La Ley de Maternidad Gratuita y Atención a la Infancia

22 Jun

In 1998, Ecuador passed this radical law called La Ley de Maternidad Gratuita y Atención a la Infancia to address their outrageusly high rates of maternal and infant mortality.  At one point, they were among the worst in the world! This law mandates free healthcare for women and children, and has been implemented all over Quito. There are still parts of Ecuador that don´t have the facilities or resources to put this law into practice, but the Department of Public Health has launched numerous projects to change that. What this means for me, as a volunteer in La Maternidad, is that I get to see the law as it works out on the ground. At La Maternidad every service, examination, lab test, hospitalization, surgery, medication, recommendation, diagnosis, and delivery is free for the patient. As incredible as this all sounds, after a few weeks of volunteering, I´m beginning to see the potentially inevitable downfalls that still remain within the program. For example, yesterday a woman called the emergency room screaming in pain. She was 15 years old, 26 weeks pregnant, and said she was bleeding profusely. She was requesting an ambulance, which is also free of charge, but the doctor responded telling her that La Maternidad was “a full“–that they didn´t have any room for any more patients. He told her to seek care at another clinic, but she responded that they were full as well. In the end, he wished her the best of luck, and hung up the phone. Today, with another patient, the doctors were worried about the condition of the fetus´ heart. They wanted to get a fetal echocardiogram to see what was going on, but the hospital doesn´t have such state-of-the-art equipment. Don´t get me wrong, La Maternidad is a beautiful hospital that seems fully equipped. Apparently, there is still some medical technology that the government cannot afford, including sufficient space to treat all of Quito´s patients. The hospital is filled with signs that request frugality with medical equipment, lists of medical supplies that doctors are requesting, and reports that show how much has been used that month. It´s interesting to see it from both sides. I see all of the good that La Ley does–the poorest of Quito receive some of the best care there is, and the rates of maternal and infant mortality have dramatically fallen. But, I also see it from the doctors´perspective–the tight budget, having to turn down patients, and the frustration they feel when they can´t provide the care they know exists. It´s undeniable that this law has changed the Ecuadorian healthcare system for the better, for it helps the women of Ecuador get the medical care they need, but it also seems to have plenty of  room for improvement. In only 13 years, they have seen an impressive decrease in maternal and infant mortality, an increase in overall reproductive health, and an increase in the quality of medical care. One of the cool, less expected repercussions of the success of this law is that it inspired there to be free internal health clinics as well! Now, families can continue to get free healthcare the rest of their lives. This law has completely turned around the Ecuadorian health care system, and I´m excited to see even more examples of it changing the lives of the people of Quito.

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Emergencia

20 Jun

Today I started a new clinical rotation at La Maternidad. Instead of the Sala de Partos, I´m working in the Emergency room. So far, it´s been really interesting–one resident allowed me to tag along all day and answered all of my questions, offered explanations for procedures and diagnoses, showed me how to do what he was doing, and asked me to help him with some physical tests. I got to manipulate a woman´s belly to see which direction the baby was facing, put on a fetal heart monitor, and help with a pap smear (called papanicolau in Spanish!). It was such an exciting day, filled with expectant mothers, their anxious partners in the waiting room, and a lot of medical Spanish. I wish I could say that my Spanish is perfect already, but for some reason I wasn´t really on it today. Thankfully, the residents and the doctors were really patient with me, and wasted some of their precious time waiting for me to spit out some story or joke in broken Spanish. I´m hoping tomorrow will be better, and that I´ll shock them with my fluency. I love learning about all of the services La Maternidad provides, and how many doctors and nurses choose to work at this free clinic because they believe in the cause, when any of them could get a higher paying job at a private hospital. Women come from all over Quito to La Maternidad for its reputation and affordability. For some, it´s their only option for healthcare. Many came in asking for Dr. Gomez, the doctor I was assigned to, because he is well known for his superb medical care and overwhelming kindness. Even though he was swamped with cases, he always made room for one more worried mamita.

