shopping

This past week, I finalized most of the purchases of medical equipment and supplies to donate to ICE, the non-profit organization in the Galapagos with which I am working.  Thanks largely to a generous donation from Steve Kemler, CEO of Conversion Partners, LLC, I have been able to more than double the amount of donations.  And during this process, I encountered a few challenges...



Open for business? Cages such as this
may stop thieves but also really
hamper business!

 One of them was of course the language and the new (to me) names for medicines and common supplies.  That was easy to overcome with the help of my Ecuadorian medical contacts and Google translate. 

A more difficult challenge involved what to purchase.  Having studied medical anthropology in college, I know how often well-intentioned donations applied in culturally insensitive ways can be wasted or sometimes even worsen a situation.  And I also strongly believe that education can help to prevent problems, which is the best treatment of all!

So, with that in mind, I bought puzzles, blocks, number games, books, and other items to help stimulate young minds.  My friend and classmate, Juan Robles, sent me educational materials from his work in health education with Latino populations in the Bronx.  Part of my work in the Galapagos will involve education on the basics of diabetes, hypertension, and nutrition.  And I bought condoms, 1250 of them!



But a dilemma appeared as I investigated the costs of metformin, a widely-used (in the U.S.) treatment for type II diabetes.  Treating 10 patients for 1 year with a minimum dose of metformin would cost $800.  Metformin helps to lower blood-sugar, but losing weight is recognized as a much better treatment.  And weight loss can actually save a patient money.  With that same $800, I can buy vitamins for pregnant mothers, exam gloves and condoms, educational toys, asthma treatments, hypertensive medications (weight loss and diet change actually help very little with high blood pressure, in contrast to diabetes), and a weight scale.



More supplies



In the U.S., overweight diabetic patients are counseled to lose weight but are given metformin as a matter of course.  Although our short-sighted and profit-driven approach to delivering healthcare will assure worsening problems in the U.S., at this moment we do not have to deal with the kind of medical-rationing that they face here in Ecuador. 





Mr. Cabdriver, does this vehicle have air-bags?

 Let's hope that educational efforts are successful!  I will keep you posted.  Another aspect of my work in the Galapagos involves a study that I must conduct for my school.  The details are still being delineated, but the idea is to measure the effects of these donations and the education I will be involved with, to see if there are positive outcomes.  Of course, a study like that will require many more visits to Ecuador during the coming years!

Ricardo still unhappy with cleanliness...

  

Obviously, I still have a lot of ground to make up in the short time that remains for me in Guayaquil.  This note was plastered to the refrigerator.  And I’m only using the kitchen for keeping my water cold in the fridge!  What can I do??  I’ve even taken to sweeping away my footprints as I back out of the kitchen.  Obviously, Senor Duquer feels his plan is still the best course of action, as he continues to drop his little presents of protest throughout the house.  I never leave my room without wearing shoes.  And every morning, while tip-toeing around Senor Duquer’s little shit-piles, I see el gato eyeing me with hurt and distrust from his uncomfortable perch on the cold tile in front of Ricardo’s closed door.  If only you could see that I'm hurting too, Senor Duquer!

las playas

Saturday was an excursion to the coast.  I rented a car at the airport early in the morning, and after only about 45 minutes of waiting, haggling, signing paperwork and noting dents I was on my way.  The driving is beyond explanation.  It’s kind of like the antithesis of the autobahn.  In addition to a complete lack of respect for rules of the road and very little common courtesy, the highway is filled with potholes, speedbumps (often home-made, apparently to increase local commerce, and often un-marked), bicycles, mopeds, animals such as pigs, and cattle, vendors, beggars, and even grain spread on the shoulders to dry.  In a country with little infrastructure and often impassable jungles, hills and swampy regions, the highway is a true lifeline and everybody is trying to use it to their advantage.

The country was beautiful heading up toward Puerto Cayo, green, rolling hills covered with various crops.  Small villages squeezed the highway with frequency, and larger cities completely swallowed the route, although I did find the signage to be at least as good as what one might find in New York City.



SUPER dangerous curve!



The coast was a series of brown, pretty beaches usually at the mouth of the local river.  Fishing Fleets and surfing signs were common in the region of Manabi, which includes the infamous resort town of Montanitas.  Heading south, the landscape dried out, and there seemed to be more industry, including salt production and shrimp farming.  Salinas, the far western point of the Ecuadorian mainland, was a noisy, busy place that reminded me of Waikiki without much in the way of charm. 



Punta Chanduy



I found a short-cut on my way further south to the town called “Playas”, and spent the next 2 hours crawling through a veritable desert, wondering if I had enough gas, enough water, and if those scrapes on the bottom of the rental car that I heard were doing any noticeable damage.  Finally, I emerged at a little fishing hamlet ear Punta Chanduy with a cliff-side view of the ocean and free parking.  I had a beer and watched the fishermen pound out past the surf to find their catch. 

