And it's time to go home

It's been a good ride these last 6 months. I've been all over Peru, seen all aspects of health care here, and met the most amazing people. So, it's back to Chicago now, but it's not the end of relationship with this wonderful country & it's people. Hasta la proxima.

Finishing up in Bolivia

I spent the rest of my week in Rurre at the clinic seeing patients. Dr. Jorge (the cuban doctor) started to come to work again so there were always two of us there, but it was never super busy. Maybe 3 - 7 patients per morning and then your occassional patient in the afternoon. A really super slow pace.

On Thursday afternoons, they have a pretty intersting program for sex workers. The program got started a few years ago after a few Rurre community members died of AIDS. The clinic and municipality partnered together on a program to check the sex workers each week for any signs of sexually transmitted diseases. Each worker has a book they carry around with them that has to get stamped saying they are healthy in order for them to be able to work. They get HIV and Syphilis testing (I´m honestly not sure how frequent it is, but at least yearly) and then weekly checks for any other STD symptoms. There´s no way to culture for Chlamydia or Gonorrhea, so i think if you suspect it based on symptoms you would just treat. They also get condoms and try to make sure they are on birth control as well. We had a total of 12 workers come in on that Thursday. Some are really young or have been at this since they were very young. Most have children. It´s good they´re getting checked, but any costs for visits/tests get taken out of their paycheck and that seems pretty unfair to me. It should be their bosses that have to pay. Anyway, it kept things interesting.

On my last day there I got to sit in during a staff meeting and it gave me a lot of insight into the struggles they are having. They are now facing competition from other NGOs and government medical teams that are starting to go out into the surrounding communities and provide health care. I don´t think they´ve figured out how to respond to this. This year La Fundacion started charging patients for medical care and medicines and it has significantly decreased their patient load (as most user fees do), but it has also made it more difficult for their work in the communities b-c the other NGOs aren´t charging. There is also concern that they will be over-visiting these communities. The people in these areas are farmers and it is hard to get them to come to the health campaigns as is, much less if it starts happening more frequently. Anyway, right now the NGOs aren´t working together - they´ve each got their mission and instead of complementing each other it seems like they´ll be repeating a lot of the same work. Work which in the long run might not be all that effective...i´m not sure anyone has clear goals their measuring as a way to evaluate these programs.

The other big problem they have is the car...it´s broken and they are using a loaner jeep that is barely hanging on and doesn´t have the ability to make it to some of the harder to reach areas while also sucking up gasoline. This is a huge problem for them b/c I think one of the main missions of La Fundacion is to reach these outside communities. They also have some staff issues. There are two doctors, but one usually goes out to the community, so if one gets sick or called away to La Paz they can´t cover both the clinic and the community work. And the Cuban doctor is leaving in October or November. They say that it is very hard to get Bolivian doctors to do this kind of work. And well, like many charities the financial crisis has made a dent on their donations as well, so they ´ve seen a pretty sharp drop in their income. They´re facing many challenges right now, but they are all very committed to the work and the fundacion so I´ll be interested to see what happens.

Anyway, so that´s it. Friday, was my last day of medical work down here in South America and it ended with a fun little celebration. Now I´m in La Paz seeing the sights and visiting with friends before I head back to Lima for a few days before I head back to the states.

La Fundacion Rio Beni

The fundacion Rio Beni is an NGO that was started by Dr. Louis Netzer. I´m spending a little over a week here checking out there program. A friend of mine, spent two years here and loved it, so I had to check it out.

Monday, was my first day of work and I hung out in the clinic. The staff currently consists of Dr. Freida, the main doctora for the clinic, a Cuban doctor (who has yet to show up for work), Jose, the administrator, Modesto, the social worker, Lolita, the nurse, Antonio, the lab and pharmacy guy, and Maura, the health promoter. Patients begin arriving at 7:30am to buy their fichas to be seen and then the patients get split up between Dr. Freida and the other doctor. I started out with Dr. Freida to get a feel for their system, but since Dr. Cuban didn´t show up they asked me if I´d mind seeing patients on my own. So I did. It´s a lot easier than at the government health center, b/c since it´s an NGO I can sign prescriptions, my charts without any worries. Anyhow, it was pretty usual stuff...URIs, headache, UTI´s, etc. There were a couple cases that stood out. There was a gentleman that fell down and broke his wrist about 2 weeks ago. He had it wrapped up in an ACE bandage, but never got any other treatment. He came in b-c it was still pretty deformed and he had really limited movement of his hand and wrist. I sent him for an xray, which confirmed his fracture and partly healing....but the thing is there is no ortho here to send him to fix it back in place. And I just don´t have those skills. The nearest place he can go to see an Ortho is a 12 hour bus ride. So, he´s going to think about it or have a permanently screwed up wrist.

The other case that stood out to me was that a mom and child came in to be seen. The child had chicken pox, which isn´t crazy, but we just don´t ever see it in the states b-c of the varicella vaccine. But her mom was pregnant...but thankfully doesn´t have any symptoms of chickenpox. but she has a 6 month old and she really doesn´t want to have this baby. And well abortion is illegal in Bolivia so she really doesn´t have any options. This family was clearly poor, the children were not well nourished, and now she has to have another baby.

So our day isn´t all that hard, we see patients from 8:30am - 11:30am and then again at 2:30pm - 5pm. The afternoon is a lot quieter than the morning, people mostly come in for labs, follow up. So, that was day 1.

Today we tried to go out to the communities. It was raining pretty hard to today so when we got to the turn off for the community we were supposed to go to, we got told it was too dangerous to go. Instead we ended up going to a town another 45 minutes down the road and de-wormed all the kids at this school in an indigenous community (Chaman). I also saw a few kids that were sick with URI´s, pneumonia, and some skin infections. These families were really, really, poor. I´m glad we treated them, but continue to be convinced that these community visits don´t accomplish a whole lot. There does seem to be some continuity here so that´s good, but still.

On a lighter note, when we got to the community, there was a monkey playing with a dog. So cute!

Making it to Rurrenabaque

So, it´s been a bit of an adventure to get to Rurrenabaque (Rurre), Bolivia. But, yay, I´m here. The first road block was at the Lima airport. Friday was Labor Day, a national holiday, and the beginning of a long weekend. A lot of people were traveling, but on top of that the night before almost all flights were cancelled or delayed due to fog. So when I got to the airport it was a mess, people everywhere and lots of chaos. Plus with the whole swine flu thing going on, there are all these people wearing masks (mostly not in anyway that´s actually going to protect them) and well it just makes things seem more dangerous. Anyway, I figured out which line to get in and was told my flight would be leaving at 7pm instead of 12pm. Ok, well at least it wasn´t cancelled and they gave me a lunch ticket. Finally made it into La Paz at 10pm their time and to my hotel by 11pm. You can really feel the altitude here. I don´t usually get affected from being at high altitudes, but when I got to the hotel, i could see my fingers were this not so pretty blue-white color and a little tingly. Nothing that a little coca tea and sleep couldn´t take care of.

Anyway, so up very early to go to the airport for my flight to Rurre. The airplane to Rurre is one of those tiny planes that seats like 15 people and makes you nervous as hell. It was a beautiful flight over the andes and into the jungle. The landing was a bit rough, but not unexpected given that the runway is made from dirt. Rurre, is just beutiful. It´s what you expect from the jungle...totally green with mountains and hot. At the airport, I was expecting to find someone from the health center waiting for me, but that didn´t happen. So jumped on a moto and had him take me to the clinic. No luck there either, so I knocked on the door of this random house and this very nice lady let me in and told me to wait for her husband who knew where the people from the clinic worked. I´m so thankful for them...it would have sucked having to walk around the town with my bag.

