“Turning a ‘No’ Into a ‘Yes’–How To Adapt Your Mission For Success When Conditions Change”
Blog by Volunteer Doctor Jordan Amor-Robertson, MD (Pediatrics; Australia)
On my last weekend with the Floating Doctors a multiday clinic was scheduled in Bahia Azul (Bluefields), a Ngobe village which is on the mainland, however is only accessible by sea. We were fortunate enough to have some rather impressive friends (JP, a doctor, and Marie, a dietician) with a rather impressive boat called ‘Domino’ who invited us aboard for the journey. We even managed to fit in a spot of fishing along the way, reeling a couple of decent sized tuna, with the first fish-catcher (luckily not me) being required to eat the tuna’s still beating heart!
We had initially planned to run the weekend as a standard primary health clinic, as well as going house-to-house conducting a survey at the request of the community leaders to establish the degree of health knowledge with regards to HIV/AIDS, risk factors of the individuals and to perform clinical screening examinations for any features suspicious for AIDs. Unfortunately, shortly after our arrival, we received word that our application to practice medicine in Bocas had finally reached the national Ministry for Health and, whilst we had been granted approval to run clinics by both the local and state health ministries over a year earlier, we were advised that we were to suspend all clinical operations until such time as we managed to clear the required bureaucratic hurdles.
Now this posed a problem. The local Peace Corps Worker had invested a lot of time spreading the word to the community that we would be coming to do a clinic and laying the foundations for our HIV surveys. How could we now explain to people that yes, we had arrived in Bahia Azul, but actually no, we would not be doing a clinic. And, even worse, how could we possibly turn away the sick patients that would undoubtedly present for treatment? Do we turn-tail and commence the 4 hour boat ride back home straight away?
As it turned out, this was not the disaster it first appeared to be, but rather an opportunity in disguise. After a hurried brainstorming session, the decision was made to host a ‘charla’ or discussion and to share a lunch with the community. This would give us a rare opportunity to develop the Public Health aspect of our operations, something that is an important long-term focus for the Floating Doctors, however is often put aside somewhat during a multiday, in the face of a hectic clinical work-load.
We split into groups of 3 or 4, heading off in different directions in an attempt to reach as many families as possible to advise them of this unexpected change of plans (and to invite them to lunch!) A casual stroll through the jungle, thought I, on this glorious tropical day. Appointed our trusty guide, a young Ngobe boy who wants to be a teacher one day, Jenny, Lorie and I set off into the jungle, stopping at each dwelling along the way. We were welcomed into homes where we were given gifts of shells, bananas and guayaba and I even managed to fit in a little shopping along the way – in the form of a colourful traditional handwoven bag.
Unfortunately Lorie had difficulty negotiating the first major hurdle – a dauntingly steep and slippery hill – and parted ways with Jenny and I. I later learned that Lorie, in true Lorie fashion, had befriended the occupants of the house at the bottom of the hill (despite speaking minimal Spanish) and spent the morning engaging them in songs and colouring-in sessions.
Meanwhile, back on the jungle trail, Jenny and I were feeling increasingly like intrepid explorers, ducking under vines, clambering over rocks, leaping over puddles. And then it got real! Our guide ushered us into a kayuke (a traditional dug-out canoe), making sure that the inexperienced gringas were carefully balanced to avoid capsizing, and started paddling up through a mangrove river. We arrived at our…destination? A patch of muddy mangrove ground, indistinguishable from the other patches of muddy mangrove ground we had passed along the way. Apparently this was the only way to access the next lot of houses up on the hill that lead around the bay.
I stepped out of the kayuke tentatively, immediately realizing that my trusty Aussie thongs (or flip-flops as the rest of the world seems to call them) were grossly inadequate for this kind of terrain, losing both in the mud at the very first step. So shoes off it was, and I set off, barefoot, through the mangrove mud, as the crabs and miscellaneous other creep-crawlies scuttled out of the way. Now this is not the ideal way to greet strangers; barefoot, sweaty, mud up to the knees (and splattered even higher as a result of various misadventures), but still the matriarch of the next house greeted us warmly, offered us water to wash out feet and proudly showed us her garden.
And so this continued, from one house to the next, until it was time to return to the centre of the village for the Charla and the delicious lunch that the village women had prepared from our supplies. And, as exciting and memorable as the morning had been, this is the moment that all our efforts came together. After a brief introduction we opened the floor to the community, encouraging them to identify their key health concerns, common issues in the community and things that they would like to learn more about.
The session ran better than we could possibly have hoped! With a very good showing from the community (we filled a whole classroom and many more peered in through the windows), and an even representation of both men and women, everyone was granted the opportunity to have their say. Quickly the conversation turned to the topic of HIV, something that we knew the community were concerned about, however we were not sure whether they would be keen to talk about such sensitive matters in the public forum.
