We will be heading out shortly for our last day in the villages. There will be an open house / celebration in the town of Chaquisqua, where I went with the SNEM men to look for bugs. All the people in the region have been invited. The schools have been closed. There will be presentations of our results and thank yous on all sides, door prizes ( the gifts for children we brought) and I think a community meal.

Rather than the long over night bus ride Saturday night, I will be heading back to Quito tomorrow mid day with the Ecuadoran staff in their vehicles. They plan to make the 15 hour trip in two days. I am looking forward to spending more time with them and seeing the scenery, instead of drugged and sick in the bus. So I will arrive in Quito Sunday afternoon / evening and be heading home on Monday!

David Drozek, D.O.

Thursday, July 12

Seven students went to the hospital with me this morning. Almost as soon as we arrived, two were sent to observe in the ER, as two ambulances had just arrived. The rest of us went to the hospital wards for grand rounds, which were done in the old school way, that is no longer acceptable in the states with our privacy laws.

As a group, we passed from bed to bed, publically, and rather impersonally discussing each patient. An intern who previously in the morning had examined the patient and gathered x-ray and lab results, presented the case in detail, answering questions from the staff physicians. Then one of the staff physicians gave a mini lecture about the case and what the treatment should be. Only then was the patient actually talked to, and maybe examined. A list of things to be done was given to the intern, and we moved on to the next patient. We saw about 6-7 patients in this fashion.

Then it was clinic time. While the interns went about their work, we paired our students up with the clinic physicians, two students per doctor, to see patients together.

We plan to meet back together for lunch at noon and debrief. It will be interesting to hear their impressions. There will be opportunity in the afternoon for a couple of them to return and work with the doctors on call, who will be manning the ER and handling any problems that come up for the inpatients.

More later.

David Drozek, D.O.

Wednesday, July 11

This morning I stayed in Cariamanga, our base town, to visit the hospital, and see what the possibilities are there for student experiences both short and long term. After breakfast I walked to the hospital and met the temporary director, an OB/GYN doc. The current director is on vacation. We talked a short time, and he introduced to me their surgeon. He was doing clinic and had a procedure this morning, so said he would call me when finished, after 10, to meet and discuss the possibilities. Both doctors said that they had been anticipating having our students work with them in the hospital, and are open to it, but when so few students applied to the program, this experience sadly was eliminated. They are willing to offer a tour to our students before we leave. We will discuss the timing and logistics of this later today.

Yesterday, we began work in the third and last village, La Palma. It was yet farther, more rural, and difficult to reach. The first hour was on a “highway” under construction; the next 20 minutes on rough road like we have been, and the final 25 minutes was like a commercial for off road vehicles. We literally could have walked faster than the car at most points.

Interestingly, even though the town was named “The Palm”, there was no palm, and no one could remember there ever being a palm tree there! I told them they needed to plant one in a protected space and grow it as a landmark.

It was difficult to call the community a “village” since there was a school attached to a church, and one visible home on top of a ridge. There were other homes widely scattered and visible in the distance from the point of the ridge. People could be seen climbing various trails carrying their stool and urine specimens, and probably their lunch too, in small bags.

Five teachers live at the school during the week, commuting in Monday morning, returning to their homes and families in Cariamango on Fridays. Their bedrooms are simple rooms, separated from the classrooms by a piece of drywall or plywood. Of all the villages we have visited, the teachers here seemed most concerned for the well being of their students. They personally approached me to tell me that their town and people were “abandoned” by the government, and presented several of their students with health issues for me to evaluate.

And yet, even here, there was electricity! When visiting homes looking for bugs, I always added my questions to the interview as we were waiting for the SNEM men to finish. Each home had an electric meter. I couldn’t imagine the job it would be to visit all these places regularly. So I asked about the electric bill. The monthly cost ranged from $3-5. The people paid on the honor system, taking their own reading to pay monthly at a central location. But they knew there was a possibility that someone would eventually come by and read their meter. They all told me of one person who lied, and owed over $100. He had his electricity cut off because he couldn’t pay. So everyone said they paid the correct amount regularly.