Late in the afternoon, I arrived in Playas, and as promised by its name, there were plenty of beaches.  Soft, brown sand that extended out deep into the break, where the warm water rolled me in a delicious respite from the heat.  A cool, steady breeze off the ocean kept any insects at bay, and although the beach harbored some flotsam and trash, it was pleasant and beautiful.  After driving a loop of over 500km, I had found a perfect spot about 90km from Guayaquil!

As the sun set, I regretfully packed up into the rental car and headed for home.  The highway was a little improved from what I had experienced earlier in the morning, which was a blessing as I drove through the dark and approached the hustle and bustle of Guayaquil. 

The rains come and the rains go and they provide only a brief respite from the voracious mosquitoes.  There is a fan in my room that runs 24/7 to help keep me cool and to help dry the clothes that I wash in the shower.  I’m getting used to the lack of hot water;  my landlord was right – it’s nice to take a cold shower when it’s so hot and muggy. 



Wanted: DEAD
Have you seen, heard, or felt this mosquito?
Warning: Armed and Dangerous

  There is a bar/restaurant called Artur’s about 20 steps from our front gate, and I’ve become something of a regular already as it’s the only option in the area that doesn’t have karaoke blasting down the doors.  They feature a pair of guitarists one of whom always seems to be playing and I’m getting know the songs and even hum the chorus occasionally. 

Valentine’s was crowded as you might imagine.  In this corner of Latin America, as in most others, every night is couple’s night, so Valentine’s is a really big deal.  And not in the way it is in the U.S., where I suspect every diamond-peddler is licking his chops and the commercial promotions are dizzying, but in a less economic, more palpable way.  People who love each other and spend a lot of time together anyway use it as an excuse to dress up and flaunt their love.  At Artur’s that night, things filled up quickly and I had the last table in the place.  Two elderly ladies, one about 70 and dressed in a red satin blouse, crowded in on me as if I was one of the family and sat down in the empty chairs!   

Guayaquil is not a tourist town, but has its charm and the dearth of gringos is something of a blessing.  The food is great, although I have been suffering from a virus of some sort that has kept me peeing out of the wrong orifice for the past few days.  My favorite dish is called “encocado de pescado” which is basically fresh fish in this fantastic, butter coconut sauce, with tasty rice, vegetables and of course, fried bananas. 

In the mornings (when I have the energy and it’s not raining too hard) I climb the cerro behind my house to get a bird’s eye view of the city and rivers.  It’s hard to see much beyond the city, because the city is so large and it’s usually cloudy.  Sometimes I’ll jog along the Malecon, which is a new riverside park with museums, shops, foodstalls, and little parks and playground equipment.    It really is a peaceful and convenient setting. 



Game on!



The city, on the other hand, is not peaceful.  It’s noisy and polluted and the traffic is kind of ridiculous and the buses are packed with people no matter when you try and ride.  I have been warned incessantly about robbers and bandits, and given very specific instructions about where to walk, shop, what to wear, and how to be less of a gringo.  Unfortunately, one of my favorite restaurants, an internet shop with a printer, a great little bakery, AND a Laundromat with a dryer I just found all happen to be on a street I was told to avoid!  It’s also a short-cut to work and very convenient.  We’ll see if Los Banditos want to bother taking the $10 or so and my cheap watch that I carry to work every day. 

 

Clean Freak



Ricardo (Clean Freak)



My landlord Ricardo left a handwritten note on the refrigerator chastising my flat-mates and I for apparently not keeping the kitchen clean enough.  I’ve used the kitchen maybe twice to make coffee and two other times on the weekends to make breakfast, and I thought we were keeping things pretty clean, but it seems I have failed.  Maybe I have been too busy swatting mosquitoes and trying not to step in cat shit and vomit to notice that spot of coffee on the kitchen floor.

But now I realize that I, like the cat, Senor Duquer, may have been seeking Ricardo’s attention by leaving cute little messes around the house.  It’s really sad and childish, but I have not found another way to break through.  And poor Senor Duquer; despite almost nightly deposits of little cat pooh in all corners of 

Senor Duquer

the house, Ricardo will barely acknowledge his existence.  Even though Senor Duquer and I have become rivals for Ricardo’s attention, it is still tough to watch Ricardo’s face wrinkle in disgust as he tries to shoo Senor Duquer away whenever he approaches for a nuzzle.   At least with me Ricardo smiles occasionally, which is encouraging.  If only I had been better!  Maybe if I tried to polish those little cat turds Ricardo would be impressed…



???

Reactions from others in the house were mixed, including surprise:



         embarrassment:

               to outright disgust:

 

I will keep you posted and let you know how the cleaning efforts are going!

       

Third-Worldistas

Last Friday, with one of the internal medicine residents, Dr. Christian Guarderas, I slipped out of the hospital for a coffee at a local gas station which happens to be the only place nearby that serves brewed coffee and not the instant variety that is ubiquitous in Guayaquil.  We were waiting too long to pay when one of the store employees came over and asked for help.  Apparently another employee had fallen in the store-room and was lying immobile in the back of the store, surrounded by her coworkers.  Christian examined her quickly and determined that although she was stable and didn’t have significant neurological deficits, she needed to be immobilized properly and transported across the street. 

