Family Medicine in Ecuador: At Risk in a Developing Nation

Despite the overwhelming need for primary health care in Ecuador, medical education and practice are still largely based on specialization. The few family physician graduates from the initial family medicine programs have a comprehensive understanding of Ecuador’s health needs but continue to face issues of visibility and credibility. Unemployment, poor remuneration, and the large pool of untrained general physicians are factors limiting the viability of family medicine. The economic dependence of the country and of the medical profession on external resources restricts the potential for the growth of family medicine. In the current economic climate, family medicine will require creative strategies and strong governmental, nongovernmental, and academic support to become a major force in addressing Ecuador’s needs for primary care.

The problems of health care in developing nations are significantly different from those facing the United States. Clean water, sanitation, primary care for both rural and sprawling urban populations, adequate resources for secondary levels of care, and reduction of high levels of infant and maternal mortality are critical issues for countries undergoing rapid development. The challenge to family medicine in such contexts is to address these problems while establishing legitimacy as a specialty. A brief look at the current status of family medicine in Ecuador reveals that, in addition to the overarching public health problems, family medicine is also facing issues of visibility, credibility, and viability in a country undergoing the acute pressures of development.

HISTORICAL BACKGROUND: FAMILY MEDICINE IN ECUADOR

Ecuador is a small country at the northwest corner of South America with a population of almost 14 million. In 2001, infant mortality was 30/1,000, maternal mortality was 74.3/100,000 births, and mortality for children under 5 was 57.7/1,000 (Pan American Health Organization, 2001). Life expectancy is about 70 years; 69% of women get antepartum care, and 69% have a skilled attendant at delivery. About 15% of children are underweight, and 27% suffer from moderate to severe stunting. Although the literacy rate is reported at about 92%, less than 60% of children go beyond primary school (UNICEF, 2001). About 70% of people live below the international poverty line, which makes Ecuador one of the poorest countries in the world. Health expenditures are at 2.4% of the gross domestic product (compared with the United States at 13%), and there are 1.7 physicians per 1,000 people (2.8 in the United States; Central Intelligence Agency, 2003) As in most other Latin American countries, health care is delivered under various separate funding methods: the public system, social security insurance, the military system, and private insurance-a hodgepodge the U.S. Agency for International Development (USAID) described as “a fragmented, uncoordinated, and duplicative health care system” (USAID, 1997).

Medical education and practice in Ecuador have traditionally been based on a specialty model. Tertiary care specialists teach medical students and run the university training programs. The curriculum at the national medical school, where most doctors trained up until 1995, focused on basic science and pathophysiology, ignoring the common problems of prevention and treatment that predominate in primary care in Ecuador. In the last decade, three new medical schools have opened in Quito, but students graduate still largely unprepared to address the health care needs of the majority of Ecuadorians. Despite their lack of preparation, graduates are legally bound to serve 1 year in rural government health clinics before they can receive their degree. This obligatory year of rural service, or ano rural, is widely acknowledged as a failure in terms of affecting health in rural areas (Cavender & Alban, 1998). The recent medical school graduate goes into a setting with no supervision and minimal equipment and resources. Graduates with pull can get “rural” postings in the major cities. The Ministry of Health is currently considering a complete revamping of the rural year, but such a change would require revoking legislation at the national level, a very time-consuming process (Ministry of Public Health, 2003). In the meantime, the old system continues.

After the ano rural, young physicians compete for the few prestigious specialty training programs available in Ecuador or try to obtain expensive foreign specialty training. If these options are unavailable, they leave medicine altogether or continue in the practice of “general medicine,” for which they have been so poorly prepared and which is held in low esteem by the medical community (Wilson, 1993). Most nonspecialized general physicians, medicos generales, are those who have gone into practice after their year of rural service without any further training. (The term medico general is not to be translated directly as general practitioner, a term that has a positive historical ring in the United States and Europe but that implies limited experience and lack of specialization in Ecuador.) No plans are currently in effect to develop an extensive retraining process that could transform the medicos generales into family physicians; the resources, educators, and commitment to develop such a program are absent. Yet at a time of an enormous need for high quality primary care in a country of 14 million people, only about 70 residency-trained family physicians are currently practicing in Ecuador, with only a few more emerging each year. This situation contrasts with that of Ecuador’s neighbor, Venezuela, which by 2001 had 11 residencies, 166 residents in training, and 827 residency graduates in a country about one and a half times as large as Ecuador (Sociedad Venezolana de Medicina Familiar, 2001).

