Prevention in Colombia

“First Call for Boat Team One!”  That’s what I heard blasted over the intercom at 5am as I then sat straight up in my rack and hit my head.  Ouch…. Dang it’s early.  Today the USNS COMFORT team of health care professionals descend upon Tumaco, Colombia and will over the next two weeks attempt to wreak as much positive health care benefit on the population as possible.   With the ship being anchored a few miles off shore there are two ways to get to land- helicopter and boat- and for me this morning it would be the latter.  The boat ride was appox. 45 minutes and as we pushed off I donned my IPod, watched the beautiful sun rising over the water, and looked aft at the American flag with the mighty USNS COMFORT hospital ship getting smaller and smaller in the background.  Next stop Colombia. 

As we pulled into the pier by the small Colombian Coast Guard base in Tumaco, I spotted armed guards, a gorgeous beach, and banana trees.  What I also saw were several semi-submersible boats that I had recently seen spotlighted on CNN that were being used to smuggle drugs (cocaine) to Central America and eventually the United States.   These boats are ideal because they have a very low profile (invisible to radar) and are able to be submerged for short periods of time if spotted.  The drug smugglers also like them because if they are caught they can scuttle (sink) the boat with the evidence, and appear to be fallen overboard and will be rescued with no proof against them. They are constructed by the drug lords and appear to be either converted cigar boats with fiberglass tops, or built from the ground up for smuggling purposes.   Interestingly, during our country brief by the Embassy attaché we learned that these boats are now illegal to even be operated regardless of what they are carrying.  Also, the attitudes of the people in Tumaco were positive towards the U.S. but they were pro-drug trade, so we were instructed not to talk about this with the locals.  I walked over by one of the drug boats and snapped a photo.   

From the pier we were taken briskly through the small town of Tumaco accompanied by Colombian guards with machine guns hanging outside the door for force protection.  An awestruck population stared at us as we sped by and waved.  Scantily clad children ran though the dirt streets, as did stray dogs often times barely averting being struck by vehicles.   Many of the box like wooden houses were propped up on stilts with a muddy base below no doubt from the heavy storms that cause flooding in the area on occasion.   The people as I suspected had a darker skin tone than the Colombian people I have seen who come from farther north in the country near Cartagena or Bogota.  This was the Afro-Colombian region.    

Our medical site is located on the far side of town at the Max Seidel School, and as we approached we could see the long lines and hoards of people already there waiting for a wristband and ticket to see a medical provider.  Each child and adult had to make the choice of one and only one type of specialist to see- optometry, surgery, dental, or general medicine.   This was designated on their wristband and they were assigned a serial number and given an encounter sheet to be taken to the respective clinical area.   I set up shop in one of the school buildings in a tarped off corner space with three chairs and a table and with rays of sunlight streaming through the small holes in the eroded concrete wall.   

We set a goal of seeing at least 1000 patients today.  Between 14 providers that would be more or less 70 patients a piece. Several Spanish translators, some from the Mormon church, showed up to assist with language barriers.  My Spanish is fairly good, but I grabbed one of the volunteers for backup and we set out in seeing the patients- with the mantra of expediency makes most difference running through my head.   

Right from the get-go I started seeing strange pathology and sad cases.  My first patient was a young man who upon extending my right hand to introduce myself extended his left hand, and not his right, because where his right hand used to be was now a stump.  “Que paso?” I asked.  He told me how he had been injured by a land mine and proceeded to show me his lower legs where large holes were evident where his calf muscles should be as well as numerous scars upon his ankles and feet.   Nevertheless, the man was cheerful and I quickly recalled the Spanish word for smile- sonrisa – because he had one.   I learned the other day that Colombia has the highest concentration of landmines than any other place in the world, placed by paramilitary groups, the FARC, and the Colombian government over the years, they are a constant source of devastating and unnecessary injuries to children and adults each year.  The Colombian singer and icon Juanes who would play for us later that night aboard COMFORT was here at the site today speaking out about Landmines as was the U.S. Ambassador to Colombia.  Throughout the day I would see several adults and children with burns, amputations, and disfigurements due to these mine explosions and it filled me with wonder as blended right in with the rest of the society, as if it were expected or something (sort of like obesity in the U.S.) 

