A Physician Couple Heads to Ecuador

Dr. Danesh Modi, and his wife, Dr. Valerie Bonica, participated in a month-long global health rotation that sent them to the Andes Mountains of Ecuador in January 2011. Dr. Modi primarily worked at two hospitals in the city of Riobamba, while Dr. Bonica saw patients in their homes or in several small clinics located in villages throughout a rural region known as Cacha.

"We had wanted to do this for a while," before graduating residency and entering the world of medical practice in the United States, Dr. Modi said in an interview. Both graduates of the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Stratford, they were able to complete their last months of residency during their time in Ecuador, where they put their Spanish fluency to the test. Here, Dr. Modi shares their experiences.

Photos courtesy Dr. Danesh Modi

Describe the medical settings in Ecuador.

Riobamba is a small city, built in Spanish colonial times, while Cacha is an indigenous community, where the people work generally in subsistence agriculture and rarely visit the town. Very few have cars, and they live in mud or adobe houses in very small communities.

There are a handful of hospitals in Riobamba. We worked at two of them. One was a social security hospital (El Instituto Ecuatoriano de Seguridad Social) and the other was a free hospital, where anyone could walk in and receive free medical care.

The social security hospital is fully privatized, and one cannot receive care there unless you have a social security card. Individuals who have these cards pay for them on a monthly basis. There are no set benefits, but they pay about a third of their salary every month, which gives them the right to be seen at this hospital.

Were there substantial differences between the hospitals?

There was a big dichotomy, as you might expect. The social security hospital has both inpatient and outpatient care. The people who are able to obtain social security cards, in general, are those who are more affluent.

In the free hospital – called the Hospital General Docente – there were six beds to a room, with no curtains, so there was really no privacy for these patients.

How was medicine practiced differently in Ecuador?

Overall, there was a much greater reliance on the clinical exam. The Ecuadorian physicians, from what we saw, performed a more-thorough physical exam than we do in the U.S. For example, in the U.S., an echocardiogram is a relatively common diagnostic study, but in Riobamba, a cardiac ultrasound is not available, even in the social security hospital. In fact, if deemed necessary, patients must be referred to one of the big cities to have an echocardiogram and it’s also very expensive.

Even a plain radiograph required explicit indications and was not often performed. We had to decide whether we really needed a chest x-ray and if it would really change our management. When radiographs were performed, we had to hold the films up to the window to read them, which made it difficult to compare them to prior studies.

What types of conditions did the patients have?

Many of the conditions among the people in the rural villages of Cacha stemmed from poverty and were related to poor sanitation, the lack of clean drinking water, poor diet, and poor personal hygiene. The people live at a high altitude in a relatively cold climate, yet we were surprised to see that many did not wear shoes. We were told that this was part of their culture and not necessarily because people could not afford to buy shoes. The indigenous peoples’ culture and values date back thousands of years, and their beliefs are often incongruous with the beliefs and knowledge of Western medicine.

These communities were fairly isolated, and the people for the most part were self-sufficient, farming their own crops and tending their own livestock. They rarely went down to the town and often by the time they presented to the hospital or to one of the public health clinics, they were quite sick.

We saw many parasitic infections from the lack of clean drinking water, as well as other infectious diseases that you rarely see in the U.S.

The cases we saw included amebiasis, thyroid disease (a common problem because noniodized salt is cheaper), alcoholic cirrhosis, blindness from uncontrolled hypertension and diabetes, GI bleeds, tuberculosis, interstitial lung disease (in miners and agricultural workers), rheumatic heart disease, and influenza.

Vaccinations were available but were infrequently administered. The infection rates would have likely decreased dramatically with improved use of these vaccines as well as continued education regarding personal hygiene. We saw many cases of both influenza and pneumococcal disease.

Because we were working at about 10,500 feet about sea level, many of our patients had secondary polycythemia. At altitudes that high, your body naturally makes more red blood cells, and we frequently saw hemoglobin levels as high as 18 or 19 in hospitalized, acutely ill patients.

