Health
 Panama
Project #17667

Keep Sustainable Healthcare Afloat in Panama

by Floating Doctors Inc
With more economic prosperity, more soda is bought
With more economic prosperity, more soda is bought

By Katherine LeTendresse, Student at Global Medicine Program, USC 

Floating Doctors Volunteer

From the first hours encountering the health professionals who volunteer with or work full time at Floating Doctors, I had the feeling that the week ahead of me would be filled with interesting cases to learn from. What I realize now is that the cases, no matter if they were routine or unique, have filled me with a renewed sense of compassion and helped me apply the concepts that I have learned this year as a student in the Global Medicine Program at USC.

The country of Panama is a culturally vibrant place in Latin America and like many of its neighbors faces challenges with healthcare infrastructure. Though it is considered an upper-middle income country by the WHO, many of its citizens struggle with healthcare access, often due to poverty. The areas in which indigenous peoples live are often isolated rural villages, further complicating the process of accessing health services, many of which they struggle to afford. One large challenge regarding healthcare in Panama is that it must address the double burden of infectious diseases, such as Malaria, Leishmaniasis, and the Zika virus, as well as non-communicable diseases such as Obesity and Cardiovascular Disease.  In addition to these challenges there are a lack of services and education in my area of interest, oral health. 

Like many other countries in the region, the children I saw in Panama had access to food and drink high in sugar, such as soda and candy. Rural populations in Latin American countries are typically thought to adhere to traditional diets high in fruit, grains, and vegetables, whereas the diets of urban populations have shifted toward Western staples. This can contribute to an array of health issues including obesity and oral health problems. The imbalance between energy expended and caloric intake is a challenge that is expanding into rural areas, which I observed in Bocas del Toro. At the end of one clinic day in an area called Quesbada Sal, I walked passed cases of soda being unloaded from small wooden boats onto the dock. This island is an hour away from the main town, and is an example of how diets high in sugar are penetrating rural environments.

The level of sugar intake, along with the use of water untreated with fluoride, was reflected in the oral health issues patients presented with at the clinic. Only a handful of children were living completely free of dental caries, and many more were living with rampant tooth decay. I had never observed such a high number of extractions of the deciduous teeth, prompted by severe tooth decay, reducing a once healthy tooth to one causing constant pain. Other children with less decay received fillings, which were performed using only basic instruments, no drill or suction. The atmosphere of the dental side of clinic was one where we did the best we could with what we had. One extraction was even done without a dental chair, on the steps of the clinic. What I admired most about the dentists as well as my peers was their willingness to improvise and to provide the best care given the circumstances. The overall community response to our presence was largely positive, with many patients waiting hours in the queue to be seen by the dentists.

One thing that struck me immediately at these rural clinics was the number of locals who had never been seen by a dentist before.  Many of these people were of the indigenous Ngobe population, and though I expected them to be hesitant of us they surprised me with their welcoming attitude. Some of the patients we saw were children at their first dental visit, but others were adults who were having their first experience as well. The reputation of Floating Doctors within these communities was a great asset, and without the trust of the community these patients may never have come out to be seen.

What was most challenging was the management of patient anxiety, especially in our pediatric patients. While I assisted the two dentists, Sarah and Philippe, I observed them using an interesting technique to calm a patient, a scared three-year-old girl. The conventional method of managing anxiety in pediatric dental patients, called “Tell-Show-Do”, was not successful with this child, so they decided to try a different method. The mother sat on the chair and held her daughter on her lap, and this calmed the girl enough so that Sarah could perform the dental exam. Over the course of this encounter the patient began to relax, and she received a filling for a cavity on one of her maxillary teeth. It was interesting to see an alternative to the usual methods of managing patient anxiety, and to gain perspective on situations where a practitioner must adjust their plans in order to be effective. Though it was challenging to calm this young patient, it is my hope that this introduction to dentistry was positive overall, and that she will be responsive to oral health education in the future.

            Though we were busy with the high volume of patients, we still took the time to hand out toothbrushes, toothpaste, and speak with the children about oral hygiene. My group created a poster that taught the techniques of brushing and flossing, which was both informative and colorful. This was one of my favorite activities while working in these communities because education is essential to changing behavior and effecting long-term health. The people in these communities were receptive to new information, the children most of all. After being taught about brushing their teeth they seemed to share what they had learned with their family and friends. The children would line up and ask for “cepillos” and “colgata”, which I quickly learned are their words for toothbrushes and toothpaste. The children seemed genuinely curious about the dental station, and on several occasions I saw their intent faces peering in at us, and I felt as fascinated by them as they were about our work.

