Clinic week

For the third week of the Interhealth program, students were placed in clinics and hospitals in Quito to shadow and work with Ecuadorian doctors. I chose to work in outpatient pediatrics with Doctora Carmita Flores; Dra Flores is a general practitioner, and the majority of her patients are women and children. I was interested in this placement because I thought it might offer an interesting comparison to the private pediatric clinic I worked in for two weeks last year in Raleigh.

The clinic is a public Centro de Salud (“health center”), which is part of a network of hospitals and clinics funded entirely by the Ecuadorian government. Since the institution of a new health care system in Ecuador in 2008, the medical services, medications, and laboratory tests offered there are completely free to Quito residents within the clinic’s catchment area. They also provide vaccinations – for both people and dogs! The volume of patients seen is fairly high (15-20 patients per doctor in a four-hour work shift), but the center does not make appointments ahead of time, so patients line up as early as five in the morning to be sure to see a doctor that day. There are private and semi-private clinics and hospitals in Ecuador as well, and those residents who can afford it can choose to pay for shorter wait times and potentially better service. I was happy to have the opportunity to work in a Centro de Salud, though, as I am interested in eventually working in public clinic in the U.S.

Dra Flores was warm and welcoming to me and Kristyn, the other student (also from UNC) assigned to her, and seemed to enjoy our questions. Because my Spanish speaking skills are still in their infancy, my role was more that of an observer than an active participant, although I was able to perform small tasks like calling the next patient, taking vital signs, and occasionally looking in a child’s ears or listening to their lungs. I did see some interesting things, such as an adult case of chicken pox, and I observed my first gynecological exams. However, the most valuable aspects of the experience were the opportunity to practice my medical Spanish, and to learn about and observe the practice of medicine with an Ecuadorian physician.

The most obvious point of comparison is the relative lack of resources in the Quito health clinic, even compared to a public clinic in the United States. There was no roll of paper on the exam table to be changed between patients; instead, a single sheet lay on the table which was never changed or washed in the week I was there. On the other hand, patients do not have to worry about the cost of their visits or treatment. From what I could tell, this did not impact the doctor’s treatment of or recommendations for the patient, at least not at the outpatient level; I do know that there are certain surgeries in Ecuador that are covered by the government and others (such as knee and hip replacements) that may not be. But it was refreshing to know that anyone who wanted or needed to could come to the doctor regardless of their income or health insurance. In addition, the government places a fair amount of emphasis on public health measures such as vaccination, follow-up appointments after illness, and nutrition; every pregnant woman in Ecuador and every child under two can receive free dietary supplements containing necessary vitamins and nutrients.

It was interesting to observe the style of doctoring practiced in Ecuador; although I only worked with one physician, conversations with many of the other students in the program suggest to me that my observations are fairly typical. In many ways, the way in which Dra Flores approached patients was the opposite of what we are being taught in medical school. In my classes last year, much emphasis was placed on the doctor-patient relationship, understanding the patient’s experience, validating their concerns, working with them to encourage behavior changes (such as changes in diet or use of birth control), etc. So it was strange to watch a physician sit across a desk from the patient, rarely making eye contact and focusing instead on her paperwork, firing off questions in rapid succession, interrupting the patient, and handing down imperatives such as “you need to lose weight – walk one hour every day and don’t cook with oil,” as if simply telling the patient to do so would make it happen. She performed interviews and exams with the radio blaring, burned incense in the office, and did not hesitate to answer her cell phone in the middle of a patient’s visit. This approach struck me as quite paternalistic and even disrespectful, so I was surprised to hear patient after patient at the check-in desk asking for Dra Flores. It was a good reminder of the fact that I interpret information based on the cultural context I know, which may not be at all applicable to a medical clinic in Quito.

