of eight children had moved seven years ago. No looking back now, she said. Tijuana was her home.

Nurse Gladys was a prim young woman in her mid-30s with a slightly officious air. Unlike the other nurses, she did not readily volunteer what medicine she was administering -- something I always asked when someone was about to inject something into my veins. "Medicine ordered by your doctor," she said condescendingly, tapping my hand two or three times as if admonishing a child. (When I mentioned this to Dr. Zúñiga during one of his visits, he added this note to his standing orders: "Allow patient to ask questions. Allow patient to express himself.") Gladys had an hourglass figure and was quite a looker, if you could get past her austere understanding of the nurse-patient relationship. She seemed more like the kind of nurse you might encounter in an American hospital -- strictly business, little time for chitchat. Either that, or she just didn't like this difficult gringo patient, full of questions, presuming to know as much about medicine as she did. When I complained of feeling as if I were in jail, she told me, a dash of contempt flavoring her voice: "You may feel like you are in a cage, but this cage you are in is a golden one -- still a cage, but golden. And soon you will be out of it."

All of the nurses seemed surprised that I spoke Spanish fluently, and they were curious as to why a gringo would choose to live in Tijuana. They attended to many gringos, most in Tijuana for weight-reducing surgery, which costs about a third as much as it would in the U.S. Very few spoke Spanish, and those who did spoke it poorly. Tijuana bariatric surgeons offer attractive packages to Americans: patients are greeted at Lindbergh Field by an English-speaking escort who drives them to a five-star hotel in Tijuana, where they spend their first and last days -- with three days in the hospital sandwiched in between -- all for $9000-$12,000. I had learned the language by osmosis over 16 years spent in relative contentment as an expatriate in Tijuana. During that time, I had lived in virtually every area of the city -- from $12-a-night hotels, where you had to sign for your toilet paper at check-in and return it to the desk before checking out, to high-density Mexican public housing in the crime-ridden dusty hills on the eastern outskirts of town, and now, in a pleasant, safe, middle-class neighborhood. Like many emigrants to the city, my living situation had improved as my economic situation improved. In the lean, early years, there were days I struggled to come up with enough money to feed myself. Like my Mexican counterparts, I came to rely primarily on panaderías -- the fresh bakeries that dot the city. Two freshly baked bolillos -- small loaves of French bread with origins in the brief French occupation of Mexico -- cost less than a dollar. And, unlike in the U.S., sandwich meats did not come prepackaged. Customers can order as little or as much ham or bologna as they desire, purchase one hot dog or eight, two strips of bacon or a quarter kilo. The system made it easy to eat on an austere budget, though the diet was not always a healthy one.

As a result of the time I had spent in Tijuana, my speech was littered with expressions picked up on the street, with turns of phrase not taught in language schools, some bordering on the vulgar. I am by no means a perfect speaker of Spanish; I still screw up verb tenses and personal pronouns and trip over trilled r's or multiple vowel sounds. Still, the nurses seemed charmed by my command of the language and said it made their job easier. It enabled them to quiz me: Why had I moved to Tijuana? Had I married a Mexican woman? Did I want to? Where was my family? What kind of work did I do? With good reason, many people who live in Tijuana harbor dark suspicions about gringos in their midst -- not so much so in places like Rosarito Beach, where an estimated 15,000 Americans live in pricey beachfront condominiums -- but in the everyday neighborhoods of the city.

