Our third day clinic brought us to the community of Cerro Brujo. At the stroke of sunrise, sleepy bodies mobilised. A hard clang of the kitchen bell signaled breakfast, and after grubbing down, it was all business, with many hands assisting in the loading of heavy pelican cases into our two boats before setting out on the water under cloudy skies. It had been raining a lot in the days leading up to my arrival, and this showed no signs of slowing. In the near week I had been here, I had failed to see a clear blue sky for more than thirty minutes, as downpour after downpour smattered the roof of the bunkhouse. We had been fairly lucky that rain never happened to catch us in moments of transit or when loading and unloading. As the boat skipped its way into the small bay marking the entry dock to Cerro Brujo however, some of the staff noticed something seemed amiss.

‘Where’s the dock?’ one of them asked.

‘That’s weird.’

‘I think that’s it there isn’t it?’ another called out. ‘It’s flooded!’

Low and behold, as we inched closer and closer to the muelle, it appeared in its usual position – just about 20 centimetres below the water instead of above it. This made unloading the gear awkward, as a few of the more heavy-lifting inclined stepped onto the submerged platform and to hoist the pelicans and carry them up the path to a portion that crept up and out of the water. The dock fed into a tortuous concrete path nearly 500 metres long that weaved into the centre of the village where the rancho was found adjacent to the local school. As I lugged the pelicans on the concrete made slippery by the misty rain, I found it difficult and awkward to keep my footing. I wasn’t the only person to notice this, as the Lead Medic herself actually slipped off the path altogether and covered her backside in mud. With caution, we moved slowly and delicately, making extra trips individually so as to avoid unnecessary risk. It was during this time that I thought about my mother a physician herself, who in the lead-up to my trip had expressed interest in joining me this time around to treat patients. Looking at the staff around me, I took notice for the first time that nobody I was working with was older than their 30s. This line of work is exhausting, physically demanding, and at times unforgiving when it comes to stamina. Every night after travelling to clinics I’d lay to sleep with sore shoulders and a brewing tension headache from all the strain of carrying heavy bags. The reality is that in many ways, this is a young man’s game. Sure, older physicians and volunteers can still make their impact in other ways, but the economy of bringing personnel that can only contribute to part of the process made me think. As much as I want this to be my life forever, at some point the time will come that I can’t pull my weight anymore and I’ll have to find different ways to make a difference. That or finally discover the fountain of youth and pour some on the rocks. Not sure what I would mix it with… Maybe tequila? To be honest I’d prefer a cow of youth so I could mix up an immortality nesquik.

I digress.

Once the wetness and dragging luggage culminated, a quick huddle in the rancho was followed by clinic setup. Now with several clinics in a few days behind us, the setup was streamlined and before we knew it we were seeing patients. It didn’t seem like there were all that many, which is a trend I continued to see that differed grossly from my first mission here. Now that FD was doing regular follow ups like had always been intended, that surge of patients neglected for months on end in desperation to see a physician was nowhere to be found. Our clinics were now controlled, orderly, and fairly regular. The bizarre seemed to come a little less often than before, which was also likely because instead of seeing everyone I was now seeing only a fraction as we split the load with the other medics. Still though, the bizarre showed itself now and again, like the home visit I saw with my medical student Leo and our clinic manager Cristobal.

Getting to the house visit was difficult enough, as it tended to be at times. The patient’s neighbour, a young girl probably no older than 11, guided us from the rancho down a muddy slope and into a large clearing with an improvised (an appropriately muddy) futbol pitch. After sloshing through the wet grass, we came to a barbed wire cattle fence that demanded far too much from my limbo skills to get under, leading to an inevitable mud stain on my scrub pants. Then, for a stretch close to 1km, we walked through fields on dirt paths, wooden planks, logs laid in muck, and rocks through a series of sloping hills until coming to a casita. This casita, a square divided into three rooms, was suspended 6 feet off the ground, and had a log standing upright with cut-out footholds to bring us up. Climbing up into the house, the smell of smoke from the cookfire in the first room stung my nostrils. We pushed past a bedsheet that marked the separation between the two main rooms, and found a 32 year old woman sitting on the floor on a mattress. I ushered Leo and Cristobal into the room and encouraged them to sit on the floor before we started chatting. We knew a little bit about her from a visit three months prior, and things were only getting worse.

She’d been suffering progressively worsening joint pains over the last five years. Starting after the birth of her third child around that time, she first noticed her right ankle became hot, swollen, and sore. This was something that came and went in flares, and over the last year in particular, she noticed her knees started doing the same, followed by her shoulders. By the time she was seen by a member of FD three months prior to my meeting her, she had pains in her ankles, knees, shoulders, and elbows with some stiffness in her hands. At that time, she had been evaluated clinically and been given a non-specific diagnosis of a condition called inflammatory joint disease. 