One other aspect I found myself thinking about during this week is the fact that, although the health care is free and in theory available to all, there are still many Ecuadorians who are not reached, such as the indigenous people who work in the urban markets who may not speak Spanish or be able to take a day off from work to wait in line for the doctor, or people living in rural areas without access to transportation such as those we saw on many of our mobile clinic health brigades. I was glad to have both experiences included in the program, as it helped me to get a more rounded picture of the health care system in Ecuador, and to observe how even “free” health care is not a panacea. It reminds me to be patient with health care reform in the United States, as every system has its strengths and weaknesses, and while I believe that everyone has a right to health care, achieving such an ideal is easier said than done.

Mindo cloud forest

I apologize for the lapse in updates; I have been without consistent internet this week. But I wanted to write about the weekend I spent in Mindo (two weekends ago) with Amy and three other students from the program. Mindo is a small town located in the “cloud forest” region of Ecuador. A cloud forest is a tropical evergreen forest where the clouds literally hover and float at ground level. It is a disappearing habitat, and it is beautiful.

After a two-hour bus ride winding through the mountains and down into a valley, we arrived in Mindo. I was immediately struck by the incredible flora – it looks like a temperate jungle, where the trees have huge leaves and vines and mosses are abundant. After a filling and very cheap lunch, we set out into the forest with a local guide, hiking across rocks and small rivers, uphill to the top of a waterfall. I learned the word for mud ("lodo"), which was slippery and thick in spite of this being the middle of the dry season. At the peak of the waterfall, our guide launched into a long set of instructions in Spanish, during which my anxiety and anticipation grew exponentially. We all strapped in to our harnesses – which, amusingly, were bright red with the word “mammut” and a picture of the corresponding animal printed squarely on the butt (see attached photo of my arse) – and then took turns repelling 80 meters down the waterfall to the river below. It was terrifying, exciting, cold, and magnificent. I would definitely do it again.

On Sunday morning, we got up at 4:30, piled into a pickup truck, and drove 20 minutes out of town to hike up another hill in the dark. By the time the sun rose, we were waiting in a little lean-to for the "gaillo de la pena," the "cock of the rock." This rare bird performs an intricate mating ritual every morning, in which the males court females by calling out, bobbing their heads, and spreading their wings. Their squawking was unique and charming, and their heads were the most brilliant red. We could hear them even before the sun came up, but over the hour or two we were watching there was a lot more waiting than seeing birds; which for me was part of the fun – anticipating the payoff when you finally catch a glimpse of such a beautiful bird.

Later that day, after a hearty breakfast, a short but necessary nap, and a very hot shower (a luxury I have experienced but few times during my month in Ecuador) I visited the butterfly farm while the other gals checked out the coffee plantation and the chocolate shop. I always enjoy the chance to wander through a place on my own, and the garden was a perfect end to my weekend. I saw caterpillars, cocoons, and countless species of butterflies, as well as the establishment´s orchid garden. My self-guided tour concluded with fifteen minutes of lounging in a brightly colored woven hammock overlooking a row of hummingbird feeders which were visited by one exquisite bird after another.

If my descriptions sound a bit over-idealized, it is because this place truly felt like paradise to me. It was hard to leave it behind, but made me excited for the upcoming visit to the Amazon rainforest… More to come!

Love you all,
Jess

Health brigades

Over the past two weeks, we have spent four mornings doing mobile clinic work in the mountain villages outside Otavalo and in the markets of south Quito, which is generally poorer than north Quito where we are staying. In groups of two or three students, we interview patients, perform a relevant physical exam (as much as possible without violating their privacy in a large room with no divisions between patients), and conduct screenings for blood pressure, blood sugar, etc. Then, working with a volunteer doctor or nurse, we help develop an assessment and plan for the patient, which sometimes includes prescribing medication; some medications (such as amoxicillin, Bactrim, and ibuprofen) we have available in our traveling pharmacy, while others must be purchased at the pharmacy by the patient. The pictures are of me and my team from various brigades, as well as one of the other students that shows the crowded quarters and tiny chairs! You can saee more photos on my friend Amy´s Flick´r site: http://www.flickr.com/photos/amysparks/sets/ The first three sets are of us in Ecuador.

