Today’s blog was written by one of our recent volunteers, Dr. Ravi Chokshi, just beginning a residency in Obstetrics and Gynecology. These are his thoughts and impressions of our 4-day mobile clinic up in the mountains to a remote village called La Sabana, or ‘The Grasslands.” Over 200 patients were seen, including pediatric and trauma emergencies. Thanks Ravi! best of luck in your residency, and I look forward to working with you again.
He was different at first glance. Quieter. Saw more, spoke little and took his time to smile.
“It hurts here” he exclaimed pointing at his 12 year old heart.
I had examined 20 chests that day, listened to 20 hearts. But only his jumped at me as I lifted his shirt.
A heart that had decided the only way to get noticed was to become outgoing. I place my stethoscope and still the squall fighting within. My ears record and my fingers feel for the familiar radial pulse. There is a flaw here. A Woosh-woosh where a lub-dub should be. I bring over some counsel and we use the portable ultrasound to perform a tropical echocardiogram. What I had heard, we now see. A hole connecting the two atrial chambers of his heart, and a chance to be normal forever taken away.
By the second morning, we had hit our stride. Awake at 7am with the hum of the village around us. I wish that I could say that I
slept wonderfully on the hammock. Tied across the wooden beams of the village Rancho, covered in a mosquito net donated by the Lake County Sheriff Cliff Matthews.
I almost did, but the cold from the two rivers that flow around La Sabana got to me.
To build your own bed where the clinic just was. Settle into it with the laughter of new friends around and your mind alive with the memories of the day before you. Of the cold stream water you had bathed in, or the hojaldras and coffee that had started your day. Sleep comes easy and you drift imperceptibly towards it as the days’ labor catches up to you and the hungry river swims around you.
The cold shudders in, and you wake up surrounded by the chatter of excited Ngobe children. A quick breakfast and swim later you are ready for work. Walking back from the river you can already see a mass of patients organizing themselves around the rancho. In 10 minutes a fully functional clinic sits where we had just dismantled our bedroom. A pharmacy lies ready and capable. Our amazing interpreters have already lined up patients, sequestered the roving bands of excited children and started patient intake. I sit with my stethoscope around my neck, a clipboard on my school desk of a chair and try to look ready.
This is impossible.
And we begin! In groups of 4 to 6 the mothers and fathers patiently answer my questions posed in broken Spanish while the kids run around, openly gawking at me and my strange tools. As I address them, smiles break out. They are terribly shy and hide their little faces in their mother’s dresses. But I bring them out and I let them listen to their heart beat through my stethoscope and I see their eyes widen and them calling out their amigos to do the same. ‘Ahh this crazy gringo is funny’.
I hear about coughs and colds, about chronic pain, about diarrhea that just won’t go away. I examine distended bellies and the scars from years of no-see-um bites and battery acid burns from cured cutaneous leishmaniasis. Most of all I see the relief as I dispense Albendazole like candy telling them, “Este Medicamento va a quitar las lombrices de su estomago y su piel”. And I urge them to eat it in front of me. I work in a chain with 4 other doctors, most with many more years of experience than me and I confer with them constantly. I learn to recognize scabies and lice and infected wounds and what treatments we can offer for such. I get called occasionally for my input on obstetric patients, being that it is my area of interest.
Using the Sonosite I am able to show a woman 7 months pregnant her unborn child’s face and lips and nose. The kick she feels – she now sees and she can’t stop smiling. In a place where most of the people have never seen an outsider, a white person, or even a TV an ultrasound is magic and we are a mystery they are too polite to solve.
We are observed constantly. And for good reason. In a place as isolated as this from the rest of the world, we are as alien to them as
imaginable. Taking a picture of the children and showing it fascinates them. Then I realize why. There are no mirrors here, no still water. Their first good look at themselves is thru the lens of my camera.
These are the Ngöbe-Buglé Indians, Panama’s largest indigenous group. After years of historical fighting they were allowed to retain their ancestral lands largely confined to the western rainforests of Panama. Here in their Comarca, they implement their own system of governance and economy. In terms of healthcare they have a raw deal. A long history of poor interactions with outside groups (pretty much everyone since the first explorers) has left the Ngöbe understandably skeptical of ‘Meriginees’ (non-Ngabe people). As the mother of a very sick Ngöbe child put it to us, “the hospital is where we go to die.” Language is another barrier. While the Ngöbe men have reason to conduct business with communities in close contact with the mainland and thus have some Spanish speaking skills, the women and children are different matters. Not being able to speak Spanish in Panama is as isolating as it gets.
La Sabaña, the remote Ngobe village that we have made our way too, is one of the more isolated communities dotting the Chiriqui
province of Panama.
Our journey there begins at 5am from Bocas marina, where the Southern Wind currently rests.
A group of 9 odd, we sleepily catch a water taxi to our first destination – the port town of Almirante. Blazing through the Caribbean on a 200 horsepower boat is enough to get everyone up and awake.
?Costa Rica!, usted? is the banner cry as we disembark.
Ahh Almirante. A hastily thatched together port town created entirely by the Chiquita Banana Company, it is best described as a jump off point to better places.
