Peruvian Amazon Elective - A Medical Student Perspective
Iquitos is regarded as one of the most remote cities in the world, deep in the heart of the Peruvian Amazon. It is described as the world's largest city that can't be reached by road. Iquitos is up to six days by boat, or a plane ride away from civilisation. The Amazon basin is a fascinating melting pot of indigenous cultures and tropical diseases. It is a far cry from studying medicine in inner city London and a unique location for a medical elective.
In preparation for the expedition, clinics were held in the poorest area of Iquitos, Belen. An opportunity to familarise oneself with the diseases and common presenting complaints of Peruvian patients and master the art of history taking in Spanish! Belen is described in guidebooks as "a floating shantytown with a certain charm to it" and by locals as the Venice of the Amazon. The harsh reality is more consistent with a slum. Houses are on stilts as the Amazon River rises and falls depending on the season. When the river is high, house calls are made by boat. Currently the river is low so "walking the plank" between houses trying not to fall into the sewage that covers everywhere is normal. Houses if you can call them that, lack electricity or running water and toilets consisting of holes in the floor of house. The sole source of water is the river and thus it is used to fulfill every need - drinking, bathing and sanitation! So it is not surprising every child presents with a huge belly full of parasites. Scabies and fungal dermatitis abound. Clinics were usually held in the "front room" of a stilted house. Word travels fast that a clinic is being held and out of nowhere patients appear. There are always far more than the team is able to deal with.
The main part of the medical elective involved a two-week medical expedition to the Yarapa and Ucayali rivers providing remote Amazon villages with medical care. The team consisted of a Peruvian doctor, a US paediatrician, pharmacist, a UK medical student (me), a US medical student, a shaman (medicine man), a cook & her daughter, guide, translator & boat driver. Clinics were held on the Yarapa River in the villages of Jaldar, Puerto Miguel and Jerusalem. Then we transferred across to the Ucayali River and held clinics on the Ucayali River in the villages of Libertad, Castilla, Vista Alegre and San Jose. The clinics were intense and consisted of a vast number of paediatric and obstetrics and gynaecology patients. But the team worked well together and using a translator when things got tough we battled through the patient's each day working late into the evening to ensure everyone was seen. Prescribing what limited medication we had and providing as much health education as possible. Common general problems were dehydration, malnutrition, body pain and parasitism. History taking was never dull. Many patients held very strong beliefs that their illnesses were due to a hex or curse "dano" being put on them. They are an incredibly superstitious people. Problems with pregnancy due to toads and wives leaving husbands because they had been bewitched by a pink dolphin in the river were common complaints. A far cry from a normal presenting complaint back home!
The breadth of clinical exposure was amazing. Here are some of the most memorable patients over the placement. The patient with the scrotal hernia that had to be evacuated out by lancha (boat) a few days into the expedition as it became incarcerated. The patient made it to hospital after traveling seven hours lying in a hammock in the lancha and three hours in the back of a jeep along a bumpy dirt track! Three metres of necrotic bowel was eventually removed and the patient is recovering well. A success story! However this all pales in significance to the enormity of the problems faced in this area. Other patients included the 80-year-old lady wasting away from long standing drug resistant tuberculosis. The 14-year-old fisherman attacked by a piranha with a chunk taken out of his thigh. The 24-year-old river worker with an enlarged liver who had suffered from malaria ten times! The patient who had recovered from leprosy thanks to intervention by a previous expedition. Numerous fishermen presented with stingray stings and machete injuries. The patient suspected of suffering from the devastating disease - leishmaniasis, who could hardly walk. The vast number of young patients presenting with sexually transmitted diseases, as a result of unprotected intercourse with multiple partners. The man with a gunshot wound in his leg with 10+ bullets still left inside. He had been unable to pay to have them removed and thus had been discharged from hospital! It makes you realise the NHS isn't that bad after all!
A day was also spent at San Juan Laboratory in Iquitos, providing a fascinating insight into tropical medicine. Time was spent being trained in preparation of thick and thin malaria films as well as at identifying some of the culprits for the children's big bellies! One of the most incredible days of the entire placement was spent getting a unique insight into the traditional medicine used by shamans and spiritualists in the Amazon. A fascinating morning was spent talking with a Palero Shaman - Don Humberto Huinapi. A palero shaman uses "cortezas" or barks of trees to treat patients. Patients are put on strict diets and given solely plant preparations daily e.g. root of Huasi, leaf of achiote, leaf of Albacha, te de caguena, chuchuhuasi and Malva to treat their diseases. I was extremely privileged to be invited to attend a shaman ceremony on the last night of the placement. An unforgettable experience!
The ceremony was held out in the outskirts of Iquitos. Severely ill patients suffering from conditions ranging from terminal cancer and fer de lance snake bites to mal aire "evil eye" were laid out on the floor side by side, surrounded by other patients and disciples of the shaman. The ceremony lasted until the early hours of the morning; an incredible blend of tobacco smoking - to contact the spirits, chanting and singing. The ceremony was absolutely mesmerizing. The entire elective was a fascinating experience at so many levels. The highlights being the immense amount of hands on clinical experience in tropical diseases, the immersion into indigenous culture and the unique insight in traditional shaman medicine. An amazing elective with so many unforgettable memories! Thanks to every single member of the August 2004 Amazon Promise team for an incredible trip.
I would like to take this opportunity to sincerely thank the following for supporting this elective: The Lord Mayor's 800th Anniversary Awards Trust, The Worshipful Company of Founders and The Vandervell Foundation.