Most of the homes had bare bulbs hanging from wires draped over the frames in their roofs, which ranged from rough cut 2x4s to bamboo poles or crude tree branches. Everyone had a radio. Most had a pretty nice stereo system with speakers that could be heard booming through the valley as we approached. Most also had TV with antennas mounted in various positions and locations. Looking at the surrounding mountain tops, towers of various types were visible, supplying radio, television and cell phone coverage. People were generally proud of their government’s commitment to provide these services to even the most rural villages, to invest in the next generation, so everyone can have light to study by, and soon hopefully computer access to the world. All the schools were teaching computers and English to even young children.

Ecuador is fortunate to have an oil industry, which provides their major export, and funding for their national programs. Oil is seen as national resource, not to benefit only the rich and business owners. Diesel currently costs $1.04 / gallon, and gasoline under $1.50 in most locations I have seen. Interestingly there is a major black market smuggling operation, with one of its hubs in Tabloncillo, where we were for our first clinics. Diesel is about $5 / gallon in neighboring Peru, so it is quite profitable to load up a vehicle with fuel and sell it across the border.

Yesterday, the people in La Palma had a difficult time in the eye clinic. We brought about 1700 pair of used glasses from the states. They had been evaluated and marked with their prescription based on the right eye. So we center our attention on the right eye during our exam. This is not exact, since many of the glasses donated are bifocals, and also include a correction for astigmatism, which we don’t have the ability to measure and correct for. This sometimes leads to some distortion in vision even though the prescription may be correct.

Being more rural, I think the people had less exposure to technology, and struggled to understand how to perform our eye exams with our simple instruments. One devise we use is a focometer, which is basically a telescope. It needs to be held to the eye and the focusing tube turned until the patient can see clearly. Then we can read a crude prescription from the tube and look for glasses that work. I had to abandon the use of the focometer for most patients. Even though my Spanish is reasonable, and I modeled how to use the device, the older patients in particular were clueless. I went directly to our lens set, which was equally difficult. It is a series of lenses representing the spectrum of possibilities mounted on what looks like a paint stirring stick, five lenses per stick. The patient is to try each one until he finds the one that is most clear, which again gives us a starting place to look for glasses. Even this was difficult for many patients. They wanted to hold it on their nose, or position it so they could see through lenses with both eyes simultaneously. After finding glasses that seem appropriate, we recheck the vision with the eye chart while wearing the glasses. In several cases yesterday, even though there was no improvement in vision, the patients insisted they could see better and wanted the glasses! So, of course I let them have them, but felt we didn’t really have the best fit for them.

Cataracts were also a big problem here, which limits the ability to improve vision much with glasses. Pterygia were also common, a scarring that begins on the part of the eye nearest the noise, and spreads out over time to cover the pupil, the central portion of the eye critical for seeing. This is due to chronic exposure to dust and sunlight. We can’t help much with the dust, but we did give or recommend sunglasses for these folks. Surgery can be done for cataracts and pterygia, when bad enough, but would require going to a major city for an ophthalmologist.

I just received my call from Dr. Paredes at the hospital, so I am on my way! I hope my spelling and grammar are reasonable today.

David Drozek, D.O.

Tuesday, July 10

Yesterday was a bit different for me. Since the eye clinic is running well, and I am not really needed, I went into "the field" with the entomology group looking for the bugs that carry Chagas disease in the houses. The group I was in went to five houses. The team consisted of two "SNEM" men, from Sociedad National para la Exterminacion de Malaria, the National Society for the Extermination of Malaria, an architect, someone to take a survey, and others to help and observe. In addition to me, one of the French engineering students came along to observe / help.

The SNEM program has been so successful with malaria that it has been expanded to work on Dengue, another disease carried by Mosquitos, and on Chagas, the disease caused by a parasite transmitted by a class of bugs that feed on warm blooded animal blood, including humans. The make the circuit of all the houses in their district once a year teaching and exterminating by spaying the homes. When the TDI teams are here, they work with them, and help catch the bugs for DNA analysis.

While the SNEM men are looking for the bugs, the architect student measures and draws a floor plan of the house, including data about the age of the house, the building materials, and the condition. This data is used to correlate with the likelihood of having bugs, as well as determine the durability of building materials and identification of families that may need assistance in repair of their homes.

