Moving Mum to Panama

Worse yet there was a mother who was manipulating me, so it was very hard to make the right decisions. We never sat down and discussed a long term plan. I tried to discuss it, but she would never share what she was thinking. Instead she manipulated the individual decisions. She came from a generation where women had no power. Instead she learned to manipulate people. I have never met a person better at it than her. She never trained me to recognize it and defend against it. I had to figure that out for myself. I am now very good at recognizing and defending against it, much to my ex’s chagrin.

I had no guidebook. I stumbled along. Only now do I understand the value of a support group. Rule #1 Join a caregivers support group!

Financial Issues

If it were not for money, everyone would stay home. So let us start here.

Our parents lived in the United States after World War II. It was a great time to make lots of money. They bought a house in 1963 for $30K, 7 acres, on the water, in New England. I do not even want to say how much it is now worth, but sadly mum made the first of many mistakes. They sold too early and built an accessible house for their retirement on the road. Lawsuits were filed both when they built the house, and when they sold the house in 2005. Still it was a lot money. While it is now no longer that much money in the US, the rule of thumb is that you are three times wealthier if you move to Panama. Of course it depends on the basket of goods you purchase. If you consume a lot of imported manufactured goods, drive a car, shop at the supermarket, smoke cigarettes, drink imported alcohol, buy inflated real estate, then the prices are the same as in the US. If not, if you take the bus, shop at the veggie market, consume lots of labor, rent an empty mansion, then you are way better off here.

There is a huge transition we make from being the child to being the parent. At a certain point in life, the kids judgement is just better. All the caregivers I talk to refer to this phenomenon. I think it is an important part of growing up. Mum did not want to sell her house, we saw the housing bubble, and her beloved son Matthew pushed her into selling. When we sold the house, I wanted us to buy gold, 1/3 of her portfolio, no matter what I did mum refused. I still thought of her as the senior adult and acquiesed. Instead she and my oldest brother John made the next big mistake, and bought stocks, without telling me, just before the market tanked in 2008. Such is life. We do not get to choose our family.

People do not talk much about money, but I hear a lot of stories of parents who made bad medical decisions. My theory is that the difference between children and adults is that children make decisions based on one issue, but mature adults are able to integrate multiple issues into their decision making. The scientific studies say that mature adults integrate both sides of their brain into decision making. Seniors lose that ability. Their decision making gets worse. You need to protect them from that. Rule #2. You are the mature adult. Protect your parent from bad decisions.

I had a lot of problems with the broker who allowed that her to purchase stock in 2008. He tried to sell us bank stocks before the banks blew up, and Real Estate Investment Trusts before the real estate market blew up. He bought highly speculative stocks with my brother without telling me. We had huge fights. He had to reverse some transactions. Finally he resigned and I could move her funds to Charles Schwab. When we asked them to trade in her account, sell her stocks and buy a global index fund, they appropriately refused to take on that legal risk. I love Charles Schwab. Even if they did not do what we needed. I trust them to follow the law. And they have filed suit against some of the too big to fail banks for manipulating interest rates downwards.

The original broker she had trusted to protect her had betrayed her. Rule # 3 is that once they need a caregiver, all large financial transactions should be emailed to the rest of the family members by contract. Putting up a mailing list is not that hard to do.

Finances are very strange in our family. Very strange in all families. Here is the problem. A person’s will is usually a static document. Worse, it is illegal to change it in favor of the caregiver, once the person needs a caregiver. So I do the work, yet my healthy, but useless older brother will get 1/3 of the inheritance. When I complained about this to another caregiver in our support group, she said in her case her brother gets ½, so I am doing well. I think it is a common problem. The incentive structure and feedback systems are all wrong and it exposes the caregiver/secretary to risk of lawsuits from the other parties. Since they inherit they have standing. I do the work, get paid nothing for it, and then am legally liable. Ridiculous! Rule #3 is that inheritance should, at least partially, be split according to the number of years of care each person provides. Anything else is an emotional disaster.

Packing Up Her House

As for me, I was divorced, out consulting, not happy so I moved in with my mother. Packed up her second house, and sold it in 2005, close to the peak of the market. She had lived in Westport for 40 years, so it took 3 months to pack up her house. Recycle things, return things, donate things, sort things, sell things. Others proposed just hiring someone to do it, but I am sure they would not have recognized my grandparents diaries in Polish, they would have been thrown out. So I am happy I did the work. My eldest brother did not help in the process. In fact after the sale closed, I had to go back to clean out his storage shed filled with garbage. It was so bad, it took 4 of us to do it. My other brother did come to help, for a day, caused lots of trouble, and in the process sold our most valuable antique, a very very old book, for a pittance. My dad was a rare book dealer,. Turns out it is very common for one child to do all the work, and the others to not help at all. Or to break something when they do help.

