By Dr. Kevin Lan, Dental Director
“You can never cross the ocean unless you lose sight of the shore.”
Now more than ever, we face a rising epidemic of dental caries in the teeth of children from the indigenous Ngäbe communities we serve. The combination of their inability to afford basic oral health products such as toothbrushes and toothpaste, poor education, lack of access to healthcare, compounded by a sharp increase in consumption of refined, sugary hot and cold drinks, has resulted in many children with decayed and broken down teeth, especially in their newly developed adult teeth, ones that will not be replaced.
2018 saw the Floating Doctors dental program explore new horizons and greatly increase our services provided to the communities of the Bocas del Toro Archipelago. We established our first mobile dental team, held independent dental clinics, provided continuous oral health education and prevention, recorded dental health in the communities for research and we have hosted dental groups from the University of California Santa Barbara and the Dental Humanitarian Outreach Program (DHOP) of the University of Southern California.
14 undergraduate students from UCSB and 3 dentists visited and stayed in the communities of Nance de Risco and Cerro Brujo, where 156 patients were seen and treated. The challenges faced by this team were numerous; it was our first dental only deployment away from the medical team, the first time we had stayed in two communities and worked 4 days consecutively, whilst setting up and packing away our equipment in between both communities and working the same day. The success of this group can only be measured by the amount of hard work put in by our FD staff and the UCSB group where despite being constantly pushed outside of their comfort zones, numerous students embraced the opportunity to learn and be part of a positive life changing experience where they sought to give to those who had less, rather than how their time with us could benefit them.
DHOP held 6 clinic days from the 9th -14th December in Bocas del Toro. A total of 90 dentists, dental students and FD staff, worked tirelessly each day from 7am – 7pm in temperatures above 85°F, providing dental care to over 700 patients from 20 communities in the Bocas del Toro Archipelago, where some were transported 3 hours by our boats. The DHOP clinic was a very emotional experience to work alongside such a dedicated, skilled and high spirited group where it was heartwarming to see people from communities that we know, receive high quality advanced dental treatment, like Root Canal Treatment which we could not normally provide when in their community. This is the difference between saving or losing a tooth. I will never forget the family of 4 who had traveled the whole day to attend our clinic, where a 10 year old girl had fallen and broken her upper front teeth 3 weeks ago and required Root Canal Treatment. Due to the required treatment time and inability for this family to return home that day, they were given accommodation as they were unable to afford this themselves. The next day, her father could not express to me without tears in his eyes, how grateful he was for the care and compassion we had shown to his family.
For me, it is not the numbers of patients that we can see that drives our ambition to care for the Ngäbe people, but it is to be present for those who have been forgotten or unable to access healthcare and being able to make one little girl smile again without losing her front teeth. Floating Doctors is proud to host groups like UCSB and DHOP so that we can try and inspire the next generation of healthcare providers to educate and improve the lives of others, so that we can leave our communities and world better than we found it.
Walt Disney once said “All our dreams can come true, if we have the courage to pursue them.” 2018 saw Floating Doctors take big steps towards continuous and sustainable dental care to the communities we serve. 2019 will see huge development and partnerships being established as our family grows with increasing support from Europe and America. 2020 is still unknown for what the future holds, but I can predict that we will continue to work hard in providing dental care and education for the people in the communities who need our time, compassion and support against the challenges we will face together.
Through the courage of our team and those supporting us, our dreams are not far away from reality.
As the last days of the year draw to an end, I’ve been handed an impossible task.
It is traditional for NGO founders to write a post at the end of the year to summarize the work of the past year and to share with everyone the vision for the year ahead. When I sat down to do so, I momentarily panicked….how can I, in a few words, convey even a small sense of what hard-won achievements by our staff and volunteers this year? We grew from a single team to two medical teams and a dental and veterinary team deploying nearly every week. We launched a surgical program and our veterinary program blossomed. We made many new partnerships and grew our infrastructure, including building a laboratory. We published research. Patients received impossible treatments such as a new heart valve. I could go on and on well into the new year and never do justice to the victories for humanity won by women and men whose names will likely never be known to the world but whose kindness and courage will never, ever be forgotten by the people whose lives they impacted.
People like to lament how there is so much ugliness in the world, and my dad is fond of saying, “Of course there are ugly things in the world. For example, there are people dying of cancer in a hammock hanging under a shack in the jungle, and that is a horrible injustice. But there are also people–total strangers–who will pull that person out from under their house, clean them up and do their best to help them not die in pain and alone. And this is a beautiful thing in the world; an astonishing miracle.”
And it was this taking such personal responsibility for strangers that I watched my team do all year long that really struck me. People talk a lot these days about ‘Global Citizenship’ and ‘Global Leadership’ but I think both of those terms lack something. ‘Global Citizenship’ seems to indicate merely living in the world, passive, and ‘Global Leadership’ smacks of the hubris of knowing better than everyone else what is needed to lead the world to righteousness.
And finally this fall I realized what it was that Floating Doctors inspires in our volunteers, our supporters, our communities, and ourselves–Global STEWARDSHIP: the commitment to stand up and make a better world our own personal responsibility, in whatever ways we can every day. And that may seem like a semantic difference, but I think it is a critical one.
Every evening that I can, I take my daughter (who just turned 1 year old) outside when the sun is setting and hold her to the west and I whisper in her ear. I say to her, ‘Look Aya, the sun is setting. This day is done, and will never come again. There will never be another day like it as long as we live; we can never return and change it. Were we kind and loving today? Were we honest and truthful, with others and with ourselves? Did we work hard? Did we find time for play? Did we find an opportunity to show compassion, forgiveness, courage? Is there something we put our hands on today that was more like us when we took our hands away?” I have no idea how much of what I say she can understand…all I know is that she definitely understands more than I think she does. So this is what I tell her…and, truth be told, I need to tell to myself every day also.
She’s too young to to know that of course, it’s impossible for us to do all of these things every day. We are not saints. But it’s important to always aim high. After all, when you study for an exam, would you aim to get a C? If that’s as high as you raise your sights, that’s all you’ll ever achieve. Living things aren’t made to aim at mediocrity. All things strive–every living thing strives in an unforgiving universe, and to be human is to often stand with our feet in the mud, but reach always upwards towards the stars.