The discrepancy between the need for primary health care of the Ecuadorian people and the training of Ecuadorian physicians had become obvious by 1980. Awareness of the need for generalist, communitybased physicians was reflected in a 1980 meeting of representative medical educators of the Andean Pact countries, who met in Quito and agreed to the creation of the specialty of family medicine and to training at all levels (Ceitlin, 1982). Mexico and Panama already had well-established family medicine training programs; Venezuela (Romero, Gruber, Rincon, & Thompson, 1994; Thompson, Gruber, & Marcano, 1992), Colombia, Bolivia, and Argentina were all initiating family medicine education during the late 1970s and early 1980s. In 1986, the rector of the medical school of the Catholic University of Cuenca (12 hr from Quito by car) collaborated with the Medical Education Department of Hospital VozAndes in Quito, an evangelical mission hospital, in the development of a family medicine training program. Calvin Wilson, a U.S. board-certified family physician, began that program in 1987 and shepherded the training of two to three residents per year for the next 8 years in the 3-year program (Wilson, 1993).

At about the same time, two Ecuadorian physicians, Drs. Ritha Bedoya and Raul Ayala, returned from family medicine residency training in Mexico and started the first family medicine community clinic in Ecuador under the auspices of the Ministry of Health. This clinic became the model practice site of the first family medicine residents from the Cuenca program. In 1989, with the assistance of Dr. Wilson and others from VozAndes, Dr. Bedoya, five family physicians who had trained outside of Ecuador, and the five first family medicine graduates established the Ecuadorian Society of Family Medicine. Their goal was to provide a source of professional support and continuing medical education to practicing family physicians. They garnered official recognition as a scientific society affiliated with the Provincial Medical Society of Quito. Thus, family medicine residency graduates could be recognized as “specialists” by the local medical society. In 1992, Dr. Bedoya initiated a second family medicine training program based on a community clinic practice model, in collaboration with the Ministry of Health. With the shortage of experienced faculty in Ecuador, graduates from the VozAndes program served as teachers in both programs at the same time. During these very exciting years for family medicine, the Ecuadorian Society of Family Medicine sponsored continuing medical education programs for family physicians and medicos generales.

Residency training in Ecuador, unlike in the United States, requires linkage with a university for the granting of the terminal degree. In 1995, the nominal long-distance arrangement with the University of Cuenca for the academic certification of family medicine graduates was dismantled, and Dr. Wilson successfully negotiated the affiliation of the VozAndes hospital-based program with the Pontificia Catholic University (PUCE) in Quito. Forging a merger between a Protestant missionary hospital and the new medical school at the Catholic University was no small feat. The dean of the new medical school, Dr. Osvaldo Chavez, agreed to the linkage between the PUCE and VozAndes to train family medicine residents because of his deep commitment to a two-part vision: medical \education centered in problem-based learning, and preparation of medical students for the primary care needs of Ecuador. He appointed Dr. Bedoya to become the director of the residency training in this new merger, and she served in this role for 5 years. This program, with 5-7 residents each year, was modeled on the U.S. 3-year program format, with a strong emphasis on hospitalbased medicine and a longitudinal family health center practice. Dr. Wilson returned to the United States in 1995, and a few months later, as part of a Fulbright grant to Ecuador, I joined the faculty of the medical school of the PUCE for 1 year to assist in faculty development. I also helped Dr. Bedoya in developing a problem-based curriculum for the 1st year of this joint program from 1995 to 1996. Since 1996, conservative political changes at the PUCE resulted in the removal of Dr. Chavez as the dean of the medical school and the ousting of Dr. Bedoya from her position as director of the residency in 2000. Such political tumult caused pervasive and lasting ramifications for family medicine education.

