Travel Fellowship Report

After hiking Peru’s Machu Picchu Trail, Renee Morales spent a month in Ecuador working with a program that combined language instruction with urban and rural clinical experiences. Photos courtesy of Renee Morales.

What is a girl to do when she wants to become a doctor but learns in college that she really does not like science, at least not enough to major in biology or chemistry? I faced that question about 10 years ago, and it took me a while to discover the answer: Spanish, plain and simple. Although I hated Spanish in high school, I found that in college I absolutely adored it. And a major made perfect sense since the Spanish-speaking population is exploding in the United States. It also opened the door for me to develop a deep passion for travel. Since then I have spent time in Mexico, Spain, and Costa Rica, improving my proficiency in Spanish, and I knew that a new adventure in a Spanish-speaking country awaited me during my fourth year of medical school.

In my third year, I fell in love with ob-gyn. It just so happens that ob-gyn and pediatrics are the two fields with the most patients who speak only Spanish. So when a few of my friends found a program in Ecuador, I became very interested. In Cacha Medical Spanish Institute, or Cachamsi, I found the perfect combination of additional language training with an organized opportunity to learn about medicine and patient care, specific to ob-gyn, in a Spanish-speaking country.

For years, I have wanted to hike the Machu Picchu Trail in Peru. It is an arduous, 26-mile hike through the Andes Mountains over four days that culminates in a magnificent display of perhaps the most famous Incan ruins. Since Peru is just south of Ecuador, my traveling buddy and I decided to leave a week early so we could climb the Inca Trail before our four weeks of school. This trek proved to be one of the most fun and challenging expeditions I have ever undertaken. We ascended from 2,700 meters to 4,200 meters and then back down to 2,700. At the end of the four days of hiking, many times in the pouring rain, we were rewarded with a beautiful sunrise over the ancient city and spent the rest of the morning learning about the mysteries of Machu Picchu.

From Peru, we flew to Quito and took a four-hour bus ride to Riobamba, the city located in the highlands of Ecuador where we would spend the next four weeks learning Spanish, working in hospitals, and also working with the indigenous people of Cacha. We alternated mornings either in the hospital or out in the countryside, where I was able to observe a hysterectomy. What a different world! Their surgical suites and equipment were not disposable, the patient was draped and prepped with cloth sheets, and the surgeons wore cloth gowns. They sutured everything with the same suture, and at the end of the surgery, they closed her up with mattress stitches—not a stapler or subcuticular stitch.

My last two weeks were spent at Hospital Policlinica; I rounded with the ob-gyn team in the mornings. I really enjoyed going there. There were big rooms filled with about six people per room. They all had a smattering of problems; some of them were postdelivery, some were still pregnant, some were in labor, and some were postsurgery. There was no privacy with our visits, no curtains to pull shut. They did close the ward to visitors, but if someone was pregnant and needed to be checked, the doctor did it in front of the other patients. Of course, the other patients really did not pay much attention while we made our rounds and evaluated each patient. Curiously, the hospital had no towels; after washing his hands, the doctor would dry them on the patients’ bed blankets. In fact, the patients had to bring their own toilet paper.

Unfortunately, I was unable to attend a delivery. However, I saw a lot of postpartum women. There was no nursery—the mothers immediately started taking care of their babies, breast-feeding them (never saw a bottle in the hospital) and sharing their hospital beds with them. They bathed their babies themselves in the morning, and really, it appeared that giving birth was rather routine, and the women carried on after childbirth hardly missing a beat.

In the mornings that we did not go to a hospital, we went into the Cacha countryside to provide manpower for the makeshift clinics and to visit the schools to give the children physicals. We worked under Dr. Viviana Aguirre. To become a doctor in Ecuador, one enters six years of medical school after high school, at the cost of about $400 a semester. One year of internship and one year of obligatory rural medicine follow; Dr. Aguirre was doing her obligatory rural medicine year.

On my first day in Cacha, a family with four children came in for checkups. They were all disastrously dirty. My patient was a seven-and-a-half year-old girl who weighed only 17 kilograms (37.4 pounds). She was terribly undernourished, and we learned that her diet consisted of coffee in the morning; rice, potatoes, or maybe pasta at lunch; and coffee for dinner. This area of Ecuador is very poor, and her story is the norm, not the exception. I never had a patient from the indigenous community over the 5th percentile in weight or height on the growth chart. We gave out antiparasitics and vitamins like candy; however, it is doubtful that the parents really ever completed the treatment. The thing about this community is that they do not have clean running water or functioning sewers. We all realized quickly that for the most part, our efforts to provide medical care were not a solution to their medical problems but rather an inadequate effort that would never have lasting effects until sewers and clean running water were a reality.

Another obstacle to health care and health in general in this area is the distrust of modern medicine by the Cacha people. They are a poor people who often wait until their disease processes are far too advanced to seek treatment. They cannot and, in many cases, will not leave their homes because there is no one else to care for their animals. Incidentally, they rarely eat their animals, but they sell them and buy cheaper, less nutritious food to eat.

Such was the case of a woman who came into the clinic for severe abdominal pain. She was jaundiced, could not eat, and had a severely tender abdomen, and we could tell she had lost a lot of weight by comparing her identification card photo with her current sallow, thin face. We told her there was nothing we could do for her in the clinic and that she needed to go to the hospital for further evaluation. She said she did not have any money or anyone to care for her chickens at home and that she just wanted a pill for the pain. We did not have anything to offer her except a requisition to the hospital. She said she would have to wait two days before she would have transportation to the hospital, but Dr. Aguirre told her that she might not have two days. She was lost to follow-up, and I wish I knew how her story ended.

Our last week in Cacha was spent celebrating their 26th anniversary of self-government. There were parades, and the director of our program, Dr. Jorge Duchicela, flew in for the festivities. He is a family medicine doctor who practices in Texas and a member of one of the prominent Cachan families. He founded the Cacha Medical Spanish Institute to help provide medical and financial support to this indigenous community and to give health care professionals an opportunity to study Spanish and Ecuadorian culture.

Every afternoon, we had two hours of language instruction. There were two classes: one for people who already knew a good bit of Spanish, and the other for those needing more basic instruction. Our Spanish professor, Dr. Marcelo Salas, was a very educated and capable Riobamban native who took a special interest in each of us as we progressed. He is truly my favorite Spanish teacher ever. We even had a class field trip to a soccer game!

On the weekends, different classmates from Cachamsi and I would travel to various areas in Ecuador. The first weekend, we went to Puyo, a small city on the outskirts of the jungle. The hot, humid climate was entirely different from the cool, dry highlands. We visited a botanical garden run by an indigenous tribe and went on a hike on which they taught us about medicinal plants and indigenous culture. The second weekend, we traveled to Otavalo and the equator, “La Mitad del Mundo” or “the Middle of the World,” place where on one side, draining water swirls clockwise and on the other, counterclockwise! Otavalo is about two hours north of Quito and is home to the biggest, most famous market in all of Ecuador. The last weekend, we stayed in Riobamba for a festival celebrating independence from Spain. We took part in the festivities by attending numerous parades and even a bullfight!

Our four weeks in Ecuador seemed to fly. During our last week, we went to the Galapagos, where we saw the most amazing flora and fauna! We spent eight days on a 50-foot sailboat traveling from island to island. We saw whales, dolphins, sharks, fish, flamingos, turtles, iguanas, blue-footed boobies, albatrosses, frigate birds, sea lions, and even penguins! The Galapagos Islands are made from volcano lava of various ages, which makes for incredibly interesting terrains and beaches specific to each island. It was such a marvelous, special place—a wonderful place to end my career as a medical student!