Rural telehealth against the coronavirus

Photo with the Araucaria trees in Santa Terezinha

Written by Danuta Ramos Duarte

Translated into english, posted and edited by Bianca Cadore Morás

Reviewed by Mayara Floss

(Portuguese below)

Being a doctor in a small town, in the middle of Santa Catarina state in Brazil, with a population of nine thousand people, imposes some challenges. But my small town has a secret name: Santa Terezinha. To get here from the coast we have to cross narrow streets amid Brazil’s Atlantic rainforest, trees called araucarias and small plantings.

The road is rough, full of hills and valleys, with rivers crossing the forest to become waterfalls. Little unpaved roads connect the districts, holding an area of approximately 450 miles.

The people who live here sustain themselves basically with farming, as the plantation of tobacco, corn and soybean are the most frequent crops. They are rural workers, little farmers descended from European migrants who took refuge here during the World War II, finding in Brazil a home beside the nazi horror. They’re polish-descendants (self-titled “polacos”), ucranians and germans who carry strong family traditions: the boundaries between public and private is lost among social relations.

At the chimarrão (mate tea) reunions in the evening, they gossip about the lives of everyone in the community with great detail – a scene capable of provoking an unpleasant sense of invasion of privacy but at the same time a growing feeling of belonging and reception among them.

To care the population, we have three Primary Healthcare Unities with healthcare teams, and other three supporting stations in more distant locations.

A lot of people living in remote areas don’t even have access to phone lines, having trouble coming to our basic care unities because of the miles between us. In realities like this, the telehealth is an essential tool to reach the people that can’t easily come for health facilities.

Fortunately, the internet and the radio are modern resources already consolidated in most homes, are helping us to reduce the distances.

So, as an educational health strategy, we are using Whatsapp and the community radio line to inform people about the coronavirus and the changing on rural basic care units working routine, since we’re attending only priority groups, emergencies and respiratory syndromes. The town provided an official telephone number as an open communication channel with the community. Besides that, the community health agents – who live in the neighborhood – spread the official information in their area of coverage, since they already have Whatsapp groups with the people they visit.

Instead of what we might think, most of Brazilians, as well as the people from Santa Terezinha, live in rural areas and traditionally put great confidence in the word of doctors and public authorities.

We use this confidence to reinforce the need of social isolation to withhold the pandemic of coronavirus which is getting close to us, many times we are going against what the federal government is, irresponsibly, preaching in their recent statements.

Educating the population, promoting autonomy and critical thinking, really saves lives.

________________________________________________________________________________

About the author:

Danuta Ramos Duarte, born in the riverside of Araguaia in a little town of Tocantins state called Araguatins. She studied in a public school, graduated in medicine at a public university, Universidade Federal de Tocantins. Danuta is a person in love with people, nature and also with people’s natures. Granddaughter of a babaçu coconut cracker and an ecologist of Bico do Papagaio, daughter of a teacher, a feminist that dares to love another woman. A resident in Family and Community Medicine for SES-SC, a member of GT Rural from Brazilian Society of Family and Community Medicine (SBMFC).

Original text in Portuguese:

Telemedicina rural contra o coronavírus

Foto com as araucárias de Santa Terezinha

Escrito por Danuta Ramos Duarte

Traduzido para o inglês, editado e postado por Bianca Cadore Morás

Revisado por Mayara Floss

(Em inglês acima)

Ser uma médica num pequeno município, no interior de Santa Catarina, de 9 mil habitantes, impõe seus desafios. Mas minha pequena cidade tem nome sagrado: Santa Terezinha. Para chegar do litoral até aqui passamos por estradas estreitas ladeadas por mata atlântica, araucárias e pequenas plantações.

O terreno é acidentado, cheio de morros e vales, com riachos entremeados na mata, formando cachoeiras. As estradinhas de terra estreitas conectam os distritos, abrangendo uma área de aproximadamente 720 quilômetros quadrados.

O povo que aqui vive se sustenta basicamente da atividade agrícola, sendo a plantação de fumo, milho e soja as culturas mais frequentes. São trabalhadores rurais e pequenos agricultores e agricultoras, descendentes de migrantes da europa, aqui refugiados durante a Segunda Guerra, que encontraram no Brasil um lar ante o horror nazista.

