And so it ends

Another hike up a the 45 degree angle cobbled street.  Another 53 patients (in 2 1/2 hours).  Another clinic packed up.  More "ciao's" from both sides of the daycare fence.  More beautiful views of the snow covered volcanoes rising more than 16,000 feet into a pale blue sky from the top of the hillside covered in cement homes.  Another ride down the mountainside to our last visit to the Camp Hope school and our going away party.  It was a going away party to end all going away parties!

You haven't lived
until you've seen
a wheelchair dance.

You haven't lived
until you have seen a grin
as bright as the sun.

You haven't lived
until you've seen a
six year old salsa.

You haven't lived,
until you've seen black
painted faces dancing.

You haven't lived,
until you've heard
the deaf sing.

You haven't lived
until you've danced
with party dots.

You haven't lived,
until you've been
kissed by 70 kids.

You haven't lived
until you've seen
a wheelchair dance.

I have lived.

We didn't save any lives, but we hugged a lot of people; the supplies we brought and didn't use are going to Dr. Marcus Nelson, who teaches and works in a family medicine residency here in Quito and in the jungle.  He and I are already scheming about exchanging residents for rotations.  I'm not sure why I was called to do this trip--I thought perhaps I would experience some epiphany;  if I had one, I missed it.  I did meet wonderful people who will be lifelong friends; I did learn to speak some Spanish; I had a great time.

As it is with international work, the benefits for those doing the work far exceeds any benefit to those receiving.  But soul sharing is magical--and who knows what that magic may wrest over time.

Seventy kisses

To see more pictures of wheelchairs dancing, go to http://www.facebook.com/media/set/?set=a.2003672414526.2095699.1325083251 .

To learn more about Camp Hope, go to www.camphopeecuador.org.   If you are looking for a good cause to support, I can vouch for this one.

Mari and Ronald

Ciao.  Thanks for reading.

The Daycare Center on the Hill

Quito spreads out below the daycare on the hill

We headed south instead of north out of Quito this morning, the sky a clear pale blue that gave us our first viewing of Cotopaxi, the volcano that normally stays hidden in the clouds.  They say if you see Cotopaxi, then you will return to Ecuador.  Once we left the busy rush hour traffic of the city, we turned up the eastern hills in our short bus, loaded with our three duffles and 4 boxes of supplies.  We have been saving the majority of our children's chewable vitamins for our two days working in this day care center for children up to 5 years of age.  We also brought hand knitted caps from a church in Virginia, a box of gliders and toys for all of the kids, several hundred tooth brushes in all sizes, 4 cases of toothpaste, and an assortment of lotions and shampoos that were donated.  We don't travel light, but we do travel well prepared.

We drove up the narrow streets until the short bus could go no farther.  So for the second time this trip, the van backed down the hill and we scrambled out to lighten the load.  The daycare center was located near the top of a long street that went straight up the hill at a 45 degree angle.  No, I'm not exaggerating.  It really is 45 degrees, and how anything that is not four-wheel drive makes it up is beyond me.  We huffed and puffed our way to the top and joined the small group of women and children sitting on the outside steps, waiting to be seen in our clinic.  The van was able to make it up the hill without us, delivering our supplies.  We set up our clinic and were ready to roll in under 15 minutes.

While we unpacked, Martin (our mission coordinator) and Jolene, the daycare director, started checking in patients, weighing and measuring all of the children, and Christy took blood pressures of all the adults. The daycare center is a large, tiered cement building perched on the steep hillside with a panoramic view of Quito and the mountains to the west.  There is a large, cement playground on the first tier, with little painting stations topped by colorful striped beach umbrellas.  Little potties is primary colors line one wall, and a classroom sits to the side.