FRAMING THE PROBLEMS FOR FAMILY MEDICINE

In the ensuing years, I have returned to Ecuador on several occasions and have met informally with various family physicians who trained in the residency. In August of 2003, I joined Dr. Bedoya in Quito in running a workshop on the image of the family doctor for the Ecuadorian Society of Family Medicine (SEMF). Of the approximately 70 residency-trained family physicians in Ecuador, about 15 from the Quito area gathered to participate in this workshop. Some of them had trained in other Latin American countries (Mexico and Cuba), a few had trained in Ecuadorian programs focused on prevention and community health, and the majority had trained in the VozAndes/ PUCE program. Prior to the workshop, several family physicians put together a preparatory document to sum up the state of family medicine in Ecuador. As is customary in Latin America, this document put forth a strong theoretical framework in which to situate the subsequent discussion. What follows is my abbreviated translation of this document (Herrera Ramirez & Garces, 2003, pp. 1- 5).

The current “antimodel” of health care in Ecuador today is centered on illness and death. It is “mechanistic and biologistic” and based on a fragmented model of specialty care that provides the illusion of the domination of nature so sought after by linear science. The health care system is based on the logic of the market and supposed economic development, which looks at health in terms of cost-benefit, gain and loss for the system, and at quality in terms of technology, pharmaceuticals, and high return on investment. This prevailing antimodel is promoted by physicians because they are tied to a system of power and knowledge dependent on the dominant ideology and by consumers because, from the point of view dictated by the market, they see health care as a consumer good that should bring happiness once acquired. The typical actors in the system are male doctors in search of accumulation as the primary form of social prestige; security in their capacity to cure; vertical management of power and authority toward patients and family members, staff and students; and development of dictatorial spaces to exercise their power (e.g., office, hospital, university, public and private institutions). Such powers require separation of public and private life and reproduction of the forms of exclusion and inequality in the society at large (machismo, racism, violence, exclusion of the poor, etc.).

At the primary care level in Ecuador, the current services do not exist to meet either technical or population needs. Primary care should be able to serve as a port of entry to health care, provide referrals to higher levels of care, engage in a dialogue with the community, and address and take responsibility for the health of a denned population. Instead, most primary care services, including those serving the rural areas, are unable to respond to these needs and expend much effort on preventive measures of doubtful efficacy. Ideally, primary care would be able to manage frequent problems according to the best available evidence: use the necessary medications and technology; have the skills to resolve psychosocial problems; recommend preventive measures at the individual, family, and community levels; and communicate and promote equality and respect in the face of difference.

The ideal model would be holistic: It would consider not only the biological aspects but also the psychosocial and spiritual as health problems; it would base care on what causes suffering, not on disease. It would be empowering: What is technically most effective may not correspond to the patient’s values and might have adverse social effectsmoreover, medicalization fosters dependency. The model would be continuous, meaning that primary care would continue the management of a patient to the end of the current problem and beyond, synthesizing the information about the patient and family. Ideally, primary care would be integrative in linking evidence- based health promotion, preventive, curative, and rehabilitative activities. (In the Ecuadorian context, the word integrative or integrated does not imply the integration of medical with psychosocial services.) Moreover, the model would be efficacious and efficient; evidence-based decisions would obtain the maximum benefit at the least cost. The quality of care should be measured by the extent of its fulfillment of the principals of continuity, comprehensiveness, and integration of care. The natural executor of this model of primary care is the family doctor acting in the community.

Understanding health promotion requires complex thought processes that are dialectical, recursive, and “hologrammatical” (comprehensively correct might be a reasonable translation of this invented word), consistent with the paradigm changes in science moving from a reductionist focus to a systemic focus and in medicine from a biomedical focus to a biopsychosocial focus. Science is a model with efficacy only for that which is incorporated in that model; family medicine should use the tools of our discipline to change the goals of medical science into a practice that can address the needs of Ecuador. The promotion of health is a cross- disciplinary objective that will take place only when the political and community forces support this goal, that is, when the conditions are created that guarantee general well-being-in other words, under conditions that are fundamental to development. Thus, health promotion requires commitment to the science and practice of development. In this context, to put family medicine services into the health care system becomes a political decision. These changes would require a transformation from the centripetal system of health with its axis in the hospitals to a centrifugal system privileging the decentralized units of health.

