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?