Avalanche of Dirt: Governance in Panama

It’s been just 25 years since the US invaded Panama and captured dictator Manuel Noriega, fortunately ousting the dictator, but unfortunately leaving the country in shambles. From the ruins has emerged an economic powerhouse, one of the few countries in the world to have averaged an 8.5% GDP growth over the past 5 years. Panama has successfully elected six Presidents since then [including Guillermo Endara, duly elected as President during the wane of Noriega’s dictatorship in an election annulled by Noriega. Endara was sworn in on a US military base moments before the US Invasion in 1989.] Even without a military, which always seems to be an impediment to democracy in Latin America, and in spite of the glitz and gleam of all the high-rise towers in Panama City, the path to true democracy has been a struggle in Panama.

US foreign policy has often been based on the assumption that US-style democracy can be relatively easily exported and copied by others around the world, an assumption that has proved tragically wrong in many instances.

The US has been working on this democratic concept for 239 years and many would argue that we still don’t have it all together.

So Panama has struggled. Every President since Noriega has made contributions to the country, but there is always the lurking specter of corruption and of lining one’s own pockets. Political patronage in Panama is more a fact of life than even in Chicago! Without an entrenched civil service when a new party comes into power almost the entire government is replaced. I once had a guy in Immigration tell me after another party was elected, “Only the janitor’s job is really secure, and even he may eventually have to go.” That makes running a country difficult. It also makes it near impossible to have long-term goals for beyond five years since the President cannot serve two successive terms. A Panamanian President must sit out 10 years before being reelected, probably because of the country’s experience with the dictatorship.

Under Ricardo Martinelli the country zoomed ahead with amazing speed: everywhere there was new construction and infrastructure. Martinelli extended the Cinta Costera around the Pacific waterfront of Panama City, a wonderful project initiated by his predecessor Martin Torrijos, the illegitimate son of the military strongman Omar Torrijos. [It was Omar Torrijos who negotiated the turnover of the Panama Canal with Jimmy Carter.] Martinelli pushed the Canal expansion forward, although the expansion was initiated and improved during the administration of Martin Torrijos. And Martinelli created the amazing Panama City METRO with the first line open and functioning and the second line under construction. [Work on the second line is being continued under the new and current President Juan Carlos Varela.]

Unable to run a second successive term, the Democratic Change party created by Martinelli pushed its own and Martinelli’s hand-picked candidate to succeed him. The election in the spring of last year was hotly contested between three candidates, all from established powerful Panamanian families, all successful and wealthy businessmen, and all slightly right of center. No great political swings or philosophical differences, to an outsider it seemed more like a contest of which family would get the political power and patronage and perhaps the opportunity to continue the Panamanian tradition of graft.

Note that all politicians tend to run against corruption, at least until they are in power. Martinelli’s famous line from his inaugural speech was, “In my administration it’s OK to put your foot in your mouth, but not your hand in the till.”  Everyone decided that what he meant was no stealing from the government and no corruption.  Now some people are concluding that what he actually meant was that only to “proprietor of the store” and have his hand in the till … and take whatever he wants.

Martinelli and much of the country pretty much assumed that his CD candidate was a shoe-in for election and much to the surprise of many a come-from-behind candidate, Juan Carlos Varela emerged as the winner in what turned out to be a very hotly contested election.  Martinelli, addicted to Tweet, Tweeted his stunned dismay.  Juan Carlos Varela had actually served as a coalition Vice President in order to get Martinelli elected in the first place, but early on the two had a very public falling out.  Varela’ is a businessman whose family owns Panama’s largest rum distillery and makes my favorite Abuelo rum.

Panamanians have shown a propensity to always change political parties in elections, maybe as a result of the dictatorship experience.  Many were concerned that Martinelli was evidencing some of the dangerous power-grabbing techniques that they had witnessed before, and that if his party would remain in power the offences they feared would continue.

Now, six months after Varela’s party took over, the chickens seem to be coming home to roost and an avalanche of dirt, abuse of power, and good old graft seem to be rolling down on Martinelli.

While the newspaper Martinelli owns defends him, much of the rest of the country seems to be piling on.  Martinelli has left the country on an extended trip of the US and Europe, stopping enroute in Guatemala to meet with an outfit called PARLACEN [Central American Parliament] which he had previously referred to as a “den of thieves.”  Martinelli made an impassioned plea for PARLACEN to grant him immunity and sanctuary because with everyone piling on back home he was a victim of political persecution.  PARLACEN denied his request.  Reportedly, before leaving Panama on his private jet, Martinelli gave his wife and brother full power of attorney in all his affairs.

