Clínica Misional "Nuestra Señora de Guadalupe"
Vicariato Apostólico de Zamora, Ecuador

Deutsch / English / Español

Katherine Landy, MD

General Medicine

Contact

USA

kzlandy@gmail.com

Volunteer Time

  • 2016, August 23 until the middle of 2017

Thank you very much for the help you will provide to our patients.

Orientation Guide for Medical Volunteers

updated 2016 by Kate Landy MD, adapted from 2004 guide by Beena Kamath MD

Welcome to the Orientation Guide for our Clinic

This information is based on the experiences of medical volunteers working here in Guadalupe.  The Clinic is an amazing place to work, where the patients are truly appreciative of your work and time, and come to call you “Doctors Who Cure.”  Many leave their homes in the early morning hours to get in line before our doors open, and wait for hours for their turn.  It has been a privilege and responsibility to have this kind of trust from the people here.

Of course, working in the Clinic is a new experience for most of us.  The cultural differences, different concepts of medicine, lack of continuity of care, lack of a variety of medicines and equipment (as well as support staff) that foreign doctors are accustomed to, as well as the language barrier, can make treatment of the patients in this region a challenge.  As the patients come to trust you more and more and see that your type of medicine works, they will follow up, and then the rewards are fulfilling in working here.  The patients and their appreciation of what you do make this job worthwhile.

We hope that this guide is helpful to you as you begin your own experiences working here in this very special place.  We have been as honest and complete as we know how to be, with the bad and the good.

The clinic is located in the small town of Guadalupe, in the Zamora-Chinchipe province of southern Ecuador.  Guadalupe is about 45 minutes by road from the provincial capital of Zamora.  It is a beautiful area where the Andes are descending down into the Amazon -- there are mountains all around, covered with green trees and jungle-like vegetation.  There are beautifully colored birds and butterflies everywhere, and the clouds hang low over the mountains in the mornings.  The weather is often warm and humid during the day (more jungle-like than the dry Sierra climate), with cooler temperatures at night, and it often rains for at least a little while every day or two.  People are very polite and friendly.  It is a lovely place, well worth visiting.

The Patients

The patients can range in age from newborn to old age, though most of the children you see will be for acute care visits.  Most well child care is done through the Ecuadorian public health system, where patients can also receive vaccines (which are not carried in our clinic).

The patients range from very poor to the middle class, from living in the countryside as farmers to living in the city.  Most of the patients work in agriculture, using their machetes, planting, and harvesting.  Patients may also have other jobs, including secretaries, teachers, drivers, construction workers, miners.  They have a range of economic wealth, some being unable to afford even the simplest treatments, to others, who travel from the bigger cities like Loja and are able to pay for many tests, consults and medicines.

There are three main cultural groups:  the Saraguro, the mestizo, and the Shuar.  They tend to intermarry within their own indigenous groups, thus are relatively culturally homogenous.  The Saraguro men usually have long braided hair, with black short pants, and easy to distinguish black felt hats.  The women wear many layers of skirts, including a top pleated skirt, the anako, paired with a colorful blouse, and elaborate beaded jewelry.  The Shuar have a typical facial appearance with high cheekbones.  Both groups use traditional medicine, things such as “uña del gato”, or “sangre de dragon,” or “horchatas” or “aguas del monte” to cure illness before seeking modern medicine.

There are some important cultural distinctions that can make treating these patients interesting.  First of all, there is a great reliance upon traditional medicines and natural remedies.  As a general rule, patients try natural remedies before entering your consultorio.  Secondly, their representation of illness is often more dramatic and the symptoms are different than what you may be used to.  Rely on your clinical judgment in these cases, as often, their history and exam do not mesh well.  The Shuar also have a reputation of putting blame on those that help them, looking for a reason that an illness was caused (there is much prejudice against them for this very reason).

Patient Knowledge

Low health literacy is a common issue.  Patients may have chronic illnesses, but have often have little understanding of what those are, and be unable to describe the condition.  In addition, they may have had surgeries, and be unable to tell you exactly why.  They may have been treated with medicine, and be unable to tell you what medicine, and why they were taking it. 

This is one of the greatest challenges in terms of providing appropriate health care.  Doing a reliable and credible Past Medical History, Past Surgical History and Current Medication List can be nearly impossible in some cases.  Some patients will say that they had “tumors” but were unable to say in which organ, and why the tumor was removed, or if it was cancerous.  It is extremely difficult to get medical records or lab / pathology reports from elsewhere, unless the patient brings them in him or herself.  Other doctors probably have not taken the time to explain illnesses and medications to patients, so taking the time to make your health education as thorough and understandable as possible is a great service to the patients, and a useful way to spend your time.  It also engenders trust in you as a caring doctor.

Many patients also come to Guadalupe for a second opinion.  It is good practice to ask if they have seen other doctors before about the condition that they are describing to you, as many times they have already had numerous tests done and a diagnosis given.  They may not disclose any of this to you unless you ask.  Sometimes they have been told they need surgery (as in cases of symptomatic gallstones, or uterine fibroids causing menorrhagia and chronic blood loss anemia), but they are afraid of surgery and want to know if you have some foreign medicine to help them.  Sometimes the patient is sick and was seen the day before by their own specialist with prescriptions already given, but they come to ask your opinion.  Sometimes people bring in lab and imaging reports, which is always very helpful.  Many times they don’t bring in anything for you.  Just do the best you can for that day, and it is OK to ask them to come back with their health records at another time.

Triage

Mainly, the order in which you see patients is in the order in which they arrive.  It is hard to place judgments on the order to see the patients when certain have traveled extremely far to arrive to see you.  Typically patients who are very ill with acute medical problems do not come to the mission clinic to be seen.  Occasionally a nurse may alert you to a sick patient who needs to be seen expeditiously, but this is unusual. 

