Why does one journey into the mountains of Peru?

Three weeks ago I didn’t even know that I’d be anywhere other than New Haven this July, and yet here I am 50 miles west of Central America headed for Lima.  I had known that I had wanted to go to South America for an international experience sometime this year – after 15+ years of Spanish classes, I really wanted to immerse myself in the language – but I didn’t think when I interviewed in June that anything would happen before the Spring at the very earliest.  As luck would have it, however, there was a mission trip going to the impoverished mountains of Peru for the second week of July, and I was invited.  It was truly quite exciting - 3 weeks ago I was told that if I could wing the arrangements and clear my schedule, I would be in the middle of nowhere just that quickly.

My thoughts are interrupted by the captain coming on over the intercom.  “Are there any doctors or other medical professionals onboard?”  My nerves tense – while I am not a doctor yet, I have just finished 3rd year of med school and have been an EMT for 10 years.  I look to see if 5 doctors stand up to head to the front, but I don’t see any response.  I haven’t even landed yet, and the medicine is already beginning.  Up front I find an English-speaking pediatrician, the only other one to answer the call, looking concerned next to an elderly gentleman in mild distress.  I quickly see why, as he has an obvious facial droop – a telltale sign of a stroke and a serious emergency.  The flight crew wants to know if we need to make an emergency landing.  After taking the patient’s history in Spanish. I find out that, while the weakness was “new” – hence the concern – he meant that it had started 2 weeks ago and that he has already seen his doctor about it.  He is in distress as his chronic back pain has flared up and is really hurting him, and after giving him some Motrin we can relax about the facial droop and continue on to Lima.

Returning to my seat, I realize that that encounter really sums up what this trip is all about to me.  Communicating directly with patients, many of whom speak Spanish only, is just so very important, and so superior to using an interpreter.  I remember an ambulance call I did once in New Haven where the firefighters on scene reported to me that the Spanish speaking patient had a history of asthma and was having trouble breathing, and that they were about to start an albuterol nebulizer.  While the patient was indeed short of breath, upon interviewing her I also found that she was having 9/10 substernal chest pain – it turns out that she was having a heart attack, and the nebulizer would have been very detrimental to her condition.  While that experience was particularly dramatic, I am full of stories about how a patient’s care was significantly improved because I could speak directly to a Spanish-speaking patient, an element vital to the doctor-patient relationship and vital to the accurate sharing of information.  This is why I want to go from being conversational to fluent in Spanish, and immersion is the key.  In Peru I will be avoiding hotels and staying with local families for just this purpose.

I also feel like I have genuinely helped this man by reassuring him and speaking directly with him for a while (I’m sure the whole plane’s grateful not to be diverted to Costa Rica as well), and this is the real privilege of the Peru program: I am going not just to observe, but to help.  I intend to make international volunteering a part of my medical career, and this would be my first foray into a truly impoverished area to not just observe, but to help.  I’ve tried to do this in the past, but most programs have little use for medical students or college-age volunteers, and those that do require an investment of $3000, something I could never do coming from a poor background myself.  I am so happy to have found an international experience which is so mutually beneficial.

Then again, jetting off on no notice to the middle of nowhere on the other side of the world, with only the most rudimentary understanding of where I’ll be living and what I’ll be doing, is also of course, plain and simple, really really cool,

***

It’s a beautiful day here at COSMA, La Comissión de Salud Mental - Ayacucho, but a daunting task lies ahead of us.  Today patients from all over central Peru are lined up throughout the facility and out the door, with complaints from unrelenting body aches to full-blown psychosis in an undiagnosed schizophrenic.  Ayacucho, an area devastated by 30 years of violent leftist terrorism and brutal government reprisals, incredibly does not have a single psychiatrist.  COSMA, a psychiatry clinic run by a truly saintly Catholic nun, cares for 3000 patients under the oversight of a group of Peruvian psychiatrists who fly to Ayacucho 1 weekend a month.  The staff badly needs support and training, and after a series of lectures over the past week, our group of American psychiatrists will try to see close to 200 patients, a dizzying feat, all in one day. 

My long journey to Ayacucho was itself really quite dizzying.  After descending into Lima’s thick garúa (the oppressive, gray fog that blankets Peru’s capital relentlessly all winter long) after midnight and after a 10 hour day of flying, I spent 4 frightful hours at a small house in a dangerous neighborhood of Lima (the area around the airport) being rocked to sleep by 45 minutes of gunfire just outside the walls of my compound.  My half-dazed drive back to the airport showed that many areas had still yet to rebuild more than a year after a major earthquake.  I sure wasn’t in Kansas anymore – taxis were an opportunity for express kidnappings, public transportation was a disorganized collection of privately owned “combis,” the water will likely make you sick, and inter-city buses are 12-24 hour odysseys with very real risks of falling off steep mountain roads, robbers demanding money, police also demanding money, and freezing without food or water the whole trip.  It was truly an eye-opening experience to see how so much of the world manages to live – in Ayacucho, 20% of the population lives on less than $2 a day, and 50% lives below the poverty level.

I arrange to work with Dr. Colón, an American child psychiatrist from North Carolina.  I worked with Dr. Colón yesterday at the United States Mission opened concurrently with our psychiatric mission in Ayacucho’s hospital, and I had been learning a ton about psychiatric diagnosis and treatment.  We had an arrangement where one of us would interview the patient while the other took notes and wrote prescriptions, and then we’d switch off roles to ward off fatigue.  Yesterday I was particularly proud to catch night sweats and cough with blood-tinged sputum in a patient while asking about difficultly sleeping, signs of a likely TB infection missed by triage – we were able to send that patient back to the internal medicine area for treatment.  Today, I see just how much of a difference erasing or easing the language barrier can be.  Though some patients speak Quechua, an Andean mountain language, many Quechua interpreters cannot speak English, requiring a double translation for the English-only American psychiatrists.  Many patients still speak some Spanish anyway, or at least their families do.  As the day progresses, not only do we get a much clearer picture of the bio-psycho-social causes behind a given patient’s presentation, but we also see so many more patients as we can work so much more efficiently.  The English-only psychiatrists see 3-4 patients this morning, while those who can speak a little Spanish see 5-7.  Dr. Colón and I see 14 patients, as we need to waste no time documenting the encounter between patients.  I truly feel that I am helping the cause here, allowing more patients to be seen and have their needs addressed.  It’s really exhilarating – addicting even.  And exhausting.