In the short-term it is a small victory to teach a child to brush their teeth and give them the means to do so, but the real challenge ahead is to address how they will maintain these health behaviors. Will they have access to basic supplies like toothbrushes, toothpaste, and floss? If not, how can this be addressed? This is something that has been in my thoughts since returning from Panama, and I realize that solutions will ultimately have to be a result of prioritization within the communities. There must also be a strong presence of healthcare providers to stress the importance of maintaining these behaviors. This is one of the many reasons that Floating Doctors is important for the area, and why the Global Medicine Program should continue sending students to participate in this valuable experience.

            Another portion of the trip that will likely have a lasting impact on my perspective of the world was visiting the local nursing home on the main island. From the moment I walked into the facility I had to challenge my expectations and reevaluate my assumptions about the culture. I met several residents who had been abandoned by their families, and others who lived there with family members. One example of this is a woman I met who lives in this facility with her mother as well as her sister. They are only in their 40s, which by US standards is a young age to be admitted to a facility for long term care, with 88% of residents being age 65 or older. However, both appeared to have mental health issues, and with nowhere else to go they were admitted to the nursing facility. 

            Spending time with these women made me reflect upon the idea of treating every person kindly and helping them live with dignity. As I stood in that room where upwards of fifteen women slept, my only desire was to give them attention, show compassion, and let them know that someone cares. I could sense this motivation in all of the volunteers there, saw it in their body language, and heard it in the kind words they spoke. This experience was one of the most humbling I have had in my life because these residents value the things we often take for granted, like a conversation or a hand to hold.

After spending time with the residents of the nursing home I have reflected on my career and am drawn to the idea of practicing as a general dentist where I can see children, the elderly, and everyone in-between. Moreover, it renews my sense of purpose for seeking out education as dentist, and where I may practice in the future.

Though we were only in Panama for a short time, the long-term impact of our visit can come in the form of support for Floating Doctors and other groups like it. Beyond giving care that is needed, Floating Doctors educates their patients at every opportunity. What has stuck with me from this experience is that while we address issues such as access to healthcare and overall health we should also empower these populations with knowledge. Perhaps one of the children I spoke to about oral hygiene will someday become a dentist, a physician, or an advocate in their community healthy living. Educating is the key to empowering all people, and it is my hope that the people of the Ngobe communities will be positively affected in their health today and in the future by continued efforts from Floating Doctors.

References:

  1. WHO Panama Profile Socioeconomic. World Health Organization. 2011 Report. 
  2. Panama – Health in the Americas 2007 – Volume II. Pan American Health
  3. <paho.org>.                
  4. Kain, Juliana et al. “Obesity Trends and Determinant Factors in Latin America”. Cad. Saude Publica, Rio de Janeior, 19 (Sup. 1): S77-S86, 2003.
  5. Farhat-McHayleh N. Harfouche A. Souaid P. “Techniques for Managing Behavior in Pediatric Dentistry: Comparative Study of Live Modeling And Tell-Show-Do based on Children’s Heart Rates During Treatment”. Journal of Canadian Dental Association. May 2009.
  6. Nursing Homes Fact Sheet. AARP Public Policy Institute. Oct. 2007. 
Consulting with the whole family together
Consulting with the whole family together
It
It's the little things...like clipping nails
My first toothbrush!
My first toothbrush!
Easy trust across cultures is a wonderful thing
Easy trust across cultures is a wonderful thing
Successfully managed dental anxiety
Successfully managed dental anxiety
15,000-gallon water bladder for the aqueduct
15,000-gallon water bladder for the aqueduct

It is great that we are able to provide a regular ongoing health service to so many communities over such a large area, but it is not enough that we can, for example, treat the chronic diarrheal disease in a community in perpetuity.  As soon as we can address a root cause, the resources tied up treating ongoing something like diarrheal disease can be freed up for other communities in need.

We need to leverage our unique position of years of experience successfully implementing interventions in this environment, and of our micro-level knowledge of each comunity--it's needs, issues, strengths, weaknesses, stakeholders, medical priorities, etc--and our unusual position of hard-earned trust with a normally elusive population to tackle the systemic issues we deal with acutely every day.

If diarrheal disease is a problem, is it because the well is contaminated?  Maybe in this community the river is the primary water source instead, and has agricultural runoff.  Do the wells in this community have high natural aresenic?  Is handwashing not prevalent enough?  Is there no access to soap?  Did another NGO build a latrine upslope from the community water supply?  We have to know the real cause--and ALL of the above causes have been identified as the major diarrheal causes in real communities in our network, and all require different approaches to sustainably address.