Diabetes (mostly type 2 diabetes) is a big problem in Ecuador as well. It is also one of the leading causes of preventable blindness globally. Unfortunately, for both cultural and financial reasons, the diet of many of the people consists almost entirely of carbohydrates. There is fruit available in the market, but few people from the villages buy it because it is too expensive. Bread, noodles, and potatoes are very cheap and taste good, so often that is all they eat, and this predisposes them to diabetes. Interestingly, because of the altitude and resultant polycythemia, the physicians in Riobamba cannot use the hemoglobin A_1c test to screen for diabetes; they use fasting blood sugar instead.

Also, alcohol abuse is a significant problem. There were frequent cultural and religious celebrations in these communities, and we often saw people passed out in the street. Alcoholic liver disease may continue to be a problem even if people are able to quit drinking. We saw many people who were end-stage cirrhotic and needed a liver transplant. But the only hospital in the country that performs liver transplants is several hours away by bus. Patients who need a transplant generally move closer to the hospital and wait until a liver becomes available.

What were the challenges to providing health care in this setting?

A major problem is that the pharmacies are not necessarily run by pharmacists. We were told that anyone can open a pharmacy as long as they have a credentialed pharmacist cosign their papers. After that, the pharmacist need not even set foot in the building, and the pharmacy could be run by just about anybody. These pharmacies dispensed medications at will. On several occasions, we saw pharmacy employees using flashlights to examine customers’ throats and then administering antibiotics or vitamin C tablets depending on what they saw. We walked into a pharmacy in the middle of Riobamba, without a prescription, asked for amoxicillin for a sore throat, and received it easily. As you may imagine, this is a huge public health dilemma.

Patients also do not receive directions about safe dosing. When a patient requests a medication for pain, they routinely are "prescribed" NSAIDs. Basically, they walk out of the pharmacy with a giant bottle of naproxen. Since the patients are seeking pain relief and have not been educated about the risks of NSAIDs, they keep popping the pills like candy. In one month, we saw four cases of NSAID-induced end-stage renal disease that required dialysis. One of the patients was 34-years-old.

The Ecuadorian physicians recognize that this is a big problem, and they have been trying to combat it for decades. These pharmacies are arguably the largest and most dangerous health problem that this population currently faces.

What were the most rewarding aspects of your experience?

It was most rewarding to work with the indigenous community. They were very appreciative of everything we did for them and, despite centuries of relying on traditional or herbal medicines, they were still receptive to foreign doctors, and they allowed us to play a small role in their care.

Also, it was a wonderful experience to work with the public health teams caring for people in their homes and in the Cacha-based clinics. These health care providers crossed an enormous cultural divide themselves as they sought out people in the indigenous communities, many of whom were suspicious of them and occasionally unreceptive to the services being offered. But the Ecuadorian team was always trying to build trust and to let people in the villages know that access to health care existed. We were very inspired by the people who worked tirelessly to meet the health care needs in these communities, day in and day out.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column online or e-mail us.

Dr. Danesh Modi, and his wife, Dr. Valerie Bonica, participated in a month-long global health rotation that sent them to the Andes Mountains of Ecuador in January 2011. Dr. Modi primarily worked at two hospitals in the city of Riobamba, while Dr. Bonica saw patients in their homes or in several small clinics located in villages throughout a rural region known as Cacha.

"We had wanted to do this for a while," before graduating residency and entering the world of medical practice in the United States, Dr. Modi said in an interview. Both graduates of the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Stratford, they were able to complete their last months of residency during their time in Ecuador, where they put their Spanish fluency to the test. Here, Dr. Modi shares their experiences.

Photos courtesy Dr. Danesh Modi

Describe the medical settings in Ecuador.

Riobamba is a small city, built in Spanish colonial times, while Cacha is an indigenous community, where the people work generally in subsistence agriculture and rarely visit the town. Very few have cars, and they live in mud or adobe houses in very small communities.

There are a handful of hospitals in Riobamba. We worked at two of them. One was a social security hospital (El Instituto Ecuatoriano de Seguridad Social) and the other was a free hospital, where anyone could walk in and receive free medical care.

The social security hospital is fully privatized, and one cannot receive care there unless you have a social security card. Individuals who have these cards pay for them on a monthly basis. There are no set benefits, but they pay about a third of their salary every month, which gives them the right to be seen at this hospital.

