UK Delegation

Last week Dr. Tom Young brought a group of UK faculty down to review things at the clinic and investigate possibilities for collaboration between various UK departments (nursing, pharmacy, social work, public health, education, family practice) and their counterparts here at the Catholic University of Santo Domingo. They came on Tuesday afternoon and were gone by Thursday afternoon, so it was a whirlwind. The group met with the bishop and leaders from FASCA (Fundacion Accion Social Caritas - like Catholic Social Services) and various individuals met with faculty at PUCE (Pontifical Universidad Catolica de Ecuador). A delegation visited a nearby community of Tsachila indians, one of the tribes of the Colorados after whom the city is named (Santo Domingo de los Colorados); there is some discussion of sending a doctor and/or nurse to this tiny pueblo which currently has very few medical services.

We had two nice dinners, one of which featured extemporaneous entertainment from the two guitar-playing clinic doctors. Rich did himself proud, considering how long it had been since he´d played much guitar.....he had had just enough wine to loosen up his fingers, I guess.... He was commanded to perform after Cristian (who has entertained professionally in the past) sang a few heart-wrenching trova (love songs).

The other dinner was a thanksgiving cena, after which the group came over to the Oviedos´place and we (Rich and I and Amarilys, the peace corps volunteer who lives next door to us) served dessert - apple pie and cookies.

This three-day event was a lot of fun, and a welcome break from our daily struggle to communicate with the world in another language. Two of the UK folks were fluent in Spanish, a fact that served the group very well, but the rest spoke exclusively English; I´d forgotten how fast I can talk!

When they left I was a little homesick, but also felt a renewed enthusiasm for the work that can be done here.

All Souls' Day

Halloween is not much celebrated in Ecuador. Rather, this country has a national holiday on November 2 - All Souls Day. It's a very important occasion, with huge numbers of people traveling back to their towns and cities of origin to join family and remember their deceased loved ones in prayer and celebration. Several times in the days leading up to the holiday we had a chance to partake of the special "colada morada" which is an essential feature of the celebration; this is a delicious and exotic purple fruit drink, thick with chunks of peaches and blackberries, often served warm, and almost always accompanied by "guaguas de pan" sweet rolls shaped like babies. On All Souls' Day itself we were in Quito, walking around the oldest part of the city, and were served colada morada and guaguas by the monks of Saint Francis church in a garden so lovely and peaceful we could have been in Assisi.

HAPPY BIRTHDAY, JEAN!!

Centro Recuperacion Nutricional

My work at CRN continues to be satisfying and frustrating at the same time. Recently I was working with a 14-year-old mother whose 9-month-old baby weighed just 6 pounds. At birth the child had weighed only two pounds after a full 9 months of gestation. This is a case of intra-uterine growth retardation, according to Rich, and there is not a lot of hope that this little girl can ever catch up to normal standards of weight and height. However, the young mom still can learn a lot about caring for her child if she continues coming to the Center.

One of the frustrations is that some of the mothers don't seem to understand the seriousness of the situation, and they aren't faithful in their attendance at the Center. The first meal is served at 8:00 a.m. and the fourth at 3:00 p.m., after which everyone joins the communal effort of cleaning up (sweeping, mopping, emptying garbage, etc.) and the moms and kids who are not staying the night are then free to go back home for the evening. I think some of the mothers, especially those with additional children at home, may doubt that this is the right way to spend their time, and they drop out, either periodically or permanently (often it is impossible for CRN staff to re-contact the mothers if they have moved.)

I wish we could offer a fuller and perhaps more interesting program of education and activities for the mothers and children. Working with them currently, besides myself, are two young women, 19-year-old Anya from Belgium, and 20-year-old Anna from Germany. We try various things....Our games are usually for the mothers, since most of the children are too young for group games; the same has been true of our singing efforts....We teach them songs in English or German, since we don't know Spanish songs and the moms seem amazingly bereft of repertoire themselves!....The crafts projects, like clay molding, knitting, crocheting, weaving bracelets - for all of which we buy the materials ourselves - have varied in their level of value, in my opinion. Usually they have little to do with childrearing, and often we're engaging the mothers to the detriment of the children, who wander around the room with little to occupy them, since there's such a dearth of toys.

