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.

Sunday, October 22, 2017

Taking the leap to experience Latin America, our third anniversary

November 1st, 2017 marks our third anniversary of selling our business with the intent of living abroad to experience a different way of life. Years before committing to changing our "location" in hopes of improving who we were, we read stories from others living abroad. Without fail, we paused after reading those expat stories and wondered, what if?  Sometimes, my wife cried thinking about a better life where families spent more quality time together. We both loved reading articles about exotic locations, where kids were free to roam, where children weren't spending so much time on computers, and where they were otherwise encouraged to be with nature as much as possible. Many of those same expat articles mentioned how spouses got closer, talked more and fought less. From our experience, though, my wife feels that she needs more alone time, less husband looking over her shoulder and watching her cook, time. We never thought about the extremes of togetherness, maybe because we were always so busy and distracted in our former lives that we could never have related.
   Prior to leaving on our driving adventure, to South America, we knew some things. We read a lot of articles and studied what we thought we'd need to know. However, we never could have anticipated how real, reality could be. My 9 year old daughter, recently said, "I see more here, I am not hidden from real life. I like real, more than perfect, it makes more sense. You know what I mean, dad?" That statement came from a young lady who has been traveling for a third of her life. My daughters are not shielded from poverty, vagrancy, sickness, or scenes from the other side of life's tracks that most try to avoid. My daughters can experience both sides of life's beautiful coin and be thankful for what they have. As parents, we are certain that their appreciation will provide the most fertile soil for their happiness.
   It wasn't easy moving abroad. However, it was not nearly as difficult as we once thought, either. Moving abroad converted our talk into actions and we were afraid, this we will never forget. Having the advantage, now, of looking back, we truly believe it was the best decision to put living our dream before fear, instead of the reverse. We have had many exhilarating moments over the years, like when a bat that flopped around in our kitchen sink. A rat buried itself in my wife's undergarment suitcase on our very first day in the country. We also had a four foot long snake hide in our shoe rack and we had more lice outbreaks than we care to remember. We got Zika, dysentery and a few broken bones along the way, as well. It wasn't all bad, though, as we also swam with penguins, seahorses, sea lions and sharks, all at the same time and in the same bay, in Galapagos. We paddled kayaks over glowing bio-luminescent waters in Costa Rica, saw the natural wonders of el Valle in Guatemala and even saved a monkey just to name a few. Most importantly, for all of the good and the bad, we wouldn't change a thing. This family adventure has been more like living a marriage vow than we ever would have realized. For better or worse, in sickness and health... we live, and together we stay.
   We have come to realize, life is more about learning how to cope with an occasional bat in the kitchen sink than living some perfect scenario. With the utmost humility, I realize that living abroad would not have been possible without my wife and daughters urging me to live this dream. I must have looked and acted more miserable and unsatisfied, in my old life, than I realized. Sad to admit, but I accepted mediocrity in myself thinking that I was giving my family what I thought they wanted. What they really wanted was a fun husband, a playful dad, a real smile, not those distracted lifeless smiles that I used to give. They wanted happiness and my girls knew we were close, but not quite there. Back then, my daughters were too young to understand my middle aged justifications and as for my wife all she wanted was her soulmate back. An old saying comes to mind, "Before Alice got to Wonderland she had to fall." I have always felt that hitting rock bottom, and being so vulnerable, was my "spark" allowing us to live fuller lives. The fullness of my wife and daughters' unconditional love for me, is yet to be told, as words escape me when I speak of love. Ultimately, my wife and daughters just wanted me to be happy, and for that, I am the luckiest man alive.
   So here we are, three years on, now residing in Nicaragua and living our quirky little life abroad. Is it perfect here? No. Are we doing everything right? Nope, not at all. We have many of the same issues other parents have. In fact, I have tried to explain in a multitude of ways, throughout this blog, that we are a regular family, probably similar to your family. Sometimes we are frustrated and other times content. Sometimes the relentless heat and humidity wears on us. For me, I can't stand the rivers of sweat dripping down my back, starting at 7am. My wife despises that our clothes don't feel clean and fresh because of the humidity. However, we both agree that waking up to flocks of parrots and an occasional toucan can really make up for a lot.
   Are we living abroad forever or temporarily? We aren't sure. The only thing that is certain is we will vote as a family, as we routinely do. Each vote is of equal weight, and to date, each vote has been unanimous. Personally,  I cannot think of anything more sublime than putting my fate in my wife and children's hands. The peace of mind knowing that we are mostly on the same page, makes any hardship more manageable because we are doing this as a team. Recently, we have wondered if we are in Nicaragua or if Nicaragua is in us. A nice feeling to have, especially since we take our happiness so seriously.
   My family and I would like to dedicate our third anniversary "wish" to all of those once happy, lovable, and approachable husbands and fathers, caught in the relentless grind that I was once in. Listen to those closest to you, hear what your kids, spouse or lover has to say. You might discover a new path, one awash in tears at first, but forever paved with the best of intentions. And if it should arise, embrace the tears, for there's probably more truth in them, then in most justifications.

