In remote Ecuador, Pandemic Health Care is thin

Karen Topa Pila He looks at the windowless reception area of ​​the small health station in Hoja Blanca (Ecuador), whose walls are stained with pale yellow. “When did the electricity go out last night?” Asks Topa Pilak, a doctor from this remote part of the country. His colleagues shrug their shoulders, glancing anxiously at a small bucket full of ice buckets. It’s only 8:30 a.m. in December 2021, but it’s already more than 70 degrees outside.

Topa Pilak closes a refrigerator with 52 Covid-19 handkerchiefs. “These tests need to be cooled and we only have one refrigerator, which is for vaccines only,” he says. His team has nowhere to store the tests, he added, so to avoid being ruined in the jungle heat, the clinic wants to use them all on the same day. The next day, he will take a health worker to the district hospital laboratory.

Topa Pila, 25, and her group arrived in Hoja Blanca in September 2021, a town of 600 inhabitants in the heart of Ecuador’s Esmeraldas province. rural year, working for one year in a rural community for a professional license or advancing to a medical degree. (Established by the Ministry of Public Health rural year This is a common practice in 1970 and throughout Latin America. The Hoja Blanca station is also the responsibility of six other communities, made up of mestizos, indigenous Chechens and Afro-Ecuadorians – a total of about 3,000 people. Some communities are so far away that to get to them, health workers cross thick jungles and then travel by canoe for a full day.

The pandemic has suffered heavy losses in Ecuador. In the early months, the bodies were sprayed on the streets of the country’s largest city, Guayaquil. In June 2020, the virus death rate reached 8.5 percent, one of the highest in the world at the time. As of June 5, 2022, the country recorded 35,649 official Covid deaths, although the actual count is likely to be much higher.

Many public health experts agree that Covid-19 has also exposed deep-rooted systemic problems in Ecuador’s rural health system. In 2022, Ecuador, the smallest nation in the Andes, had a population of over 18 million; 36% live in rural communities. As with private health care providers, the country’s public health system is fragmented, divided between various social security programs and the Ministry of Public Health. There are an average of 23 doctors and 15 nurses per 10,000 people. But only a small fraction of the country’s health professionals — about 9,800, according to John Farfán of the National Association of Rural Physicians — serve more than 6.3 million rural Ecuadorians.

Although economically stable in Ecuador, many Ecuadorians do not have access to adequate medical care and the country has one of the highest health expenditures out of the pockets of South America. In rural areas, access to hospitals — as well as clinics such as Hoja Blanca — is hampered by poor infrastructure and long distances to facilities. Before the pandemic, Ecuador was making budget cuts to deal with an economic crisis; Public investment in health care went from $ 306 million in 2017 to $ 110 million in 2019. As a result, in 2019, about 3,680 employees of the Ministry of Public Health were fired. Ecuador has also experienced long-standing inconsistencies in health leadership. In the last 43 years, the country has had 37 health ministers, including six since the start of the pandemic.

Before the selection system of the Ministry of Public Health put Topa Pila into service, he had never been to Hoja Blanca, and it took him more than eight hours to get there. He says when he got to the humble health station, he says he thought “this is going to fall apart”.

Early in the pandemic, which plagued Ecuador’s shortage of everything: face masks, personal protective equipment, medications, and even health care workers. By April 2020, the government had moved dozens of doctors and nurses from rural areas to the city’s hospitals and health centers, leaving many communities without medical care.

At one point, says Gabriela Johanna García Chasipanta, the doctor who spent it rural year In Hoja Blanca between August 2020 and August 2021, his team did not have any basic pain like acetaminophen or ibuprofen. It was an “exciting” experience, he says. “I also had to buy it out of my own pocket to give to some patients who really needed it and didn’t have the financial resources to get it.” Some rural areas have had to resort to desperate DIY solutions during the worst months of the pandemic, says Esteban Ortiz-Prado, a global health expert at the University of Las Américas in Ecuador. for example, and using plastic sheets to create “isolation tents” in a one-room health center.

The pandemic has strained rural doctors in other ways as well. In 2020 and 2021, the National Association of Rural Physicians of Ecuador received numerous complaints of salary arrears, some more than three months later. “There were rural health workers who even threatened to fire landlords,” said Dr. Farfán, a former president of the association.

Even in better conditions, remote health care posts are provided only for primary care. The most serious is the need to go to a local hospital, which in the case of Hoja Blanca involves a 300-kilometer journey to the parish of Bourbon.

The health administration took into account the geographical and cultural diversity of Ecuador and its poor infrastructure in rural areas. But in 2012, the government restructured the system according to public health experts in nine coordination areas that no longer follow geographical logic. “You can’t have a head or a tail,” said Fernando Sacoto, president of the Ecuadorian Public Health Association. “This is not just a matter of bureaucracy, it’s also something that has affected the health of many people.”