Were there substantial differences between the hospitals?

There was a big dichotomy, as you might expect. The social security hospital has both inpatient and outpatient care. The people who are able to obtain social security cards, in general, are those who are more affluent.

In the free hospital – called the Hospital General Docente – there were six beds to a room, with no curtains, so there was really no privacy for these patients.

How was medicine practiced differently in Ecuador?

Overall, there was a much greater reliance on the clinical exam. The Ecuadorian physicians, from what we saw, performed a more-thorough physical exam than we do in the U.S. For example, in the U.S., an echocardiogram is a relatively common diagnostic study, but in Riobamba, a cardiac ultrasound is not available, even in the social security hospital. In fact, if deemed necessary, patients must be referred to one of the big cities to have an echocardiogram and it’s also very expensive.

Even a plain radiograph required explicit indications and was not often performed. We had to decide whether we really needed a chest x-ray and if it would really change our management. When radiographs were performed, we had to hold the films up to the window to read them, which made it difficult to compare them to prior studies.

What types of conditions did the patients have?

Many of the conditions among the people in the rural villages of Cacha stemmed from poverty and were related to poor sanitation, the lack of clean drinking water, poor diet, and poor personal hygiene. The people live at a high altitude in a relatively cold climate, yet we were surprised to see that many did not wear shoes. We were told that this was part of their culture and not necessarily because people could not afford to buy shoes. The indigenous peoples’ culture and values date back thousands of years, and their beliefs are often incongruous with the beliefs and knowledge of Western medicine.

These communities were fairly isolated, and the people for the most part were self-sufficient, farming their own crops and tending their own livestock. They rarely went down to the town and often by the time they presented to the hospital or to one of the public health clinics, they were quite sick.

We saw many parasitic infections from the lack of clean drinking water, as well as other infectious diseases that you rarely see in the U.S.

The cases we saw included amebiasis, thyroid disease (a common problem because noniodized salt is cheaper), alcoholic cirrhosis, blindness from uncontrolled hypertension and diabetes, GI bleeds, tuberculosis, interstitial lung disease (in miners and agricultural workers), rheumatic heart disease, and influenza.

Vaccinations were available but were infrequently administered. The infection rates would have likely decreased dramatically with improved use of these vaccines as well as continued education regarding personal hygiene. We saw many cases of both influenza and pneumococcal disease.

Because we were working at about 10,500 feet about sea level, many of our patients had secondary polycythemia. At altitudes that high, your body naturally makes more red blood cells, and we frequently saw hemoglobin levels as high as 18 or 19 in hospitalized, acutely ill patients.

Diabetes (mostly type 2 diabetes) is a big problem in Ecuador as well. It is also one of the leading causes of preventable blindness globally. Unfortunately, for both cultural and financial reasons, the diet of many of the people consists almost entirely of carbohydrates. There is fruit available in the market, but few people from the villages buy it because it is too expensive. Bread, noodles, and potatoes are very cheap and taste good, so often that is all they eat, and this predisposes them to diabetes. Interestingly, because of the altitude and resultant polycythemia, the physicians in Riobamba cannot use the hemoglobin A_1c test to screen for diabetes; they use fasting blood sugar instead.

Also, alcohol abuse is a significant problem. There were frequent cultural and religious celebrations in these communities, and we often saw people passed out in the street. Alcoholic liver disease may continue to be a problem even if people are able to quit drinking. We saw many people who were end-stage cirrhotic and needed a liver transplant. But the only hospital in the country that performs liver transplants is several hours away by bus. Patients who need a transplant generally move closer to the hospital and wait until a liver becomes available.

What were the challenges to providing health care in this setting?

A major problem is that the pharmacies are not necessarily run by pharmacists. We were told that anyone can open a pharmacy as long as they have a credentialed pharmacist cosign their papers. After that, the pharmacist need not even set foot in the building, and the pharmacy could be run by just about anybody. These pharmacies dispensed medications at will. On several occasions, we saw pharmacy employees using flashlights to examine customers’ throats and then administering antibiotics or vitamin C tablets depending on what they saw. We walked into a pharmacy in the middle of Riobamba, without a prescription, asked for amoxicillin for a sore throat, and received it easily. As you may imagine, this is a huge public health dilemma.

