These were just a few of many heart-wrenching cases I was confronted with during my second annual medical mission with Lingkod Timog, a United States nonprofit based in Rhode Island, which has been providing medical, surgical and dental care since 2005 to both indigeneous populations and to some of the most deprived communities in remote areas of southern Philippines.
This year, the medical mission targeted New People's Army-influenced communities in Taytay, El Nido and Coron (Busuanga island) in North Palawan. Previous missions served the Badjaos in Zamboanga and Basilan Island, the Lumads in Davao and the Aetas in Zambales.
In my native Portugal, the abovementioned patient would be referred swiftly by a family doctor like me and undergo surgery without the need to make significant out-of-pocket payments. The universal coverage of the population with a chiefly tax-funded national health system would’ve taken care of it. Portugal's financial crisis and austerity measures have been putting tremendous pressures on the health system, with co-payments for consultations and drugs rising significantly. But no one will be denied healthcare for inability to pay.
One special thing about Lingkod Timog's medical missions is that it depends entirely on a complex yet efficient logistical machine manned by the Armed Forces of the Philippines, which reflects the fact that the organization was founded by two Philippine naval officers’ wives. Military staff provides security and transportation for volunteers and medical supplies; they cook meals for everyone, transport patients who come from remote areas, help in translating non-Tagalog Filipino languages, and some are even talented entertainers! I don't get to interact very often with the armed forces back in Portugal, so I learned to admire and respect this class of professionals, who although not specifically trained for this type of community initiative (apart from the medical and nursing corps), can clearly step up to important roles.
I had the chance to work alongside some military doctors and nurses, which is very important when you're not so familiar with the particularlities of the Filipino health system or the medical approach of certain prevalent health problems. It’s also crucial when you need a second opinion. Each “foreign” doctor like myself would work balikatan (shoulder to shoulder) style with a civilian nurse, who doubles role as a Tagalog intepreter. It was also often necessary to involve a second interpreter if the patient chiefly spoke another Filipino language, like Visayan or an indigenous language like Cuyonon. In Portugal, I also often face language barriers with some non-Portuguese-speaking patients, and it is often problematic because I have no interpreters around!
One thing that really surprised me about the health system in the Philippines is the level of empowerment of nurses, many of whom are nurse practitioners. They take on many roles (like prescribing) that in Portugal and in other parts of Europe are the exclusive responsibilities of doctors. There have been many public debates in Portugal about changing the status quo and providing more empowerment to nurses, but the medical community has been opposing it. I visited a rural health unit in El Nido and a district hospital in Coron, and I got the feeling that it was the nurses who were running the show, as there are very few doctors there. The high levels of nurse empowerment in the Philippines actually make a lot of sense when there's such an overall lack of doctors and difficulty in enticing them to settle in remote areas. While home births practically don't occur in Portugal anymore, I was surprised to learn that in the Philippines it is still a common occurrence carried out by midwives. Again, it makes all the sense if we consider that many patients face significant geographical and other types of barriers to healthcare.
Practicing medicine in the context of a medical mission is challenging by itself for a number of reasons: fewer resources available; language barriers; fatigue from constant and strenuous traveling between different mission sites, etc. But I think it’s important to become familiar with local guidelines and the nuances of prescribing drugs. For example, mefenamic acid seems to be a widespead anti-inflamatory drug in the Philippines, but is not used very much in Portugal.
Unlike my practice in Portugal, the caseload in Palawan consisted mostly of children and young adults and very few elderly patients. The scope of health problems encountered is very similar, but I found a high incidence of respiratory problems in children and an unusually high prevalence of thyroid disorders (like goiter) in adults. I also noticed that very few patients in Palawan, both young and old, were either overweight or obese, which in a way safeguards them from certain chronic conditions like diabetes. It’s perhaps a sign of poverty, of working in physically demanding livelihoods like farming or fishing, and the need to walk everywhere for many miles each day. At home, it's exactly the opposite. I struggle with high prevalence of patients with excess weight, obesity and sedentary lifestyles. It’s difficult to counsel them about lifestyle measures, because getting patients to change their behavior is such a hard thing to do.
In Palawan province, it strikes me how hard it is for many patients to access health care (or pay for it). It’s a sharp contrast to Portugal, or even Metro Manila where one can access internationally renowned hospitals in Makati or Alabang, if one can afford it. And many foreign tourists with chronic health problems would probably think twice about coming to El Nido's posh resorts if they knew that there are no facilities there to treat most life-threatening medical emergencies. The existing medical facilities there have shortages of equipment.
From a European perspective, I think the Philippines needs a health system based on strong primary care, with highly qualified family doctors being the system’s first point of contact with the patient. Actually, some of the best health systems in Europe have the best primary health care systems in the world. Providing continuity of care that’s easy to access and comprehensive, as well as patient care coordinated with other levels of healthcare, also would be needed.
The Philippines doesn't need a health system based on super-specialists, even though it saddens me to hear that most Filipino doctors want to be super-specialists. But it doesn't surprise me. You need strong financial and other types of incentives for doctors to settle in remote areas, and there aren't many. In the meantime, I am hoping to continue going back to the Philippines for future medical missions. Our efforts are merely a drop in the ocean considering the needs of local communities, but I firmly believe that little things mean a lot.
Tiago Gutierrez Marques is a Lisbon-based doctor and writer for the specialist medical press. He graduated from the University of Lisbon in 2005 and completed a family medicine residency program in 2011. He has been working in the Portuguese national health service.