Larry Robbins, M.D. Associate Professor of Neurology, Chicago Medical School. Professor of Research, DMU College of Osteopathic Medicine. Private practice in Riverwoods, Ill.
Genesis Mejias, M.D.
In the beginning: We started out small in 2017: 1 patient, 1 chart, and one doctor, in a tiny borrowed office. We now have a busy, sprawling neurology, headache, and psychiatry clinic that is too busy really. I didn’t design it that way, but I couldn’t resist adding: a built-out clinic, nurse administrator, pharmacy, 2 Honduran neurologists, 2 psychiatrists, portable EEG, and labs. All free for the patients. We are rural, an hour twenty minutes from the major city, Tegucigalpa. I was lucky enough to locate within a well-run general medical clinic, that provides lots of support. Patients are recruited by word of mouth, letting surrounding clinics know about us, and a bit of radio ads.
The goals of our Honduras neurology project are to: 1. provide care to as many patients as possible, including providing free meds and labs, 2. teach med students/residents/attendings about headache and neurology management, 3. publish headache treatment guidelines in Spanish, 4. use the Honduran headache society (which we recently created) to help educate providers on headache issues, 5. upgrade the infrastructure of our rural medical and neurologic clinic, and 6. encourage, advise, and support other physicians or providers who might want to establish similar clinics in underserved areas.
Our Staff: We have four idealistic and dedicated young physicians, two neurologists, and two psychiatrists. We do pay them, but they could make about the same money in the city, and not trek out to our clinic. We also have a nurse who runs the clinic, who is invaluable. We are located within a larger medical clinic. The staff there is very supportive, and we in turn help them out. They run a small 24/7 ER without very much equipment. They handle everything, including strokes and status epilepticus.
We also have interpreters, for myself and other U.S. doctors who may come with me. The two women who staff our little pharmacy are invaluable. They handle a large volume of refills, as patients usually only receive one month of meds at a time.
The Medications: In the beginning I decided, for a primary epilepsy med, I would bring in lots and lots of levetiracetam (LVT). LVT does not require blood tests, is fairly safe. However, it often causes tiredness/moodiness. This was a mistake. I should have chosen lamotrigine: little tiredness or moodiness, and better with pregnancy. Lamotrigine also is significantly less expensive (we buy the meds here). It’s difficult to bring in meds to Honduras. I think they are concerned that people will sell the meds on the black market. They don’t want donated medications, and they won’t accept meds that may expire soon. We need all receipts and there is lots of official paperwork. It often takes hours to get through the airport. Sometimes our medications are held up for weeks. If we use DHL or FedEx, which are very expensive from the U.S., it can take up to a month.
Other medications include: topiramate, sodium valproate, amitriptyline, fluoxetine, sertraline, sumatriptan, carbidopa/levodopa, risperidone, quetiapine, lithium, pyridostigmine (occasionally), and others. For the first time in Honduras, we brought in atogepant (Quilipta). That was a big hit. I will bring in 400 atogepant (or similar) tabs with each visit.
At times we buy medications in Honduras. Some medications are cheaper in the U.S., others are cheaper in Honduras. Phenobarbital and phenytoin still are the most frequently used antiepileptics and are inexpensive.
I bring in 100,000+ tablets of meds at a time (every 3 months). They fit in 2 or 3 large suitcases.
Occasionally, the young army men at the airport bring the police dogs to sniff the baggage and meds. On several occasions this has led to some tense times.
Our Charts: There is almost no paperwork in Honduras. I try to mimic the charts I use in my Chicago area office. I push the staff to keep up the medication flow sheets. Practicing medicine in Honduras is fairly easy: it is just the doctor and patient. A simple chart, no insurance, no malpractice (there is some malpractice for the Honduran doctors, but minimal).
We have several physicians treating the same patient. I have asked the staff to list considerations for the future at the end of the visit. I do that with our charts here in the U.S.
Sometimes I do telemedicine via Skype. The patient sits in our Honduras exam room with an interpreter while I sit in my Chicago area office also with an interpreter. It works okay.
Cultural Differences: It has taken awhile to adjust and adapt to the culture. The patients are reluctant to engage in psychotherapy (and it is difficult to find therapists). Patients don’t usually complain about the adverse effects of the medication, unless the effects are moderate or severe. Family bonds are very strong, and they take care of each other. The patients and physicians don’t usually use herbal remedies, expense being one reason. Physicians in Honduras tend to shy away from “natural” remedies, as several have told me “well, they cost a lot, and they don’t work very well”. There is significant stigma surrounding people with epilepsy, but of course we encounter this in the U.S. as well. I have found many of our patients to be on the stoic side. It takes years to learn some of the cultural differences.