Her husband arrived and took me to the main doctors house and she was super nice. People always seem to sort of know you´re coming, but also seem a little surprised. At least they´re nice and very welcoming. She was able to locate Jose, the man with the keys to my room and he got me settled. I´m staying in the clinic. My bedroom is literally in the clinic. Anyway, it´s really nice, so it´´ll be great.

I´ve been walking around the town today and it´s pretty big. Has a lot more infrastructure than the jungle area I was in in Peru. It´s a tourist hub for people that are going on jungle expeditions so there are lots of foreigners and pretty much everything you could need. They even have plenty of coca cola light here. Anyway, so since there is no work tomorrow i´m joining the rest and going on a day trip to Madidi National Park. So, it´s good to be here and looking forward to the week ahead.

Water

This is going to be really short, but one thing that comes up over and over again almost anywhere you go in Peru is access to water. Diarrheal diseases are among the most common reasons people visit health centers in any region of Peru. And they are all linked to access or lack of access to clean drinking water. The lack of sanitation in many places also does not help. Anyway, it seems like an obvious thing to notice, but it’s just not a problem we have to deal with much in the states and it’s such a problem here and it seems so unfair. It’s 2009 and there are so many people with access to safe, clean water. If this problem isn’t fixed, the other one won’t go away. Although the government does work on water issues it is mainly a problem that local governments have to address and most aren’t effectively for many reasons. Got to get people clean water.

An Emergency in Huaripampa

The first day Marisol thought it would be good to one of the further sites in their network. Huaripampa is about an hour car ride outside of Huaraz. The road is not paved, but compared to Julcan it seemed like a breeze and the views during the drive are great. We arrived at the health center at about 2pm and the nurse and a technician were the only one there. She sat down to talk with us about her experiences and shortly into the conversation we were interrupted by the tecnica who said an emergency had arrived. There was no doctor there so she asked if I’d come see the patient. They pulled an unconscious lady out of a taxi and brought her into the topico. She did not look good. She had a grayish hue to her. I checked for a pulse and felt nothing, listened for a heartbeat and nothing. I calmly told the nurse that I there was no pulse and she quickly got an ambu bag and we started CPR (the whole time I was thinking, well this sucks). We gave her some epinephrine and kept going at our CPR, but it didn’t work. It’s not clear what she died from maybe a heart attack, stroke, but who knows. The family said she had heart problems but there was nothing in the chart. She was only 56, but looked about 70…not an easy life. Once the family was settled we went back to our meeting and the nurse told me all about her experiences in Huaripampa.

Being by herself was not unusual. The doctor works 6 hours and that’s it. After that he’s gone and who knows what he does b/c the town is really small and not a whole lot to do. She says if there is an emergency he will usually come if he’s around, but sometimes he’s just not there. So, it can be pretty scary for her. But her main goal in an emergency is to stabilize patients and get them to Caraz and they have an ambulance so they can get transport their patients. Ambulance really just means big van with a bed, there’s no oxygen or anything really helpful. Anyway, like most places in Peru her biggest issues are human resources and money. The budget is incredibly small. The money that they get from the government from seeing patients with the SIS health plan has to go towards maintenance, community work, and buying medicines. There is really no money left over to expand or improve things. The main illnesses they deal with are respiratory and diarrheal. There is no lab or ultrasound. Their staff consists of two nurses, two midwives, a couple tecnicos, and a doctor. The midwives also cover other health posts that are even further away. The nurse has been at this health center for 3 years and really wants to improve things, but just doesn’t have the means.

Caraz & Huaraz

A medical student I met last year in Chicago who was a Peace Corps volunteer in Peru put me in touch with one of the midwives she met while working in the Ancash region of Peru. Marisol, is a midwife who has been working in this region for almost ten years. I first have to say that the Caraz/Huaraz area is amazingly beautiful. The mountains just take your breath away. And we luckily arrived at the end of the rainy season so we were lucky enough to get great weather.

Marisol just recently got promoted to a management position within the ministry of health. Her job focuses on improving quality at all levels so it’s a pretty important job. But she spent much of her time prior to this working in health centers delivering care and she spent a couple days with me showing me the realities of healthcare in this region of Peru.

Out in the Comunidad

While in Huaral, besides doing some of the MAIS forms I also spent a lot of my time going out into the community with the health center staff to participate in health education activities. The centro works with people on a family level by doing home visits and at a community level by organizing charlas in a community member’s home. They also have a escuela saludabe and a centro laboral saludable program.

Our outing into the community was with the midwives for a charla on family planning as well as free rapid HIV tests. Like most community work it takes a little convincing to get people to participate. The internas told me that they had canvassed the neighborhood the week before to let people know about the talk and when we arrived no one was there. So we went knocking on doors and ultimately I think it was the free rapid HIV tests that brought them to the talk, but at least they came. The health center has only two patients from their catchment area that have tested HIV positive, but there is a big push by the ministry of health to test as many women of fertile age as possible. Most women who are HIV positive in Peru contract HIV from their husbands/partners. If you test positive the ministry of health will pay for HIV treatment. There is currently a rapid HIV test campaign, but otherwise the test is fairly expensive.

The escuela saludables program is a partnership between the health center and two schools in the area to work on a few specific health topics. There are four health topics they want to cover during the year and they are currently focusing on nutrition. Huaral has a mix of children with chronic malnutrition and then others who are on the road to obesity. Like many places in Peru people eat an abundance of carbohydrates, but little proteins, fruits, and veggies. Unlike other places in Peru, b/c there is not as much poverty as in other areas some children do have a little money to spend at the school snack bar and tend to buy unhealthy snacks (potato chips, soda, etc).

There is a school health committee and they are in charge of choosing the areas they would like to focus on and work with the health center on how to address the issues. First, the health center staff meets with the teachers to get them to buy into the program b/c ultimately it gives the teachers more work to do. The health staff is supposed to mainly educate the teachers and the teachers are then supposed to work the topic into their education plans. The health committees decide how to best involve/work with parents. I was able to attend three nutrition-focused events. The first was a meeting with teachers to explain the escuela saludables program and then we had another session with teachers where we went over what a healthy diet consisted of and some sample meals. The teachers are a tough bunch and they had many critiques about the suggestions made, most of which were totally reasonable. Mostly they were concerned about the ability of parents to afford healthy foods. Our last nutrition talk was with a parents group at an elementary school and we adjusted the talk to come up with very concrete examples of affordable, but nutritious foods. The parents seemed to be open to the talk and asked lots of good questions. On our way out we were offered a snack of cow lung with potatoes. First time for me…probably good, but I had a hard time getting past the idea of lung.

The last talk we did was at a pig farm. This is a new area of work for the health center and they chose a farm whose owner is already very active in the community. We didn’t see much of the farm, but overall it looks like a pretty nice place. We met with all of the workers as well as the veterinarian, the head manager, and the owner. The session started off by naming employees to the health committee. Then everyone was asked to list problems they’d like to address and they were really some very basic hygiene, sanitation, and biohazard material disposal issues. My thoughts while listening were that this place would be shut down in a second if it were in the states. I think the important thing is that the owner is open to addressing these issues and the vet is very interested in making real improvements. We then proceeded with a very basic talk on hygiene that was very needed given some of the issues the farm is facing. When it was done we got served some very yummy pork sandwiches.

While in Huaral, we were fortunate enough to be housed by the nicest family on their farm. They were some welcoming and the food was amazing and I got to go on runs through some of the nicest scenery, including some of the biggest mangos I’ve seen in my life. It was just one of those unexpected bonuses you get when you’re doing this stuff.

