Where There is no Doctor: Un-Met Needs & The Challenge of Access
A couple of months ago, I was asked by at contact at the Wyss Institute (Harvard) to develop a list of medical conditions that would benefit from rapid diagnostic tools. In rural Amazonia, rapid diagnostic tools would be a major game changer in providing timely and appropriate patient care. As I started the list, my latent OCD kicked in, and this is the result. I was assisted in this process by three other NGO's that also provide health-care services in the Peruvian Amazon - they are acknowledged at the end of this blog.
The Amazon rainforest basin presents particular challenges for meeting the health needs of its inhabitants. The area is vast but lightly populated with a majority of the existing population living in a few larger urban centers where most health infrastructure and expertise is also located. Remote roadless rural areas are always at the tail-end of the medical service chain in terms of access, presence of medical professionals, diagnosis and treatment. Health systems in Amazonian countries are inadequately financed already, and resources and personnel are prioritized for urban areas where people (and votes) are clustered.
This is not a unique situation to the Amazon. The Congo Basin, New Guinea, Borneo, the Indonesian, Philippine and Melanesian archipelagos, and other rainforest locations in south-east Asia present similar challenges, as do the very sparsely populated northern regions of North America and Eurasia, and mountainous or desert regions worldwide. While this document is specifically focused on the Peruvian Amazon, I believe that it will be widely applicable to other locations as well.
Before going into the specific medical and diagnostic needs of the Amazon, it is important to consider the environment that has created these needs. From a patient’s point of view, this can be broken down into four considerations:
On the larger rivers of the Amazon, there are regularly scheduled boat taxi services that link large urban centers such as Iquitos (~500,000 population) with smaller towns that are more distant such as Pevas (or Pebas) with an urban population of ~5,000 and a district population of ~17,100. I’ll use the example of Pevas as a pretty typical example of the issues of access to health care and treatment. It is by no means an extreme example, however, with communities on the Putumayo, Pastaza, Corrientes, Yavari and other rivers having dramatically less access.
Pevas is one of the oldest towns in the Peruvian Amazon, and the first to appear on maps in the 18th and 19th centuries. Like other larger settlements in the Amazon, it is located at a river junction of a major river (the Amazon proper) with a smaller river (the Ampiyacu), giving it access to resources in the hinterland (lumber, bushmeat, rubber, indigenous labor [formerly slave labor], etc.) and access to markets (other towns up or down the Amazon). The location of Pevas within the Amazon Basin, and in relation to Iquitos (a younger but much larger center) is shown in Map 1. Iquitos is also the location of the only commercial airport in the region and where our Esperanza riverboat, which we use for medical service campaigns, is based.
Map 1: Location of Iquitos and Pevas in the Western Amazon basin in Peru
Pevas is the capitol of the Municipality of Pevas, and has government offices, free Wi-Fi (sometimes) in the central plaza, and a Centro de Salud (CS = Health Center), along with a daily market, many stores, a high school and various primary schools and kindergartens. There are no banking services or ATMs. A cell tower (Movistar) provides cell service to the town and immediate surroundings (within ~5 km). The town has electricity for a couple of hours each morning, and again from 6-10 PM at night (or later if there is a really good movie or a soccer match on).
There are no road connections to Pevas, but there is (almost) daily hydrofoil service to Iquitos which takes 4-5 hours. The hydrofoil is very expensive for subsistence fishers and farmers, and much too costly for anyone wishing to take produce or forest products to Iquitos for sale. Most locals traveling from Pevas to Iquitos take pamacari-style riverboats or river launches which are much more affordable, but also take 16-24 hours to make the trip, depending on river levels and the number of stops that they make.
Like other Centros de Salud in rural areas, the Pevas CS is staffed by 1 or (occasionally) 2 MD’s, a dentist, several nurses, lab and other techs, a biologist, an obstetrician, a pharmacist, and administrative, cleaning and service staff. There are 25-30 persons on the payroll. The MD’s are invariably recently minted doctors who are completing their obligatory rural medical service if they want to work at a Peruvian government institution (as opposed to going directly into private practice or getting a job at a private clinic). They are usually from large cities (Lima, primarily), and are mostly unfamiliar with the local culture, environment, and medical situation. During the more than 20 years that I have been visiting Pevas, none of the MD’s at the Centro de Salud have ever requested being posted there after having completed their obligatory service. Any Peruvian MD’s who are willing to work in remote areas generally head for Brazil where the pay for remote service is 4X greater than Peru pays for equivalent work.