In the past, when the Ecuadorian public health system essentially excluded the poor, doctors at the clinic would have to limit the number of patients seen to 30-40 per day.  However, in the past several years the government has made great improvements to its health system to make care much more inclusive.  Patients using the public health system (including the health dispensary or “Subcentro de Salud” across the river in the town of Guadalupe) can receive their care for free.  As a result, the demand for care in the mission clinic has diminished.  The average patient load is about 10-15 patients per day, but can be as few as 3 and as many as 25 or so.  Some patients come primarily to see the dentist, and will buy a “consulta” with you while they are there, to discuss whatever is bothering them.  Sometimes there are lacerations to suture (every family owns and uses at least one machete), but for an actual emergency to come in is quite rare. 

Medicines

The Clinic has an nice pharmacy, with a good variety of medications.  There are antibiotics, analgesics, antiepileptics, oral antidiabetic medications, antihypertensive, and lipid lowering, among others.  There is currently a government ban on importing any medication, so we are not able to use donated medicines as we have been in the past.  However, there is still a general belief that we have foreign medicine that is different from what is generally available in Ecuador, and patients will travel to see us in hopes of finding something new and different.

Challenges that we have faced regarding the prescribing of medicines includes:

  1. Incorrect use of medicine:  In any store or local pharmacy, a patient can walk in and buy medicine without a doctor’s prescription.  Thus a patient will often self-treat with medication or natural remedies before arriving to the Clinic.  Most commonly, people will buy one Ampicillin (Ampibex) tablet for a headache or skin infection, or a Naprosyn (Apronax) for pain or infection.  
  2. Desire for Injections:  Many patients want injections.  There is a belief that injections work faster and stronger than other medicines, even though they are more expensive and last for a shorter time.  In addition, patients think that one injection will cure an illness.  Sometimes they will say that other doctors have only prescribed pills for their ailment, as if oral medications are nothing.  Many Ecuadorian doctors treat musculoskeletal pain with B vitamin injections, which seem to have a placebo effect.   Another example is IM Diclofenac for musculoskeletal pain -- I had a patient who was kicked by a horse, received one diclofenac injection when seen by the doctor, and was not prescribed any pain medication in pill form to take home.  The most dangerous example are the patients who desire IV calcium for their bone pains, which can cause cardiac arrhythmias.  You will frequently be called upon to do some education about why oral medications are often better treatment, last longer, and are in the patient’s best interest as they can have something to take for their arthritis pain at home when it flares up (for example).  We do have DepoMedrol and lidocaine for intra-articular injections when you feel it is appropriate to do so in clinic.
  3. Misunderstanding of Chronic Treatments:  Because of this desire for a “quick fix,” an injection that will quickly cure their illness, it is helpful to educate patients regarding chronic illness, for example, high blood pressure and diabetes -- illnesses that are monitored on a chronic basis and not treatable with a quick ten day course of medicine.  There is a common perception that high cholesterol can be treated with a month of medication as a cure.  Patients need to understand that they have a chronic illness, and when you want to see them back.
  4. Vitamins:  The patients are very concerned regarding vitamin deficiencies, although it is rare to see a clear cut case of vitamin deficiency.  Many patients who feel tired, or have bone pain, or stomach discomfort, want vitamins to help them feel better.  I have often tried to explain that while multivitamins are unlikely to hurt them, what they feel is not due to a lack of vitamins -- and supplements are unlikely to be a panacea.  On the other hand, many poor patients have difficulty affording food and are probably not eating a balanced diet, so a multivitamin may not be a bad thing.  I have sometimes prescribed B vitamins to newly recovering alcoholics, and calcium to postmenopausal women.  Use your clinical judgment about when they are warranted, and when they are just another unnecessary expense.
  5. Stopping Treatments Early:  Because of their desire for a quick fix, some patients are unsatisfied if the medicines do not work right away.  They are impatient to take a full course of medicine for 7 to 10 days, and will often take the treatment for a day or so before visiting another doctor, who will most likely change your treatment.  For this reason, I try to reinforce the duration of treatment, and why it is important to complete the treatment, and if the treatment does not work well, make sure you tell them to come back.  If they know that you want to see them again, they may return instead of going to someone else.  Also, I try to give a clear idea of how many days they will need to get better, and return precautions, symptoms or scenarios in which I will worry that the treatment is not working well. 
  6. The patients often want some sort of medicine:  This can be a challenge, because many patients feel that they must leave with something.  It is important to use your clinical judgment in the context of the situation.  If my giving a child with a cold a cough syrup prevents them from going to another doctor for a shot of penicillin, I may prescribe the cough syrup.  It is also important to note that people here do not have a supply of routine over the counter medicines (such as acetaminophen) at home, so it is often very reasonable to prescribe something mild if you feel it is warranted.
  7. Many patients like polypharmacy:  Sometimes it is unavoidable, and you have to give one person four or five medicines, but you may want to try to stick to a fewer number of medicines to avoid confusion.  If the patient comes in with a complaint for every organ system (and there are many of these patients!), it is OK focus on the most bothersome.  Sometimes patients have traveled far to be seen and I feel bad leaving complaints unaddressed, so I will err on the side of prescribing relatively benign medications such as ranitidine and Tylenol.
  8. The patients share medicines:   If one person uses a medicine that helps them, they will share it with their neighbor or husband whether or not they have discussed it with a doctor first.  Just beware that this occurs. (Of course, it occurs elsewhere too.)
  9. The patients do not always buy the course of medicine as you prescribed.  I have prescribed a 3 month course of iron for anemia, and the patient bought 4 pills.  Many patients are limited by their finances.  Also, it is a very polite culture, and people may not want to say no to your face when they disagree with your treatment plan.  
  10. Antibiotic resistance is a bit of a problem, as it is everywhere.  I still start with the common first line drugs (Amoxicillin for ear infections, Bactrim, Amoxicillin or Cephalexin for UTI in kids or Bactrim or Ciprofloxacin for UTI in adults, for example)  and give the patient guidelines for returning.