The survey questions included basic data such as names, ages and education level of everyone in the house, a brief health history, where they go for health care, family income, family employment, types of food that they grow, types of animals, water source and treatment, sanitation facilities, types of electrical devices, source of heat for cooking, and other questions.

At the end of the visit, the SNEM men post a calendar with pictures of the bugs to look for, and update extermination information that is kept in a plastic folder inside the front door of each house.

The trip in was over some pretty rugged road, following the river valley, but about half way between the mountain top and the river. The road was very narrow affording quite the view out the right side of the car, while the left side hugged the mountain.

While visiting the houses, We walked probably about 5 miles to visit a string of four houses. We started at the road, headed downhill, sometimes taking the wrong path and retracing our steps, following the zig zagged paths formed by years of erosion, used by man and animal.

I'm out of time and to see patients. I'll send this tonight. If I get beck in enough time, I'll write more.

David Drozek, D.O.

Friday, July 6 (part 2)

As we approached our hotel this evening, we encountered a crowd, barricaded streets, and piles of wood for bon fires. At first I bought maybe there was a protest, but then heard the music, saw the stage and the frame of a castle like structure, all strategically placed directly in front of our hotel. It is a weekend festival celebrating the wounded heart of Christ. There are live bands, with loud music amplified in typical Latino style. Some are quite good, others, not. The firecrackers have started sporadically in the streets. There is a large fireworks display planned for midnight, long after I had planned to be asleep. We still have breakfast at 6 tomorrow.

Mario is going to allow our team to go out as a group, under the watchful eye of our poor tired TDI staff. I took some pictures out the window of the band and the fires, will close the windows and try some white noise through my earbuds via my phone or iPad. I am afraid this won't be too helpful, especially since the music seems to be gaining tempo and volume and the bass is now a throb that permeates everything causing even the lights to vibrate.

Oh well. It is a cultural experience. Even though it is one that I am accustomed to, having lived near the dance hall in Balfate, and one i would gladly forgo, it is exciting for many others. Maybe a Dramanine or two will help for this too?

David Drozek, D.O.

Friday, July 6 (part 1)

Today half of our clinic team went to start in Usaime, while the other half went back to Tabloncillo to finish. The personnel logistics was complicated by the rotation of many of the student into or out of the clinic component of the program to or from the field work looking for bugs and squirrels.

We also had a slow start when we realized one of our critical (so we thought) bags for the eye clinic was left either in Tabloncillo 20 minutes away, or possibly even worse, in the hotel an hour and a half away. We began eye clinic with crude measurements using newspapers and school maps, which was sufficient to get us in the ballpark. We then lined up a series of glasses and began checking which worked best. About 2 hours into this, our lost bag arrived and we were able to resume our usual routine.

It is indeed a highlight to watch people smile as they read or see the cows on the hill for the first time in quite awhile.

As the lab folks are finishing, the students are playing volleyball. The teams include a few ecuatorians from TDI, but none of the locals are playing, despite bing invited. They actually set up the net when I jokingly suggested a game with the gringos against the equatorianos. I think the integrated teams are working better. The locals are watching and working as the backstop. The court is situated on a hillside, actually a mountainside with quite a drop off. If the ball got away, it may never be seen again!

The TDI staff is showing fatigue. They are up late each night, actually to 2:00 AM this morning, finishing the data preparation for the clinic the next day. The seem to be getting a head start on it this afternoon, so they hopefully will get some rest tonight.

We take Sunday off, so there is a party planned tomorrow evening at a nearby farm with a swimming pool. I am sure the young people are up to it, but I think I would prefer an early night to bed with a book. Sunday, there is a sign up sheet for a hike up a mountain. I plan to do an eye clinic for a group of handicapped children in the afternoon on sunday with a couple of students. I am not sure how well it will work. The students will need to be able to cooperate and communicate for us to be able to help much.

While writing I noticed the students had switched to basketball for a short time, but are now playing soccer, with a bit more participation by the locals.