Not all of the physicians at the workshop would have agreed with this entire analysis, but all were concerned about the failure of the existing health care system and the need for a different system based on a comprehensive, continuous, integrated model of primary health care. Unfortunately, the current situation in Ecuador makes it difficult to pursue their ideals.

These family physicians share an intuitive and sometimes explicit understanding that without economic and social development, they will be unable to promote the health of their patients. Inherently, they agree with the constitution of the World Health Organization (WHO; available at http://policy.who.int/cgi-bin/omjsapi.dll? hitsperheading=&infobase=Basicdoc&softpage=Browse_Frame_Pg42), which recognizes that unequal development prevents the attainment of the highest possible standard of health, “‘one of the fundamental rights of every human being without distinction’” (Jong-wook, 2003). In the context of a developing nation, they see that health is a luxury. They are acutely aware that their patients’ health is directly related to their economic status, that steady employment, stable housing, safe food and water, and protection from environmental contamination would solve many of the most common problems. At the same time, these doctors are increasingly aware of the damage of chronic diseases; vascular diseases related to hypertension are now the leading cause of death for older adults in Ecuador (Anselmi et al., 2003; Pan American Health Organization, 2001). Weight control, exercise, avoidance of tobacco, dietary measures, and medication are the obvious solutions, but for reasons similar to those of patients in the United States, preventive measures and behavioral change are just as difficult. Medications to lower blood pressure and cholesterol are a fantasy for many Ecuadorian patients, who are often unable to pursue a lifetime course of even the cheapest generic medication.

CONCERNS OF FAMILY PHYSICIANS IN ECUADOR TODAY

What follows is a distillation of the concerns expressed at the workshop by these committed Ecuadorian family physicians, as they struggle to pursue their vision of family medicine in a challenging and sometimes hostile environment.

Lack of Public Understanding of What Is a Family Physician

Ecuadorian family physicians see their invisibility as one of their most serious problems. There is a general lack of public awareness of how residency-trained family physicians differ from medicos generales. In reality, there are thousands of medicos generales practicing in Ecuador and only a relative handful of residency-trained family physicians, so most consumers are unaware of the distinction. (This situation is somewhat parallel to the U.S. situation in 1972, when there were only 1 or 2 years’ worth of residency-trained graduates of family physician programs around the country.)

Lack of Prestige for Family Physicians

Ecuadoria\n family physicians are painfully aware of their lack of prestige. Although many of the medical school faculty at PUCE are young, residency-trained graduates of the VozAndes program, even students there are reluctant to choose a postgraduate program in family medicine. The specialties offer more power, money, and glamor. Although family medicine is officially considered a specialty, remuneration of family physicians is not equivalent to that of specialists, even for the same tasks. Part of the lack of prestige is based on the public’s lack of awareness that family physicians are residency trained, and part is due to the confusion between family physicians and medicos generales. Urban specialists likewise see little to admire in generalism. The SEMF lacks the resources to mount a public relations campaign to bring family medicine into the public eye and thereby enhance the status of the residency-trained graduates. Students and residents see that only the specialists are admired at the hospitals, which results in few applications for residency training positions from medical students and demoralization in later phases of professional development. Such lack of interest in family medicine is typical among medical students and trainees all over Latin America (Knox, Ceitlin, & Hahn, 2003).

Inadequate Remuneration for the Complex Work of Family Physicians

If family physicians in Ecuador practice in poor urban areas or in rural areas where the need is greatest, the level of income is insufficient. Two to four hundred dollars per month is not an unusual salary for a physician at a time when the Ministry of Labor estimates the cost of the basic market basket of food plus other essential items at $288 per month (Lobe, 2002). With the Ecuadorian economy now “dollarized,” this level of income is totally inadequate for the physician to maintain even a modest standard of living. Thus, family physicians need to have several jobs-it is not unusual for an Ecuadorian family physician to have three different sources of employment. Young family physicians who work as faculty (tutores) at the PUCE earn in the range of $800 per month, still a low figure. Many supplement this income with night and weekend work to make ends meet. Simultaneously, many graduated physicians are unemployed and are forced to take jobs in other sectors-such as pharmaceutical companies, administration, or public health-instead of direct clinical care. (Although income potential is important, surveys of interns in Mexico, another country where physicians face high unemployment, show that attitudes toward primary care and public vs. private service are still largely shaped by the medical school and internship experiences; Frenk, 1985. Thus, low pay alone cannot account for the problems of family medicine in Ecuador.)

