It’s Beginning to Look A Lot Like Christmas

Turns out that my fears of blow up Santas were unfounded. While the guests were mostly ashore in Aruba, teams of Santa’s elves arrived from a professional decorating company and transformed the ship into a Christmas wonderland. There are beautifully decorated trees everywhere and the atrium is festooned with garlands, lights and poinsettias. It looks a little like a shopping mall, but it is tasteful and well done!

Atrium Christmas

The culinary department and bakery are busy preparing the gingerbread houses that will likely not appear until the next cruise, the Christmas cruise, which leaves Ft Lauderdale December 19th. On most of the longer cruises one of the activities offered to passengers is the cruise choir, and our choir on this cruise is busily rehearsing Christmas songs for the final sea day when they do a little concert in the atrium. Now, if I only could find some Christmas music!

Yep, I’m going to miss being at home for Christmas. My daughter Rebecca is going to be in Panama for the holidays, but I’m sure her and Nikki will find some fun adventures. I’ll miss decorating the house, playing Santa, and sitting by the fire Christmas Eve with my daughter, Nikki and our three dogs and having our traditional Christmas Eve “dinner” of snacks, munchies, and drinks.

When I was a pastor I always ended up spending Christmas Eve at church working, sometimes doing as many as five Christmas Eve services. Once I retired from the ministry, one of the real joys was just sitting by the fire relaxing on Christmas Eve.

Actually cruising over the holidays, although quite a challenge for the ship staff, is really a fantastic way to spend the holidays with someone else doing all the work! And, since a week out, this cruise is still being offered on line for $80 per person a night for a minimum inside cabin guarantee, it’s not a bad deal.

It’s Good to Be Back!

It’s been over a year since I’ve been out at sea, and it’s good to be back. Being new to any ship is like the first day in high school, and it takes a few weeks to find your way around, to know if you get to sit at the “cool kids” table or make YOUR table the “cool kids” table, and to try and get the school running your way. Although, as I figured out in high school, things don’t always run “your way,” but you take what you can get. On this ship, which will remain nameless, not only don’t I get to the “cool kids” table … I don’t even get to eat with in the same mess (nautical for “dining room”.) I must eat with the passengers to represent the cruise line as the “perfect host.” Nothing wrong with eating with guests, and I’ve met some really neat people that way. But … when I was with another cruise line they used to assign me to host an “officer’s table.” Folks would always assume the were going to eat with the captain … then ended up with me. But as the perfect host I could at least buy wine for the table and charge it to the cruise line. Well it’s no longer that way with that particular cruise line, or this one. Whatever! Everyone is pinching pennies … including me.

But I’m enjoying it, glad to be back and meeting a lot of interesting folks. And I’m adjusting. To succeed in shipboard life you have to learn to “go with the flow” and always have a plan “B” and “C”, and after ten years as an expat in Panama, I’m an expert on going with the flow and having multiple plans. It’s a great retirement job and, like I’ve always told the cruise lines, “when it’s no longer fun, I’m outta here!”

Sometimes on land this job sounds so glamorous to folks that they make comments like, “They must give you a suite or a pretty nice cabin on board!” If they only knew. Crew live differently than guests … because we are working. I actually have a very nice cabin, at the back of the ship, but I adjust nicely to the constant sound of the engines and when they shift I’m instantly awake and primed for action. (They never really shift unless we are coming into port or there is a problem.) I live on a hall with singers and fly-on fly-off entertainers who go from ship to ship. Compared to most crew members I have a fantastic cabin … all to myself. It’s called a “fleet officer cabin” and I’ve got two portholes … portholes which for some unknown reason get closed when we go into the Canal. Maybe they are expecting pirates or the Embera Indians to attack: who knows? All the passenger cabins on this deck have huge picture windows and it seems if anyone was going to attack they’d aim for the picture window and not the tiny porthole! But many things on board ship you don’t try to figure out or understand. What I like about a “fleet officer cabin” … kind of an exaggerated name … is that I have a seven foot desk, so it is designed for work. Guest cabins have “desks” which double as make up tables and are too small for actual work.

So here’s my cabin … decorated for the holidays!

Fleet Officer Cabin

So far there is no hint of Christmas, or Chanukah. I’ve been on ships with lavish four story trees and artificial snow floating down from deck 8, huge menorahs, and I’ve been on ships where the Christmas decorations were dying poinsettias and blow-up Santas from Wal Mart, with a tiny menorah probably picked up at a garage sale … so we shall see.

Unfortunately, universally on all ships, Internet is expensive and slow, so that impacts my ability to keep the blogs coming. Today I’m in the Renaissance Hotel Starbucks in Aruba. Good coffee and good Internet.

But the reviews and comments are in and the guests like me and found the talks enhanced their cruise experience which is what is important.

“We have really enjoyed all the presentations by Richard Detrich. [They even spelled my name right!] His talks have been entertaining and informative and helped us to get more out of our cruise. His enthusiasm and love of Panama and surrounding areas really brings the subject to life.” Cante B316

“Outstanding local knowledge – excellent presentation – very approachable” M/M LW D234

“Dr. Detrich did an amazing job as the Port Lecturer and we never missed one of his very interesting and informative talks. His broad knowledge and witty commentary always kept you riveted and he was a highlight of our sea days to look forward to.” Glenn & Tammy D210

“Richard the Port Lecturer enhanced our cruise. Excellent.” Janet & Michael C518

“Excellent presentations! Knowledgeable, entertaining and great delivery! Well traveled!” Richard A516

“Very informative lectures maximizing our understanding of the history of the Canal and related factors encompassing the entire experience. We totally appreciated his input, books and humor.” Shaun & Susan E224

“Very interesting. Enjoyed very much.” Virginia B347

“His port lectures were informative and made the visits more enjoyable. His knowledge of the area enhanced the voyage.” Patricia A328

“Went to all six lectures and found them very useful, informative and humorous!” Kenneth C527

“Extremely informative and interesting lectures – we learned a great deal” Robin B324

More On Medical Care

“What’s the medical care like?”

