Pay to Play in Panama

Memo to the Tea Party followers, Revolutionary War costumes and all: upending things in a fit of pique is easy. Creating real, sustainable change is hard.

Panama has two health care systems, one accessible to the poor and one that is private and pay-as-you-go. Yesterday, with the help of a client here in Panama, Gloria and her husband Luis and I took their 15 year old son, Luis, to a highly recommended orthopod in the private system. Our wait was 15 minutes past the time of the appointment, instead of the four or five hours that Gloria and Luis typically spend waiting in the public system. The doctor was professional, quick to assess the situation, compassionate, and knowledgeable. He spoke directly with Luis, treating him like the young man that he is.

What sent me over the edge a week ago was Gloria and Luis’ return from the public clinic with the news that the doctor had been too busy to remove the cast and check the progress of Luis’ latest fracture.  Luis was also in pain because one of the metal pins used to stabilize the foot had been inadvertently left behind when the cast was put on. Luis said it felt as if the pin had worked its way to the surface of his foot and – wedged between his skin and the cast – was causing him great pain. To be told to come back in two weeks when the doctor might have more time seemed to me intolerable.

Many good things happened yesterday. The doctor confirmed that the previous surgeries to correct the club foot and remove extra toes had been adequate, and that what was needed now – and should have been ordered before – was intensive physical therapy for the withered leg. Gloria had removed the cast over the weekend when Luis could no longer bear the pain, and now the doctor removed the offending piece of metal. He answered all of Gloria and Luis’ questions, and provided a road map for going forward. Since further surgery is not on the table at the moment the cost of what he is recommending is not high, about what we would pay for a health insurance co-pay.

Gloria will accompany Luis back to Panama City – a round trip of four hours – for his 45 minute therapy session three times a week for the next five weeks. I’ll give her the employment flexibility for the grueling trip. The goal is to get Luis the best possible care at the outset of his treatment, especially given the badly deteriorated condition of his leg. Then, we might be able to transfer his physical therapy to a public clinic in Penonome, which is closer and less expensive. The new doctor will continue to supervise his care as long as there is $50 to pay for the visit each time Luis needs to be seen – perhaps three or four times a year.

The problem is that we can’t take this young man out of the public system entirely, because he will need complex care for the rest of his life. Unless I want to assume responsibility for all of his care going forward – which I don’t – we have to maintain his access in the public system. Right now, for reasons too complicated to write about, navigating between the two systems is proving very difficult.

Today Luis is not in pain. His parents have a better understanding of his condition and his range of future outcomes, and they feel heard. They also have something to do: help him with the therapy by learning some of the exercises at home. They have some hope that he will be able to avoid a wheelchair when he reaches the full weight of a man and the leg in its current state will no longer support him – something they didn’t have before.

All of that is good.

The longer term resolution remains less than clear. Forty years ago, working here as a Peace Corps volunteer, I dealt with similar challenges of integrating advanced country solutions with developing country problems.  I feel a little wiser, but not much, in coming up with a way forward.

New Orleans by Two and the Dog Died

No one expected the Saints to beat the Colts by two touchdowns, and no one expected my sister Wendy’s dog Maggie to die on Super Bowl Sunday morning.

Maggie, a rescue dog, came into Wendy and George’s life not long after our mother died, and easily won everyone’s heart. When Maggie developed canine lymphoma last summer there was no question that Wendy and George would do everything possible – including chemotherapy and the care of several specialists – to keep their beloved dog alive. The treatment seemed to be working well. Maggie’s death, although not unexpected, was sudden and swift.

After a fallow time there will be a new football season, each team starting with a clean slate and at least theoretically, with an equal chance to play in the Super Bowl.

Quite soon Wendy and George will receive Maggie’s ashes, and after a time of reckoning with love and loss, I wish for them the spark of willingness to love anew. Maggie was so special, in part, because of the fullness of their welcome.

New seasons, and new opportunities to love … we call that living with hope.

Day of Rest

Not everything works out, even in a place where the sun shines every day.

Last night was Georgethe’s 7th birthday. She is Jennifer and Pedro’s daughter, Josue’s sister, Teri’s grand-daughter, and Minga’s great grand-daughter. The party was to begin at 4pm, and like good time-conscious Americans, Sally and I picked Minga up and the three of us were there right about on time.