We have seen some fairly complex health problems at the health brigades: congestive heart failure, kidney infections, intestinal parasites, and a superficial tumor six inches in diameter! However, we have all been generally frustrated by our inability to do much for these types of problems. We can cure an ear infection or give someone reading glasses, but have relatively no ability to ameliorate chronic health concerns, and end up referring patients to doctors they will never see at facilities they are unable to travel to. Even with Ecuador´s recent decision to make health care more accessible – including many free procedures and services – the waiting lines are long, and not all of the service is free. For example, a hip replacement operation is free, but according to one patient the prosthetic hip itself costs $5000, which even well off folks in Quito generally cannot afford.

On the other hand, the health brigades have provided an opportunity for us to work with two organizations committed to improving the health of economically marginalized Ecuadorians. Jambi Huasi in Otavalo (where I received my “cleansing” treatment last week) is a collaboration between MD’s and traditional healers, and focuses on reaching out to indigenous populations who are often more comfortable seeking care from curanderos and shamans than from medical doctors. Two doctors, an administrative assistant, and a translator from Jambi Huasi accompanied us on our health brigades outside Otavalo. In Quito, an organization called CENIT (Centro de la Nina Trabajadora), which began as a school for girls selling goods with their families in the outdoor markets, now provides a range of services for working girls, boys, and their families, including remedial schooling, vocational training, health services, family planning and contraception, outreach to street children, and psychological assessment and counseling. Most of their staff is Ecuadorian, but they also command a small army of rotating international volunteers to aid in administration, planning, and service implementation. The people who work with Jambi Huasi and CENIT are an inspiration to me, as they continue to work toward empowerment and health for those most at risk.

So the health brigades have been a mixed experience, full of frustration, helplessness, insight, and hope. Next week we will conduct three more brigades in the rainforest of the Amazon. I will try to keep reflecting and learning and, as with my time in Kosovo, know that I am taking away many lessons that will influence and inform my work in the future. The sense of overwhelming need seems to be ubiquitous in global health, and part of the challenge is figuring out in which ways I want to contribute to the struggle.

Con amor,
Jess

Temascal

Last night we participated in my favorite experience yet: a sweat lodge, or ¨Temascal¨ in Kechwa, the indigenous language in this region. The lodge is a small hut, a circle with a diameter of ten feet and about four feet tall. Thirty-two people in bathing suits and shorts squished into the hut, sitting on woven mats and dirt, around a pit in the middle. A tall, slender woman explained the ritual of the Temascal to us while volcanic rocks, heated in a fire for hours ahead of time, were piled into a dirt pit in the center of the lodge. The ceremony began with the passing of tobacco juice, which we snorted into our nostrils, inducing a slightly dizzy and intoxicated feeling. Then the door of the hut was closed and the only light was the glowing of the rocks. Our guide poured water and herbs into the pit, and the sweating commenced.

At first, many of the participants seemed hesitant or uncomfortable, and the guide had difficulty quieting the group as people cracked jokes or complained about the lack of leg room. I felt frustration rising in me about what I perceived to be irreverence for this spiritual space and ceremony, but also realized that we were all a bit nervous about what was to come and had different ways of dealing with it.

However, once the door was closed and we were plunged into darkness, all side conversations ceased immediately. Our guide led us in prayer and song as the temperature and humidity in the room rose, and it became impossible to think about anything besides the sensations of the Temascal. We sang traditional Andean melodies, popular Western songs like “Let It Be” and Leonard Cohen’s “Hallelujah,” and Sanskrit chants from yoga class – “Om Shanti, Guru Dei Namo.” The ritual continued through four rounds of tobacco, newly heated rocks, steam, and relief as the door was opened in between rounds and cool air allowed to flow in. In each round we gave homage to and benefited from the energy of one of the four elements: air, water, fire, and earth. The first three rounds became increasingly intense, as more stones were added to the pit; seven for the first round, nine more in the second, then thirteen for the round of fire – the round of transformation. When the guide poured water over the thirteen volcanic rocks, the temperature of the air in the room surpassed anything any of us had ever experienced. As she played the drum, she invited us to express whatever we were feeling out loud, and the tiny hut became filled with the primal yells of the normally inhibited and controlled medical students. I laughed out loud as the people on either side of me yipped and wahooed with abandon. It was exhilarating.

