And this too shall pass

And now, it’s time to pass on the torch to the next Pirate of Paradise. Earlier than I had hoped, but time does not matter in Paradise. Life goes on….

If you want to be in Paradise, remember:

Happiness is where you are and what you want to be
If you look you’re sure to find the rainbow of your dreams
Tomorrow maybe brighter than a thousand yesterdays
With a vision of a new day in your heart

I will cherish fond memories of time spent here, but the fondest will be those of the children-if we can see the world through the eyes of a child, Paradise is always at hand.

A picture is worth....

Casebook: Challenge and Opportunity

Child health services here are limited to delivery of primary care through a few pediatricians, GPs and NPs. There are very limited resources in the public sector, and access to the private sector is constrained by geographic, cultural, language and socio-economic barriers. Other health delivery challenges include cumbersome licensing processes, poor compensation paired with high cost-of-living and inadequate infrastructure. Patients go "off-island" for both emergency and subspecialty care, often paying out-of-pocket for expensive care on the mainland. Many locals use different varieties of “bush-tea” for common ailments (one such preparation contains phenobarbital). Misconceptions and superstitions abound despite the efforts of schools and churches.

When I got here, the exam room had open electrical outlets, no phone access or exam materials, and no one expected me to show up till I completed a week of orientation!!
I used the time to understand work processes and patient flow, prepare protocols for scheduling and intake, and communicate with providers throughout the islands about needs and opportunities. I also spoke with several local agencies to understand how patients used their community-based services.

Over the next few weeks, a network of health professionals (“champions for children”) began finding ways to establish services. They provided me with feedback, patients and opportunities to engage the community. I met with nurses, school officials, and community providers to learn and teach about child health programs. I also talked with physicians in Puerto Rico to extend the network beyond the USVI territory.

In the first week of seeing patients, I was lucky to get some early wins: a child with myoclonic epilepsy who showed a remarkable turnaround after correct interpretation of EEG and medication change, a child with glycine encephalopathy who “woke up” after high doses of cough syrup(dextromethorphan); parents who were relieved after education, support and counseling for neurological illnesses. After a month of seeing patients on St Thomas, we set up child neurology clinics on St Croix and St John.

Several partners are helping to consolidate the programs. I worked with private enterprise to establish video-EEG and sleep lab services. The American Academy of Neurology, Epilepsy Foundation of America and industry contacts provide patient-directed educational materials. I am in early-stage talks to enlist support of the World Foundation of Neurology.

What’s next? Patient education through open houses; training of allied health personnel about neurology basics; talks with the Dept of Education about screening for neurological diseases; establish protocols to streamline neurological evaluation for sickle cell disease; network with other pediatric sub-specialists to set up multi-specialty clinics; evaluate extension of services to British Virgin Islands.

Yo ho and a bottle of rum!!

Once upon a time, these islands were a haven for pirates. When the economy slowed, the governments of bygone years encouraged pirates to sell their wares in local markets. This creates an interesting heritage for the islanders. Products and buildings named after Bluebeard and Blackbeard are reminders of that era, and the Jolly Roger (pirate flag) name can be seen on cocktail lists and seaside inns. Pirate tales abound in folklore, along with stories of slavery and cane plantations.

Rum is a modern-day product of the old sugar cane industry. In the 1700s, steep mountain sides were terraced to grow cane. Slaves were brought in for low-cost labor. A tour of the Annenberg sugar mill ruins reveals the harsh conditions under which the slaves toiled and lived. The life expectancy of a cane worker was about six years, and children as young as six years were put to work in the cane fields. As the sugar trade waned in the mid-1800s, traders and owners abandoned the plantations and left the workers to fend for themselves. Without a market for sugar, rum became the preferred product for consumption and trade.

While duty-free goods draw tourists to the islands, the local population faces significant problems with alcoholism. I saw a young man with Wernicke encephalopathy (loss of memory caused by poor nutrition and chronic alcohol consumption) He had to quit his job, lose his home and move in with relatives. Another man was digging through the dumpster. When offered a granola bar, he asked for a drink instead. I gave him a bottle of water.

Pirate artifacts make for interesting tourist diversions. Divers explore old wrecks along ancient reefs. Antiques from shipwrecks are sold in waterfront stores - doubloons, swords and pistols. While bargaining for a deal at roadside stalls, beware of modern-day pirates who take off with your wallet as the booty.

Who are the modern-day seafarers? The folks that arrive on boats these days are not one-eyed swashbucklers. They are usually people from nearby Caribbean island-nations who come over to work and start families on US soil hoping for a better life for their children. Mega-yachts dock in the new and expensive marina to shop for designer brands in exclusive stores. Cruise ships unload tourists who arrive with currency and curiosity, and leave with duty-free goods and…...rum balls!!

