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Ecuador PCV Erik Janowski on the Road to Pedro Vincente
Ecuador PCV Erik Janowski on the Road to Pedro Vincente
The Road to Pedro Vincente
The drive from the town of Pedro Vicente Maldonado, on Ecuador's coastal plain, to the capital, Quito, 9,500 feet up in the Andes Mountains, is roughly 75 miles of spectacular and sometimes white-knuckled travel that lasts two hours -- except when David Gaus, shown left, is at the wheel. Undeterred by rock-slide rubble on the highway and undistracted by the lush green Andean mountains that spear breathtakingly up into the clouds, Gaus can usually knock at least 15 minutes off that time.
Today he apologizes to his passengers for passing on blind curves and bouncing them over rough pavement. "I guess I've learned to drive like an Ecuadorian," he says. Not so; Ecuadorians are much more cautious.
Caution is not a prominent part of Gaus's personality. If it were, he wouldn't be here in Ecuador forging a health service for a rural population with sparse access to modern medicine, or dealing with exotic health hazards like deadly vipers and assassin bugs. More likely, the 1984 ND graduate would be holding down a humdrum accounting job somewhere in the States, maybe in Milwaukee, where he grew up.
Accounting, after all, is what Gaus studied at Notre Dame -- the first time through. That was before he spent a couple of years working with poor kids in Quito, before he returned to Notre Dame to take pre-med courses, before he earned his M.D. at Tulane, before he intrigued friends like Erik Janowski '87 into joining him in the pioneering venture called Andean Health and Development, Inc.
And before Elizabeth.
* * *
David Gaus has just reached for a piece of breakfast toast when there's a knock on the door and a flurry of Spanish. He hustles out of the apartment in Pedro Vicente Maldonado and moments later trots into the office of a local doctor who is trying, without much success, to find and tie off a severed artery in a young man's ankle. A blood pressure cuff just below the knee serves as a tourniquet, and a discarded anesthetic-syringe lies among a litter of blood-soaked gauze pads around the examining couch.
The patient, in his late teens, was clearing a field with the razor-sharp machete that's a ubiquitous tool here in rural Ecuador when he sent the blade slicing through his heavy rubber boot. The severed artery spurted blood with each heartbeat as the youth was hurried into town. Now the doctor probes the wound, trying to clear an operating field. The patient winces and grinds his teeth.
Gaus peers over the local doctor's shoulder, answering an occasional question but not intervening. Finally the frustrated local physician gives up and dispatches his patient to a hospital in a larger city. The youth's frantic father helps load his son into a car; as it pulls away, a bandaged foot protrudes from a window.
Back at the breakfast table, Dr. Gaus explains his low profile at the scene. If the patient had come to his clinic, he says, he would have placed the tourniquet just above the ankle rather than on the upper calf. And he would have had access to cauterization to buy some time in locating the artery. But the Norteamericano is careful not to act like a know-it-all among the Ecuadorians who are his colleagues, his patients and his friends: "The last thing I want to do is tell the local doctor: try this, try that -- unless it's a real emergency." This morning's event, though bloody, was far from a real emergency. A leg tourniquet, Gaus observes, can be kept in place safely for as long as four hours, and the hospital is a two-hour drive at most.
Gaus explains these matters to Paul Heinzelmann and David Derdzinski, a pair of freshly minted doctors from the University of Wisconsin Medical School who are here for a short tropical-medicine residency. Gaus did his family-practice residency at a UW-affiliated hospital in Milwaukee and holds a faculty appointment at the medical school. Most of his teaching now is done when young residents visit him in Ecuador.
The town of Pedro Vicente Maldonado, named for an Ecuadorian scientist, is a county seat for some 15,000 mostly rural souls and boasts a paved main street and a highway bypass. It is an ideal ground zero for Andean Health and Development, Inc., a health-delivery system Gaus hopes will become a model for other parts of South America.
* * *
Without a little help from some friends, David Gaus would not list M.D. after his name. The key friends: Father Ted Hesburgh, CSC, and Ann Landers.
When Gaus left Notre Dame in 1983 with an accounting degree, he went "directly to a mid-life crisis at the ripe age of 21." Next stop Quito, as a volunteer in a boys' home. There he underwent "a kind of life-changing, radicalizing experience, and I decided to go back and do medicine and then return to Ecuador."
First he needed to supplement his undergraduate education with pre-med math and sciences courses. That took money he didn't have. So he wrote to Father Hesburgh, who recalls what came next:
"I get a letter from David saying he's had a great experience working with the kids, and he's come to the conclusion that one man can't change the world but he might make a little difference. He's noticed that in the slums they don't see a doctor from the day they're born till the day they die. He said, 'I don't know whether I can become a doctor but it's worth trying.'
