Duffle Bag Medicine

"Duffle Bag Medicine" is a term that became popular after an article was published in JAMA (Journal of American Medical Association) in 2006 with this title.  The article describes a typical medical mission trip to rural Guatemala and describes what often happens when good-intentioned people go to third world countries in an effort to provide medical care.  We have seen this here in Belize as well.  A group comes down from the U.S. with bags full of vitamins, medicines and medical supplies.  They set up clinics in rural villages to see as many people as possible for a week and then leave to go back home.  On first look, this is seen as a great thing and those providers who come down and sweat it out in the jungle seeing lots of patients often feel really good about what they are doing but there can be huge problems associated with this approach.  First, these groups have no continuity of care and often operate without any knowledge of the patient's medical history.  The short-term work is not integrated into the local health infrastructure and so after the group is gone and the 30 days of dispensed medications have been taken, the patients are right back where they started.  These medications are sometimes not even available in the area and so even if sought, the treatment is not sustainable.  Second, public health and preventive health measures are usually not a part of the goals of the transient clinics.  All together, the result of these mission clinics do nothing to improve the overall health of a people and can even be harmful.

Here in the Toledo district of Belize, we at Hillside have attempted not to approach the delivery of healthcare in this way but to complement the present Belizean healthcare system and provide true primary care.  This past week Bill and I were able to sit down for a few hours with one of the Belizean doctors from a local government clinic, Dra. Peitra Arana, and her clinic administrator as well as Joyce, our clinic administrator.  Dra. Arana started about the same time we did in the Toledo district after finishing her training in Guatemala and although she initially seemed very reserved with me, we have been slowly building a relationship.  The big breakthrough came when she had a family of 9 from an outlying village who were infested with worms.  She had tried the traditional medication that the government clinics provide, abendazole, with no success.  She mentioned these cases to me one day at the government clinic when we did our regular morning stop to pick up charts for one of the villages.  We had recently acquired a large bottle of Ivermectin which I was able to share with her for this family.  Although she has few resources, she is passionate about her patients and was willing to try and speak out about the issues confronting us at the medical conference in Belize City.  

Barranco - our only Garifuna village

We sat down with them to make a strategy for this next year.  The geographical distances and lack of transportation in the Toledo district is huge.  The government physicians have no way to get out into the villages consistently to provide care and so have staffed more centrally located clinics while we have provided the mobile clinics into the villages in addition to our own centrally located clinic in Punta Gorda.  Even with these arrangements, we are able to only cover a bit over half of the villages and then only once every 3-4 weeks per village. There are a handful of villages which do not have roads into them and we rely on them to walk 1-2 hours out of the jungle to one of the other villages where we are holding clinic.  The question is, is that adequate?  Shy of recruiting many more volunteer physicians who could live in each village, is there another way to approach the needs?  Can we really call it primary care medicine instead of "duffle bag medicine" if we are only in a village once a month?  Yet we do keep medical records on all of our patients and have continuity from month to month with each of our villages.     

There are definitely no easy answers.  No decisions have been made as of yet but will need to be soon.  With 70% of our monthly in-country budget going to vehicles and gas to get us out to the people, it is something that needs to be contemplated.  There are not as many chronic patients out in the farthest villages but that is most likely because they have not been diagnosed.   I feel that we are doing the best with our current restraints and lack of resources while Bill has been brainstorming about staffing outlying clinics more consistently that are placed central to several of the farthest villages.  Transportation remains one of the biggest hurdles to care.  Would we be able to provide transportation to our patients with chronic illnesses like diabetes and hypertension to leave the village for their care?  If we were consistently in a particular place, would we make those diagnosis of chronic illnesses better and be able to treat?

The Forgotten District

This past week Bill and I went up to Belize City to attend the Belize Medical and Dental Association International Congress.  It was two days of medical education lectures for physicians practicing in Belize as well as Guatemala and the Quintana Roo area of Mexico.  It was nice to see the advances being made in medical care in Belize and there were some very well presented lectures in English as well as in Spanish.  The care in Belize City is still decades behind that of the U.S. in many ways but there are some good, very intelligent physicians working hard to make a difference.

We had the opportunity to meet an American doctor and her husband who are running another mission clinic in the northern part of Belize.  Although the north is far more developed, has a very different culture being so close to Mexico and has much more access to care, it was great to spend some time together.  Even though they are from Indiana, there was great camaraderie and a good exchange of ideas.  Their clinic is better outfitted than ours and they gave us some stateside contacts that might be helpful for us.  We live a bit more rustic and quite a bit more isolated than they do but she is jealous of my clothes dryer!  (Something I requested of Hillside before we came.). They have 3 girls - the oldest is Caelan's age and the youngest is Quinn's age and the boys enjoyed visiting with them over dinner.  

What was striking from the conference was the number of foreign physicians practicing in Belize - particularly Cuban and Guatemalan.  Belize does not have a medical school and has traditionally relied on the goodwill of Cuba to provide primary care physicians and more recently to train Belizean physicians.  It creates huge barriers in communication as the official language in Belize is English and the street language is Creole and unfortunately the Cuban physicians speak very little English.

