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Dear Editor,
We write to you as two family medicine researchers from Spain who have followed with keen interest the recent article by Fortes-Filho, de Araújo Melo-Fortes, and Aliberti entitled “The Floating Primary Health Center Model in the Amazon Rainforest” (1). The authors’ comprehensive description of a system in which boats equipped with primary care facilities navigate remote riverine communities in the vast Brazilian Amazon resonates with many of the challenges we face in our own country, albeit in a different geographical and cultural context. We found the report particularly thought-provoking in terms of its capacity to highlight key factors of resilience and preparedness in the face of health emergencies, especially in territories with significant barriers to health care access. In addition, we believe that the notion of harnessing technology and telemedicine to support mobile health units, while only briefly alluded to in the article, deserves further consideration, especially as an adaptable model for regions prone to environmental emergencies or seasonal influxes of population.
As family medicine researchers who had practiced in areas of Spain where population density can be low, where infrastructures are spread over large distances, and where climatic or seasonal dynamics complicate the planning of health services, we have seen firsthand how vital it is to ensure continuity of care during emergencies. This challenge was made abundantly clear during the early stages of the COVID-19 pandemic, but it also surfaces each year during periods of intense tourism or in the face of natural disasters, such as forest fires, floods, or storms, which are becoming more frequent in southern Europe (2,3). The Amazon model, as showcased by Fortes-Filho and colleagues, offers a bold illustration of how healthcare services can be deliberately adapted to overcome considerable geographic and infrastructural constraints. In this letter, we aim to explore two main aspects in depth, drawing parallels and lessons for Spain and other European contexts. First, we will reflect on the role of resilience and preparedness for health emergencies in remote or hard-to-reach regions, and second, we will consider the potential for telemedicine and technological solutions as supportive tools in such contexts, especially under the extreme conditions of a catastrophe or seasonal crisis.
Our own experiences and discussions with colleagues in rural clinics throughout Spain have demonstrated how important it is to possess both the physical infrastructure and the organizational culture conducive to emergency readiness. Although our context differs greatly from Brazil’s Amazon region in terms of climate and transportation networks, many Spanish provinces still have small health posts that serve expansive areas characterized by low population density. In some mountainous or coastal zones, travelers increase the local population three or fourfold during holiday seasons, further straining limited medical services (4). During these peaks, standard care delivery becomes challenging, and any sudden emergency, be it an infectious disease outbreak or an environmental event. can push local resources beyond their capacity.
The Amazon’s floating primary health centers, as the authors describe, exemplify a methodology where adaptation is built into the healthcare model. The vessels are fully equipped to address basic to moderate healthcare needs, including medical, nursing, and dental care, pharmacy services, vaccine delivery, and certain diagnostic procedures such as simple laboratory tests (1). These services are scheduled in a rotational manner, ensuring that residents in remote communities can access regular healthcare without having to undertake lengthy or expensive journeys. The parallels to certain regions of Spain are manifold: there, many villages lie up to 50 or 60 kilometers from the nearest hospital, with public transport limited or nonexistent, especially in winter. While Spanish roads differ from the Amazon’s waterways, the principle of “bringing care closer to the patient” is shared. In terms of resilience, such an approach effectively acknowledges that waiting for patients to reach a centralized center is not sufficient in times of crisis, nor is it equitable for routine care.
1. Resilience in Remote and Vulnerable Contexts
Resilience has been defined in multiple ways, but in the context of healthcare systems, it often refers to the capacity to absorb shocks, adapt to changing conditions, and continue delivering essential services (5). In the Amazon setting, the “shock” might be seasonal flooding or river-level fluctuations that threaten connectivity among communities. In Spain, the shock could be a sudden rise in patient demand during holidays in coastal areas or a natural disaster such as a wildfire in forested regions of the interior. Resilience in both situations relies on an appropriate combination of infrastructure, trained personnel, and flexible organizational procedures. The floating health centers described by Fortes-Filho and colleagues have carefully adapted to local constraints: they incorporate ground-floor operating rooms for minor procedures, a pharmacy, and even a vaccination area, thus reducing the need for specialized external facilities or frequent restocking. This design allows them to stay operational and effective under conditions that would otherwise hinder land-based units.