The best part is that we don’t have to achieve all those great things every day in order to change the world. We don’t have to free a nation or launch a movement or solve world hunger. As Bobby Kennedy said, “Few will have the greatness to bend history itself, but…it is from 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 which can sweep down the mightiest walls of oppression and resistance.” That still chokes me up very time I read it.
As you watch the sunset tonight wherever you may be, decide how you want to mark the end of the end of this year, for it will never come again. There will never be another like it as long as we live; we can never return and change it. But it is not too late–there is still time to show compassion, to be kind and loving, and to choose to be a steward of this world and send forth a tiny ripple of hope. 2018 was a year of staggering accomplishments by our staff and volunteers…but we are just getting started. A million different centers of energy and daring are building; the current against oppression and suffering will continue to grow but only with your help. A very funny and very wise lady, Lily Tomlin, said “I always thought ‘Somebody should do something about that.’ Then I realized I was somebody.”
Be somebody today, so that when the sun sets tonight, you can look to the west and hold your head high because in the twilight of the 2018 you put your hands on the world and made it a little more like you–a little more compassionate and caring–when you took your hands away.
Thanks for an amazing year, everyone. If you thought what we all accomplished together this year was something, just wait. We’re only getting warmed up. Happy New Year Everyone! Próspero Año Nuevo!
Dr. Ben LaBrot
by volunteer Trisha In
“Be sympathetic to the weakest, because the odds of silver and gold are what determines our lives. Some do not have the same fate as us, so if one day we have the ability to help others, do not overlook that.”
I took this quote from a reflection that my mom wrote in Khmer, the official language of Cambodia, which makes up half of who I am. The similarities between Cambodia and Panama in terms of healthcare was also a large reason why I wanted to go on this particular trip to begin with, but beyond that, something about this Panama trip instilled a strong inclination within me to get a passport and apply. I just felt like this particular one was meant for me. And it was, truly. There are a couple of things in my life that I feel like were absolutely bound to happen and this trip was one of them. It’s a bit funny though, because even a few days after coming home, I still find it hard to describe to others what my experience was like when asked. So much had happened, and it feels like an injustice to just pick one or two things to tell them about.
However, with that being said, there are a few instances that really stood out to me, ones that I hope to never forget as I continue on my pathway to become a dentist one day.
My most difficult moment occurred immediately after doing my oral health and education charla with my partner, Jamie, as well as doing a solo one for the adults as part of my DK Fellowship. It was not doing the “charlas”, per se, but I remember debriefing with Mary about everything afterwards and I couldn’t help but tear up. I think in my mind, I had always thought that education would be the solution to everything (to a certain extent, I will always believe that). After all, that is why I spent so much time in the states trying to focus on making educational materials both in and out of dentistry. However, I don’t think I realized that education can only take you so far when you are in a really resource-limited setting such as this one. I could preach all that I want about flossing, mouthwash, toothpaste, etc., but it doesn’t do the community any good if they cannot access these materials. Mary seemed to understand what I was saying despite my ramblings, and she also mentioned that it’s similar for nutrition—a lot of these families don’t work. They might harvest foods for their families, wait for rainwater, and fish for their survival. So for an outsider to come in and say to do X, Y, and Z can be insensitive to their culture, resources, and way of life. I related this to how ridiculous I find it in the states that we often preach to eat healthy, but if one goes to McDonald’s, a salad costs $7 and a hamburger costs $1.50. Mary and I concluded our discussion with her telling me that despite all challenges, we must remember that we are helping the community as best as we can, given the resources that both we have, and that is something to be proud of.
That moment was also special to me, because a few of the children from the schoolhouse followed me after the charla. I couldn’t recognize them at first, because they had changed out of their uniforms, but they told me in Spanish that they were our students from earlier. They kept following me around and it was one of the cutest things that ever happened to me. I was a little confused as to what they wanted, though. When I saw them a bit later in the day, I realized that they had seen the plastic bag of sunglasses in the pharmacy, and that was why they followed me. Unfortunately, I wasn’t as popular as I thought I was! I was, however, popular the following day in clinic when I was shadowing some of the other charlas. Since I was the one handing out water for a demonstration, I had about a dozen children follow me telling me to refill their cups so they could drink. Those cute faces made it so hard to say no, that I ended up giving them all of my water and eventually had to run away…but then they found me near the jerry can and I had to explain, “No tengo más aqua, lo siento.” On the surface level, it makes for a cute and funny story, but I could not help but remember the fact that this community does rely on rainwater as their main water source, do not have typical toilets or constant electricity.
Juxtaposition is one of my favorite words in the English language—my friends always make fun of me for using it, but it’s the perfect word to explain another aspect of my time in Quebrada Sal. A hilarious and unbelievable experience on our first day there: we walked to the beach in order to shower but were kicked off due to the filming of an upcoming reality TV show. Even more hilarious was when I learned that they wanted it to seem remote, which is why nobody could be on the beach. I couldn’t help but think: that seems so contrived, especially when we literally just walked through mud from an actually isolated community, on this same exact island, but instead here we are on this beautiful, white-sandy beach, that has a sign “Welcome to Paradise” right when you set foot. I had wondered if all of the cameramen and actors knew the life that existed right outside of this beauty.
Speaking of the community, there is something to be said about it here. Within the first 15 minutes of setting foot in it, while trying to find the Floating Doctors lodging area, a woman came running out of her house and asked us if there would be a dentist at the clinic the following day. When we told her that there would be, she told us “Mañana, yo voy.” I was surprised, honestly, because even in the states, I feel like going to the dentist is something that is severely under prioritized. I believed that most did not understand that oral health is an important part of overall health. It truly touched my heart that my first encounter in this community was dental-related. I also had learned how much the community respects Floating Doctors. Of course, I knew about this already from talking to Dr. Ben and learning about the organization online, but I didn’t really get it until I experienced it myself. Even in Bocas del Toro, I would use my broken Spanish to explain that I was a part of Floating Doctors and two people gave me their phone numbers to contact them if I ever needed help. One of those people was Toby, who apparently is a boat driver for Floating Doctors?! Dr. Ben also explained a while back in one of our pre-departure meetings that families will come from far away and dress up in order to visit the clinic. I witnessed this, as a line started to form before we even finished setting up the clinic, and despite rain.