São descentes de poloneses (autodenominados "polacos'), ucranianos e alemães, de tradição fortemente familiar: os limites entre o público e o privado se diluem nas relações sociais.

Nas rodas de chimarrão ao entardecer toda a vida da comunidade é discutida e recontada aos detalhes - cena capaz de provocar uma desagradável sensação de invasão da vida particular, ao passo que faz nascer o sentimento gostoso de acolhimento e pertencimento à comunidade.

Para atender a população, temos 3 postos de saúde com equipe saúde da família, com outros 3 postos de apoio nas áreas mais afastadas da sede.

Muitas pessoas em suas localidades não têm acesso a rede de telefonia e enfrentam dificuldade de acesso aos postos devido às grandes distâncias. Em contextos como este, a telemedicina é ferramenta essencial para alcançarmos as pessoas que não alcançam os serviços de saúde com facilidade.

Felizmente a internet e o rádio são recursos modernos já consolidados em grande parte dos lares dessa gente resistente, nos possibilitando reduzir as distâncias.

Então, como estratégia de educação em saúde, estamos usando o whatsapp e a rádio comunitária para informar as pessoas sobre o coronavírus e as mudanças na rotina das UBS e postos de saúde rurais, já que estamos atendendo apenas grupos prioritários, emergências e síndromes respiratórias. O município forneceu um número de whatsapp oficial como canal aberto de comunicação com a comunidade. Além disso, as agentes comunitárias de saúde, que moram nas localidades, repassam as informações oficiais para as famílias da sua área de abrangência, pois já possuem grupos de whatsapp com as pessoas que atendem.

Ao contrário do que possamos acreditar, a maior parte dos brasileiros, tais como os terezinhenses, vive em zonas rurais e tradicionalmente depositam grande confiança na palavra de médicos e autoridades públicas.

Nos valemos dessa confiança para reforçar a necessidade de isolamento social para impedir que a pandemia chegue até nós, indo, muitas vezes, em contramão do que governo federal tem apregoado irresponsavelmente, nas suas declarações mais recentes.

Educar a população, promovendo autonomia e criticidade, salva vidas.

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Sobre a autora:

Danuta Ramos Duarte, nascida na beira do Araguaia numa pequena cidade do Tocantins (Araguatins). Estudou em escola pública, formada em medicina pela Universidade Federal do Tocantins, apaixonada por gente e pela natureza e pelas naturezas das gentes. Neta de quebradeira de coco babaçu e do ambientalista do Bico do Papagaio, filha de professora, feminista e que ousa amar uma mulher. Residente em Medicina de Família e Comunidade pela SES-SC, membro do GT rural da SBMFC.

How did we find Rural Medicine? By Matt and Sue Masel

Free medical outreach to Mountanous Somorika community with no access road

Community members receiving medical care during the free medical outreach

Dr Dako Mamudu

I am Dr Dako Mamudu, a family physician based in Lagos metropolis, Nigeria. I am the chief medical director of Dako Medical Centre and also founder and Chief Executive Officer for Dako Foundation for Rural Healthcare and Education. I lead my team to carry out healthcare delivery in remote, rural and difficult to reach communities. 

I was born and raised in a rural community where ninety percent of the houses were roofed with thatch. My empathy for rural healthcare led to the founding of Dako Foundation for Rural Healthcare and Education (Dako Foundation). Dako Foundation is a registered Non-Governmental Organization in Nigeria and it works to improve the living conditions of underserved and difficult to reach communities in Nigeria through education, empowerment, provision of social amenities, public health programmes and direct medical interventions. 

Somorika is an ancient city in Akoko Edo Local government area in Edo North, Nigeria. It is about five kilometers north-east of Igarra in Edo North. It is a community with a wealth of cultural heritage. However, the rocky geographic terrain of this community (several hills that go as high as 1700 feet interspersed at unequal intervals) and the often inaccessible road to the location result in a great inequality in access and provision of healthcare services to people in this location. 

