Archive for the 'Rural Health' Category

Dealing with HIV in Uganda


I know the exciting stuff these days is healthcare reform, but I happen to be in Uganda for a month, taking care of the female ward at Kisoro hospital.  

I was recently called away from rounds for an urgent admission. I arrived to find a thin woman in her 50s, dressed in swaths of colorful fabric. She was carrying one of the little black plastic bags that people use to bring vegetables home from market. Before I could ask her anything she coughed, hard and wet. Then she spit a mouthful of bright red blood into the bag. She had a fever of 101F and had a big right side infiltrate. I didn’t need a laboratory to tell me this woman likely had TB. 

This woman is a cardiac patient in the chronic care clinic. There are several pages of notes documenting her heart condition, which is known as endomycocardial fibrosis. She’s been seen by the legendary Jerry Paccione, who politely rebutted the previous resident’s opinion of hypertension with a “not likely” scribbled in the margin. 

We talked for a while, and eventually I thought I had a pretty complete history. I started to finish up, and sent my mind back across the most likely diagnosis. Why did this woman get TB? 

“Have you ever been tested for HIV?” I asked her. 

The way her eyes went left and right, scanning for nosy ears, immediately told me the answer. I stepped forward so she could whisper, and motioned my translator to do the same. The words she muttered were barely audible. 

“She has HIV,” my translator said. 

I looked down at the five pages of “Chronic Care Management” notes I was holding. They went back as far as 2006, and she’d never mentioned the fact that she had HIV. 

“Do you have a doctor taking care of your HIV?” I asked. She said she went to the HIV clinic in this hospital for her care. 

So she wasn’t telling her heart doctor that she had HIV. And she wasn’t telling her HIV doctor that she had a heart condition. The two sets of doctors were a hundred yards away from each other, and for three years this duplicity had been maintained. 

It makes me angry. I can’t help it. You don’t want to talk about HIV? You don’t want to bring it into the open? Fine. But other societies have been down this road before. I was just a kid when the HIV epidemic started in the U.S., but even I remember that Silence = Death.

(more about my time in Uganda at

Action alert: Honduran physician Luther Harry Castillo menaced with arrest

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Dr. Luther Harry CastilloWe have been asked by our friends at MEDICC to pass on this action alert regarding Dr. Luther Castillo, a Honduran physician who has been threatened with arrest in the wake of the recent coup. Dr. Castillo, a member of Honduras’ Garifuna community, was one of the first graduates from the Latin American School of Medicine (ELAM).  After receiving his MD degree he returned home and constructed the first Garifuni rural hospital.  Dr. Castillo was featured in the film Salud and you can read an interview with him in English at this link.

July 7, 2009—The life of Dr. Luther Castillo, indigenous Garifuna physician in Honduras, is in imminent danger. MEDICC has learned that the Honduran army has orders to capture Dr. Castillo, and if he resists, to shoot him.  He was already included on a list of persons whose lives and personal integrity were declared “at risk” by a July 3rd communiqué from the OAS Inter-American Commission on Human Rights.

We have been able to verify that Dr. Castillo’s cellphone communications have been cut.  The last conversation with him took place at approximately 2:30pm today, in which he reported on continued demonstrations demanding the return of elected President Manuel Zelaya, despite security forces’ repression.

Just weeks ago, Dr. Castillo was named director of International Cooperation in the Honduran Foreign Ministry. Since 1999, he has directed the Luaga Hatuadi Waduheñu Foundation (“For the Health of our People” in Garifuna), dedicated to bringing vital health services to isolated indigenous coastal communities.


Call the White House and the State Department, urging the US government demand:

  • safety for Dr. Castillo, his colleagues, and all persons protesting the coup,
  • an end to the repression, and
  • the unconditional return of constitutional President Manuel Zelaya.

