Operating air ambulances effectively in Latin America
Robin Gauldie learns that knowledge, experience, good contacts and clear communication are key factors for air ambulance companies facing the special complexities of operating in Latin America
Vacation travel to destinations across Latin America – from Mexico in the north to Argentina and Chile in the south – is rebounding briskly from the slump caused by the Covid-19 pandemic, with the region’s leading destinations reporting international arrivals approaching or exceeding pre-2020 levels.
With more than 38 million arrivals in 2022, Mexico dwarfs all other regional destinations in terms of numbers thanks to the proximity of the huge source markets of the US and Canada, the region’s best developed tourism infrastructure, and a portfolio of tourism lures that includes Caribbean and Pacific beaches, UNESCO World Heritage sites set in rainforest reserves, coral reefs, and vivid cultural events like the legendary Día de Muertos.
Other key Latin American destinations lag far behind Mexico in terms of numbers. Argentina was projected to receive around seven million visitors last year. Brazil and Chile each receive around six million visitors annually, Peru and Colombia around four million. Proving that size isn’t everything, tiny Costa Rica manages between 2.3 million and 2.5 million arrivals annually.
While the huge outbound market of the US overshadows all others, including European markets, travel within Latin America has also increased significantly over the last decade, and may soon amount to more than 50% of visitor arrivals.
As in other parts of the world, motives for travel to LatAm countries have evolved over recent decades. Sun (especially winter sun), sea, sand and a whiff of an exotic cultural heritage are still key drivers for mass-market travel to Mexico from North America and Europe. Cruise travel is predicted to return to above pre-pandemic levels this year, with cruise ships set to bring mainly older and predominantly North American passengers to ports in Mexico, Brazil, Colombia, Peru, Ecuador, Chile and Argentina. Newer developments include ecotourism, trekking and off-beat adventure travel.
This varied portfolio of tourism styles presents multiple challenges for air ambulance operators, who may be called on to evacuate or transfer patients from situations as different as the rainforests of Brazil’s Amazonia and the Andean peaks of Chile and Argentina. Communication, education and teamwork are key to managing buyer expectations in potentially tricky circumstances, said Anne Rodenburg of Guadalajara-based AirLink Ambulance.
“Flying in Latin America is very different from flying in Europe or the United States,” she pointed out. “Much of Latin America is mountainous and high terrain. Weather can change very fast. Some airports are located at high altitudes and runways can be extraordinarily short.”
The impact of volcanic activity – common in many parts of Latin America – is another factor, she said. “Airports and air traffic control centres are much more dispersed. In many regions they are few and far between, and in very remote areas communication during flights can be interrupted for extended distances, conditions not typical in more densely populated geographies.”
Many airports are not open 24 hours a day, do not have international customs and immigration services, and sometimes operate with minimum staff, Rodenburg explained. “Even the official operating hours can be affected if someone key to airport operations falls ill,” she said.
The realities of the region
When planning an air ambulance mission to one of these zones, managing the expectations of the insurance or assistance company and of the patient and family members is important, and experienced air ambulance providers have a responsibility to bridge the gap between their expectations – which are normally based on typical air ambulance missions in less challenging regions and conditions – and the realities of operating more demanding scenarios in some parts of Latin America, Rodenburg said.
“As the operator, we should take the time to clearly communicate and explain the characteristics of the region and the different scenarios or causes that may change planned itineraries and service,” she added.
Cai Glushak, Medical Director and Chief Medical Officer, AXA Partners North America, agreed.
“We find our clients quite understanding about the real-time challenges we may face overcoming geographical challenges and other environmental realities,” he said. “Everyone knows that mountains, jungle and islands are special remote destinations and that it may take exceptional resources to respond to serious emergencies.”
Other regional challenges include aviation procedures that may vary from country to country and alter over time without notice, Rodenburg said.
“At AirLink, we have an extensive network of direct contacts in most countries. This enables us to set up local handling support beforehand. Standard operating procedures per country or region are constantly updated so that the knowledge is current within the operations team. Our pilots are highly experienced in executing arrival and departure procedures throughout Latin America,” she said.
Communication is also key to coordinating wing-to-wing or helicopter to fixed-wing transfers at small and sometimes remote airports, Rodenburg added.
“Communication goes much further than language. There is standard aviation communication, but – and especially in more remote areas – communication sometimes has a large cultural component that can complicate understanding what someone means to say (or not say). In Latin America, there are many valid variables that may interfere with a pre-established itinerary. All these variables must be carefully considered and taken into account when planning a mission. Again, experience and good contacts are key.”
A robust labour supply
Recruiting and retaining aircrew and medical staff is a lesser challenge, Rodenburg and Glushak agreed. LatAm-based air ambulance companies currently find it easier to recruit than their counterparts in North America.