When I am on cruise ships the single question people ask most frequently about living in Pamana is, “What’s the medical care like?”

When we were considering countries we’d like to retire to, the question of medical care was obviously close to the top of our list as well. So here are some of our experiences with medical care in Panama, and some of our conclusions.

“Better than anyone else!”

There is amongst US Americans I think a universal assumption, well, at least until the past few years, that everything in the US must be the best in the world: after all, the thinking goes, “We are the brightest, most powerful, most knowledgeable, most generous, most blessed, most prosperous, most wealthy, most envied, most lucky, most free people in the world!”, aren’t we. To suggest anything else, was to risk being called “Anti-American!” That in itself reflects the common US assumption that, “Weare the Americans, and everyone else [Latin Americans, South Americans, Canadians] are, well . . . chopped liver.”

Lately we’re discovering that we, like everyone else, are a flawed and struggling people.

And certainly that is true when it comes to health care.

So, before we talk about medical care in Panama, we need to think about medical care in the US.

Some quick comparisons, courtesy of the CIA [CIA Worldbook]:

Death Rate:
USA 8.38 deaths/1,000 population
PANAMA 4.66 deaths/1,000 population

Life Expectancy at Birth:
USA 78.11 years
PANAMA 77.25 years

Life Expectancy at Birth Country Comparison to The World:
USA 50

My wife worked for the County of Ventura. Every year the County, looking to save a few taxpayer dollars, would shift to a new HMO. One of their choices actually went under taking with them, and destroying, all of the medical records of the county employees. Before we moved to Panama, my wife paid one last visit to her HMO to collect her records, have a final check up, and get prescriptions renewed. Meeting with the doctor, the doctor asked, “So how are you doing with your diabetes?”

My wife said, “You must be looking at the wrong chart. I don’t have diabetes?”

Doctor, “Oh yes you do. We diagnosed you with diabetes a year ago. Didn’t anybody tell you?”

No, in fact they didn’t! How is that for “quality” health care?

According to the Council on Foreign Relations, talking about the impact of the cost of health care on US competitiveness in the world,

“Factoring in costs borne by the government, the private sector, and individuals, the United States spends over $1.9 trillion annually on health care expenses, more than any other industrialized country. Researchers at Johns Hopkins Medical School estimate the United States spends 44 percent more per capita than Switzerland, the country with the second highest expenditures, and 134 percent more than the median for member states of the Organization for Economic Cooperation and Development (OECD).”

Of course the Iraq War will end up costing about $3 trillion (according to the WASHINGTON POST) . . .

We all know the US health care system is broken and may . . . or may not . . . be fixable. So let’s just drop the assumption that we have the “best” . . .

Three Systems

Panama has three health care systems:

  • National Heath Care – “Salud” – you see these white, yellow and green buildings in almost every Panamanian community. It is a basically “free” or “low cost” – 50 cents to see a doctor, $1 to see a specialist – system designed mainly to treat the enormous and poor Indigenous population and those without Social Security health care. It is underfunded, understaffed, and plagued by inefficiency and bureaucracy.
  • Social Security – Everyone who works in Panama must by law pay into the Panamanian Social Security system. Basically the employer pays half and the employee pays half. For our Indian worker I think we pay about $4 a week. Long lines, understaffed, and plagued by inefficiency and bureaucracy. Often doctors prescribe drugs that are supposed to be “free” but the Social Security system doesn’t have them, so users must buy them at pharmacies. Pharmacies sell drugs here by the pill. So if your doctor prescribes something, you buy only as many as you can afford, when you can afford them!
  • Private System – Is the system used by many middle and upper class Panamanians, by expats, and by the increasing number of people who are coming to Panama to have procedures done, a growing industry called “medical tourism.”

Likes and Dislikes

Based on our experience, here’s what we like . . . and dislike . . . about medical care in Panama.

Like . . .

  • It is personal – Your doctor has time for you. An appointment takes as long as necessary. The doctor isn’t part of an HMO and required to see 20 patients an hour to keep his or her job.
  • Doctors are allowed to practice medicine – Their diagnosis and treatment plan isn’t being second guessed by a 20-year-old kid with a high school diploma sitting at a computer terminal in the HMO office.
  • It is affordable – There are several reasons for this. First, Panama is not a litigious society, so the doctor doesn’t have to order dozens of unnecessary tests to cover his butt. And the doctor isn’t paying out half or more of his or her income for liability insurance. We have the bells and whistles, and the latest equipment, but every hospital isn’t competing on the basis of having the latest equipment, the fastest (and perhaps most dangerous) helicopter evacuation service, and the plushest offices and facilities.
  • It is accessible – And in this regard I’m talking mainly about the private health care facilities. At the national health and social security hospitals people endure and endless run around. But for those able to pay, and it is a little by US standards, you can quickly see a doctor and get a needed procedure.

Dislike . . .

