There have been some interesting developments in the last few hours, and I am going to break slightly from the pre-ordained chronology of these posts for just a moment. On my call with the big man himself today, Dr LaBrot, I was informed that the expected lead medical provider who would be filling my role after my departure has been grounded in Holland and prevented from travel by the Dutch authorities.

This means that with my departure, the patients of these islands, the many that turn up during the week in their moments of need, as well as those within communities miles and miles away from organized medicine, will once again be left in the dark. Every woman with a painful breast mass or hernia, every malnourished child with a fever, and every epileptic with no access to drugs will have no chance at getting well. It’s a daunting realisation. Our work here makes a difference, because there is nobody else here to do it. Sadly, this isn’t America where the match machine just takes the algorithm one decimal place over and fills a spot with another eager beaver who will take whatever they can get. This isn’t Ireland where during the madness of a pandemic the HSE can re-deploy their interns into whichever department needs them like a life-sized game of Tetris, or Canada where they have the luxury of turning thousands of Canadian trainees away every year because the MCC decides it can. I am not even a real doctor, but I’m the best there is for them. It’s insane when you really think about it.

What I find more insane is that this isn’t even the ass of nowhere. There is a tourist town nearby, with retired nurses, physician assistants, and people who could probably paper over the cracks crudely until the next doctor arrives. Imagine what it’s like in Syria, Yemen, in the trenches of war-torn Sudan, or the deepest holes of Afghanistan? It blows your mind. I get that sometimes that’s life, but I am here now and I’ll be damned if there isn’t something I can do about it. I sent an email to the college, a dramatic one penciled more like poetry than professional. I cc’d all my highest order contacts, I am asking them for another month here. Ireland is basically on fire at the moment, with the highest incidence rate in the world as I write this. All of our teaching has gone online, I would need a PCR covid test legally before I fly, and I don’t even know where I can get access to that here… I suppose we’ll see.

Getting back from my mission on time this week meant I was actually around for base clinic on Thursday, Alison, the PA from Colorado who I had met before when I was still isolating, was on base joining me. She brought a different perspective on medicine as a preacher of integrative health. She brought something that at times we sorely lack in western medicine, which is the quality of the therapeutic relationship. You can call it alternative medicine, complimentary medicine, you can even call it nonsense if you want, but I’d probably call it patient care. The market for all of these alternative health options has grown massively, and not just in America, because people like having someone actually listen to them and give a damn. When someone makes an appointment with their GP you might get fifteen minutes, twenty if you are luck. The value in having someone who gives you an hour, actually asks you how you are doing, not just how you are feeling, is massive. It is the biggest thing I took from my psychology undergrad. It blows my mind how many times I have seen a seasoned consultant or attending just completely miss the plot with a patient. I don’t pretend to know that much about medicine, but I think I know a few things about people. Alison brought a lot. I served as her translator throughout the day, and it was a nice relief for me to be the one taking orders for a while.

We had four pregnant women in the clinic, some of them fairly late in their pregnancies presenting to healthcare for the very first time, which was not uncommon. They all planned to give birth at home, which seems irksome at first but actually made a whole whack of sense. Think about it this way, if the average woman has eight children, and they all have an average four sisters, working as a team your standard person had seen their fair share of action—Giving birth is no joke; they call it labour for a reason. Don’t be fooled by Hollywood depictions of birth being an in and out affair, many women wait for hours for the baby to decide it’s coming out. It’s an arduous process not to be taken lightly. Evolution has designed a woman’s blood supply to increase by 50% during pregnancy to offset blood loss in a normal, uncomplicated delivery. Before labour even begins, the placenta can detach prematurely, causing a hidden bleed that swells up in the uterus, oftentimes equal parts painful and dangerous; or the placenta can form in the wrong place, between baby and the exit, causing delivery to puncture it, leaking litres of blood in the process. The placenta can also burrow in too deeply, so that its vessels penetrate like roots beyond the womb, causing them to shear off during birth, leaving parts attached inside to get infected, that is if the bleed itself doesn’t kill you first. Pregnancy puts you are greater risk of blood clots, heart failure, kidney damage, back pain, diabetes, and depression. Every woman who goes through it should get a medal, and every man should take off his hat before he speaks to a mother—One of our women in that day was 17, undoubtedly on the beginning of a long journey, her prenatal history and Doppler revealed a baby that appeared to be doing well, although it’s hard to get any definitive impression without an ultrasound, of which both of ours were broken. I was disappointed, as I had spent the evening before running through YouTube tutorials and practicing on myself for the real deal. Maybe next time. That all being said there is still nothing like the look on a woman’s face when you find the fetal heartbeat on the Doppler thumping away. Gets me every time.