Casebook: To look and not to see...the “too-normal” EEG

The mother placed the one-year old girl gently on the exam table. The child had seizures since early infancy. She was on medicine, but all it did was make her sleepy. So the family gave her the additional supplements and tonics: bush tea (containing Phenobarbital), honey (blessed by a preacher) and saffron water (sent by relatives from the old country). All to no avail. The parents appeared resigned to their fate. I was just another stop on the way to nowhere.

The girl was utterly charming. Tight curls framing a cherubic face. Clear complexion, a pretty lace dress and new shoes covering her tiny feet. Something was missing, though. She had a blank, expressionless gaze. No noises, no interest. She made no effort to move around, not even when I tickled her. Every few seconds, she would startle to an unseen stimulus, flailing her arms off the bed. No cry, no fuss. She turned her head away as the worried mother made futile efforts to feed her.

Another challenge, another opportunity. I looked through the chart. An EEG report indicated the child had normal brain waves. A couple of pages of the tracing were included with the report. I was impressed by how normal the EEG appeared: too normal to represent the brain waves of the child lying before me. I asked the family to repeat the test. The following week, the family returned with a tracing that appeared identical to the first study. Something was amiss. I decided to check the machine on which the EEG had been performed.

To my surprise, the default settings on the machine had been set to display only normal brain frequencies!! What I was looking for was not visible with the preset filters. When I reset the filters, the full picture emerged. The screen was filled with chaotic, abnormal patterns that indicated a serious form of childhood epilepsy. The first EEG showed the same patterns. The “too-normal” EEG was in fact, severely abnormal. What you see depends on how you look.

It was time to get to work-a year had gone by, a year with a “hidden” diagnosis, a year of inappropriate medications. We switched medications, stopped the sedating supplements, and I asked the family to come back in a few weeks. Before the follow-up visit, a health worker brought news: You will not believe your eyes, Doc.

The girl that returned was a new person. She was smiling, making lots of baby sounds, blowing bubbles. Big, bright eyes lit up when she engaged her parents’ attention. The muscle jerks were few and far between, and subtle enough that she could sit without support for a while. The child was making up lost time, fast. A month later, she was walking on her own.

Filters hide reality. But if one knows how to look, miracles unfold everyday. Welcome to Paradise.

To market, to market…, where the locals shop

There are two kinds of shopping in Paradise. The stuff that you take back with you, and the stuff that you use on island. You can find out about the former in travel brochures. I’m writing about the latter. If you want what the islanders produce, go where the locals shop.

Saturday mornings are the best time to check out The Market. Situated in Charlotte Amalie, Market Square’s newest addition is the renovated Sanderilla Thomas Bungalow. The old structure collapsed in 2003 after being struck by a tractor trailer-it took over a million dollars and 4 years to rebuild it using the original roof in a new steel-reinforced design.

Get an early start - the market opens at sunrise. Vendors line the streets with homemade jams and jellies, spices and sauces. Fresh seasonal produce is plentiful and priced to sell quickly (It takes a day to go from raw to overripe in the tropical heat) Tropical fruits and vegetables are usually smaller than the mainland counterparts, but the deep colors and concentrated flavors are a treat for the senses. Talk to the vendors if you see something unusual, and you will get a story and a recipe to go with your purchase.

Harvesting the best of land and sea, the French community (or Frenchies, as they are known locally) carries on the traditions of early European settlers. Seasoned divers even go free diving for lobster off the ocean floor. Fishermen sell fish off the dock. Seafood sells quickly, so the early shopper gets the best catch of the day. Beware of ciguetera toxin in the large reef fish. It is safer to buy pellagic fish (free-ocean swimmers, like tuna) or the catch from the north side of the islands.

During the week, roadside stands and carts sell local produce all over the islands. It is not unusual to see a car stopped in the middle of the road, while someone makes a quick purchase (or waits for a stray goat or chicken to cross the road).

What if you miss big-city shopping? There are no shopping malls in Paradise. If you need household supplies, you simply can’t do better than K-Mart!! It’s enough to make you go postal, and order from a catalog.

Civil Servicitis: He not in

I first heard the term civil servicitis at a regional conference. The common symptoms: a government position that guarantees a job, but not a service. That’s not entirely true, but one has to first recognize the condition before finding a solution.

There a person for each function, and a function for each person. Sharing functions is hazardous to job security, or so the thinking goes. This often leads to stalemates, especially if one wishes to expedite a process. I got a first-hand experience of civil servicitis shortly after leaving for Paradise.

