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.