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by Serle M. Epstein, MD, December, 2010
Zamora-Chinchipe Province in Ecuador is home to about 90,000 people and abuts other Andean provinces of similar size. Most people in this agrarian region are indigenous, being Shuar, Saraguro or mixed heritage Indian/Spanish. They live in rural villages and some larger towns which serve as trade, political, and religious centers. The vast majority are subsistence farmers, miners, and small shopkeepers.
The government has placed inadequately supplied and staffed health centers in most of the larger villages. They perform vaccination drives, and provide family planning services, manage direct observed treatment of tuberculosis, perform some acute adult services, child, and maternal care. There are private physicians for those who can afford them. Regional hospitals are present and some have outpatient services. The quality of care is variable and in general not the same standard available in the large urban centers and in the high Andean plateau in the north of the country. Most of the people do not have consistent access to quality medical providers.
Padre Jorge Nigsch is the parish priest at a Catholic mission along the main trade route into the Ecuadorian Andean cloud forest zone. This mission was already a center of religious activity and teaching for the province when he opened a medical facility in November of 2001. The building was to house examining rooms, dental suites, an operating theater, a pharmacy, and a laboratory. The first foreign physician volunteer arrived in December 2001. With an accompanying nurse practitioner they proceeded to set up the examining rooms, sort through boxes of donated equipment and supplies, and to see patients. They set up charts and reviewed the pharmacy inventory. Many drugs were from Europe from a mass donation. The operating room had a table and old anesthesia machines.
Medical volunteers were recruited, initially for primary care then surgical and subspecialty care. This was done by listing the venue on a variety of web sites, sending faxes and letters to organizations, and talking with colleagues. Padre established an “experience” section on the mission clinic web site as well as standards to be followed when soliciting personnel. From January 2001 through October 2010 there were only two months without a primary-care physician. General surgeons, ophthalmologists, otolaryngologists, gynecologists, anesthesiologists, plastic surgeons, dermatologists and gastroenterologists have visited and provided care. An operating microscope was located; and a donor subsidized its purchase and transport to the facility. This and an additional microscope have allowed a variety of surgical procedures to be performed including, among many others, cataract implants and tympanic membrane reconstructions. Optometric equipment was donated, and the Lions Club International forwarded thousands of recycled eyeglasses to be distributed. The clinic was certified to receive discounted pharmaceuticals from international relief organizations, supplemented with locally purchased supplies. New electrocardiographs were brought down. A laboratory was set up including centrifuges, a semiautomated desk top chemistry analyzer, a QBC blood count machine, two laboratory microscopes, a lipid meter, technicians were recruited to further establish procedures and establish local avenues of restocking material. Dental x-ray machines were installed. Since 2003 there is an obstetrical Doppler and in 2006 a complete portable ultrasound capable of both vascular and visceral studies. General radiology remains beyond the scope of this rural facility. In 2009 an electronic health record was installed.
In the first eight years of existence through 2009 this remote health center had recorded more than 60,000 patient visits.
Outreach is now being done via mobile health fairs. An additional 30,000 individuals were served. As an example of one such “Jornada Medica,” in October 2006 three American physicians and a German dentist, accompanied by an Ecuadorian translator, an American nurse, and a Colombian medical assistant, participated in such an event for one week. They visited a gold mining town high in the Andes and a remote village, deep in a valley, reachable only by mule. They saw 465 medical patients in addition to giving adjuvant dental services, including extraction of 120 severely rotted teeth. In November 2006 a group of American nurse practitioners and emergency physicians, with Ecuadorian civilian and military support, provided gynecological and pediatric services to remote villages only reachable by motorized canoe, returning to adjacent pueblos one year later. The local village church, school, and civic groups orchestrated meals and accommodations, advertised the arrival, and sent townsfolk to portage the canoes when they were stuck in shallow waters.
Each of these mobile health clinics was within one to two days travel from the main facility in Guadalupe, allowing continuity of care. A transportable dental unit now allows for more sophisticated mouth care in the field.
A German organization, Förderkreis Clinica Santa Maria e.V, has sent dentists on a continuous basis since 2001.
The following is a summary report from November 28, 2009 through March 26, 2010. This was compiled by a Costa Rican internist and American cardiologist. During this time period 1,676 patients were seen, of which 51% were adult females, 38% adult males, and 11% children under the age of 12. Most of the patients came from the provinces of Loja, Zamora-Chinchipe and El Oro, although a few were from each of nine different provinces. There were a total of 2,354 diagnoses for 1,676 patients, indicating that many patients had more than one active problem. It demonstrates the primary care practiced and the broad population served.
From November 1–27, 2009 there was an American otolaryngologist accompanied by two German anesthesiologists and an American internist. Eighty-two patients were examined on the first day and about 60 patients showed up every day thereafter, totaling 750 patients for the month. Over 140 operative cases were performed, most under general anesthesia using a larynx mask. The procedures ranged from otoplasty to cleft surgery to rhinoplasty to resection of a cholesteotoma. Patients with otosclerosis traveled up to 13 hours by public bus from the coast to have access to affordable care.
Medical providers of many faiths and nationalities have attended to the needs of the poor at this facility. From 2001 through 2007 there were 135 individuals from 13 countries. They have come from as far as New Zealand and as close as Loja Ecuador across the Andes. Select medical, dental and graduate level nursing students, with supervision, have been integrated into providing care.
Primary-care physicians are asked to stay one month to more than one year and surgeons, accompanied by their operative team members, from two to six weeks as necessary.
At the 2004 American College of Physicians annual meeting panel discussion on international volunteerism, this medical facility was highlighted. It is also listed on many volunteer web sites.
In 2006 a project was begun to fundraise for this venue. A foundation was established: “The Friends of the Mission Clinic of Our Lady of Guadalupe, Inc.”
As much as any volunteer has given to this endeavor, each of them has gained more. Each individual is fulfilled by the knowledge that his or her efforts have impacted favorably upon the quality of life of those living in an underserved community in the developing world.
For more information about the Clínica Misional “Nuestra Señora de Guadalupe” go to guadalupe-ec.org or contact Padre Jorge Nigsch at .
Dr. Epstein is a private practitioner of internal medicine and primary care, Associate Professor of Internal Medicine, Yale School of Medicine