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16 | student.bmj.com
STUDENT BMJ | VOLUM E 22 | JULY 2014
life
Providing healthcare on dry land can be
di cult, especially in the face of limited
infrastructure. Providing healthcare on a
boat has di erent set of challenges. Medical
boats provide healthcare in resource
poor settings. The most well known of
such projects are Mercy Ships,
1 which
o er, among other things, cle palate
reconstruction. Other oating clinics provide
dental care to isolated populations. These
include the Amazon Hope boats that we
volunteered on in July 2013 in the Loreto
region of Peru.
Healthcare in Loreto
The Loreto region of Peru contains the
largest part of the Peruvian Amazon river
and has a population of just over a million
people—of whom about a third live in rural
communities.
2 Poverty is widespread—42%
of the population is classi ed as living
in poverty, which is measured in various
ways including households living on less
than one US dollar per day. Nearly a third
of children under 5 years are chronically
malnourished.
2
Healthcare is di cult to implement in
Loreto because of its geographical isolation
and the wide dispersal of its communities.
Although the government plans to increase
the coverage of social inclusion programmes
that aim to increase equitable access to
healthcare or provide socioeconomic support
to impoverished families in the region,
at present, only 17% of the population
is enrolled.
2 Because of poor access to
healthcare, and the region’s limited road
access,
3
4 mobile medical clinics like the
Amazon Hope Project can play an important
role in local healthcare provision.
Amazon Hope Project
The Amazon Hope Project was founded by
the Vine Trust charity in 2001. An ex-Royal
Navy tender was converted into a medical
clinic. The project now has two adapted
medical boats ( Amazon Hope I and II ) that
sail along the Peruvian Amazon and its
tributaries in the Loreto region each month
and serve around 100 000 people per year.
5
Aboard the
Amazon Hope
I
or
II
The team meets in the capital of the Loreto region—Iquitos—the largest city in the world that can be reached only by river or air. The next day, we are
transferred to one of the Amazon Hope boats where we are introduced to the technical team and undergo half day staff training workshops. During the
trip, the boat will normally moor up overnight at the riverbank of the community to be served the next day. The days start early with breakfast before 7
am, after which patients come aboard via the gangway or in small motor boats. Many patients come from surrounding villages on foot or in canoes or
boats. Some travel up to four hours to come to the clinic.
Peruvian translators accompany each UK doctor or nurse during their consultations if required. It is often mothers who present with their children.
They may have to wait up to three months for the subsequent visit of the medical boat so all children will be registered and seen. It is common for
a single consultation to involve a brief history and clinical examination of a family of five or more individuals, with children of all ages. Many of the
presenting complaints are often associated with low socioeconomic position and are seen in general practice surgeries worldwide. Some complaints,
however, are more geographically distinct.
Conditions in the Loreto region that are not often seen in the UK
• Skin —Cutaneous larva migrans, chronic skin changes secondary to exposure to river water (for example, a patient might have been working in a
waterlogged rice field), foreign objects under skin secondary to old trauma, snake bites
• Eyes —Severe pterygium
• Gastrointestinal —Bacterial diarrhoea (Shigella, Yersinia, sporadic outbreaks of cholera), Entamoeba histolytica
• Respiratory —tuberculosis
• Obstetrics and gynaecology —pregnancies proceeding without antenatal care or check ups, unattended home births
• Multisystem —Malaria, dengue fever
Once patients have been seen, the doctor writes a short summary on their registration card, prescribes any appropriate treatment, and sends
the patients to the pharmacy, which is on the boat. Guidance on common complaints and their locally appropriate treatment are provided to all
the healthcare professionals on board.
The healthcare staff on the ship principally provide primary care, but intravenous fluids and intravenous or intramuscular antibiotics or
quinine are available, meaning that a basic level of secondary care can be provided. Some examples of common cases requiring immediate
attention and referral to local hospitals include complicated malaria, sepsis—for example, secondary to urinary tract infections—and
complicated labour. No imaging is available aboard the ship apart from hand held ultrasound probes and echo-Doppler, so healthcare
professionals rely on taking histories and clinical examination to make diagnoses and management plans. The boat’s pharmacy is stocked with
drugs sponsored by donations. Pharmacists and pharmacy technicians are trained to give simple advice on how and when the drugs should be
taken. Sometimes the pharmacists use drawings such as symbols for the sun and moon on tablets to explain to patients who cannot read. The
ship also has a basic laboratory where simple investigations—such as urine microscopy, dipstick testing, and malaria antigen tests—can be
done.
There is a focus on preventive healthcare. Before clinics begin, the Peruvian lead doctor delivers a health promotion lecture to the families of
patients. Themes in these talks are dental and personal hygiene, clean water and sanitation, and avoidance of tropical illnesses such as dengue
fever, which is endemic in the area. About 25% of children who attend the clinics are not up to date with their immunisations, and they are
offered immunisation free of charge aboard the ship.