Birthday girl

Georgethe was still swimming with her cousins and friends in the big blowup pool that Pedro’s mother bought for the family. The boom boxes were booming. Neither food nor drink nor much in the way of party decorations were in sight. The no-seeums were biting. People were very slow to arrive; indeed, Jennifer was on her cell phone appearing to try to round everybody up.

By 6pm – two hours later – the decorations were up, the birthday girl was dressed for her party, and Tia Mari was painting faces for the younger kids.

The sign says Happy Birthday Georgethe

Tia Mari, the artist, and Josue

I’ve been to many birthday parties, and in terms of timeline, we weren’t even to first base on this one. The other grandmother hadn’t arrived, nor had Ita and her crew, nor Rufina … and they weren’t going to start without them. The no-seeums, miniscule black flying bugs that leave a bite with a terrible itch, were out in force. The boom box was deafening.

At 6:30pm, I told Minga that Sally and I had to go because Sally was expecting a call from her significant other, Joel. That was true enough – as the internet had been down all day – but not the total reason we left. We left because I was simply out of gas, and wanted only to sit in the air conditioned living room of the villa, have a light dinner, see the evening news with a glass of wine in my hand and rest. I also told Mari why we were leaving before the meal and pinata, and both she and Minga seemed fine.

Jennifer and Pedro were devastated. There’s no way to explain – in terms they would understand and accept – why I would stay until well after dark for the baptism and the quinceaneros, and not for the event honoring their child.

In our culture, we sometimes place our own needs first, and consider that a healthy option. But not in theirs …

Sally and I got back to the villa around 7pm, and from then until I went to bed around 11pm I had a lovely, quiet time.

No Conversation

This morning and into the afternoon we had a widespread and prolonged internet outage. The problem wasn’t with the house or the complex, but with Cableonda in Panama City. We were back online mid-afternoon.

If I miss a day with the blog, please check in the next day. It won’t be for lack of something to write about, but more likely an infrastructure problem. I’ll be back at it as soon as I can.

Silly Conversation

The running club was hanging around cooling off under the tree in front of Minga’s house when she remembered I like tamarindo. She sent her grandson Luis to pick a tamarind pod from a tree in back of her house and bring it to me.

As I cracked open the pod and popped a piquant tamarind seed into my mouth, Ita told me with a smirk that eating tamarindo gives you diarrhea, or at least bad gas. In case I missed the Spanish word for fart she made the appropriate noises with her mouth. That sent the kids into falling-off-the-bench hysterics.

I expected Minga to rebuke everyone for inappropriate third grade potty talk. Instead, she began to giggle – and she is a serious woman who hardly EVER giggles. She said that when her son Humberto drinks too much he farts all night in the room adjacent to hers and that she sometimes has to go outside for a breath of fresh air.

At this point the kids were out of control laughing, and we adults were too.

I ate my tamarindo anyway, and Ita warned Tia Sally that if she couldn’t sleep in the room next to me there was an extra bed at Minga’s where she could come and spend the night.

I love it on those rare occasions when Minga joins in a silly moment.

Hard Conversation

Gloria made a really outstanding lunch for us, grilled chicken and vegetables on skewers, rice, and salad.

Chef Gloria

Sally and I invited her to sit with us and savor the wonderful food, and that’s when she told me everyone in her family wonders why I, a rich white woman, would want to help Luis when both I and they know they can never pay me back. She looked at me expectantly, awaiting an answer.

The religious explanation – that I am God’s light in her soul, a living witness that God does not abandon the poor  and the humble – works for her but works less well for me.

As she awaited my response a lot of thoughts ran through my mind. I’m willing to help because I can, and because a reasonable amount of money will do a lot in this case. There is a window of opportunity, because her son Luis is about to undergo a growth spurt as he turns from adolescent into a man and his bones are going to be growing and changing anyway. There is also a crisis: if he doesn’t get some physical therapy on that withered leg, it will fracture anew every time he puts weight on it, and he’ll wind up in a wheelchair. I’ve given a lot more to philanthropic causes in Rochester over the last several years, and have not been very excited about the results.

But I didn’t say any of that to her. I simply said that we are both mothers of sons, who are dear and precious to us, and that I wished no less for her son than I would for my own. I said the pieces I am going to do – money and access – are small compared to the work Luis will have to do to regain strength in that leg through physical therapy. I said that she will have to fight for her son, even in the private system, where people may treat her as ignorant or insignificant because she is poor and dark and uneducated.