  • Appointments mean nothing: prepare to wait for 30 minutes to 2 hours. Busy doctors? Not really. Flaky receptionists, yes . . . but what’s different about that? Pretty much it’s just a Panamanian “thing” with everyone, not just doctors. Your time is theirs, their time is theirs . . . it’s the land of “manana”, and it’s just the way things are.
  • No, you don’t need the most sleek and modern of everything . . . but often things “feel” grungy, which sometimes translates into feeling, dare I say, “dirty”. I know it’s not necessarily germ dirty, but . . . how much would a coat of paint cost?
  • You get nervous when in the middle of a pandemic the hospital bathrooms lack soap and hand towels, especially if you come off a ship with a Purell dispenser every five feet, and Viox wipes to open the bathroom door with . . .
  • Did I mention hospitals don’t necessarily have hot water? Now I grant you most Panamanians don’t have hot water: the national old wives tale is that taking a warm shower will make you sick. I know hot water isn’t necessary if you are scrubbing with anti-bacterial soap, but . . . as my wife discovered in Hospital Punta Pacifica, one of the best in Panama and affiliated with John’s Hopkins, when nurses give you a bed bath in cold water . . . well something is missing in the “bedside manner”, of which there was none.
  • We don’t have emergency services, like a US-style 911 system, or fully equipped ambulances with trained EMTs … you just have to take your chances.

Our Experiences

Riding Mr. Ed . . .

Picture 139When we first came to Panama we used to enjoy riding horses with our friends Brad and Jackie. We found a local guy who rented out his horses for $5 an hour. It was great fun! My kids were visiting so we all went horseback riding, all five of us. I guess the guy only had four horses of his own, so he borrowed one from a friend, which turned out to be a problem horse not used to amateur riders. My wife rode horses as a kid on her Grandpa’s ranch in Montana, and although that was a long time ago, she was comfortable on horses, but all this horse wanted to do was run. The equipment was, well Panamanian, meaning, at times improvised and cobbled together. As it happened the bit was cobbled together and came apart just as the horse was acting up. The horse took off, the bit was broken so my wife had no way to control the animal . . . she ended up being thrown off and landing on the pavement on her head.

Fortunately my daughter Rebecca is a “wilderness outdoor first responder” or something like that, somewhat equivalent to an EMT except she can’t deliver babies but can pronounce people dead if they are a certain distance from a hospital. Rebecca immediately went into EMT-mode. We were a long way from town, and my older daughter said, “Dad, you have to get a doctor since we don’t know where to go!”

So I rode off for town, not knowing at that point whether my wife was dead or alive.

I rode quite away until a car came along. The driver had seen the riderless horse so knew there must be a problem. We tied up my horse and he took me into town to the doctor’s office. We got in his brand new Toyota with gray seat covers and rode back to the scene of the accident. By this time my wife was somewhat responsive. My daughter gave the doctor a quick summary. With a head wound there was blood everywhere, but the doctor put my wife into his brand new car and we went back to his office. It took 3 hours and 70 stitches for him to sew Nikki’s head together, and he saw her three times a week for 10 weeks. The total cost was $850 . . . probably the cost of an ambulance ride in Southern California.

The really interesting thing was on one of the follow-up visits the doctor greeted us with, “Nikki! I’m so glad to see you! I had a dream last night that you didn’t come in, and then I couldn’t get back to sleep worrying if something was wrong.” How many HMO doctors in the States even know your name, if they aren’t looking at your chart, let alone wake up at night worrying about you?

And this guy made house calls!

I told that story on the ship and a guy sitting in the front row said, “I’m a doctor, and I still make house calls and wake up nights worrying about patients!” So there are still a few guys and gals out there . . . but, in general, it’s not the face of managed health care in the US.

So what happened? Nikki is fine! After spending a lifetime wasting 25 minutes every morning doing her hair, she discovered a new no-fuss, no-muss hair do that better suits our life in Panama. We ended up buying helmets in the States, which we haven’t gotten around to using. The guy is still renting horses, and still sometimes using the same horse, and sometimes we see obviously totally inexperienced riders on that same horse . . . If we found a reliable place to rent horses, we’d probably ride again. [One of the things about a non-litigious society like Panama is folks don’t worry about being sued.]

Every man’s favorite day at the doctor . . .

I went in for my “every five year” physical . . . new doctor, internist, $20 plus my insurance coupon, and another $40 for tests . . . and of course he told me “it’s time” for that guy-favorite, a day with Mr. Sigmoidoscopy. So I called to make an appointment, expecting to enjoy weeks of eager anticipation . . . only to discover I had an appointment in three days . . . only three days because I needed to “prepare.” I forget the exact cost, but most was covered by our local insurance (more on that tomorrow), but it was quick, easy and relatively “painless” . . . unless you enjoy that type of thing.

Roto Rooter . . .

My wife has heart disease and has had several angioplasties. This time last year she knew it was getting time to return to the hospital for another procedure. Her last angioplasty had been 12 years earlier, but the familiar symptoms were returning. We did not have a cardiologist in Panama so we began asking around and talking with gringo friends to find out who was the best cardiologist in Western Panama. There was universal agreement on one doctor. So we called and asked for an appointment . . . expecting to wait weeks . . . and he gave us an appointment the next evening. We sat down with him and he spent an hour with us, going over Nikki’s records, reviewing her medication, examining her, and explaining the situation. Although his English was somewhat limited, we received the most understandable explanation of Nikki’s condition we have received from any doctor. There was no rush. He took Nikki’s records and said he wanted “to take them home to study” and set up an appointment for stress tests. A week later we returned for a series of stress tests at his office, and began a two-month series of exams, tests, adjusting medication and diet, etc.

At the end of the two months, and shortly before I was scheduled to leave on Holland America for five months, it was decided that yes, indeed, Nikki did need an angioplasty and probably one or two stents. The doctor made an appointment with the best guy in Panama City who works out of Hospital Patilla which is affiliated with Johns Hopkins. We had the appointment right away, but it took about a week to shuffle papers between our insurance provider (more about this tomorrow) and the cardiologist to get approval for the procedure in Panama City.

