Tuesday, November 21, 2017

Fathers work day

All I have to say is, "When working under a tree becomes distractingly beautiful then you found the proper place to work!" Last weekend, the fathers from our school got together for a work day to build playground equipment and picnic tables for the school. The dads, and some moms of course, worked hard and even used reclaimed wood from the very tree that we were working under. We jokingly asked, "If the tree knew we are using her wood right now?" We eventually finished the picnic tables and all of the parts for the playground. The pieces will be moved in January to their new location at our new school facility just outside Granada town. 
   Working together was fun and we accomplished a lot considering the playground that we really wanted is not available anywhere in Nicaragua. A set of building plans, lots of wood, and plenty of hard work paid off. The school saved money, the kids will be happy and we used reclaimed wood from a fallen branch. It really does not get any better than that. Oh wait, the gigantic burgers, filet mignon, and unlimited beer for lunch made it better :)   

This massive tree was beautiful to work under. The bottom left of the tree is where the branch broke during last year's terrible drought.
Everybody had a job to do.

Expats from the U.S., Canada, Europe and Australia as well as locals all chipped in.

Laying out our design before cutting was crucial.

Volunteering runs deep with a lot of these people.

The beginnings of the monkey bars are starting to take shape.

The beautiful home of our school's founder.

The clear and cool day was a treat.

The five languages spoken by these men were: Country-bumpkin, Nicaraguan Spanish, Dominican Spanish, Spanglish, and English. After the beer started flowing we all spoke various forms of Country-bumpkin, though. Interestingly, the more we drank the faster the saw blades spun and the straighter our cuts were, go figure. Just kidding we were responsible dads (because some of the moms were around). Otherwise, left to our own manly devices, we might have had to make a trip to the hospital with a thumb in someone's pocket :)  

A subdued day of the dead

We had a subdued day of the dead with some of our daughters friends coming over to our house to help decorate flower bouquets. We were limited in our ability to get to the cemetery and experience the food, flowers and music as we did not want to wheel Zoe through the throngs of humanity. Also, and more notable than that all the girls said, "If Zoe can't go then none of us will go." As a father of an injured, semi-mobile child, I was so touched with how the girls supported Zoe in her time of need. So there they were, five little angels, building floral arrangements from the abundant flowers from the day of the dead. Proving, in their own little way, that celebrations aren't for the dead, but the living. 

A better way

   Years ago, when my daughter was 3 years old, she drew this picture. It's not my favorite because she was going to be the next Picasso. It's my favorite because she drew this happy image less than a month after we lost our house, and everything in it, to a wildfire. Did she find her happiness again because she knew the grass and flowers would grow back? Did she realize that her cuddly buddy, Nico, went to pet heaven? Or did she find her happy groove again because she learned to let go? As parents we will never know. What I have learned, though, is that the power of gratitude is profound and being thankful is essential to happiness. My daughters have taught me a lot in the shortest of time. They have shown me a better way to live. My teacher is in their laughter, in their butterfly kisses, in their quivering taps on my shoulder when they are afraid of the night. We are all students of life and if we listen with more than our ears, messages abound. 

I'll leave you with this thought:

When asked, "What surprised him most about humanity?" the Dalai Lama answered,
"Man sacrifices his health in order to make money.
Then he sacrifices his money to recuperate his health.
And then he is so anxious about the future that he does not enjoy the present;
the result being that he does not live in the present or the future;
he lives as if he is never going to die, and then dies having never really lived." 


Wednesday, November 1, 2017

Renewing Nicaraguan tourist visas has become more difficult

We had to renew our 90 day tourist visa for Nicaragua and did our regular border run, this time, with Zoe's favorite teacher by our side. The moment we presented our passports to the immigration officer we got questioned about our stay in Nicaragua. The questioning and verification process lasted for nearly 2.5 hours. During the questioning period they asked where we lived, what school the kids went to, do we have friends with phone numbers, and so on. They took tons of notes and when the agent went into the back office he called our person of reference and spoke with her for 10 to 15 minutes. Thankfully we were honest with our responses and all the info squared up. We are now in the process of obtaining our residency as this cannot continue. The whole border run took about 4.5 hours not including the drive time. If you are going to renew you tourist visa be prepared for lots of questions and allow extra time.
   As for Costa Rica, they still require proof of onward travel or they will make you purchase a bus ticket prior to gaining entry. To save money, all you need to do is create a free fake ticket, prior to going to the border, by using this link or some similar website Show the Costa Rican immigration officials your e-ticket in your smart phone and you are good to go after that.  

Zoe's first excursion with her cast was going to the border.

I had a sore heal so I took a rickshaw with Sierra. 
Experienced border crosser.

