UK/USA team, La Independencia, Ecuador

17-31 JULY 2010

On our first visit to the Hospital Padre Damian in La Independencia, Ecuador, we encountered a very good sign. As Samuel Shillcutt, our organization liaison or fixer, was leading us on a tour of the multi-building, rudimentary space, we ran into Jovita, the head nurse. There she was crouched in the dressing room of the Operating Theater, dressed in jeans, flip-flops and paint spatters, with a brush in her hand, laying a new coat of paint on the locker doors... On her day off.

UK/US Team - Equador
UK/US Team - Equador

 If there ever was an image that could sum up our experiences in Ecuador, the smiling and shy Jovita crouched on the floor of the dilapidated hospital floor, doing her very best to gussy up the old hospital and make us feel welcome does a nice job. The people we encountered in Ecuador were the heart of this adventure. Their sense of pride in community and make-do attitude are certainly what made our journey such a success.

We arrived in Quito in pairs on a Saturday evening; everyone tired and cranky after delayed flights or long lines through customs, and desperate to lie down. We were greeted at the gate by the eager face of Samuel, smiling broadly (and at least a head and a half taller than the crowd at the gate!), and we made our way to the Airport hotel across the street. Over a breakfast in the hotel cafe the next morning the group introduced ourselves. Our ranks included Samuel, our fearless leader; Professor Andrew Kingsnorth (whose wife Jane, a GP, joined us a week later), and senior registrar Mr. David Sanders, a veteran of 2 OH trips to Ghana. The neophyte OH surgeons were Dr Brigid Glackin of Springfield MA and Dr. David Oberdorfer of Kansas City, KA. Dr. Glackin travelled with myself, her daughter, Deidre Murphy and my father Michael Murphy. Our anaesthesiologist, Dr Lorenzo Dimpel of the UK joined us later that day, trailing along his son Toby.

After a fairly brief introduction, the team decided to fast-track getting to know each other by cramming ourselves into a van and zooming off on the journey to La Concordia. The Concordian cabbie Otto , who shepherded us across the Andes, pointed out places of interest as we rose and fell out of the breathtaking rain forests, stopping for photo ops. He also managed to slip into conversation that his father had a hernia and was hoping we could help him. It was a very common occurrence to meet people, have them treat you like family, then slip into the conversation that a friend or family member was suffering from some type of hernia. The people in Ecuador always seemed to have some friend who could help us as well as someone who needed our help. During this 5.5 hour trek we all had quite a bit of time to ponder what our destination would be like; this being the first Operation Hernia trip to Latin America, no one knew quite what to expect.

La Concordia is a town of between 50,000 and 100,000 inhabitants- there is no real census there, nor any type of street map beyond Google Earth- but it does exist and it is bustling. It has two main roads and a market abutting the main square, surrounded by a grid of dirt, alley-type streets and, beyond that, small slum-like rows of houses. La Concordia is situated about midway between Quito and the Pacific coast in a lowland rain forest region that is mostly used for the farming of Palm Oil. Our hotel, Atos, was owned by Sandra Ocampo, the very sweet and friendly mayor s sister. We found our stay there to be very comfortable and accommodating, as well as an air conditioned and be-cabled escape from our very dusty and chaotic surroundings at the end of a long day.

Initially, we operated in two locations: Clinica Guayaquil, run by Dr. Morante in La Concordia, and Hospital Padre Damian, located in the neighboring village of La Independencia. Every morning those of us who made the trek to the hospital ambled down the 4 blocks to the main square, through the dusty chaos of La Concordia s main drag, and attempted (sometimes successfully, sometimes not) to negotiate the local buses. After the first week, all surgical procedures were done at Hospital Padre Damian, and it s been adopted by the project as the main base of operations for future missions. Used mostly for gynecological surgeries and as a clinic devoted to a day to day changing schedule of visiting doctors for many different purposes, the Hospital Padre de Damian sits down a narrow bumpy gravel road off the main highway that travels from La Concordia to the coast. It houses one operating theater, and several rooms for patients to stay during preparation and recovery. In the past, this theater has been used mainly for cesarean sections; a surgery much in demand in a country with a 40% cesarean rate. The electricity is run by generator and the running water is stop-start, the back-up water supply was contained in large barrels of rain water that the nurses would bale over surgeons hands during scrub-in.

