Below is a piece written by Matthew Nelligan, a student at the University of Notre Dame, who did a service learning project in Ecuador with Andean Health and Development in the summer of 2011.
Global Health in Rural Ecuador
Head tilted downward and eyes focused on the barely visibly dust rising below me, I walked up the street towards Hospital Pedro Vicente on my last night in the pueblito. Rehearsing the well-practiced goodbyes to the doctors and my host mother, a pharmacist, my mind was racing through thoughts of reflection and nostalgia. To my surprise, I noticed a large crowd of people huddled closely together outside of the hospital mumbling softly in Spanish as I approached. The mood was somber and withdrawn; mournful cries could be heard from an old woman refusing to back away from the entrance. Suddenly, my nervousness shifted from the foreboding farewells to the accident waiting behind the doors in front of me. I entered with caution to the front of the pharmacy window to see the smiling face of my Ecuadorian mother, Maribel. She immediately informed me that a young boy had been hit by a car and was in what seemed to be grave condition. Avoiding any kind of disturbance to the doctors, Maribel guided me through the emergency room where lay the injured child. We shared a passing glance. Fear exploded from his eyes as a nurse took appropriate measures to ensure his safety. The rest of the night was a blur of tear-filled goodbyes to friends, a new family, and to a town that so anxiously embraced me as one of its own, yet what I remember most vividly from that night was the passing moment in the hospital emergency room.
It seems ironic that all of the many lessons I learned about the Ecuadorian health care system were so aptly summarized in my final night. My experiences with global health in Ecuador were shaped by my work within both Hospital Pedro Vicente Maldonado (Hospital PVM) and the Subcentro de Salud Nº11. While Hospital PVM has a public-private partnership with the Ministry of Public Health (Ministerio de Salud Pública) and the Ecuadorian Institute of Social Security (Instituto Ecuatoriano de Seguridad Social), the Subcentro de Salud Nº11 is a public clinic ran completely by the Ministry of Public Health. Therefore, in order to maintain a financially stable public-private partnership and continue providing top-of-the-line medical care, the hospital must hold its patients accountable by charging them when possible, even if it means only a small financial contribution. In contrast, the Subcentro provides government-funded medical care at no cost to the patient. Before arriving in Ecuador, the most egregious health issue that both my site partner, Alejandro, and I had researched was the lack of proper medical care and attention for its rural inhabitants. What we quickly realized after just a few days in-site was that Pedro Vicente was most certainly not a typical rural Ecuadorian village. Hospital PVM provides services beyond what is possible for a Ministry of Public Health facility like the Subcentro. It is this secondary and tertiary care in a rural setting that is conspicuously absent in nearly all of rural Ecuador, Pedro Vicente being the exception. The opportunity to understand the relationship and differences between the Subcentro and Hospital PVM was a learning experience unlike any other. Overall, the absence of secondary and tertiary care in rural Ecuador is a significant global health issue that I encountered on a daily basis throughout my time working in Pedro Vicente.
With just this one patient that I encountered on my last night in Pedro Vicente, I came to better understand what life would be like in a rural village that was not equipped with the services that Hospital PVM offers. In thousands of pueblos across Ecuador and other South American nations, the medical protocol would have included a costly transport to the nearest urban center. After that, placement of a rural patient often unfamiliar with and without support in a new city would include unimaginably long waiting times, putting the innocent patient in inevitable danger (Gaus, et. al). The lack of appropriate medical care for the rural and indigenous peoples of Ecuador is a problem of grand proportions. Children and mothers die during childbirth, automobile and motorcycle accidents end with unnecessary casualties, and patients are forced to stand for hours waiting for a consultation with a doctor that is cut short due to time constraints. “According to the Life Conditions Surveys (INEC-BM, 1995 and 1998), the MSP provides health services to 30% of the Ecuadorian population. The Social Security Institute through the General Insurance and the Peasant Social Insurance covers 18% of the population, 2% is covered by the services of the Armed Forces and the Police; the Guayaquil Charity Board, the Association Against Cancer (Sociedad de Lucha contra el Cáncer), and other NGO’s provide care to an estimated 5%; private services cover 20%. Twenty-five percent of the population is not protected by one of the formal systems; it is basically constituted by poor communities, most of them Amerindians, of rural areas located in the central provinces, the Amazon area and in urban shantytowns” (PAHO). One-fourth of the Ecuadorian population is denied the Ministry of Public Health services, leaving them at complete risk without any realistically attainable medical attention. Overall, it is clear that the lack of medical services for the indigenous and rural population is a serious issue in Ecuador.