So my wife flew to Panama for three days and had an angioplasty and two stents implanted, and then flew back to Chiriqui. The total cost for an angioplasty and two stents (including hospital and surgeon) was $14,000.We have a friend who had the same procedure performed in Boston, and his hospital bill alone was $60,000! Because we had a hospital insurance scheme with Hospital Chiriqui in David, and because they do not do invasive cardio procedures, our local insurance picked up half of the cost, so our out-of-pocket cost was $7,000.

Hospitals . . .

Chiriqui Hospital David PanamaIn David, the third largest city in Panama, 45 minute drive from Boquete, there are four large hospitals. The Maternal & Child Hospital is a National Hospital focusing primarily on material and pediatric care. It is only two years old and was a gift from the people of Taiwan, with whom Panama has diplomatic relations. Almost next door is the Social Security Hospital which serves people who are working in Panama and paying into the Social Security system. Just down the Pan American Highway is Hospital Mae Lewis, a private hospital that is used by locals and gringos. And a few blocks off the Pan American Highway is Hospital Chiriqui, a private hospital that is generally preferred by expats because of their “insurance” program (more on that later). Hospital Chiriqui. Additionally, scattered around David, there are almost a half-dozen tiny private hospitals owned and run by a consortium of doctors. In some ways it isn’t very efficient, yet the hospital costs are low. A private room runs about $60 a day! Of the private hospitals, Hospital Chiriqui has the most “bells and whistles” including a state-of-the-art MRI machine, one of two in Panama.

Unlike in the US, in Chiriqui any doctor can practice in any hospital and you are not limited to only certain hospitals where your doctor happens to be on staff.

Emergency Care . . .

Here is where things can get a little dicey.

If you happen to be one of the very few people to get bitten by one of our famously poison snakes, like the fer de lance which is fairly common in Chiriqui . . . and let me quickly add that your chances of getting bitten by a poisonous snake are about the same as your chances of getting struck by lightning or winning the lottery! . . . if you are bitten by a snake anywhere in Panama you are generally about 45 minutes from a Social Security hospital which is where the anti-venom is kept. So you have plenty of time to get to the hospital where you will find that rather than immediately giving you anti-venom there is a long waiting/observation period while they test your blood and wait to figure out what kind of snake bit you and what type of anti-venom you need. Almost everyone, except for Indians living in very remote areas, recovers. So although the fer de lance and bushmaster can be “deadly”, your chances of dying if you get assistance are very slim.

OK, we got that out-of-the-way!

When we first came to Panama my wife asked our Boquete doctor, “So if I’m having a heart attack, what do I do?”

His response: “First you call me. I’ll come to your house and call an ambulance. We’ll stabilize you in David, and if necessary, once you are stabilized, we will fly you to the Panama City where the hospitals and doctors who specialize in invasive procedures are located.”  Nice, but that doctor moved to Panama City years ago.

Good enough . . . but when we say “ambulance” do NOT think of ambulance service in the US! There have been times in Boquete when we had four different ambulances . . . and none were working! And an ambulance here is primarily a means of transportation. Don’t think a team of trained “EMTs” on call . . . or an ambulance with any sort of equipment on board. Over the years we’ve been in Boquete the expat community has worked hard and raised money to improve ambulance service, but it still is nothing like what we were used to in the States.

Our experience . . .

Chiriqui HospitalOne afternoon my wife started having some kind of episode. She was dizzy, had no feeling in her arms, was weak, and couldn’t stand up. It looked like some kind of allergic reaction and I feared she was going into anaphylactic shock. [We have experience with this: I am highly allergic to shellfish of any kind in any amount, and my daughter is highly allergic to chocolate.] Without 911 or any similar kind of emergency help, I called our friend Brad, and together we carried Nikki to my car, and I went to the doctor’s office (the same guy who treated her when she was thrown off the horse . . . the story I told yesterday). It turned out the good doctor was on vacation and the gal who was filling in not only didn’t speak any English, but wasn’t that familiar with his office. Eventually she found the oxygen mask, started an intravenous drip, got Nikki stabilized and agreed we needed to get to the hospital in David. She called the ambulance . . . and the “fun” began.

The doctor called the ambulance, then said to me, “They don’t have any gas. They want to know if you can pay for the gas?” Yes!!!

So the ambulance and attendants arrived . . .

First problem: the doctor’s makeshift treatment room and the gurney that wouldn’t fit in.

Second problem: the ambulance crew hadn’t the slightest idea how to move a patient from a bed onto a gurney. Somehow we managed.

Third problem: Nikki was too big for the ambulance. Panamanians are shorter. So they couldn’t close the back doors of the ambulance all the way. She wouldn’t fit! So the creative solution was for the ambulance attendant riding in the back to wedge himself between the side of the ambulance and press his feet against the gurney to keep Nikki from sliding out the back doors, which were flapping in the wind.

Fourth problem: Nikki had an IV drip going and there was no place to hang the drip in the ambulance. The attendant in back was busy trying to keep the gurney from flying out the back, so Nikki had to hold her own IV bag.

OK, we stopped and got $20 worth of gas. Then we began racing down the mountain to David with lights and sirens going.,

Fifth problem: Nobody in Panama is going to move for an ambulance! Only the expats will pull over out of force of habit. So I’m in front, the driver is laying on the horn so people eventually will move out-of-the-way.

