Remembering Peru: What Those Who Made the Journey Had to Say
Nicholas Whipple, MD

Abstract
Each year, the University of Mississippi Medical Center (UMMC) Department of Infectious Diseases teams up with Project Amazonas (www.projectamazonas.org), a humanitarian aid organization whose home base is Peru. Together healthcare workers and humanists travel by boat to the wilds of Peruvian Amazon to bring aid and education to a beautifully hidden and underserved world of Amazonian River people.

The Medical Team
Two weeks of infectious disease training from physicians and professors in Mississippi, multiple vaccinations, and a bit of fundraising prepared the team for departure. Dr. Svenja Albrecht led our 2010 Project Amazonas team with Medicine Resident Elizabeth Paine and Medicine-Pediatrics Resident Johann Hsu at her side. Four M4s, Priya Srivastava, Christian Paine, Jennifer Samples, and Nicholas Whipple, brought the UMMC total to seven.

Caring for Caretakers of the Amazon
Nicholas Whipple, MD, Pediatrics PGY-2, University of Utah Medical Center, Salt Lake City, Utah: When we first docked on shore, a beautiful swarm of dark-skinned children ran to meet us at the Amazon River’s edge. Children between three and fifteen years of age began to board, many of them carrying a much younger sibling in arms. Little muddy footprints now decorated the bow of the boat, all excited to see American doctors coming to visit their small village. Hundreds of miles from any city with streets or lights, our UMMC team of one attending, two residents, and four students had finally arrived in Peru. Surrounded by a mysteriously attractive jungle and at the mercy of an untamed river, we had made it to the Amazon.

Each morning began with a delightful breakfast including fresh local fruit and juice—papaya, mango, chirimoya, guanábana, and maracuyá. Water pumped directly from the Amazon River below gave opportunity for freshening up and was much needed after a night of Deet repellant and profuse sweating. For 12 days, we traveled the Peruvian Amazon to remote villages in need of both simple and advanced healthcare. One village in the morning and one village in the afternoon was our routine with a break at midday for lunch and a swim in the Amazon. Our fourteen-passenger boat provided an excellent 15-foot-high launching pad into a river of gray and pink dolphins, piranhas and anacondas, and a steady traffic of thin wooden canoes which provided the only mode of transit for our Peruvian friends. In the evenings, a cool river breeze provided the perfect spot atop our boat for reviewing tropical medicine, reading fun books, and remembering our fun day. For those who dared, there were nighttime safaris through the dense Amazon jungle with our biologist guide, Devon Graham—rubber boots and more Deet being our only hope of prevailing against nature. And, just before bedtime, a quick inventory of the pharmacy helped prepare for another day.

To the credit of Peru’s government, each village boasts a school made of concrete blocks and mortar. Bright blue, yellow, and red paint often decorate the outside walls. Amongst a community of simple huts made from bamboo, palm leaf, and local wood—always raised on stilts in anticipation of rising waters and annual flooding—these schools stand as a sign of advancing civilization in each river village. It was in these schools that we set up clinic and made new friends. It was in these schools that we came to know a truer meaning of preventive medicine. It was in these schools we shared with the Peruvian River people how to enjoy safer, healthier, and perhaps more rewarding lives.

Teams of two sitting at old wooden schoolhouse desks welcomed recently triaged patients. Upon entering the clinic, each village resident was immediately given Albendazole to treat probable worm infestation, each sharing the same small red plastic cup for water. Their weight, temperature, and history were noted on pieces of 8 x 11 inch paper cut half wise. Along with each patient’s subsequent diagnosis and course of treatment, this information was later meticulously entered into an ever-growing medical database to promote research-based advances in care. Crowds of people lined the walls of each schoolhouse inside and out. We quickly became thankful for the simple architecture of our makeshift clinics, for it allowed a welcomed breeze to pass through easily.

Mothers of big-bellied children frequently gave histories of pinworm (nighttime anal itching secondary to small, white worms which exit the anus at night to lay eggs) and Ascaris (giant intestinal roundworms 15-30 cm in length that exit the GI tract via stool and emesis). Scabies was nothing less than endemic, for we could not count the number of times we applied full- body Permethrin Cream to cute, itching infants and toddlers. Fungal infections ran rampant and included tinea versicolor, corporis, cruris, capitis, and pedis. Urinary tract infections, otitis media, pneumonia, pharyngitis, amenorrhea, headache secondary to dehydration and unrelenting sun exposure, rheumatoid arthritis, osteoarthritis, trauma, conjunctivitis, pterygium, pinguecula, pregnancy, heart failure, and fever of unknown origin were conditions encountered daily. Less common and more devastating discoveries included scorpion and snake bites, physical findings suspicious for cancer (breast, cervical, skin), neurofibromatosis, genu varum, cerebral palsy, suspected Meniere’s disease, tuberculosis, malaria, and malnutrition.

Education And the Need for Change
In most villages there is a designated health promoter. This individual receives no remuneration and often has very few supplies at his command, yet he stands guard as best he can in preventing disease outbreaks and in transporting the very sick to the nearest health post for whatever medication is available. At the end of each village’s clinic day, the local health promoter met with our medical team to hold a year- in-review discussion. It was during these conferences that unique, perplexing cases were discussed, the severity of malaria season was reported, and concerns were resolved. Praise and training were provided them in the same rudimentary but sincere fashion a parent would congratulate a student for a commendable report card.
By the end of our jungle adventure, we were all spending as much clinic time educating patients as we were treating them. The following phrases became routine expressions: “Sir, you must allow Project Amazonas to build latrines in your community. Otherwise, you will continually contaminate your drinking water.”

