In April 2019, we plan to take an eighteen-member medical team consisting of twelve physicians, five nurses, and one physical therapist to serve in the community of Andajuaylillas, Peru. We will plan to have three days of clinic in the town center, three days of outreach health fairs, and one day of home visits. We are estimated to see five hundred patients, which will include children, adults, and home bound elderly or frail patients. We will address both acute and chronic conditions, perform screening to reduce the risk of cardiovascular disease, and provide palliative care when possible. With our outreach health fairs, we commonly see patients that have never seen a doctor. We hire local Quechua interpreters, who speak the local native American language to communicate with non-Spanish speaking patients. Medications for acute and chronic diseases will be purchased and brought to treat this community. We will partner with local community leaders and the local community to assist with continuity of care. When possible, we will provide educational tools such as diet, physical therapy exercises, and recommendations on lifestyle modifications to prevent disease and maintain their health. In previous years, there was a single trip to Andajuaylillas, but in 2019, there will be three different trips to this community. We will be leading the second group. We plan to coordinate with the other two medical teams to better prepare and address the needs of the community.
We chose this rural agricultural population for several reasons. Within this community near Cusco, Peru, there is a large population of indigenous Quechua farmers that are highly underserved and limited in resources. Within the town center there has a single small clinic, but it’s not utilized by the surrounding Quechua communities due to lack funds, lack transportation, and occasionally feelings of discrimination amongst their population. Commonly encountered conditions include hypertension, obesity, diabetes, musculoskeletal conditions, gastritis, dermatological conditions, women’s health issues, infectious diseases, mood disorders, well child checks and palliative care services.
Our goal is to screen for and treat both acute and chronic diseases.
We hope to prevent the consequences of uncontrolled medical conditions like high blood pressure and diabetes. This will be accomplished by measuring vital signs, history collections, physical examinations, and simple lab tests (urinalysis, urine pregnancy, blood sugar test, A1c blood test). When appropriate we will treat acute and chronic conditions with lifestyle changes, medications, and physical therapy. We will attempt to partner with local community leaders and medical services to foster continuity of care. We will also share our demographic findings (age, gender, medical conditions, medications used and needed) with the other medical teams for later trips. The medical team members will also continue to benefit from this experience back in the USA by learning about cultural differences in healthcare and treatment in Peru, challenges of providing medical care in low resource communities, and work with interpreters to provide better care.
I was awoken just after sunrise by a farmer whistling a beautiful song that I have never heard before as he walked to his fields to harvest corn. We were in Andahuaylillas, Peru, which is about an hour south of Cusco. Cusco is a large old beautiful city visited by millions of tourists each year since it has a rich Incan history and is the gateway to Machu Picchu. We felt like we were a world away in this sleepy agricultural community, only known by some tourists for its beautiful old church. As I write, we sit in our modest residence with glass windows and a stunning view of the Andes mountains, bright green with shadows from the clouds. Then below is the river valley with a tapestry of farms of quinoa, wheat and corn and our village with mostly white structures with red tile roofs.
As we walk down the steep cobble stone streets to clinic, we are frequently interrupted. First, we are stopped by parents rushing their kids to school. Most walk to school. One parent parks his hatchback and six small children climb out of the back, like clowns at the circus. Each is neatly dressed in their bright red school uniform with their wide brimmed hats to protect them from the strong sun. As they smile and say to us, “Buenos dias doctor”, I notice their dark skin, short stature, bright white teeth and wind burned scaly cheeks. The sidewalks are very narrow, so we are forced to walk in the middle of the street. We are also stopped by the the occasional passing of a loud and smoky motorcycle taxi. Then we are passed by a woman who looks over eighty years old, but is likely less than fifty. She is wearing a traditional tall hat, bright colorful sweaters, a long skirt and leg warmers. Her shoes are as damaged as the skin on her face. She is tending more than ten sheep through the city streets.
When we arrived at our make shift clinic, we were greeted by the more than fifty patients already waiting to be seen that day. Each exam room consisted only of 3-4 plastic patio chairs. We were able to see over one hundred patients per day as a group. We treated mostly common conditions that we see at home. We treated a lot of musculoskeletal conditions and injuries because most of these people do hard physical work as farmers. We evaluated many patients with eye conditions called pterygia. A pterygium is scar tissue on the surface of the eye caused by sun and wind damage. We acknowledge that part of the problem is that nobody wears sunglasses. We also saw more gastrointestinal conditions than at home because the water supply isn’t as clean, especially in more rural areas. When we diagnosed patients with chronic conditions such as diabetes or high blood pressure, we provided education on lifestyle changes and we referred them to follow up with local providers. Occasionally, patients had serious health problems and were referred to a hospital in a neighboring town about ten miles away.
