El Centro de la Niña Trabajadora (CENIT) was founded by a group of nuns in 1991 to provide opportunities to young working girls in one of the poorest neighborhoods in southern, Quito. CENIT’s programs include a street outreach program where volunteers from both Ecuador and around the world go out into the local working sectors to interact with the working children and to provide opportunities for them to play and learn. Also, within CENIT’s building there is a kindergarten, an elementary school, and a vocational high school to provide children with a safe environment to learn, play and develop technical skills which are applicable to the formal working sector. Finally, within one of the working sectors, there is a support center (Centro de Apoyo) where children learn the necessary skills to transition from street culture to a formal educational setting. The most recent addition to CENIT, and where I spent most of my time is the medical clinic, which was founded in 2001 (see www.cenitecuador.org for more information).
During my twelve weeks at CENIT, there were anywhere from two people working in the clinic to ten people, none of us having any formal medical training. Although there were no medically trained people working within the clinic on a daily basis, every Thursday afternoon from 2pm until 5pm a doctor would come and attend for the people in the community. Usually in these three hours the doctor could see between 25 and 30 patients. Therefore, in order to see as many patients as possible one or two of us would work in the waiting room getting the patients ready to see the doctor by helping them fill out medical sheets and taking their temperatures, blood pressures, and pulse rate. One fortunate person was actually able to attend in the clinic with the doctor. Finally, another group of us would put together a “charla” or short presentation on a health topic to present to those patients waiting to be seen by the doctor. Seeing as most of the medical problems seen in the clinic were preventable problems such as anemia, scabies, parasites, cavities, and unwanted pregnancies, we tried to focus our “charlas” on various affordable and practical ways diseases and unwanted conditions could be prevented. We focused on inexpensive foods, like vegetables and beans that could be eaten to combat such things as anemia in pregnant and lactating women. We focused on the importance of boiling water before drinking or cooking, and on various permanent and nonpermanent forms of birth control.
On top of the Thursday visits by the doctor, we also opened the clinic from 3pm until 4pm in the afternoon everyday, mostly for the kids in the kindergarten, elementary school, and high school to come if there was anything bothering them. Mostly we would put band-aids small scratches and lotion on dry faces. However, one of the most rewarding experiences for me was when the high school girls would come in with headaches or stomachaches, giving me the opportunity to talk with them about what they were experiencing in their lives, and what hopes and fears they had. Often they would be quite shy and passive at first, but once a level of trust was built they seemed to open up more. I remember one girl coming in with a stomachache, to find out that what was really bothering her was that her grandma had recently died and she was afraid she too was going to die soon. Another time one a young high school girl came into the clinic because she was menstruating for the first time and wanted to talk about it. Even though she seemed to know more than I did about menstration, I was flattered that she came to talk with me.
One benefit that came with working daily in the clinic from 3pm-4pm was that on Thursday I was aware of the problems different patients had who would be seeing the doctor. Therefore, when I would attend with the doctor in the clinic I would be able to provide additional information that helped not only with the diagnosis and treatment of the patient, but also with the efficiency of the visit (we were almost never able to see all the patients who would come to the clinic on Thursdays). One of the young kindergarteners, Luisa, had come to me early one Thursday morning with a stomachache and an overall depressed look to her. Not being medically trained I couldn’t rule out such things as parasites, appendicitis, or food poisoning but it seemed to me that more was bothering her than just her stomach. After speaking with her for a while I found out that her baby sister was sick and in the hospital, and that her father had been upset and yelled at her early in the morning. Could it be possible that Luisa’s fear and sadness for her sister and her father’s anger were making her stomach hurt? I had no idea, so I had her see the doctor in the afternoon. After running through some tests, the doctor was fairly certain she did not have parasites, diarrhea, appendicitis, hunger, dehydration or any other condition that could cause stomachaches, so I told her, the doctor, about our conversation in the morning. She too thought that it was possible that Luisa’s anxiety was affecting her physically, so she sent her over to talk with a social worker. Remarkably, the next day after Luisa’s sister returned from the hospital and the social worker had spoken with the father, she was back to being a happy young five year old. Seeing young girls like Luisa happily playing one day after being so sick and depressed was like a lightning bolt for me, giving me the jolt of energy I needed to work with these kids daily. Not only was I learning invaluable skills through observing our doctor, but little by little I was able to see that my presence was in a small way improving the lives of some of the young children at CENIT.