So we sold the house, and off we went to Hawaii and California. I wanted to go further afield. Mum was scared of the third world. First of all she did not want some third world woman catching. She had the money to live in the US, did not care about leaving money to others, in fact wanted to die broke. Little did she understand that off shore we would have had a way way better life. Fear is so strong in some people. So we spent way too much money in the US in Hawaii and Silicon Valley close to my kids. Although I did like the big Island! Rule #4. Sure it is their money, but it is also everyone else’s inheritance. You have to look at financial decisions from both perspectives, using both halves of your brain.

Lessons from my brother.

One day we got a phone call. My brother, Matthew, had a bicycle accident causing severe brain injury. We rushed off to Los Angeles to be by his bedside. My mother had always wanted to live in Los Angeles, I can’t stand the place. So it worked out perfectly for her, although it was not until much later that I realized what had happened. She got to choose where we lived without considering my concerns.

We spent a lot of time at my brother’s bedside. What I learned taking care of him, I later applied to my mother. Since I knew nothing about medicine, I was way out of my league. I needed a source of knowledge and expertise for how to interact with the hospital. I started a yahoo groups medical blog about his condition. What a great source of knowledge our friends had collectively. I would report what had happened, someone on the list would always have the right advice or question to ask. I recommend the process highly if your loved one has a medical emergency. Since eventually Yahoo Groups will disappear, I printed the blog out for his son’s 21 birthday present and will give it to him in 7 years when he turns 21. It came to about 4 inches of paper.

One of my friends said about taking care of my brother: “Never give up”. That is rule #6. The corollary is keep trying things until you find something that works. Here he was in bed, unable to move. We later found out physical therapy is very good, but at the time, we did not understand it, the insurance companies would not pay for it and my sister-in-law refused to allow us to pay for it, let alone pay for it herself. Something about losing Medical if there are private payments. Actually she withheld all insurance information and access to the doctors. And did not try anything to get him walking. Quite the reverse.

So we tried Chinese medicine. It worked brilliantly. Matthew could not move his arms, there were so stiff, they were even stiff for us to move. We brought the Chinese doctor in, brewed up large vats of herbs, like some scene out of Shakespeare. “Boil Boil Double and trouble.” Pretty soon his arms were moving. But that was not enough. I now understand that what he actually needed was physical therapy and chinese herbs together, but when we were able to provide the Chinese medicine, there was no physical therapy, and I did not then know enough to provide the physical therapy myself. Later when there was physical therapy, they would not allow Chinese herbs. To this day he is still stuck in bed.

Dealing with his wife was so hard. The wife has all the power. Refused to share information, doctor access, or decision making. While I hung out at my brother’s bedside powerless, she went off and worked. We tried everything that was within our limited power and knowledge.

I did learn a lot about caring for the sick. But I had not the medical authority to do what was necessary to get him walking. The family is supposed to fight with the hospital for better care. Instead we spent our time fighting the sister-in-law. And she had all the legal power. As for me, I was not able to protect my brother from his wife. If your wife does not love you, give medical power of attorney to someone else. Maybe I could have gotten him up and walking. She did not even try. At least I would have tried. My sister-in-law is going to rot in hell for what she did to him. I am pleased to say that she has already suffered enormously.

We fight so hard for our families life. I had no idea how passionate I was about my brother’s health, nor about my mother. I may dislike my mother, but I also love her deeply. Feelings for family are so strong.

When Matthew was first in the hospital I talked to the minister. I had a sense of spiritual connections between loved ones. The minister confirmed that. And said that the spiritual connections to others are all connected. Every time you lose someone, it brings to mind all the other losses of loved ones. That is why we fight so hard for the lives of our family. Because to lose them, is an injury to our spiritual bonds with them. It is an injury to ourselves.

Never give up, unless you have no legal authority! Eventually we gave up and went off to Panama for a while. Mum met and liked my friend Sandy, and liked Panama. That is why we were able to move here later. She had already visited Panama, and was comfortable with it, and Sandy. A year later, we found out that they were going to provide physical therapy to my brother, so we moved back to California to try again to help my brother.

Mum’s Aging.

Every person ages differently. My grandmother-in-law cooked her own meals every day of her life, and died in her sleep. Most people do not have such a graceful ending. I do not know what path your loved ones will take, I can only tell you the path my mother took. We all fall apart in different ways.

While we were attending to my brother’s bedside, my mother was getting older and weaker. A smelly room. Poop on the mattress. Rather than dealing with it, I kind of tuned it out. That cost us $1000. But dealing with an aging mum was just getting more and more depressing. I could not take it. As it got worse, I became so depressed that I was not able to get out of bed. At that point I realized it was time to make a transition. Move her to a nursing home. I could not handle it myself anymore. At that point there was no guilt. I had done all I could.

On Nursing Homes.

Since Matthew was in a nursing home, it was only natural to take my mother to the same nursing home. So my immediate family consisted of two people in adjacent nursing homes, mum was in assisted living, Matthew in skilled nursing. Talk about pitiful!

