Panama Viejo

Our group visited Panama Viejo on Friday.  The Panamanian people are a people who are exceptionally proud of their rich history and Panama Viejo is a living exhibit of this history. A direct translation of Panama Viejo is “old Panama” a fitting name for the oldest structures in the country of Panama. Founded on August 15, 1519 by Pedro Arias de Avila, a Spanish conquistador, the original Spanish settlement of Panama served as a convenient home base for gold excavations across the Americas. This area served as a Spanish stronghold for more than 150 years until 1671 when the English, led by Sir Henry Morgan, attacked Panama Viejo leaving the city to deteriorate into the ruins that remain today. Over the years the area surrounding Panama Viejo declined economically and the houses in the vicinity of the ruins are those of the poverty rampant across Panama. It was not until 1997 when UNESCO declared Panama Viejo a world heritage site that restorative and tourism initiatives began in the old ruins.

During our group’s visit, the large majority of our time was spent in the cutting-edge museum at the foot of the ancient ruins. The museum is a chic two-story building with a multitude of brightly colored rooms walking visitors through the history of Panama Viejo. On the walls are informative plaques, like the one displayed in the photograph, describing the history of the old city. The exhibitions start all the way back with the Spanish conquest and as one walks from room to room the exhibits contain more recent history. Several of the rooms had interactive components including a replica of the city in the 1500s and a room mimicking a Spanish colonial household.

Once one finishes the route through the museum and enters the courtyard, the view of the ruins of Panama Viejo stick out alongside the skyscrapers of present day Panama City. Several old buildings and walls remain, and the area is open for adventure. One particularly tall tower, pictured below, still stands 70 meters tall and after an arduous climb up several flights of stairs offers a beautiful view of the ruins and surrounding cities. After scaling the tower, our group of students was able to spend time observing the walls and structures sleft standing in the courtyard and once the searing sun reappeared after a brief shower our group quickly reloaded the buses.

Indigenous Communities of Panama

Tusipono Emberá – Where the River Takes Life

The Tusipono Embera are just a small part of the Embera people with about 30,0000 still living in the Darien Gap and 50,000 living in the Choco region of Columbia. Whether the Embera migrated to Panama or not is still unknown, however, they have been there for centuries. The Panamanian government has seven Embera Comarca’s, which are like reservations for the tribes. Panama did not recognize the Embera people until 1975 when they gave them rights to education and health. Currently, they have access to health care, vaccines, and schools but they often may have to travel great distances to access it. The Embera tribe that we visited near Panama City lives in an area that is now a national parks meaning the Embera cannot use the land or trees for their traditional living habits. Therefore, the Embera cannot farm, use trees for building materials or clothing, or hunt on the grounds. However, through tourism many Embera, such as the Tusipono, make their living. Tourism allows the tribes to have money for staple needs and be able to keep their traditions alive. Though tourism has become a part of their life, one begins to wonder how increased tourism will adversely affect the tribes. Yes, the people can achieve a healthier life and maintain cultural traditions, but at what cost? One hopes as Panama grows, it does not lose its culture for the sake of money.

At 9:00 AM, we departed Panama City to meet the Tusipono Emberá Tribe located in the Chagres National Park along the Alajuela Lake, which feeds the Panama Canal from the Chagres River. On our way to our destination, we stopped for fruit, water, and ice. During this stop a few of us went with our tour guide to the fruit stands where we were able to try fruit that we don’t normally encounter – fruits like lychee and pig spine. Back on the bus, as we headed to Chagres National Park, we learned more about the educational system in Panama and the differences between public and private schools as well as what the government has done to incentivize parents keeping their children in school. In many communities, public school operate on two shifts, in the morning and afternoon, in order to accommodate all of the pupils, but in private schools students attend full days. However, lower-income families do not have access to a private school education and receive a stipend for each child enrolled in public school if they perform to ‘standard.’ While on the road, we drove through some rural areas that do not have piped water or sewer systems.  People who live here have tanks that fprovide potable water to their homes.  Water is trucked in and pumped into these tanks, which is ironic since the nearby Chagres River is the main water source for Panama City. 

We arrived at the Chagres River at 10:30AM and boarded canoes that took us down the Chagres towards the Tusipono Emberá village located about 15 minutes away from the loading dock. We hobbled into two canoes and were led by two indigenous men, one steering and pushing the canoe from the front and one steering and pushing the canoe from the back. Because rainy season had just begun, the waters were low. Because of this, some of us got in the water to help push the canoe. But we were still able to enjoy the beautiful water and surrounding area and two baby alligators that were sunning on the banks of the river. We arrived and climbed up a hill to be welcomed by several women of the tribe shaking our hands and a few men and boys playing instruments to greet us as we walked to the main center and then into a man-made palm structure where we were welcomed by the “Noco” or chief of the community.

