In spite of universal free healthcare, the impoverished Ecuadorians often lack access to adequate medical care. Statistically, there are 15,866 doctors in Ecuador who serve a population of roughly fourteen million. These numbers are not particularly alarming; they are, in fact, similar to those in most other Latin American countries. Yet, they are not indicative of the realities found in many Ecuadorian communities. Citizens living in poorer and more rural regions, such as the Cantón of Chinchipe, face a far bleaker situation in terms of their health. Often there are no doctors within hours of some communities.
Ultimately, although medical care is guaranteed under the 2008 Constitution, those living in the mountainous jungles of Chinchipe and other widely impoverished and rural zones do not have access to adequate healthcare. Fortunately, there are efforts underway to remedy the problem...no pun intended. A group of American doctors, for instance, recently conducted a health brigade in underserved communities throughout the county including Vallalodid, Porvenir, Palanda, San Fransisco, Zumba, Chito, and San Andres. As a local Peace Corps volunteer, I was asked to accompany the group and provide cultural insights while helping in any way possible (mainly by providing basic information on the importance of boiling drinking water, adequate hydration, and sun protection). Throughout the week, I had the opportunity to observe many of the obstacles hindering universal access to adequate healthcare as well as the impact basic medical care can have on an entire town.
Why do many Ecuadorians lack access to healthcare? In some communities, such as Chito, there is simply no healthcare facility. The town's sub-centro de salud closed more than seven years ago and has yet to reopen. Given that Chito lies more than three hours from the nearest “sizeable” community—Zumba-- along twisting dirt roads prone to landslides (I should know...our medical team's bus was almost pushed off a precipice by a river of mud streaming across the road), residents cannot easily trek to the doctor. One town, San Andres, is so remote that there is significant in-breeding and incest, which has resulted in many severely disabled residents. Thus, many forgo medical care in spite of the obvious need. One woman, for instance, had broken her arm years ago and never received car. The bone was never set; thus, it now protrudes from her arm and she cannot use the arm without enduring agonizing pain. In another, more disturbing case, a man had cut his leg while using a machete several years ago. The wound had since become infected and bacteria had consumed much of his lower leg. Our doctors prescribed an antibiotic that may kill the bacteria, but without the possibility of a skin graft, he will most likely never have a usable leg again. Had he visited a doctor in a timely manner, perhaps this disabling wound on his leg could have been avoided.
Yet, simple access to a hospital, sub-centro de salud, or a pharmacy does not guarantee access to quality healthcare. In one of the most alarming cases seen throughout the week, a twelve-year-old girl visited the clinic with her mother. The young girl—who had already dropped out of school to work on the family's farm—had a bacterial infection in her lungs complicated by an untreated case of asthma. Her mother, recognizing the severity of her daughter's illness, had brought her to a local pharmacist who sold her a large supply of medications including codeine. In many patients, this would not be problematic, but codeine is contraindicated for those with restricted airways (asthmatics for example). Such medicines could, therefore, severely harm the girl. Yet, the untrained pharmacist did not recognize the problem and sold the drugs; had the mother not sought out one of the few sources of medical aid in the community, her daughter may, in fact, have been better off. Yet, not knowing, the mother purchased the drugs. Luckily, the mother then brought the girl to our clinic and the doctors purchased the dangerous drugs before giving the child a more appropriate drug regimen to heal her lungs. A happy ending—except for the sad reality that the asthma is a chronic condition and the girl's mother admitted that it is unlikely she will be able to refill the medication when the girl's new inhaler when it runs out of abuterol in a few short weeks.
The absence of enduring medical care highlights a major problem facing the medical brigade. We are only in each community for a few short days at most; yet, many common conditions require on-going care. For instance, one major healthcare issue is high blood pressure. Although this cannot be cured, it can be regulated by various medications provided the patient follows the same regimen for the rest of their life. If they stop taking the pills, perhaps because they run out, then they blood pressure will spike. It is, therefore, better to never medicate than to begin the drug regimen and stop. Given that follow-up is impossible, our doctors thus needed to decide whether the patient would even be able to refill the medication before deciding whether to give it in the first place. Moreover, some conditions cannot even be addressed as it is far too dangerous to do so without ongoing care. Perhaps one the most delightful patients was 74-year-old Rosa. Always smiling and giving unsolicited advice on marriage, the elderly women lives far in the countryside caring for her severely disabled daughter alone. She has thrived under difficult conditions since the loss of her husband nearly two decades ago. Yet, it is becoming increasingly difficult as she suffers from a severe case of Parkinson's disease. She trembles constantly; she can no longer walk for long periods without toppling over. Medication would help her; unfortunately, the powerful drug regimen must be overseen by a doctor and, as this is impossible, the best remedy available was a relatively benign sleeping pill to help her sleep and calm her nerves.