"I called Eppie (Eppie Lederer, Ann Landers' real name) and said, 'I need 20,000 bucks to get this guy through two years. She said, 'I'll send you $20,000 tomorrow morning,' but I said, 'No, I only want 10; we'll give him a year and see how he's doing.'"
He did just fine. Medical school was the next hurdle and Gaus chose Tulane, one of the few U.S. schools to offer training in tropical medicine. "I called Eppie again," Hesburgh recounts, "and said, 'I'm not asking you for money, but you might have some friends in the pharmaceutical business.' She said, 'Yeah, there's a guy at one of the big companies -- I'll be having lunch with him in New York.' At their lunch this fellow only wanted to talk about George Bush, who was running for president. Eppie said finally, 'I didn't come here to talk about Bush. Does your company have any scholarships for kids going to medical school who can't hack it but are highly qualified?' He said, 'No, but we could -- what are you looking for?' She said, '$100,000.' He said, 'Done. Now let's talk about Bush.'"
* * *
The three most important people in David Gaus's life are named Gabriella, Christopher and Elizabeth. Gabriella is a 3-year-old charmer who, when she "reads" a picture book, is as likely to name the animals in Spanish as in English. Christopher is Gabriella's baby brother.
Elizabeth is the young Ecuadorian woman Gaus met during his volunteer years in the middle '80s and married in 1989. "I met her brothers first, playing soccer. Then I met Elizabeth and we became friends. Then I went back to the States, and two summers later, after we had corresponded by mail, I began to develop some of those strange funny feelings for her. The summer before medical school I decided we should figure out how to get married. It turned out the fastest way to get her in the country was to obtain a fianc?e's visa.
"She came to New Orleans July 1 in 1989, and we had 90 days to get married to fulfill the immigration requirement. On the 90th day we were married by a J.P. Then on December 29 we had a church marriage in Milwaukee with all my relatives there."
During the next eight years while the couple lived in New Orleans and then Milwaukee, Elizabeth attended college and earned a bachelor's degree in bilingual elementary education. In her senior year, 1996, she became pregnant. Gabriella arrived not long after her mother's graduation. Christopher followed in January 1998, after the couple had returned to Ecuador.
The Gaus's live in a home on a steep Quito hillside with a stunning view of the city and the Andes. One or more of Elizabeth's seven siblings drop in frequently, and the dinner table always has a couple of spare places. Elizabeth's mother sometimes stays with her daughter and grandchildren on nights when David is in Pedro Vicente. He goes there twice a week, as a rule.
When friends ask him how long he plans to stay in Ecuador, Gaus says, "For a long time - at least until the kids finish high school." That works out to 17 years.
* * *
Jacinto is about 7 years old. Like his mother he has blue eyes, a startling feature in this part of the world. He is swinging slowly in a porch hammock this afternoon, one bare foot inflamed and suppurating. Two weeks ago he stepped on some dirty glass.
Jacinto does his best to be brave as Gaus talks soothingly and squeezes out pus. He prescribes a seven-day round of antibiotics, telling the boy's mother, "I want him to take the pills religiously -- and I don't mean just on Sunday." Both laugh. One of Gaus's trademarks is an active sense of humor, and often he'll top off a laugh with a spontaneous touch. This 6-foot-1-inch Gringo, who towers over many patients, takes to pains to be unintimidating.
This afternoon Gaus and his partner, Dr. Carlos Burneo, are visiting the village of Salto del Tigre ("Tiger's Jump"; the name traces to a tiger that once leaped across a broad nearby confluence of two rivers). The village contains a small general store, a handful of houses and one of Andean Health and Development's satellite clinics. To get here from Pedro Vicente takes an hour of tooth-rattling driving along rutted dirt roads with frequent twists and turns, at speeds that sometimes dare not exceed 5 miles an hour. Farther along this road is another satellite clinic which, since a 1997 flood, can be reached only by abandoning the pickup truck and using a cable and pulley system to cross a river cascading through a 50-foot-deep gorge.
As Gaus opens the clinic building to fetch Jacinto's antibiotics, a small family group -- grandmother, mother, a sprinkling of children -- approaches him. He invites them inside to sit and chat and share a laugh or two. Gaus never telegraphs haste or distraction in his dealings with patients; while they have his attention, this family feels they're the most important people in his world.
For Gaus, treating patients is only part of his job here. The other part is creating a system of health care that will outlast him. "I love the administrative part of what I do," he insists; it is a statement of fact. But animation creeps into his voice for what comes next: "I love clinical medicine too. And I would take that over administration in a heartbeat. These are great people; I love doing this."
