Saturday, September 19, 2009
When Ecuador last year instituted free health care, it wasn't the first time a government there proclaimed a commitment to some form of universal coverage. Previous governments have also made ambitious promises. But the on-the-ground reality has never matched what is on the books, experts say.
The government made most basic doctor visits, surgeries and medications free and increased health spending. But improving the struggling public health system will take years, even under the best conditions, said Elizabeth Roberts, an assistant professor of anthropology at the University of Michigan who has extensively studied the Ecuadorian system.
Doctors and other public hospital employees are grossly underpaid -- a 2002 survey found that public hospital physicians made as little as $450 a month -- pushing many of the most talented to private hospitals and clinics, Roberts said.
Some public hospitals are crumbling and lack basic medical equipment. Even at Ibarra's Hospital San Vicente de Paúl, which is well-equipped for a public hospital, budget constraints can leave the place without the film necessary for most X-rays for months at a time.
Despite a 36 percent budget increase at the 166-bed hospital over the past two years, lines are longer because demand skyrocketed with the free care, said Dr. José Albua, the hospital's assistant director.
Routine consultations to see an Ecuadorian doctor are free, but they're an ordeal for many.
"I came here Sunday at 6 a.m." said Nancy Andrade, 46. Now it was Monday afternoon and she was still waiting in line to see a doctor. Dozens of people stood or sat in the line, filling the hospital hallway.
The smell of plantain chips and the sound of rustling snack bags sometimes punctuated the air, as patients tended to their rumbling stomachs.
"I spent the night," Andrade said. "If I'm lucky, I can see someone today. If not, I have to sleep here again tonight."
Many patients said a one-night wait is typical. Some said they have had to wait at the hospital as many as three or four nights, forcing them to lose pay from their jobs. Hospital lines have always been long, but not as bad as now, patients said.
On most nights, the hospital lobby is filled with people sleeping on plastic chairs or on the floor. If the patients go home, they lose their place in line.
Once patients get prescriptions, they often cannot find what they need at the hospital pharmacy. The pharmacy stocks most basic medications -- and offers them free -- but sometimes runs out. It doesn't carry most expensive medications, patients said. Privately run pharmacies line the street directly across from the hospital entrance.
Some patients endure pain because they can't afford medicine, or they ration pills, using them for temporary relief instead of long-term care. One woman said she took a second job to pay for expensive medicine for her son's nervous disorder and severe depression.
Some complex surgeries and procedures are not offered, and patients often have to travel to the country's two biggest cities, Quito and Guayaquil, to see specialists. Most Ecuadorians do not have cars, and nearly 40 percent of the population lives in rural areas. Bus rides can cost more than a day's pay for the poor. Many people stay home rather than make the trek.
Mercy Castro, 35, said she and her sister are still paying off the $8,500 cost of their mother's breast-cancer surgery and follow-up chemotherapy and medicine. Cancer operations are subsidized but they're not free.
The government pays for basic surgeries, such as hernia repairs and gallbladder removals.
Simón Puedmag made an appointment in April for a hernia procedure for his 28-year-old son. But when his son was wheeled into the surgery room in early July, the anesthesiologist wasn't there. The operation was canceled.
"Here it's a bit disorganized," said Puedmag, 53. "That's why we waited for the Americans."
The help from the Rancho Mirage-based International Medical Alliance, along with an annual visit by Spanish doctors and two annual missions of Ecuadorian medical volunteers, reduces wait times for surgeries and consultations, alleviating patients' suffering, Albua said. The alliance's giveaway of medications allows the hospital pharmacy to buy more medicine to give to patients, Albua said.
Despite the government's lofty ambitions, it will always be hamstrung by financial realities, said Dr. Salomé Gordillo, health coordinator for the city of Ibarra.
"This is not a rich country," she said. "We will never have the money to pay for everything."
Ecuador made health care strides even before last year's expansion of free care, according to a 2008 report by the World Health Organization. Free childhood vaccinations, in place since the 1980s, have eliminated diseases such as measles, diphtheria and whooping cough.
Yet 23 percent of children younger than 5 suffer from chronic malnutrition, the report says, citing a 2005 survey. The leading reasons for hospital visits are diarrhea and gastroenteritis, which in the developing world are typically caused by contaminated food and water and can be fatal if left untreated.
Tap water is not safe to drink in Ecuador. Those with enough money for cooking gas boil it first. But kids like 8-year-old Angela Meza sometimes drink from the faucet anyway.
She arrived at the hospital after her family worried about blood in her stool. It was probably from parasitic worms, said Denalee Valler, a physician's assistant from Palm Desert who prescribed an antimicrobial drug.
Dr. Antonio Gonzalez, a Pasadena dentist, said basic medical and dental disease prevention is often difficult in a country in which many struggle to earn enough money to eat. The decayed teeth that he examined each day in Ibarra betrayed years of neglect.
He and a fellow volunteer taught more than 260 patients about proper brushing and flossing. But he realizes many cannot afford to buy a toothbrush, toothpaste or floss.