Over time, my translator and I came up with a system by which we saw patients expediently.  I would make the introductions and ask, “Cual es tu problema?” He would then listen to the details as I wrote on the patient encounter form, and he would fill in the story detail gaps that I did not catch.  Then I would do an exam, prescribe treatment or medicine, and talk a bit about lifestyle and healthy behaviors.  Since the translator had been living in this town for a few weeks, he taught me some of the local slang for hello (Q Bo Pey lau), and hey brother (papi), hey sista (hermana).   That elicited some smiles on the faces of the patients.  

A young twenty-two year old girl really got to me mid-morning.  She told me how for the past 11 years she suffered from constant headache, and it was unbearable.  I queried her on whether the headaches waxed and waned, if anything made it better, or worse, and to all she said no, it is constant.  I then asked her if she had ever taken any medication for it, and she replied no.  I said, ok, well then let’s try some “pastillas” (pills)  of Tylenol or Aspirin.  I was optimistic that they would help.  However, at this the girl began to shout and said she didn’t want the pills, but instead wanted me to “fix” her headache.   I became frustrated as did she and she started swearing at me.  I pleaded with her to just try the Tylenol and see if it helped.  She finally gave in and with tears in her eye shouted back again, “Yes doctor, I will take them if they are free, but what about when they run out, what then?  I cannot afford any of these pain pills and my headache will come back! Hoder! (Spanish obscenity)”  Wow.  I was stunned.  She was right.  That was the reality.  I apologized and realized again how we take things as simple as Tylenol for granted in the United States.   The woman quickly collected her things, said gracias and left the office, leaving me stunned and speechless sitting there with my Mormon translator.  

Late-morning a gentleman came into my “office” and right off the bat I noticed a bulge in his pants.  We did the typical question and answer in Spanish and then I put on my gloves and proceeded to the exam expecting to find a fairly significant inguinal hernia (protrusion of intestine through the inguinal canal into scrotal sac).   However when the man dropped his drawers what I saw was incredible.  This man had an enormous “bladder” like protrusion from his lower abdomen.  I had never seen anything like this before.  As I lifted the mass of skin and tissue, urine came trickling out from below.   Wow!  An external urine tract from the external mass.  Upon further questioning it turns out that the man had had a prostate removal through his abdomen over 14 years ago, and the incision site had not been closed effectively.  Years later the man experienced a herniation of his insides (tissue, bladder area) out of the scar site and external to his body.   It had scarred down and he had been living this way for over a decade, with the mass filling up with urine, and then when he went to the bathroom deflating somewhat.  Unbelievable.   “Le Duele?”, I asked.   (does it hurt).  “No” , he replied.  “Not at all.”  And he smiled as if he were proud of his condition, as if it gave him an identity amongst his people.  “Como puedo ayudarte?” (How can I help you?), I asked him.  He replied that what bothered him the most was the pain in his knees and shoulders and that he wanted some vitamins.   When I gave him some Tylenol and Multivitamins he was overjoyed.  When I took him over to see Dr. Donahue the head of Surgical Services to see about an operation for his neo-bladder, the man could care less.   It turns out that a surgery to fix this condition (which Dr. Donahue, a urologist, had never seen before either) would take several steps and be extremely involved.  We couldn’t do it with our capabilities here anyhow.  Bottom line- the man left happier than he came- even with urine dripping out of his lower abdominal “appendage.”  

