Pesticide use in highland Ecuador is concentrated in the high-risk, commercial production of potatoes. Small farm families experience considerable exposure and adverse health consequences. The authors describe a three-pronged strategy to reduce health impacts: 1) a community-based process of education and provision of personal protective equipment to reduce exposure; 2) farmer field schools to increase agro-ecosystem understanding and to reduce pesticide use; and 3) policy interventions to restructure incentives and to reduce availability of highly toxic insecticides. They discuss the challenges faced by each and the ongoing need for integrated interventions both to reduce adverse pesticide health impacts in the developing world and to promote sustainability of agricultural production in highland ecosystems.