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.
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.
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
- 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.
- 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 4th 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.
- 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!”
(below is the picture of the leg…not for the squeemish…cough, cough Dad)