Another thing that I noticed particularly in the dental clinic during the two days that I got to assist was how respectful all of the patients were to us. They were willing to hold the tray of materials if I needed to go get up and reload a syringe. They would wait patiently for their turn. But something truly incredible was something that I bridged what I learned in my Palliative Care class and this Panama trip: that different cultures express pain differently. In the states, I have watched everyone, from young kids to grown men, throw tantrums from receiving one anesthetic. I’ve seen patients push the dentist’s hands away, creating an unsafe environment for everyone there, especially with all of the sharp materials.
That brings me to my favorite patient: my first one. I was really lucky to swap places with the other assistant at this particular time, because I ended up with the coolest case that we had seen in the two days as my first one. We saw a young teenage girl present with an abscess on top of a tooth, and this this made me realize just how different dental care is here versus a resource-rich area. Elsewhere, this would be an easy-fix with a root canal, but here, we had no choice but to just extract her tooth. Despite being in pain because all of the anesthetic that we gave didn’t seem to work after a certain point, I saw tears in her eyes, but she still sat calmly and let us finish. My time in the dental clinic was one of the most meaningful: I was able to meet Dr. Philippe, who is one of the most humble and inspiring dentists that I’ve ever shadowed, I realized the disparities that exist, and got to assist for the first time in my life. I have always said that if I cannot become a dentist, then I don’t want to do anything else in the healthcare field because that’s just how much I feel like dentistry is for me, and that thought was solidified when I stepped into the dental clinic after being around intake and realizing how uncomfortable and foreign that space made me feel. My friends noticed this too, that even though I was nervous to be assisting, I also was elated to be there in that moment.
I feel as though a shout-out needs to be given to Dr. Philippe, who I learned has been with Floating Doctors for four years now. I do not think my experience would have been the same without him: in clinic, I told him it was my first time doing any sort of restoration mixture so I was very nervous. He told me that it was okay, and that after a few times, I would be better than him. Of course, that isn’t true, but the fact that he was so humble was very inspiring. Even outside of the clinic, he went with me to refill the can of water to clean our dirty feet and even held it for me when I tried to get all of the mud off my sandals. But the most heartwarming moment was when we were on the boat leaving Quebrada Sal, he was holding some of my DK Fellowship papers that I asked for feedback from, and despite us all getting completely drenched, he made sure to keep my papers dry despite me telling him that I had more copies. Sometimes in this field, especially in the states, I become disillusioned by all of the dentists that have admitted to me that they simply pursued a career in this path because it was lucrative or because the hours were good. It was refreshing to see someone who genuinely just wanted to help others.
My mom said something funny—that every time I called home, I was in tears. I’ll ignore the fact that she put me on blast like that, but there is some truth to that statement. I couldn’t help but think of a meme that I had seen (as ridiculous as that sounds), talking about how us first-generations are so lucky to be struggling with the highest tiers of esteem and self-actualization, when our parents were dealing with the lowest physiological and safety needs. I realized that the Ngäbe community is dealing with the same needs that my mom went through, yet somehow I managed to remove myself from that in my life of privilege. So in that sense, it’s hard for me to pick a favorite experience because I think I needed all of the aforementioned aspects to come together as a whole to make my time in Panama as meaningful as it was. I had thought that I lived a hard life, given that I’ve experienced what it was like to not access dental care because of my low socioeconomic status and didn’t know where my next meal or shelter would come from. But now I can say that I don’t understand, at least not in a global context.
People have always asked me what I imagine my end-all- be-all is, and I’ve always thought that it was to simply be a dentist. I had thought that if I made it that far, despite all obstacles that I thought I had faced, I would be eternally happy. I realize now that perhaps my purpose is greater, that I should do something more for the communities around me, both domestically and abroad. I hope that one day, I will be able to come back to Floating Doctors as a provider and do more for these communities. Thank you so much to Floating Doctors for making my first experience abroad an unforgettable one. I’ll always remember it as I continue my pathway in dentistry!
by long-time volunteer Dr. Anna Bazinet
At 9 years old, Mariana was confident, outgoing and so excited to see all the equipment we were unpacking that morning for the day’s medical clinic. She eagerly watched us set up the small pharmacy with medications, a scale, and a few blood pressure cuffs. She was wearing a bright green nagua, a traditional dress of the Ngäbe-Bugle people, but this was not the most striking thing about her. On her left cheek, she had a 3×3 centimeter ulcer that fortunately she seemed relatively unfazed by. As we continued to set up for clinic, I leaned over to Dr. Ben LaBrot to ask him about this lesion. Without skipping a beat he said, “leshmaniasis, a skin parasite that is carried by the sandflies.” I have since learned more about leshmaniasis and other fascinating parasites, but see this moment as the beginning of my interest in tropical medicine.
We later saw Mariana and her entire family in clinic and after learning more about her and performing an exam, we helped with the things we could but ultimately had to make the recommendation that her parents take her to the district hospital for treatment. The medication used to treat these lesions, a long course of pentavalent antimony, was beyond the scope of a one-day clinic. The family thanked us, and Mariana gave me a hug at the end of the day. I think she enjoyed watching us work and seeing patients.
This encounter happened during one of my first clinic days 7 years ago when I was first a Floating Doctor volunteer. From then on, I was hooked. I loved learning whatever I could about tropical medicine. Who would have guessed at my fascination with intestinal parasites and leshmaniasis? But, beyond the medicine, I loved the communities we were serving. I loved learning about the culture and language all while traveling by boat and regularly seeing porpoises on our commute to work. During this first trip, I had the opportunity to be in Panama for about 7 months before needing to return to Seattle to start medical school. I remember feeling very torn, both excited for the next step in my training, but sad to have to leave a part of the world I had grown to love and a set of incredible people.
Looking back, my current career path was heavily influence by this time in Panama. The mentorship and leadership that I received by Dr. Ben LaBrot and some of the other providers is one of the reasons I am currently training in family medicine. I love family medicine as it allows me to develop long-lasting patient relationships, connect with the broader community, and tackle some of the challenging issues facing patients today including healthcare disparities. This work is not unlike that of the Floating Doctors.
This September, after 7 years, I finally had the opportunity to make it back to Panama. I honestly didn’t know what to expect, I had heard rumors of new volunteer bunkhouse and base, 20 staff members, and a formal pharmacy, all of which were just dreams 7 years ago. And indeed, I was astounded by the amount of progress Floating Doctors made!