Another part of my experience at CENIT was accompanying women and children to the various heath centers and hospitals in the area in both emergency and non-emergency situations. One instance, I arrived at CENIT around 9:00am like any other morning, and like most other mornings there was a member of the community waiting for either Elizabeth (the director of the medical clinic) or I to arrive. Only this morning was not like most other mornings. Both Elizabeth and I could see the panic and lack of sleep on the face of Senora Panela, holding her half asleep, half awake five year-old daughter, Anitia, in her arms. The senora explained to us that the evening before they had visited the emergency room in the local hospital, but the doctors had told her that her daughter’s injury was not severe enough to be seen by them. Elizabeth and I removed the white gauze provided by the hospital to discover a mess of blood and dirt covering an open wound running vertical down the back of her head and measuring over twelve centimeters long. Realizing that Anita would need stitches, I walked with Senora Panela and her daughter to a small clinic just up the road. Unlike the night before, when we arrived at this clinic, the medical staff, seeing a white gringo from CENIT, moved us to the front of the line of people extending far outside the confines of the clinics doors. Soon the doctors discovered that not only did Anita need expert medical care for the large wound on the back of her head, but her fall had actually fractured her skull, and we were rushed by ambulance to the children’s hospital, Baca Ortiz, in the north of the city. Ultimately after fifteen stitches she was just fine and back at school with the kindergarten in a couple of days, laughing and playing as if nothing had ever happened.
This experience highlights one of my dramatic visits to hospitals and clinics in Ecuador, but there were also other more organized visits. We spent time building relationships with local private clinics that would give discounts to the women from CENIT who wanted various forms of birth control from a coil to hormones, or even a tubal ligation. By taking women to get echograms, or children to get x-rays I got to know the social workers at the public heath centers who usually would end up canceling their medical bills.
In fact, much of what I felt I accomplished during my fellowship was helping to build medical connections for CENIT, and helping to develop a system and procedure within the medical clinic so that new non-medically trained CENIT workers would be able to enter CENIT’s medical clinic and be able to add onto what has already been started, instead of trying to run the clinic without any direction from the past. With this in mind, and with the help from our doctors and a medical student I lived with, we made simple diagnostic flow charts that tried to diagram what to do in the case of headaches, stomachaches, diarrhea, and sore throats. We took the most common medications given out at the clinic and made index cards for them, spelling out what the medication is used for, what the precautions are, and what the proper dosage is.
Ethically, this project became one of my bigger challenges while working at CENIT. Where is the line drawn between trying to leave sound advice for future clinic workers, and extending our suggestions beyond our medical understanding or capabilities? Should we, not being doctors or nurses, really be giving recommendations on antibiotics? How accurately can we diagnose parasites or scabies? Should we really be giving injections of birth control hormones, pain killers, and tetanus vaccines without the supervision of medical staff? Ultimately I decided that it was important that a plan be available to future workers on over-the-counter medications like ibuprofen and acetaminophen, but on what we consider to be “prescription drugs” I found I was morally unwilling to enable non-medically trained people to play doctor. Did I make the right decision? Will a young child who needs antibiotics for a treatable ear infection lose her hearing because we were unable to give her the simple antibiotic she needed early enough? I’m not sure, but I’m also unsure how I would live with myself knowing that someone was sickened, or worse, killed because my uneducated medical advice was used improperly to treat a patient at the clinic.
Some other projects I undertook while at CENIT were trying to bring the medical clinic out into the streets with the outreach programs. We made first aid kits, and had a training session for all the street volunteers, teaching them basic first aid skills. I met with a women who owned a private eye clinic, and she and her husband came and did eye tests for all the kids, and provided over 30 kids with eye glasses for only five dollars (they were actually free, but she encouraged us to charge five dollars so that the children would give them value). I helped with the weekly running of the clinic by buying medicines to stock our small pharmacy, and reviewing and logging all the patient’s charts, both new and returning.