 

On Wednesday I have a meeting with an organization called Copprende, a Public Health initiative of Quito that focuses on sexual health and reproductive health education. I´m supposed to start volunteering with them by the end of this week. I´m really excited to do some more Public Health focused work–I´ve realized through all of this medical work how much I love the Public Health model of education and prevention. I´m not sure exactly what work I´ll be doing, but I´m not too particular; I just want to help somehow! I have so much to look forward to this week, with all that I´m learning at La Maternidad and with this meeting coming up, plus we´re going to the Galapagos on Friday! Pictures to come, and an update soon!

Comida Típica

15 Jun

I say that I knew before arriving in Quito that my diet would generally consist of rice, beans, meat, and eggs.  But I swear, if I knew how few fruit and vegetables I would be eating, I would have eaten a hearty salad and a basket of fruit every meal for two weeks leading up to my departure. Ecuadorian food is considerably different from the Mexican food we eat in California–they don´t use spices, sauces, or pico de gallo to add flavor to their white rice, pinto beans, and meat cooked in butter. They occasionally cook fish, but it is very expensive, so it´s mostly in pieces in a soup. Speaking of soup, I´ve never had this much soup in my life. Instead of starting meals off with a salad, each person is given a generous helping of chicken broth with a mix of yucca, defrosted peas and corn, and some pieces of meat. Ecuadorians don´t eat anything unless it´s boiling hot, and I always get asked if I dislike the soup if I wait too long for it to cool. The next course is almost always a plate of rice, beans, and meat. Sometimes we get things made of corn, like un tamal (it´s still unlear to me how it is different from a tamale, but everyone assures me that it is) or una humita (basically a sweet tamale with cheese inside). After dinner, we drink tea or Nescafé. Shocking fact: They don´t drink real coffee ANYWHERE! Even some coffee shops give you instant coffee!

I´m sure that my experience with Ecuadorian food is not all-inclusive, since I have to make sure to follow a gluten-free diet. I didn´t think this would be that hard, but Ecuadorians use harina de trigo in a surprising amount of their dishes. Luckily, my señora is great about it, and often gives me alternative meals. It´s my señor that I have to worry about! He´s quite mischievous and tries to convince me to try other things, mostly types of bread. I´m wise to his tricks, and laugh, say thank you, but no thank you, and often Yolanda, mi señora, comes running in and yells at Renè for trying to poison me.

Honestly, after almost two weeks, the gluten-free food here has become kind of redundant. It´s all cooked with love, and generally tases delicious, but I´d be lying if I said I didn´t miss some food from home. After my battle with Ecuadorian salads last weekend, I realize that I need to make sure that everything I eat here is cooked and disinfected. However, I can´t tell you how hard it is to walk by the supermercado every day and see people buying vegetables and fruit. So, today I said no! to un tamal at Bon K-fe and went to the supermarket to do some research. Unprepared to wash, disinfect, and potentially quarantine vegetables and fruit, I settled for some string cheese, lunch meat, and tortilla chips. I reluctantly decided to save the war against E. coli for another day. Stacked together, the cheese, meat, and chips kind of looked like sandwiches (if you squinted your eyes a bit and used your imagination), and it surprised me how much they reminded me of home. I think I´m going to do this more often, occasionally allow myself a break from la comida típica and enjoy some more familiar flavors.

First thing to cross off the list: Snickers. I finally found a Snickers here in Quito, and I have to say, it was the highlight of my day. For a country that produces so much chocolate, they sure don´t seem to enjoy it enough. I was tempted to buy two extra to share with my señor y señora, to show them what my family stashes in our chocolate cabinet, but I decided I should only give chocolate to diabetics once. Regardless, these small tastes of home seemed to span the 3,800 miles and make my little bit of homesickness disappear. At least until I finished licking the caramel off of the Snickers wrapper.

