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Articles and Publications by Dr. Serle Epstein:
We had the opportunity to be medical volunteers at the Mission Clinic in December, 2001. At that time we had no laboratory or radiology support but a small pharmacy with most classes of drugs represented. The clinic was well organized with the Receptionist greeting patients, setting up charts and determining the order in which patient’s were seen. This same individual dispensed medications from the adjoining pharmacy.
There were 3 examining rooms. Two rooms were adequately furnished, with an examining table, desk, chairs and basic equipment. An electrocardiograph machine was available with readable tracings if one used some imagination. Dental rooms were being built and a surgical suite being furnished.
The patients were exceedingly polite and appreciative of the care rendered. Although depression, musculoskeletal problems and parasitic infestations were common, all manner of pediatric and adult illnesses were seen. Surprisingly, malaria, tuberculosis, and major injuries were rarely, if ever, seen. Although people were poor and for some growth and intellectual development were stunted, overt malnutrition was rare. For those who could afford it, laboratory, radiology and specialty care were 2 hours away.
The accommodations at the Mission were very comfortable with private rooms with showers and communal meals. We were treated as honored guests. The Parish Priest, Nuns and workers could not have possibly made our visit more pleasant. In the evenings, we visited the surrounding villages and were fortunate to participate in a local religious and secular festival.
Although working with limited diagnostic and ancillatory support leads to misgivings about quality of care issues, I believe the opportunity to serve as volunteers in this setting was rewarding both for the health care provider and for the greater Community.
Guadalupe, 8 of december 2001
Serle M. Epstein, M.D. F.A.C.P. and Jana Siman, M.S, A.P.R.N.
We were at the Mission Clinic for one week in December 2001 when it opened. There is a local physician Dr. Jaime Ortiz who has been hired to attend once per week. There have been a stream of foreign dentists and last week 4 physicians from a city 3 hours away. The clinic has examining rooms, 2 dental rooms complete with dental x-ray, a surgical suite including a scrub room and recovery, and a pharmacy. The surgical area is not yet functional. Although the pharmacy has limitations we were able to treat most of what we saw. The clinic may soon have a basic laboratory. There is x-ray, laboratory, and surgical services in a city (Loja) 2 hours away for the few who can afford it and when the road is passable.
The people were indiginous subsistance farmers with a few shopkeepers and miners. The gold mines are about one hour away. The oil companies are not in this particular region. There is malaria in the general area but little in the immediate vacinity. Similarly we did not see dengue or yellow fever. Mosquitos were present but not in great numbers. The water is not clean and that coupled with often the people sharing accomodations with their animals, giardia and worms were endemic. We saw some acute diarrhea and perhaps one person with typhoid fever. Many people had back pain (called kidney problems!) as well as depression, alcoholism, hypertension, and children with chronic ruptured tympanic membranes. We also saw all manner of other medical illness from dysfunctional vaginal bleeding to rheumatoid arthritis to parkinsonism to kidney stones. Some access to birth control is available in the city. Remarkably some people of greater means came from the city to this jungle clinic for second opinion, records in hand. Surgical supplies were present for suturing, draining, packing and casting, but analgesics and local anesthetics were deficient. Hopefully this has been rectified. The examining rooms are equipt but you may wish to bring a portable ophthalmoscope/otoscope as a backup as well as a glucometer, gloves, gel, and hemoccult cards.
The parish is clean and accommodations quite comfortable with our own rooms and hot shower. The Nuns supplied us with preboiled water to drink and hearty meals safe to eat. We even felt comfortable eating the salads served to us by them, usually not a good idea in this setting. The Padre is from Austria. He has done remarkable things for his people in a place where the church does the social service tasks that are usually the purvue of the government. The government gives vaccinations sporatically and thus far this is not being performed by the clinic but perhaps in the future. The village is in the high tropical jungle along the main trade route to the amazon in Ecuador. It is poor but beautiful. I suggest that you be up to date for dT, polio, hepatitis a+b, and obtain yellow fever vaccine. You will need malaria prophyllaxis. I suggest a book Handbook of Medicine in Developing Countries by Catherine Wolf M.D. and Dennis Palmer D.O. Although mainly geared to the hospital it has usefull information in table format.
The weather is most pleasant. It is about 75*F during the day, sometimes warmer, and 65*F at night, again sometimes warmer. It rains every day. I brought scrubs and a laboratory coat to work in and was most comfortable and felt adequately attired. One has to be wary of crime in Quito or Guayaquil but I felt perfectly safe in Guadalupe, especially as a guest of the parish mission. The currency is the US dollar. It goes far in Ecuador. There is little to spend it on in the village. We did not have a chance to be tourists but the beauty of the surroundings and the reward of helping others who appreciated the effort more than made up for it. They could use an operating microscope. If you know of any institution who might be able to donate one that would be terrific. That way ENT and basic Ophthalmology could be performed. Many children have ruptured TM's and many adults have cataracts and pterygeums.
Serle M. Epstein, M.D. F.A.C.P.
Today I saw a 43 year old woman, six months pregnant, afraid of her alcoholic husband who beats her. The next patient was her husband... A 4 year old girl presents with a draining fistula from her tibia with osteomyelitis and possible osteosarcoma. She does not cry. Her father cannot afford to take her to an orthopedist. At an average of 20 years complaint per person with vaginal discharge, all told, today I saw 200 years of vaginal discharge.
I believe that here, unfortunately, family planning begins at menopause. Large families are common despite the poverty. This is because of lack of resources, fear of child mortality and tremendous peer pressure to marry young, often to separate from parents and in order to leave home. Depression is common. Being poor, working in the fields, gold mines, and jungle with little help for those unable to care for themselves (at any age) and with many mouths to feed with little food, does not lend to merriment.
Yet people are appreciative and enduring, with a strength and at times grace that we would be unable to muster in less harsh circumstance. There is music, dance, and religious festivals. And all is not without humor: “Doctor, I have terrible headaches in the sun.” ..."What make it better?" ... “I wear my sombrero.” ... "Then I suggest that you wear your sombrero"... Many complain that their bones hurt when it is cold. However, we are in the Amazon! Yet many individuals have multiple problems that impact their quality of life and ability to work and subsist.
Even though the medicine we practice may give us pause in terms of quality, the peasants have such tremendous problems, and so few places to turn for help, that our worst efforts become models of exceptional care. And the clinic that Padre has built could be placed in the middle of any city in the United States and not seem out of place. The people line up by the dozens to be seen. It is 10 o’clock at night and they are already showing up to be seen tomorrow. We just finished our day’s work. I will need to rest in order to have the energy and spirit to try to do, in my own way, GOD’s work”.