In Spain and other parts of Europe, mountainous regions such as the Pyrenees, parts of Galicia, or the Cantabrian Mountains often face substantial challenges in winter months due to snow and hazardous roads. Similarly, Mediterranean islands may see a surge in tourism, leading to overcrowded health facilities. The concept of resilience in both contexts demands robust, autonomous health units that can cope with disruptions in supply lines or transportation networks. Some Spanish autonomous communities have begun experimenting with mobile medical units that deliver diagnostic or screening services to remote towns, yet these initiatives remain relatively sporadic and often do not integrate all the required primary care services into a single mobile platform. One of the lessons gleaned from the Amazon model is that a wide range of services can be integrated aboard a single mobile facility. Instead of small, fragmented, single-service vehicles or buses, the Amazon approach bundles multiple specialties (dentistry, nursing, pharmacy, and general practice) in one place (1).
Furthermore, resilience is also a question of workforce preparedness. Family physicians, nurses, and other health professionals serving in rotating ships in the Amazon must be trained not only in standard clinical practice but also in navigating the logistical and psychological challenges of remote care. This goes beyond clinical expertise, involving the ability to manage unforeseen contingencies such as power outages, fluctuations in medication supply, or the necessity of urgent medical evacuation from remote communities. Similarly, in Spanish rural areas, healthcare workers in isolated clinics often must attend to diverse emergencies with limited referral options, especially when poor weather or an overstretched ambulance service delays patient transport. The 2022 wildfires in parts of Spain, for instance, highlighted the importance of training local clinicians in acute care, triage, and in forging cooperation protocols with local emergency services. The academic literature underscores that effective emergency response in rural contexts often depends on leadership within the local health facility, well-developed communication strategies, and the support of community stakeholders (6). These elements can be facilitated by policy frameworks that recognize the unique challenges of sparsely populated territories and enable flexible staffing solutions or financial incentives to attract well-prepared professionals.
Beyond the immediate scope of acute care, resilience also requires continuity of preventive measures during emergencies. The floating centers in the Amazon pay special attention to vaccination campaigns, specifically mentioned for COVID-19 vaccines, an approach that ensures that sudden surges in vaccine demand can be met without disenfranchising remote populations. Spain encountered parallel demands for mass vaccination during the height of the COVID-19 pandemic, and mobile vaccination points (set up in buses or temporary tents) proved helpful in reaching certain rural pockets. Yet these campaigns often relied heavily on local volunteer networks and did not benefit from the kind of consistent scheduling or stable infrastructure that a floating or otherwise self-sustained mobile clinic could offer. In the event of a new pandemic or an emerging outbreak, having a fully equipped, mobile center of care that can roam across a region would likely be beneficial in delivering both preventive and acute interventions.
2. Preparedness for Emergencies and Large-Scale Crises
One of the fundamental insights we glean from the Amazon model is the importance of designing healthcare units with an eye toward the most probable risks or crises they might face. In the Amazon rainforest, floods and isolation are predictable challenges. In Spain, wildfires, heatwaves, and potential outbreaks of diseases such as seasonal influenza or even vector-borne ailments (e.g., West Nile virus in certain southern regions) represent comparable threats. Planning for these events requires dedicated resources and well-coordinated logistics. According to the World Health Organization, preparedness includes not only stockpiling essential materials but also ensuring that personnel at all levels are ready to operate effectively under disruptive circumstances (7). The Amazon floating centers offer a model of how these preparations can be embedded within day-to-day operations. The staff’s routine includes long stretches in isolated communities, so they are already in “emergency mode” to some degree and are accustomed to dealing with limited external support.
This contrasts with the situation in many European rural health centers, where staff may go months or even years without facing a major crisis and may not have systematic drills or robust contingency plans in place. During the first wave of COVID-19, some rural clinics in Spain had to improvise isolation units and source personal protective equipment (PPE) from informal local channels. That experience has prompted calls for a more structured, regional approach to preparedness, including the distribution of emergency kits, creation of telemedicine-based triage protocols, and ensuring that building designs can be temporarily modified for infection control. However, these measures often remain contingent upon municipal or regional budgets and political priorities, resulting in inconsistent levels of preparedness across different territories.
In this light, a crucial point in the discussion of floating or mobile health centers is financial sustainability. Fortes-Filho and colleagues note that the cost of each vessel can be around $400,000 for construction and roughly $20,000 per month for operation (1). Although these numbers may sound considerable, the long-term benefits and potential savings (from reduced patient travel, improved disease control, and earlier intervention) could offset the investment. In Spain and other European countries, it would be necessary to evaluate the cost-effectiveness of deploying robust mobile health units in rural areas prone to emergencies or seasonal spikes in population. This would entail comparing the investment in specialized vehicles or even amphibious or maritime medical units for coastal and island regions against the potential cost of delayed care or overwhelmed hospitals during tourist seasons or when disasters strike. A thorough economic analysis might show that while initial capital outlays are high, the enhanced resilience could translate into better health outcomes and fewer catastrophic burdens on secondary and tertiary care facilities.