The Noco told us more about his community of about 75 people made up of about 22 families, the majority of which had come from the Emberá community come in the Darien. He shared with us that its name, Tusipono, is derived from a tree with a very striking flower that stands out among the tropical rain forests that surround the mouth of the river. Then he taught us a few words of the Emberá language like friends and thank you or “bia bua”. Then we saw the fine crafts that the Emberá are known for and were told more about tagua seeds and the art carved from those as well as the cocobolos wood crafts, and fibers used for making baskets. We watched one the girls weaving a basket and passed around things like turmeric and mud that are used to dye the fibers for the baskets, bowls, and vases. From this, the Noco answered some of our questions like what they do if someone is sick and where do the children go to school. He told us that they use herbal medicine, but if the problem is drastic, they will use more westernized medicine. He also informed us that women birth their babies in their homes unless there is a complication. We also learned that the children attend the nearby school with members of the community that we passed through on our way to the river. We then got to experience more of their culture as we ate freshly fried tilapia and yucca from heliconia leaves that they had folded into cones for us.

Once we finished eating, we were allowed to roam the grounds. We saw the homes of the families as we walked to the Butterfly Room where we viewed seven species of butterflies in a garden containing the plants and flowers of the region. We viewed the life cycle from the cocoon stage, to the pupa, and then a fully grown butterfly. After this we were led to the main gathering point where we were treated to traditional Emberá dance and music. The Emberá use inspiration from their environment to imitate the behavior of animals and relationship with others to create different dances and music. Here we saw two traditional dances: The Dance of the Monkey and the Dance of the Two Sisters. We also heard music known as the Music of the Rumba of Panama and were then pulled from the audience to participate in some of the dancing as well. Afterwards, several of us received temporary tattoos from the community as well as opportunity to purchase handcrafted goods created by the different families. Before we left, we were greeted by Princesa, an orphaned Spider Monkey, that was adopted by the Noco as he had found her in the forest hurt by a Harpy Eagle. Many of us were able to hold her and feed her the bottle of human breast milk that they were giving to her. We then returned to the canoes to head to the Alajuela Visitor’s Center to read more about the artwork that we had seen, the materials used, and wildlife and flora in the Chagres National Park, as well as viewing a map to see where we had traveled.

From canoeing to bus rides, we arrived back in Panama City to prepare for our return to Birmingham. It was hard to believe that our time in Panama was finished for now.

Group 4 – Panama Special Viral Unit

Tim McWilliams

Wilnadia Murrell

Leahgrace Simons

Santo Tomas Hospital (HST)

This hospital is the largest public hospital in Panama. This hospital is what the Panamanian Ministry of Health refers to as a level-three hospital and provides the highest level of care through the Ministry of Health. Santo Tomas was officially founded on September 22, 1702. It was mentioned for the first time in writing on April 11, 1703, when Juan de Argüeyes, the Bishop of Panama City, wrote a letter to King Phillip V of Spain begging him to change the name to reflect a hospital and not just a hospice facility for treating women. Later in 1819, construction of a new facility began. After the new hospital was built, they began treating men at the facility. Starting in September 1924, new buildings were built where the hospital currently stands on Balboa Avenue in Panama City.

Several former wards of the hospital later became independent facilities. For example, the pediatric ward became Hospital del Niño (Children’s Hospital) and the oncology ward became the Instituto Oncologico Nacional (National Oncologic Institute, located at the former Gorgas Hospital). Currently the hospital serves patients 15 years and older, and includes a maternity ward, an emergency department, outpatient clinics, internal medicine, general surgery, an infectious disease ward, and more. Some of the medical specialties available are cardiology, endocrinology, general surgery, internal medicine, neurology, obstetrics and gynecology, orthopedic surgery, psychiatry, and radiology. Santo Tomas is the only location for these specialties for people without private or social security insurance. Keep in mind that this includes 40-60% of Panama’s population that depend on the Ministry of Health’s clinics and hospitals as their only access to healthcare.

Today, Santo Tomas has 632 beds, and is the largest teaching hospital in Panama. It serves as an integral part of Panama’s public healthcare system and is the only access to healthcare for the poorest residents of Panama.

HIV in Panama

While at Santo Tomas Hospital, we received a tour of the adult infectious disease ward and then the HIV/AIDS clinic from Dr. Ana Belen Arauz, an infectious disease doctor. Hearing her speak about treating infectious diseases, specifically HIV/AIDS, amongst adults at the largest hospital in the country, was encouraging and discouraging at the same time. It was so profound to hear from a physician who was educated in the United States but has chosen to return to Panama to work in the field of HIV/AIDS. Yet her work seems daunting with 60 AIDS patients currently admitted to the hospital (10-14 die monthly), and hearing her speak so candidly about infectious diseases and their control made us feel like we were getting to see behind the curtain. So much of what we have heard about clinical medicine in Panama has focused solely on prevention, however, we learned that no one is being tested for gonorrhea or chlamydia, and treatment of these and other sexually transmitted diseases is based solely on symptoms.