DFRHCE staff going from the residence of the traditional ruler to the health centre where the medical outreach took place.

I lead my team to this mountainous Somorika community for free healthcare outreaches between 2017 and 2018. Members of my team and I climbed several rocks of varying heights in order to get to this community. Our first point of reach was the resident of the community leader. From where we climbed more rocks of varying heights to access the local primary health centre where we carried out the free medical outreach. Similar to my previous missions to rural communities, health care professionals from my team were brought from urban cities of Lagos, Benin City and Auchi to carry out this medical outreach at this community. This was a four day mission and my team consisted of 20 regular staff of the Foundation comprising of doctors, pharmacists, public health experts, nurses, community health extension workers (CHEWs) together with 15 local volunteers. The attending midwife in this facility together with the assistant; a nursing aid also participated in this mission.

DFRHCE outreach team preparing for Somorika mission

DFRHCE staff on the road to Somorika Community, Edo State, Nigeria.

This comprehensive outreach which includes free surgeries is in tandem with the Sustainable Development Goals aimed to ensure healthy lives and promote wellbeing for all at all ages. The outreach activities consisted of community health education and sensitization, general consultation and treatment of endemic diseases, vitamin A supplementation for children and at risk population, mass drug administration of Albendazole to community members, distribution of lifesaving prenatal and post natal vitamin supplements to women of childbearing age and distribution of easy to use water purifying units to households in the community. Hospital equipments were also distributed free to the dilapidating community Primary Health Centre; the only source of healthcare in the community and its environ. The distributed equipments include artery forceps of different sizes, drip stands, hospital beds and mattresses, bedcovers and delivery couch.

Patients who required surgeries were referred to our partner hospital (Dako Medical Centre, Lagos) for free surgeries and follow up. Surgeries performed include breast lumpectomy, emergency caesarian section, and undescended testis (jointly sponsored by Amazing grace Hospital, Dako hospitals and Dako Foundation).

The community leader conducting the DFRHCE staff round his ancestral palace built in 1900.

The community leaders taking the DFRHCE team round the dilapidating infrastructure of the health centre.

Medical consultation for the Community Head of Somorika

Medical examination for optical refraction for patients with refractive errors.

Community members queuing up for registration for treatment.

Children receiving vitamin A supplementation

Over 5,000 rural patients were reached through repeated visits to the community for free medical mission. This is my passion and I am glad to work with a team that share same passion to bring healthcare to the hard-to-reach and underserved communities. 

My mission to take healthcare delivery to the underserved and difficult to reach communities in Nigeria will continue to take us to the underserved and almost forgotten people across communities in Nigeria. In the next edition, I shall publish our outreach work to Okorogbo and Akatakpo in the ‘urban rural’ communities in the heart of Lagos metropolis. Below are some of the images depicting our outreach activities.

_________

Dr. Dako Mumudu MBBS,DFM, is the Chief Medical Director of Dako Medical 

Centre, Lagos, Nigeria and founding Chief Executive Officer, Dako 

Foundation for Rural Healthcare and Education.

Life Member, WONCA

Email: info@dakofoundation.org

Post flood disaster intervention to victims of flood ravaged areas of Anegbette, Osomegbe and Ekperi Udaba communities of Etsako central local government area of Edo state of Nigeria

 Outreach team work distance into the communities. 

Dr Dako Mamudu 

I am Dr Dako Mamudu, a family physician based in Lagos, a mega city, Nigeria. I am also the founder and chief executive officer of Dako Foundation for Rural Healthcare and Education. I was born and raised in a rural community where ninety percent of the houses were roofed with thatch. The inhabitants of my village and its neighbouring communities were peasant farmers, hunters and petty traders. The only sources of water supply were about half a dozen of deep wells and a stream which was about five kilometers away. The six room block of classrooms in the community primary school which I attended was one of the buildings roofed with corrugated iron sheets. These were the prevailing situation of the communities in the region where I lived. 