The other striking thing was, like we experienced in rural U.S., the distribution of healthcare is not equitable.  The southern Toledo district covers an area of 1795 square miles and a population of over 30,500 but with only a handful of primary care physicians (including Bill and I).  Many of these people have very little or no access to the healthcare centered around Belize City.  Unfortunately, the people responsible for the healthcare decisions in the Ministry of Health do not seem to understand the access problems faced by those in the Toledo district.  For one of our patients in the village of Dolores to access care, they have to walk about 1 hour to the village of Otoxha where they can catch the Monday, Wednesday, Friday or Saturday bus at 4:30 am for a 2+ hour bus ride to Punta Gorda.  They have no access out of the village to care on Tuesday, Thursday or Sundays.  As I have mentioned before, if they need an x-ray, they have to take another bus about 2 1/2 - 3 hours north to Dangriga.  All the specialty care is centered around Belize City and Belmopan, 6 - 8 hours by bus north of Punta Gorda.  We have given many people bus fares for the trip north but they still have to come up with a place to stay as well as food to eat.  We have known these things for quite a while but our time at the conference in Belize City solidified our concerns - the Toledo district is really "the Forgotten District."

Thanksgiving in Belize

The Thanksgiving Day holiday celebrated with pilgrims, turkey, stuffing and cranberry sauce is a unique holiday to the U.S. however, people all over the world celebrate the harvest season.  At the beginning of November, the Harvest Thanksgiving is celebrated here in Belize.  The children practiced in school for their parts in the program and places are decorated with stalks of sugar cane, citrus fruits and dried ears of corn.

The corn has been harvested here in the villages and this a major staple in their diets.  When you are in the villages you can hear the corn mills before every meal as they grind the corn for masa to make their tortillas.  The citrus is also coming ripe - the market is now full of grapefruits, oranges and limes.  The Stann Creek District north of the Toledo district is home to many citrus orchards and there are trees scattered around our area as well.  

Quinn, his teacher and some other people in the community helped educate us on our part in the Harvest celebration.  Traditionally people bring a small part of their crops as a gift to the church in brightly decorated containers.  The church then distributes it to the poor or sells it to bring in some money.  Living in town with no fruit bearing trees, we did not have any "crops" to bring so our basket was filled with homemade banana muffins and cookies.  We decorated our basket with flowers from around our house to make what I call our Belizean cornucopia.

Belizean Cornucopia

The boys of Quinn's class presenting their gifts and telling what they are thankful for

 Girls in Quinn's class doing a Liturgical dance to Give Thanks With a Grateful Heart

Give thanks with a grateful heart

Give thanks to the Holy One

Give thanks because he has given 

Jesus Christ his son

And now let the weak say I am strong

Let the poor say I am rich

Because of what the Lord has done for us

Give thanks

- written by Henry Smith

The "Christmas Breeze" Is Coming

One of the best things that has happened over the past couple of weeks is that the weather has cooled a bit.  The temperature during the days is still in the 80s with a heat index in the low to mid 90s but it is much better than a heat index of 115-118 degrees everyday!  It is also cooling down at night to the mid to upper 60s which makes for great sleep.  You will still sweat during the day, particularly if you are in the sun, but overall it is a welcome relief.  Everyday now I find myself thankful for the wonderful temperature and the lack of the oppressive heat.  I actually have appreciated my surroundings a bit more and understand why some people like to vacation in Belize.

Now that school is in full swing, we have begun planning our health education and community outreach for the year.  This past week I met with all of the principals of the 7 schools in the Punta Gorda area (not the villages) as well as with the head of the Ministry of Education's Health and Family Life Education agency to find out how we can help provide health education to the school children in the Toledo district.  It will start this next week with the small school in Cattle Landing (on the outskirts of P.G.).  They have less than 30 students but many are infested with lice.  We have asked that all the parents come to the school in the afternoon so that we can educate both parents and children.   We plan on treating all of the individual students at that time.

Bill and I met with Dr. Solomon, the local Ministry of Health dentist, last week.  Dental needs often seem to outweigh medical needs in the Toledo district.  Hillside does not have a dentist but has tried to facilitate some dental care.  Dr. Solomon was very anxious to have Hillside help in providing dental care, particularly in the villages.  Last year a private donor provided enough fluoride for us to treat all the young children in the villages once.  Our goal is to do that again this year and this time include the children in the Punta Gorda area.  Hillside had applied for a grant from the American Academy of Pediatrics to fund the fluoride but we just found out that it was rejected so we will need to look for other sources of fluoride.  Dr. Solomon did give us clearance to use the dental chair that is in the San Antonio clinic as well as the mobile dental unit when we go out to the villages if we have a visiting volunteer dentist.

We have an eye doctor in town this month.  He is a volunteer from Australia working with Belize Council for the Visually Impaired (BCVI).  They are a non-profit group that provides free eye exams as well as treatment for a nominal fee.  They try to have an optometrist here in Punta Gorda for a few days each month and an ophthalmologist a couple times a year who can do cataract surgery and other procedures.  When they are not in town, we have to send people to Dangriga (a 2 1/2 - 3 hour bus ride away) so it is nice having an eye doctor for a consistent time, even if it is brief.

Rio Blanco