The Centro de Salud in Pevas (left). View over the town of Pevas with the Ampiyacu River in the foreground and the Amazon River in the distance (right).
For many years, the dentist, a resident of the town, was the clinic head, and it is the nurses, obstetricians and techs who ensure that the clinic runs smoothly. Clinic hours are 7 AM to 1 PM Monday through Friday, and 7 AM-noon on Saturdays. Only emergency services are available on Sundays.
The Pevas clinic has its own generator for power and several computers, but patient files are still entirely on paper. The dental chair is in good condition, but there is no X-ray capability, and no capacity for major surgery of any kind. A small clinic speedboat can evacuate patients to Iquitos or take vaccination or malaria control teams to outlying communities. Under the local health network, the Pevas Centro de Salud is responsible for five outlying Puestos de Salud (PS) which are operated by 1-3 medical personnel – generally a technician, nurse-tech or midwife. If the PS is operated by a single person (usually a technician), it is obviously impossible to provide 24/7 emergency care. The technician will have to travel monthly to pick up salary and supplies, and regularly has to travel to the CS to submit reports or for training purposes.
The only diagnostic capabilities of a Puesto de Salud are (sometimes) a light microscope for examining malaria smears, a glucometer, and urine dipsticks; many PS may lack any of those. A Puesto de Salud basically provides first aid and serves as a vaccination and education center, with a focus on maternal, fetal and neonatal health. Out of necessity, a single technician (with three
years of training) at a PS may perform some of the functions of a nurse or obstetrician (each with five years of training), and clean and stitch wounds, give injections, deliver babies, and more. Of the five PS under the jurisdiction of the Pevas CS, four are located on, or very close to the Amazon River with its greater level of year-round access (see Map 2). Between them, the 6 health facilities serve a total of 56 communities.
Map 2: Location of health facilities in the Pevas district, and communities on the Ampiyacu River. Yellow pins represent communities on the Ampiyacu River that have neither a PS or a CS.
Travel times on Amazonian rivers vary widely throughout the course of the year. At highest water in the Peruvian Amazon (March-June) all river channels are full and many short-cuts can be taken to reduce travel times. At low water (August-November), exposed sandbars, shallow water, tree trunks and other obstacles greatly increase travel times, and often it is physically impossible to get to communities in the headwaters of smaller rivers. Over the course of the year, there can be a 15-meter (45+ foot) change in water levels on the main rivers. Smaller rivers don’t experience the same extreme, but river headwaters can rise or fall by 1-2 meters (3-6’) in the course of 24-36 hours depending on local rains. Looking at the distribution of communities on the Ampiyacu River and its tributaries (Map 3) illustrates the difficulties of access for more remote communities.
Map 3: Ampiyacu and Yaguasyacu River communities in relation to Pevas
During April and May, we are able to take our 72’ live-aboard Esperanza riverboat to all the communities on the river, including the most remote ones of Ancon Colonia (on the Yaguasyacu River) and Nuevo Porvenir (Ampiyacu River). Even then, the crew keep a close eye on river levels and rainfall, and if river levels start dropping quickly, the boat retreats downriver to deeper waters. It takes us a full 6-hours to travel from the community of Tierra Firme to Nuevo Porvenir, due to the extreme meandering nature of the river. This is characteristic for all lowland Amazon tributaries once the river moves away from the floodplain of the Amazon River itself. At low water, our riverboat can access Pevas and a short distance upriver (to Pucaurquillo), but after that only smaller boats can safely navigate. For headwater communities, only the smallest of boats (canoes with dragon-tail motors) are capable of movement at low water.
For residents of Nuevo Porvenir, even at high water it might take 12-16 hours to travel the 34 km straight-line distance to Pevas (62 km by river). Though the community is only 13.2 km distant from the closest point on the Amazon itself, swamp forest and overgrown (but water-filled) ancient channels of the Amazon prevent overland access to the larger river. At low water, travel from Nuevo Porvenir to Pevas might take the better part of two days, assuming that fuel for a motor is available. Paddling a canoe would take 3-4 days.
