06/12/2021
According to data from the 2018 Moura Diagnosis Report, in a city where there were around 14,654 users registered at the Moura Health Centre in the same year, this scenario is worrying. Even more so if we consider the fact that health facilities, such as pharmacies and clinics, tend to be located in Moura, which means that parishes with a lower population concentration, which in turn have an older population, don't have easy access to this care.
In the village of Santo Amador, it was just after lunchtime and the wind was already carrying the people's lamentations, letting them escape through the stone of the houses and echo through the streets.
THE LAMOURS
Mariana Batista was the first start talking. She sat down at the table, clasped her hands together and remained that way for most of the interview. She began by telling her story with a big smile on her lips. Although she was born in Santo Amador, she left the village at the age of 47.
She left for Switzerland, where lived for 16 years. If it hadn't been for this move, she wouldn't have received a pension. At the mention of this topic, the smile that was once on his lips disappears and a serious look takes over his face."They sent me a small pension from Switzerland, because I worked there. And so far, they haven't given me a cent in Portugal."
She goes on to say that at 85, the only thing she receives from Portugal is the exemption, thanking a doctor in Lisbon who, when Mariana had a tumour in her chest, wrote her a letter asking for exemption for her treatment.
"I think we should have more assistance because we don't just need it two days a week, we often need it more, but that's it... people like us can only do so much."
Mariana Batista, 85
Mariana Batista, 85
When asked about her conditions of access to healthcare, Mariana put her hand to her chin. "These are my conditions, not being able to do certain things now, and having to get a woman in every fortnight or every month, depending on what I need, because I'm on my own." And that's not all. Even to go to the health centre, she says she has to pay for a station wagon because her husband, who used to go everywhere with her two years ago, has had a liver tumour and can no longer work.
She also told us that the village has only one family doctor, Dr. Lurdes, and that although she provides credentials to exempt them from paying for exams, this is not the general rule. "I needed physiotherapy for my knee and she didn't give me credentials and I still had six sessions. My daughters were here and went with me to Moura and I then had to pay for them. It was a hundred and something euros. I had twelve booked, but I couldn't do them because I couldn't pay."
With regard to appointments, she said that she needs to go to the health centre regularly, something she still manages to do thanks to the help of the Canadian woman. However, her family doctor only comes to the centre twice a week: on Tuesdays and Thursdays. As if that weren't enough, the time she spends here is around two hours. "She comes at half past two, and then sometimes it's according to the staff. Between four and five o'clock he leaves."
She tells us that doesn't think she has the medical assistance she needs. "I'd like to, but I don't know how". Mariana believes that something that could change would be for the doctor to send her to do things that she didn't have to pay for, bringing up the example of physiotherapy again. "I really missed it. And I couldn't pay for it, I couldn't continue."
Even to have the operation on her knee, which she broke about two years ago, Mariana says she had to go by ambulance to Beja Hospital, and this is where she reveals another problem: it's the family doctor who has to make the request to call the ambulances or else the population is forced to pay for the transport. Transport that cost 200 euros when her husband needed to go to Curry Cabral in Lisbon, which was the only hospital where he could have the operation he needed. If the doctor isn't there, the people's alternative is to call an ambulance, and then "The fire brigade takes a long time."
These situations worry the daughters so much that they often come from Switzerland to help their parents. "But they can't be here for long, they have their obligations."
She goes on to say that the lockdown was a very complicated period. Despite this, she says she had friends to help her. "They would leave things at my door." When the first symptoms appeared, she went to the doctor and told her that her husband was very ill. She asked her to go and see him, but the doctor refused: "I can't go there now. I can't go anywhere now and neither can he," said Mariana, trying to imitate Dr Lurdes. With that, the doctor simply phoned the centre to book a Covid test.
"The doctor told me he wouldn't prescribe glasses because I have to have cataract surgery. So I asked him urgently and to this day he hasn't turned up."
