Friday, July 29, 2011

21-June-2011: Jungle Medicine

Yesterday the other students and I pressed through the thick of the jungle to the Shuar community with which we're now staying.  After a two hour bus ride and a five hour trek, we were all pretty tired, so we spent the evening getting acquainted with our friendly hosts.  As I understand it, the "community" is in truth one large family consisting of a patriarch, his several wives, and their many children.  The compound had several basic wooden houses (we rolled out sleeping bags and hung our bed nets in one such home), a dining building, a schoolhouse, several covered areas, and a schoolhouse.  Oh, and lest I forget, the requisite soccer field and Ecuavolley court (like volleyball...but more Ecuadorian).

After dinner, the father and many of the children gave us a traditional welcome ceremony, which involved singing, dancing and ritual humiliation of the guests (maybe that last part was unintended).  Then, we separated for bed and tried to avoid/ignore the innumerable cockroaches that skittered in and out of the cabins.  Our host was genuinely confused at even our light squeamishness. "No pican," he said (they don't bite/sting).  Why would they bother you?

In the morning, we rose with the sun and met our patriarch for a lesson in jungle medicine.  You might have expected, given that this is our second intensive instruction on Shuar medicine, that much of our education would be a review.  While this had some truth, the lessons emphasis and breadth were completely different.  I can now tell you, with confidence, that there are now less than five key plants utilized for machete wounds.  I suppose this makes sense.  If I lived in the jungle, I'd want to know how to staunch bleeding pretty quickly too.  My favorite strategy, however, wasn't a plant at all: it was an ant.  When these aptly-named "surgical ants" bite your skin, they inject a potent vasoconstricting agent that promptly tightens surrounding tissues and slows the bleeding.  Sweet...or as the locals say, "super chevre".  We also saw a good deal of snake bite treatments.  Turns out those are the priorities here - gaping bloody wounds and poisonous snakes.  I saw one of the latter, though my parents will be happy to hear that I declined to pet him/her.

One of their most important plants, however, has no directly medicinal value.  Instead, this powerful hallucinogen is regarded as a cultural essential to the health of the community.  Much like other indigenous traditions around the world, the ritual surrounding this drug is as important as the experience itself.  As Shuar come of age, they undergo a five-day preparation ceremony with increasing levels of worldly abstinence with each day.  The final three days are passed without food, and the last day without water.  Then, at the culmination of the personal journey, the participant takes the preparation in a sacred location and submits to its hallucinations.  Our guide told us how he saw his wife and many of his children in those visions and experienced glimpses of the life that lay in his future.  While there are a few other situations that call for the use of this powerful drug, he was adamant that none are as important or pressing as when a child has come of age.

Wednesday, July 27, 2011

17-June-2011: Botanic Medicine

Today was a change of pace from our typical multi-hour rides into the jungle.  Instead of spending the day serving rural clinics, we remained in Puyo and spent it as students of the local ethnobotanical park, "Omaere".

The park was founded some 18 years ago as a means to preserve and cultivate medically and culturally important plant life as well as educate the public about the history and importance of the peoples who use it.  The park still produces traditional medicines today and makes them available to both medical and non-medical personnel alike, typically within a few hours of Puyo.  While this approach to healing is certainly not embraced by everyone in Ecuador, those who welcome it see the practice as a much-needed blending of Old and New World knowledge.

Over the course of the next several hours Teresa Shiki, the founder and a local Shuar woman, guided us through the park identifying various plants and their numerous uses.  Some, such as "Sangre de Drago", had names in Spanish and English as well, while others were identifiable only by their local Shuar or Waorani labels.  Shiki was adamant that with proper methods and understanding, one could make remedies for any number of ailments - including, but certainly not limited to: infertility, ulcers, blood disorders, cancers, snake bites, gastritis, and diabetes.

Like any young scientist, I've been trained to face any claim with a certain degree of skepticism, so I can't say that I was entirely sold on the curative power of these home-made remedies.  However, I am also skeptical that our grasp of science can, or will ever, hold all the answers to the world around us.  Who's to say that the Shuar, in their centuries of intimacy with the rainforest, haven't stumbled upon something we Westerners have only just met?

She also spoke passionately about Shuar culture, and her concern that the knowledge of her people would be lost to acculturation and modernization if they failed to nurture its growth in the next generation.  I'll be backpacking into "La Selva" on Monday to live with a nearby Shuar family, so I'll have a first-hand look at how they navigate their lives in an increasingly modern world soon enough.

Friday, July 22, 2011

16-June-2011: The Language of Medicine

Today we've returned to Arajuno, this time clinic-bound and open for walk-in patients.  Arajuno has a defined "downtown", a long grass strip runway, and is considerably larger than Pitirishca (which is effectively a collection of homes around a long stretch of road).  Arajuno is also home to a large Quichua community, something the bilingual school and the Subcentro's signage reinforce.  People may be surprised to hear that Quichua have a strong presence in the jungle.  I always thought them a people of the Andean highlands, and having visited both regions, the differences in dress and appearance are often stark.

