The Ecuador-Colombia border. Plans are to connect the coastal provinces of the two nations by highway at this site.

Recent development work in the province of Esmeraldas, Ecuador has the potential to influence the burden of infectious disease. A new highway is currently being built which will connect remote villages in this region with the rest of Ecuador, and eventually, Colombia. The road, for which construction began in 1996, will cross through the southern end of the last remaining Pacific rainforest in South America.

Volunteer health promoters are leaders and important resources to their communities. The health promoter of Wimbicito (left) and UCB researcher Joe Eisenberg.

My work was with an Ecuadorian research team that was studying a variety of health outcomes in the isolated region of northern Esmeraldas. Because of the remoteness of the study communities, most only reachable by boat, there is a lack of accurate information on the extent of disease burden in this zone. As part of the investigation that looked the presence of intestinal parasites, I examined potential risk factors for transmission and recorded local health beliefs concerning diarrheal diseases. The risk factor information will be correlated with the lab results of stool specimens obtained from study participants. Because UC Berkeley will have a larger role in a future study in northern Esmeraldas, the summer work will serve as a pilot study for providing baseline surveillance information on enteric pathogens, ethnographic data from which survey instruments can be developed, and information regarding community perceptions of development in general. I was also involved in the development of the survey tools, as well as assisting in their translation.

Carlos of Chiyabí- destined to be a local celebrity. Diarrheal diseases are particularly dangerous to young children, accounting for more deaths worldwide than any other cause of mortality.

I had six main activities towards completing my objectives. Additionally, I had many peripheral tasks that were a part of working with the Ecuadorian team. The six official project activities were:

1. Sanitation surveys. With permission from the homeowners enrolled in the study, I performed household walk-throughs collecting observational data concerning sanitation. The walk-through involved looking for parasitic transmission risk factors like an unsealed latrine and then flies in the kitchen. These surveys were also important for identifying economic indicators and learning about regional diet.
2. Health promoter interview. One promising component of the health sector was the existence of a community epidemiology program in which volunteers from the villages were trained as health promoters. In a prospective study in northern Esmeraldas in which ongoing disease surveillance will play the central role, the health promoter becomes essential to the project's success. I interviewed health promoters about local health status, their understanding of diarrheal disease (we discuss diarrhea as a proxy for parasites), migration patterns, and water use. Getting to know the health promoters was the highlight of my project activities, as it was an inspiration to talk to people with very little formal training dedicated to the well-being of their community.
3. Community meetings. The first activity when the research team arrived at a new village was to hold a community meeting. Apart from an orientation to the project, qualitative information was collected in a participatory discussion of local economy, major events in the last ten years, and attitudes towards the highway. Although I was not involved in the design of the activity, I took notes on the meetings.
4. Intake interviews. These were mostly done by the team nurses, however I completed some of these interviews with families on as needed basis. Part of the four-page form was to collect health data on fever, vomiting, stomachache, and diarrhea, which make up the classic symptoms of a parasitic infection.
5. Extraction of available epidemiologic data. Towards the end of the summer I worked with a public health nurse at the regional hospital in Borbòn, Esmeraldas. I brokered a deal with her to have access to the hospital's rural health statistics in exchange for the Excel spreadsheet summarizing that data. It was clear from this job that the disease surveillance data is largely incomplete.
6. Data entry. The unglamorous mountain of work that concludes large amounts of data collection is the time spent putting it into the computer. On the good side, I did get experience with Epi-Info, a program popular in the developing world because it is distributed free by the CDC.

...and I learned how to take blood pressure, too.

Our work schedule was 22 days on, with eight days vacation in between. Because we usually spent nights in the communities that we were working in, there really was never any "off" time. If I wasn't doing one of these aforementioned activities, I was loading the canoe, taking weight, height, and blood pressure measurement of patients, coding tubes and slides for blood draws, or pipetting blood serums in the lab. Many of these things I had never done before, so I easily learned just as much when I was wasn't working on my specific project objectives. And, of course, I loved the opportunity to communicate primarily in Spanish and to gain a profound admiration for the rainforest.

Urine and fecal samples were collected from all participating families. Samples were analyzed for the presence chlamydia and intestinal parasites.

The work I did this summer will help inform my thesis project. I am hoping to do a meta-analysis on studies that evaluate the impact of roadways on sexually transmitted diseases. One of the components of the overall investigation was measuring the burden of STDs, including HIV. It is predictable that when the Esmeraldas highway opens to Colombia, the socioeconomic pathway will also be in place for increased transmission of these diseases. Witnessing firsthand how remote communities are willing, although not without reservation, to join a larger market economy, I see that pathogens, like HIV and enteric parasites, will enjoy the benefit of greater human mobility.

Part of the health assessment was to identify risk factors for parasitic transmission. This pig bathed only meters upstream from a site where people extract water and wash clothes.

My involvement in this research in Ecuador affirmed my interest in working in Latin America. If I choose to seek employment opportunities that include international work, this project will have given me needed work experience. It was challenging to work in Esmeraldas, but I found that it was a privilege as well.