Signing Off

It is hard to believe that I’m here already, but I have reached the end of my journey in South America. I have got a few minutes now, so I am going to do my final blog entry and sign off after an incredible year.  I think the best way to approach this is to go through a few different subjects and address each one individually:

1.       The Status of the Mini-Clínica in Kacllaraccay

So, most importantly, the building is still upright.  On top of that, it is fully stocked and we have gotten everything that was promised to us by the alcalde of Maras back in May of 2012.  As I have talked about repeatedly through these past few months, getting the clinic fully furnished and ready to be used definitely wound up being one of my major focuses this year.  I am proud that I did not burn down the building (though our shoddy electricity did its best too) and that I was able to complete this goal.

With regards to the health promoter program, unfortunately we hit our snags with funding and are still trying to figure out a sustainable option for the future.  This was always going to be our biggest challenge, and is for every international effort.  As I have witnessed first-hand this year, money guaranteed by someone never comes as easily as the words they say.  Then, to further complicate the matter, with every change of the group, or person, in power the negotiation has to start over.   One of the main options we are looking into is creating a proposal for the Ministry of Health that we will submit in the fall before they create their budget for 2014.  We have had meetings with the Director of the Cuzco area and will continue to work with him in the future to try and figure out the best path forward.

Unfortunately, with regards to the actual person, everything hit a standstill in early May with the beginning of the harvest season.  Quite simply, no one has time to work on anything outside of that and cooking for their families.  So, we have not yet been able to figure out who will be Dina’s successor.  I’m confident that it will get arranged this summer with the arrival of the new students working in coordination with Justine.

Along those lines, the future is really exciting.  As I have mentioned previously, there are 2 Temple medical students coming for 6 weeks each to work at the mini-clínica and at the Centro de Salud in Maras this summer, there is also a social worker who has volunteered to come and work for an entire year in the Maras region, and we have an Emergency Medicine trained doctor doing his International Health Fellowship who will be focusing his work in the Maras region.  In other words, as sad as I am to leave, I know that there are many other, more capable, hands coming in to continue the work (or helping it Crescendo….sorry Liz and Justine, couldn’t help myself).

2.       The Status of the Centro de Salud in Maras

The future of the Centro de Salud, while certain in that it won’t be disappearing anytime soon, is very much uncertain.  For much of the Spring it has been operating with 2.5 of the 4 doctors it is supposed to have.  Unfortunately, at the end of April, Doctor Edú stopped working there, leaving only Dr. Victor and myself.  With my exit, they were down another 0.5 doctors, and to make matters more complicated, Dr. Victor (who also happens to be the director of the whole clinic) is leaving in mid-June to do a surgical residency in Lima.  In other words, they will be without their director and without any doctors come the end of June if they cannot find new docs.  I’m assuming this is one of those problems that won’t get solved until the second week of June when someone above Dr. Victor finally realizes that he is serious about how understaffed they are, but it is too bad because some of my best memories and experiences from the past year happened at that health post.

Aside from this future conflict, there were 2 patients that really stood out in my last few weeks of working at the Health Post in Maras.  The first one was a 38 year old man who came in with the worst case of cellulitis (that was probably osteomyelitis – bone infection) that I have ever seen.  Besides the actual look of the leg (scroll all the way to the very bottom of the post) and the smell, the reason that this case stood out to me is the debate about vaccines.  The cause of this gentlemen’s skin/bone infection was a slight stumble 2 years prior.  Now, normally, a small fall should not cause a tibia or fibula to break in a young healthy man, however, he had polio (never received his vaccines) so the trauma of a small fall caused his tibia to break.  This break was then inadequately treated and subsequently got infected.  The terrible thing is that, the infection was so deeply entrenched that if a 1 week course of IV antibiotics does not eradicate it (with the national healthcare program, more than 1 week of hospitalization is not covered), he will need to get his leg amputated.  Normally, cases of osteomyelitis can require weeks to months of IV antibiotics (and more powerful antibiotics that we had at Maras) to treat.  So, because this poor man never received his vaccines when he was younger, he is on track to have his leg amputated in his late thirties, which will severely limit his future productivity.

The second patient that I will not forget was a 3 year old that fell off of the back of a motorcycle and hit his head (no, he was not wearing a helmet).  Besides the fact that the driver rode off and there was lots to deal with legally with the police, the economics of medicine became a focal point for me with this case.  Fortunately enough, this child only had a few scrapes on his face and did not require any stitches nor were we very concerned about any bone breaks.  That being said, in the US, he would have gotten a CT scan pretty immediately to rule out the potential of a brain bleed.  The Centro de Salud does not have a CT scanner and we wanted him to get one because of how devastating the bleed could be if not discovered early on.  There was one problem: the health post does not have an ambulance to transfer the child to Cuzco to get a scan, therefore the family had to pay the $60 soles ($24 USD) to get their kid to the scanner.  In the US, this is not even a question up for debate, the scan happens before the family can debate the cost.  However, in Peru, the family spent close to 2 hours acting like they were debating the issue, when in reality they did not have the money and could not afford to pay for the taxi (let alone the consult fee or the cost of the scan itself), before we found someone to bring their child to Cuzco at a cheaper fare.  Ultimately, though, that whole process of having to watch a family seriously debate a test that was necessary was very hard to watch.  It was a discussion and dilemma that simply never presents itself in the United States healthcare system.

3.       Final Status of the Campeonato de Kacllaraccay

CHAMPIONS!!!!! Enough said.  In an epic battle that went into overtime, we finally won 9-8.  It was a struggle until the end, and after giving up 4 goals almost immediately, we were able to overcome and take the lead for the first time with only a few minutes left in overtime.  I actually scored 5 goals including the go-ahead goal in overtime (2 headers and 3 one touches), but I’m still useless if I actually have to dribble or do anything that requires finesse with a soccer ball.  It was a great game and really fun tournament to have created and participated in before leaving.

The Champions!

With Familia Ayma, 2nd place finishers

This is another effort that I think we will continue to work with in the future.  Promoting sport and a healthy lifestyle in the town, while also giving everyone a diversion away from the fields that brings the town together.

4.       Questions

Throughout the course of this past year, there have been many moments where doubt found its way out from the recesses of my mind and made itself known loud and clear:

    Professionally – What should I do when a patient does not want to take themselves, or their child, to see a doctor in Maras or even to the mini-clínica in Kacllaraccay?  At what point do we have a professional responsibility to step in versus standing back and expecting people to take charge of their own health care?

    Culturally – For me, this really centered around one thing:  chicha, the home fermented corn alcohol (that should be around 4-5% alcohol, but is occasionally spiked with other alcohols – rubbing/grain – to make it more potent).  What is our role as physicians when you see 5 year olds already trained to bring 10L jugs of this fermented corn alcohol out to their fathers in the fields?  Or when you see 8 year olds splitting a cup with their mothers on a Sunday afternoon?  Or when a mother tells you that she used it as a treatment for her sick 6 month old?  It is alcohol.  But at the same time it is ingrained so thoroughly in their culture; who are we to step in after hundreds of years of tradition and try to change their custom?

    Politically – Can we get frustrated with the alcalde and try to prove a point by withdrawing aid when he so clearly reneges on contracts and is clearly not thinking about the future of his rural constituency?  Would withdrawing our support prove a point or just isolate Kacllaraccay and alienate any future groups from working with the mayor and the municipality?  How do you work with someone who says one thing and then does something else, especially when that person holds all the cards?

5.       Overall Notes

At Maras:

• Ecogrofias (ultrasounds) cure everything
• If the ultrasound doesn’t work, an injection ALWAYS works – I still love that one day when I was speaking with a few people from Maras about how people kept asking for injections at Kacllaraccay,one of the techs seriously offered the option of sending me up with 2cc bottles of saline.  He definitely did not shy away from knowingly using the placebo effect.
• Aggressive/Angry birth coaching does NOT work……….EVER.
• Unlike the US, we had plenty of shifts without an actual doctor present.  When there was not an MD, it became “medicine by committee,” as I liked to call it.  Everyone pitched in and did as much as they knew.  This is a necessity at the Centro de Salud, seeing as in my 7 months there, I have witnessed an entire turnover of the physician staff, as well as 2 mid-wives and 3 nurses.  It is a constant cycling.

At Kacllaraccay:

• Developing a relationship with the town is extremely important and cannot be rushed.  They need to trust you before they will really begin to trust any work you are doing.
• In rural villages, you need to adapt to when you are free to see patients. I saw the bulk of my patients between 5:30-6:30a and 6-7p as they were on their way out to, or back from, the fields.  It would not have mattered if my “office hours” were 8-10a.  They were only free in the early mornings or late afternoon.
• Preventative Medicine is the most difficult kind.  It was really difficult to get people to come for vaccines and well-checks when they were healthy (just like the US).