Nothing says loving like a bat in your kitchen sink. A funny video for sure.

Below are images from our most recent year in Nicaragua.

The 4 amigos riding off into the Selva Negra coffee plantation.

My wife just had to buy this placard when she saw it. 

We saved this turtle from certain death as it was stuck in the sand and sinking fast.

The moment my daughter came home from school and saw her injured sister for the 1st time.

My daughters are great divers and even chase nurse sharks on occasion.

My kids love ziplining at the base of Mombacho volcano.

Buying a bed is quite the adventure in Granada.
Enjoying Laguna de Apoyo at my friend's house.

The kids made great friends in such a short period of time.

Zoe's birthday and everybody had special powers. 

Paco is our very nice doggy.

Stunning views at Laguna de Apoyo.

Broken bones will mend but the memories of the injury will live on.

Having friends visit us is a wonderful feeling.

The sunsets at Playa el Coco are truly breathtaking. 

My daughters like to dive old shipwrecks.

The clear waters of Aguas Agrias are as beautiful as they are disorienting.

Cows strolling along a beach.

My daughters love to surf.

Kids playing outside, like nature intended.

Roasting marshmellows after a long day of swimming, chasing animals and horsing around.  

Eine Waldkirche (a forest church) in Selva Negra, Northern Nicaragua.

Enjoying a lakeside breakfast at Selva Negra.

Our monkey "Sport" that we rescued. 

Murphy's Law: A water pipe burst, hours after getting a house full of visitors for a week.

King and Queen of the school for 2017

Kids can find anything to play with and enjoy it. 

Best friends having fun.

Kids joking around aboard the party boat, Bella Mar. 

Nothing quite like waking up to a squirrel on your head.

We love how fresh fruit is delivered to your doorstep in Granada.

My Carnival experience.

My wife is not only happier here, she also made lots of very nice friends as well.

Pacific coast of Nicaragua.

There is always some parade or festival going on in Granada. 

Country living.

Renting a Halloween costume from a real life funeral parlour - PRICELESS

All dressed up and ready to go.

Corn Islands are gorgeous.

I have two wonderful ocean loving kids.

This beats X Box, Playstation or any artificial reality game, anytime.

Kids breaking all health codes by dancing on a bar to Calypso music, and everyone loved it. 

Nurse sharks are all around the Corn Islands.

Beautiful lady multitasking.

Best friends being angels for the school performance.

Cannon ball into the clear waters of Aguas Agrias. 

My cowgirls.

We adopted these ducklings until they were old enough to fly away, and be free.

Sierra counting the growth rings from a once mighty tree.

An 8 year old, shoeless, and riding bareback showed us what chores are like in other countries.

We love it when friends come down to visit us.

People you meet on the road are sometimes the best because they end up being so similar to you.

Partying in Lake Cocibolca.

On our very first day in Nicaragua, this rat dove into my wife's undergarments.

The movers arrived to help us move between houses.

My daughters looking into the inferno of Masaya volcano.

My wife's best friend and family loves visiting us and we love having them here.

Date night.

Catching an iguana is much tougher than you think.

Setting our drinks down so we can enjoy a quick swim.

Lia jumping into lake Colcibolca from the second floor of the Bella Mar

Carnival Granada style.

Local children folk dancing at a fundraising ceremony for a community library. 

Children love swim-up bars just as much as adults do.

Some of the cool dads, that we've met, that moved down here as well.

Corn Island beauty.

Christmas in Granada.

Our friend, Kelly, amassed nearly 2,000 books from a North Carolina book company as donations for our school. She has made such a big difference in so many lives. She is awesome!

Country living.

Beautiful Aguas Agrias.

The colorful flowers of the Java apple.

The coolest neighbors anyone could ask for.

History, culture, and pride on display.

Romance over the Masaya caldera.