I will admit I was a bit nervous getting into the boat on the morning of the first clinic. Would I know enough? Would I live up to the providers that encouraged me along the path I am on? My nerves quickly faded as I picked up the first set of patient charts and sat down with a mother and her 4 children. My Spanish slowly came back and I started taking a history like I have done hundreds of times in many different situations. Despite the surroundings, seeing patients in Panama feels similar to the US. The chief complaints are for the most part similar; headache, rash, knee pain, back pain and insomnia. One thing I must admit is that for abdominal pain, I was not as accustomed to asking patients if they have seen worms in their stool!
Although so much has progressed with the Floating Doctors since I had been away, I was also amazed at how similar it felt. Even though they have been able to see more patients, do more clinics and keep better records, the sense of mission and commitment to the Ngäbe communities was completely intact. The feel of the clinics, the patients, and the empathetic care they receive was all just as I remember it. And finally, the organization still depends on everyone bringing new ideas, energy to problem solving and the occasional stroke of brilliance to push things forward.
There’s a lot of need for good problem solving when it comes to community healthcare in Panama. Even with all of the progress, I worry about the Ngäbe communities and the individuals I met. I worry about their increasing access to processed foods, snacks, sodas which is leading to increasing obesity rates, hypertension, and diabetes. These can be challenging issues to treat in remote communities where medication adherence and the need for at least occasional monitoring is important. This is coupled with a national health care system that makes it challenging for Ngäbe patients to get the care they need when they go to the larger hospitals.
During this most recent trip, I couldn’t help but think back to Mariana and wonder how she was doing. I could imagine her as a great doctor herself someday, with her inquisitive mind and openness with me 7 years ago. Unfortunately, I know that is a long shot for her as she is likely still living in a community where ~60 percent of people over 10 are illiterate and ~91 percent of people make less than $2 a day. For me, this is the challenge of working in Global Health and what keeps me engaged and passionate. The inequalities seem vast and sometimes insurmountable. I am constantly reminded of the work that needs to be done. I am so thankful for organizations like Floating Doctors who are able to slowly work towards change. After my time in Panama, there are a lot of projects I would love to work on, but alas, this only ensures that I will be back, hopefully sooner than 7 years…and when I come back, I can’t wait to see what Floating Doctor’s dreams have become reality.
by Veterinary Lead Dr. Thomas Easley
Veterinary Public Health (VPH) is an essential component of public health and incorporates various types of cooperation between the many relevant disciplines involved in the interaction between people, animals and the environment they share. VPH programs should not be viewed as operating in isolation, but as making an important contribution, as part of an inter-sectoral collaborative approach, to the improvement of a country’s infrastructure, economy and rural development.
Since the profitability and therefore the supply of private veterinary services is governed by several factors arising from economies of scale, such as the size of the livestock enterprises in the locality, the nature of potential or actual diseases, and the types of animals raised in the production systems, in areas where private veterinary work is unprofitable or where other types of market failure occur, economic or social concern usually makes some type of public intervention necessary. Providing this intervention to the marginalized indigenous communities of the Bocas del Toro archipelago is where Floating Doctors shines like a beacon in the night.
Floating Doctors has integrated a VPH program into their daily operation for two important reasons. The first being focused on human health in that domestic animals (including cattle, goats, sheep, pigs, poultry, and dogs) of poor people can be important reservoirs of zoonotic diseases that impact on their health, either through direct or vector-borne transmission routes. In addition, history has shown us that zoonoses falls disproportionately on poor people with poverty, and unsanitary living conditions associated with poverty, being considered potential risk factors for zoonotic and food- and water-borne diseases in many areas of the developing world. The low standards of education and veterinary public health services commonly associated with poverty and marginalized communities increases the risk of transmission of zoonoses and food-borne diseases.
More importantly, and the second reason, Floating Doctors understands One Health and perseveres to integrate its implementation into all of their activities. While One Health initiatives have traditionally focused on threats to human and animal health, such as zoonoses and a secure food supply, they have not typically promoted an understanding of the many beneficial physical and psychosocial impacts of human-animal relationships and how these can be leveraged to improve both human and animal health around the world. Additionally, current One Health initiatives are undertaken at international, federal, and provincial levels yet often fail to have an impact at a community and primary care level, especially in poor/marginalized areas.
The Centers for Disease Control and Prevention’s definition of health is “a state of complete physical, mental, and social wellbeing.” This definition has included not only physiological, but also emotional and social (behavioral and natural) states as are often described in the definition of good welfare. It is well-recognized that where there are poor states of human welfare there commonly exist poor states of animal welfare. Similarly, animals often act as indicators of human health and welfare, as can be seen in the link between animal abuse and family violence. Considering health and welfare together — because of the interconnections of human-animal-environmental factors — helps to describe context, deepen our understanding of factors involved, and creates a holistic and solutions-oriented approach to health and welfare issues.
The North American Veterinary Medical Education Consortium (NAVMEC) has identified knowledge of One Health concepts and principles as a core competency for veterinarians who will graduate in the 21st century. Despite widespread exposure and support of One Health concepts, a recent survey of veterinary students at Colorado State University demonstrated that few opportunities exist within veterinary curricula for students to get involved and gain practical experience in this area. To fully realize One Health concepts and principles and ensure their promotion by future health professionals, veterinary students require tangible, specific applications.
Important goals in teaching are to challenge veterinary student perceptions and facilitate opportunities for not only applying and practicing core learning, but also learning how veterinarians are connected with their communities and with society as a whole. By understanding these concepts, opportunities are provided for long-term personal growth. For many veterinary students, identifying their role in the community as an individual and a professional can be challenging. After all, most of their adult lives have been spent in a focused pursuit of admission into veterinary college. Moving away from this singular goal and exploring their sense of self, their perception of service to others, and recognizing their inner potential to care and empathize with marginalized individuals is desirable both personally and professionally, with significant positive impact for society as a whole.