She nodded at all of that, and then repeated her belief that God will never abandon her, and because I am here, she has living proof that she and her son are not alone in their struggle.

Quite a hard conversation to have over chicken on skewers and rice.

Running Club, Week One

Team Minga has completed its first week of running/walking a one mile loop that begins and ends at Minga’s house. The first order of business was to get everyone running shirts, decent sneakers, and a water bottle. When we got to Minga’s today Jarinelys had soda in her water bottle. I reminded her that water bottles are for water, and that drinking water is important when you work out. She poured the full sugar soda down the sink, and filled her bottle appropriately. She’s definitely enthused about the running club, and wants to do the right thing.

Tia Sally helping Jarinelys lace her new sneakers

Sally and I go to the village on Monday, Wednesday, and Friday at 4pm. We all meet up in front of Minga’s house, across the road where there are some old broken down chairs and benches. The breezes are better there. We encourage them to run the other days if they can. To get a prize at the end of the week, each participant has to run /walk at least one mile three times a week. This week, Luisito ran 13 loops, or 13 miles.

Here are Jarin, Luis, Teri and Minga before running. Minga has tiny feet, size 4 1/2. She will be 69 on February 24, and these are the first sneakers she’s ever owned. When she stood up in the store after getting the shoes fitted she told me she thought she was going to fall. I assured her gently that this is what cushioned shoes feel like. After a little practice, she likes the sneakers just fine.

Luis, age 10

Here is Luis after completing three fast laps. He, Jorge, and Jarinelys have been the most serious runners. Fourteen year old Jorge didn’t work out today because of a sore testicle [yes, that's what they said] but he has already run four times this week and so is eligible for a premium.

After every workout, each participant logs the date and the number of laps in a simple notebook. They are fastidious about making their entries.

Luis documenting his run.

Here are Gloria and Yanelys – our housekeeper and her niece – arriving for their workout. Gloria walks the one mile route. Yanelys, who suffers from a heart condition, merely watches.

Yanelys and Gloria

Here are Jennifer and Ita coming in from their loop. Ita is carrying Jarineilys on her shoulders.

Today those who had worked out three times got to choose a premium from a big plastic bowl of small gifts Tia Sally had bought. Minga drew the first number and chose nail polish. Some of the kids chose school supplies.

Minga making her choice.

Jennisbel got there really late, pushing baby Gris in a stroller,  and almost missed getting her premium. She had to pick out of the back of the car, when we had already packed everything away. She chose hair scrunchies.

Jeorgethe and her aunt Jennisbel.

Truth to tell, our 4pm start time is more aspirational than real. The little kids are usually ready, and Sally and I head out no later than 4:05pm to make the point of starting on time. The rest arrive between 4pm and 5pm, and commence doing their laps. Sally and I leave at 5pm, often to get in a last swim of the day. The rest wind up and enter their laps in the journal. Minga takes the book and pen inside and puts them in a safe place. Team Minga is a much more raggedy operation than any US sports club, but we’re making a little progress on fitness, the kids are spending less time hanging around watching TV, and everyone is having a good time.

We’ve also become the afternoon’s entertainment for the village, which is fine by me.

Access

Gloria’s son Luis, fifteen, was born with what we think is a club foot. He’s had four surgeries in the public health system – the one to which his poor family has access. The early ones left him able to walk, albeit with a deformed foot and badly withered leg.  The latest was a disaster. For the first time, he was left with a 2 centimeter difference between the good leg and the bad leg, throwing his whole muscular-skeletal system out of whack as he tried to navigate.

Luis

As far as we can piece together the history, Luis had surgery in May 2009. Crutches were prescribed, but his family couldn’t afford them. Physical therapy was also prescribed, three days a week, in Panama City. He lives in Rio Hato, some 90 minutes and a $6 round trip bus fare away. When other renters are at the villa, his mother Gloria is required to stay 7 days a week, 24 hours a day. His father works an hour away and can’t get time off either.

So Luis hopped around on his good foot, surely putting the surgically repaired foot down now and again. In August he complained of pain, and an x-ray determined he’d fractured a bone in the bad foot. His leg was then casted. He continued hopping around – including hopping to the road from his house, catching a chiva to Penonome for summer school to make up the class he missed while in the hospital, returning to the village after class and hopping back to his house. He finally got crutches in January, when I arrived and bought them.