Patients also do not receive directions about safe dosing. When a patient requests a medication for pain, they routinely are "prescribed" NSAIDs. Basically, they walk out of the pharmacy with a giant bottle of naproxen. Since the patients are seeking pain relief and have not been educated about the risks of NSAIDs, they keep popping the pills like candy. In one month, we saw four cases of NSAID-induced end-stage renal disease that required dialysis. One of the patients was 34-years-old.

The Ecuadorian physicians recognize that this is a big problem, and they have been trying to combat it for decades. These pharmacies are arguably the largest and most dangerous health problem that this population currently faces.

What were the most rewarding aspects of your experience?

It was most rewarding to work with the indigenous community. They were very appreciative of everything we did for them and, despite centuries of relying on traditional or herbal medicines, they were still receptive to foreign doctors, and they allowed us to play a small role in their care.

Also, it was a wonderful experience to work with the public health teams caring for people in their homes and in the Cacha-based clinics. These health care providers crossed an enormous cultural divide themselves as they sought out people in the indigenous communities, many of whom were suspicious of them and occasionally unreceptive to the services being offered. But the Ecuadorian team was always trying to build trust and to let people in the villages know that access to health care existed. We were very inspired by the people who worked tirelessly to meet the health care needs in these communities, day in and day out.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column online or e-mail us.

Dr. Danesh Modi, and his wife, Dr. Valerie Bonica, participated in a month-long global health rotation that sent them to the Andes Mountains of Ecuador in January 2011. Dr. Modi primarily worked at two hospitals in the city of Riobamba, while Dr. Bonica saw patients in their homes or in several small clinics located in villages throughout a rural region known as Cacha.

"We had wanted to do this for a while," before graduating residency and entering the world of medical practice in the United States, Dr. Modi said in an interview. Both graduates of the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Stratford, they were able to complete their last months of residency during their time in Ecuador, where they put their Spanish fluency to the test. Here, Dr. Modi shares their experiences.

Photos courtesy Dr. Danesh Modi

Describe the medical settings in Ecuador.

Riobamba is a small city, built in Spanish colonial times, while Cacha is an indigenous community, where the people work generally in subsistence agriculture and rarely visit the town. Very few have cars, and they live in mud or adobe houses in very small communities.

There are a handful of hospitals in Riobamba. We worked at two of them. One was a social security hospital (El Instituto Ecuatoriano de Seguridad Social) and the other was a free hospital, where anyone could walk in and receive free medical care.

The social security hospital is fully privatized, and one cannot receive care there unless you have a social security card. Individuals who have these cards pay for them on a monthly basis. There are no set benefits, but they pay about a third of their salary every month, which gives them the right to be seen at this hospital.

Were there substantial differences between the hospitals?

There was a big dichotomy, as you might expect. The social security hospital has both inpatient and outpatient care. The people who are able to obtain social security cards, in general, are those who are more affluent.

In the free hospital – called the Hospital General Docente – there were six beds to a room, with no curtains, so there was really no privacy for these patients.

How was medicine practiced differently in Ecuador?

Overall, there was a much greater reliance on the clinical exam. The Ecuadorian physicians, from what we saw, performed a more-thorough physical exam than we do in the U.S. For example, in the U.S., an echocardiogram is a relatively common diagnostic study, but in Riobamba, a cardiac ultrasound is not available, even in the social security hospital. In fact, if deemed necessary, patients must be referred to one of the big cities to have an echocardiogram and it’s also very expensive.

Even a plain radiograph required explicit indications and was not often performed. We had to decide whether we really needed a chest x-ray and if it would really change our management. When radiographs were performed, we had to hold the films up to the window to read them, which made it difficult to compare them to prior studies.

What types of conditions did the patients have?

Many of the conditions among the people in the rural villages of Cacha stemmed from poverty and were related to poor sanitation, the lack of clean drinking water, poor diet, and poor personal hygiene. The people live at a high altitude in a relatively cold climate, yet we were surprised to see that many did not wear shoes. We were told that this was part of their culture and not necessarily because people could not afford to buy shoes. The indigenous peoples’ culture and values date back thousands of years, and their beliefs are often incongruous with the beliefs and knowledge of Western medicine.