Starting a Clinic:

• It is really important to have a good idea of what services already exist in the area that you are going to work in.  Then, as opposed to imposing a system that you think will work, you start by working within these systems to establish a functional arrangement.  The name of the game is coordination and increasing participation in existing efforts, then afterwards you can work on implementing your own ideas.
• Money and sustainability are always the crux.
• All political agreements need multiple witnesses (from both sides) and need to have something signed ASAP to finalize the agreement.
• Patience! Expect twice the expected/agreed time frame and four times the time frame it would take to get done in the US
• When attending a meeting – always have a book/Kindle for the delay.
• Nothing gets done if you don’t badger people.
• It’s never as bad or hopeless as you think.
• It’s never too early, or too late, to step back and reassess your progress
• Be ready to experience one of the most incredible times of your life.  There will be so many unforgettable moments (here are a few of mine):
  • My first night in Maras getting invited to eat dinner with a local family celebrating a birthday
  • Delivering lots of babies
  • Increased autonomy – I’ll never forget what Dr. Edú told me on my first rounds after I reminded him that I was only a 4^th year medical student:  “Here in Perú, you’re a Doctor”
  • Challenges – pronouncing my first death
  • Successes – Affiliation Campaign
  • The Soccer Campeonato de Kacllaraccay
  • Finally getting the computer and leaving the mini-clínica fully stocked
  • Augostine’s Birthday (see pictures below)
  • Leaving and seeing the look on Mario’s face that I had made a really good friend and he was truly sad to see me leaving.

Personally:

• Living alone for 6 months is tough.  I have had a lot of moments of loneliness and challenges to deal with on my own.  I love traveling and this is my second really extended trip alone.  I think this phase of my life is done.  Future trips will be shorter, or with loved ones.
• Patience and Persistence are the name of the game.
• Language barriers are hard – it was difficult negotiating with the municipio in Spanish, which I’m now pretty fluent in.  However, trying to explain our programs or treat patients in Kacllaraccay, where only 30-40% speak Spanish (everyone’s first language is Quechua) was a whole different battle.

6.       Things I cannot wait for in the US and things I’ll miss from Peru

Can’t Wait for:

• ICE – this is always the top of my list when traveling.  I love ice.
• Not tucking my pants into my socks and my shirt into my pants when sleeping to prevent bug bites
• Electric toothbrush
• Tex Mex….Mmmmm
• Being able to exercise again.  Especially after the rainy season, it always felt wrong to shower after a run when there were families without enough water….so I stopped when I was out in Kacllaraccay
• Daily showers….no, scratch that.  Daily, HOT, showers
• No more sleeping bag

Going to Miss:

• “Joe time” being early.  My family and friends can attest to “Joe time,” or showing up around 30-60 minutes late.  In South America, however, that always meant I was 30-60 minutes early.
• Waking up and immediately thinking in Spanish
• Maras Dress Code:

(New Zealand All Blacks jersey under the white coat with my red, Bolivian house slippers)

• Seeing patients I had just treated in clinic walking around town the next day
• The stars….They were incredible at night on the porch of the mini-clínica.  Brushing my teeth and staring at the stars was always one of my favorite times of the day
• Running.  The sites were incredible – the mountains, the sunsets, dodging bulls/donkeys while running, and the walk back to the Centro de Salud after a run – seeing little brothers holding up a homemade tetherball pole so his sisters could play every night.  I loved it.
• Lack of BS from patients – everyone here was just glad to receive care.  There was no threat of an impending law suit.

7.       The Final Book Count – 22

Catching Fire, Suzanne Collins

Mockingjay, Suzanne Collins (I watched “the Hunger Games” on the plane over and reread these books after…..)

The Lost Throne, Chris Kuzneski

The Sign of the Cross, Chris Kuzneski

Dream Team: How Michael, Magic, Larry, Charles and the Greatest Team of All Time Conquered the World and Changed the Game of Basketball Forever, Jack McCallum

On the Road, Jack Kerouac

Atlas Shrugged, Ayn Rand

Cutting for Stone, Abraham  Verghese

The Hobbit, J.R.R. Tolkein

Zen and the Art of Motorcycle Maintenance: An Inquiry into Values, Robert M. Pirsig

A Game of Thrones, George R.R. Martin

A Clash of Kings, George R.R. Martin

A Storm of Swords, George R.R. Martin

A Feast for Crows, George R.R. Martin

A Dance with Dragons, George R.R. Martin

The Spirit Catches You, You Fall Down: A Hmong Child, Her American Doctors, and the Collisions of Two Cultures, Anne Fadiman

County: Life, Death and Politics at Chicago’s Public Hospital, David Ansell

The Old Man and the Sea, Ernest Hemingway

Killing Floor, Lee Child

Die Trying, Lee Child

Harry Potter y La Piedra Filosofal, J.K. Rowling

Harry Potter y La Camara Secreta, J.K. Rowling

8.       A few last Pictures

Making cotton balls one afternoon

Our massive role of gauze for making….

Yep! 4x4s.  Our other favorite afternoon Maras activity.

BBP – Building Bull Protection.  Look at each corner: there is a spikey plant nailed in.  This is to prevent bulls from scratching their heads/horns on the corners as they walk by.

El Chicon – the mountain on the other side of the Urubamba Valley in front of the mini-clinica in Kacllaraccay.  It was one of my favorite sites in runs both in Maras and in Kac and was the first/last thing  leaving/entering the clinic.

With my Peruvian mother – she made all my meals when I worked at the Centro de Salud in Maras.

The next group of shots are all from Augostine’s Birthday back on May 5th:

With my present – his new blue stunner shades

Making the Cuoys

Some more of the spread

1.1L bottle of beer in one hand, 24 oz cup of Chicha in the other….it was a real Peruvian party

Me with the boys

And then the dancing started

To close, I’m going to post a few more pictures from Machu Picchu, because it truly is one of the most amazing places in the world:

The ability of the Incans to fit their stones without mortar is just incredible

I also love how they would leave natural rocks to represent the mountains behind them.  It was homage to the mountain gods, or apus

The view down from Huayna Picchu

The view from the guard tower across the whole site, with Huayna Picchu in the distance

After emptying all of my plastic bins, clearing the desks/shelves and packing up all of my things, it was really bizarre locking the doors for the last time.  It was definitely one of those moments where I very literally felt the close of a period of my life.  At the same time, I am very excited to go home to my family, friends, and loved ones.  It was an amazing year, but it is time for me to be home.

To end, I want to thank my family and friends for all of their support throughout this year, thank the Crescendos Alliance for their guidance and for providing me the chance to help, as well extend a huge thank you to the GHI for allowing me the opportunity to pursue this dream of mine.

Currently listening to – CeeLo Green’s “The Lady Killer”

That does it.  As the Hawk says back in Chicago…. “He GONE!”

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(below is the picture of the leg…not for the squeemish…cough, cough Dad)

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Touristic Cuzco

Well after nearly 7  months apart, last week I was reunited with my family and our next-door neighbor for a great 10 day break from all the work out in Kacllaraccay and Maras.  And, amidst our travels, I finally got to see some of the great sights Cuzco has to offer (including Machu Picchu….I’d lived in the Sacred Valley for close to 6 months and still had not visited it!).

Seeing as I’m no Faulkner and cannot spend 2 pages describing a single grain of dust blowing across the plains, I think I’ll let the cameras do the talking.  So, here we go:

Our first evening we had a fantastic dinner at an Italian-Peruvian fusion restaurant called Inkantu.

The next day was an easy one to acclimate in Cuzco.  I think I’ve mentioned it before, but the Starbucks in the Plaza de Armas has one of the best views in the city:

After a nice cup of coffee (yep, it tastes the same down here), we spent some time chatting on the Starbucks porch and then a bit more in the Plaza.  Following the catch-up time, we visited the 2 cathedrals in the Plaza de Armas.  These are both worth seeing, though you cannot take pictures inside so I don’t have anymore to add.  I loved getting to see the painting of the last supper with cuoy as the main dish (the Incan artist also painted Francisco Pizarro as Judas).

For lunch we went to one of my favorite places in town – a sandwich shop named Juanitos.  The route there cruises through some of the narrow cobble-stoned streets of Cuzco:

On our way back down, my sister Kate and I just had to take the requisite llama shot:

That afternoon, we visited the Mercado de San Pedro before an evening performance of traditional Peruvian dance:

Along with fully prepped produce (and a few flies to boot), this market has some of the best fruit in Cuzco (mangos and pomegranates are just awesome…and really cheap – about $1.25/kg and $2.00/kg respectively).

The next afternoon we started our touristy tour through Cuzco and the surrounding areas.  One of the main things to know is that admission to a number of the sites in and around Cuzco is only possible with the boleto touristico (tourist ticket).  Side note: this ticket and admission to Machu Picchu are also the only 2 things that I’ve found in Cuzco that have discounts with an International Student card.  Here was our card at the end of the week:

One of the famous sites we spent a while at is called Saksayhuaman, it’s the largest, closest Incan ruin to Cusco and has some amazing architecture.  It didn’t matter how many times we saw it during the week, but the fact that the Incans were able to get such tightly fitting stones together without mortar still blows my mind:

This is one of the coolest figures in the ruin – there is actually a llama buried within the ruins.  If you look directly above where the path hits the rocks, you will see a trapezoidal rock – that is the llamas head.  Above is another trapezoid in the opposite direction (it’s ears), then it’s legs and body go below.