Not only are many of our patient's conditions untreatable due to their living conditions, but these same living conditions also create many of the conditions. The most common complaints—“machete” elbow and parasites—are virtually unavoidable for the majority of the patients. “Machete” elbow is our nickname for pains caused by farm work; a shocking percentage of the patients arrived with chronic pain stemming from farm work. Logically, to address these pains stemming from repetitive motions, the farmers should avoid using their machetes, milking cows, etc. This is not, however, an option in agricultural communities in which there are few jobs other than farm work and the complete lack of income make retirement utterly impossible. Moreover, many of the patient's conditions stem from the environment in which they live. Amoebas and parasites, for example, proved endemic as many tap water is far from clean and many families get their water from nearby brooks and streams. While boiling water can certainly help, it is not a certain cure as dirty water is often unavoidable; after all how many can refuse a nice cool juice offered by a neighbor who does not boil their water when temperatures soar? Thus, as one mother aptly pointed out, her children have parasites simply because of where they live. They don't do anything and it certainly isn't their fault. It just happens.
A lack of infrastructure capable of supplying impoverished families with clean water is only one of many structural problems hindering the Ecuadorian healthcare system. As a teacher, one of the most bothersome related to education—often the patients lacked the knowledge necessary to protect their health. From not boiling water to eating diets consisting solely of rice and yucca while discarding fruits, the lack of knowledge was constantly imperiling their health. Moreover, many did not have the skills necessary to follow complex drug regimens. No one can be expected to remember how to administer a handful of medications; yet, we often could not write out instructions given our patients never learned to read which is not particularly surprising given that many eleven and twelve-year-old patients had already dropped out of school.
Not only did local structural problems hinder the brigade's ability to help its patients, but the structure of the brigade itself often compromised its success. Many of its problems were, however, unavoidable. For example, the brigade often worked in churches with several doctors crammed into one room. Thus, there was very little privacy for patients reporting their health problems, which proved particularly uncomfortable for many women reporting gynecological problems (unsurprising given that the average women probably had at least ten children). Thus, many seemed reluctant to provide relevant details and, I suspect, some refused to acknowledge such problems at all which is to be expected as their neighbors were often peering through the open windows or crowding around nearby tables eager to hear their complaints.
Moreover, the doctors in the brigade only spent a day in each community; thus, they were often unaware of other resources available to patients. For example, a fourteen-year-old girl arrived with a baby. Both appeared healthy; the girl just had a lengthy list of somatic complaints. The doctor soon began peppering her with questions, trying to find why she seemed to unhappy and reported so many complaints. He soon learned that her significantly-older husband was abusive; yet, she felt she could not leave nor return home. She needed counseling and help, yet apart from some advice, there was little that could be done. No one on our team was familiar with any support available in Palanda for women in abusive homes or even if such resources exist.
In spite of it all, the brigade made a difference. Given the lack of follow-up care, we will never know how many of our patients thrived. Yet, their gratitude, smiles, and the endless stream of “Dios le pagará” (literally, God will pay you) indicated that many will awake feeling better tomorrow, even if its only a bit of a placebo effect. One middle-aged man, who walked for hours to the clinic with his elderly mother, even returned the following day to give us a trash bag stuffed with machete guayabas (a delicious fruit) as a means of saying thank you. Others offered us a place at their table even though they can only feed their children white rice a few times per day. Their generosity was often overwhelming; without a doubt, whether cured or not, their reactions suggested that even the mere attention of a doctor truly mattered.
And, for some, the doctor's advice did cure. Last year, many of the doctor's had treated a three-year-old boy about to die of pneumonia. While they provided the best care possible given the circumstances, they had to leave before it was certain he would survive. Imagine their delight, therefore, when the same four-year-old boy with and enormous smile bounded into the clinic to say hi and thank the doctors who likely saved his life.
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