As noted earlier, this is by no means an extreme example of the difficulties of accessing medical care, but it illustrates the key problems:
• An understaffed central clinic with a single boat can’t send key personnel (MD’s) to outlying communities on even an irregular basis (the Pevas CS is responsible for 56 communities!).
• Residents of remote communities often lack fuels or functioning motors to make the trip to the central clinic (our mechanic often does “motor clinic” in tandem with our medical clinics).
• Peripheral clinics can offer little aid to seriously ill or injured patients, so they have to travel all the way to the central clinic. Many times a patient may show up to a Puesto de Salud only to find that the operating person or personnel are not present, and the PS is locked up.
• Critical patients many only be able to be treated in Iquitos, but expenses for that care is only covered (in part) if they are referred by the central clinic in their district (even though that may mean traveling in the opposite direction of Iquitos to go to the central clinic first)
• Cash is very short in more remote communities, so patients (and family members transporting them) need to take produce, fish, chickens, or bushmeat to sell to cover their costs of accommodations, medications, lab tests, and the like.
• Prescribed medications are often not in stock at rural clinics, so patients need to purchase those from independent pharmacies at higher prices (if they are available even at such pharmacies). Even in Iquitos with dozens of pharmacies, patients may be prescribed medications which simply aren’t available unless they are special ordered (i.e., expensive) from Lima.
• Medical samples (blood, sputum, biopsies, fecal, urine) often need to be sent to Iquitos for analysis, and Iquitos may even send them on to Lima. Results can take days or weeks to come back, resulting in considerable additional expense to patients.
What happens? People ignore or rather suffer with “minor” conditions or injuries hoping that they will go away, or that they will heal on their own. The rationale is that if they do make the expensive and time-consuming trip, that even if there is an MD present, they may be told to purchase medications that they can’t afford, or be told to wait an indefinite amount of time for lab results (another major expense). Alternatively, they may be told to come back in one or two weeks to receive the results. Not surprisingly, most people in more remote communities choose to rely on traditional medicine (although they may prefer Western medicine), and in consequence many people live (and die) with debilitating conditions that could have been remedied had they been diagnosed and treated early on.
And so goes the saga of “access”.
Many of the problems of access could be ameliorated with reliable and real-time communications capabilities. A bit of recent history then.
Alberto Fujimori, president of Peru from 1990 to 2000, was the very first president to provide educational, health, and economic opportunities to rural Peruvians. It was a strategy that successfully drained rural support for the Marxist Shining Path domestic terrorist movement, a movement fueled by the extreme inequities between urban elites and rural people. One of the measures that Fujimori implemented was providing isolated communities with short-wave radio units, and the creation of local radio stations to provide news and communications. In the Peruvian Amazon, the Voz de la Selva (Voice of the Jungle) provided the means for people to send messages to others. Even if the intended receiver wasn’t listening in when a message was read out over the airwaves, someone else in the community probably was, and the word would be spread. The system worked quite well, and communities each had a radio operator who would call in to Iquitos at designated times to pass on news, requests, and messages to be read on-air, and communities could also contact each other directly provided that their radio operators were active at the same time of day. Government institutions including hospitals and the police, army, navy and coast guard also communicated by short-wave radio until the early to mid-2000’s.
As satellite services became more affordable and accessible, the Peruvian government inked a contract with Gilat, an Israeli satellite communications company, to install satellite phones in rural communities (see next images). Not every community received one, but you were generally not very far away from one. This worked great and functioned much like a land-line telephone service. You could purchase a scratch-off phone card from a vendor (generally the homeowner closest to the physical satellite unit), enter the revealed code, and then dial a 6-digit number to reach another satellite unit (in another community) or a full phone number to reach a landline in an urban area. You could also call internationally, even from a remote location like Nuevo Porvenir or Ancon Colonia, although you needed to talk fast or have a lot of phone cards.
Gilat satellite phone unit in Santo Tomas, Rio Orosa (right) in 2011, and in 2018 in Brillo Nuevo, Rio Yaguasyacu (left). Both units have been inoperable for several years.