***

I spent 2 weeks in Ayacucho, seeing patients at the clinic, attending lectures given by and for the staff of the clinic, rounding at nursing homes, hunting down needed psychiatry medications wherever we could find them, speaking for hours with the local university professor nice enough to house me, going out with the psychologists at the clinic, and seeing a bit of the mountainous countryside.  We even made home visits, such as going out to the home of a family struggling with a new presentation of schizophrenia where the patient had scared the family out of the house.  Ayacucho is a beautiful little city that was unlike anything else I have ever experienced, and it will certainly be the most memorable part of my trip.  After my time in Ayacucho, Las Fiestas Patrias, a national week-long celebration much like July 4, shut down both the clinics in Ayacucho and the psychiatric hospital in Lima, so I took the opportunity to visit a wonderful psychologist’s family in Cuzco and see Machu Picchu.  It is easily one of the top 5 most breathtaking sights I have ever seen, a stunning wonder of the world which is truly not to be missed.

In Lima, Dr. Massa (a psychiatrist who trained at Yale and now works in Lima) has been generous enough to arrange for me to live with his mother in a lovely area of northeast Lima known as La Molina.  One aspect of Lima living I have particularly enjoyed has been figuring out the muddled patchwork of combi-bus routes which constitute Lima’s public transportation system, something few gringos ever attempt – there are no maps, no fee tables (well, no accurate ones, at least) and little guidance.  You learn by getting on a bus – some get very crowded – and seeing where it goes.  It took me 3 hours to get to the hospital from Sra. Massa’s house the first time, but I eventually got the system down.  I’m so glad that I did.  Not only is the system infinitely more affordable than “radio” (ie safe) taxies ($0.50 vs. $5-$20 each trip), but I can come to understand how the locals live.  It’s also so much more efficient than most public transit I have encountered, as buses can come every 2 minutes because everyone takes the combis to get around.  Conductors speak quickly as well, which made for excellent Spanish practice.

I have spent my days between the psychiatric emergency department, ECT suite and outpatient clinics of Hospital Hermilio Valdizan, a major psychiatric hospital for the capital.  It has been really interesting to see and understand how a unique psychiatric system addresses similar problems seen in the United States.  On the one hand, Peru (particularly the clinic in Ayacucho) really addresses ancillary services in a positive way which should make America think twice about our commitment to such services.  Talk therapy, one-on-one support, social conditioning and occupational therapy were really so much more developed in Ayacucho, and I am convinced that this had enabled some of the dramatic rehabilitations for patients that I saw there.  It is, of course, also resource poor – Ayacucho has no inpatient facility, and medications frequently need to be switched based on availability, even when a current medication is working very well.  I have been particularly interested in the finances of the system, where psychiatrists are all paid by the government and there is no expectation of free care or free medication on behalf of patients anywhere.  Even for impoverished patients, a modest cost for services and medications are never questioned and are generally not too burdensome for needed treatment, and this personal investment seemed to lead to a far higher compliance rates compared with experiences I have had in the United States.  Free generic medications could be arranged for those patients who truly needed it, but most patients never sought this support.  Ridiculous designer drugs with outrageous prices are, of course, never mentioned. 

Because there is, however, a shortage of psychiatrists, the experience has been unusually educational, as I have been able, for the first time, to see pathology advance to a level generally prevented in the United States.  I have seen schizophrenics untreated for years, debilitating agoraphobia, and even a dystonic reaction from typical antipsychotics, a medical emergency I will have to be able to recognize in the ED.  I also frequently have the chance to discuss concepts extensively with Dr. Massa, learning many subtleties in psychiatric practice such as potentiating antidepressants with other classes of medications, and common side effects and interactions of commonly used medications.  Furthermore, we frequently discuss medical practices unique to Peru’s system in order to discuss their merits.  For example, Peruvian psychiatrists routinely prescribe daily benzodiazepines for anxiety, continuing the prescription for months or even years, a practice which differs from American practice, and were able to discuss how this can lead to dependence and addiction and will actually reset the anxiety baseline reducing long-term effectiveness, and we talked about how antidepressants could be far more helpful.  I have also been struck by the ECT (electroconvulsive therapy) practice here, where paralysis is not used (in the United States, a short-acting paralysis agent prevents the shaking of a seizure, resulting in limiting the induced seizure to therapeutic brain activity.  This practice allows for violent shaking during the induced seizure, which certainly carries risk, but this is balanced by reducing the risks associated with paralyzing breathing and the breathing support needed (including advanced backup procedures if something goes wrong).  It’s a really interesting trade-off, particularly for resource-poor areas.  It has been fascinating to see how Peru’s psychiatric care system has used the resources available to it to provide the best care possible for its patients.

***

My international experience in Peru will most certainly be one I continue to treasure for the rest of my life.  I got the best kind of language practice one can get – immersion.  The medicine was fascinating, educationally valuable, and also was particularly language-based.  My Spanish has improved considerably, including both conversational and medical Spanish.  It has been the first step towards increasing international work into my career.  It was a fascinating exposure to a people and a culture I knew little about beforehand.  And, of course:

It was an adventure.