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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.