Family shot – this is to give perspective on the size of the rocks – my father is 6’8″ and I am 6’6″.  In other words, these rocks are HUGE!! The largest one at Saksayhuaman is reported to weigh nearly 120 tons.

After Saksayhuaman, we went to Qorikancha – the navel, or dead center, of the Incan empire.  Like many other Incan ruins, it was leveled and the site built over by the Spanish

Here is quite literally the center of the empire, inside the church that was built on the original site.

That night, after the long day of touring, we went to one of my favorite water holes in Cuzco – Ukukus and saw a local band perform:

From Cuzco, on our third day we made our way out to the Sacred Valley.  This first picture is taken from a look out point on the descent into Pisac, and shows the Urubamba (“Sacred”) Valley in the background:

Our first site that day was the ruins above Pisac, and other than the very Incan-style tiered land, it actually reminded me a lot of the houses in Braveheart:

Here’s another family shot at the top terrace in Pisac.

After visiting the ruins at Pisac, we went down nto the town itself.  The town is really well known for having one of the oldest and largest bread ovens in the Cuzco area as well as having a fantastically large market.

Two adorable girls in the market that Kate got a great shot of.

After a nice lunch, we continued on through Urubamba to another famous Incan site:  Ollantaytambo.  Geographically, the town lies at a really neat intersection of three different valleys.  An amazing thing about this site is the fact that all of the granite used in construction was actually harvested from a mountain peak on the other side of the Urubamba River.  To get the granite to the location, the Incans would harvest the granite, roll it down one side of the valley, then re-route the river during one dry season, move the rocks up to the river edge, then during the next dry season re-route it behind the rocks so they could finally bring the rocks up to the construction site! A neat bit of history regarding this site is that it is the location of the only battle against the Spanish that the Incans won.  Apparently, they flooded the valley so that the Spanish could not ride their horses up to the base of the structure and had to walk in their armor, then the Incans tumbled huge boulders down on top of them (they are still visible at the base of the structure).

That night we checked in to a new hotel in Urubamba and it wound up being our favorite.  It was nestled back up in the base of one of the valleys, a good 30 minutes off of the main road and was just wonderful.  It’s called the Sacred Dreams Lodge and you should definitely check it out if you visit the area.  The house on the right was just for the 5 of us.  It was amazing.

Our second day in the Sacred Valley was spent visiting Kacllaraccay (a town tour, seeing the mini-clinica, and giving out gifts to the kids that my family had brought), the Centro de Salud in Maras, Moray, and Salineras.

Here’s the whole group out in front of the mini-clinic

Here Kate got one of the best shots of the electric job – you can see the line dropping down from the pole and connecting to the mini-clinic.  Then it runs to that far building where we strung it under our neighbor’s eave and it plugs into a socket in his kitchen

With the man himself – Mario, our contact in the village.

Mom and Kate wanted to both meet some cuoys and see a kitchen – here you can see both.  This is Augostine’s kitchen from which I get lunch/dinner daily

The next series are when we started giving out the gifts that my family brought – we made little packets of 6 crayons with a toothbrush, along with glow bracelets, stuffed balls, and some animal shaped wash-clothes for the infants.

Linda also brought a small soccer ball that we gave to my little buddy Danielho.

Eventually we had to bring it to the school so we could figure out who all had gotten gifts and who had not.

After a great morning in Kacllaraccay, we went to see the Maras clinic.  My mom is a NICU nurse practitioner, so we got a shot of her with the one incubator in Maras:

We had another wonderful lunch – this time in Maras.  One of the highlights were the massive ears of Urubamba Valley corn (the kernels are so big that an entire ear is enough for a meal, especially when accompanied with cheese as is often done here):

After lunch we visited Moray – a recently discovered Incan ruin that is thought to have been a big science experiment.  Each of the levels experiences a different micro-climate and the Incans were thought to have used this set-up to figure out the best location for growing their crops (based on altitude, humidity and sun exposure).

And to finish a busy day off, we visited Salineras – the Incan salt mines.  They are fed from a spring that is supposed to have twice the salt content of the ocean, and each little plot is flooded, then dried out leaving approximately 7-10 cm of salt on the top to be harvested.  Each little plot is owned and maintained by a different family.

The next day was a travel day to Aguas Calientes.  Then we got to see it; the one-and-only, Machu Picchu.  It is most definitely one of those famous sites in the world that 100% lives up to the hype.  Absolutely breath-taking:

This is one of the cool examples of Incan architecture where they used a rock that is in the distance (just to the left of the roof peak) that mirrors the mountain in the far distance.

Then, midday, my Mom, sister and I went and did the Huayna Picchu Climb.  It was a challenge for all of us; first the climb to the top that required the three of us to work together and then once at the top Kate had to face her fear of heights to get back down.

Here we are mid-climb with Machu Picchu in the distance.

At the peak (got to love Kate’s forced, freaked-out smile)

Back at the bottom after the climb….Success!!!

And after our day in Machu Picchu we flew out to the Peruvian part of the Amazon via the town of Puerto Maldonado:

Dad relaxing in our little cabanas.  Unfortunately, in an effort to be eco-friendly, they shut down the electricity…aka no fans…from 4-6p, the hottest part of the day.  The resort was a neat set-up though; they did 3 excursions out in to the jungle daily.  One of the highlights was the trek to Lake Sandobal:

First we had a 3 km hike into boats through the jungle

A walking palm – those are new roots that allow the tree to move according to nutrients and sunlight over years

A spider monkey poking his head out to check us out

Our journey by boat to the Lake

Lake Sandobal

Monkeys in the trees

A giant river otter off in the distance playing.  They can grow up to 2m (approximately 6’6″!).  The lake is pretty remarkable in that there are otters, pirhanas, and anacondas all living in the same habitat….my Dad was a bit disappointed that we didn’t run into any 30 ft anacondas (Kate, not so much).

Another shot of Lake Sandobal

Woody the Woodpecker doing his thing

A Macaw parrot

The last morning before we left, we did an early morning excursion to see the Macaws eating clay pellets and also ran into this little guy – a sloth, cruising slowly through the trees:

And then, all of a sudden, it was time for everyone to leave, and I was getting off the plane as it touched down briefly in Cuzco before continuing on to Lima.  After tearful goodbyes, it was time to return to work and reflect on what a great adventure the Brown family had just had.  Truly unforgettable!

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Currently listening to – The Dream’s “1977”

A new favorite traveling phrase – “ABC Syndrome,” also known as “Another Bloody Cathedral Syndrome,” for when you’ve seen so many cathedrals that all the churches have started blurring together.

A new favorite Spanish phrase “cheberengue.” It’s the Spanish equivalent to throwing up the “hang-loose” sign with your hand (thumb and pinky out).

And one last picture to finish the entry – a sunset out on the Amazon River:

It’s hard to believe, but I’m rapidly approaching my flight home on the 26th of May.  For my last entry, I’m going to do a big year summary of the whole experience.  Until then!

Weeks in Review and Spotlight: Kacllaraccay

It has been a few weeks since the last entry and this one is long overdue.  Unfortunately because we’re using a USB with a limited amount of upload/download capability and I have been out in Kacllaraccay and Maras for the last 3 weeks, I haven’t been able to upload the pictures or a new entry.  Anyways, the short and sweet of it is this:  we finally got our exam bed and lamp as well as the computer and printer from Maras the first week of April.

Our Computer and Printer set up with the Municipio rep.

Our Exam Bed and Lamp

In other words – Mission ACCOMPLISHED!!!! The mini-clínica is now fully stocked and ready for action.  The one setback we had, well I had, was the second day of having the computer, I moved the monitor around and the power cord short circuited and gave me one of the stongest shocks I have ever had.  I don’t know if it qualified as a full-blown electrocution, but it was solid enough that I had a wicked headache for the rest of the day and did not get much done.  True to form in Peru, the solution was not at all something I would have thought of.  The following week an electrician from Maras came up to fix a socket that had become disconnected and while he was there, I asked him to take a look at the monitor.  Well, he figured out that it was the cord and not anything internal in the monitor, so what did we do?  We cut open the power cord, found where the electrical wire had become separated, shaved back the rubber coating, rewound the wire, taped it and when it was all reconnected….Voila! The monitor worked again!

During these past few weeks, I also set myself on the task of creating the Kacllaraccay map version 2.0.  I made my original based on a map from an old project in the Centro de Salud Maras, and then laminated it and mounted it by using a bit of thin PVC pipe on the top and bottom with a rope run through the top pipe slung over a nail.  It was a great starting point and allowed us to start our whole process of doing background health checks on the town.  The drawback with this map, however, is that it is not “interactive.”  So, with the new one, I mounted it on top of a piece of corkboard so that we can use pins with different colored spherical heads (I think they’re normally used when sewing to mark different stitches or areas or something like that) to mark the location of different types of patients – pregnant women, recently born children, follow-ups, or the old-fashioned sick patients.