So as an expat do all these symptoms of democratic and government dysfunction, cause me to question my decision to live in Panama?  Not really, no more than all the symptoms of democratic and government dysfunction in the US cause me to want to give up my US citizenship.

All this for those of you who might not be familiar with the ins and outs of the Panamanian political game so I could share this from PANAMA NEWSROOM supposedly quoting at length from Britain’s prestigious Guardian newspaper. I confess that I was unable to find this Guardian article on their website … so it could just be an example of folks piling on the former President, but sometimes where there is enough smoke there is indeed fire.

MEDIA WATCH: MARTINELLI -“GREED, PRIDE, LUST AND ENVY”

RICARDO Martinelli loved to parade himself on the world stage and made more overseas flights than any of his predecessors. During one of his trips to the US, he boasted to CNN that the reason for Panama’s “success” under his management was that his was a cabinet of businessmen..With the ongoing corruption and spying revelations he is now getting the attention he never envisaged from media around the world.

On the day after thousands of Panamanians representing all levels of society paraded through the streets of Panama denouncing corruption and calling for his imprisonment, Britain’s prestigious Guardian newspaper carried the following report revealing behind the scene’s details that have not appeared in local media although they have been the meat of many rumor mills:
The Guardian reports:
WHEN THE UNITED STATES rejected former Panamanian President Ricardo Martinelli’s request for spying equipment to eavesdrop, , on his political enemies, the former supermarket baron turned to another source: Israel.
Now scores of Panama’s political and social elite are learning that the eavesdropping program that Martinelli’s security team set in place sprawled into the most private aspects of their lives – including their bedrooms. Rather than national security, what appears to have driven the wiretapping was a surfeit of the seven deadly sins, particularly greed, pride, lust and envy.
Nearly every day, targets of the wiretapping march to the prosecutors’ office to see what their dossiers contain, often emerging in distress. Martinelli, who left office in July, is facing a rising tide of outrage not only over the wiretapping, but also over reports of vast corruption. His personal secretary has left the country. The eavesdropping equipment has vanished.
“Martinelli was obsessed with knowing what everybody was gossiping or saying about him,” said Álvaro Alemán Healy, the Cabinet chief for the current president, Juan Carlos Varela. “He used to brag that he had a file or dossier on everybody who is important here in Panama.”
Martinelli’s request for U.S. assistance in setting up such a program – and the U.S. rejection – has been known for years; it was detailed in one of the tens of thousands of State Department cables made public by WikiLeaks.
But new details of what happened after that rejection are just now emerging, and Panama is shocked.
A few days ago, prosecutors summoned legislator José Luis Varela, the current president’s brother, to review a partial dossier of emails and transcriptions of conversations that government snoops had culled from him and his family. Among them was an email his wife had sent to one of his grown sons.
“It said things like, ‘You never finished university, you’re sleeping too much and you don’t have a goal in life,’” Varela recalled.
Wiretapping scandals are not new in Latin America, even under democratically elected governments. Colombia was rocked by a tapping scandal in 2008 that eventually led to the dissolution of its domestic investigative agency. Around the same period, reports of wiretapping under Peru’s then-president, Alberto Fujimori, were partly responsible for his eventual jailing.
Alemán said the government believes Martinelli’s security team kept active wiretaps on “between 150 to 175 people,” among them the Roman Catholic archbishop of Panama, opposition political leaders, rival business tycoons, supreme court judges, U.S. Embassy personnel, his own Cabinet members and even the woman identified publicly as his mistress.
Some of the targets say they long suspected that Martinelli’s security team spied on them, but they voice abhorrence at new details of the surveillance that have emerged in recent weeks.
“What shames me about this is how they used this information to destroy families, harm marriages, obtain business, hurt rival business, and even affect diplomatic relations,” said Miguel Antonio Bernal, a law professor and human rights activist who has filed a criminal complaint against Martinelli over the wiretapping.
When Martinelli first approached U.S. diplomats about helping him with wiretapping, he asked them to expand a U.S. program aimed at suspected drug traffickers, known as Matador, according to multiple secret U.S. diplomatic cables released by WikiLeaks in late 2010. When U.S. diplomats noted that U.S. and Panamanian law forbade such wiretapping, Martinelli turned to Israel, purchasing a $14 million package from MLM Protection Ltd., which offers “cutting edge, customized security solutions.”
Two of Martinelli’s former top security chiefs, Alejandro Garuz and Gustavo Pérez, were detained earlier this month in the wiretapping scandal, while two other security technicians are fugitives. An employee of the National Security Council has cooperated with prosecutors and is now under protection, apparently overseas.
“Former President Martinelli has no relation to these supposed events,” a spokesman, Luis Eduardo Camacho, said in a brief telephone interview.
Once Martinelli left office, Alemán said, “the (wiretapping) equipment disappeared. It’s not here. We don’t know if it’s been taken out of Panama.”
The Israeli equipment offered sophisticated capabilities to the Panamanian snoopers, allowing not only the monitoring of cell and fixed-line telephone calls and emails but also Whatsapp and Blackberry texts. Moreover, the techs could burrow into hard drives and extract data and video, and remotely activate functions. They could also detect signals of nearby cellphones to determine who might be meeting.
“They can turn on the video (function) of your cellphone when it is resting on a table, and can turn on the microphone to hear who you are meeting with,” Bernal said.