The food was terrible, so I bought my mum a small fridge and a microwave and kept it full of reasonable instant food from Trader Joes. Then one day at 12:50 I arrived and found her laying on the floor. A urinary tract infection is incredibly debilitating, and probably caused by their not changing her diapers regularly. I never liked that nursing home, but if they could not even do an inventory of their patients at lunch time forget it. We moved her to a far better nursing home, but then I had to visit two different places every day. Unbelievably, I could not get my sister-in-law to move my brother to the same place as my mother.

The new place was way better, but also not really good. We were fooled by the presentation. It turns out that you cannot really evaluate a nursing home by visiting it. What matters most is the process they execute, their quality of the care, the relationships between the patients and maybe the quality of the food. When you go and visit a nursing home you can see how nice the building is, how nice the room is and that is about it. The only important thing you can really evaluate is the food.

In this case the food was way too fattening. They said the residents liked it that way. Donuts, Bacon, greasy food. All kinds of junk. Sorry I do not have the records of how much weight my mother gained there, but here in Panama we are eating way healthier home cooked meals and she is losing weight.

This place already had a lovely lobby. They further remodelled it while we were there. They had recently been spending huge amounts of money making the place look better. Which is actually way cheaper than paying for good care, and helps more with the sales cycle.

This nursing home had remodeled the lobby to make it look great, and did their best to whisk the patients out of the lobby, not to be seen by new customers. It never ceased to amaze me that all their hundreds of customers spent most of their time by themselves in their bedrooms, only 10-20 could be seen at any one time in the public spaces. I now recognize that as a very bad sign. A clear measure of how good a nursing home is, but you have to be trained to spot it. The statistics to look for are how many patients are there, and how many are interacting in public spaces at any one time.

There is a reason the nursing homes make the lobbies look great, because they do need to focus on the sales cycle. An average nursing home stay is 1.5 years. Which means that every month you lose 5% of your customers, and have to replace them. Instead,I think, nursing homes should exercise their patients twice a day, Keep them alive for 3 years, and reduce the cost of new sales. But that is not what they choose to do. So ask how long patients live on average when you do visit. Ask if there is a required exercise class twice a day.

A great nursing home would have all the patients sitting in the lobby talking to each other. The best such environment, I ever saw was CNS in Bakersfield California. They treat brain injury survivors, such as my brother. Part of the organization has individual specialists doing specialized exercises with the patients. The other, later stage, better part of the organization, has all the more functional individuals, the first stage graduates, in a room interacting with each other. My brother got so much better there. This is a model all nursing homes should adopt, where the healthier patients interact with the older patients. It is good for both of them. Instead so many nursing homes isolate the patients in their bedrooms with no stimulation except television. So choose a nursing home based on percentage of patients in the lobby interacting with each other. Although I dare say most have few.

What we have done in Panama is we have created an environment where the family, but mostly the paid staff provide this kind of stimulation to my mother.

Since my mum was an emergency case, they gave her their only empty room. A lovely 2 bedroom suite on the top floor, far from everyone, with a great view. They only charged us for a studio. At first I lived elsewhere, and visited her every day. Later I would be gone from town half the time, then I would come and visit and stay with her. No one minded. As time went on, and she got sicker, I spent more and more time just living at my mum’s nursing home. No one seemed to notice or care. I was quiet and discrete. Everyone knew I was there, but no one said anything. It took two years for the CEO to notice and kick me out. It happened just when the front desk management changed to a more nazi manager. My girlfriend was asking way too many questions of the inmates and got noticed. O got rudely kicked out. I left, found a dirt cheap place to sleep, and came back to my nursing home office during the day time to keep an eye on my mum. I must be the only healthy person in history to have lived in a nursing home. It gave me great insights into how they actually function.

My being there was great for my mum. Those families that pay attention get better service. So few people visit their families in the nursing home. Check the sign in sheet to see the percentages. While most people get ignored we got way better service. Here is the schedule they agreed to for us.

Many patients get breakfast in their room. The patients often fall asleep, and they would come and take away the full tray, and leave her sleeping in her chair for hours. With me there, I made sure she ate, shooed away the staff who came too early to take her tray, and walked her back to bed. I did a lot of the work the nursing home should have been doing. But instead of getting a discount, they eventually raised the rent to the full price of the apartment. $5500 a month.

After breakfast she slept until her exercise nurse came at 10 am. She cycled for an hour, I made sure the exercise nurse brought her back for another hour’s nap. Then the regular staff came to take her down for lunch, brought her back for yet another hour’s nap. She then slept until exercise nurse came at 3pm, then waited an hour for dinner. After dinner, on those two nights a week when they had movies, I would wheel her up to the movie, at least they would bring her back to her room. If it was getting too late, when they were understaffed, I would go and get her.