Inflammatory joint disease falls under the greater category of auto-immune diseases, in which (for reasons that are not yet fully understood) some people can develop immune systems that are dysregulated, and confuse normal tissues for foreign pathogens. This triggers immune cells to attack that normal tissue just as they would an infection. When auto-immune diseases involve the joints, we call that inflammatory joint disease, which comes with many different subtypes. At the structural level, this manifests as hot, swollen joints that are often painful and stiff. Patients can also describe other symptoms associated with the immune response like fevers, loss of appetite, rashes, or general fatigue. Over time, as local inflammation progresses, the joints get slowly destroyed, leading to irreversible structural deformities. 

Since there are so many different subtypes of inflammatory joint disease distinguished by their own genetic signatures and cellular pathways, making a diagnosis based on a clinical exam alone can be tricky. Essentially, all you can say is that some form of immune mediated inflammation is happening, and this makes it more difficult to find the right treatment because treatment involves immune system modulating drugs that are specific to each subtype. Treating pain and inflammation with Tylenol and ibuprofen could help reduce her pain, sure, but it wouldn’t do anything to slow the inevitable destruction of her joints. Last time she was seen, she had been given a letter to take to a hospital in Changuinola, the nearest proper city several hours away by boat and bus, asking for more specific lab tests and a specialist appointment to make the appropriate diagnosis. In that time, she had been unable to go due to cost related barriers, not to mention the inherent difficulty of mobilising through the fields of muck for such a stretch in her condition. She told me that she planned to go soon, and was waiting on a family member to send her money to finance her transport. I nodded along as she spoke, and probed her periodically with questions to get a better handle on how she was doing. In her current state, she was bed bound; unable to cook or clean, and she was defecating into a bucket in the room with the help of family who would then empty it outside. 

She was in rough shape.

As I spoke to her, I rested my hands on her ankles first, and then her knees. She had notable swelling in both, and they were hot to touch in comparison to the meat of her leg. The same went for her shoulders and elbows. When I moved onto her hands, a gentle squeeze of her wrists made her shudder in pain. With Leo closely watching, I did a targeted rheumatoid exam, just like I had been taught to do in medical school, which involved a series of manoeuvres to determine her functionality. Her ability to extend or flex her wrists was gone due to pain and stiffness. Her knuckles and small joints of her fingers were sore to touch (notably, rheumatoid arthritis, the most common form of inflammatory joint disease, impacts the small joints of the hand with exception to the joints on the edge of the fingers, the so called distal inter-phalyngeal joints, which was also the case in this lady). I then handed her a pouch with a zipper and asked her to open it and remove its contents. With some minor difficulty in the setting of the pain, she opened it without problems, which was at the very least a sign that she still had some salvageable function. However, her condition worried me. Every day delayed was a step closer to joint destruction. I spent the majority of our visit talking with her about the importance of following up with a specialist, which she understood.

‘I know, I know,’ she said. ‘I still have the letter, and it is my plan to go next week as soon as I receive the money from my family.’

‘Are you sure you will be able to go?’ I asked. ‘If I wanted to get in touch with you from far away, just to check in and see how you are doing after the hospital, how would I do that? Do you know somebody who has a cell phone?’

‘My aunt,’ she answered. ‘I will have someone give you her number.’

So, after all that, I left her with two bags of Tylenol and ibuprofen, and took with me a crumpled piece of paper with a number on it. Those kinds of visits are often-times unsatisfying. I had no way of knowing if she’d go at all, despite her promises. I am not blaming her, obviously if she could go she would go, but you feel as a doctor in these settings sometimes that your hands are tied. I can accept when there is nothing to offer, but it’s a bit harder when you know these patients could get help if we just managed to dissolve some of the simpler barriers to healthcare such as transport. Giving patients money for transport doesn’t seem to guarantee any of these barriers are overcome either, as sometimes it’s the time and distance that plays just as big a role. Then again, I recognize that their remote nature is part of their way of living, and if I wanted to remove their barriers that might mean compromising some of those things intrinsic to the nature and lifestyle of the Ngabe people. Even if she does go to hospital, and even if she does see a specialist, what’s the likelihood she can make two trips a year to see a rheumatologist that far away or get access to the necessary medications to treat her disease? If we’re being honest, probably slim to none. Still, we offer what we can.

The journey back to the rancho was coloured with grey and rain, a nearly fitting backdrop. By the time we got back, there were few patients left, and a sexual health talk was being given at the rancho in homage to global AIDS awareness day. From a distance, I sat near the admin table as Fermin, the medical director, spoke to a group of about 20 men and women about HIV/AIDS, sexual health, use of contraception, and general safe sex practices. I even learned something new myself about something called Feline Immunodeficiency Virus or FIV, which is basically cat HIV – who knew!

With the tides receding and the dock exposed, we began packing in the afternoon for our return to base. That evening, after our debrief session and dinner, we set up the projector on the top floor of the dining hall to watch a movie. Once it ended, everyone scattered, leaving me to my thoughts and reflections under starlit skies. Something wasn’t quite right, I could feel it. I should have been happier to be back, and despite a great week of clinics, seeing old familiar faces, and meeting some lovely new ones, my mind kept drifting elsewhere in my moments alone. In truth, I always drifted to the same thoughts of my recent relationship and how I felt her absence since we’d split up. 