That said, it turns out much of the spread of the language "Quichua" was independent of the Quichua people.  First off, Quichua was the language of the Incan empire, and its presence throughout the Andes and beyond tracks Incan conquest fairly closely.  It wasn't the original language of the Inca however, but rather that of several cultures they conquered (think Roman cultural adoptions).  "Quichua" (of Ecuador) and "Quechua" (of Bolivia and Peru) are two flavors of the same language (much like "Castellano" and "Spanish"), though the people of each are more culturally associated to their indigenous ancestors than to a single dominant tribe.

In that light, the "selva Quichua" (jungle) and "highland Quichua" are likely quite distinct in their culture and lifestyle, but no less bound by a shared tongue.  Shuar on the other hand, one of the dominant selva cultures, were never conquered by the Inca (nor the least militarily) and retained an entirely independent cultural trajectory.  Pitirishca in contrast, is a Shuar community.  They also have a bilingual school, giving their children an additional tool to be successful in a developing Ecuador.

While I noted these differences, I didn't give much thought to the challenges they presented until faced with them in the clinic.  Most of the "year of service" doctors come from wealthier parts of the country (Quito, Guyaquil, or other major cities), are of "mixed" or European background, and only speak Spanish.  Though the government, and other local healthcare professionals, try to create ample translations of their materials, they're no replacement for bilingualism.  So today I was intrigued to watch a scene play out that I foolishly imagined restricted to the U.S.

I called the next patient, an elderly indigenous woman, back to the office (thankfully, most names are phonetic), but before I could begin interviewing her she spouted off something in Quichua.  Most patients I would interview and begin to examine as the physician listened, and then he would jump in to focus on specific issues and questions.  This time, however, he started in immediately.  "No hablo Quichua. hablo Quichua!"  As the woman continued to speak in rapid Quichua, clearly not understanding the problem, the doctor stormed out of the room in search of a translator.  She looked at me expectantly, and I tried to signal through charades that I knew no Quichua either.  Eventually, the doctor returned with a nurse from the area and hastily tried to complete the interview, clearly uncomfortable with the need to translate.

As far as I could tell, we identified the source of her problem...a painful, growing abdominal mass...but I couldn't help but feel there was something lost in the process.  While her condition wasn't debilitating yet, it remained serious and would need to be addressed if she hoped to improve.  Further, with such a significant language barrier, it's difficult to determine if the severity of the situation was impressed upon her, or for that matter elucidated by a physician with a significant handicap.  In either sense, it's clear that such a case requires a measure of sensitivity, care and an empathetic ear, which were no doubt absent in any reasonable quantity.  As I watched these events unfold, and I watched the pain and frustration on faces that should be signalling comfort, I thought to myself, "THIS is why I want to learn Spanish."

Thursday, July 21, 2011

15-June-2011: Learning About Parasites

A new day, a new village.  Today's stop: Arajuno.  Two hours outside of Puyo, we hit the ground running when the bus pulled into the local Subcentro de which I mean we actually jumped into the back of a pickup truck and sped off into the jungle with the rest of the Subcentro staff (about ten of us in all).  We arrived 30 minutes later at a nearby Quichua-Spanish school, piled out, and split into groups to see the kids.

The school ranged from "wawas" (probably the greatest word for "babies/infants" I have ever heard) to high schoolers, and our mission was to spend the day giving checkups to all of them.  I was paired with a young doctor and a nurse and we started our rounds with a group of 4 and 5 year-olds.  The doctor planted himself at the teacher's desk and began filing through records while I went around the room asking the kids questions and giving them basic exams.  If there were any problems, I was to send them to him for a more detailed look.  "Open your mouth...stick out your tongue...I'm going to listen to your heart..."  At first I wasn't sure if I was all that effective.  Is my Spanish okay?  Wait, this is a Quichua they know even understand much Spanish?  How are my physical exam skills?  I've never really practiced with kids before...

For a few minutes these questions raced through my head, when ultimately I realized are kids.  They DID understand me, they were just 4 and 5 year-olds and a little bashful about the process (especially in front of their friends).  I finished up the exams, pointing out one or two with notable lesions and another with a respiratory issue.  As we wrapped up the room, the doctor passed out liquid vitamins and anti-parasitics to all the kids and instructed them how to take them (teachers too...these are little kids after all).  Most of their families don't have good access to clean drinking water, and given that they play in the rivers and have a high exposure to vector-borne illness anyway, regular doses of anti-parasitics don't seem like a bad idea.