State Department: 202-647-4000 or 1-800-877-8339
White House: Comments: 202-456-1111, Switchboard: 202-456-1414

More Background
After his 2005 graduation from the Latin American Medical School in Havana, Dr. Castillo returned to the Honduran coast, where he led construction of Honduras’ first Garifuna Rural Hospital, now serving some 20,000 in the surrounding communities.  The hospital opened in December 2007, just months after Dr. Castillo was named “Honduran Doctor of the Year” by Rotary International’s Tegucigalpa chapter. “Thank you for inspiring me,” said California Lieutenant Governor John Garamendi, speaking at the hospital’s opening ceremony.

The hospital and its community health outreach are supported by a number of U.S. and other international organizations, including the Sacramento, California Central Labor Council, Global Links, The Birthing Project, and MEDICC.  Several US medical schools also have cooperative arrangements with the Garifuna hospital, including Johns Hopkins, Emory, Charles Drew and University of California (SF).

Dr. Castillo is featured in ¡Salud! (, a documentary film that received the Council on Foundations Henry Hampton Award for Excellence in Film & Digital Media (USA). MEDICC (Medical Education Cooperation with Cuba),, is a US non-governmental organization working to enhance cooperation among the U.S., Cuban and global health communities aimed at better health outcomes.
posted by Matt Anderson, MD

Doctors, Medical Student Volunteers Needed in Rural El Salvador


Catlin Polley in Estancia

This note comes from our friends at Doctors for Global Health:

Could I…

…Take a year out of med school between my third and fourth years?

…Delay residency for a year after graduation?

…Leave my practice as a physician or my retirement for a time?

In Estancia, El Salvador, a clinic in a remote, rural community needs you. To trek up mudslicked hillsides in the dusk to find a pregnant women who can´t move her limbs or a man in a hammock with a toothache run out-of-control. To think about and act upon the lack of latrines and the rampant childhood malnutrition. To face the health effects of rising food prices and strip mining projects, and to be called to speak out…

Come, work with Doctors for Global Health, a volunteer-run organization of health providers, teachers, psychologists, artists, and anyone with a mind for health, that seeks to foster a vision of Liberation Medicine through accompanying grass roots projects in Latin America and Uganda.

It is an amazing education in being a community physician, in public health, and the need for activism on the policy level. You will be challenged in your medical knowledge, but mostly in your personal sources of energy, motivation, courage, and strength. You will changed by people living in poverty who work for liberation.

For more info on this amazing international health opportunity, please visit the website for Doctors for Global Health, If you want to talk about volunteering in Estancia or about what it’s like to break from the traditional course of medical education, feel free to contact us.


Don Lassus and Caitlin Polley

Current 4th year medical students from Baylor and Penn volunteering in Estancia, Morazan, El Salvador

Note: This posting was corrected on 2/14/2009.  The original posting had a photo that was not from Estancia.

Ricardo Nimo (RPSM Internal Medicine 1998): Working in Rural Mississippi

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What is it that social medicine doctors do? Here is one answer from RPSM Internal Medicine graduate Dr. Ricardo Nimo:

Ricardo Nimo, MDAfter RPSM in the Bronx, as a foreign graduate from Uruguay, I decided to come to Mississippi as part of a waiver program in order to change my legal status in the US. Mississippi was a challenge from the start at a personal level, as an individual, and as a physician. I came to Centreville Mississippi and took over the only internal medicine practice, working along with a general surgeon (whose father, also a surgeon; is a local legend here in Mississippi and was then still practicing). Centreville is a town of 1800 with a small rural community hospital with 30 beds, an ER, PT/OT, US, CT and Nuclear Medicine Scans, among other services.

