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.
Friday, August 17, 2007
Wednesday, August 15, 2007
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.
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.
Sunday, August 12, 2007
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.
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.
Wednesday, August 8, 2007
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.
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.
Sunday, August 5, 2007
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
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
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