Satellite phones were pretty ubiquitous until the spread of cellular technology took off in the early 2010s. As cell phone units and service plans dropped dramatically in price, their use in urban areas skyrocketed, and all middle and upper-class urban residents now have their own cell phones, as do many Peruvians in poorer neighborhoods (my Peruvian monthly unlimited cell plan that includes 200 minutes of calls to the US and Canada costs under $20!). The demand for higher speed, and geographically expanded cell service in urban and peri-urban areas has resulted in the government encouraging cell service providers to construct more towers in high demand areas, namely urban areas. About 65% of the population of Loreto is urban (2017 census), but at the national level, about 78% of Peruvians are urban residents.
The shift in focus to providing cell service to urban areas has left rural areas in a communications black hole. The satellite phones have not been maintained, and are mostly non-functional now, and over the past 2-3 years, numerous community leaders have repeatedly told me that their most critical need is communications. Some communities have attempted to revive their short-wave radios, but there are no operators in urban areas or at Centros de Salud in larger centers (which now have cell signal) to take their messages anymore. Their former short-wave buddies are all busy posting selfies on Facebook on their smart phones.
Naturally, the cell towers are all being built in locations that are deemed to be the most profitable, so small isolated communities are once again at the very end of the supply chain. Enterprising individuals in some communities that are on the edge of cell range have, however, built their own cell towers. For a modest fee, you climb the tower and use a battery powered land-line phone which receives marginal signals better than cell phones themselves do. The “cell tower” at left is in Apayacu at the mouth of the Apayacu River, and receives cell signal from a tower at Huanta (Map 4).
Map 4: Location of Apayacu relative to the cell tower at Huanta.
There is, however, the possibility of a dramatic change in this situation with the deployment of the Starlink satellite network (www.starlink.com). With Starlink Beta pricing at $99/month plus $500 for the receiver (as of November 2020 in the USA), this could still be an unsurmountable cost for small communities, but hopefully there will be flexible pricing for developing countries and/or sponsoring non-profits as service is expanded beyond the USA and Canada in 2021.
With real-time communications, a lot would change overnight. Community Health Workers (CHWs) with basic training could alert their Centro de Salud of outbreaks or suspected outbreaks of infectious and zoonotic diseases - malaria, dengue, leptospirosis, yellow fever, amoebic dysentery, rabies, a new coronavirus and more. Both CHWs and SC and PS staff could participate in telemedicine, and clinicians could follow up with patient recovery and medication use without the expense and time of physical travel, unless it was actually necessary. The savings would likely more than compensate for the cost of a Starlink system even at its current pricing (though convincing politicians of such things is another story, especially when they can’t siphon off a hefty percentage).
Project Amazonas in collaboration with Wired International (www.wiredinternational.org), recently completed a three-week World Health Organization compliant Community Health Worker training session at our Madre Selva Biological Station (see Map #2). Future training sessions could easily incorporate technological aspects to enable CHWs to take full advantage of real-time communications.
Real-time communications would also open up additional exciting possibilities. Recall that Nuevo Porvenir is 62 river kilometers from Pevas, or 34 km in a straight-line distance. But it is only 13.2 km straight-line distance from the Amazon River, with boats going up and down that river on a daily basis. This could open up the option of future drone delivery of medications and/or rapid-assay tests, either on a “right-now” critical-need basis or on an ongoing “maintenance” basis. A good example of drone delivery of medications over significant geographic areas can be seen at www.flyzipline.com. That particular model might not be the best (financially or otherwise) for the Amazon, but it is certainly indicative of the potential.
In short, running a speedboat with a drone to the closest location on the Amazon and then doing a drone delivery from there, would be a great deal faster and cheaper than doing a direct river delivery from Pevas to Nuevo Porvenir. Doing a drone delivery directly from Pevas (if drone operating range allowed) would be even cheaper and easier.
Of the first three issues pertinent to health care in the Amazon – access, communications, resources – once the first two are addressed, the issue of resources (financial, material, time) becomes much more tractable, both from the viewpoint of patients and of health care providers.
Patients will be much more willing to invest resources (time, fuel, other costs) in traveling to a clinic if they have been in direct contact with the clinic, know that the clinic personnel are waiting for them to arrive, and that any necessary medications or supplies are on hand when they arrive.