I have this dream of a perky little early-childhood graduate student descending from above to help us out!!! Anybody out there know someone?

Jaqueline's Wedding

Rich and I were honored to be invited to the recent wedding of Jaqueline Iza, the Hombro A Hombro clinic administrator. The church ceremony was held in her hometown of Latacunga, an hour or so south of Quito. (They had earlier been married in a civil ceremony, which is a legal requirement in Ecuador....a subsequent church wedding is optional.)

Many facets of the Saturday evening "boda" were similar to a U.S. wedding - several bridesmaids in pink satin dresses, flowers bedecking the church pews, a reception with a meal, dancing, and a big fancy cake. (And plenty of hooch). However, there were several differences in the formalities. There was no bridal procession: the bride and groom entered from the side of the church, sat down in the front pew and waited with everybody else for the priest to start things. Similarly, the bridesmaids (no groomsmen) were just seated individually among the congregation with the rest of the guests. Evidently it's the local priest's call, whether there's a procession, and this man must have been of the more conservative bent - nothing too flashy. The music was provided by a church choir and a mariachi group; the latter also provided some enteretainment later in the evening. I think the biggest difference between this wedding and those back home was the informality and inclusiveness of the invitations. Jaqueline and Ramiro basically just invited the whole pueblo, and included Jaqueline's Santo Domingo co-workers in the blanket invitation. The reception was held under a huge tent (dirt floor), with guests seated in six or eight rows along each side, and dancing in the middle. The serious eating began at about 11:00 p.m. with a big bowl of chicken soup for each guest, later followed by a huge plate of rabbit and potatoes, with cake sometime later, but I can't say when...the partying went on until 5 or 6 a.m., a typical amount of time for a wedding celebration, I'm told.

Jaqueline and Ramiro took a "luna de miel" (honeymooon) to a nearby resort in Puerto Quito for a week, after which things returned to normal at the clinic....She was very appreciative that the whole clinic staff made the trip to the big event, and we were very grateful for having been included!

Hombro Clinic Update (from Rich)

Let me start with last week's "paro", or work stoppage. We have a lot of taxis in this town, and Tuesday at dawn, every big intersection in the city was blocked by 8 or 10 yellow cars. No one was going anywhere, except on foot; the highways through and around Santo Domingo were also blocked, and nothing was moving along these important transit routes connecting the highlands and

Cristian, Leonardo Oviedo, Rich, Jemina, Jaqueline, Maricela & Rocio

Quito with big ports on the coast. The reason for this general strike was to procure provincial status (comparable to statehood) for the Santo Domingo area. A one-day paro two weeks ago had failed to get the attention of the national power base in Quito, so this paro was widely reported to be indefinido, lasting as along as it would take to get the job done. It didn't take long. The national assembly acted within 10 hours, and Santo Domingo, to everyone's gratification here, is now officially a province.

The local folks feel that this is their due because Santo Domingo has grown so rapidly over the past 40 years. From elsewhere in Ecuador and Columbia and other places, people move here for a better life; Santo Domingo is the land of opportunity. There are jobs here. A taxista can make maybe $20 a day, handsome pay in a country where the mean annual income is perhaps $1200. And there are places to live, places that range in level of organization and affluence from "invasiones" (invasion zones) - where a person can find themself a little unoccupied turf, sink some roots, and petition the local government later for property rights - to cooperativas, which are more or less organized efforts on the part of a large number of people to pool their resources, buy a tract of land, parcel it out and set up residence.