In a One Health model, factors contributing to each sector — humans, animals, and environment — are studied. Within veterinary medicine and particularly within the veterinary curriculum there is understandably a focus on the animal sector relative to the human and environmental sectors. However, in clinical practice and in community health, equal knowledge of all sectors is required. With Floating Doctors, the outreach experience provides students with the unique opportunity to gain more knowledge, acceptance, and understanding of a marginalized human sector and how the well-being of both animals and owners are intertwined. Through a One Health lens, the increased empathy, compassion, and stewardship of early career veterinary professionals will undoubtedly lead to improved animal and human welfare, and thus improved community health.
Floating Doctors’ One Health engagement initiatives with the marginalized indigenous communities of the Bocas del Toro archipelago include the integration and community-level collaboration of veterinary teams with human healthcare providers. This team approach serves to cooperatively improve the health and welfare of humans and animals, demonstrating that veterinary care can act as a direct avenue to improve health and social service delivery for underserved populations.
Not only do students gain an appreciation for the power of the human-animal bond, but they also witness how it can be leveraged to motivate changes in behavior that benefit both human and animal welfare. By supporting and maintaining the human-animal bond, students also begin to appreciate that their work extends beyond the health and welfare of animals, but also directly benefits the psychosocial and physical health of their clients.
By Gloria Obialisi, USC Medical Student
I don’t know how to swim. Well, if I had to freestyle across a pool, I can maybe do it for 25-50m, but honestly, I’m not even sure if I can do that anymore. I’ve taken three swimming classes and have never been able to let go of the wall in the deep end. It’s just too scary. Of course, I’ve known for months that I would have to commute via boat to not only get to the Floating Doctors’ base, but also between islands for clinic. However, I just didn’t pay it much attention. Prior to leaving, I did not give myself a pep talk, because I had confidence in the captains hired by FD and certainly didn’t want to entertain the thought of anything going wrong while I was on a boat. I was either in denial of my fears, not in tune with them because of all the hype and energy from the other members of my group, or I simply was unaware that the fear no longer existed.
It wasn’t until the middle our first boat ride from Bocas del Toro to Isla San Cristobal, that as I looked from left to right and saw nothing but miles of seawater that I thought, “Oh crap, what am I doing here?” Had I let my mind run wild, I probably would have started hyperventilating, but I tapped into my deeper feelings and realized that I actually loved it. I loved the cool gentle splashes of water hitting my sweaty face, I loved knowing that we were free from 405 traffic, and I loved sitting atop that beautiful water with not a care in the world. After several boat rides -some a little bumpier than I would have liked, I started to envision myself surfing the waves. This newfound love grew day by day and to this moment I am still eager to become a better swimmer, so I can finally explore the world of surfing.
When I signed up to volunteer, I thought at most I would be able to further delineate my niche under the umbrella of public health, but thanks to Floating Doctors, I’ve now discovered a love for the seas and a hungry desire to learn how to surf. Sure, it’s great having become aware of this, but it was but a single jewel compared to the heaps of treasures unearthed during the entirety of this trip.
The Asilo is a government-funded nursing home for individuals who are without family or friends to offer care for them in somewhat their later stages of life. Several students and I had the opportunity to visit this place while other members were at the first multi-day clinic for the week. We split into pairs to check the resident’s blood pressures, play games, color pictures, chat about life before the Asilo, and so forth. While all residents were quite impactful, two stood out to me the most, a woman and a man who I’ll refer to as Emilia and Arturo.
Arturo was the first male patient I interacted with there. He was sitting in the corner of the male quarters in worn-out clothing facing a wall, and fidgeting. I walked to him with a fellow Global Medicine student and asked if I could sit on the bed across from him. As my partner turned the pages of her book to locate his file to record his BP, I commenced to make small talk, asking him what he did today. He made eye contact very rarely and spoke slightly incoherently. Perhaps I would have caught more had I practiced Spanish more frequently. In the middle of his ramble, he turned 90 degrees to me, looked square into my eyes and said, “I am very sad. Do you know what it means to be sad?” As I tried to comfort him and ensure him that I understood, he simply turned his head back to the original position, facing the wall, and continued mumbling.
As bleak as this experience was, I found gratitude in the Asilo. People here have no one to look after them. I spoke with colleagues later, and they shared that he cheered up after receiving some cookies. I cannot imagine what his life would consist of would it not be for the Asilo. There he had caregivers, other men to keep him company, regular meals, and visitors like us who understand the importance of caring for these populations.
Emilia was the opposite of Arturo, but again, gave me an overwhelming sense of gratitude for the Asilo. It was almost as if she was running to meet us when we arrived. Her joy and eagerness to mingle with each of us enveloped the whole room. She was extremely excited and bubbled all about the room. Emilia like her sister has a cognitive disability and if I am remembering correctly, was brought to the Asilo because her mother could no longer care for them. Well into her 30’s, Emilia was the only future I could think of when I later met a boy on a different Island, who was12 years old and also with a cognitive impairment. Was this the life he would end up living? He too was characteristically full of life and quite bubbly, but his community lacked the resources to give him the attention and specialized care he needed. Even if he didn’t end up in the Asilo, I am incredibly grateful that it exist for people like Emilia and Arturo. There they have a new family and support during their vulnerable years of life.
On Day 2 of the multi-day clinic at Playa Verde, I was invited to go on a house call with Dr. Ben, a fellow USC student, and several medical students from Dublin. As we walked from our clinic area into the community, we briefed ourselves on the case and reviewed the patient’s file which was only gathered from her visits to previous FD clinics (talk about building your own health system, huh). We were prepared for what we would potentially face once at her home, but we did not anticipate such a long, steep trek there. At the top of a hill, we gazed out from behind the luscious trees at the beautiful beach. It was a metaphor to me of the incredible outcomes of doing such mission work. We push ourselves and give our best to serve these people, and in the end, with sweat pouring down our faces and oozing from all crevices, we reap beautiful results.
Something particularly funny to me after having seen the patient with Dr. Ben and later discussing a possible case of metastatic uterine or abdominal cancer, was my encounter with some of the local children. I climbed over the ledge of her house and jumped down only to meet a little girl that was utterly fascinated by my skin complexion.
“Where are you from?” she asked
“The United States, but before that, Nigeria in Africa.”
“Yes” (She looked at me with both confusion and skepticism.)
“Where is that?”
“Far, far away from here.”
“How many countries do you have to pass to get there?”
“A lot, maybe 10” (of course I didn’t know)
“Are the people good or bad there”
I tried to hold in my laughter as I replied, “Both. Same as you have here and everywhere else in the world.”
