A humane society at large.

North American upper and middle classes are a rich elite in the current world economy, and many people of this social standing feel an obligation to share their good fortune by donating time or money to humanitarian organizations. Some of these organizations, however, often are more effective at uplifting the moral conscience of their supporters and members than working toward their explicit goals of helping other people. In fact, some are actually creating problems for the people that they are trying to help.

In this category, I witnessed a five-day Church of Christ medical mission to the indigenous reservation of Kuna Yala, formerly called San Bias, in the Republic of Panama. Prescription pharmaceuticals were liberally distributed to thousands of people who did not need or understand the medicine and, consequently, misused the drugs. Nonetheless, mission participants returned to their comfortable North American lifestyles genuinely feeling that they had done good deeds, unaware that their visits were creating harm.

I first encountered these missionaries while I was seated on the sandy floor of the puberty ceremony house, fulfilling my responsibility for community work for the small Caribbean island where I was conducting an anthropological study. I casually chatted with representatives of the other households on the island as we helped prepare inna, a dark alcoholic drink, for a huge coming-of-age feast to be held in some weeks' time. Everyone suddenly grew silent as a North American man dressed in blue hospital scrubs walked into the dimly lit, palm-thatched building. Someone whispered in Spanish (for my benefit) that the man was one of the doctors. Two similarly dressed white women stood at the door and started taking pictures with a flash camera, which caused an outburst of shouts.

All of the missionaries, including the high-school-aged volunteers, wore blue hospital scrubs, which invited the label doctor. There were two teams of medical missionaries staying on the island where I was living, and they were sponsored by several congregations in the southern United States. Each team had only a single doctor, along with an optometrist, a pharmacist, a dentist, five registered nurses, and over a dozen volunteers unconnected with the medical profession. They had come to Kuna Yala in order to set up a temporary health clinic where, according to their own figures, in five days they saw 1,966 medical patients, filled 8,229 prescriptions, extracted 391 teeth, scrubbed 322 heads for lice, and handed out 303 pairs of eyeglasses. But the outcome of their visits is not as straightforward as their figures suggest. For example, I recorded several accounts of individual Kuna who in years past had taken the missionaries' free pills and, when they did not immediately produce the desired results, swallowed the rest of them, inadvertently nearly killing themselves in the process.

Most of the people who participated in this medical mission genuinely believed that they were helping the Kuna. Many of the volunteers made great sacrifices to come on this trip and paid a large portion of their,personal expenses out of their own pockets. One woman, who had been coming to Kuna Yala for years, told me, "I broke my arm the morning that we came, but I came anyway... I love these people. I take care of these people. They know I do. I'm seventy-seven years old, and I hope that the Lord gives me many more years to come down here and be a part of their life." These are only the best of intentions. This desire to help other people is widespread in our culture, and my own motivations for documenting the consequences of the missionaries' visits are related to those same ideals.

Latin American Missionaries (LAM), whose explicit purpose is "to reach 77,500,000 lost souls," is the parent organization of the medical team that visited Kuna Yala and a ministry under the Elders of the Forest Park Church of Christ in Valdosta, Georgia. A promotional brochure reads: "The hungry have been fed; The sick have been healed; The poor have had the Gospel preached to them; And the work continues to grow." According to Larry Calendine, a professional missionary who I met in Panama, the organization has an operating budget of about $1 million (U.S.) per year to support programs, which include a school for preachers in Panama City, native preacher support, evangelistic campaigns, a Spanish printing press, and medical missions.

In October 1997, I went to LAM's "emphasis weekend" at the Church of Christ in Mount Juliet, Tennessee, along with people from congregations all over the southern United States. In a speech to encourage those attending to donate more time and money to the organization, Calendine said that the elders have taken out loans in order to support their new programs. This group is now operating in Honduras, Nicaragua, Costa Rica, Panama, Columbia, and Peru.

The LAM medical teams' activities are quite broad in scope and affect an astonishing number of people. According to a promotional website put up by the group, "1997 was the busiest year yet. A total of 331 people from the US went on 10 different teams. Those teams saw 18,063 patients in 13 different villages. Almost 70,000 prescriptions were filled; 1900 dental patients with 3,139 extractions; over 4,000 heads scrubbed for lice." The aim of this program is for "professional and non-professional Christian campaigners [to] go where doctors are few and needs are greatest." With this in mind, it is interesting to note that the island that they visited in Kuna Yala has a clinic that the Panamanian Department of Health operates year-round.

