I spent one week at a Sub-Centro de Salud (public health clinic) in the town of E. Valle, about a 30 minute bus ride from Cuenca.  The town is quite small but the catchment area includes a large number of families working small plots of land on steep slopes.  The clinic itself is new and clean.  It houses three general practitioners, one dentist, a pharmacy, a pediatrician, psychologist, vaccination center, and room for x-rays and ultrasound.  In an office there is a map of all the households, their inhabitants and risk factors.  Housebound patients are visited by a physician and nurse once a month (or at least once every two months) and the physicians regularly visit outlying areas to provide routine care such as well child visits.

For complex problems patients are referred either into the regional public or military hospitals.  This system seems both efficient and thorough.  Since 2009 when a new constitution was written, all public health care in Ecuador is free and, according to physicians, there has been a distinct increase in the level of services provided and the resources available.  My favorite day in the clinic was when we went to a distant area to see patients.  First we had to figure out how to get there.  Fortunately there was a policeman parked in front of the clinic waiting for his family to be seen and we hitched a ride with him on a bumpy dirt road to a tall, unlabeled building.  Because it is often very cold in the Andean Mountains, all activities in this building happened in the warmest room, the attic.  The space is set up for children’s activities and we quickly converted it into a clinic.  Tables and chairs were moved, a tape measure taped to the wall, and a scale placed nearby.  Two nursing students triaged the patients, immunized the mothers against tetanus, and provided general health education while the other physician (Dr. Castro) and I saw patients.  For the most part the children were healthy and well cared for.  However, one patient came with his cousin.  He is 5 years old and smaller then his 2 year old cousin.  While this is partly due to genetics, malnutrition is common here.  The problem is both related to poverty but also culture; as the diet is mostly carbohydrate and meat based with locals rarely eating the wide variety of vegetables available in the markets.  These two children also had visible cavities; dental health is overall very poor in Ecuador.  When I first arrived in Ecuador I was amazed at how nice everyone’s teeth appeared, until I realized that they were fake.   Many have dentures starting in their 20s and 30s.  It was simple to refer these two children to the sub-center where they will be cared for by a pediatrician.  In addition, the dentist was scheduled to visit the same site in 2 weeks for dental screenings. 

After seeing about 20 children we made home visits.  One patient was paralyzed in an accident 2 years ago and is now in a wheelchair (a metal frame with mountain bike tires and a plastic lawn chair bolted on).  The doctor examined his colostomy and tended to his massive bed sores.  There are no special beds or cushions here and, though the family was caring for him attentively, it is hard to imagine how these, or future, sores could be prevented.  As happens so many times here, this encounter added yet one more thing to the list of skills I would like to learn in residency, wound care.  Dr. Castro applied table sugar to the wounds when he was done cutting away the dead tissue.  This was something I had not seen before but, after researching, seems like a very cheap and effective way to treat open wounds and prevent infection.

Another couple is in their 80s and the husband has Parkinson’s.  The wife had run out of medicine for her husband and we tried to convince her, with questionable efficacy, to buy more.  As in the States, it is often difficult to convince patients to take medicine for chronic problems.  While most of the home visits were planned, we were also able to check in on patients who were referred by concerned neighbors and dropped in on one woman who was not feeling well.

At the end of the day we hitchhiked back to the main road where we caught a bus into the city.  After working in the public and private hospitals in Ecuador, I now know that when I work internationally in the future I would like to do so in a public health center.  It is exactly the type of career I imagined for myself when I decided to become a doctor.