A large truck rumbled down the gravel path and turned in next to the canopied basketball-court-turned-clinic. The other volunteers and I watched in surprise as fifteen passengers piled out and splashed down on the muddy road to the check-in. Other patients milled about the village center while our team triaged the families who had traveled miles for a simple check-up. 

I had come to Ecuador to volunteer in a mobile medical clinic that provided healthcare to patients in the most remote areas of the country. Despite Ecuador’s reputation for exceptional affordable healthcare, I soon discovered that geography, gender inequality, and indirect healthcare costs severely limit the care available to those living outside the country’s metropolitan centers.

Although mobile clinics offer critical support to under-resourced rural clinics, they still cannot offset the obstacle that geography represents for individual patients. Pablo and his passengers had driven for hours over mountain terrain, and they had put off the long trip until their symptoms were severe enough to impact their work. When a clinician recommended a visit to a distant city for more specialized care, Pablo explained that he couldn’t afford to make the longer trip.

Geography also limits clinicians’ access to even the most basic supplies. Since the government distributes essentials along a meandering delivery route that begins in central urban areas, the most remote clinics are left with only meager offerings. At one clinic our team visited, I found the medicine closet contained less than a dozen over-the-counter medications that treated only short-term treatment for mild ailments. This lack of basic resources discourages rural patients from seeking care in the first place.

Gender inequalities further shape the care that women in general receive, and, in turn, affect their abilities to contribute in their roles as families’ primary caretakers. One woman who traveled with Pablo had to be examined in a private examination room and left her baby with the child’s father. I noticed how the man held the baby away from his body, like a pizza tray, so that the child’s head rolled to one side. I was surprised by his awkwardness until I reflected that he’d likely had only a limited experience as a caregiver. 

Because women in rural communities are primary caretakers, they typically cannot afford to attend even routine checkups without compromising their children’s care. Putting off regular checkups of course only compromises their health, and the consequences can be grave. Given their essential role as caregivers, their experience represents the way gender inequities harm the family and the community as a whole.

Finally, Pablo’s journey highlights the risks of healthcare’s indirect costs. Pablo and his passengers needed to unite even to cover the travel expenses involved in their trip to our mobile clinic. Families who were directed to cities for more advanced care faced an even greater financial burden, and, in most cases, the food and lodging required for extended stays would have made the trips impossible. Even though they technically had access to excellent free healthcare, they still lacked the resources to take advantage of it. 

The extreme gaps in care in Ecuador’s remote countryside lie in contrast to the reputation of Ecuador’s healthcare system, but a comparison with healthcare in the U.S. reveals that geography, gender inequality, and indirect costs are common to both countries’ struggle to define and provide true care. Even though the U.S. has the most expensive healthcare in the world, its healthcare performance is ranked eleventh, based on population health, access, efficiency, equity, and quality. 80% of rural US is considered “medically underserved.” The US does not provide additional services for these populations. 

In Ecuador, women are less likely to seek out healthcare due to their duties at home, while in the U.S., are more likely to get misdiagnosed because of gaps in trust and knowledge than men; in both cases, inadequate healthcare disproportionately affects women. Economic inequality likewise exacerbates limited healthcare access in both countries: 34.6% of Ecuadorians get paid under $5.50 per day and therefore cannot afford to miss work or journey to take advantage of Ecuador’s excellent healthcare, and even middle-class Americans struggle to pay healthcare expenses due to the structure of the U.S. insurance industry.

A comparison of Ecuador’s and America’s healthcare systems highlights the grim experience of patients seeking care in either country. On the one hand, Ecuador’s exemplary free healthcare system still fails to serve much of the country’s population; on the other, America's abundance of technologically advanced hospitals produces a healthcare system that is both prohibitively expensive for many, as well as geographically inaccessible. 

If such different medical systems are affected by the same inequities, should we assume that these limitations will shape healthcare in all contexts? Although the pervasiveness of these challenges makes them seem unavoidable, it also helps us focus on solutions that could benefit people throughout the world. 

Another answer lies in the example of Pablo’s trip. Despite the limited care Pablo and his passengers received, they were able to make the trip because they joined together––to take the time off work, to share their transportation expenses, and even to support one another with family labor. Pablo’s journey points to a solution that lies not in profit and endless innovation, but in cooperation and community.