INTIMATE VIDEO
Among the victims angriest about the surveillance is Zulay Rodríguez, a 43-year-old lawyer and legislator from the leftist Democratic Revolutionary Party.
“They stole a video of my husband and me – intimate,” Rodríguez said. “They use a technology that lets them take intimate scenes inside your bedroom.”

Unlike many of those affected by the domestic spying, Rodríguez found out about the video not from the boxes of files and printouts and hard drives at the prosecutors’ office, but from officials close to Martinelli long before he left office.
“They called me to threaten and say they had the video,” Rodríguez said.
Rodríguez believed them, because cellphone conversations that she’d had with her husband while they were in a period of difficulties had been tapped and uploaded to YouTube earlier in the Martinelli administration to embarrass her.
Rodríguez said prosecutors told her they have only a fraction – 20 percent – of the material captured by the National Security Council spies. Most of it was carted away when Martinelli’s handpicked candidate lost the presidential election in an upset last year, but the team overlooked a hard drive.
When Rodríguez went into the prosecutors’ office to peruse the dossier gathered on her earlier this month, she found a stack of material.
“They had transcripts of conversations I had with my family, my father, with party leaders, with activists,” she said.
Rodríguez has joined Bernal and many others in demanding that the former National Security Council members and Martinelli face criminal trial.
Panama, a nation of less than 4 million, has a small ruling elite, and many power brokers socialized with Martinelli even as they learned of his propensity to regale them with outrageous details of others’ personal lives, relishing the most intimate “information.”
“He wants to know who is screwing whom,” Alemán said.
Party leaders and legislators took action to protect sensitive discussions.
“When politicians would meet, it was almost like a ritual. They would leave their cellphones outside the room,” said Guido A. Rodríguez, a former editor of the Panama America newspaper [now controlled by Martinelli] who is now a prosecutor overseeing the auditing of public accounts.
“There was almost a collective paranoia,” he added.
Even the most innocuous incident could unleash the talents of the spy team.
One politician recalled that he’d been at a social event with Martinelli and his mistress. When he raised his phone to snap a photo, the two raised their middle fingers at the camera.
“I sent (the photo) to him. He told me his people erased it from my phone,” said the politician, who asked not to be publicly linked to the incident. THE PANAMA NEWSROOM

Telling It Like It Is vs. Hype

There is a lot of hype about moving to Panama.

The other day I had a guy on the ship come up to me with a tattered, glossy magazine that he’d obviously devoured all about moving to Panama.  He asked me if it was all accurate or just hype.

Unfortunately, there is a lot of hype about moving to Panama.

Yes, Panama is a great country for expats and retirees, depending on where you are coming from and what you are seeking.  But it’s not for everyone.  How do you know if it is right for you?  Well you have to invest the time, effort, and money in studying, reading everything you can get your hands on but taking it all with a grain of salt, and talking to as many people as possible seeking out folks who will tell it like it is and give you the straight scoop.