I know from firsthand experience that many of my compatriots in Tijuana come to the city with bad motives: pedophiles taking advantage of the huge income differential to buy sexual favors from minors; SSI pensioners "disabled" by alcoholism, who pass their days and nights in cheap bars drinking beer at less than a buck a bottle; lawbreakers on the lam from justice; and con men of all varieties. I, too, had come to look upon other gringos with suspicion and disdain. I had spoken to many of them and been shocked by the assumption that all gringos shared their perversities. "I've already had three boys, and I've only been downtown for five hours," one dirty-old-man type had bragged. Others introduced youngsters 40 years their junior as a "girlfriend" or "boyfriend." Still others solicited "investments" for diamond mines in South Africa, promising returns in the millions, or asked me to smuggle bullets or guns into Mexico, a federal crime in a country where possession of a weapon is prohibited. The local news was full of reports of gringos arrested in pedophile sex rings, peddling child pornography, operating from their homes Internet sex sites offering "paid escorts," or nabbed with huge supplies of Valium or other illicit drugs. I still remembered a photo in El Mexicano, one of the city's four daily newspapers, of two drunken old gringos sitting handcuffed on the porch of a house in Playas with two huge marijuana plants growing openly in pots in the background. A neighbor had called police. And consider this September 8 posting on craigslist Tijuana: "Important note to owners/managers. Always check references thoroughly, especially when renting to Americans. Why are they in Tijuana if they are not of retirement age? Why would a 'professional person' cross the border to work? Check their car registrations, their driver's licenses, their visa status. Beware especially when people tell you how wonderful they are. Talk to at least one of their former neighbors. Helpful reminder from someone who knows the pitfalls of not checking ruthlessly."

At the hospital, the food cart from the kitchen would arrive on the brightly waxed third floor five times a day. Everything had the look of being maintained by someone's crazy, obsessive aunt, who would not let children sit on her living-room furniture, covered in plastic, for fear of an inadvertent spill. Hospital Angeles took its food service seriously. A crisply uniformed worker would carry the food into the room, flanked by two administrative types carrying clipboards and dressed in blue skirts, navy jackets, and white blouses. The worker who placed the food on my table always had a bright smile, and she lifted the aluminum cover over the plate with a flourish, as if serving someone in a five-star restaurant. There was real silverware and food plated on white china with the hospital logo. "Look," the server would say, pointing to each item, "chicken breasts with garlic, peeled pear with strawberry sauce, rice with corn, yogurt with fresh fruit, and decaffeinated coffee." She made eye contact, looking for signs that I was happy with the fare. Meanwhile, the two administrative types stood by, ready to take notes: "Patient allergic to shellfish. Patient prefers whole-wheat bread to tortillas." At every meal I was informed that I could send the food back if it did not suit me or return it to the kitchen for reheating if it were not warm enough. Sometimes, the chef would call my room and ask if I wanted chicken or tuna, oatmeal or dry cereal. Did I need more coffee? These little food-presentation dramas became something to look forward to each day and helped me keep track of time: breakfast at around 8; midmorning snack (Special K cereal and a side of mango) at 10:30; the biggest, most filling meal of the day at 2:00 p.m. -- a creamy soup; a well-prepared thin slice of steak, maybe two ounces; one-fourth of a baked potato, turned on its flat side so it formed a cone that stood up on the plate, with a design carved on the top to give it the look of a ready-to-eat potato sculpture; two tiny pieces of whole-wheat bread cut to form perfect circles, with a light spread of cottage cheese. Late afternoon, around 5:00 p.m., another snack -- a fruit salad, or five crackers and a glass of skim milk. Then, around 8:30 p.m., the final meal of the day, a snack of mixed fruits and a small bowl of cornflakes with 1 percent milk and a glass of freshly squeezed juice, sometimes a ham-and-cheese or a tuna sandwich with nonfat, artificially sweetened yogurt and strawberries on the side.

Two days before I was to leave the hospital, I had a bitter argument with Dr. Zúñiga, not the first in our five-year doctor-patient relationship. The doctor had sent over a note by way of his secretary outlining how much he would be owed when I was allowed to go home: $4500 U.S. dollars. That was $1500 more than what we'd agreed upon before I was admitted, and, angry, I picked up the phone and called the cardiologist's office. Maria Elena, a buxom, saucy, and a-little-too-familiar receptionist who knew me well, answered. I said, "I just got the bill from your boss, and it is absurd! If he thinks I'm going to pay him $4500 in fees for a week in the hospital, he's crazy. That's more than $600 a day, and for what? All he does is stop by for 20 minutes twice a day. That's more than the hospital is charging me for room, board, nursing care, and medicine. You tell him I am really angry and I want to talk to him right away!" Maria Elena sighed heavily. She had been in the middle of this before and knew better than to take sides. "Okay," she said, "I will tell the doctor to call you. Right now he is with a patient."

