Posted by: cmoscetti | 03/30/2011

Double burden of disease – on the ground in Ecuador

This is a posting by Kelly Healy, Policy and Government Relations Intern at the Global Health Council

I just returned from a nine-day medical service trip with 28 other students from schools of public health, medicine, and international affairs through an organization called MEDLIFE (Medicine, Education, and Development for Low Income Families Everywhere). In reflecting on the trip to friends and family I mused that Ecuador was beautiful, its people kind and welcoming, and my experience of seeing how a mobile health clinic functions incredibly valuable. But what was most notable from a global health perspective was the range of ailments we saw among the children and adults who lined up each day at the clinics.

Having read much about the double burden of disease, I expected to see malnourished and obese people in the same villages. And we did. Many of the older men and women suffered from obesity, diabetes, and hypertension, despite the fact that they work in the fields all day, well into old age. This was not surprising given the rising number of deaths from non-communicable diseases in Latin America. At the same time, many of the children were stunted due to years of malnourishment. This also was not surprising given Ecuador’s high stunting rate of 23%, which is concentrated in the rural poor. Even children who were not stunted had vitamin deficiencies and parasites. But what was most surprising to see was the lack of basic hygiene. Patients came in with fungus everywhere, even on their faces, because most of them do not bathe regularly. In some cases this was because of lack of access to water, while cultural differences also came into play. Similarly, even though most patients knew they should brush their teeth two or three times per day, many told the dentist they did not because their water is dirty and infested with bacteria.

This snapshot of conditions on the ground demonstrated the double burden that weighs on health systems in many developing countries and reinforced the need for integrated, cross-sector approaches. For example, with limited resources, should the government tackle parasites and basic hygiene, focus on malnutrition and deficiencies in children, or work to change diets to reduce obesity and heart disease in adults? Or, perhaps the most effective health intervention might actually be extending basic water and sanitation systems in rural areas. (In fact, when not staffing the mobile clinics we also helped build toilets for a rural school.)

Questions like these no doubt weigh heavily on Ecuador’s health and government officials, especially with limited resources. At the national level, Ecuador has made a notable commitment to improving health and laudable progress toward the Millennium Development Goals, but clearly much work lies ahead, especially in reducing inequality within the country. I am hopeful that with continued awareness of the government and the people, as well as the help of NGOs like MEDLIFE, Ecuador will be able to tackle the whole range of health concerns it faces and make a brighter future for its people.

In collaboration with other members of civil society, the Global Health Council has already engaged in trying to address some of these challenging health systems issues related to the double burden of disease. Last year, the Council published a report on the growing burden of cancer in developing countries, and this year’s Global Health Council annual conference will examine the critical issues around the double burden of disease, like those seen in Ecuador. Also, launching a new roundtable on NCDs, the Council is helping facilitate a policy dialogue with members of civil society, including the private sector, around how best to approach NCDs at the upcoming UN Summit on NCDs and beyond. Lessons from Ecuador provide valuable insight into this policy dialogue and how health systems need to adapt to meet the growing double burden of disease seen in many countries.


  1. Great article, Kelly! It’s definitely a good eye opener to realize that children have to live with fungus growing on their faces due to the of lack of general hygiene. It’s hard for people in developed countries to imagine not having access to something as simple as being able to wash your face. Of course, my opinion is to start with developing a sanitary water system and let the rest “flow” from there. But I admire your hopefulness even while enduring the sight of others’ serious health concerns and I appreciate your effort in the international health sector as I, for one, would break down of a broken heart every day.

    • I really enjoyed reading your article, and being from Ecuador, would like to thank you and all of your colleagues for your hard work! I came here at a very young age, and was one of the lucky ones to get out. Yes, Ecuador is a very poor country, with inadequate water supply, severe inequality in healthcare, and misuse of government funds. My mom works very closely with several non-profit organizations who visit Ecuador several times a year, and perform free reconstructive surgeries on hundreds and thousands of underprivileged children and adults who were born with birth defects. I remember being a little girl, and feeling so confused as to why so many of their people had such severe birth defects. I sometimes even blamed it on the water! In reality, the water may or may not have anything to do with these birth defects, but many of the problems start there. How can a human population flourish without one of the basic necessities of life, water, as this is something that we literally cannot live without! Add malnourishment, and serious vitamin deficiencies to that, and you really do have a recipe for disaster! It truly breaks my heart to see human life live in these conditions. The sad reality is that many of these children will never make into mainstream society due to being shunned out by the fellow community. We simply cannot ignore! Efforts to reverse this critical issue lie first and foremost, on providing adequate water supply to each and every individual! Thank you for helping the part of the Ecuadorian population that needs it most, and shining light on this grave matter.

  2. Thank you for your article and mostly thank you for taking the time to help the people of Ecuador. I appreciate that you address complexity of the situation in and recognize that are many problems that need to be addressed.

  3. Good blog, Kelly! Within the last five years, the global health community has started to address the underlying social and economic factors of disease that you saw in these Ecuadorian villages. Disease is not a random, isolated event but a symptom of social inequality, community barriers, and social conditions. Paul Farmer and his Partners in Health are pushing a model of public health that you touch on–the need to not only treat the clinical aspects of a disease but also the environment around the disease. In 2009, Merrill Singer published a book called Syndemics that goes into this in detail. Anyway, best wishes and good luck in your career!

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