Sixth problem: We start to get one of our famous, afternoon “rainy season” cloud bursts when the water is coming down in torrents. In front the windshield wipers are barely working and in back the doors are flapping in the wind and the water is coming in soaking Nikki and the attendant who is bravely still holding the gurney in place with his feet.

The reality: Supposedly “laughter is the best medicine” and Nikki, although the center of the drama, couldn’t help but find the humor in the situation.

Fortunately we arrived at Chiriqui Hospital and into the tiny emergency ward. It took a while, but Nikki was stabilized and a team of internists eventually discovered that she had developed an allergy to aspirin. She spent two nights in the hospital, before coming home. The ambulance ride:(for those of you who remember the original Disneyland . . . definitely an “E-ticket” ride!) $20 for gas, and another $5 (in gratitude) for beer for the guys. Hospital: emergency room, two nights, and physicians $225.

Yet another story . . . my wife keeps things interesting!

Nikki was experiencing tingling in her arms, chest pain, yada yada . . . with her history . . . “Come on, Nikki, don’t be a hero! Let’s get it checked now. If it’s nothing, fine . . . if it’s not, “golden hour” and all that stuff.” So we go to Boquete to the new clinic for such emergencies that Hospital Mae Lewis has opened. The only problem is there’s only a receptionist staffing the clinic. No doctor . . . not even a nurse . . . receptionist and janitor. The receptionist informed us that the doctor was going to be coming in an hour and that we could sit and wait. OK, so this is to be an “Emergency Clinic” . . . right. And if it is a heart attack, we’re going to sit here and twiddle our thumbs for an hour and hope that the doctor actually does show up as scheduled . . . which, in itself, would be somewhat of a miracle anywhere, let alone in Panama. And I’m about to have a “Richard-goes-ballistic” attack . . .

I remembered that a friend I had met because he had read this blog, lived in an apartment upstairs. He is a retired neurosurgeon who still consults via video cam in complicated surgeries around the world. Although he wasn’t a cardiologist, I knew he had his own personal encounter with a massive heart attack and open heart surgery, so I went upstairs and asked him if he could just come down and take a look at Nikki. Gracious friend that he was he put on his slippers, found his stethoscope and came down and took a look. His verdict, “I can’t say what is going on, but I can say with 99.9% certainty that she is not having a heart attack.”

So . . . forget paramedics and 911.

As a reader, “oldsalt1942″, once commented, “You get better or you die, and that’s the reality of health care in the vast majority of the world. You get better or you die. Period. And let’s face it, you can’t take life too seriously because none of us are getting out of here alive.”

Insurance . . .

Folks handle insurance in different ways. People who worked for the Canal or the US military in Panama have their own insurance. Some people worked for companies who still provide their retirees with the insurance they were promised when they retired. Some have their own policies from the States or some international insurance policy. Like most insurance when you are trying to get insurance after retirement you find that the insurance companies don’t cover preexisting conditions, which is exactly what you are worried about. And by the time most people reach retirement age they have preexisting conditions.

When you turn 65 of course and are collecting US Social Security you have Medicare. However, Medicare only covers treatment in the US. So unless you want to return to the US when you need medical care, which some folks elect to do, you are not covered. When I looked at the cost of Part B for me, and what all was not covered by Part B, I decided that for me it was cheaper to just pay the full amount for the procedure in Panama. So we, basically, self-insured . . . with a couple of exceptions.

InsuranceSince we travel a lot, we purchase annual travel policies from a company in Scandinavia that cover us when we are away from Panama for emergency medical care except in the US. When you include the US the cost is prohibitive, and at least when we are in the US, I could use Medicare. It is important for us to have insurance that covers medical evacuation. I think anyone is crazy who takes a cruise without having travel insurance that includes coverage for evacuation. The cruise line wants you off the vessel and into a hospital as soon as possible, firstly for your own medical welfare, and secondly to avoid legal responsibility. A medical evacuation from a ship by helicopter can easily run $50,000 to $100,000! Get insurance!

Hospital Chiriqui does have an insurance scheme called Medical Services Chiriqui, or MSChiriqui, now MSPanama, which we use. It is not really “insurance” but more of a discount plan. A doctor visit that usually would cost $40 with a MSChiriqui coupon costs us $20. There are discounts on many hospital services and treatment.  In our case when my wife required an angioplasty and stents several years ago, because the procedure is not available at Hospital Chiriqui, we went to Hospital Patilla in Panama City and the MSChiriqui plan covered half of the cost. After you have belonged to the plan for 2 years it does cover pre-existing conditions. The plan now costs us about $1200 per year for both of us.  HOWEVER, the folks who thought up the plan really didn’t do their actuary homework.  They sold the plan mostly to older expats and … guess what?  So the original plan has been taken over by MSPanama, the prices have gone up, and the benefits have been curtailed.

Younger expats can still get world wide medical insurance coverage at really rather good rates, but it depends on your age.  Many of these plans will not cover you after you reach age 70.

When my wife turned 65 she decided to take Medicare Part B & D and a Medicare Advantage insurance policy in the US.  Based on her experience I now have decided to also take Medicare Parts B & D, paying the penalty for not taking it out when I turned 65.  Now with grandkids, we spend more and more time at home in Seattle, and our plan is to use Medicare for foreseeable medical care and continue to use Panama insurance and doctors for emergencies.

I welcome your questions, comments, and suggestions, and as much as I am able, I will answer them. Understand that when I am at sea I have limited Internet access, so there may be some delay in answering when I am on a ship.

Happy Thanksgiving

Well, we don’t have Thanksgiving in Panama, officially that is.