Steep steps lead to a second tier, with a small kitchen and dining room, and up just a few more steps, the nap room, with bunk beds on one side and 4 cots on the other.  These four cots became our exam tables.  The pharmacy set up in the office.  Each child from the daycare has a little file folder, which includes a growth chart.  There is a big effort in Ecuador now to decrease the high prevalence of "stunting", undergrowth of children due to malnutrition.  Ecuador has one of the higher rates of micronutrient malnutrition and undersize children in the world--as bad as some of the poorest African countries.  We were impressed to see a list of the children who are undersized listed out neatly in the office, along with a list of children who are on vitamins.  


The indigenous people here are often very tiny, but this is apparently due to a lack of nutrition, not solely genetics--the higher the altitude where people live, the worse the stunting, due to a lack of food variety.  The first two years are the most critical--if children are stunted before age 2, they never catch up.   We've learned all kinds of interesting things while working here.  It didn't take long before our tiny space was crammed full of children, and their parents, siblings, and grandparents.  We saw 80 people today, and only 30 of them were the daycare children--the majority were their family members.  We have 50 more daycare children to see by noon tomorrow!  The children of Ecuador are a pure delight--they are very open, friendly, loving and playful.  We had a great (if exhausting) day.  Our mission ends tomorrow.  We will spend the first half of the day seeing the remaining 50 daycare children, and then we have a going away party with the children at Camp Hope in the afternoon.  Today was the last day with our whole team, however, as we had to say good-bye to Dr. Carrie Wilcox tonight--she flys back to the States tomorrow so she can take call Saturday night.



Life just keeps on moving, even when we are ready to stand still.  Hasta manana.  learn more about Camp Hope

Dr. Mimi Choate with twins and their mom

A special place full of special people

Our day was full of special children, disabled and not, special staff, who provide loving kindness and care to the children every day, and special parents, who often sacrifice to send their children to school here.  We continue to work in four teams of physician and pharmacy student, although we divided up these past two days--two groups saw the 18 children from the orphanage.  These are the children and young adults with the most severe disabilities--many are on medications which needed adjustmented, some have behavioral problems which have not responded well to medications, others have club feet with ill fitting shoes; there is the girl, now 18 years old, with severe cerebral palsy who was abandoned at a police station at age 13, pregnant; another child was found lying in the street.  Each of these children have horrific stories prior to finding their way to Camp Hope's orphanage, called Camp Hogar.  Those children that can smile now, do--big, happy smiles.  Our work here is slower paced by design--there is time to look through the medical files of each child, which include notes from the neurologist who volunteers from Germany every year. Lab tests where obtained prior to our arrival--basic blood work, a urine analysis and a stool analysis for parasites--and is in the chart for our review.  Our medical mission here is pretty simple--provide primary care to these children and see what we can do to improve their quality of life.  In many cases, its as simple as alleviating their constipation.

Dr. Shariat carries a 22 year old woman with severe cerebral palsy back to her wheelchair

 The other two health teams saw staff, students and parents of the students.  Most of the children who attend the Camp Hope school live at home with their parents.  Many have special needs that cannot be addressed at a public school, such as being deaf or unable to walk unaided.  Many of the children have cerebral palsy of varying severity, and they receive physical therapy while at the school.  Some of the children who attend have no special needs, but their parents send them due to the smaller class size and the individual attention they receive.

 All of the children must pay a tuition, which is needs based, ranging from $35-$70 a month.  The average income of the families here is $400 a month.  Its not hard to do the math--that is a huge financial sacrifice.  For some of the children, their snack and lunch at the school is their only meal.  Camp Hope is completely supported by donations through a church in Texas, Impact Ministries (where one of the missionaries who started the school is a member), and individual children can be supported through the church foundation.  Elsa, who is a 68 year old woman from Atlanta, here with us on her fifth mission trip to Camp Hope, supports several Camp Hope children.  It is truly amazing what a big heart and a little money can do.  We have seen 91 children, staff and parents during our two days at Camp Hope.  We have one more day working at the school, seeing everyone who wants to be seen.