Within 15 minutes the phone in room 319 rang. Caller ID showed it was a call from the cardiologist's office. I picked up the phone, ready for a fight. "Yes," I said. "What do you want?" Dr. Zúñiga was on the other end, also itching for a fight. "Look," he said, "that's what I charge. I am expensive. You want the best, you have to pay for it. And if you don't pay me, I won't sign a release allowing you to leave the hospital." Many Americans hospitalized in Mexico, especially those who don't live here but who have encountered some medical misfortune during a visit, have bitterly complained about this aspect of Mexican medicine: if you don't pay your bill, you can't leave. There have been repeated news accounts about gringos held in hospitals under police guard until their hospital bills are paid in full. But I wasn't some tourist unfamiliar with the way things work in Mexico. I decided to call Zúñiga's bluff. "Listen," I told the doctor, "I'll pull this damn IV out of my own arm and walk out of here. Call the police if you want, put me in jail. Go ahead. But you will not screw me over. You told me $3000, and now you want $4500! Forget it."

Dr. Zúñiga quickly adopted a different tone, lowering his voice and speaking more slowly. "All right, all right. Listen, I will come by later this evening and we can talk about this. Calm down. This is very bad for your blood pressure and heart -- these damn fits you have. You create hurricanes in a glass of water! I will be by later, and don't worry. We can work this out." About an hour later, a nurse came to my room with an off-schedule injection. "What is that?" I asked. "Something to calm your nerves," she said.

That evening, around 7:00, Dr. Zúñiga, a short, balding fellow wearing blue jeans, a white shirt with the first three buttons open, and brown shoes styled after cowboy boots came to visit his angry patient. Over the hours since our phone conversation I had strengthened my resolve not to pay the extra $1500. But by the time the doctor arrived, he had already decided to honor his $3000 prehospitalization agreement -- $4000 for a week in the hospital, medicines, bandage changes, and meals included, and $3000 for his professional services. "Look," he lectured. "You are a very difficult patient to treat -- heart problems, diabetes, high blood pressure, blood clots, chronic bronchitis, morbid obesity, and now this damn infection that won't go away. Remember, we are trying to keep you from needing surgery, which would really endanger your life. But you are a complicated patient, and you are a stubborn man with a bad temper. You know that. We are alike that way. Remember, too, that I have called in a surgeon, an infectious-medicine specialist, a hyperbaric doctor to look at you -- and I have to pay their fees, too. But okay, I will accept the $3000." Then Zúñiga looked me squarely in the eye, full of Mexican hyperbole: "You are the kind of patient that makes a doctor nervous. I go home at night worrying about you; sometimes I can't sleep. I worry that something may go wrong, and it could, anytime. You are in very delicate health. Surely the worry you cause me is worth something."

By the time our chat was over, we had shaken hands and all was well again. These spats had been a feature of our relationship since 2003, when breathlessness and chest pains had first led me to Dr. Zúñiga. I was in bad shape when I was referred to Dr. Zúñiga by an internal medicine specialist at another of Tijuana's premiere hospitals -- Hospital Excel, known for heart and kidney transplants and bypass surgeries. One night in early winter of 2003, as I was preparing for bed, I fell unconscious to the ground -- just like that, awake and alert one minute, unconscious the next. I was awakened by my mixed-breed Chihuahua nervously licking my face. I picked myself up off the floor and went to bed. The next morning, I called my internist at Excel, who referred me to an Excel cardiologist. But that doctor's 48-hour heart-monitoring equipment was on the fritz, so by sheer chance I was passed on to Dr. Zúñiga. His office was on the third floor of a prestigious medical building in Tijuana's River Zone, one of the best areas of the city, and equipped like any other first-class cardiologist's: EKG, Doppler echocardiogram, a cardiac stress-test machine, a two-bed cardiac intensive-care unit, and a small, fully equipped emergency operating room -- just in case.

