In July 2006, Dr JON COSSAR Vice Dean, Faculty of Travel Medicine RCPSG, celebrated his 60th birthday at 5,895m atop Mt Kilimanjaro. One year on and for those who reckoned his 61st would be a bit of a downer, he came up with an equally exhilarating experience at sea level. We just wonder how on earth (or where) he will be celebrating his next birthday!
Hands-on travel medicine in Peru’s Amazonia
Having heard about the work of the Vine Trust, I made contact and after an enquiry was allocated to a team scheduled for the Amazon Hope 2 (AH2) last July.
Not surprisingly, this stimulated a number of anxieties and apprehensions, both professional and personal. The professional concerns included having adequate skills for the task, no longer being in active clinical work, unusual and unfamiliar illnesses, an uncertain clinical working environment, very limited access to supportive clinical investigation, and restricted and unfamiliar availability of medications.
My personal concerns encompassed the exposure to new, exotic pathogens, hazardous flora, fauna and disease vectors, language inadequacy and uncertainties about what was expected of me as well as limited or no knowledge about the composition, skills and personalities of my team colleagues.
Not for the faint hearted
Pre-departure guidance notes included information on the Peruvian Health System, a typical drug formulary onboard ship, prescribing policy, common illness presentations, recommended immunisations, health advice and a “kit” list.
Also – alarmingly – I found the protocols in the event of severe or life threatening illness or accident in the local people or in members of the medical team (evacuation by seaplane), all rounded off with the Australian Management of Snake Bite! Although comprehensive, there remained many unanswered questions.
The outward journey began at 3 am UK time and ended at 12.30pm Peru time the next day, encompassing a total of 39 hours. This included the time shift (+six hours), three flights, four hours in bed and a final three and a half hours on a fast boat to reach the AH2.
We had lunch on arrival, then were asked: “When can you start?” By 2.30pm consultations were underway.
Multi-national and multi-skilled
Our multi-national team was comprised of two doctors (Scotland and Canada), three dentists (Scotland and Isle of Man), one nurse (Scotland), one medical student (Scotland), one translator (England), and one translator and medical student (Trinidad and Tobago) – along with a Peruvian doctor, nurse, midwife, laboratory technician and translator.
Amazingly and reassuringly, our broad skills mix of general practice, travel medicine, emergency paediatrics, operating theatre work and dentistry were complementary and met the medical needs of the indigenous village populations which ranged from the acutely ill adult/child requiring intravenous therapy to the more mundane.
A typical day could begin at 5.30am with an optional exercise class, then morning devotions (7am), breakfast (7.30am), a village walk (8.30am), consultations (9.30am–1pm), lunch, more consultations 2.30–4.30/5pm), football/volleyball match in the village (usually losing), dinner 7pm and staying awake until 9pm (on a good night!).
The boat would move on to another village location in the evening, early morning or occasionally at lunchtime.
Bonding as a team
The Peruvian medical team, translator and boat crew (captain, engineer, cook et al) were extremely supportive and helpful. They were not only fellow work companions, but also became our good friends – essential in such a close working environment with 23 of us in total sharing confined facilities aboard ship. Although there were physical and psychological stresses to endure we bonded as a team and “felt special”.
During our nine days on AH2, over 850 indigenous Amazonian villagers attended the boat for medical treatment. Conditions treated ranged from snake bite, the acute abdomen, the “fitting” child, life-threatening dehydration, osteomyelitis, abscesses, and malaria to the removal of a bullet. There were also as many cases of skin infections/ infestations, and diarrhoea and vomiting.
The diagnostic breakdown (approximate) was gastro-intestinal 15 per cent, anaemia 12 per cent, musculo-skeletal 10 per cent, urogenital seven per cent and “other” 36 per cent, many with multiple diagnoses.
Everyone attending was treated for parasitosis (an additional 732) and we also provided childhood immunisations and antenatal care. The dentists carried out over 100 fillings and 250 tooth extractions.
Reaching the poorest
There were conditions which were outside the scope of our treatment resources, but it was a comfort to be able to advise that as from 1 August 2007 a law had been passed in Peru such that medical treatment is to be freely available to the poorest.
This still leaves the problem of transport and associated costs in getting to Iquitos, the largest jungle city in the world which is accessible by boat/plane but not by road. This is the nearest and only available medical facility.
There were times when we all felt inadequate and overwhelmed by the sheer scale and nature of the problems we encountered. Perhaps we gained a relevant perspective faced with the reality of the Amazon at Iquitos, some 2,000 miles from the Atlantic and yet still over a mile wide with a drop in level of 30-50 feet between the wet and dry seasons. One of nature’s true “giants”.
Suddenly the nine days, which initially seemed to stretch ahead in an almost impossibly daunting timeframe, came to an end. The boat took one and a half days sailing to arrive back in Iquitos and there we visited the clinic in Belen and the residential school for orphan boys at Puerto Allegria, facilities run by Scripture Union Peru, an associate partner of the Vine Trust in Peru.
Then time to leave – and reflect
For some it was straight back to the UK and for others, a few days to take in the tourist sites of Lake Titicaca, Machu Picchu or Cuzco before returning.
The whole experience, although personally and professionally testing, was hugely rewarding. It engendered great admiration for the dedicated, local medical and support team who undertake this work on board ship every three months with unknown alternate UK and USA teams of volunteers and who, between times work in the Belen Clinic, a district of abject poverty and squalor in Iquitos.
It was a great opportunity for the medical enthusiast, for minimal “high tech” interventionist medicine and certainly for maximum use of age-old medical skills, like basic history taking and clinical examination. And with it came a realisation that although the local problems seem almost insurmountable, even small contributions can make a difference.
And finally there was the humbling experience of a generous smile or a token piece of handicraft from people who have such a small share of the resources of our world – people who have so little access to health care facilities and yet exude such genuine appreciation for the efforts of the medical team.
More about the work of Vine Trust at: www.vinetrust.org