Serle M. Epstein, M.D. F.A.C.P.
I had the good opportunity to return to Guadalupe Ecuador for one week in October 2003. I brought a nurse practitioner student with me, Ms. Stephanie Motter. Between us we saw about twenty patients each day. This was my third visit to the mission and clinic. That we were less busy than on previous occasions reflects the maturity of the health care facility. With almost continuous medical coverage there is less of a pent up and almost desperate need to be seen, allowing for a more comprehensive approach to care. In addition the small laboratory can perform blood counts with differential, urinalyses, skin scrapings, pregnancy tests, and vaginal smears. PAP smears can be sent to the local cancer hospital several hours away. Some access to commercial laboratory and radiology is now available within a couple of hours bus ride. The pharmacy is remarkably complete for such a remote facility. The full time nurse, Amanda Anderson, is knowledgeable of the local health care needs and resources. The reputation of the clinic draws patients from rural and urban locations hours away.
The pueblos are noticeably more prosperous. For many people cement walls have replaced porous wooden slats. In part this represents a largely successful attempt by the government to uplift the life of it's citizenry through a subsidy program for construction. The struggle for sustenance remains the dominant theme of life, punctuated by song, dance, sport, and religious festivals. There is greater ability to educate about health issues. Although the quality of care remains limited by the resources available in this venue, it is greatly improved compared to the early days of the clinic.
The sound, sight and smell, and even feel of the jungle engulfs you. The rich fusion of European and Indian culture is enticing. Hopefully all of this will remain as development very slowly encroaches upon an agrarian society. Words cannot describe what it is like at dawn and dusk to sit on the verandah of the volunteer's dormitory and just listen to the sounds of the tropics. Poverty cannot be idealized. The people have a harsh life. They persevere against great odds in order to survive and raise their families. As a volunteer, even for a short stay, there is the satisfaction of making a difference for a few people by providing modern medical care. Each time that I visit I receive back much more than I give. I plan to return to Guadalupe next year.
Serle M. Epstein, M.D. F.A.C.P.
I am an internist in private practice in Madison Connecticut. I have an academic appointment at Yale University, bringing both medical students and graduate nursing students into the office. My wife Jana Siman is an APRN. We work as a team. It is difficult to volunteer when in a small practice. I helped to run a venue for the Special Olympics when they were in New Haven in 1995, as well as volunteering at the Primary Care Clinic at the Hospital of St. Raphael as a preceptor when I first opened my practice in 1983. Jana donated services to the poor visiting clinics in the Middle East and Brazil during a previous international business career. Over the years I was disappointed to find that as a primary care physician most international and even domestic venues wished you to attend for many weeks, months or even years at a time. This was impossible. In 2001 I was in the midst of arranging to volunteer in the Carribean. I met a patient in the office on a saturday afternoon. His father, Frank Glowski, accompanied him and told me a story of a former AFS (exchange student) from Austria, Georg Nigsch, who many years earlier had lived with him for both a year of high school and then seminary school. He had become a priest at a rural mission in the tropical highlands of Ecuador along the Peruvian border. He was building a medical clinic. Already an Ecuadorean doctor, Dr. Jaime Ortiz, had been attending intermittantly. I decided to get in touch with Padre Jorge Nigsch in the Amazon, or as they say the Oriente. Sometimes he has telephones, so I sent him an e.mail. We planned to close the office for two weeks and go. Then came September 11. After some soul searching my wife and I decided to keep our plans. What better way to be embassadors for our country during a time of turmoil. Off we went in December 2001. In Ecuador there are few people with health insurance. In theory if you are pregnant or a child of five or younger there is universal access to care. Unfortunately the government clinics are poorly equipped and with few medications. There are private physicians with variable quality of training, particularly in rural regions. The doctor often owns the pharmacy with incentive to prescibe, particularly injectables. In addition the fees charged are often beyond the reach of the poor peasants, the majority of those in the mountains and jungles. They use self remedies, shamans, lay midwives, even villagers who have taken upon themselves the business of suturing wounds, both for cultural reasons and economic necessity. The population is mainly indigenous peoples, small farmers, shop owners, and gold miners. Many speak primarily their Indian language. My wife and I are not Catholic. We knew minimal spanish and less tropical medicine. With naiveté and misgivings but anticipation we left to join the team of international medical volunteers at the mission clinic. To our surprise we were the first volunteers, and the only health care workers within many kilometers. The nearest hospital was at least one hour away, muddy roads permitting. We had translaters to help us. The pharmacy was extensive but with gaps in coverage. The medications were often labelled in german, a language in which fortunately my wife is fluent. Some of the drugs were unfamiliar. We broke open boxes and set up examining rooms, set up charts, and began to see the villagers. By the end of the week we were seeing about twenty patients daily. The clinic has two fully equipped dental suites, and operating theater, three examing rooms, a pharmacy, laboratory, and a fully set up optometry facility. After we returned home we set about using the internet to recruit doctors, nurse practitioners, and physician assistants. A German dentist, Dr. Eberhard Pierro, through a charitable organization began to attract dentists. Internists, pediatricians, ophthalmologists, and an otolarygnologists have attended. Dr. Scott Soloway, an ophthalmologist from Branford Connecticut brought a team to the facility. A dentist from Madison Connecticut, Dr. Alan Friedler, has worked at the clinic. I applied for a Robert Wood Johnson International Health Scholarship but was not accepted. Despite this, my wife has returned, my step daughter Molly Brady has visited twice, and I have served on another two occasions and will again in december 2004. Individuals, religious groups, and nongovernmental organizations have donated supplies and devices ranging from an operating microscope to semiautomated desktop chemistry analyzers. Thousands of eyeglasses have been donated by the Lions Club, coordinated by the Madison chapter. Remarkably in almost three years there has been less than one month without a dentist and less than six weeks without a primary care health care provider. There have been a few trainees including a senior Yale APRN student, Stephanie Motter, brought by me. Washington State University School of Nursing, led by Dr. Lorna Schumann, has contributed physicians, nurse practitioners and graduate nursing students to yearly mobile health clinics, traveling to even more underserved areas, an activity organized by the clinic. The facility is now averaging about forty patients daily, and when surgeons, dentists, and primary care physicians are present, up to two hundred, many camping out on the steps to be certain for a consultation. Among others, REMEDY, an organization based at Yale that donates recycled surgical