I went into town that afternoon to make some much needed upgrades to my gear. I purchased some clean new flip-flops and a pair of water shoes (a genius move in my opinion, essentially eliminating the need for socks in my kit and allowing easy walking in lighter mud without the fear of a flop sucked into the nether realm on every step). Like all things in the universe this would come at a trade-off though, as later that day I washed my running shoes and left them out to dry on the back porch of the house. As the rains came down over night the wind was so incensed at my disrespect that it blew one of them clean off the porch; at least I think, all I know is the next day the chair had been flipped and one shoe was gone, likely into the water never to be found. I wished her well on her adventure; maybe she’d even meet my lost watch out there in the big blue. I wonder what they’d have to say about me behind my back, I like to think I was a good owner.

Friday was a lot of housekeeping, before preparing for the week ahead. I was trying to get a pediatric neurologist to arrange a consult for my 16 year old with headaches and cranial nerve findings in Bisira, the system here seemed to provide one of two divergent paths towards achieving such a goal. It was either laughably easy, in this circumstance I called one phone number for the hospital, got transferred to a secretary, who then gave me a direct personal line to the consultant through WhatsApp. Or it was absurdly difficult, like the week before with the patient who had a breast mass that needed an urgent mammogram. I jumped through so many hoops and called so many people only to find out at the end that the system was so backlogged the ER was the best possible option. Trade-offs I suppose. The week ahead, my third mission, would be to the mainland village of Rio Caña, on a peninsula only accessible by water. Apparently it is one of the most distant but also one of the most advanced communities we visit, with a schoolhouse that even gets WiFi at times. The journey would involve another lengthy boat ride, this time through a decent stretch of Open Ocean before the river mouth. Not bad.

That Friday night, a friend of the crew here was moving to Panama City for good. She was a hostel owner. I was lucky enough to receive a cordial invitation to a bodacious evening soiree in her honour. When the moment came I called a boat taxi to motor me into town. I was going to take a risk and wear a nice shirt, knowing full well the risk of rain always lingered like a hungry dog. Thankfully I got there dry and had a great evening. There was a couple of Argentineans there, Panamanians, and Venezuelans alike. I felt like a backpacker again, and for a moment it was like I was on vacation. One of them was an apprentice astrologist. Feeling momentarily compelled to see the principles of what I consider to be utter bollocks in action, I asked him to give me a go. He brought out all the books and a clean looking MacBook and I got the whole shebang. It turns out my Jupiter is retrograde and my moon is stressed. I’ll be damned.

The next day I hung around, having spent the night at the hostel. Everyone was headed to the beach, which meant that so was I. We went to a beach called Red Frog, a real cracker, one of the nicer ones I have seen.  It always makes me laugh when I talk about beaches with the Irish back in Dublin. They seem convinced that Ireland has nice beaches. I mean don’t get me wrong, they are nice. They are nice for Ireland, but there is just no comparison. I’m sorry lads. This was golden sand against the baby blues of sky and ocean without a cloud in sight, and ocean breaks producing delicious white fluff, sputtering across the water like children playing at school. The sun was shining, and I even got a daiquiri which I drank sitting in the sand.

There was a group of Americans, real frat types with the ball caps and the red white and blue muscle shirts playing volleyball. I remember eavesdropping on one of them ordering a shrimp taco. I found myself for a moment wondering if they had any idea what was going on these islands deeper to the beach. How the people lived, and what kind of dichotomy existed between our own position and theirs. I often think about how luck has built my palace, it was only that I was born where I was born, and who I was born to, that gave me this life and this platform to do the things I do. When I was in India, as a fourteen year old boy I remember looking over the slums in Mumbai, where people actually have nothing. We say that as a joke ‘Bro I’m broke I actually have nothing.’ Then you see a grown man, standing thirty feet in front of you butt naked cupping his genitals because he doesn’t even have the cloth required to cover himself, or the children that pick through garbage to get their daily calories. I remember thinking, what would these people do if they my kind of opportunity? What might they achieve? Maybe at a younger age it was a feeling of guilt that motivated me to want a career as a humanitarian, but as I grew I felt it more like a sense of duty. It doesn’t come from guilt at all really, as much at comes from compassion for my fellow man that is less fortunate. I almost felt like I owed it to myself just as much as I did to those people who never had a fighting change, to make the most of what I had. I think my entire life changed in that moment, in that way how it lights a spark that grows over time. Everything that followed led me here, onto this beach drinking this daiquiri, with the luxury to contemplate these things from the comfort of sand between my toes. It isn’t fair I know, but maybe enough of us together can give those without a hope a fighting chance. I think that’s what I’m really trying to do with this blog, and with my career. Alone I can only do so much, but if I can bring to light some of these issues, or paint the work in a way that sounds appealing, others might hear the rally cry and join the cause. It’s the same reason I started the Humanitarian Medicine Conference at the college, which I hope remain long after I am gone; because all it takes is to inspire one person, and then they might inspire another, and the exponential growth of silent influence becomes greater than any single part. Big dreams I know, I have always been a dreamer, but in the words of Edward Norton in the mediocre 2002 film Death to Smoochy

‘You can’t change the world, but you can make a dent’