3. Telemedicine and Technological Support for Mobility
Although the article by Fortes-Filho and colleagues does not focus extensively on telemedicine, it alludes to the use of vaccine storage and dispensing technologies that allow medical teams to operate in remote settings with minimal reliance on central facilities. We wish to build upon that observation and reflect on how telemedicine can bolster resilience in mobile units, particularly when geographical isolation or a sudden rise in demand complicates the physical movement of specialists. Telemedicine has become increasingly important in rural healthcare (8–10), with evidence suggesting that remote consultations and monitoring can significantly improve patient outcomes in chronic disease management (11). In Spain, teleconsultation has been partially integrated in primary care networks. However, robust implementation is often impeded by connectivity issues, limited training among clinicians, and uncertainties around reimbursement models (12).
Nevertheless, the presence of a stable, or at least predictable, communication link is vital for mobile clinics operating in remote or disaster-affected regions. The Amazon example demonstrates that even in a region with significant infrastructure challenges, it is feasible to bring basic laboratory capabilities and to systematically collect epidemiological data. Extending this framework, we imagine that a ship or mobile clinic in Spain could be outfitted with satellite-based internet connections or telemedicine platforms that enable synchronous consultations with specialists in urban hospitals. When an emergency patient presents with a complex condition (for instance, a trauma or a suspected stroke) local staff could instantly connect with neurologists, orthopedic surgeons, or other specialists who provide guidance on stabilization and transfer decisions. This is an approach that has already been tested with some success in emergency telemedicine projects in the United States, Australia, and parts of rural Europe, where outcomes for acute stroke patients have improved when local physicians received real-time teleconsultation from a distant stroke center (13).
In situations of large-scale catastrophe, such as a major earthquake or a region-wide flood, the ability to sustain telemedicine links becomes even more pertinent. Once roads or bridges are damaged, a mobile clinic that can physically move to accessible areas and maintain digital contact with advanced care centers offers a dual advantage: immediate on-site evaluation and rapid specialist support from a distance. This can expedite triage, limit complications, and reduce mortality. Of course, these benefits hinge on reliable power supply, data security, and well-defined protocols for teleconsultation. Implementing such systems in Spain would require collaboration between national health authorities, telecommunications companies, and local emergency management agencies. The Amazon floating center model underscores the possibility of bridging these gaps when the political will and logistical planning align with community needs.
It is also worth noting that telemedicine can play a strong role in training and maintaining the competence of the medical teams themselves (14). In the Amazon, as Fortes-Filho and colleagues mention, staff must be prepared for emergencies in a riverine environment (1). Similarly, in Spanish contexts prone to wildfires or floods, local health workers must handle scenarios that rarely occur in routine urban primary care. Through tele-education (15) and distance mentoring (16), staff in remote areas could continually refresh their skills, practice simulations, and remain aware of the best evidence-based interventions for crisis management. This ongoing professional development would directly support the overarching goal of resilience, ensuring that mobile or isolated units remain effective throughout changing circumstances, and do not become obsolete or underutilized.
4. Further Reflections and Contextualization
The floating health centers in the Amazon have highlighted certain barriers that must also be considered if a similar model were to be adapted to any large rural or geographically fragmented zone, including parts of Spain. Specifically, Fortes-Filho and colleagues acknowledge the logistical challenges of maintaining steady water and electricity supplies, repairing vessel parts, and ensuring that staff remain motivated and well-prepared in a frequently mobile environment (1). These concerns are valid for mobile units in any context, whether traveling by river, road, or across mountainous terrain. Vehicle breakdowns, the risk of accidents, limited repair facilities in remote locations, and the emotional toll on healthcare workers who spend long periods away from their families are issues that must be addressed. Indeed, staff burnout has been recognized as a significant risk factor in rural primary care (17). Mitigation strategies might include flexible rotations, the provision of comfortable living conditions on-board or in situ, and clear career incentives, both financial and professional development (18,19).