We love all the smiles and hugs we get from everyone we see.  Last Friday, Pastor Fernando said to us that every child we had helped was as if he himself had been helped--a take-off of Jesus' words.  For us, for every one we care for, it is as if we ourselves had been cared for.  I don't know if that makes any sense--but we are so lucky to be here, working with these amazing kids, their families, and the staff.  If you are interested in learning more about the school and how you can help, their link is www.camphopeecuador.org. To see more pictures of this special school, go to www.facebook.com/media/set/?set=a.1995452129024.2095423.1325083251

Special Children

Eric, age 6

There are some experiences that are difficult to translate into words due to the jumble of emotions and thoughts they evoke.  Before starting our work at Camp Hope this morning, the social worker took us to homes of three of their students.  Each of these children introduced themselves to us at Camp Hope before we left--there was Eric, age 6, with a syndrome that I've never heard of, his perfect mind housed in a small, twisted body.  When Dr. Mimi does her checkup on him later today, he tells her he is going to be a doctor when he grows up.  He has extraordinarily large brown eyes with long lashes, an Incan nose and a sharp little chin that gives him an elfin look.  His voice is very soft as he repeats the words that he has clearly practiced many times...in Spanish..."Good Morning, my name is Eric. I am six years old".   I was pretty much sold by then.  His father is with him, and he has the adult version of Eric's face, but with a perfect body.

We head up the mountainside to the fields of cement houses about which I previously mused--do they have roads up there?  The answer is yes, they do--think San Francisco streets but pitched much steeper.  We drive up and up and up the mountainside on cobbled streets past densely packed neighborhoods dotted with small vegetable shops, soda vendors and grocery stores.  The roads are not wide enough for two cars, which does not deter these drivers at all.  I've learned to just stop watching.  We continue our climb past the last of the painted cement homes to the unpainted, unfinished gray cinder block structures that are anchored to the steep hillside with rebar pillars rising up into the thinning air.   We turn off the cobbled street (these cobbled streets are a marvel themselves) and turn straight up the hillside onto a muddy, potholed dirt road much better suited to a Land Rover.  Our van does not make it very far up the hill.  We get out and follow Eric's father further up the hill to a row of cinderblock where individual homes are demarcated only by the colorful laundry hanging out to dry in the intense sun of 10,000 feet.  We are warmly greeted by Eric's grandfather, elegant in his poor clothes.  Each of us receive a gracious handshake with a cheek smack before being escorted up a set of very steep steps to a dirt landing.  Precariously stacked cement cobble stones create a wobbly set of steps up to the door.  The interior of the home is dimly lit just with sunshine through their one window by the front door.  The floor is rough, unpolished grey cement; the walls grey cinderblocks with mortor. Bare unlit bulbs hang from holes in the ribbed, cement ceiling.  A knickknack rack hangs on the grey living room wall, displaying delicately painted china cups.  The room is too small to receive us all and the host remains outside on the dirt ledge.  The air in the home is almost unbreathable due to cement dust.

Eric has Kniest dysplasia, an uncommon genetic dwarfism
http://ghr.nlm.nih.gov/condition/kniest-dysplasia

Standing with Martin as the translator,  Eric's father explains that Eric previously lived with his mother until she died of influenza not quite two years ago.  Eric and his father now live with the grandparents, as they cannot make it alone.  They share this tiny little cement abode, each dreaming of a brighter future--Eric's father is attending university.  Eric needs surgery to help straighten his tiny leg bones which are not growing--he started walking only about 9 months ago.

 They struggle to pay the $35 a month for Eric to go to school at Camp Hope, because he receives not only an education there, but also physical therapy and help navigating the public medical system.  The public schools have 50 children to a classroom and no support for a child with disabilities.  After touring the tiny, dark, cement home, the grandfather asks us to climb up another set of incredibly steep stairs lined with scavenged eclectic  containers of flowers to his rooftop--he smiles as he shares his vista; Quito spreads unending below us.  If this were San Francisco, this is where the million dollar homes would perch.  Here, this is where the illegal homes are built for squatters who barely eek out a living.  I have no idea how they get water and electricity up here to the thousands of poor who share this mountainside in incredibly close quarters--house after house after house stacked over, under and next to each other.

