Quebrada Sal meaning ‘Salt Creek’, would be the final community I’d service as a member of this crew. It was on the far end of the nearby island Bastimientos. By virtue of its proximity to the greater Bocas del Toro, it had familiarity with tourists and town-folk who frequented a series of nature trails that had their origin in the community. Walking in through the concrete path, I was stopped by a woman who offered me some crafts in a little tourist shack. I told her I’d come back. Immediately after, I was stopped again, by a man in his forties and woman.

                ‘Do you attend asthmatics? My wife has asthma’ he asked me. He wore glasses, clean pants, and a polo shirt.

                ‘We are here only to see patients on the chronic list,’ I said ‘but anyone with asthma should be on our list already, or we can add them today. So yes. Does that answer your question? If by some catastrophe we cannot see her today, you are always free to come by the base in San Cristobal on Thursdays when we hold open clinic’. I always have a roundabout way of answering simple questions. I am working on it.

                ‘We are here from Bocas town on a job’ He said. ‘The services there are so poor. They don’t even have inhalers, and she has been without salbutamol for a time now. Can she attend with you?’

                ‘The two of you live in Bocas town?’ I asked ‘Or are you from the community?’

                ‘We are from Bocas’ he said.

This development I had not foreseen. We had very special permissions only to service the Ngäbe in their communities. Operating within Bocas was outside our jurisdiction, as the state run health service was fully active there. Any patient care delivered on that island was strictly faux-pas. This was always tricky, since at the moment, health services in greater Panama were in the midst of a national shortage of many crucial drugs that we were sourcing from North American NGOs. I had been stopped in the street in Bocas town before by people asking for refills of their Metformin, or anti-hypertensives. By virtue of the Panamanian two-tiered health system with both private and public arms, the public hospitals were completely out, whereas many of the private pharmacies continued to have stock. Word on the street was that shipments of these drugs arriving to the public centres were quickly turned over out the back door to private clinics. This was all speculative, but in Latin America I’d say there is a pretty fair chance that it was true. At the very least it was plausible. Thankfully I was well versed in the counter-tactic. Where I come from, we call it hacerse el boludo or playing the fool.

                ‘We are only here to service people from the community. Very very strict permissions. I have no way of knowing who is from where though…’ I said as I looked him in the eye. ‘ I am just the doctor who sees the patients. If someone comes to clinic with asthma asking me for salbutamol, as far as I know they are from here right? Why wouldn’t they be?’

                He nodded.

I continued along the path. There was an entry point to a jungle trail that cut straight through the island all the way to a beach on the other side. I would find out later that this beach was Red Frog, the same one I had visited for a weekend earlier in my placement; that beautiful mirage with all the gringos, a lovely resort, and a restaurant with six dollar daiquiris.

Less than ten kilometres away on the other end of the island, I was dodging chickens, dogs, and cattle wandering through the village on my way to the rancho. Our examination room was an old storage shed 20 yards away, which had bunch of construction materials ditched in front of it that had to be stepped over just to get inside. I got myself changed and ready before seeing my first patients.

The first I saw was a 15 year old girl who had asthma, and her father was actually a former community healthcare nurse. He knew everything about her disease and was on top of her medication use and technique. He also wanted me to take a look at a rash she had in her armpits. On closer examination it was not only in her armpits but also along the creases of her neck, her cubital fossa (the inside of the elbow where the fold is), and between her fingers and toes. The itching was worse at night. Asking the father if anyone else in the house suffered from the same, I knew what his answer would be before he spoke. This was the classic work of scabies.

Scabies, also know as the ‘seven year itch’ is a localized reaction to the work of the scabies ectoparasite, an eight legged mite that derives from the same family as spiders and ticks (Arachnida). They are not microscopic but very small, at their largest reaching around half a millimetre, and are fairly contagious.  Females in particular cause the most problems, because they dig into the first layer of skin to deposit their eggs, which germinate and hatch after a period of a few days. After birth, these move about and develop into adults, living within the skin for a period of up to four weeks. The itching is often a function of the localised immune reaction to the eggs, which is why symptoms only develop several weeks after infection itself. As you can imagine, people living in these conditions with seven or eight of them to a home the size of the typical Irish living room and kitchen, make a breeding ground for the little buggers. Thankfully we have decent treatments in anti-parasitic oral medications and topical creams. I needed the father to go home and collect the other five children and his wife so I could weigh them all to determine how much to give them each. I also told him to get onto the wife about washing all the cloth inside the house, sheets, hammocks, towels. He thanked me for the help and went off to round up the troops.

A few patients later I saw a woman who was having abdominal pain. It wasn’t a severe amount of pain, but she was concerned because it all happened after her last child was born six months ago, her fifth. She had a retained placenta after giving birth that had to be removed via instrumentation—This can sometimes, happen when the placenta burrows too deeply into the uterus and then doesn’t detach properly. The biggest risk is that on removal you might cause a tear, which severs all that highly vascular tissue and causes bleeding. Successful removal sometimes meanings scraping off a lot more tissue that you want, which can lead to scarring of the uterus that hurts for a while, can compromise future fertility, and places you at risk for highly problematic pregnancies in the future. She had been given a contraceptive implant in hospital and told she would likely never have children again—Her menstruation had not returned after delivery, although she was breastfeeding and her period normally didn’t come back after about a year. That was another perk of this population, you can forget all the anxious first time moms in Ireland that freak out about every little thing. All of these women knew what to expect, which inversely means that you should really take them seriously when they say something is wrong. Despite her not having any paperwork, it sounded to me like fairly open and shut. She had endometrial scarring, and I was willing to give her another three months for the pain to settle and all that granulation tissue to normalize before going any further. After all she sat before me quite well. I presented her to Nicole.