Dr. Arauz spoke to us at length about HIV/AIDS rates and the associated opportunistic co-infections they see in Panama, including TB, histoplasmosis, toxoplasmosis, and meningitis. Often times people are not diagnosed with HIV/AIDS until the signs and symptoms of these opportunistic infections drive them to seek medical care. She shared that currently 4,000 HIV-positive patients are being seen at the clinic at Santa Tomas, and estimates that another 5,000 are being seen at the Social Security Hospital. Dr. Arauz estimates that there are currently 30,000+ HIV-positive individuals in Panama, this is an increase from previously reported estimates of approximately 16,000 in 2017 and 18,000 in 2018.

Dr. Arauz also discussed Panama’s efforts to reach the 90-90-90 targets, 90% of HIV cases diagnosed, 90% of those diagnosed receiving treatment, and 90% of those on treatment achieving viral suppression. That is the goal, but Dr. Arauz explained that the reality in Panama is currently closer to 70-60-60. She believes that there are a number of reasons that are preventing Panama from reaching the 90-90-90 targets, including: 1) Stigma associated with high risk lifestyles which leads to low testing rates in that population, 2) Diagnosis is difficult because blood tests must be administered in a clinic by a lab technician and many people find it difficult to travel to a clinic , 3) Many HIV diagnoses come late, after signs and symptoms of opportunistic infections are occurring, 4) Funding for HIV testing, treatment, and care services is low, and is expected to decrease when PEPFAR funds are reduced, 5) It takes a month or longer to get an individual who tests HIV positive linked into care, 6) Viral loads are only checked every six months and the currently available ART has a 12-14% resistance rate, 7) There is only one social worker for all of Santo Tomas, and 8) Sex education is not allowed in schools and there are high rates of HIV diagnoses among 15-18 year olds.

In wrapping up, Dr. McCormick asked Dr. Arauz, “How do you keep a positive attitude?” This was a great question considering the challenges that she faces on daily basis. Dr. Arauz answered, “After being here eight years, I have noticed change, although it is not fast.” Santo Tomas Hospital is fortunate to have someone like her on their team.

The Biodiversity of Panama

This afternoon we visited the Biomuseo, a museum that celebrates the biodiversity of Panama. The museum was designed by world-renowned architect Frank Gehry and was designed to tell the story of how the isthmus of Panama rose from the sea, uniting two continents, separating a vast ocean in two, and changing the planet’s biodiversity forever. The museum houses ten different exhibits which explore different aspects of biodiversity in Panama and how it affects life in Latin America.

One of the exhibits highlighted how human beings are an integral part of nature, and how human activity has impacted nature in Panama over the last 15,000 years- the estimated date when the first settlers arrived to the isthmus. It was easy to see how environment and health are so interrelated as we moved through these exhibits.

Hospital Cecilio Castillero

On our last morning in Chitré, we had the opportunity to visit Hospital Cecilio Castillero, a Ministry of Health system hospital that provides services for people living in the Herrera, Los Santos, and Veraguas provinces. The services at this hospital are one step above what we observed at the clinics that provide preventative services and include a major focus on maternal and child health. They also provide outpatient services, including pediatric dentistry, breast, and cervical cancer screening, general surgery, internal medicine, and pediatrics.

This hospital has 135 beds and averages 85 births per month. The maternity ward contains three beds for labor, two for preparation and delivery, four for newborns, and two for women with complications. Once a mother gives birth, she is moved to an OB/GYN ward for post-delivery monitoring. Before mothers are discharged, they are given any necessary vaccinations. There are several services that are similar between the United States and Panama, including providing HIV testing to expectant mothers. However, in Panama, any costs related to maternal health, labor and delivery, and child healthcare through age five are covered for everyone through the Ministry of Health by law.

While this facility is convenient for those that live near Chitré, it can be difficult to access for those that live further away. As a level two hospital, it does not have the resources to provide specialty care such as cardiology, nephrology, or oncology. Patients needing these services are referred to larger level 3 hospitals, such as Santo Tomas in Panama City. It is evident that this hospital is attempting to maximize the resources they have to provide a wide array of services. There is an effort to control nosocomial infections in the hospital, as we were introduced to their infection control nurse, but the facility has so many limitations that the task must be daunting.