On his most recent visit to the clinic in Panama, the doctor he sees was too rushed – after Luis and Gloria had left the village by bus at 3am in order to arrive early for their appointment – to remove the cast and do another Xray. The doctor simply felt the cast, pronounced it intact, and brusquely told Gloria and Luis to come back in two weeks.

My guests last week, Phyllis and Marilyn, are both nurses. They urged me to work with them to try to get Luis some better care, either here or in the U.S. As part of that, we coached Gloria to ask Luis’ doctor if he would write a summary of what care had been given over the years so that we could get a second opinion.

The doctor was furious, declared he hadn’t made a mistake with the surgery to create the 2 centimeter difference, said he wouldn’t write anything, and told Gloria that she could take her son anywhere but that he, the clinic doctor, would no longer treat Luis if she did.

I contacted a wealthy client of mine here in Panama, and he has agreed to gain us access to the best orthopedic practice in the city. I will pay for the consultation. We’ll have some hard decisions to make after that, as the full cost of whatever repair might be done is likely beyond me, and Gloria has no way to pay for care in the private system. And, her public system doctor is in a snit and may refuse to treat Luis in the future.

Gloria tells me that her faith in God is what sustains her. She says that in her darkest hours, God always sends a ray of light, and right now I am God’s light in her soul.

I’m deeply agnostic and have been for decades … yet how can I not accept and affirm her belief that God intervenes to lessen the harshness of her life? She smiles, and encircles me in a hug.

Killing a Chicken

For the despedida – departure celebration – of Phyllis and Marilyn, Minga prepared home-made sancocho panameno: a broth-based chicken soup containing a root vegetable called “name [pronounced nyah-meh]” and served with a side of white rice.

Marilyn, Phyllis, Sally, and Minga

For some reason, killing the chicken right before it goes in the pot is considered crucial. The chicken you see us eating here was no doubt running around Minga’s yard earlier that morning pecking at bugs and dirt – the ultimate free range chicken. That means someone has to corral the chicken and kill it fast, before its frantic flapping allows working its way free.

That someone was Jari, Ita’s 14 year old, with her back to the camera.

Family eating their soup

This is Jari at the quinceaneros, in her own white dress.

Jari

Jari is a city girl, more sophisticated than her village cousins. Yet she also retains her country girl skills. When I asked how she killed the chicken, she grinned.

She used her long legs to sidle up to a likely bird, then chased it down. She quickly laid a sturdy stick across the chicken’s neck, braced the stick with her foot, and then yanked the head off.

Yes, when a chicken is killed this way blood spurts. No, the chicken didn’t run around without its head because Jari had the body braced down with the stick.

The chicken had been simmered all morning, and the meat was still as tough as nails. But it was fresh … very, very fresh.

Unexpected Honor

Each part of the quinceaneros ritual was carefully scripted. To my complete surprise, I was called up to help Harlennys change from the flat shoes of a girl to the high-heeled silver shoes of a young lady. I suspect that this was an honor that would have gone to her mother, Mari. Mari decided to pass the honor along to me … which leaves me speechless.

Pam helping Harlennys change her shoes

I haven’t yet been able to talk with Mari about why she gave this wonderful moment to me. She has said that I was there for her at an excruciatingly difficult part of her life, which happened during my last visit. She has said that she is deeply grateful for the interest I take in her children, the most important thing in the world to her. Even so … this was a unique moment in time, and it will never come again. Mari’s gesture astonishes me.

After the changing of the shoes the lovely ring was brought forward, and her father Luis slipped it onto her finger.

Wine was poured into three beautiful glasses, and she and her parents drank.

Then Harlennys and her father danced. There wasn’t a dry eye in the house, including the young senorita and her dance partner.

Luis and Harlennys dancing

One by one, her male relatives came forward to take their turn.

Changing partners

After the dancing, Harlennys took the microphone from Tia Daira to thank us all for coming. Again the beautiful young senorita dissolved into tears, and so did we.

The formal ritual was over, and the party went on all night. Sally and I left about 2:30am.

Friend Mary Ross asked how important this event, this marking of a life transition, was for Harlennys. Mary and I were both confirmed in the Catholic Church at a similar age, and both of us pretty much dismissed that ritual as a crock.

Not so Harlennys. She is different, changed by the extraordinary outpouring of love and support from those closest to her. I too am changed by the opportunity to bear witness.

And to think that because of the late hour, I might not have gone back.