A British GP visits Misiones in rural Argentina
Dr Debbie Hipps is a young British doctor who recently took sabbatical leave and undertook volunteer work in primary care in remote Argentina. Dr Lidia Caballero, the President of the Association of Family Doctors in Misiones, a province in the north-east tip of Argentina kindly offered to host her visit and arranged a multitude of connections to various primary care organisations in the region. Dr Hipps is pictured above (centre) visiting a Primary Health Care Centre (CAPS = Centro Assistencia Primario de Salud) in Alem, a small town east of Posadas, with (right) one of the local GP team Dr Caesar and (left) one of the health promotors.This article details Dr Hipps’ experiences and reflections about the sabbatical.*
About the region
Misiones is in the subtropics and the climate is very hot in the summer and generally wet and fertile all year round. The local industries are mate production (a tea-like drink), forestry and tourism (Iguazu Falls and other attractions).
The population lives partly in the cities but is also spread in farmland in the interior. There are also populations of Guarani, the local indigenous people who were once nomadic but are now more settled in remote villages. Health is heavily influenced, as elsewhere in the world, by the social, economic and political factors in the region. There is much poverty, poor nutrition and dentition and an education system that struggles to retain children in the cities let alone those in the countryside. The proximity of borders with Paraguay and Brazil and historical migration from Europe into the area results in a population of mixed ethnicities and a certain amount of health tourism as the Argentine system is relatively well organised and free at the point of care.
Photo: Typical side street in Posadas
The public healthcare system provides care to the population via a three layer system – the primary health care hospitals run clinics staffed by generalists and also may have some specialist clinics such as dermatology, cardiology, gynaecology etc. The second level hospitals have an emergency department, surgery and in-patient facilities. Anything complex is sent to the third level hospital in Posadas and failing that to the capital Buenos Aires some 12 hours drive away. There is also an extensive private medical system, as there is a perception that the public health system is second rate. Doctors commonly work for both the private and public systems (or just the private system) partly in order to make ends meet in this country of high inflation and poor public funding.
I spent most of my time visiting at the first level public Hospital Dr Pedro Balina, in Posadas (pictured), which was originally built in 1940 as a leprosy colony, and now has out-patient clinics and a small inpatient building for patients with infectious diseases such as TB and HIV.
Hospital Pedro Balina is a site which is involved in training new generalist doctors and had an education programme which I was able to join and contribute to. I gave a talk (in Spanish) to the maternity hospital staff about how maternity care was organised in the UK – they were most impressed to hear that we had teams of community midwives who could provide care for women wanting home births. This is not available in Argentina and probably partly influenced by this, they have a high caesarean rate of over 30%.
Photo: Patients waiting outside clinic
Other than participating in ward rounds and clinics, I was also able to go out with the health promoters into the surrounding areas, to try to bring vaccinations to children living there (knocking door to door and vaccinating standing in the muddy front yard).
I also visited community clinics in some of the smaller towns and villages outside of the provincial capital where teams of health promoters, nutritionists and GPs run out-reach services for the local populations. The state system encourages families to bring their children to the hospital or community clinics by giving powdered milk to those who have complete health records, with regular height and weight checks and a full immunisation history. (1)
The challenges caused by poor infrastructure are massive and make health improvements hard to achieve – unsealed roads impassable after rain; villages without electricity or even secure water supplies; and housing, often overcrowded, that is constructed of whatever materials a family could find. (Photo shows a single room home for a three generation family of nine
Poor education and little aspiration lead to high rates of teen pregnancy as young as 12 years old. Although contraception is freely available through the primary health clinics, without education it is too little and too late. The issues of drug misuse, alcoholism and domestic violence are the same around the world and complicate the situation in Misiones as resources to tackle these problems are sparse.
I spent several days with a programme which tries to get children off the streets into day centres where they can access medical care, food, clothing, schooling, sport and social skills. It was heart-warming to see how the children flourished in a more stable and nurturing environment. Another striking experience was a day spent visiting the local prison to see the healthcare provision there. Alongside typical problems of general practice, the visiting Doctor was challenged with high levels of self harm and a unit of mentally unwell adults all on clozapine to keep them calm but with no other psychological input.
Similarities amid the differences
Whilst I was in Posadas I was also able to attend a multidisciplinary congress of all the primary care providers from the three northerly Argentinian provinces and was able to join in a discussion about the management of alcohol misuse. Again the similarity of the challenges facing the programmes in the UK and Argentina were striking and resources to fund the projects a crucial issue.
The visit made me appreciate how much we take for granted in the UK – a joined up service with registered lists of patients and computerised records which help us to provide comprehensive and continuing care. There was much interest throughout my stay in how the NHS worked and the exchange of information and experience was very stimulating.
I return now to my own practice with many new friends across the world and with the intention to look for local opportunities to assist and support those less fortunate than ourselves.
WONCA Editor notes:
(1) Colleagues in Argentina report that: The incentive for mothers to take their children to medical checks is a public policy called "Asignación Universal por Hijo", a universal money benefit for children under 18 years old, where the condition to receive the benefit is to make medical checks, receive the appropriate vaccinations and remain in school. It is a public policy that has improved some health indicators and social inclusion in Argentina.
*the views expressed are personal and based on Dr Hipps’ experiences. The descriptions given are not necessarily accurate and do not necessarily reflect the views of WONCA.