Back in June of 2010 and also in September of 2011, this newspaper published two articles that described the situation of the EBAIS clinic in Nosara and also the lack of funds to fix those problems. The most critical issue was the growth in the population of Nosara and the surrounding areas, but having the same amount of doctors, supplies and space at the clinic to provide the needed services. Yet, we recently received a letter from Tannia Tánchez Avila, regional director for Costa Rican Social Security (CCSS), telling us that some people are showing signs of frustration against the EBAIS staff, in some cases even threatening them, because they don’t understand what the real mission of these clinics is. Hence, we interviewed the current staff.
The Real Mission of the Nosara EBAIS
“People believe this is a hospital,” noted Juanita Gomez Morera, who has served as the doctor the Nosara EBAIS since November of 2012. But that is not the case.
The letters EBAIS stand for Equipo Básico de Atención Integral de Salud, or Basic Integral Health Attention Team. With that in mind, preventive programs are their strong point, aimed at promoting health and preventing illnesses rather than curing them.
“The most important for us is early detection or prevention. Afterward we enter into the curative part. The idea is to give integral health care,” explained Tannia Tánchez Avila, regional director for Costa Rican Social Security (CCSS).
Services include preventive care and immunizations through consultations and house calls, as well as caring for chronic illnesses and early detection of diseases such as diabetes, high blood pressure and cancer. Case in point, in April Dr. Gomez detected bone cancer in a child from Garza who went to the clinic complaining of pain in her leg. The doctor sent the child to Nicoya for exams and x-rays, and now the child’s leg has been amputated and she is receiving chemotherapy.
In theory, the doctor should see about 25 to 28 people per day, but in Nosara her workload never drops below 30 and is often much more. For example, on August 14 during a PAP smear campaign, she saw 69 people.
Emergencies aren’t included among the EBAIS’s functions. Emergency cases should go directly to the hospital, but Dr. Gomez said she attends to emergency cases anyway because of her personal commitment as a doctor and the distance to the hospital in Nicoya, although she acknowledged that there is little she can do beyond assessing the situation and sending the person in an ambulance to Nicoya.
Many people misunderstand what constitutes an emergency, often yelling and sometimes threatening the doctor in an effort to get immediate attention, for example telling her that they will send men to beat her up. “You have to wait everywhere. Even to die you have to wait,” Gomez quipped.
Things like fever, ear infections or scrapes from falling from a bicycle aren’t classified as emergencies, she explained. “Emergencies are those events where life is at risk, where if they aren’t attended, they die,” she said, citing examples like appendicitis, severe bleeding, heart attack or stroke.
The EBAIS doesn’t have an x-ray machine and their oxygen tank has a damaged regulation valve that they aren’t able to repair so they can’t administer oxygen. What they can do there are physical exams, electrocardiograms, PAP smears, serums, vaccinations and nebulizer masks for asthma patients.
Appointments are given from 7 to 8 a.m. and consultations take place between 7 a.m. to noon and from 1 to 2:30 p.m., giving the staff an hour from 3 to 4 p.m. to take care of administrative duties.
Facing the Challenges
Aside from the overload of patients, the staff of six faces other challenges. For example, the archives room is so full that files are in boxes under the desk, the lighting is poor and no air enters the room. The doctor bought a fan for the room with her own money since there is no budget for assets or for infrastructure. Flora Chinchilla Mora, who maintains the medical records, is hoping that the community health committee will be able to help enlarge the room at some point.
The pharmacist, Dr. Irene Castro Conejo, is also struggling to keep up with her workload and when shipments of medications arrive, she ends up working overtime for several days in order to unpack and organize the medications. In July, she filled 3206 prescription coupons. She has no technician to assist her and the workflow for filling orders is inefficient.
The primary attention technician (ATAP), Jhonny Chacon Jimenez, makes house calls in all of the communities served by the Nosara EBAIS, including Garza, Delicias and Esperanza. The standard is one ATAP per 600 houses, but Chacon has about 1300 houses in his territory, making it impossible to visit them all in one year, let alone three times a year as should be done in high-risk cases, for example when there are uncontrolled or teenage pregnancies or indications of domestic violence, drug use or alcoholism. The ATAP provides this service free to everyone, if they are insured or not. During house calls, which usually last 30 to 45 minutes each, he administers vaccinations, makes a record of the medical history of each member of the household and inspects the yard for possible dengue breeding grounds.
Some improvements have been made to the EBAIS this year. According to Tánchez, 12 million colones ($24,000) is being invested in the clinic. In July they received two new refrigerators from CCSS for vaccinations, which are designed to protect the vaccines for longer when the electricity goes out (which happens often).
In addition, some painting and electrical repairs were performed, and after the earthquake a telecommunication service and videoconference system was installed to connect Nosara with Nicoya and San Jose. Also efforts are being made to implement laboratory services by sending a technician and a car from the hospital, but at this point Tánchez said it is in the discussion phase.