This facility, like most we’ve visited in Panama, was not accessible for those with physical limitations and had poor signage with directions for navigation written in sharpie on the walls. There were several private clinics surrounding Hospital Cecilio Castilerro, but those clinics only accept patients who can afford private insurance. This creates an inequity in the community around access to health services.  

We want to thank the staff at Hospital Cecilio Castilerro, as well as everyone we met in Chitré. We are taking the lessons we learned here as we head back to Panama City to continue our exploration.

Culture: Tinajas Restaurant

Our first evening back in Panama City we had the opportunity to attend a dinner show at the Tinajas restaurant. Tinajas hosts a space for visitors to experience Panamanian food and cultural dances.  The exterior of the restaurant reminded us of an older Spanish-style house, while the area that we were ushered to was designed to look like a back patio with lines of tables in front of a stage. Tinajas’ food selection consisted of traditional Panamanian fair such as tres leches cake and fried plantains. While we ate dinner, we enjoyed listening to Panamanian folk music, which was performed by a band that included an accordion, guitars, wooden drums, and a la guachara, which is an wooden instrument played by running a stick across the carved notches. Then we were introduced to several genres of Panamanian folkloric dances that dated back to as early as the 17^th century. One of the dances, El Tamborito, meaning small drums, is the national song and dance of Panama. A few other dances they performed were Cumbia Suelta, Cumbia Amanoja, and Punto Panameno. There were frequent costume changes so that the dancer’s attire matched the period and dance. At one point, the female dancers wore hand-embroidered pollera with decorated beaded headpieces while the men wore formal montunos along with traditional leather sandals.

The cultural component of our day helped provide context to the things in society Panamanians hold dear, which is important for understanding motivations to perform certain behaviors or think in certain ways. For instance, because dancing is such a central part of Panamanian culture, it could be a more welcomed form of exercise than running in areas that don’t have sidewalks or even surfaces. This was evident in our visit in Chitré earlier in the week when working with seniors on the importance of exercise. Most of the ladies that we met indicated they enjoyed dancing and would participate often as a form of exercise. Now we’ve seen evidence of how culture can influence health.  

Educating the Community: A Key to Preventative Health

Today we were not mere observers in public health, we engaged the community via service learning activities working with two different populations in Chitré, Panama. During our first stop we worked with aging adults to discuss the importance of physical activity and demonstrated several low impact exercises. Our second stop was at an elementary school in an at-risk area right outside of Chitré.  Here we worked with Kindergarten and 1st grade students to teach the importance of and techniques for hand washing and dental hygiene and with 4^th graders to discuss vector borne diseases and vector control. We completed the day by traveling with fourth year nursing students from the University of Panama to learn about their community assessment of the neighborhood where the elementary school children reside which gave context to the student’s daily lives.

Dancing for Health

Our first stop was at a community center operated by the University of Panama and the CSS (the Social Security Fund in Panama). The center offers a variety of services to retired individuals including classes on language, dancing, handcrafts, and exercises. The center also offers jobs and skills training through its University of Trabajo including the creation of handcrafts, house ornaments, and sewing. The courses empower the people, primarily women, by teaching them a trade.

For our project, we worked with a group of retired women between the ages of 65 and 80 discussing the importance of remaining physically active. We provided an introduction to the benefits of physical activity including improving quality of life and reducing chronic illnesses. We engaged in conversation by asking the ladies whether they were physically active and what activities they enjoyed, most of which replied they enjoyed dancing. From there, we taught a few seated exercises and provided the ladies a handout of the exercises to practice on their own. After our seated instruction, we taught a few popular ‘line’ dances that we enjoy in the United States (i.e., the Cha-Cha Slide, the Electric Slide, and the Macareña.) The ladies, in turn, promised to teach us a few Panamanian dances, but only if we danced with them, which of course, we did. At the end of our energetic service-learning activity, we parted friends and appreciated the enriching cultural exchange.

The Eneida M. Castillero School

Yesterday, we spent time at the Hipolito Perez Tello School, a top-ranked elementary school in the country. Today, we visited with students at the Eneida M. Castillero School, which serves a low-income population and has limited resources. This school is more representative of what you would see in other rural areas of the country. As students studying public health, it is vital to understand disparities, and the area that this school serves stands out in stark contrast to what we saw yesterday.

Our service learning began by meeting with fourth year nursing students from the University of Panama. The nursing students have been working in this community to complete a community needs assessment of the neighborhood and have been working to treat the elementary school students in the area with iron supplements due to a nutrient deficiency, as well as to provide needed vaccinations. After learning a little about the community and the children in the school from the nursing students, we split into four groups, two groups taught oral hygiene and the importance of handwashing to Kindergartners and 1st graders while the other groups taught vector control to 4th graders.

