HOJA BLANCA, ECUADOR — Karen Topa Pila looks around the windowless reception area in the small health care station of Hoja Blanca, Ecuador, its pale yellow walls stained with patches of mold. "When did the electricity go out last night?" Topa Pila, a doctor in this remote corner of the country, asks. Her co-workers shrug, throwing worried glances at a small container filled with ice packs. It's only 8:30 a.m. one morning in December 2021, but outside it's already over 70 degrees.
Topa Pila closes a cooler containing 52 COVID-19 nasal swabs. "Those tests need to be refrigerated and we only have one fridge, which is exclusively for vaccines," she says. Her team has nowhere to store the tests, she adds, and so to avoid their spoiling in the jungle heat, the clinic wants to use up all of them on the same day. The very next morning, a health-care worker is going to take them to the laboratory in the district hospital.
Rural COVID care
Topa Pila, 25, and her team arrived in Hoja Blanca, a village of 600 located in the heart of Ecuador's Esmeraldas province, in September 2021. As freshly graduated health-care professionals, they all are required to serve an año rural, working one year in a rural community in order to get their professional license or advance into postgraduate courses in medicine. (The Ministry of Public Health implemented the año rural in 1970, and the practice is also common across Latin America.) Topa Pila's team is the third deployed in Hoja Blanca since the start of the pandemic. The Hoja Blanca station is also responsible for six other communities, made up of mestizos, Indigenous Chachis and Afro-Ecuadorians — about 3,000 people in total. Some of the communities are so remote that to reach them, the health-care workers traverse thick rainforest and then travel by canoe for a whole day.
Ecuador has suffered big losses from the pandemic. In the early months, corpses littered the streets of the country's biggest city, Guayaquil. By June 2020, the mortality rate from the virus reached 8.5%, one of the highest in the world at the time. As of June 5, 2022, the country recorded 35,649 official COVID deaths, although the real count is likely far higher.
Many public health experts agree that COVID-19 has also surfaced deep-rooted systemic problems in Ecuador's rural health-care system. In 2022, Ecuador, the smallest of the Andean nations, the population reached more than 18 million inhabitants; an estimated 36% live in rural communities. As with private health-care providers, the country's public health-care system is fragmented, divided among various social security programs and the Ministry of Public Health. There are about 23 physicians and 15 nurses per 10,000 people on average. But only a small portion of the country's health care professionals — roughly 9,800, by the estimate of John Farfán of the National Association of Rural Doctors — serve the more than 6.3 million rural Ecuadorians.
Although Ecuador is relatively financially stable, many Ecuadorians lack access to adequate medical care and the country has some of the highest out-of-pocket health spending in South America. In rural areas, access to hospitals — as well as clinics like Hoja Blanca's — is hampered by bad infrastructure and long distances to facilities. Before the pandemic, Ecuador was undergoing budget cuts to counter an economic crisis; public investment in health care fell from $306 million in 2017 to $110 million in 2019. As a result, in 2019, around 3,680 workers from the Ministry of Public Health were laid off. Ecuador has also experienced long-standing inconsistencies in health leadership. Over the last 43 years, the country has had 37 health ministers — including six since the start of the pandemic.
Before the Ministry of Public Health's selection system placed Topa Pila for her service, she had never been to Hoja Blanca. It took her more than 8 hours to get there. She says that when she first arrived at the modest health-care station, she thought, "This is going to collapse."
Running out of everything
Early in the pandemic, Ecuador weathered shortages in everything: face masks, personal protective equipment, medications and even health-care workers. By April 2020, the government had relocated dozens of doctors and nurses from rural areas to urban hospitals and health centers, leaving many communities without medical attention.
At one point, says Gabriela Johanna García Chasipanta, a doctor who spent her año rural in Hoja Blanca between August 2020 and August 2021, her team didn't even have basic painkillers like acetaminophen or ibuprofen. It was an "infuriating" experience, she says. "I even had to buy medication out of my own pocket to give to some patients, the ones who really needed it and didn't have the economic means to get it." Some rural outposts had to resort to desperate DIY solutions during the worst months of the pandemic, says Esteban Ortiz-Prado, a global health expert at the University of Las Américas in Ecuador — jury-rigging an oxygen tank to split it between four patients, for instance, and using plastic sheets to create "isolation tents" in a one-room health center.
The pandemic has strained rural doctors in other ways, too. In 2020 and 2021, Ecuador's National Association of Rural Doctors received many complaints of delayed salaries, some more than three months late. "There were rural health -care workers who were even threatened by their landlords that they were going to be evicted," says Farfán, a doctor and former association president.
Even under better conditions, remote health care outposts are only equipped to provide primary care. Anything more serious requires referral to the district hospital, which in Hoja Blanca's case means a 300-mile roundtrip to the parish of Borbón.
The health administration used to take into account Ecuador's geographical and cultural diversity and the poor infrastructure in rural areas. But in 2012, the government restructured the system into nine coordination zones that public health experts say no longer follow a geographical logic.
"You cannot make heads or tails of it," says Fernando Sacoto, president of the Ecuadorian Society of Public Health. "This is not just a question of bureaucracy, but also something that has surely impacted many people's health."
