The alarm went off at 5:45 and signaled the beginning of our day. Sleepy eyes floated in silence, zipping backpacks and snapping buckles, as the lingering cold snap from the night worked its way out of my grumbling bones. Soft voices exchanged a word or two, prompting the four us to set out into the blackened morning, with the sulky glow of headlamps lighting the way towards the river. Arriving at the riverbed, I quietly took my distance until no one else was visible, and got ready. Knowing the likelihood of us encountering the locals was small, I stripped down into my underwear and waded out into cold, crisp water until I was at knee height. With a hesitated count, I closed my eyes and fell backwards. Chills rose from the centre of my back up into my ears. My chest tensed up. This brought my head up from the water, and I opening my eyes to see the last few stars saying their goodbyes.

My right hand clutching a bar of soap, I scrubbed. Standing up from the water, a light breeze made me shudder. The water was cold, certainly, but it was rejuvenating. It gave me life. One pass from my face down to my butt, and then a ginger rub between the toes was all we had time for, and l felt myself drawn back to the riverside. This early morning bath had been Nicole’s idea, and it was a good one. The four of us came together again and walked back up through mud, taking careful steps. We made it to the kitchen house on time for breakfast at 630, where Chrystian was already waiting for us. The hojaldras were still frying, our breakfast of choice.

Hojaldras are a Panamanian classic that I will crave undoubtedly once I leave. It’s a very simple flour mix that is deep fried and eaten with any cheese, meats, eggs, or my favourite: lathering them still hot with peanut butter and then sprinkling some condensed milk on top. They warmed me. A cup of coffee followed, which I never usually drank, but something about those mornings made it all feel right. Despite all of the nights’ poor sleep I often got in that hammock, after our breakfast with this blend inside me prepared by our native hosts, I felt ready to face anything that came my way. This day was no different.

When the car arrived at 7am we loaded and moved out for Rio Oeste, arriving to set up clinic in short order. Rio Oeste, Jack’s home, is a hub for cacao farming, and the fruits dangled overhead in their many colours of ripening. Clinic that day had me seeing a lot of malnourished children, which is as common here as the bugs.

The source of malnutrition is often a variety of factors, environmental, social, and nutritional. There is a usual workup that should be done for every child anywhere and anytime, which involves taking basic measurements of weight and height and plotting them on what we call a growth chart. A growth chart is a measurement tool that enables you to see where a child compares to the norm for growth based on percentiles for their age. In Ireland, the most common cause for a small baby is small parents, and we often tolerate children who are small for their age so long as they are meeting their developmental milestones and trending in the same percentile over time. The real concern comes when children begin to cross centiles, which indicates that a child should be at a baseline that they are not reaching. Oftentimes we see children here that are small for their age and I tend to take it with a grain of salt, I mean if you look around all the Ngäbe are short. Whether that is because they are a short people or because so many of them suffer from malnutrition is to be debated, but I am usually happy enough to keep the kids  on fortified rice and give them time to come around, especially if they look okay and mom isn’t terribly worried. I have spoken to so many mothers that tell me their fussy children used to not want to eat and then over time developed more of an appetite that sees them normalize, and they often times grow back within a normal range but still wind up being small. Dr Nicole had a different approach, she exhibited a lot more concern when children didn’t improve and wanted them to see pediatric services nearly every time we saw one who remained in the same centile, especially considering how nobody had gone to see any doctors for the better part of a full year. Dr Nicole was really admirable in her commitment to give patients what she believed to be the standard of care. She was happy to refer patients to go to hospital because that was what should be done, regardless of what the repercussions might be if hospital services wind up being very disappointing or if their difficulties make the execution of that trip a mighty pain. I found myself wondering if I had maybe been too quick when I got here to accept giving patients less because of the circumstances. The law of this land was different, and I was happy to accept that. More than once I found myself presenting her a case that I would not usually refer and have her tell me otherwise, to which I simply nodded and accepted this new approach, even if at times I disagreed.

