Download Peru - ECELA - 2013

Mia Maamari, JMC ‘13
February 2013
Foerderer Grant Report – Lima, Peru
How I found the location and organized the trip
As a 4th year medical student, I went to Lima, Peru in the month of February 2013 as an elective in
Family Medicine 404. I went with another classmate of mine, Noa. We were given the idea to go there
from friends in medicine, some of whom have family in Lima and some are from there and have done
some training there. We made some contacts in a public hospital from those connections. For further
experience, we searched for other hospitals in Lima and personally emailed any doctors and compiled a
list of those that replied, were willing to have us work with them and spoke English.
One reason we decided to go to a South American country was to improve our Spanish skills. During our
clinical years at Jefferson, it became evident that we will be treating many patients whose primary (and
only) language is Spanish. Although the language line phones were available, we found it would be
beneficial to be able to conduct simple patient interviews without them. For these reasons, we included
a component of Spanish classes at a local Spanish school, ECELA (Español y Cultura en Latino America),
which we found on the Foerderer Study Abroad website. We started as beginners in Spanish, but as the
month progressed, our comprehension increased tremendously, and by the end, we did not need much
translation to follow the discussions during clinical rounds.
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At the school, we met students with the goal of learning Spanish. We met people from Brazil, Germany,
Switzerland, England, Australia, Canada, and the USA. Most days, the school held after school activities
to explore Lima or get lessons in salsa or cooking Peruvian dishes.
The medical system and different hospitals and clinics
On the clinical side, we rotated at several different hospitals around Lima. One of the hospitals, named
the Clínica Anglo-Americana is a private hospital that caters to the most elite of the patient population
and does not usually see medical students unless they are in their final year. The residents there are
called Assistantes and most of them are studying for the USMLE boards to eventually come to train in
the US. The clinic had many similarities with American hospitals in that each patient had his own room
with electronic monitoring of vitals both in the Emergency Department and in the wards and some lab
results could be checked on the computer. In the mornings, we listened to their sign-out and
participated in discussing patient-relevant medical literature with the attending during morning report.
After Spanish classes, we returned to the hospital in the afternoon to finish rounds.
Patients in this hospital usually have purchased private
health insurance to afford care here. However, the
majority of the patients in Peru will have public health
insurance and will attend public hospitals.
In Peru, medical school starts after high school and lasts 7 years. Then, the last year of medical school is
the intern year, after which residency is optional, so some may choose to go into general practice.
Alternatively, one may choose to pursue fellowship in many of the same options we see in the USA.
On Thursdays, we attended lectures given in Tropical Medicine at the Universidad Peruana Cayetano
Heredia Hospital. These lectures are part of the Gorgas course, which invites several trained physicians
from the US, Canada, Australia, and the UK. We would round with the team, be presented with a patient
and offer differential diagnose, keeping in mind a likely infectious etiology. We saw a patient who had
numbness and weakness in her lower extremities found to be due to a Brucella infection in the spine.
This infection is one that we had to keep in mind in Peru, but was a less likely diagnosis in the US.
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Another patient was diagnosed with colitis due to TB or HIV after complaining of chronic diarrhea. This
hospital saw a wider variety of socioeconomic levels of patients.
Some of the interesting things we noted were that at this hospital there was an office devoted to
studying Leishmaniasis. In fact it was one of the only laboratories in the country to be able to diagnose it,
and many patients were transferred to be diagnosed there. We also noted posters with algorithms on
treating suspected Dengue fever, especially if patients had a history of being in the jungle, in the north
of the country.
At our Spanish school, we made a contact with a representative from a tour company, Haku, that builds
homes in villages in need. With a few other students, we helped build a common kitchen in the town of
Villa El Salvador. This district of Lima provided a stark contrast to the developed districts we had seen.
Here, homes were build from only the basics, wooden walls and ceilings of corrugated aluminum, called
calamina. Even the climate seemed to differ, resembling more of a dusty desert than the lush
neighbourhoods of Miraflores. There were many stray dogs that would weave through the streets. At
night, I noticed the village streets still had light, and that despite being a shanty town, because it had an
electric grid, it was still not one the poorest areas. Below, that is me hammering on the roof.
