Interview: Miguel Pasquel – Endocrinologist, Metropolitano Hospital and Former President, Ecuadorian Endocrinology Society

Miguel Pasquel, endocrinologist at Quito’s Metropolitano Hospital and former president of the Ecuadorian Endocrinology Society shares his point of view on the country’s healthcare system. He recognizes the good will of successive governments but regrets their inability to give Ecuadorians access to health across the country, highlighting the differences between the access to health of urban and rural citizens.

During his presidential campaign, Lenin Moreno said his administration would make free, high-quality medical services for Ecuador’s poor a “top priority.” At this point, do you think the country – the educational system, the university system and the government – see the life sciences industry as a strategic direction for the country’s future?

“Undeniably, our successive governments have taken a high point to develop new healthcare systems and to improve the situation faced by Ecuadorians with regard to their health.”

Undeniably, healthcare is a priority for the government. However, I believe there needs to be a radical change in the way government is running its public health policy. Generally speaking, the government’s investment policy is inadequate. There have been several investments in large tertiary level healthcare infrastructure, which are not efficiently contributing to health in Ecuador. Rather, these investments are a burden to the government budgets and will result in an unsustainable system due to their high running costs. Unfortunately, these politically oriented investment choices have prevented much needed developments to promote a healthy living in Ecuador. Indeed, I believe that preventive campaigns directed to mothers and investments aimed at developing access to clean water would be cheaper and more effective. One living in the urbanized areas of Ecuador might not realize it, however; the conditions in which certain rural populations live in are archaic. Additionally, constructing a strong network of health facilities across the country and allowing rural communities to benefit from care appears urgent in the process of creating sustainable healthcare coverage across the country. The large investments in tertiary level health facilities have also posed the problem of drug availability in the country. With close to no caricature, paracetamol is always the product doctors resort to regardless of the patient’s condition.

You have mentioned multiple issues regarding the government’s investment decisions on the healthcare side. What can be said about the country’s research status?

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Ten years ago, research was properly funded by an array of privately held foundations. Bridges between private capital and public research were widely considered as an acceptable collaboration for the benefit of Ecuadorian patients. However, during his second mandate, former President Rafael Correa put a hold on the possibility for such foundations to fund the research of academics. It was only in late 2017, a few months after Lenin Moreno’s election that such foundations were allowed to fund research again, because the government had no other option but to admit that it could not provide sufficient funds for research in the country. As a result, the collaboration between academia and the pharmaceutical industry has not reached its full potential- worse, it has almost disappeared. In the rare cases scientists have the opportunity to collaborate with the private sector for the purpose of their research as they face suspicion of corruption and their ethics are put into doubt. In fact, the government’s position remains severe with regards to the perception it has of public-private collaboration. Congresses should be an opportunity for the sector’s actors to join forces. Academic congresses can only be considered as such if no pharmaceutical enterprise has contributed to it. This situation also affects the quality of education our future doctors receive. With regards to the lack of funding in medical schools and the inability for pharmaceutical firms to offer their help, we face great difficulty in forming our future health professionals. I sincerely believe the contribution of pharmaceutical companies is our only option for the implementation of continuous education.

As a renowned endocrinologist, could you comment on the country’s epidemiological profile?

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Generally speaking, developed countries are known for high prevalence of non- communicable diseases as a result of their population’s lifestyle and developing countries face problematic levels of infectious diseases related to poor water sanitation and tropical parasites. Ecuador is unfortunately confronted with both types of burdens. Indeed, basic sanitation is not widespread across the country and therefore, Ecuador has accumulated high levels of infectious diseases with the high prevalence rates of non-communicable diseases such as diabetes, hypertension and cholesterol- notably among poorer classes of the population due to bad nutrition and low levels of activity. As a result, the budget allocated to solving both problems is split into addressing both and none can be properly resolved.

As a matter of fact, diabetes is among the top three leading causes of death in the country. For example, in 1982 the cumulated prevalence rates of diabetes and hypertension were of 5.2 percent of the population. Currently, 28 percent of the population is either suffering of hypertension or diabetes and these diseases have increased hand in hand with the prevalence rates of cholesterol. Despite being considered non-communicable diseases, diabetes and hypertension have not received the same level of attention cancers have, due to being associated with the poor living conditions of disfavored categories of the population rather than with the affluent.

What should be done about it?

We don’t need a lot of money to address this issue. Change could easily come with a few pills and interest in the causes and solutions. You need activity and healthy nutrition, which is not an expensive investment for the government. If the problem were taken at the root, patients with diabetes would not need to go to hospitals to be amputated; this only happens in the case of poor control of the disease. I believe that the government should take heed of the epidemiological situation in the country and adjust its policies according to it rather than with a political purpose.

What is so interesting about studying endocrinology in Ecuador?

Endocrinology is an essential field of research in which I have chosen to focus on nutrition and diabetes. When I made this decision, no one seemed to be considering the field as a crucial element of the health system. Fifteen years ago, I carried out research on children. When my associated researchers and I found that 20 percent of the children population survey was obese and presented high levels of cholesterol, we were not taken seriously. The ecosystem considered that under nutrition was a more preoccupying situation to deal with at the time, and assumed the case we presented was not accurate. Nothing had been done about activity and nutrition prevention, de facto, as were conducted the same survey on the same population the situation had worsened. Other researches such as the Carmela study carried out across the Latin American continent has found that Quito, the capital of Ecuador, was the city with the highest rates of high cholesterol in Latin America. In light of the fact that diabetes and related ailments are still problematic in Ecuador, and, given that the government has not implemented measures that can be considered adequate, my mission is not finished yet.

What do you consider as the main assets of the healthcare system in the country?

Undeniably, our successive governments have taken a high point to develop new healthcare systems and to improve the situation faced by Ecuadorians with regard to their health. Realistically however, the pace at which reforms have been passed, erasing previous efforts, has not allowed potential improvements to take place.

Secondly, we have several social regimes that are properly adapted to the various situations Ecuadorians can find themselves in. For example, militaries have their own social regimes and so do workers.

Finally, I appreciate witnessing high quality healthcare received by the higher income classes as it proves that Ecuadorians have the ability to deliver exceptional care services. Nonetheless, I would prefer to see a friendlier system for the population. We need a healthcare system capable of providing high quality care regardless of the economic situation of an individual. One could imagine developing ambulatory services to increase the access of Ecuadorians living in rural areas.

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