Thursday, March 24, 2016

Health Insurance in Ecuador

Today I went to our pharmacy, Farmacia Desarollo Social y Ninez para la Familia (owned and operated by the Ecuadorian government, by the way) and thought since it's close to the start of April, might as well check with our health insurance provider, Instituto Ecuadoriano de Seguridad Social, or IESS for short and find out how we start using their system for health services.  So I took off to El Centro (downtown) for these things.  

After taking the Cuenca Transito bus to the Mercado 10 de Agosto stop, I hoofed it as usual five blocks north to Farmacia Desarollo Social.  Takes ten minutes and is good walking exercise for me.  Carlos, the pharmacist on duty virtually every time I go there, filled our expensive but short list of prescriptions - just two of them this time - and I wished him a Feliz Pascua (Happy Easter).  Nice to not have to go to another surcusal (branch) of the Farmacia to get the rest that might be lacking at this main location.  That usually entails a walk along Calle Simon Bolivar several blocks to the San Blas location, which is also the name of one of Cuenca's older Roman Catholic churches as well as its namesake park.  Fifteen minutes with a gentle downslope to it.  

So I have some time to ask some questions of the folks at IESS.  I head there on foot for several blocks, about a ten minute walk.  On the way I encounter some tourists from as it turns out Norway.  They speak English, but it's not their home language.  First day these young gals have been in Cuenca, and is their first time in Ecuador.  Veterans at exploring Argentina a few years ago, though.  I ask them if they have a map and know their way around.  They do.  We smile and continue our separate ways.

Gran Colombia, one of the main east/west streets in Cuenca, is closed off to vehicular traffic due to construction on the Tranvia, or light rail system that was supposed to be finished at the end of 2015.  Now we hear that it will be done by the end of 2016, according to the mayor's office (la oficina de la alcalde).  There's 24 hour a day nonstop construction to help get the work done and allow the businesses affected to retain their customers to the extent possible.  I saw quite a number of storefronts closed shut and locked. . . not a good sign.  Some said they had relocated, one to the El Arenal sector (where Feria Libre is located, the largest mercado in all of Cuenca).  The larger businesses and those with more than one location in town (or in the country) tended to be the ones that stayed open.  The little guy with a family owned and operated tienda truly has suffered during the Tranvia construction.  

I reflected as I was walking along Gran Colombia how we had first entered Cuenca along this very street on the intercity bus.  It took us from the west along Ordonez Lasso, through the El Centro/downtown where it changes name to Gran Colombia, and out to the Terminal Terrestre bus station by the airport on the eastside.  Now it was all torn up, some areas in dirt, some with orange plastic piping holding electrical cable of some kind - an educated guess - and some already done in concrete and ready for the rails to be laid.

At the end of walking several blocks, I came to the IESS building at Gran Colombia and Mariano Cueva.  This is where my wife and I came when we enrolled for IESS health insurance.  This time I was by myself.  
I knew I needed to go to a different floor to get information about medication coverage and the like.  Was it the third floor?  I looked at the directory in Spanish, and decided that perhaps the third floor was a good place to try.  I encountered a few employees doing this, and eventually ended up in the presence of young Andrea, on the sixth floor.  She spoke conversational English, having spent time living in New York.  This happens more than one realizes. . . quite a few Ecuadorians travel abroad to practice their English and to work for more money while they are young, as well for further educational opportunities at the university level.  

Back to the Tranvia before I forget.  One of the employees there at the third floor asked me about what I thought about the Tranvia.  I told him I thought it was going to help Cuenca and Azuay Province quite a bit, but in the short term there was a high price to pay with shuttered stores, people's livelihoods at risk due to the construction dislocations, and the ever inflating cost of the total construction expense.  That last one hit home with him.  He clearly thought it was too expensive for the people to afford.  (Yes, this conversation was in English.)  

Looking over the document on medications I had prepared, Andrea on the sixth floor searched on her desktop computer to find out if they were provided free of charge to insured IESS members or not.  A good number of them were.  Those that were not were typically name brand drugs, or expensive medications that were not made in Ecuador and had to be imported.  The end result after going through all of these medications line by line was that IESS will from all accounts likely pay for around $70 of our (currently) ~$300 monthly prescription bill.  These lower cost prescriptions IESS will be happy to provide to us at their dispensary.  This is less than what I hoped they would provide, but any help at this point is welcome.  One way to look at it is that we pay the IESS health insurance premiums of around $85 each month, and the free prescriptions we get are around the same cost of the premiums.  So we do get to enjoy a cost reduction from this point on, just not as much as we might have hoped.  

Up next for IESS health coverage and care: calling the call center for getting an appointment to see an IESS doctor.  They likely will ask questions, and determine if you need to stay on the medications you are currently using.  They may authorize providing for free some medications that Andrea at the IESS central office didn't say would be provided for free, but that's just an educated guess on my part.  