Baños

13 Jun

Baños is a beautiful rural town about 4 hours outside of Quito. Hidden in an Andean valley, it is surrounded by waterfalls, filled with tourist agencies, and is known for its nightlife. The long, windy, bumpy bus ride couldnt keep our group of 27 students away. We arrived with just enough time on Friday to find some dinner and check out the salsa clubs. After a delicious meal of arroz con pollo (reminiscent of Costa Rica!!!), we ran to the discotecas. We stood out like 27 sore thumbs. I must have been called gringita a thousand times, and the men are so forward it´s shocking. Realizing this scene wasn´t what we were interested in, we found a small karaoke bar and sang American songs with an Ecuadorian karaoke star. Everyone went to bed fairly early, because we had a crazy day to look forward to.

The thing about the small town of Baños is not that there isn´t anything to do, but that there is too much to do. It took us until 10am to decide which activities we wanted to do–most people planned on doing at least three! I was part of a group of 16 people who decided to try canyoning, a bike tour of the waterfalls, and dinner at the natural hot springs. Canyoning is as intense as it sounds. You´re given a rope, a harness, and 30 seconds worth of instructions on how to repel down a waterfall. After a few bruises and cuts, you begin to figure it out. However, no number of trial runs could have prepared me for the last waterfall. Being the gringita that I clearly am, I thought they said it was 38 feet tall. Turns out Ecuadorians don´t use feet…they use meters. 38 meters and 38 feet are VERY different heights. After desperately trying to explain to the tour guide that I´d rather take the 3 mile detour than go down 38 meters vertically on a rope that had begun to feel incredibly flimsy, he laughed and lowered me down to a point in which I had no other choice but to repel down. It was terrifying, but I made it to the bottom. Unsure if my hands were shaking because of fear or the freezing water, I quickly found a place to sit down and catch my breath next to the river. We then walked about a mile out of the river, to where the bikes were waiting for us. Within moments it began to downpour. I realized quickly that my shorts and tshirt weren´t going to be enough to keep me warm, and tried to bargain with the guy to let me keep my wetsuit to bike in…apparently no one bikes in wetsuits. Determined to continue no matter what, we biked along what we thought was going to be a trail, but instead was the freeway. It didn´t have a bike lane, and was along the side of a cliff, so falling either direction meant almost certain death. As stated before, traffic in Ecuador is not pedestrian, nor biker friendly. So biking along the freeway, in the rain, to try to see waterfalls that were closed due to foul weather was pretty miserable. Eventually we got to the end of the 12km ride, and took a truck back to the hostel to shower before heading to the hot springs aka los baños.

Around then, I realized that I´m really not feeling well. I thought maybe I was carsick, but after showering and lying on my bed for 30 minutes, I knew something was seriously wrong. I ran to el baño and vomited until there was nothing left inside of me. Now is when I add to my “Lessons I´ve Learned in Quito” list:

#7. Don´t eat anything fresh that you can´t peel–In this case, salad. I knew this rule, but was reassured by a friend that any salad at a restaurant was safe. Hungry, and not really sure what I was in for, I ate the entire thing right before running to catch the bus to Baños. They say E. coli takes about 24 hours to hit you, and at this point, I was at hour 25. After about 6 hours of running to el baño, I had lost enough fluids and energy to concern any of the med students I was traveling with. They insisted on taking me to the private hospital, where an English speaking doctor was on call 24hours. The differences between this hospital and the ones I had seen in Quito were shocking. It was clean, there were three people reopening the hospital just for me, they performed tests within 15 minutes, and gave me an IV and a bag of antibiotics within the hour. The doctor said he studied in the States, but came back to Baños to help his people. This kind of surprised me, because he said he generally only treats tourists–he charges too much for the general population. He said that generally, tourists get E. coli or some other infection from traveling in the jungle. Groggy, empty, and still nauseous, I hobbled to the car as he handed me a piece of paper that he explained was so I could file a claim with my insurance to get reimbursed. The meds, an IV, and after hours care cost me a grand total of $64–the equivalent of nearly 2 weeks pay for a local. After spending time here understanding the health care system from the doctor´s perspective, it was fascinating (yet miserable) to see it from the patient´s perspective as well. Although I don´t think my experience can compare to that of that of a woman in labor in a room she shares with 10 others, it definitely allowed me to see some of the disparities within the Ecuadorian healthcare system. The antibiotics are working, the IV definitely helped, and I´m going to go back to clinic tomorrow. It´ll be a different clinic this week, and I´m sure it will continue to broaden my understanding of the different forms of healthcare here. So, tomorrow, when I´m starving after clinic, instead of the fresh, healthy looking salad, I´ll gladly order the beans, rice, and eggs that I´ve recently gotten sick of, because at least they won´t give me E. coli.