The pressure to make more money leads some family physicians to undertake more procedures (e.g., ultrasounds, culposcopy, and deliveries) to garner higher earnings. In the city, specialists are hostile to family physicians taking over some of these specialized sources of income, but little competition exists for providing these services to people of low income and those outside the city, where access to specialized procedures is markedly limited. At VozAndes, missionary physicians are discussing the development of a 1-year procedural training program aimed at missionaries and other family physicians who will be practicing in remote areas (Roy Ringenberg, personal communication, January 2004). Specialists will probably be willing to train family physicians for these posts, because the physicians will not be in competition with the specialists in the city.

Although these Ecuadorian family physicians are acutely aware that patient education and preventive measures are essential for changing the health status of their patients, they are stymied by the lack of remuneration for preventive activities. Patients of very limited means are likely to attend only at times of acute illness; preventive visits are a luxury most are unable to afford. In the face of the need for improved nutrition, better sanitation, more information on reproductive choice, and prevention of communicable diseases, many family physicians have pursued careers in the public health arena, where international nongovernmental organizations (NGOs) often fund projects. Although in theory health prevention and promotion belong in the domain of the family physician, in practice many family physicians see these nonclinical, unremunerated activities as the work of dedicated public health workers, salubristas, who work directly with the community. They distinguish themselves sharply from the salubristas, who are not clinicians and who have not had the extensive hospital-based residency training experience. These family physicians see their own role as providing treatment and hope that through treatment they might engage patients in preventive care once the acute episode has resolved. They report as well that patients do not view prevention as the family physician’s primary role. Additionally, the technological bases of prevention-blood tests, Pap smears, mammography, and endoscopy, to mention the most common-are often unaffordable for Ecuadorian patients. In Quito, patients with very limited means are referred to Sociedad de Lucha Contra el Cncer del Ecuador, a nonprofit cancer prevention organization, for Pap smears and mammography, which takes these procedures even further away from the practice of the family physician.

The document summarized above clearly identifies psychosocial problems as falling under the purview of the family physician. Ecuadorian family physicians are very conscious that personal problems, problems of family life, and social problems such as unemployment are common causes of symptoms that generate a visit to the doctor. Such problems, as they do elsewhere, require that the patient have the opportunity to talk and be heard, to reflect, and to make connections between emotional and physical health. Yet patients are understandably reluctant to lose a day’s salary for a visit that has such intangible results. Referrals to psychologists, social workers, and other therapists are a luxury available only to middle and upper class patients. Family physicians for marginal populations must serve this role in brief visits during which acute illness, prevention, and need for psychosocial care compete for the precious minutes of the visit.

The Dangers of Dependence

Ecuadorian family physicians in search of sources of support are often faced with the choice of relying on external support for continuing education, medication, and direct income. The pharmaceutical companies are frequently tapped to fund lectures as well as national and international scientific congresses. Such dependence is seen as an unfortunate necessity. There is no apparent acknowledgement that the acceptance of such support is likely to influence prescribing patterns and that the indirect source of such funds is the high cost of the drugs to the consumer (Caudill, Johnson, Rich, & McKinney, 1996). Pharmaceutical corporations are seen as a great resource rather than a danger. Such dependence has a direct parallel to the dependence of the Ecuadorian economy on other external sources of funds, such as the International Monetary Fund. At times of chronic economic crisis, the short-term dependence appears absolutely necessary, but the longterm result of such dependence is an economy that favors the interests of the donor rather than the Ecuadorian economy. The themes of dependence and autonomy pervade the discussion of health care from the microlevel of the patient’s relationship with the physician to the macrolevel of the economic and political reality of Ecuador in relation to the global economy. These physicians have a practical understanding of what the director general of the WHO terms

today’s complex service delivery landscape, in which non- governmental organizations and the private sector operate in the gap left by states’ withdrawal from health-care provision-a withdrawal often encouraged by international financial institutions and interests uncritically supportive of health-care privatization. (Jong-wook, 2003)

