by Hari Balasubramanian
Observations and pictures from a visit in October 2014 to the Andean town of Cuenca and the surrounding area.
1. Surgeries in an Isuzu Truck
Since 1994, a small team of clinicians has been bringing elective surgeries to Ecuador's remotest towns or villages, places that have do not have hospitals in close proximity. From the city of Cuenca – Ecuador's third largest town, where they are based – the team drives a surgical truck to a distant village or town. Though a small country by area, the barrier of the Andes slices Ecuador into three distinct geographic regions: the Pacific coast in the west; the mountainous spine that runs through the middle; and the tremendously bio-diverse but also oil rich jungle expanse to the east, El Oriente, home to many indigenous tribes. Apart from a few major cities – Quito, Guayaquil, Cuenca – towns and villages tend to be small and remote.
Each year the team goes on 12 surgical missions, roughly one per month. A trip lasts around 4 days: a day's drive to get to the place; 2 days to conduct 20-30 surgeries (sometimes more sometimes less); and then a day to return. Patients pay a nominal/reduced fee if they can: the surgeries are done irrespective of the patient's ability to pay. The clinicians belong to a foundation called Cinterandes (Centro Interandino de Desarollo – Center for Inter-Andean Development).
Amazingly, the very same Isuzu truck (see above) has been in use for more than 850 missions and has seen 7458 surgeries from 1994-2014! The truck itself is not very large; in fact, it cannot be, because it has to reach places that do not have good roads. The mobile surgery program has the lowest rates of infection in the country (see [1] for more details). Not a single patient has been lost. The cases to be operated on have to be carefully chosen. Because of the lack of major facilities nearby, only surgeries with a low risk of complication can be done. Hernias and removal of superficial tumors are the most common. Hernias can be debilitating, yet patients may simply choose to live with them for many years rather than visit a far-off urban hospital. For many, leaving work for a few days and traveling to get a health problem fixed is not an option.
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Cinterandes was founded by the Ecuadorian surgeon Edgar Rodas Andrade. In his seventies now and internationally recognized, Rodas continues to work for the program he conceived. He had always felt compelled to serve the medically underserved of Ecuador. From 1999-2000, Rodas was the Health Minister of the country, but eventually left to further develop his healthcare vision.
A few things struck me about Cinterandes. First its longevity: it's never easy to keep such a vision going for 20 years: many ideas simply fizzle out after the initial excitement. Second, the fact that its core group was small and had held together. Perhaps it was this that allowed Cinterandes to stay focused for so long. In the PBS video on Cinterandes' work, The Most Distant Places, filmed seven years before my visit, I saw the same faces carrying our elective surgeries in a fishing town on the Pacific coast and in the stifling humidity of the Amazonian jungle. Third, I was impressed by the degree planning and communication have to happen before a surgical mission – screening and eligibility, tests if needed – and after the mission is over, to follow-up and check if the patients are doing well. This wouldn't be possible without local doctors who know and keep in touch with their patients, and communicate regularly with the surgical team by phone, email and fax: forms of telemedicine.
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When the team is not on a mission in a remote location, surgeries are done in Cuenca. A modern city, Cuenca has a public hospital as well as private hospitals and clinics. Yet patients are willing to be operated in the Isuzu truck: clearly, they trust the process. Most of the Cuenca patients who need a surgery come because of they have heard of Cinterandes by word of mouth.
On a Tuesday morning in October last year, I observed three surgeries [2]. The truck was parked in a lot at the University of Cuenca campus. Edgar Rodas Junior was the surgeon that day and Dr. Anita the anesthesiologist. They are featured in the image above, discussing the first case in the small scrub area to the front of the truck. The rest of the rectangular, boxlike frame of the truck is taken up by the operating room. A picture below of the interior of the operating room.
