Chronic conditions require routine care and strict medication regimens, but for millions, transportation stands in the way of accessing timely health care.

From rural communities to urban cities, patients struggle to make routine appointments. Some can’t afford a vehicle, others live hours, if not days, from the nearest point of care. The distance–and lack of transportation–leads to delays in medical care, which for some, can be deadly.

On this episode of the podcast, we explore how transportation poses a barrier to care for patients around the world, from rural Nepal to the United States, and what the consequences are for those in need of chronic care.

Direct Relief provides many local health organizations, including Casa de la Amistad in Mexico and Mountain Heart Nepal, with funding to purchase vehicles and provide transportation services to patients and health care providers. The organization has also provided funding for mobile health units that can be deployed to communities without regular access to health care or after a disaster, including rural communities in the United States.

Transcript:

Chronic conditions like diabetes, heart disease and cancer require routine care and strict medication regimens. But sometimes, getting to the doctor is the hardest part.

Five months ago, Rosa Hernandez moved to Mexico City with her son, Andry, who has been undergoing chemotherapy since being diagnosed with leukemia last year.  “La verdad ahora sí, necesitamos estar cerca del hospital,” she said.

Before the move, Rosa’s in-laws helped drive Andry to and from his appointments, but the constant travel became expensive and time consuming. Now, they’re living at Casa de la Amistad.

“My name is Leonardo Arana and I’m the general director of Casa de la Amistad Niños for cancer in Mexico.”

Casa de la Amistad is a full-fledged support center for pediatric cancer patients and their families.

“They will come to Casa de la Amistad here in Mexico city and we will take care of everything. We will take her of the medicines, housing, and transportation, which is very important,” explained Arana.

According to a study by the American Association for Cancer Research, 38% of cancer patients in Mexico report transportation as a barrier to timely care.

Most cancer treatment centers are located hours if not days from rural communities. For those undergoing consistent treatment—like chemotherapy–the distance is a problem.

“Cancer needs to be treated in years, over years. That that’s the way it has to be. So if you bring somebody once and then you don’t give them the possibility to go back they will die.”

Across the globe, in Nepal, a rural population experiences similar challenges. “In Nepal, healthcare facilities are mostly concentrated in urban areas,” explained Dr. Aban Goutam, the founder of a non-profit health care organization, Mountain Heart Nepal, that The group transports doctors and nurses into rural communities to provide healthcare services.

“Mostly the rural villages are located on hilly or mountainous reasons,” he said, “and they consist of smaller health care clinics or community hospitals with limited treatment options.”

On average, it takes Nepal’s rural population more than 2 hours to get to a clinic for basic care. And 92% don’t have a vehicle they can use to traverse the distance. Most walk, bicycle or rely on the public bus. “In many villages, when the mode of transportation is by foot, this often results in delay of treatment.”

While delays can be fatal for those with emergent medical needs, chronic conditions are just as deadly when neglected. In Nepal, getting diagnosed with diabetes or heart disease before it becomes an emergency is rare. Without consistent treatment at the onset, chronic conditions escalate.

For example, unmanaged diabetes can lead to poor circulation and nerve damage, putting patients at risk for developing ulcers and wounds in their limbs.

“These patients with diabetes, the wounds, they do not heal and it takes a long time to heal. So for those people in rural areas, they are mostly farmers, so they have to work and they’re not, they do not consider it as important.

If patients delay care, these wounds can become severe enough to require amputation. Goutam says it’s not uncommon for those with diabetes to lose legs and feet. And, survival rates after amputation are low.

“There are some studies which have highlighted that people with diabetes and have their feet amputated did not live more than five years. So that is more deadly than, uh, cancer.”

In the United States, transportation also poses a barrier to care.

In 2017, nearly 6 million people delayed medical visits because they didn’t have a way to get to their doctor. And according to a study published in JAMA Network—a peer reviewed medical journal–a lack of transportation is associated with a higher number of emergency department visits among Americans.

But in some places, primary care is right around the corner – thanks to the community health center.

“We have clinics in neighborhoods, hence the name and so many, many of our patients walk to our clinics.”

Dr. Charles Fenzi is the CEO and Chief Medical Officer of the Santa Barbara Neighborhood Clinics – a network of federally qualified health centers in Santa Barbara County, California.

“We’re in the neighborhood and we provide transportation. In fact, that’s written into our contract with the, with the Feds.”

Under the Public Health Service Act, federally qualified health centers are legally obligated to provide enabling services. These are services that break down barriers to help patients access care. Transportation is one of them.

If a patient needs to use a driving service to get to their appointment, the health center pays the fee.

For the most part, Fenzi says transportation isn’t a major problem for patients because they ensure it’s not.

That’s the model of community health centers, he says.

This transcript has been edited for clarity and length.