Clínica Misional “Nuestra Señora de Guadalupe”: An Opportunity for Medical Volunteers

Global Focus
Reports From Physician Volunteers Around the World

Zamora-Chinchipe Province in Ecuador is home to about 90,000 people and abuts other Andean provinces of similar size. Most residents of this agrarian region are indigenous Shuar, Saraguro, or mixed heritage Indian/Spanish. They live in rural villages and in some larger towns that serve as trade, political, and religious centers. The majority of the people are subsistence farmers, miners, and small shopkeepers Figure 1.

AN UNDERSERVED REGION
The government has established a Centro de Salud in the larger villages. Each center gives vaccinations, treats tuberculosis and Leishmania infections, gives perinatal antiretroviral treatment for pregnant women infected with HIV, provides family planning, and is a venue for child and maternal care. Under President Correa the centers are rendering more general medical care and are expanding pharmacy resources. However, they remain poorly staffed and undersupplied.

A few regional hospitals are present, some with out-patient clinics. In general the standard of care is not comparable to that available in the urban communities along the coast and in the high Andean plateau in the north of the country. Although there are private physicians for the more affluent elite, most residents have inconsistent access to quality medical providers, and preventive care services are unaffordable.

START OF A MEDICAL MISSION
Padre Jorge Nigsch is the parish priest at an important Catholic mission along the main trade route into the Ecuadorian Andean cloud forest zone, the Oriente, or Amazonian, part of the country. This mission was a center of religious activity and teaching for the province when he opened a medical facility in October of 2001. Over time, the building came to house examining rooms, dental suites, an operating theater, a pharmacy, and a laboratory.

Accompanied by my nurse-practitioner wife, Jana Siman, I arrived in December 2001. We set up examining rooms, sorted through stacks of donated often non-functional equipment, set up charts, and reviewed the pharmacy inventory. Labeled in German, many drugs were donated from Austria. Though useful, they also included many inappropriate or expired medicines, and European herbal preparations. The operating room had a table, old anesthesia machine, and non-functional monitors. Dental rooms were being constructed. Assisted by the Mother Superior, we proceeded to see patients. No volunteers were scheduled after us.

RECRUITING VOLUNTEERS
AND DONATIONS
Several tasks needed to be accomplished for the Clínica Misional to succeed. The most pressing need was to recruit medical volunteers, initially for primary care then for surgical and subspecialty care. This was done by listing the venue on a variety of web sites, contacting professional organizations, and talking with colleagues. Padre was encouraged to establish an “experience” section on the web site and criteria for potential volunteers. A German organization sought dentists.

Success has been measurable. From January 2001 and as scheduled through May 2012 there are only 2 months recorded without a primary care physician, such as internist, pediatrician, family physician, or general practitioner. Advanced nurse practitioners and physician’s associates have attended. General surgeons, ophthalmologists, otolaryngologists, gynecologists, dermatologists, anesthesiologists, plastic surgeons, cardiologists, tropical disease specialists, and gastroenterologists have visited and provided care.

A donation allowed the purchase and transport of an operating microscope to the facility. This and an additional microscope have enabled a variety of delicate surgeries to be performed, ranging from cataract implants to otosclerosis and tympanic membrane reconstructions. Also seen have been cleft palate repairs, herniorrhaphies, partial mastectomies, removal of parotid tumors, and many other procedures. Optometric equipment was donated, and the Lions Club International has forwarded thousands of recycled eyeglasses to be distributed. They have subsidized the purchase of more. The operating theater has been modernized, and an electrical generator guarantees uninterrupted service. An electronic health record was installed.

The first 4 years, pharmaceutical companies donated large amounts of medications. More than 140 boxes were mailed from Connecticut to Ecuador. This surpassed the donations from Austria and Germany that had been the mainstay of supply. The facility ultimately was certified to receive discounted medicines from international charitable organizations such as MEDIOR and BLESSINGS. Since 2010 it has become increasingly difficult to bring supplies into the country and by necessity more are bought locally.

An electrocardiograph was brought to the facility. About 2 years later a laboratory was established. This included centrifuges, a semi-automated desk top chemistry analyzer, a QBC blood count machine, two microscopes, a lipid meter, and an assortment of quick screen tests and reagents. A laboratory technician established protocols. Dental x-ray machines were installed. Since 2003 an obstetrical Doppler has been available and in 2006 a portable ultrasound unit capable of vascular and visceral studies. General radiology remains beyond the scope of this rural facility. Additional laboratory and radiographic services are available in the regional capital Zamora.