That’s what I try to do on this blog and in my book THE NEW ESCAPE TO PARADISE: OUR EXPERIENCE LIVING AND RETIRING IN PANAMA.  First, it’s our experience.  Talk to a dozen different retirees and/or expats living in Panama and you will likely get a dozen different stories.  Some of those who “package” Panama and make a living off selling the expat lifestyle have a tendency to gloss over some of the realities in order to paint a rosy picture.  Panama hasn’t been perfect for us, but it has been fantastic.  Nikki and I are both mature enough to realize that there is no “perfect” place, but for us Panama, with all of its frustrations, has been wonderful.

When I get comments on Amazon, like this from Keith Dick, I’m delighted!

“No rose-colored glasses here – Panama is not for everyone. If you’ve never lived outside the US before, particularly in a developing country like Panama – don’t even think about making a move without thorough research. Richard’s book is one of the best. Extremely valuable advice – take it to heart!”

Or this from Daniel Bridges …

“An outstanding, insightful book about the author’s experiences in Panama. It is a very sobering look at his and his family’s experiences, both the good and the not so good. The reader can tell they’ve landed in their paradise. My wife and I are considering relocating to Panama and we’re using Richards book as one of our primary sources of information for an anticipated visit to the country next year. Because Richard does not sugar coat life in Panama, rather he tells it like it is, we feel like we have a more realistic expectation of what life is like in Panama. He most definitely has us studying up on the many aspects to be considered.”

Or this from Dorothy …

“No bunnies and rainbows here, both sides of the coin are exposed. Like any country, Panama has it’s issues and beauty and Richard gives insight to the reader/expat on both so we don’t arrive and end up shocked to find bugs in our paradise. Good job.”

I’m even happy when I get a comment like this one from Ida Freer, a writer who actually helped edit the book …

“You provide a lot of useful information. Overall it led me to decide against Panama, except maybe as a tourist for a month or two. Too bad! I had high hopes.”

Just think, I saved Ida several hundred thousand dollars plus a whole lot of hassle! What if she had moved to Panama and THEN discovered it wasn’t for her?

So in that vein, I want to respond to this comment from Ophelia Robinson …

I am so confused??? I just happened across this blog and I was really shocked to hear that the pensionada program is NOT what I thought it to be. I have been dreaming about relocating to Panama and primarily because of all the positive things I have read via Kathleen Pedicore’s (excuse misspelled last name) newsletters. This is the first time I have read that the Pesionada program may not be all that Kathleen taut it to be. I’m sure you know about the expensive seminars she regularly holds around the country, and even in some of the Latin American countries. I have planned on going to at least one of them, but now I am not sure whether I would be wasting my money. Do you think it is best that I just visit Panama and see for myself what it is like, then schedule one of the these seminars with Kathleen afterwards if I am still interested? After all, she brings in all the experts—in banking, attorneys, relocation, currency, language, those that actually live or who have lived there, etc., etc., etc…. Supposedly, she introduces you to all of the experts who can answer all the questions you have about relocating…what do you think???

First, about Panama’s much-touted Pensionado program.

“Pensionado” refers to a retired person living on a pension. There are many retired folks in Panama, Panamanians, who live as Panamanians on pensions of $150-300 a month. With the inflation in Panama it is a struggle, but they do it. However they have a lifestyle that’s considerably different than most expats would appreciate. The Pensionado discount program was supposedly created to benefit these folks, although I doubt that those at the lower end stay in fancy hotels or take international flights. Panama has generously extended this concept to foreigners who have pensions and want to move to Panama.

The Pensionado visa is a very attractive option for expats who don’t want to work or expect to work in Panama.

I think it is important to realize that the Pensionado discount program was created for Panamanian retirees, not for gringos, but Panama has generously extended these benefits to expats. I sometimes encounter expats who think that the whole world revolves around them, or at least it should, and the Pensionado program was created for them and it is their right. The Pensionado discounts are a wonderful thing, particularly when it comes to drugs, and sometimes restaurants. Hotels like to play games with the discounts, often setting up an artificial “rack” rate (which nobody pays) and then taking the discount off the rack rate. Of course hotels have always done this all over the world. Whether the airline discount helps you or not depends on your age. If you are 65 the airline senior discount, when offered, is the same as the Pensionado discount. If you are under 65 and are a Panamanian resident you can get the airline senior rate so its a good deal for you. In restaurants I used the Pensionado discount judiciously. If it’s a local, small, typical Panamanian restaurant, often family run, with fair prices, I’d never ask for the discount. If it’s a large, expensive restaurant, then I’ll ask for the discount. If I see they’ve jacked up the prices anticipating folks using the discount, I’ll ask for it. Interestingly many of the gringo-owned and operated restaurants flout the law by listing prices “with the discount already included” or “offering the discount to everyone.”