The second patient, a 34-year old woman, was having her gallbladder removed. At one point, apart from the patient herself, there were ten people in the operating room – the surgical team and a few medical students from a local university who had come to observe. Still it didn't feel too cramped. The surgery took around two hours. From what I learned, it wasn't an easy case. The woman's husband waited nervously outside. Also waiting nervously was the third, and last, patient: a Peruvian man who had come across the border to have a benign tumor removed. He had come at the suggestion of his friend who now lives and works in Cuenca.
When a surgery is done, the patient leaves the operating room at the back end of the truck. The image above is of the woman whose gallbladder was removed. She recovered in one of two dark green tents that are setup adjacent to the truck. She spent the next two days at a nearby private hospital (obviously this option would not be not available were the operation to happen somewhere remote). Because she was a Cinterandes patient, the hospital stay was subsidized. Three days later, I saw her walk in for a follow-up appointment. She had recovered well.
2. The Ecuadorian Context
Rodas realized early, back in the 1990s, that while the mobile surgical unit fulfilled an important health need, by itself it could not address the bigger problems – high rate of infectious diseases, child and maternal mortality – that Ecuador faced. These problems were particularly prevalent among the rural and indigenous populations (most Ecuadorians have both American Indian and Spanish ancestry, and approximately 25% belong to diverse indigenous groups). To have a deeper impact, Rodas realized that primary healthcare focused on prevention, maternal and infant health had to be made more accessible in rural Ecuador. And so his vision, which had started with the mobile surgical unit, grew bigger.
One of the advantages of carrying out elective surgeries in remote places is that it has an immediate, tangible impact. A patient suffering from hernia, say, suddenly finds relief within a few days. Family members notice the improved quality of life. An entire community, which may not have been exposed much to western medicine, indeed may have been suspicious of it, now begins to trust doctors. This makes it more receptive to primary care and family health programs that have long term, if somewhat less tangible, benefits.
That's exactly how Cinterandes started family health programs in small towns. One example was in Santa Ana, a town of 5000, 46 km southwest of Cuenca. From 2002-2007, years when the family health program was active, malnutrition rates among children, nearly 20-30% in 2002, dropped to 2-7% in 2007 [4]. These decreases notwithstanding, the programs could not continue due to “political reasons”.
I did not delve into the exact details, but political obstacles certainly aren't surprising. Cinterandes has found it harder to operate since Rafael Correa took office in 2007. Correa, who wants to usher in 21st century socialism in Ecuador, does not like NGOs taking the lead. In March 2014, a Cinterandes surgical mission to Perucha, in the province of Pichincha, had to be cancelled because the local minister did not approve. Maybe – and I am only speculating here – Correa's socialist government wants all the credit for itself, especially when it comes to health initiatives for its principal constituency: the urban and rural poor. In fact, Correa has even funded some mobile hospitals, though from this video, it looks as if such the trucks are far too large and unwieldy, require detailed assembly and lots of trained people, and lack the compactness that is the essential feature of the Cinterandes unit.
Rafael Correa began after a chaotic time when the country had something like ten presidents in ten years. In February 2013, he was reelected for the third time, winning 57% of the vote. A charismatic leader, he remains extremely popular, despite criticism on how his government harasses dissenting voices (there is criticism too of his 2013 decision to explore oil in the as yet pristine Yasuni National Park of the Amazonian Ecuador). Two residents of Cuenca I spoke to felt that Correa was someone who had brought stability as well as development, and “put Ecuador on the global map”. Like Evo Morales of Bolivia, Correa is firmly allied with the leaders of Latin American left. He has used the nation's considerable oil revenues and taxes to reduce income poverty (from 37.6% in 2006 to 28.6% in 2011); start a $240 per month stipend for 300,000 disabled persons; support for mothers and older adults; build 5500 kilometers of new roads (something everyone, even those not pleased with Correa, admitted as an achievement); and expand government funded healthcare and education [5].