My coverage starts April 1, and Carolyn Anne's starts May 1, being listed as my dependent on the IESS application.  As you can see, if you know our story from the many posts here at this very weblog, due to the length of time it took to get our pensionado retirement visa from Ecuador due in large part to the fingerprint requirements set out by Ministario, we are way behind the curve on getting IESS insurance benefits compared to other extranjeros that arrived in Ecuador the same month and year we did.  But that's life.  Never fair, but we have to roll with the punches.  And we have been, paying for doctors and medications out of pocket since we have arrived. . . without complaint, I may add.  

I asked Andrea if IESS has a specialist for arthritis pain such a rheumatologist in the United States.  "!Oh, a reumatologo!" she exclaimed.  "Sure!  We have one that we refer patients to that is at Hospital Monte Sinai.  He's available to her if she needs one.  Remember to see the IESS doctor for the referral first, though."  I smiled and thanked Andrea for the patient, and thoroughgoing information afforded me this afternoon.  Hospital Monte Sinai is where Carolyn Anne had her last fall, if you remember, and went to their emergency room (cost: $68 as it's a private hospital).  It also has the one farmacia in Cuenca that carries medications no one else seems to carry.  A quality hospital in our estimation.    

Upon coming home today, Carolyn Anne remarked - again - that she needed to go immediately to bed for rest due to arthritis pain.  An 8 out of 10 today, she said.  I don't enjoy hearing that and frankly I'm at my wit's end on what to do. . . but pray.  That's the beginning and the end of what I can do.  I can't make the pain go away.  I can see what can be done about it, and I am delighted to hear that a pain specialist such as a rheumatologist is available through our new IESS health insurance.  Hopefully there will be some new treatment or medication regimen that will help my dear wife.  

In the interim of late, Carolyn Anne has been seeing a doctor at Clinica Hogar in El Centro where she has spent a good amount of time volunteering to see what if anything can be done to help with the arthritic joint pain all over her body.  Her advice to her is to change the diet to some degree by eliminating items such as cheese, red meat, tomatoes (tomatoes!), oils including salad dressings, and breadings on meats.  I'm sure the doctor means well, but after looking at information on the 'Net from the Arthritis Foundation, I can see that the jury is still out on some of these statements.  One person's solution may not work for another.  Every person is an individual, and there is likely not one uniform method or diet that works for all sufferers.  

This lady doctor did put her on a couple of new (expensive) medications.  I told Carolyn Anne we can try these things - medications, diet - for a month give or take and evaluate how she is responding from there.  I think that makes some sense given the level of pain she is suffering and has suffered.  I can tell you one thing, though: here in Ecuador, with the care and easygoing thoroughness the doctors provide in caring for their patients, Carolyn Anne would likely never had gotten that level of individual attention and care if we had stayed in California.  That you may be assured of!

Saturday, March 5, 2016

The Ambassador

The ambassador was in Cuenca yesterday.  It's not every day one gets to meet an ambassador, and a good number of expats decided to make plans to meet him in person by sending their reservations to the consulate.  The agreed upon meeting space was at the Camara de Comercio - Chamber of Commerce - of Cuenca, which had a meeting room on the ground floor that could hold around 150 seated attendees.  

This man, who looked to be in his 50's, had traveled to other countries during his life and had life experience behind him in knowing where some desirable places to live were in the world. . . and where there were some - ahem - real hell holes.  It was a "Town Hall" style meeting, and naturally there were a number of questions asked of him on a wide range of topics.  Knowing the type of crowd that was present, a request was made to *not* release what was discussed to the general public, and I think that request was honored, respecting the person from whom it came from.  It's helpful to have people from one country working together in a unified direction and having a common purpose.  Nice to see that for a change.  

Here's an ambassadorial story that came from a high source: one who had joined the Foreign Service some time ago knew of a newly appointed ambassador to a foreign country.  To be appointed by the President of the United States of America for such a post was indeed a high honor, and this new ambassador was bursting with enthusiasm upon selection.  The day came not too long afterwards when he got the call from none other than the then US Secretary of State George P. Shulz, who had the honor of serving under President Ronald Reagan.  "Why don't you come up to my office for a chat before you go and leave Washington," he messaged this new emissary.  The reply was immediate, and he went up to Foggy Bottom to pay a visit shortly afterwards.  

"Where exactly is your country on a map?" Secretary Shulz inquired.  The eager young ambassador looked at a globe on a nearby shelf and grabbed it, spinning it around to where his country was.  "Here, Mr. Secretary, here's my country!" beamed the young appointee.  "No. . . that's not your country!  HERE'S your country!" retorted Mr. Shulz in a fatherly tone as he spun the globe back to the Western Hemisphere and pointed directly at the United States.  ". . . And don't you ever forget it!" he barked at the wet behind the ears confirmee.  