Here in Panama she gets a movie every day. She sleeps less and exercises more.

That was her schedule when she left the nursing home to move to Panama. It had evolved over the years. The nursing home would have done none of that, it was only because I was there to push it, that they adapted to her needs. Once the schedule was set, even while I was gone, they maintained it. The problem with all nursing homes is that they do not execute the process that the patient needs, they just execute the same process for all clients. It was only because I was there all the time that they did at all what she needed.

Here in Panama, they do exactly what she needs. Every day we observe and adapt to her actual needs. The staff do this with minimal intervention on my part. In fact now, I get it wrong more often than right. And they tend to listen to me.

The dreaded WheelChair.

We will now back up a little bit to the time when she started using a wheelchair.

Our room was on the top floor and far end of one building. The cafeteria was in another building. Initially the nurses would walk my mum up and down every day. Remember she had just come from the other nursing home, and a debilitating Urinary tract infection. At first she got stronger, later as she got older she slowed down. Remember each nurse had 15 patients, and had not the time to be walking her, nor any motivation. Quite the reverse, the only reason they did not put her in a wheelchair right away, was because I was there to discourage it. But I was not there all the time.

There were times when I spent months in Los Angeles next to my families bedsides. There were times when I was gone, visiting my kids in Northern California. I would stay in Youth Hostels, and even lived in Yosemite Valley walk in campground for a few weeks. One day it snowed on my tent. That was fun. I would come and go. That seemed like a fair compromise between what my mother wanted and what I wanted.

I tried so hard to get my brother to walk. Eventually it was clear it was hopeless. Not only did I lack my sister-in-laws support, she actively got in the way. It is okay for my mother to be dying in a nursing home, but it hugely violates the natural order for my brother to be in that situation. Eventually I gave up in disgust, went off depressed to Canada for 3 months. On that trip, when I was not watching, is when my brother,John, bought the stocks just before the 2008 market crash. That is when the nursing home, put her in the wheelchair.

Once a person is in a wheelchair, things get much worse quickly. They do not walk. Their blood pressure goes up. They get vertigo, fall over break their hips, and go to the hospital. Only 50% come back from the hospital. The statistics say that if a patient walks less than ¼ mile they will be dead in less than 5 years, and the less they walk the sooner they are dead. Clearly exercise keeps the elderly alive.

Here in Panama we only use the wheelchair for outings. She walks all around the house, leaning on the staff.

This did not look good. Time to do something. For 40 years we had begged with mum to exercise. She never did. This time I insisted. Experiencing vertigo she was scared, and she complied. We hired a nurse to come and exercise my mum on an exercise bicycle. $12 an hour, first for one hour, then for two hours a day, 30 days a month , came to $760 a month. It worked great. Her blood pressure came down. By December she was starting to get up out of her wheel chair by herself. That is a wonderful thing, but of course the nursing home staff discouraged it. Time to move on.

Romance In Chile.

I thought it would be great to move to Chile. Mum seemed to think it was a good idea, so off I went to check out the country. Only much later did I understand she never wanted to go to Chile, but was trying to avoid the conflict. Send me off to get it out of my system. Who knows what her plan was. She did find a way to manipulate the decision.

Chile is such a wonderful country. This was January of 2010. My instincts and timing were great. They had just been accepted into the OECD, Organization of Economic Cooperation and Development. The 20 most industrialized countries in the world. The roads are brilliant, the buses are brand new Mercedes buses, with clean pillow covers. And yet they still have the third world vendors who walk onto the buses selling sweets, and newspapers. And salaries of about $300 a month. I love Chile. If we had bought a house there then it would have appreciated a lot.

Valparaiso was so good for my health. The health of caregivers often suffers so let me speak to this point. I thought we were moving to Valparaiso, so I went looking for a house to buy. . Six weeks walking up and down hills got my blood circulating like crazy. I am diabetic, the sugar clogs the arteries. Aerobic exercise cleans out the arteries, and made me so alive. As soon as my mum dies, off I go to hike the hills of the world, San Francisco, Valparaiso, Krakow and Turkey. In the meantime, I have been stuck in flat Los Angeles, and more recently in too hot Panama. My health has suffered accordingly.

Chile was also great for my love life. For reasons I do not understand the Panamanian women are not chasing me, but the Chileans were. I was divorced in 2000, quite happy being mostly single until 2010, but since then I have been keen to find a partner. I met my current “wife” on the flight back. She hugely supports my caring for my mother. She is also looking towards her old age and values my expertise in these matters. In contrast so many of the people in my support group have problems with their spouses not supporting their caregiving choices.

I am not sure why but the Panamanian women do not find me attractive,and I do not find them attractive. Sure you see a number of older gringos dating younger Panamanians. One old gringo with a wife also past her prime honestly said: “But I can’t afford an upgrade”. Another such couple we sat next to did not say a word to each other throughout dinner. I choose not such a relationship.