Maria Monteiro, 69
Next door, Maria Monteiro, a 69-year-old woman who shares the same opinion as her neighbour Mariana, welcomed us. When she arrived in the backyard, she pulled up a chair and straightened her shawl, preparing for the conversation that was soon to begin. She told us that she grew up in Santo Amador and had lived there all her life. The family doctor was Lurdes Sá, who, as Mariana Batista had said, was the only one the village had.
Asked if there were any reasons to complain about access to healthcare, Maria paused thoughtfully before answering. "I mean, we're not attended to straight away," she finally said. As an example, she said that she had gone to Moura for an eye test and the doctor who saw her didn't prescribe any more glasses because she had to have a cataract operation. She needed them urgently four months ago. Until then, no operation, no glasses. She knows, however, that the operation will take place at Beja Hospital. She's very worried about this because she has no transport and believes that she won't be given an ambulance.
In addition to the eye problem, Maria is being followed by a psychiatrist in Beja. Or she should be. Her appointments, which used to be every three months, have now increased to every six months and, with the pandemic, are now being made by telephone. The problem is that Maria lost contact with her doctor when she changed mobile phones, and for this reason she hasn't been able to access her appointments.
She also says that when she broke her arm, she went with her husband to the Moura Health Centre and ended up being taken by ambulance to Beja Hospital for an X-ray. The resulting consultations were all carried out in Beja. "I was treated there in Beja, so it was in there that I did everything."
Despite the long distance, the doctor, who prescribed physiotherapy, gave her a pass to go in the ambulance two days a week during the five months of treatment. She compared this doctor to her family doctor, saying that although the latter was a general practitioner, he only wrote prescriptions and didn't provide the most comprehensive care.
As far as family members are concerned, the daughter who supports her the most lives in Lisbon, and her husband only accompanies her when Maria has no one to go to appointments with, which are quite complex. To book an appointment, people have to go to the Centre on the first Tuesday of the month, which is the only day to book appointments for the rest of the month. If you fall ill or have an emergency, you run the risk of not being seen. "They say there are three emergency rooms if there aren't many people, but we have to stay until the end of the appointment." This situation saddens her.
"You don't know when you're going to be sick, and sometimes you are sick and you go and don't get an appointment." What's more, this is a recurring situation, both because the family doctor is only at the centre for two hours and because there is a limit of three emergency rooms. "If there are, for example, three emergencies, she still does them, but the rest she doesn't do, she sends them to the other Health Centre."
As well as the Health Centre, the pharmacy is only open for two hours a day, from 10.30am until 12.30pm, and even then they often don't have the medicines she needs. "Sometimes I go to get my nerve medication and they don't have it. Then they bring them round the next day."
"Sometimes we wish they'd pay more attention to us, but we know there are a lot of people who need it.
I think they should have a normal timetable."
Mariette Guerreiro, 78
I think they should have a normal timetable."
Mariette Guerreiro, 78
A few streets away, it was Mariette Guerreiro's turn to open her door to us and sit us down at her table. Born in Santo Amador, she lived there until she was eleven, when she went to school in Moura. After that, she also spent time in Beja, returning to Santo Amador for her first year as a primary school teacher. She travelled to other places along the way and returned to the village to finish her professional career, where she has remained to this day.
About life in Santo Amador, she told us what we had already heard from Mariana Batista and Maria Monteiro: they only have a family doctor twice a week. She wishes they'd pay more attention to them, but she realises that many people need this kind of care. She adds that there should at least be a normal timetable, and that if there is one criticism she has, it's in relation to making appointments.
"They almost demand that we make appointments at the beginning of the month, but how do we go to an appointment? At the beginning of the month, if we're ill we can't get an appointment, and at the end of the month we may no longer be ill." He ends up saying that appointments should be booked the day before, or even on the same day. If that were the case, twice a week would be enough.
She admits that, in her opinion, they're not doing badly at all, they have the right to a GP and a nurse who supports them, but it would be important to change a few things. "Just two months ago I went to the Centre for an appointment and when I arrived I was unwell and the doctor immediately took me to Moura, so there are no problems." But she believes that if the doctor hadn't seen the situation, she would have had to ask her to see if she thought there was any reason to call an ambulance.
