The day a friend arrived to join me in Khartoum, it was 117° F and zero humidity. With a journalist's relentless curiosity, she was eager to see and do as much as she could. Our itinerary even included a visit to the camel market in nearby Omdurman. By evening, she was near to heatstroke.

We operated for 3 days, and on the fourth morning, we gathered the entire crowd of patients and their families outside the hospital and handed out the eye medicines. I thought the Cataract Camp was over. But then, the people began coming up to us, placing khatas—white scarves traditionally presented as a way to honor and give thanks—around our necks. I was overwhelmed and sought refuge in the building. The people gently followed, placing layers of khatas around my neck. I stood there in the large, worn hospital entranceway, embarrassed and in tears, until it seemed I could politely retreat again. When I went upstairs, an elderly man in a shabby, gray traditional Tibetan overcoat followed. He spoke to me while placing another khata around my neck. “He says that he will pray for you and pray for your children and pray for your safe journey home,” said the translator. “And he says that after he is reincarnated, in his next life, again he will pray for you.”

We first saw this child in 1995 and again in 1997, read the textbooks about her problem, and consulted famous eye plastic surgeons. We learned that it's impossible to make her eyes anything close to normal and unlikely that we could permanently improve her vision much. We debated trying to improve one eye, but were dissuaded by Dr Palden, a Tibetan doctor. He explained that with her appearance, she would have a secure life as a beggar and we'd destroy that if we operated.

A photographer for National Geographic told me about fighting with the picture editors when he returned from an assignment in rural Africa. They wanted images of Africans in “traditional native dress,” but in his pictures, people were wearing western castoffs, such as worn-out rock concert t-shirts. I've seen the same thing, such as an elder of the Karamoja tribe in the wild Northeast corner of Uganda attending a tribal rain ceremony wearing nothing but a woman's tweed, oatmeal-colored winter overcoat that I'll bet was worn previously by an elderly woman in Chicago. Clothes travel and the journey tells a compelling story about the global economy. From the sweatshops of the developing world, shirts, jackets, trousers, and skirts make their way to the shelves at Walmart and even the boutiques of Fifth Avenue and Rodeo Drive. After they are worn out or unfashionable, we dump them in thrift shops for a tax writeoff and, finally, the cycle is completed when the residue that no one in America wants is sold by the ton and shipped to the rural markets of Africa. Clothes are an emblem of the westernization of the world and the reach, power, and inequity of the global economy.

Sith Nihm was a Cambodian refugee, the wife of a high-placed official who had been murdered by the Khmer Rouge. She was near death when she arrived on the ward. Malnourished and diabetic, she had tuberculosis or multiple bacterial lung abscesses or both (we were never sure), and a terrible breast infection. Her damaged grace and vulnerability seemed to embody the Cambodian refugees we were trying to help. We gave her high doses of penicillin intravenously for the lung abscesses and triple drug therapy for tuberculosis. We administered insulin and developed a schedule so that different family members and even other patients on the ward took turns feeding her and helping her walk around the ward. Finally, after a mastectomy (even with antibiotic therapy her breast infection could not be controlled), she started to regain her health. Her breast was still bandaged a week after surgery when I made this photograph. Like many physicians, I've had patients that become part of the landscape of my memory—vivid figures that never entirely leave my life. I dreamed about Nihm, the first dream I had after I returned to San Francisco from Thailand, A month later, a colleague returning from the Thai-Cambodian border called to tell me that Nihm had relapsed and died.

Health care in developing countries is not a "zero sum game"

When I worked in a refugee camp on the Cambodian border in the spring of1980, we encouraged breast-feeding as an important measure to reduce infant mortality. We regarded Nestle Corporation, then the most aggressive peddler of infant formula in developing countries, as the devil incarnate. We circulated information sheets denouncingNestle, and we posted signs all over camp and our ward that baby bottles were forbidden. One day, I caught a woman bottle-feeding her infant on our ward. Later, when I continued my rounds, I notice her still in tears, and I learned that she had tried to breast-feed but hadn't any milk. She had spent a small fortune with a Krou Khymer, a traditional healer, trying different herbs, and then went to the black market and spent more money buying western medicines.She'd tried quinine, penicillin, and chloramphenicol, all without success. I regret harshly chastising her, but there were good reasons for us to encourage breast- over bottle-feeding. There was often no clean water to mix formula and no refrigeration to prevent the formula from turning bad. Formula offered lower quality nutrition compared to breast milk and none of its antibodies. Bottles were also expensive. But now, there is an HIV epidemic. In some countries of sub-Saharan Africa, up to 20% of women of childbearing age are infected. Breast-feeding may carry a death sentence by transmitting HIV from mother to child.

To the Editor.— We have made two observations relevant to the article "Predictors of Bleeding During Heparin Therapy," by Walker and Jick (1980;244:1209). First, commonly used therapeutic doses of heparin sodium may cause a substantial reversible platelet dysfunction as measured by the bleeding time. Heparin sodium was administered to a population of healthy young volunteers in an intravenous bolus dose of 100 units/kg. Before heparin, the template bleeding time1was 5.3±1.9 minutes (mean±1 SD); ten minutes after injection it was 9.8±5.6 minutes (P<.001). In these experiments heparin's effect on the bleeding time varied considerably. In 20 of the 46 studies (43%), there was a negligible bleeding time change (one minute or less). In another 20 of 46 studies (43%), the bleeding time prolonged beyond a normal limit of nine minutes. In seven of this latter group (15% of the total), the incision was still bleeding at 20 minutes