We do a lot of targeted projects:  so far, we have partnered with other groups to build a rural birthng center for community midwives, done aqueduct and water storage projects in a number of communities, and library and education projects.  But something needed very badly is actual ongoing acess to real, skilled health care that comes from here, not from an outside group like ours.

We do a lot of one-on-one health education and a lot of community education training to empower individuals to better protect their own health, but the villages do need real, trained medical capacity on-site all the time.  When bad weather strikes, the poverty in these remote indigenous villages isn't even the most challenging factor in getting to help--you could be a millionaire and still be trapped by the stormy weather as you hemmorhage during a difficult birth at home.  Someone in the communities needs to be trained on how to handle the kinds of things that come up all the time...and at the worst possible times.

Here's our thought process for what's needed to make real medical care locally availabe all the time without dependance on our presence:

1.  We need to train Community Health Workers who have a high skill set

2. The training course specially must be tailored to the major health needs and most practical management strategies for these communities

3.  We need a full-time dedicated team working on this monumental project for at least 2 years, and need to get that team at almost no cost

4. We need infrastructure to ensure more adequate health care until the first cohort of trainees are ready to assume the role 

5.  The trainees need months of regular access to 'apprenticeship' opportunities with medical providers to develop the skill set we view as safe and approrpiate to manage.

6.  The program needs Ministry of Health ceritifcation and support for the trainees when they become functional

So here's what we are doing:

1.  We partnered with communities and other groups to build 3 remote medical outposts in strategically located comunities. Ultimately the goal is that these will be taken over by the Health Workers, but for now our teams will deploy to them regularly to provide care, to conduct health worker training, and to have the health worker trainees sit and see patients with them as an apprenticeship.  

2.  We partnered with Peace Corps to provide Peace Corps volunteers who have finished their service to return and support them while working with us on this dedicated project as the developers and trainers.

3.  The Peace Corps volunteers working with us develop the training modules with input from Floating Doctors physicians and other groups within our network and implement the training.  To date, about 1/4 of the program has been written and taught.

4.  Work to get our course recognized by the Ministry of Health in Panama as a professional certificate making people eligible to apply for Centro de Salud or hospital postings as well.

When these communities have their own health workers and our doctors only need to visit from time to time, we will turn our attention to other communities and continue to duplicate the capacity expansion until the whole region has adequate care.  It is still us doing things like, for example, searching out and coordinating patients with cleft lip/palate being treated in OpSmile's annual surgical clinic, but we believe it would be better if there were local health workers who could shoulder these kinds of responsibilities--and with training can probably do it more effectively than we could anyway!

It's a mountain of work to build an entire indigenous rural medical service from nothing, but it is very satisfying to be able to tackle the real lack of access to care--not just planning for tomorrow, but for 10 years from now.  Plus, multi-disciplinary projects like this are the nodes around which we and many other stakeholders and supporters gather and share the task, and it is very rewarding to meet and work with such extraordinary people who create so much out of sheer will and air.

This is a project that still needs many hands!  To support making real improvements in health access, support our cause today or visit our website to volunteer or find other ways to get involved.

Fair Winds,

Dr. Ben La Brot

Community Health Worker Training Course Starts!
Community Health Worker Training Course Starts!
Our third and newest Remote Medical Outpost: done!
Our third and newest Remote Medical Outpost: done!
Awesome to have a private space for ultrasounds!
Awesome to have a private space for ultrasounds!
Partner with Operation Smile: Cleft Lip/Palate
Partner with Operation Smile: Cleft Lip/Palate
Bringing down a child
Bringing down a child's high fever

Links:

A new year upon us, and what a year 2015 was for the Floating Doctors. I would like to update everyone with the progress our dental program has made and share a few stories of the past year. Our work and development would not have been possible without your support and kind donations, I would personally like to especially thank Don Scott and Ted Hannig for their tireless efforts in raising over $10,000 to help with the advancement of our program in acquiring essential equipment and materials.


At the close of 2015, we have extracted over 300 teeth, placed more than 100 fillings and incised and drained multiple abscesses. We are now able to provide a wider range of treatments with our newly acquired portable dental chair and equipment from
Dentaid and Aseptico, as well as receiving several thousand toothbrushes from GlobalGrins and supplies and tools from Henry Schein.