After the round of fire, we drank cool water and rested before one last round of seven rocks, nearly as intense as the round before, but at that point we knew we could handle anything. The whole ceremony lasted just under two hours; then the door was opened from the final round and I crawled out of the lodge to a cold, invigorating shower (but not before taking this picture of the whole sweaty group). Rinsed of dirt and sweat, and wrapped in soft, warm clothes, I returned to the fire where our rocks had been heated earlier that afternoon. Sipping on tea, we marveled at the experience while the owners of the lodge prepared a unique meal for us. Pachu Manka is an ancient Incan tradition of cooking food underground, buried in a pit with heated volcanic rocks. We watched the uncovering of the food, then piled our plates high with beans, corn, peas, chicken, pineapple, banana, carrots, beets, and several kinds of potatoes (salty, bitter, and sweet). Eating with my hands by the fire that had warmed both my body and my food, I felt deeply content and peaceful. After dinner, I drank a large quantity of water, slid under the wool blankets in my hostel bed, and fell quickly and happily to sleep.

Otorrinolaringologo and kechwa...

... are just two of the fun words I have learned so far. The first is, of course, otolaryngologist which in the U.S. we conveniently shorten to “ENT,” but there is no Spanish abbreviation so we have to say the whole word. Kechwa is the language spoken by indigenous people in and surrounding the mountain town of Otavalo where we have been staying since Wednesday. Amy and I are rooming together in a basic but nice hostel where we have a room and bathroom to share.

Last week we got a tour of the area, visiting members of the indigenous community who still work by weaving clothes and reeds. One couple in their 70’s makes a living weaving lovely wool scarves, ponchos, hats, and other goods. They are some of the last people in the region to still perform the entire process for the wool goods themselves; they shave the sheep, card the wool, spin it, dye it, and then weave on a loom. I took a turn spinning the wool, with moderate success (photos to come), but it was tiring, and I can’t imagine spinning for eight days straight to make one spool of yarn.

On Thursday we visited a clinic called Jambi Huasi where western medicine and traditional medicine is practiced together. I really appreciated the effort to incorporate both methods into the treatments there. We learned about the different approaches of the Yachac and the Frigadora, both indigenous healers similar to shamans. One of the most interesting practices to me was the use of a guinea pig (“cuy” in Spanish) to diagnose illness. The cuy is shaken all around the person (alive, and held by the neck) to absorb the negative energy of the illness, then skinned, and the place in the pig’s body where there are dark spots indicates the location of the person’s problem.

We also visited the hospital in Otavalo, which reminded me immediately of the hospital in Kosovo. Both included all of the departments of a hospital in the United States, but lacked the sterile feeling and bright lights that we are used to, and seemed generally understaffed and undersupplied. As these are the only two hospitals I have been in outside the U.S., I do not have much of a basis for comparison, but it did seem to me that the similarities outweighed the differences. My favorite part was a visit to the birthing room, which is equipped with a bed, a birthing stool, rails on the wall, and ropes hanging from the ceiling for women to keep their balance while delivering babies standing or squatting. The women there are attended by midwives instead of doctors, and while there is a surgical delivery room across the hall for emergencies, the birthing room certainly seemed like the more friendly place to labor and give birth.

Our education regarding the medical services available in Ecuador has also included receiving some of the treatments offered. Yesterday I went to the Yachac at Jambi Huasi for “una limpia,” or a cleansing treatment. It consisted of lots of herbs and oils in icy water rubbed all over my face, neck, arms, and hair. Although I was scheduled for a half hour, the whole treatment lasted under five minutes, and at first I was a little disappointed. The smell was so strong it made me cough, and I couldn´t open my eyes for a minute afterward because they were stinging. But then, as the air began to dry off my face, it felt warm and cool at the same time, like VIck´s or icy hot. The sensation was invigorating, and people were telling me for hours afterward that I looked so happy!

