No Vale la Pena, or Why a Chief of Medicine Aspires to Become a Taxi Driver

My first day in the Puyo clinic, and things were rather slow. This seems to be a pretty common theme in this tiny city of ~35,000, everyone claims that they prefer Puyo to Quito because it’s “mucho más tranquilo”. And although tranquilo is a kind of a false cognate (it translates more directly to “quiet” than to “tranquil”) I can’t help but feel that the connotations surrounding the word “tranquil” actually do the city better justice. It’s situated a on the edge of the Amazon rainforest in the crotch of the “Y” at the intersection between the lazily meandering Río Puyo and the larger Río Pastaza. Everyone seems to know each other, and the whole city is within walking distance.

And so, on a lazy day, my host doctor and I sat in his office chatting, but when I began to ask him about his life as a doctor he became noticeably agitated. He was eager to talk about his situation, but it didn’t make him very happy. There’s a sort of general unrest about the state of the government right now in Ecuador, but it seems that doctors have been acutely adversely affected. While the government has been commendably spending a ton of money to subsidize/promote quality education (although unfortunately the majority of the money has been going to top students/schools, rather than being more evenly distributed), there has been a burgeoning mistrust for medical professionals. Wages have plummeted as the boundaries for what constitutes medical malpractice have  broadened, and this creates quite the uncomfortable environment for the current Ecuadorian doctor.

Dr. Jimenez, general surgeon and chief of medicine at a small but high-end government-run hospital, makes under $22,000 per year. Granted, there is a lower cost of living in Ecuador than in the US, but it is apparent that the salary is not substantial enough. With the growing prevalence of lawsuits, skyrocketing lawyer fees, and the inherent need for doctors to be part of a global community/market, this is clearly not  an adequate salary for a doctor, let alone a chief of surgery. To stay on top of his craft, Dr. Jimenez explained to me how he studies for hours each night after he returns home. But even to do this, he’s got to buy the latest medical textbooks, which run upwards of $300.00 each. That’s a quarter of his monthly paycheck gone, just to try to stay up-to-date. It’s just not sustainable.

But the government has been reducing salaries while tightening regulations. Initially you might think that it’s a good thing to tighten the rules to regulate malpractice, but when doctors live in legitimate fear of being thrown in jail for a misdiagnosis or flawed treatment, it’s impossible for them to work at full efficiency.

It’s like you’re shooting a free throw at the end of a basketball game. There’s tons of pressure, and even the best shooters in the world are going to miss once in a great while. But for doctors, rather than maybe losing a basketball game, they get tossed in jail.

No vale la pena” (It’s just not worth the pain).

Dr. Jimenez sat pondering the state of medical affairs and eventually looked at me and said, “It’s just not worth it, I can’t keep this up for much longer. Once my kids are out of college, I’m going to try something new”. When I asked him what he was thinking, he responded, “I’ve put some thought in… think I’m going to become a taxi driver”.

Guinea Pigs and Shamans

Two weeks into my Urban/Rural comparative health, and I finally had the chance to see the rural side of the Ecuadorian healthcare system. It involved a shaman, some oily rocks, rhythmic chants, and a (briefly) living guinea pig.

I had spent my first two weeks in bustling Quito, the  vibrant capital city of Ecuador, shadowing doctors in standard western practice hospitals. It was a great experience watching surgeries, learning how to conduct patient interviews and examinations in Spanish, and picking doctors’ brains about various specialties and their lifestyle implications. In all, an incredible experience, but not unlike those I had in Chile last year, or those I would have been able to have in the States if I had remained at home this summer.

In our meeting with Quito’s CFHI medical director, we were warned that the traditional medical methods practiced by portions of Ecuador’s indigenous population could be quite shocking to the unprepared—Ecuadorian and foreigner alike. But even then, we had no idea what was in store when we stepped through the door into the Jambi Huasi alternative clinic in the town of Otavalo. After getting a tour and basic overview of the services offered by the ~10 bed indigenous clinic, we were notified that a limpia con cuy was about to start downstairs, and the four of us were bustled into the room to quietly observe. A limpa con cuy directly translates to “wash with a guinea pig”, and is pretty much exactly what it sounds like, only about a million times less cute.

The patient and shaman, both weather-wizened older ladies still spry and full of energy, chatted amicably while the former disrobed. Once she was down to her undergarments, the limpia began. Still distrustful of Western medicine, some indigenous people maintain the belief that a “copy”—for lack of a better term—of one’s malady can be transferred into the body of a guinea pig and that the guinea pig can be examined to decide on the best course of action. This transfer is made by vigorously scrubbing the patient’s body up-and-down with a live guinea pig. The scrub continues, with the poor animal flopping like a rag-doll by its neck and feet until its squeaking subsides and eventually stops altogether.

Once the cuy had stopped squeaking, our patient re-clothed herself and pulled up a chair to hover over the shining steel washbasin procured by the shaman. With a few deft cuts, the shaman had the cuy skinned and disemboweled, leaving only the thoracic organs, liver, and kidneys. Setting aside her knife, the shaman spent more than 30 minutes poring over of animal’s remains with the patient, pointing out abnormalities and explaining their significance within the patient’s body. As the two conferred mostly in the indigenous Quichua language, we weren’t able to decipher much, but in the end it appeared that the guinea pig’s entrails suggested a pending renal failure in the patient. She stood up and gravely thanked the shaman, nodded to us, the pale foreign observers, and exited with dignity.

As an outsider, I was initially shocked at the seemingly pointless, wasteful and overly brutal nature of the ritual. But then my conversations with the shaman led me to believe that she wasn’t a mean person. And her stolid belief in the worth of her ritual, combined with the complete, faithful confidence of the patient, forced me to take pause and try to shed my cultural bias, to try to understand that the ritual is important and valid from the point of view of the believers. So although I still cannot personally understand the value of the ritual, I have a hard time condemning the continuation a practice that has been passed on by the Quichua ancestors, generation to generation for thousands of years.

After that eye-opening experience, I returned to Quito to head off to Chone, the coastal town where I will be continuing the rural portion of my comparative program. For the next two weeks I will be shadowing with five of my peers in the much more traditional, though somewhat undersupplied, hospital Napolean Davida. I’m very excited to get back into the western hospital setting and to continue working to grow within and understand the healthcare system in place here.