We continued like this, going from room to room as we made our way around the school.  I got the hang of the routine and started to feel more comfortable explaining things to the students on my own.  Eventually we ended up in the "wawary" (I'm not making this up) and looked over the babies as well.  Upon finishing, the teachers asked us to wait a moment, appearing several minutes later with glasses of juice in thanks.  After several nervous glances, the medical directer nodded, assuring us we'd be fine.  So we drank, thanked the teachers for their offer, and stepped out the door.  As we did, the director handed us a box.  "What's this?"

"It's for the parasites."

 *Many patients, especially indigenous, prefer not to be photographed.  In that light, we elected not to photograph the children.

14-June-2011: Vaccinations

Yesterday they told us we were going to spend the afternoon traveling the village giving vaccinations.  Pitirishca is a rural jungle village and most life there moves at a steady, amiable rate.  People casually amble into the Subcentro de Salud when they have a problem and tend to stay home when a big rain comes.  For this reason, community visits and checkups seemed like a great idea.  How do you keep tabs on the health of a population if you only have intermittent and irregular contact?

My assumptions betrayed my naivety.  We were in fact keeping tabs on a population...just not the species I expected.  It turns out "vaccinations" meant "rabies vaccinations", and the Pitirishca nurse was setting out to vaccinate all the local dogs with myself and another CFHI volunteer in tow.  Walking from house to house with a chorus of "Buenos Días" at each, we'd ask owners to gather their dogs and cats and then hold them down for shots.  In addition, one person would document the incident with name, date and age of the animals and owners, as well as present a certificate recording this year's vaccinations.  As you might imagine, watching white coat-wearing medical students inject dogs and cats was quite a comical sight (we rotated regularly to give everyone an opportunity).

While animal enthusiasts will likely be pleased to hear of all the animals we helped, it's important to remember that humans were the target benefactors in the exchange.  Rabies remains the most universally fatal infectious disease on the planet, and animal vaccination plans are the primary reason incidence has declined as much as it has (only one person has ever survived the disease once it progressed to symptoms, and not without extraordinary intervention and severe neurological damage).  Like in much of Ecuador, there can be hundreds of dogs in a community, some stray...some not, and the damage from a rabies outbreak could be enormous (the jungle exacerbates those risks, as most mammals are capable of being infected and spreading the virus).  Think about that next time you look into the face of buried rage...and always vaccinate your animals.

Wednesday, July 20, 2011

13-June-2011: A Year of...Service?

The next few days I'll be based in Puyo and traveling daily to the rural settlement of Pitirishca (1.5 hours by bus) to work in the Subcentro there.  The clinic is staffed by a nurse, a local administrator (w/ nursing-equivalent training), and a doctor and dentist in their year of service.  This is an interesting aspect of Ecuadorian health care, so let me take a moment to elaborate. 
Here's a side-by-side comparison with the US system:

USA                                    Ecuador
High School                         High School
4 years Undergrad               6 years Medical School
4 years Medical School       1 year of service
3 years Residency                --Attending Physician--
--Attending Physician--

A few points: First, the six-year medical school following basic education is not uncommon throughout the world, and likely foreign only to us.  Many Western countries (England, France, etc.) have similar systems in which the student plunges into a career track without "the luxury of a liberal arts education".  The first two years include all basic science requirements (effectively a pre-Med curriculum), and the later four more closely resembling the medical school we estadounidenses have come to know and love (although ecuadorianos start intensive clinical work in their fourth year).  Another big difference's free.  As you would imagine, that makes admission competitive, although probably for the better...presuming the state is still able to train enough physicians for the country's needs.

While this strategy of medical training is all well and good, I struggle not to take issue with the "year of service".  On paper the approach seems a banner idea, and perhaps even an indication of strong national values, but in reality the practice creates a number of sticky ethical issues.  For one, graduating students are placed in their respective sites in much the way the match system in the States works.  Not all sites have attending physicians, and those that do are often in larger, more popular, and thus more competitive towns.  This means that many sites (including Pitirishca) have fresh medical school graduates practicing with only the supervision of an administrator and/or nurse for advice.  There is typically a two month (or so) overlap with the previous year's physicians, but still...that's not a lot of oversight for young doctors still very much in the learning stage of their careers.  Further, one of the primary goals of the "year of service" is to provide medical care for the poorest (often indigenous) rural communities.  This may be achieving that goal in an explicit sense, but one has to question the quality of care received and the population receiving it.  You can make the argument that some care, even not top-quality is better than none, but that's not a statement I'm prepared to stand behind (and one that sounds vaguely reminiscent of...oh...every civil rights/inequality struggle ever).

