Jamaica is an island known for its magnificent beaches, fantastic hotels, and ‘no worries’ attitude. But beyond the beaches, hotels, and tourist shops lies the heart and soul of Jamaica, where taxes are high, incomes are low, and Jamaicans struggle to provide for their basic needs. On the rare chance that health care is accessible, little money is left to pay for it. This paper reflects my first hand account of the sights I saw, the people I met, and the emotions I felt while spending two weeks with a medical mission team in the Jamaican town of Falmouth.
One of the first things I noticed before even speaking or treating a single patient is the attire the Jamaicans where when they are going to the doctor. The women are wearing their Sunday’s best, in dresses or skirts with their hair pulled back while the men are wearing their nice slack and Sunday shoes. On several accounts there would be patients waiting all day to see the doctor out in the stifling waiting room dressed in their suits with a simple hanky to dab he sweat off their brow.
This simple decision of what outfit to wear to the doctor’s visit reflects the respect Jamaicans show towards healthcare professionals, especially those from America. They are grateful for the opportunity to be seen and treated even if the only treatment you can offer are vitamins. They are appreciative of the time you took to listen to them and care for them. The attitude is the polar opposite compared to some patients I have see in the U.S. If you don’t have the newest medicine to give them or they may have had to wait 30 minutes in the waiting room they are angry and confrontational.
One memorable patient was a woman who came in for a fungal infection of her fingernail. Over the previous few months she slowly watched her fingernail become discolored and finally it started to thicken, lifting up from her nail bed. The patient knew there was some kind of infection in the nail but her chief concern was the cosmetic appearance. She hated the way the nail looked and wanted the discoloration fixed. The only solution we had to “fixing” the nail was to remove it, which is a painful process and medically not indicated. However, after explaining to the patient that nail bed would be left exposed and it would be painful when doing such chores as hand washing her clothes didn’t sway her decision. The woman understood the potential risks but was persistent that she wanted the nail removed. After discussing the risk and benefits with the patient we went ahead and removed the nail for this patient.
After the nail was removed I explained to the patient how to take care of the exposed nail bed. She nodded in agreement with the instructions and repeated them back to me. However, since there were several instructions I decided to write them down for her on a piece of paper. I did this then had her read the paper back to me. This is when I realized that what I thought I had written as simple instructions the patient didn’t have enough education to read. She could not read the word “exposed” or the word “bandage” to name a few. For me these are words we use all the time and I thought even a lay person would know them. This was an awakening to me on how easy it is to be surrounded by highly educated people who all speak the same language then apply that same level of education to my patients who are hesitant to speak up when they don’t understand.
On a rural clinic day I saw an elderly woman in her late 80’s came to the clinic accompanied by her daughter. The woman lives up in the hills with her adult son who is mentally retarded who she cares for. The elderly woman still cooks, cleans, and washes the clothes. Her daughter checks on her daily but the patient is still completely independent. On physical exam she had poor breath sounds with a possible pneumonia so we treated her with antibiotics. We thought it was necessary to err on the side of caution. If the woman did have pneumonia it could easily progress and kill her. In addition we gave antibiotics to her daughter because they are regularly in contact and did not want the daughter to re-infect her mother.
This was a situation where the standard of care in the United States or evidence based medicine management for this patient could not be obtained. The circumstances surrounding her illness including the lack of follow-up and limited resources required us to give the patient antibiotics. We didn’t have the luxury to follow up and see if she got better or worse. We didn’t have the luxury to obtain a chest x-ray. Despite these limitations I strongly believe that we gave her the best standard of care we were capable of at the time.
There were several challenges faced when trying to treat patients in Jamaica. One commonly encountered issue was in the management of patients with hypertension. The patients would come to the clinic with their medication (most of the time) and tell you they came to have their pressures checked. They would be able to give you a history of when they last saw the doctors and some would even go to the extent of telling you they know their pressure is really high because they develop severe headaches. However, most of these patients would then go on to tell you that they didn’t take their medicine this morning because they wanted you to see that their pressures where high. This makes it extremely difficult to know if their current medication regimen is working or not. Adjustments are almost out of the question unless you saw them during the first week and can have them follow up the next week.
Perhaps they don’t take their medication because they are afraid they won’t receive refills on their medications or perhaps they don’t think the doctor will believe them if the numbers don’t reflect high pressures. I don’t know the exact reason for this commonly occurring hurdle to treating hypertension in Jamaica. What I do know is that an important part of successfully treating these patients was educating them on their disease and explaining how important it is to continue taking their medication before seeing the doctor. Educating the patient may not have impacted the treatment provided by our medical team but hopefully when the patient sees future teams they will be able to make medication adjustments.
When people ask what we did in Jamaican I tell them we worked at a free clinic and set up mobile clinics into the hills. Yet this isn’t exactly the entire truth. The Jamaican patients are actually charged a fee to be seen in the clinic by the American doctors. Even though the foreign medical staff is volunteering, there were always at least two Jamaican nurses who were working the intake station. Their job was to pull the patient’s chart, help record their visit and on multiple occasions give background information and relevant medical history when the patient couldn’t remember. These women were community members so they know the people and process of the community. They are an invaluable asset when walking into a clinic and seeing a patient for the first time. These nurses are paid by the Jamaican government, which comes from a small fee paid by each patient to be seen in the clinic.
In my opinion the fee required by each patient provides multiple assets to the clinic. One it employs the Jamaican nurses helping currency circulate in the economy. Two it makes the patient’s invested in their clinic visit. This decreases the number of patients who are simply there to just see the doctor or for some very minor complaint. Which then also allows patients who are more acutely or chronically ill to see the physicians because the clinic can only see a certain number of patients each day.