Likewise, healthcare providers can better prioritize resources, implement interventions more effectively, and even gain access to additional resources (telemedicine expertise, additional funding sources, etc.). Perhaps with the ability to post selfies from the middle of the rainforest, some of those young medical professionals might actually decide to dedicate a few years to rural service rather than fleeing back to the big cities at their first opportunity.
Apart from the construction and increased staffing of additional health facilities (Centro de Salud, Puesto de Salud), the next most pressing need is having adequately trained Community Health Workers (CHWs) (promotores de salud) in each community. Many years ago, the government health system actually provided substantial training for these volunteer individuals. Due to budget constraints, such training has been essentially abandoned in the past 10-15 years with a few exceptions where health-minded municipality leaders have dedicated local funds for that purpose. Non-profit organizations such as Project Amazonas, Amazon Promise, DB Peru, Wired International and others have been working to fill that void, and will be coordinating efforts post-Covid. In September and October 2020, we completed the first three-week CHW training session using WHO-compliant materials prepared by Wired International, and we will be applying for grants to continue with more workshops in 2021 and beyond.
With adequate communication capability and additional training, community health workers would be fully capable of administering many, if not most, rapid assay tests, and communicate those results to the appropriate medical establishments. The CHWs would thus become the front-line early detection agents of both communicable and non-communicable disease events.
After CHW’s are trained, it will also be critically important to provide them with annual continuing medical education, and to incentivize them to initiate health promotion and disease prevention education in their own communities. Providing CHW’s with a modest monthly stipend that is based in part on completing set tasks (such as visiting each household on a regular basis, organizing a regular health promotion day at the community school, etc.) would be a big step forward. Currently, community health workers are strictly volunteer members of the community, and like all other community members, they have to farm, fish, tend their animals, sell excess produce to earn cash, and build their own homes and boats. This greatly limits the amount of time that they have to engage in health promotion and monitoring activities.
COMMON MEDICAL CONDITIONS AND NEEDS
Medical conditions that we regularly encounter in rural areas include the following (non-exhaustive) list. Note that most of the diagnoses that are made on such trips are symptom-based diagnoses, as lab testing capacity is unavailable other than for urine dip strips, pregnancy tests, HIV tests and glucometer. Rapid assay tests would likely be most useful for items in red.
· Tineas (very common for all ages)
· Contact dermatitis / rashes (particularly in farm workers, children)
· Infected insect bites / impetigo (mostly children)
· Nail fungus
· Boils / carbuncles / abscesses (all ages)
· Sebaceous cysts (adults only)
· Parasites (lice, scabies, pinworms) (very common for babies and small children)
· Stings/bites by scorpions, wasps, ants, bees, bedbugs & other arthropods
· Melanoma (not common, but present)
· Leishmaniasis (not strictly dermatological, but most often evidenced dermally)
Gastrointestinal / Urinary
· Ascariasis (mostly in children)
· Diarrheas (periodic and chronic / giardia / bloody stool)
· Stomach & abdominal pain (chronic)
· Food allergies
· GERD / gastritis
· UTIs, dysuria (more common in adults)
· Nausea, vomits
Respiratory & Ear, Throat, Nose
· Asthma (mostly children)
· Viral URIs (coughs, colds, runny nose) – extremely common in children
· Pneumonia (much less common, but still regularly encountered)
· Oral sores (children)
· Ear infections (super common in children)
· Pink eye
· Pterygia / cataracts (long term exposure to strong UV light, especially for people who spend a lot of time on the rivers has made pterygia very common among rural people who don’t have access to sunglasses)
· Visual deficiencies (need for reading or distance glasses)
Dental & Oral
· Caries & severe caries (super common across all ages – many teeth are beyond restoration and have to be extracted)
Work- & Age-Related Conditions
· Lower back pain
· Generalized muscle pain
· Neck pain
· Joint pain (shoulder, elbow, wrist, knee, ankle)
· Repetitive strain injuries
· Work-related cuts, lacerations, embedded foreign bodies
· Dehydration / dizziness / light-headedness / headache
· Arthritis / rheumatoid arthritis
Infectious & Zoonotic Diseases