Most of the physicians I've spoken with have described their years of internship/residency as one of the most intensive periods of growth in their medical educations.  While that's not to say that the world should mimic our approach, it's hard to see how young physicians can expect to continue learning, or even recognize mistakes, without some form of guidance.  I believe there's great value in encouraging, and possibly mandating, a year of service from highly-trained professionals, but unless those professionals are appropriately trained and ready, their practice is a disservice to the communities they treat.

10-June-2011: My Water Tastes Like Catholicism

Today I finished my first week in Quito and left for the jungle town of Puyo where I'll be stationed for the next few weeks.  In light of this, I thought I'd give the more conservative Catholic capital a send-off with a few notes on RELIGION.

Quite frankly, Catholicism (and its history) is everywhere.  The Old Town is filled with reminders of Spanish-colonialism, old-style churches and monasteries chief among them.  Nearly every block has a steeple, "sainted" plaza, or Catholic school-house (the best have the trifecta) and overlooking all of them is the "Virgin del Quito".  The massive statue sits high atop "El Panecillo" (a hill in Old Town known as "the bread loaf"), and the winged-virgin holds a chained dragon resting on the world as she gazes out over the city (maybe I'm reading too far into things, but that dragon seemed to be covering most of North America and Europe...a cultural critique anyone?).

The Jesuits seemed the most determined to leave their mark here.  Over two centuries they built La Compañía de Jesus, a remarkably ornate church just off Quito's main plaza in which nearly everything but the paintings is covered with gold.  Across the city in "New Town" is a Jesuit hospital known as Vozandes (now of a chain), which I've been told had a less glorified history.  Apparently two generations of Jesuits were killed off by local peoples in their attempts to found a mission hospital...until a third generation was successful at "civilizing the natives" and establishing some permanence.

Though public hospitals are not technically Catholic, the influence of Catholicism on the Ecuadorian legal system has effectively guided them to operate like Catholic institutions elsewhere.  Many public health clinics list a patron saint or display religious imagery.  Abortion, an issue admittedly far more complex than the religious overtones it often carries, is strictly forbidden (a fact numerous posters of fetuses are quick to remind people) and while contraception is legal, access is limited and often stigmatized.

Similarly, much of daily life is shaped by the church as well.  No alcohol of any sort is to be sold on Sunday or beyond midnight Monday through Thursday.  Quito is effectively dead on Sunday and for Saturday mass with the exception of church-goers, and many museums close as well (because they either are or are run by churches).

Perhaps most interesting is the juxtaposition of religious imagery with Western civilization or even sinfulness.  I have yet to see a taxi or bus that wasn't covered with crosses, Jesus, saints or rosary beads, but they're often at odds with the other symbols.  Naked women, peeing boys, or cartoon bears with hats that say "Speed Sex" just aren't the environment I would have expected to surround Baby Jesus.  Most vehicles also tend to claim a patron virgin (the "Virgin de Agua Santa" being one of the most popular; she's also the resident virgin of Baños, where I'll be spending the weekend en route to Puyo), though how they decide which virgin is best I haven't the foggiest.

Tuesday, July 19, 2011

9-June-2011: Fundación Médica Ecuatoriana "Mosquera"

The clinic I've been working with this past week is something of a rarity in Ecuador and doesn't fit cleanly in the aforementioned boxes.  The "Fundación Médica Ecuatoriana 'Mosquera'" is a not-for-profit (?) organization that aims to provide affordable, high-quality care to children and the poor.  Established in Quito 26 years ago, the Fundación now has several sites throughout Pichincha province (the region surrounding the capital) and a variety of specialty-care clinics, some of which are open 24 hours a day.  Their main location is centered on the beautiful "Plaza del Teatro" in the historic district, or "Old Town", of Quito.

As far as I understand, the organization operates via donations, fundraising, fees from their medical courses (they run a school as well), and the relatively minimal charges for patient services.  Patients pay a low, flat rate for seeing a physician, while their material expenses operate on a per use basis and are charged immediately.  Most of the services are scattered throughout each building, so patients hop from department to department with each step.

A visit may go as follows:
1) A woman with gynecologic problems goes in to see the Ob/Gyn, where she is told she needs a colposcopy (cervical exam).
2) She pays for the consult and a disposable speculum (which she is handed) and goes next door for the exam.
3) The doctor makes a diagnosis, writes a prescription, and orders another test to rule out other issues.
4) The patient walks down the hall to the pharmacy to pick up the prescription (usually less than five dollars),
5) and then heads to the lab to have her blood drawn and give a urine sample (maybe around $2.50 in total).
6) The tests will be conducted in-house, and the patient will be contacted with the results when they come in.

While the operation may be time-intensive overall, the Fundación fills a niche in Quiteños' healthcare demands.  They can get high-quality care for little money, and without the waits and limitations that sometimes accompany the Centros de Salud.  For more information or history, feel free to check out their website.