It was hard to imagine a more beautiful setting for a brigade than Tabloncillo, which was situated on a small plain overlooking a river valley and the Peruvian Andes rising on the opposite side, with the Ecuadoran Andes peaking behind. But Usaime is higher, near the summit of one peak, with a fresh breeze, and a spectacular view of the surrounding mountains with some very steep and barren slopes. It definitely gives the sense of being near the top of the world.

David Drozek, D.O.

Soccer in Usaime

Usaime

Usaime

Wednesday, July 4

We are sitting on the side of a mountain watching the sunset, waiting for the rest of he team to be shuttled up the road from the village we have been working in. Our vans are too low to manage the ruts and bumps in the road, so we relied on our trucks to get us up and down the mountain side. The breeze is turning cooler and the sky flame from the rays of the setting sun.

The people in the village where we are working are pretty healthy. They are pretty free of western diseases; little diabetes or hypertension. No one is obese. They walk long distances up and down the mountains. It was pointed out by Dr. Katy that there are no little shops selling Pepsi or coca cola, chips or snacks of any kind. The litter on the ground is also devoid of evidence of unhealthy snacks and food.

The people appear to be subsistence farmers with little income. The village itself has a church and school, and only a handful of houses. The rest of the thirty families have walked up to 3 hours to get here. Surprisingly the little village does have running water and electricity. Certainly the cost of installing electricity in such a small rural village will never be offset by what little the people could pay. I am curious about the decision to run the electric lines to such a place. The decision was certainly more humanitarian than commercial in motivation.

It will be a late night tonight, as we need to head down the road in the dark.

David Drozek, D.O.

Tuesday, July 3

Breakfast at 6, we left for the village at about 6:40. I was fortunate to ride in a land cruiser like we had in Honduras, but the shorter version. It was owned by a research organization and driven by a British physician who is researching intestinal parasites with the organization.

Off we went, soon onto roads that were identical to those we drove over in Honduras between Jutiapa and Balfate, speed bumps and all! People wet down the stretch of road in front of their houses to keep the dust down. Dogs, pigs, burros and chickens were running everywhere. The houses looked like rural Honduras, as did the people. I felt at home!

The major differences, however, were the mountains and the climate. We were up in the peaks of the Andes, with a layer of clouds above us, and another layer below us obscuring the valley. It looked like an ocean at first glance. The landscape was dry, so we also drove through a cloud of dust kicked up by the vehicle in front of us. The air was cool, and the humidity low.

Not a hint of car sickness, gracias a Dios!

The village was about the size of Balfate. TDI (Tropical Disease Institute, based at Ohio University) had registered about 280 patients to see over the next four days. On earlier visits, the TDI folks had arranged for facilities for the clinic, which is being held in the school, as well as enrolling families to come to the clinic. Each registrant was given a container to bring their stool specimen, and a date to arrive for their first appointment.

Today, the first wave of patients arrived. Only about 70 of the planned for 110 showed up. Consent forms for the research were explained and signed, and the families then went through a series of diagnostic lab tests. In addition to evaluation of the feces, urine and blood was also collected. Many of the tests were done on site by the team of lab techs with their microscopes, but the blood was sent to Quito for evaluation.

The families then went to the eye clinic for screening visual exams. Those that needed glasses went through additional evaluation and were given eyeglasses. Adults were screened for glaucoma. It took a while to develop a system, but it should run smoother tomorrow.

Tomorrow, the initial 70 patients return for an appointment to see the physician. They will have their vital signs checked, go over their lab results, have a physical exam, and be treated as needed. Also tomorrow will be another 100 plus patients planned for lab and eye screening, plus probably some who didn’t come today. They will then return the next day to see the physician while on that day the last 60 plus patients from the village arrive for lab and eye exams.

The fourth day we split up. Some will return to the same village to do the physician exams and pack up, while others will head for the next village to begin the lab and eye exams there. We repeat the process as above, going to a third village afterwards.