MAIS

MAIS stands for Modelo de Atencion Integral de Salud (Integrated Model of Healthcare Delivery)– it’s a new model that the ministry of health wants to implement in all it’s primary care level health centers. They started implementing the MAIS in the health center in January, so it’s in the beginning stages. Right now, they are working on doing new MAIS histories, which involve two parts, one, a very detailed personal history (there is one for children, adolescents, adults, and geriatrics) and the second part is a family history. The family history is not only a standard complete medical history but also an evaluation of the family’s socioeconomic status. There are questions about the housing conditions (construction materials), if there is potable water, if they have a sanitation system, and animals within the home. After the two histories are done the health care worker has to come up with an integrated health plan that addresses all the health needs of the family. It looks at health in the big picture and asks for the health center to address all the factors that affect one’s health. It is a very ambitious plan. Housing, employment, sanitation, safe drinking water, and education are all clearly determinants of health, but a lot to ask a health center with limited resources to address.

Even with their limitations the health center has taken this head on and is starting to make their plans for each family and family member. They haven’t really identified how they are going to evaluate what kind of impact the MAIS is making on their patients. We discussed this and they did say that they would at least try to come up with some short-term goals for the MAIS, but I’m not sure I convinced them of the needs for a control group. Anyway, I’ll be interested to see where this goes

Huaral

I got hooked up with the Centro de Salud La Querencia in Huaral through the family medicine doctor I know in Lima. Huaral is a city of about 100,000 two hours north of Lima on the coast. It’s sort of a fertile valley in the middle of the desert. You have this beautiful ocean view on the way in and then there are farms mixed in with all this dust.

Huaral’s main industry is agriculture like much of Peru, but Huaral is particularly know for it’s productions of fruits: mangos, apples, passion fruit, mandarins, pears and Avocados. Plus there is a fair amount of pork and cattle farming/raising. This makes Huaral more well off than the other places I’ve visited on my trip and it has more access to services. But it is by no means wealthy. A farm worker makes on average 60 soles a month – less than 3 US dollars a week to support a family.

Because Huaral is not considered an area of extreme poverty, the SIS insurance is applied based on a sliding scale. A large percentage of the patients do qualify for the SIS program, but they must be evaluated to determine their eligibility. And there are a fair number of patients that pay out of pocket for their consulta. It’s not much – 6 soles (2 dollars), but these patients must pay for their meds and any other items necessary if they have a procedure done. I did notice that the pharmacy was better stocked – but not sure if that’s due to better management or b/c the clinic has more paying patients they can afford to buy a better stock of medications from MINSA.

La Querencia is led by Dra. Doraliz Campos. She is a general medical doctor that has been working in the area since 1996. She’s amazing. She’s been very committed to this area and she has had some serious impact on the area. Dra. Doraliz is consistently advocating for the community and particularly for improving the health center. It started out as a small clinic and now has grown to two floors with a lab, ultrasound, and physical therapy. This is the first time I’ve seen physical therapy at any MINSA health center. Dra. Doraliz says that they‘ve been able to make such progress b/c the community has supported the growth both financially and physically. She also makes it a priority for the health center staff to spend a lot of time out in the community doing health promotion charlas in people’s homes, schools, and work places.

Holy Huamanga

Ayacucho also happens to be the place to be for Easter in Peru. They have some of the most dramatic/beautiful processions and wildest parties you’ll find. The weekend is this strange mix of religiosity and debauchery. I’ve honestly never seen so many people in line for confession, but I’ve also never seen so many people drunk on the night before Easter. There are 33 churches in the city of Ayacucho. It’s a lot of churches for a pretty small town and they are all really old. It has one of the oldest churches in South America, built in the 1540’s. The Catherdral, built in the 1600’s – is amazing. It has all these altars to different saints that are made out of cedar, but covered in gold leaf and they are huge and intricate.

The main weekend activities are a procession at night on Good Friday, a full on party on Holy Saturday, and another procession on Easter morning.

Good Friday there is a procession of el Senor del Santo Sepulcro– he’s lying in a clear coffin of sorts and it’s representing that he’s dead. Prior to the procession, the churches give out candles to anyone that wants one and then at about 8pm they turn off all the lights in the Plaza de Armas and people light there candles. It’s beautiful. Then the procession starts from on of the churches and there are all these men dressed in black carrying the Christ figure. He stops at every corner, they say a prayer, sing a song and then keep going around, shortly after the Virgin Mary is lead out by a group of women all dressed in black and a similar process occurs. It’s just really beautiful and has a very appropriate somber tone to the evening.

Saturday is a whole different story. It’s basically a full on party. We spent our day visiting the beautiful valley of Huanta and eating Pachamanca, but my friend stayed in Ayacucho to participate in the running of the bulls or Jalatoro as they like to call it.

The evening is one huge street party, with bands on all four corners, people dancing and drinking and mostly getting drunk. Then around 10 – 11pm they set of fireworks…like 4th of July fireworks and these “castillos” are built which are set off throughout the night and in the early morning. It’s definitely got a different feel from any Saturday night before Easter in the US.

Easter morning is the highlight of the whole weekend. Mass starts at 4am and it is followed by the procession of the resurrected Christ. It’s this immense “Anda” completely made of wax candles and carried by 500 locals. It was raining pretty bad, but it was still amazing to see…as they walk the men all cheer “No Pesa Nada” and I couldn’t help getting a little teary eyed.

Ayacucho: At the Center of History

For Easter weekend, my mom, a friend from medical school, and I traveled to Ayacucho. Ayacucho is in the southern highlands of Peru. It’s about a 1 hr flight or 8 hours by bus. Although it’s name was changed to from Huamanga to Ayacucho in the 1800’s the locals still call it Huamanga.

Ayacucho seems to always find it self at the center of Peruvian history. It is the place where there is evidence of the first human remains in South America (about 20,000 years ago) in the caves of Pikimachay. It is also where the decisive battle for Peruvian independence was fought in 1824. Most recently though, Ayacucho was the center of the terrorist movement that plagued Peru from 1980 – 1992. The leader of Sendero Luminoso, Abimael Guzman, was first a teacher at the University in Huamanga. Although Sendero Luminoso terrorized all of Peru, Ayacucho was the center of their activity. But what was particularly difficult for this mostly indigineous population was that they were caught between the terrorists and the army. Approximately 70,000 people died during this conflict. That part of the country was pretty much inaccessible or cut off from the rest of the country during those years. Los indigenos fled their farms/villages and moved either to the city of Ayacucho or to Lima which were somewhat safer that their homes in the mountains. We heard many stories while we were there that weekend of the atrocities that were committed. I cannot even begin to imagine what it was like to live through that time. It is such a different city now, calm, beautiful, and peaceful.

A Talk in San Juan de Lurigancho

The last time I was in Peru, I was lucky enough to meet some friends of my father who have dedicated their lives to doing public health work here in Peru. Dr. Jesus Toledo and his wife, Maria Elena Toledo, a nurse, have spent much of their spare time supporting different health projects around Peru. They put me in touch with the folks in Julcan and were instrumental in getting funding for it to be able to expand as a network and to build their labor room.

They have also showed me different projects that they are supporting in Lima. On a Saturday morning Maria Elena (or Mamalena, as most people here call her) took me to one of the barrios in San Juan de Lurigancho - Casuarinas de Martires. San Juan de Lurigancho is the biggest district in Lima and although it has areas of much economic activity, it is also home to pueblos jovenes and much urban poverty.

We first stopped by the health post and got a quick tour of the tiny establishment, which is significantly less well equipped than either health center I worked with in the provinces. We then went up to the top of the community – where they are now just installing water systems and I gave a talk on hypertension followed by taking everyone’s BP. It was a group of about 20 young women and children. They listened attentively and had good questions for me after the talk. What came across during those talks was that these women seemed very similar to the patients I see in Chicago. Young, many children, poor, worried about how to feed their kids, send them school, how to make ends meet. And these worries spill into true physical symptoms.