Yes, the banks often have two lines and a special line for Pensionados. If there is a line of ordinary, working Panamanians, I’m not going to go stand in the Pensionado line where there may not be anyone. Why? Just good manners and realizing I’m a guest. But if there are two lines, each with a good number of folks, and the Pensionado line has Panamanian retirees in it already, I’ll go stand in the Pensionado line. OK, it’s me. I know some gringos who take the attitude, “I’m here. I’m entitled. I deserve it.” Different folks, different strokes.

OK, now Kathleen Peddicord, Live And Invest Overseas …

I don’t know Kathleen, have never met her but I’d like to meet her, since I am familiar with her news releases and admire her advertising and promotional efforts. As I understand it, she was much of the original force behind International Living before leaving and launching her own brand, Live and Invest Overseas. I’ve never been to her seminars or those of International Living. I suspect that Kathleen would be the first to tell you that she does not “answer all the questions you have about relocating” nor does International Living or Jackie Lange’s Panama Relocation Tours. In my opinion there is nothing better than getting out and into the real Panama and experiencing and seeing for yourself what life here is all about. You can’t experience that in a fancy hotel room in Panama City. These companies are in the business of selling Panama. And that’s OK, as long as you realize what it is. We know many folks who’ve ended up in Panama because of International Living and are delighted to be here. 37% of the folks who’ve taken Jackie Lange’s Panama Relocation Tours over the past four years are already living in Panama.

So here’s my advice …

1. Get my book THE NEW ESCAPE TO PARADISE: OUR EXPERIENCE LIVING AND RETIRING IN PANAMA. Read it. I’ll show you how to decide what it is you’re looking for and how to evaluate and compare different countries. I don’t sugar coat it. Panama is not for everyone, but it may be the perfect place for you.

2. Scour the Internet and get all the information you can, but take what you read with a grain of salt. Sort through and try to separate hype from fact. Start following the various Internet boards that gringos in Panama post on. You’ll find almost as many opinions about everything as there are expats in Panama. No one, including me, has a lock on everything!

3. Carefully study the offerings and promises of the companies offering tours and seminars. Study the recommendations. Search out the company names on line and see what folks have to say. Weigh the cost and benefits. Anyone who promises to tell you “everything you need to know” is clearly blowing smoke.  You want to meet as many expats along the way as possible and have opportunity to learn from them and listen to their unfiltered comments.  Tour organizers tend to feature expats whose stories are in tune with the story the tour company is trying to tell.  Take everything with a grain of salt.  Some tours are built around selling one thing or another, which is not always made clear up front.  There are real estate tours, carefully designed to allow time for you to see only the developments and properties where they’re getting a commission.  For those of my readers who’ve taken any of these tours, I’d welcome your comments and recommendations for others.

Avoid ones where you are just going to sit and listen.  You need to have your boots on the ground.  If you’re unfamiliar with a place, these may be the way to get started and feel comfortable exploring on your own. Whatever seminar or tour you choose, come early to experience and explore Panama City doing some of the tourist things like seeing the Canal or taking the Hop On Hop Off bus. And set up your return flight so you have time, a week if possible, to visit and explore in depth areas that you think might be possibilities for you. In Panama we pretty much have everything in a tiny country. Big city life, small town living, or life in the country. Mountains or beaches Lowland hot or mountain cool.

4. Once you go back home and sort through your experiences and impressions plan to come back to Panama for an extended stay of several weeks to explore further both as a tourist but also as someone considering living here.  Again talk to as many expats as possible.  You are the visitor so take the initiative: “Pardon me, we’re just visiting here and thinking of maybe moving to Panama.  It sounds like you’ve been here a while.  Can I buy you another cup of coffee (or drink!) and ask you a few questions?”   Most expats are going to be happy to share.

5. If you then still are excited about an expat lifestyle in Panama, arrange to come down for 3 to 6 months, rent a place, and actually experience day-to-day life in the area you like best.

Then, when you are convinced this is the right move, pack up and move here, either renting or buying the home of your dreams.

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
PANAMA 58

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.