My first day on the job (i.e. the real job) had me busy as a bee. The day’s schedule was sent in the day before via whatsapp, delivering and then some. I got to meet the rest of the team; I met Jack, a local boy, about my age, who had a knack for caregiving. I was told he was a phenomenal babysitter. There was also Kelly, a perky woman with short hair, also young, and full of life. She spoke near perfect English. Our week layout was easy to follow, Monday packing, Tuesday and Wednesday mobile clinics with myself, Jack and Chrys forming the dispatch team. We’d be going to Pueblo Nuevo and La Sabana, two pueblos that are usually overnight trips themselves, but we were going to try and squeeze them both out in one trip, boating and hiking up the mountains to La Sabana on Tuesday, then sleep there, and descend the following morning to Pueblo Nuevo which was located near the base before returning Wednesday evening. Not a bad introduction to the gig, I thought to myself.

In essence, the day revolved around preparation, which I would come to understand is the lifeblood of mobile medicine. A proper understanding of where exactly we were going, who exactly we were expecting to see, and what our limitations in transport and in manpower formed the holy trinity. The morning was spent going through our records for the chronic disease management patients in the communities we were targeting for that week for Tuesday and Wednesday mobile clinic. Knowing what their prescription top ups were going to be, enabled us to prep their prescriptions from the pharmacy. I spent a good chunk of the morning cutting pills, bagging, and bottling different combinations of prescription bundles that would go to the patients. It was only this point that I think I understood the scope of our work. In any other place I have been, the patients themselves as well as other moving parts within the healthcare machine shoulder some responsibility in the delivery of care. Patients have to make an appointment, go to it, go get their prescriptions filled, and then arrange their follow up appointments as needed. We were taking the patients themselves as far out of the equation as necessary. We were coming to them, right into the heart of their communities, bringing them their prescriptions, and we were arranging their follow up.

My understanding is that these communities had no real understanding of chronic disease management before FD showed up. Like many of the world’s low income populations, the pervasive mindset was that you either get sick and die, or get sick and get better. The idea that you get sick, and live sick, was something new to them when Dr LaBrot and his team showed up. This in combination with a limited capacity to mobilize to the centres of care closest to them meant that without FD these patients would fulfill their preconceived notion of disease: Elderly patients with type two diabetes would just deteriorate, die with CKD and the rest, those with rheumatoid arthritis would lose function of their hands, and those with cataracts would go blind. It’s not that treatment of disease was unheard of, these people didn’t live under rocks, but disease happened and took its toll, and that was quite simply a part of life. Compare that to how we demand solutions to everything in the occidental west, how people dissatisfied with their care can go doctor shopping until they find someone that listens to them. This breeds greater patient satisfaction at times, but also abuse. People are so desperate to get cured they will spend fortunes in exchange for hope.

I finished that book, that I talked about before, Cutting for Stone, and there was a passage in there that really echoes this notion. It describes the inner monologue of an Ethiopian surgeon who winds up discussing disease with his first patient in the US:

I took my own deep breath. I sat on the edge of his bed. I held his hand. “Mr Walters, I’m afraid to have some bad news. We found something unexpected in your belly.” This was the first time in America that I had to give someone news of a fatal illness, but it felt like the first time ever. It was as if an Ethiopia, and even in Nairobi, people assume that all illness—even a trivial or imagined one—was fatal; they expected death. The news to convey in Africa was that you’d kept death at bay. Those things that you couldn’t do, and those diseases that you couldn’t reverse, were left unspoken. It was understood. I don’t recall any equivalent word for “prognosis” in Amharic (the language of Ethiopia), and I’d never tried to speak to a patient about 5 years survival or anything like that. In America, my initial impression was that death or the possibility of it always seemed to come as a surprise, as if we took for granted that we were immortal, and that death was just an option.

After lunch, a few surprise consults showed up having heard that the doctor was out of isolation, and I was able to give a small bit of counseling on diabetic management and check an elderly gentleman’s blood pressure and sugars. He had a daughter who was fairly on the ball and was driving him mad that it’d been too long since he was last assessed. His numbers were in the clear, and I watched both him and his daughter breathe in a collective sigh of relief. I suppose that is another thing that comes with Western medicine, that being Western health related anxiety. For better or worse, it was just something I noticed.

I got the chance afterwards to learn more about our patient population with a teaching session from Jack, who was himself, like many of the staff, of native upbringing. The Ngäbe (pronounced no-veh), were the largest of the five indigenous tribes of Panama. They had negotiated the rights to govern their own land, sort of like reservations, and maintain rights to their land and administrative autonomy. While their commerce is driven by agriculture and fisheries, they continue to suffer from high rates of infant mortality. This amongst their barriers to access of medical care and social care, drives their life expectancy to be ten years lower than non-indigenous Panamanians (67 vs 77). Jack also taught me a lot about the framework of Floating Doctors clinics, their story, and how funding is distributed. (I learned from my time exploring various humanitarian groups that a publically available breakdown of how budget is spent is a telltale sign of a solid NGO).

That evening I had a zoom call with Dr LaBrot to go over the chronic patient list and resolve any queries I had regarding what to do if I encounter certain things. He was putting a lot of faith in me, perhaps more than he should have in a medical student whom he has never really seen work with patients before, or even met in person himself. I was determined to repay his good will, and I found his advice encouraging ahead of my first journey. I spent the rest of that evening packing my bags, chomping at the bit for the next morning to come, and then I got a call. It was a friend of mine back home. He was having his own symptoms, a tiny increase in urinary frequency for three days, some discomfort in his perineal region. No fever, discharge or discomfort with act of urination or pain with ejaculation. His symptoms were fairly non-specific, in a man his age probably a urinary tract infection, something that would in 99 times out of 100 run its course, which I explained to him. I advised him to give it a week and then maybe see a real doctor. He called me back two hours later, having left unsatisfied from our discussion, he made a call and saw his GP virtually, even had a prescription of antibiotics already. He had just driven his urine sample to the lab. That just made me laugh.