Despite significant developments in the healthcare sector over the past 15 years — including universal health coverage and $ 16 billion in public health investment from 2007 to 2016 — it has focused primarily on hospital construction, Ortiz-Prado said. But the country’s leadership “has not paid much attention” to prevention and primary health care, he added. “The system was not built to prevent disease, but to treat patients.”

In 2012, the government also disbanded the National Institute of Tropical Hygiene and Medicine, Dr. Leopoldo Izquieta Pérez of Ecuador, which was responsible for research into emerging diseases, epidemiological surveillance and vaccine production, among others. (It was replaced by several smaller regulatory bodies, one of which failed miserably, according to Sacoto.) The majority of a nationwide laboratory network was also shut down. Sacoto and other experts believe that if the government continued to invest in the Institute, it would reduce the severity of the pandemic in Ecuador.

Initial plans to pursue and prosecute Covid-19 cases failed; the country had almost no machines to process PCR tests, the gold Covid-19 tests. “In the early days of the pandemic, samples collected in Guayaquil were taken to Quito by taxi,” says Sacoto, as it was the only place where PCR tests were being studied. But public transportation to rural communities is limited, so even a few rural residents who had access to the tests sometimes waited two weeks to get the test results.

Topa Battery team he tries to convince everyone who crosses paths — the butcher’s wife, the people waiting for the bus, the rooster fighters — to take a Covid-19 test. Although the PCR results are faster than before, it still takes a week for one of the health workers to personally take the samples to Bourbon – a 3-day commute, a motorcycle, two different buses and a crossing. a river with a poor ferry. “Until yesterday, we did a quick test of Covid-19. [district] the leader did all the tests we had, ”says Topa Pilak. The district hospital called for quick tests, he added, “because the tests are exhausted and they need them.”

Because Hoja Blanca is relatively isolated, the community has had a few cases of Covid-19, all of which were mild. Topa Pila fears that having a sick person in a serious condition, Covid-19 or otherwise, can only be done by asking the villagers and the ferry operator for transportation assistance. There is no ambulance. “We don’t have oxygen because the tank we have there is expired and you can’t use it anymore,” he says. “We asked for a replacement, but nothing happened.”

As Topa Pilas sees it, it’s a lot to ask inexperienced health workers for theirs rural year. “We start from scratch every year without knowing anything,” he says, recalling that the previous team had already left by the time they reached Hoja Blanca. “And they lose treatments that have been controlled by a doctor for a year because they knew the doctor was going to come home,” he says. “We’ve arrived and we don’t know where they live. As you can see, there’s no address here.” The Covid-19 pandemic has pushed rural doctors further away from patients, he added. Among the blockages and coronary artery disease, other health issues such as childhood vaccines have been suspended.

As elsewhere in Latin America, the Covid-19 crisis in Ecuador has also exacerbated corruption. Sacoto says he believes the healthcare sector has become a “barter” exchange among politicians. “For example, there are mafias embedded in public procurement,” he says, “because the public procurement system is so complicated that only those who know how the fine print works can benefit.” Between March and November 2020, the country’s Attorney General’s Office reported 196 Cases of corruption related to the Covid-19 pandemic, including allegations of embezzlement, inflated medical supply prices.

Lately, there have been signs of improvement. Following his inauguration in May 2021, the government of Guillermo Lasso has stepped up vaccination efforts against Covid-19, approved a new program to combat child malnutrition, and announced a Ten-Year Health Plan to Improve Health Equity.

Sacoto says he continues to question whether these plans will be concrete and sustainable actions. A good start would be to decentralize the health care system by building more rural clinics, he says, which could create a network of preventive care from child malnutrition to future pandemics. Ortiz-Prado says the country should better integrate fragmented health systems when it is necessary for patients — and their records — to move more easily between them. And it needs to improve the working conditions and wages of rural health workers to make work more attractive, Farfan says, also creating more permanent jobs for rural communities. “There is a lack of concern, a lack of budget,” he said. “It’s a crazy circle, and unfortunately the government is trying to apply Band-Aid solutions to health problems here.”

But all this is in the future. Now, back at the Hoja Blanca health station, the lights come on in less than a day. Vaccines in the refrigerator are safe. But 52 Covid-19 tests are still in jeopardy: a health worker has to take the refrigerator to the Bourbon lab. The day before, however, it rained heavily and the water level did not drop enough for the river ferries to resume operation. In the end it’s just the first part of what will be a 13-hour journey, and the ice balls are melting rapidly between the sweet warm equator.

Kata Karáth is a freelance journalist and documentary filmmaker living in Ecuador who specializes in science, the environment and indigenous issues.

This reporting project was supported by the International Center for Journalism and the Hearst Foundations as part of the ICFJ-Hearst Foundations Global Health Crisis Reporting Grant.

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