Columbian women are much more beautiful. A third friend found his wife on ColumbianSingles.com He has a child, she has a child, they have a child. It was the commercial attache to the Canadian consulate in Chile who told me that it was well known that: “if you go to Columbia single, you come back married. If you go there married, you come back single.” Meaning your wife divorces you for being unfaithful.

There was one Panamanian woman who did find me interesting. She sat down next to me on the bus. It was dark. She “fell asleep” leaned her head on my shoulder, her body close to mine. I really enjoyed it. My girlfriend who was sitting across the aisle was so angry at me! “But I did not do anything” I protested. “That is the problem” she replied.

My mum never wanted me to have a girlfriend. She worried that I would ignore her concerns and focus on the girlfriend. It is a legitimate concern, reinforced by my abusive elder brother’s behavior. When my eldest brother brought his russian wife and her daughter to live in her accessible house, it freaked her out. And for the longest time I was broken hearted from divorce, and did not really want to be involved with anyone. So that worked out. It is only in 2000 that I wanted a partner. And fortunately I managed to find an angel who not only approved of my taking care of my mother, but was hugely interested in the process of elder care for herself in her later years. It has worked out great. Except for mum who stares at her, wanting her to leave, clueless that if I am happier, mum is better taken care of.

Not everyone is so lucky. Many caregivers have problems with their spouses. While I am blessed with one who supports what I am doing others range from unhappy to ready to find an upgrade. I even heard of one case where the wife, a professionally trained nurse, wanted to take care of the mother-in-law, but the husband dumped his mother in a nursing home.

Two very sick years.

While I was gone in Chile, the nursing home threw out the exercise bicycle. Remember they prioritize the facility looking good over people’s health. And it was an old bike. They did not care if a lot of people were using it. My mother spent a few weeks without exercise, and no one told me. The exercise staff did not tell me. I called mum twice a week, but mum did not tell me. She just said come back soon, without telling me the reason. I should have called her nurse once a week.

Meanwhile in Chile I had not found a nursing home for her. I needed another week. By the time I returned to the US, she was a complete lump. And I was under the 3 week tax rule, I could not spend more than three weeks in the country, and still qualify for the $92,500 foreign earned income tax exclusion. I was so angry at her screwing up our move to Chile. At the time I did not understand that she had never wanted to go there. I was desperate to stay in the country less than 3 weeks. Fortunately I had met a Japanese woman on the airplane home, she invited me to her country. I bought my mum a new bicycle and off I went. Big Mistake.

Of course when I got back, mum was doing even worse. She had not been using the bicycle, she was quite catatonic. You have to keep an eye on your staff or they do the wrong thing. For one thing they just do not have my understanding of biology, physiology, and health maintenance. For the other thing, they just do not care. Probably I should have called them twice a week also. Rule #6 Keep a close eye on your staff. They do not love your parent.

I cannot describe it medically, but when I got back, there was the feel of death around her. It was terrible. Now she is older and weaker, and slowing down, but does not have that horrible sense of death about her. From January 2010, every time I would leave Los Angeles her health would go down hill. I was stuck in Los Angeles. I could leave and my mother would die, or I could stay and be depressed. I chose the later. I ended up finding a girlfriend I was not proud of. My diabetes was the worst ever. I did not take good care of my health, lost a front tooth, and needed 4 crowns altogether. It was a terrible time for me.

Now a wonderful panamanian dentist has now created the 4 crowns for me, $450 each. But I had to fire two very bad dentists before finding this one awesome one. He even had USB x-ray film, a technology none of my US dentists had. His dental processes are so different. He gives me wonderful time and attention, something often lacking in the US medical system.

It is amazing both how bad and how good the dentists are here. “This is Panama.” Rule #9 Consider the caregivers emotional, and physical health in your decisions.

Sadly I could not move my mum to Chile. First she did not want to go, and more importantly the elderly people who are moved against their will usually die quickly. It is called relocation trauma, it is an observed phenomenon. We were stuck. It was a terrible situation. I chose to stay and keep her alive. If you are reading this article, You would too.

Fortunately nature took its course. Mum kept getting weaker. Eventually she required two nurses at a time. The nursing home said she had to move out of assisted living, and into skilled nursing. Here we had this lovely two bedroom apartment far from everyone All very private. In skilled nursing it was small and crowded, and lots of nurses nearby. Worse yet it smelled, as do so many later stage nursing homes.

So we took mum to go and look at the place. There were all these zombies sitting at lunch. I was a bit naughty. I wheeled mum around so that she could look at their faces. She took one look, and said “Get me out of here”. We were free to leave Los Angeles. HURRAH! Out of the frying pan and into the fire!

By now my mum had been living in nursing homes almost 3 years, well past the expected 1.5 years. Her nursing home insurance had run out. That was another reason to move on.

