Reports from Ecuador

Throughout our visits to Yatzaputzan and Planchaloma, we have made slow but steady progress on developing both the Community Health Outreach and OB/GYN backpacks.

CHO Pack

We quickly learned that the CHO pack, originally designed for community outreach workers in Malawi, would be used by the promotores de salud at Fundación Futuro’s health centers in Ecuador.  We have talked extensively with Marta from Planchaloma and Angel and Evita from Yatzaputzan about ways to improve the backpacks, and have learned that while they have the medical training to use all the supplies currently provided, their focus is more on health education in the communities surrounding the clinic.  As such, we have designed a series of educational flipbooks (hygiene, oral health, nutrition, family planning, vaccinations and recycling) to put in the backpack that they can use with individual patients or during larger brigades.  We’ve also included a dry erase board and markers that they can use to improvise additional lessons.  They also requested additional medical supplies, including an adult scale, masks, suture kits, a WHO Colour Scale, a sharps container and a pediatric blood pressure cuff, some of which we have been able to find in Quito. We also need to find new containers for urine samples, since they only use sterile cups here.  We hope that once we finalize these changes we will be able to take the CHO pack on another brigade to assess the impact of these improvements.

Reviewing our new educational materials with Angel and Evita before printing the final copies.

OB/GYN Pack

This issue of sterility has posed several major challenges for the implementation of the OB/GYN backpack.  Patients here will not use speculums that have been used on other women, even if they’ve been properly sterilized.  Instead, they use disposable speculums.  Furthermore, the obstetricians use individually-packaged spatulas and brushes in order to keep them sterile, whereas those in the backpack are contained in one large bag.  Until these changes are made, we are unable to use the backpack in the field.  In the meantime, we have translated the backpack’s educational materials into Spanish, and have discussed the frequency of use of each of the backpack’s procedures.  While pap smears and birth control counseling are common, the doctors at the clinic do not perform biopsies, but rather refer patients to a larger hospital.

We are eager to finalize these modifications so that we can bring the new and improved versions into the field for use with patients.

FYI: Given the unreliable internet situation, Lila and I have decided to split up blogging responsibilities so that our entries do not overlap.  To read about our experience in its entirety, visit ecuador.blogs.rice.edu.  Thanks for reading!

Wednesday marked our first day back in Planchaloma and another medical brigade to Yugsiche Alto. This time we were accompanied by Maria Alicia, Monica, a gynecologist at the clinic, and Don Juan, another health promoter from Planchaloma. When our truck pulled up to the school, we were greeted by a mass of smiling kids running up to greet and hug us. They even remembered our names! Once we got them to settle down a bit, Maria Alicia reviewed with the kids and parents what Lila and I had taught them the last week about hand hygiene and recycling. And they did very well on their little quiz! They remembered the important points that we covered the in our lesson week before. This is great news for Lila and me: our ‘charlitas’ with the kids are a success! The kids are actually learning and retaining the knowledge that we give them. Now, we just hope that they are using it as well.

During the brigade, the doctors from the clinic, including Lorena and Monica, took every child’s height and weight. Sandra, a health promoter in training, sat behind a small table and gave the kids bottles of multivitamins. Monica also gave all of the kids de-parasiting pills, which essentially will detox them of all the parasites that linger in their bodies and could potentially cause them extreme harm. Lila showed the ever-curious kids all of the devices in the backpack and how they worked. She also took care of various cuts, scrapes, and burns that the kids complained to her about by using the First Aid items in the CHO pack. After the wounds were taken care of, the kids found serious interest in Sally, which she demonstrated to them and let them take turns pushing the button for the allotted 10 minutes. I had most, if not all, of the adults ask me to take their blood pressure and glucose, a few of them telling me they were concerned about their health because of diabetes. I used the glucometer, test strips and antiseptic wipes from the Lab-in-a-Backpack to test their blood glucose levels and also used the blood pressure cuff from this backpack. There were no more lancets in the Lab-in-a-Backpack, so I used the ones from the CHO pack. I tested over 25 people and of these, one woman had a glucose level of 319. This is extremely high, given that normal is between 80 and 120. When I told her this, she said she knew that she has diabetes and has painful headaches all of the time. I asked her if she had medicine for this or if she had even been to the clinic to see a doctor about her condition. She responded no because she didn’t know that they could help her or give her medicine.

The kids using Lila´s Sally Centrifuge

After the brigade, the teacher and parents expressed their thanks to us and the doctors and health promoters that had done so much for them. In particular, the woman whom I had spoken to about her serious condition stood up and said that, if not for this brigade, she would never have known that anyone could help her, let alone give her medicine to help get her condition under control. She, along with other families, declared that they would be visiting the clinic in Planchaloma very soon.