The New Map

The Map Legend with different colored pins for different patient groups

The one really sad bit of news is that Dina can no longer work with us as a health promoter.  Unfortunately due to her work at Moray (a local Incan site) selling her hand-made products and with her elder daughter starting school in Urubamba she is finding that she is constantly in and out of Kacllaraccay and this is making her life so hectic that the extra responsibility of being the health promoter is too stressful for her.  It is very sad; but in the end, it’s better now than in a few months when the full on training has happened.  It is one of the things that has been hardest for me to stomach, but with the setbacks with the salaries and then having to constantly be in Maras to badger the municipality for the supplies originally agreed upon in our convenios (contracts) from May of 2012, I have not gotten to do as many of the capacitaciones (trainings) as I would have liked.  Fortunately, the clinic has 2 awesome medical students from Temple University (Lauren and Carlo) coming this summer for 6-8 weeks and they both have experience working with health promoters so they will get to do the bulk of the training.

That about brings us up to today, there have been a number of brief acute care visits at the mini-clínica, and I have spent the last week working at Maras.  There haven’t been many cases that really stood out to me so there’s not much to report.  However, Justine got in on Tuesday and we have had a lot of big things to work through as we transition her into being the primary contact in the region for Crescendos.

After Dina quit, I spent a few days reading articles from “Partners in Health” as well as a document Dr. Cartwright created for her health promoter program in Idaho – “Salud Para Todos” about the establishment of a health promoter program and think we’ll try a new for identifying our next promoter.  Last time, we had Mario and Gregorio make announcements over the town loudspeaker about having all those interested in the program come to the school for interviews.  This time, we are arranging to speak at the next town assembly in Kacllaraccay.  This way, we have more of the town’s captive attention, we can better explain the program – our expectations, the job, and the compensation – and we will have the town nominate 3-4 people whom we’ll interview and then choose from.  This will help to make the town feel more involved in the whole process and have a bigger investment in who is actually representing them as their health promoter.

That pretty well does it for now, but I realized the other day that I haven’t given a good summary/picture tour of Kacllaraccay…..so:

Spotlight:  Kacllaraccay

Nickname – California

Altitude – near 11,000 ft.

Located in Sacred Valley, opposite side to Urubamba/Ollantaytambo and Machu Picchu

Primarily Quechua speaking – everyone understands Spanish, though only around 30-40% speak it, generally the younger crowd

Around 1.5 hours from Cuzco

1 hour from Urubamba

20 minutes from Maras by car (around 11 km)

1.5-2 hour hike from Maras by foot path (around 8 km)

Wednesday and Friday there’s a camione (cattle car truck) that takes people down to Urubamba at around 7:30-8:00a and brings everyone back at 4:30-5p

The camione loading up to go to Urubamba

The 20^th of the month the garbage truck comes

         ***For the garbage truck, the camiones, or when someone comes through town selling fish or chicken, there is one method used to notify everyone – drive down all the streets honking repeatedly and/or banging metal on metal.  While annoying as all get out, I have to give it to them.  It works.

There are around 140 different houses in the community, though only 90 are occupied full time.  Many people live in Urubamba and return occasionally to manage their chacras

Houses are made out of mud bricks (adobe)

There are around 300 people in total living in the town

Public Spaces:

Primary School –

New Church –

Old Church –

          Losa Deportiva (concrete soccer field for futbolito – a tweaked version of soccer) –

The view from one end of the Losa across to the church

          Town Center = plaza between main intersection of roads, with church and losa deportiva.  A.k.a. chicha (fermented corn alcohol) bar on Mondays/Tuesdays when the truck drops off the heavenly Urubamban chicha.  Everyone swears it’s waaaaaay better (not so sure).  Apparently it’s just like beer – it’s all about the water

The town is primarily funded on farming.  Most of the town operates by trading their crops for food and chicha.  There is actually very little use of money in the town.  It is only used when going into Urubamba to supplement food or when buying other things for the house.

Farming – lima beans, potatoes, corn, trigo, oats, corn, oca, onion, just started with Quinoa last year

There is a curandero/paqo (traditional Incan healer)

No huesero (traditional bone setter)

Here are a number of shots from just walking through the town:

Augostine (our cook) walking down the street into town from the mini-clínica

A shot looking into the main square

Looking back out of town towards the mini-clínica from the main square

Headed into town away from the main square (if you look at the map above, this is if you took a Right at the main intersection)

Continuing along that path

There are lots of little mini-front room stores to supplement income

Near the end of that main road

A shot into one of the houses

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Currently listening to – Phoenix – Bankrupt!

and Kendrick Lamar’s – “Good Kid, M.A.A.D. City”

(no White Sox hat updates in a while because I’ve been here so long that I’m seeing the same hats repeatedly.  The great thing about the hats here is that they’re customized with flames on the bills and all sorts of other images….I’d say that that’s totally different from the hats in the US, but as my Dad has told me repeatedly – “White Sox hats should be black with the white logo on it, not all of those crazy colors and designs you’ve bought.” So I guess they’re not that different from the states)

Soccer update – We’re 1-1 in the last 2 weeks:

Lost our first game 5-3; it was raining and the mud definitely threw us off our game more than the other team.  I did score my first goal in a soccer game since I was 13.  To be honest though – we’re playing futbolito, it’s on a smaller concrete field with different rules.  One of them is that on a corner you do a throw in (because the field is so small). This rule directly aids us seeing as I’m about a foot-foot and a half taller than everyone; so perfect for headers for me.  And best of all, it doesn’t require me trying to use my feet.

Won our game this last week 5-4.  I scored 3 goals in this game! (and only 1 off of a corner).  The other 2 goals were all 1-touch redirections because I still have zero skills with ball control.  We were up 5-1 and then the other team went on a rage in the 2^nd half that we barely held off.  Pretty awesome end to the game though – a guy on the other team got pissed that they didn’t score a 5^th goal and threw a punch at our goalie (Gregorio), and then it was like old-school schoolyard rules.  We watched as they each got in like 4-5 good punches and busted a lip/nose and then we broke it up.  Apparently futbolito operates on hockey rules…..I like it.

Here’s a closing picture of one of my favorite little guys in town – Danielho saying good-bye for now:

A Dark Day into a Bright Night

To fully understand my day, I need to rewind a bit and talk about a patient who was hospitalized at the Centro de Salud in Maras back in mid-February.  She is an 87 year-old female and had one of the worst cases of COPD (Chronic Obstructive Pulmonary Disease), or EPOC (Enfermedad Pulmonar Obstructiva Cronicá), I have ever witnessed.  Something very unique about the disease in Peru in contrast to the U.S. is the fact that it is not due to cigarette smoking as few people smoke here.  It is pretty well always caused by using leña, or wood, burning stoves in kitchens that do not have windows, chimneys, or sometimes even a smoke hole in the ceiling.  Accordingly, it is especially common in the women who cook for their families in these smoke-filled, poorly ventilated kitchens for most of their lifetime.

We learn all about the signs and symptoms of COPD in medical school and you definitely see a few cases while on the wards during medicine; however, this woman’s lungs sounded like the worst symphony I’ve ever heard.  Throughout inspiration and expiration there were wheezes and other noises, but what really stood out was the ever-present sound of bubbling fluid.  She sounded like her lungs were actively boiling water.  We kept her in the hospital for 6 days on IV antibiotics to treat any possible infections and nebulizer treatments to try and help her mobilize the fluids.  While she was slightly better by the time she left, Doña Francisca was by no means cured.

That was back in February, this past week after a slow Friday morning in clinic for “Dr. Brown,” (when there aren’t any docs at Maras I help out however I can, sometimes by running clinic) Francisca’s son came by just before lunch because his Mom was mal, or sick.  I went with one of the technicas to their house to do a home visit.  Apparently, since being discharged, Mrs. Francisca had gotten out of bed less and less frequently to the point that over the past few days she had not once gotten up.  Furthermore, she was no longer eating and it was making her children really concerned.  I wish I could say that both my memory and skills with a stethoscope were such that I could definitively say that she was “worse,” however, the truth is she just sounded terrible.  Her vital signs were stable and she was afebrile, but one thing that stood out to me was the fact that now you could hear her lungs bubbling even without auscultating, she was that full of fluid.  Unfortunately, a doctor was not scheduled to arrive until later that evening and because it was a weekend and there was limited staffing.  He would be the only MD on the premises for the whole weekend and only for the night.  I called Dr. Victor and he decided that the best plan would be to give her an injection of Penicillin, do a follow up check the next morning and probably admit her on Monday once the staffing would be better.

I explained the plan to her son, went back to clinic got the injection ready, and gave it to her.  That night was unremarkable and so was the next morning.  While I was grabbing breakfast, Doña Francisca apparently got a ride to the Centro de Salud and then was able to walk from the car to the topico or emergency room.  That was a promising sign to both the doctor who spoke with her and the tech who had seen her with me the day before.  They reaffirmed the decision that she did not need to get admitted and sent her back with paracetamol (Tylenol) in case any fever or pain presented and decided to follow up again early the following week.  Shortly after I returned from eating, the doctor left for the weekend and I was back to holding down the fort by myself.