supplies, and the American Medical Resource Foundation in Boston Massachusetts, have contributed supplies. Medications have been locally purchased in Ecuador and donated from Europe. They have been given to me by pharmaceutical representatives who visit my office. I have been able to in turn forward them to South America. The pharmacy in now remarkably complete. The laboratory can perform a variety of tests. A technician is soon to arrive from the United States to expand services and train local personnel. Radiology is available about one hour away, for those able to pay. The fee for a consultation is one dollar, to see the dentists the charge is by the tooth. Cataract surgury is fifteen dollars. Medications are a few pennies to the pill. For this region these are significant sums, but less that twenty percent of that charged by the local physicians. For those truly unable to pay, services or produce can be bartered. But no service is free. It is thought that this gives some ownership to the health process, and a sense of pride. There is education on sanitation and other health issues, including AIDS and other sexually transmitted diseases. And in this Catholic community, the church preaches respect for women and care of children, but in practical not abstract ways. Parasitic infestation such as ascariasis, giardiasis, amebiasis and bacterial infectious diarrhea, are common. At two thousand feet, with few mosquitos, malaria, yellow fever and dengue rare. Tuberculosis is mainly referred to government facilities. Common illnesses are seen, such as depression, musculoskeletal ailments, diabetes, and hypertension. As a practicing internist and adult nurse practitioner we were actually well prepared for most of what we encountered, even among children.. Severe surgical emergencies could be sent to the hospital, minor injuries cared for at the clinic. Vaccinations are given through the government health center. Thus far the provincial officials have cooperated, allowing Padre Nigsch to utilize in his medical building any provider licensed to practice in his or her own country. If desired, longer term volunteers can obtain malpractice through the Catholic Medical Missions Board in New York City. Volunteers have come, or are scheduled to arrive, from the United States, Switzerland, Germany, Austria, Ireland, England, Scotland, and Canada. Many of these were recruited via the internet. The Albert Schweitzer Institute at Quinnipiac University is now exploring ways that college students can both be benefited by the experience and do creative developmental work for the community. This has been a remarkable and satisfying journey, but still with long term success uncertain. Please visit the website guadalupe-ec.org and explore the links. If you wish to donate services or resources contact Padre Jorge Nigsch at
Serle M. Epstein, M.D. F.A.C.P.
In November 2005 I had the privilege of returning to Guadalupe Ecuador for my fifth visit. I was accompanied by a senior student from the Yale School of Medicine, Ms. Dara Arons. We flew from Quito to Catamayo. Then we took a taxi to Loja, where we were met by Pepe. A long time employee of Padre Jorge, he drove us across the Andes into Zamora-Chinchipe Province and the jungle road to the mission. The route is now paved much of the way, shortening the trip to two and one-half hours from the prior customary four. The pavement turned from concrete and the terrain increasingly severe but lush. We soon knew that we were approaching the Oriente as clouds began to drape the mountains.
The Mission Clinic of Our Lady of Guadalupe is a truly remarkable oasis of modern medical care in a remote region. There have always been local physicians of various skills and moral turpitude, private, or fresh from local medical schools and assigned prior to residency training, to tend to the indigenous poor. With the providers unaffordable, inaccessible, or ill equipped and inadequately trained, the populace has turned to shamans and folk remedies, or self medicated with whatever drugs were available from the local pharmacies. Lisa Greenfeld, a Peace Corps worker stationed in this area from 1998 through 2000 recently contacted me. She was based mainly in Piuntza. She describes visiting the various communities and without medical training or experience, and using a lay book ‘Where There Is No Doctor,’ she and her husband attempted to use local remedies to give health care to those otherwise going without. In addition the province and river valley, under the tutelage of Padre Jorge Nigsch, was only recently beginning the slow process of integration of remote villages and ethnic groups into a more cohesive civil as well as religious unit. A local physician, Dr. Jaime Ortiz would visit the church mission a few hours once weekly. In this environment Padre Jorge and Mother Superior Consuelo Carvajal chose to build a new health care facility, initially to be staffed by foreign volunteers. When I first arrived with my wife and APRN Jana Siman in 2001, the facility was still being constructed, provision of regular dental and medical care and surgeries a romantic dream of an Austrian Priest and Colombian Sister. The dental suites were just being finished, an operating room bereft of equipment, and a limited pharmacopoeia of German herbal and mainstream drugs. We stayed in the Casa de Encuentro, the residence hall of the religious community. The volunteers’ residence was a cleared lot above the church grounds.
Dara and I arrived at the Mission of Our Lady of Guadalupe. During our week we saw many patients of all ages with various primary care ailments. The daily work load ranged from ten to forty two persons for the medical doctors and about fifteen daily for the German dentists. Many of those seen now had charts, with documented histories. Some continued to follow up for their chronic ailments. Frequently, prescribed medications had been discontinued as personal supplies grew short, but with education and ongoing affordable access to health care providers, some of the clients are now continuing their medical regimen. The pharmacy on premise has allowed, with some creativity, continuous care for chronic ailment, and almost universal ability to treat acute disease. For the last three years we have begun to see surgical and other volunteer specialists coming into jungle. I was fortunate this trip to witness such an event. An ophthalmologist from Loja and his team descended upon and invaded the clinic. Well planned and well executed, more than ninety people were seen by the surgeons and medical staff. In the afternoon and well into the night cataract and pterygeum procedures were performed, giving sight to the blind. At a surgical cost of about ten to fifteen dollars, not insignificant to these poor people, many were able to be cared for who otherwise would have needed several hundred dollars for similar operations.
Not all was work for us. On slower days we were able to visit a hamlet and a pueblo. On one such excursion, accompanied by the Sisters, we participated in a local lesson and mass. Prior to this Dara had the experience of educating a couple about their child with Down’s syndrome, alleviating the guilt that added to the parent’s burden.
The lessons of the religious services are seldom that of saving souls. Never have I heard talk of fire and fury, but rather that the path to salvation lay through personal betterment and proper treatment of one’s children and neighbors, always with respect and compassion. This is expressed in concrete ways, never abstract. It applies equally to farmers, professionals, and politicians. The form and content of services combines European and Indian traditions. Fiestas abound, giving color and celebration to a difficult subsistence existence in a harsh environment. As a Non-Christian I never miss the opportunity to participate in the cultural life of the village.