Another complaint she has is that there is no psychological or psychiatric counselling other than in Beja. But it's not all criticism and Mariette appreciates the fact that the local authority has helped those who don't have transport with vaccinations.
She regrets the lack of human resources in the village, because although people help each other, they can do little when someone is ill. She says that, in her case, the most she can do is put them in the car and take them to the Health Centre, something her father used to do.
Despite this, she is grateful for the existence of her family doctor. "I sometimes hear on the telly that they go for ages without a doctor and here we have one twice a week. A population of 300-something people." He tells us that there were times, more than twenty years ago, when the village had a doctor every day. "But that was an exception. I think he did it voluntarily."
Still talking about the past, Mariette explains that with the increase in the number of private cars, the number of buses has decreased, and now they are practically only used to take children to school. For this reason, if someone needs to go to Moura, they have to take a private car or call a taxi or ambulance. "The bus from here is of little use when you're ill, unless you want to go on the bus and subject yourself to being there? Go in the morning and come back in the afternoon."
Towards the end of the conversation, he nostalgically recalled the times he spent with his father, with whom he always shared a love of helping others. "It's a tradition in my house." He says that there were times, when there were no mobile phones, when people would come to his house to tell him that family members were going to call and ask if they could come and take the call.
"There were times when we didn't go out because we were going to see people." She also remembers her father going to Moura every day, but he often didn't go to do anything, just to help out. Now, she says, it's different: "Not only are people better informed, but it's easier for them to get around."
THE WORRY
Even for those on the outside, the worry is felt.
Marianita, as her mother calls her, is Mariana Batista's daughter. At 49, she divides her time between Switzerland, where she lives, and Portugal, where her parents are. She tells us that it's difficult to help them when you live so far away, so the solution she found, together with her two sisters, was to ask people they trust to do it for them.
"Sometimes we have to pay, but at least there are possibilities back home for people to help, since we can't always go with my parents to the health centre or hospitals."
Unfortunately, they don't visit them very often either, but it's here that the sisters' mutual help gains strength. "We always try to go at least twice a year, if not more." She adds that since she knows her mum always has tests to do in Évora or Beja, due to a serious health problem she had, she books them for the summer, when she visits, to make sure she can keep up with her.
Unfortunately, she doesn't visit them very often either, but it's here that the sisters' mutual help gains strength. "We always try to go at least twice a year, if not more." She adds that, as she knows her mum always has tests to do in Évora or Beja, due to a serious health problem she had, she books them for the summer, when she visits, to make sure she can keep up with her.
She also tells us that an emergency has happened and she has had to travel to Portugal within 48 hours. Although she works in an office, which makes travelling easier as she can telecommute, this situation affects her, mainly because of the time zone difference."I have a lot of meetings in the morning and I always have to start work very early."
What's more, as she can't work while accompanying her parents to their appointments, she has already worked until 2am to make up for the work she hasn't done during the day. It's a small sacrifice she has to make for the sake of her parents. "For now it's possible for me. Not for my sisters."
"O que me preocupa é, realmente, a falta de médicos que há na terra porque com a idade que os meus pais têm, não é fácil deslocarem-se e irem a certos sítios."
Mariana Valente, 49 anos
Mariana Valente, 49 anos
His biggest concern is the lack of doctors in the village. To give an example, she said that the day before she had spoken to her mum and found out that she had been waiting all morning for the doctor and that he hadn't turned up. Elderly people have to wait there for an hour or so and then realise that the doctor isn't coming, that no one informs them that the doctor isn't coming - that really confuses me."
She also highlighted a problem that had already come to our attention: appointments are only booked at the beginning of the month. This doesn't make sense to her, because people who aren't ill continue to go to their appointments, but when someone falls ill, they run the risk of not being able to see a doctor. "It's totally absurd to have to guess whether you're going to be ill this month or not."