But since I’m on the ISLAND PRINCESS with lots of folks from the USA, I will have Thanksgiving today right on schedule! We left Ft. Lauderdale yesterday, so today is a sea day and it’s really best to celebrate a holiday at sea. And Thanksgiving – someone else does the cooking and the cleaning!!

But except for expats, there’s no Thanksgiving in Panama. But this is a country where there are 21 HOLIDAYS a year! Additionally, after working one year, they get 30 PAID VACATION DAYS, plus 18 SICK DAYS, plus “13th Month”. “13th Month” is a neat scheme were by one is actually paid for an extra month’s work each year, without working – cool, huh? This is divided and paid out over the year in three equal payments. Doesn’t actually build up a “work ethic”, but hey, not bad if you can do it. But the lack of a motivated work force with a good work ethic hurts development and foreign investment, leads to high unemployment, and hurts Panama.

The “Holiday Season” starts with Independence from Columbia (November 3), then Independence from Spain (November 28). Pretty cool, TWO Independence days! The biggest holiday of the year is Mother’s Day on December 8. Then Christmas with all of it’s fireworks (big tradition here as the sky explodes on Christmas Eve!). From Christmas to New Years nothing happens. In January Boquete has its Fair of Coffee and Flowers when it’s party time for two weeks. Then comes Carnival and more partying! Forty days later is Holy Week when many businesses are closed and nothing happens. Good Friday is a legal holiday, then Easter. So from November until after Easter it’s hard to get much accomplished.

But today is the traditional US Thanksgiving . . . so what am I thankful for?

  • A wife who is partner, companion and friend and who has put up with me and all the BS all these years
  • Two great kids who I enjoy as adults and are more than I ever hoped for and a great son-in-law (our kid choose well)
  • Rian Patrick Eaton and Caiden Riley Easton, my two fantastic grandsons
  • Two young friends who’ve kind of adopted us who, despite some real shaky years, turned out to be two neat men. Tragically we lost one of them this year./li>
  • Friends, new and old
  • The opportunity to be living in paradise, having fun, exploring the world, growing and enjoying the journey
  • The chance to cruise the world with Princess
  • A beautiful home in Panama
  • A Christian world and life view that helps the world make sense, believing that God loves us and has a wonderful plan for our lives, and that it’s a plan for our good
  • A Hebrew cosmic view that believes in spite of all the injustice that in the end justice will triumph

That’s a lot to be thankful for!

“Rejoice always, pray continually, give thanks in all circumstances; for this is God’s will for you in Christ Jesus.” I Thessalonians 5:16

But What About Medical Care?

THE most frequent question I get on board ship about living in Panama is, “But what about medical care?”

Amongst USA folks there is an assumption that everything, EVERYTHING in the US is better than anywhere else in the world. The infrastructure. [Obviously these folks have never driven in Europe or Singapore, or flown into Bangkok on Delhi!] The freedom. [Probably they haven’t looked at “The Patriot Act”.] Security. [I grant you no country in the world performs this grand illusion, worthy of David Copperfield, better than the US!] And of course health care. If it is the most expensive, then it must be the best, the US government’s own figures of life expectancy and health care in other countries notwithstanding.

Talk to different folks who have experienced the health care here and you will get different stories. You will NEVER get the total story reading the Internet or any public forum. To get the real story you need to talk and talk and talk to a LOT of people and listen carefully to the Coconut Grapevine. Why? Simply put, Panama is not the US. Panama does not have free speech.

“If you can’t say something nice, don’t say anything at all.”

That’s what my mother used to say and, believe me, it applies in Panama. If you say something that isn’t nice, even if it is true, you can have all of your assets sequestered while you are sued in a law suit that drags on for years. “But I thought it was hard to sue people in Panama?” Yes, but . . . say the wrong thing about the wrong people and you can be ruined. So no one is going to give you the complete story about health care in Panama.

I can, and will, tell you our story, and it’s a good story. We have used the health care here, are satisfied, and have found it far superior to what we were getting in the States. Others have some far different, and frankly very disturbing stories. I get emails and comments from folks who have what I would consider horror stories . . . and I can’t risk publishing them. Of course pick ANY hospital or medical institution in the US and you will hear the SAME stories. Medicine, despite all the fancy machinery and “science”, is still an art. People are still people. Shit happens. People make mistakes and sometimes people die because of those mistakes. And sometimes people just die because it is their time, medical science or no medical science.

Are costs of medical care rising in Panama. Yes, like everything else because, remember, we use the US dollar. Also Panama is on an economic roll . . . some might say an economic boom . . . and that means costs and prices rise. But I have seen what I would consider some outrageous, even for the US, charges for hospital rooms, surgeons and anesthesiologists. Again, I don’t know all the background, but one certainly would not expect hospital stays in Panama to be more than in the US. Is their gouging of gringos? I don’t know. I DO know that, although technically it is not legal, there have always been “gringo prices” and “Panamanian prices” in Panama for everything. As an expat you are perceived to be fabulously wealthy and expected to be anxious to spread that wealth around.

So, provided you have the luxury, before you “jump” I would do a lot of asking around, put my ear to the ground, and find out the experiences of as many people as possible. I can only give you OUR experience.

For example: it’s time for me to get a checkup. I’m off on the ship for months at a time so it just makes sense to occasionally get a physical, have baseline EKG to take along with me and results of the usual battery of lab tests and have an MD tell me I’m still kicking. We have insurance with MS Chiriqui at Chriqui Hospital and we have had this since we came to Panama. Under the insurance plan they paid for half the costs of my tests, and I will pay $20 for my doctor visit. [It used to be $10, so that’s a 100% increase.] My EKG at the Emergency Room at Chiriqui Hospital cost $20. My lab tests here in Boquete costs $80, of which MS Chiriqui insurance paid $40. The doctor I use runs his office as a “clinic” so it is first-come-first-served which is OK by me since medical “appointments” in Panama don’t mean anything.