In Kuna Yala, the missionaries set up an assembly line to process large numbers of people. This resulted in misdiagnoses and the inappropriate distribution of prescription drugs. The Kuna who wanted to see the doctors had to wait in line first to get a paper sack with a form that had a place for their name and personal information on one side and a checklist of different drugs on the reverse. Next they filed into the community meeting house where Panamanian health officials shuffled through papers checking immunization records and occasionally giving shots. The people were then ushered out into the blazing sun, where they waited in line to be diagnosed by a nurse, who served as a gatekeeper to the rest of the operations. Few of the missionaries knew any Spanish, and only some of the Kuna spoke Spanish fluently, so the interview by the nurse was usually translated from English to Spanish to Kuna and then back again. In addition to this linguistic confusion, the diagnoses of the nurses were further clouded by the fact that they were asking people to disclose embarrassing personal information with large numbers of people crowding around.

A registered nurse who currently lives near New Orleans told me that she enjoys medical missions in Latin America because she does not have to worry about malpractice suits and can treat each person the way she thinks is best. On the second day of the missionaries' visit, I sat by the nurses' station for several hours, helping with translations when called upon and observing the procession of people. The bulk of the Kuna who came complained about headaches, runny noses, congestion, and joint pain and were given Tylenol to relieve the symptoms. For the sake of efficiency, the nurse rapidly diagnosed such things as scabies and pinkeye and checked the box on the form, for the appropriate type of prescription medicine.

From the nurses' station, the people were directed either to the doctor, to the pharmacy, to the dentist, to the optometrist, or to get their head scrubbed for lice. Children were indiscriminately sent to the head-scrubbing station, where they were publicly dowsed with insecticide. The only thing that the dentist had time for was teeth extraction, and I watched as a nurse sent one howling young boy, against his will, to the dentist in order to get his rotting front teeth pulled out.

Some people who came to the doctors considered themselves sick and wanted treatment. But it was no secret among the Kuna that many healthy people came to see the doctors for handouts of soap, shampoo, and toothpaste, which they preferred to get free rather than buy from one of the general stores on the island. Even some of the missionaries recognized this. At the meeting in Tennessee, a registered nurse from Kansas City told me, "Most aren't sick when they come." The Kuna man that I lived with told me that, several years ago, when the doctors gave out large tubes of Colgate and lots of soap and shampoo, people from all of the surrounding communities swarmed in for their visits. But now that they only give out tiny tubes of toothpaste and no soap, not as many people come. The people who come for the free personal care products are also given a bag containing prescription drugs, with little explanation of their uses and no mention of their hazards.

At the pharmacy, set up in the shady school house, there were half a dozen missionaries packaging or handing out drugs or otherwise standing around and watching people file through. The Kuna would hand in their forms and receive small ziplock packets of pills and sometimes bottles and tubes of medicine for every box that was checked on the form by a nurse or the doctor. Everyone received a packet of mebendazole to kill worms, as well as a package of generic vitamins. The label on the worm pill packet reads: "Mastica 1 pastilla 2 veces al dia para 3 dia para lombrices, presentado por la Iglesia de Cristo" (chew one pill two times per day for three day [sic] for worms, presented by the Church of Christ). There was little on the printed labels to distinguish the different types of drugs from the vitamins or one another. All that was written was the frequency with which they should be taken and a single-word description of the indications--that is, pain, cold, fever, or infection. These packets were given to the Kuna by translators who had neither the time nor knowledge to communicate much more than was written on the package. Latin American countries, in general, have more relaxed policies regarding the dispensation of drugs compared with the United States, and LAM has had to obtain a permit from the U.S. government to buy, transport, and dispense pharmaceuticals in other countries.

North Americans and many other people from industrialized areas have a great excess of material resources and high standards of health. We commonly feel the need to help those who do not have ready access to medical facilities or otherwise lack such fundamental resources. The missionaries are simply acting according to this belief. They are trying to alleviate the needs that they perceive in less fortunate people.