Another problem she points out is that, with so much waiting around, people end up giving up on going to the Health Centre. He gives us the example of his father, who practically doesn't go to the doctor any more because he finds it too complicated. She also tells us that this year she went with her mother to physiotherapy, to a private doctor, so that she could start therapy as soon as possible. However, as she could no longer afford to pay, she went to the public clinic with a report to ask for an accreditation so that she could finish the six sessions she had left. The doctor refused, claiming that she hadn't gone to the doctor she had been sent to.
"Why send my mum to Beja hospital for exactly the same appointment just because the doctor isn't private? It doesn't make any sense, because she had the report, it's not like I decided 'Look, my mum's going to have physiotherapy now'." She went on to say that her mum's treatment fell apart after two weeks, all because the doctor refused to issue a credential and she didn't have the money to pay for the appointments in the private sector.
Still on the subject of the difficulties experienced by the elderly in accessing healthcare, Marianita, also known as Mariana Valente, mentions the fact that things have to be done over the Internet, a world that is very unfamiliar to these people. She also recalls the time her mum phoned to make an appointment and was answered by an answering machine. "I remember her saying to me 'I phoned, you spoke and then look, you didn't speak anymore', because she didn't realise it was a machine."
As she left Portugal when she was 12, Mariana doesn't know the Portuguese state well, but she blames it for what happens in the village. Where she lives, she says it's often the state or local councils that have to decide on health issues. "These smaller communities shouldn't be forgotten and I think they are often totally forgotten." For this reason, Mariana believes that the village should have an open office, a place where people can turn to for help and information.
ON THE OTHER SIDE OF THE LINE
On the other end of the line we met Maria Ventura and João Ramos, two health professionals.
Maria Ventura, 50, is a nurse at the Hospital do Litoral Alentejano in Santiago do Cacém. Throughout her career, Maria has worked in various specialities, such as neurology, otorhinolaryngology and the intensive care unit, where she spent 14 years. However, she tells us that, over the years, she was faced with aggravating injuries from overwork and had to ask for a transfer to the outpatient department two years ago. Before moving to the hospital where she currently works, Maria worked at the Hospital de São José, in Lisbon, and at the former Hospital de Santiago do Cacém, the Conde do Bracial.
João Ramos, 49, is also a nurse. He currently works at the Moura Health Centre, but has been away from home more than once. Throughout his career, he has worked in the Algarve and then in Mértola, but he has always worked in primary health care. "I've never worked in a hospital, it's always been in health centres. My work experience has always been in primary healthcare because it's what I like and where I feel comfortable." He explains this preference by saying that in primary healthcare, social and emotional relationships are crucial in the therapeutic relationship to help patients recover, while in hospitals, support is more centred on acute health situations. In addition to health, João was involved in politics for a long time, as a member of the Portuguese Communist Party (PCP) in the Portuguese Parliament.
STATE OF SITUATION
Asked about the age group that most frequents the health centres where they work, Maria and João say that most of the patients they see are elderly. "Generally speaking, the population of the Alentejo is very old and that's why they are clearly the ones who seek out the health services and are also the ones with the most health problems," says nurse João. According to the two nurses, the most frequent pathologies related to this age group are essentially diabetes, heart failure, oncological diseases, lung diseases and hypertension.
With regard to access to healthcare, the experts claim that the biggest obstacle is the lack of human resources and the enormous dispersion of the district. Both say that there is poor management when it comes to placing doctors and nurses in hospitals and health centres. However, João Ramos reports that the organisation of family doctors is a very sensitive topic, because as there isn't enough support for everyone, the practice of hiring clinicians is adopted, which consists of hiring doctors to solve just one situation.
She also says that the focus of primary care and family doctors is frequency and follow-up. "Every person should have a family doctor because it's important from the point of view of monitoring those illnesses that need to be monitored, to have regular follow-up so that they don't get worse."
"I find it more difficult to respond when I need to refer my patients to medical specialities."