Common problems

You will see a variety of common primary care problems -- colds and coughs, joint pains, dysuria, etc.  However, there are some common issues that, depending on where you practice, you may not see very often in your current practice, and you may want to read a bit about before you come:

  1. Sun-related eye diseases are very common here, such as pinguecula and pterygium.  There are also lots of cataracts.
  2. Because of imperfect water sanitation and home bathroom facilities, problems like intestinal parasites (ascaris, giardia, amebiasis) are endemic.  You may want to review their life cycles, manifestations and treatments -- albendazole and tinidazole are readily available in the clinic pharmacy.  I find that for adults, albendazole 400mg x 1 and tinidazole 2g daily x 2 will kill most intestinal parasites if you want to treat empirically.
  3. Gastritis is also very common, and can be due to parasites.  Because of sometimes poor sanitation, H. pylori is also endemic.  Most people will be H. pylori seropositive, so if you are clinically suspicious of it, you may just want to treat empirically.

 

Writing Prescriptions

When you have decided what medicines you will use, you will write these down in a prescription.  Be aware that the prescription is not merely something that is given to the pharmacy to translate for the patient -- the patient keeps the prescription, and it is their user guide.  Medications dispensed by pharmacies are not labeled with patient instructions, as they are in the US.  The patients need everything written down very clearly, and will probably ask you for specific times that they can take the medicine.  I write every detail as clearly as I can on the prescription, including the indication for the medicine.  Many patients are elderly, cannot see, cannot read, and are forgetful.  They will hopefully have someone to help them read your prescription later, and if you have written everything down completely, it will be a big help to this third party who did not hear your explanation.

For example:
Enalapril 5 mg #30
Toma una tableta antes del desayuno diario  (presión)
Aspirina 100 mg #30
Toma una tableta antes del desayuno diario (circulación)

Instead of putting down specific times, I tended to say “before breakfast” for one time per day medicines or “before breakfast and dinner” for twice a day medicines, just to make things easier.
Also, in addition to signing your prescription, by Ecuadorian law you need to stamp the bottom of your prescription with a name stamp -- which will be provided to you by the clinic staff.

Often times, patients will ask you to write for medicines for patients that you have not seen.  I have made it my policy to only write prescriptions for patients that I have actually seen, except for over the counter medicines.

The Clinic Schedule

The Clinic opens at 8 AM and closes at 5 PM, on Mondays through Fridays.   On a busy day, you may be working for most of the day, though most days you will be done by 3pm or so.  On a slow day, you may work for part of the morning and be free in the afternoon (although you need to be available by phone in case a patient comes in).  Lunch at the Convent starts at noon, and it is best to plan your day accordingly to be down at lunch as punctually as possible, although it is understood that you may be late on occasion, when dealing with a tough patient, etc.

If you are a volunteer bringing your family or non-volunteer spouse to Guadalupe, please be aware that, for various reasons, the sisters are unable to accommodate larger families and children at their table.  Please see my separate document regarding volunteer families for details.

Dress Code

Scrubs are the preferable dress for the doctors in the Clinic, as it identifies you as a member of the clinic staff.  There is a supply of scrubs that you can borrow during your time here, or you may want to bring your own that fit, and then leave them upon your departure to increase our supply!

Work-life balance

Working in the Clinic is rewarding, but it can be tiring.  In the medical field, there is always a balance to be had between service and self-preservation.  A burned out doctor is not good for anyone, so if you are feeling overwhelmed, please let the clinic manager know.   However, with the current patient numbers, the workload is usually quite manageable.

Occasionally patients may knock on your door after hours to ask for a consulta or for some medicine.  There is no retail pharmacy in town (aside from the mission clinic pharmacy and the public health center), so on weekends people may ask you for some kind of medication.  Some people perceive that you have your own little private pharmacy in your home.  Even if you do have a private stash (of allergy medication or something), I would not recommend giving it out and encouraging this practice.  It is OK to ask patients to wait until the clinic is open.  In an actual emergency, please do your best to help out -- after all, you are the doctor in town.  (The Ecuadorian doctor at the public health center lives 45 minutes away in Zamora.)

Perception of Foreign Doctors

Some people will prefer your care to that of an Ecuadorian doctor for the sheer fact that you are a foreigner.  Many patients think that because you come from elsewhere, you brought “good medicine” with you.  Other patients will think that because you do not use vitamin shots or natural medicine, you cannot help them.  Because of the doctor shopping that often occurs, you may have one chance to make a difference to a patient.   If you really communicate well your treatments despite the language barrier, and take the time to show that you care about their well-being, they will come back, as long as they do not live too far away.  If you give them the opportunity to know that you want them to follow up to provide continuity of care, they will.  Give them a time frame for when they will get better, and when to come back if they are not.

Other Doctors

Across the hanging bridge that leads from the Mission to the town of Guadalupe, there is a Subcentro of health, staffed by an Ecuadorian doctor (Dr. Alan).  There have been mostly friendly and cooperative relations between the staff at the Subcentro and our Clinic.  Their clinic has its own pharmacy, though sometimes they do run low on medication.  They also offer vaccines for children and adults that are not available at the mission clinic.  Dr. Alan has a good reputation.  During my time here there was a concern about a rabies exposure, and Dr. Alan proactively contacted the family and started rabies prophylaxis treatment.  The mission clinic staff mostly works in parallel with the public health clinic, but there is a lot of crossover with patients using both clinics.  The Subcentro is generally staffed by 1-2 doctors, at least 1 nurse, and a dentist.  They dispense medications for free to patients.  The Subcentro is also able to provide contraception for patients, which is not available at the Mission clinic (though I have felt free to discuss methods and make suggestions to patients).