My wife saw her cardiologist a few weeks ago. It took two trips to David (40 minutes away) since the first time the doctor had an emergency and wasn’t available for her “appointment.” She had to wait a few hours for her “appointment’ but the doctor saw her, spent an hour (60 minutes!) with her and her cost, with the insurance picking up half, was $20.

We like the fact that the doctor is free to practice medicine. He/she doesn’t have to see 10 or 15 patients an hour. He can spend whatever time is necessary with you (unfortunately for you or the others who end up waiting). He doesn’t have to answer to a 20-something kid sitting at a HMO office with no medical training for his diagnosis or treatment. The doctor isn’t being hounded by malpractice attorneys nor does he/she have to carry enormous amounts of malpractice insurance, so he/she doesn’t have to order a battery of unnecessary tests just to cover his/her own butt. Your are not a number, or a “file”, but a person, which we find refreshing.

The hospitals have most of the bells and whistles. They may not look expensive and “clean” by US standards, and they may not even have hot water, but although my wife didn’t like the cold baths, she found the care adequate. This is Panama, and some things that are important in the US are not important in Panama. [Many Panamanians still think that taking hot baths will make you sick, and besides this is the tropics so tap water is rarely ice-cold.]

When my wife needed an angioplasty and stints she went to Panama City because our local hospital wasn’t performing those procedures. Our good friend Feliciano Ballesteros gave support and help in Panama City. Nikki went to Hospital Paitilla in Panama City which is affiliated with Her cardiologist in David had recommended the “best guy in Panama” for this procedure. Hospital Paitilla has relationships with a number of hospitals in the US and Spain including the Cleveland Clinic. With the exception of the cold sponge baths, Nikki found the care good and in a few days flew back to David. The total cost of the angioplasty and two stints was $15,000, of which MS Chiriqui paid 50%, so our out-of-pocket cost was $7,500.

So we have no complaints.

However, there are others who have different stories.

Life is all about risk. Are there risks, sure. More or less than in the US, or Canada, or Europe . . . depends.

Nikki worked 18 years for Ventura County Public Health. Every year the county shifted health care providers for its employees always looking for the cheapest option. Before we left Ventura, Nikki visited the HMO who provided the county employees with healthcare, to get a final check up, stock up with medicine, and pick up her records. Well, some of her records, since in all the switching of health care providers a lot of the records had just been dumped in dumpsters and carted off to landfills. The doctor breezed in and looking at her chart asked, “How are you doing with your diabetes medication?”

To which Nikki answered, “Diabetes. I don’t have diabetes. You must have the wrong chart.”

The doctor replied, “Oh yes you do! We diagnosed it a year ago. Didn’t anyone tell you?”

How’s that for quality medical care?

My Day in The Panama Canal

In what may be a classic case of over-reaction, Carnival Corp following the Costa tragedy has now decided that nobody is allowed on the bridge of its ships except the bridge team and the pilots. You will recall that the captain of the COSTA CONCORDIA was entertaining his dancer-girlfriend on the bridge when the ship veered to close to the island and slashed open the hull.

Always in the past I gave my “Bridge Commentary” while passing through the Panama Canal, well, from the bridge! Not anymore. So I was somewhat pissed yesterday to have to give the “Bridge Commentary” from the Horizon Court surrounded by passengers chomping away on breakfast and with, for me, a very limited visibility plus the need to describe the play-by-play without being there.

I was to start at 5 am. I was there, but as so often happens on ships, the right hand didn’t have a clue what the left hand was doing. It was almost 7 am before I managed to get the right people awakened, and get a mic in hand and begin my commentary.

While our normal “Pilot on Board” is scheduled for 5 am, yesterday was not a normal day in the Canal. The pilot was scheduled to come on board at 5:45 am, something nobody thought to tell me about. Normally I check everything out with the Bridge the day before to confirm the schedule … Of course every ship is different and operates differently.

For me it’s a long day … 5 am until about 3 pm when we get through the final locks, with me talking much of the day. So, with both me and Princess looking disorganized, we managed to get things going at 7 am.

I learned that sometimes changing things, even in ways you don’t want, actually works out for the better. I loved doing the commentary from the Horizon Lounge with all the guests right there asking questions. If one person asks a question, or really didn’t “get” how something works or why, the likelihood is a score of other folks have the same question or misunderstanding. And I had stewards filling my coffee and all the food was right there. So eventually it worked out great!

So why wasn’t it a normal day on the Canal? First they were doing a lot of dredging in Culebra Cut. [Culebra Cut was renamed Gaillard Cut by the Americans to honor David Gaillard who was the American engineer who was largely responsible for the success the US had in digging through the Continental Divide. Since the Turnover, Panama has been returning to using the original Panamanian names, so it’s now usually called Culebra.] the dredging forced one-way traffic through the cut. And, the big news, in more ways than one, they were moving one of the giant new gates for the Pacific Locks through the Canal.

The rolling-type gates that will be used in the new locks are made in Italy, then brought across on specially designed barges. The gates for the new Atlantic locks have all been delivered and are sitting beside the Canal near the present Gatun Locks, awaiting installation. The gates for the new Pacific locks have to be brought through the Canal over to the Pacific side. So we got to see the process when we passed one of these gigantic gates, not the largest by the way, in the Canal making the transit. The largest of the new Pacific gates is 11 stories high!! On the picture you can see the centipede-like method of specially constructed vehicles that moves the lock gates.