ORGANIZATION OF CARE: IDEAL VERSUS REALITY

Although Ecuadorian family physicians are tenaciously committed to the ideal of continuous primary care for their patients, as evidenced by the document summarized above, economic pressures force them into acute care offices, like “doc-in-the-boxes,” that are cropping up all over Quito. Called “emergency centers,” these sites appeal to patients’ sense of urgency once they get ill and negate the importance of prevention or continuity. Thus, the economic context forces both doctors and patients to focus on acute care to the detriment of the ideals of family medicine and of the long-term health of patients. When Ecuadorian family physicians do run their own office, they are likely to work as isolated individuals, perhaps with one nurse or a spouse functioning to run the practice. They are unlikely to be part of an extensive referral network, and they lack the ability to connect with psychosocial resources in the community, even if patients could afford such a referral. Family physicians functioning in public clinics may work with nurses and salubristas around community health issues, but psychosocial team members are a rarity. Although integration is a hallmark of the care that the family physician would deliver individually in the ideal model, the concept of the integrated primary care team is still foreign in Ecuador.

THE IMPORTANCE OF CULTURE IN THE CONTEXT OF DEVELOPMENT

The importance of community is central to the understanding of family medicine in Latin America (Romero et al., 1994; Thompson et al., 1992; Ventres, 1997). In Ecuador, despite the lack of availability of psychosocial specialists, family physicians h\ave a particularly strong understanding of the role of family, community, and culture in health and illness. Because of enormous geographical variety and because Ecuador is home to dozens of indigenous peoples, each with unique beliefs, practices, dietary preferences, and exposures (from the respiratory illnesses prevalent at 11,000 ft to the leishmaniasis, malaria, and snakebite that are commonplace in the jungle), Ecuadorian family physicians are accustomed to situating health and illness within the specificities of culture, community, and geography. They would, for instance, anticipate that patients may be reluctant to undertake an expensive Western treatment without family or even community approval; a whole community may need to be convened to agree to spend the resources to transport an ill member to a distant hospital for treatment. The multiplicity of cultures and geographies gives Ecuadorian family physicians a particularly rich understanding of the meanings and implications of illness often invisible to family physicians trained in more homogeneous settings. Thus, despite their discouragement, Ecuadorian family physicians are certain that family medicine is the appropriate form of primary care to meet the needs of their country.

Beyond ethnic diversity, Ecuadorian family physicians know that many world views coexist in Ecuador, even within the same family or individual, melding premodern (magical and religious), modern, and even postmodern understandings of health and illness. They also know that Ecuadorian patients choose and combine many different paths to healing. Western medicine, although respected for its technological and scientific advances, is viewed with ambivalence; modernization, with its homogenization of language and culture, poses both benefits and losses to Ecuador. In a country with a huge chasm between rich and poor, with a state polity mired in corruption, and with a bankrupt economy dependent on untrustworthy external powers, it is clear that the benefits of development accrue to a fortunate few. In this setting, Ecuadorian family doctors cannot be optimistic that further “development,” including scientific and medical advancement, will result in further health and well-being for the vast majority of the populace (Diego Herrera Ramrez and Marisol Garces, personal communication, September 25, 2003).

OPTIONS FOR THE FUTURE: ECUADOR AND BEYOND

In the face of multiple Stressors, what options do these hard- working Ecuadorian family physicians see? The possibilities they raised at the workshop included strengthening the SEMF to build networks of support among themselves. They hoped that by improving communication and drawing on each other as resources they could energize themselves for the challenges ahead. They would like to develop a research base to foster academic presence, prestige, and self-esteem; to this end, they imagined approaching the NGOs and the pharmaceutical companies for support for ongoing projects. Their suggestions emerged as concrete, low-cost endeavors that could be implemented in the near future. At this workshop, they did not propose long-range solutions to the problems of family medicine.