Lab Tests

Many patients love lab tests!  Some will screen themselves for different diseases, and can go to a privately owned lab, where the lab owner is only too happy to mark up a lab sheet charging the patient for a CBC, lipid panel, BUN, Cr, SGOT, SGPT, C-reactive protein, ASO, Rheumatoid factor.  The patient may then bring these tests to you, without them having been  interpreted by a physician before.  It is an opportunity for you to explain to them where their health is good, and where it could use some improvement.

There is no lab at the clinic, nor xray or ultrasound machine.  We are able to do the following point of care tests, at the following out of pocket cost to the patient:

Fingerstick blood glucose      $1
Spun hematocrit                     $1
Urine dipstick                         $1
Urine pregnancy test              $2
You can do your own wet mount free of charge. 

Otherwise, if you feel it’s important to get lab tests, you can give a patient a piece of paper with the lab tests that you want written on it, and they can go to a private lab to get it done.  They pay for the tests, have them drawn, and and need to return to the lab another day to retrieve the results themselves and bring them back to you.  Often it does not happen, either because of expense, or because the process is too cumbersome and the patient has other priorities.  So, your diagnostic options are VERY limited.  It is disconcerting, but a really interesting intellectual exercise to rely solely on your clinical experience when treating people, based on probabilities and the rule of “first do no harm.”  Since I am unable to do appropriate follow up on high risk medications, I often err on the side of prescribing the medicine that I think is most likely to help, and the least likely to do harm.

A few words about diabetes -- often patients with diabetes will come to the clinic for a check-up and a glucose check without having taken their medication in the morning.  Although it gives them reinforcement that they need their medication, it does not give you a good sense of how well controlled their diabetes is on their medication.  Patients do not have any way of checking their blood glucose at home, and Hemoglobin A1C testing is not readily available.  When managing diabetes in this setting, you often feel like the blind leading the blind.  All I can really do is base my treatment plan off of today’s blood sugar, and whether they are having any symptomatic lows.  It is not ideal, but it’s better than nothing -- and patients appreciate the time you spend with them, explaining the importance of good dietary choices and exercise.

Your Consultorio and Resources

There is one general medical examining room in the Clinic, two rooms for the dentists, an operating room (used during surgical campaigns), a room for storage, a room for sterilization, and a room with a bed.  We do have supplemental oxygen if needed in an emergency, and there is a small supply of emergency medications though not a full ACLS/PALS crash cart.  There is a microscope to view wet preps.  The main medical examining room has an examining table, with stirrups to do pelvic exams.  In addition, there is an adult regular blood pressure cuff, and an ophthalmoscope/otoscope unit attached the wall.  A private bathroom is attached.

There is also a computer in the main consultorio, with a simple EMR that is basically a list of prior SOAP notes.  It is helpful to see whether the patient has been seen in clinic in the past, and if so what has been done before.  There is no running problem list, medication list, allergy list, etc -- so you need to collect pertinent information as you go.  Since we have physician volunteers from multiple different countries, it is helpful if you can do as much of your charting as you can in Spanish.  There is also a computerized list of medications from the pharmacy, how much of each medication is available, and how much it costs.

The computer in the consultorio has internet, and we are working on getting wifi in the consultorio as well.  It is great to be able to access online resources such as UpToDate to help you with clinical questions (you do need to have your own UpToDate account, as the clinic does not maintain one).  There is a small library of medical books, some of which are 10+ years old -- but texts like dermatology and ophthalmology atlases and tropical medicine books are always helpful, even when older.

Patient Finances

The patients come from a variety of economic backgrounds.  Our Clinic offers inexpensive medical care.  Still, there are some patients who may have a hard time affording what we offer.

Every patient must come with $2 for the initial ficha, the number in the line to see you.  We do not change or lower this price for anyone.  We practice the philosophy that everyone must contribute something to keep the clinic going, for their dignity, and plus in order to value the service that we provide.

It is good practice to communicate with patients about their finances, and whether they can afford the medicine that you are prescribing.  There are times when it may be best to shorten a course of treatment, or have patients buy their medicine in smaller increments to that they can afford it.  Sometimes you need to be creative to increase your chances of successful treatment.

Vital Signs

For the most part physicians need to do their own vital signs.  This is generally do-able since the patient load is not overwhelming.  I have been doing whatever vital signs I feel are warranted.  For sick children, I think it is reasonable to get a temperature, pulse and respiratory rate.  For older patients, I think documenting a blood pressure and doing a quick cardiorespiratory exam (with at least a gestalt for pulse and respiratory rate) is usually warranted, with a documentation of those vitals if they are abnormal.  You will need to decide what vitals you think will be useful and high-yield for each individual patient, so that you can use your time wisely.

Perception of Illness

Because of the language and cultural barrier, it is even more important to take the time with the patients so that they understand your treatments.  They will then be more likely to follow them.  For that reason, try to be as complete as possible in my explanations of the disease, whether it is curable or the symptoms can be expected to occur, when they should follow up, and exactly how they need to take the medicine.  The more that you can explain to the patients, the more likely they will succeed in following your treatment plan and following up.

There is a sometimes inaccurate concept that people have regarding illness, that everything can be cured.  The most common example is arthritis.  Many people do hard manual labor for most of their lives, and have worn out joints.  They have never been told that arthritis does not have a cure, only medicine to treat and calm the pain -- or they have been told, but do not want to believe it.  When they understand that a medicine exists to help them, and they can return when they finish the medicine that you have given, they are more likely to come back, instead of thinking that you have failed.