Samuel had been working out of the hospital previous to our arrival, on his own research as well as preparation for our project. His research determined that the actual cost of Hernia Repair including the fabrication and laundering of new OR sheets and gowns, electricity, and nurse/staff wages, was thirty dollars per patient, excluding costs for surgeons or anaesthesia staff. Locally in La Concordia, there is no public hospital, and private clinics there are offering Hernia Repair, usually without the use of mesh, for $300-600 U.S.

In total we operated on 72 patients to repair 79 hernias and one cystic lesion. 79% of hernias were inguinal, 10% bilateral, with one triple hernia. 80% of patients received local anesthetic. The mean length of time with hernia was 9.8 years. 75% of patients were in pain before surgery, 8% had vomiting, and 63% had daily living activity limitations. Based on the number of untreated hernias in the area despite the availability of surgeons and operating theatres, many probably would not have received surgery otherwise. 76% of our patients with inguinal hernias received mesh, as opposed to 80% of surgeons in Ecuador opting for use of Bassini technique without mesh normally. Patients don't fully understand the benefit of mesh, and saving $100 is the dominant decision making factor usually. Many of the surgeons in the area are focusing on cesareans, which is more urgent and amenable to supplier-induced demand than hernia.

The local political atmosphere was a bit turbulent during our stay in La Concordia. A visit by the president, Rafael Correa, was spurred by a land dispute in the region. Prof K and several team members were able to meet Correa , who stayed in our hotel for one evening, and hear of his desire to establish a public hospital in La Concordia (The Prof.even has photographic evidence of the meeting!). We got an up-close-and-personal view of security necessary to protect a national leader in such turbulent times. Security guards, police, and military filled the lobby of the hotel and spread out across the front entrance and street for much of the duration of our stay. On the evening of the President's public address the street in front of the hotel was filled with protesters.

The disparity of wealth in the country is glaring; we met doctors and business owners who seemed to be Upper Middle-Class by U.S./European standards, and farmers suffering greatly from something so simple to treat as athlete s foot. Lack of infrastructure is an enormous issue for the poor of the region. Sewers, storm drainage systems, and drinkable water are nowhere to be found in the poorer parts, resulting in a lot of preventable illness. As almost the only health care available to people in the region is private, a lot of simple medical care is out of reach to the majority of people. Many of the clinics seem to run like businesses, and patients seemed very skeptical of the quality of care we must be providing for the $30.00 US that the program was charging.

Dra. Kathia Tinizaray, the local Public Health Doctor, shared with us at our farewell dinner that she had her own initial skepticism about the project and its prospects. She expressed great satisfaction that the initial hectic start had been followed by the unbelievable overall success of the effort. She is prepared to bring an Ecuadorian Government mobile surgery unit to Hospital Padre Damian for the next Operation Hernia Project. This expanded technological capability should enable the project to include services for children under 10 and patients with incisional hernias who couldn t be served in the initial project.
The people in the area were extremely excited about the idea of our return, and the nurses of the hospital buzzed around with a new life and energy as their empty, forgotten hospital filled with patients and bustled with activity. Gifts were bestowed upon us and we tried our best to reciprocate some of the doctors even left their theater shoes for the nurses of Hospital Padre Damian (If you re looking for a good present to bring along on future missions, a nice woman s pair of Crocs is hard to beat). I can think of nowhere else in the world where the people are more deserving of good care nor more grateful to have it, and consider myself a very lucky person to be included in this mission.

Deidre Murphy