Before arriving to Pedro Vicente, my knowledge of healthcare in rural Ecuador was purely second-hand. I remember feeling assured that my weeklong experience last summer in Honduras would be a window into the language, culture, and healthcare problems that exist in Ecuador. The ignorance of my presumption was realized in mere hours, and I began the trip with a clean-slate mentality. Hearing lectures from esteemed Ecuadorian politicians and talking with Dr. David Gaus, an alumnus of Notre Dame who started the hospital in Pedro Vicente, I was introduced to the economic and political dimensions of the healthcare problems in Ecuador. Living with an indigenous host family for two weeks allowed me to gain insight into the cultural traditions of the Pichincha province. Through conversations with locals at the market or on the main street, I became more familiar with the Ecuadorian dialect. Forging friendships with doctors at the hospital allowed me to learn more about the education system in the area. My daily life in Pedro Vicente also brought its own host of struggles. I had my bouts of sickness, problems with robbery, and other day-to-day issues of adjustment in Ecuador, but it was in the passing events of everyday life in which I learned some of the most valuable lessons about Ecuadorian language, culture, religion, politics, and much more. By immersing myself in Ecuadorian life, I gained an appreciation for all that was around me. In hindsight, this appreciation was an essential part of understanding the heart of the rural healthcare issues of the area.
My exposure to substandard healthcare in Ecuador invited me to reflect on the importance of the Catholic call to serve the poor. I can directly relate to Josef Cardijn who once wrote, “In them [the hospitals] I saw the way those poor workers were treated, how their confessions had to be heard, how one had to help them in their last agony, the way they were abandoned, the heedlessness about the duty of letting their relations know of their death. I suffered greatly at seeing this immense distress of the working class” (Local Theologies). Catholic Social Teaching calls us to create and be a part of an option for the poor. Gregory Baum writes, “The option [for the poor] involves two commitments: to look at society from the perspective of its victims; and to publicly manifest solidarity with their struggle for justice.” My understanding of global health most definitely has a religious component. Helping those who have been given so little seems to be when I find myself happiest. The human right to proper healthcare is something that I am willing to zealously work for. Michael Himes seems to put it perfectly when he writes, “There is also where the cross is found, because the cross is our desire to give ourselves away. It is our hunger to genuinely hand ourselves over, to give ourselves to others, because it is in doing so that we are most who we are. If you hold onto your life, you will not have life, but if you give it away, you cannot exhaust life. It becomes everlasting life. You become absolutely you. And who, finally are you? You are the image and likeness of God.” Through my summer experience in Ecuador, I can now understand this feeling of completion, oneness, and inexhaustibility that Himes describes. What a strange and exciting paradox: it is by living for others that I have felt most alive.
The words of the Prayer of Saint Francis constantly ran through my thoughts during my two months in Ecuador: for it was in giving that I received. Interestingly enough, my call to provide service through healthcare in an international context was also solidified through receiving. The end of the “fiestas”, a two-week celebration of the founding of Pedro Vicente, was marked by a colorful and culturally rich parade that marched down the main street on a Thursday afternoon. The sun was blaring through the clouds—a heat that I was frankly unaccustomed to. After marching with the daycare in the parade, I took a break on the sidewalk in front of a shop. Surrendering to the heat, I sat cross-legged watching the rest of the parade file by. For the natives, I was always a site to see: the tall blonde and abnormally white boy who seemed to have lost his way. After about a week in Pedro Vicente, I was immune to the stares. While watching the parade, the gaze of a little boy walking by caught my eye. Upon making eye contact, he yelled, “Hola teacher!” with an unabated excitement. Since Peace Corps and German volunteers often come to the town to teach English in the schools, it was a common misconception that I was there to do the same. The boy was so overjoyed to see me; he immediately ran to his mother. One of the special treats of the fiestas was a cinnamon donut-hole dessert. The boy sprinted back to me with a donut-hole in hand smiling from ear to ear. He quickly handed me the donut and then ran away. There was something indescribably special about this passing moment; it was the beauty of the generosity of a boy who clearly had very little to give. I will always remember the look on that boy’s face. Having returned home, I think this short exchange is representative of my time in Ecuador. No matter how much I gave to the people of Pedro Vicente, they always gave me back more. In my giving, I quite literally received. Everyday walking up and down the street, each person I encountered offered a greeting to me: a foreigner, an outsider, and a misfit. Jesus calls us to be a comfort to both the poor and the misfits; they taught me how to be exactly that. Overall, the pure kindness of the people of Pedro Vicente strengthened my commitment to my Catholic faith, but also my commitment to global health as a vocation.
Reflecting and comprehending the healthcare problems of rural Ecuador in a Catholic context aided me in making the next steps towards educated action. Dr. Gaus often encouraged Alejandro and me to think about our experience with a wider perspective. As preprofessional students at Notre Dame, the amount of help we can provide to the rural healthcare community in Ecuador is underwhelming. With education in both medicine and public health, we could bring a more relevant opinion and helping hand to Latin America. On an individual level, I see my summer in Ecuador as a launching point to a position in global health in the future. I undoubtedly learned a lot about healthcare, Ecuador, and myself during these two months, but I cannot help but be thirsty for more. The field of global health needs appropriately educated doctors to be proponents for the least fortunate. After many talks with Dr. Gaus, Alejandro, doctors at Hospital PVM, and even friends in the town, I feel an obligation to give what I can to this field of health.