“Ma’am, please boil your water and do not drink straight from the river. Your children will have fewer episodes of bloody diarrhea if you do this.”

“Citizens, bathe and wash clothing downstream from your water source. Drink two liters of water a day, instead of two glasses, and we promise that your headaches and fainting episodes will subside.”

“If your infants and toddlers must ride in a canoe, please have an adult and not a 7-year-old accompany them.” Similar to our own problems of obesity, hypertension, and diabetes at home in Mississippi, the major medical problems facing Peru, we learned, are largely preventable—choice, personal drive, and education being the key determinants of success.

There is a growing, in fact spiraling upward, trend of global outreach to the medically misfortuned. It is penetrating every country and climate and becoming curriculum
at all medical institutions. I finally came to appreciate, after a week in Peru, what must become ubiquitous in these extracurricular excursions if there is to be sustained success—namely, education. Education will promote long- term change more effectively than temporary treatments and yearly Albendazole, albeit necessary they are. Repeated moments of both spontaneous and orchestrated education will slowly though surely teach stepwise behavior changes that will build communities and improve health. Education, time-consuming and usually frustrating, is what will, in the end allow our friends along the Amazon River—and at home in charming and quaint towns near our own mighty river, Mississippi—to take control of debilitating diseases and untimely handicaps. In the form of fireside chats, colorful pamphlets, encouraging encounters, or relay races, we can provide this. We were thankful for the opportunity and pleased to provide our new South American friends with education on preventive health care and progressive reform.

We will miss the welcoming parties of elementary school children who loved to board our boat and have their picture taken. We will miss the minutes shortly before sundown when we put away our books and stared at the Amazon and its jungle. We will miss the muddy walks uphill to schoolhouses, the skinny canoes floating by, and afternoon swims with the dolphins. We will miss the thrill of tropical diagnosis, the circus of jungle animals made pets by the villagers, and watching Peruvian children nap in hammocks. We will miss little Eduardo and Lupe asking for money and food in Iquitos before boarding our boat. We will miss trading clothing, fishhooks, and batteries for beautifully crafted arts, woven baskets, and tribal masks. We will miss little Ruth Katerina and her proud smile while wearing new clothes at the fiesta in Comandancia. We will miss grateful mothers leaving clinic with vitamins for their children and a resolve to boil drinking water more frequently. We will miss our new friends and their lovely world along the Amazon River. And we are grateful that UMMC will have the opportunity again each year to visit them, to help them, to love them.

Priya Srivastava, MD, Pediatrics/Psychiatry/Child Psychiatry PGY-2, Mt. Sinai Hospital, New York, New York:
Last February, I was fortunate enough to travel with Project Amazonas to Peru, my first medical trip abroad. While I knew that medical care and resources in Peru would be grossly inadequate compared with those we have available in the U.S., I was nevertheless surprised by how much I had to rely on my own medical judgment rather than lab tests to diagnose and treat patients. Adding to this enhanced sense of responsibility,
I knew that my treatment and instruction would have to be even more comprehensive as these patients would not receive follow-up care for several months, or perhaps, not at all.
I walked away from this experience with a greater confidence in my ability to rely on clinical history and physical exam. More importantly, I developed the desire and a sense of responsibility to seek opportunities to practice global medicine again in the future.

Devon Graham, PhD, President / Scientific Director of Project Amazonas, Inc.:
Over the past 10 years, Project Amazonas has partnered with the University of Mississippi Medical Center in conducting medical service expeditions in the Peruvian Amazon. These trips have treated many thousands of patients living on isolated rivers, providing curative and preventative care, education, and improving overall health standards in indigenous and mestizo villages in the region. Equally important, UMMC students and faculty have worked closely with Peruvian colleagues, developed professional contacts and friendships, practiced tropical medicine and medical Spanish, and experienced what it is like to work in situations where the most basic laboratory and diagnostic resources are non-existent. Exactly the sort of people I’d want on my side in the event of a natural or other disaster back home! Mississippi can be justly proud of the training and professionalism of UMMC staff and students, and I’m delighted to have this opportunity to express my thanks on behalf of the people of the Peruvian Amazon.

Svenja Albrecht, MD, MPH, Assistant Professor of Medicine, University of Mississippi Medical Center:
Over 60 UMMC trainees and faculty have participated in our medical outreach in the Peruvian Amazon. For many North Americans this is often the first exposure to healthcare in a developing country, and participants have benefited from the opportunity to see tropical diseases firsthand. This program has allowed our trainees to encounter and solve health challenges unique to the tropics. The biggest benefit, however, comes from witnessing the improved health of our local partner communities.

Acknowledgement
Indeed, a debt of gratitude is owed to our supporters who made the trip possible— UMMC Department of Infectious Diseases; Central Medical Society; Children’s Medical Group; local churches; and Drs. Jerry Clark, LouAnn Woodward, Helen Turner, and Frank Bowen. UMMC dental students greatly supported our cause by providing over 400 toothbrushes and tubes of toothpaste to distribute to dentition- poor Peruvian patients. For your time, unselfish donations, and support, we thank you. For the change you made possible and the experiences you created, Peru returns its love.

Correaponding Author: Nicholas Whipple, MD; 150 South 800 East, #D4, Salt Lake City, UT 84102. (nicholas.whipple@hsc.utah.edu).