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Wound Care Around The World: Brazil

  No matter where one travels, one thing remains consistent: We as humans share the same anatomy regardless of language, politics, or potential socioeconomic obstacles; therefore, we experience the same consequences to poor physical, mental, emotional, or spiritual health.

  I have been fortunate to travel extensively throughout the US during my career, getting to know many wound care providers along the way. Many friendships have resulted and my experiences have been memorable and fulfilling. Never did I imagine that I would have the opportunity to visit other countries and have the opportunity to observe wound care and other aspects of medical care firsthand as a student in medical school.

  What I have witnessed and learned through my visits abroad are the basis of this new addition to Today’s Wound Clinic. No doubt that a number of you have had your own experiences and impressions of wound care from around the globe through mission work and the like. This column is meant to foster the sharing of the care and compassion that we as healthcare providers extend to those living with chronic wounds and to acknowledge the healing that we can provide and the building of general goodwill to the patients we see everyday, everywhere.

Some Background on Brazil

  The country of Brazil (which is actually spelled “Brasil” in the country’s predominant language of Portuguese) is known for its beautiful beaches, multicultural population, soccer, and the thong (no, not the flip-flop version), among other things. In 2007 I was invited to visit and evaluate clinical trials of a wound care product that had been developed there — a membrane scaffold derived from the Brazilian rubber tree plant — that had shown promise in expediting wound healing.

  Evaluation of the product and trials turned out to be just one aspect of my visit. What I experienced will never be forgotten and has helped me realize that we do not really have a healthcare “crisis” in the US; rather, we are blessed with resources that are often only reserved for the more fortunate who reside in Brazil.

  One thing to note: Everyone living in Brazil has access to public healthcare, but, despite this universal coverage, a huge disparity in quality of care exists. Apparently, those with the means to purchase private health insurance can receive care and treatment in private hospitals. I personally witnessed care rendered within two public hospitals and an outpatient clinic. I felt as if I had been transported back in time 75 years when I visited one public hospital in particular based on its physical setting, including rooms being shared by up to six patients. I should also disclose that my trip was completed before the election of President Obama and, hence, Obamacare. Still, in my opinion, what I witnessed could await the US healthcare system with the division that could exist between private vs. public insurance.

Arriving in São Paulo

  São Paulo, Brazil’s largest city and the seventh largest city in the world (by population) is about an hour’s flight from the capital of Rio de Janeiro and is a complex urban sprawl, with 11 million people living among eight downtown areas. While leaving the airport in São Paulo, I made my first encounter with whom I refer to as the "Brazilian Daredevils on Two Wheels, "known locally as “motor boys.” Ubiquitous wherever paved streets exist, the rules of the road do not apply to these individuals who weave in and out of traffic at high speeds and in between moving cars and trucks without concern. Per my driver, who spoke limited English, and one of my hosts, casualties and wounds are a common daily occurrence among the motor boys, although I did not see any wounds during my visit that were such related.

  My first glimpse of actual wound care in São Paulo occurred in a 500-bed public hospital, a multilevel building located within a residential area. The “wound care center” within this hospital consisted of a wooden bench located in a shower stall. There was one physician present to provide wound care for patients. He performed debridement within the stall, using a showerhead attached to a hose to irrigate wounds.

  Another hospital’s emergency department was filled with people who remained quiet, well mannered, and patient while waiting their chance to be seen. This facility was smaller in size and the wards did not include any private rooms. Again, this hospital served those who possessed public health insurance, and while the staff appeared to be caring and compassionate providers doing the best they could with, what they had to work with the resources at their disposal were so limited that expecting them to “heal” patients would not be considered rational.