Cirugía

9 Jun

Today I was only at La Maternidad for 3 hours because the doctor wanted the rest of the day off. It surprised me that he could just leave when he wanted to, but I asked someone about it and they told me that it´s very common for doctors to just decide not to work. This is a huge reason there is a shortage of doctors in Ecuador. Today was way less crazy than yesterday–the room with 11 women in it yesterday only had 3 today. No one was scheduled for abortions, no one was far enough in labor to have their baby anytime soon, and there was only one cesarean section scheduled. Lucky for us, our doctor led us into the operating room and let us watch. Now, this was the first time I had ever seen surgery before. I had no idea what to expect other than what I had seen on television, and let me tell you, surgery in Quito is nothing like House. Sterility and confidentiality were lacking, and while I was told that their procedures were normal, it still seemed incredibly aggressive.

The residents were performing the cesarean section, allowing us and med students to watch. After the first incision, the doctor put her hands into the abdomen, and literally stretched the skin apart to create a bigger opening. Everything seemed fairly simple: cut, spread, pull the baby out, and sew her back up. Maybe I´m realizing that surgery really isn´t for me, but something about the way they did it seemed inhuman. As if there weren´t anything behind the cloth of the woman´s gown. As if she weren´t awake listening to what they said, and the noises their tools made as they cut into her flesh. It was all incredibly interesting, but I was mostly struck by the nurse who realized how scared the woman was to be so alone during all of this that she sat down next to her, held her hand, and talked to her throughout the procedure. I kind of laughed at myself for being shocked to see this kind of kindness, when initially I was surprised by their detachment. The procedure went well, the baby came out crying, and the sutures they gave the woman looked seamless. As quickly as it all started, it was over. And everyone (including the doctors) went back to sitting in the hallway, waiting for something to happen. This is when Dr. Marquez left, and dismissed us as well.

Jaime and I decided to use the extra time we had to check out old town Quito. I wish I could upload the photos, because they´re breathtaking, but this internet cafe won´t let me! We visited the first cathedral of Quito, and hiked up a hill that makes San Francico look like the midwest just to get to a gothic cathedral known for its view. I had no idea what we were getting ourselves into when we decided to climb up the stairs to get to the spire on top of the church. The “stairs” were strips of metal, maybe 2 inches wide, on the side of the tower, so you´re climbing up almost vertically. The first floor was okay, but the higher we got, the less sure I was that I could make it. It was so far down!! But, we made it to the top, took a windblown “we made it!” photo, and realized we had to make it all the way back down! 10 minutes later, we were back on solid ground, running to catch el troleybus so we would make it back to school in time. We were 20 minutes late, because the troleybus came off of the wires it runs on. Apparently this is typical, and the driver jumped out and reattached them as quickly as he could.

In class, we took a fieldtrip to the botanical gardens. It was beautiful! So many flowers, trees, plants, and climates in one place! The only thing that was a bit funny was that Jaime and I ran back to class, and the botanical gardens were right by the cathedrals…

Tomorrow, we´re going to a town called Baños. Apparently it´s super picturesque with waterfalls, jungle, and hot springs. Can´t wait!!

