Floating healthcare in the Peruvian Amazon
The Amazon Hope project provides vital care to remote communities
Providing healthcare on dry land can be difficult, especially in the face of limited infrastructure. Providing healthcare on a boat has different set of challenges. Medical boats provide healthcare in resource poor settings. The most well known of such projects are Mercy Ships, which offer, among other things, cleft palate reconstruction. Other floating 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. Poverty is widespread—42% of the population is classified 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.
Healthcare is difficult 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. Because of poor access to healthcare, and the region’s limited road access,  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. 
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. The floating clinic is run by a team of full time Peruvian medical and technical staff, 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.
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
- 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.
The benefits of boat clinics
The Loreto region is a difficult 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, understaffed, 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. This means that many people are put off seeking healthcare. The Amazon Hope boats are an alternative form of primary healthcare in isolated communities and is free of charge.
Some of the most effective public health interventions offered 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, fixed establishment. Such sporadic follow-up not only makes chronic disease management difficult 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 staff could be working in this remote and resource limited environment for the first 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 difficult to check that patients have understood the consultation or to provide them with simple health promotion advice because of time constraints and high patient-staff 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 difficult or costly to obtain. Consultations such as these often reduce the time available to see unwell patients and provide patient education.
In isolated regions that lack fixed, easily accessible healthcare, floating 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 different healthcare services (mobile, static, and traditional) on local populations is essential in planning sustainable, future healthcare in the Peruvian Amazon.
- 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
1Infectious diseases and Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, UK, 2University of Bristol Medical School, UK
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
- Mercy Ships website. www.mercyships.org.uk.
- Peruvian Ministry of Social Inclusion (MIDIS) website with interactive regional maps. www.midis.gob.pe/mapas/website2013/.
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- Vine Trust Charity website. www.vinetrust.org.
- Williamson J, Ramirez R, Wingfield T. Understanding disease and access to healthcare in isolated communities of the Peruvian Amazon. Abstract and oral presentation at Research in Progress meeting, Royal Society of Tropical Medicine and Hygiene, December 2013.
Cite this as: Student BMJ 2014;22:g3839