A few hours went by and I enjoyed a lazy Saturday; reading in the sun in the courtyard of the clinic and playing with the technica’s 15 month old.  At about 12:15p, one of Ms. Francisca’s other sons came running up to the health post and said that we needed to come immediately.  The tech and I grabbed a few supplies and went.  When we showed up to their house, Doña Francisca was rigid as a board in a semi-fetal position lying under the covers.  That’s when the son explained that he had been sitting at the foot of the bed about 15 minutes ago when she had gasped a few times and then stopped breathing.  Upon auscultation, there was no heartbeat, there was no more bubbling, nor other sounds of respiration; she had no carotid or radial pulse, and her pupils were fixed and unreactive.  After waiting and repeating the exam 5 minutes later, I had to do something I have never done in my extremely short medical career:  declare a patient deceased.  Furthermore, I had to do it in Spanish.  When we told the son, he immediately started crying, then called a number of siblings.  I sent the tech back to the health post, and then sat with the son for the next 20 minutes.  He was initially very stricken with the grief of feeling like he did not do enough, so we spoke through the fact that there simply was not much he could have done differently, his mother’s lungs had just run their course.  He had brought her to the clinic that morning, he tried everything he could.  I tried to reinforce how important it was that he was with her through the end, but really, we sat together in silence for a lot of the time.  Eventually, we left to go to the clinic in order to arrange for the legal documents to get drawn up.

The next few hours are very hazy.  I cannot say that I was depressed because she had been struggling to breathe so much that in some ways her death was a relief.  Furthermore, I felt very happy for her to have passed calmly at home with her son (as opposed to something like struggling for life at the Centro de Salud while we did CPR).  However, it was very heavy to pronounce someone dead.  I did it.  I did not defer to a resident or an attending.  I myself did the exam and then told the son that his mother was no longer living.

No one else came to the clinic for the next 3-4 hours and I spent it out in the courtyard, not really reading, not really thinking, just sort of sitting there.  Then, the woman who does the laundry for the health post showed up and said that she had a dead man in her yard.  I was absolutely convinced that she was mistaken and speaking about Doña Francisca who lived across the street from her.  But, she was insistent, so the tech and I grabbed some supplies again and accompanied her back to her house.  This time, instead of walking in silence like we had to Doña Francisca’s, the woman explained how this man had come for lunch around noon, had some food and chicha (fermented corn alcohol) then laid down in her yard next to the bulls.  She didn’t think twice about him and then around 4p she realized he was still there so she went to check on him and found he was unresponsive.  She had waited another hour, but he still had not moved and now he wasn’t breathing, so she covered him with a tarp and came to get us.

When we got to her house, there was a body lying under a blanket and covered by a blue tarp right there next to the bulls as she said.  Upon lifting the tarp his mouth was agape and frozen, his eyes open and looking straight ahead, he wasn’t breathing, no pulse and no heart sounds.  TWO, in one day, after not a single death in my entire time in Peru, I could not believe it.

The man was a roaming alcoholic and we did not have a chart for him at the health post, so (according to the tech) we had to leave him for the police to collect and arrange for the autopsy and exam.  Either way, it was a bizarre walk back to the Centro de Salud, and I could feel myself gravitating towards the desire to use morbid humor to help deal with the strangeness of the day.  I had never truly understood the use of humor by physicians during grave situations, but after seeing a second death in 4 hours, I got it.  It is about self-preservation and trying to get your own mind back to center so that you can continue.  That does not make it acceptable, but it was odd to me as to how quickly my own mind tried to do something to get me back to normal even if it was not appropriate, like making light of a sad situation.

As we walked back to the health post, the tech put it best:  “¿Pero, que seas?  La vida es asi.”  (But, what can you do.  That’s life.)

The crazy thing about life is how short its memory is.  Within 5 minutes of walking back into the clinic, we had a woman present in active labor.  She was 19 year old and was already fully dilated to deliver her second child when she showed up.  Unfortunately, the mid-wife who was supposed to work that night was not due to arrive for another hour, so the tech and I took her straight into the delivery room.  Initially, the girl just cried.  She could not coordinate pushing with contractions and cried non-stop.  The tech immediately started with the normal barrage used by Peruvian delivery room nurses – telling her how if the baby died inside of her because she didn’t push right it would be her fault, or how if she didn’t start pushing correctly she would get sent to Cuzco for a C-section (not a desirable option).  Either way, after about 60-90 seconds of it, I couldn’t handle it anymore and asked her to be quiet.  We stopped everything and I just spoke with the woman.  We tried to figure out if something else was causing her pain or if she was worried about something, and even though we did not find the cause, when we started again it was much better.  I stayed at her side for another 2 minutes talking her through the contractions, and was about to move to deliver the baby when I noticed the tech had moved to grab something right as the baby was coming out, so I got to do an over-the-patient’s-knee delivery that I will (hopefully) never repeat in my career.  She delivered her placenta about 10 minutes later and by early evening we had her and her new son happily settled in the post-partum unit.

Ultimately, talk about an incredible swing in emotion.  After such a sad day to close the evening with such a successful delivery was truly wonderful.  I know that I will have days in my career where the swing will go the other direction, but that day, March 23^rd, 2013 will not be one easily forgotten.

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Currently listening to – Justin Timberlake’s “The 20/20 Experience”

Fun personal life news – I got a spot at Highland hospital in Oakland to do an Emergency Medicine rotation in August.

Don’t worry!  Here comes a picture (although only one this week):

The Peruvian Carbohydrate Special….That’s a bed of fries with rice and spaghetti on top, with a few slices of hot dog for good measure.

Thanks be, to the 501c3!!!

(the comma’s supposed to be there, put in the pause and it rhymes!)

Well, shortly after the last blog, I started getting e-mails asking if I was okay and whether I was going to stick it out in Kacllaraccay.  I can say that after quickly pricing out flights back to Chicago in a fit of frustration, I was able re-focus and I am still working down here in Peru.  There is no denying the fact that the last few weeks of February were my lowest since I left the States back in October and that I was extremely frustrated with the Municipality and what looked like a dismal future for our mini-clínica and health promoter program.

Thankfully, Elizabeth Cartwright and Diana Schow were coming down in early March and I had the Centro de Salud in Maras to fall back on.  So, after realizing that we were at a stand-still regarding the salaries of the health promoters, I moved back into Maras and worked there from the tail end of February through the first week of March.  It was a huge relief to actually get to see patients and do medical work again after weeks of sitting in the Municipality and trying to arrange the salaries and whatnot.  During my 10 days at Maras we had 5 births, a lot of fun clinic days and two insecticide poisonings (both attempted suicides).  Fortunately both patients survived and, all around, it was just plain nice to work in a medical capacity.  And seeing as I wanted to wait to speak with both Liz and Diana about proceeding with the salaries, it was nice to put that on the back burner for a bit.

While working at Maras I found that Dr. Victor had been having his own issues with the Municipality and funding.  They are supposed to be staffed with 4 medical doctors, 4 nurses, 3 mid-wives and a number of techs.  At least one of each of those positions is supposed to be funded directly by the municipality, however, the municipality offers such a low salary that everyone was leaving to go elsewhere, meaning Maras is currently operating with a staff of 2 doctors, 2 nurses and 2 mid-wives.  And, with most everyone also working in Cuzco as well, it just means that the shifts are super short-staffed…..insert medical student/”doctor” Brown to cover everything.  I was actually working with just a tech on one of the nights of the poisonings and was in charge of the treatment plan.  We injected Atropine every 2.5-5 minutes until her pupil’s finally dilated, meanwhile doing the gastric lavage with liters of water through a G-tube to induce vomiting to get rid of any residual insecticide.  In the end she received 22 amps of Atropine over an hour and a half and it took close to 7L of water before she was finally regurgitating clear fluid.  Pretty scary experience, but she came through okay and did not have any residual deficits the next morning.  Unfortunately, one of the other positions that is not funded adequately by the municipality is that of a psychologist, so follow up care will be sorely lacking for our patient.

By the time Diana and Liz got to Cuzco, I had had the 10 days to calm down and while still frustrated and unsure as to what we were going to do, I was no longer of the mind to call it quits.  We spent a few days in Cuzco talking through our options and that was when I got “the glorious news” from Liz.  Shortly before she had left, she got the letter from the IRS that the Crescendos Alliance got its official 501c3 status and we were officially a recognized non-for-profit organization.  What is most important about this is that we can accept donations and we already had interest.  Thus, we could use some of that money to cover the salary for one health promoter.  Seeing as we initially had 3 this could have been an issue, but Roxana had a big falling out with her mother and had moved to Urubamba in the last week of February and Gregorio had found that his duties as president of the community were not allowing him much time to work as a health promoter.   As a matter of luck, over the previous few months, I had found Dina to be the most well connected and effective of the three promotores anyways, so we were left our best option.  (It’s also nice that we have such a personal relationship with the town’s President and that he is still looking to help in whatever way he can.)

