Impacted by the Amazon: A Reflection of my Rotation with Amazon Promise in Peru
You could see the high water marks on the tree trunks towering 20 plus feet above the muddy banks of the river. They stood there, as if laughing, as our team contemplated our plans for clinic the next day. It was dry season now, and the small branch of the Maraňon River we had planned to take to Bella Horizonta was too shallow for our boats. It was a small community of less than 10 families that we had planned to visit, but the obstacle we faced highlighted the issue of access in a very tangible way. We would serve 9 communities while in the Pacaya-Samiria National Reserve of the Peruvian Amazon, who would all experience the tyranny of isolation to varying degrees. Many of these areas were hours from the nearest medical outpost, with the nearest regional hospital even further away in city of Iquitos. Iquitos itself was isolated from the rest of Peru, accessible only by boat or airplane. At our 4 clinic days in the impoverished areas of Iquitos, we would see how even in a city, one can be isolated from care. It would be easy to ignore villages in the jungle, such as Bella Horizonta, as being too remote to reach. In concept they have access to care, but as someone that views a 20 minute office wait as an insurmountable barrier to an annual physical, I can acknowledge how problematic the regions access truly was. In the rainforests of Peru there exists a gap in healthcare access, a gap Amazon Promise (AP) seeks to bridge.
Untreated primary care problems can be insidious for populations lacking access to longitudinal and acute care. Back pain, when left untreated without instructions on exercise and stretching can debilitate. Intestinal parasites can lead to malnutrition and reduced growth. Hypertension and diabetes can kill when poorly managed. The impact of Amazon Promise ripples beyond the smiling faces of a child receiving a toothbrush or the grateful handshake of a patient receiving antibiotics for a UTI, as access to primary care impacts whole life spans, whole communities and whole regions.
Amazon Promise gave me as a student a unique opportunity to work with a variety of providers. I learned from a family medicine PA, APRN, transplant surgeon, emergency medicine physician, and Peruvian family medicine physician. As teachers, all would give me a unique perspective, specialized insight into the patient presentations before us. My own knowledge on how to treat bacterial vaginosis, UTIs, diabetes, or tinea corporis would be tested, and I would see how seasoned providers would improvise in order to provide high quality care to patients, even without the conveniences of a local pharmacy or consultations.
As a team, we really were the sum of our parts, as each practitioner brought their own strengths to the team. Collaboration was king for our group, with each members contributing and second opinions being sought regularly. It was not just medicine that my mentors taught me about but teamwork. In the PA profession, an emphasis on Optimal Team Practice has become an overarching theme. In the Amazon, the far reaching benefit of cooperation was evident.
Though Primary Care would be the majority of our effort, there would be many acute pathologies requiring further work up. One of the many strengths of AP, was its persistent follow up of patients. A patient’s relationship with our team would not be a transient event. At our Belén clinic, we saw a patient with severely progressed HIV, who was unable to get care because he was in a region where his insurance did not work. Our team followed up with his care, making sure he was set up in a program that could provide first a higher level of care and then longitudinal access to antiretroviral medications. This experience was illuminating on how the Peruvian Health System operates, and also showed a eerie parallel to our own system, especially with state run Medicaid.
The continued follow up and access of Amazon Promise was further evidenced by a patient we saw outside of clinic. She was an indigenous patient, who had been given Implanon birth control on a previous trip. Months later she began to attribute this medication to headaches she was having. She wanted the implant removed, even though medical opinion would suggest the two were unrelated. Even after months, AP took her call, coordinated her arrival in Iquitos, and our team removed her Implanon.
The experience highlighted two important issues present in remote care, often especially significant for NGOs in long term follow up and patient autonomy. Here, patient care was done right. She had access to our team, even coming from an even more remote area than we were on my trip. She also had the final say in her care. She was communicated the medical opinion and unlikely link between her headache and birth control as well risks of going without birth control and made her decision. As a medical team, we followed what the patient’s wishes were in removal. She was in charge of her own care. It was a powerful reminder that medical management does not occur in a vacuum of time and treatments can often have long term impacts and perceptions on a patient. As I progress with my own global health goals, I hope to always keep these principles in mind, as they are fundamental to appropriate care.
As I reflect on my time spent on rotation with Amazon Promise. I can say without a doubt I strengthened my knowledge of primary care. I saw, learned about, and helped manage diseases such as malaria, TB, parasitosis, and many dermatological manifestations, which I may have never seen in a US career. From our Peruvian staff to translators to medical providers, I saw how teamwork makes even as sizable an undertaking as clinical care in the Amazon manageable. I witnessed principles of longitudinal care and patient autonomy be upheld even in austere environments. I will be a more competent, compassionate and innovative provider because of my time in the Amazon. This experience was transformative and made me even more dedicated to being an impactful provider both domestically and globally. I hope to return to Amazon Promise as a volunteer again, with even more passion, knowledge and skill.