This trip we also learned to make empanadas, as a guest in a private home. We had an adventuresome meal of tilapia, guinea pig and frog at a local restaurant. Mostly we ate our largest meal lunchtime with the Padre and Nuns. Breakfast we made ourselves with breads, fruits and grains supplied to us. For dinner we joined the priest, prepared food ourselves, or made outside arrangements.
Our visit to Guadalupe combined hard work and cultural emersion. Our week ended far too soon. As we left a new dentist from German and an Otolaryngologist from Maryland arrived. A family physician from Alaska was en route. Other doctors from Austria, The United States, and Canada are due to visit. Many other international healthcare workers have served, are scheduled, or are being solicited.
It is gratifying to me to see the continued maturation of the Mission Clinic of Guadalupe, and its tremendous impact upon the health and financial status of the Indigenous residents of southern Ecuador.
I am certain that the unspeakable beauty and serenity of the region will sustain me for yet another year until I return.
Serle M. Epstein M.D., F.A.C.P.
From October 6 through 17, 2006, Dr. Joseph Connelly, Dr. Margaret Weiss Rivera, both Family Physicians, and I, an Internist, were in Ecuador for a Jornada Medica organized by the Clínica Misional "Nuestra Señora de Guadalupe."
We traveled from Quito to Cuenca, the airport in Catamayo temporarily closed for renovations. The bus to Zamora suffered a broken tire rim. The driver was able to change the tire and continue. We eventually arrived in San Carlos, a small town at about 1300 meters of altitude.
We held a clinic in the parish house the next day. The following morning we went to a gold mining town, Nambija Alto, at several thousands of meters greater elevation. The last 45 minutes we trekked up a steep trail with medications on our backs. Carrying a fifty pound back pack with pharmaceuticals, I had mild problems with the exertion, a racing heart and shortness of breath. Fortunately I quickly recovered.
People live in ramshackle homes on the polluted slopes. Later we learned that 400 people perished there four years ago in a landslide. We saw patients in the local school. Many of the men suffer from cough and congestion from the dust exposure when blasting in the mines.
The following day we had a poorly attended clinic in another town, Nambija Bajo. Apparently large mining corporations may move back in. The families were at a meeting to discuss this.
After a night in Guadalupe, basking in the relative luxury of the Mission and Residencia, we traveled to Tutupali, a very remote Indian town. When the road ended we finished our trip by mule, initially straight down at a 45* angle on mud and stone. This frightening but beautiful ride brought us to a rugged small pueblo by a rushing clean mountain stream. Along the way we passed magnificent vistas, with trees sprouting purple buds. The pueblo of Tutupali thrives on an economy based upon horses and mules, and by cultivating banana, sugar cane, corn, and a variety of cracked wheat. Many of the villagers spoke Quichua, and little Spanish. The local public health nurse, a middle aged Saraguro woman, translated for us.
After a day and one half of seeing patients, we mounted our mules to climb the mountain. Dr. Weiss Rivera slipped off of her mule, striking her head on a rock. Using dental antiseptic and available supplies, we sutured her 8 inch laceration. We immobilized her. The townsmen built a stretcher and, in turns, eight of the men carried her the two hours up the steep muddy slope. We were able to arrange an ambulance for the 9 hour drive to Loja. Dr. Connelly accompanied her. She ultimately did well.
For the last three days of the Jornada I was the only physician. We went to a small village, Esperanza, seeing only a handful of villagers in the small church on a hill. We then journeyed to a larger town, Yacuambi, staying for two busy days. All told, we saw in one week 465 medical patients. One day I was to examine 90 persons. All of this was possible with the able assistance of Amanda and Claudia, who served as translators, and Karen and Yolanda, working the pharmacy and doing patient intake. Many patients had parasites, presumed helicobactor pylori associated peptic ulcer disease, respiratory problems, musculo-skeletal complaints, depression, chronic vaginitis, prostatitis, diabetes, and children with failure to thrive. Many infants had poor nutrition from excess sugar water replacing other lacking dietary components. We also detected congenital heart disease, various fractures, hypothyroid goiter, and a missed congenital dislocation of the hip in a now young teenager.
Sigrun, the dentist, came with us. She saw truly advanced caries in young people, pulling more than 120 teeth.
During our visit to Yacuambi, presidential and provincial elections were held. Every citizen was required to vote. The ballots were guarded by armed soldiers. The conservative and leftist candidates garnered the greatest number of votes, but not a majority. There will soon be a run off election. Ideology does matter in this country, but how it will affect the rural regions is yet to be seen. At 6 AM Sunday mass in Yacuambi the lesson taught was that there is an obligation for the wealthy to assist the poor. Dr. Weiss Rivera was extolled for making a great sacrifice in coming to Ecuador from the United States, and for her being willing to risk grave injury to care for the poor citizens of the Oriente.
After a brief night's stay back at the Mission, I rejoined the other doctors in Loja for our trip home, again via the road to Cuenca. Back at work in the USA, in the office, on house calls, and rounding in the hospital, I remain fatigued, but energized by the experience. We were at remote, poor, at times stunningly beautiful locations. My companion physicians, Amanda, Sigrun, Karen, Claudia, Yolanda, and other personnel, were wonderful to live and work with. We were in truly remote high and low altitude venues, and carrying our supplies were able to effectively treat most of what we encountered. There was clearly danger, but under difficult conditions we rallied in a crisis, and continued our mission.
Jornadas Medicas serve to provide medical care to isolated communities. More importantly this represents out reach services for the Clinica Misional in Guadalupe, giving continuity to our efforts. I look forward to returning to Ecuador in another year to again participate in the remarkable story of Padre Jorge Nigsch and his, and our, clinic.
Serle M. Epstein, M.D., F.A.C.P.
October 22, 2006
I returned to Guadalupe September 29 though October 7. For one week I worked at the Clinica Misional. Padre Jorge had advertised my coming. This, and the growing reputation of the health care center, ensured a significant turnout of patients. Up to 55 were seen in a day, averaging 40 persons. The clinic has an ultrasound for those able to use it, a well equipped laboratory comprised of a variety of chemistries and quick tests, an electrocardiograph, a large pharmacy with most classes of medications available, and almost full dental services. Specialists ranging from Plastic Surgeons to Gynecologists, Otolaryngologists, and Ophthalmologists, are scheduled to arrive in the coming months. We have an incomplete but growing network of local surgeons and specialists to which we can refer. I saw the usual variety of parasitic infestations, rashes, musculoskeletal problems, depression, metabolic syndrome, occasional asthma and other maladies. Also presenting de novo were probable uteran and testicular cancer, and congenital heart disease.