As we walked into the Kindergarten class, we were greeted by the children singing a welcome song. We introduced ourselves to the class and explained that we would like to discuss why and how they wash their hands and brush their teeth. The lesson for hand washing included teaching the children the English words for hands, wash, water, and soap. We asked the children to demonstrate how to wash their hands and asked children to recall the English words they learned. A little boy in the front of the class was eager to participate and set the tone for the class by answering questions. The young boy was ecstatic to win a little Blaze mascot for answering the question correctly and immediately opened the package to play with his new toy. For brushing your teeth, we taught the English words for teeth, toothpaste, and brush, which we asked for the children to recall and they did quite well. Then it was our turn to play a song for the students. We played a song about how to brush your teeth in Spanish and acted out brushing our teeth. The Kindergartners enthusiastically joined in on the second round and were excited to receive their goody bag that included a dental hygiene activity book and dental care supplies. We spent about 30 minutes with the students and ended our time by taking a group picture.

Walking into the 4^th  grade class, all of the students, and the teacher, gave us their full attention and were actively engaged throughout the entire experience. We started with a question-and-answer session to gauge prior knowledge about the topic of vectors and vector control, with our wonderful translator/USF representative Rolando Trejos. The children did not recognize the word vector when asked, but they had substantial knowledge about mosquitoes, fumigation, and how to protect themselves from vector borne illnesses. After our Q&A, we moved on to our activity which consisted of using a flipchart to identify where mosquitoes breed. The students were very excited to participate in the activity and were awarded prizes for correct answers. The first child to answer a question correctly, immediately put on his prize, a UAB t-shirt. The children were great at recalling and demonstrating that they understood the lesson. At the end of the lesson, we asked if there were any questions and a little boy energetically raised his hand and reminded us to not fumigate at night! The class told us to not forget them and waved goodbye as we departed on the bus.

The Community

After we left the school, we visited the community and were able to observe the social determinants of health and health inequities that directly impact the children we just met. The majority of the people who live in this community are low-income families who struggle to make ends meet. It is a common practice for parents to take their children out of school so they can keep the government allocated stipend for public school tuition. Due to the extreme poverty, parents are faced with the harsh reality of deciding whether they want their child to eat or attend school. Shortly into the community observation, we approached a landfill that was located in the center of the community. As we drove into the entrance of the landfill, we immediately noticed malnourished livestock feeding off of garbage and the sparse polluted grass. The nursing students explained to us that this is where all of the trash from the district of Herrera is dumped. They further explained that community members sometimes fight over trash when they are desperate for food or resources to sell for an income. This is clearly a social determinant of health as poverty and the polluted environment are impacting the health of the community.

Next, we traveled to a nearby port on a polluted river where men were weighing, sorting, and gutting the local catch. The local guide explained to us that it was a common practice for families to rely on subsistence fishing from the river. This concerned us since we know that eating fish from an unclean water source for an extended period of time can result in serious adverse health effects such as liver damage, gastrointestinal distress, and cancer. We know this first-hand because of the negative health outcomes associated with subsistence fishing on the Warrior River in Alabama. As we concluded our tour, we realized how many representations of social determinants of health we had seen. The quality of the water, access to food, housing, education, and ability to have a steady income, all contribute to the communities overall health and the ability of current and future generations to reach their full potential.

Our goal today was to create a culture of prevention. We were able to teach older adults the importance of exercise while at the same time demonstrating fun physical activities. Elementary -aged children were taught to recall their knowledge of handwashing, dental hygiene, and vector control while teaching new knowledge to emphasize the importance of these preventative health practices. The entire healthcare system in Panama is centered around prevention rather than reaction and establishing healthy practices is vital to effectively prevent negative health outcomes, such as vector borne diseases and chronic illnesses associated with dental health, physical activity levels, and handwashing to promote health for all.

Team 1 –

Nekayla Anderson (Public Health Undergrad)

Sloan Oliver (Public Health Undergrad)

Jennifer Schusterman (HCOP Graduate Student)

University of Panama Regional Center

To begin the day our group loaded the bus at 7:45 AM and made our way to the University of Panama Regional Center in Chitré. The University of Panama is the largest university system in the country with the main campus located in Panama City and 10 regional campuses throughout the country. Today we visited the regional campus of Centro Regional Universitario de Azuero based in Chitré. This campus offers a variety of majors and technical certificates in fields such as human resources, nursing, business, social work, engineering, and architecture to 3500 students.