A MEASURABLE SUCCESS
From the end of 2001 through 2009, this remote health center had more than 60,000 patient visits (Figures 2 and 3). People travel hours braving mudslides, driving storms, and rutted and perilous mountain roads to queue up eight in the morning and receive a “ficha” (see Figure 1). There may be extended families or even children alone (Figure 4). When specialists are present, they may wait up to 9 hours to be seen. Many are dressed in their finest traditional garments. They are invariably polite and grateful, even when their problems are intractable.

The following summary reports are typical. From November 28, 2009 through March 26, 2010 1676 patients were seen, of which 51% were adult females, 38% adult males, and 11% children under the age of 12. Most of the patients came from the provinces of Loja, Zamora-Chinchipe, and El Oro, but a few were from each of nine different provinces. There were 2354 diagnoses for 1676 patients, indicating that many patients had more than one active problem. From November 1 to 27, 2009 there was an American otolaryngologist accompanied by two German anesthesiologists and an American internist. Eighty-two patients were examined on the first day and about 60 patients examined every day thereafter, totaling 750 patients for the month. Over 140 operative cases were performed, mostly under general anesthesia utilizing a laryngeal mask.

OUTREACH TO REMOTE VILLAGES
Outreach is done to even more isolated or underserved villages via mobile health fairs. One such “Jornada Medica” in occurred in October 2006. Three American physicians (including myself and two family physicians), a German dentist, an Ecuadorian translator, an American nurse, and a Colombian medical assistant traveled for 1 week. We visited a gold mining town high in the Andes and a remote village reachable only by horse deep in a valley. We ministered to 465 medical patients and gave adjuvant dental services, including extraction of 120 severely rotted teeth.

Although starkly picturesque, this trip was with near tragedy. One of the physicians fell from
her horse in a remote pueblo, sustaining a concussion, large scalp laceration, and whiplash injury. After suturing, immobilization, and being carried up the steep slippery slope by the villagers on a hastily fashioned stretcher, she was eventually evacuated to the nearest hospital with a CT scanner 9 hours’ drive away. The medical trip continued to various cities, towns, and villages.

Through 2009 more than 30,000 patient visits have taken place on such missions, including house calls. Coincidently the schools are often visited for dental hygiene screening and mouth care instruction. Each health fair is within 1 or 2 days’ travel from the main facility in Guadalupe, or in communities served by a Centro de Salud, allowing for continuity of care. Such mobile missions continue to be organized by the Clínica Misional two to four times annually.

WORLDWIDE SUPPORT
FOR THE MISSION
I have absented myself from my private practice 10 times to work at the Clínica Misional and will return towards the end of 2011. On a few occasions I have brought down Yale medical students and once a Yale graduate-level nursing student. A young physician stayed 3 months. She performed a thesis study proving the almost universal prevalence of exposure to Helicobacter pylori. Medical providers of many faiths and nationalities have attended to the needs of the poor at this facility. From 2001 through 2007 there were 135 individuals from 13 countries. They have come from as far as New Zealand and as close as Loja, Ecuador across the Andes. Primary care physicians stay from 1 month to more than 1 year, surgeons, accompanied by their operative team members, from 2 to 6 weeks as necessary, and dentists and dental technicians 3 weeks or more. There are dormitories, and food and board is covered once on site.

The 2004 American College of Physicians annual meeting panel discussion on international volunteerism highlighted this medical facility. It is listed on many web sites.

A clinic for the poor cannot survive on collected revenue. A 501 C3 tax exempt foundation was established: “The Friends of the Mission Clinic of Our Lady of Guadalupe, Inc.” Donations may
be forwarded: c/o Serle M. Epstein, MD, 6 Woodland Road, Madison, CT 06443.

As much as any volunteer has given to this endeavor, he or she has gained more. Each volunteer is fulfilled by the knowledge that his or her efforts have had a favorable impact on the quality of life of those living in an underserved community in the developing world.

For more information about the Clínica Misional “Nuestra Señora de Guadalupe,” visit www.guadalupe-ec.org. To serve at this remarkable facility, contact Padre Jorge Nigsch at padre.jorge.nigsch@guadalupe-ec.org. ■