After we talked a bit more, I learned that I was the first black person she had ever met. How interesting that she was first curious about the character of our people. I’m grateful to be the first “Chomba” she met, thanks to FD, and hope I left a good impression for others. How I’d love to re- visit and teach her a lot more.
Aside from gaining exposure to many health issues and recognizing common chief complaints, one of the benefits of being assigned to the intake station during clinic is that you have a chance to meet many families and entertain their children while other team members try to take mom, dad, or grandma’s pulse. As a pre-school Sunday school teacher, I appreciated this opportunity to express my heart for children. Sometimes I had to play games to try to vitals from toddlers, and once I had to carry a very heavy, sleeping 1-year old while quietly altering my voice to feign excitement at nail clipping supplies to console his hysterically crying cousin.
These kinds of situations though somewhat difficult, are valuable because they highlight some of the difficulties in these communities like the lack of enough children supervision. The child’s mother would not have been free to provide a urine sample if I were not watching after her kids, and my partners could not perform the test if they were also holding a baby or trying to quiet another. I believe this patient had the confidence to travel to clinic with her children because Floating Doctors had already established a reputation that we will do all in our power to advance the delivery of care.
“Why do these people even matter? Why did Dr. Ben start this and why has Floating Doctors grown to the extent that it has? What do the few staff and revolving volunteers see in continually coming and putting themselves through this?” These are the questions that surfaced one morning as we traversed soaked and huddled, head down, through the pounding, blinding rain. It literally felt like it was blinding because our eyes were burning. One girl was moved to the point of tears, others found it exhilarating, some felt numb, but all I could do was try to find the answer to those questions. We weren’t traveling with a camera crew, there was no Noble Prize waiting for us at home, we weren’t getting paid exorbitant salaries, and we certainly weren’t getting guaranteed acceptance letters to the doctoral programs of our choice.
So, why then? It was a rough start to the trip and probably one of the most difficult second to having to use the possibly toxic latrines outside of clinic. I am grateful for that incredibly uncomfortable and trying time on that boat because it was at that moment that everything became real to me.
Certainly, as an aspiring physician and one who is especially interested in helping under- served communities, I knew this type of work was important to the development of my career and these were at minimum, valuable steps we could make to aid the physicians and bring healthcare to neglected communities. Here we were literally sailing to a remote island with people who would probably find a way to keep happily surviving even without our service, and all I could think of for that brief moment in time was that jarring question “Why do they matter?”
It was as if the sun emerged from the behind clouds and the rain vanished when I finally began to answer those questions. Health is a human right. So long as you are living and a human being, you deserve medical attention. In a world where technology abounds and people have been flying to the moon, surgeons are transplant faces, and we’re able to eradicate monsters like small pox, these people deserve to receive even the most basic form of healthcare. Whole communities shouldn’t be afraid to name their children until age 3 due to the unacceptably high infant mortality rates. Loving fathers and husbands deserve get treated for chronic pain or injuries sustained by the difficult lifestyles they live in order to provide for their families. Health is a human right.
This is why that short moment of salt water burning my eyes and having my wet scrubs clinging to my entire back was so important. Because health is a human right, and they matter. Neglected communities are also our responsibility. We seek not fame or recognition, just satisfaction in knowing we helped another person and we are strengthened by the beautiful, grateful smiles.
By Katherine LeTendresse, Student at Global Medicine Program, USC
Floating Doctors Volunteer
From the first hours encountering the health professionals who volunteer with or work full time at Floating Doctors, I had the feeling that the week ahead of me would be filled with interesting cases to learn from. What I realize now is that the cases, no matter if they were routine or unique, have filled me with a renewed sense of compassion and helped me apply the concepts that I have learned this year as a student in the Global Medicine Program at USC.
The country of Panama is a culturally vibrant place in Latin America and like many of its neighbors faces challenges with healthcare infrastructure. Though it is considered an upper-middle income country by the WHO, many of its citizens struggle with healthcare access, often due to poverty. The areas in which indigenous peoples live are often isolated rural villages, further complicating the process of accessing health services, many of which they struggle to afford. One large challenge regarding healthcare in Panama is that it must address the double burden of infectious diseases, such as Malaria, Leishmaniasis, and the Zika virus, as well as non-communicable diseases such as Obesity and Cardiovascular Disease. In addition to these challenges there are a lack of services and education in my area of interest, oral health.
Like many other countries in the region, the children I saw in Panama had access to food and drink high in sugar, such as soda and candy.
Rural populations in Latin American countries are typically thought to adhere to traditional diets high in fruit, grains, and vegetables, whereas the diets of urban populations have shifted toward Western staples. This can contribute to an array of health issues including obesity and oral health problems. The imbalance between energy expended and caloric intake is a challenge that is expanding into rural areas, which I observed in Bocas del Toro. At the end of one clinic day in an area called Quesbada Sal, I walked passed cases of soda being unloaded from small wooden boats onto the dock. This island is an hour away from the main town, and is an example of how diets high in sugar are penetrating rural environments.
The level of sugar intake, along with the use of water untreated with fluoride, was reflected in the oral health issues patients presented with at the clinic. Only a handful of children were living completely free of dental caries, and many more were living with rampant tooth decay. I had never observed such a high number of extractions of the deciduous teeth, prompted by severe tooth decay, reducing a once healthy tooth to one causing constant pain. Other children with less decay received fillings, which were performed using only basic instruments, no drill or suction. The atmosphere of the dental side of clinic was one where we did the best we could with what we had. One extraction was even done without a dental chair, on the steps of the clinic. What I admired most about the dentists as well as my peers was their willingness to improvise and to provide the best care given the circumstances. The overall community response to our presence was largely positive, with many patients waiting hours in the queue to be seen by the dentists.
One thing that struck me immediately at these rural clinics was the number of locals who had never been seen by a dentist before. Many of these people were of the indigenous Ngobe population, and though I expected them to be hesitant of us they surprised me with their welcoming attitude. Some of the patients we saw were children at their first dental visit, but others were adults who were having their first experience as well. The reputation of Floating Doctors within these communities was a great asset, and without the trust of the community these patients may never have come out to be seen.