Thus, by the time we three (along with Diana’s husband Roger) made it back out to Kacllaraccay we were ready to fund our Promotora de Salud.  But before we met with her again, we spent a while reviewing the past few months to see if we needed to change our approach.  As part of that process, we met again with the Alcalde (mayor) of the Maras district and Dr. Victor Gutierrez at the Centro de Salud.  They both emphasized that their idea of the Health Promoter was someone who was more of a liaison between the community and health professionals, and someone who in case of an emergency could perform basic first aid.  Neither saw the role as someone who would be treating people and operating independently at times as i had initially been thinking.  So, we re-tooled our own ideas and have adapted Dina’s job-description.  Her job is now going include 2 office hours Monday, Wednesday, Thursday, and Friday during which the community can come to her if they have questions or need support.  A nurse from Maras also will come out on Tuesdays for a full day and together they will use that time to visit anyone who might have visited Dina during the week.  They will also follow up with any pregnant woman in the village, any woman who recently delivered (as well as the newborn), and any follow ups from visits at Maras.  Furthermore, they will check in with every kid under 5 and every woman over 65 once every 2 months as just a quick check.  Finally, we have arranged it with the primary school in town such that we will have an hour a week there to do a basic health training – like how to brush your teeth or hand hygiene – and to track heights/weights and make sure everyone is healthy.

Thus, Dina will become the vital connection between the village of Kacllaraccay and the nurse/health system in Maras.  We will also be training her in communication skills so that she can eventually become a link between the village and national programming available through the Ministry of Health – there already exist trainings on alcoholism and domestic violence, two issues that we have not started trying to address in the village.  Having the morning office hours will also be a perfect time in the upcoming weeks in which to do short trainings, or capacitaciones, on basic first aid and simple treatment options for diarrhea and other common conditions.

For the time with Diana and Liz, I had also arranged for a few meetings/events within the village.  Our first was the night of Sunday the 10^th.  The village is starting a training program centered on chickens and with micro-investments from the organization Kindness in a Box, close to 40 families will receive chickens.  Then, based on the returns from the eggs they will pay for the next round of chickens for 40 new families in the future.  On the evening of the 10^th was the meeting to sign up for the program, so we just hopped on to the end of it and spoke with all of the families.  Liz and I got to spend around 45 minutes re-introducing ourselves and the clinic, speaking about our goals for the clinic, asking about the town’s goals for the clinic, introducing Dina as our health promoter, and responding to any questions/concerns that families might have about the mini-clínica.  It was also our last chance to promote a big event I had been working with the Centro de Salud in Maras for the previous month – a Campaign of Affiliation with the free national health care system, which was scheduled for Monday the 11^th.  Other than not having lights for an evening meeting (thank goodness Liz had her headlamp on hand), the meeting went really well and the town was super excited for the Campaña.

Here we were in the dark for our meeting*

Knowing the speed of things in Peru, the morning of the 11^th, I hopped onto my motorcycle around 7:15a to try and get everyone in the Centro de Salud, mobilized for our “9:00a” start in Kacllaraccay.  As is normal, despite everyone’s schedule saying they are supposed to start at 8:00a, the first workers showed up at 8:15a.  We immediately went to the Municipality to get our pre-arranged van to take us up to Kacllaraccay (this time we even had a signed agreement with the Alcalde).  Well, the van wasn’t there, but we were told it would be back by around 9:00a and that it would come and pick us up at the health post.  So the technica and I went back to the health post to get our team ready to go.  By around 9:15a, most everyone was ready, but we still had no van, so I ran back to the Municipality and it turned out our Comvey was MIA.  After trying to call a number of times, I got fed up and hijacked a station wagon (the driver was a friend through the number of hours I’d spent waiting for meetings in the Municipio).  We went back to the health post, got everyone and we finally made it to Kacllaraccay at around 10:15a.

I can truly say that the next 5 hours were some of the best that I’ve had in Kacllaraccay.  Everyone was really thankful to get affiliated and it felt wonderful to know that through this simple act we were getting each person free access to medications and medical attention for as long as this government is in power (as long as you have a seguro, or this affiliation, you also get a free coffin, which is really helpful, but kind of morbid).  Most of the workers from the health post wanted to leave around 2:00p, but we still had a line of about 4 people that had waited since 10:00a, so I just refused to close my laptop or budge, and at around 3:00p we finally finished.  Our totals were really great – we got 61 people signed up out of a town of around 250-275 permanent residents (of whom maybe 25-30% previously had seguros).  Our team also consisted of the orthodontist, a few nurses, and a mid-wife, so while I worked with the woman who is in charge of the affiliations at Maras, they did a number of capacitaciones on dental hygiene, alcoholism, and birth control.  All around, it was a fantastic day.

Yours truly signing people up for their Seguros*

The mid-wife doing a talk on birth control*

Dr. Jhon doing a talk on Dental Hygiene*

Happy families with their forms to sign up (all you needed was your national ID card and last paid receipt for lights – as proof you live in Kacallaraccay)*

This Campaign was the first big act by the Crescendos Alliance through the mini-clinica in the village and it has definitely changed the town’s perception of us.  Since that day, when walking down the streets, people have been much happier to see us and chat and just hang out.  It has been really incredible.  Thus, after Monday, I was really feeling like we were back on track.  We had spoken with Dina and gotten her happy with our plan and future together; we had checked in with the Alcalde and have the nurse’s salary and mobilization agreed on (we have made new contracts to be signed and formalized shortly); and we have made some strong in-roads with the town.  So, I don’t feel like the floor is falling out from under me anymore.

Then, Thursday, just before Liz and I left to come into Cuzco for her flight back to the US, we started one of my other pet projects:  a soccer league.  There is already a concrete soccer field in the middle of the village, and most everyone in town loves soccer (it is South America after all), so it had been an idea of mine for some time to start a league for the town and invite teams from Maras and other villages if they were interested.  We are going to have 3 groups:  sub-15, 15-40, and over 40, and this past Thursday we had teams sign up and then had a free play for a number of hours.  It was super fun to get the town together and hanging out while first the kids and then the adults played games.  The buzz in town was palpable, people laughing and smiling and just hanging out together in the middle of town.  We are going to play every Thursday from now until I leave in early June and will have playoffs and a championship the last week of May.  I’m super excited about the reception so far – we have at least 4 teams signed up in every division and more are supposed to be coming next week for our first round of games.

The futbolistos!

 The futbolistas!

The town watching the games (as you can see, perfect time for a large, foaming glass of chicha)

Soccer goals not just for futbol

  

Some of the older kids/adults playing*

* *

*

The younger guys watching games

 

The women watching the games*

Me hanging out with the youngsters – soccer provides the perfect excuse to get everyone out of the fields and having fun for the afternoon*

More desportistos and our own Mario after the games*

All-in-all, I’m very happy with where we are now, and was taught the all-important lessons of perseverance and patience during these past few weeks.  We are in a much better place, with a brighter future in front of us.  What’s very hard to believe now is that with Dr. Justine Macneil’s return in mid-April, my main job will become one of transitioning her in.  We’ll work a few shifts at Maras so that she gets in tight with all of the workers there; we’ll need to spend some time in the Municipality so she’s well connected with all of the workers there; and then we’ll have to spend time with the nurse and Dina in the village so that the village becomes well acquainted with her.  It’s hard to believe, but before I know it, I will be getting on a plane and coming back to the US.  I’m sure it will be here quicker than I can think.

***Thanks to Elizabeth Cartwright for a number of the photos

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Currently listening to:  The Lone Bellow – “The Lone Bellow”

Currently reading – A Dance with Dragons by:  George R.R. Martin.  I can’t believe I’m almost done with the first 5 books.  I hope he goes ahead and hurries up with book 6, because I’m not patient enough.  (Though I am excited for what’s on deck – the Harry Potter series in Spanish. Thanks Kricket!)

Interesting occurrence in town the other day – I was walking to lunch at Augustine’s when I saw a group of 5 men walking into town, each with bloody arms and knives/machetes.  A few were cradling things in their arms like footballs, so I sped up to see what was going on and then I saw the front 2 holding either horn of the head of a bull.  I subsequently realized that it was the bull’s legs that were being cradled in the other men’s arms.  Apparently during this time of year, there is a plant with large yellow flowers that causes a bull’s stomach to swell to the point of exploding and can kill them.  It is an understood risk during this season so families try to be extra careful when their animals are grazing, but it is a devastating blow to their financial situation because a bull can have the value of 2,000-4,000 soles.  If a bull dies, however, the town is notified and whoever helps chop it up gets to keep some of the meat.  This was what I saw as they were coming into town and it is an example of ayni, a Quechua word that is means “reciprocal labor,” essentially, you work for me and I’ll work for you.

Final pictures of the day:

Max Roni…resident Johnny Cash (but what do I do with my hands???)

A drawing from one of the girls in town, and I still have those gangly legs!