New health centers and hospitals have been built across the country. Since 2008, basic doctor visits and medications are now free. But the doctors I spoke to said that the media-savvy Correa had overstated his contributions, and that the government had simply not done enough. Despite increased budgets, public hospitals, such as the one in Cuenca I visited on a busy Friday evening [3], remain in dire need of resources. The government had promised an increase in the number of rural doctors but had not followed through – at least not completely.
In sum, there was the narrative of Ecuador's considerable social progress in the last 8-10 years, and there were caveats to that narrative. Probably there was truth to what both sides claimed. I wanted to get a sense for myself, so I spent a morning at government health center in a village called Santa Rosa, about 30-40 minutes northwest of Cuenca [2,3]. I'll describe this next.
3. Centro de Salud (Government Health Center) in Santa Rosa
The health center was a single story structure, basic but very clean and well organized. Daniel, a medical student from Cuenca on rotation at this center, showed me around and answered my questions. There were consultation rooms, a pharmacy, a building at the back for labs, a few beds in case temporary, short-term hospitalization was needed. Four full time staff members ran the places: two primary care doctors (Drs Ana and Belen), two nurses (Alexandra and Maira), and community health worker (Guillermo) who was from Octavio Cordero and therefore knew many residents personally. The waiting area bustled with patients, mostly women. Around 50-80 patients visit each day.
In the image left, we see a woman who had brought her eighty year old aunt for a consultation. Here, in the exam room, they look serious but in the lobby, where I first met them, they were in excellent spirits, full of smiles. The niece told me that her son was now living in Chicago, but that she herself had no interest in going there even though she had residency. Many young men in this village have left for the United States – possibly taking the undocumented route through Mexico – tilting the ratio of males to females also leaving many older men and women without a care-giver.
As I looked around more, it became clear that the health center wasn't just a place for outpatient consultations. The doctors were also trying, proactively, to reach out to the sickest patients in their homes. These were the patients who couldn't make it to the health center. As evidence, there was in the exam room, a map – Mapa Parlante, literally, the “map that speaks”. The parish of Octavio Cordero is divided into four sections. One staff team (a doctor, a nurse, a community health worker) visits patients who live within the blue boundaries, and the other team visits patients within the orange boundaries. The patients' homes are marked with the colored pins: yellow for patients with disabilities; red for pregnant women; green for patients with hypertension and diabetes.
Daniel had been visiting a 19-year woman who lived alone in Octavio Cordero. She had become pregnant and had an abortion. It wasn't clear why or where she had aborted. But Daniel learned during his home visits – it would take them an hour each time they visited, and they visited her once a week – that she was on the verge of committing suicide. It was through her that he also learned of another young man who had fractured his leg and was unable to move in his own home. Citing these examples, Daniel said that such home visits were crucial because they allowed a doctor to sense what exactly was going on in the community.
When patients come for a consultation, they get a comprehensive assessment, and it wasn't just focused on physical health. There is cardboard folder, provided by the Ministry of Health, with plenty of color coded information that the doctors were supposed to fill about the patient and her family: data on whether required vaccinations have been completed, risk factors that affect health, sanitation, whether trash at the patient's home was being disposed adequately, the physical condition of the patient's home, socio-economic status, where exactly the family lives and so on.
Something about the folder, its smooth feel and pleasing colors, and its emphasis on detailed data collection, including the calculation of a consolidated risk score, suggested that Ecuador's Ministry of Health was serious about quantifying rural health indicators. The image below shows the risk scores in the three categories – biological, sanitary and socio-economic – for one patient; a tree diagram of the patient's parents (who had passed away and were hence crossed out), children and grand children, and a dotted boundary to indicate which family members currently live in the village. There was also a hand-drawn map of the exact location of the patient's house.
The data is eventually turned into an electronic database. This was the principal use for the only computer in the health center. Many graphs, bar and pie charts were prominently on display in the waiting area. These charts enabled a random visitor like me to get a clear demographic and health snapshot of Octavio Cordero. The important charts, closely monitored by the staff, were the vaccination rates for children who lived in Octavio Cordero. There were also leaflets for all kinds of prevention and education programs. The doctors often spent time socially with their patients, organizing games and dinners, so that they could get to know them better.