The problems faced by these courageous Ecuadorian physicians in their own small country are the same problems confronting family medicine throughout Latin America and other developing parts of the world. Many more practicing and teaching family physicians are necessary to promote visibility, strengthen interconnections, promote academic quality, and develop a research base if the specialty is to survive. In other Latin American countries commitment and funding from academic institutions and governmental ministries have been essential for family medicine’s survival (Irigoyen-Coria & Gomez-Clavelina, 1994). Likewise, in Ecuador, major international support and commitment from the Ministry of Health to build a high quality primary care system is necessary for family medicine to become a major actor in the health care sector in Ecuador. A hopeful sign was the convocation in December 2002 of the National Forum of Family and Community Health-a coalition of governmental, nongovernmental, community, and international organizations-which adopted a “model of integrated care” and resolved to urge political and educational changes to bring about decentralized primary care in Ecuador (Foro Nacional de Salud Familiar y Comunitaria, 2002).

In a country where specialization is associated with prestige and general physicians have been excluded from hospital practice and continuing medical education, family physician educators in Ecuador still tenaciously adhere to many ideals identical to those of family medicine in more developed nations. To begin to implement such ideals, they have many tasks ahead of them. To train an adequate number of comprehensive family-oriented physicians to provide primary care to the people of Ecuador, change is necessary at multiple levels.

Medical Schools

Training focused on family medicine as a specialty is necessary to recruit interest among students; as with medical schools in other Latin American countries, students continue to show lack of interest in addressing the primary care challenges in their country and hence are unlikely to choose family medicine. This problem is widely recognized among family medicine educators in other Latin American countries with a longer history of family medicine education. Leaders in family medicine from Argentina, Colombia, Mexico, and Panama surveyed 100 medical school deans in their countries and, with a 65% response rate, found that only 26% had departments of family medicine; only 63% had some kind of training at any level (Knox et al., 2003). The responding deans reported problems with lack of financial support, lack of sites for clinical training, failure to define family medicine as a legitimate specialty, and lack of demand from students-problems exemplified in Ecuador as well.

In addition, Ecuadorian medical schools need to undergo substantial university reform. Faculties need to turn away from enticing students into lucrative but elusive careers as subspecialists. Modeling of an integrated teaching approach and training in educational methods and problem-based learning are urgent needs. In a country dominated by specialty training, senior faculty with a generalist approach are lacking; young faculty, just out of training, are the teachers for the residents just 2 or 3 years behind them. Enhancing the academic training of the early graduates of the Quito family medicine residencies would strengthen the potential family medicine leadership necessary for lasting reform. Once residencies are well established, strategies to encourage research would enhance the academic quality of training and program development. In addition, tighter linkages to the community, as in Venezuelan programs (Thompson et al., 1992), are important in family medicine training, in contrast to the VozAndes program, which had no discrete community base. To place doctors in rural areas and small towns, schools need to recruit students from those regions, as the desire to live near the extended family is very strong in Ecuadorian culture. As long as medical students come from the largest cities, it will be impossible to ameliorate the shortage of physicians in rural areas. Such changes are very similar to those recommended for the development of family medicine elsewhere; the success of family medicine in other Latin American countries suggests that the task is not impossible (Flores Arechiga, Riquelme Heras, & Quintanilla Cantu, 1985; Haq et al., 1995).

Postgraduate Family Medicine Training

Given the limited number of residency-trained family physicians at present, the field of family medicine must make a renewed commitment to increase the numbers of trainees by developing additional residencies. To increase the number of generalist and family physicians, Ecuador could develop 2-year programs with a stronger emphasis on ambulatory and community health, much like Venezuela’s early programs. This model was the original basis of the community health residency begun by Dr. Bedoya, later subsumed within the 3-year American model at VozAndes. Such programs will require funding from the Ministry of Health and Ecuadorian Institute for Social security (IESS), the insurer for many employed Ecuadorians. (Both in Venezuela and in Mexico, the social security systems have been instrumental in underwriting family medicine.)