The nurse who told me that all of the Kuna are not sick, feels that everybody should be able to have some "basic things." She says that, when she comes to the island once a year for three or four days, she wants to be able to fix everything. Such genuine good will is hard to come by these days, and it is unfortunate that unanticipated problems have arisen from these efforts.

The Kuna do not share our assumptions about disease causation and our awareness of the dangers and benefits of modern medicine. In fact, no matter how many people I asked and in what context, the Kuna simply do not have a word for health (salud in Spanish). This is not to say that they are inferior in their understanding of such things but, rather, that their system of disease explanation is founded on entirely different precepts than our own. For example, the sore, itchy eyes that we commonly call pinkeye and explain as a bacterial infection (conjunctivitis) is described in traditional Kuna terms as contact with the poni, or the unseen, malevolent form of a jellyfish. Giving someone a packet of pills to take "three times a day for infection" could have serious implications if that person does not use words that easily translate into infection.

The worm medicine that everyone received is known to be toxic in doses higher than the recommended two 100 mg tablets per day. It can cause nausea, vomiting, fever, diarrhea, abdominal cramps, and a variety of complicated internal disorders. Since none of the labels contained warnings about taking more than the recommended number of pills, the stories about people almost dying from overdoses are not surprising. One year, the missionaries also treated the whole island with lindane, a prescription drug used to treat scabies. Known under the trade name of Kwell, this strong insecticide can cause anemia, neurotoxicity, nausea, vomiting, diarrhea, respiratory failure, giddiness, and fatigue, followed by tremors, convulsions, and coma.

The parasites targeted by these drugs are so common and benign that they are not viewed by the traditional Kuna as being pathological. Gregorio Martenez is a Kuna physician who earned his medical degree in the United States and operates a clinic on an island near to the one where I was staying. He told me that it was naive to expect to eliminate these annoying problems by washing the children with insecticide and giving everyone anti-parasite pills once a year. Usually he does not treat these problems unless a patient develops serious complications. It is not clear that the potential benefits of a temporary reduction in the numbers of annoying parasites outweigh the risks of using these toxic medicines.

Individual Kuna who were sick had difficulties communicating their problems to the missionaries and understanding the medicines that they received. The ninety-year-old grandfather from the household where I was living had a chronic cough, which he called asthma. I talked the nurses into letting him see the doctor. After listening to his chest and talking to him through a translator about his asthma, the doctor said, "He probably has T.B. [tuberculosis], but we'll call it a respiratory infection." The man was sent to the pharmacy for a long list of drugs (pseudoephedrine HCL, erythromycin, theophylline, plus the usual worm medicine and Tylenol) and a bottle of cough syrup. The cough syrup was finished off in a couple of days, but several days after the doctors left, the man gave the whole mini-pharmacy to a friend who worked at the health clinic. He said that the medicine was not strong and that he didn't understand it. On the original English label of his generic Robafen DM cough syrup there was an explicit warning: "Do not take this product for persistent or chronic cough such as occurs with smoking, asthma...." Such a blatant inconsistency would be immediately noticed and questioned in the States, but in places where few speak (much less read) English, this goes unnoticed.

The children, who were even less able to understand the foreign goods, were each given their own bags of medicines. All of the intact commercial packages I could find, even the Tylenol, carried the universal warning in English: "Keep this and all drugs out of the reach of children." I did not see this warning on a single one of the labels that had been printed in Spanish by the missionaries, nor did I ever hear this communicated verbally to any of the masses of families as they received their drugs.

The day after the missionaries boarded their plane and flew off to Panama City, I came back to the island to find all of the young girls in the house where I was staying playing doctor. The only other adult who was there, besides myself, was the old grandfather who lounged around in his hammock and then wandered outside. In the bathing area, the children played head scrubbing. They told the two-year-old boy from next door to sit in a blue plastic chair. The seven-year-old daughter of the woman whose home I lived in smiled at me, opened the bottle of Lice-Aid shampoo with her teeth, and squirted it all over the boy (the shampoo is an insecticide made of pyrethrum extract and piperonyl butoxide). The flock of girls soon ran into the back room, and one of them a brief time later stood next to me and flashed open her palm, revealing red and white pills. They then covered up the littlest girl in the center of a bed, where she started crying. The other girl, who had just showed me the pills, then came bouncing back to show me her now empty hands. These pills could have been any of a number of prescription pharmaceuticals. I remarked in my notebook how much more exciting playing doctor must be with real drugs and wondered how many other children on the island were playing similar games.