It was fitting that our last dental clinic of 2015 would finish in the community of
Norteno, where our program first started. 70 patients were seen over two days working from the early hours of sunrise until the company of the moonlight and stars. Rice and beans after the last patient, have never tasted so delicious with a splash of chicken. Working in this environment is very tiring and back breaking, the list of patients is always growing and there is always the fear of not being able to see everyone. Our last family of 2015 had waited for 5 hours to be seen and faced an hour walk back home. Reading their notes from our first dental clinic, the two young boys (Raul and Daniel) had been very anxious and were unco-operative during treatment, but our team had successfully extracted some of their teeth. Having had such a long wait, I was expecting to use my last reserves of persuasion, but much to my surprise the chicos were fighting to be first in the chair. From an anxious patient to becoming a dental assistant was a big step for Raul; armed with head torch and gauze, he diligently cleaned his mums teeth as we restored two cavities.


As we were planning to bid farewell to the community of Rio Cana, a 5 year old girl called Natalia presented with a large left sided facial swelling extending up to her eye. She had been unwell for the past two days with a fever and was unable to eat due to the swelling and pain. The team unpacked our equipment and after much reassurance we were able to extract the problematic tooth and drain the dental abscess. This took some of our volunteers by surprise at how much infection could result from one decayed tooth. Moments like these, when we are able to provide care where there are no alternatives and change the outcome of an unwell patient, or witness a positive change in the attitudes of the communities we visit, makes every second spent in our work worth while. It has been a pleasure to see the communities embrace our
programme and it is very disheartening when no dentists are available to provide dental care.


Our dreams are big for 2016 and in the new year, we will strive to continue and improve our provision of oral healthcare. Plans are in place for a mobile floating clinic where radiographs can be taken and surgical operations can be performed.Agreements have been made to start water testing and implementing water fluoridation in the communities' water supplies.

Many of the Ngobe people have been forgotten or must suffer in pain, it is a privilege and honor being welcomed into their communities, to give them the opportunity and education to leading a healthier life. Together with your support we can overcome these challenges and ensure that every child has a toothbrush and toothpaste, no one has to suffer with toothache for over a month, and we are able to provide dental care in a clean and comfortable environment for our patients.

9:00 AM and our clinic is filling up fast!
9:00 AM and our clinic is filling up fast!

I love when our reports are written by our volunteers--their perspective is often unique and I love to have their voices added to support our project, but today I want to personally share an experience with you all.

We visit about 25 communities spread over 7,000+ square miles of jungle-covered mountain and mangrove island mazes.  Some of the communities are a shorter boat ride from our base, but some are VERY far away--and the Ngabe community of Rio Caña, where we went last month, is the furthest community we currently visit, on the exposed, open-ocean side of the Bahia Azul peninsula.

Rio Caña is about 70 miles by boat from the nearest small community hopsital, and VERY hard to get to--it requires a lot of planning and the willingness to endure pretty bad weather and rough seas to get there.  It is about 6 hours in a huge dugout canoe, at the end of which there is a treacherous river entrance blocked by a sandbar with big surf.  I know longboard surfing is widely popular, but until you have surfed a 50' hollowed out log down the face of turbulent waves to enter the Rio Caña, you have not truly longboarded.

In this community, small emergencies are almost always big emergencies--because the chance that the patient may be able to travel to help is VERY low--at best, the trip would cost more than most families live on for 2 months; at worst, bad weather and 15-foot seas make the trip a complete impossibility even if you were a millionaire.  These are the communities we specialize in serving--the ones where a lot of people see a doctor for the first time in their lives when they come to our clinic.

On this visit, there were several 'small' emegencies--a horribly infected ax wound on a young man's foot, a young girl with acute appendicitis, a young boy whose entire scalp was an infected mass of pus and fungus...the list goes on.  All of these things are dealt with in more developed regions by a trip to the family doctor or to the emergency room; here, they are treated mostly with hope, which unfortunately is not always enough to prevent a terrible outcome.

We saw 250 patients, pulled about 60 abcessed teeth, ultrasounded about 25 pregnant moms, and made sure the 'small' emergencies STAYED small and were dealt with promptly.

No one who has not shared a journey to distant communities like Rio Caña can truly understand what it takes to make it out there and to provide good health care so far from the comforting presence of a nearby hospital with specialists and advanced services, but if we don't go out there...the young man loses his foot (and perhaps his life); the young girl's appendix ruptures and she dies, the young boys' scalp infection poisons his blood.  

This is why our volunteers endure such hardships to get there, and why we go to such great lengths to reach these communities.  I wanted to write the report myself today because I wanted to bear witness both to the courage of our patients, and to the dedication and endurance of our medical teams.  Am I a hero?  Absolutely not--but I am priviliged to work with heroes every day.  Hope in Rio Caña and other rcommunities is no longer the only care available.  