There were a couple occasions where information was learned during the second week that would have been helpful to know the first week of clinic. One tid-bit of knowledge was that limited lab tests were available to the population at the local hospital free of charge. These labs included a CBC, CMP, lipid panel, and T3/T4 levels. This would have perhaps changed the medication options provided to the patient or in some cases even diagnosed their primary disease such as hypothyroidism more quickly.
On the other hand even if we were aware those tests were available multiple factors played in to being able to utilize them, such as did the patient have the transportation means to get to the hospital and once they are complete will the results of the test be provided to the physician in time before they leave? One method we used to overcome these challenges was to first ask the patient if they had access to the hospital and second we told the patients that they needed to physically get a copy of the lab result themselves and bring it to their follow up appointment.
There was one cluster of patients that were frequent in the clinic, those who needed refills or needed medications. These patients would complete their medical history and when you asked for what medications they were on they would provide you with a list of medications on a prescription note from the local doctor. They had seen the local doctor who had diagnosed him and given them a prescription for treatment. Yet the patients didn’t have the money to buy the medicines. They simply had to wait until the next US team came to provide medications.
In this instance there is access to health care services but there isn’t adequate access to medications due to cost barriers. Instead the Jamaicans are reliant on the free medications from the foreign missionaries who do not come on a regular basis and when they do come there is no guarantee that they will have the same medications that the patient has been taking or was prescribed. There is a part of me that wonders if the free medications being provided for the past 20 years has created a dependence of the Jamaican people on the foreign missionaries. My thoughts include that why would the Jamaican government step in to change the current system if they can rely on the Americans to keep coming down month after month and provide them for free?
During the two weeks in Falmouth, Jamaica I expanded my medical knowledge but more importantly I made lasting relationships and was exposed to a culture different from my own. I would recommend this trip any student who wants to push them self. However, I would also offer them the following advice.Be prepared for unexpected challenges. This includes new diseases and diagnoses. This includes workspace limitations. This includes drug and supply limitations. This includes improvising when schedules change. This includes dealing with the heat. No one area is excluded from challenges.
In regards to people, the Jamaican’s are very friendly and this is their chance to see a physician while a team is in town. They respect the doctors highly in the community and will watch out for you while you are there. However, this being said it also perhaps provides a false send of safety and security. I never once felt threatened, scared, or endangered. Perhaps this was due to certain Jamaicans watching our backs and knowing that if the doctors feel things are dangerous they will quit coming to the community. Those drug dealers or gang members know the money making ways of the street but those shady characters also know who their ill mother goes to receive her health care. If the medical teams feel the area is dangerous they will not return.
Faith, vitamins, and water are three very important treatment options for the patients you will see while in Jamaica. There are illnesses when you are limited in the fancy evidence based, stand of care treatment options and a simple prayer with the patient to give them strength and hope can do wonders. Also reminding the patients that when working out in the fields all day in the extreme heat and they become lightheaded that it is important to drink water while working is more often than not presented.
Manual labor is a way of life and a method of survival. There are patients who have terrible excruciating arthritis but continue to work in the fields swinging a machete. The simple obvious answer is to quite performing the movement that is causing you pain. On the other hand, if your entire family is counting on the income from the repetitive movement causing you pain more times than not the patient will continue to swing that machete, they don’t have a choice.
The volunteers who help run the clinic are not always medically trained. You learn to work with those who have never been involved in medical treatment except their routine doctor visits. But don’t discount their value in making the clinic run. It doesn’t take an MD to be able to count 30 pills; it doesn’t take an RN to be able to perform urine dipsticks. Each team member is important and it is crucial to respect and accept his or her level of medical knowledge. That being said I am sure that any student going on the trip will be able to find several ways to make the clinic run more efficiently, However the clinic has been established for over 20 years so just because you see better ways to run thing make sure to approach it in a respectful manner and not in a critical one.
Most importantly be willing and open to admit when you don’t know a diagnosis or treatment. The trip is one learning experience after another. Especially when it comes to skin rashes in dark skinned populations, guess what their routine textbook pictures in white skinned people present completely differently in dark skinned individuals. Don’t worry too much there is a book in the clinic that gives pictures of diseases in dark skinned patients. It is very helpful. All of the physicians are more than open to answer questions and discuss treatments.
Other tips…the helpers in the hostel will do your laundry daily so there is no need to pack very much. The hostel is actually very nice, it isn’t a five-start hotel but there are clean sheets, clean modern toilets, showers with hot water (most of the time), and electricity. There is never a shortage of food especially if you like carbs and jello. If you enjoy veggies be prepared you intake will drop substantially while on this trip. Don’t worry though you can simply ask Ruth, the Jamaican cook, to go to the market and purchase some vegetables for your personal stash.
Before writing this paper I looked over the goals I had prior written prior to departure and realized I met them all and many more over the course of the two weeks in Jamaica. I learned about the use of alternative treatment plans since what we term the ‘gold standards’ of treatment in the U.S. are not always available in a developing country. I was able to integrate my knowledge of public health and primary care to help treat the Jamaican patients I saw. I learned about the culture, beliefs, and attitudes towards medicine and health the population holds. I learned how socio-economical factors such as access, cost, and educational levels affect healthcare in a third world country.
Treating patients can and should be an opportunity to improve their health, whether they are in the land of opportunity or one of the impoverished sections of the world. Committing to that standard will make me a better physician wherever I end up and this trip taught me valuable skills that no doubt I will use in my future practice of medicine in the states and abroad.