All this was quite impressive. In the United States, the equivalents of Ecuador's Centro de Saluds are federally qualified community health centers, which serve medically underserved areas irrespective of the patients' ability to pay (Indian Health Centers in reservations are another example). Comparisons are always inadequate without a proper context, controls and data. Nevertheless, I couldn't help hypothesizing that the depth of patient engagement in Santa Rosa and knowledge of what went on in the community was far greater than what I'd observed of family and primary care practices in the United States.
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I asked Daniel what the shortcomings were. He said that the government was aggressive in its approach and demanded too much. The five staff members were overworked (that certainly was true the morning I visited). There was too much paperwork to fill, too many things to report. The government hadn't given them resources to do the data entry electronically. All things had to be typed by hand first and then entered manually into the computer. The Ministry of Health expected all the data to be summarized in charts and sent to them at the end of every month – by no means an easy task. There were some of heavy-handed rules. Pointing to a document that listed clinical protocols, Daniel said very seriously: “If we don't follow the rules listed here, we can be put in jail.”
“Technically, you can't spend more than ten minutes with each patient,” Daniel continued. “Here, at this remote health center, nobody checks on such things. We often spend a long time chatting with older men in the village who come not for health reasons, but looking for someone to talk to because they are depressed. We tolerate and allow that. But in a city hospital, there are people watching how much time you actually spend with patients.”
“Before Correa became president,” Daniel said later, “this health center would have still been there. But it would have been poorly resourced and ineffective: it wouldn't have had any impact. Correa's arrival has certainly revitalized rural health centers, no doubt. But even with better funding there is no guarantee. Now, we have Drs Belen and Ana working here who are doing a good job. But just a year ago, the doctor who was posted here did not care about his patients, and the nurse who worked with him was always angry at everyone. So no one came. Things have changed, and now patients are willing to come and trust the staff. But there is a government policy of rotation; after two years, the current doctors will be posted somewhere else. Just when you've begun to know and understand the community, you have to leave; all the hard work is undone.”
Despite these concerns, I left that afternoon with a positive impression. In the last 15-20 years, well before Correa's election, a number of key indicators of the country's health, such as malnutrition, infant mortality, incidence of infectious diseases, the availability of good drinking water and sanitation, were already showing improvement. River blindness, for example, has been brought to a complete halt and the number of cases of malaria reduced dramatically [6]. And I felt that if there are more rural health centers in the remote corners of Ecuador like the one I visited in Santa Rosa – where the doctors and nurses were trying their very best to put what government resources there were to good use – then Ecuador's health indicators can only get better.
Acknowledgements, References, Links Etc.
1. “Taking surgical services to rural Ecuador”, Lancet, Volume 368, Nov 4, 2006. The very first image of the truck is from this article.
2. Carolina Danoso, the development director of Cinterandes, coordinated many of the details of my visit, the observation of surgeries in the truck, and conversations with clinicians. Errors in this piece are entirely my responsibility.
3. Dr. Anita, the anesthesiologist, also is a faculty of family medicine at the University of Azuay. At a very short notice, she arranged the visit to Santa Rosa. Daniel, who hosted me at the health center, is her student.
4. Dr. Edgar Rodas Reinbach allowed me to accompany him for a couple of hours at the public hospital in Cuenca where he is a trauma surgeon.
5. Cinterandes Annual Report in Spanish, 2009.
6. The numbers I have cited are from this article, and this detailed 2012 report by the Center for Economic and Policy Research.
7. The World Health Organization report provides a quick snapshot of Ecuador's health here.
8. Other healthcare related essays I have written can be accessed here and here.
9. Al Jazeera created a short film, the week after I left Cuenca, about Cinterandes' work. You can watch it here.