The health care our volunteers provide is some of the most loving, caring medicine I have seen anywhere in the world.  In 2016, the infrastrucutre we have worked so hard to build this year will more than double our capacity.  It has been a tough journey to get this far; travelling to Rio Caña is like a microcosm of the journey of our organization.  When I look back at how far we have come in such a short time, the daunting challenges in the future suddenly don't seem quite so insumountable. 

When someone tells you something is impossible, alwyas remember what Tom Hanks' astronaut character in 'Apollo 13' tells visiting congressmen while giving them a tour of the space center:  "You know, there's nothing remarkable about us going to the moon.  We just decided to go."  

What will you decide today?

Shy but trusting; a little girl talks to our docs
Shy but trusting; a little girl talks to our docs
A boy brings his sister to clinic from far upriver
A boy brings his sister to clinic from far upriver
Jungle Dentistry:  60+ extractions!
Jungle Dentistry: 60+ extractions!
Emergency extraction:  acute appendicitis
Emergency extraction: acute appendicitis
Lots of rain, lots of chest infections to treat
Lots of rain, lots of chest infections to treat
The most beautiful beach
The most beautiful beach

Today's update comes from Abteen Asgharian, who, while one of our younger volunteers, proved himself to be a huge asset when he joined us for a week in the remote community of Ensenada.

Going to a foreign place without electricity or running water was a concept I had never before experienced.  I didn't know what to expect on this mission.  In the beginning of this arduous yet exciting mission, my mother and I traveled to the heart of Panama- Panama City.  It was a beautiful city; it had an adequate amount of diverse fast-foods from all around the world and wonderful tourist sites such as the Panama Canal. After almost a week in Panama City, we traveled to Bocas del Toro, where I met some interesting members of Floating Doctors.

Bocas del Toro is located on the island of Colón, on the outskirts of Panama.  On the Sunday of June 21st, we went to the Floating Doctors warehouse.  It was the orientation.  A few of the members talked about their experiences in the past and what to expect on this fun experience.  I felt a little bit shy and uneasy at first just thinking about no phone for three nights, no pleasant bathroom, sleeping in a hammock instead of on a regular mattress, and the same food for three nights.  Honestly, I had never thought of being in a situation like that.  I never lived too wealthy or too poor- I loved my life just the way it was and thinking about the whole new experience of living a poor life in a foreign community just sounded astonishing.  I didn't worry too much about this idea that night, though, for I really wanted to see what it was like to live life "differently."

The next day was the first day of our journey to Ensenada, and our group dropped all our bags on the boats for the start of a two and a half hour boat ride.  It was a relaxing, enjoyable ride as the scenery was quite exquisite and a few droplets of water splashed when the boat approached the big waves.  When our group arrived at Ensenada, I was dumbfounded.  My first glimpse of the scenery there was a few rooftops made out of wood, something I usually didn't see coming from the United States.  We set up our hammocks that day and went out to the beach for a peaceful swim.  Wow- that beach was easily one of the best beaches I've ever visited!  The sand was smooth and soft, the water was not too cold nor hot, and there were a ton of trees all scattered together, making it look like a jungle.  It was a great first day at Ensenada, but my journey was only beginning.

The second and third day of Ensenada were busy, as we had to see over 100 patients each day.  I was working in administration with a couple other hard-working members.  it was a difficult, tiresome task, but I really improved my Spanish in those two days I was working.  Moreover, I had the opportunity to gain a sense of satisfaction from looking on the faces of the locals and knowing that my hard efforts are for a good cause.  Although I didn't help with the prescribing and handing out of medication to patients, I still felt that my work had helped Floating Doctors a great deal.  Surely, these two days I won't forget in a long, long time!

The following morning, our group packed our items once more for a trip back to Bocas del Toro.  It was an amazing experience, and I've been truly blessed to have the opportunity to help others and live the lives of the locals for three nights.  I really loved the environment I worked along with the friendliness of the locals there, and the love of the members of Floating Doctors.  Without these three elements, I don't think I would have enjoyed the trip as much.  In my previous years, my parents and I have made donations to many different causes, but I didn't feel the special impact from those donations compared to what I experienced first-hand in Ensenada.  For certain, I would go on this journey again (hopefully more fluent in Spanish) and maybe I'll feel a bigger impact than the first time.  I recommend this to everybody, as it teaches you the other side of live people don't usually experience and the feeling people get when they help others in need.

 

Photos courtesy of Sam Paci

Not a typical view in the US
Not a typical view in the US
 

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Organization Information

Floating Doctors Inc

Location: Topanga, CA - USA
Website: http:/​/​floatingdoctors.com/​
Floating Doctors Inc
Project Leader:
Sky LaBrot
Chief Executive Officer
Topanga, CA United States

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