Healthcare

Because I am working and studying medicine here, I decided to try and describe the Peruvian medical system. I use the word try because language and opinion are big obstacles. Even when you know the language and work within a system, it can still be difficult to compose a concise, understandable and accurate description. I know because I found it to be similarly difficult when I worked in Canada and the UK.  Forget the US.  Please don’t view this as a whitepaper report. These are my observations from watching, listening and asking some questions. It focuses on my encounters which are mostly in hospital. I have little doubt that there are nuances that I have missed along the way.

For hospital care, there are essentially 3 tracks.   As in the US, you are responsible for your bill, less that part covered by any insurance you might have. The private option is just that. I don’t know if people who utilize this system have insurance or if this is all out of pocket. The appearance of the hospitals and clinics suggest that at least the quality of the facilities if not the medical care is superior to that found elsewhere. I have never visited one of these. There is also what some people refer to as social security. This is a system available to everyone (?) who has a job.  These people have public insurance that is subsidized by employers and employees. Who pays what toward the insurance depends in part on the work that one does. The actual  opperation has evolved over the past 15 – 20 years so it is a work in progress.  Not unlike the US, your coverage has limitations. The third group includes those who are poor and have no insurance.  These patients find themselves in large wards holding 6 or more people.  And many of these people put off seeking care until they are really quite ill.  Ironically, often they turn out to have conditions that are covered by government programs (see below).  I have no idea about the insurance status of most of the patients that we see at UPCH and the other facilities but I do know that at least part of our tuition here helps to subsidize care for some of our patients. 

It is not clear to me that there are COBRA-type regulations in Peru, where everyone is entitled to a screening evaluation and medical stabilization regardless of one’s ability to pay. In the US the definition of this level of evaluation and treatment is very broad and can be quite intense and comprehensive in part because of medical legal concerns. Although US hospitals ask about insurance coverage in the emergency department (ED) no one can be denied an evaluation, care or admission for stabilization of a serious medical problem. Most of the time, decisions about testing and treatment are not consciously weighed based on a patient’s ability to pay. Our system seems to do what is necessary and then hand over the bill. Things are different in Peru. It is clear that testing and medical treatment are predicated on the cost and therefore a person’s ability to pay for it. Tests and treatment can and are withheld for financial reasons. I have seen more than one person await necessary and important surgery, because as I understood it, a surgeon willing to do what amounted to charity work could not be found. The financial consequences are more in the forefront here while in the US we act first, sometimes bankrupting our patients afterwards.

There are some caveats. A hospital bed is much less expensive in the public hospitals. There are also physicians who see patients without apparent regard for a person’s ability to pay. Some work in more than one venue, earning their income one place and doing work pro bono in another.  Those who I have met are compassionate and dedicated to do their best with limited resources. It is remarkable how creative they can be when diagnostics and medications are limited because of money concerns.

Before you allow your indignation to get the better of you, there are some other wrinkles here that, quite frankly, embarrass me about our own system, such as it is. Certain people and diseases are covered by the government. These include HIV/AIDS, tuberculosis (Tbc), sexually transmitted infections (STI), pregnant women and children up to at least 2 years of age. Peru is not a wealthy country but some forward thinking people within healthcare have made some hardball decisions about where to focus limited resources for the biggest bang for the buck. There have been conscious, medically sound decisions about which to include. For example, all children receive vaccinations for free. Although kids receive most of those given in the US, decisions have been made based on epidemiologic factors such as infant mortality data. They do not administer varicella (chickenpox) but do give BCG, against tuberculosis. It is possible to point to monitoring data and demonstrate the validity of these decisions based on concrete results. The other really interesting feature is the community clinic system that is an integral and important part of sound, affordable health care policy.  I will say more about this later.

PS

It turns out that the women controlling traffic from the booths do not wear the jodhpur-style slacks.  Those are reserved for officers on motorcycles, including the men. 

It is amazing what you learn if you keep your eyes open.