Our practice has grown from 2000 visits per year to close to 10,000. I have a roughly 50/50 mixture of outpatient primary care and inpatient practice. Six of physicians staff the ER year long. The surgeon and I receive medical students from Tulane University in New Orleans, and I have a faculty appointment with the Community Medicine Department at Tulane as an Associate Clinical Professor. I also deliver care in nursing home settings. I am medical director of the local nursing home with 80 patients. For 2 years I worked in correctional medicine at a private facility about 20 miles away with 1000 inmates. I have been involved with CME activities as well as strategic planning and policy analysis regionally and with the National Rural Health Association. Currently I am chief of staff for our hospital. Maybe I can regret not having developed any meaningful relationship with the only academic tertiary care center in MS: the University Medical Center in Jackson. This is probably a consequence of the 120 miles of distance; I am available full time over 95% of the time here locally. Also (and this is more of a personal opinion) UMC is completely disconnected from rural medicine and providers in spite of being the main academic player in a rural state. In other words, UMC functions within the academic walls of UMC in “big city” Jackson, MS. It trains MDs who have a completely different conception of medicine from the actual reality of the state.

Our hospital serves a rural community of 30,000 who live in 2 counties with Centreville located in the middle. We are in the southwest corner of MS; right on the border with Louisiana, about 50 miles from Baton Rouge and 120 miles from Jackson. It’s a place in the middle of nowhere. Although we are close to urban areas and small towns, it is still definitely rural and under-served. Most people work in Louisiana, The hospital is the second largest employer. The first is a Georgia Pacific paper mill. Agriculture, logging and timber are also dominant activities. People are generally employed in jobs with little or no benefits or don’t work as a consequence of a semi-voluntary time & generational habit. Large segments of this population are uninsured or carry policies that are of little use (i.e. a logger with a $20,000/year salary and a family of 6, whose Blue Cross policy carries a $5,ooo deductible); among active patients, dual eligibility (Medicare & Medicaid ) are predominant; sole Medicaid is a 20-30%; commercial carriers I would think less than 20%. I am speaking here of active patients. Keep in mind that the the largest group, the uninsured, don’t come to see us unless mayor crisis happens. Years ago somebody defined this community to me as one characterized by work, family, church and Friday night ball games; my personal addition is ” let’s eat something fried ” (not necessarily chicken).

Predominant problems are the usual suspects: They include obesity (Misssissippi has the highest rate in US); hypertension (unique and very difficult to treat among blacks here in the South), diabetes, coronary artery disease (also different here in the South). There is also a large amount of alcohol and drug use, but virtually no organized system to deal with substance abuse. Mental illness is common but there is a complete absence of psychiatric care in rural areas. In the year 2008 patients are still held in jail while awaiting placement after commitment. This is a whole other story. HIV disease is highly stigmatized and patients travel long distances to receive care – when they decide or can afford to do so – in order to maintain anonymity. And there is trauma of all sorts. Other characteristics of the community include a high rate of illiteracy, very low educational standards at the school system (still divided into private & white on the one hand and public & black on the other). Lots of things in Mississippi still happen in black and white; no grays. Here is a second “I owe you” for me; I have failed completely to try to introduce health related educational activities at either school system. I’m not sure if it is because of “me or them.”

The health care system organization has changed in recent years. Four original free-standing and private clinics have evolved into 3 hospital run clinics with physicians employed by Field Memorial Community Hospital (now known as Hospital & Clinics). They are staffed by one surgeon, 2 internists, 3 FPs and a GP (he’s the busiest one; his father was a nearby town sheriff; therefore part of his “allure”); 3 Nurse Practitioners; one per clinic. Having a CFNP allows the clinics to qualify for what is called “rural health denomination”; this is a cost-based reimbursement system which compensates for part of the uncompensated care we deliver. Collection rates are sometimes less than 50 % of billings. The Hospital take over of these clinics resulted from the 2002 malpractice insurance crisis. All of the MD’s lost our coverage when our former carrier left Mississippi because of the legal climate. We all became uninsurable, unless we were willing to pay six-figure rates for coverage. The solution? We all became employed by the hospital which is privately operated but county-owned. Thus, we all became state employees; and therefore qualified to have caps on our malpractice liability. In this way we were able to afford insurance. Six years later, things are more stable (or maybe we all got used to the situation). I still pay around $40,000/ year for malpractice insurance. Having shifted the administrative tasks to the hospital (which is a Critical Access Hospital and is also reimbursed based on a cost basis rate rather than DRGs ) has had a good impact on the practices and there is a mutual benefit for both parties. This has allowed us to both survive and continue serving patients locally. No physicians were lost to the malpractice insurance crisis of 2002 in this area.