Much to our delight both men and women stood up and spoke openly and frankly on what they knew about HIV, giving us the opportunity to dispel a few myths and to outline the basic facts about disease transmission, progression, symptoms, treatment and, most importantly, prevention strategies. As one older Ngobe woman pointed out to me – topics of sex and sexual health were traditionally taboo, however now the discussions are too important to be avoided. For the sake of the health of her children she wanted to make sure they were educated on such matters so that they would know how to protect themselves.
Rather than being upset or annoyed that we were, on this occasion, unable to provide the primary health care services that are so needed, and so inaccessible to the people of Bahia Azul, they were excited to have the opportunity to discuss the key health concerns of the community, knowing that this would help the Floating Doctors and the local community to work together better in the future. That weekend was just the beginning – on subsequent visits to Bahia Azul the Floating Doctors intend to have ongoing conversations with the community about what they want and ongoing Public Health Education sessions. We are also hoping to do some capacity building with the local parteras (midwives) and other interested members of the community, many of whom have already nominated themselves as wanting to up-skill in basic health care so that they can act as Community Health Workers, allowing for a permanent health-care presence in the community.
That particular weekend was special, but it was in no way unique. During my time with the Floating Doctors there were countless occasions where we had the opportunity to engage with the local community, working with them and for them, to enact change and to begin establishing grass-roots health initiatives. I returned to my home in Australia revitalised and inspired, already planning my next stint in Panama with the Floating Doctors and the Ngobe communities of Bocas Del Toro.
When I last posted in June, a couple of months in, we had just started to really connect with the various subcultures in the Bocas Province, and some situations we quickly identified for interventional projects were as yet beyond our reach. Now we have many more friends and contacts in the community, and we can tackle much more ambitious projects for far less cost.
• Partnered with local group Operation Safe Water to help transport and install raincatcher systems at local schools when we run clinics
• Arranged CPR certification for the fire department
• Worked with the Ministry of Education to train local high school students as trainers for health education in the community and give them medical work experience by participating in our mobile clinics
• Created pictorial and written information sheets on health issues we have identified and that we make available at our clinics
• Gathered and data-entered over 600 patient health data sets and begun doing surveillance of our own interventions and identifying health issues from the data to help guide our mission activities
• Microfinanced patient transports to care on the mainland and chaperoned them in the hospital system (many Ngobe don’t speak Spanish, and are VERY shy, so they easily fall through cracks in systems)
• Connected with an indigenous Curandero to identify and investigate the plants he uses medicinally and are helping him develop his small botanical laboratory always keeping a lookout for.
• Arranged and executed a CPR and First Aid Seminar for the cruising community in Bocas
• Partnered with the Mayor’s Office to run mobile clinics in conjunction with the government visits to the community
• Partnered with the local Lion’s Club to work in a community they support and help supply the neonatal support unit they built with Direct Relief International supplies
And, as always, sometimes we find situations that are just not right. Por ejemplo…
While I was in California, Dr. Barney found out about a 14-year-old girl with what turned out to be undiagnosed cerebral palsy in a small squatter’s community called La Solucion. I have been told it used to be where the airport is now (right next to a mangrove swamp), and when they built the airport the community moved out onto shacks built on stilts over the mangrove mud.
She comes to land at most twice a year…land is about 100 feet away over the sewage-contaminated swamp (all the homes
have outhouses and sink drains that drain directly into the water below). She has never gone to school…she has a wheelchair, but rarely uses it because she has nowhere to go; she has to be carried over the dangerous footbridge by her grandfather, and she is too big now for him to carry (Noah noticed he has drop-foot also…potentially a serious falling hazard, especially if you are carrying your 14-y.o granddaughter over a wet slippery footbridge). She is COVERED in bug bites…she can’t really swat bugs away or keep moving to keep them off her, and she lives in an open unscreened house on stilts over mangroves.
Her grandparents have always thought they were at fault for her CP because she fell out of bed at 6 months (though she had never crawled, which makes me think it probably was CP at birth)…they have carried that burden and they always worried they would get in trouble if the hospital found out, so they have indicated that she has never seen a doctor.
If I were a Hollywood writer writing for some medical drama, my editor would probably throw me out of the building for it being so unbelievably challenging emotionally and physically…but this is real life…this is somebody’s actual life. Sometimes people ask if I miss ‘the real world’…let me tell you, it looks pretty real from where I’m standing.
We said we would build her a walkway, and now—6 months into our time in the community—we called on the community to help and EVERY level of Bocas society came together to make it happen. Mangrove posts from an indigenous community, lumber and funds and food from local Panamanians and expats, help from boat owners, crew on other boats, locals from La Solucion, local taxi drivers, local restaraunts…at the last minute we even had no trouble rounding up 2 sledgehammers (one from the fire department and one from the fish market, which I sometimes haunt in the afternoons when the fishing canoes come in).