The kids curiously watching as I take their teacher´s blood pressure

Once back at the clinic, Maria Alicia thought it would be a good idea for me to teach everyone who works at the clinic how to use the glucometer. It is a very simple machine to use and they caught on quickly. Now the health promoters as well as the doctors can use it for patients. Also, after seeing me use the blood pressure cuff on the patients in the clinic one day, Marta asked me if it was easy and if I could teach her how to use it. So, this next technology lesson will hopefully take place tomorrow, in which I will teach the health promoters in Planchaloma how to use and read the blood pressure cuff.

FYI: Given the unreliable internet situation, Lila and I have decided to split up blogging responsibilities so that our entries do not overlap.  To read about our experience in its entirety, visit ecuador.blogs.rice.edu.  Thanks for reading!

This weekend was also successful in terms of my project. In Planchaloma, Lila and I noticed that there are plastic bottles, wrappers, cutlery and bags strewn all over: in the streets, bushes, pig pens and fields. Also, since there is no garbage truck that comes by to pick up the trash in the area, so the promoters at the clinic throw all the trash in a large hole in the back of the clinic and burn it. I thought this would be a good time to practice what we preach, so I decided to start a recycling system in the clinic in Planchaloma, and eventually one in Yatzaputzan.

The night before we left Quito, Maria Alicia brought me to MegaKvwi, where I was able to buy 6 large recycling bins to put in the clinics. The bins are absolutely perfect and were just what I was looking for. Since there are no recycling trucks that come by the community and it would be too costly to get a company in an near-by town to come pick it up, I settled on an alternative mode of transportation. I found a recycling company in Quito that will buy the recycled glass, plastic and paper. Since Maria Alicia visits the clinics very often, once or twice a month, she agreed to pick up the bags of recycled items when she visits, bring them back with her to Quito, and sell them to the recycling company. She has also told me that she feels very strongly about recycling and will make sure that the clinic’s members are indeed using the system that we have set up for them. On Wednesday, I set up the bins in the clinic and Marta, the health promoter, and both Lorena and Monica thought they looked very nice and all thanked me for starting such a simple system that will benefit the community and environment in the long run. Each of the bins are conveniently labeled with a list of what items should be put in them. However, today Lila and I remembered being told that some of the people who come into the clinic can’t read Spanish or even Quichua. So I placed signs above each of the bins with pictures of what should be recycled into that particular bin. I officially recycled the first items yesterday: a Mac&Cheese box and a jam jar (this should speak volumes about our diet here…).

Marta and I and the clinic´s new recycling bins

However, I feel that setting up the bins and transportation of the recyclables is not enough. I really want to find a safer way for the clinic to dispose of their trash. Such a large fire so close to the clinic can never be good. And after several years, the trash will eventually begin to pile up. Of course, all they have to do is dig a new hole, but that would make the back of the clinic a kind of landfill. Maria Alicia said trash disposal here is a complicated matter, but I am still working to find a safer and convenient way for the clinic to get rid of their trash.

FYI: Given the unreliable internet situation, Lila and I have decided to split up blogging responsibilities so that our entries do not overlap. To read about our experience in its entirety, visit ecuador.blogs.rice.edu. Thanks for reading!

Lila and I on our carriage ride though Quito

After arriving back in the much warmer city of Quito, we spent our weekend being the ultimate tourists. On Saturday we accompanied Maria Alicia to the Historic District of Quito. While she had a business workshop to lead, we had a few hours to explore all that the city had to offer. We began by taking a tour of the most ornate cathedral in the whole country of Ecuador. It took 160 years and over 100 pounds of gold to complete it. We then took a 20 minute carriage ride (with the horse and all!) around the Historic District and scoped out some more places to visit. We bought guanabana-flavored ice cream and visited a few of the shops that are in the plaza. We bought movies, sweets, souvenirs, handicrafts, and a new digital thermometer for the CHO pack, since the one that was in it initially was inaccurate by a few degrees. We also found a few pharmacies in this area that could possibly have the items needed to restock the backpacks when the time comes.

On Sunday, Maria Alicia and her adventurous mom Marta took us to La Mitad del Mundo: The Middle of the World. There is a large monument in the small town of San Antonio where the latitude is 0*0’0”. At this spot, the equator is perfectly perpendicular to the solstice line, the path that the sun takes on the longest day of the year. After taking an endless amount of pictures, we could not resist the urge to shop some more, especially since there were so many of our favorite cute, bargain-priced shops selling local handicrafts. We finished the day off with a delicious lunch, a mound of chocolate ice cream, and a quick glide on the mini-zipline in the kid’s park. It took some convincing but we finally got Maria Alicia to give it a try; and she had a blast.