Something that stood out to me that day was a young boy who came up to me and told me that his brother had TBC (Tuberculosis). He said he was on treatment, but he asked me worriedly if his brother could get better or if he would die? I’m not sure why this question rattled me for a second, especially after the other things I’ve seen and heard here. I said that yes, if he took all his treatment he could get better and with that the boy smiled and ran off, and returned to give me a big hug when I left.

TB is a big problem in Peru and multi-drug resistant TB an even bigger problem, particularly in the pueblos jovens/slums of Peru’s big cities (Tracy Kidders Mountain Beyond Mountains has a good section on this problem). TB is the 4th leading cause of death in Lima and about 3% of new TB cases are multi-drug resistant. Anyway, these experiences make me think that there is plenty of work to still be done in the city and it’s what we do in the states, provide care to the urban poor, we could do a lot for these communities too….All in all a good day.

Meetings

I've spent a lot of time lately at meetings. It's good because I'm meeting people that are tackling health care issues from many different sides, but it's frustrating because I'd rather be out there doing work.

So this week I met with a Dr. Alex at the offices of Es Salud. Es Salud is the health care system for those that are formally employed. It's pretty decent coverage and well much more comprehensive than the MINSA system. Access to most technology, medicines, specialists, etc. The doctor I met with has been working on their special projects. They basically go out and do "campanas" (they love those here) in provincias, where they bring specialists, medicines, xrays and they treat anyone. Anyway, he wanted to here about the work we are trying to do here and gave me some ideas of areas that he thought would be good fits. He suggested Ica/Pisco because of it's proximity to Lima and also because it was devastated by an earthquake in 2007.

Then yesterday, I met with a lady from the NGO Yanapana Peru. Yanapana was started by this group that owns these luxury lodges on this super fancy Inca Trail. They are trying to be eco-friendly and trying to give back to the communities they work in by supporting them in different areas: education, agriculture, business development, and health. Last year they also did a "campana", but they brought doctors in from Lima and Cusco and took them through the trail visiting all these people, many who had never seen a doctor. Apparently, it went pretty well, but it was expensive and not sustainable. So, she thought we might be able to help. We're not so interested in the campana model, but if they decide to invest in a more long-term, sustainable model of health care, I'd love to explore this, especially since it would be serving a population that has very little access to care.

Then today, I went to an Es Salud hospital, El Hospital Almenara, apparently one of the biggest referral centers for Es Salud in Lima. There I met an ENT doc, Dr. Luis, who does some volunteer work en el cono sur de Lima. He works with a Catholic parish there that provides care to the poor and he thought we could be a good fit. So hopefully I'll get out there to see it.

Then I went off to Universidad Peruana de Ciencias Aplicada (UPC) to meet with a doctor and professor who teach a class to medical students about evaluating community health needs. The university is relatively new, 15 years old, but the med school is really new, just 3 years old, but it's really well financed. It is definitely one of the nicest and most modern campuses I've seen. During their second year of med school the students learn how to do an assessment and then go out to one of the poorer communities of Lima and do the assessment. Since the med school is only 3 years old, they haven't been doing it long enough to develop programs around the health problems identified. Anyway, I'm going to try and go out with them when they go to do their evals and see what they do. The professors love the idea of an interchange between universities and are open to US med students coming to Peru.

So, like I said, really neat meeting this people, just wish I was more hands on...just part of the process. Just thinking that this Peru thing is going to take longer to get in place than the six months i'm here, but at least I've got lots of options.

Living with Terrorism

Last night I went out with my cousins for dinner and while there the topic of Peru's years of terrorism came up.  The Shining Path caused some major chaos here from in the 80's the worst of it being from 1895 - 1990.  Thousands of people died, mostly in the rural parts of Peru caught between the Shining Path and the military, but Lima had it's fair share of attacks.  They talked about all the places that had been blown up, having curfews, always wondering if it was safe to go out or not.  And although I had come to visit during that time and remember once going to see the ruins of a building that had been bombed, I can't imagine having to live your life with constant threats.  They said you just have to keep living, nothing else you can do.  

Around Lima

I spent most of the first week back from Julcan helping my mom move from her apartment to a new house.  Moving is just as painful here as it is in the states, but we're settled now and feeling more like I really live here.

This last week the goal of universal health insurance got a little tiny bit closer when the Peruvian congress made the it a law.  Still far away from a reality, but it's a first step. 

This week, I spent some time with some family practice doctors.  It was really good to start seeing what they are doing down here.  There are scattered family practice programs around the country, but there doesn't appear to be any association that sets guidelines, so they can vary pretty widely.  The family practice program that I'll be spending some time with is based out of la Universidad Peruana Cayetano Heredia.  It is arguably one of the best medical schools in Lima.  

The family medicine residency has been in existence for about 6 years, but they haven't always had residents.  There is a national residents committee that determines how many spots to grant a residency program each year and it varies widely.  3 years ago Cayetano got ZERO residents, the next year they got 6 residents, and this last year they got 18.  They haven't heard how many they'll get for the next year.  It's partly determined by the hospitals where the residents spend their first year and half.  My understanding is that they assume the cost of these residents and their budgets fluctuate (although I'm still trying to figure this out).  

So the family practice residency is 3 years, but they spend their first 18 months rotating in different, mostly hospital based specialties, with one day in family practice clinic each week.  The last year and a half is spent in the community.  They spend a 6 month block at one of two health posts seeing patients, but also doing some serious community work.  The rest of their time is spent rotating in other community settings.  During this whole time they continue to have family practice clinic at Cayetano.  I don't think there is really a concept of continuity care here for patients, but I haven't spent enough time with them to know for sure.  

I went to visit one of the health posts where the residents spend an extended period of time.  It's in one of the poorer parts of Lima.  It's a small, but nice facility.  The resident just started there about 2 weeks ago so she's just starting with her community assessment.  She has the help of a volunteer preceptor doctor who is employed by MINSA (the ministry of health) and an intern (med student in their last year of school).  She is expected to see patients in the clinic for 4 - 1/2 sessions - each week and the rest of her time is working out in the community addressing the problems they've identified.  The amount of stuff they have to cover is pretty daunting...but she starts and the next resident will continue.  Anyway, hopefully I'll get to see some more of how this works.

The last week in Julcan

So my last week in Julcan was pretty good. I had 3 medical students from Loyola come up for their spring break. They received funding through the global health program at Loyola. They came to get a first hand view of my experience and learn what they could about health care in rural Peru.

Overall, it was a really good week. They came in on Sunday and we did a quick little tour around Trujillo. We saw the beach, ate ceviche, and went to the Huaca del Sol y Luna. Monday we headed to Julcan and basically just got settled and took them on a tour of the health center. Plus they got introduced to the super room in the "hotel".

Tuesday morning we did home visits on pregnant women. We reviewed warning signs and started explaining how to make suero casero. The students were excellent...Beau and Dina took turns explaining the warning signs and Mark entertained many of the children with his camera. In the afternoon we took an hour walk to the caserio of Oromalqui with Rebecca, Christopher, Marianela, and Juner to see their talk on Microbios and do home visits of families identified as at risk by their community.

Wednesday we sat through a semi-painful sesion demostrativa. It was so long and complicated and the women really didn't participate. The practice session was so much better. We got to present our suero casero...so that was pretty good and it's so simple: water, salt and sugar.

Thursday morning the students rotated through the different services in the health center so they could get a sense of what a day in the health center was like - so this included medicine, family planning/OB, nursing/well child checks. Oh and that afternoon we took a walk to El Rosal to go check out an Incan mummy that is just hanging out in a lawn chair in this guys house. Crazy, but cool. Then we had a very wet walk all the way home.

Friday we went to another caserio, Santa Rosa, where Christopher checked out the water system which is completely non-functional. Beau and I presented the suero casero again and did home visits. These home visits gave you a better sense of people how in the communities further away, actually live. They definitely aren't eating the portions of milk, veggies, and meats they're being told to eat. Friday night was capped off with a pretty rocking party.