She believed that regardless that these people were tremendously humble and of low resources, that they still deserved the same level of care as they might get in the Netherlands. ‘In Holland I would refer this patient, and that shouldn’t change because we are here’ she’d say. She’s right.

This wasn’t Holland though.

I wasn’t going to pretend that it was. Maybe that was my flaw, creating a self-fulfilling prophecy that further perpetuates the circle of inequity, I don’t know. In my eyes, referring someone to hospital who looks completely well for them to not be seen, or for them to just be told by a non-healthcare staff worker to come back post covid, only serves to dissolve an already fragile relationship between them and state-run healthcare. All it takes is one bad experience, and I wonder if setting them up for one just keeps them from going the next time when I really need them to. Either way I kept this to myself; once our relationship grew stronger I would get my chance to discuss these things with her, but right here and now was not the time.

As always the clinic brought vaginas, children, diabetics, back pain, and headaches in bunches. At one point I had a consult with a young guy, twenty or twenty-one, who had a previous diagnosis of HIV. He was known to the HIV service. He had been diagnosed three years previously and was very good at taking his medications. Over the last five weeks he had been having some febrile symptoms on and off, with diarrhea and vomiting most days. He had a little bit of blood in both, although this was more than likely due to irritation causing some minor trauma, which is fairly common. All of these alarming signs were buoyed by him saying he was getting better. Still, with HIV, you have to be on high alert for anything and everything. He did cite some new genital lesions, which on examination with Nicole were definitely present, but not terribly convincing of anything herpetic or bacterial. Gastroenteritis would be the most common culprit to produce these kinds of symptoms, but he needed an infectious disease and HIV specialist to know what to look for. He had his next appointment scheduled for a month later, and we encouraged him to move it up to as soon as possible and attended with a letter written by us explaining our concern. That plus a heavy handed treatment for any and all possible sources of GI infection would see him on his way.

After him, I saw a 16 year old girl who was born who had an insanely loud heart murmur. According to her mom, she was born with it, and had been followed up as a young kid with cardiology services until she stopped attending and was lost to follow up. For the past four years she had been suffering from central chest pain during exertion – a worrying sign that she might have some kind of congenital heart disorder. She was trying to re-enter the cycle of care but just couldn’t seem to get appointments sorted. Our consult was purely logistical, she had to see a specialist, and Nicole and I went back and forth discussing different ways to get her in the pipeline. That’s where real world experience of hospitals and the enterprise of medicine really goes a long way, and I was glad I had someone with that to provide some guidance.

That evening we had dinner inside a restaurant within the community—the first of its kind I had ever encountered—it was owned by a gentleman who was known to Jack from his days working in Cacao tourism. We ate as he shared stories with us about the native importance of Cacao, how it is farmed, and what kind of work has to be done to the trees throughout the process of growing and harvesting. Things had been tough for many of the farmers in the last few years, after an invasive species of fungus was introduced by cacao trees imported from Brazil and planted on Panamanian soil. The Ngäbe have tremendous spiritual connectivity to the plant and refuse to use harsh pesticides on their crops. The end result has been a great reduction in their yield while competitors willing to spray their plantations flourished.

After dinner we got a tour of the community from the local boy himself, and after the team went to bed I visited Jack’s sister with him. She was very friendly. There were a lot of chickens that roamed around the house clicking and clucking their way about like little robots. I don’t know why but I have always found chickens amusing. The cocksure idiocy with which they roam around always brings me a smile, with their beady little eyes and sharp turns of the neck. I identified with their confidence. It wasn’t uncommon for them to wander into our consults and roam around pecking at things like they owned the place. Same goes for all the dogs. The dogs were everywhere. At least once a clinic a dogfight broke out just outside the rancho, causing a ruckus. They were not strays as much as they were community dogs, all with their own names, but scoundrels they all were nonetheless. As a matter of fact, for assessing height we had started to use a different measuring tape, one made of metal, after our last roll got ripped off the wall and chewed up by a dog at a previous clinic.

Can’t imagine that ever happens in Holland.