Traffic jam on the Pan-American highway.

Monday, October 30, 2017

Health care in Latin America, beyond the myths and legends

We have been bombarded with comments asking us why we stayed in Nicaragua for my daughter's knee surgery. We have also been inundated with questions about or our impressions of healthcare abroad, costs, access, etc. We will try to be as objective as possible but some of what we are asked to present is our opinion of healthcare abroad. So whenever possible we will try back up our opinion with facts. Remember, I am just a regular guy that needed immediate medical assistance for my injured daughter and we did what we thought best. What made it a little easier for us is, we happen to know a pediatric physician and she recommended the top pediatric surgeon, in the country, for us. The surgeon we used has practiced medicine in 3 countries and appeared to know what he was doing. In the end, seeking medical care is as much a matter of trust as it is science. For us, it was an emergency surgery and we did not have the luxury to shop around.
   Regarding all those questions about what healthcare is like down here, my wife and I broke it down to some basics.  As best we can describe, we feel there are three major components of healthcare: access, quality, and affordability. Below we will try to share some of our experiences but keep in mind there are other opinions on this as well. We will rate each category on a scale of 1 through 10, with 10 being the highest, 7 being average and 1 being the lowest.

Access: We have had 4 experiences with urgent/emergency healthcare in Nicaragua, and one in Peru. In addition, we have spoken with American, European, and Canadian citizens who have received medical care in Panama, Nicaragua, Colombia, Mexico, Peru and Argentina. Some of the Americans that we spoke with were doing stem cell therapy abroad as the procedures are banned in the states. We have spoken with people who had acute appendicitis, altitude sickness, broken bones, or heart issues. In every case, without exception, the patients spoke highly of their quick access to care. None of them, or us for that matter, had to schedule an appointment a month in advance. In fact, each of our stories were similar, we called and got same day help, or worst case we had to wait a day for care.
   If you feel like you want blood work done, all you need to do is go to the neighborhood laboratory and tell them what you want tested. No doctor approval needed here. This is such a huge time saver and allows the patient to narrow down the concerns without a doctor's visit. If after all, you decide to visit your doctor, you'll already have the results of the blood work which enables the physician to correctly diagnose you and eliminate the guess work. We have a family member in the United States and he needed to see a cardiologist  and there was a 4 to 6 week waiting list for an appointment to see a cardiologist. Here a friend made a next day appointment and I was there when it happened. On a scale of 1 to 10 we would rate accessibility of healthcare for expats, in Latin America, an 8. Our score reflects a negative hit for lack of ambulance services throughout large parts of Latin America. We realize ambulance service is available in most major cities but response time outside the populated centers is either non existent or unacceptable.

Quality: The single biggest criticism that we hear on developing world healthcare is quality. This is, in our opinion, more an aspect of believing in myths and legends than in reality. 
Myth: healthcare is better in my home country. 
Legend: we have the best physicians in the world, in my home country. 
   So let's look into quality of healthcare, which we believe can be roughly divided into three categories: facilities, equipment and care.

Facilities that we have seen in Panama, Nicaragua and Peru actually make many U.S. hospitals look like third world facilities and that is no joke. As a person walking into a hospital or using the emergency room you notice a lot of superficial things fairly quickly. Are there a lot of desperate patients in the waiting room? Is it clean, does the staff look rushed, irritated? The list can go on and on. The facilities that you see are your impressions for the entire hospital. When we checked my daughter into the emergency room in Miraflores, Peru it felt more like we were checking into a Four Seasons hotel than a hospital. In fact, to this day I have never had a cleaner, more elegant hospital experience than in Peru.

Equipment has a funny way of being the same or very similar all around the world. Just like you can buy an iPhone or a pair of Nikes anywhere in the world, so too can hospitals buy the same ultra high tech hospital equipment regardless of location. Access to modern medical equipment is the great equalizer in healthcare around the world. As for my daughter, her digital x-ray was done with the same GE equipment that would have been used back in the states. In fact, the gurney that she was shuffled on, at Vivian Pellas. was brand new and from Indiana. In fact, it feels like everything is brand new at Vivian Pellas hospital in Managua.