After walking a set of papers several blocks between the personnel office and the police department, I arrived near lunch time. The security officer (there’s one at every building entrance) was only letting a few people sign in before closing for the day-at noon!! I made the initial cut. A security clearance and a walk through metal detectors brought me to the documents window. I paid the cashier for the required services, and went to the next window for fingerprinting. It was still ten minutes before noon, there was no one waiting, but this was the civil service. We close at noon. I’m leaving for lunch, come back tomorrow. There was little civility or service, so I had to back-track and make a fresh start. I chatted up another worker who knew someone in the department where I was to work, and things fell in place. I walked out with a set of fingerprints, only to find the personnel office had closed for the day. As I left the premises, I noticed the two crossing guards-one at each side of the two-lane road. Just another day in Paradise.

The government is the largest employer in Paradise, with a third of the workforce in civil service. There are 19 paid holidays, along with impromptu days-off for carnivals, election days and other civic events. As the number of retirees rises steadily, the pension plan is straining to meet the defined-benefit pension obligations. How about the employees? If you ask for service: he not in!! A private-sector worker informed me that the government’s function was to provide jobs, not services. As far as the he-not-in dilemma, his antidote: call in and ask to leave a long message. The person usually shows up at the other end or you get a contact number.

My suggestion: Show how to make things easier. I came up with a formula that works (sometimes) as a remedy for civil servicitis:

Lot of work in a lot of time: Hard Work
Lot of work in a little time: Smart Work
Little work in a lot of time: Hard Time

Advisory: We got weather comin’

As I write this post, a dull grey haze hangs over Paradise. There is no patch of blue in the sky. The Caribbean hurricane season is underway. People have been preparing for this challenge for days. Or years, depending on your point of view.

This morning, I got on a seaplane that was headed toward the hurricane path. The co-pilot promised a gusty ride, especially at take-off and landing as the winds whip up the water into high surf. Everyone appeared a bit nervous. The next announcement emptied the plane: flights are suspended for the rest of the day. No one wants to be far from home when you are looking at a hurricane.

Driving around the island, I saw the locals preparing for stormy weather. Shutters are up, traffic is down. There are no cruise ships in the harbor, shops and businesses are closed. Lines form outside food stores and ATM machines. I hear hammers at work as houses are boarded up. Power outages are expected later in the day. While the worst of the weather is expected tonight, a sense of isolation builds up as lines of communication break down: cell phone reception is patchy, the power has been going on and off throughout the day, everyone is hunkering down behind closed shutters. Occasional sirens break up the eerie calm between the gusts of wind.

The weather channels are providing constant updates-surf advisory for marine interests (that means get off the boats and tie up the vessels). I see a coast guard vehicle checking up on strays. Calm bays give rise to high surf as gusts of wind blow across the island. Trees bend at unnatural angles, windows and columns rattle with the howling winds. St Lucia lost all power last night as the Lesser Antilles took the brunt of the storm. A colleague in Jamaica tells me he is an avid storm watcher-that’s where the storm is headed over the weekend.

Churches held services (hurricane supplication days) earlier this month. The rescue agencies have rehearsed disaster scenarios and protocols. In event of a weather emergency, health personnel are expected to man the rescue stations. If torrential rain, downed power lines and mudslides block roads, it will be difficult to access emergency services. The bigger challenge is yet to come-the aftermath.

I am on call tonight. Despite all my years of work in this field, somehow tonight is different. Tonight, Mother Nature is in charge. More than ever before, tonight I feel the truth of the adage: an ounce of prevention is worth a pound of cure.

Casebook: The Challenge

Setting up health care services in Paradise is akin to sowing the seed. Picking the place, people and process to yield a rich harvest is the challenge. I came looking for an adventure, and got what I was looking for. In spades.

The first day at work, no one in the clinic had expected me to show up. Lesson One: Don’t start work without orientation. I went for orientation, only to find the clinic director was off island. Lesson Two: Make the time to orient yourself to the ways things work-island style.

Ferry and seaplane schedules dictate the time available for providing specialty services. All patients arrive at the start of the day, and sign-in for service. No name, no service. Specific subsets of patients register along with routine visits, creating bottlenecks at the start of the process. No surprise that waiting for hours is the norm. The waiting room is always busy and bustling, creating an illusion of high demand.

Social constraints abound at all levels. Literacy and language (Patois, French, Spanish, Creole) barriers limit communications at every step. Social and cultural norms often run counter to Western medicine standards. For instance, bush tea and herbals have been traditionally used to treat seizures. Preventive health is not a high priority without resources to meet basic needs. Parents have to be educated, reminded about visits and occasionally escorted to the clinics. Schools are understaffed and underfunded to meet special health needs, leaving families to fend for themselves.