DJ

A day in the life

As each week goes by, I feel like the victim of a frontal assault. Yet another different presenter offers wave after inevitable wave of new information. Don’t get me wrong, I am not complaining. This is what I signed up for. They have delivered on all of their promises and then some. My knowledge (I hope) keeps growing.

Taken as a whole, this is an outstanding course. Their evolution seems similar in many ways to what we have tried to do at Wilderness Medical Associates. I have picked up some good ideas from how they do things. Like us, they hand out a printed version of each PPT lecture. Because they use 6 images per page, some of the graphs and charts are nearly impossible to read. 3 per page would make everything more readable but would double the amount of paper. I would have to hire a caravan to get everything home. Fortunately, we have online access to all of the lectures until we leave in April. This is great because you can read the charts and see the color version of all of the picts shown in class. We also have a case study book, much like our SOAP notes book, in which we can record information about all of our patients.  Combined with the photos of x-rays and other clinical findings recorded and shared by one of our group, we will leave here with some wonderful clinical information.  The lab sessions relate directly to things that we have already covered in class – e.g., microscopy of parasites. On some days, instead of a lab, we use case presentations to generate discussions about some important and interesting topics. These discussions can revolve around different clinical manifestations of a disease, differential diagnoses of a a symptom complex or dilemmas in treatment. They are frank and with regard to treatment, don’t always agree with the CDC, WHO or Partners in Health.

The late morning and early afternoon sessions (clinic and lab/discussion) are conducted with small groups. These are the most fun for me. There are 5 – 6 people in the clinical group; 8 in the lab/discussion. Each of the 2 groups is composed of different combinations of people. You stay with each for the full nine weeks. It is obvious that they tried to mix the groups up to reflect the heterogeneity of the class. Personally, I relate most closely to my clinical team because it is smaller and we talk about our patients in a more intimate and interactive way. This group includes two Canadians. One is a family practice physician who has finished an infectious disease fellowship and is now doing one in critical care medicine. The other is a nurse from BC presently doing ED locum work in RI. There is an infectious disease fellow from the Dominican Republic, a family practice physician from VT, and an internal medicine resident from Boston who will ultimately do dermatology. Each is motivated and bright.  I will say more about them later if they give me permission. The other group is equally diverse.  It is a pleasure to be with either group. 

In general, we are given an introduction to a topic and then revisit it in different formats several more times. Malaria is a good example. It has been covered in one form or another each week. After some introductory information we have talked about the 5 different types, their natural history, prevention, diagnostics (high and low tech) and treatment of both routine and life threatening presentations. In the lab we have looked at smears, made them (thick and thin), seen the rapid tests, and then looked at smears again. On Friday, we spent nearly 6 hours looking at pictures and then perused known and unknown slides. We got another chance on Sat including a guided tour on a multiuser scope, driven by an expert from Montreal. Then at the end of the course, we will traveling to Iquitos on the Amazon to visit a malaria research station (think Fitzcaraldo).  Malaria is much more complex than I realized but, with some apprehension, I believe I could approach a potential case with some confidence. That represents a huge amount of progress.

I am working on a couple other dispatches but given my writing skills, they are taking a long time. I hope this will suffice.

DJ

Getting to know Lima

Living and working (or going to school) in another country is a wonderful experience. It allows for a more relaxed pace than tourism and therefore more of an opportunity to learn about the people and the way of life in another place. It should come as no surprise that this will not be about the subtleties of cerviche or some of the other Peruvian delights. I am an observer of behavior; I don’t let my local illiteracy get in the way.

There is no better way to get a sense of your surroundings and see people in action than to watch and be involved in traffic. Each place has its own rules and customs. Those of you who have traveled outside of N America and W Europe have some idea what I am talking about. Lima is no different. Although I don’t drive here, I walk a lot and each day we ride a bus more than 45 minutes to and from UPCH. When I can, I ride shotgun.  This is a wonderful vantage point from which to observe Lima’s own brand of chaos and convention.