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While we were building, the women of the village provided us a
quinoa-based beverage sweetened with orange. As for food, we
tried a local dish of guinea pig with a side of potato and sauce
(pictured on the left). Eventually, for desert, we bought churros on
our way back to a local market.
With the children of the village, we
played a game with a live guinea pig (not
the same one that became dinner),
where we built a circle of boxes and
guessed on which one the guinea pig
would run into first when it was released.
The child who guessed correctly won a
prize—usually an article of clothing.
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The public hospitals in this region were set up in converted shipping containers. In this village, we also
got in contact with a small local parochial clinic that serves as a primary care center. We sorted,
organized, and made a list of medications that were donated to them. These donations included
antibiotics, anti-hypertensives, anti-diarrheals, allergy and asthma medications that will serve many of
the patients that visit.
In Villa El Salvador, we encountered several unique findings in children. Some were born with
deformities in the hands and fingers for which nothing had been done. One mom had asked if we could
provide a prosthesis for her daughter with only her thumb on her left hand (her right hand was normal).
This was unfortunately not something we could provide, but it illustrated to us the need for more
specialized medical involvement, like with orthopedics and plastic surgery.
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Finally, on Fridays, we spent the day in the north of Lima, in Collique, at Hospital Nacional Sergio
Bernales. This is a public hospital that serves a mostly poor population. Here, the Emergency
Department is much more crowded than at the Clinica. Due to the prevalence of TB, we were
encouraged to wear N-95 masks when seeing patients. There are no private patient rooms, even on the
wards, and it is common to have 6 patients in one room. We were put in contact with one the
Gastroenterology attending there. We shadowed her doing upper endoscopies, colonoscopies, as well
as proctoscopies. In the mornings, we rounded with the team, similar to rounds in clinical years at
Jefferson. We also accompanied the attending during consults completed in the ED, on the general
medicine wards and in the OB/GYN department.
Many patients who underwent procedures had
complaints of upper abdominal pain. Upper endoscopies
often revealed bumps in the gastric mucosa, suggesting H.
pylori infection. We also observed banding of esophageal
varices caused by portal hypertension due to alcohol
injury to the liver. Interestingly, the bands used are made
by thinly slicing a Foley catheter in cross-sections. This is a
much more cost-effective alternative to the bands that US
hospitals buy. However, Foleys have not been formally
studied. Colonoscopies often revealed polyps which were
removed by using biopsy tongues.
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Living arrangements
The city of Lima is quite expansive and has numerous districts, but the most renown one is the district of
Miraflores, where safety would not likely be a major concern. It also bordered the ocean, and provided
breath-taking views of the landscape, the ocean and the sunset.
Once we chose to live in the district of Miraflores, we were lucky to have found an apartment online
rented by one of the doctors at the clinica anglo-americana. It was 1 bedroom apartment that we shared
between both of us. The location we soon came to realize was perfect walking distance from everything
necessary. It was central enough that many taxis drove by, and this became a common mode of
transportation for us. The prices are much lower than prices in the US, and some negotiation with the
driver was necessary. Another mode of transportation was to take the Metropolitano, which was a new
bus system that had dedicated lanes in the highway, essentially functioning like a subway or by avoiding
traffic.
Our Spanish school, ECELA, offered us housing with a family for a price, however we chose a more
independent lifestyle with an apartment. There would be definite benefits to living with a host family,
including more consistent immersion as well as prepared meals. However, we had made a number of
contacts in Lima prior to arrival and were comfortable without a host family, though it would have been
an enriching experience.
Recommendations for living in Lima for a month
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Cash: It is easier and cheaper to pay in cash, so we incrementally exchanged American dollars to
the local currency, the Nuevo Sol, also known as Soles. We found the best rates at some of the
major restaurants and at a cash exchange station.
Transportation: It is very convenient to travel by taxi because they are much cheaper than in
Philadelphia. It is important to know the price range to your destination since there is no meter.
Before getting in, negotiate the price with the driver. If you are not happy with the price, wait to
get into another cab. We also took the metropolitano bus.
Cell Phone: I had my iPhone unlocked before going and I inserted a local SIMcard in my phone.
Home Phone: we had landline, but it could not make calls to cell phone numbers without a
special card.