Financial and political factors create additional challenges. A Medicaid cap severely limits the amount of federal funding for the territory. Poverty level is defined at annual incomes below $9500 for a family of four (in contrast to $28000 on the mainland). Combine that with wages at half the mainland rate and a cost-of-living 30% higher than Washington D.C., and you have a large uninsured sector. The territorial delegate does not have voting rights at the federal level. State senators are elected every two years, leaving little time for long-term planning. In less than a year’s time, Paradise is on its third commissioner of health. On the neighboring British Virgin Islands, the government dissolved earlier this year.

Lesson Three? In Paradise, every challenge is an opportunity. The adventure has just begun. Come along on the expedition in future Casebook postings.

Water, Water, everywhere

Living on an island Paradise means water on the horizon-in every direction. When one is new to the islands, it is a welcome change from land-lock, but stay awhile and you get rock fever: the urge to get off the few square miles of rock and find terra firma. After all, on an island, water dominates the view and the lifestyle.

On land, potable water is a precious commodity. Most new construction begins with a large water cistern that is built along with the foundation. Rainwater is directed into the cisterns, which hold several thousand gallons of water. The cistern water is difficult to access during power outages, but is often sufficient for daily needs. If you need more, you buy it. Trucks deliver water to replenish depleted cisterns. Stores sell containers of potable water. The water and power authority (WAPA) provides water to portions of the islands.

Water pollution is easy to spot when you live in the islands. Health officials warn against swimming after heavy downpours, since the runoff increases bacterial contamination in the bays. Ferries have regulations for littering-no plastic overboard, no aluminum within 500 feet of shore, and so on. Divers find man-made debris scattered on the ocean floor.

Trade and tourism are conducted over ocean routes. Cruise ships arrive daily, bringing vital trade to the area. Large barges with cargo containers transport vehicles, furniture and equipment. Ferries transport people between islands, while yachts, sailboats and catamarans entertain an exclusive clientele. Waterfront shopping and dining is popular on all islands.

One cannot go long without playing in the water. Snorkeling, diving and water sports keep both locals and visitors engaged in the magic of Paradise. Try your hand at deep sea fishing, along with the sport fishermen who compete for coveted marlin and sailfish. And after you are done playing, relax on the beach with some coconut water: 'tis good fo’ de back.

Positive Is How I Live

Positive Is How I Live, US Virgin Islands. This is by far the most popular bumper sticker in Paradise. The author is a senator who calls himself Positive. I met him recently, and he was as good as his name. He is not the only one with the infectious attitude.

How can I ruin your day? A twinkle in the eye belied the words of the service representative. While processing the item exchange, she kept up a lively conversation. The Lord is looking out for me. That got my attention. I had a root canal, and it hurts to eat. The Lord knows I need to shed some pounds, and he’s helping me lose weight. Did I tell you about my water problem? I wondered what was coming next. You know, the water settles around my legs, and every time I look down at my feet, they are fatter than the last time. Then I saw this lady walking around with a bionic leg, and my legs started to look real good. Have a blessed day!! As I was leaving the store, a familiar quote came to mind: I complained I had no shoes, till I saw a man who had no feet.

What did you notice first in the picture of the sky? Most folks see the clouds, some see the rainbow, a few keen eyes pick out the moon. Look for the blue, they say in Paradise. As long as there is a patch of blue, the storm will be over soon. Thundering clouds and blinding downpours may threaten to ruin your day, but in Paradise, a patch of blue is all you need to make it through the rain. When you are here, Positive is the only way to live.

Casebook: Saying Goodbye...

Leaving for Paradise sounds easy; explaining it to those who stayed behind was quite a bit harder. I wrote a letter for the children.

My dear little princes and princesses,

I am writing to wish you a happy and healthy new year. I always enjoy listening to your adventures and helping you with some of your challenges. This letter is to tell you about a new adventure that I am undertaking this year.

There is a special group of children who live on an island. They are like you in many ways-they live with their families, go to school and play with friends. They also have health-related challenges similar to yours. However, unlike you, they do not have a doctor to help them if they get sick. I am going away for a while to arrange for them to get help with their seizures, learning and development. While I’m away, the other doctors who are here will help you, should you need it. They are very good doctors, and I know you will be in good hands.