Dr. Zúñiga quickly got to the bottom of things: first a 48-hour recording of my heartbeats, later an angiogram. He went over the recording carefully. "You see that," he said, pointing to a series of squiggly irregularities in the EKG tracings. "Four of them in a row. And here...and look here. This is happening over and over again, all through the day. Three or four of them in a row and you might fall down. More than that, and your heart might lose its rhythm altogether and your friends can call the funeral parlor."

Dr. Zúñiga was blunt, but I liked his direct approach. He made things crystal clear -- no medical obfuscation, no BS. Besides, the doctor had made himself available 24 hours a day -- given me his home phone, his cellular, and his Nextel Walkie radio-phone number. "The slightest thing, I don't care what it is, you call me," Zúñiga advised. Once, when I had fallen ill in the wee hours, I opted to go to the Hospital Angeles emergency room. There, blood tests and a urine exam were performed, and I was given an IV with a medicine that erased the pain shooting from my loins to my groin. I was pleasantly surprised by the bill: $80.00. But Dr. Zúñiga became angry when he learned of the ER visit. "I told you to call me!" he shouted. "Why didn't you call me? Why didn't they call me from the emergency room?" I told him, "Look, it was after 3:00 in the morning." Zúñiga called me a stronger, Mexican version of "a stupid idiot" and warned me that, given the nature of my various infirmities, it was downright dangerous to seek medical attention elsewhere.

Often, the doctor would phone out of the blue in the middle of the afternoon or in the early evening to ask how I was doing. Whenever diagnostic tests were performed, Zúñiga would call me at home to explain the results -- and fax over a copy of the report. (In Mexico, the patient owns personal lab studies, X-rays, MRIs, whatever -- they are your property and you are responsible for toting them to and from your personal physician and storing them at home.) Dr. Zúñiga treated me like a close friend, not just a patient. When a good friend of mine fell into deep legal trouble, it was the well-connected Zúñiga who recommended the lawyer who resolved the problem. ("The biggest fucker in Tijuana," said Zúñiga, by way of recommendation.) Every year at Christmas, Zúñiga invited me to a posada. He had invited me to meals at his home, to meet his mother, to USC football games, to Padres baseball games. But, except for the referral to the attorney, I had never taken the doctor up on any of his offers. Once, he gave me a copy, in Spanish, of All Quiet on the Western Front.

Following that initial angiogram, during which dye was injected into an artery near my groin -- later outlining arteries in my heart on a special X-ray machine -- Dr. Zúñiga showed me the results. "You have several bad arteries, but this one right here -- see it? -- is really bad, almost completely stopped up. You need an angioplasty and a stent to keep open the artery, and you need it right away." That was how the relationship began, with a balloon angioplasty and placement of a drug-eluting stent, performed at Tijuana's Hospital del Prado in April 2003, once considered the best hospital in the city but which, depending on who you talk to, now takes a back seat to Hospital Excel and Hospital Angeles. Dr. Zúñiga's assisting cardiologist, Dr. Patricia Aubanel, had treated Mother Teresa's heart problems during her 1992 visit to the Sisters of Charity order of nuns in Tijuana. By the time I arrived for my most recent stay at Hospital Angeles -- and this most recent argument with my cardiologist -- I had undergone two more coronary angioplasties (November 2004); an angioplasty on two of my right renal arteries, with placement of stents (June 2006), during which I almost lost my life; and a year later, in April 2007, a triple surgery: removal of a suspicious and painful inguinal cyst, repair of a strangulated hernia, and removal of my gallbladder.

My illnesses seemed endless -- kidney stones, urinary tract infections, postsurgical blood clots that traveled to my lungs, the need to breathe pure oxygen 24 hours a day -- and, on several occasions, I was ready to throw in the towel and let God take me, by passive suicide, by doing nothing. At least I would be able to prepare myself for judgment before I died. I figured that might be preferable to a sudden, unexpected death, during which I would die more likely than not in mortal sin, with really bad prospects for eternity. But I was able to endure, thanks to the good counsel of friends who shared my faith, who helped me put my suffering into perspective, to see that it had meaning and purpose. Most of all, that it was important and beneficial.