T.I.P…….This Is Peru

Not stealing the rap mogul’s moniker for the title of this entry….I’m actually ripping a line from the movie “Blood Diamond” and tweaking it for my past 7-10 days.  [Spoiler alert, if you haven’t seen the movie and want to – it is really good if you have not – skip to the next paragraph].  In the movie, Leonardo DiCaprio plays a diamond smuggler and towards the end of the movie, he and a former partner/boss named ‘the Colonel,” (Arnold Vosloo) have a big shoot out over a massive diamond.  As the Colonel lies dying (because of course Leonardo wins, he’s so dreamy), he looks at Leo and says “T.I.A., eh Danny Boy.  T.I.A.….This is Africa.”

The basis of that sentiment; a feeling of limited resources and dog-eat-dog mentality combined with an inability to overcome “the system” is how I’m feeling now (except for the dog-eat-dog bit).  To fully understand the story, we have to back-track to May 2012 when Liz and Justine first met with the Mayor of the Maras municipality and Dr. Victor, the local representative for the Ministry of Health.  (insert the “dweedly do, dweedly do” noise and finger wiggling from Wayne’s World).  They met with both of them and at the end of this meeting; they had a contract that our Health Promoters would receive a salary for their work.  Fast-forward to November and Justine, Dylan and I met with Dr. Victor again but this time he said that they could supply us with medications as well as supplies and a weekly nurse visit, but that he did not have the money in the budget to pay for the Health Promoters’ salaries.  He quickly followed that by saying that the Municipality was supposed to cover their salaries (even though it was in our contract with him).  Walking out of that meeting, all three of us had a sinking feeling in our stomachs because the key to the sustainability of our project is the Health Promoters, and if they are not being adequately reimbursed for their time and efforts, they won’t stay on after we leave.

We walked from that meeting over to the Municipality and had a meeting with the Mayor.  He quickly reversed our sickly feelings when he said that they could cover the salaries and that we should not worry about it.  We clarified it with him a few times and he was willing to pay at, or close to, the minimum salary for the promoters (750 soles or around $250 USD per month).  We left it at a hand shake (big mistake) and everyone left smiling.

Before Dylan left back in the middle of December, we went by the Municipality again to try and arrange for the furniture in that original contract from May to get delivered to the clinic.  (We’ve gotten our bunk beds, 3 desks, and a stand up filing cabinet, but are missing our exam bed, exam lamp and computer….T.I.P.).  While speaking with people at the Municipality, we double checked and everything was in order regarding the salaries.

Shortly after returning to work from the holidays, I had a meeting with the Mayor’s representative to finally arrange for the delivery of the furniture (because they wouldn’t deliver the furniture to the clinic without a “Doctor” present….T.I.P.).  I also made sure to double check and we were still in agreement about the salaries.  I tried to speak directly to the Mayor, but shortly before Christmas, the major bridge that links Urubamba to Cuzco had been washed out and he was constantly in-and-out dealing with that (it wound up taking close to 2.5 months before even just a single lane bridge was finally installed and functional….T.I.P.).

We started with the trainings for the health promoters in mid-January and everything was going really well there.  It was really neat to get to teach in a different language and the health promoters were all very engaged.  Then, at the end of January, the “registro” of Kacllaraccay – local representative to the Municipality – mentioned to me that the municipality was only going to pay in “productos,” or rice and sugar.  They called it a program of “incentives.”  Seeing as I had spoken with the Mayor on multiple occasions about salaries for the health promoters, I was non-to-pleased.  Unfortunately between the bridge and subsequent floods in Ollantaytambo due to the rainy season, it took another few weeks before I could get a meeting arranged with the Mayor.  That meeting finally happened on February 18^th.

After waiting for close to 2 hours for our 10a meeting to start at noon (T.I.P.), I spoke with the mayor and he immediately said that everything was fine and I only needed to speak with the human resources woman.  I went and spoke with her and explained how it was always in agreement that the Health Promoters would receive a salary of Peruvian Soles and not food stuffs.  Mid-way through our discussion, the Mayor’s representative I had previously spoken with stopped in and tried to say that they could only do food products, but with a bit of persistence and some stubborn American negotiating, I finally broke them and they agreed to pay each Health Promoter a salary.  The big issue, however, was that it was only 200 soles per promoter.

This was a massive drop from what the Health Promoters were expecting and when they found out about the salaries, neither Roxana or Dina was interested in continuing to work.  The problem was that it was such a small re-imbursement for their time, that even though they enjoyed the work, they would not be able to support their families on the small stipend and each could make more money doing other work.  That night, we spent awhile speaking about the salary and their expectations, and they said that 300 soles per month would actually be enough for them to continue.  I figured that we should be able to accommodate, so I went back to the Mayor the next day to plead for the small increase.  I spoke that morning with the HR woman and she said that she thought that they should be able to cover that increase, but that there was only enough money to pay the salaries for 3 months.  Better than nothing though, so I jumped at it.  Only one catch:  we had to clear it with the Mayor and he was out of the office for the next 5 hours.

Luckily, I had brought my Kindle (I quickly learned about the massive delays and necessity of always having something with you to pass the time, after all…T.I.P.), so I found a bench and read for that time.  When the Mayor finally arrived, I gave him a few minutes and then went in to his office, figuring we would have a quick conversation, shake hands and I’d be on my way.  Unfortunately, when I showed up, the HR woman had a disgruntled look on her face and would not make eye contact with me, so I knew something was up and it was not going to be such a breezy conversation.

The next 5 minutes were like a swift punch to the gut and left me extremely frustrated.  The Mayor had decided that not only was he not able to do the increase to 300 soles, like the HR woman had thought, he had also changed his mind and was not going to even pay the 200 soles we had initially agreed on.  Now the only offer on the table was the equivalent of 150 soles per month of the aforementioned “productos.”  He cited the fact that the promoters were not professionals and as such, the Municipality could not create contracts for actual money with them.  The only offer they could make was the program of incentives with food stuffs.  When I tried to call him out on the fact that he was going against everything we had previously agreed on, he just said “the past is the past, let’s look to the future.”  It was one of those statements that had such finality strewn throughout it, that I realized his mind was made up and no amount of bickering would change it.  And, seeing as we will be working with him throughout the future, I had to take it as the final offer.

Walking out of the Municipality, I felt so deflated that all I really wanted to do was hop a cab to Cuzco and get the first flight back stateside.  So this was that setback that everyone had told me to expect while doing international healthcare in a 3^rd world country.  In a matter of a few short days, I had gone from prepping my March and April lessons for the Health Promoters to now not even having any Health Promoters because they were not receiving appropriate compensation (compensation that had been agreed on multiple times – although that was where our error was;  we never had a contract that was signed with an actual number/salary on it).

Luckily for me, Liz and Diana are coming down the first week of March for 10 days and after shooting a ton of e-mails with them and Justine (the 3 founders of the Crescendos Alliance), we started forming a plan of attack, and at least I know that I won’t be trying to solve this riddle alone.  And with their extensive international health experience, I know that we will be able to figure out a solution that will get us back on track.  And as Liz has said multiple times – it’s just the way politics work in developing nations.

With the stall in the mini-clínica, I went down to Maras and got a good week in working with Dr. Victor and crew down in the Health Post there.  I am also in the process of finalizing my “Campaña de Afilizacion.”  On March 10^th, a group from the Centro de Salud in Maras are going to come up to Kacllaraccay and we are going to spend a day getting everyone  in the town set up with the free national health care so that they can get all of their meds and the majority of their treatments for free at the health post in Maras and therefore from the mini-clínica as well (as of now, I´d guess that only 25-30% of the town has their ¨seguro¨ or insurance set up).  A few nights ago, while we were discussing the details for the campaña, we started speaking about the clinic and I explained what had happened at the Municipality and Dr. Victor looked and me and said simply:  “Esto es Peru Joey.  Esto es Peru.”  And he’s right, we’ll get this figured out with perseverance and patience, but in the end, these hiccups are to be expected because:  “This is Peru.”

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[movie-reference heavy opening right?!?]

White Sox Hat Count – 4 these last 3 weeks, bringing the Peru total to 9

Currently listening to:  Lord Huron’s “Lonesome Dreams”

Another interesting situation developed the other day in clinic that’s worth retelling – someone’s elder father came in a few weekends ago during shift change and one of the doctors wrote a script and signed it, but didn’t write the patient’s name on it and no clinical encounter was ever created.  Apparently the tech gave out the meds and the patient left, but then the patient passed away 5 days after being in the “Topico” (our Emergency Room).  The family came the other day to try and clear up what all had happened, but we had no register of the visit and couldn’t add much clarity to the situation for them.  Then, to further complicate things, we had to fill out an official form that the patient had deceased and we couldn’t find the patient’s chart.  Fits in with the general theme of T.I.P., but it’s interesting how much you take computer charts for granted until you are placed in a situation like this – we have some 3,000 charts that are all paper and no way to find a missing chart other than to go through them one-by-one.  The whole shift thing really boggles my mind as well, there are times when the whole health post is just manned by the security guard or a tech because there are only cars back to Cuzco at certain times, so people leave early for home and don’t check whether anyone is actually covering them.  Very interesting.  Fortunately, the family was very understanding and didn’t raise a big stink about it all.