“In the US and Canada, air ambulance companies are still struggling to replenish staff that became in short supply during Covid-19,” Glushak said. “Our providers, say, in Mexico, have not had the same struggles – likely an indication of the medical labour supply there.”
Conversely, in Latin America, the supply of pilots outstrips demand, said Rodenburg. Additionally, salaries of medical professionals and paramedics are significantly lower than the cost of similarly qualified staffers north of the border, she added.
On and off the beaten trail
With a good private health infrastructure comprising surface transportation, fixed-wing and helicopter air ambulances, clinics, private hospitals and emergency rooms with highly qualified, multilingual doctors, international airports serving all major cities and resort areas, and close proximity to the US, Mexico is arguably the least challenging of LatAm destinations from the assistance sector’s point of view when repatriation by air ambulance is required. The vast majority of North American vacationers to Mexico also head to just a handful of Caribbean and Pacific coast resorts or to Mexico City, with relatively few heading off the beaten track.
Other destinations may present greater challenges. Peru’s well-trodden Inca Trail, a four- or five-day hike to the ancient city of Machu Picchu at altitudes of up to 4,200 metres, attracts not only fit younger trekkers but seniors too.
“Visitors to Machu Picchu often come down with acute altitude illness, often combined with concomitant maladies, such as injuries, pneumonia and cardiac issues,” said Glushak.
Costa Rica, the region’s top ecotourism destination, is another hot spot, he added.
“While care in the capital, San José, is excellent, geographical obstacles make rapid evacuation difficult without using a helicopter. As the crow flies, it may be only 100 kilometres or so, but ground travel time is more like six hours – too long for a delicate patient with an emergent condition.”
Aconcagua in Argentina, the highest South American summit, is nicknamed ‘the mountain of death’. Voyaging into the Amazon rainforest conjures up imagined perils like giant anacondas, alligators, voracious piranhas and insect-borne parasites. Yet the reality is mostly less exciting. Surprisingly few travellers require medical evacuation from the Inca Trail. Despite its nickname, the 6,961-metre Aconcagua is no more lethal than Scotland’s 1,345-metre Ben Nevis, with around three fatalities each year. Most air ambulance operations in Latin America are for much more mundane causes. The majority of AirLink’s patients are senior citizens requiring repatriation for heart disease, neuropathy or trauma, according to Rodenburg.
Cash under the counter – don’t ask, don’t tell?
Latin America is widely perceived as a region plagued by endemic corruption. That may not be entirely unfair. The monitoring organisation Transparency International’s 2023 Corruption Perceptions Index, which ranks 180 countries by levels of public sector corruption, places many of Latin America’s most popular destination countries well down the scale, with Argentina ranked 98th, Brazil 104th, Peru 121st and Mexico 126th.
A culture of corruption creates yet another headache for air ambulance operators, who may face none-too-subtle hints that anything from clearing paperwork to access to fuel may become difficult without under-the-table payments to local officials.
“Anyone who states that they never face these challenges working regularly in certain regions in Latin America is not telling the truth,” Rodenburg said. “It is a complex reality that many people feel uncomfortable talking about.
“The anti-bribery and corruption policies we sign as air ambulance companies are very important, but the downside is that such contracts might make it more complicated to open up about what is really going on,” she added. “Not talking about the subject does not help to find ethical, case-by-case solutions. The truth is that situations are often not as black and white as the theoretical amendments written by people sitting behind their desks. The key question in these situations is how to solve these situations in a legal and ethical way, but without jeopardising the safety of the patient, crew and the mission as a whole.”
“There is a lack of clarity,” Glushak agreed. “The process of getting permissions is not transparent to us.
“Our offices have come to recognise providers who seem to be able to streamline getting permissions compared to those who typically have more delays. We are not privy to how they choose their handlers or what is involved in the process,” Glushak added.
“One issue which has persisted for years is the opportunistic approach of helicopter providers in certain areas to evacuate patients at enormous cost before contacting the assistance/insurance provider,” he noted. “Not infrequently we have found this approach to be not as urgent as represented and prohibitively expensive.” Such incidents are not unique to Latin America, he conceded.
Culture clashes
Alongside a reputation for corruption, Latin American countries can be perceived as being a little too easygoing. That’s a misunderstanding, Rodenburg said.
“There is a tendency in Latin America to try to please, and a reluctance to be a bearer of bad news. We want people to be happy and satisfied, but wanting people to be happy can make it difficult to say no clearly, even when the answer has to be no,” she added.
That tendency to hope for the best can allow people who are culturally more direct in their communications to have unrealistic expectations and make it hard for partners to make the right decisions to ameliorate upcoming problems. “Someone who is not familiar with this occasional cultural trait might feel people are avoiding the subject, when, in reality, people often are just trying to be polite, to help and not inconvenience you and themselves,” Rodenburg concluded.