These communities were fairly isolated, and the people for the most part were self-sufficient, farming their own crops and tending their own livestock. They rarely went down to the town and often by the time they presented to the hospital or to one of the public health clinics, they were quite sick.

We saw many parasitic infections from the lack of clean drinking water, as well as other infectious diseases that you rarely see in the U.S.

The cases we saw included amebiasis, thyroid disease (a common problem because noniodized salt is cheaper), alcoholic cirrhosis, blindness from uncontrolled hypertension and diabetes, GI bleeds, tuberculosis, interstitial lung disease (in miners and agricultural workers), rheumatic heart disease, and influenza.

Vaccinations were available but were infrequently administered. The infection rates would have likely decreased dramatically with improved use of these vaccines as well as continued education regarding personal hygiene. We saw many cases of both influenza and pneumococcal disease.

Because we were working at about 10,500 feet about sea level, many of our patients had secondary polycythemia. At altitudes that high, your body naturally makes more red blood cells, and we frequently saw hemoglobin levels as high as 18 or 19 in hospitalized, acutely ill patients.

Diabetes (mostly type 2 diabetes) is a big problem in Ecuador as well. It is also one of the leading causes of preventable blindness globally. Unfortunately, for both cultural and financial reasons, the diet of many of the people consists almost entirely of carbohydrates. There is fruit available in the market, but few people from the villages buy it because it is too expensive. Bread, noodles, and potatoes are very cheap and taste good, so often that is all they eat, and this predisposes them to diabetes. Interestingly, because of the altitude and resultant polycythemia, the physicians in Riobamba cannot use the hemoglobin A_1c test to screen for diabetes; they use fasting blood sugar instead.

Also, alcohol abuse is a significant problem. There were frequent cultural and religious celebrations in these communities, and we often saw people passed out in the street. Alcoholic liver disease may continue to be a problem even if people are able to quit drinking. We saw many people who were end-stage cirrhotic and needed a liver transplant. But the only hospital in the country that performs liver transplants is several hours away by bus. Patients who need a transplant generally move closer to the hospital and wait until a liver becomes available.

What were the challenges to providing health care in this setting?

A major problem is that the pharmacies are not necessarily run by pharmacists. We were told that anyone can open a pharmacy as long as they have a credentialed pharmacist cosign their papers. After that, the pharmacist need not even set foot in the building, and the pharmacy could be run by just about anybody. These pharmacies dispensed medications at will. On several occasions, we saw pharmacy employees using flashlights to examine customers’ throats and then administering antibiotics or vitamin C tablets depending on what they saw. We walked into a pharmacy in the middle of Riobamba, without a prescription, asked for amoxicillin for a sore throat, and received it easily. As you may imagine, this is a huge public health dilemma.

Patients also do not receive directions about safe dosing. When a patient requests a medication for pain, they routinely are "prescribed" NSAIDs. Basically, they walk out of the pharmacy with a giant bottle of naproxen. Since the patients are seeking pain relief and have not been educated about the risks of NSAIDs, they keep popping the pills like candy. In one month, we saw four cases of NSAID-induced end-stage renal disease that required dialysis. One of the patients was 34-years-old.

The Ecuadorian physicians recognize that this is a big problem, and they have been trying to combat it for decades. These pharmacies are arguably the largest and most dangerous health problem that this population currently faces.

What were the most rewarding aspects of your experience?

It was most rewarding to work with the indigenous community. They were very appreciative of everything we did for them and, despite centuries of relying on traditional or herbal medicines, they were still receptive to foreign doctors, and they allowed us to play a small role in their care.

Also, it was a wonderful experience to work with the public health teams caring for people in their homes and in the Cacha-based clinics. These health care providers crossed an enormous cultural divide themselves as they sought out people in the indigenous communities, many of whom were suspicious of them and occasionally unreceptive to the services being offered. But the Ecuadorian team was always trying to build trust and to let people in the villages know that access to health care existed. We were very inspired by the people who worked tirelessly to meet the health care needs in these communities, day in and day out.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column online or e-mail us.