The problems of the health center are a function of its success. We needed to turn away several individuals each day in order to give adequate care to the rest. Amidst the poor and underserved, at least a dozen of whom had never before visited a physician, were the middle class and well to do from Zamora and Loja. I would treat a poor farmer for worms, an abandonned single mother for depression, and then give a second opinion to a young woman being treated in Cuenca for Lupus Erythromatosis. It is difficult to do a means test for those who come, so all are seen.
Despite this, the humanitarian mission remains strong. While I was attending at the main facility, the other doctors, along with nurse practitioners and dentists, were on a Jornada Medica to remote villages reachable solely by canoe. Although there may be issues of continuity of care, illnesses were identified, health education promoted, and some treatment given, to the hundreds of children identified by local church and government organizations. For a brief time these isolated Indiginous people came to know that they were not forgotten. The conditions of travel were difficult, the surroundings rustic, but the volunteers were welcomed as graciously as possible.
The region is beautiful but poor. One can swim in a clean mountain stream or hike in the jungle. There remain some wildlife. A tiger like large cat was hunted for food. It was brought to us to appreciate.
I had the good fortune of eating a meal of frog cerviche prepared personally by the mayor of Guadalupe, Dr. Alan Fuentes..
I traveled twice to small barrios, one Mistizo, another Shuar, and attended mass in a small town up the Yacuambi river. Attending church service is as much a cultural as religious experience. The homilie gives practical lessons in coexistence and good public and private governance. As we turn to each other to wish peace, la paz, we descend from our vaulted place as guest foreign physicians and replace this with an awareness of comradery and commonality.
One need not belong to any religion to appreciate the mystery and responsibilty that accompanies practicing our profession. This is an essential part of who we are as doctors, from ancient times prior to the rites of Eskalipeus and the Greeks. Each volunteer takes home from Guadalupe and the Clinical Misional as much as they give.
Serle M. Epstein, M.D., F.A.C.P.
October 7, 2007
Once again I found myself in the Orient of southern Ecuador, amid the rain, greenery and mustiness of the jungle. Many of the indigenous people cannot afford their traditional clothes, but more have motorcycles rather than horses, and concrete homes rather than the ubiquitous leaky wooden shacks. The rainforest faces defoliation, and families now cook with gas rather than firewood. The muddy and oft landslide closed automobile road is slowly being paved but the raw mountain paths remain unchanged. The new government has promised expanded health care services for the populace, but each Centro de Salud remains inadequately staffed and poorly supplied. They do provide significant peri-natal and infant care, including for acquired immunodeficiency disease, and family planning, and tuberculosis screening and treatment. For general medical and surgical care there are few doctors affordable to the impoverished classes. During turbulent times some individuals have stridently asserted traditional tribal land rights, often at the expense of their neighbors. The transitional government leadership has not yet effectively asserted power. Jobs remain scarce, dangerous, and poorly paid, and subsistence farmers are paid pennies for their harvest as imported foods and supplies rise in price. Many of the young men leave their families for the cities or to work as migrants abroad. To compete, new coffee and banana cooperatives have been formed. Most people still till small plots of land, mainly for plantains, yucca, and sugar, occasionally for cocoa. Other fruits and vegetables remain uncommon. A few chickens, guinea pigs, and livestock share the household. Men blast and haul stones for the gold mines. A few people have small businesses in the larger towns. There are entrepreneurs who have opened wireless telephone booths, sell jewelry to volunteers, run restaurants, and have other profitable ventures. Life pulsates to the rhythm of the religious calendar, centered on the parish, directed by the priest, and with catechists and nuns as ambassadors. Against this backdrop we have the Clinica Misional Nuestra Senora de Guadalupe. The longer term volunteers have left a mark. Charts are more complete, and care better organized. The clinic functions efficiently. Although fewer people may be seen when dentists and surgeons are absent, when they are present a chaotic mass of humanity presents at dawn impatiently waiting for portals to open. The seemingly reduced patient census is deceptive. A mobile health fair to surrounding cantons, from villages to small cities, drew long lines. During two weeks more than 750 people were examined, and multiple medicines prescribed, each for the same one dollar fee. The unmet needs of the poor were amply demonstrated. In one city replete with local physicians, no one would see the house bound elderly, the crippled, or the dying, leaving it up to us as visiting professionals to provide a modicum of home care. The purpose of the clinic is as an accessible and affordable venue to care for the acutely and chronically ill, provide medications, promote healthy lifestyle, bring surgical specialty services, and give second opinion when requested. Outreach programs extend practice to the needy in urban areas or to remote underserved regions. The facility has helped to spur economic development, and add to the parochial mission of unifying the community. As an eight year old institution it is imperfect. Each passing year the maturation of the Clinica Misional is palpable. Much of this is owed to Amanda Anderson, the full time nurse and clinic administrator, to Padre Jorge Nigsch, to the full time Ecuadorian support staff, and to the hundreds of volunteers who have found a temporary calling as humanitarians. We each gain personal insight and grow as professionals. We share a unique comradeship. For these reasons I plan to return next year.
Serle M. Epstein M.D., F.A.C.P.
November 2, 2008
I returned to Ecuador to work the last two weeks of November, 2009. My short stay was an extraordinary experience. At that time I overlapped with an ENT surgeon who arrived prior to me and left just after me, completing a month long visit. Between seeing "medical" patients and screening, and usually treating, the hordes of people coming thinking (often wrongly) that they needed an operation, I attended to about 40 patients a day. Dr. Burger Zapf performed 150 surgeries ranging from tonsillectomies to parotid tumors to cholesteatomas, and of course many ear and nasal reconstructions. He was assisted by a rotating group of German anesthesiologists, and Johannes, a nephew of Padre Jorge Nigsch, who served as an able surgical assistant. Select patients recuperated overnight at the facility. Amanda Anderson, the full time nurse, slept in the clinic. She used her skill and compassion to complement the family members caring for their relative recovering from a procedure. It was efficient, and as safe as possible for a rural venue. We also had coincident full dental services, and the usual selling of pharmaceuticals at a discount, and the fitting of donated eyeglasses. It was a remarkable, but at this facility not uncommon, occurrence. Each year witnesses improvements at the Clinica Misional. We now have electronic medical records, and a back up generator. We have a portable dental care unit. Since its inauguration in November 2001 through the beginning of 2009 it has witnesses about 60,000 patient visits. This does not count those seen by health fairs organized in surrounding communities. When surgeons and specialists arrive, people travel from many hours away, even the coast, for consultation and treatment. We are open to all who come, but remain true to our mission to primarily provide affordable healthcare for the poor. For the four months following my visit we will have a primary care and tropical disease specialist physician from Costa Rica, and a cardiologist from North Carolina. The heart specialist will be able to perform cardiac ultrasound when necessary with the machine on site. The laboratory has not been optimally maintained nor utilized. I have charged the current doctors to restore it to as it was last year. Tests need to be used judiciously, but available when necessary. As usual the accommodations were clean and spacious. I stayed at a volunteer apartment in the town, although often sharing the companionship of the other volunteers there and at the residence on the mission grounds. The evenings and weekends were punctuated by the song, dance, processions, lectures, and services that in the guise of municipal or religious fiestas or displays of fealty mark the passage of time and season in the cloud forest. Most meals were shared with the Sisters and Padre. Some we prepared as a group. We went to a local restaurant for a frog and tilapia feast, with rice, salad, and yucca, to celebrate the leaving of one of the anesthesiologists. Even the Madre Superior attended! The sights, sounds and smell of the jungle, and the clouds rising to summits of the Andes, highlighted our mornings and evenings. Local and national politics were at times the grist of discussion, as both politicians and church figures came to observe the developments in town and talk of change. Drawn in by idealism and sustained by a sense of purpose, I continue to come back.