In the "suburbs" of Santo Domingo served by the Hombro A Hombro clinic, we have both types of communities, ranging from pretty rough, the coop part, to really poor, the invasion part. None of the roads are paved. Lots of chickens. As far as I know, we are the only clinic serving this area and we are up to about 25 patients per day, about 60% pediatric. Jubileo is currently providing the salary of our nursing assistant, Mercedes, and for half of the salary of our dentist, Jemina. We have also purchased or are purchasing a refrigerator for the clinic, and a sterilizer. We are paying to have the clinic cleaned twice a week, and are beginning a program which will pay for the prescriptions and specialty referrals for patients who can't afford them.

Our staff, in addition to Mercedes and Jemina, includes Maricela, the receptionist; Rocio, the nurse; Jaqueline, our administrator; Cristian Carrion, our general doctor who sees both adults and children; and our pediatrician (me). We are open every day from 8:30 a.m. until 2:00 pm. and have recently started Saturday office hours. We don't give appointments (not really a concept here), so whoever needs to be seen just shows up and the parents chat in the waiting room and the kids play on our front porch. We do lots of immunizations, of course, and are involved in a very successful goverment-sponsored food supplementation program for nursing moms and young children up to age 3.

Our little pharmacy stocks most of what we need and we can sell prescribed medications to our patients at a reasonable cost, usually less than $2 per prescription (medicines here are generally no cheaper than in the states, and Ecuador has no government subsidy, so this is a substantial saving). Subject to need, we charge $2 per visit if the patient is ill, but don't charge for preventive visits or for immunizations. We recently started a program for cervical cancer screening and have regular outreach to the three local elementary schools and one high school in our area; this outreach includes yearly blood screening for anemia, stool screening for parasites, growth monitoring, vision screening, dental screening, and, for adolescents, education regarding the prevention of sexually transmitted diseases.

We are very excited about this effort. Our staff is enthusiastic, hard-working and competent. Like us, they see this as a mission which has made a good start but has lots more to do. Thanks for your interest, and we hope you check in with us periodically to learn more about our progress.

Daisy

Here's a picture of Daisy, who has spent the fourth month of her life recovering from starvation. I've been the food monitor and hygiene police for the baby and mom since they came to CRN from the hospital, where Daisy had been fed intravenously for 3 weeks. The mother, Lana, told me that her breast milk gave out after two months, and due to lack of money, they fed Daisy "aguas aromaticas" (flavored water). After a month of that, Daisy was brought to the hospital with Stage 3 malnutrition: She looked like a newborn, but she had a swollen belly and limbs, and chronic diarrhea; her hair was falling out; and she had dermatitis due to Vitamin B deficiency.

Now she's better - weighs about 6 pounds - and is becoming sociable and very smile-y. But she has a long way to go to achieve normalcy. She's bascially having to re-learn how to eat - i.e., suck from a bottle, bring up the gas bubbles, keep going until she's full and stop before she's too full. Today as I was feeding and burping her while Lana washed the clothes and diapers, I thought how sad it is that she had this horrible setback, and how inefficient it is for governments and charities to treat hunger instead of prevent it.

Ecuador has instituted a program to provide a free food supplement for children under 3 years of age and nursing mothers. I'm not sure why that program didn't save this family from the catastrophe that has befallen them; maybe it's too new, or the family's pueblo is too remote, or the family is just too dysfunctional. Lana has seven living children (she has lost children to illness before, most recently just one year ago), all fathered by Ivan, who is 17 years her senior. The oldest child, 15, is already married and living away from home. The 13 year old is at home caring for the four younger children while Lana is at CRN with Daisy. The father is a farm laborer who earns about $5 per day.

At any rate, Lana told me that the 2 children closest in age to Daisy are also "desnutrida" (malnourished), so I need to nudge the CRN staff to get those kids to the center, too. But the social worker is considering permanently removing Daisy from the family, and may be more concerned about building a court case than addressing the needs of additional children.