A beautiful German Shepard perches on one of the roofs,  his monotonous barks blend with loud pop music; the children who attend afternoon school play in doorways; mothers and older children wash clothes on the washing stones built into common courtyards.  I think that millions of children live like this across the world.  It is too much for my heart to hold.  I can think about Eric's father, who studies for a better future and hopes of surgery for his son; I can think about the grandfather, who holds his family together in a dry, safe--if dark--cement home on a high mountainside above Quito. I can think about Eric, who at age 6, has a dream.

We said good-bye with happy tears....

We said farewell to the church and the community of Carapungo with tears in our eyes...truthfully, tears on our cheeks and a few sobs. Many of the patients we saw earlier this week came back with other family members to be seen, and they greeted us like loved familia. Hugs, smacking cheek kisses, huge smiles and such warmth. We saw sicker people today-- I think we had worked our way through all the chronic stomach aches and back pains the first three days to the kids with colds, rashes, allergies and parasites. Calvin and Dr. Bridget treated one family with six kids for parasitos--popped the medication in each mouth down the line to the baby. I saw a 94 yo woman with severe constipation, a man with hypertensive emergency who refused to go to the hospital-- I was worried he would have a stroke right in front of me--a woman with a kidney infection, and a case of pinworms in a baby. Every day has been so different in the types of problems we see-- it's completely unpredictable. We saw a lot more kids today than the first few days--they all give us a big hug and a kiss and a big smile before skipping out after consultation. You may think we do this for them, but in truth, we receive far more than we could ever give. We saw about 80 patients today, gave out as many medications as we could, finished early and packed up.

The Pastor and his wife preparing our Ecuadorian feast

Pastor Fernando and his wife prepared a traditional Ecuadorian feast for our final lunch today--maize on the cob, hominy, cured pork chops (they tasted a little like ham).

Eating the feast!

Our translators, cousins Daniella and Fernanda

Pastor Fernando blows the Jewish Shofar for us

At the end of the day, we were each given a tiny clay figure, representing the different regions of Ecuador, as goodbye gifts from the church. Although we are a secular medical mission, Camp Hope is supported by a Christian foundation, and we were serving within a church, so before we left, the pastor had us join hands, and he said a prayer first in Spanish, then in English. I wish I could remember the words well enough to share them with you, but I can tell you there was not one dry eye in that room when he finished. I do remember the part where he asked the angels to continue to watch over us. I rather liked that, as they have done a great job so far.

Our dinner hosts, Jackie and Rita, with a fuzzy Dr. Choate

This evening, we were further treated to more fabulous Ecuadorian food and salsa dancing lessons at Jackie's home. Jackie is the president of the foundation. Rita, the exec director of Camp Hope, and Mari, with foster son Ronald, joined in. Martin was picking my husband up at the airport, so he missed out. We had such an amazingly good time-- but what happens in Ecuador, stays in Ecuador (but I do have video's)!


Tomorrow and Sunday, we will be experiencing Ecuador outside of Quito-- traditional markets, the equator (we will go from spring to fall and back again), llamas, volcanos, lakes, waterfalls and cloud forests. The team has coalesced into an incredibly efficient, functional and fun group, and we are looking forward to our time together as new friends outside of our work. We will spend three days starting Monday with the special children at Camp Hope, with a very different approach from our rapid triage free clinic this past week. Thanks for sharing our journey--we love that!  www.camphopeecuador.org to learn more.

