The study was conducted to compare available medical treatment options and the actual medical need in an Columbian indigenous population called Wiwa. Confirming a recently stated suspicions [2], common and mild to moderate diseases and infections, for which monotherapies with, e.g., penicillin derivates are sufficient, were covered well. As long as the infections are in an early stage, e.g., in case of bronchitis and as long as the causative pathogen has no specific requirements (e.g., due to antibiotic resistances), the treatment options can be described as safe and sufficient. If medical conditions become more complex, the diseases can be treated only initially and/or incomplete. Therefore, they can progress to severe courses with complications, sequelae or even result in death. In addition, often just symptoms are treated, as suspected diagnoses cannot be confirmed and/or differential diagnoses cannot be made. E. histolytica infections, which were shown to be common in a previous assessment [15], are just an example. In case of amoebiasis, the acute infection can be treated with metronidazole or tinidazole onsite, however, the gut decontamination with paromomycin is missing, which is necessary to eliminate cysts. This can lead to relapsing disease including abscess formation in the liver [17].
As soon as complications and/or severe diseases occur, the medication list showed missing first and second line therapy options. For example, a bronchitis, which does not respond to amoxicillin treatment, can expand to a pneumonia, potentially leading to death. Even simple betalactam-betalactamase inhibitor combinations like amoxicillin/clavulanic acid are not in place. It is noticeable that for many other partly life-threatening diseases, e.g., diabetes mellitus type I, no medication is available at all. Looking at emergencies, the situation is even worse. For example, a myocardial infarction cannot be treated with anticoagulation and i.v. antihypertensive medication is not available. For complications during delivery, no therapeutic option is in place that could regulate or control the situation.
Another study question was the likely neglect of diagnostic categories in the documentation, which could be confirmed for several categories to be discussed in the following. First, although birth complications often show a fatal outcome for the child and/or the mother as reported for other indigenous populations [18], these events were rarely documented for the Wiwas. In contrast to this, mistreatment during childbirth in Colombian individuals has been addressed a problem for Colombian indigenous people by Gleason and colleagues [19]. The likely reason for the neglect in the Wiwas is the missing physician or midwife and the missing registration at all. Thematically closely related is the ICD chapter on child deformations, delivery complications and related topics, which were not represented at well. As known from the personal experience of the authors, these topics have to be considered as very stigmatized in the Wiwa communities. Further, no male physician is allowed to participate in a child birth. Midwifes are not in place, just elderly women trying to help the younger ones, but without the necessary medical education. A stillborn child is not mentioned any more, a deformed child is neglected and often dies due to missing medical support. E.g., a child with a harelip that cannot drink will die as first, the operation will not be covered in most cases and second, the mother cannot solve the situation by herself.
Further, it has to be assumed that many diseases are not even recorded at all as, e.g., accidents and other occasions, where the patient is not able to walk to the next far away health point or hospital, are not registered. This is also true for many chronically ill patients or elderly ones who cannot walk the necessary distance. This has also to be considered for severe ill persons, weak ones (e.g., individuals in need of a blood transfusion), women with birth complications, as well as weak or immature newborns.
Some ICD chapters are very neglected in the datasets at all. Cancer, for example, is one of those. Of course, Colombian indigenous persons suffer from cancer as well [20], but to get a treatment is basically impossible for the Wiwas. This is true for two main reasons: Most indigenous people are poor and have no or just a very basic health insurance. This health insurance covers, e.g., an x-ray analysis but no chemotherapy. Even some surgical procedures are excluded (e.g., transplantations). Secondly, it is too cost-intense for them to attend necessary examinations, as there is no adequate infrastructure nearby and distances are too far. Also psychiatric disorders are barely mentioned. On one hand, this is related to the traditions of the indigenous population, as, for example, psychiatric diseases like depression are neglected and respective complaints are socially discouraged by the communities. On the other hand, this could also be a matter of lacking knowledge, as many psychiatric diseases are not known to be a disease (alcoholism, etc.) among the communities. The neglect of psychiatric disorders, as practiced by the Wiwas, has been reported for other indigenous populations from other parts of the world as well [21]. Also, there is an increasing body of evidence that more specific disease entities that ocular disease entities are insufficiently treated in South-American indigenous populations as confirmed by Colombian authors as well [22].
Taken all this together, previously reported high morbidity and mortality rates [2,3,4,5,6,7,8,9,10,11,12,13,14] find additional explanations. To improve the situation, many efforts are necessary, starting with the expansion of the medication list by, e.g., second and third line antibiotic drugs to increase therapeutic options for the quantitatively dominating infectious diseases. However, their appropriate use will also require the necessary expertise in place. In line with this, more medical staff is needed to permanently work on-site at the already existing health points. Health points should be expanded and health brigades should stay longer and/or come more often. In addition, better infrastructure is essential. Life situations need to improve, that would prevent many diseases, e.g., by providing clean water, sanitation and safe housing. Trainings should be offered to educate the Wiwa communities about infections sources and prevention.
The study has a number of limitations. The most important limitation is the degree of uncertainty and imprecision necessarily associated with such holistic approaches due to errors by chance during data assessment and management as well as by the fact that the data by the healthcare providers were not specifically collected for the here-assessed study purpose. Second, the analyzed composite datasets did not discriminate between individuals claiming more than one complaint and individuals with just a single one, as only the number of diagnoses was recorded. Finally, funding constraints just allowing the financing of only a single study physician limited the time spans of medical on-site assessments in the included villages and thus the amount of data collected in this well-controlled way.
Add Comment