The Story of Carlos

One can learn a lot about the difficulties people face down here from Carlos. I met this little three year-old boy on Monday afternoon. We were pretty much finishing up clinic when a woman ran in to the clinic with Carlos in her arms, wrapped in a big fuzzy blanket, dressed in a tee shirt and yellow shorts, looking tiny in the middle of this big blanket bundle. He was unconscious and thrashing around and she had found him minutes before in a neighbor's house.

It was unclear who takes care of him usually, but apparently he is living with an aunt, who was ill herself and the neighbors had come in to visit her. People had seen him around the neighborhood the evening before--he spends a lot of time out and about on his own--and he was happy and active and cheerful. After checking on the aunt, one of the visitors noticed Carlos in his bed. They grabbed him and off they ran at full gallop to our place, several muddy blocks away.

The first problem to figure out was how to get him to the hospital. We aren't really equipped to deal with an unconscious three year-old and we were worried about things like head trauma or the possibility that he could have gotten into something while no one was looking, at his house or on the street. Problem is, in Ecuador, you can't just go off to the ER with someone else's child, even if they are deathly ill. The doctors will refuse to see him without the permission of the family. So off the neighbors--two women and and a man, wonderful people--go, back to the house to see if they can pry the aunt from her sick bed so we can take her, with him, to the hospital.

Eventually they all show up again: Carlos, his aunt who's looking pretty rough, and the three neighbors. Cristian, the other doctor at the clinic, piles everybody into his tiny little car and off they bump on the muddy road out of our subdivision to the local public hospital. I need to find a cab and that takes twenty minutes so I'm figuring Carlos will be in the middle of his initial evaluation by the time I arrive at the hospital maybe 40 minutes later.

Unfortunately, no. He's sitting, still completely unconscious and thrashing around, on his aunt's lap. She looks like she's about to pass out and they are at the end of a long row of patient souls, sitting quietly against the wall, , waiting for the nurse to get them registered into the emergency room. Everybody needs their vital signs checked and the paper work filled out and everybody has to wait their turn even when you're unconscious. I grab a nurse and we find a little spot for Carlos to lie down; the aunt disappears and the neighbors reappear and we get started on an evaluation.

Or we try to. We need the pediatrician on call for the hospital and she is nowhere to be found. Finally track her down and she's a big help. Gets the IV started and the bloods off to the lab and we get a chance to really look at Carlos. No evidence for an injury and he's got some spasms in his left arm and leg so we don't think that this could be some type of poisoning--though we can't know for sure because there is no way to do toxicology in this hospital--that's three hours away over the mountains in Quito. We can do a CT of his head, which is certainly a good idea. The bad news is that Carlos doesn't have any health insurance--few people do down here--and nobody's packing the forty dollars necessary to pay the guys who do the CT scans--cash on the barrel head up front, thank you very much. Jubileo springs for the CT, which turns out to be negative. It's a relief to know that he doesn't have a cyst or a tumor or a bleed in his brain but we still don't have a diagnosis. More tests, including a lumbar puncture, my suggestion, but I get a little weak in the knees when it becomes apparent that they are expecting me to actually do the procedure--haven't done one in many moons.

We get it done, though, but apparently the laboratory in this regional public hospital, the only one for this city of 500,000 people, can't do the tests necessary on the LP fluid. By this time it's six in the evening and apparently this is too late for the lab. The good news? One of the private labs in town will do the tests and we send the neighbors out with the fluid in her hand to deliver it to the private lab, costs Julileo a few more dollars.

Carlos continues to deteriorate and starts having focal seizures and we are thinking that maybe this is some kind of encephalitis. By the next morning it's clear that he needs to go to the Children's Hospital in Quito and off he goes in the municipal ambulance.

And then? Not a clue. My efforts to follow up on this little boy have so far been totally futile. Don´t know if he got admitted, got a diagnosis, got better or came home......The network for finding out such things is simply non-existent.

