State of the World's Minorities and Indigenous Peoples 2013 - Case study: Honduras: first Garifuna community hospital offers alternative model for community-based health care delivery

The approximately 700,000 African-descendant Garifuna community in Honduras represents nearly 10 per cent of the country's total population.

According to ECLAC, the per capita GDP in Honduras was US$1,519 in 2011. Consequently, the 6.8 per cent of GDP the state allocated for health care was not likely to go very far. The limited expenditure meant that during 2012 Garifuna medical professionals needed to continue their efforts to develop and finance their own community-based health care delivery system. Their initiative has links with the devastating Hurricane Mitch of 1999 which destroyed more than 50 per cent of Honduran infrastructure; the predominantly rural indigenous Miskito and Garifuna communities were completely cut off. Nevertheless, this ill wind ended up blowing some good in the form of a revolutionary change in Garifuna health care options.

The disaster produced an immediate response from the international community. This included a medical contingent from Cuba that reached some of the most remote and hardest hit Garifuna villages. Besides providing urgent immediate help, according to Garifuna community health care pioneer Dr Luther Castillo, it opened the way for some young Garifuna to also become health professionals. Given the low per capita income and a national history of ethno-racial discrimination a career in medicine had always seemed too remote a possibility.

Although founded in 1847, the School of Medicine of the National Autonomous University of Honduras (Universidad Nacional Autónoma de Honduras, UNAH) did not graduate the first Garifuna doctor until 1962. Since then, high costs, social marginalization and the difficulty in gaining admission had ensured that the dream of pursuing a medical career would continue to elude the majority of Garifuna high school graduates.

Latin American School of Medicine

The chance for change came with the 1998 establishment in Cuba of the Latin American School of Medicine (Escuela Latinoamericana de Medicina, ELAM). ELAM then also initiated a scholarship programme to train several thousand doctors from Latin America, Africa and Asia. As a result, by 2012 11 Garifuna medical students had become doctors This is more than had ever graduated in the entire 115-year history of the UNAH, and new classes were being trained at the ELAM during 2012.

Student work brigades

Among the earliest graduates was Garifuna community health pioneer Dr Luther Castillo, who was in the very first ELAM graduating class in 2005.

While still in medical school, Garifuna students began looking for ways to immediately start contributing to community health improvement. The result was the creation of Garifuna Medical Student Work Brigades. All Garifuna students since then donate 15 days of their annual vacation from medical school to work alongside the Cuban and Garifuna doctors in various Garifuna communities.

From 2001 onwards, the student work brigades have helped run the permanent clinics established in at least 12 of the 46 widely separated Garifuna communities along the Honduran coast.

In 2005, three Garifuna doctors set out to build the first clinics for communities that had no prior access to health care. They also worked to develop a comprehensive system of preventive health care and patient education that focused on Garifuna community cultural realities. They organized a broadly based community volunteer structure to assist with all aspects of fund-raising, construction, service development and sustainability.

As the first phase, they decided to develop a free community hospital. They established a camp at the proposed site and began treating the first patients even though construction was still under way. It helped to generate interest and hope.

They also created alliances between faith groups, women's organizations, students and workers. The organizers used online social networks to link their efforts with similar health care delivery models. This included international research institutions, universities, international medical volunteer teams, health care NGOs and social movements.

According to the organizers, acquiring the support of Garifuna women was crucial. In addition to spearheading the mobilization process, they worked alongside community carpenters and bricklayers in getting the building finished and played a key role in the overall success of the project.

Following a substantial effort at fund-raising and community mobilization, the group of young doctors headed by Dr Luther Castillo gradually completed the first Garifuna hospital in Honduras.

The hospital is located in the community of Ciriboya, Colón, in the north-east of the country. It is a very remote marginalized area with few roads – all unpaved – no electrical connections and no government health services. Patients need to walk for many miles along the beach with the sick suspended in hammocks in order to receive any medical attention.

This is also an area where both Garifuna and other indigenous peoples continue to lose their ancestral lands and ocean fishing rights to land grabbers and international corporations that have established extensive palm oil plantations in the Baja Aguan region. According to MRG partner in Honduras OFRANEH (National Fraternal Organization of Black Hondurans), armed paramilitaries are used to crush indigenous community protests, and there are also instances of verbal harassment by the rifle-toting company 'guards'. The latter park on public access roads and are prone to showing displeasure at the presence of the young 'rights-defending' Garifuna doctors and nurses in the area.

