Overcoming obstacles to Care

It is a most relaxing scene… the beach… the shade of the almond and palm trees… the azure blue Caribbean Sea beckoning… but the people who visit this tranquil location often come not to relax but because they seek medical care. Hopkins, a small coastal fishing village in Southern Belize and a popular tourism destination, is, like other rural communities in Belize, served by a small health center and a visiting doctor. There are no beds to house an inpatient emergency, and no specialist doctor or medical laboratory to provide testing or imaging. Health complications requiring more intensive or specialist care must be referred to larger polyclinics, community hospitals and in cases requiring more serious medical intervention, to a Regional Hospital, like the Southern Regional Hospital.

The Southern Regional Hospital and Dangriga Polyclinic serve more than 75,000 people in the Stann Creek District and all its villages as well as the southern district of Toledo and its 55 communities. The hospital is managed by a team of dedicated, eager and relatively young administrative and medical staff. They include Dr Aimee Hunter, who has worked as Chief of Staff for three years.

“Our population is largely transient Central American immigrants attracted to work in the seasonal citrus, banana and shrimp farms. It is difficult to track them at times because they move around depending on where work can be found. In addition, sometimes they don’t give their full names, they may not have identification cards and often, they visit multiple health centres depending on proximity. Most are Hispanic and in their culture, they have two names so sometimes, patients give a different last name at the centres they visit. All this makes it difficult to track patients in the region.

We are thankful for the BHIS as it helps us to track them, reduce and link multiple records in the system, and maintain a single accurate record for each patient.”

The BHIS is the Belize Health Information System. It records and tracks the medical interventions offered to every patient and maintain their medical records. In this system, each patient receiving a unique client number, used to identify the patient no matter where in the entire country the client seeks medical attention. Dr Hunter described the benefit of the BHIS to patients from the Toledo communities. “Given the distance many patients have to travel to get to health posts and centres for tests and care, because of the BHIS, medical professionals at the nearest facilities to our patients, can access laboratory results and other patient information, discuss this with the patient and proceed with immediate care without the patient having to travel to more distant facilities that provided the initial testing. We visited the Southern Regional Hospital and Dangriga Polyclinic on their maternal and child health clinic day. The hospital and clinic were brimming with patients. The small waiting areas, narrow corridors and even outside clinic verandah were flowing with people seeking medical attention. The diversity of the population being served was fully on display. True to Dr. Hunter’s words, the majority of the patients were Hispanic Central American immigrants now living in southern Belize. A few were from the original ethnic group of Stann Creek - the indigenous Garifunas, and a still smaller number were Creoles. Despite the heavy patient load, the staff, such as Dr Nyreese Castro at the Polyclinic, were eager to show us their working conditions, discuss the population’s medical demands, and let us witness first-hand the level of capacity not only of the laboratories, but of the human resources in general, the complete medical facilities and available equipment.

The hospital and polyclinic serve the entire Southern Region of Belize. While the Regional Hospital handles more complex medical cases, the Polyclinic offers all primary and preventative services and offers these free of charge. This is made possible through a National Health Insurance (NHI) scheme financed by the Belize Social Security Board. “The south is the only area for the NHI that doesn’t have a co-pay for enrolled subscribers,” says Dr. Nyreese Castro. In principle, this includes any laboratory service offered by the PolyClinic or the Southern Regional Hospital. Special measures to ensure access to care have been put in place by the NHI for the southern region due the higher levels of poverty across the region. As in other regions, she explained, each client must present a Belize social security identification card to be enrolled in the scheme. However, since a large part of the population in the south are immigrants many of whom are not Belizeans, many don’t have a social security card. Medical services are still offered to all clients in the south free of charge for the most part, but all non-subscribers are required to pay a fee to receive laboratory services. Speaking about this additional patient load, it was clear that Dr Nastro was relieved by the decision of the NHI management to cover some costs for the increased numbers, “We were allotted 14,000 as a maximum number of clients for the NHI for our entire southern area but we have already exceeded that. We have a total of 22,000 clients.”

The Southern Regional Hospital has recently introduced a fee for inpatient service and medication. “A small fee is assessed for services for any patient who has to be admitted,” says Dr. Hunter. She quickly followed that statement with a chuckle saying, “But we do not insist on payment. We do not have a collection system and we do not refuse future care because a patient did not pay a past bill.” The hospital is therefore almost totally reliant on the budgetary allocation from the Ministry of Health. Once more with a chuckle she explained, “Our budget comes to us from Government. While we submit our request annually, the final allocation is determined by the Government. It is never what we asked for, and never enough, but we must find a way to make it work.”

The Southern Regional Hospital, a 52-bed hospital, provides both primary and specialty care services in four areas - gynaecology, surgery, paediatrics and internal medicine. Support services include mental health, laboratory, radiology and pharmacy. The medical laboratory provides diagnostic services for the hospital in the areas of haematology, chemistry, urinalysis, parasitology, serology, and immuno-haematology.