Daily Life

The pattern of life is not too different from our schedule in Lexington, but many of the details are. We sleep under a big mosquito net. We shower under one of those "widow makers" which gives out a little hot water (glory be - what a gift!) and we have to be very careful not to drink the water as we bathe and brush our teeth and prepare food. (Already did that for 6 months in Honduras - no big deal). We have a rudimentary kitchen, no tv, no car, no laundry machines (but we use Marcia's to spin the water out of our clothes before hanging them out to dry on the roof), no iron or hairdryer, no porch, garden, or barbecue grill; no coffee shop, library, swimming pool or bookstore. On the other hand, we have a huge fresh-produce market a block away where we can buy local papaya and pineapple, and roses for a dollar a dozen; we have music on the ipod; and we have the very real pleasure of knowing that the size of our environmental footprint is smaller. AND we have the unbelievable luxury of electronic communication....This morning I called one of my sisters for a recipe!

The need to conserve water is a constant; water is "delivered" from city pipes every three days, and our job is to make it last. Electrical service is also tenuous, though as far as I know, when that goes out, it's completely arbitrary - we aren't culpable for having used too much.

Rich goes to the public hospital a couple of mornings a week to check on patients, then heads to CMHH or CRN for clinic. He comes home after he and the other doc at each location have seen all the patients, and spends part of each afternoon or evening inputting data for an investigation of stunting in this population of children.

I go to the Hombro (CMHH) clinic once or twice a week and do whatever they have for me there. (Last week I washed windows.) I've visited two of the primary schools near the clinic, offering them some beautiful donated Spanish-language textbooks; Jan Swauger of the UK Development Office and Newman Center is working on raising funds for shipping the books, which are at the International Book Project. I have also been working on translating the UK Hombro A Hombro website into Spansh - still a work in progress.

Three days a week I have been at the CRN working with the mothers and children. The work requires mostly just being available to help the mothers care for the children or to take charge of a child or two while the mothers have educational activities. Some of the babies and tots are wonderful and seem little affected by their poor nutritional status. However, the majority seem backward and under stimulated, and without any training in early child development, I feel a little at a loss as to exactly how to help them.... It is quite a challenge to think of appropriate activities (if any of you have ideas for me, please send them!) Of course I make noises and faces and talk to them....but shouldn't I be doing more? There are almost no toys. One day I brought in four balls - one for the mothers and their older children to play soccer with, one to give to a particularly aggressive little boy who needed to work off energy, and two easy-bouncers for the babies and tots. I will never forget the look of fascination - I could even say joy - that lit up one baby's face when the 7-inch purple ball rolled toward her.

Most of the mothers are unmarried, and many have crushing family responsibilities (e.g., three additional children at home besides the three with the mom at the CRN, and no father in the home). Often the malnourished children are being shepherded by aunts or sisters-in-law, because the mothers are working and/or live too far away. Some are extremely young; some, especially the more indigeonous women, are extremely quiet and shy; and although there is a sense of heavy hearts about the condition of their children, still they generally have happy dispositions and seem appreciative of the opportunity to interact with other mothers.

I think we need music in the facility, and have been giving some thought to how I could provide some. If it weren't for the language barrier, I'd simply start singing. But....what to sing????

Centro Recuperacion Nutricional

The place where I am spending most of my time, and where Rich works in an outpatient clinic two mornings a week, is a rehabilitation center for malnourished children. There are inpatient rooms to accommodate families from outside the area (there is no geographical service boundary), but most of the children come with their mothers each morning to the center, where they receive five high-nutrition meals and the mothers get instruction on nutrition-related topics and parenting in general.

The CRN is one of many projects sponsored by FASCA (Fundacion Accion Social Caritas), the local Catholic social-services agency. The nutrition center began more than 20 years ago, and has grown from a small effort housed in a few rooms in a diocesan office building into the current complex, which was built about ten years ago with funds from several international aid organizations and private philanthropists. Although the physical facility is large and the kitchen is impressive, there is a crying need for equipment, toys and programs for the children.