Nonetheless; provider retention rate is low. Since 1999 I can think of 5 physicians and 4 CFNPs coming here; all others I have mentioned before were born and raised here. Only one of the nine remains: me. I am probably one of the few success stories of the J-1 waiver program which is meant to recruit providers to under-served rural areas. However, the vast majority leave after an initial commitment of 3-4 years. I had a 4 year contract and now I am on my 9th year and have no plans to leave. Somebody recently asked if I was planning to stay and my answer was that I was not planning to leave; staying is more complex and depends on other factors. There is such a delicate balance in a small rural practice that every so often there is a general sense of uncertainty. Having said that, I have probably survived a mayor crisis in our practice every year; so, again the “get used” factor at play is big. Our most current source of anxiety in Mississippi is the debate on a Medicaid tax for hospitals which has been proposed by the state legislature and Governor Haley Barbour. Governor Barbour has a long track record as a tobacco lobbyist in DC and has blocked efforts at taxing cigarettes as an alternative way to close the current 380 million deficit of the Medicaid program for this fiscal year. Small hospitals like ours are particularly threatened by this tax and by the loss of Medicaid dollars. They are a much need source of cash flow and are particularly useful by small institutions who get paid based on cost and disproportionate share formulas. You can imagine that it doesn’t really matter if Medicaid drops reimbursement or even if Medicare cuts MDs payments. Where are our patients going to go? Or, to look at the issue from the other side: who will be able to continue to see them?

Why stay? The easy answer includes a certain laziness. Start all over somewhere else ? After all these years here ? However, a less mentioned fact is that rural MDs are fairly well compensated and have lower operational and living costs. But they do have to work. It is not uncommon to have 80-90 hour weeks on average all year long. In the final analysis I don’t think I can live & practice anywhere else for now at least.

In my opinion primary care and internal medicine in a rural community are more challenging than in urban or suburban settings. There are far greater rewards at the personal level. You need a solid training background and constant updating. Delivering standard levels of care in tertiary care settings is easier and less challenging than taking care of patients in a small hospital or clinic in the middle of nowhere. Here resources are very often limited, but we still maintain a sense of standards of care. Furthermore, small rural community hospitals have a social and vital reason to survive and remain in business. They are needed locally. I will always be an outsider in Mississippi, and that is absolutely fine with me. It actually works to my advantage in helping to maintain my sanity and avoid burn out. But, still, for me the clinic and hospital is where my life is happening everyday for the last 9 years.

Ricardo Nimo

Out in the Rural: A Health Center in Mississippi [with Jack Geiger]


Out in the Rural
Produced by Judy Schader Rogers, 1970
If you have problems with the streaming video, you can download the film here. It is 22 minutes long and may take some time to download.

A classic film in community health…

Shot in the fall of 1969 and the winter of 1970, “Out in the Rural: A Health Center in Mississippi” highlights one of the very first Community Health Centers in the United States: the Tufts-Delta Health Center of North Bolivar County, Mississippi. The film captures the broad vision of a community health center involved in far more than traditional medical diagnosis and treatment. For more information on this film, please see an article published in Social Medicine by Dr. Carolyn Chu. This film is posted with the kind permission of Dr. Geiger.

Juan Manuel Canales, Recipient of Jonathan Mann Award

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Juan Manuel Canales in Mexico

[This was originally posted in July of 2006]

The 2006 Jonathan Mann Award for Health and Human Rights was given to Juan Manuel Canales, a Mexican physician who has worked in the war zones of rural El Salvador and Chiapas, Mexico. This month the Social Medicine Portal highlights the work of this remarkable doctor who has spent over 25 years working alongside Central American and Mexican peasants and indigenous people in their struggle for a better life.