La Maternidad

8 Jun

So I know you´re all desperately waiting to find out whether or not I passed out today. I didn´t, but I think that my first glance at La Maternidad, the maternal health hospital in Quito would have given me an adequate excuse.  La Maternidad is awesome because it provides all sorts of healthcare services including cesarean sections, labor and delivery, abortions, sexual health education, contraception, and nutrition education for free! They´re paid for by La Ley de Maternidad Gratuita y Atención a la Infancia, an Ecuadorian law that mandates free health care for women and children under the age of five. Some of these procedures are incredibly controversial, especially abortion and contraception, because Ecuador is a Catholic country. However, the current government supports these services and allows them to be provided.

Anyway, I walked up the stairs to the second floor of La Maternidad to La Sala de Partos, the labor and delivery ward. After being chastised for my scrubs´vibrant shade of green, I was guided to a medium sized room filled with 11 screaming women who were each delivering a child without any pain medications, let alone an epidural. I still can´t figure this out, because I met three male anesthesiologists there who were assisting in abortions and cesarean sections, but they didn´t seem too worried about the poor women who were delivering vaginally. The women were naked from the waist down, legs spread, beds within six inches of each other. Every single one of them was alone, and they were all so young that one woman who was 26 almost seemed too old to have a baby in comparison.  Every once in a while, a nurse would examine them, but generally they were exposed for absolutely anyone to walk by. The room was ridiculously crowded–we had no idea we were going to be fighting with medical students, nursing students, and midwives for our doctor´s attention! Every time he moved, the mass of around 20 people followed.

He then led us all into a small room with only three women in it. He explained that these women all had preeclampsia, and that the only way to cure this life-threatening condition is delivery. Only one woman was close to full term. Apparently the rate of preeclampsia in Ecuador is around 17%, which is shockingly high when comparing it to the rate in the U.S.: 2%-6%. We asked why this was, but the doctor said there wasn´t a real explanation for it–that it maybe has something to do with their diet.

During the four hours I was there this morning, I saw 5 vaginal births. Each time, the woman was completely alone, the doctors were hardly sterilized, and medical students were taking pictures on their cell phones. Not a single room had a door, so anyone could walk in and out as he or she pleased. Doctors outwardly displayed their  frustration with women whose pushing wasn´t satisfactory, and there was only one time that the baby cried immediately after birth. All five of the babies were very blue, and were rushed off to a small room with one table in it: the NICU.  One doctor said their lack of oxygen had something to do with the altitude here in Quito.

We also observed two abortions, both of ectopic pregnancies. Since their pregnancies were relatively early on, it wasn´t too gruesome, but I was shocked by how much the doctors talked to each other about the procedure in front of the patient, cleaning scalpels and speculums as the patient waited for the anesthesia to kick in.

One of the goals of Child Family Health International is to show people the differences between their health care system at home and those abroad. I was talking with a girl in my program yesterday about how surprised I was that I hadn´t experienced any real sort of culture shock here. Now, I can say that it was because I hadn´t worked at La Maternidad yet. Nearly every aspect of my experience shocked me, from the lack of privacy to the lack of cleanliness to the obvious emotional detachment that the doctors had toward the patients. One girl was in so much pain that she thrashed her arms and her IV fell out. The doctors yelled at her, then laughed in front of her and said she was acting childish–she was 14. I´m realizing quickly that any Grey´s Anatomy-planted notion of what a maternity ward should be like is not even close to how it is, especially in third world countries.

Tomorrow, I will walk back up the same stairs, meet the same doctor, be given different colored scrubs (embarrassing!), and walk back into the room filled with women in labor. I´m excited to learn more about medicine, women´s health, and the Ecuadorian health care system, and I´m sure that with a better idea of what to expect, I will be able to look further than the shocking exterior to get a more complete understanding of it all.

Vote here! :)

7 Jun

Everyone laughed when I told them tomorrow is going to be my first time in surgery. As if it were planned, they all said in unison: “you´re definitely going to pass out.” Shocked and a bit nervous, I told them that I´d be fine…hopefully? I´ll know at 8am tomorrow! What do you guys think?

What will my reaction be to seeing surgery in person for the first time ever tomorrow?
(polls)