Saturday, July 2, 2016

From the Rainforest of Peru to the Mesas of Arizona

 Late entry. Originally written June 12, 2016:

It has been almost 3 years since my last blog post -- one of many things in my life that went on hold during Family Medicine Residency. On reflection, residency does seem like a bit of a black hole that has consumed more time and energy than I ever could imagine I had to give, week after week, year after year. On the other hand, it has also given me so much: knowledge and skills, incredible friends and colleagues, and the opportunity to bear witness to so much joy and sorrow in the range of the human experience.

Now those three years are coming to a close and I’m fortunate enough to be spending my last month of residency on an away elective at a hospital in the Amazon Rainforest of Peru. It is absolutely incredible here; it feels like a combination of medical school in Cuba and working in Santa Ana, Ecuador, which have been two of the most incredibly rewarding and life-changing experiences of my life. I am working in a small town called Santa Clotilde on the Napo River in the Amazon Rainforest of Peru. Santa Clotilde is only accessible by boat, by an approximately 7-hour journey by motorboat from Iquitos, the capital of the region which is in turn only accessible by boat or plane. Remote as Santa Clotilde is, it is home to several thousand people and is the district capital and houses the government and the hospital for a vast region of rainforest. I am working as one of five doctors at the local hospital, which has a 20-bed unit for hospitalized patients, one delivery room for vaginal births, one operating room for cesarean sections and other basic surgeries, and an outpatient clinic area with four exam rooms. There is a lab which can run some basic tests (blood counts, some kidney and liver function tests, as well as checking for malaria and intestinal parasites) and an ultrasound machine, but no x-ray. Many of the staff at the hospital are recent graduates from their areas doing their year of “social service” which is required before being able to move on to further study such as residency for physicians. I am living in the same large house they all stay in, which is part of what reminds me of my time at ELAM (medical school in Cuba) – cooking, washing clothes, eating communally with young medical professionals from all different parts of Peru. The ingredients available to buy are rather limited, but we are always discovering new ways to prepare the basic stables (flour, oil, rice, beans, lentils, yucca, platano) and a few fruits and vegetables (tomatoes, onions, carrots, cabbage, beats, peppers) in new and different ways. Today I taught them how to make flour tortillas from scratch and we made tacos which turned out delicious.

The rainforest here is amazing. Yesterday afternoon after we finished seeing patients, one of the local staff members took us on in a ‘peke-peke’ (homemade boat with a small motor for going short distances in the river) up the Napo River to a neighboring community named Wiririma. We swam in a tributary of the Napo River that has an intense black hue to the water due to some kind of mineral. The river was high due to the recent rains, with the bases of many trees swallowed by the black waters. It happened to be Wririma’s anniversary celebration, so after we swam, we went up into the community center to watch the soccer tournament and taste the local homebrewed fermented yucca alcohol Masato. It is an opaque white liquid that tastes a bit like yogurt or kambucha mixed with some fibrous remnants of yucca. Traditionally women would chew the boiled yucca and the saliva would provide the enzymes necessary to produce the sugars for fermentation to produce alcohol. In this region, people have generally switched over to alternative methods such as adding sugar cane juice to facilitate fermentation. It is fascinating to see the blending of tradition and modernity in Santa Clotilde and the surrounding communities. In general, the influence of modernity seems to predominate more in this area than in Santa Ana, Ecuador, the community in which I previously had worked for years on water treatment. Even though all of these communities here in Peru are accessible only by river and Santa Ana has road access, fewer people speak their native languages here (although some do speak kichwa and I’ve gotten to use a bit of what I remember from Santa Ana), there is less traditional music and dance, and more integration of modern expectations of hygiene and lifestyle. But people still maintain an incredible knowledge and intimacy with the natural environment, from the chakras where they still grow a lot of their own food, to the rivers that provide fish and transportation, and the tributaries where people wash clothes and swim. Although some seem to live more of a "city" lifestyle, there are limits in that there is only electricity here from 6pm-11pm because it is generated here, the paved roads only go so far within the city, and it is impossible to escape the mosquitos and the diseases they carry, especially malaria. Most people around here have had malaria at least one, if not many times in their lives, and we see and treat it every day in the hospital and clinic.

I have been very impressed by the Centro de Salud Santa Clotilde where I work both in the care it provides and the integration in the community. The inpatient area is an open ward meaning all the beds are in the same two rooms except for an isolation room and two rooms for moms and babies. I often seen the patients hanging out with each other within the ward or in the courtyard. Although there are only 5 doctors, there are so many other staff members here: laboratory staff, maintenance staff, nurses, nursing techs, pharmacists, midwives, administrative staff, public health staff, and they do an incredible job with very little resources to care for a large number of patients each day (approximately 30-50 outpatients and 10-20 inpatients). In addition to seeing patients in clinic and taking call every fifth day, I have also brought water testing equipment and am teaching the public health team how to use it to assess water safety and encourage treatment (generally boiling or chlorination) as I have done previously in Ecuador and Uganda.

Working here feels like a merging of many threads in my life – public health and medicine, water and health, living and learning in another language and culture. It has been 10 years now since I first traveled to Santa Ana. I am not sure what it says about me that I still love this work just as much and have the same goals and dreams as I did 10 years ago. Maybe I was a precocious 19 year-old. Or maybe I am stunted in my ability to grow and evolve. Or maybe it is simply that I have come to the end of an 11-year educational process of university, medical school, and residency, and am just now finally be able to start to do the work that I have always intended to do from the beginning.

Sometimes I really do wish I could just move here to Santa Clotilde and work full time after I graduate in a few weeks, but I still have too much debt from medical school to make that a reasonable option. Instead, I have chosen a rather parallel job within the United States for after I graduate: working for the Indian Health Service at the Hopi Health Care Center on the Hopi reservation in Northern Arizona. I start in October and will be working in the outpatient clinic, as well as in the emergency room, on the 4-bed inpatient ward, and the tiny labor and delivery ward for low risk vaginal deliveries (women who are high risk or might need a cesarean section for any reason deliver at Tuba City instead which is 45 minutes away), along with three other physicians and a handful of nurse practitioners and physician's assistants that run the small critical access rural hospital. There is a laboratory and radiology department on site with x-ray, CT scanner, and ultrasound capabilities and an MRI that comes in a trailer twice a month. The Hopi reservation is both incredibly remote and stunningly beautiful albeit in a slightly austere way. It is in the high desert of Northern Arizona with few trees and little water, but incredible mesas with endless trails for hiking and running. The Hopi are a pueblo people and have lived continuously in some of their communities at the top of their mesas for almost 1,000 years. Their traditional culture, including language, religion and farming practices are still very much alive and the Hopi have a reputation for being very open and welcoming to medical staff, often extending invitations to ceremonies and dinners. I am very much looking forward to this opportunity for a cross-cultural experience as well as the opportunity to apply the skills and knowledge I have gained over these last 7 years in a place where they are very much needed.