Even if you don’t see me, I will find you in my heart (remember the Little Prince’s secret-it is only with the heart that one can see clearly; what is essential is invisible to the eye) And if you have a particularly challenging day, here is a rhyme to help you:

In facing life’s vicissitude
For certitude of fortitude
Gratitude is the attitude

Be well, and all shall be well.

Your friend,

DOC

Powerless in Paradise

Living on a tropical island means sunny days and moonlit lights-guaranteed. Electricity is another matter.

The local advice: Get the biggest surge protector you can find and connect everything through it. Hardly a day goes by without a power outage. It can last minutes, hours, or days. When the electricity comes on, the surge takes out any unprotected electronic equipment.

The locals take the power outs for granted. Light a candle or two, keep some bread and peanut butter handy, stock up on canned food (and a mechanical can-opener), use a pail to draw water out of the cistern. Buy a propane or charcoal grill if you want to fix some hot food. Homeowners often fit the house with a generator for extended power outages. Without signal lights, traffic becomes a messy gridlock. Most shopkeepers wait by the entrance to the darkened stores, while others use flashlights to direct customers to cash counters-no credit cards, please. What if you are visiting? Then it gets more interesting-here are a few examples:

At a local hotel, a gentleman was checking out because the heat created health problems for his family. He was headed for a resort facility that had full power while the island was in darkness (one does have to pay dearly for such luxuries). Several guests replenished their beverages and headed to the beach. Others gathered in the lounge, hoping for news and tips about dealing with this unforeseen situation.

The next morning-just another day of being powerless in Paradise. At the airport, the generator keeps a few fans whirring. No computers, no air-conditioning, a few lights. The check-in is on manual mode. IDs are verified against preprinted itineraries brought by the passengers. Connecting flights? No sir, you have to do that on the mainland. Open seating, but please don’t rush the plane. People fan themselves with newspapers and pamphlets, but moving hot, humid air around doesn't provide any relief. Cell phones have stopped working by now, and there is a general sense of frustration. Everyone is ready to leave Paradise, but ….there is a mechanical problem with the plane, and the airplane mechanic has to be flown in from San Juan!!

That’s when you realize that being powerless in Paradise provides an opportunity to empower yourself: to let go of expectations, do the best with what you have at hand, live in the moment. If you can do that, life's journey becomes an adventure. And you become a Pirate of Paradise!!

Hook him up

Once I had a place to stay, getting hooked up for utilities and TV was the obvious next step. Obvious, but with a twist. After all, this is Paradise.

I went to the business office to request a TV connection. That requires a cable box, and to get one, one has to apply in person at the business office. The sign-in procedure was familiar (see: We’ll learn her to wait). The waiting room was a good place to discover customer concerns. I got the wrong bill. I’m not getting the service I signed for. I need another installation time. This cable box does not work. I took notes for the sign-up process.

At the service counter, a déjà vu experience was in store (see: Going Postal): We don’t have any cable boxes. How do I get one? Apply and wait. It was the same routine as the post office. I knew what had worked there; would it work here, too? It was worth a try, especially since Super Bowl weekend was coming up.

Would you take my customer information now? Sure, here are the forms. While returning the paperwork, I added a reminder about the upcoming Big Game. The lady that entered the data into the computer noticed my occupation.

You a doc? Yes, Ma’am. You don’t need a box. I don’t? No, I’ll give you basic service without the cable box. Just a minute. She got on the phone. Doc wants to see Super Bowl. Hook him up. No, not next week, this afternoon. Installation time, cable box and service issues were bypassed in an instant. I set up credit card billing to avoid monthly trips and lines to pay bills.We agreed on an installation time a little later that afternoon.

The cable company truck beat me to the apartment. They didn’t give you a box? No problem, mon!! Apparently, the installers liked this challenge. By the time they were done, I was surprised how many channels one could get without a cable box. I had TV; the utilities could wait till after the Super Bowl.

As with other things, it takes the patience of a saint to get hooked up in Paradise. I found a few short-cuts: wireless for phone and internet service, a cistern for water, and a shared electrical bill. Now, all I needed was electricity.

That’s the next story: Powerless in Paradise

Here comes the Bride

The beaches of Paradise are a popular spot for destination weddings. The wedding parties are usually small, and the occasion is semi-private. The best spots are often popular with tourists, who join in to serenade the couple as they exchange vows. Here is a typical scenario.