Over the years, quality of health care delivery in rural communities has gone from bad to worse in most underdeveloped and developing countries of the world especially Sub Sahara Africa. In Nigeria in particular, the situation is worse in rural, riverine and difficult to reach communities. My empathy for these communities and its people led to the founding of Dako Foundation for Rural Healthcare and Education (Dako Foundation). Dako Foundation is a registered Non-Governmental Organization in Nigeria and it works to improve the living conditions of underserved and difficult to reach communities in Nigeria through education, empowerment, provision of social amenities, public health programmes and direct medical interventions. 

Anegbette, Osomegbe and Ekperi Udaba are parts of the riverine communities in Etsako Central Local Government Area of Edo State, Nigeria where we regularly carry out our activities. The main occupations of the people of these communities are peasant farming and fishing. Together, the population size of all the riverine communities in this local government area is about 250,000. The closest accessible point of good healthcare to these communities is about 50km away and for about six months of the year, there is no access to these communities by road. 

Recently, just like it happened in previous years, tributaries of the River Niger, especially River Alika overflowed their banks (climate change) and swept over the communities; covered their farmlands and swept away their crops. Their homes were covered with water for over two months and they had to take refuge in refugee camps. 

Houses submerged by flood in the affected communities. 

As the flood started to recede, I led a post flood disaster intervention to these communities through Dako Foundation aimed to alleviate the pains inflicted on these communities and its people by the devastating impact of the disaster . Also, this outreach is in tandem with the Sustainable Development Goals (SDGs) SDG 3: to ensure healthy lives and promote wellbeing for all at all ages. 

DFRHCE team at our base station preparing for takeoff for the mission.

Still at the base station; donated clothes awaiting transfer to our work location. 

Health care professionals from my team were brought from urban cities of Lagos, Benin City and Auchi to carry out this medical/social outreach. This was a four day mission and my team consisted of 22 regular staff of the Foundation comprising of doctors, pharmacists, public health experts, nurses, community health extension workers (CHEWs) together with 20 local volunteers. Some health workers from the local health facilities were co-opted to participate in the outreach. 

I have previously carried out some health care missions with Dako Foundation to some of these communities in 2016. The only accessible road to the index communities was through a wooden bridge across a deep flowing river. 

 A Dako Foundation staff guiding the outreach vehicle through a wooden bridge (the only accessible road to most of the communities). 

During the post flood disaster intervention to the communities, myself and my team travelled over 500km from Lagos by road to our local base in Edo North. We then travelled another 35km on a daily basis through a lonely, rough, winding and dangerous road to the only accessible village in the community by road. From here we either walked to the near community or drive across a dangerous wooden bridge across a deep river to the communities. On arrival, we carried out health education and sensitization for community members followed by free medical consultations, prescription and treatment of local prevailing diseases (Figure 6, 7and 8). Also, items distributed include antifungal drugs; clothes; prenatal and postnatal multivitamin supplements for pregnant and lactating women; bread, medicated soaps, toothbrushes and toothpastes. Vitamin A supplementation was given to children and other at risk population (Figure 9). There was also mass drug administration of Albendazole to community members. 

Lactating woman received free drugs distributed by DFRHCE. 

Nursing staff carrying out blood pressure and vital signs measurements after registration.

Community members queue up to get registered for medical consultation 

Distribution of Vitamin A and albendazole to children during the outreach. 

In addition to the above, we distributed easy-to-use potable water sanitizing units with storage tanks to households in the communities (Figure above). This equipment does not require electricity and it is user friendly. It functions in such a way that when it is filled with water, and pressure is applied through the external hand pump, the buildup pressure within the unit drives water flow through the filtration component into its external tap where water is collected and stored in a clean storage. Water that flows through this filtration unit is suitable for drinking. 

Water purifying units distributed to heads of community households.

Overall 5,132 rural members were reached through three targeted visits to the communities for the free medical mission and distribution of relief materials. This is my passion and I am glad to work with a team that share same passion to bring healthcare to the hard-to-reach and underserved communities. I hope to arrange additional interventions to other communities in this locality that were not accessible at the time of this intervention. 