· TB (pulmonary and non-pulmonary)
· Covid-19 (and future coronaviruses)
· Measles / chickenpox
· Leprosy (virtually eradicated)
· Yellow fever (not present in our immediate area, but regular in more remote areas near the Ecuador border)
· Hepatitis A, B, C
· Menstrual pain, menorrhagia
· Vaginal infections, yeast infections
· Uterine cancer
· Cervical cancer
· Breast cancer
· Prostate cancer
· STDs (gonorrhea, chlamydia, herpes simplex)
· Diabetes (very common in urban areas, increasing rapidly in rural areas)
· Anemia (often, but not always post-malaria)
· Depression / anxiety
· Abuse (spousal or child)
· Drug use (increasing, even in rural areas)
· Alcoholism (quite common in rural areas)
· Liver disease (from various causes)
· High blood pressure
· Epilepsy (infrequent in older people – many epileptics in rural areas die [drown] at a young age)
· Down’s syndrome and other genetic abnormalities (decreasing in prevalence as young people become more mobile and have greater choice in partners)
· Venomous snakebite (primarily by Bothrops atrox, or “jergon”)
· Hunting, fishing & logging accidents (stepping on a shotgun shell trap for armadillos, piranha bites, stingray and catfish-spine injuries, blunt-force trauma from falling branches/trees, etc.)
· Broken limbs (children falling out of trees is a fairly common source of broken limbs)
· Neurological conditions
· Cancers (other than reproductive ones)
· Mercury, cadmium & other heavy metal and hydrocarbon contamination (increasing problem in oil & gold extraction areas with water and fish directly affected)
· E. coli contamination of water sources (a rapid assay to detect presence would be very helpful)
Thanks in particular to the following individuals for their input in preparing this document:
Patty Webster - Amazon Promise www.amazonpromise.org
Diana Bowie - DB Peru www.dbperu.org
Gary Selnow - Wired International www.wiredinternational.org
Rushdie Ahmad - Wyss Institute https://wyss.harvard.edu/
About the organizations operating in Peru:
The organizations below are registered as non-profit organizations [501(c)3] in the USA. The first three are also registered as an organización no gubernamental (i.e., NGO) in the Republic of Peru, while the fourth has collaborated with Project Amazonas over several years. The three in-country organizations do not overlap much geographically in the areas that they serve, so there is little duplication of effort, but there are also abundant opportunities for collaboration.
Project Amazonas (www.projectamazonas.org): Founded in 1994 with initial focus on conservation activities. It soon became clear that conservation without attention to the medical, educational and other needs of rural communities would be a dead-end route. In 1998, the first boat-based medical service trip was initiated, and that has grown to 10-12 trips annually, serving some 80 communities on 10 rivers. Project Amazonas also works with communities on education and sustainable development projects and operates a rural clinic on the Orosa River.
Amazon Promise (www.amazonpromise.org): A like-minded NGO formed in 1993, which has had similar experiences bringing aid to remote regions of the Peruvian Amazon Basin. Amazon Promise provides on-going essential medical/dental services and health education to 35 geographically isolated mestizo and indigenous jungle communities located throughout Loreto, as well as to residents living in impoverished neighborhoods in the city of Iquitos and neighboring Belén. They travel by boat (or helicopter) to communities to provide services that also include laboratory diagnostic testing, family planning, cervical cancer screening and treatment, as well as rainwater catchment systems for clean water.
DB Peru (www.dbperu.org): DB Peru was founded in 2003 and aims to provide healthcare, outreach and health education to the remote communities of the lower Napo River, Loreto, Peru. At present, it serves over 5000 people living in 25 villages in the lower Napo region. DB Peru currently runs health education programs in the areas of infectious diseases and tuberculosis, antenatal care, breast and cervical cancer screening and dental health.
Wired International (www.wiredinternational.org): Wired International has quite a different history from the other three organizations, growing from seed planted during the Balkan Wars and the breakup of Yugoslavia (check out “about us / history” on their website for some fascinating reading). The focus of Wired is to provide fully free and accessible digital resources for health professionals, educators and the general public in local languages. Starting in 2020, Wired International began implementing community health worker training sessions that meet all World Health Organization standards, and have completed trials in Kenya, India, Peru and Nicaragua.