First Garifuna hospital

The modest two-floor hospital was inaugurated in 2007 by the left-leaning President Manuel Zelaya – who was subsequently unseated in June 2009. By 2012, there were well-equipped rooms for delivery, a pharmacy, ultrasound department, a small laboratory and a dental room. Electrical power was supplied by solar panels.

The hospital directly serves the more than 30,000 residents in the Ciriboya zone and, if the surrounding area is included, regularly reaches a total of 60,000. According to the staff, who essentially work as volunteers, the hospital has provided almost half a million free consultations since 2007.

In addition, using the free hospital and clinics as a base, the far-ranging bilingual Garifuna health team and brigades provide medical consultations and medicine without cost to the more than 500,000 Garifuna living in the isolated Garifuna communities on Honduras' Caribbean coast.

Organizers claim that to date over 240,000 free medical treatments have been administered. Based on local rates, this totals about 144 million Honduran Lempiras (US$7.2 million). It is money that the Afro-Honduran population – marginalized and discriminated against – did not have to find in order to take care of their own health needs.

Comprehensive care strategy

Part of the health strategy also involves encouraging community projects that aid mental and physical well-being. Health system founder Dr Luther Castillo describes it as 'inter-culturally oriented medicine'. It takes a broad-based inclusive approach.

While using modern medicines, it matches the cultural modes, practices and material needs of the community and its traditions.

This means that a female patient with back pain from carrying heavy bundles of fuel wood will be treated for the physical ailment, and also the underlying causes. In addition to prescribing rest and medication, efforts will be made to provide the patient with a community-built solar stove to reduce firewood needs.

The health teams have been able to provide health education to more than 200,000 youth. They have also organized interventions in schools on topics ranging from intestinal parasites to alcoholism, sexually transmitted diseases to self-esteem. This includes setting up health-promoting soccer fields and volleyball courts.

International solidarity

Since the hospital and the community health system receive no support from the Honduran government, the support they get from voluntary service networks at the national and international level is very important, say the organizers.

The hospital receives help from an average of 30 international medical brigades that visit the community annually from North America. Almost all of the material used in the medical work comes from donations and fund-raising, including within North American migrant Garifuna communities.

Assistance also comes in conducting scientific studies in conjunction with US-based academic and other institutions. They conduct medical research on chronic illnesses that particularly affect Garifuna communities. These include diabetes, high blood pressure, kidney failure, sickle cell anaemia and venomous snake bites.

In addition to providing patient care, the hospital also runs a two-year nurses' training programme for local women and works with international NGOs to help train Garifuna women to be midwives.

Given the training costs and other aspects of hospital and system maintenance, the organizers need to expend substantial time and effort in local and international fund-raising.

Unhealthy relations

While efforts at international linkage and fund-raising have borne fruit, the Garifuna health system organizers have been much less successful in getting the model incorporated into the official Honduras health structure.

In November 2008, a commission for the improvement of the health sector (Proyecto de Reforma del Sector Salud, PRSS) examined the hospital in relationship to the state.

An agreement was signed in April 2009 between the Department of Health and the Association of Honduran Garifuna Municipalities (MAMUGAH). It was due to be renewed in July of that year making the hospital an official part of the Honduran Department of Health. Then a coup happened.

Following the June 2009 presidential ouster, the new administration proposed a significantly modified new agreement. The original model had focused strongly on preventive health care and direct Garifuna community involvement in management and control using the Garifuna native language. It favoured the training and employment of local community health workers. It took into account modern medical practices, as well as socio-economic and geographical conditions, and indigenous Garifuna preventive care, healing methods and medicines. It was all based on the free, prior and informed consent principle.

After the coup, the Department of Health proposed changes that centralized all aspects, including staff appointments. This meant that an agreement could not be reached, and the Garifuna health system has remained outside of the national framework.

According to the programme's director Dr Luther Castillo, health investment in Honduras is already low, plus people of African descent feel they are still treated as 'folkloric objects', and exposed to racist ridicule, belittling media images and xenophobia. Therefore, Garifuna communities consider it important to maintain control of their health delivery process.

'We were expecting official recognition and respect for our cost-effective community-based system, but the Department of Health was unwilling to change the long-held attitudes to our communities. So we just have to find ways to keep going and expanding the services on our own,' Castillo said.