I’ve already mentioned the difficulty I had with discovering the line between giving sound medical advice and trying to play doctor, but I would like to also mention a few other challenges I encountered. The first challenge I would like to mention, and the most obvious from the moment I started working at CENIT, was the racism and prejudice that exists toward people living in poverty, most of whom are indigenous. A perfect example of this racism is little Anita’s experience in the emergency room the night she split open her head. Any doctor looking at a twelve centimeter cut down the back of anyone’s skull could never in his or her right mind turn this patient away. Then how is it possible that just a sterile gauze was placed on her head, and she was sent home? One possible explanation is that this doctor was busy and didn’t want to waste his or her time with a patient who obviously would not be paying, for her clothes were dirty and she smelt like a campfire because she has been living outside. Yet from a human perspective wouldn’t this doctor understand that it was especially important for this child to receive medical care because she would be living on a dirty street where the chances of infection are exponentially higher? If he viewed her as his equal, as a human being, he would never have been able to refuse her treatment. The only explanation I can rationalize is that he truly believes that his status, his heritage and his culture give him rights and privileges that poor indigenous people in Ecuador do not have.
When I think of medicine in the United States, I would like to believe that we are not racist and that we are not prejudiced, and that we will treat all sick people in a humane and dignified manner. However, the more I learn about our health care system, and the more I learn about the restrictions that are placed on both legal and illegal immigrants I begin to wonder what makes us feel “we” but not “them” have the right to quality health care. One day I hope to be a part of the medical system in the United States, and I’m certain a life-long challenge for me will be finding ways to provide humane and unbiased health care to all the sick, no matter their rank in life.
Another challenge I encountered while working at CENIT was accountability among the patients. More often than not, the doctor would give an antibiotic out for bronchitis or an ear infection, and the patients would never take them, or would not take them according to plan. I worked with a young girl who had an infection in the tissue around her eye. The first week she came to the clinic our doctor prescribed an antibiotic, but she did not take it. The next week the infection was so bad she was sent to the hospital, and received antibiotics intravenously. Nonetheless, the infection would not go away, so our doctor prescribed an antibiotic that cost over fifty dollar (a lot when the whole medical clinic is run on 5000 dollars for the year). We sent notes home with the girl, we spoke with the mother, and even stopped by her house, but she just would not take her medication. Finally we had to make the threat of her losing her eye, and the possibility of months in the hospital real enough for this girl’s mother to be responsible in giving her daughter the medication. I could never understand what I viewed as the complacency of the mother. How could she refuse to do such a simple, but vital thing as give her daughter a pill three times a day for a week? Interestingly enough, when I returned home late this summer I was given a book to read by Anne Fadiman, The Spirit Catches You and You Fall Down. It is about an epileptic Hmong child, Lia, and her parents’ difficulties in dealing with the US doctors, especially in complying with medications. Lia’s doctors failed to take into consideration cultural aspects when treating Lia. They viewed her as a patient who was sick with epilepsy, and whom they would treat like any other epileptic patient. Looking back to my interactions with the young girl with the eye infection and her mother, I realize that I too was very black and white in my dealings with them. Did anyone really explain to them what exactly was wrong with her eye? Did we ask them what they thought was wrong with her eye? Did the mother know how to read or count? Did they trust medicine? Did they even think she was sick? As a future doctor, I will be working with a diverse group of people, and again, part of my challenge will be to respect different cultures and ideas while providing necessary medical care. What care is essential, and what parts of our care are merely cultural and can be adapted? How will I interact and learn from and about the different cultures and peoples I will be serving as a doctor? Thinking about these challenges is both exciting and uncertain, but has helped me realize that practicing medicine will be about much more than understanding diseases, diagnosis, and treatments, it will also be about how creative and open I am in extending medicine to a diverse group of people and cultures.
As I conclude my experience at CENIT, it has become apparent to me that I have made the right choice in deciding to pursue a career in medicine. Furthermore, I cannot envision myself working in medicine without being involved in human rights, especially as it pertains to medicine. I learned much about the medical system in Ecuador, and I am eager to gain a better understanding of our complex system in the United States. I’m especially interested in learning more about the care that is granted to children and to immigrants, both legal and illegal, and have been trying to stay involved with the local Latino community in the St. Cloud area. I’m excited that this report will be placed on the internet giving others a chance to learn about my experience in Ecuador. I’ve also created a simple slideshow that I presented to the Spanish classes at the St. John’s Preparatory School, in Collegeville, Minnesota where I am working right now. I’m hoping to have more opportunities to share this slideshow with its many pictures and stories, and my incredible experience as an Upper Midwest Human Rights Fellow this summer.
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