Also she was getting much older. As they were getting ready to kick her out, one day she was not even able to stand. What to do?

Korean Medicine.

The lessons I learned taking care of my brother proved invaluable in taking care of my mother. There was a Korean student intern at the nursing home, and she had been offering a class in Chinese Herbal Medicine. I signed up for it, and had scheduled an appointment to visit the Jaseng center in Los Angeles. The doctor there was trained in both Chinese and Western Medicine.

Coincidentally the day before the appointment, mum was not able to stand up. They could not transfer her to her wheelchair. Big trouble. The whole structure we had set up would collapse instantly if she were bedridden. I physically helped the nurse for a day. Fortunately we had an appointment with the Korean doctor the next day, he gave her some medicine for her kidney chi. The following day she was standing up. Amazing! To this day she is dependent on her daily dose. Every time we reduce it, she fades. It is a bit hard bringing it into the country. And worse yet we have not found a local Chinese or Korean doctor we like to customize the prescription for her. Such specialized services are more available in the US.

Turns out Korean Medicine is even better than Chinese Medicine. . We met one Korean woman whose mother was completely cured of a stroke with Korean medicine. You see during the cultural revolution, Mao Tse Tung simplified Chinese medicine. But Korean medicine dates back thousands of years.

Western medicine and oriental medicine have very different models. Western Medicine is very reductionist down to the biochemistry level, and infectious processes. If you are in a car accident use a western doctor. Korean medicine is more strongly based on empirical observation. Their focus is on the health of the organs. It operates best on time scales of months. As you get older your chi expires. The kidney is the source of your chi. In fact my mother was always worried about her weight, never drank enough water, and that is hard on the kidneys. So her kidney chi is weak. And that is the source of all the other organ’s Chi.

The reason Chinese medicine is better than western medicine for elder care is that they have a superior model of the ageing process. They look at how the individual organs age. Rule #7 Use Chinese Medicine to understand and manage the aging process. Use western medicine to understand disease processes.

Anyhow mum was getting weaker, it was time for her to move to skilled nursing, she did not want to go there, so this time we were able to leave town.

So where should we go?

Thank god I had been working on relocation plans literally for the previous six months.

When I take a look at the world, I see the first world nations as highly desirable places to live. Canada, USA, Europe, Japan, New Zealand, Australia. Sadly wage rates for elder care are prohibitively expensive. A lot of the other countries are just too dangerous. No point listing them all. I walk a lot, getting hit over the head once ruins your whole life, as I found out with my brother Matthew. In the Americas the three safest places are Cuba, Panama, and Chile. Turns out Panama and Chile have the best internet access, Cuba the worst. Since I work on the internet that is important to me. While Americans are allowed to travel to Cuba, it turns out trading with the enemy act prohibits us from spending money there. For reasons based on her false notions, more than on reality of the country, mum refuses to go Chile. That left Panama in the Americas. But neither mum nor I was excited about the choice.

Looking at the broader world, the three “Third World Nations” that get my attention are South Korea, Chile and Turkey. I use the quotes because they are really first world countries with third world prices. All three of those have modern infrastuctures, way way better than the crumbling US infrastructures, and yet labor is typically $300 a month. Sadly asia is out, too alien for mum.

Mum always wanted to go to Turkey. And I speak Polish, so the plan was to go to Poland first, and from there I could travel to Turkey, set things up, and we could all go. Also as people get older, others watch for elder abuse. We even got visited by one such agent, thankfully mum passed the interview with flying colors. To avoid problems, The simple solution is to make decisions that all her family and friends agree to. Her friends all said that she always wanted to go to Turkey, so that was an acceptable legally defensible plan. It is good to be mindful of the law, even though the statues on elder abuse are hugely vague.

So we were planning on going to Poland then Turkey. We even bought tickets. Me, I am young at heart and male, I would have just packed my backpack, bought a copy of Lonely Planet guide and gone. But my mother is old and fragile, and with her I move much more cautiously. I asked everyone for their opinion, I even asked her Chinese Doctor for permission to travel. He cued us into the problems with travel. If she flies to Poland “she has a 70% chance of being uncomfortable!” He said in his broken English. “What ????” said my dear friend ZVI. “When I travel I have a hundred percent chance of being uncomfortable.” We later understood that what he meant is that she has a 70% chance of not surviving the transfer. Jet lag is so exhausting, even for the young. For the fragile elderly it is perhaps life threatening. Yes flying to Poland meant that she had health insurance when she arrived, and for the three months she is allowed to stay in the Schengen countries, but I would rather not take the risk of having her admitted to the hospital there.

Anyhow it was good advice. Sure I could move mum, but don’t go too far. I am male, naturally too aggressive, wanting to go far afield. The wise advice was to just go a short distance. And then it is easier for friends and family to visit, and for me to go back to visit my kids. So the first stop is Panama, who knows if we will ever leave for Chile or Turkey. Maybe we are stuck here.

