By Frist Global Health Leader Yvonne Carter, RN
"One may observe in one's travels to distant countries the feelings of recognition and affiliation that link every human being to every other human being." – Aristotle
At the age of nineteen I scribbled this quote on the inside cover of a journal I kept while interning at an HIV/AIDS clinic in Kampala, Uganda - a one month experience that I, in my naïvety, had assumed would shine light on answers to the world's problems and provide me with direction in my future studies and career choices. Not so shockingly, I returned home with more questions than answers about the all-too-exhaustive list of social injustices in this world and how I could possibly play a role.
Seven years later, I am a new grad family nurse practitioner still grappling with the same questions. However, it is the pursuit of these questions that has led me here, to the opporunity to live and learn in another corner of the world that I have come to love, a small pueblo named San Eduardo nestled in the rural coastal region of Ecuador. I was asked if Ecuador had been a long-term goal of mine shortly before packing my bags to depart for what has thus far been my most unique global health experience yet.
The short answer would be "no." As a nursing student, a global health coffee date with a Nurse Practitioner (NP) two and a half years ago led to an invitation to apply for a week-long medical trip to Ecuador the following spring. My undergraduate studies had led me to be weary about short-term medical missions, but I am grateful that I said yes.
That year, I witnessed the benefits of a longitudinal relationship between the community here in San Eduardo and a multidisciplinary team from Nashville. Efforts began in 1997 with an elementary school, and an annual medical clinic component focused on family wellness was added in 2002.
In 2009, a community health assessment conducted by a VUSN graduate NP identified the need for a preventative health clinic; this allowed for more protected educational space regarding issues such as oral health and hygiene, child development and nutrition, women's health and family planning, and parasite prevention.
In 2014, when I first joined the team, I was asked to help with a 5-year follow-up community health assessment to evaluate effectiveness and areas for growth in the preventative health clinic. I learned that in the span of five years, immense progress had been made in the areas listed above. However, we also learned that there was a vast opportunity for growth in educational areas regarding noncommunicable diseases such as hypertension, diabetes, and dyslipidemia. Despite South America's reputation for infectious diseases such as dengue and malaria, it is the noncommunicable diseases such as diabetes mellitus, hypertensive disease, and cerebrovascular disease that have been competing against one another for Ecuador´s leading cause of death in both men and women since 2008.
I am humbled to have been granted the opportunity to return to this community for an extended period of time in order to reassess biopsychosocial barriers to primary care that continue to threaten prevention and treatment of both communicable and noncommunicable diseases, in hopes that what I learn can strengthen our clinical and educational efforts every spring. I am grateful, as well, to be able to continue the third phase of a longitudinal health assessment that began long before my time - while I was still an overwhelmed, wide-eyed undergrad in Uganda witnessing the magnitude of global healthcare disparities for the first time.
And yet, after years of work experience and a grad school education, I find myself feeling like that 19-year-old undergrad more often than I'd like to admit. My 9th day here marked the longest I had ever spent in San Eduardo, and my 31st the longest I had ever spent in another country. Despite arriving with an adventurous spirit and an open mind, I have learned that nothing could have truly prepared me for the realities of living alongside the very people I am aiming to serve. "Real life" (or "la vida real" as referred to by community leaders here) differs vastly from what is observed and experienced in a week-long visit, as one can imagine.
Among other things, I have learned that the narrative of San Eduardo which occupies my mind the remaining 51 weeks of the year is not entirely accurate. The little boy who came in for a wellness visit and greeted us with smiles and hugs last year is now crying to his peers because he lacks money to buy lunch. The little girl who made bracelets for the team is now missing her exams at school due to parasites. The sisters who sing songs and perform traditional dances at the conclusion of the trip each year are now my neighbors. Some days they have access to clean drinking water, some days they don't. Some days they have enough to eat, some days they don't. The few teeth their kid sister has are half-black, as it makes sense to save the money on toothbrushes and toothpaste for family expenses such as food or clean water, since her baby teeth will eventually fall out anyway.
It is heartbreaking at most and overwhelming in the least, but moreso humbling to remind myself that this is the reality in which a large majority of the world's population lives. I was soon confronted with a startling truth; this is the first time I have ever truly lived alongside community members of a "patient population." Although I accompanied practitioners on house calls and home visits in Uganda, my peers and I lived in a district of the capital inhabited by ambassadors and members of the country's most wealthy.
While my clinical assignments as a nurse practitioner student were in medically underserved areas, to this day I have no idea what it's like to live in rural Tullahoma, TN or off of Murfreesboro Pike in downtown Nashville. And as a night shift RN on an a medical oncology unit in rural Western Kentucky, I commuted to and from my apartment in cozy West Nashville every week. I may have attended a renowned nursing school and be equipped with knowledge as a family nurse practitioner, but I am a novice in navigating the lived experience of the women, children, and families here in San Eduardo among several other corners of the world.
The feelings of recognition and affiliation that link every human being to every other human being are present in San Eduardo, and in Tullahoma, and in Uganda, and off of Murfreesborro Pike. People are people, regardless of what they do and do not have. Patients choose “the most important” prescriptions to fill because they cannot afford all of them. Mothers and fathers continue to work despite injuries or chronic illnesses to provide for their families. Children miss school due to preventable diseases and get behind, or they struggle to pay attention in class on empty stomachs. Will money this week be spent on medicine, or on food? A mother is sick with fever, but the nearest doctor is half an hour away, and the bus fare to and from the clinic is enough to feed the family dinner.
These are the harsh every-day realities that exist across the globe; yet despite their overwhelming nature, I must remind myself that this only means that there will always be work to do. I am beyond grateful for this learning experience and the opportunity to challenge my commitment to global health, as uncomfortable as it may sometimes be.