In the evenings after clinics I’d walk out onto the dock and sit alone in silence mulling the incongruence I felt with missing her so deeply despite knowing the relationship ended rightfully. I couldn’t force a square peg into a round hole for the rest of my life, even with love on my side. I found myself contemplating what it’d be like if she was here with me, how she’d respond to the chitras, the always cold showers, or the lifestyle. Would she fit in with the staff, or would I find myself looking over my shoulder constantly worried that she wasn’t having fun or failing to integrate? A part of me thought that maybe she could have learned to love it the same way I do. In reality though, none of these ruminations served much purpose since there was no going back. 

I just told her the truth, that our futures were incompatible; I wanted the jungle, the mud, and a hammock, she wanted the suburbs and a big house with a family car. Despite the effort, my attempts to gently coax her into considering a life of humanitarian work fell flat. She supported me in my endeavours in the best ways she could, encouraging me to take it up, insisting that she’d wait for me while I went away. That’s not what I wanted though. This life isn’t just a ‘for a year or two’ thing to me. I knew in my heart I had to be straight with her instead of wasting her time in a relationship that had no future. She didn’t like that, understandably, and ultimately decided that it was best for us to move on even though it hurt. I obliged.

However, in the moments that came after, when that severed connection manifested itself in that suffocating melancholy I couldn’t seem to shake months and months later, I asked myself if maybe I made the wrong decision. It’s not like my life had been hard after the breakup, I didn’t spiral into a depression or lose my passion for living, but I struggled to reconcile how much I missed her. On a daily basis I’d catch myself reflecting on when we first met and I walked home from our first date so infatuated that I lost interest in anyone but her. I’d find myself constantly missing her company which just felt easy, like we vibrated on the same wavelength despite being wired so differently as people. In the time since we split, I’ve failed to find the same connection with anyone else, and the more time that passed, the more I thought about it. These are the pains of life and love I suppose. I have to tell myself it was the right move, because I think it was, even if at my most vulnerable I question whether I may have let something slip that I won’t find again. I write this in the hope that maybe someone facing similar dilemmas can read this and feel like they’re not alone. I don’t regret the decisions as much as I lament them. All you can do is move forward and learn I suppose. 

Life lesson: find a girl that likes the Jungle.

Those moments came and went, particularly at night when tired before bed, but they passed. Thankfully I never had too much time to linger on it, the next morning I was up again at 7 for breakfast followed by base clinic.

Base clinic gave us the opportunity to follow up with patients that had been seen during the week, especially those from the day clinic communities relatively close that could manage the trip fairly easily after starting a new medication. In the end, none of the patients I saw that morning proved to be too complex, some just requiring repeat blood sugar checks or blood pressure discussions after starting on drugs. 

I worked through until the afternoon with Leo before we packed our bags for a Friday night spent in town indulging in all the hostel-vibes, drink specials, and general debauchery of a beach-town that I didn’t get to see at its fullest during the pandemic. A bunch of the Crew made it out: there was Kevin, our director of finance and futbol fanatic. Lisa, our Dutch gynecologist, Kasia, the head veterinarian, Trenton, the tall California bro who reminded me a lot my myself at his tender age of 19, the New Zealanders Leo and James, and of course my man Jack, the barefoot Cacao farmer who I had formed a tight bond with on every clinic since I first set foot on the islands in 2020. We went to a place called the Tequila Republic and I declared myself commander in chief of the infant nation. First presidential order: everyone has to watch me attempt a handstand on the dance floor.

The next day, on Saturday morning with a sore head, I took a rumbling boat back to base before resting in the cocoon of my blankets under scattered rain. 

On Sunday, myself, Fermin, and Ber had plans for an Asado, or barbeque. Things started out okay, given the impressive dampness of everything, including the wood chopped down from nearby trees. As the embers slowly lit and heat began to manifest, the rain started coming down again. At first it fell lightly, giving us time to source a tarp from nearby to form a makeshift cover to our operation. The tarp proved to be somewhat ineffective, as it had several defects. Several deliberations about abandoning ship were had but we pressed on valiantly, even as the rain evolved to tropical showers and the ground beneath us began pooling water around the fire itself. Some modifications to the setup added time to the process, but that’s the nice thing about Sunday’s isn’t it. All the time in the world. 

Whether or not the food turned out okay hardly mattered to me, it was more about the process: lighting the fire, chatting, and just enjoying the company. Fermin and I spoke about life, this journey in humanitarian medicine, and the different paths that brought us here. We talked about some of the ethical difficulties in trying to do your best with not enough, and the economic model of volunteer-based organisations. Fermin took a path very different from my own, initially starting out his residency in Argentina, he also split time as a sports physician with the athletic club Boca Juniors, and got to travel the world to fascinating places with the club. Like so many in this space, the twists and turns of life landed him here, for now anyways. I told him of my own path, my family history, and my personal struggles. Overall, it was a beautiful Sunday spent in good company. The food even turned out pretty decent in spite of damp firewood bleeding vapour out all under the tarp. 

That night I called the family to let them know how I was doing, and I was glad to find everyone doing well. I wouldn’t get the chance to reach out to them for another week, since we set out the next morning on a four day clinic covering two communities inland. Thankfully, I knew how to pack appropriately this time around.