Pushing open the door of the medical laboratory, we quickly appreciated that the team of five laboratory technicians worked in a seriously cramped space and while their creativity in distributing the space and their dedication to the work were nothing short of extraordinary, the need for an expanded laboratory and additional equipment was clear. Lab Supervisor Ms. Desiree Joseph is not to be underestimated. She certainly pulls the medical laboratory ship together tightly leading the medical testing services for any of the 75,000 plus persons who may visit the facilities on any given day. “We have a new bio-chemistry machine,” she said but it needs to be installed and we need training for the staff. We cannot perform CT scans and all specialized studies are done in Belmopan or via a private laboratory in the area,” says Ms Joseph. (Belmopan is the capital city of Belize and is located some 55 miles from Dangriga where the Hospital and Polyclinic are located).

The challenges that both medical practitioners and the population face to give and receive service can’t be over emphasized. A population considered by the country’s 2009 poverty assessment to have the highest concentration of poor households, also faces multiple dimensions of poverty, such as lack of electricity in homes, shortage of potable water, nutrition challenges resulting in the country’s highest levels of stunting and wasting, along with real deprivations in relation to access to critical social services. The far-flung communities are reached only via sub-standard dusty, stone and gravel roads. A private vehicle owned by a family is a rarity and the people travel these roads, long distances by foot for the most part and then by bus. The buses are sometimes more than twenty years old, and their schedule is often sporadic and unpredictable. Their travel experience varies depending on whether it is the rainy or dry season, each presenting its own complications. During the rainy season, roads become quickly flooded and the makeshift bridges connecting many communities become submerged by fast-moving rivers, creating precarious travel conditions. So where, in this context, do people in this community find hope and motivation to make such journeys in search of care?

We found the answer to this question during our own journey to visit the facilities and labs. We travelled for two hours from Dangriga in Stann Creek to Punta Gorda, the main town in Toledo District. As we drove past communities and clusters of homes with zinc roofs, wooden walls and earthen floors or thatched houses made from the leaves of the xate plant, we there were miles of natural beauty to observe in the scenery surrounding the culturally diverse communities. Belizeans refer to the South as its cultural capital.

Typical to these culturally-rooted communities is a strong belief in traditional medicines and some reluctance to seek the intervention of modern medicine. Community health workers trained in modern medicine, often work alongside traditional birth attendants but social services are generally far- removed. It is no surprise then that analysis of the birth registration progamme found the highest proportion of unregistered births in these areas and the recent fifth round of the Multiple Indicator Cluster Survey (MICS5) similarly demonstrates higher levels of under-nutrition, stunting and wasting in these communities than anywhere else in the country. Given this backdrop, our team was overjoyed to encounter a dedicated Belizean doctor working deep in the Mayan community of Santa Theresa – we dubbed him our ray of light and hope for a people most vulnerable and in need of critical health services.

A contrast to the population he serves, Dr. Raheel Jamaal Elijio is an imposing towering man. He received his medical training in Cuba and this included a year of study in traditional healing. So he fully understood the value of traditional medicine and healing to these communities. He welcomed us into an office almost too small to house his desk and computer, let alone an examination table. He could not use the ceiling fan installed in his office because it would hit the metal pipe he had installed to hang a privacy curtain around the examination table. Instead, a standing fan circulated hot air throughout the room. Despite the small space and mediocre facilities, Dr Elijio was exuberant as he showed us around the facility and spoke about the community and his patients.

“Not many doctors want to come to these communities,” he said. “I like it. I learn so much and I am most satisfied to know that I am giving service to my people most in need. I believe every doctor in Belize should spend a year in these communities. It is truly a laboratory for learning.”

We observed Dr Elijio as he attended to a baby girl. Although she seemed fine, she seemed small for her age. At one year and three months, she appeared about the size of a ten-month-old. As Dr Elijio spoke to the child’s mother it became clear that he had seen this baby before as he was well knowledgeable of her medical history.

After the mother and baby had left, Dr Elijio recounted of one his many experiences with another Mayan mother and child; a story that highlights the reservations towards modern medical intervention in this community. Dr. Elijio described a day a baby was brought to the clinic covered in thick body rash and running a high fever. His Santa Theresa Clinic is not equipped with a medical laboratory and he knew the child needed urgent, more specialized medical care. He told the mother to return to her home, gather clothing for herself and the child and come back to the clinic so that he could take them to the nearest hospital – the Punta Gorda Town Community Hospital. He told us he had waited for over an hour and when the mother had not returned, he set out on foot to find her home. Being a small community and because he was familiar with the people, it was not difficult to find the home. He approached the home nestled on the top of a small hill, calling out. He entered the home carefully only to find no one in the small, one-bed room structure. He looked around the property, calling out as he walked. As he began to walk away to return to the clinic, he took a last glance back at the house only to see the mother emerging from the bushes behind the home with the baby in her arms. He ran back but as he ran, so did the mother. He was able to catch up with her and warned her sternly, explaining that if she did not go with him to ensure that the child received the necessary attention, he would have social services come to remove the baby from her home. Reluctantly the mother left with him and he was relieved as the baby received the medical testing and attention she so urgently needed.

Dr Elijio’s experience is rich with these kinds of tales, but each one only serves to underscore that communities such as the poorest in Toledo district, Belize, are in dire need of expanded medical services, health education and outreach. For UNICEF, an organization with a mandate #foreverychild, we were encouraged. The mission of the PROBITAS Foundation, the financial partner in the equation, with a Latin name that means “honesty”, would easily find home in Belize and in the project working to improve medical laboratories in the area. Improved medical laboratories mean invaluable support for health services and in the long term, overall healthier children, mothers, families, communities and country.