Contraception: Centro de Salud and Machismo

An interesting topic that has come up over-and-over again at the Centro Medico Hombro a Hombro is the issue of contraception. From my experiences in Santo Domingo, based on the patients I have seen in Carlos Ruiz Burneo, the average age of first pregnancy seems to be around 17 years old. I have seen pregnant patients as young as 15 years old and 22 year old women with five children.

The issue of contraception is very controversial and multifaceted in Ecuador:

• The vast majority of the patients served at Centro Medico Hombro a Hombro are Catholic, which is the most common religion in Ecuador. The Catholic Church is against contraception and teaches abstinence only. Thus, families in Ecuador tend to be HUGE. I met a 33 year old patient with thirteen children.
• Contraception generally requires money, which can be an issue for patients. (Although, one might argue that a child costs a whole lot more!)
• Within the past few months, the government of Ecuador has begun offering free contraception at the Centros de Salud, which is similar to the US Health Department. However, there are significant issues with the birth control services provided at the Centros de Salud. The contraception offered is IMPLANON. IMPLANON is plastic rod implant that releases progesterone hormones to prevent pregnancy for up to 3 years, shown below.

  

• While IMPLANON is generally regarded as safe and effective, the patients receive very little, if any, counseling on the contraception. Many patients have come to Centro Medico Hombro a Hombro very distressed because they do not understand the common side effects of the birth control. They do not understand how the contraception works and why they have bruising or a foreign object in their arm.
• Finally, machismo has a great impact on the use of contraception in Ecuador. Machismo describes a strong sense of masculine pride and power. Whenever a patient requests contraception, the physician asks if the woman has discussed the issue with her husband. The majority of the time, the patient replies that her husband does not want her to use birth control and the contraception must remain a secret. 
• Apparently, the reason why many men do not want their wives to use contraception is that they believe the women want contraception because they are having or desire to have an affair.  
• One question I asked was, "What happens when you do not get pregnant? Won't your husband know that you are using birth control?" All of the women have had the same reaction. They simply laugh and say that it will be fine. 

Brigada Medica Survival 101

Based on my experience over the past 10-days, I believe there are three basic steps to a successful medical brigade.

STEP 1: Be Flexible.

Things will change suddenly and often. Be ready to accept change and react. There probably will not be hot water for showering or "normal" food. However, these cultural differences are all part of the experience. 

STEP 2: Get Creative.

I cannot emphasize the importance of this step enough. Resources we expect to be available in the United States are often not available while on a medical brigade.

We often set up our pharmacy outdoors and "built" counters out of various desks. Our medications were left in suitcases except for some of the "fast-movers". 

Inevitably medications are misplaced or run-out. Instead of simply doing without, it is sometimes possible to compound the medication from available supplies. The dentist's topical lidocaine gel was misplaced for the first three days of the brigade. The pharmacy team was able to compound a viscous suspension of lidocaine using toothpaste, 1% lidocaine and water. In the end, the dentist actually preferred the compounded suspension over the gel because it made less of a mess when suction was not available.

 

 

Situations arose where patients did not speak English or Spanish! Sometimes the patients would even reply that they do speak Spanish when asked. This created a large communication barrier. It is important to learn how to utilize the resources in the community you are serving to help with translations from indigenous languages. 

Additional communication barriers included illiteracy, which was fairly common among the elderly populations. In order to help patients understand how to take medications, pictures of the sun and moon were drawn on bags containing medications. 

STEP 3: Do the Best You Can.

Perhaps this step is a cliche, but at the end of the day this is all anyone can ask. There are moments where you feel that you are truly helping improve the life of a patient, while there are other moments where you feel completely helpless. At times I could not help thinking, is 30 tablets of ibuprofen really going to make a difference in this patient with significant deformities due to rheumatoid arthritis? However, there are patients with no primary care provider, and patients that will benefit greatly from not only the medical care but also the emotional support from medical providers.

Carlos Ruiz Burneo

A group of about 25 people came down from the University of Kentucky last week for a medical brigade around different parts of Ecuador, including Santo Domingo and Salasaka. We were fortunate enough to be able to participate in the 10-day long brigade.It was a tremendous experience and I have learned a great deal about being part of a multidisciplinary medical team. I also met some amazing people!

I was finally able to take some photos of the clinic where I have been working for the past month. The clinic is located in the neighborhood called Carlos Ruiz Burneo.

Centro Medico Hombro a Hombro (Shoulder to Shoulder Medical Center):

The street where the clinic is located:

Typical homes in Carlos Ruiz Burneo:

One family was kind enough to allow us to tour their home in order to help us better relate to our patients.

Outside of the home:

Kitchen:

Bedroom for four of the ten family members living in the home: 

The only water-source for the home: 

More to come on the details of planning for a medical brigade in a third world country!

Thank Goodness for the FDA and the CDC

For the past week, we have been spending a great deal of time at the Consultorio Central, which serves urban patients residing in the central part of Santo Domingo. It seems that around 30-40% of the patients we have seen are presenting with Salmonella typhi. Salmonella typhi is a bacterium that is transmitted via the fecal-oral route and causes Typhoid Fever. Signs and symptoms of Typhoid fever include sustained high fever, stomach pain, headaches and weakness. A stool or blood test is used for diagnosis. Typical antibiotic treatment includes ampicillin, SMX-TMP or ciprofloxacin. A vaccination is available – however, the vaccine is not completely effective.

There are many street vendors in Santo Domingo, which sell a large variety of food – raw fruits and vegetables, warm bread and muffins, fish, cooked chicken, rice, fruit juices and smoothies.  The vendors wheel out their carts, some very elaborate with grills and blenders, every morning on our walk to the bus stop. An example of a street vendor:

Often the food looks and smells very appetizing. However, there is very little ability to account for sanitary practices. Thus, many people contract Salmonella typhi by eating food sold from street vendors. After witnessing multiple patient consults involving Salmonella typhi, we have concluded gastrointestinal infections simply seem to be a way of life here. An alternate source of contamination is the water supply. It is extremely important to only use bottled water in Santo Domingo – even to bush teeth! 

 In the United States, the FDA closely regulates the safety and quality of food. Even hot dog vendors must meet certain health standards. Outbreaks of illness due to food contamination are taken very seriously by the CDC, as one might recall various recalls on peanut butter, tomatoes and Jimmy John’s sprouts over the past few years. I have never truly appreciated food safety and the absence of concern over whether or not my food is contaminated in the US – I sure do now!

Weekend Trip to Mindo

This weekend we took a trip to Mindo, which is a small town outside of Quito. It is an extremely beautiful town known for its cloud forests, bird watching and zip lining. 

We stayed at a great hotel called Caskaffesu, which is owned by musicians originally from Arizona. Our first adventure was zip lining through the jungle after a few mile hike – it was really nice to get some exercise after two weeks with none!

Next, we had a chocolate making experience where we made our own chocolate – all the way from cocoa bean:

 

To delicious chocolate fondue:

 

We also visited Mindo Lago where we experienced a frog concert and an after-dark walk through the forest.

 Our last activity in Mindo was a tour of a butterfly farm, which was really neat.

 

Butterflies hatching from their cocoons:

 

My favorite:

 

I really enjoyed this weekend and would love to go back to Mindo at some point!