Sleep was a bit stressful for me that night, the paranoia from having already caused one partial collapse of the dilapidated schoolhouse kept me scared stiff in my hammock. In the morning Kelly started setting up for clinic while Jack and I made our first a house call; one of our chronic patients who I was told was in a wheelchair. She had gotten her leg amputated from complications of diabetes in June. She was on our full kit of anti-diabetic medications and her blood sugar that morning was still three times above the threshold for diagnosis. Trying to counsel her on lifestyle changes was almost a moot point, her physical limitations prevented exercise, and good luck trying to scrape together a low-sugar diet in one of the communities—she’d have to resort to eating air. I put my main focus on trying to get her some way to increase her mobility, whether we could somehow get her a prosthesis or her own personal wheelchair (she was using the only one available in the village, borrowed from the health pos). She was one of those patients that you left knowing full well things would only get worse for her, her disease completely controlled her life, and the battle scars were going to pain her more and more. Best we can do is mitigate the damage, control her hypertension and salvage some comfortable living, patients like this were sad enough back home let alone out here.
Realising that in my morning daze I had left the schoolhouse wearing my Boca Juniors jersey, I changed into clinic clothes as the numbers were already gathering at the rancho. It’s important for me to be well dressed in the clinic, even when those in-front of me are wearing old stained shirts with holes in them. I am not ashamed to wear clean shoes, button up shirt, and dress shorts like I would in any other hospital, to me it’s a sign of respect. Again the day was wet, but not as bad as the day before. I saw a little girl who I had been warned about before I came. She was born with spina bifida that was surgically corrected after birth and a had VP shunt in situ—Spina bifida, for my non-medical friends, is where the wall that cases the spinal cord (the meninges) herniates outside of the body cavity due to malformations during pregnancy. These malformations are most commonly due to a lack of folate in the maternal diet, hence why pregnant women are put on folate supplementation during pregnancy. The outpouching of these meninges can be corrected at birth, but a brain malformation commonly results which prevents the normal drainage of cerebral fluid, which in turn increases the buildup of fluid pressure in the brain which can lead to all kinds of neurologic impairment, for that reason many children with spina bifida get what we call a VP shunt, a small tube running under the skin from brain to belly that drains this excess fluid into the abdominal cavity where it can be resorbed normally—Not only that, but she also had a chronic full body eczematous rash that baffled specialists as to its origin. Not having the money necessary to travel inland for any kind of further pediatric follow meant that the family had accepted this full body desquamation as a part of her normal existence, and she came to our regular clinics for emollient creams and to have her skin bandaged to prevent infection of her sores. She is 6. I dressed her wounds after bathing her in coconut oil and counseled the mother on how to detect signs of a subtle shunt block, something that is often insidious and requires a trained pair of eyes. When I moved down to dress her legs, I noticed her left knee was swollen like a grapefruit and wouldn’t bend at all. Mom told me she had broken a bone and gotten a fixating screw into her knee, which was never taken out because they could not afford to pay a boat back in to see the surgeons. I wondered whether she might have some genetic syndrome that predisposed her to all this misery. I told her again to leave it with me and will try to arrange her to see the orthopedists and arrange for her to travel.
The numbers were starting to swell, and I called a snap meeting of the team just to get on the same page in terms of our timelines. I wanted a direct answer, from the captain and the team as to when the latest moment we could leave the village was. I knew we were aiming to be done at noon, but I wanted an official last call. We agree on 3 pm, giving us 4 hours to get back to Bocas in time to meet the 7pm covid curfew. Just knowing that alone helped me manage my stress, because the boogeyman of when are we leaving was no longer in the closet but now sitting at the table. That was all the time we had so we had to work with that. The numbers were simply too many, and a quick glance over the registrations showed many of them were here for their depo injection. We hatched a plan to give these patients their injection in hand, and have them walk up the health poset where one of the resident nurses could administer it saving us a huge amount of time. It made me both pleased but also frustrated, something which I would later discuss with Kelly who felt the same way. How is it possible that with a government health building in this village, with resident trained medical staff, that we were here caring for all these patients? Is the problem really just resources and money? Is it in management? Incentive? I wanted to get the chance to talk to someone there, to understand what they actually do and where the barriers to efficacy lie. I suppose this is really the all ending question to global health as we know it. I am hoping that enough time spent in the field will help me to understand these things, because in my eyes the solution to health inequalities lies not in one man running a monthly clinic but in public systems overhaul; that’s where the real value is.