Stepping off of our bus the street view of the university was fairly subdued. The entrance to the campus resembled a bus stop with white brick divider walls surrounded by an iron fence. After passing through the gate and walking down a few steps the University of Panama campus opened up into all of its hidden beauty. All of the academic buildings are surrounded by green spaces and the modest white bricks are embellished with inspirational quotes and murals. Pictured above is the building, which houses the office of the regional campus president, the site of our meeting for the morning. Leonardo E. Collado Trejos is the president of the regional campus in Chitré and was the main speaker during our meeting. Mr. Trejos is an incredibly welcoming man who exuded a genuine excitement to speak with us during our brief visit. During the meeting, Mr. Trejos described the history of the university and the opportunities and degrees offered. During the meeting we had the opportunity to meet with a handful of nursing/community health students and various professors. We learned that these students and professors have been conducting health assessments in communities outside of Chitré, and we will be joining them tomorrow as we visit these areas. After leaving Centro Regional Universitario de Azuero, our next stop for the day was the Ministry of Health Herrera Health Clinic in Chitré.  

Herrera Health Clinic

Today we learned just how complex the Panamanian healthcare system is. Panama is divided into 13 provinces. Chitré is located in the province of Herrera, which is a relatively well-off province compared to the rest of the country. The Ministry of Health Herrera Health Clinic provides preventative care to the poorest citizens in the province. Most of the patients seen at this clinic include those that do not earn enough income to participate in the country’s social security health system or cannot afford the private system. Similar to the other Ministry of Health Clinic that we had visited, the Herrera clinic has a relatively modest exterior with the Ministry of Health insignia plastered above the entrance. Once inside the doors of the clinic the first thing that catches the eye is a huge mural of a woman breastfeeding her child directly above the reception desk.

The walls in the clinic are filled with intricately designed bulletin boards informing the public about heart health, fall avoidance, and services offered by the clinic. After a brief wait in the crowded lobby, our group toured the clinic with the chief nurse. She explained to us that all medical services are free or provided for a cost of one dollar. Of the free services a large majority are related to maternal and child health with all vaccinations, yearly check-ups, and prenatal care offered for free. Other services provided by the clinic, like routine dental visits, may require a small fee. During our tour the nurse described  the general flow of the clinic as a patient may experience it. The clinic, similar to other Ministry of Health clinics, opens at 5:00 AM where it is common for long lines to be waiting at the door. Contrary to the US system, patrons can scan their “cédulad”, a Panamanian ID card, and enter their cell phone number to be called into the clinic closer to the time they will be seen. For more specialized services like dentistry or an appointment with the mental health provider, patients can book appointments in advance to avoid long lines and be guaranteed to be seen on a particular day.

This appointment system is crucial due to the incredibly low staffing in the clinic. On a typical day there are seven doctors, three dentists (one of which is a pediatric dentist), and a number of nurses and nursing assistants working in the clinic. We were told on an average day they have about 21 people working in the clinic.  Each doctor sees about 25 patients a day, while nurses and nursing assistants, depending on their expertise, may see anywhere between 20-30 patients each day. The chief nurse estimated that they may see upwards of 400 patients each day in the clinic. She also shared that they are expecting a crowd of 1000 patients this next Thursday and Friday for a community clinic preventative program. They will have the same 21 healthcare workers staffing the day. The good thing is that these healthcare workers all seemed to love what they do and every nurse we met seemed vivacious and happy to speak with us. However, there was a common message throughout the day of the difficulty of having such a limited number of staff working in the clinic. During our time at the clinic it was easy to see that these healthcare providers were doing everything they could to care for the community but the number of people they can help with such a small workforce is limited.

Herrera Immunization Program – “En Panamá, no perdemos la oportunidad de vacunar (In Panama, we don’t miss an opportunity to vaccinate).” 

After leaving the Herrera Health Clinic, we visited with the nurses who run the province’s immunization program at the Ministry of Health.  Just like the immunization programs in the rest of the country, vaccination rates in the Herrera province are high, with some vaccination rates as high as 100%.  The nurses explained that Panama has one of the best immunized populations in the world. In the Herrera Province, with a population of around 118,000, in 2018, 89% of the population was vaccinated for influenza. We were also told that 100% of all healthcare personnel in the country are up-to-date on all of their immunizations. As a comparison, in the United States during the 2017-2018 season, influenza vaccination coverage among healthcare professionals was only 78.4% as reported by the CDC.