* * *
Erik Janowski entered David Gaus's life when he returned to Notre Dame in the mid-'80s. The two hit it off, in part because Janowski also wanted to experience another culture. "David was very enthusiastic about his experience in Ecuador," recalls Janowski, who was double majoring in English and biology. "He kept telling me, you've just gotta go there. I applied to the Peace Corps and they assigned me to Ecuador."
When Janowski finished his Peace Corps stint, Gaus was at Tulane. Says Janowski: "I started looking around for graduate programs. I wanted to combine Latin America with something in the health field. It turned out that there are such programs in a few universities, and Tulane is one of them. I was lucky enough to get a fellowship and join David once again."
After completing a master's degree, Janowski spent a year in Tegucigalpa, Honduras, as a volunteer working with street kids. Then he returned to Tulane and entered a Ph. D. program. He is presently trying to complete a dissertation for the doctorate in public health.
At Tulane, Janowski and Gaus met the third principal in what would become Andean Health and Development: Tom Chiller, M.D., now a fellow at Stanford University's division of infectious diseases and geographic medicine, and the stateside partner in AHD. The trio -- Gaus, Janowski and Chiller -- began dreaming. Says Gaus: "I had this kind of half-baked, germinal notion of what I wanted to do. It was very ill defined, and Tom and Erik put a lot of intelligence and creativity into it."
Adds Janowski: "In '94 it was time to put our money where our mouth was, and we thought a good first step would be to invite Father Hesburgh to become president of our board of directors. To our surprise and delight, he accepted."
What the trio had in mind was more than just staffing a medical clinic. They wanted to build a health delivery service stable enough to outlast their personal involvement in the project and successful enough become a replicable model of rural health care for a continent. With a grant from CARE/USAID, Janowski spent three months in Ecuador in 1996 doing a feasibility study. He chose Pedro Vicente Maldonado as the program site and talked CARE into providing startup money. In January 1997, Janowski officially launched AHD. Gaus joined him that July.
With help from Hesburgh, Gaus and Janowski made contact with some of the 70-plus Notre Dame alumni in Ecuador. One of them, Marco Flores '78, was the country's minister of finance. He helped secure a major government grant to underwrite a new building in Pedro Vicente that will become a 12,000-foot clinic/hospital/health-education center, and to equip the satellite clinics.
Meanwhile, Janowski won the support of the mayor of Pedro Vicente to refurbish a dilapidated set of buildings for an interim clinic. "Fortunately," says Janowski, "we have very good working relations with the mayor's office. He understood that we didn't just want to train individuals to run the project when we were gone; we wanted to be connected with a public institution to guarantee sustainability. We wanted to be catalysts in forming partnerships with public and private-sector institutions."
So far, progress toward these goals is encouraging. AHD, originally formed to serve one county surrounding Pedro Vicente, has already expanded to serve three, with a population base of 60,000 people. The private sector has bought into the project thanks to ND grads like Francisco Cobo '66, an Ecuadorian car dealer who donated half the cost of a pickup truck for AHD's use. Of the $650,000 in private gifts and pledges AHD has received to date, Janowski notes, over $500,000 is from sources within Ecuador.
Money problems nevertheless plague AHD. Payroll dates are still approximations, and inflation in a country not famous for political stability has severely eroded the value of funds for the new Pedro Vicente health center, although the steel framework is in place and AHD hopes for occupancy yet this year. Janowski spent much of the first half of 1999 in the States doing fund raising, and Gaus's sister, Sue Bowen, now accepts and manages gifts to Andean Health and Development at her home at N3543 Knight Road, New London, Wisconsin 54961.
* * *
When Gaus is in Pedro Vicente, he stays with Dr. Carlos Burneo, the Ecuadorian physician who works for Andean Health and Development. Burneo is also a regional official of the Ecuadorian national ministry of health, a serendipitous role as far as AHD's relationships with the national government are concerned. AHD can also call on a moving cast of other health professionals, including young Ecuadorian-educated physicians, nurses, nurse-obstetricians and dentists who are required to serve a postgraduate year in rural settings.
Both Gaus and Janowski consider Burneo indispensable in building local trust in AHD. The Ecuadorian doctor gives the project credibility and a deep knowledge of the local culture. "I'm not kidding myself," Gaus admits, "I'll never be from Pedro Vicente -- they have their own reality -- but that doesn't mean I can't bridge gaps. It's an important part of a doctor's job; if you just have your head buried inside a clinic and don't understand what's going on in the community, especially if you're a primary care doc, how can you call yourself a doc?"