_________

Dr. Dako Mumudu MBBS,DFM, is the Chief Medical Director of Dako Medical
Centre, Lagos, Nigeria and founding Chief Executive Officer, Dako
Foundation for Rural Healthcare and Education.
Life Member, WONCA

Email: info@dakofoundation.org

Rural island medicine in Minamidaito island, Okinawa, Southwest of Japan

By Ryuichi Ota

I am a young Japanese family physician working in rural areas of Japan. Training for Japanese family physicians has officially started recently, so there is a variety of training systems, though sometimes not always so systematic. I became a physician in Osaka and moved to Okinawa, southernmost part of Japan to become a rural island physician. I have experienced many fruitful things on my island to become a real rural physician. It can be said that rural islands and the citizens educate the physicians. This time, I want to introduce my experience in Minamidatio island, one of the rural islands, as a young rural physician.

I have worked as a young rural physician on a rural Japanese island. It is located in the most southeastern part of Japan. Its name is Minamidaito island, and it is located in Okinawa prefecture. It is about 400 km away from the mainland of Okinawa prefecture. By ship, it may take 14 hours from the mainland. Even if you use an airplane, it may take 1.5 hours. On this island, the population is about 1,400, and most of them work as sugarcane farmers. There is only one clinic without beds appropriated for admission. There is only one doctor, nurse and medical clerk. I went to this distant rural island after finishing my 3-year basic medical residency program, and I have been there for three years now. Is this a rare case in the world? This working style may be controversial in Japan. However, the experience as a young rural physician may affect their future as a physician in an effective way.

The responsibility of a solo physician in a rural island

First, the feeling of responsibility as a physician may increase. For example, on a rural island like my case, a physician has to take care of various kinds of illnesses. All of the patients there have to go to a clinic to get specific care, even if they do not like to go there. The rural physician cannot avoid studying various kinds of medical issues. Emergency cases are especially stressful for rural physicians. At rural island clinics, there are not enough instruments to treat the patients for a long time. The rural island physicians have to transfer their emergent patients to general hospitals on the mainland of Okinawa if they need long admissions or ICU care. However, to transfer the patients, doctor helicopters are needed. It takes 3 hours to reach the distant islands like my island (Ohta & Shimabukuro, 2017b). The rural island physicians must care critical patients until the arrival of the helicopters. The worse thing is, the duration of emergency may depend on the weather. The emergency case in summer was challenging for me. In one day in summer, one patient came to my clinic with the chief complaint of shortness of breath. He voluntarily stopped regular visits to my clinic one year ago. His past medical history was chronic obstructive lung disease. His symptoms had started a few days ago, which gradually exacerbated to the point where he came to the clinic. The vital signs were the blood pressure of 84/40 mmHg, heart rate of 132 beats/min, respiratory rate of 45 breaths/min, oxygen saturation of 79% in ambient air, the body temperature of 37.6 and Glasgow coma scale of E3V5M6 (total 14/15). I listened to his lung sounds, bilateral lung sounds, I diagnosed him with severe pneumonia causing septic shock. Soon, I intubated him and prepared for transportation. However, it did not come at once. This season, Okinawa is attacked by a lot of typhoons, and this year was not rare. This time, one big typhoon was approaching my island, and this prohibited doctor’s helicopter from coming to my island. To make matters worse, the typhoon approached the mainland of Okinawa after passing through my island. As a result, I had to observe this patient with only three members and restricted medical instruments (Ohta & Shimabukuro, 2017b). Without a ventilator, a nurse, a medical trainee, and I performed hourly vital sign measurement and did manual ventilation. Fortunately, his condition was stable with oxygen, antibiotic, and vasopressor. 27 hours after his arrival, he was transferred to a general hospital in mainland of Okinawa.

Diagnostic skills of rural physicians

Also, their diagnostic skills may be improved upon. It is only one physician, and he or she has to diagnose patients with vague symptoms or with certain diseases which they have not experienced yet. They may feel particular pressure and study hard. As they can get a lot of medical information by using the internet and communicate with their senior physicians via a social network, they may be able to approach their patients with various sources of help. For example, when I encountered patients with rheumatoid arthritis following ciguatera poisoning (Ohta, Shimabukuro, & Kinjo, 2017) or with vague bilateral shoulder pain leading to the diagnosis of Parsonage-Turner syndrome (Ohta & Shimabukuro, 2017a), I could diagnose them with literature reviews and my colleagues’ help. Through this process, rural physicians may become competent in diagnosis and inter-physician communication.