MOVING TO PANAMA.

I could not have moved to Panama but for the help of my dear friend Sandy. I travel easily, but when dealing with my mother I made sure every detail is accounted for. I had a million questions. He answered them all. Health Insurance, banks, staffing, labor law, rental law, hospitals, dentists. You name it. I found a house to rent on the web, and asked him to go and inspect it. 5 bedroom mansion for $1000 a month. He liked it so much, he moved in with us, which worked out brilliantly. We had a local spanish speaking expat in our house. Another real estate agent highly recommended his deceased friends caregiver. Sandy set up the video conferencing interviews with a fluent translator. Same for the second interview. When people showed up late, he told me not to worry, “This is Panama. “ It is a phrase you will hear frequently. He set my expectations and standards for how things work here. I thank him enormously for providing a soft landing. But all good things come to an end. Eventually we outgrew him, tensions increased and we were both happy to part ways.

The interview felt more like she was interviewing us, than the other way around. She had a job, was happy and safe. We were the ones who had to perform. It is not like the US, where someone would take this job sight unseen. Here the employees have so much power. So much pride. They are not hungry.

I had the idea all wrong. I thought if they were making so little money, I can treat them like dirt. Actually they are quite wealthy at that income level. Sure they share a house with their family, and yes they borrow from each other frequently, such as when school starts. There is a tremendous social safety net. Free school, free breakfast and lunch in school. Free medical clinic here in the valley. The kids get a free laptop once a week. They get paid for a 13 months. They get a month’s vacation every year. Lots of other things I do not know about. But they are happy, and have their pride. They have tremendous pride. Which is one reason why they do not chase the foreigners romantically, because they would lose respect in their community. And it means that you have to treat your staff with respect. Sure the Panamanians treat their servants like dirt, but as the economy picks up, the staff also picks up and leaves.

Another reason they are financially well off is that they use a different basket of goods than we consume. They eat rice, beans and chicken all the time. There is a huge chicken farm near here. They have so many trucks going up there, the farm paid to repave the dirt road out to the farm. Basically I do not understand their lifestyle, but I know that I do not understand it. More importantly I listened to my friend Sandy on how to deal with them.

A big part of their compensation is living with us. They have a lovely house here. They sleep in the same room as mum, they feel safer that way. We have excellent food here. Some of the caregivers joke about the fat staff who eat too much, not that I have seen it. Their friends drop by to visit. They spend way too much on their cell phone bills. One of our staff had a romance with the gardener, at our first house but we have not seen him in a while.

On with the story. . We needed a second person, so our first person found an acquaintance to take the job. When our second employee did not show up for work one day, our first employee worked her shift, happy to get paid extra. When this happened a second time, I had her recruit a replacement for us. Paid her $80 for finding us our new second person. All is well.

We live in El Valle, three hours by bus $5.00 one way, from Panama city. It is the only inhabited caldera in a dormant volcano, anywhere in the world. It is higher here, and much cooler. Almost tolerable for those of us who come from nordic backgrounds. A lot of the wealthy Panamanians have houses here. That has two effects. First of all,it politically suppressed the high rises and golf courses found in so much of Panama. And secondly here and in another wealthy enclave, Isla Contradora they have free local hospitals. The service here is great, although their equipment is lacking. Labor rates are lower than in the capital, as are rental prices.

MEDICINE.

Well my mum had some minor problem recently, and just to learn the lay of the land, we rushed her to the local hospital. Wheeled her out into the street, and flagged a passing taxi. $1.50 for all of us one way. They even have an ambulance donated by Japan. This hospital is open 24×7, but I think the ambulance is not available on weekends. I think they have 4 doctors, of which 1 speaks english, one understands it and the other two do not. The service was free. FREE! We had to show our passports. Actually the service was excellent. Although their equipment is limited. There are other hospitals, and strong libel laws, so I need to be careful what I say. But most people here know what are the good hospitals, what are the bad hospitals, and which hospital is good, but nickels and dimes you to death. You just have to ask. There was also some story of an infectious disease in some of the hospitals, something like MRSA. But I am sure that is everywhere, not just in Panama. And of course it is worse in some hospitals, better in others.

Someday she may have a problem, and the local hospital should be able to solve it. Or maybe they have to rush her an hour down the hill to a larger place. And we are well aware of the risk that she may not make it to the life support systems they have there. But maybe it is better that way.

Actually my mother is on life support. Not the traditional tubes and ventilators we think of. She lives off the energy of her staff who literally keep her alive. Who now know how to do it so much better than I could.

A large part of elder care is keeping the body going. In Panama they are doing an great job with my mother. It is not just elder care that she is getting here, she is getting Physical therapy. They put her on an exercise bicycle twice a day. They play catch with her 15 minutes a day. Great for coordination. And since she does not throw the ball back very well, it is great exercise for the staff as well. She never liked a rocking chair, but they now put her in a hammock every day for an hour. Rule #8 Physical Therapy is central to longevity and a happy ending.