Tonight, we visited a local Curandera (another type of indigenous healer) who performed a more extensive cleansing ceremony on another student, a young woman named Vanessa who has become one of my friends here. Whereas the herbs and oils were sprinkled on me from the bag in my treatment, the Curandera actually took large swigs of the solutions and spit them on Vanessa, who was then instructed to rub them into her skin. There was music and chanting, and the Curandera danced around her patient, tapping her with leaves and grasses and even lighting the mat under Vanessa’s feet on fire with homemade whiskey. It was exciting to watch, and yet I could not help but note what seemed to me like paradoxes, including the Curandera’s persistent cigarette smoking before, during, and after the ceremony, her casual clothing (jeans, a T-shirt, and sneakers) under her traditional beads and headdress, and her taking pictures of us when we first arrived. But these details were interesting in their demonstration of the mix of indigenous and modern culture that seems to predominate in the communities here.

These experiences have all served as exposure to the health beliefs and practices of the patients we see in our community health “brigades,” which I will write about soon. In the meantime, I want to wish everyone a safe and happy Fourth of July!

Buenas noches
Jess

First photos!

On Sunday, my friend Amy and I wandered around the ¨ciudad antigua,¨the oldest part of Quito, and visited the largest church in town: La Basilica. It was a beautiful gothic cathedral, with pointed arches and stained glass windows, and tall clock towers which we had a grand old time climbing. Unlike Notre Dame, which requires flight after flight of stairs, the marble stairs in La Basilica take you only about half the way up the tower; the rest of the climb is by rickety spiral staircase, wooden plank bridge, and ladder. From the towers, there is a beautiful view of the city of Quito and the surrounding mountains. I have posted a couple of photos below, but you can see the rest on Flickr at: http://www.flickr.com/photos/amysparks/sets/72157624263134489/

Enjoy!

En Quito!

I'm here! I arrived last night in Quito, the capital city of Ecuador, after an enjoyable trip with my classmate Amy. One of Amy's bags didn't make it until this morning, but all in all I consider that to be all a successful trip. We were picked up at the airport by a driver for our program, and I strained to see the city as we sped through streets with lots of cars but few pedestrians. When we got to our home stay, it was very plain and small from the street, but this was an illusion since the moment we stepped inside it was large and beautiful. Our homestay "family" consists of a couple in their late fifties or so, Elsa and Jose. They call each other "Mami" and "Pepe." They are so welcoming, and we ate wonderful food while conversing (with much effort) in Spanish. Amy and I have our own adorable rooms with a shared bathroom - it really is so much more space than I expected - I think the hammocks and bugspray come when we are in the mountains...

The mountains! After a yummy breakfast and tea this morning (decaf! I'm going to have find myself some good South American coffee after this), we ventured out to walk around the city a bit and find an internet cafe. And the first thing we see when we turn the corner out of our neighborhood is mountains - tall and craggy ones, smaller and rolling ones, the lower portion studded with houses and the higher altitudes a deep evergreen color. It is beautiful. And against this backdrop, a colorful city, each building different than the next. The plants and trees are unfamiliar to me, and Amy was patient with me while I inspected leaves and blossoms, but I will have to come back out on my own soon to really take some time to look at them.

I had the immediate urge to take pictures of everything I am seeing, but have limited myself to a couple of irresistible shots of the mountains, as I want to take things in first. So I'm taking deep breaths of cool mountain air (it is winter here and high altitude, so the temperature is in the sixties today), mixed with the occasional smells of charcoal and roasting meat, and the less pleasant city smells of exhaust and garbage. There are dogs everywhere, and I can't tell whether they are strays or pets; many of them seem to be following people around or laying possessively in front of houses, but the people aren't paying too much attention to them. The dogs all seem friendly, well-fed, and not a bit skittish. I promise I won't bring one home this time :-)

So those are my first impressions of the city on a quiet Sunday. Our Spanish language classes begin tomorrow morning, so today we plan to head over to the "ciudad antigua," the oldest part of the city, to explore a bit and probably find a cafe to relax in and watch the World Cup.

I don't have a phone here, but I will have internet access most days, and will look forward to Skype conversations. For now, hasta luego!

Love
Jess