Serle M. Epstein, M.D., F.A.C.P.
I had the opportunity to serve at the Clinica Misional Nuestra Senora de Guadalupe the last two weeks of November. The first week I overlapped with an otolaryngology surgical team from Germany and the United States. Also during my time I worked with German dentists and anesthesiologists, an Austrian physician, and Swiss dental hygeinists. Each member of our medical crew had different volunteer experience. For some this was the first time abroad, for others one of many. We had new practitioners just completing training, active private professionals, and those recently retired. The clinic was busy during surgical days, and quiet at the end when the specialists had left. I did a two day Jornada Medica to rural villages in a remote valley. It was advertised immediately before we arrived and we had about 75 medical and 20 dental patients, but with extensive dental preventive care teaching in the local schools. With our free time at the end of the week we returned there to climb the mountains, explore a cavern, and swim at the base of the waterfalls. The government has made great strides in improving access to care, now open to all ages and both genders at the Centro de Salud in each town. Prenatal and early child care, vaccinations, birth control, tuberculosis and HIV treatment are handled by them. There is some access to basic dentistry and chronic medical management. As usual the care is rendered mainly by asigned young physicians and public health nurses, although in Guadalupe we are blessed with a long term health care provider, Dr. Alan Fuentes. Resources, though more plentiful than under previous administrations, remain limited and uncertain. The Clinica Misional is in general better equipped and able to offer specialty services unavailable otherwise. It is anchored by well trained primary care physicians, and coordinated by Padre Jorge Nigsch and Amy Anderson, R.N. Our pharmacy remains well stocked by local standards but with increasing difficulty with both purchasing drugs locally and bringing in material donations from abroad. The laboratory is in temporary disarray, and the ultrasound machine needs repair, but with plans for maintanance and improvement as community needs are assessed. We have a new generator to ensure uninterrupted surgery and support the electronic medical record. This enhanced charting allows for rapid recall of previous visits, legible documentation, access to the pharmacy formulary, ability to perform rapid internet searches, and the capacity over the long run to better analyze our accumulated data as to who we are seeing and how we are treating them. The system is evolving, just recently allowing the scanning if of diagrams, and not yet expanded to dentistry. The affilated dental organization in Germany has been supportive in the past, but at times has not coordinated the calendar well with the local administration, so that this month we had no dental technician and too many hygeinists. In the future this will be better controlled from Ecuador and the relationship with this charitable organization is evolving and uncertain. Despite this I attended to about 230 patients in my brief stay. We saw the usual assortment of general medical illness and parasitic infestation. The trend continues for better understanding of chronic illness, as many people presented for management of hypertension and diabetes. As I left a doctor arrived from the United States with his wife and young children to remain for the ensuing three months. A family physician, he has had previous experience in Africa. His son and daughter will attend the local schools. I had the opportunity to share with him some of my insights, as have each doctor before me to those who followed. The web site remains invaluble in this process. I am proud of each of the volunteers who take the time to come here and contribute their expertise and caring. I remain confident in the future of the Clinica Misional Nuestra Señora de Guadalupe, and it's role in the growth and maturity of this culturally rich great nation.
Serle M. Epstein, M.D., F.A.C.P.
I returned to Ecuador the end of November through the middle of December 2011. I was accompanied by a medical student Jordan Sloshower from Canada by way of Yale University School of Medicine.
Student Dr. Sloshower did an excellent job. We worked collaboratively in the Clinica Misional Nuestra Senora de Guadalupe and more independently, but utilizing me as a resource, on the Jornada Medica mobile health fair. At the main facility he introduced himself to each patient, performed the interview in Spanish, did the appropriate examination, and developed a plan. Each patient was in turn presented to me, usually in the room. Jordan established the plan with input from me as appropriate. He was then responsible for implementing the plan as well as providing targeted patient education.
Outside the medical setting he was interactive with the other volunteers from Germany and Austria. He participated in various community events, particularly those surrounding both a religious and a secular festival that overlapped our visit. He befriended people in the community. As is true of all of us he brought his own perspectives and preconceived notions with him to Amazonia, but was able to adapt to working at a secular and professionally run rural clinic that happened to be based at a religious center in an overwhelmingly Catholic community. Having previously completed studies in International Health he saw the conflict between theory and practice, particularly in a country with so much change occurring in social structure and governance. He began to understand the pitfalls that occur when central planning and distant bureaucracy are in conflict with the immediate needs of the populace.
Along the way I hope that his innate kindness, cultural sensitivity and sense of responsibility were fostered in this setting.
This is one example of how the clinic gives back to us while we serve.
The last couple of years there have seen many changes but much remains the same. The government has established a Subcentro de Salud in the larger villages. Each center gives vaccinations, treats tuberculosis and Leishmania infections, gives perinatal antiretroviral treatment for pregnant women infected with HIV, provides family planning, and is a venue for child and maternal care. Under President Rafael Correa the centers are rendering more general medical care and are expanding pharmacy resources. Even dentists may be present to perform extractions, place fillings, and do cleanings. However, the centers remain poorly staffed, often with one year rotations by assigned young physicians, or by public health nurses. They are undersupplied, with a limited and inconsistent formulary. The doctor sometimes is available in each village only one or two days each month.