As in the US, there are traffic control lights to help manage flow. On the whole, people obey intersection lights much like we do, pushing the late green to early red. Curiously, there are also traffic lights in some of the traffic circles (rotaries /roundabouts). A stream of traffic can be stopped right in the middle of the circle by a red light to allow a fresh stream of vehicles to enter it. This system works surprising well during rush hour. Eventually everyone gets in. Getting out is a different story.

Where there aren’t traffic lights or where bottlenecks occur, police officers help control the flow. Without exception each one that I have seen is a young and attractive woman. Each wears her hair pulled back tightly in a bun, covered with a hard hat. All of them wear a crisp tan uniform that includes very tight-fitting jodhpur-like slacks. None is overweight. Whether they are stationed in curious little elevated booths located off to the side of the road or standing out in traffic, with whistle in mouth they have a remarkable degree of control. The other night I walked up to a usually busy intersection and found it completely gridlocked. The intersection was uncontrolled – no traffic lights or stop sign . Blaring horns and flashing headlights were no more effective here than anywhere else. But then, one of these traffic control officers materialized out of the darkness on a small motorcycle. She drove it onto the sidewalk, pulled it up on its stand, and went to work. Wading into and contributing to the cacophony with her screeching whistle, this young woman took control. With her arms waving and pumping she muscled and finessed the traffic back into its usual disorder. In less than 15 minutes she left as stealthily as she had arrived. It was a scene out of the Lone Ranger. Where does this control come from? Perhaps these women appeal to a secret desire to be controlled by mother or some sort of mistress in the uniform of a disciplinarian. All they need is a riding crop.

Traffic flow and navigation are mysteries to me. What they do and how they respond probably says something about Limeños (not Limones, those are lemons). In heavy traffic, the goal for all of us is to get ahead to get home.  The goal may be the same in Lima but drivers here have their own unique twists. In Lima, the concept of yielding does not seem to exit. There are very few such signs.  If they are observed, they are not obeyed. Size and position rule. Opportunity is also important. Drivers straddle lines, signaling in one direction while veering subtely toward the other. I don’t believe that these are acts of willful deception.  Rather, they seem to indicate that any action is possible. As a result, very close calls occur moment to moment but actual collisions don’t seem to. I have not seen one despite MANY opportunities. The most amazing move, however, is the right hand turn from the far left lane, turn signal optional, direction unimportant. Although these turns feel and look impulsively dangerous because of how abruptly they are executed, I have come to realize that this and other similar tactics are neither.  As traffic creeps slowly but surely forward en masse, no one yells, gives a finger or otherwise expresses anything other than determination and resignation. 

The concept of pedestrian right of way is simple to understand here, there is none. Size and speed matter. Horn toots and flashing lights somehow modify intent and meaning but the subtleties of these messages escape me. Most turning vehicles (and all taxis) accelerate as they approach uncontrolled intersections. These attitudes help to define the concept. At an intersection, drivers look past you to oncoming traffic. If there is space, they continue accelerating into and through the turn as they move ahead. Although crosswalks are not demarcated by the familiar thin, double, parallel lines that run perpendicular to the flow of traffic, they have what I thought were the other style. At many intersections, whether or not controlled, they have wide and fat, white parallel lines painted parallel to the flow of traffic, marching from curb to curb like a column of hypens in tight order.  Many are preceded by a broad, white line.   At home, these mean traffic must stop for any pedestrian in the area bounded by them. Not here. As best I can tell, their purpose is to highlight a person crossing the street by offering a contrasting background. It is like shining a different color light on a target from behind for better visibility. Again, I have never seen anyone hit. I don’t’ push my luck.

DJ

Ticlio trip

I am rested this AM after our tour up the W side of the Andes.  Going from Lima to 4800+ m in 5 hours is a big jump.  At rest my oxygen saturation dropped from 96% at sea level to 69% at Ticlio.  It improved to the mid 70s once I got up and around.  It was one of the lowest in the group.  I felt a little lightheaded so I was reluctant to walk around much on the surrounding rocks.  Tandem gait was okay but I was unable to recite a few things that I knew well.  It was very difficult to stay focused. 