One problem that we encountered repeatedly was children with serious dental problems. One seven year old boy, Vincente, had daily tooth pain. He could not eat on the left side of his mouth for the past month and had difficulty sleeping at night. On exam, his left lower molar was broken in half and the remaining portion of the tooth was black. He couldn’t afford to have dental treatment. Unfortunately, we did not have a dentist on our team. You could ask, “Why don’t you just pay for his dental care?” The problem is that there are hundreds of children in this area in the same situation. This example reminded us of the importance of education and prevention. During our trip, we gave out over three hundred toothbrushes.
It is one thing to see poverty on television or to have a person on a street corner ask for some spare change. It’s completely different when you are seeing a seven month old baby that should be sitting on her own, but is unable to even hold up her head due to starvation. Her mom’s breast milk had dried up. One of my colleagues was so moved by this experience that she took a taxi to the next town to buy the baby more than two months of infant formula for the child. Our physical therapist taught the parents some basic exercises to help improve the baby’s strength. However, we all left that interaction feeling empty, knowing that we didn’t really help the underlying situation. Problems like starvation and dental caries will not be solved one on one. These problems need to solved through advocacy, laws and government led social programs.
One day our team of providers divided into three groups of smaller multi-disciplinary teams (faculty and resident physicians, nurses and physical therapy) to provide home visits. These patients were too sick to make it to our clinic. We carried a thirty pound bag of medications and supplies from house to house. We were followed closely by multiple dogs wherever we walked. They were hoping for a snack. Two dogs followed us for four hours while we did multiple home visits. The dogs seemed to know that we are visitors too. Our local contact created the list of patients to see. Our interpreters served as our guides and led us from house to house. During the home visits, we treated patients who had strokes, were born with birth defects, had traumatic injuries, such as leg fractures that were not treated or inadequately treated. In many cases, other family members would arrive and ask about their own ailments. We happily and patiently also addressed their concerns and questions. In every case, these patients were very welcoming and grateful that we visited them.
When you walk through town, the narrow cobble stone or dirt streets are lined by high walls made of adobe or cement covered with white paint of varying degrees of decay, which conceal what is behind those walls. When the door opens, sometimes a restaurant or mini market is revealed. The homes vary greatly. Some have glass windows, are neatly kept and have paved patios in the courtyard. In most cases, a dark dirt tiny entryway leads to an open courtyard, which is on average 500 square feet of farm land growing corn. Along the periphery are enclosed areas for sleeping. Sometimes similar adjacent spaces are full of animals. In one case, the entire outdoor area where we evaluated the patient was full of sheep feces. The sheep had as much covered space as the couple who lived there.
One of our memorable visits was to a couple in their seventies who owned a soda shop/bar. They lived in a humble residence above their shop. They both had bad knee osteoarthritis and requested steroid injections in their knees to reduce their pain. When we walked outside of their shop, our interpreter had another woman waiting and requesting an injection. She looked about a hundred years old. We sat her down on a large stone outside the soda shop to evaluate her and prepared to perform the injection. However, we soon realized that we might soon have a line a block long of older people requesting shots, as word of mouth quickly spreads through a small town. So we asked the shop owners if we could perform her injection inside their shop. Meanwhile, two men on their break from work sat down at a small table in the corner and were enjoying a beer. They were entertained by our evaluation of the patient and then her knee injection.
When I was in this same community in Peru two years ago, I saw a man, who I had not forgotten. I remembered that he lived with his daughter. He was blind. She had to leave him home alone all day while she went to work. I was happy when one of our home visits was to his house. His teenage granddaughter was there helping to take care of him. We treated him for indigestion and evaluated his other mild symptoms. The frustrating part of this visit was that his blindness is caused by cataracts. If he could afford cataract surgery, a low risk procedure that takes minutes to perform, it is likely that his blindness could be reversed.
We also went to schools in smaller nearby agricultural communities and set up health fairs. The people in the smaller towns were clearly poorer and they have less access to care. We brought backpacks, filled by a local San Diego girl scout troop, for the children full of small gifts including crayons and coloring books. One lesson in global medicine is flexibility. One day we were in Pinipampas. We set up our clinic in an elementary school. We had access to two large classrooms. One we converted to our pharmacy. The other room was our clinic with six work stations consisting of a table and four kindergarten sized chairs. It was funny to see our team treat over one hundred twenty patients, mostly kids that day, sitting in those tiny chairs with our knees to our chests.
After each day at work, we were exhausted. We have been on our feet for most of the past ten hours, struggling to communicate because most of our patients didn’t speak Spanish. They speak Quechua, their Native American language. Although it is sometimes a struggle, it is a pleasure to do this work because these are some of the kindest, gentlest, welcoming and appreciative people that I have ever met. One man that we treated took the time to shake the hand and say thank you to every member of our team.
Our contributions did not solve the deep routed social problems facing the indigenous population in agricultural communities in Peru, but at least, we let the people in that community know that they are important and that we do care about them. I feel like we made a small positive impact on many of the patients that we treated. In the future, we can definitely improve our interaction and integration with existing providers and systems in that community. On behalf of my medical team and the patients that we served, I want to express my deepest gratitude to Doximity for your generosity and helping us change lives and improve the health of the people in the communities around Andahuaylillas, Peru.
