Medications and services can be costly and difficult to obtain for many Honduran patients.
By Kaitlyn Alleman, Prof. Lawrence Robbins, Genesis Mejias, MD, Sofia Dubon, MD, and Nelson Betancourt, MD
Our rural Honduras neurology and psychiatry clinic conducted a simple survey. The primary purpose of the survey was to assess patient satisfaction. We also asked the patient to rate the most important aspect of the clinic. We collected diagnoses and demographics.
This free clinic was established by neurologist Lawrence Robbins, MD, in 2017, and was featured in the Aug. 9, 2021, issue of World Neurology. There are three neurologists, an EEG technician, two psychiatrists, and a clinic nurse. The neurologists and psychiatrists are dedicated and idealistic. Several thousand patients regularly attend the clinic. The clinic provides free physicians, tests, and medications.
Sixty-seven patients were surveyed: 41 were female and and 26 were male. The ages ranged from 18 to 86. The specific age breakouts were:
Ages 18 to 20: 11 patients
Ages 21 to 40: 23 patients
Ages 41 to 60: 13 patients
Ages 60 and up: 20 patients
The majority of patients resided in rural areas surrounding the main city of Tegucigalpa (there are neurologists in the main cities of Honduras). Most of the patients could not afford neurology or psychiatry services. The patients were randomly chosen, and the survey results were anonymous. Verbal consent was obtained. An Institutional Review Board was used.
The survey collected basic demographic data and diagnoses. Three questions were asked:
What is the most important reason for coming to our clinic?
a. To see the doctor and find out what is wrong
b. To receive medicines
Are you satisfied with the services at the clinic?
a. Yes
b. No
Has your life changed for the better since coming to the clinic?
a. Yes
b. No
The survey also solicited additional comments regarding the clinic.
Results
Question 1: Sixty-two out of 67 patients indicated that seeing the doctor and finding out what was wrong was most important. Only five patients listed receiving the medications as most important. Of these five patients, three had epilepsy as the primary diagnosis, one had migraine, and one was diagnosed with Parkinson’s disease. This was surprising, as we thought the free neurologic and psychiatric medications would be the primary reason for attending.
Question 2: All 67 of the patients listed themselves as satisfied. This is not surprising, as these patients have had no access to neurologic or psychiatric services.
Question 3: Sixty-six patients indicated that their lives had changed as a result of coming to the clinic. One patient did not provide an answer.
Patient comments: Forty patients made positive comments. There were three negative comments. Thirteen comments expressed thanks, 12 mentioned the good service, 10 praised the physicians or staff, three mentioned that everything was free, while two said they liked the medications. The negative comments mentioned that the pharmacy could improve, other specialties were needed, and the clinic should offer better instructions on how to pay.
Neurology Diagnoses in 67 Patients
Epilepsy: 16 patients (10 females, six males)
Headache (primarily migraine): 13 patients (nine females, four males)
Parkinson disease: 9 patients (two females, seven males)
Miscellaneous: one patient each: dystonia, cysticercosis, muscle disease, fibromyalgia.
Psychiatric Diagnoses
Depression (includes unipolar and bipolar): 12 patients (eight females, four males)
Anxiety: 11 patients (seven females, four males)
Insomnia: 1 patient (female)
Discussion
The Honduran patients expressed a high degree of satisfaction with the clinic. Most patients indicated their life had changed for the better. One main reason for attending the clinic was to receive a diagnosis. This was surprising, as we would have thought that obtaining the free medications was most important. If we only surveyed patients who had been attending the clinic for some time, the medications may have become the most important aspect.
Epilepsy was the most common neurologic diagnosis, followed by headache and Parkinson’s disease. Depression and anxiety were the primary psychiatric diagnoses. This was a limited number of patients. If we had surveyed 2,000 of our patients, headache probably would have been the most common diagnosis, followed by epilepsy. Although headache is more prevalent than epilepsy in Honduras, patients with epilepsy may be more motivated to seek medical care.
Most Hondurans cannot afford more than basic medical care. There are numerous free clinics providing this care. Medical missions to Honduras are numerous. The Honduran neurologists and psychiatrists are excellent. However, neurologic and psychiatric care is scarce for most of the population. Access to free neurology services is available in the main city of Tegucigalpa, but wait times are long, and rural patients usually cannot make the arduous trip. Patients must pay for an EEG or MRI, both of which are usually unaffordable. An MRI may cost three or four weeks of wages. In our rural clinic, we do 25 EEGs per month at no cost.
Honduran patients have access to basic neurologic medicines. For epilepsy, these include phenobarbital and phenytoin. But even these basic meds may be difficult to access. There is a reasonable selection in Honduras of the various anti-seizure medications. These include carbamazepine, lacosamide, valproic acid, vigabatrin, and others. These are usually unaffordable for most Honduran patients.
For migraines, basic preventives are available, including amitriptyline, beta blockers, topiramate, valproic acid, and a few others. However, only a fraction of patients with migraine are prescribed the preventives. Most cannot afford these medications. Triptans are available but are unaffordable for 95% or more of patients. NSAIDS (both PO and injections) and ergotamine compounds are often prescribed. Opioids are almost never used.
Epilepsy is frequently encountered in Honduras. There is a relatively high prevalence of epilepsy in Latin America. Infectious disease and trauma may account for some of this. Many patients are never diagnosed or treated. Despite the difficulty in obtaining MRIs and EEGs, Honduran neurologists are adept at treating epilepsy. There is an epilepsy surgery program in Tegucigalpa.
Migraine is a major health issue in Honduras. Migraine greatly affects the Honduran patients’ work and home life. For many of the impoverished patients, missing work due to a migraine presents an enormous financial burden. Migraine is vastly undertreated in Honduras.
We can provide many of the neurologic and psychiatric medications, although the Honduran health system does provide basic drugs for neurologic disorders. In this clinic, we provide about 19 neurologic and psychiatric medications. We try to choose medications that are relatively safe and do not require blood testing. They also must be available in Honduras. Although Dr. Robbins can obtain the medications in the U.S., when we run short, we purchase them in Honduras until we can get resupplied from the U.S. Many of the medications are expensive in Honduras.
In summary, this survey indicates a high degree of satisfaction with a rural clinic that provides basic neurologic and psychiatric care. Even though technology and advanced laboratory tests are scarce, the patients greatly appreciate being able to see a neurologist or psychiatrist. The free medications are also a vital part of their care. By providing basic neurologic and psychiatric care, we can significantly improve quality of life. •
Kaitlyn Alleman is a medical student at Rosalind Franklin University in Chicago. Lawrence Robbins is an associate professor of neurology at the Chicago Medical School. Genesis Mejias, MD, is a physician from Venezuela. Sofia Dubon, MD, is a neurologist in Tegucigalpa, Honduras. Nelson Betancourt, MD, is a neurologist in Tegucigalpa, Honduras.