Follow-Up and Feedback

This environment can be tough in encouraging follow-up for a multitude of reasons.  It may be costly and time consuming for a patient to follow-up -- if a patient has to travel for 4 or 6 hours to get here, they will not return often.  Many times patients will go to their local doctors to have sutures removed, or will remove them themselves.  This also occurs with chronic illnesses such as hypertension:  when the patient’s hypertensive headache is relieved by your medicine, he/she may not come back, if he does not understand that once he stops taking the medicine, his headache will return.

Oftentimes, the feedback part of patient care is lacking.  Most of us in medicine like to see our patients after they have (or have not) been helped by our treatments, but in the cases where our patients are better by our treatments here, they will not come back.  Also, sometimes a patient that has not gotten better with a treatment may switch to another doctor and not give you another chance to make them better.  Stress that you want the patient to return if they are not feeling better, and they just might.

Transport of Care

Currently the emergency medical system in Ecuador is centralized, and you (or your nurse) dial 911 for an ambulance.  The call goes to a dispatcher in Quito, you explain to them what the problem is, and if they agree that the patient needs to be transported they transfer to call to Loja.  Loja then contacts the hospital in Zamora, which sends the ambulance.  This has been a relatively rare occurrence, but historically it has taken about 45 minutes for the ambulance to arrive after making the call.  Some ambulances are well-equipped and staffed by well-trained EMS personnel, and others are very basic without much life support capability.

If patients need to go by bus, they are subject to bus schedules and bumpy roads.  Taxis are prohibitively expensive for most families.  Zamora is about 45 minutes away by bus.  Loja is 2-3 hours away by bus, and has larger hospitals with greater capability.

Living at the Mission

Living and working in Guadalupe is a unique experience all its own.  You are living at a Catholic Mission with an international flavor, with volunteers from the US, Europe, and Latin America.  We speak Spanish, English and German.  People from a variety of religions faiths volunteer and work at the Mission.

Many volunteers eat meals with the nuns, the Sisters of Teresita.  Getting to know the sisters is one of the great side benefits of working in Guadalupe.  They have a wonderful sense of humor, and are very caring.  People are very appreciative of the work that you do, and becoming a part of this wonderful family is a great experience.  It is certainly not a requirement to attend Mass, though you are always welcome.  There is very little separation here between secular life and religious life, and people in the community do appreciate seeing you at Mass from time to time.  Religious festivals here are fun and colorful, and it is interesting to take part in them.

When dining with the sisters, please keep in mind that you are a guest in their house -- and use basic politeness and manners that would befit a guest in someone's home.  They are likely more conservative than you are in their dress, and they appreciate it if you cover your shoulders and your legs down to your knees when you are dining with them, as a courtesy to your hostesses.  Thank you for understanding!

Volunteer Residence

There is a residence for single volunteers or couples behind the clinic.  In addition, there is an apartment building just across the hanging bridge in town where families or couples may stay.  They have kitchens equipped with the basics, private bathrooms, and a washing machine for clothes (which you then hang dry).  There is wifi in the residences.  Compared to how most people live in Guadalupe, it is quite luxurious!  The power and water occasionally do go out, but they are mostly reliable. 

There is cell phone service in Guadalupe, and the cell company that works well here is called Claro.  You can buy a Claro sim card for your phone, which will give you service here, and will give you an Ecuadorian cell phone number while you are using the Claro card.

Climate

This region is a transition zone between the Sierra and the Amazon -- where the Andes are descending into the Amazon basin. The weather here is often quite warm and humid during the day, and the sun is very strong.  Even when the air temperature is not that hot, it will feel hot if you are standing in the sun.  It often rains at least a little bit every day or two, which does cool things off quite a bit -- and the rain can come in unpredictably.  It does cool off really pleasantly at night.  It is good to bring a variety of clothing to be prepared.  If you plan to travel to higher altitudes like Quito or Cuenca, the weather can get pretty cold there -- so bring layers.  There are also biting insects that may take advantage of bare skin, and I tend to wear lightweight long pants and sleeves when I go out, to protect myself from the sun and the bugs.  From a cultural standpoint, it is OK to wear shorts and tank tops in town.

Because of the high humidity, some kinds of clothing (like jeans) do not dry quickly.  Especially during the rainy season, when there is less direct sun, things may take a long time to dry -- and may actually start to grow mold on them before they dry.  So try to bring mostly technical, quick-dry clothing. 

Good luck as you prepare for your adventure!  It is a special place, and almost all volunteers leave with smiles on their faces.  Many come back again and again.  We hope you will join us as a part of this great big international extended family.

 

 

A Guide for Volunteers Bringing Families and Children
Kate Landy MD
2016

Taking a family sabbatical and having a big new adventure as a family has so many rewards.  Guadalupe is a great place to bring your family for short or long periods of time.  Some volunteers have brought spouses and children down for a month during the summer, and others (like us) have made it their home for a year.  As parents considering this kind of experience, there are some things that you want to know about life in Guadalupe.  I will try to give some practical information here.

So that you have some perspective of who we are -- we are a family of four from the United States.  I am a family physician volunteering in the clinic for the better part of one year.  My husband is a social worker by training, and has mainly been volunteering teaching English in schools and to the community (a pastime that he fell into not by design, but by popular demand).  We have two children -- a 10 year old son and a 7 year old daughter.  We are blond and blue eyed, and generally stick out like sore thumbs.  My husband’s Spanish was “muy poquito” when we arrived in Ecuador, and our children had basically no Spanish background.  We live in a mid-sized city in the Pacific Northwest, so living in a small town on the Equator is a big change for us.

Getting to the point where you can leave your home for an extended period of time is actually the hardest part -- it is not easy to shore up your life such that it will not implode while you are away.  I found Elisa Bernick’s book The Family Sabbatical Handbook to be a helpful practical guide about how to get it all done.