Lila and I at La Mitad del Mundo

Of course being back in Quito didn’t mean all fun and no work. On Monday and Tuesday we went back to the Fundacion office and started working on some more education materials for the lessons that we’ve been doing at the schools in Planchaloma. In our ‘charlita’ on handwashing and recycling, we decided to add another topic: nutrition. Many of the kids, and even parents, here are not getting all the vitamins and minerals they need to stay healthy and prevent sickness, especially in these conditions (such as non-potable water). In our lesson we will talk about what kinds of vitamins and minerals we need to stay healthy. We will talk about the kinds of foods that our bodies need and how much of each kind of food we should be eating per day. We also decided that the kids would get more out of the lesson if it were interactive; so we made it a sort of game. We made a large poster of a colored food pyramid, minus the food items. We printed and laminated pictures of various food items and, after our lesson, the kids have to place the food items in the right category. During our lesson at the next escuelita, we are hoping to incorporate our nutrition lesson into our talk and see what kind of response we get.

Having returned to Quito with María Alicia on Thursday, we made out second visit to Yatzaputzan early Friday morning.  This time, rather than working with the women’s cooperative, we were able to meet with the staff at the clinic in order to get feedback on the technologies we brought with us.

Though Amanda’s AccuDose syringe clips have not arrived yet (fingers crossed that they’ll be ready soon!) she had the opportunity to discuss the design with the “promotores de salud,” Fundación Futuro’s version of community health outreach workers.  Overall, the staff seemed very excited about the idea and certainly thought that the clips would help prevent overdosing.  They use 5 mL syringes and doses range from 1.5 mL to 3.5 mL, so we are hoping that the clips that are currently being made at Rice will be compatible.

We also reviewed the CHO pack with the promotores, who gave us great feedback on the design.  They told us that they do use everything currently in the pack, but they also requested an adult scale, thermometer (ours broke) and a pediatric blood pressure cuff (which we were unable to find in time for our trip).  Also, one of the main responsibilities of the promotores is health education in the community, so they liked our idea of including educational materials such as flipbooks and diagrams related to hygiene, family planning, vaccinations and nutrition in the backpack, something we’ll be working on developing this week.

Finally, we demonstrated Sally, the salad spinner centrifuge, to the promotores.  Again, they were disappointed that it required 10 minutes of spinning, but expressed that it would be useful in their clinic, which occasionally loses power.  Their apparent favorite aspect of the design was the reader cards.  Anemic hematocrit levels depend on age and gender (i.e. hematocrit of 38 is healthy for women but not men), so Lauren and I designed a set of reader cards (seen above) to accompany Sally that indicate anemia levels directly on the chart, making it eaiser to diagnose the condition.  With these reader cards, they would be able to test for anemia without the lab technician who visits only once a week.  While we’re working in Quito this week, we hope to make a similar set of reader cards for ZIPocrit so that they can screen for anemia more frequently.

On Wednesday of last week we spent the day at a school in Yugische Alto–about a 30 minute drive from Plancha–doing our recycling and hand-washing charlita with the kids as well holding a mini-medical brigade.

The doctors in Planchaloma were hoping to use Sally to screen the kids for anemia, but since it’s not ready for use on patients yet, we suggested using the tools in their lab-in-a-backpack instead.  Currently, the health center in Planchaloma lacks a lab technician, so they haven’t been able to use the lab-in-a-backpack as planned, but Amanda and I realized that there are many technologies in the backpack that with a quick training, the doctors and nurses could easily use themselves.  One such device is the ZIPocrit (the electrical centrifuge used to find hematocrit and diagnose anemia) that we used many times to evaluate Sally in the lab.

We arrived at the school, and the kids were really excited to see us once Nicolas, the clinic administrator, reassured them that they would not be getting any shots (little did they know that we would be pricking their fingers ).  They responded really well to the talk, and it was great to do it in front of the doctors and nurses from the clinic so that we can get their feedback on ways to improve the lesson.  After the educational portion of the visit, we went ahead with the plan to screen the kids for anemia using the lab-in-a-backpack.  While the process initially seemed straightforward enough, we ran into some problems.

We quickly realized that one finger prick on the small children did not produce enough blood to adequately fill the capillary tubes currently in the lab-in-a-backpack.  We went ahead and centrifuged the blood we were able to collect, hoping to use the tape measure to determine packed cell volume, but after five minutes in the ZIPocrit, the blood had not separated, and instead had clotted.  We believe that this can be easily fixed by using smaller, heparinized capillary tubes like the ones we brought to use with Sally.  That way, we wouldn’t need so much blood and the blood would not clot.