WiFi: Lima has public wifi in parks and grocery stores. Almost all major restaurants also offer wifi
to which we had to ask for the password.
ISIC: For many tourist attractions, especially in Cusco and Machu Picchu, there are student
discounts, for which the ISIC (International Student ID Card) is necessary. It provides a 50%
discount as well as emergency travel health insurance. It may also be used as a Debit
MasterCard, but cash is still cheaper to use.
Food: Wong, Vivanda, and Plaza Vea are major grocery stores with many familiar products and
some unfamiliar produce if you know to look for it.
Pharmacies: Many antibiotics and acetazolamide (for altitude) are very cheap in the local
pharmacies with no prescription required (if you choose to self-diagnose).
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Tourism: Buy a package tour that includes transportation (train from Cusco to Aguas Calientes,
Bus from Aguas Calientes to Machu Picchu, and entrance to Machu Picchu). You will also be
asked to buy a Boleto Turistico to see many of the attractions. An ISIC card provided 50%
discount if under 25 years of age.
Summary of expenses and money-saving tips
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Flight JFK-Lima – 600$
Apartment x 1 month – 350$ (700$ for 2 people)
Hostel + tour in Cusco 5 days/nights – 400$
Food – 400$
Transportation – 100$
Spare cash for shopping and emergencies – 500$
Places to Visit
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Larcomar – shopping center and restaurants by the ocean (first pictures of this report)
South of Lima – beaches
Centro de Lima – downtown (below)
Calle Capón – Chinatown (right)
Cusco and Machu Picchu
Cusco
Cusco is a much calmer, quieter city than Lima. It is in the South of the country, away from the ocean,
and is located at high altitude, in the Andes mountains. We decided to take some Acetazolamide (500mg
daily) a day before reaching the altitude to get our bodies to acclimate faster. I actually noted some
symptoms, tingling in my fingertips while taking the pills. Once in Cusco, this continued for the first day,
and after that, I decided the side effects of the pills were worse than the effects of the altitude and
stopped taking the pills with no further symptoms.
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We stayed in a hostel where we purchased a package tour, including transportation costs to see the
surroundings of Cusco, the Sacred Valley and Machu Picchu. This strategy was very highly recommended
by everyone we knew in Peru and we noticed many tourists and locals making the same decision. In
February, the Inka trail is closed because it is the rainy season in the Andes. In March, it is possible to do,
but the risk of rainfall is high. It is a 4 day walk, and if you plan to walk the trail later in the year, the
tickets run out very quickly and are limited. The tours introduced us to many of the Inka traditions,
which still persist to this day. We also heard the native language Quechua that has survived Spanish
colonization. In a food market in Cusco, we can see the word bread in Spanish (Panes), Quechua (T’anta),
and English (Bread).
Another trick we used to avoid altitude sickness is drinking ‘mate de coca,’ which is tea of coca leaves.
There is also a candy that is sold prevalently to provide coca. There are no psychogenic effects of coca
because it has to be heavily processed before it take the chemical form of cocaine.
Machu Picchu
Machu Picchu is breath-taking. It is the ruins of an ancient community from the Inka empire. Next to it is
Huayna Picchu, a mountain open to climb (on stairs). We took 3 hours to go up and down, catch our
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breath and take many pictures. And spent the rest of the day taking a tour of Machu Picchu. We learned
that in a room with ‘espejos de agua’ (mirrors of water) the women of the ancient village would grind
potent herbs to serve as medicinal agents to take care of the sick.
Our trip was unforgettable and absolutely worth the effort in research and fund-raising. It was an eyeopening experience to see health care in conditions that are different from the standards in the USA. I
now appreciate the benefits we have to practice and to get treatment at a level that a minority of the
population in Peru can access. Culturally, Peru has so much to offer, and Lima alone has numerous
neighborhoods with distinct appeal. For those who are interested in a culinary experience, Peru has
some of the best food to offer and is renown especially in South America and the world for its unique
dishes (I could even write a separate report with pictures on my food experiences alone!). We made
many new friends there and found everyone to be extremely warm and welcoming and made our
experience truly amazing.
For any questions or information about contacts: [email protected]
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