Another patient later that day entered the clinic with the most bizarre gait I have ever seen. She was a young women in her twenties, thin at just over 100 pounds, and covered in keloid scars. She told me she suffered from epilepsy, and like so many others was dependent on the health post for her prescription that ran out months ago. Her seizures were often and severe, and the repetitive trauma of falling time and time again was the source of her many scars. I began to take a thorough history (so I thought at the time) and full neurological examination. From a cognitive point of view she was completely sharp, able to verbalise and understand complex commands, but her physical function was another story. Unilateral sensory deficits on her entire left side, combined with cerebellar deficits that were oddly more pronounced on one side had me concerned and also wonderstruck. I asked her for permission very carefully to publish the videos of her findings for my colleagues as part of a story I am writing about the many indigenous communities and their medical needs. In my excitement at exploring every nook and cranny of her findings I overlooked some of the most basic questions, namely how long she had been suffering from these motor issues, and whether things were getting worse or had remained the same over time. All she had told me was that she’d had epilsepsy ‘for a while’. When I made my call later that week with Dr LaBrot, lacking those details made any possible conclusions impossible and null. From a clinical point of view it is probably the most bone-headed move I have ever made. I still kick myself about it as I write this. The reality is that this information while useful doesn’t really change much for what we are going to do, which is just assess her ourselves at our next visit again to see if her regular medications are enough to normalise her findings. Even as I grow in confidence as a clinician, celebrated by the locals everywhere I go, it’s in our post clinic meetings that I encounter these constant reminders that I’m still very young and have a tremendous amount to learn. I think this is good.
The sky was clearing up and the sun came out, which completely turned my mood. Behind the sorrowful cases and the dilapidated abandoned government buildings I saw a strong community who supported one another. People from all around came around to say hello and stood by offer help. When I saw a patient that I thought too frail to carry a full bag of food home, the men would immediately offer to take it straight over themselves. Older women hung around just to help me communicate with some of the locals who were slightly more impaired or misunderstood questions or commands during examination. Even the children helped us move our pelican bags and pack our boat when the moment came.
One of the last consults of the day I had was with an old farmer. He wore an old fishing hat and radiated positivity, with a squint in one eye gave him that twinkle of an old sailor with incredible stories. He was picking up medications for him and his wife, who was not well enough to walk the distance from the farm where he still laboured daily. I was nearly floored when I looked at his file to find that he was 81. ‘Eighty-one’ I said to him ‘My god I can only hope to look like you at the age of eighty-one my friend!’ We spent a time talking, the physical labour was giving him bilateral tendonitis of the wrists for which I gave him ibuprofen and walked him through some stretches to help him out. When we had finished he pulled me to one side.
‘You know why I come here and talk with you?’ He told me, hiding a cheeky grin beneath his bristled moustache. ‘For forty years I sat where you did here. Community nurse for Bisira. We started in 1963, before there was any of this that you look around. This was all farm before, farm everywhere.’
‘Wow’ I said ‘I bet you didn’t have one of these!’ I said clamping a pulse oximeter onto his finger. We both laughed, as did the few remaining helping hands that stood around just for the craic. He would go on to tell me about how little they had to work with, barely so much as blood pressure cuffs. His chest beamed with pride. He thanked me for my stretches and made fun of my artistry on the piece of paper where I tried my best to draw them out so that he wouldn’t forget. Despite his tendonitis he gave me a handshake that nearly broke my hand. I would loved to spend more time with him just to ask about everything and anything, but time was starting to get tight and we had another house call to make before the boat headed back for base.
The house call was a woman in her thirties with painful urination and a positive leukocyte count in her urine dipstick (white blood cells usually means infection of some degree, usually). After speaking to her for a while, what started out as a UTI began to sound more like a vaginal problem, discharge down below, white, for the better part of three months. When I got to her house with Kelly as my chaperone we took a look down below and I found candidal deposition everywhere. She had in on her labia, in her thigh folds and around the back passage. An examination revealed no cervical discharge or cervical tenderness, so I gave her a fat tube of antifungal cream and instructed her on application. The poor woman had been dealing with this for three months, and this was the first chance she was getting at having some treatment for an incredibly irritating and yet simple condition to fix. I felt equal parts bad for her and alleviated that she was finally getting some treatment. I hustled back to the boat afterwards and there were three women waiting there, they had come up from a different community downriver to get their babies looked at, all with different febrile ailments, diarrhea and the like that infants get. It was 3:10, so I was completely out of time. We agreed to give them a lift back to their village and I had to examine the children in the boat. Auscultation is much harder when you have a roaring propeller engine 6 feet away from you. After dropping them off with a little chat about infantile fevers and how to manage, my clinic mode finally switched off.
In classic moronic fashion the first thing I did was change into my bathing shorts while we switched boats at the river mouth and in the process I dropped my watch into the river. I lunged for it blindly against the mud brown flow, where it was undoubtedly immediately swept away. It was my favourite watch. As our boat peeled away it was hard for me to feel all that upset about it though. I developed a tiny fantasy in my mind that some little boy or girl might fish it out somewhere in however many years’ time. Good, I thought, keep it. I can always get another.
I took away something much different from Bisira than the other two communities. I felt a deeper sense of genuine poverty, and need. Perhaps being in the mountains, the isolated nature of la Sabana romanticized the many elements of a simple wholesome life for them. Bisira’s crumbling infrastructure and patients in dire need left me a sour taste. This of course was slightly buoyed with some degree of hope stemming from their strength of community. I only wonder how many other villages, deeper up the river plus a hike, those without their own health-posts and access to cargo by boat, live in situations just like these. Does their far removal from the influence of modern living serve to their benefit or to their detriment? Would it be worth scouting up river trying to find the deepest and most underserviced clusters, or might they be better off to live in their own way without amlodipine, processed cheese, or American sugar cakes. I certainly wasn’t willing to be the one to scout them; if I were them I’d probably shoot the white man in the heart with an arrow the moment he set foot within my reach.