Visas

At the time that I am writing this guide, you do not need to get a visa if you are coming from the US or Europe and you plan to stay in Ecuador for less than 90 days -- you automatically get a tourist visa stamped into your passport at the airport.  If you plan to stay longer, you will need to apply for a missionary visa.  Volunteers and first degree relatives qualify, and with the missionary visa you can stay in Ecuador for up to a year or more. 

It was frustrating for me that I was unable to find good information about what documents we would need to get our visas.  What we ended up needing was our passports, and the children’s original birth certificates with Apostilles and official Spanish translations (of both the document and the Apostille), plus $20 per visa.  These requirements can change quickly and without notice, and I was happy that I erred on the side of being over-prepared rather than under-prepared.  We had to go through the Conferencia Episcopal Ecuatoriana, which is the main office of the Catholic Church in Quito -- they work with the embassy and the Ecuadorian Ministry of the Exterior to help you obtain the visa.  The mission staff should be able to help you with the process for obtaining the visas -- you will need to be in Quito (probably for several days) in person to get them done.

Housing

The mission provides a nice apartment in town, just across the hanging bridge from them mission.  It is a small building with 3 units -- one for nurse Amanda, one for a volunteer couple, and one for a family with children.  The family apartment has 2 bedrooms, a kitchen, a living / sitting room, a dining area, and 2 bathrooms with hot showers.  One bedroom has two twin beds pushed together for the adult couple, and the other bedroom has bunk beds with an additional trundle bed underneath (sleeps 3 comfortably).  The kitchen has a full sized refrigerator, a gas stove / oven, a microwave, two large stainless steel sinks, and quite a bit of usable counter space.  There is a small balcony that looks toward the river and the mission.  There is also a washing machine on the 3rd floor of the building, with space to hang dry your clothes.  There are screens on many of the windows, so you can get some fresh air at night when the temperature is nice and cool. 

Food

It is important to know that while adults are welcome to eat lunch and dinner with the sisters, children generally are not .  The sisters only have limited space and energy, and having children at the table can be stressful for them (and sometimes for the family)..  So please expect to eat mainly at home.  The mission has given volunteer families a food subsidy to help cost the cover of food.  We have spent about $400-500 per month on food for our family of four, without eating out much or being very extravagant -- and the mission covers about half of that.  This is helpful to know for budgeting purposes.

There is a lunch break from 12-1pm at the clinic, and you can go home to each lunch with your family.  Depending on your circumstances, you may decide to hire a local woman to come and cook lunch for you and your family, and do some cleaning and child care if you so desire -- the clinic staff know the local people well and can help you arrange this with someone trustworthy.  As a reference point, we have paid about $30 per week for someone to cook us a hot lunch and keep the apartment clean, and apparently we are paying pretty generously.

You can get a lot of basic food items in town -- milk, fruit / veggies, pasta, rice / grains, eggs, cooking oil, some seasonings and spices, chicken, beef (though tends to be stringy).  For other items that are harder to find, you may have to go to a larger supermarket called Tia in Yanzatza or Zamora, each of which is about 45 minutes away by bus.  There you can get somewhat healthier cereal (most of what you can get in smaller stores is sugar cereal), yogurt, butter (instead of margarine), granola, whole grain bread, cheese, crackers, etc. 

Money

Finances are different for everyone, but it helpful to know more or less how things work here.  Ecuador uses the U.S. dollar and has an almost entirely cash economy -- very few places accept credit or debit cards (besides larger hotels, airlines, etc).  Ironically, many places don’t have change for larger bills such as $20’s, especially if you are buying something small. 

There is no bank or ATM in Guadalupe.  There are ATMs in Yanzatza and Zamora, and we have been able to use our home debit cards to withdraw cash from our US checking account most the time.  Occasionally an ATM may not be working, but generally we have been able to find one that does work.  We generally need to go to either Yanzatza or Zamora to do grocery shopping once a week anyway, so we tend to withdraw cash while we are there.  It has not been necessary for us to open an Ecuadorian bank account. 

Schools

As parents, our children’s education is paramount.  Of course, there is no one right way to approach your children’s educational experience -- but it is helpful to know what the options are.  As the principal of our children’s school put it, any academic deficit that they have when the return will be totally insignificant and overshadowed by what they will have learned in their year abroad.  Here in Guadalupe there are three elementary schools to choose from, and they are all in close walking distance to the Mission.  All of them are tuition-free public schools.  (When reading this, please realize that circumstances can change quickly and without much notice, so all I can tell you is what is true today.)

First is the large public school called Pio Jaramillo (elementary) and Daniel Martinez Ordoñez (the only middle and high school in town).  This is where most of the kids go, particularly the Mestizo kids.  It has more of a traditional classroom structure, with one grade level and one teacher per class.  The classes tend to be somewhat large, and I have heard from a few sources that teachers sometimes have trouble maintaining discipline (but not dangerously so).  It may be difficult for teachers to give an individual child extra attention in this setting.  I think the major up side of this school is that children have a larger pool of children their age from which to draw friends.  The school also sometimes puts together a soccer team that competes against kids from other towns on occasion -- so if your child is a soccer enthusiast, that could be a draw as well.

The next option is the mission school, which is quite small (about 20-25 kids) and serves mainly Shuar families.  The woman who runs the school is a good friend of Amanda’s and is very nice, and would undoubtedly look out for your kids.  On a cultural note, the Shuar have historically been more of a fierce hunting and gathering society, with families mostly traveling around on their own rather than living communally -- so I understand there is not as much of a sense of community unity among the Shuar.  Because it is such a small school, children from multiple grade levels will be in the same class room.