Another dimension that relates closely to resilience in emergencies is the question of specialized care, an aspect that Fortes-Filho and colleagues point to as a limitation in the Amazon. The floating centers provide general primary care, but they cannot address all specialized needs. In Spain, certain rare but urgent conditions, such as advanced cardiac care or complex surgeries, require transfer to tertiary hospitals. This highlights the need for a robust referral system and the capacity to rapidly evacuate patients who exceed the capabilities of mobile primary care units. During catastrophic events, roads and communication lines might be disrupted, so a planned strategy to rely on helicopters or other forms of rapid transport is critical. If we imagine a large-scale flood scenario in southwestern Spain or the Balearic Islands, a mobile clinic could manage triage and stabilize patients, but definitive specialized care might demand air or sea evacuation. Again, the feasibility of these measures depends on well-designed operational plans, multi-stakeholder cooperation, and political commitment to invest in integrated emergency preparedness.
Finally, the question of community engagement and local cultural adaptation, briefly mentioned by Fortes-Filho and colleagues, also pertains in Spain, though in different cultural contexts. The Amazon’s riverine communities have unique traditions, languages, and perspectives on health and illness. Rural Spain has its own diversity, with older populations sometimes hesitant to adopt new technologies or approaches, and with cultural practices and local dialects that can influence health-seeking behavior. The success of any mobile health model depends on local acceptance and participation. In the Amazon, the floating centers have adapted by docking for one to three days and returning every three months, establishing a predictable cycle of care (1). Similarly, in Spain, building trust with communities requires consistent scheduling, outreach efforts, and possibly the involvement of local municipal councils or community health workers who can serve as liaisons between the health team and the population.
5. Conclusion
Fortes-Filho, de Araújo Melo-Fortes, and Aliberti’s account of the Floating Primary Health Center Model in the Amazon Rainforest offers a compelling view of how primary care services can be redesigned to address extreme geographical barriers and to build resilience in the face of routine and emergency challenges alike. Although the Amazon context is unique in its scope and topography, many of the underlying principles (particularly those relating to preparedness, flexibility, and mobile deployment of health resources) are transferable to other parts of the world, including rural or semi-rural areas in Spain.
From our perspective as Spanish family medicine researchers, it is evident that providing accessible, continuous care in remote or seasonally overburdened settings demands not only investment in physical resources such as mobile clinics, but also in human capital (20,21), training, and policy frameworks that encourage innovation and adaptability (22). The Amazon model underlines that well-structured, traveling health teams can deliver comprehensive primary care, maintain preventive measures such as vaccination, and engage in community education. even without the permanent on-site presence of a brick-and-mortar facility. Integrating telemedicine solutions to supplement these services amplifies the potential impact, allowing for specialist input, remote diagnostics, and ongoing professional development, especially in times of crisis when standard referral patterns might be disrupted.
Nevertheless, we would emphasize that the success of any such initiative depends on careful planning of logistics, sustainable funding, and robust referral pathways for specialized care. Moreover, a culture of preparedness (manifested in regular drills, the availability of emergency protocols, and the training of local staff) must accompany the physical infrastructure. Resilience, after all, is not simply a question of building a stronger boat or buying a faster vehicle. Resilience must be designed in advance: It relies on the systems and people behind those material assets, who must remain ready to adapt to unforeseen challenges. In this regard, the lessons from the Brazilian experience, as outlined by Fortes-Filho and colleagues, echo many of the needs identified in rural and semi-rural Spain. We find a strong impetus for national and regional policymakers to look beyond conventional primary care models and consider integrated solutions that draw on the synergy of mobile facilities, telemedicine support, and a well-prepared, well-motivated workforce.
The Amazon’s floating primary health centers show that a strategic alignment of resources, even in a geographically challenging environment, can significantly broaden access to care and thereby promote health equity (23). In so doing, they remind us that resilience is not solely the capacity to withstand emergencies; it is also the ability to maintain continuity of essential services, uphold preventive measures, and adapt to evolving community needs, all while anticipating that crises (both large and small) are inevitable. We believe that these insights are highly relevant to our ongoing efforts in Spain, where rural depopulation (17), environmental hazards, and seasonal fluctuations in population underscore the need for innovative, flexible healthcare delivery models. The experience from the Amazon provides valuable lessons for rethinking how primary care can be organized in diverse contexts, and invites reflection on how similar approaches could be explored, adapted, and evaluated in other regions facing comparable challenges.
REFERENCES
1. Fortes-Filho S de Q, Melo-Fortes J de A, Aliberti MJR. The Floating Primary Health Center Model in the Amazon Rainforest. Ann Fam Med. 2024 Jan 1;22(1):67–67.
