Culturally conscious care for remote communities in Colombia

Twenty hours earlier, Yessica, in a state of alarm, had knocked on the door of her neighbor in Bocas de Apartadó, an Afro-descendant town on the Baudó River. Although her due date was still two months away, Yessica’s water had broken and she had severe abdominal pains. The neighbor, María Daicy Mosquera, urged her to head to the health center an hour upriver in Pie de Pató.

When she reached Pie de Pató, Yessica was told she needed hospital care, so she traveled another two hours by river to Puerto Meluk, and then four hours by ambulance to Quibdó, the capital of Chocó. 

Yessica’s baby was born with extremely weak vital signs, but a nurse was able to resuscitate him. Eighteen months later, he is a healthy toddler. “The child would have died if we hadn't referred Yessica,” said María Daicy, who is well known in the Bocas de Apartadó community for her work. She is one of 42 Afro-descendant and indigenous community health workers Doctors Without Borders/Médecins Sans Frontières (MSF) has trained to support 133 communities where people struggle to access health care. 

A game of chance for hospital care

To see a doctor in Baudó requires a certain degree of luck. It helps to get sick during the day, because at night people avoid traveling on the river—the main means of getting around in a region with few roads—on the perceived orders of armed groups (who deny having issued such orders). Such movement restrictions are commonplace. According to figures from the Colombian Ombudsman's Office, in 2023 there were 124 incidents of ‘forced confinement’—in which people were ordered not to leave their villages—affecting more than 40,000 people across Chocó. 

It also helps to fall sick when it is raining, so the river contains enough water to travel three to 15 hours to reach the nearest sizeable town to see a doctor. Owning a boat with a motor—or having a friend who will lend theirs—is another advantage as there is no public boat or river ambulance for the almost 100,000 people who live across the Alto, Medio, and Bajo Baudó areas. 

Many residents of Chocó have also been subjected to mass displacement. Local people live under the constant threat of forced disappearances,  mines, and unexploded ordnance, while health care providers have been targeted with violence.

The challenges of everyday life in this region have influenced the shape of MSF’s project, which brings health care access to people living in the most remote and under-served communities.

“Because of multiple effects of the armed conflict, the significant gaps in health care provision, and the geographical conditions in the Baudó sub-region [of Chocó], MSF believes that its health model has to be community-based and decentralized,” said MSF project coordinator Javier Mattos.  

Culturally informed and respectful care 

MSF’s model incorporates knowledge of beliefs and customs linked to people's health in the Afro-descendant and indigenous communities in the area. Using this knowledge, MSF has trained people within the community to help prevent and detect common diseases early, when they are still easy to treat.

“Most of the medical consultations we provide are linked to malaria, diarrhea, respiratory syndromes, and skin conditions,” said MSF medical advisor Dr. Johana Vinasco. “All of these diseases are preventable or can be resolved with basic medical care.” 

Community health promoters are trained to speak on topics such as hygienic food preparation and storage, mosquito nets, and how to use the water collection tanks MSF installed to provide communities with clean, safe drinking water. MSF also trains them to provide basic treatment for common ailments and to identify warning signs so they can refer patients to health centers for specialized care. 

A decentralized model to expand access 

MSF maintains a referral network that pays for patients’ transportation to health centers and for food during their time away from their community. We have also helped reinforce services at the medical facilities to which patients are referred. 

Over the past two years, the project has marked several successes, including reducing serious medical complications among young children and bringing down mortality rates among children under two years old.  

“Our decentralized model has helped prevent serious complications in children under five, who make up the largest number of referrals, and has helped reduce mortality rates in children under two from diseases that are preventable or treatable, such as malaria,” said Vinasco.

From March 2022 to February 2024, community health workers trained by MSF provided 9,985 medical consultations and psychological first aid to 72 people. They also arranged 2,097 referrals to health centers, including 1,388 urgent cases. Meanwhile, MSF-trained health promoters reached nearly 47,000 people through more than 5,000  sessions educating the community about preventing health problems.

Two doctors for every 10,000 people in Alto Baudó

Despite these successes, the difficulties of daily life in Chocó continue. Movement restrictions and landmines continue to prevent people from reaching health centers and from finding enough to eat. Many residents are unable to access their vegetable plots and cannot go fishing or hunting, resulting in a risk of malnutrition, primarily in children. 

The existing health system also has serious flaws. “For medical conditions that arise without warning—such as trauma injuries, accidents, and complications in childbirth—urgent referrals need to be made, but we're dealing with a system that is both unstable and inefficient,” said Vinasco. 

The World Health Organization recommends a minimum of 23 doctors for every 10,000 people in a community. While the nationwide average in Colombia is 24, there are fewer than two doctors for every 10,000 people in Alto Baudó. 

For people in the most remote areas, it can take a whole day to reach a doctor. If a higher level of care is required, patients have to go to the San Francisco de Asís hospital in Quibdó, and some indigenous patients report being discriminated against by health staff. 

“We are calling for improvements to people’s access to health care in Baudó, and for the development of decentralized models of care," said Mattos, as well as consideration for ethnic-based inequities.

Vinasco agreed, adding, “The community model is based on the actual conditions of patients’ lives. It helps them recover their dignity because it respects their life practices and strengthens their access to basic rights, such as health care.”