* * *
In the Pedro Vicente clinic this morning, an asthmatic old man hunches on a chair, trying desperately to breathe with the help of a machine that dispenses a vasodilator mist into his respiratory system. In the waiting room are a dozen or so patients: a child of 3 with a fractured finger, a girl of 12 who's been suffering from long-term nasal congestion, a pregnant woman seeking treatment for an abscessed arm. The clinic is open from 8:30 till 1 and 2 till 5, and 24-7 emergency coverage is guaranteed.
"Part of what we try to do administratively," says Gaus, "is to make sure that the quality of care patients receive is not based on me or Carlos being there but on the quality that the other doctors and staff are delivering -- how the nurses are taking care of patients, how the front-door personnel are receiving people." Adds Janowski: "We want our patients to leave with a sense of their dignity."
Much of the challenge to sound public health here is convincing people that cleanliness and safe water make a difference. Other issues are common the world over: diarrhea, respiratory infections, trauma, violence, alcoholism and sexually transmitted diseases. But there are also health hazards unique to the tropics, and one of them is an insect known as the assassin bug. In his teaching role, Gaus has just opened a matchbox containing a prime specimen of the bug to show Drs. Heinzelmann and Derdzinski.
"This is the vector that causes chagas disease," he explains. "These things live in thatched roofs and adobe walls, and it's not unusual to find a house that's got thousands of them. At night while you're sleeping the bug comes out and lands on you. It draws a blood meal through its needle-like proboscis, and it gorges itself so much that it poops out the back. The feces, which is the parasite, gets dragged over the wound and the parasite gets in. You can contract a virus that may be dormant for 10 or 15 years, then go into heart block. It's a common cause of sudden death in Latin America."
The visitors pay rapt attention.
Another tropical hazard is leishmaniasis, a parasitic infection transmitted by sandflies that produces ulcers on the legs, feet, hands or face. Half the population or more have a history of leish (pronounced lesh). The Wisconsin residents are excited to encounter a leish victim at the clinic today, a young woman with an ugly lesion on the side of her nose. They ask permission to take her picture to show colleagues back home, and at first she shakes her head no. With a little more talk, it emerges that she assumes she'll have to pay for the photo. When they assure her it won't cost anything, she smiles for the camera.
Worms are a common problem here. Snake bite is a deadly threat. The most dangerous snakes are Bothrops, a viper that killed five people in Pedro Vicente last year: one child and four adults. Anti-venon can arrest the progress of the venom, but it's hard to come by. Because of his connections with the ministry of health, Dr. Burneo has been able to maintain a supply for the clinic.
Another hurdle for doctors is folk-medicine. Burneo recalls one boy who was bitten by a viper and went to a curandero, or healer. "When he turned up at our clinic three weeks later, his leg from the knee down was cold and as black as charcoal." Although he acknowledges that some folk treatments are commonsensical and positive, others embrace myths that delay sound medical treatment. "Diarrhea in children is often untreated because of a belief that it results from the child being frightened. Parents will first take the child to a curandero, and only then to the clinic."
Gaus acts surprised at the remark: "I don't see that very much among my patients." Burneo can't resist a friendly jab: "They don't tell you because they don't trust you."
* * *
One night last February, David Gaus and Eric Janowski stood in the McKenna Center for Continuing Education on campus to accept the applause of the Notre Dame Alumni Association officers and directors. The pair had just received the 1999 Thomas Dooley award, conferred for "outstanding service to mankind." Their parents and siblings were in the room. So were Elizabeth, Gabriella and Christopher. And Tom Chiller. Carlos Burneo was back in Pedro Vicente, minding the store, and Father Ted was in the Middle East, helping to implement the Israeli-Palestinian peace pact.
In his thank-you remarks, Janowski raised "a question that David and I have been asking ourselves ever since we got your call: Are you sure this isn't a mistake?" The crowd instantly made it known -- no mistake.
When his turn came, Gaus got a laugh by crediting his destiny in Ecuador to the fact that "I was coldly rejected by the Holy Cross Associates." Then the emotion that underlies that destiny crept into his voice. He talked about "the fellowship of those who bear the mark of pain," a concept of Albert Schweitzer's mentioned by Dr. Dooley in his books. The room grew quiet as he spoke:
"When you have personally endured a tragedy or an illness, or have lived through that of a family member or a close personal friend, that mark of pain is something that changes you and stays with you forever. But it doesn't stop there. Schweitzer argues that from that moment on we are moved to reach out to others who have been suffering pain or hardship. That happened to me when I was in Ecuador the first time back in 1984. All the pictures you see of malnourished children -- for me they took on a very personal meaning in Ecuador because some of my friends were actually living that way. And that changed me. That has a lot to do with why I'm still working in Ecuador today."
The ovation went on and on in the cold Indiana night, 3,000 miles from the equatorial heat of Pedro Vicente Maldonado and the hundreds of people whose marks of pain these men now help bear.