One’s ability to adjust at altitude is highly individual.  It depends on climbing strategy and genetics.   Above 2500 m or so, the safest and best way is to ascent slowly and take appropriate rest stops.  Drugs are sometimes used as well.  They fool your body and compensate or provide shortcuts.  Purests view them as cheating; highly motivated, goal oriented climbers view them as a way of life.  Suffice it to say that we did not take sufficient time for acclimation and no drugs were involved.  Normally, I seem to do fine up to 6000 m as long as I take my time.  I would like to blame my Mom and Dad (genetics) but my Dad is dead and my Mom wouldn’t know what I was talking about. 

Headches are a big feature of altitude travel.  Interestingly (at least to me), I did not develop one until an hour or so later, when we were down below 2000 m.  While at the top, I did have some scotomata (flashing irregular lights) and obscuration in my peripheral fields.  I infrequently have migraine equivalents that are characterized by these kinds of symptoms.  The headaches that follow are annoying, not the brain splitters that many people experience.  Part of the pathophysiology of migraines has to do with vessel dilation.  The same thing happens with altitude because of low oxygen.  Curious.  Did I have a migraine or an altitude related headache?  This has never happened to me at altitude before.

There is also research to suggest that our brains are much more vulnerable to altitude effects when we don’t acclimate.  That is a topic for a WMA blog.  So what was I doing up there anyway?

DJ

First impression

Lima is an enormous city, 8 million I am told. I am living in a section of the city called Mira Flores. Its major roads begin at the Miraflores Oval and then radiate out like the spokes of a wheel. They end at the rim, a coastal cliff at least 100 m (over 300 ft) above the beach. The coast is oriented NW to SE. There is a coastal road below and a thoroughfare along the edge made up of a continuous series of quiet streets that contain Malacon in their names. It is pretty upscale. There is a well-maintained park with running and bicycle paths paralleling the Malacon. The park is populated by painted cows – seriously. It is part of a campaign to raise money for charity. We had something similar in Portland a few years back. Instead of cows, they were lighthouses. The temperatures are moderate (mid to upper 20s down to low 20’s/lower 70s to lower 80s) and with the breeze, very comfortable day and night. Despite the proximity to the Pacific, I am told not to expect any rain in Lima. In fact there are areas S of here that quite literally never receive any rain.

Mira Flores and its neighbor, San Isidro, are pretty prosperous. The course directors did not make this choice serendipitously. There is a lot to do and the food is good. It also seems generally clean and safe, especially compared to some parts of the city that we travel through on our trips to other hospitals outside of our home base at the Universidad Peruana Cayetano Heredia (UPCH).

We are carted off to the UPCH at 0715 and then deposited back in Miraflores at about 1730. The campus itself looks like a low security “green zone.” The area is fenced in and entry is controlled at a security gate. Our day begins officially and promptly at 0800. This makes me feel right at home. The only difference is that I am sitting looking toward the front at one person rather than back out on a pod (or is it gaggle?) of students.

The morning consists of 2 one hour talks followed by a 2 hour, small group clinical session. At the later, we review the relevant clinical information, perform focused exams and then discuss possible causes and treatments of 3 – 4 interesting patients. After lunch, we participate in daily labs (malaria introduction and helminths or worms this week) and then attend a final 1 ½ hr lecture. There are field trips on some Saturdays as well. Tomorrow, for example, we head to the Andes to look at working conditions in some of the high altitudes mines.  Our final destination will be at about 4700 m (over 15000 feet).  On the whole, this seems like a well thought out course that is packed with great information.  It is and will be a challenge for me. 

We have 32 students from around the world but most are from Canada, Australia, and the US. Infectious Disease physicians are heavily represented. They all seem bright, knowledgeable and eager. I will talk about the trip if it is interesting and give a little better idea what a typical day is like later.

The word for the week is tuberculosis.

DJ