Since we didn’t have the alternate capillary tubes with us, we went ahead and used the WHO Color Scale with the kids, which was much easier to use.   It requires much less blood and is ready for interpretation in 30 seconds.  We discussed this semester in our independent research class that the flaw in the color scale is that its results are very subjective, which we did find to be true, but it seemed to be the best option given the constraints of the environment.

One big take-away from the trip was that contrary to their preconceptions, doctors, nurses and community health outreach workers can perform many of the tests in the lab-in-a-backpack without the help of a lab-technician.  Because lab technicians are unavailable to many clinics, we believe that with a quick training, these medical professionals can diagnose diseases that they currently do not even screen for.  This was a theme that would also present itself in Yatzaputzan…

FYI: Given the unreliable internet situation, Lila and I have decided to split up blogging responsibilities so that our entries do not overlap.  To read about our experience in its entirety, visit ecuador.blogs.rice.edu.  Thanks for reading!

Lila and I giving our "charlita" at the school

After Lorena took our lesson posters to get them bound, we set off to give hygiene lessons to the students of Chisulchi Grande and Chisulchi Chico. These are two smalls schools in the communities about 30 minutes away from Planchaloma. On Friday and Saturday, we went with Nicolas to Chusulchi Grande to give the kids lessons on “Cuando y Como Lavarse las Manos” and “Por Que es Importante de Reciclaje” For the handwashing lesson, we have an interactive activity in which we use glitter to represent germs: Lila and I put glitter on our hands and then shook every student’s hand, and had them shake someone else’ hand, in order to show how germs spread. We also had a short sorting game for the recycling lesson in which the kids have a bag of items and have to decide whether each item should be recycled as Paper, Glass or Plastic. On Tuesday, we went to Chisulchi Chico to give the same lessons to a group of younger kids. All in all, the kids seemed to get the message of the lesson and really liked the activities. They were very attentive and engaged. Nicolas has a whole slew of schools that he wants us to visit within the next few weeks, to which we will be giving the same “charlita”, or little talk, to the students there as well.

Me explaining the recycling game

The kids and Lila engaged in the activity

Living in the clinic at Planchaloma has taught Lila and me a bit more about the constraints of the developing world. For the first few days, we had to take ice-cold showers because there was no water heater installed. There were also some electricity problems for the first few days. But we learned to cook and get along with only the minimal light of our solar powered flashlights (great idea, BTB!). Internet is also impossible to come by in the clinic itself, so we venture down the street to a conveniently located internet café. Worst of all: Planchaloma is very cold. We are over 9,000 feet in the mountains and the clinic is not heated. At night, we lock ourselves in our room to keep in the heat from the small space heater.

However, we are still immensely fortunate compared to the living conditions of the people in the community, who don’t have electricity, filtered water, a heater (or water heater for showers for that matter), or the luxury to spend $1 an hour for internet at the local café. Lila and I are by no means “roughing it”, but the conditions have put us out of our comfort zones. This is how the people in these communities live every day, and to us it’s uncomfortable; but to them, its home.

We arrived in Planchaloma on Thursday with María Alicia, Richard and Lorena.  Richard is a Belgian/German/Ecuadorian chemical engineer who is collaborating with Fundación Futuro in an agriculture project.  The aim of the project is to introduce canola as a crop here and eventually build a refinery so that people here can sell all-natural canola oil to restaurants in Quito.  It was so interesting to learn more about this out-of-the-box way to grow the economy in Planchaloma.  Lorena is a local sociology student who is also working with a foundation in downtown Quito.  She is shadowing María Alicia in order to learn more about how microfinance works so that her organization can implement it with the urban poor.  Having spent extended time in the US, she has been especially great in helping us navigate some of the cultural differences we have already encountered here in Planchaloma.

After a quick introduction to the health center here and a trip to Latacunga for “chugchucaras” (a typical local meal of pork, plantains, potatoes and empanadas) and groceries, we finally settled in at our new home.  We are staying in a room in the corner of the clinic with bunkbeds, a kitchen, and showers (which as of this morning provide hot water!).

The community is absolutely lovely.  The town itself (no more than 30 small buildings) is nestled in the mountains with Cotopaxi (the volcano that lends its name to the province) directly out our window.  Walking down the cobblestone street in front of the clinic, we immediately find freely-roaming pigs, cows, donkeys and sheep.  Everyone here has been so welcoming and generous.  The experience is more than worth the lack of amenities like consistent power, warm showers and familiar food.