Brushing off the taxi drivers, we find ourselves in a car on a 90-minute ride to the sleepy little village of Pueblo-Nuevo. A tasty Panamian breakfast of fried bread and coffee awaits us and now we are ready for our hike. Ben has hired horses to carry the supplies up the slope, while we carry only water and essentials on ourselves. A 3-hour hike when dry, 5 plus when wet and we approach La Sabaña by late afternoon.
La Sabaña – literally translating to ‘The Grasslands’ is a mesmerizing place. Found at the crossing of two rivers, its thatched huts and raised wooden floors are as living artifacts to the age before Panama won the geographical lottery and started collecting revenue from the canal. The Ngobe here live simple lives, the men work in agriculture and raise animals. The women take care of the children and keep the house, all while dressed in the colorful patterns unique to their culture.
It is here we are most in need.
Along with the storm, comes the call from up the mountain. A child has been hurt severely, on his foot by a self-inflicted machete cut. Ben quickly
dispenses half our group with the general surgeon on a race up the slope. I am part of the group that stays behind, together seeing the last few families waiting to be seen. The number of patients has been growing larger every day. Word has gotten around about us and families have traveled on foot for many hours to see a doctor, possibly for the first time in their lives. I have to remind myself of this, as I quietly ache to learn what is transpiring with our other half.
Hours we wait, the rain pouring down, the darkness absolute. The conversation feels forced, every one’s mind on our missing party and what has transpired with them.
Moments before a search party must be raised, their lights are spotted, little moonbeams making their way down the muddy path. They have returned, soaked to the bone but with stories to tell.
It had been necessary to amputate the 10 year old child’s little toe. Amputate it. In the darkness, working on a wooden floor guided by headlamps.
They had quelled the bleeding, stitched it together and addressed his pain as best as they could. We would return the next day with antibiotics and supplies to redress the wound. To leave supplies and to teach the family to keep the site clean. And a phone number to call, just in case.
By our last night the hammocks come up like clockwork. Clinic today had been a sold out success. Patients came from all around the mountain, with many families walking a day’s journey to reach us. We had worked like a well-oiled machine.
As we pack our boxes for the long journey back, the stories come through.
And its not the number of patients seen that we count, but the tooth brushes we had run out of. The soap we had no more off. The medicine for scabies we had to deny.
If there were patients to count, they were the ones we now had the responsibility of following up on. The 12 year old that needed to see a pediatric cardiologist. The women with suspicious breast lumps that needed mammograms, and the ones we couldn’t quite put a diagnosis on out in the field.
Ben and his crew will arrange transport, appointments with the necessary consultants and provide a voice of advocacy to accompany these patients.
What I have seen here erased all presumptions I had before the trip. We were there to see patients and dispense medicine yes, but much more importantly we were there to build trust. To raise the community up bit by bit. To give out toothbrushes and teach kids how to clean their teeth. To teach mothers to recognize dehydration in their children and how to make ORS. Most of all, to provide the village with an avenue of communication they could rely on when posed with a serious problem.
I had been promised an experience of a lifetime when I signed up to volunteer. I say they undersold it.
Four days I lived alongside the Ngöbe Indians. Absolute cutout from the world I knew and an absolute outsider to this hidden world that time had forgotten. I almost died. I very nearly lived. I fell in love again. I yearned to go on, to live this fantasy of waking up in a hammock with lines of patients to see and a fast flowing river to bathe in. Four days is much too short but somehow felt like a lifetime in terms of lessons learned.
In a few short weeks I will return to the US to train in one of the most developed and technologically advanced healthcare systems in the world. I will learns volumes everyday and gain skill sets I ache to possess. But it will always be in a remote Ngöbe village in the protected area of western Panama where I first really learned the gravity of the promise we make everyday on saying these words, “Me llamo Ravi. Soy su Doctor”.
Added by Ben La Brot:
“It is from the numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal or acts to improve the lot of others or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”
–Robert F. Kennedy speech in South Africa, carved in stone on his grave.
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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…
Petit-Goave, Haiti–Almost a Year To The Day We First Arrived Here In 2010
This is the overdue final chapter of our voyage from Honduras to Haiti, bringing supplies for the cholera relief and personnel for a string of clinics and villages along the north coast.
After our repairs in Kingston were complete, all that remained was to chomp on the bit while only 40 miles away on the north side of Jamaica’s Blue Mountains a series of storms swept down the Windward Passage and collided with a SE swell across our path. At the first day when the swells and wind subsided, we left Kingston at first light and made all speed for the Windward Passage. Once we got out of the shadow of Jamaica, we encountered the most disorganized sea I’ve ever seen—in the space of five minutes we would encounter NE, SE, W, and N swell…thank god the wind had died or it would have been a horrible bathtub; as it was it was merely uncomfortable until we ghosted into the protection of the Bay of Haiti and at last dropped anchor in Petit-Goave, the first place we ever went for a mission…almost a year to the day that we first arrived in Haiti.