FOOD.

I am always hungry up here. I walk to the open air market every day and bring back as much food as I can carry for the three of us. It is great fresh vegetables, for not much money, 50 cents to a dollar a pound, and there is ground beef and chicken. The regular beef is too tough to chew, even for me, let alone mum who is losing her teeth. And that is about all there is up here. We have to cook everything from scratch. Yes there is processed food in the 5 chino stores, but it is mostly cheap, with high sugar content, and so we do not buy it. Instead we have this very healthy diet close to the earth. One market stall even grows food in the garden behind it.

And of course the best food in the market is on the weekends. That is when people drive up here, my American friend with the gorgeous Columbian wife shows up every Saturday, as do many others.

Is it organically grown? I think not. They do not care about chemicals. But they do care about money. So I believe that they use way less chemicals than American producers, and way more labor. Who knows for sure.

Since I am always hungry, I am a huge fan of desserts. I know every single dessert available anywhere in El Valle, and also many of the sources of dessert in Coronado and Panama. We even had an ice cream party up here. No sliced almonds anywhere in town, but I now know one family that stocks them in their freezer, and will lend in an emergency. That is a common trait. To know exactly what is available in which store, and to talk about it with others. It is so different from the US.

There is no cheese in town. Well almost none. Cream cheese is available. American cheese with plastic wrapping that I hate is everywhere. Occasionally we can find an Asiago in Centro Commercial. That is about it. For good cheeses we have to catch the bus an hour each way to Coronado. We have these two big shopping bags. And of course we are almost the only ones on the bus with groceries. The expats drive. The Panamanians shop locally.

We do get milk from the store. And fruit juices with sugar. Sugar free orange juice is available in Centro Commercial. A new bakery opened that distributes small bread rolls through the Chino stores. Delicious. There is an organic milk source in town. There is an organic farm, but I was not impressed.

We eat a lot of popcorn. The dutch butter is better than the local butter. You have to get the western herbs to flavor it from the big cities. Our spice rack is a precious commodity.

Forgive me for giving such boring details about what to buy where, but it is really how we think about food here. It is not that we drive to the super market and get what we want. We have to eat local produce. Locally grown. Everything else is a luxury. Very primitive really. So we are always thinking about food. I am sure our ancestors were the same way.

Next Year a big supermarket chain, El Rey is opening in town. I am kind of sorry to hear it.

INTERNET

Sometimes I work on the internet, so internet access is critical to me. Panama and Chile are the only two South and Central american countries with internet competition by law. In many other countries, such as Costa Rica internet and telephone is government controlled monopoly, so the service is intentionally bad. In Costa Rica they charge 10 cents a minute for phone calls. That is way too expensive for call center kinds of work. So skype makes sense, but hugely drains the government income. Accordingly the government blocks it, and internet telephony in Costa Rica, and many other countries is terrible. Maybe a VPN will get you around those problems, I am not sure. When we were in Costa Rica, VPN’s were not so readily available. In contrast, Panama and Chile have competitive networks, and one can get great service.

There are three internet service providers in El Valle. Strong libel laws here so I cannot tell you who has the better service, just ask anyone and they will know. Reportedly there is a third wireless provider in town.

It is so boring here in El Valle. We would go nuts if not for the local expat who has a lending library of DVD’s. Another friend of mine is much more high tech. He downloads movies off of bittorrent. He port forwards across his DSL modem, so he gets a movie in about two hours. Then he bought a openvpn VPN server, so that no one can track his IP address. Not that anyone cares in Panama. Finally he pops the downloaded movie on a USB stick which he then plays on a new High Def TV. Every night he cuddles up to his Panamanian wife, and watches some independent or foreign film with Spanish Subtitles. Not all gringos are that technically sophisticated of course. Some pay more attention to copyright law.

DEATH

Here is the final chapter, which I am not yet able to write since both my brother and mother are still alive. But I do know that death is a normal part of life. Rule #10 Like the song says. There is a time to die. One mother in our support group is in pain, and wants to die. The other day my mother lifted her other foot, so that it would get massaged next. She wants to live.

CONCLUSION

What do I think of Panama? My local Chinese doctor said it best. There is a certain energy in Panama. If it suits you, you are happy here. If not, you are not happy. No one follows the rules, no one even seems to know the rules. When asked what the rules are, everyone gives a different answer. My friend the libertarian loves it. Me, I prefer Chile. The rules there are well defined. Everyone knows them. If you do something wrong you get caught quickly, and released quickly. Here the rules have lots of different interpretations. Almost no bribery, just different interpretations. Panama is great for some, not so great for others. It all depends on who you are. Remember “This is Panama”

10 Commandments again.

So here are the 10 simple rules of eldercare repeated. .