What was most challenging was the management of patient anxiety, especially in our pediatric patients. While I assisted the two dentists, Sarah and Philippe, I observed them using an interesting technique to calm a patient, a scared three-year-old girl. The conventional method of managing anxiety in pediatric dental patients, called “Tell-Show-Do”, was not successful with this child, so they decided to try a different method. The mother sat on the chair and held her daughter on her lap, and this calmed the girl enough so that Sarah could perform the dental exam. Over the course of this encounter the patient began to relax, and she received a filling for a cavity on one of her maxillary teeth. It was interesting to see an alternative to the usual methods of managing patient anxiety, and to gain perspective on situations where a practitioner must adjust their plans in order to be effective. Though it was challenging to calm this young patient, it is my hope that this introduction to dentistry was positive overall, and that she will be responsive to oral health education in the future.
Though we were busy with the high volume of patients, we still took the time to hand out toothbrushes, toothpaste, and speak with the children about oral hygiene. My group created a poster that taught the techniques of brushing and flossing, which was both informative and colorful. This was one of my favorite activities while working in these communities because education is essential to changing behavior and effecting long-term health. The people in these communities were receptive to new information, the children most of all. After being taught about brushing their teeth they seemed to share what they had learned with their family and friends. The children would line up and ask for “cepillos” and “colgata”, which I quickly learned are their words for toothbrushes and toothpaste. The children seemed genuinely curious about the dental station, and on several occasions I saw their intent faces peering in at us, and I felt as fascinated by them as they were about our work.
In the short-term it is a small victory to teach a child to brush their teeth and give them the means to do so, but the real challenge ahead is to address how they will maintain these health behaviors. Will they have access to basic supplies like toothbrushes, toothpaste, and floss? If not, how can this be addressed? This is something that has been in my thoughts since returning from Panama, and I realize that solutions will ultimately have to be a result of prioritization within the communities. There must also be a strong presence of healthcare providers to stress the importance of maintaining these behaviors. This is one of the many reasons that Floating Doctors is important for the area, and why the Global Medicine Program should continue sending students to participate in this valuable experience.
Another portion of the trip that will likely have a lasting impact on my perspective of the world was visiting the local nursing home on the main island. From the moment I walked into the facility I had to challenge my expectations and reevaluate my assumptions about the culture. I met several residents who had been abandoned by their families, and others who lived there with family members. One example of this is a woman I met who lives in this facility with her mother as well as her sister. They are only in their 40s, which by US standards is a young age to be admitted to a facility for long term care, with 88% of residents being age 65 or older. However, both appeared to have mental health issues, and with nowhere else to go they were admitted to the nursing facility.
Spending time with these women made me reflect upon the idea of treating every person kindly and helping them live with dignity. As I stood in that room where upwards of fifteen women slept, my only desire was to give them attention, show compassion, and let them know that someone cares. I could sense this motivation in all of the volunteers there, saw it in their body language, and heard it in the kind words they spoke. This experience was one of the most humbling I have had in my life because these residents value the things we often take for granted, like a conversation or a hand to hold.
After spending time with the residents of the nursing home I have reflected on my career and am drawn to the idea of practicing as a general dentist where I can see children, the elderly, and everyone in-between. Moreover, it renews my sense of purpose for seeking out education as dentist, and where I may practice in the future.
Though we were only in Panama for a short time, the long-term impact of our visit can come in the form of support for Floating Doctors and other groups like it. Beyond giving care that is needed, Floating Doctors educates their patients at every opportunity. What has stuck with me from this experience is that while we address issues such as access to healthcare and overall health we should also empower these populations with knowledge. Perhaps one of the children I spoke to about oral hygiene will someday become a dentist, a physician, or an advocate in their community healthy living. Educating is the key to empowering all people, and it is my hope that the people of the Ngobe communities will be positively affected in their health today and in the future by continued efforts from Floating Doctors.
- WHO Panama Profile Socioeconomic. World Health Organization. 2011 Report.
- Panama – Health in the Americas 2007 – Volume II. Pan American Health
- Kain, Juliana et al. “Obesity Trends and Determinant Factors in Latin America”. Cad. Saude Publica, Rio de Janeior, 19 (Sup. 1): S77-S86, 2003.
- Farhat-McHayleh N. Harfouche A. Souaid P. “Techniques for Managing Behavior in Pediatric Dentistry: Comparative Study of Live Modeling And Tell-Show-Do based on Children’s Heart Rates During Treatment”. Journal of Canadian Dental Association. May 2009.
- Nursing Homes Fact Sheet. AARP Public Policy Institute. Oct. 2007.
By Dr. Kevin Lan
Lead Dental Provider
A new year upon us, and what a year 2015 was for the Floating Doctors. I would like to update everyone with the progress our dental program has made and share a few stories of the past year. Our work and development would not have been possible without your support and kind donations, I would personally like to especially thank Don Scott and Ted Hannig for their tireless efforts in raising over $10,000 to help with the advancement of our program in acquiring essential equipment and materials.
At the close of 2015, we have extracted over 300 teeth, placed more than 100 fillings and incised and drained multiple abscesses. We are now able to provide a wider range of treatments with our newly acquired portable dental chair and equipment from Dentaid and Aseptico, as well as receiving several thousand toothbrushes from Global Grins and supplies and tools from Henry Schein.
It was fitting that our last dental clinic of 2015 would finish in the community of Norteño, where our program first started. 70 patients were seen over two days working from the early hours of sunrise until the company of the moonlight and stars. Rice and beans after the last patient, have never tasted so delicious with a splash of chicken. Working in this environment is very tiring and back breaking, the list of patients is always growing and there is always the fear of not being able to see everyone. Our last family of 2015 had waited for 5 hours to be seen and faced an hour walk back home. Reading their notes from our first dental clinic, the two young boys (Raul and Daniel) had been very anxious and were uncooperative during treatment, but our team had successfully extracted some of their teeth. Having had such a long wait, I was expecting to use my last reserves of persuasion, but much to my surprise the chicos were fighting to be first in the chair. From an anxious patient to becoming a dental assistant was a big step for Raul; armed with head torch and gauze, he diligently cleaned his mum’s teeth as we restored two cavities.