Our weekend began with a tour of the state medical school in Trujillo and one of the big public hospitals...El Belen. It was good to see the hospital where patients get referred. While there we learned that the patients who get pap smears in Julcan, not only have to wait three months to get there results, but SIS doesn't cover a colposcopy...so not sure how you actually do a diagnostic test if you have an abnormal pap? Ah, got to love SIS.

The rest of the weekend was spent in Huanchaco enjoying the sun, beach, food, and hot showers!

MIsh Mosh

2/27/09

On Wednesday, I went to do home visits of our pregnant women with one of the midwives, Irlanda. We were able to speak to 11 of them, so felt like a pretty successful day. Plus we got good exercise walking all over the city…even through part of a garbage dump to get to a patient washing her clothes in a stream. We had a goal of speaking to about 40 pregnant women in two weeks and I think we’ve been able to find about 25 total. We haven’t been as successful at speaking to the whole families…it’s just hit or miss whether anyone else is home and wants to talk to us. Anyway, most women seem interested in learning how to make their own suero, so hopefully we’ll get to do some of that next week.

Thursday and Friday this week are the celebration of Carnaval in Julcan. It’s one of the big parties here in the city. The festivities started at 6am with the different barrios in the communities, putting up their palo cilulos – a palo is a stick…so I was expecting some small branches, but these are full grown trees that have all kinds of things hung on them (t-shirts, household appliances, etc). So each tree was lying on the ground in the plaza and it was pretty crazy watching everyone working to get them lifted up and put in the ground. The barrio with the best tree wins a prize.

On my way down to the clinic, I was approached by a family who asked me to come see there sick 3 year old at home. They said he was sent home from the big hospital in Belen and wasn’t doing so well. That’s what I understood but when I got to the clinic the nurse said that she was told that the child was dying and they needed a doctor to see him before he actually died so they wouldn’t have any difficulty getting a death certificate later. So they picked me up on a moto and took me about 15 minutes down hill to the home. I found a tiny very pale boy taking very slow breaths…the mom showed me his CT scan which showed a huge mass in his abdomen and the report stated it was most likely a Wilm’s tumor. The mom said that they had been in Trujillo visiting family and she noticed that his stomach looked big suddenly and when she took him to the hospital they found the mass, but it was too large and advanced for treatment. Kids don’t really get regular physical exams here …so not sure how anyone would’ve picked it up. While I was there examining little Maycol, he died. People here often say that families in the sierra don’t mourn their kids in the same way…I don’t know if that’s true, but this family broke down immediately. It was heartbreaking, I just met the family that morning. After that, I got jolted back to the craziness of Carnaval in Julcan proper.

The clinic was not very busy, b/c most people we’re out celebrating. Most of us went to go see the parade of floats put together by the different barrios. Each barrio has it’s own float and it’s own band…so there were 6 bands playing simulataneously in the plaza. A huge part of carnaval here is people throwing water filled balloons at people. I was for the most part spared any significant hits, but not sure I appreciate this part like Peruvians do. The rest of the day was just one big party in the plaza…people dancing and doing some serious drinking. Later on in the evening, the trees that aren’t in the top three get knocked down and it’s a free for all for the items on the tree (imagine a piñata, but a humongous tree). Our evening ended with a centro de salud outing to one of the discotecas. It was a blast.

The carnaval continued today. Today was pretty much just people dancing and drinking along to a bad that they brought in from Cajamarca and of course, more water throwing. I honestly don’t know how people drink as much as they do here. Surprisingly we only got two Carnaval related injuries and they were both pretty minor. Anyway, I’m glad I saw this side of Julcan.

How many patients can you see in one day?

2/24/09

Yesterday I went on another campana. This one was significantly further away…we got there on motorcycles, locals say it’s about an hour and half walk, which is probably 2 hours for those of not used to walking those distances. It was beautiful in the morning and we were put in a building adjacent to the school. It started nice and slow, but by lunch time we were swamped. It was just family after family…most families were 4 or 5 people. Most people came with complaints of headache, colds, diarrhea, or heartburn… not very complicated, but with the amount of people that came in, it was hard to be thorough or do much more besides give out a ton of Tylenol. So much for education. I was the only doctor that went, but thankfully to medical technicians also saw patients. I think I’m the only one that actually examined any of the patients and I’m pretty sure I also give out the least amount of antibiotics. We finished around 6:30pm and by that point it was raining, freezing, and our room was dark and I was glad to be done. Feeling pretty strongly that this is no way effective or good medicine. I can’t get an exact number of how many patients we saw…but somewhere around 200…crazy.

Today my home visits were thwarted by the threat of a supervision visit by the ministry of health. I spent the morning seeing patients with one of the fill in docs. He’s pretty cool, so the morning went fast and there was yet again someone for me to stitch up. In the afternoon, we had a capacitacion (training) on how to do a sesion demostrativa (educational demonstration). It was specifically about how to teach pregnant women and mothers how to prepare well-balanced nutritious meals. The idea is to give them a talk, but then to have them actually prepare four different meals – for children age 6 – 8 months, 9 – 11months, 12 months +, and then for a pregnant woman. So after we got our talk we prepared the dishes. It was good hands on learning. We are going to do something like this next week with the nutritionist and pregnant women so we’ll see how it goes with a real group.

Dia de Mercado

2/22/09

Ok, so the rash is not scabies, but most likely 14 flea bites…that’s right, 14! Yuck!

Apparently, Sunday is the day to be in Julcan. It’s market day. People come from all the surrounding towns to buy and sell their goods. It’s the most people I’ve seen in the town. All the stores are open, there are restaurants open I didn’t know existed, and there is a lot of potato and livestock being sold. I went to Rebecca’s house for lunch, but luckily they had run out of the sheep head soup!

Sunday is also one of the busiest days for the health center. Since people come in from far away for the market they take advantage of their trip to come to the health center. The vast majority of patients are for the midwives and nurses. The consultorio de medicina had a steady flow of patients, but nothing like the other services. My bike accident patient came in for a wound dressing. Besides looking pretty bruised, the wounds like ok, although his mouth looks pretty painful. Anyway, I stressed the importance of cleaning his wound everyday and finishing his antibiotics, so hopefully it’ll look ok when he comes in to have stitches removed on Wednesday.

Going on a Campana

2/21/09

So I spent the rest of this week making a stab at home visits of pregnant women. Our home visit team consists of Vania, Rebecca, and I. We are just finding it hard to actually find the women and their family members at home. The idea is to not only visit the pregnant women, but also her family (husband, mom, mother-in-law) and review the emergency signs of pregnancy and labor and then also address other health concerns they may have, especially about their children’s health. And we wanted to teach them on a second round how to make their own oral rehydration solution. Anyway, we’ve only found 7 of our pregnant women. The one’s we have found have been nice and open to what we are reviewing and all have said they are willing to be transferred to a referral center if needed, so that’s good. So we start again on Monday to see if we can find some more pregnant women.

Today we went on a “campana”. A campana is when the team responsible for a certain sector of the outlying communities goes out to them to see patients. It is, I suppose, their attempt to get out to the communities, so people don’t have to come in to the health center, since most of the communities are anywhere from a 1 – 3 hour walk away. I think it could be a good thing if there was any continuity/consistency in the staff that was responsible for the different sectors. This mostly felt like any band-aid campaign, where people come in with pretty typical complaints of colds, diarrhea, heartburn and mostly just want medicine to get by…there’s not much time for education. The good thing is that they are connected to the health center so if there was something serious they could follow up. I don’t think they can fix this until they fix their staff turn-over problem. It was really beautiful on the way down, the way back was a good 45 minute walk up the mountain to a part of the road where the clinic car could pick us up. And I came home with a seriously itchy rash on my arm, as long as it’s not scabies, I’m ok.