Flowers are arranged to demarcate the wedding area, with red, white and pink bougainvillea petals strewn along the bridal path. Photographers check the light and position themselves as the sun dips towards the horizon. The groom, wearing a stylish white tropical outfit, waits for the bride in a coconut palm grove. When the bride arrives to the music of the ocean and gentle tropical breeze, the wedding ceremony begins. Vows and rings are exchanged, kisses and hugs go around and everyone gets caught up in the magic of the moment. After photos and champagne, the couple takes a stroll down the beach, accepting congratulations and leaving paired footprints in the soft sand. Once the beach ceremony is over, some wedding parties get on a boat to continue the festivities. As the boat sails away into the sunset, the sounds of happy times carry over the water and echo off the hillsides. Later, the moon rises to add a silvery backdrop to the twinkling boat lights on the horizon.

Marriages maybe made in Heaven, but for weddings, there is no place like Paradise!!

We’ll learn her to wait

The first thing you need in Paradise is…, you guessed it, the patience of a saint. In case I forget that fundamental rule, there is always someone “from stateside” to remind me.

I walked into the bank, and saw a helpdesk with no one behind it. A book was propped up on the counter. Following a local person’s lead, I wrote my name and time of arrival. That is the way to get in line in Paradise. A few glances were cast my way to see if I had figured out the routine. I did what the locals do-sat on a lounge chair, and waited. Every few minutes, a bank employee would stroll across, call out a name and a person would follow the employee to a cubicle. Everyone waited till their name was announced. No name, no service. No financial problem could be big enough to rush things. It seemed like a fairly typical day at the bank.

Typical, till a New Yorker (at least the T-shirt said so) stormed into the reception area. She leaned over the helpdesk as though she was searching for someone under the chair. Next, she went around it to be sure, and then started pacing the reception area. She peered into offices, called to get attention and demanded service. She intercepted an employee who was working with another client, only to be greeted with a steely glance and a finger tap on the book. She either missed the point or it did not suit her. So she got on the cell phone to make things happen. Apparently that did not go well either, since with every call, her voice got louder. A few calls later, she announced her intention of getting some service, or else…… Through it all, she did not write her name in the book. No name, no service.

My name was called, and I proceeded to one of the offices. After completing some paperwork, I discovered another reason why things work on island time-the notary was in a corner office, the printer was at the end of one hallway, and the copier was at the other end. An official document in Paradise needs to be printed (often in color), notarized (at five dollars a stamp), and copied (sometimes in triplicate).

In an adjoining cubicle, a couple of employees were whispering to each other while watching the damsel in distress. They dispersed, and the word came around: She in a hurry, we’ll learn her to wait. By the time I left a half hour later, the lady was still being “learned to wait”

I wondered how long it would take her to learn the lesson: No name, no service. And learn to wait. Why rush when you are in Paradise?

Going Postal

The mail does not come to you in Paradise; you go to the post office to pick it up. Since the post office box also serves as the local address for all official correspondence, the first order of business in establishing a residence is getting a P O Box.

We don’t have any available. The postal worker’s response to my request for a mailbox was matter-of-fact and nonchalant. I was speechless for a moment. How do I know when one becomes available? Apply, and wait. When someone turns in their key, we’ll call you if you are next on the list. Apparently that is what everyone does. How do I get my mail in the meantime? I had hoped for a better response than a shrug. Next in line-can I help you? I retreated from the counter to consider my options.

There are private mailboxes available at various locations, which serve the clientele that prefer not to go to the post office. They perform the same functions as the post office for an additional charge. Commercial carriers deliver express shipments to a local address. I did not have one (see: Leaving for Paradise) But if you want to ship packages (in Paradise, all things big and small come in packages) the post office offers the best rates and hours. IF you can get a mailbox for a shipping address. I knew I had to start with heart. I got back in line.

I am a doctor taking care of children. I am waiting for medical supplies that need to be shipped urgently. Can you help me find a way? The response was very different this time. Talk to this person when he gets in around 9AM-he knows how to help you. I was still not used to island pace, so I showed up on time. Half an hour later, I met the person who made things happen at the post office. He heard my story, and asked me to write my name on a slip of paper. Then he did the magic trick-he went to the back office and came out with a P O box number written below my name!! Follow me, said the Pied Piper of Paradise.

He headed over to mailboxes, replaced the lock on one of the boxes and handed me the keys. I was glad to get a mailbox so quickly, but something bothered me. What about the person whose mailbox had just been turned over? They haven’t paid the rental fee for three months, despite several reminders. I paid several months fee in advance before leaving the post office. A few weeks later, the supplies began to arrive. Yes, weeks in earth time is regular island time.

The Post office is a social networking place in Paradise. The TV screen behind the counter announces faith-based charitable campaigns, raffles and bake-sales are held in the verandah, people stop to exchange stories and news, and the rhythm of daily activities resonates in the parking lot. Workers, schoolchildren, businesspersons and retirees all have their routines while visiting the post office. Going postal in Paradise is a way of life.