Challenge to community-based medical education

Second, a rural island may be a good practical learning situation for medical students and medical residents. They can learn specific things in various medical situations. Through the learning in rural islands, they may learn multiple important issues as physicians. There are many kinds of research to clarify the learning topics in rural areas, especially about community-based medical education (CBME). As learning contents have been shown to depend on the situation, we did one qualitative study to inquire about the learning contents of medical residents in Minamidaito Island. Through this research, we were able to identify four categories: a strong connection among the Islanders, the necessary abilities for rural physicians, islander-centered care, and the differences between rural and hospital medicine(Ohta & Son, 2018). In contrast to hospital medicine, various kinds of learning occurred in deep relationships with the Islanders. Furthermore, we clarified that the learning contents of medical students on this island, as a result, were alike. Rural physicians can learn not only medical issues but also CBME. They may acquire the possibility to become medical educators.

First trial of community-oriented primary care

Third, community-oriented primary care (COPC) should be mandatory in rural islands. Especially, in Minamidaito Island, there is only one physician and a nurse. They are the only medical resources. They have to collaborate with the members of the community to improve community health conditions. There are various stakeholders in the community. Empowering them may drive COPC. The stakeholders may play the central role in community health improvement. For example, public health nurses specialize in community health. They can analyze their communities and find various approaches to improve health conditions there. Their collaboration with medical staff in clinics may improve quality of life. There are two public health nurses on Minamidaito Island, for both pediatrics and older people. The public health nurse for pediatrics is interested in pediatric wheezing because of sugarcane harvesting. Through my collaboration with her, we were able to do a prospective cohort study. As a result, it was discovered that there was some cause and effect relationship between pediatric asthma and sugarcane harvesting (Ohta, Mukoyama, Fukuzawa, & Moriwaki, 2017). Additionally, we make up the specific approaches to diabetic patients on a rural island by using their feelings comparatively. Also, by collaborating with the public health nurses for older people, we were able to increase the opportunities for older people to have a dialogue with each other and share information about their conditions. Through COPC, rural physicians are able to learn the skills for how to approach communities such as leadership and empowerment, and how to analyze and make progress the community condition such as research skills.

The ecology of medical care in a rural island

Besides, an ecology of medical care in clinics is essential for understanding islands’ medical conditions. It is important to know what kinds of symptoms and diseases are common when medical staff inquire into information on epidemiology and do various interventions in communities. Also, the comparison of this data over several years may be useful for knowing the change in the prevalence of medical conditions there. For example, we collected the patients’ data based on International Classification of Primary Care-2 (ICPC-2) between 1990 and 2015(Ryuichi Ohta & Makoto Kaneko, 2017). As a result, in addition to the common cold, the frequency of asthma attack and other chronic diseases increased. This fact might lead to the consideration of the effects of aging population and the deteriorating air pollution. Rural physicians can express their opinions based on precise data and motivate their communities to improve their health conditions.

How to control negative emotion as only one physician in a rural island

At last, rural physicians need effective emotion control. On rural islands of Okinawa, every physician is only one medical staff that can perform medical treatment. They are special there, so rural citizens look at them as a physician wherever and whenever the citizens see the physicians. Additionally, they may feel the negative emotion in interprofessional collaboration. These conditions may lead to the physicians’ stress and negative emotions. Based on our research, rural physicians feel negative emotions in differences in recognition between rural physicians and patients, invasion of professionalism, suppression by one’s role as a rural physician, discordance with multiple occupations, and relationships with unfamiliar hospital physicians(R. Ohta & M. Kaneko, 2017). Also, to relieve negative emotions, time flow, refection, acceptance of islanders’ characteristics, and growth through their role were suggested(R. Ohta & M. Kaneko, 2017). Through rural experiences, physicians may improve their ability to control their negative emotions by recognizing the existence of controlling methods.

Working at rural islands, although there are lots of difficulties for your generation, can give various fruitful experiences for the future. Not related to their foreground carrier, these experiences can make them more balanced physicians and happier than ever.