The most surprising part of the presentation was that Panamanian immunization nurses travel to places where clinics are inaccessible and where community members lack transportation. They said they need to visit these people because receiving free vaccinations is a right for all, nationals and non-nationals. The nurses explained that if a child becomes sick with or dies from a preventable disease, the parent could face hefty fines or even jail time. There are laws in Panama that ensure a child’s right concerning access to vaccinations. If a parent refuses to vaccinate their child, their parental rights may be removed. Since 1997, Panamanian children have received comprehensive vaccines to guarantee their right to health, and this trend continues into adulthood. In Panama, the following vaccinations are available for the following age groups:

• Children 0-1 year old receive 5 shots: Hepatitis B, BCG, Conjugated pneumococcus, a 6-1 for DPT, Hib+Hepatitis B, Polio), the flu shot, and the rotavirus shot.
• Children 1-4 years old receive 7 shots: Pneumococcal conjugate, Triple Viral MMR, Hepatitis A, Varicella, Yellow Fever, Pneumococcal polysaccharide, Polio, inactivated polio, Tetravalente (DPT-Hib), DPT, and Influenza.
• Children 5-19 years old receive 9 shots: Poliol, inactivated polio, Hepatitis B, MMR, Conjugated pneumococcus, Pneumococcal polysaccharide, influenza, Tdap, papiloma virus. However, the HPV shots needs parental consent since it is administered in schools.
• Women 15-49 or of child-bearing age receive 3 shots: Tdap Adulto, MR, Influenza, Tdap.
• In addition to this, the general population receives 2 additional shots: Tdap for adults and varicella.

As a comparison, in the United States, the CDC recommends that vaccines are for those who meet age requirement, lack documentation of vaccination, or lack evidence of past infection. In Alabama, verification of vaccinations occurs at enrollment in daycares, some K-12 schools, and higher education institutions. Additionally, Alabama has medical and religious exemptions from vaccinations, which are not allowed in highly conservative Panama.

Providing Health Education at the Hipolito Perez Tello School:

As part of our time in Panama, our class was requested to visit the Hipolito Perez Tello School to provide health education sessions to kindergartners and 4^th graders. Specifically, we were asked to cover personal hygiene topics with the younger students and to talk about vector control and vector borne diseases with the older students. Another reason for our visit was to give students of Hipolito Perez Tello the opportunity to interact with native English speakers so that they could practice the language. 

Hipolito Perez Tello School serves roughly 900 children from an upper/middle class neighborhood in Chitré. As we entered the school grounds we were led through a beautiful courtyard, with a covered outdoor play area where children were playing ball. We were all a little nervous as this was the first time that many of us had interacted with a group of elementary age students. But our fears were quickly laid to rest when we were greeted by curious faces and vibrant hellos once we entered the classrooms.

In the weeks leading up to our arrival at Hipolito Perez Tello, we had prepared sessions for each grade and had been fortunate enough to secure donations to bring with us from the Alabama Department of Public Health, the Montgomery County (AL) Health Department, UAB’s School of Public Health, and UAB’s New Student Programs.  We brought a variety of items to give the students including toothbrushes, toothpaste, floss, and dental hygiene activity books for the kindergartners, and backpacks stuffed with vector control activity books, colored pencils, and stickers.

Our group chose to work with one of the Kindergartner classes. When we entered the classroom, we were warmly greeted by the teacher and 20 or so students.  Classroom walls were adorned with student artwork and, interestingly enough, reminded each of us of our time in elementary school.  One of the UAB students in our group is fluent in Spanish, so we immediately began teaching the children the words for hands, washing, soap, water, teeth, toothbrush, paste, etc. in English.  Miming washing our hands and brushing our teeth, the kids mimicked our movements and repeated words in English with such confidence that we almost forgot that English was not their first language.  One young lady was so outspoken and smart, she had her fellow classmates quickly engaging with us. It is safe to say we learned a lot about communicating and interacting with children.  Because of this experience, I think my group will be more confident as we begin to work in the community.  In fact, before we left the school the children began sharing other personal hygiene tips with us including the importance of washing our face, eating well, and drinking plenty of milk.  It was the best information received from the cutest experts ever.

Down the hall my fellow Blazers were teaching 4th graders about vectors (specifically mosquitos) and how to protect yourself from them.  The kids in these classes were more than ready to answer the questions and enjoyed playing the game Mosquito Vector si o no?.  Students competed for prizes as they answered questions posed to them about the topic.

What did we learn?  These kids knew a lot more about these topics than we expected.  We were surprised that they were able to communicate with us about the health topics in even more detail than we had anticipated.  After our visit we learned that this particular school is consistently a top ranking public school in Panama.  They have a respected and devoted principal and teachers who are doing their best to improve their students’ educational outcomes. We left the school energized and hopeful that the information we shared will be useful to the kids as they learn and grow.