By lunchtime my translator and I had seen about forty patients, referred some to surgery, given some pain medicine like Tylenol or Aspirin, some anti-worm medicine, and largely given all positive reassurance and healthy recommendations.  I ended each encounter prescribing smiling- sonreirse.   It was exhausting and despite my best efforts to remain unaffected, I felt the compassion fatigue of seeing a lot of suffering and not being able to do anything about it.  It was time for a break and some lunch.   Outside my exam hut, and down the way the Official Opening Ceremonies were going on with dignitaries from both countries. I plopped myself down on the ground in the shade, opened an MRE (meal ready to eat) and watched the ceremony.  The Tumaco mayor spoke, as well as the U.S. Ambassador to Colombia.  Special guest Juanes emerged and the crowd went crazy.  The media was all over him and the mob moved where he did, getting autographs, photos, etc.  It was nice to be on the other side of things and for the most part anonymous just doing my job as a doctor.   

Back to work and a whole afternoon of patients to see.  My Mormon translator had abandoned me to go work in Physical Therapy, so I tried to have a go at it on my own.   Let’s just say that a lot gets lost in translation, even if you do speak the language fairly well.  My friend Michelle (an ICU nurse from Puerto Rico) stepped in to help when I needed it and I was grateful for that.  Throughout the afternoon I started to realize health trends of the people here in Tumaco.  First- there were a significant number of patients (more than a dozen that I treated) over the age of 80 and many in their seventies who were in good health save for their complaints about arthritis and generalized body pain.  Therefore longevity of life was comparable if not more than a 1^st world nation like the United States.  What was notably absent was chronic disease as we know it in the U.S. – there was very little obesity, heart disease, diabetes, high blood pressure, or lung problems.  Why you may ask?  Well, I began to ask a lot of questions of my patients.  Drug/Alcohol/Tobacco use?   Nearly every single patient I interrogated did not smoke, consume alcohol or use drugs.   In fact the way they answered the question so emphatically no, made me realize that it was almost “taboo” to do such a thing in this community.   There was a social stigma against those who polluted their bodies, did not work hard, eat healthy, and drink a lot of water.  What an inverse relationship to the United States!  It was especially striking in light of the work I have been doing lately with the U.S. Surgeon General fighting childhood obesity.  There was one particular gentleman in his mid-70s who had been born, raised and lived his entire life here in Tumaco.  He prided himself in working construction, and came with a complaint of rotator cuff tendonitis in his right shoulder that was preventing him from lifting and doing construction.  He wanted some pain medicine.  He was so excited when I gave him some simple Tylenol and Aspirin to help with the pain as well as exercises to do to strengthen the rotator cuff muscled. This guy was 75 and couldn’t wait to get back out there in motion and action! 

He smiled showing his crooked and missing teeth and said “Muchas gracias.  Vaya con Dios.”  A similar joyful female patient stood out to me when she invited me over to her casa (house) to have a home cooked Colombian meal of fish, coconut rice, and bananas.  I wish I could have taken her up on the offer.   In lieu of that she was content with a photo together, in fact she was so overjoyed she tried to walk off with the camera too. No camera for you senora!  This diet and habits that these two patients spoke of was consistent across the board for these coastal people- a diet rich in fish, fruit, vegetables, and a lifestyle that involved much activity late into life.  These people had hardships of a different kind.   What they lacked in access to specialty care for problems like the trauma, burns, birth defects, hernias, infections and arthritis, they made up for with an obvious lack of chronic disease states (due to lifestyle) that ironically is what plagues us (the U.S.A.) the most.   As we come in with our big ship, and our big guns to help this  “health care deprived” population, we as the United States ironically can learn a thing or two from them, especially with our looming health care crisis. Tumaco with its limited “sick care” resources and its socioeconomic predisposition toward healthy diet and activity, is in reality a case study demonstrating how important and effective prevention is in limiting chronic disease.   Perhaps the United States (and Congress) should pay attention.   

Day 1 finished.  70 patients treated. 152 surgeries scheduled.  Total of 1500 seen by all.