The Lord blessed me today!!

The Lord blessed me today. The lady behind the desk paused for a prompt after this intriguing comment. A story was coming my way. An encouraging nod got her started.

I had a doctor appointment this morning. When I got to the parking lot, the car had a flat. (I didn’t get it; seemed a bit odd to be blessed with a flat tire to start one’s day. I waited to hear more). Lord, I said, how am I going to get to the doctor’s? You know, the Lord sent this woman who was going my way, and I got to the appointment on time. When I came out of the doctor’s office, I said: Lord, how am I going to get back to work? Well, the Lord sent me this man who was going my way, and I got back here.

Luck, coincidence, synchronicity or a miracle? For the lady who was telling me the story, there was only one answer. She was pleased that God had made her day, but I was still curious. What about the flat? Oh, that’s still there; I’ll deal with it after I get off work, she said calmly.

The story made me realize I had been similarly blessed. While loading the suitcases to leave for Paradise, I noticed the van had a flat. No time to fix it-I would miss the plane. With everything else that was going on at the time (see: Leaving for Paradise) I did not feel particularly blessed that morning. If anything, it did not appear to be a good omen. I overlooked the blessing in disguise. My car hadn't shipped out as planned (see: Getting Around). If the paperwork had gone through on time, I would not have a car at hand to get to the airport. I made it to Paradise on schedule. What about the flat? A friend fixed it later that day. The car got to Paradise eventually.

Moral of the story: Adversity can provide an opportunity to count one’s blessings. After all, in Paradise, one doesn't just believe in miracles; one depends on them.

Next: Going Postal

To the left, to the left..Getting around

KEEP LEFT. Shoulder to the shoulder. (Steering)Wheels near heels.

Pick your favorite memory aid. It still takes a good bit of mental gymnastics to back out of a hard-to-find parking spot. Here is my story of getting around in Paradise.

Before relocating, I had arranged to rent a private vehicle. The owner would pick me up at the airport, I’d drive him back to his place, and then head over to my apartment So far, so good. Then things got interesting.

I called to confirm pickup time at the airport the day before departure. Are you coming in on Sunday? I’ll be off-island, said the owner of the car. He was not going to be back till the following evening. No one else was available to drop off the car. I did not know where I was going from the airport (see: Leaving for Paradise). No problem, Doc. The owner had an idea: I’ll leave the car at the airport. I had never seen the car, but I was listening. What about the key? Oh, I’ll leave it under the mat on the passenger side. The mental image was not encouraging-getting arrested at the airport for allegedly trying to break into cars and check under mats, looking for a key to a car I had never seen. We eventually worked out a transfer arrangement that involved two drop-offs and three other people.

Months later, I shipped my car to Paradise. The cost of shipping, taxes and insurance added up to a third of the book value of the car. But buying a car is even more expensive, since those costs are passed on to the buyer as DOMA (Dealer Overseas Marketing Allowance) If you choose to work with a commercial agency, rental rates start around $800/month (best rates in town, the ads claim) And the gas prices are nearly a dollar higher than the mainland. Need a spare part? Expect to wait for weeks-ships may make a few stops along the way. (The patience of a saint-always get a chance to see if you still have it).

When I get on the road, each trip is a roller-coaster ride. Every hill-hugging narrow road resembles San Francisco’s Lombardi Street. If that’s not enough, the traffic goes both ways on undivided roads without shoulders. Steep slopes and hairpin bends add to the thrill of driving in Paradise. Did I mention the rain and wind? Through it all, one rule applies: To the left, to the left….

Any other options? Sure(check out the photos). All things considered, the best value in town is the “dollar ride” on a safari taxi. Between islands, there are seaplanes (or airboats, if you prefer) ferries and private boats . Each of these rides has its own special charm. And that is the secret of getting around in Paradise: you don’t have to drive to enjoy the best rides. But if you get behind the wheel, remember: When in Paradise, it is right to keep left.

Next post: The Lord blessed me today!!

Leaving for Paradise

Two suitcases. A dream. And a laptop.

Three decades earlier, I had made a similar journey to start my professional training (minus the laptop) Faith, family and friends had helped then; I was leaving two of the three behind this time. In Paradise, faith is all one needs to get started.

