After more than a decade of operating a solo medical practice in Mendon, Ohio, Dr. Cal Morris was able to retire in 1998 and take his medical career in a new direction – south to Central America, to provide medical care for the Ngöbe people in a remote region of Panama. Dr. Morris earned his medical degree at the University of Cincinnati College of Medicine in 1982 and completed his internal medicine residency at the Good Samaritan Hospital in Cincinnati.

What first inspired you to go to Panama?

A few years after closing my office, I wanted to give something back. Pardon the cliche, but mission work was something I had been called to do. When I had a solo practice, time off was rare, so mission work was simply out of the question while I maintained that practice. I had an early opportunity to leave practice, so I took it and started preparing for mission work.

After a lot of study I chose Panama. A new health care team was forming through the Volunteers in Mission program, which operates under the auspices of the United Methodist Church, and they needed a second doctor for the team. The need is great in Panama, and it is relatively accessible from the United States.

Dr. Cal Morris examines a hand fracture and laceration in an Ngöbe man in a remote part of Panama.

Have you returned to the same location each visit?

We climbed a steep learning curve that first year. The entire team was new, so we were all feeling our way. At the end of the first trip, we took a vote and decided to return to the same location. The second trip was transformative. The lessons we learned from the first trip made us much more effective and cost effective. Both the Ngöbe people and our team benefited greatly. I have returned to the same location every year, and twice a year when I can.

What were some of the challenges and lessons learned about practicing medicine overseas, compared with the United States?

One of the harder lessons we learned was how to work with translators in Panama. My Spanish is good enough to fake it in a restaurant, but not good enough to be effective for rendering medical care. Many of the Ngöbe do not speak Spanish, so we need two translators much of the time – for English to Spanish, and from Spanish to Ngöbe, and back again. The hard lesson was that in addition to crossing two languages, we are also practicing across two sets of very different cultures – from 21st-century American sensibilities through Third World Spanish perspectives into the Ngöbe world, which is best described as late Neolithic. Theirs is a world filled with spells and demons, spirits and curses. Many turn to a curandero (a form of folk healer or witch doctor) for care. In some cases, clinically depressed patients believe that they are under a spell. Back home I would have started an SSRI and arranged at least counseling, if not a full psychiatric consultation. That is simply impossible in the Ngöbe nation.

Other obvious challenges include the lack of specialist support and the absence of any modern lab and diagnostic equipment. For example, we have considered taking an EKG machine, but it would consume many precious pounds of luggage, and if an EKG for a patient was abnormal, there would be nothing we could do about it. I am in the process of buying a GE Vscan ultrasound scanner, which is small and light enough to be worth hauling to Panama. I can’t wait to start training with it.

What other primitive treatments are common in this area?

What the local healers will often do is take a nail that has been heated in the campfire and inscribe a pattern around the affected area, whether it is the knee, hand, or abdomen. We see a lot of these marks around the abdomen as an effort to treat chronic abdominal pain. Usually, there is no infection from this. The marks are small, and the nail is sterile because it has been in the fire.

What are some of the treatments that you rely on?

In the Ngöbe culture, if people don’t work, they don’t eat, so they push themselves to degrees that we simply don’t see in the United States. As a result, there are many repetitive stress injuries. Many of the women support themselves by weaving, and men spend hours doing machete work in the sugarcane and pineapple fields.

For many of these people, a supply of ibuprofen is a real boon, and even modest doses of ibuprofen give them noticeable relief. This medication we give them is worth the 4- to 5-hour walk. When we first started this program, we were advised to give a 30-day supply of medications for chronic conditions, but we have been able to expand our formulary and give people 6 months’ worth. We currently make trips to Panama every 6 months, and people know that they can return at 6-month intervals for more medication.

What are some logistical challenges of treating patients who have to travel such a distance?

We use a lot of plastic bags and sealed bottles for medications, and we learned the hard way to show people how to take care of themselves at home. We had one patient who had a splint put on, and they came back the next day because the splint washed away when they were crossing a river to get home.

There are no roads in the reservation, and the Ngöbe people have no access to wheeled vehicles. It is not uncommon for people to walk 4-5 hours each way to see us for medical care, so if people lose the ability to walk, that is a severe handicap for them, and they effectively become homebound.

What are some common conditions that you treat?

We see a lot of cases of iron-deficiency anemia because the Ngöbe people can’t afford to eat meat. On one trip, we took a hemoglobin meter, and when we saw how low the levels were, we were able to change our formulary to include more iron supplements.

We see many cases of dengue fever, and the treatment for that is supportive therapy. We also see many burns – the Ngöbe cook over open fires at home, and people are often burned by hot coals or flames. But because of the time and distance needed to receive care, it is weeks or months before we treat burn patients. I have seen more cases of superficial gangrene in Panama than in my entire career in the United States.

How are the people becoming more receptive to your regular visits?

One real transition we have seen in the last few trips is that more and more men are coming in for medical treatment. At first we saw mostly women and children, but now we have been around long enough, and we are earning the trust of the Ngöbe people. They are starting to recognize us as people who can help.

Could you describe the setup of your clinic?

We have a concrete building, but the only time medical care is given there is when one of our teams is there. There is no air conditioning or running water, and we learned right away that the concept of a sterile field is impossible – we think in terms of “less filthy field,” rather than “sterile field.”

One of the most important things we have to be aware of for ourselves is to stay hydrated. The clinic can be extremely hot, and we do 8- to 10-hour shifts. You can get busy and forget to hydrate, so we have a lay volunteer on the team whose main job is to make sure that everyone in the clinic stays hydrated.

There are starving dogs that live with the Ngöbe that are periodically running through the treatment area, and we have even had vampire bats in the clinic. Once I was in the middle of procedure, and a bat flew in. I took a clipboard and chased it into a fan, which stunned it. When I took a closer look, I thought it looked like a vampire bat, and I was told that they are indigenous to that region.

What do you do for individuals with serious illnesses or injuries?

We try to get the seriously ill and injured to a hospital, but the closest is several hours away by bus, and the increasingly socialized medicine system in Panama has made referrals more and more difficult. That has been frustrating, and we don’t have a good solution at this point.

What are some of the key factors in making a difference overseas in a short time?

I must say that going back to the same place repeatedly makes the most of every trip, the most of every minute. From clinic setup to formulary selection, each trip we get better and deliver better care. That said, I make it a point to travel with other teams to other locations, and I have taken something great from each of those adventures.

What advice would you give to physicians who are considering medical mission work?

My advice to anyone working in these settings is to tune in to what is important to the people, even if we might think it nonsense. By showing sensitivity we can be so much more effective in our work.

View a video from Dr. Morris’s trip to Panama in March 2010.

-Interviewed by Heidi Splete

Crossing Languages and Cultures in Panama