Quite a lesson on whose country we represent from a Foreign Service perspective. . . one that quite likely still gets passed down throughout the Foreign Service Officer corps over the years.  

It really is an honor meeting an ambassador.  Not everyone is one, of course, and so seeing one in person is special.  Getting to know an ambassador means getting to know the country he represents, its people, its purposes, and even benefitting from the gifts it gives to the world.  

An ambassador is also a public face from one country to another.  So the ambassador put on slacks, shoes and socks, a clean shirt, and came looking like the professional representative he is. 

Everywhere the ambassador goes, whether he realizes the high position of his office or not, he creates either good or bad will towards the people who see him.  At least in Ecuador, according to one ambassador, the people in Ecuador look favorably on Americans (United Statesians, to be precise) and this is especially true here in Cuenca.  Good behavior creates goodwill, to be sure, and that ambassador surely enjoyed experiencing it as he came to Cuenca for the very first time.  

Reading up on Ecuador, his new assignment, the ambassador quickly found information on the large and increasing expat population here in Cuenca.  He read some of their weblogs, viewed a number of photographs extolling the beauty and opportunities here, and even viewed some of the videos uploaded to YouTube. . . and laughed at a number of comedic moments they captured!  What talent among the expats!  What an engaging, welcoming community that awaited him!  He couldn't wait to get here.  

On the other hand, the ambassador had experienced less than desirable living locations and situations at previous diplomatic posting locations.  Riots and their aftermath with the ensuing ethnic and spiritual tension, effects of illegal drug trade, deprivation up to and including loss of life lie in the back of the ambassador's mind.  Recently one such ambassador has had to experience the grief of hearing of the massacre of a fellow ambassador and the associated death of fellow embassy officials while living in that part of the Muslim world.  In answering a question about the Quito embassy facility, he remarked, "I too lament that a visit to our embassy often is a less than welcoming experience for those of our country.  But, in light of the very real threats towards our country and its diplomatic corps, one has to understand the need for that kind of security.  It's very much required, frankly."  

You may have thought I have been speaking of newly appointed US Ambassador to Ecuador Todd C. Chapman in my reflection above.  Not totally.  Actually, I too am an ambassador. . . I too represent my country wherever I go, like it or not.  How do I know this?  Mr. Chapman astutely stated so in his remarks to the assembled audience he spoke to at the Camera de Comercio in Cuenca.  I take that duty directly from him.  And there's a whole lot more of us US expats here in Cuenca and Ecuador than him.  We see plenty more people in country than he ever will.  The official US Ambassador is merely the tip of the iceberg so to speak when it comes to (high level political) representation of the US towards Ecuador.  

Few know it, but I am also the nephew of a since deceased US State Department official who gallantly served his country in the European Theater of World War II, as well as in the Korean War.  He was one of the very few survivors of the Battle of Pork Chop Hill, as it turns out. . . something that a member of what television journalist Tom Brokaw called in his eponymous book "The Greatest Generation" would never mention to his extended family on visits.  After serving in the US Army during both wars in succession, my uncle William Cox had a career in the US State Department, serving in such posts as Canberra, Australia and Tehran, Iran.  It was his Tehran experience that lent him to perform his last official duties, briefing the press each morning for 444 days on the Iranian hostage crisis, where 52 fellow Americans - a good number of whom he had to have known and worked with - were held against their will at the US Embassy compound in Tehran, Iran.  

ABC News' Ted Koppel, creator of "Nightline," originally envisioned to be a temporary news update program on the hostages in Iran, never featured my uncle. . . likely due to a different time schedule Mr. Koppel worked that prevented him from attending those morning press briefings.  He was instead mentioned as the State Department spokesman in the daily AP news wire stories.  All my uncle wanted was to be allowed to turn in his retirement papers so he could visit his extended family across the country in his gold 1973 Volkswagen Super Beetle.  He had been diagnosed with cancer, and time was of the essence in making those family visits he so cherished.  You see, at the core of being a diplomat is personal and especially family relationships.  

The apostle Paul, writing to the church at Corinth a second time, made the case for representing Christ Jesus.  As one who walks with Jesus Christ, I take heed to the following words: Therefore, we are ambassadors for Christ, God making his appeal through us.  We implore you on behalf of Christ, be reconciled to God.  (2 Corinthians 5:20, English Standard Version)

That, my friends, is the ultimate ambassadorship!  I for one do not take that position lightly.  I thank US Ambassador to Ecuador Todd Chapman for his seasoned, well considered perspective on being an ambassador for one's country - the United States of America.  Yet, according to the apostle Paul elsewhere in his letter to the church at Philippi, "but our citizenship is in heaven, and from it we await a Savior, the Lord Jesus Christ"  (Philippians 3:20, English Standard Version)  Those of us who name the name of Christ are dual citizenship: of earth, and of heaven.  As is true of any ambassador, the world is watching us.  It's doubly true here for my wife and I in Ecuador.