In the middle of a cabbage farm, an hour’s drive from the Andean town of Otavalo, Ecuador, is a small radio station on the ground floor of a farmhouse. Radio Ilumán is the local indigenous radio station, presented entirely in Kichwa. Each week Dr Nadia Montero and the director of Jambi Huasi drive to the farm to present a programme on healthcare. At 24 years old, Nadia is the only doctor at the Jambi Huasi clinic, managing up to 30 patients a day. She presents in Spanish, and the director translates into Kichwa. It’s one of the only ways much of the indigenous population will receive any medical care at all. Most of those living in and around Otavalo never once visit the doctor. This week Nadia is covering infant nutrition. A shrill panpipe song interrupts her at certain intervals, a little too early most of the time, as she gives her recommendations.
Nadia trained at a top medical school in Quito. As part of her first year as a doctor she was posted to Otavalo, to be the only western trained medic at the Jambi Huasi clinic. Nadia is in charge of everything; she manages births, and documents deaths.
During my time there, Nadia and the clinic staff had a difficult decision to make. An American woman, nine months pregnant, had just turned up at the clinic. She had travelled all the way from La Jolla in California, determined to have a natural birth at Jambi Huasi.
“Many Americans come to the clinic, seeking alternative therapies,” Nadia said. “Usually this isn’t a problem, there is little wrong with them and we can perform a limpia cuy and they are satisfied. But occasionally we get something we can’t deal with. Like now.”
The issue was not just the birth – Nadia and her team had managed many labours at the clinic – the problem was that the woman was refusing any kind of Western medical intervention: no prenatal scans, no blood tests, and no action if things started to go wrong. Every labour the clinic manages undergoes rigorous prenatal tests at the local hospital. All sorts of things can go wrong in birth, most of which are preventable with a well-positioned ultrasound scan. The clinic also has a protocol, in the case of emergency, and following it means using drugs, monitoring equipment, and calling an ambulance. The woman was refusing to consent to anything.
The legal position in which the clinic stood was unclear. With America’s litigious healthcare culture, what would the woman do if something went wrong?
The same week, a teenage boy appeared at the clinic. He was fifteen years old, spoke only Kichwa, and was in extreme distress. He had been having intermittent chest pains that were sharp and radiated all across the front of his chest. After a brief examination, and an interview with a Kichwa translator, Nadia referred him to the hospital. She was being over-cautious: there had been a number of cases like this in the last six months: teenage boys with non-specific chest pain that was un-related to exercise, and coincided with periods of intense emotional distress. Critically, after running some tests at the hospital, no physical cause had been found. Nadia was hoping the same for this patient.
In Ecuador the primary care services are
almost non-existent for mental health. Care in
the community really means care by the community.
This boy and the others suffered from a somatomorphic disorder: when extreme distress or emotion presents itself with pain or disability. It is one of the more common psychiatric illnesses seen in the indigenous community, along with depression, anxiety and alcoholism.
According to Nadia, it is poverty, and with it economic migration and the disruption of families, that is partly to blame. As in many cultures, there exists a deeply rooted sexual and physical violence towards women. She sees it in the clinic every day. One woman had been raped at ten years old. Now at 23, she had never been treated. She viewed it as “just one of those things”. In a consultation with another patient, Nadia attempted to convince a young woman that she could start contraception without her husband’s approval. It’s a common situation. According to Nadia the husbands fear that, with birth control, their wives could risk being unfaithful. Drugs and alcoholism are a problem too. Young children sniff glue, and many are addicted to the powerful hallucinogen San Pedro, similar to ayahuasca.
But psychiatric treatments in the Andes are limited. Talking therapies and medications are available, but they are expensive and not subsidised by the government. Most patients are cared for in institutions, but like in the UK, there is a move towards primary care. But in Ecuador the primary care services are almost non-existent for mental health. Care in the community really means care by the community.
Psychiatry in Ecuador is suffering the same fate as in the UK. A lack of training at medical school, and cuts to funding has meant a dearth of bright, driven leaders in the field. And it is taking its toll.
The indigenous population are reticent about visiting the Western doctors with psychiatric issues; they prefer the doctor to be indigenous. Their relentless marginalisation over the years, while much improved, has left a defensive attitude.
But, according to Nadia, traditional medicine is no better. Although they have the access to the problem, the same language and culture, their methods do little to help. If a Western psychiatrist were given that level of trust and confidence, she thinks, they could do a lot more.
As I left Otavalo, the young boy was swept off to the hospital by his family, and the team were still debating what to do with the American woman. I felt nervous for them, and angry at the unreasonable demands she was placing on them. Later, I found out that Nadia eventually managed to convince her to undergo the prenatal tests, and agree to medical intervention. The tests were fine and the birth, thankfully, went smoothly.