La Reunion

2/18/09

So today was the meeting with all the CODECOs for Julcan. CODECOs is an abbreviation for Comites de Desarollo Communitario (or something very much like that…abbreviations are sometimes hard to figure out here). Anyway, they are these community groups that are made up of the leaders of the community and they are charged with the development and improvement of their communities. No small task. The health center has taken on the job (or be given) to help organize the CODECOS to meet the health needs of the community and the other larger issues they have…they see it as all being interconnected anyway. So the plan for today was for them to come and go over some of the areas they had identified previously as priorities and meet with some of the leaders/authorities in Julcan and start developing a work plan.

Anyway, so it was interesting to be an onlooker…they of course introduced me as the American doctor although I had no role in the meeting except as an outside observer. About 70 CODECO members and health promoters came…so it was a good showing. And there was also a good turn out by heads of other organizations like education and agriculture. The meeting concluded with each CODECO coming up with a specific list of priorities for their particular communities and a list of what their health promoters should focus on. Anyway, it was nice to see some community health in process.

An added bonus to the meeting was that I got to see Rebecca and Christopher the Peace Corps volunteers. Sometimes it’s just nice to meet a fellow US citizen and swap experiences. Which we did plenty of tonight.

The afternoon was good…Vania, Rebecca and I sat down to review the work plan and try to make a schedule. So I think we have a plan for the next week and half at least. I think I’m finally going to get out and see some caserios (small communities). So YAY! And then another emergency came in…a 20 year old who fell off his bike and his face took a serious beating. So I volunteered to stitch him up…which went well, especially with the help of the very skilled tecnica…(Delicita).

The evening ended with some good discussion with Rebecca and Christopher and now I’m going to sleep.

Me Mato

2/17/09

Well the substitute doctor finally made it last night. He brought along with him a patient with pre-eclampsia. When I arrived in the morning I went to see if there were patients to round on and he was trying to convince her to be transferred to the bigger hospital in Otuzco for further care and likely a C-section. The patient was a young girl in her late teens whose bag of water broke yesterday (over 24 hours ago) …they were going to induce her in her village, but when the midwife checked her blood pressure she noted that it was in the 150’s. So she recommended she be transferred and apparently it took them hours to convince them to even come down to Julcan. So then when they got here and she continued to have high blood pressures and protein in her urine…they could not convince her to go to Otuzco. When I got there the patient and her parents said well if she dies that is God’s will…they both felt they knew better and that they would rather take her home than transfer her to Otuzco. So why not just keep her in Julcan? Well, one there is no C-section ability in Julcan and not much emergency equipment and secondly no one really wanted to take responsibility if something went wrong. The family refused to sign any kind of form that said they would release the center of any responsibility since they weren’t following medical advice and b/c they wouldn’t sign the doctors didn’t want to try and doing anything that could potentially help, but has it’s risks. I recommended she be put on continuous magnesium sulfate and be induced with oxytocin, but no one wanted to take the risk…so we prayed and tried to find their pastor. Somehow about 4 hours later after almost everyone in the health center talked to them they decided to go to Otuzco with one of the midwives. But she went w/o any Mag….definitely some stuff to go over here. And definitely an area to target in outreach is churches…ridiculous what we heard today.

The other patient on rounds was a 17 week pregnant patient that was admitted two days ago with pyelonephritis. She was clinically doing well…no pain, no fever, eating well, but as we reviewed her chart we noticed she’d had 4 UTIS during this pregnancy already. Anyway, so we decided to keep her for one more day of IV antibiotics and then she’ll go home one oral antibiotics. Per our guidelines this patient should be on antibiotic prophylaxis for the rest of her pregnancy. The doc says that it’s not covered by the insurance and most patients can’t afford it so she’s essentially out of luck and at risk for more UTIs.

I spent the rest of my morning with the nutritionist trying to bone up on that…I think I’m starting to get a better idea and hopefully by Thursday we can be out seeing patients.

So the rest of the day proved to be an adventure…after lunch I went back and did some reading and had fun talking to a little girl named Ana, who said she’d like to be a Pediatrician one day. Then I was lucky enough to have the pleasure of sowing up a 3 year olds gaping forehead. He was hit lightly by a motorcycle and came in with a pretty big gash on his forehead…so fun to stitch him up while he screamed “me mato” (literally I am killing myself) over and over. Anyway, at least I got to use my doctor skills.

Then I sat in a 3.5 hour staff meeting. I will never complain about another PCC meeting…I mean this was so long and at such an awful time, 5pm – 8:30pm. I’ll have to say that since the head honcho was there they talked about every single thing under the sun and they’ve got a lot of management issues…it was painful, but interesting. I really think they could use a fulltime management person, that is at the center all the time just to deal with all the management issues so the staff can really focus on taking care of patients. Anyway, tomorrow is a big community meeting…so should be interesting.

Julcan, Attempt #2

2/16/09

So, I came back to Julcan today to give it a second chance. I took the bus back and the road was amazingly smooth…what a difference no rain makes. I got back and for a while could not find Rolando, the midwife who was going to help me make my schedule for the next few weeks. I roamed the center for a while and had a nice talk with the psychologist. She’s been in Julcan for about 4 months now and she says she’s focusing on domestic violence. She says there is a high prevalence of both emotional and physical abuse. I then went and hung out with two of the midwives for a while and they explained to me the whole system of care for a pregnant women.

Decreasing maternal mortality is a priority in the region of La Libertad (La Libertad has the highest maternal mortality in all of Peru), therefore the care of the pregnant woman has been a big focus of the health center. Julcan is divided into sectors and each sector has a team that is responsible for that sector. The team consists of (in theory): a doctor, a midwife, a nurse, and a medical assistant. The sectors don’t affect prenatal care all that much, but at least there is one midwife assigned to each sector, although it seems like they all cover for each other. Pregnant women are supposed to get seen as soon as possible in the center…they don’t want them to have to wait, b/c they say that otherwise they’ll leave. The care is not dissimilar to what we do in the states and at PCC. Each pregnant woman has to see the doctor, the midwife, the nutritionist, the psychologist, and the dentist. She gets a prenatal panel done twice and she gets two ultrasounds (I’d say this is truly different than in most MINSA health centers). They also get home visits on a weekly basis from 36 – 40 weeks. Lastly they also are encouraging family planning in all girls 15 – 49. The methods available are the pill, the IUD, Depo, or condoms.

I did finally get to meet with Rolando and we made a plan. I’m going to try and visit all the pregnant women in Julcan city proper…which is about 40. And we made a very extensive list of things for me to cover…from prenatal care issues, to post partum, newborn care, diarrhea, URIs, and nutrition. It’s a pretty ambitious goal to cover all that stuff, but we’re gonna give it a go and see what happens. Tomorrow I need to really get the nutrition stuff down. It would be nice to see if what we were going to do made some kind of difference. We’ll have to keep really good track and maybe we can come up with something to follow.

Oh, and in other news…we are currently doctorless, well, besides me. Dr. Paola did finally leave, the new doc has a vacation day, and the other doc that was working here just never came back from his vacation. They have called a doc to come in from one of the other health posts, but that leaves that health post all by itself. It’s a no win situation…anyway, so I’m it for any emergencies…although I doubt they’ll call me...I still don’t think they fully trust me in that sense. OK that’s all.

The Road to Julcan

It's been a bit of a bumpy ride, both literally and figuratively, to get to my next stop on my Peruvian travels, Julcan. Julcan is a district in the northern highlands of Peru. In order to get to Julcan you have to first get to Trujillo, the capital city of the province of La Libertad. My mom decided to join me for the first part of this trip because she wanted to see one of the places I would be working. We arrived in Trujillo and were supposed to be met by my Peruvian hosts, but weren't. So we jumped in a cab and headed to a hotel in the Plaza de Armas. Trujillos Plaza de Armas is beautiful, it is an old colonial town that has kept it's charm. We did eventually meet up with our hosts and made plans to leave the next day for Julcan. But it was not meant to be...the car broke down and so I had another relaxing day in Trujillo. Finally on Tuesday we were able to leave for Julcan.