João Ramos, 49
João Ramos, 49
Nurse João goes into more detail about the organisation of doctors, explaining that they should be responsible for a population of around 1,500 people. "If we think that the village has three hundred citizens, this is equivalent to a fifth of the fifteen hundred, which means that this population should be available one day a week. Because if there are five days in the week, maybe what should be available to this population is one day a week so that the other twelve hundred people can enjoy the other four days."
Since there are a considerable number of villages, those responsible for placing doctors and nurses should be able to balance the books. However, what happens is that this travelling is very unbalanced. Sometimes "moving from one village to another is no longer the same as having 1500 users clustered in Moura alone."
João adds that this lack of management influences the process of monitoring patients and their medical history, where "for some who are ill, this can be problematic, because the family doctor who is present is replaced by one who works on a temporary basis, and they won't have the same attention and concern."
In fact, there are several episodes of doctors giving up and cancelling appointments for unknown reasons. João Ramos says that this is a problem that is difficult to avoid, since at the beginning of the month the doctors can't predict their schedule for the whole month, as there is a possibility that they will be called away for training or to provide vaccination services. However, João emphasises the patients' feeling of uncertainty.
"This is more than worrying, from the point of view that if the person realises they've suddenly fallen ill, they feel they have help available, so it won't generate anxiety. That's why the best way to combat anxiety is with regularity. Sometimes what the doctor does is, for example, when it falls on a public holiday, he doesn't come and then those appointments are moved to another day."
"Sometimes it's surreal to see a doctor here at the hospital doing 40 consultations. I don't believe that at the end of those consultations he'll have the same attention and patience as he had for the first patients"
Maria Ventura, 50
Maria Ventura, 50
The hospital environment that Maria Ventura describes is similar to that mentioned by João Ramos. Maria says that there aren't enough doctors to fill the vacancies for consultations, which is why doctors from other districts are called in to do 24-hour emergencies in various specialities. "For example, in intensive care we have our own doctors, but since there aren't enough of them to fill the week, other doctors from Lisbon or Beja come in and rotate, making up a rota. This rota is drawn up at the beginning of the month, and according to the availability of each doctor, this is how it ends up being managed."
In this way, the nurse describes how there are often too many patients for a single doctor or nurse, which sometimes leads to less attention and concern for their patients at the end of a working day.
Focusing on the reality of the Alentejo coast, Maria says that there is also a certain lack of motivation on the part of nurses to travel to the Alentejo. According to Maria, "the standard of living is the same as on the outskirts of Lisbon," due to the refineries in the industrial zone of Sines, where labourers earn a considerably high salary. This situation directly influences the financial management of nurses, who earn a salary that is insufficient for their standard of living, leading them to opt for immigration.
"Our state doesn't provide any support for training nurses."
Following on from this, the nurse raises the issue of the devaluation of the nursing profession. She justifies this by saying that migration is frequent, as there is a huge demand for nurses from Portugal, thanks to their dense training which, according to her, is not valued by the Portuguese state itself. With regard to dispersal in the Alentejo, Maria was more concerned than nurse João, as she works in a service where she receives patients from all over the Alentejo region, most of whom are elderly people who travel several kilometres in precarious conditions.
"People die in the ambulance before they get to the emergency room because of the huge distance to be travelled on bad roads."
João Ramos, 49
João Ramos, 49
On this subject, João Ramos says that even though the Beja hospital still has the capacity to respond to some situations, there is a shortage of services that are not available in the Alentejo district, which leads to people travelling to the São José hospital in Lisbon. "The problem of access is the problem of dispersion. For example, in Barrancos, which is more than 100 kilometres away from Beja hospital, they may have a small population, but there are always people who need medical help."
Santo Amador is just one of the villages in Portugal that lives in these conditions, but there are more, and many of them in even worse situations. In a country that, according to International Living's Global Retirement Index 2020, ranks first in the Health category and is thus considered the best country in the world for healthcare, the data doesn't reflect reality, especially in primary care. The population that requires greater concern in terms of health is easily overlooked if it doesn't belong to a large concentration of people.
Original article: https://em-linha-de-espera.mobirisesite.com/