The employees seemed unsure of what to do, and said that their boss was coming and would make the call.  Christian, a little annoyed at the unnecessary delay, said he understood but that she needed to go to the hospital.  We decided to take our coffee in the store instead of leaving and make sure the girl was transported.  Christian told me he was embarrassed that they were hesitant to call for an ambulance to take her across the street because of the costs involved.  I assured him that similar incidents happened every day in the U.S.



Dr. Christian Guarderas



When not in the hospital I have spent time settling in to my new abode.  I bought a cheap guitar and a Panama hat (a misnomer; they are made in Ecuador), and lots of bottled water.   A large part of the weekend was spent  hanging out with my new friend Christian.  I met his family and we shopped for lunch, ate a terrific meal of specialty seafoods and then took a little siesta before going to play basketball.    After that we attended a belated birthday party thrown for Christian’s wife, Gabby, who is also a physician. 



El Malecon





Las Penas



This week has been spent working with another neurologist recently returned from the U.S., Dr. Mosquera, and spending additional free-time in the emergency ward and the intensive care unit of the hospital.  While leaving the emergency room one afternoon, I overheard an administrator angrily addressing a crowd of family members and friends of the patients.  Because many poor people come to Luis Vernaza hospital from distant corners of Ecuador to receive low-cost, competent care, the waiting rooms, hallways, and areas surrounding the hospital are always full of people who have nowhere else to stay while

they support their loved-ones.  But apparently, this group had worn-out their welcome.  “This is why we are referred to as Third-World” the administrator fairly shouted, gesturing to the people lying benches, empty food containers and other trash on the floor.  The people stared back blankly, not protesting, hardly even raising an eyebrow. 

I have recently settled into my new home of Guayaquil, where I am completing my neurology rotation and learning a bit about the country of Ecuador and its people.  In 2003, I visited the capital Quito and traveled to Esmeraldas, a very poor region in the northwest where the U.S. government was soliciting for wharf repairs on behalf of the Ecuadorian navy.  Esmeraldas borders the portion of Columbia under control of the FARQ rebels, who fund their revolution mostly by promoting the production and distribution of cocaine, much to the chagrin of the U.S. and Columbian governments.  Regardless of one’s politics, it was stunning to witness the poverty and desperation that existed in Esmeraldas, and it was experiences such as this that convinced me that I could do more to help this world as a healthcare provider than as a construction contractor.  



Guayaquil digs



During medical school, while searching for opportunities to return to Latin America, an ER doctor named Neil Waldman who has spent time in the Galapagos volunteering his medical services for a non-profit called ICE - “Immerse, Connect, Evolve” – put me in contact with Emily Pozo, the program’s president.  ICE envisions a Galapagos community in which everybody has access to education and adequate healthcare, improving their ability to promote efforts to protect the fragile ecology of the Galapagos islands.  The idea of helping to educate and care for the local population and in turn contribute to preservation of the unique and inspiring flora and fauna of the Galapagos islands was enticing, and the opportunity to improve my Spanish and learn more about Latin American culture in such a setting cinched the deal.

During this process, I also took the opportunity to extend my time in Ecuador by completing a required neurology rotation at La Junta de Beneficencia’s Luis Vernaza hospital in Guayaquil, Ecuador.  Mrs. Pozo has a contact with La Junta, Senora Isabel Valdez de Escala, who graciously accommodated my request and has been selfless with her time, helping me with accommodations, transportation, and in securing additional medical supplies to donate to ICE.

Mrs. Pozo told me that ICE can manage their diabetic clinic for an entire year with approximately 2,000 glucose testing strips.  Apparently patients have their blood sugar tested about once per week.   In the U.S. we are taught that good diabetes control usually requires 3-4 glucose tests per day!  As is often the case in poorer countries, people simply do without and do not receive what one might consider the standard of care.  Knowing what a devastating disease that diabetes can be, my goal was to bring 2,000 glucose testing strips to donate to ICE.  Thanks largely to a generous donation from Mr. Steve Kemler, who is CEO of Conversion Partners, LLC, that goal should be surpassed, and many other basic necessities will be provided to ICE and the people of the Galapagos, all free of charge or obligation.

Glass Only

But I do not leave for the Galapagos until the 6^th of March, and until then, I would like to share more experiences in Guayaquil.  Working in the Neurology wards, I have seen mostly hemorrhagic strokes caused by uncontrolled hypertension.  Commonly, people don’t feel any symptoms from high blood pressure and decide to spend their money on other basic necessities instead of their prescribed medicines.  The results can be devastating.  We have a 42 year-old woman who had an aneurysm clipped in her brain, presumably stopping a hemorrhage.  The operation was done in another hospital, but when the patient could not afford to pay for the services, she was discharged and ended up at Luis Vernaza, where the poor are often treated at a reduced rate or gratis. 

Her head has been shaved and she has staples holding her scalp together from above her left eye to behind the ear.  Her right side is immobile.  She cannot speak, but she understands, and whenever I try and talk to her she only cries.  Her left hand grips mine tightly, and it is difficult to tear oneself away, physically and emotionally.  I can imagine without benefit of words in any language that she feels the desperation of a castaway. 

People Watching