Pain and Headache Patients: We see many pain and headache patients. The most common condition is migraines. For headache and patients with migraine, we give handouts in Spanish that describe all of the non-medication aspects of pain. Our headache handouts include the usual migraine triggers, an emphasis on exercise, along with deep breathing/relaxation/meditation. The migraine medications we provide include some of the usual preventives (i.e., beta blockers, topiramate, sodium valproate, and amitriptyline). For abortive use, we give away thousands of tablets of sumatriptan each year. I bring in the sumatriptan from the U.S., thousands of tablets at a time. Sumatriptan is technically available in Honduras, but there are several problems. Sumatriptan is too costly for 95% of Hondurans, and also the Honduran sumatriptan seems to be of poor quality. Recently, I introduced a CGRP medicine, atogepant, to Honduras. This was the first CGRP medication in Honduras.
Most of the population (95%) cannot access a neurologist. For migraines they take ibuprofen and acetaminophen. They can obtain diclofenac injections at a pharmacy without a prescription. Ergots are available. Relatively few patients are on preventives. Many patients cannot afford any medications other than NSAIDs and acetaminophen.
We also see many patients with back and neck pain. Physical therapy is almost impossible to access. We do give instruction and exercise sheets to the patients. Most patients do not have a smartphone or computer, so we print out the information. Opioids are sparingly prescribed. Tramadol is available, as is codeine. However, most physicians will not prescribe these for chronic pain. We do prescribe some of the usual pain preventives, but most physicians don’t utilize these. Benzodiazepines are widely used, and often in higher doses.
There is a pain clinic in the main city, Tegucigalpa. However, for those without means to pay it is not available. The Public Hospital does not, to my knowledge, have a pain center. I have not been able to locate a pain psychologist.
Unfortunately, there is a great deal of chronic pain in Honduras as elsewhere. The pain generally goes untreated, except for OTC ibuprofen and acetaminophen.
Teaching, Articles, Honduran Formulary: I go to the main city, Tegucigalpa, to teach neurology residents. The physicians are competent and dedicated. The general physicians are barely able to make a living, but the specialists do reasonably well financially. For new doctors, there is only one test per year to determine if one is allowed into a specialty residency.
The “Public Hospital” in Tegucigalpa is like our county hospitals, but with more patients. Outside there are vendors serving up food, and booths with all kinds of stuff. It is wall-to-wall people, teeming with life. I made the mistake of filming it on my iPhone. It could have easily been snatched.
We had to walk up five flights. This reminded me of my training at the old U. of Illinois charity hospital in Chicago, where the elevators would crawl ever so slowly. We often walked up the 12 flights. I gave a talk to the students, residents, and attendings titled: “Deconstructing the Art of Medicine and Headache Medicine”. I gave it in my mix of crummy Spanish and OK English. During the talk, I was speaking about bipolar and personality disorders. A young psychiatrist, Laura M., spoke up in perfect English. She has now been working in our clinic as one of two psychiatrists. Psychiatrists are few and far between, and we are lucky to have two excellent ones.
We have published articles in Spanish on migraine management, as well as cluster headache. It took over a year to piece together a formulary of available meds. There is no published formulary. We usually have to call various pharmacies to see what might be available.
Most patients have no smartphone or computer access. I miss directing patients to “Dr. Google”. Instead, we hand out pre-printed sheets on various topics including diet, exercise, migraine, epilepsy, back pain, insomnia, and meditation.
Accommodations and travel: Travel to Tegucigalpa is fairly easy. Our clinic is now 2.5 hours from the new airport. I stay in a nice house within a large orphanage. I sponsor three children who were unceremoniously dropped off by their mom five years ago. In our clinic we see many of the children who live in the orphanage. The food is wonderful. I have internet and usually air conditioning. However, I have to “interview the mosquitoes.” Temperature is almost always 70 to 85 degrees.
Helping others start similar clinics and resources: I wrote an article geared towards helping neurologists interested in a similar adventure: A Neurology and Psychiatry Clinic in Central America, with suggestions for starting a clinic in: World Neurology, July/August, 2021, page 13-14.
The Future: I am hoping to bring back psychotherapy services. We have had a therapist off and on. The main barriers to therapy are stigma, reluctance of patients to open up, and finding and keeping a good therapist. We are attempting to bring in physical therapy services. The issue is finding a therapist willing to come out to our rural clinic. Ideally, I would like to find a partner to help with the clinic, and maybe eventually take over. It’s not that difficult since we have a great support staff in Honduras. The major challenge is raising money.
If you are interested, or know of someone, I can always be contacted at lrobb98@icloud.com. We also have blogs and videos on our site, chicagoheadacheclinic.com: Honduras section.
Part 2 of this article will be available in the next newsletter, October 2023.