One of the intriguing things about mission work or anthropology is that travel to fascinating places is often involved. Kuna Yala is viewed as an exotic vacation destination by tourists from around the globe, and thus these medical missions are holidays for many of the participants. The nurse from outside New Orleans said the reason she comes on these trips is that they are the most fun thing she gets to do all year, and to come she takes one of her two weeks of annual vacation. In a formal interview, the doctor who was on the first Church of Christ trip to this island in the early 1980s said that the original reason to work in Kuna Yala was because they "were kind of entranced by the wind and the waves and the seas and the sun" when they had come there for a day of relaxation while on another mission trip in Panama. The Kuna recognize these motivations. One man told me that it is like a vacation for the doctors to come to the islands, see the sea, and look at the "Indians." One missionary brochure reads: "Select a trip and be ready for an experience which will change your life... a spiritually uplifting event." Providing these experiences to the North Americans is costly and adds up to the bulk of the expenses incurred on such expeditions.

People back in the United States would probably not be so quick to give away their money if they could see exactly where it was being spent. Kuna Yala has accommodations for tourists that range from simple, bungalows to resort hotels with swimming pools. The missionaries stayed in the most expensive resort on the island. As this team left, I watched Larry Calendine pay their $8,575 hotel bill for a five-night stay with eighty-six crisp $100 bills and receive $25 in change, This is a fraction of the total amount of money that was spent on this trip to transport and attend to the needs of the participants.

The Church of Christ congregation in Valdosta, Georgia, centrally organizes the funding for LAM through donations from some of the more than 15,000 other Church of Christ congregations and from private individuals. In addition, the individual participants on these missions are responsible for finding much of their own support. Depending on where the mission trip is located, the amount that each person must raise ranges from $1,200 to $1,400. This pays for a series of plane flights, the hotel bill, meals, taxes, and translators. Each participant is also encouraged to bring about $500 in spending money I talked with one man on the trip who said that there was a special donation plate passed around at his church for the people going on this trip and that it paid for about two-thirds of their personal expenses.

According to Luther "Creepy" Hodge, the pharmacist on the trip to Kuna Yala, the missionaries brought approximately $13,000 worth of drugs with them. When asked if they were giving them all away for free, he replied, "Ask the chief here if he can pay for it," indicating the sahila who chants ritual songs at nightly meetings. And many people simply threw out the medicine after the doctors left.

Individual participants in these missions are genuinely trying to help the Kuna, but these events show how sincere ideals can backfire. LAM is organized so that there is little dialogue between the missionaries and the people they are trying to help. As a result, mission participants do not perceive the full consequences of their visits. They return to their lives in the States feeling uplifted, thinking their work has relieved some of the world's problems.

The people who participate in such efforts by making monetary contributions from a distance are even less aware of the ramifications of their support, since the promotional literature they receive is tailored to only present information that is consistent with the purpose of supporting the group. The ideals which motivate this group are widespread in our society and should not necessarily be discouraged. However, it is imperative that such humanitarian institutions act responsibly and that their members are made aware of the often complicated outcomes of their benevolence.

On my last night in Kuna Yala, the man whose home I was living in told me a story about a big white man who went to South America where he saw that the local "Indians" were sleeping in huge holes at night to keep warm. Feeling sorry for them, he built a nice modern concrete house with everything that they needed. The people tried to live in this house, but every day it got to be unbearably hot and at night it was cold, so eventually they moved back into their holes. The big white man came back and saw his house abandoned and was furious at the stupid Indians for not knowing anything. The moral of this story is that whites usually try to help without knowing what is going on and often make problems where there are none.

S. Eben Kirksey is a student of anthropology and biology at New College of the University of South Florida. He has studied in Indonesia, Panama, and Costa Rica and is currently a visiting student at Harvard College. He can be reached at [e-mail] usf.edu and www.fas.harvard.edu/-kirksey/index.html.