Nicole wanted her to be seen by a gynecologist. Completely reasonable. I asked the patient if she would be happy to attend and she agreed so. That is always a decent gauge for me, just suggest the notion and see how they react. She seemed happy enough, with very little grumbling. She also had the benefit of being close enough that she could catch any boat at the time of her choosing.

As the day went on more patients came and went. The gentleman with the scabies-riddled family came by with his kids and a big bag of fruit. He gave us the fruit as a gift. They were a local fruit, something I had never seen before, with the texture of a pear, but more round and not as sweet. I crushed a whole whack of them throughout the morning. Then Jack pulled me aside just before lunch.

                ‘Juan, today is your last clinic.’ He said ‘I spoke to Nicole, and she agrees that we will let you do the house calls today. There is only one, he is a chronic patient that we always see, and lives thirty minutes by walk. You will go with Cristobal after lunch, is that okay?’

                ‘Hell yeah that’s okay’ I said.

Since Nicole joined me on the ground she had been taking all the house calls, but they still remained my favourite part of deployment. After eating my sandwich in the solitude of the exam room smacking away a few hornets and making friends with a dog, I got all my bits and prepared to set out. The same community nurse from before knew where the gentleman lived, and agreed to act as our guide. He wore a ballcap and light blue shirt, with strong cheekbones that nearly hid his eyes beneath his mask. He told me his real name, which I forgot, but he told me people who knew him called him Indio.

As we set out, we quickly left the wooden houses of the ‘centre’ and found ourselves in open fields. The sun was blazing, and cooking me as we traverse the sweeping hills of grass, which were grazing territory for the cows. I asked Indio if I could share his story and he had no qualms. In the two hours that I spent with the guy I grew very fond of him. When I mentioned that I was writing about the communities, like a form of pseudo-journalism, I caught the ear of Cristobal. I had been working with him for nearly a month now and never knew that he was an aspiring writer as well. He loved reading Stephen King, and had written a lot of fiction himself. It didn’t really surprise me; at just 21, I felt wisdom in his words that would translate well to telling stories. We agreed to share notes at a different time and they both began telling me more about the land.

‘A lot of this was forest not that long ago’ Indio told me. It had been chopped down to make more room for grazing during the pandemic. ‘We needed something to do with no work’ he said. I envisioned all the lads out there swinging machetes for hours and hours as the days went by. At the time I didn’t consider how they might have hauled the trees out without the use of quads or forklifts. I don’t think those vehicles would survive the mud. That mud was something else. Time after time we came to swampy clearings with thin lumber making a balance-beam path through the tantalizing syrup. I always walked with extreme caution, like a careful sloth, while the natives floating right through it without a break in conversation.

                ‘All this land, in all these islands, belonged to the Ngäbe’ they said. ‘When the gringos came they bought the nicer plots, the beaches, the coast, the farther end closest to Bocas’

                ‘Anselmo told me all about that’ I said. ‘It’s interesting, in Canada believe it or not, much of the land was actually taken, or sold against the will of the people for development. We have our own history with the indigenous. When I got here I figured it was the same, but ultimately the locals chose the sell their land, which I think is much better.’

                ‘You’re right Juan’ Cristobal said ‘At that time, all of those resorts that you see now, all of the beaches, Red Frog, Play Estrella, everywhere in the islands, they were owned by the Ngäbe. The gringos showed up and bought that land for pennies. They saw the capacity for development in way the locals could never. Now the gringos turned it over for a hundred times the profit.’

                ‘You mean to say they took advantage?’ I asked.

                ‘You have to understand Juan, that to the Ngäbe it was money. Money unlike they had known before. They hardly knew what they had.’ I didn’t hear any anger in words. Almost more like lament.

                ‘That there is no denying’ I said.

We passed by herds of Cattle, and I talked to them about beef. Their cows were the same species we bred in the north of Argentina, the Zebu. They have a characteristic hump on their backs, which makes them easy to spot. In the Argentinean mountains, they are suitable because of their hardiness and ability to tolerate droughts in dryer climates. They are decent cows for dairy, beef, and hide, making them solid all arounders, as opposed to breeds like the Scottish Angus (primarily used for beef), and the famous white and black spotted Dutch Holstein (used almost exclusively for dairy). I talked to Indio and Cristobal about my inability to find decent beef at the supermarkets in Bocas, despite seeing some fine looking cattle in many of the communities. ‘You have to chew it for hours and hours’ I said.

I remember raising this point with the rancher I had met in the community of Norteño. ‘All the good beef goes into the city, or for exports. The rest that is decent, we keep for ourselves in the communities. I am not surprised to hear you say this’ he told me. Where can a man get some damn beef in these parts? If I could just find a fish that moos at the very least…

Finally, the tips of straw housing came into view in the distance. I was oozing sweat from everywhere, and feeling positively swampy in many places that are best not mentioned. When we got to the house, a voice from inside told us to come up and wait. There was a half portion of the upper floor that opened up to the outside world with a wooden ledge, and I remember I sat out there just dripping sweat for about two minutes before he called us in. I had been told that he was a quadriplegic with mobility issues, the source of which was unknown to us.

What I didn’t know was that I was about to see a patient with one of the most impactful diseases in human history, a terrifying pandemic that rocked the fabric of many of the world’s major populations and influenced the birth of industrialized vaccination. Most of what I knew about it I got from my mother, because it had been eradicated a lifetime ago almost everywhere, and now had no more than a half a page in any text I ever read in college.

Polio