References

Ohta, R., & Kaneko, M. (2017). Effects of practicing in remote Japanese islands on physicians' control of negative emotions: A qualitative study. J Rural Med, 12(2), 91-97. doi:10.2185/jrm.2934

Ohta, R., & Shimabukuro, A. (2017a). Parsonage-Turner syndrome in a patient with bilateral shoulder pain: A case report. J Rural Med, 12(2), 135-138. doi:10.2185/jrm.2933

Ohta, R., & Shimabukuro, A. (2017b). Rural physicians' scope of practice on remote islands: A case report of severe pneumonia that required overnight artificial airway management. J Rural Med, 12(1), 53-55. doi:10.2185/jrm.2925

Ohta, R., Shimabukuro, A., & Kinjo, M. (2017). Rheumatoid arthritis following ciguatera poisoning: A case report. J Rural Med, 12(1), 50-52. doi:10.2185/jrm.2921

Ohta, Ryuichi, & Kaneko, Makoto. (2017). Health Problems in a Rural Island of Okinawa: Changes Over 25 Years. An Official Journal of the Japan Primary Care Association, 40(3), 143-149. doi:10.14442/generalist.40.143

Ohta, Ryuichi, Mukoyama, Chikako, Fukuzawa, Yasunori, & Moriwaki, Yoshihiro. (2017). Relationship between Pediatric Wheezing Attack Frequency and Sugarcane Harvest Work: Prospective Cohort Study. An Official Journal of the Japan Primary Care Association, 40(1), 21-26. doi:10.14442/generalist.40.21

Ohta, Ryuichi, & Son, Daisuke. (2018). What do medical residents learn on a rural Japanese island? Journal of Rural Medicine, 13(1), 11-17. doi:10.2185/jrm.2950

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Ryuichi Ota is  a Japanese Family Doctor based in a rural remote island. 

Curatorship: Mayara Floss

Watercolor

Carnaúba dos Dantas - Brazil

Your eyes have

A non-defined color

And, perhaps because of this,

You ​can see the other tones in everything

From the cold gray

Of few shades,

That I coldly plan,

You can identify a small

Sick pink

That motivates my grit

In the green-water lies

That I tell to please you.

You only see the red

Bloody one

That burns me!

You see the invisible notes

With your eyes

Which color, then,

My mother,

Is the soul

That I have mixed

With mine?

__________

Alexandre Dantas is a doctor, teacher and writer. He was born and lived most of his life in one of the driest backlands of Brazil - where he returned 4 years ago, working as a rural doctor. He created the project "A Medicina Rural" on Instagram (@amedicinarural) in order to give visibility to the rural spaces in which he works and voice to the people who live in them.

Je suis étudiant!

Another intense afternoon at the clinic. Malnutrition and infections are already routine work.

Suddenly arrives a young man of 8 years of age and, well articulated in his words, appears and speaks directly with me, in French: Je suis étudiant!

Son of the arid land of Ambovombe, the little boy tells me about the difficulty in school because he can not see the blackboard. He struggles but has headaches.

He is the only child who attends school for all the children I attended in the entire first week of work. His case was not the priority and seemed absolutely far from our possibilities at the moment. However, #FraternitywithoutBorders was his and his grandmother's only hope

I took a deep breath. I had to do something. And I did...a modified Snellen test was enough to diagnose myopia. Concerned, I tell the translator..."He needs glasses, but we can not offer."

As we have learned in the FWB, we are many united hands working for Love. Dani, my translator and right arm (and left too!) Showed readiness to respond that we had a chance. The next day, we were all going to talk to the priest who had received a mission from the Catholic Church the week before. We introduced the FSF and we got another partner.

A week later, he and his grandmother return to the clinic. Main complaint: a little hand holding a package, a smile that can not be restrained on the lips and a tight hug from anyone who never loses HOPE to see it happen!

Janaina doing the modified Snellen test with the patient during her work 
in Madagascar

Janaine Camargo is a family doctor and works at the NGO Fraternity Without Borders in a rural area in Madagascar

Translated into English by: Bianca Silveira
Posted and Edited by: Ana Júlia Araújo