Julcan is about 3 hours outside of Trujillo in the mountains. The first hour is a decent paved road. The last two hours are a bumpy and sometimes a bit scary dirt road. The road is particularly rough right now because it is the rainy season and much of the road turns into huge muddy craters. I was thrilled to arrive in Julcan, but it is a drastic contrast to Trujillo.

It is winter right now in Julcan...which means cold weather and rain. There is no heat so it is really pretty cold in all of the buildings. I'll have to admit it took me a day or two to adjust to the complete change in weather and scenery. When the sun comes out, Julcan is beautiful. It's in the mountains and it's incredibly green...but much of the time it's cold and rainy.

Besides the fact that I was adjusting to a whole new climate my first week at work was less than ideal. The doctor with whom I had been coordinating my stay here, left Julcan for meetings in another city and no one in the center was sure what to do with me or what my purpose was in Julcan. I decided to make my own schedule and spent some time doing rounds, seeing patients that came to the clinic, spending some time with the nurses, midwives, and nutritionists....just to start getting a feel for what the work was like. By the end of the week though I decided I needed to meet with the Jefe to see if we could come up with some more constructive experience, because this was not the best use of my time and I wasn't getting a sense of how we would be able to help them in the future. After a frustrating meeting, I decided to come down to Trujillo, talk to a few of the nurses that were down here for a capacitacion (training) and decide how to proceed.

While here, I met with Rolando, a midwife and Flor, the nurse in charge of community education. They were great. I explained why I had come and they explained better the work they do and we came up with a plan for the next three weeks. We also decided that it would be best if Rolando was the main contact as he has more time and is more available that Dr. Henry. So, I head back to Julcan tomorrow and am hoping for a fresh new start. There is NO internet in Julcan, so when I get back I'll have to play catch up on the blog.

Puno & La Virgen de la Candelaria

I spent this past weekend in Puno for the festival de la Virgen de la Candelaria. Puno is a town of about 200,000 located in the southern highlands of Peru. It is most famous for Lake Titicaca, the highest navigable lake in the world. It's at about 12,000 feet - that's higher than Cusco. It is also known as the folkloric capital of Peru. I've been to Puno before, but this time we went because their festival is supposed to be amazing and it did not disappoint.

The Virgen de la Candelaria is the patron saint of Puno and her festival combines both catholic and Andean traditions. She is associated with the purity, fertility, Pachamama (mother earth) and mining. The festival lasts for 2 full weeks, but we just went for the first weekend. The first weekend there are two main events: the competition of folk dances and the procession of the Virgin.

We went to see the competition and it was great. There were 81 teams competing from towns all over the province of Peru. They wear these bright costumes and play their instruments and dance all in sync. Apparently towns, save all year to be able to come to the festival and compete. After they are done dancing, they dance their way to the Plaza de Armas until they get to the church where the Virgen is hanging out. I think I liked the street dancing even better than the formal competition. The only negative part of the day was when we went to sit down at the competition they didn't want to let us into the tourist section b/c we didn't look like tourists. Basically we didn't have blonde hair. I had to show my drivers license to get in...but what annoyed me more was that everyone in the section paid the same price, so even if I got in, it didn't make any sense that other Peruvians couldn't get in when they had paid the same price as I did. Alas, racism is alive & well in Peru.

The next day we had an excellent city tour. But the main attraction was the procession of the Virgen. Before the procession different groups decorate the streets surrounding the cathedral with designs that are filled in with flowers. I'm not describing it well, but it's super cool. I went in to the church to get a close up look at the Virgen and she's beautiful. They take really good care of her. The procession was preceded by a small ceremony in front of the church that involved blessing the virgin, offering her gifts, and a dance by men dressed in devil costumes. Then they processed. I've never been to a procession like this before and I thought it was really neat to be part of a towns tradition. That was the extent of our festival experience. This weekend is the end of the festival and it's supposed to be huge party....I'll have to make it down for that next time.

The rest of our time was spent seeing beautiful Lake Titicaca, the floating Uros Islands, the island of Taquile and the Sillustani ruins. It's all just so beautiful.

Images from Santa

Goodbye celebration with the whole gang.

On a walk through the rain forest with friends.
Bringing our snake bite patient from Rumi Tumi to Santa.
Learning to tell the difference between Malaria Falciparum and M. Vivax.
On the way back from the discoteca, only to find out that there was a repeat C-section waiting for us at the center.
The town motor broke, so there was no electricity for 2 days in a row, but that didn't stop us from going out.

A Conversation with Father Jack

I had a chance to sit down with Father Jack once he came back from his trip to ask him a little bit about what he'd like to see for Santa Clotilde in the future and I'm going to try and sum it up...

• He'd like someone to take over as medical director. He's 65 and has a heart condition, he's ready to hand over the reins, but hasn't had any takers. The Peruvian doctors tend to stay for a few years and then move on.
• He'd like to develop a relationship with a bigger institution to get some more outside funding. He has been too busy running the place to tell people about Santa and fundraise. But they could use the money.
• He'd love to dedicate some more time to prevention. They provide great medical care at Santa, but they barely skim the surface of dealing with the underlying causes of some of the most common things they see. People need clean water, latrines, better nutrition. And he'd like to be able to send more people out to the surrounding communities.
  

So, any takers?

Hunger

So hunger is pretty much a steady state in Santa Clotilde. I had regular lunches, the ability to go out and buy food every day and still felt pretty hungry most of the time I was in Santa. What I experienced is nothing compared to what the people of Santa experience everyday.

One day after lunch, I asked what people in Santa and the surrounding communities ate normally. I could guess from what I got served that it involved a lot of bananas and yuca. The answer was, that most people were lucky if they ate one full meal a day. They mostly sustained themselves on a diet of Mazato, a local drink that is made of yuca that is mashed and then chewed and spit out and fermented. I have a really hard time thinking about drinking anything that involves something that someone spit out, but in Santa and on the Napo it is a staple. They say that they'll drink this for breakfast and take it with them to their farms and drink it continuously throughout the day to feel full. Then when they come home in the afternoon lunch is either some other form of yuca, or a form of banana and maybe rice or fish (depending on the season). Not a whole lot of protein in the diet. Yuca is a starch and banana is a banana. Buying food in the markets was more expensive than you'd think, b/c of the costs of transporting things all the way to Santa.

I started asking people if they ate well and they always said yes, but if you asked them if they felt they had enough to eat, most people would say no. There is a supplemental nutrition program provided by the government to families with children under the age of 3 and to pregnant women, but includes only a couple of bags of rice, some oil, sugar, and few cans of milk. Not much to make a dent in improving the nutrition of these families. This problem is much bigger than anything we can fix on a clinic visit.

The ones you can't save

I had mentioned in an earlier blog that we had an 8 month old come in for pneumonia and chronic malnutrition. So the first photo is of Roberto, when he came in, weighing 4.2 kilos, lethargic, dehydrated, but at the time with no fever or respiratory symptoms. We went ahead and treated him for a possible pneumonia and sepsis with heavy duty antibiotics (Ceftriaxone). He had a rough time at first, but then progressively got better.








And after a little more than a week, he looked good enough to go home, eating well and had gained a couple pounds.

So we were all surprised when he returned to the center 3 days after his discharge with fever, diarrhea, and this time really junky sounding lungs. Well, now we were flat out of Ceftriaxone, so we put him on what we thought were the best combination we had, but this time it didn't work, he just got worse and worse and 3 days after he came in he died. I'm not used to seeing kids die and this was particularly hard, b/c I had seen him get better and we don't know what happened. This is the second child this mother had lost to a severe pneumonia.