I had talked with a realtor about getting an apartment. A small, but convenient, place was offered at a sharp price. There was a tenant in the apartment, but the realtor expected it would be vacated soon. What if it wasn’t? No problem, Doc, I’ve got this covered. That was a month before departure. No problem? The tenant in the soon-to-be-vacant apartment decided against leaving Paradise. Calls and e-mails were exchanged as I tried to arrange a lease. I was hundreds of miles away, and within two weeks of relocation. An independent search for a place was discouraging. A week left, no lucky breaks. Chill, Doc, I’ll take care of you. Three days before the scheduled departure, I was informed that I may have to stay in a hotel till……. Needless to say, hotels were sold out except for premium rates. High season weekly rates were in four-figure amounts, far beyond what I could afford. I was going to be homeless in Paradise!! Or go broke trying not to be. Faith is all one needs, right? I also needed Plan B.

The day before leaving, I spoke to a co-worker, who was able to locate a temporary “shelter” till I could get settled. I had a roof over my head, running (cold) water and electricity. The cooking range emitted fumes and odors when I plugged it in; I never figured out the TV connections. Plan B worked out…for about two days. Then it was time to pack my bags to nowhere. That’s when I found out how JIT (just-in-time) works in Paradise.

The realtor found another apartment that needed plumbing and fixtures. I’ll have it ready in two days, Doc. I did not have two days to spare. Time for Plan C. My realtor friend rose to the occasion: I have an idea, Doc-a friend sold a condo unit, but the closing is not till next week. What happens if the apartment is not ready by next week? No problem, Doc; I know the lawyer, we’ll postpone the closing!! You guessed it-I was a stowaway in a “sale-pending” condo for two weeks. Then it was time to move, again. This time, I had a place and a lease. Faith works if you have the patience of a saint.

The apartment has basic amenities, quiet neighbors and a million-dollar view (photo above taken at dusk from the balcony). I see cruise ships enter and leave the harbor, hear planes take off for faraway lands and feel the tropical breeze as it cools the sun-drenched, lush green mountainsides.

In Paradise, you can unpack your suitcases and your dreams. The laptop is optional.

Next post: To the left, to the left… Getting around in Paradise.

License, Please!!

Accepting an offer to work in Paradise was easy. Getting a license to do so is the story of the day.

I sent in my papers as soon as I accepted the offer. Several weeks later, I got an e-mail that the papers had been received. Then it was Carnival time (we’ll go there later). By the end of high season, I had called several times; each time I was assured that progress was being made. (Remember, the patience of a saint). The summer came and went, but no license was forthcoming. About eight months after the initial submission, a letter brought the much-awaited news: the papers had been processed. I came down to make arrangements for relocation and pick up the license.

At the license office, a blank look greeted me. Apparently, they had never heard of me. I showed the letter from the license bureau-it was the real thing, but they did not have my papers. I looked around in disbelief. As I tried to come up with something to say, something caught my eye- it the legal-size envelope I had mailed months earlier, lying in the midst of a pile of unopened mail. I reached over and pulled out the envelope. Sure enough, the seal was still intact!! The seal was opened, a file prepared and now, all that was needed to issue the license, was a check for the license fee. As fate would have it, I did not have my checkbook handy. No problem, mon. Just mail the check and the rest of the process would go smoothly. I did my part the next day. And waited….

When I arrived to start work the following month, I went to pick up the license. Not so fast, my friend. The check had not been received, so the file was still incomplete. By now, I knew where to look. Sure enough, there was the envelope with the check, in another heap of unopened mail. I pulled out the envelope and handed it over. Everything was in order, and I got a lucky break - the license board was meeting the next day. I waited some more….

The next morning, I called and was informed that the license had been approved, but it was not ready. The papers had not yet made their way to the office that issued the license-call at the end of the day. Two days and several calls later, I went to the conference area (second floor), and hand-carried the file to the office (a few floors above, in the same building). You see, the machine for laminating the license was in the upstairs office, and lamination was a requirement before issuing the license.

Finally, I had the coveted license in hand. Eleven months had passed since I had sent in my papers. Apparently, earth time does not work in Paradise.

Lesson learned: In Paradise, things happen in God’s good time. DON’T RUSH GOD!!

Next post: Leaving for Paradise

Saints and Virgins

US Virgin Islands. America’s Paradise. St Thomas, St Croix, St John.

Balmy tropical weather, cool ocean breezes, clear blue skies and turquoise water stretching to the horizon. Any takers?

I signed up when an opportunity came my way. True to the name, it is virgin territory for my area of professional expertise. Call it an Adventure in the Caribbean-that makes me a Pirate of Paradise. Follow along as I share tales of how things work in Paradise. As you embark on your journey (actual or literary), here is the first thing you’ll need: the patience of a saint.

Let’s try that again: the patience of a saint. Now let’s find out if you have it.

I’ll be back with the first story this weekend, titled: License, please!!