Centro Medico Hombro A Hombro

The recently-organized medical clinic where Rich is spending most of his time is named after the organization which has worked with Dr. Tom Young and the University of Kentucky in getting it established. Hombro A Hombro [Shoulder To Shoulder] is an aid organization jointly based in Honduras and Cincinnati, dedicated to establishing long-term community-based institutions to improve health and education in poor communities; this project in Ecuador is its only one outside of Honduras.

The CMHH clinic is in an outlying area of Santo Domingo known as Carlos Ruiz Burneo. It expects to serve the approximately 1000 households of that sector, plus 1500 families in a poorer nearby sector known as Luz del Dia, and about 5000 families in the equally poor Plan de Vivienda sector. Nobody has definite figures, but probably this means that there are 30,000 to 35,000 potential patients in the service area. The building is owned by the local Catholic diocese, which years ago tried to establish a clinic there but was unable to sustain it.

We are expecting that Jubileo funds will be put to use mostly in connection with this clinic - purchasing equipment, paying for costs of particular activities, etc. - and the related projects will be reported here. For more complete information about this clinic, or to follow its development, you can go to the website at ShoulderToShoulderEcuador.uky.edu.

Santo Domingo De Los Colorados

Santo Domingo is a boom-town midway between Quito and the Pacific coast. When Rich first visited Santo Domingo in about 1986, there were just a few paved roads and very little infrastructure, and people were moving to the area at such a rapid rate that no one seemed to know how big the city was. Now there is Serious Urbanization, and although population estimates vary, the city currently states that there are 450,000 residents of the area. We are living in an apartment in the center of the city, where commercial activity is intense....On some days comparisons to Tokyo or Hong Kong are apt. Cars and trucks and vegetable carts are a constant serious threat to pedestrians, but no one seems deterred. Churning through stores that sell, separately or together, goods of every variety -- clothing, appliances, grain, furniture, fabric, tools, shoes, paper, pet food, plastics, meat, internet service -- people make their way on sidewalks filled with hawkers, food vendors, and restaurant tables. American concepts of safety seem quaint; mothers with babies and children in tow slip past vats of boiling oil and four-foot-long spits of chickens rotating over red coals.

In contrast, the neighborhoods where we are volunteering have dirt roads, and the level of activity is more like that of a back-country road in the American South. Most of the houses in these neighborhoods have electricity and at least part-time water, though not bathroom plumbing. In one respect, many of Santo Domingo's poor residential areas are better served than the rich or poor in most American cities: They have frequent bus service, and Richard and I gladly use it. The buses struggle slowly over huge ruts and bumps and rocks, and when the drivers reach the smooth sailing of the paved arteries, they drive like madmen.

We still have much to learn about this city, but one thing I found out today when Rich returned from a several-hour episode at the hospital (I guess there's only one hospital) with a three-year-old boy who'd been rushed to the clinic by neighbors: Santo Domingo doesn't have an MRI machine. In order to get that type of brain image, Rich would need to send the child to Quito, a three-and-a-half hour car trip through the mountains.

Ecuador

Ecuador is a small country on the west side of the fat part of South America. As a tourist destination, its biggest claim to fame is the Galapagos Islands, far to the west in the Pacific. Ecuador is a spectacularly beautiful place, full of volcanoes (several still active), tropical flora and fauna, and many different indigeonous peoples. There seems to be a growing middle class (at least lower middle class), but much of the demographic information I have read varies widely from one source to another, so I hesitate to give statistics. I can say with certainty that the population is very dense, poverty is high, and the rates of infant mortality and malnutrition among children less than 5 years of age are good reasons to come to this country as missionaries.

Ecuador uses the American dollar as its currency, a change that was made in 2000 in an effort to stabilize the economy. If working for the government can be considered a good job, as it is in most countries, then good jobs here pay between $300 and $500 per month (the salaries of city workers are posted on the Santo Domingo website.) Yet the prices of many products here equal or exceed those in the U.S. for the same goods. Hence it is hard to fathom how families survive, particularly those with only one parent or where there is illness in the household.