For Juan Manuel, the regular trip to one of the most isolated communities where he works starts before dawn. It begins with a two-hour ride in the foggy darkness. By the time he reaches the place where he has to start walking, the sun has come out and the fog is gone. The mostly uphill walk through pine forest and coffee fields takes another two hours, much of it on narrow footpaths.

Juan Manuel, supported by Doctors for Global Health (DGH), works with indigenous Mayan communities surrounding Altamirano, a rural community in Chiapas, Mexico, many of which are small and geographically isolated. Most of these farmers are supporters of the Zapatista movement, and consider themselves to be “in resistance.” The main component of his work entails training health promoters from these remote indigenous communities and helping them carry out projects in their villages, such as vaccination campaigns, to address the broad health needs of their communities. He also works with volunteer doctors and public health students to introduce them to Liberation Medicine, a model of rights-based, community development work.

Juan Manuel has devoted his life and career to helping oppressed peasant and indigenous communities demand their right to health care by establishing community medicine and public health programs. His understanding of and commitment to human rights and humanitarian law led to his belief that health care is a right, that the Geneva Conventions should protect civilians’ right to medical treatment in the midst armed conflict, and that a rights-based approach is an important tool for indigenous communities to protect themselves.

Championing this cause took no small amount of courage El Salvador in 1980s, where rightwing death squads roamed freely throughout the country and community-based health care was considered a subversive activity. (The support of the US for repression in El Salvador during the war has been well documented by the National Security Archive.)

Juan Manuel lived and worked in areas of heavy conflict, where the population was continually forced to flee bombings and incursions by the Salvadoran army. The violence eventually caught up with him, leaving him with loss of vision in his left eye and an injury to his leg that resulting in a permanent limp. (See photographs of the war in El Salvador taken by renowned war photographer John Hoagland.)

After the El Salvador civil war ended with the 1992 Peace Accords, Juan Manuel stayed in one of the most devastated communities — Santa Marta. He worked closely with the Pan American Health Organization and other groups to aid returning refugees and establish mental health programs for traumatized communities. It was there that he first began to use community radio as a public health tool. He worked extensively with health promoters and midwives to develop simple radio dramas that were humorous, but effective and engaging to teach about human rights and health.

In 1999 Juan Manuel turned his attention to the politically oppressed but fiercely independent populations of indigenous Mayans in Chiapas, Mexico, who are struggling for self-determination and respect for their human rights. (Read some of the history of this struggle, and stay up to date on the latest developments). There Juan Manuel continues to put into practice his belief in the interconnectedness of health and human rights on a daily basis, helping to construct a basic community health system that respects the needs of the indigenous population without imposing the priorities of outside health professionals.

Juan Manuel was honored at the annual Global Health Council awards banquet on June 1, 2006 in Washington, DC. You can read his powerful acceptance speech on the DGH website.

The Jonathan Mann Award was established in 1999 to honor Dr. Jonathan Mann and highlight the vital link between health and human rights. Sponsored by the Association Francois-Xavier Bagnoud, Doctors of the World, John Snow, Inc. and the Global Health Council, the award is bestowed annually to a leading practitioner in health and human rights.

Despite his untimely death in a 1998 plane crash, Jonathan Mann is considered by many to be one of the most important figures in the 20th century fight against global poverty, illness and social injustice. History will especially remember Dr. Mann for bringing to the world’s attention the basic notion that improved health cannot be achieved without basic human rights, and that these rights are meaningless without adequate health. Juan Manuel embodies Dr. Mann’s principles in his daily work. He exhorts us to “invertir en cabeza,” loosely translated, “invest in the mind,” as he trains the future leaders of indigenous communities.

– To read more about Juan Manuel and his work, read the DGH Reporter article “DGH Profile: Juan Manuel Canales”. If you would like to make a donation to help continue to make Juan Manuel’s work possible, you can do so through Doctors for Global Health.