It was after the kidney surgery that I had begun to have problems with my back. I had lost several pints of blood during the surgery and, according to Dr. Zúñiga, my heart stopped beating and my blood pressure fell to zero. "My balls were in my throat," Dr. Zúñiga would later tell me. But Zúñiga, again assisted by Dr. Aubanel, was able to save me, though what was supposed to be an hour and a half in surgery turned into nearly five hours, and I required multiple blood transfusions. "Now you really do have Mexican blood running through your veins," Zúñiga later joked. But two days after the surgery, I began to experience a stinging, burning pain in my lower right back. Tiny blisters formed in rows, and a large, angry red patch appeared. Diagnosis: herpes zoster, a reactivation of the chicken pox virus that had lain dormant in my nerves since childhood. Eventually, the blisters burst and the skin seemed to heal, but the angry red remained, and the stinging, scalding, stabbing pain got worse over time, to the point that I became consumed by it. It seemed ironic that, after so many more serious surgeries, a little viral infection was causing me more pain than I had ever experienced in my 56 years on earth. Dr. Zúñiga threw everything he knew at the problem, sent me to dermatologists and pain-management specialists, but the problem grew worse, until finally a foul-smelling wound about the size of a deck of cards appeared, seeping green-and-black liquid into my clothing. The smell lingered in any room I entered, a stench of raw sewage or rotting meat. It took a long time, but a diagnosis was ultimately arrived at: the herpes virus had opened up the skin, and, during my recent stay at Excel, I had contracted a hospital-borne "super bug," resistant to most antibiotics. My current stay at Hospital Angeles was the third time I had undergone a series of intravenous antibiotics, based on a culture of the wound. Surgeons had suggested cutting the whole mess out and applying a skin graft, but Zúñiga was against it: "This is very painful surgery with a very long recuperation -- maybe three or four months -- and would leave a big hole in your back. I'm not sure you would even survive the anesthesia, and there is no guarantee that the infection would not spread."

So here I was, back in the hospital in Tijuana. Now Zúñiga was talking about having me undergo treatment in a hyperbaric oxygen chamber, in which a patient breathes 100 percent oxygen under the pressure of two or three atmospheres. It is a standard treatment, apparently, for wounds that will not heal. As on almost all other occasions in which my cardiologist had suggested an expensive, complicated, or unusual procedure, I decided to check with the medical establishment in the U.S. before going ahead. I don't know why I persisted in this neurotic pattern: time after time, Zúñiga had been correct, both in his diagnosis and his recommended treatment. The hyperbaric chamber treatments, estimated to cost $9500 in Tijuana, would cost a lot more in the U.S. I checked with UCSD Medical Center and Paradise Valley Hospital: their price for the same treatment, $36,000. Besides, as a longtime expatriate, I had come to loathe American medicine. I have lived in Mexico since 1991 and over those years have received all my medical care in Tijuana -- from $10-a-visit general practitioners to top-of-the-line physicians like Zúñiga. Each time I ventured to the U.S. for a second opinion, I went home to Mexico vowing never to return to an American doctor. Doctors in the U.S. spend so little time with their patients -- processing them through in assembly-line fashion, barely familiar with their lives at all. I had seen cardiologists and dermatologists and surgeons in Chula Vista. Each time, I had to wait far longer than my scheduled appointment, and the modus operandi was always the same: fill out a medical history, be screened by a nurse, who took vital signs and made a brief note of "reason for today's visit." Then I was taken to an examining room, told to sit on an exam table and that the doctor would see me soon. I was left sitting in those exam rooms for as long as 45 minutes before the doctor arrived. I could hear the doctor pull my chart out of the box on the exam room door and leaf through it before entering, satisfied, apparently, with the CliffsNotes version of my medical history. "What can I do for you today?" was the usual query from the doctor, who spent maybe 15 minutes -- 20 minutes max -- with me.