New residencies alone are not enough to address the shortage of generalists, because their impact is delayed. For a rapid increase to occur in the number of family physicians, new systems capable of retraining and certifying large numbers of medicos generales need to be developed. Initiatives within WHO to address the “workforce crisis” in developing countries-extreme need in the face of high unemployment in the health care sector (Jong-wook, 2003)-may be applicable to the high number of medicos generales in Ecuador. In Mexico, the social security system has invested heavily in a retraining scheme, facilitating medicos generales to enter training programs conducted in the social security clinics where they practice. There, the extensive government-funded system enables these physicians to maintain their current practice and income in an effort to increase both the quantity and quality of primary care physicians (Fernndez Ortega et al., 2003; Perez-Cuevas et al., 2000). Coupled with such methods to increase the numbers of well- trained generalists, a nationally recognized method of certification would ensure that family physicians, however trained, receive the recognition and remuneration they deserve. The development of such an educational program and a certifying mechanism for generalists was the original mission of the SEMF over 10 years ago (Wilson, 1993), but it has languished for lack of energy and r\esources.

Building Leadership Potential

The movement needs charismatic leadership capable of influencing policy at a national level. Because countries with renowned international leaders in family medicine have difficulty with the establishment of the field’s legitimacy, we can see the challenge for Ecuador, which does not have, at the moment, such strong leadership. Faculty development is necessary to prepare family physician educators for leadership. Programs in Spanish are now available in other Latin American and Central American countries as well as in Cuba, Puerto Rico, and Spain, but individuals will require economic support to make use of them. Knox et al. (2003) recommended governmental support and the development of internal advocates to address the leadership issue. “Future leaders in family medicine must be identified and provided with training in political advocacy, in medical education, and in the curriculum change process” (Knox et al., 2003, p. 594). Such leaders are necessary to develop models of how primary care can work with the specialties to decrease opposition and to convince governments, public health officiais, and the academic community of the important role family medicine can play to resolve the health needs in their countries. Unfortunately, in Ecuador the potential to produce such leaders, which seemed so possible in 1993, has been stymied by changes in leadership at the one medical school initially dedicated to producing primary care doctors. New initiatives in family medicine training, funded by the European Union at the University of Loja in southern Ecuador, hopefully may begin to reverse this trend (Dr. Ritha Bedoya, personal communication, June 5, 2004).

International Linkages

To promote family medicine in Latin America, the established leaders recommend partnering with the World Organization of Family Doctors, the Pan American Health Organization, and the International Development Board (IDB) to convene meetings that could result in new initiatives for family medicine. They recommend the formation of an international advisory group of leaders in academic family medicine to help medical schools incorporate family medicine into medical education. Such a group could apply for funds from the IDB to promote curricular change. The Society of Teachers of Family Medicine and the World Organization of Family Doctors could offer assistance in the formation of suitable predoctoral curricula and shape and share their resources for use in Latin America, including the promotion of faculty development fellowships for Latin American faculty (Knox et al., 2003). Ecuador appears to be at the beginning of this process, as the Ministry of Health has begun to take a larger role in the promotion of generalist training.

CONCLUSION

As in the United States, the future of family medicine in Ecuador is uncertain. Economic forces dictate a retrenchment away from the ideals of continuity, comprehensiveness, and prevention that family physicians themselves espouse. The leadership within the small group of family physician in the SEMF tires from the constant struggle to promote the field. Only with a persistent commitment at multiple levels-political, educational, and economic-can Ecuador build a comprehensive primary care system based on well-trained family physicians strategically located throughout the country. These family physicians need to be linked to the public health and psychosocial resources necessary to provide comprehensive preventive and integrated care. Without such commitment, the health care system will devolve into more of what it already is-a disorganized, underfunded public health sector already being dismantled in the pursuit of privatization; a private sector characterized by scattered specialty services competing with each other for paying patients using the most expensive technologies; and a specialty- based educational system poorly preparing students for primary care. Put this way, the problems family medicine faces in Ecuador are not so different from those in the United States. The culture is vastly different, but the problems faced by generalism are very similar. I hope that national and international economic and institutional support, combined with their own courage and tenacity, will enable Ecuadorian family physicians to overcome these challenges.

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LUCY CANDIB, MD

Correspondence concerning this article should be addressed to Lucy Candib, MD, Family Health Center of Worcester, 26 Queen Street, Worcester, MA 01610. E-mail: lcandib@massmed.org

Copyright Families, Systems & Health, Inc. Fall 2004