Although there have also been significant developments in the health-care sector in the past 15 years — including universal health coverage and a $16 billion investment in public health from 2007 to 2016 — it mostly focused on the construction of hospitals, says Ortiz-Prado. But the country's leadership "didn't pay too much attention" to prevention and primary health care, he adds. "The system was not built to prevent diseases but was built to treat patients."
In 2012, the government also dismantled Ecuador's Dr. Leopoldo Izquieta Pérez National Institute of Hygiene and Tropical Medicine — which was responsible for emerging diseases research, epidemiological surveillance and vaccine production, among other things. (It was replaced by several smaller regulatory bodies, one of which failed completely, according to Sacoto.) The majority of a nationwide network of laboratories shut down as well. Sacoto and other experts believe that if the government had continued investing in the Institute rather than dismantling it, it would have lessened the severity of the pandemic's impacts in Ecuador.
Initial plans to track and trace COVID-19 cases faltered; the country had barely any machines to process PCR tests, the gold-standard COVID-19 tests. "During the first days of the pandemic, samples collected in Guayaquil were taken to Quito by taxi," Sacoto says, because that was the only place PCR tests were being analyzed. But public transportation to rural communities is limited, so even the few rural residents who had access to tests sometimes waited two weeks for test results.
A team with a mission
Topa Pila's team tries to convince everyone they cross paths with — the butcher's wife, people waiting for the bus, men at the cockfighting arena — to take a COVID-19 test. While the PCR results are faster than they used to be, they still take a week, as one of the health-care workers has to personally shuttle the samples to Borbón — a 3-day roundtrip that involves a motorcycle, two different buses, and crossing a river with a shabby ferry. "Up until yesterday, we had COVID-19 rapid tests. Today, the [district] leader took all the tests we had," says Topa Pila. The district hospital had requested the rapid tests, she adds, because "they've run out of tests and they need them."
Since Hoja Blanca is fairly isolated, the community has had very few COVID-19 cases, and all were mild. Topa Pila fears having any patients in a critical condition, COVID-19 or otherwise, because all she can do is ask the villagers and ferry operator for help with transport. There are no ambulances. "We don't have oxygen because the tank we have over there is expired and you can't use it anymore," she says. "We've asked for replacement but nothing has happened."
The way Topa Pila sees it, it's a lot to ask of the inexperienced health-care workers on their año rural. "We start from zero without knowing anything every year," she says, recalling that the previous team had already left by the time she arrived in Hoja Blanca. "And all of those patients whose treatments have been supervised by a doctor for a year lose their treatments, because they knew the doctor would come to their house," she says. "We arrive and don't know where they live, since as you can see there are no addresses here." The COVID-19 pandemic has further distanced the rural doctors from their patients, she adds. Between the lockdowns and the coronavirus, other health matters like childhood vaccinations have been put off.
As in other parts of Latin America, the COVID-19 crisis in Ecuador also allowed corruption to fester. Sacoto says he believes the health-care sector has become a "bargaining chip" among politicians. "There really are mafias embedded in, for example, public procurement," he says, because the public procurement system is so convoluted that "only the person who knows how the fine print works benefits." Between March and November 2020, the country's Attorney General's office reported 196 corruption cases related to the COVID-19 pandemic, including allegations of embezzlement and inflated pricing of medical supplies.
Lately, there have been signs of improvement. After taking office in May 2021, the government of Guillermo Lasso has accelerated vaccination efforts against COVID-19, approved a new program to tackle children's malnutrition and announced a Ten-Year Health Plan to improve health equity.
Sacoto says he remains skeptical whether these plans will translate to concrete and lasting actions. A good start would be decentralizing the health-care system by building more rural clinics, he says, which could build up a network for preventative care for everything from childhood malnutrition to future pandemics. Ortiz-Prado says the country should better integrate its fragmented health-care systems to make it easier for patients — and their records — to move between them when needed. And it needs to improve the working conditions and salaries of rural health-care workers to make the work more appealing, Farfán says, while also creating more permanent positions focused on rural communities.
There is a "lack of concern, lack of budget," he says, adding, "It's a vicious circle, and sadly, governments are trying to apply Band-Aid solutions for the health issues here."
But all of that is in the future. Now, back at the Hoja Blanca health-care station, the lights flicker back on in less than a day. The vaccines in the fridge are safe. But the 52 COVID-19 tests are still at risk: A health care worker must take the cooler to the lab in Borbón. There were heavy rains the night before, though, and water levels haven't dropped enough for the river ferry to restart operations. It's just the first leg of what will ultimately be a 13-hour journey, and the icepacks are quickly melting amid the balmy equatorial heat.
This story originally appeared in Undark, a non-profit, editorially independent digital magazine exploring the intersection of science and society. Kata Karáth is an Ecuador-based freelance journalist and documentary filmmaker covering science, environment, and indigenous issues.
This reporting project was produced with the support of the International Center for Journalists and the Hearst Foundations as part of the ICFJ-Hearst Foundations Global Health Crisis Reporting Grant.