Care, being our third component of quality, is more subjective. We are talking about physical care, not access. We have always had wonderful care here. What can I say, we went in for something and left better, for going. The physicians seem well trained, attentive and helpful. Heck, the physicians will even make house calls in Latin America, without blinking as eye. I am sure there are medical situations that can spiral out of control here just as back in the states. But if someone would assume care is automatically better in the states than in Latin America, that person would be wrong. Care is a case by case comparison. For example, when we were in Panama and spoke with Americans obtaining life saving stem cell therapy abroad, we were shocked. We weren't shocked in the medical tourism aspect of it. We were shocked that some of their physicians at John Hopkins University in Panama City we actually physicians from Chicago, New York and other American cities. You see, reality is odd sometimes. Imagine the irony, American physicians expanding their medical knowledge, in a foreign country, because of the prohibitions back in the states. It isn't too difficult to see why we shake our heads when we hear blanket statements about substandard foreign healthcare. For quality of healthcare we would rank Latin America a 8 out of 10. We deducted two points because the best quality healthcare is, again, limited mostly to the largest cities.

Affordability is matter of perspective. For example, for a Canadian most healthcare abroad is expensive but for an American, the healthcare is ridiculously cheap. Here, we can share more facts  than opinions. Our emergency room visit, in the most beautiful hospital we've ever seen, was in Peru and the cost $40. At Vivian Pellas, in Nicaragua, three days of out patient observation with a cardiologist, blood work, stress test, angiograms and so on, just $500. For the record, the cardiologist personally spent 4 hours with the patient during the testing, which would be an unheard of in most other countries. Furthermore, if open heart surgery was required the total cost would be around $20,000. We know of another retiree who was admitted to Vivian Pellas with acute pancreatitis and was hospitalized for 8 days and her bill came out to about $8,000. Finally, my daughter had a knee operation along with a full leg cast and our total out-of-pocket expenses were $5,200.
   These are just some of the examples that we have seen abroad. True $5,000 or $8,000 is a lot of money, but for first class healthcare, it seems affordable to us. Coincidentally Vivian Pellas takes most reputable insurance plans from around the world. So theoretically one could even get a direct payment set up from another country, though we have not done that as we are self insured. For affordability we rank Latin America a 10 out of 10 by American standards and maybe a 5 out of 10 by European standards, as most healthcare in Europe is extremely inexpensive.

   The scoring average for an American expat is 26 out of 30 or 87% . The scoring for a European or Canadian expat is 21 out of 30 or 70%. An American would benefit from the affordability more than a person from a country that practices socialized medicine. For the average expat seeking medical attention in Latin America one would see very few differences other than language spoken. Even language should not be a factor as most hospitals can arrange a translators for you, if needed.

   What I have not mentioned, thus far, are the many local hospitals and clinics throughout Latin America. Most are free and offer residents access to much needed medicines and care. However, many of the free clinics suffer terrible supply shortages, often use lesser experienced doctors, and are plagued by mismanagement. True, there are many well run community clinics but those are more the exception than the rule. Most expats would volunteer or fund raise for rural clinics than actually go there for medical treatment. We have seen some of the poorer clinics using dirty plywood for exam tables, we saw dogs walking through hospital lobbies, and we have even been to a clinic that didn't have running water. Think about that for a moment, the filth of not having running water in a medical clinic. Free or not, some minimum standards, like running water, should not be optional. For most expats who fear third world medical care, these are the visions that first pop into mind. I am here to say, most people with money, even Latinos with money, prefer paying extra for better care. It is human nature to want better, so too would it be for any expat seeking medical help down here. Most expats, including us, are lucky for having options to obtain better care in the premium hospitals throughout Latin America.
   I am not trying to take sides, not trying to say what is better. I am just trying to give balance to what healthcare looks like in other countries. Cali Colombia specializes in breast augmentation, so much so, that most wealthy Latinos call Cali, silicon valley. Panama specializes in stem cell therapies while Nicaragua has a world class burn center and trauma unit. As for most things in life, seeing it with your own eyes is more beneficial than hearing about it from someone else. Sorting through the negativity and stereotypes can be difficult at times, but with persistence you might find exactly what you were always looking for. On-line research is important but actually visiting these places for yourself is priceless.

The bustling gem of a hospital in Miraflores, Peru.

Post operative recovery in our spacious hospital room. 

Clean and uncrowded hospital.

Vivian Pellas is a well run hospital 

Ordering blood work is a simple process in Latin America.

How about this clean and not chaotic emergency room 

Oktoberfest Granada style

Celebrating Oktoberfest in Granada is like living a Cheers episode, "Where everybody knows your name." Living in a smallish city and getting to know the locals and other expats, pays dividends. Often times, the friends you make abroad are more like family than what would otherwise be the case back in your home country. We need each others' help with border runs, shuttling friends to the hospital, or helping each other with translations, and so on. The outreach this community gives creates trust and with it, bonding relationships. I cannot overstate how nice it is to go into a German restaurant to celebrate Oktoberfest and see mobs of friends, greeting you with open arms. That is the way Oktoberfest should be, boisterous greetings, genuine smiles, and an eagerness for revelry. We are so blessed to be living that spirit of open arms all year, with our friends, in Granada.