The third option is another small school (also about 20-25 kids) called Inti Pakari, which serves mainly Saraguro families.  It is a bilingual school, with class conducted mainly in Spanish, but also with regular lessons in the traditional indigenous Kichwa (Quechua) language.  There are two classrooms, with a teacher in each room --  one for the younger children and one for the older kids -- with mixed grade levels in each room.  The Saraguro have traditionally been more of an agrarian society, with multiple families living together -- and so my understanding is that they tend to have more of a strong sense of community than the Shuar.  Inti Pakari has an active parent group that takes an interest in the school. 

Of course, the final option is homeschooling -- or doing some kind of hybrid between the two.  We decided to bring our children’s math books from their school in the states, so they could keep up with what their classmates at home were learning.  (They do 2 pages of their math books per day, in addition to whatever homework they have from their local school.)  There is wifi in the residence, so you can use online resources as well (more on electronic gadgets below).  Our feeling was that going to a physical school would be important for our kids, both to learn Spanish, and to make friends and feel like the had a community of their own.  We ended up choosing Inti Pakari, as it felt like a close community with an interest in cross-cultural exchange.

Of note, any of these schools is likely to feel more chaotic and less focused that what your child is used to.  There is also more of a focus on memorization and copying passages out of a book, rather than teaching critical thinking.  This is true in many developing countries.

In order to register your child for school, you will need to go to the school district office in Zamora before school starts.  We needed our passports, and a copy of the kids’ report cards (ideally with some kind of explanation of educational standards) from the previous year.  To save yourself some headaches, you may want to have it translated into Spanish.

A word about grade levels -- they are numbered differently in Ecuador.  Children enter school when they are 4 years old, which is considered “the first year of basic education,” or first grade.  Kindergarten is then numbered as “second year,” or second grade.  For this reason, both you and the school district may be confused about what grade your child should be in -- that is why it is helpful to have something in writing about what standards your child has already achieved. 

Ecuadorian kids wear school uniforms, generally a white shirt (t-shirt or button down shirt/blouse), dark navy blue or black pants or skirt, white socks, and black shoes.  You can buy uniforms in town pre-made if they have your child’s size, or you can have uniforms made here in town to fit your child more precisely.  Shoes are generally of pretty bad quality, so you may want to bring some black shoes/sneakers from home for your child to wear to school.  The school system also gives out grey sweatsuits to kids, and it is OK to wear those as well.

Of note, Ecuadorian kids do not eat lunch at school, as the school system does not have the facilities or resources to feed children.  You can send a midday snack with them, but they come home to eat lunch.  School here runs from about 7:30am to 12:30-1pm.  Here in this part of Ecuador the school year runs approximately from early September through the end of June.

Friends

It is not easy for kids to leave home and start over someplace new, and they will doubtlessly be worried about whether or not they fill find any friends.  We have found people in Guadalupe to be very open and welcoming, particularly the children.  Foreign kids are particularly interesting, and the local children will probably be drawn to them automatically.   Since Guadalupe is such a small town (it is about 7 blocks long by 3 blocks wide), we have felt pretty comfortable giving the kids a much wider berth of independence than they would have at home.  The kids play spontaneously in the street, and can’t really go far.   Our son is a soccer enthusiast, which has helped him tremendously in making new friends among the school age boys -- kids often play pickup games of soccer of basketball at the “cancha,” or covered play area (sort of like a concrete sports field) in the middle of town.  There is also a small river where people swim, often on hot afternoons and during the weekends.  The river running right through town is contaminated by an upstream mine, but about a half mile walk from town is a cleaner river that is swimmable.  The current is a bit strong for our younger child so we don’t let her go there without us, but our son is a strong swimmer and we allow him to go there with his friends.  (As a note of reference, we barely let our kids play in the front yard alone at home.) 

With regard to the language barrier, the kids here in Guadalupe have been quite patient and willing to figure out what we are trying to say.  I do think there is a gender difference between how boys and girls socialize that can make things a little challenging.  Boys tend to bond over a shared activity, such as sports or swimming the river together -- and they don’t really have to talk about it.  Girls tend to bond over the conversation that happens around the shared activity -- they tend to be much more verbal than boys in their relationships.  For that reason, I think at first it may be more challenging for girls to make close friends than for boys.  That is merely my observation, and certainly may not be true for all children.

Gadgets

Of all the electronic gadgets that you have at home, you may be wondering what is useful to bring, and what would even work down here?  Depending on how “unplugged” you want to be, you may or may not want to bring much down.  From experience, I will say that living in a foreign country is an intense experience from which everyone may want to “escape” sometimes.  It may not be a bad idea to bring some kind of movie player (DVDs are the most reliable), a device to play music, and certainly some kind of computer with which to communicate with family and friends back home.  You may want to keep a family blog of your experiences so that others can follow along with what you’re doing.

There is wifi in the residence.  The speed of the wifi can vary tremendously and unpredictably -- from pretty darn good, to practically nonexistent.  It seems to be a little slower in the evenings.  Most of the time it is good, to the extent that you can stream videos from Netflix or YouTube -- but not reliably so.  If you are planning homeschooling that requires a lot of online work, it is good to be aware of that.

Laptop computers and tablets generally work well.  We bought Kindle e-readers for our children, so that we could avoid the problem of having enough English language books to keep them occupied -- and that has worked out wonderfully.  Our kids have been so excited about their Kindles that they have actually read a lot more here than they did with “real” books at home, and there is an endless supply of books (as long as the budget holds out).

Cell phones can be interesting.  The Ecuadorian cellular company whose service works best down here is called Claro, so when you arrive in Ecuador you can buy a Claro sim card to put into your phone.  This will give you a new Ecuadorean phone number, so be aware of that.  You will need to make sure that your phone is “unlocked,” as some phones are actually proprietary to your cell carrier company.  I have an iPhone with 3G service, and while I could get Claro cell service just fine in larger towns, it wouldn’t work in Guadalupe.  I went to the Claro office in Zamora to ask why, and was told that my 3G phone was too fancy for the Guadalupe network, which was only 2G.  I then bought a cheaper phone that gets service in Guadalupe.  Go figure.