An hour after we dropped anchor, in the dead of night, our first friend from Petit-Goave,
Aniel, came out in a canoe…the next day, we saw dozens of people we knew; we went back to the DesGranges clinic and saw Meomene and ‘Cheeks’ and the kids who were there when we left. The two schools we built are now surrounded by larger concrete structures in mid construction; a larger future school sponsored by Korea, I think…but when we walked up to our little schools, each one was packed with kids and classes were in session as they have been since we built them. That was a great feeling…the pharmacy we cleaned and reorganized, and the day patient treatment room and the minor ops room were all organized and cleaned as when we left, and more rebuilding and expansion was still going on. We left a box of supplies for Dr. Cutler, an MD from L.A. who we arranged to go out ahead of us last year and who is returning to Petit-Goave to volunteer again this year—I think he actually arrived yesterday, as a matter of fact.
It was so different arriving here this time…amazingly, most of the rubble had been cleared, and most of the tents crowding every street were nowhere in sight. Some houses had been rebuilt (in concrete block without much rebar and suspect cement), but we saw hundreds of wood frame and tin roof one-room structures, on new poured concrete foundations from (apparently) a Swiss-led European consortium. More commerce was happening, some small businesses had reopened, and the central park was clear of tents and refugees.
I admit, when we left Petit-Goave after witnessing both the massive problems the
Haitians wake up to every morning and the effects of much of the relief efforts after the earthquake, I was not expecting the level of improvement that we saw. My journey to Port-Au-Prince to drop a volunteer off at the airport, however, was much more depressing…a city imploding on itself, with little visible progress over the past year of funds and relief being poured into it. Petit-Goave’s determination to pull itself out of its downward spiral it gave me a renewed hope for Haiti, a hope that I could see in the faces of all of our friends and the new people we saw.
The best moments for me came during the mobile clinics we ran, on the beach at Fort Liberte and in the ruins of an old French fort back from the coast a mile or so. I saw babies that I had ultrasounded 8 months ago and were born while we were away, patients showed me their thin scars where large machete wounds used to be…when I pulled onto the beach in the first load (two trips in the skiff from the boat to our clinic), the kids in the village saw us coming and ran down the beach yelling ‘Sky?! Rachel?!’ and we were surrounded by everyone we knew and treated in the mobile clinics last year. We wormed everyone again, handed out thousands of vitamins, and saw the usual litany of problems great and small—but we saw one patient in our first mobile clinic–less than 18 hors after we arrived–that made the whole 38 days of struggle and travel to get to Haiti worthwhile.
In the little enclave of cactus on the shore west of Petit-Goave, sitting in the same spot
that we did our very first ever mobile clinic as Floating Doctors, we saw a 6-day old baby with an eye infection from Chlamydia or gonorrhea (or both) acquired during birth. This is a very serious, time sensitive problem–a few more days untreated and scarring develops, blinding the child forever (and cross infection and blinding in the originally uninfected eye are very common). We treated the mom and dad and used several days of rigorous cleaning and washing, and antibiotic eye ointment, and the greatest moment of our return for me was watching the pus-filled swollen eye lose its swelling and turn clear—just a few more days and the baby would probably have been blind forever.
It’s not about saving the day, or being a hero…it’s about timing. It’s about being there, and being available as a resource to people who have no other options. A single patient treated at just the right place and just the right time to prevent a lifetime’s worth of suffering for a baby already born into a hard existence. If we had not been delayed by bad weather and bad fuel on the way from Honduras to Haiti, we would have arrived and departed Petit-Goave for Cap Haitian weeks before the baby was born…and when we finished working around Cap Haitian and returned to Petit-Goave, we would have found a blind 1 month old baby.
Life tends to unfold on schedule…not always the schedule I want, and most of the time I never get to know why things happen just the way they do. But sometimes we get a glimpse of a purpose…sometimes what we endure in life makes sense after the fact, and every moment of struggle and frustration and discomfort and fear during the voyage here suddenly became a price I would pay a hundred times over if it meant being able to be there at that exact moment with everything necessary so that baby will get the chance to grow up with both its eyes working.
Dr. Holly saw the baby and when I wandered over to investigate and the problem became
clear, I though “Ahhhhh….so THAT was why we had to go through that crossing.” If we saw not a single other patient there are people who would say the journey was wasted…the old numbers game; people always want to know how many patients seen (over 5,000 so far), how many vitamins (over a million given away so far), etc…and those numbers are important in making sure the investment of resources is not ‘wasted’…but when I get a patient like that baby, the numbers become meaningless and that one patient becomes, for a moment, your whole reason for existing at all.
To that baby and her parents and to me, it seemed pretty worthwhile that we were there and equipped to help…and we see hundreds of people like this, whose paths cross ours at crucial moments when only a small intervention is necessary to change a life forever.
And with each such patient, our lives are also changed forever and a memory is created that I know I will playback to myself many years from now when my adventuring days have ended and smile and wonder how that little intervention in time played out on the world’s stage ove the years. I’ll likely never know–the years-later effects of what we do aren’t ultimately up to me, but I’ll always remember that we were able to help give people a chance at better lives and futures, and no one will ever be able to take that away from us.
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