Mogi das Cruzes

  Our second day of clinical visits took us about an hour’s drive southeast of the hospitals in São Paulo into the urban municipality of Mogi das Cruzes. Small in comparison to São Paulo, the population is about 350,00 and the area had a quaint feel after the congestion we had left behind. However, understand that São Paolo has eight distinct “downtowns.” There are many high-rise office buildings and apartments, and traffic is constantly bumper to bumper. While here, my group, which was comprised of businessmen and the president of a company that developed the aforementioned scaffold, had the chance to visit a clinic that saw its providers functioning in a public setting that also offered minimal healthcare resources but was abundant in compassion to those being served. Still, Mogi das Cruzes presented its own emotional challenges in that the region is home to many people living with leprosy, AIDS, and HIV. I had never observed a patient in the US living with leprosy, even though there are cities back home (such as New York and Boston, to name two) where the disease can be found among the patient population. This gentleman’s ulcers appeared very similar to those of someone afflicted with wounds due to chronic venous insufficiency and he was appreciative of the care and efforts of the physician and nursing staff. As a group, the providers encompassed a team approach to wound care with the same diligence and compassion as any team I’ve observed in the US. Interestingly, however, this humble clinic had more resources dedicated to wound care than the 500-bed hospital. Though I only had the chance to spend a few hours in Mogi de Cruzes, I have never forgotten the experience and the warmth and dedication of the people I met while there. Upon returning to São Paulo, I began to pay more notice to the presence of shacks that were constructed of plywood, metal sheets, and even cardboard. These shantytowns, known in Brazil as “favelas,” are found not only outside but well within major city limits, a contrast to high-rise buildings within the same locale. The contrast of abject poverty to cosmopolitan life is of an extreme that I have never seen in the US, even in our most rural areas or inner cities. This was also in stark contrast to the beautiful hotel I stayed in at the World Trade Center in São Paolo. Every modern amenity and comfort was available to us as visitors, including cable TV.

Rio de Janeiro

  What trip to Brazil would be complete without a visit to Rio? The beaches did not disappoint and the area around Ipanema was "hopping." Drinking fresh coconut water from the source is a common local custom and kiosks are found all along the beach. I must confess, the coconut water was not as tasty as I had hoped, but was one of only a few disappointments of my trip. Getting to see the statue of Christ the Redeemer, one of the New Seven Wonders of the World, high above the city at the peak of the Corcovado Mountain, was a fortunate tradeoff. My ears popped at least a half dozen times while driving from the base of the mountain to the base of the statue.

  However, one disturbing note to make that I learned during my first night in the capital city was that our host’s car, like many cars occupied by travelers, required thick, yellow window glass that prevents one from getting a scenic view while driving due to the increased risk of kidnapping that can occur to those who are perceived to have money. The fact that the windows were also bulletproof as a standard precaution was only slightly reassuring in the moment. Despite the difficulties we experienced as a group and the sheer amazement of the realization that healthcare could “function” as it goes here, there was also a lot to take away from the excursion that will leave me with fond memories.

  For one, Brazilian cuisine is amazing. If you have never been to a Brazilian steakhouse, aka a “churrascaria,” I highly recommend one. I also found a local favorite desert known as “crème,” a blended ice cream and fruit concoction that is worth the calories! Most importantly though, I will never forget the hospitality, warmth, dedication, and kindness of the healthcare providers, researchers, patients, business people, and everyday Brazilians I had the good fortune to meet. Still, when I returned home, I honestly knelt down in my driveway and kissed the ground to once again remind me of how fortunate and blessed I am, and we all are, despite the trials and tribulations that exist, to be practicing our passion here in the US.

  Des Bell is the co-founder and executive board member of the Save A Leg, Save A Life Foundation, a multidisciplinary, nonprofit organization dedicated to the reduction in lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach. He is a board-certified wound specialist and a fellow of the American College of Certified Wound Specialists. He presently serves on the board of directors of the American Board of Wound Management. He also founded the Limb Salvage Institute and Wound Care on Wheels LLC, a service that provided wound care to patients in the hospital, home, and long-term care settings. A graduate of Tulane University and Temple University School of Podiatric Medicine, he is a frequent lecturer and author on the subject of wound care, peripheral arterial disease, and diabetes. He’s also a member of the editorial board of TWC.

Des Bell, DPM, CWS
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