While we were going through the Canal, with me accessible in the Horizon Court, people were coming up not only just asking questions, but wanting pictures (pity their friends who need to watch them, but I guess it’s easier to watch friends’ vacation pictures on iPad than a full-scale “come over for drinks and see my vacation ‘slides’” presentation), express appreciation for my lectures (Princess take note!), or get me to sign copies of my PANAMA CANAL DAY books. Incidentally, we sold out the books I brought on board and I’m hoping to have more to pick up when we get to Ft. Lauderdale.

Panama Canal Day Gates 1Panama Canal Day New Lock GAteNew Pacific Lock Gate in the Canal


Along The Pacific

Between the time we left San Pedro [Los Angeles] and begin our transit of the Panama Canal, ISLAND PRINCESS called at three ports, leaving a lot of sea days in between which are great for me because I get to talk about Panama and the Canal and give people the information they need to get the most our of their experience in Panama. If you can’t join me personally on a ship, you can get the same great information in my book PANAMA CANAL DAY: AN ILLUSTRATED GUIDE TO CRUISING THE PANAMA CANAL.

I thought you’d be interested in the places we’ve stopped en route to Panama.

Cabo San Lucas


Years and years ago the first time I went to Cabo it was still a sleepy, fishing village. Not any more! It is one of the “Top 5 Tourist Destinations” in Mexico, crowded with tourists, time-share sales people, surrounded by mega resorts with world-class golf courses, and in general, pardon me … a touristy zoo.

One of the best views of the rocks at the tip of the Baja is actually from the deck of the ship, which along with the rest of the cruise ship fleet, is anchored off shore. Local tenders assist in a rapid off loading of guests eager to explore the wonders of Cabo. This is where the Pacific Ocean meets the Sea of Cortez and it is a popular area not just for tourists but for sea lions. There is a natural arch in the rocks formed by the massive erosion of the sea that is three stories tall. Cabo is great for fishing, snorkeling, diving and beaching. If you work at it you can even still find beaches that aren’t jammed with tourists and tequila-fueled party people. One popular beach is nestled between the rocks and known as “Lover’s Beach.” Supposedly it was a private and secret place to carry on a tryst in the sand, which by the way is highly overrated. Nikki and I tried it once and it can get very uncomfortable as in the throes of passion sand gets where it was never intended to be. Today, like most things in Cabo, “Lover’s Beach” although still spectacularly beautiful, is crowded with tourists.

San Juan del Sur

Every time I do a contract I’m hoping for at least one port that I’ve never been to before, and this time it is San Juan del Sur in Nicaragua.  This is a very interesting port, as is Nicaragua, partly because it has so many volcanoes.  If it wasn’t for the volcanoes of Nicaragua the canal might never have been built in Panama.  Now, aside from the colonial charm of places like Granada, and the beautiful vistas of Lake Nicaragua, the area is of particular interest to me because this is where the proposed Nicaragua Canal being built by China is supposed to begin on the Pacific side.

Las Isletas in Lake Nicaragua, one of the areas environmentalists feel may be threatened by the proposed Nicaragua canal and the rush to begin without adequate environmental impact studies.


Although pretty much a nothing town, except for a fairly nice town beach just a short walk from the pier, Puntarenas is mainly a jumping off point for some fantastic shore excursions that explore the Pacific coast of Costa Rica.

Beach in Puntarenas is withing walking distance of pier

Beach in Puntarenas is withing walking distance of pier

Tour of a beautiful coffee farm high in the mountains of Costa Rica

Tour of a beautiful coffee farm high in the mountains of Costa Rica

John is an old gringo like me who lives outside of Puntarenas.  Every week before the ships come in he gets Tarazzu coffee, my favorite Costa Rican coffee grown at 5,000 feet and roasts it.  He sells it as Shade Lady Coffee.  But be careful, there is another business in Puntarenas called “Shady Lady” … and from her you may get a lot more than you bargain for!  Anyway John sells his coffee and even although we grow excellent coffee, my wife always asks me to bring home some Shade Lady coffee.Puntarenas 028

Now we are off, heading for Panama and the Panama Canal.

Volendam Mar 08 043

A Great Opportunity

Bob Adams is a guy I respect and enjoy listening to.  I think Bob gives one of the best analysis of the economic of Panama and does an excellent job objectively evaluating Panama as a place for investment and/or retirement.  He is a frequent guest on the Panama Relocation Tours and has two very interesting Web sites, and

Bob has spent his life working in international development and humanitarian assistance for a wide variety of private and public agencies, work that has taken him to more than 40 nations since he first began as a US Peace Corps Volunteer in the Philippines in 1967. He chose to settle and retire in Panama City in 2004. Since then, like a lot of us, he’s been frustrated with the big outfits promoting expats moving to Panama based mostly on hype, often inaccurate hype, and presenting only a rosy picture of life in Panama without dealing realistically with BOTH the joys and challenges of living in another country and culture.

Bob has a great idea and offers you a great opportunity to check out the facts, something many of the big “conference” promoters are light on, and that is an internet teleconference. For folks considering Panama, here’s an opportunity to get some factual information without spending thousands of dollars to sit in a hotel ballroom in Panama City, or actually fly down to Panama. If you sense Panama may be for you, it makes perfect sense to come on a Panama Relocation Tour which, unlike the hotel ballroom conferences, is a boots-on-the-ground opportunity to see and experience the real Panama.

So here’s the information about the Internet teleconference, a great opportunity at a really great price, only $37.  [Unfortunately I will be at sea with slow, poor and horribly expensive Internet and unable to attend.]