For the past few weeks, I have been living in Iquitos, Peru and rounding at the regional hospital (Hospital Regional de Loreto) as part of a Global Health elective that I applied for through a foreign university.
We are here to see what medicine is like in another country, learn about the challenges of delivering health care that are particular to this part of the world, and broaden our understanding of the practice of medicine in a lower-resource setting. Personally, because of my academic interest in safety and quality, I am particularly curious to learn more about how surgical and anesthetic care is provided here. (Read more about global anesthesia here.)
The Loreto region is comprised of 8 provinces in the northeastern part of Peru that together cover almost a quarter of the landmass of the country. The region’s population (1 million people) is concentrated in Iquitos and a few other major cities, while the vast majority of the land (Amazonian rainforest) remains uninhabited. The population density averages out to 1-2 people per square kilometer.
In preparation for this trip, we were asked to read La Doctora: An American Doctor in the Amazon by Dr. Linnea Smith, a physician from Wisconsin who decided to establish a clinic in Loreto (not too far from Iquitos) in the 1990s and provide care to the people who lived here. That is to say that we had some description of what we might encounter.
Several things have struck me about this experience so far.
First of all, the Hospital does fine with the resources that it has. Yes, it lacks the luxuries of a hospital with excess money to spread around, and its physical plant could use significant renovation, but it honestly seems that the conditions are no worse here than at some of the hospitals I have seen in the US. Even the big-name ones. Most of the equipment is old or showing wear and tear, but it does not mean that it works any less well.
Second, I am gripped by the simultaneous paradox of access to medical care here. On the one hand, Peru essentially has universal healthcare for all citizens, and some get an extra level of care either through their employer or can pay for private insurance. All care is therefore free in this country, and if you need treatment, you get it at no cost. They also have free drug treatment programs for HIV, TB, malaria, and others. (My Peruvian colleagues are shocked when I tell them that there is a part of the US population that is not covered or is underinsured.)
But on the other hand, Loreto struggles significantly with geographic, linguistic, and cultural barriers to care. Since there are no roads between villages here (and any significant travel must be done via slow and difficult to navigate waterways), sometimes the patients who need help just physically can’t make it to an local Punto de Salud (which itself can be anywhere from 6-20 hours by boat to the province capital’s Centro de Salud, which itself can be 6-10 hours by boat to the Regional Hospital in Iquitos). Factor in extreme poverty (making prohibitive both the access to transportation as well as the time investment in the trip to the hospital), lack of basic education, lack of cultural support for sanitary living conditions (such as drinking only pre-boiled water, or using hygienic practice for the latrine), and general distrust of what medicine can offer – this means that many people are not even coming in contact with the care they need.
Despite all these challenges, I have found many more similarities than differences here. Some diseases might be more prevalent than others, and some barriers to access might be more difficult to overcome than others, but medicine is medicine, and public health is public health. Wherever you go, we all suffer the same types of diseases in the same ways. Physicians will always work to improve the lives of those who seek their care. We all want the same system-wide goals: access, coverage, quality, and safety.
Medicine is people helping other people – talking to, caring for, and supporting each other. It doesn’t matter if one place has newer equipment, newer facilities, or more financial resources. It’s not just the transaction of goods and services that matters. Medicine is as much a social act as it is a physical thing such as an injection, a pill, or a tube.
This experience coincides with my finishing reading the House of God for the first time, and I believe that the last three Laws of the House of God (quoted from a reflection by Samuel Shem penned “34 Years After ‘The House of God’”) apply especially:
“Law 15: Learn empathy. Put yourself in the other person’s shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.
Law 16: Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.
Law 17: Learn your trade, in the world. Your patient is never only the patient, but the family, friends, community, history, the climate, where the water comes from and where the garbage goes. Your patient is the world.”