2
Floating healthcare in the
Peruvian Amazon
The Amazon Hope project provides vital care to
remote communities
The
Amazon Hope I
medical boat moored at an
Amazonian village
student.bmj.com | 17
STUDENT BMJ | VOLUM E 22 | JULY 2014
life
Each boat is equipped with an operating
theatre, dental surgery, pharmacy, and
treatment rooms. The boats are able to travel
down some of the Amazon’s shallowest
tributaries, reaching the remotest villages
including those of the Huitoto and Bora
tribes.
5 The oating clinic is run by a team
of full time Peruvian medical and technical
sta , who are supported mainly by UK
volunteer doctors, nurses, and dentists who
join them for two week working holidays.
Care provided on the boat is free.
The bene ts of boat clinics
The Loreto region is a di cult area in
which to provide healthcare because most
settlements can be reached by river only.
Although some of the villages that Amazon
Hope visits do have small government
health posts, these can be poorly equipped,
understa ed, and might charge for certain
consultations, medicines, and auxiliary
treatment such as bandages. Also, patients
might have to wait for a long time to be
seen.
6 This means that many people are put
o seeking healthcare.
6 The Amazon Hope
boats are an alternative form of primary
healthcare in isolated communities and is
free of charge.
Some of the most e ective public
health interventions o ered by the
Amazon Hope project are likely to be its
simplest: health promotion and education,
antiparasite provision and treatment
for any accompanying clinical anaemia,
vaccinations, visual checks and provision
of graded glasses, and antenatal checks.
In some of the communities visited,
these measures are not provided by the
government, meaning that the Amazon
Hope represents the only form of primary
care available. In addition, although
sometimes overlooked by patients and
healthcare professionals, dental care and
visual checks—both of which are provided
on the boats—are essential for wellbeing.
The challenges of working on a boat
clinic
At most, a community will receive a visit
from the Amazon Hope every three months.
Ideally, healthcare provision would be
available every day in a stable, xed
establishment. Such sporadic follow-up not
only makes chronic disease management
di cult or potentially risky—for example,
when a patient is starting to take a new
drug—but it can also mean that patients
might wait three months for free healthcare
provision on the boat rather than seek local
care, which can be detrimental to health
and quality of life.
Although the medical clinics of the
Amazon Hope are set up well, with
experienced medical translators and
detailed clinical information provided
before the trip, many of the UK medical
sta could be working in this remote and
resource limited environment for the
rst time, and they might not have much
primary care experience. Initially, this
could mean that consultations take a long
time and common regional diagnoses
are missed. Finally, the clinics can be
extremely full, and it can be di cult to
check that patients have understood the
consultation or to provide them with simple
health promotion advice because of time
constraints and high patient-sta ratios.
In some villages, the Amazon Hope
boats might be working in parallel with
an existing local health post. Without
adequate communication between the two,
there may be unnecessary overlap of work
and coverage of medical services. Healthy
individuals and their families might attend
the Amazon Hope in the hope of receiving
free medicines, such as anti-pyretics and
multivitamins, which they might not
need at the time of the visit but which are
di cult or costly to obtain. Consultations
such as these o en reduce the time
available to see unwell patients and provide
patient education.
In isolated regions that lack xed,
easily accessible healthcare, oating
clinics provide a unique opportunity to
support the healthcare services that are
sometimes limited. Understanding local
health and health beliefs is essential for
the medical teams on such trips, and
might help to untangle pathology in time
pressured clinical consultations in a
language foreign to the doctors. Literature
on healthcare beliefs and practices
in this region—the understanding of
which could facilitate appropriate and
better quality care—is scarce, however.
Further understanding of the social and
behavioural impact of di erent healthcare
services (mobile, static, and traditional) on
local populations is essential in planning
sustainable, future healthcare in the
Peruvian Amazon.
Tom Wingfield infectious diseases specialist
registrar training year 5, Innovation For Health and
Development PhD fellow , Infectious diseases and
Immunity, Imperial College London, and Wellcome
Trust Imperial College Centre for Global Health
Research, London, UK
Jonathan Williamson fourth year medical student ,
University of Bristol Medical School, UK
Competing interests: None declared.
Provenance and peer review: Not commissioned; not
externally peer reviewed.
Reference are in the version on student.bmj.com.
Cite this as: Student BMJ 2014;22:g3839
Key points
• Medical boats provide a complementary
healthcare service for isolated communities
in the Peruvian Amazon
• Medical boats are not a replacement for long
term, stable health posts in these regions,
but they might provide an alternative while
infrastructure improves
• Patients and communities with minimal
access to healthcare can benefit from simple,
educational interventions
• Understanding local health beliefs and
behaviours will allow effective healthcare
provision by medical boats and clinics
• Rigorous evaluation of the impact of medical
boat projects is essential and can be
achieved by measuring associated health
outcomes of the communities served
Patients are registe red on the
Amazon Hope I
medical boat
VINETRUST