Clearly, one person cannot possibly direct and solve the problems of rural healthcare in Ecuador. Concerted and focused efforts from doctors of different backgrounds will be necessary to bring about change. The change that is needed is self-evident. Instead of transporting emergency patients to an urban center hours away, the secondary and tertiary medical care needs to be brought to the rural communities. Unfortunately, many Ecuadorians have been forced to move out of their homes in rural areas to urban centers in order to obtain appropriate medical treatment. Walker writes, “However, rural-urban migration does not always ensure better health. In fact, rapid urbanization more often leads to high unemployment and a dramatic grown in slums where health conditions are often worse than those of rural communities…As the poor, urban population sharply increases, the supply has a difficult time meeting the demands and the quality of the care offered by institutions and workers decreases.” Therefore, the aforementioned solution of bringing the healthcare to the rural communities is the only option.
My personal exposure with the Subcentro de Salud Nº11 opened my eyes to the understaffed and tremendously overcrowded realities of the primary care offered to the people of Pedro Vicente. I shadowed two different doctors both of whom had just completed their studies in university. Swarmed with patients from a rural area they had little interest in, I couldn’t help but be frustrated with the system. Inexperienced doctors were sent to serve two years in a rural area as a rite of passage before they could work in the capital city, Quito. Overwhelmed with the problems of the area, these doctors were paralyzed with work. Both were passionate and intelligent doctors, but they had been placed in a rural health center that was incapable of appropriately helping the inhabitants of the town. Forced to rush through consultations, the personal connection of primary care was completely lost. I found myself writing prescriptions for the doctor as she diagnosed a patient in order to save time. I learned a lot at the Subcentro de Salud because they truly needed my help. The nurses and doctors were working around the clock serving countless patients every day. My first-hand experiences at the Subcentro de Salud proved to me that the solution to the lack of healthcare in rural areas lies beyond public Ministry of Health-sponsored centers.
Due to the political and economic challenges involved, organizing a self-sustaining rural hospital to bring secondary and tertiary care services to the people is a challenge unlike any other. In my time working at the Subcentro de Salud, I would often hear complaints about Hospital PVM. In a perfect world, the primary care services offered by the Subcentro could be paired with the secondary and tertiary services offered by the hospital. Gaus states that this is not the case when he writes, “If the primary care network is largely public and the rural secondary-care hospital is not, this can result in an antagonistic relationship, with factors such as institutional policy barriers preventing cooperation.” Communication and cooperation with the Ministry of Health-sponsored health centers proves to be more complex in practice. In addition to this divorce between primary and secondary care, developing a financially sustainable model in such a poor area is also difficult. With all these obstacles in place, Hospital PVM seems to be a beacon of hope and optimism for the future of rural healthcare in Ecuador. The hospital is fulfilling its mission to “fundamentally change rural health care in Ecuador by providing sustainable quality medical care.” Hospital PVM has also taken the next step by developing a commitment to the future of rural medicine. The family physician training program that Hospital PVM hosts educates the rural health care leaders of tomorrow. The idea is to pique interest in rural healthcare as a profession and encourage well-trained physicians to serve the less fortunate population of their country. Hospital PVM marks the beginning of bringing healthcare to the rural community of Ecuador in a financially sustainable manner without forgetting the importance of foresight.
My International Summer Service Learning Program experience led me to better understand the developing solution to an international health problem in a rural community that became my home. I will carry the lessons learned, faces of new friends and family, and unforgettable memories with me wherever my life takes me. There will always be a little part of Pedro Vicente in me, and for that I am thankful. In reflecting on a problem of global health, I discovered a commitment to serve that I never knew I had. I think that my experience changed my life path in ways that I do not fully understand yet. My time in Ecuador will long outlive the two months that I spent there. The excitement of the paradox still excites me: through living for others, I can feel more fully alive.
Gaus, David, Diego Herrera, Michael Heisler, Barnett L. Cline, and Julius Richmond. “Making Secondary Care a Primary Concern: the Rural Hospital in Ecuador.” SciELO – Health Public. Revista Panamericana De Salud Pública, Mar. 2008. Web. 8 Aug. 2011. <http://www.scielosp.org/scielo.php?pid=S1020- 49892008000300013>.
“Health Situation Analysis and Trends Summary: Ecuador.” World Health Organization. Web. 7 Aug. 2011. <http://www.paho.org/english/dd/ais/cp_218.htm>.
International Summer Service Learning Program: International Issues Seminar. Notre Dame, IN: University of Notre Dame, 2010. Print.
Walker, Daniel. “Urbanization’s Effect on Health Care Disparities – The Case of Ecuador.” Danny Walker 101. 2009. Web. 8 Aug. 2011. <http://sites.google.com/site/dannywalker101research/my-research/- urbanizations-effect-on-health-care-disparities>.
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