As we were planning to bid farewell to the community of Rio Cana, a 5 year old girl called Natalia presented with a large left sided facial swelling extending up to her eye. She had been unwell for the past two days with a fever and was unable to eat due to the swelling and pain. The team unpacked our equipment and after much reassurance we were able to extract the problematic tooth and drain the dental abscess. This took some of our volunteers by surprise at how much infection could result from one decayed tooth. Moments like these, when we are able to provide care where there are no alternatives and change the outcome of an unwell patient, or witness a positive change in the attitudes of the communities we visit, makes every second spent in our work worthwhile. It has been a pleasure to see the communities embrace our programme and it is very disheartening when no dentists are available to provide dental care.
Our dreams are big for 2016 and in the new year, we will strive to continue and improve our provision of oral healthcare. Plans are in place for a mobile floating clinic where radiographs can be taken and surgical operations can be performed. Agreements have been made to start water testing and implementing water fluoridation in the communities’ water supplies.
Many of the Ngäbe people have been forgotten or must suffer in pain; it is a privilege and honor being welcomed into their communities, to give them the opportunity and education to leading a healthier life. Together with your support we can overcome these challenges and ensure that every child has a toothbrush and toothpaste, no one has to suffer with toothache for over a month, and we are able to provide dental care in a clean and comfortable environment for our patients.
by Dr. Ben LaBrot
I love when our reports are written by our volunteers–their perspective is often unique and I love to have their voices added to support our project, but today I want to personally share an experience with you all.
We visit about 25 communities spread over 7,000+ square miles of jungle-covered mountain and mangrove island mazes. Some of the communities are a shorter boat ride from our base, but some are VERY far away–and the Ngabe community of Rio Caña, where we went last month, is the furthest community we currently visit, on the exposed, open-ocean side of the Bahia Azul peninsula.
Rio Caña is about 70 miles by boat from the nearest small community hospital, and VERY hard to get to–it requires a lot of planning and the willingness to endure pretty bad weather and rough seas to get there. It is about 6 hours in a huge dugout canoe, at the end of which there is a treacherous river entrance blocked by a sandbar with big surf. I know longboard surfing is widely popular, but until you have surfed a 50′ hollowed out log down the face of turbulent waves to enter the Rio Caña, you have not truly longboarded.
In this community, small emergencies are almost always big emergencies–because the chance that the patient may be able to travel to help is VERY low–at best, the trip would cost more than most families live on for 2 months; at worst, bad weather and 15-foot seas make the trip a complete impossibility even if you were a millionaire. These are the communities we specialize in serving–the ones where a lot of people see a doctor for the first time in their lives when they come to our clinic.
On this visit, there were several ‘small’ emergencies–a horribly infected ax wound on a young man’s foot, a young girl with acute appendicitis, a young boy whose entire scalp was an infected mass of pus and fungus…the list goes on. All of these things are dealt with in more developed regions by a trip to the family doctor or to the emergency room; here, they are treated mostly with hope, which unfortunately is not always enough to prevent a terrible outcome.
We saw 250 patients, pulled about 60 abscessed teeth, performed ultrasounds on about 25 pregnant moms, and made sure the ‘small’ emergencies STAYED small and were dealt with promptly.
No one who has not shared a journey to distant communities like Rio Caña can truly understand what it takes to make it out there and to provide good health care so far from the comforting presence of a nearby hospital with specialists and advanced services, but if we don’t go out there…the young man loses his foot (and perhaps his life); the young girl’s appendix ruptures and she dies, the young boys’ scalp infection poisons his blood.
This is why our volunteers endure such hardships to get there, and why we go to such great lengths to reach these communities. I wanted to write the report myself today because I wanted to bear witness both to the courage of our patients, and to the dedication and endurance of our medical teams. Am I a hero? Absolutely not–but I am privileged to work with heroes every day. Hope in Rio Caña and other communities is no longer the only care available.
The health care our volunteers provide is some of the most loving, caring medicine I have seen anywhere in the world. In 2016, the infrastructure we have worked so hard to build this year will more than double our capacity. It has been a tough journey to get this far; traveling to Rio Caña is like a microcosm of the journey of our organization. When I look back at how far we have come in such a short time, the daunting challenges in the future suddenly don’t seem quite so insurmountable.
When someone tells you something is impossible, always remember what Tom Hanks’ astronaut character in ‘Apollo 13’ tells visiting congressmen while giving them a tour of the space center: “You know, there’s nothing remarkable about us going to the moon. We just decided to go.”
What will you decide today?
In the early months of 2015, Floating Doctors added another paddle to its ever-expanding Cayuco (wooden canoe) by launching its dental programme in tandem with the flourishing mobile medical clinics. It has always been the dream of Ben LaBrot, the founder of Floating Doctors, to have a long-term dentist join the crew. The need for dental treatment is in high demand but unfortunately very rarely accessible to the Ngäbe communities.
In its inception, the team’s first clinic was set in the mountainous village of Norteno. From dawn till dusk, spanning over two days, 80 patients were seen by our tireless dentists who maintained high spirits despite the failing light and increasingly limited resources. It is this drive and motivation to deliver healthcare in such challenging conditions that epitomises the spirit of our leadership team and volunteers representing our organisation.
Since then, we have visited multiple communities where we are continuously amazed by the extent of dental caries prevalence, especially in young children. On each clinic, we will see an average of thirty patients, many of whom have suffered in pain with toothache or infections for several months or even years! Imagine, or can you remember, the debilitating sensation of dental pain and being without access to dental treatment for that length of time? Our clinic is currently restricted to extractions and minor oral surgery, but with time and correspondence to those with invaluable resources or expertise, we will strive to make Ben’s dream come true.
The development of the Floating Doctors dental programme would not be possible without the support and kind donations from our benefactors and organisations. For this we cannot extend our gratitude enough. We have set a target of $10,000 which, once achieved, would provide all the equipment necessary for a fully functional dental clinic to serve the Ngäbe communities. We have a fantastic opportunity to implement positive changes to the oral health of the communities in Bocas del Toro.
It is a privilege to share this journey with you. Our working environment is such a challenging, exciting, very tiring, but thoroughly rewarding experience. Improving a patient’s quality of life is not based on what procedure or medication I give them, but my ability to show compassion and care to a person where they are expected to expose their problems and fears to a stranger whilst overcoming language, cultural, and social barriers.
Written by: Kevin Lan, Floating Doctors Lead Dental Provider
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