Skype or Face Time works somewhat well, depending on the speed of the internet signal at the time you are making the call.  Sometimes it works great, other times it keeps slowing down or freezing, and you catch about half of what the person on the other end is saying.  Still, it is a lot better than nothing!  WhatsApp is a free app that lets you call or text people over wifi internationally for free, and that works great as well -- though the person you are communicating with also needs to install WhatsApp on their phone for it to work.

Entertainment

What is there to do down here?  A reasonable question.  For sure, you will be getting used to a much slower pace of life than what you surely have as a working family back home.  Aside from trips to the corner store to get various food items, there are no errands to be run.  You will not be shuttling your children back and forth from school or activities, and you will not be attending to the seemingly endless list of home improvement projects.  After the millions of things that you have to get done in order to leave for a period of time, it is a welcome relief.  On the other hand, the slow pace of life is both the best and the most challenging part of acclimating to life in Guadalupe. 

To a large extent, this is a make-your-own-fun kind of place.  As noted above, the kids play in town or go to the river.  Adults also play soccer and a variation on volleyball called Ecua-volley.  There are several decent swimming pools where you can swim for a few dollars within a 30-40 minute driving radius, including El Arenal in Cumbaratza (on the way to Zamora, with a fun water slide!), El Castillo Real (also on the way to Zamora), and Tierra Dorada in Yanzatza.

There are a couple of tiny restaurants in town, but they don’t seem to be open very reliably.  We have ordered takeout food in advance at times.  There is a frog and tilapia farm in Piuntza, the next town over, that will sell you fresh fish or frog meat (have a culinary adventure!).  My husband and I often go out for walks in the evening as the sun is going down, when the temperature is cooler.  My daughter and I have been taking beadwork lessons from a local artisan who makes really beautiful beaded jewelry (Amanda can help you find someone to teach you, if you are interested).

My kids have really enjoyed interacting with the animals.  Amanda, who lives upstairs from us, has an incubator in her apartment and raises chickens and quail.  She also has a docile old female horse who is gentle with children.  At the mission there are chickens, geese, guinea fowl, rabbits, cows and pigs.  Since we are city folk, this is a fun new experience for us! 

Health Concerns

Definitely go to a travel clinic before you leave -- you will all probably need yellow fever and typhoid vaccines, plus whatever else you may be lacking with the usual vaccines (Hepatitis A, etc).  There aren’t really mosquitoes here, and you do not need malaria prophylaxis or mosquito nets here in Guadalupe, but it is recommended if you are visiting the coast.  You might give some consideration to rabies prophylaxis vaccines -- rabies does exist here, although the vaccine seems to be pretty readily available if there were an exposure.

Although there aren’t many mosquitoes, there are certainly other biting insects that cause very itchy bites.  Bring along hydrocortisone cream as apparently it doesn’t really exist here.  The sun is super strong and it is not easy to find good sunblock, so I suggest investing in sunblock from home (and maybe insect repellant).  Bring long sleeves, long pants, sun hats, mainly technical clothing that dries fast in the high humidity here.  (You can also bring short sleeves and shorts, but you want to have the option of covering up for sure.) 

There are venomous snakes around, especially hiding in high grasses.  Some of the bad snakes are pretty tiny (a little bigger than a pencil) and hide really well.  We try to stay out of brush and tall grass as much as possible. 

Intestinal parasites are endemic here.  We drink bottled water whenever possible, though tap water is fine for bathing, washing dishes and cooking (if you are boiling it).  Salads are high risk, and we avoid eating uncooked vegetables or unpeeled fruit unless we have soaked them in bleach water ourselves.  Still, we have had to take parasite meds from time to time!

Spanish Language Learning

There are many ways to go about learning Spanish, if you don’t already know it.  You can start lessons before you come, or use an app like Duolingo to get a head start.  There are also many Spanish language schools in Ecuador, many of which are happy to teach children as well.  We ended up spending a month in Quito going to Spanish school in the mornings before we arrived in Guadalupe.  If you plan to go this route, be aware that the accent on the coast is apparently very different than that from the rest of Ecuador, to the point where people in Quito say they have difficulty understanding people from the coast.  The Quito accent is quite pure and easy to understand, and is similar to that in Guadalupe -- so keep that in mind if you deciding on a location for Spanish school.

There are teachers and other locals in town who would be happy to earn some extra money tutoring in Spanish, but they are unlikely to speak English.

Safety Standards

In the USA safety is paramount, and you will immediately notice that it is NOT paramount in Ecuador.  Drivers do not care about pedestrians.  No one uses car seats or booster seats, and you are lucky if you have a taxi with seat belts.  The hanging footbridge in town is sometimes missing planks.  People ride motorcycles without helmets, with infants or toddlers, and with machetes in their hands.  Sometimes it is kind of funny, like looking at one of those pictures in a kids’ puzzle book where you have to figure out how many things in the picture are wrong.  There is a certain amount of inherent risk in life, and a little more when you are living in a developing country.  Chances are that everything will be fine -- after all, we all survived our helmet-free childhoods.  Just be aware that you will have no choice but to ease up on some of your safety standards.

Summary

If you are considering a family experience, please do consider Guadalupe.  It has been a wonderful experience having more family togetherness time, and watching our children learn Spanish and blossom in their new found confidence.  Getting back to basics, and getting used to having a lot less “stuff” around is a great thing.  Guadalupe is a very family-friendly place, and the kids really love the degree of freedom that they have here -- freedom that we just would not feel comfortable giving them at home.  I can see the kids becoming more giving and thoughtful before my eyes.  We are all learning a lot, about what makes us tick, what we can live without, and what we can’t.  I feel sure that our experience this year will pay dividends for years to come.