The other patient we lost died right after I left Santa. Her name was Rosa, she was a 35 year old woman who had become paralyzed from the waste down after a tree had fallen on her during a storm. She was doing ok until she got pregnant and then during her pregnancy developed awful bed sores (stage 4 decubitus ulcers). The family took her to their local health post when her sores were very bad and they sent her to Santa. When she arrived it was clear that her sores were severe, her nutritional status was poor and Rosa was severely depressed. She too suffered from our shortage of ceftriaxone. She had some good days, but ultimately, I think Rosa became septic and didn't have the reserve to be able to fight the infection.

These patients, stay with you, always wondering what you could've done differently, how much difference would it have made to have more technology, more medicines, no way to know.

Catching Up

So I pretty much took a break from writing in the blog during my last week in Santa. Now I'm in Puno for the festival de la Candelaria and while I'm resting to adjust to the altitude thought I'd catch up on this blog.

So my last week in Santa was jam packed with a busy call, a trip out to a distant community to pick up a patient, lots of interesting discussions, dancing, and the sad loss of a patient. So where to start....

My last call was filled with three semi-emergencies, but thankfully they all happened before 11pm. The first was a 3 year old girl that took a 3 meter (just over 9 feet!) fall right onto her head and per her mom had lost consciousness for a few minutes. Luckily they brought her right in and she was awake and screaming...and it was a good sign that every time I came near her she tried to push me away with both her arms and legs. There wasn't a whole lot to do, except observe. I checked her complete blood count....mostly to have a baseline in case later she showed signs of internal bleeding. After a few hours and some ibuprofen she was much calmer and was able to go home the next day.

The next patient that rolled in for me was, Cristian, a 14 year old boy who had a generalized seizure while working out in the country with some family and friends. One of the medical assistants who works at the center had been out there with him and she witnessed the seizure. She told us that it lasted almost 20 minutes and she was really afraid he was going to die. He'd never had a seizure before, so it was particularly scary for his family. When he arrived at the center he was post-ictal (the sleepiness that comes after a seizure), but he was able to answer my questions and move all his extremities. My main goal for him was to prevent him having any more seizures. Finding the cause for the seizures would be much more difficult. Thankfully the clinic has dilantin, but there are no automatic IV pumps, so with the help of one of the Peruvian docs we figured out how to dilute the loading doses and how fast to run them. I definitely want to get better at figuring out dilutions of medicines, preparing IV fluids, etc. It's crucial here. Anyway, I made my nice list of possible causes for his seizure and that was pretty much the extent of his work up. We ruled out meningeal malaria, he didn't have any signs/symptoms of infection, and his CBC looked good. There is no CT scanner or EEG and no one could say that he would definitely get either of these if he went to Iquitos. He also had a heart murmur which may or may not fit into the whole picture. Anyway, he didn't seize anymore and we sent him home the next day on oral dilantin. His family was going to see about going to Iquitos to see a neurologist.

The last emergency patient I had come in was a man in his 60's who was brought in lethargic and semi-responsive. His family had brought him by canoe to Santa from a village 4 hours away. I hated the thought of that man being on a canoe in that condition. When he arrived he was too weak to move himself from the stretcher to the bed and he was semi-responsive to my questions. We found out that he had had pretty bad diarrhea for about 5 days and then as it was settling down he decided to take a "natural purging solution" to cleanse out his system. Not a good idea! So then he started to vomit everything and couldn't stop. Thankfully his family brought him in, b/c 5 days of steady fluid loss is bad. Anyway, all we did for him was hydrate him and give him some anti-nausea medicine and it worked. And told him to never take another purging solution ever!! He was able to go home the next day as well.

So that's it my last call!

Just some random thoughts

Father Jack comes back from his vacation today so Iĺl be back to sharing computers with everyone else and probably won't be writing as frequently in the blog. We had two beautiful, incredibly hot sunny days followed by the best thunder and lightning storm I've ever seen. The sky was this amazing orange-yellow. Now we are back to our usual cloudy humid days.

Last Friday, there was a staff meeting and they discussed the difficulty they are having collecting statistics from all their health posts on the Rio Napo. MINSA requires each health center to turn in monthly statistics on the patients they've seen, especially about malaria cases, TB cases, vaccines, and for their nutrition program. The workers at the health post don't see the value in the information and the forms are time consuming. I'm sure the data collection is tedious, but it's so important from a public health standpoint. To know what's going on to be able to deal with it effectively. And on a much more practical level it can affect the amount of money, medicine, or employees that get put towards a certain disease or area. But the reality is no one likes to do paperwork. There was no clear solution they came up with, but to discuss it again once Fr. Jack returned.

I'm on call again tonight. My little boy with chronic malnutrition and pneumonia gave us a bit of a scare last night, droping his oxygen levels down into the 80's but he's doing better today. Hoping to get some rest so I can watch some of the Obama inauguration online tomorrow. Yay!

A few more patients

As I was on my way out for a walk along the river I decided to stop by and see what was going in the hospital. Jorge was on call and a 15 year old had just arrived who had been shot in the foot by a animal trap! It's some kind of contraption that is rigged to a bb-gun and he had accidentally walked into the trap. There was a small chunk of the right side of his foot missing, you could clearly see a few of his tendons, but bone wasn't immediately visible. I put on a pair of gloves and started to help Jorge. Once we were sure he was stable we decided to irrigate the wound and take a good luck. As you can imagine, it was pretty painful, so Jorge decided to sedate the kid with Ketamine, the wonder drug. While he did that the nurse and I cleaned the wound to try and get a better idea of what had been damaged and to control the bleeding. Once we did that we put a pressure dressing on his leg and started working at setting up a transfer to Iquitos. The wound continued to bleed so about an hour later, we took him back to the OR and Jorge ligated one of the veins that was bleeding and was able to find one of the bb pellets. He continued to ooze, but there was nothing else we could find to ligate. So we dressed the wound again and hoped for the best. He left for Iquitos the next morning with one of the nurses and there they were able to do an xray and said his foot is full of bb-pellets. They were planning on taking him to the OR to see what they could do.

We have two other patients in the hospital I wanted to make sure and mention. One is Holbert, a 11 year old boy with aplastic anemia. Aplastic anemia is a pretty serious condition where your bone marrow doesn't produce enough of the blood cells you need. It can be life threatening. He was diagnosed a few years ago and was on immunosuppressive therapy for a year and did well for a while, but then relapsed this year and has been at the hospital for the last four months getting occasional blood transfusions and antibiotics. He is from a community that is far from Santa Clotilde so it is safer for him to stay at the hospital than to go home. He is in need of a bone marrow transplant and so he waits with us.

On Thursday afternoon, in clinic, a mother brought her 8 month old son because of a fever and cough for 3 days. When I looked at him I had to double check the date of birth, because he looked like a 3 month old, weighing only 4.2kilos (9lbs). I have delivered babies in the states that weigh 9lbs! The mother told me that for 3 days he had had fever, cough, some vomiting, and diarrhea. She said that he had stopped breastfeeding at 5 months and she was supposed to be getting milk from the nutrition program at the health center, but hadn't received it steadily and the child ate very little other food. She has 5 other living children, one child died at the age of 6 months from pneumonia. She is a single mother and her only income is from what she raises on her chacra. As I examined the child he was truly lethargic (something you rarely see in the states) and had all the classic signs of severe dehydration and an awful fungal rash that had gotten super infected. It broke my heart. This mom clearly cares for her child, but she just does not have the resources to take care of him well. I admitted him for IV hydration, antibiotics, and feeding. So far he's doing well and eating like a champ, not sure how long we'll keep him, but the nurses have already set up extra food supplies for the mom and baby.