Halloween in Granada, chasing spirits and mending them too

Our school had their annual Halloween bash for the kiddos. How can I say it any other way, than the school's children took the Calzada by storm. Though Halloween is not widely celebrated in Nicaragua, it happens to be so close to their day of the dead, that most see the good in the celebration. Halloween, for the children, is quite an affair, I can still remember my excitement nearly 35 years ago. Back then, deciding on costumes, where to go, the mountains of candy, was all so exhilarating. I eventually learned that Halloween was started by the Celts as a way to end their lunar year by scaring away all the demons and spirits from the past year so they wouldn't return in the new year.
   Chasing spirits is part and parcel of experiencing a good Halloween. Little did I know, that one day, mending spirits would be equally as important. As Zoe's friends ran from restaurant to restaurant collecting their bounties we struggled just getting there. Wheelchair accessibility, what's that? Down here, the streets are historic and so too are their inaccessibilities. Zoe was so sad, though she tried not to show it, she was crushed. I eventually rolled her aside and got on my knees so I could be at her eye level, and chatted with her. She confided about her frustrations, and how hot and sweaty she she had become sitting on her pillow. She was right, and there was nothing I could do, except support her. I let her know that we were there for her and listened. I was instantly reminded of times in the past, when my wife would vent about something and I offered my solution and she, in return, got mad at me. My wife would say, "I want you to hear me, not give me advice, aarrhh." Thankfully I remembered how important it was for my wife to be heard. I looked Zoe in the eyes and quietly listened while she cleared her mind, and she felt a little better for it.
   Zoe had one Charlie Brown experience after another. She messed up carving her pumpkin. She wanted her pumpkin to have a couple of teeth but accidentally cut too far, and they fell out. She bemoaned how messing up the pumpkin had nothing to do with her being in a wheelchair. Her art work, that she worked on for countless hours, was blown by the wind right into the rain and ruined it. The list of follies literally goes on and on, and for a child, failure is seen as personal fault. Thankfully, she has a lot of really good friends and an awesome sister to help her through this very tough period.
   Then it happened... We were told that Zoe's 3 lb. meatloaf skull won the scary food competition. She said, "Really...really? Really!" Zoe was ecstatic, bouncing up and down, as much as one can possibly do in a wheelchair and then softly mumbled, "I didn't do it daddy, you helped me." I wasn't expecting that at all! I mean, it was her idea after researching it on-line, she decorated it entirely on her own, and put the blood and goo all over the meatloaf. I literally just shaped the perimeter, because it was a 3 pound ground beef behemoth that need parental assistance, and that was it. Still, in her mind, the meatloaf skull wasn't hers, and I could not overcome that. So much of our sadness, as humans, feeds off of how we perceive things at that moment.
   The opportunity came to change her perspective without being, however minimally, involved in changing it. T'was announced that Zoe had won a pizza, for her meatloaf creation, and she of course likes pizza very much. This was the moment, I leaned forward and whispered a congratulations in her ear and gently said, "Because you won the prize, once you are able to jump again, mommy and daddy are going to rent the party boat and have everybody show up for you ." The school children were clapping and cheering because she won, she teared up, heck I teared up. She finally got the opportunity be overwhelmed, hearing the claps and knowing she is loved made all the difference.
   It would be remiss of me not to acknowledge the real difficulties many have and will always have, just trying to move around. We have seen first hand how stairs provide access for some and are barriers for others. I am so appreciative for the help my daughter received from perfect strangers, who acted perfectly. Prior to Zoe's injury I couldn't even fathom the difficulties one would have maneuvering a wheelchair, through a city like this. Seeing how spirits can break just as quickly and profoundly as bones can, has taught us all a lesson about hidden pains.
  Making the world a better place isn't someone else's job, it's ours. We are the generation that you and I have been waiting for. Be thankful by being helpful.  Please volunteer, give to charities, be a superhero, and not just on Halloween.

Some of the most beautiful pumpkins come from mistakes. 

A wicked witch, Harley Quinn, Ladron (robber), and a black cat.

Sierra was happy to have fun and we encouraged her to run around with the other kids but she always checked up on her sister to see how she was doing.

Daddy and daughter, inseparable. 

The award winning meatloaf monster.

A picture is worth a thousand words.

The kids got lots of candies while trick or treating.

Parental involvement made the kids parade possible.

Lots of spooky, cute and scary in this group.

Our school director and her son dressed up as dinosaurs.

Sisterly love, nothing like it, nothing better.

We went to Pan de Vida bakery for the food, games and awards.

Spooky ghost were everywhere.

I thought this pineapple carving was awesome.