Team 4: Panamá Special Viral Unit

Tim McWilliams (MD/MPH Student)

LeahGrace Simons (Graduate EPI Student)

Wilnadia Murrell (Public Health Undergrad)

The Panama Canal

The Past: “An aquatic elevator,” as our tour guide Gabriel described it, is the perfect name for the 80 kilometers long canal. Considered one of the largest waterworks in the world, the Panama Canal has been serving Panama, along with about 160 other countries since its formal opening on August 15, 1914. However, we learned that building the Panama Canal was no easy task. The idea to connect the Atlantic and Pacific Oceans began in the early 16th century when the Spaniards arrived to the isthmus in search of gold. It was not until 1880 that efforts to build the canal through Panama began with the French, but the initiative was halted because of financial problems and tropical diseases that affected the Canal Zone. Dr. William Gorgas, an Alabama native, was recruited and put in charge of abating the transmission of tropical diseases  during the United States’ construction of the Panama Canal. Dr. Gorgas is credited with eliminating Yellow Fever and Malaria during this time, which allowed the Panama Canal to be built and opened. Since 1969, the canal has brought neutrality to Panama. Our tour guide explained how important it is that the country abolish its official military. This decision was made to protect the canal and the people of Panama in case of any conflict, as this way, the canal can continue to operate regardless of affiliation with world powers. The United States controlled the canal until Panama gained full operation through the Panama Canal Authority (ACP) on December 31, 1999.

The Present: The Panama Canal continues to be at the center of global trade. Since 1963, the canal has been operating 24 hours a day. With this constant operation, 6% of the world’s merchandise passes through the canal. The most recent expansion of the canal added a new lane that can accommodate cargo ships that hold over 13,000 containers. These type of ships carry about 27% of the world’s cargo. Through this expansion, the Panama Canal is seeing more ships than ever utilizing the canal to travel between oceans. In order for ships to utilize the canal they must make a reservation six months in advance; otherwise, the cost goes up significantly. The fee varies depending on the size and weight of vessel. A small catamaran may pay as little as $500, while larger container ships may be charged upwards of $500,000. As an alternative, for those who show up without making a reservation, they can try to make the highest bid to pass through. This helps the Panamanian economy by providing additional funds to the government via the canal. Through the Panama Canal, Panama houses some of the largest ports in the world, with the Colon Free Trade Zone (CFZ) having the second largest free port in the world. Through these venues, the canal adds a huge boost to the economy, not only by financial revenue, but also by providing jobs and bringing resources to the country.

Casco Viejo

Casco Viejo of Panama City was built during the colonial period. It was designated as a UNESCO World Heritage site in 1997. Casco Viejo, which means ‘old compound’ in Spanish, was constructed along the coastline of the Pacific Ocean in 1673 following attacks by Welsh pirates who destroyed the Panama Antiguo, the original city, which is five miles away from this site. The Spanish king commissioned this new site to better protect the city against future attacks. From its inception, the newly constructed Casco Viejo was full of travelers, adventurers, and workers from other countries. The cultural atmosphere was influenced first by the Spanish; then later an amalgamation of French, North American, and Caribbean customs and traditions entered the mix.  During the first part of the 20^th century when the Panama Canal was under construction yellow fever killed thousands of workers who came here to build the canal. Many hygiene improvements were made by Dr. Gorgas and his team to Casco Viejo including eliminating standing water and building infrastructure to handle sewage and water treatment. The main streets were paved and open air ditches were eliminated making streets more suitable for heavy traffic. A water system was established bringing water into homes and businesses eliminating leaking and uncovered water tanks. Also, there was house-to-house fumigation, oil was sprayed on the surface of all uncovered water to eliminate mosquito breeding, and windows and doors were screened to protect citizens from disease-carrying mosquitoes. Our tour guide Gabriel brought us to the outside of an old church in Casco Viejo. He explained that if not for the presence of this very stable arch, which was built in the 1600s, shown in the photo above, the Panama Canal could have ended up being built in Nicaragua, The flat stone arch demonstrated that Panama did not have earthquakes that could destabilize structures, nor did the country have active volcanoes; both of which are common threats to Nicaragua. This made Panama the ideal location for the massively engineered canal. 

Today there is a ‘Renaissance,’ what we would call gentrification, taking place in Casco Viejo. After decades of deterioration of buildings in this area, along with the deterioration of its infrastructure when squatters started inhabiting the structures, Panamanian and foreign investors are now pouring money into beautifying this colonial section of the city. Since 2014, infrastructure has been updated, including the water system. Roads and streets have been repaired using historically accurate materials from the early 20^th century. All of this is being done in efforts to draw tourists to the area so that the local landmarks and history can be preserved and shared.

Through both of these visits we were able to explore Panama’s past and see how history has shaped the current state of the country. The Panamanians have honored the past in order to build their future. In reflecting on everything we’ve learned thus far, it is clear the Panama Canal is the economic driving force in Panama.  And the work done by Dr. Gorgas and his team in the early 20th Century is still shaping Panama’s public health landscape today.

Team 3: PanaBamians

Lakeitha Seroyer (MPH Health Behavior Student)

Sally Engler (Global Health Certificate Graduate Student)

Madison Turner (Biology Undergrad)