Government specialists in some cases may also run private offices on the side.
A few regional hospitals are present, some with out-patient clinics. Access has improved but the standard of care is inconsistent. There remain private physicians for the more affluent elite. They now charge as much as $20 dollars for a consultation, and owning their own pharmacies, prescribe as much as $50 dollars each visit for various tablets and injections. This far surpasses the average family weekly income of less than $60. The poor are disenfranchised. Furthermore if they failed to register in advance with their local government health center on the assigned day they are not eligible for free care.
Patients can be seen without charge at the government run facilities. Yet they clearly endorse the value of the Clinica Misional Nuestra Senora de Guadalupe by lining up as early as five o’clock in the morning for what is perceived as good care.
Our laboratory still includes centrifuges, a semi-automated desk top chemistry analyzer, a QBC blood count machine, desktop microscopes, a lipid meter, and an assortment of quick screen tests and reagents. Not all of the equipment is in good working order or with reagents available. It is difficult to maintain. In part this is because not all physicians agree upon the utility of performing these examinations and with notice of the economic status of our patients tests are ordered selectively.
The most common tests utilized include blood glucose, CBC, spun hematocrit, urinalysis, and urine pregnancy test. There are quick screens for elevated TSH, Chlamydia, Helicobactor Pylori antibody, Infectious Mononucleosis, and HIV. KOH and wet mount microscopic examinations can be performed on vaginal secretions and skin scrapings. India Ink, Giemsa, and Gram Stain material are available.
During our visit we saw an average of 20 patients each day. We did not overlap with surgeons. When they are present the volume dramatically rises for all personnel, with the primary care physician called upon to examine about twice as many individuals. Electronic health records facility patient care.
I participated in an Jornada Medica. In two days the medical student, a German dentist and nurse, and Amanda Anderson, who for 10 years has served as the clinic administrator, joined me in visiting two small towns three hours from the main clinic site of Guadalupe. 194 medical patients of all ages were seen and 66 rotted and painful teeth extracted.
The first 4 years of the clinic, pharmaceutical companies donated large amounts of medications. This supplemented donations from Austria and Germany. The facility ultimately was certified to receive discounted medicines from international charitable organizations such as MEDIOR and BLESSINGS. Since 2010 it has become increasingly difficult, and prohibitively expensive because of regulations and tariffs, to bring supplies into the country. We can no longer rely upon outside sources. By necessity more items are purchased locally including increasingly available generic drugs. Our pharmacy is now without access to significantly discounted pharmaceuticals and will soon run at a loss as we insure that medications remain affordable to those who most need them. Consultations remain priced at $1 each visit and for some of the less fortunate even this fee is waived. To increase the charge would mean that large segments of this rural population will no longer be seen. A clinic for the poor cannot survive on collected revenue. During my visit we had extensive discussions as how to ensure the economic viability of the facility while remaining faithful to the mission’s founding charitable principles.
Generous public support is essential to sustain the facility. Secure donations may now be made electronically through the website to the A 501 C3 tax exempt foundation “The Friends of the Mission Clinic of Our Lady of Guadalupe, Inc.”
The 10 year anniversary of the dedication of the clinic occurred just prior to my coming. The outpouring of public officials and community leaders attests to the high respect in which the health facility is regarded. Plaques were awarded and are now mounted for each of us to see.
Despite these many difficulties the Clinical Misional Nuestra Senora de Guadalupe is increasingly successful at meeting the unmet health needs of the region, giving additive value to the services rendered by the government run Subcentro de Salud.
It is a remarkable place to volunteer.
I am already planning my next visit.
Depression is always in the background whenever someone visits with chronic and recurrent difficulties. Also musculoskeletal problems are rampant in this setting.
Serle M. Epstein, M.D. F.A.C.P.
I had the opportunity to return to Ecuador the first three weeks of December 2012. The first week I overlapped with Dr. Burger Zapf. He is an otolaryngologist and long time volunteer at the Clinica Misional. Prior to my arrival another otolaryngologist and an anesthesiologist had been present. With no anesthesia specialist that week the government hospital in Zamora donated the use of an operating theater and a staff anesthesiologist for several days. The level of cooperation between the local health ministry, facility administrators and Padre Jorge Nigsch and Amanda Anderson RN speaks volumes about the importance of our facility to the community. With a surgical brigade present the volume of general medical patients was high so that I averaged about 23 encounters a day and up to 35. After Dr. Zapf left, and with the impending Christmas holidays, the volume fell considerably to 5 to 15 clients daily. The dental census remained steady. The pharmacy has slowly been simplified to include those drugs available in Ecuador and affordable to the poor. At times our options for treatment are limited. The awareness that the public health system is better supplied than in the past also necessitates our adapting our prescription habits to be more appropriate to each individual’s situation. In addition there have been outside quazi governmental organizations more active in Ecuador including Cuban physicians providing some mental health services and even hearing aids. The national health minister is expanding care for the disabled, although services remain rudimentary in the rural regions. As usual I saw a variety of acute illness and chronic disease, the poor and some other less destitute seeking second opinion. We continue to see patients who otherwise receive sporadic fragmented care. Our electronic record allows our volunteers to provide a remarkable degree of continuity of care. Having attended at the clinic annually since its founding, I had several patients who I had seen in the past. It was gratifying to see that my colleagues have provided good services despite at times difficult conditions. There is no question that access to medical care in the community has improved. Yet we are reassured every day by the patients who we see that we remain an essential part of the regional health care delivery system. Of course it is not all work. I participated in cultural events honoring the patron saint Our Lady of Guadalupe. I accompanied Padre to the small and more remote barrios as he celebrated mass. I also hiked one weekend in the Podocarpus national park. As usual the collection of volunteers made for good companionship, as the residence hall was full of the sounds of Spanish, German and English with younger and older individuals from the United States, Austria, Bulgaria and Chile sharing stories, experiences, and meals. The ecclesiastic staff as usual welcomed us with open arms. I will return next year.
Serle M. Epstein, M.D. F.A.C.P.
I returned to Ecuador to work at the Clínica Misional Nuestra Señora de Guadalupe November 10 through November 29, 2013. I overlapped with a dentist Dr. Ekkehard Schlichtenhorst, a German otolaryngologist Dr. Weibke Eisfeld, a North American otolaryngologist Dr. Paul Fortgang, an Austrian anesthesiologist Dr. Viola Bissbort, an Suisse nurse anesthetist Ms. Doris Bislin, a German dental technician Ms. Anne Coordt, a Colombian general practitioner Dr. Miguel González Vélez, a recent medical school graduate Dr. Christina Eisfeld and an operating room assistant, really an Austrian farmer and the brother of Padre Nigsch, Mr. Hanspeter Nigsch.