By contrast, an office visit to Dr. Zúñiga lasted from one to two hours. Once buzzed into the doctor's office -- for some reason I had to press an intercom button and be cleared for entry first as the doctor watched from a closed-circuit camera in his office to give the thumbs up or thumbs down -- the doctor's staff greeted me by my first name, and they were always solicitous of how I was feeling. Before any tests or exams, Dr. Zúñiga always spent about 20 minutes catching up on my life: How was work? Romance? Home life? Any interesting new projects? Dr. Zúñiga would also share a little of his life -- problems his kids were having in school, discussions of Mexican and American politics, border traffic, the latest headlines. Then he got to the medical problems, checked my vital signs, and performed whatever diagnostic testing I needed. On one or two occasions I needed emergency, after-hours diagnostic tests, a CAT scan or an MRI, and Dr. Zúñiga always accompanied me. Zúñiga was attentive to details other doctors might forget: if I were told to fast before coming to my appointment for blood tests, Zúñiga always suggested that after the blood was drawn, I grab a sandwich and something to drink at a tiny cafeteria two floors below his office. It was a slow, thorough, deliberate kind of medicine that Dr. Zúñiga practiced. The doctor called it "clinically based medicine." He said American doctors focused too much on the abstract -- on textbook theories and impersonal tests. Zúñiga said he preferred making his medical decisions based on a broader collection of facts -- his "clinical judgment," developed over many years of seeing many patients.

Mexico Has the Same Standard of Care as the U.S.

So it was always vexing to Dr. Zúñiga when I would return from one of those visits to the U.S. with concerns of one kind or another put into my head by American doctors: that the medicines I was taking could have serious side effects; that a particular surgical procedure was too serious to have done in Tijuana. "The chances of side effects are minimal," he told me. "Yes, there could be side effects. That's why I keep tabs on your status with blood studies. But the chances are very small against the help to you. I think these American doctors worry too much about being sued. Sure, there could be serious side effects. These are powerful medicines. But you could also leave my office and be run over by a bus. You have about the same chances of having a serious complication." As for having complicated and dangerous surgery in Tijuana, Zúñiga fumed, "You get the same standard of care here as there," he said. "Only it costs about half as much." Then he would recite a litany of places where he had studied in the U.S. over the years, pulling out certificates and diplomas from the Cleveland Clinic, the Mayo Clinic, a heart-specialty hospital in Texas, and international cardiology conferences in Paris, Madrid, and Amsterdam. In fact, in the years I had been seeing Zúñiga, the doctor was always traveling to one conference or another to update his skills. And he had U.S. contacts to vouch for him. Before the renal angioplasty, when I was balking at having the procedure, Zúñiga put me online with a doctor from the Cleveland Clinic who reassured me that my "malignant hypertension" would destroy my kidney and ruin my heart, that the surgery was necessary. When I told him that a U.S. surgeon had insisted that the only way to treat the wound on my back was by radical surgery, Zúñiga responded, "Of course he thinks surgery is the way to go. He is a surgeon. That is what surgeons do -- surgery." But any surgeon would need clearance from a cardiologist first because "such surgery could kill you."

Zúñiga was not without his detractors, although, as it turned out, the reasons some doctors did not like Zúñiga had little to do with medicine and more to do with longstanding grudges, nurtured for years because of some perceived slight. On the advice of a priest friend, I had sought a second opinion before my kidney surgery from a cardiologist who had once been a professor under whom Zúñiga had studied at the Autonomous University of Baja California. (The priest, it turns out, did not like Zúñiga because of his association with Dr. Aubanel, who had renamed the cardiology service at Hospital del Prado the "Mother Teresa Cardiology Center." Father was miffed by the doctor's expropriation of the saintly nun's name.) As far as the former professor was concerned, Zúñiga had pestered the professor for a letter of recommendation to a prestigious residency program in Mexico City -- but once Zúñiga had been accepted, reports came back to the professor that the young medical student had skipped some classes. "He was not a serious student," the erstwhile professor, now returned to private practice, fumed. "He embarrassed me." The ex-professor recommended against the surgery and placed me on tranquilizers. In the meantime, my blood pressure was surging out of control. Even though I was taking six different blood-pressure medicines, my blood pressure stayed dangerously high, and the walls of my heart muscle were thickening from all the extra work. A third cardiologist had me wear a 24-hour monitoring device of my blood pressure and came up with the same diagnosis as Zúñiga: renal stenosis. Before-and-after radioactive imaging studies of my right kidney showed a remarkable change: my right kidney, once perhaps a fourth of the size of the left, had begun to grow again once the blood supply had been restored. And my blood pressure, taken repeatedly over the course of a year, had returned to normal. Zúñiga had been right again.

