I was privileged to work in many different settings during my time in Ecuador giving me a wide range of exposures. First of all, there is private versus public medical care. The perception among those that seek care in the private hospitals is that they are receiving a superior service in exchange for paying for services that are free elsewhere. In some ways this is true. They are treated with more individualized care, the facilities are less run down, the rooms have 2 as opposed to 12-16 patients, and they were not subjected to such things as laboring on a bed without a sheet. However, in the public hospitals international standards of care were followed. For example, at the public hospital babies were placed directly on the mothers’ chests for skin-to-skin contact and breastfeeding was started immediately. In the private hospital babies were routinely fed formula and breastfeeding was delayed. These have significant impacts on morbidity and mortality in the first year of life and beyond.
Primary care appears to be widely available through clinics set up around the country. While traveling one weekend I was impressed to find a functioning public clinic in a village accessible only by foot and donkey. To what extent the public has bought into the value of primary care is another story all together. There were programs that addressed this in a way I think the US could copy. For example, one day everyone in a district was invited to come to the public clinic and while I performed pap smears as fast as I could, a community health worker spoke to the waiting women about nutrition and other public health issues. Another day we walked into the district to make house calls on elderly patients unable to make it to the clinic and also set up a temporary clinic for well child visits. Medical charts were kept in files that had detailed maps on the front so that homes far from roads could be found. The doctors who work in these clinics are paid by the government and skilled though often not residency trained. This is not to say there aren’t problems. For example, the H. Influenza vaccine series is too short to insure protection and so epiglottitis must remain on physicians’ differentials.
What seemed to be lacking was access to tertiary care. Most specialists could only be found in one or two cities within the country. Even provincial hospitals lacked specialists such as rheumatologists. There is also a lack of emergent care and the rapid transportation it requires. For example, the only helicopters are used by the military and not for medical transport. The Cinterandes Foundation serves an important need because surgical care is not accessible to much of the population both because of cost and distance. For a subsistence fisherman the cost of transport, about a dollar an hour for bus rides, made trips of 5-10 hours into tertiary hospitals impossible.
The medical education system in Ecuador is currently undergoing a great deal of change. While there has previously been very little oversight or standardization (there is no equivalent of the USMLE), an accreditation process is starting. In addition, they will be using the Spanish national medical exams with the intention of eventually meeting WHO standards. This will most likely start a difficult period during which many medical schools may close. There are policies in place that encourage women to become doctors but this means that many of the medical schools have very few male students. This will mean a lopsided workforce in the future and, just as an all male system is not desired, an all female one is unlikely to be ideal. Another issue is the ‘rural’ experience. Graduates are required to work in rural hospitals and clinics before they can enter residency, should they wish to practice in Ecuador. While this certainly helps staff remote areas, it does so with physicians lacking in experience. And while working in a remote clinic certainly opens the eyes of the new doctors, it is considered a period of stagnation in their learning and people who wish to pursue training abroad will sometimes forgo this year and move directly into foreign residencies. This is concerning because it makes it very difficult for them to return to Ecuador with their advanced skills. One surgeon I met had practiced for many years in the U.S. in an academic center but was required to fulfill his service obligation before setting up in Ecuador. I can only imagine how many physicians simply never return.