We spent Friday getting to know the clinics staff–Nicolas, the system administrator; Marta, the health promoter; Lorena, the nurse; as well as the general medicine doctor, OBGYN specialist and dentist.  After observing the clinic’s routine for a while, we rode with the regional president (who was elected to preside over the communities in a 2-hour drive radius) to a local school to teach about hand washing.  We got to meet the children there as well as their parents, who came for the Día de los Niños festival.  They were so welcoming–especially the little kids who each shook our hands one by one.

Saturday is the clinic’s busiest day, but we managed to find time to demonstrate the backpacks to the staff there.  They seemed enthusiastic about the contents, but we are slightly concerned that they don’t need the backpacks so much as they need the supplies since Marta told us that they’ve been doing fewer brigades in recent years.  The real test will come on Wednesday when we go on our first medical brigade!

We spent this morning (a half-day for the clinic) demonstrating Sally to Nicolas, who really liked the concept of the centrifuge, but was disappointed that it wasn’t ready to test on patients.  We hope that somewhere down the line we will have Sally at that stage of development!

We’ll spend the rest of the week in two more schools and then on the medical brigade before returning to Quito for the weekend.

Sally–the salad spinner centrifuge Lauren, Kelly, Nazima and I have spent the past year developing–made her Ecuador debut today!  Amanda and I drew six samples of blood and demonstrated the centrifugation process to María Alicia, Marisol, Daniel (a volunteer at the office) and a member of the custodial staff.  We centrifuged all six at the same time (meaning that one of the five comb segments was holding two blood samples).  The staff at Fundacíon Futuro seemed excited about the process for collecting  blood samples and loading them into the centrifuge, but was ostensibly disappointed that it would take 10 minutes of spinning for the blood to separate, a known disadvantage of the device.  However, everyone was surprised at how quickly the time passed, and so excited for the results!  Everyone took turns using the adapted reader cards, and they appreciated that we had marked the anemic zones directly on the reader card.  While we did not run control samples in the Zipocrit, the benchtop model widely used in the US, Sally seemed to work beautifully!  There was one exception: one blood sample did not entirely separate, leaving a pinkish region occupying about one-fifth of the blood volume.  We observed severalpossible reasons for this anomoly.  First, when we drew this sample, we were having difficulty collecting enough blood, creating three large air bubbles.  Of the other samples, there was a small bubble in about half of them, but not as big or as many as in this unsuccessful sample.  On that note, it was exciting to see that for all samples with bubbles, Sally worked well enough to force out the air, something that we had struggled with in lab.  Second, this blood sample was the one sample that was not centered within a comb; it was at the extreme end of one of the combs, although I did make sure that it was still lined up with the middle correctly.  The other possibility is that we drew this blood sample last, meaning that it had the least amount of time to separate naturally via gravity.  Hopefully we will be able to determine what exactly caused the problem when we take it to the communities.  Overall everyone at Fundación Futuro seemed very, very excited about Sally, so we are eager to see what the health promoters in Plancha Loma think about the design.

FYI: Given the unreliable internet situation, Lila and I have decided to split up blogging responsibilities so that our entries do not overlap.  To read about our experience in its entirety, visit ecuador.blogs.rice.edu.  Thanks for reading!

We took yet another day-trip on Saturday to Otavalo, a town about 2 hours north of Quito. On the way, we passed the Equator and a large sign welcoming us to “La Mitad del Mundo.” It was so cool that we were able to be in both the Northern and Southern Hemispheres at the same time! And once we were in Otavalo, there was non-stop shopping. Otavalo is essentially a massive outdoor market where locals sell their handicrafts. We were accompanied by Marta, Maria Alicia’s clever and savvy mother who showed us Americanas a thing or two about bargaining with Ecuadorians. Lila and I spent the day haggling for our souvenirs and finished it off with another traditional Ecuadorian-style meal, which included the inescapable Ají, along with moté, queso and llapingachos.

The sickness has struck.

Unfortunately, after our wonderful trip to Otavalo, I became very ill. Maria Alicia called a doctor to the house to make sure it was nothing very serious. Fortunately, it was simply due to the drastic and sudden change in my diet; the doctor gave me medicine and the order to rest so my body could adjust. I stayed at home in bed on Sunday and Monday to give my body time to recover and returned to the office on Tuesday to help Lila finish up the hand-washing and recycling posters. Lila also brought her Sally Centrifuge in order to demonstrate it for everyone here in the office, including Maria Alicia and Marisol. On Thursday, we will be leaving Quito and heading out for Planchaloma. We are excited to finally see the community and clinic there and to get to work with the Backpacks and Sally.

At our desks in the Fundacion office.