The morning after I was released from Hospital Angeles, as I stood in my front yard drinking my customary cup of strong black coffee and enviously watching people going about their normal routines, my next-door neighbor Raquel, a homemaker in her early 60s, walked up. "How are you feeling?" she asked. I told her I was feeling better but not the best. "Well, these things take time," she said. "We have all been worried about you. Glad to see you are back home. Can I offer you anything?" "No, not at the moment," I said, thanking her. "You be sure to let me know if you need anything. You've got my number. Anything at all." It was not as if Raquel did not have her hands full already. She was taking care of her elderly mother, who lived with her, and babysat her granddaughter while her daughter studied at Southwestern College. ("A big waste of time," her father had once confided to me of his daughter's studies. "But what can I do? I'm outnumbered three-to-one by the women.")

Back Home... in Tijuana

Other neighbors -- the same ones who every Christmas brought me gifts of food and wine, matched Raquel's kindness. The young wife of a fellow who lived in an apartment above an ice-cream store around the corner and sold water heaters for a living also had stopped by to ask if I needed anything, as did the 86-year-old matriarch of the extended family next door. That was another feature of this neighborhood I liked a lot -- the big Mexican families all living together. All around me, families of grandmas and grandpas, their children and their grandchildren all live together in the family home. Everyone knows everyone, and suspicious strangers are quickly noted. Once, a friend had come to visit me around 11:00 p.m., but I was away. The friend decided to wait and fell asleep in his car in front of my home. Raquel called the police. More recently, I had fallen asleep midafternoon and left the front door standing open. I was awakened by Beatriz from across the street, who came to my door shouting, "Robert! Robert! Are you okay?"

In the ensuing days, perhaps six other neighbors had tapped at my gate, inquiring about my well-being. A young barber and his wife strolled by with their two children, a boy of one, a girl in first grade. They agreed to take turns cleansing my wound and changing my bandages three times a day. It was not a totally altruistic gesture, I knew. I pay them $35 a week for their help -- not much to me, but for them, a way to put food on the table. They are careful, honest, considerate, and punctual. And I did not have to make repeat trips to the hospital every day for the service, so it was a good deal as far as I was concerned. The latest round of antibiotics did seem to be working. The wound had shrunk and was less painful, the foul smell was gone, and it was leaking only a straw-colored liquid, which Dr. Zúñiga said was a good sign. Lots of pink, new tissue was growing in where before had been an open sore. Zúñiga called off the hyperbaric chamber for the time being, waiting to see what course the illness would take. Although the final outcome still remains uncertain, I am getting better. But best of all, I am back home.

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I also am an American living in Mexico and loving it. Agree with the author about the medical care. Since I have no med insurance I receive all my care here and agree that the standard of care is as good as, and even surpasses the care I have received in the US. The doctors here do spend so much more time with me and seem to be more thorough and LISTEN. I have had nothing but great experiences with both dentists and MDs. A nagging bladder infection was cleared up after years of suffering under the care of an Hermosillo urologist. A son in law found relief with a simple cream subscribed by a dermatologist for his bad case of phoriasis (sp?), and this after considerable expensive care in the US. The Cima Hospital in Hermosillo is one of the best and comparable to any US hospital, but at a cost of 25% to 50% of what a US hospital charges. Our friends are shocked that my husband and I get our medical needs taken care of in Mexico!

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