2. Salvia R, Quaranta G. Place-Based Rural Development and Resilience: A Lesson from a Small Community. Sustainability. 2017 Jun;9(6):889.
3. Kapucu N, Hawkins CV, Rivera FI. Disaster Preparedness and Resilience for Rural Communities. Risk Hazards Crisis Public Policy. 2013;4(4):215–33.
4. Fragaszy EB, Warren-Gash C, White PJ, Zambon M, Edmunds WJ, Nguyen-Van-Tam JS, et al. Effects of seasonal and pandemic influenza on health-related quality of life, work and school absence in England: Results from the Flu Watch cohort study. Influenza Other Respir Viruses. 2018;12(1):171–82.
5. Maybery D, Pope R, Hodgins G, Hitchenor Y. Fostering resilience: Empowering rural communities in the face of hardship. Gatew Int J Community Res Engagem. 2020 Aug 23;3:55–69.
6. Kirsch T, Sauer L, Sapir DG. Analysis of the International and US Response to the Haiti Earthquake: Recommendations for Change. Disaster Med Public Health Prep. 2012 Oct;6(3):200–8.
7. Organization WH. Managing epidemics: key facts about major deadly diseases [Internet]. World Health Organization; 2023. 352 p. Available from: https://www.who.int/publications/i/item/managing-epidemics-key-facts-abo...
8. Tenajas R, Miraut D. Learning to Listen Again Preserving Clinical Presence in a Digital World. Ann Fam Med. 2025 May 4;22(1):eLetter.
9. Tenajas R, Miraut D. Clinical Strategies for Creating Safe Online Spaces to Protect Vulnerable Patients. Ann Fam Med. 2025 May 4;22(1):eLetter.
10. Tenajas R, Miraut D. From Flat Screens to Deep Care, Designing Telemedicine for Human Connection. Ann Fam Med. 2025 May 4;22(1):eLetter.
11. Wootton R. Twenty years of telemedicine in chronic disease management – an evidence synthesis. J Telemed Telecare. 2012 Jun 1;18(4):211–20.
12. Bajowala SS, Milosch J, Bansal C. Telemedicine Pays: Billing and Coding Update. Curr Allergy Asthma Rep. 2020 Jul 27;20(10):60.
13. Tunkl C, Agarwal A, Ramage E, Velez FS, Roushdy T, Ullberg T, et al. Telemedicine networks for acute stroke: An analysis of global coverage, gaps, and opportunities. Int J Stroke. 2025 Mar 1;20(3):297–309.
14. Tenajas R, Miraut D, Tenajas R, Miraut D. El pulso de la Inteligencia Artificial y la alfabetización digital en Medicina: Nuevas herramientas, viejos desafíos. Rev Medica Hered. 2023 Oct;34(4):232–3.
15. Miraut D. El sueño de Isaac y la transformación de los sistemas educativos en la sociedad de la información. Teoría Educ Educ Cult En Soc Inf. 2011;12(1):240–66.
16. Tenajas R, Miraut D. The strength of connection: The virtual adaptation of Twelve-Step programs’ meetings. Front Health Inform. 2023;2023(12):1–3.
17. Tenajas R, Miraut D. Maternity Care in Rural Spain Through Inspired Lessons From North Carolina. Ann Fam Med. 2025 Apr 20;22(1):eLetter.
18. Tenajas R, Miraut D. A Shared Struggle: The Recruitment and Retention of Family Doctors in Deprived Areas of Japan and Spain. Ann Fam Med. 2024 Sep 30;22(5):eLetter.
19. Tenajas R, Miraut D. Balancing Employment and Autonomy: Insights from Family Medicine in Spain. Ann Fam Med. 2024 Sep 20;22(4):eLetter.
20. Tenajas R, Miraut D. Performance Incentives and Their Unintended Consequences for Family Physicians. Ann Fam Med. 2025 Apr 20;23(2):eLetter.
21. Tenajas R, Miraut D. Primary Care Challenges and Commitments Across Different Health Systems. Ann Fam Med. 2025 Apr 27;22(2):eLetter.
22. Tenajas R, Miraut D. Why Metrics Fail When Meaningful Care Is the Goal. Ann Fam Med. 2025 Apr 13;23(2):eLetter.
23. Tenajas R, Miraut D. Governing AI to Serve the Patient in Front of Us. Ann Fam Med. 2025 May 19;23(2):eLetter.