Everyone gave a little (some more than a little), and in 5 hours we sank thirty 10-foot mangrove tree trunks 7 feet into the mud, from the shore all the way to her grandparents’ house. The walkway went on in the next few days, and then this little girl went to shore (we still have some work to do to finish the walkway and make it safer for a wheelchair). I asked if there was anything in particular she wanted to do on shore (which she can see, 100 feet away) and she said ‘Quiero pasier’—‘I just want to go.’
This is my favorite, favorite kind of project…one where the whole community comes together when it learns about a situation like this. When the walkway is done, it will have been done right, with the right material (always seek expert advice) to make it last for many years. No matter what, this girl’s life is going to be changed forever—and here’s the best part: total cost for all the lumber, food for the volunteers actually building the walkway, gas to go pick up the posts from another island, hardware, etc: less than $1000.
There’s opportunities for helping, constantly around us…when we are alone we can help in small ways…but mira aqui, look what we can do when we all come together! Poco a poco para cambiar el mundo.
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The last time I wrote a blog, an unconscionable number of months ago, we had recently arrived here to Bocas del Toro and I ended the blog excited by what might be possible over the coming months…now those coming months have passed, and it is time to catch everyone up and take stock of what we have accomplished here in.
6 months ago feels like a million years ago…with more long-term volunteers, we’ve been able
to really expand some parts of our project, including self-surveillance. I looked at what we had done—how many mobile clinics, how many volunteers, how many projects, how many patients…it is overwhelming to try and describe. I should either write bullet points, or a 3-volume novel to describe everything since my last update.
Over most of our time here, for example, for every 3 days we were here, we ran one day of mobile clinic work—even counting rained-out days (and it rains 150 inches a year here) and days we were involved in any other kind of activity, whether it was working on boat projects, escorting patients to the mainland to get treatment, holding office hours in our consultorio, working in the asilo, eating, sleeping, or doing anything else. We’ve seen over 3,000 patients in more than 17 communities that we visit on a roughly 2-month rotation across the entire province of Bocas (an area of over 4,500 square kilometers), in addition to all our other activities.
No matter what other projects we get involved in, the core of Floating Doctors is our mobility—even the permanent clinics we are now working to establish are to serve as bases from which to continually run mobile clinics by panga, as we have done everywhere we go. I’m incredibly proud of all my volunteers and my crew for maintaining that level of dedication to work one day of mobile clinic for every 3 days we were here.
We’ve seen a lot of different communities, and noticed that there are enormous clusterings of health issues in different small communities that at a glance may seem similar. Why does one community have an incredibly high rate of obesity and diabetes, while the neighboring community has no obesity or diabetes but has lots of parasites? We have gathered detailed demographic and health data on over 550 patients so far, community assessments on a dozen different communities, and are beginning focused projects based on issues we have prioritized based on the data so far. Results of our first survey project coming in the new year…
We’ve started doing overnight and multi-day mobile clinics—getting two or more clinic days for the price of one day’s travel, since our accommodations have almost always been in the homes of local members of the community, or expats who notify the community that we are coming, house and feed our team, and often allow us to use their facilities to hold our clinic and arrange our transport to work in communities near their homes. I have been overwhelmed by the generosity of the expat and local community here…I have never worked anywhere—in the developing or the developed world—where the community at every level will actually deliver on its promises of support like here. From the Mayor sending trucks to help us cart garbage out of the nursing home, and letting us use his old consulting room to open for patient consults two days a week to the local marina workers who are giving their Sunday to help drive 36 10-foot posts into stinking mud to build a wheel-chair walkway, this is a wonderful community, with many eccentric people (after all, we are here too) and many people with good hearts who have shown us enormous kindness and support for our work here. Thank you to everyone—this is what makes Floating Doctors possible. A thousand hands holding us afloat…
We’ve also joined forces with the Peace Corps volunteers scattered throughout the province;
Peace corps Volunteers have thus far been 100% reliable—individual peace corps volunteers live (very often alone) in a community and work on a project. We got in contact with one, on the mainland, and ran a mobile clinic at his village…it is so awesome to arrive with everyone notified, a place to work, directions, someone to help interpret and to give us the inside scoop on patients we are meeting for the first time, someone to pre-arrange accommodation in the community, and best of all, the Peace Corps volunteers can and do follow up with patients that we have identified as needing more advanced care. This has been our experience with the Peace Corps every time we have worked with them, and we look forward to our upcoming multiday clinics to some new communities we are visiting through Peace Corps, including a Ngobe community way up in the mountains that I have heard a Peace Corps volunteer visited but that he thinks has NEVER been visited by a medical team. Looking forward to that later this week…
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