Our guardian, Martin

Martin with Dr. Mimi's daughter

If Mari is our angel, Martin in our guardian. Martin (pronounced like Martina without the 'a'), is Mari's older brother and the coordinator of our mission. He makes sure we get to the church every morning and to our hotel every afternoon. He has been our tour guide around Quito, and counts our heads like a mother hen, rounding up those who lag too far behind (for some reason, it's usually me). Pickpocketing has been honed to a fine art here, so he is constantly cautioning us and keeping us within reach.

We insisted on visiting the local market a block down from the church where we have been working, because we've seen so many patients who work there, mostly middle aged women who look years older than they are and complain of back and leg pain from standing all day. Martin thought it was too dangerous, but we were undeterred, so he finally gave in today and walked us through. We had already seen half the people who work there, so it was like visiting old



 friends. The market is housed within a open-sided, graffiti covered cement and metal building. The air--heavy with the stench of rotting meat--hits us as we walk in. There are tiny meat stalls-- that hog's head is for sale--lining one wall. The middle hallway is bursting with color from an incredible array of fruits and vegetables, far more than is found in the US. A woman sits hunched over an old manual sewing machine in a third hallway--I remembered her from our first day, complaining of headaches and back problems, no surprise there--it's hard labor.  We see an acorn squash as big as a pumpkin.






Outside along the back wall are the grain stalls with burlap bags full of corn, beans, wheat and other grains. Children work along side their parents--one boy of 10 or so comes out with black rubber gloves on-- I wonder what type of work he is doing and how hard it is. A traditionally dressed woman sits on the sidewalk shelling some type of flat bean with her son. He asks me to take his picture- yay! Thanh and I take pictures, and his mother asks for money for the photography session-- seems like a fair bargain to me. The picture taking, however, has separated us from the group and poor Martin must retrieve us, with a sigh. I am sure he is very happy when we get into the van and head home. It was very instructive, however, to see not only how hard people labor, but where the neighborhood buys their food and goods.

Neighborhood market--notice the broken bottles that line the top of the walls

We were able to finally tour the market today because we actually finished on time. We had asked for less patients today (we saw 60), as Dr. Mimi (Choate) went to Camp Hope with Mari to do Pap smears on the staff, so we were a doctor down at the church. While Mimi did pelvic exams using an upside-down hospital bed pan and a headlamp in place of stirrups and a lamp in the blue infirmary at Camp Hope, we were once again greeted by a waiting room full of patients from 45 days old to 80 something. Gotta love family medicine. The last patient we saw yesterday-- the one who had helped me bring order to the chaos of the waiting room--was there with the rest of his family this morning. Since he had sat from 8 am until 4 pm with his two year old son the previous day, I took them as my first patients-- probably out of order (don't tell Martin! Martin had the clinic VERY organized today-- the #'s were stapled to the chart notepaper and every person had their own number and was seen in order). This family arrived from Columbia 8 days ago with their 45 day old baby, and they were concerned about him. The mother (20 years old) asked about her weight, as she sat and breastfed her baby-- she weighed 88 lbs, far below normal for a 20 year old. Her ten year old brother said "hello" in English, very proudly. We passed out a lot of vitamins and calcium and advice on diet. They were just the nicest family ever.

Remember Edison from our first day? The one with the seizures....his mother returned today with his seizure medicine level and reported he hadn't had a seizure since Tuesday when Dr. Carrie (Wilcox) increased his dose. But the mother was out of medicine and out of money-- and we had neither to give her. Angel Mari, however, has a friend who works at the Children's Hosp, and this friend was able to secure an appointment with the neurologist to see Edison next Wed. Normally to be seen at Children's, the parents have to stay overnight in the street in a queue in order to just be able to make an appointment to be seen in a few months. Score, Mari!