This is actually only a very small part of what TDI is doing overall! Another part of the team is inspecting homes in another village, looking for the bugs that carry the parasites that cause Chagas disease. They will be fumigating the homes after collecting the bugs. The bugs will then be processed in the TDI lab in Quito, tracking which species of bug is where, and even doing DNA analysis to determine how the bugs are spreading. Another part of the team is in the “jungle” catching squirrels to analyze for Chagas, and checking their nests for the bugs. And yet another part of the team called “Healthy Living” is going to other villages to hold educational programs and do community organizing to tackle the problems that villages themselves determine are their major priorities. And still another part of the team, from France, who may be engineers without borders, is working at constructing water systems and experimental homes in other villages. An architect gave us a fascinating presentation on their efforts to find the best building materials that will be the most comfortable for the inhabitants, good at resisting insect infestation, inexpensive using local materials, and culturally acceptable to the communities. She had several infrared photos showing heat conduction and radiation from different materials. Adobe seems to be best in this category. So they are building a series of these homes to evaluate over the next few years to see how they do.

TDI is an impressive and complex organization! The 118 of us on this team are housed in three hotels in the village of Cariamanga in the region of Loja in south west Ecuador. Dr. Mario Grijalva, from Ecuador, is a professor at the medical school at OU, and has formed a relationship with the Catholic University in Quito. With his many grants, he has built a state of the art lab at the university in Quito, and has many Ecuadoran researchers working with him, doing the leg work. From what I know about preparing teams, the preparation and attention to detail I have seen is second to none! Everything has been on time. The Ecuadoran staff is top notch! I am completely impressed!

That’s about it for now!

Happy 4th of July!

David Drozek, D.O.

Sunday, July 1

We have arrived in Cariamanga after 15 hours on the bus. Unfortunately, I was curled up in a ball struggling through motion sickness most of the time, and was able to catch only momentary glimpses of the surroundings.

The bus was enclosed so that I had no forward view of what was coming, and was constantly caught off guard by the acceleration and breaking, the turning to the left, then the right, all at speeds that seemed to drastic. But I soon came to wish the bus only would go faster yet, to more quickly bring the trip to a close.

We started with several hours of winding through the Andes. The mountains at one point were reminiscent of Scotland, covered in green, with animals grazing that didn’t look quite like cattle, so I assumed were llamas, even though I couldn’t manage a better look. The homes were more of red brick, and the people wearing traditional dress resembled native of North America. The effects of Dramamine did bring on drowsiness, so I fitfully slept, awaking suddenly at times to catch myself from rolling out of the seat when there was a sudden change in trajectory.

Mid trip, we hit a plane, with smoother riding. The effects of the Dramamine wore off, and I was able to join the world again to see landscape and villages that were identical to that on the coast of Honduras; platanos and bananas, cacao trees, sugar cane, cattle grazing. The people and towns could have been lifted from the path between La Ceiba and San Pedro. We stopped at a typical restaurant which again was like many in La Ceiba.

The last part of the trip was again in the mountains. I took another Dramamine and tried to think about anything else but the summersaults my stomach was doing. The last couple of hours were on very bumpy gravel roads. It was dark, allowing no view past the extent of the headlights unless we passed through a village.

Finally at 11:00 PM we arrived. I was expecting a very rural, humble village with minimal facilities, but was surprised to see a decent sized city. The hotel was very modern (although lacking in hot water, which was a shock to my system this morning!), flat screen TV, WiFi (that isn’t working currently) and a nice restaurant. At the site and smell of food, to my surprise my stomach recovered and begged for attention. Again to my surprise, while everyone else was served a tasty looking plate of pork cutlets, rice and vegetables, I was presented with a specially prepared vegan meal of palm hearts, pickled broccoli, cooked carrots covered by a delicious sauce, and a side plate of white rice. It was wonderful.

I fell into bed at midnight with the sounds of disco music and roosters crowing, and quickly was asleep. The cool, clean air in the mountains was great for sleeping. At 6, I awoke to the ringing of bells and the sounds of a city awakening, took a refreshing (?) shower and arranged my belongings for the next two weeks of work. As I looked out of my window, I could see emerging from the darkness a good sized city nestled in the mountains.

Breakfast was supposed to be served from 7-9, but as of 8, no one was there, and no coffee was available. I appeared to be the only one up in the hotel. I am starting to hear some movement in the hall now, and am ready for some coffee and food.

I will send this, and a picture of my meal last night, when the Internet works!

David Drozek, D.O.