The second and third week about 50 surgeries in total were performed, with uncountable ambulatory consultations and treatments given. On the general medicine side of the clinic about 27 patients daily were seen, as many as 40 in one day. The dentist and dental technician had equally busy schedules. Although we remain hampered by our inability to bring into the country medicines and other supplies, the local resources, albeit still limited and at times too expensive for the poor, are expanding and slowly becoming more affordable. Access to urgent care and elective surgery can be difficult and we partially fill this role. We are better equipped than the local Centro de Salud to care for many common chronic illnesses.
Individuals will travel great distances not just for surgery but to use us for second opinions, coming with records and radiographs in hand. The clinic has adapted to the ever changing array of government regulations, yet again having undergone a health ministry inspection. The mixture of illnesses remains the same, including some presenting quite late in the course of disease with only limited care possible. The patients remain cordial and appreciative of whatever we are able to do for them.
As usual the hospitality of the nuns and other mission personnel made our stay pleasant and productive. One weekend a group of us hiked at an ecological park a short bus ride away. We were fortunate to have dry weather with perfect conditions for our excursion. We remain cognizant of the politics but are certain that our efforts are appreciated and supported by the indigenous population that we serve.
In the near future we will have further specialty brigades with ophthalmology, another otolaryngology team, and tentatively urology, gastroenterology and gynecology. General surgeons were here recently and will return. As the public health system expands coverage for primary care we continue to supplement their efforts. I will be returning to Guadalupe next December to give a respite to a longer term volunteer. I anticipate my visit fondly, knowing the positive impact that we have had on the community.
Serle M. Epstein, M.D., F.A.C.P.
Ecuadorian Newspaper La Hora, on page 5, Friday, November 29, 2013, More...
I had the opportunity to return to Ecuador the first three week of December 2014. The volume of patients is always high when surgical teams are present. In between, as during the time of my recent visit, there are fewer individuals to be served. I saw between 6 and 20 patients each session, averaging 11 patients daily. We experimented with Saturday and Wednesday evening hours but this had little impact. The dentist was busy but with sufficient time to treat multiple oral issues. There was lack of a technician to fashion partial dentures. Despite these short comings I would say the experience was generally a good one.
Our role has changed. The public health system has improved access considerably but continues to struggle with providing urgent and specialty care in a timely manner. It suffers from inadequate supplies. Some health centers are staffed by younger less seasoned and prepared medical and dental providers. I had a young man with a presumptive central retinal artery occlusion. This required an immediate visit with an ophthalmologist. Through the government system this would take weeks. Privately it would cost $30 to walk in the door and more for medications and treatment. He went home and presumably lost his vision in that eye.
For about one half of our patients we render both primary and acute care services. For the others we do urgent visits, consultations and second opinions with referral back to their usual physician, usually at a local Subcentro de Salud or a smaller Puesto de Salud. I have changed the management on a number of such patients, stopped unnecessary surgeries or have suggested a course of evaluation. A few acute emergencies were seen and handled. One was sent away. A woman with a severed tendon in her hand presented to the clinic in the evening. I chose to send her to the hospital. 10 years ago I would have attempted the repair myself despite my lack of training. She would have had an even less experienced doctor to attend to her in the emergency room and incurred significant expense. She most likely would have refused to go. Now the chances are greater that she will see a surgeon.
The government is considering consolidating the smaller health stations into larger more regional community medical centers. Specialty care may be moved into the cities. This may make sense in terms of quality. The unintended consequence is that this change, and centralized appointment scheduling, but may further hinder access from the more distant barrios. It is doing the same with small schools, planning to close many of them and build larger and more central facilities. It is uncertain how the children from the remote villages will attend.
It is now the Dispensorio Misional. It was so legally designated from the former name of the Clinica Misional to better match government regulatory requirements. Our much more complete and subsidized pharmacy is predominantly for our own usage. Surgeries may be performed on an ambulatory basis but with the discouraging of the overnight bivouacking of patients. Despite this in 2015 we have a German ophthalmology brigade for three weeks starting mid January, a North American otolaryngology team for three weeks in March and another otolaryngology group from Germany for several weeks in November. We may have an Ecuadorean general surgeon for several days this coming year but this is yet to be scheduled. Our general medical and dental volunteer calendar is evolving.
I am fortunate to continue to be affiliated with the Dispensorio Misional. I am proud of its accomplishments. It is complementary to an improved government health care system. It continues to provide an essential service.
Serle M. Epstein, M.D., F.A.C.P.
After an absence of one year I returned to the Clinica Misional Nuestra
Senora de Guadalupe short stay of only five days. I saw 84 general medical
patients and assisted with history and translation during the surgical
screening of 12 more. The surgeons performed about 4 major and 4 minor
procedures daily with many cleft palates but also a variety of scar
revisions, nasal surgeries, a nerve repair, skin grafts for burns and a few
cosmetic surgeries to help defray clinic costs. The fall in volume for
primary care reflects an improved public health care system but I still saw
a man unable to afford colostomy bags, a child with inflammatory arthritis
on chronic steroids because her parents cannot take her back to the
rheumatologist or pay for steroid sparing medications not covered by the
state, and a woman choosing between her medications for gastritis and her
antibiotics. The area continues to develop with expanded paved roads, better
walking bridges across the Yacuambi River, and even a rural Shuar village
getting an improved water supply. There is a new hotel in town, inaugurated
with fire works and a priestly blessing, but so far without guests. Padre
Jorge built a modern dormitory for catechists complete with solar heated
water for the showers and rooms for the handicapped. Should he eventually
return to Austria he will fix up the old place. The Austrian plastic
surgical team spoke no Spanish and little English, have worked together
before, and therefore were an insular group. The Austrian dentist and German
dental technician were quite busy but most cheerful and social. I had been
staying at the main parish priest residence. I took early morning walks and
after work one day I took a swim in a local cold mountain stream. It was
refreshing in the close to 100* weather. We ate together as a group for
lunch and dinner and overlapped for breakfast. It was remarkable how the
region continues to advance despite the national challenges of falling oil
prices and the aftermath of the devastating earthquake along to coast.
Serle M. Epstein, M.D., F.A.C.P.