The true hero's of this story are the Ecuadorians who have dedicated their lives to caring for and about the poor in their midst-- from the pastor and his wife who provide breakfast to the poor every morning, to the social worker who is with us every day, to Mari and Martin who have given up their lives for two weeks to shepard us and are always doing something for Camp Hope, to the teachers and therapists and volunteers that allow this to happen. People are very appreciate of the time we spend with them, but the reality is they need care over the long term with followup and monitoring-- which we can't offer. I hope the longer term benefit will be for someone like Edison, who perhaps wouldn't have been able to get into the system without first being able to come to a free clinic. Maybe. No se'. Tomorrow is our last day of our church clinic in Calderon. Next week we begin our work at Camp Hope.

The Journal

Family Medicine residents

This trip is not just a service journey, it is an international medicine rotation for family medicine residents and pharmacy students, hence, we are also teaching while we are working. We have three family medicine residents-- two from the Univ of Colorado and one from Ft Collins-- and four pharmacy students from the Univ of Wyoming in their sixth and last year. The students and doctors range in age from 23 to 33 years with wildly different backgrounds but a common cause-- serve, learn and experience (our consensus team goals). One of the objectives of the rotation is to process what we are experiencing, so every day, one person takes our team journal and writes. That person then reads it to the team at the breakfast table the following morning. When we are done, it will be written up for everyone to keep. I have been grateful for the thoughts they have shared-- the weathered stoic old man who looked like pictures of a Colombian grandfather rarely met, first experiences serving in a foreign country and seeing the world through others' eyes, careful detailing of the churches and cathedrals we visited in the old town, and writing about shared laughter and silly moments that make trips like this even more delightful.

We laugh a lot at meals and in our short bus going back and forth-- so many ridiculous situations occur in the course of one day, it's impossible not to laugh-- and it helps release stress and anxiety from a very busy day. I probably shouldn't tell you that we joked about our journals entries being one liners, "The soup was very good today" or "Slept well". Well, we thought it was hysterical-- maybe you had to be there.

Today when we arrived at the church--on time-- everything was already humming along. The volunteer had given up on blood pressures so was very efficiently weighing and measuring and assigning numbers. We were able to start seeing patients efficiently. I like efficiency. But then a funny thing happened on the way to efficiency--we started noticing that families were all given the same number, so a family of 5 was all given "19". Yep-- you got it-- if you give out 70 numbers in multiples of the same ones, it adds up! Then we noticed people had numbers we had already seen-- they were passing their # to friends after they left. We had people everywhere. Little kids were running in and out of my little exam space squealing and playing, the older kids were flying the little gliders we handed out over and into people, people kept poking their heads around the sheets to see what we were doing and if it was close to their time. We were short a translator for a third day-- thank goodness Mimi is fluent; we work in teams of a physician, pharmacy student and translator-- ideally.

University of Wyoming pharmacy students

The pharmacy students are really getting great clinical experience, since they work side by side with a physician, as well as dispensing the medications and educating the patients about how to take them. Calvin worked with me today-- his favorite patients were the couple in their 70's, clearly still in love after all these years-- worried about each others health; he with blocked arteries in his legs causing pain and keeping him homebound, she with back pain and bone pain.
Amanda ran the pharmacy today-- a tough job that rivals the busiest Walmart pharmacy. Christine worked with Bridget, and they saw a beautiful two yr old boy with a funny looking tongue-- looked like it had a map plastered to it; he and his father sat and waited all day-- the father started helping me keep track of who was next. Thanh worked with Carrie, after running the pharmacy yesterday. It looked like an ant den today with white costs flying back and forth from room to pharmacy and back again. We gave out a lot ibuprofen, Tums, Tylenol, vitamins and stomach meds. We did start collecting the little pieces of paper with #'s to halt the constant influx of people, but we saw everyone. We lost count after 80. We were late leaving and that meant the Camp Hope kids were late getting their bus back. That made us sad. We finished up our day by taking ourselves out to dinner in the old part of Quito, where we laughed until tears rolled as we told stories about our day, and finally returned exhausted. I can't wait to hear the journal entry tomorrow morning.