And to close the T.I.P. theme for the week, here is the transportation I take down to Urubamba on Wednesdays, ¨el camione,¨ or the cattle car (not for the claustrophobic):

Here we are loading up the truck

Closing in the doors (I climbed in over the side)

A broad shot looking back

Zoomed in on the little cutie.

A Day in the Life

Typical day in my life these days:

6:30-7:00a – Wake Up, read a chapter of whatever book I’m working on (currently A Clash of Kings, book 2 of the “Game of Thrones” series.

7:00-7:30a – Breakfast – I’m currently eating my way through a 5 kg sack of oatmeal that I bought in Cuzco.  Spice it up with a little bit of brown sugar, cinnamon and banana and it is ready to fuel my day.  (Next run into town, I’m going to buy a nice satchel of raisins for some extra flavor).  Option 2 is Muesli and banana with yogurt, for when I get sick of oats every day.

7:30-10:30a – Office Hours with one of our three Promotores de Salud.  These past few weeks, we have keyed in on finishing up the 2 page histories (or fichas in Spanish) that we are doing on everyone who lives in Kacllaraccay.  The form is now in its third iteration and focuses on a number of different pieces of information; ranging from education level and occupation, past medical and surgical history, how many animals live in a household, what type of fuel and ovens a family uses, to what types of shoes people wear in the fields and how often they wash their feet.  Each version was re-worked as we realized that it was yielding redundant information or wasn’t really translatable into Quechua and therefore not giving us very good data at all.  I worked and edited each previous version with Dr. Dylan Cole and Dr. Justine Macneil and while version 3.0 isn’t perfect, it is better than the version before and is going to be our starting point.

In an effort to try and organize our “charts,” I tried my hand at cartography, and made a map of the town and then numbered off all of the houses.

                

We have since worked to identify every person living in each house and have broken down the town into 3 different groups – one for each Health Promoter.   Now, as opposed to randomly doing the histories with friends and neighbors, the Promoters are able to focus on their respective groups and work through whoever does not have a history done.  This way, they can also start introducing themselves to their families as that family’s specific health promoter.  Our goal is that in the future, if a person in town is sick, their order of contacts will be:

1. Their respective health promoter.  The Promotor de Salud will either come to their house or have the patient come to the mini-clínica for an exam.  If the illness is not too severe and they can solve the problem without medications or further help then everything is all set.  (They will have access to basic medical equipment 24/7 – things like thermometers and first aid wraps)
2. If the Health Promoter does not know what to do, they will then contact the nurse from Maras who is scheduled to come out every Thursday.  The Health Promoter will arrange to have the patient come back to the clinic on Thursday so the nurse can examine the patient and determine a plan of action.  In the dorm side of the mini-clínica, we have a limited set of medications like antibiotics (Amoxicillin, Ciprofloxacillin, and Dicloxacillin), analgesics (Ibuprofen and Paracetamol-Tylenol), and anti-parasitics (Albendazol).  We decided to keep these locked and only accessible to the nurse so that we do not have issues with missing medications as well as the fact that forms have to be submitted back to the Maras clinic every time meds are given out and it is easier to leave the nurse in charge of that.  If the illness can be managed with these meds, then everything is all set.  I came up with the meds list based on the most common conditions I’ve seen at Maras over the past 3 months – things like pharyngitis, UTIs, cellulitis, and intestinal parasites.
3. If the nurse realizes that a patient has a condition that cannot be managed out of the mini-clínica, then we figure out a way to transport the patient to Maras, or if needs be on to Cuzco (that has not happened yet).  Fortunately, at some point in the next few weeks, Maras’ ambulance is supposed to be ready for action to support the surrounding 6 communities.  But it’s Peru, so if I see it before I leave in June I’ll be pleasantly surprised.

The hiccup for now is that the town knows I’m living in the clinic, so people are by-passing step one (their health promoters) and coming straight to the clinic.  Oftentimes a person will come at 5 or 6p asking for pastillas (pills) or the all-mighty inyección to help their son or daughter who is mal (sick).  First off, I’m not going to just hand out the few meds we have without doing an exam, so I always ask them to bring the ill person by the clinic.  Secondly, we don’t have any injections in the mini-clínica, so I guess we won’t ever be able to cure anyone (I kid, I kid.  But wow do people in Cuzco love their injections and Ultrasounds as well, oddly enough).  Third, in an effort to try and expose everyone to the future course of action, I always ask them to come to the clinic during next available office hours (so we can work with the Health Promoters), however, few people come for that return visit.  It is still very early in the process though, and we’re trying to establish a new system in a town that feels like a time warp back at least 150 years.  It will not happen quickly, as nothing does here, but I’m hoping that by trying to establish the system early on we can create the expectation of how it will function once there is not a foreign medical presence in the clinic.

After organizing the fichas, the health promoter and I go out and do some more histories.  Then if there is extra time, I have the Health Promoters read through pages in Donde No Hay Doctores that correspond with our latest Monday night lesson.  These past 2 weeks we have started our program of Capacitación (training) and had 2 very broad lessons about what it means to be a Health Promoter and how they can help people.  Our next 4 lessons are going to be much more focused on things like how to approach an ill patient; how to interview, examine, and care for an ill patient; and first aid.

10:30-10:45a – Mango break.  Unreal.  On par with Hawaiian pineapple.  So good.

                

10:45a-12:00p – During this time, I note down a bit about the office hours and do any further organizing of the fichas.  I also work on future lesson plans.

12:00-1:00p – Lunch with Augustine.  Some goodies recently – Quinoa soup; rice and beans; rice with a green goulash of potatoes, cheese and home grown herbs (aka, I have no idea what they were)

1:00-3:45p – Work some more on lesson plans or any other projects in the mini-clínica (I just painted an extra coat of brown on the doors and windows…basically, anything that needs to get done for the clinic).  I have also been using this time to read health promoter based literature (read – Paul Farmer, Partners in Health, Paul Farmer) or a book called Medical Pluralism in the Andes, a series of anthropological essays about this region of South America.  They have been really interesting reads – my favorite one so far was called “Setting it straight in the Andes: Musculoskeletal distress and the role of the componedor,” by:  Kathryn S. Otis.

3:45-4:00p – Carrot break.  Augustine doesn’t always have a lot of fruit or veg, so I like to supplement with my second snack of the day.

4:00-5:30p – Run and shower.

5:30-7:00p – Read and relax or play some guitar.  It has been really pleasant these past few weeks with the rains to sit in the entrance to the clinic and listen to the rain while reading or learning a new tune.

7:00-8:00p – Dinner with Augustine.  Usually more rice, some meat, potatoes, a salad of onions and tomatoes.  Always tasty though.

8:00-9:30p – Journal and take any other notes about the day, then read a bit more before going to bed.

Other wrinkles during the week – Monday nights we have our classes from 7:00-9:00p and on Thursdays when our nurse comes out we start at 9a.  She is supposed to start coming near the end of February and we will work until we have seen all the patients that need to be seen on those days.  I envision in the future doing pre-natal checks on these Thursdays with the nurse and arranging for other medications to be brought out if needs be.  It will be the day that really anchors the whole program once it is functioning on its own.

I’m also spending Thursday afternoon through Sunday morning back in the Maras clinic so I get to keep working at their clinic as well as get exposure to the births and higher acuity emergencies (last week, a field worker was drunk in the field and dropped his pick-ax on his toe, so when he made it to the clinic it was barely being held on by skin and I got to stitch it all back on….he may or may not have been inebriated enough that the anesthesia barely made a difference when we placed the nerve block on his toe)

 

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Currently Listening to – Gary Clark Jr.’s “Black and Blu”

Fun Spanish for the week – “madura” = ripe (as in fruit), while “mordedura” = bite (as in an animal bite).  Very close and similar connotations….I wonder if an animal describing biting a human would say that the human was “madura por una mordedura.”  That’ll have to go in the basket of questions that’ll never get answered.

And, I think this year’s Super Bowl Sunday can go down as another first for me, just like Thanksgiving was.  After spending the day installing lights in the mini-clínica on Thanksgiving, we wound up in a standing room only big bus back into Cuzco for an hour ride….not my typical day on a couch with copious amounts of food and family.  And for my Super Bowl Sunday:  it was spent in a 5 hour town hall meeting, all in Quechua.  Definitely not at that level of understanding yet, so it was like watching a class in Japanese, I could only tell you a few things that we talked about in that meeting when the speaker swung into Spanish.  Although, now that I think about it…we probably did only cover a few things during that meeting.  That’s just the speed of life down here.

A few pictures to close, with all the rains, we get some cool scenery:

The road leading back to civilization (if you’re brave enough to enter the mist)

The fields and my favorite trees looking out from the porch of the clinic

How cool is this?….a DOUBLE rainbow