Cusco

Aside from a few words for directions and foods, my only solid recollection from high school Spanish was a section in one of our books on Cusco and Machu Picchu. It was the first time that I recall seeing the famous image of Huayna Picchu and the surroundings. Despite the years of fascinations, I have never traveled there. It has become a very popular tourist destination, the biggest by far in Peru. Inevitably there have been efforts to gain permission to route a local tramway directly to the site and build hotels locally. Beyond development in Aguas Caliente (a 30 minute bus ride away) the jackals have been held at bay, in part because Machu Picchu is an UNESCO World Heritage site. Knowing of these omnipresent threats and hoping to see it before things get worse, coming to Peru and Cusco really excited me. The rains this summer (here) washed away my hopes and I must say disappointed me. I should not have been. As a result, I was able to spend more time in Cusco and travel to some of the other sites in El Valle Sagrado de los Incas (the Sacred Valley).

Cusco is located about 1200 km (720 mi) south and east of Lima by air.  Because it is at 3400 m (over 11100 ft), all of us had to make an adjustment to a significant increase in altitude. The course organizers offered, and in fact encouraged everyone to take acetazolamide. Ideally, a leisurely ascent in incremental steps over a few days is preferable and usually makes medication unnecessary. If there is no alternative to a rapid ascent (e.g., flight in here), chilling for a couple of days is another acceptable acclimatization strategy. Our tight schedule made both of those choices impossible so the medication option was a reasonable one. Because it was free and I had never tried it before, I waddled up to the trough with everyone else for my share.

Acetazolamide is used to help one adjust more quickly to the consequences of the low oxygen content at altitude. The short version is that it stimulates breathing. Increasingly rapid respirations decreases the amount of carbon dioxide in the lungs leaving more room for oxygen.  As a result, there is more oxygen available for red blood cells to pick up as they circulate through the lungs. Additionally, acetazolamide neutralizes the normal physiologic consequences of rapid breathing, adjustments that would otherwise slow breathing down. This is especially important at night when you are asleep. Acetazolamide buys your body some time. I found it not unpleasant; I would use it again under similar circumstances.

Given that it is a big tourist destination, Cusco is a wonderful place. We stayed in an old section of town surrounded by open plazas connected by streets and walkways.  There were a lot of people there but you could escape them with little effort.  The larger streets were lined by small shops.   Being a walker and not a shopper, I was drawn to the walkways and smaller side streets.  These later thoroughfares where bracketed by tall outwardly sloping walls constructed of large stones, placed in the familiar Inca construction style. Unlike brickwork that is orderly (and monotonous), the stones used are of various sizes, laid up bereft of any notion of parallel lines or symmetry. Unlike typical stone construction up north, they did not use mortar. The resulting effect is interesting, paradoxically logical and very pleasing to the eye. That they have been around for hundreds of years is a testament to the style and technique. Where more modern construction had been employed, the walls were clearly less stable. I saw a number whose bulging sides were being restrained by wooden poles, each wedged in at an angle between the wall and the cobblestone surface of the street.  I don’t think any of them will last anywhere near 500 years; one, maybe.  It reminded me of La Sagrada Familia, Antonio Gaudi’s unfinished cathedral in Barcelona. Finishing the project after the Spanish Civil War has been difficult in part because no one remembers how to reproduce the design effects using his style of construction. How soon people forget.

Depending on your inclination, the walkways and narrow streets could have a menacing, claustrophobic feel or an inviting one, close and intriguing. They were cool and often damp because of the rainy season. Some were steep; most had a shallow v-shaped contoured surface, presumably for water drainage. All were cobblestoned. Walking was a joy because the you never knew what to expect 20 m ahead or around the next corner. Although not as grand in scale, not unlike Rome, sometimes one of the little side paths opened up into a courtyard with a garden and other interesting structures. Of course, sometimes it was tourist schlock. In three directions, these roads and walkways led up, eventually revealing an elevated view of the city. Except for the churches, most buildings were no more than a few stories high in this section of town. The view from each vantage point at these heights was of a sea of  rounded, terra cotta-hued tiles, open courtyards and plazas with hills in the distance.

The food in Peru is very good if a bit light on vegetarian cuisine. Surprisingly I had no difficulty finding a variety of good quality vegetarian food in Cuzco. This is probably in consideration of the tourist here. There were few beggars but I lot of people selling local goods on the streets outside of the many shops. Although persistent, a polite “No, gracias” was usually enough to send them off to someone else.

I will talk about the Inca sites next time.

Medicine in Cusco

 After landing in Cusco (see separate post on Cusco), we were given a couple of hours to get settled before heading off on clinical rounds at Social Security (SS – for the working insured), public, and catholic charity hospitals.  The visits were followed by some case study presentations.  The hospital patients had been scoped out by the Gorgas staff just before our arrival.  They were either newly arrived or people with diagnostic dilemmas. 

This was not Lima.  Although the SS hospital seemed fairly well equipped, it was hard to get a real feel for it because we only saw patients in a clinic-style venue.  The public one was pretty well staffed but it was apparent early on that the resources for evaluation and treatment were not what we had seen in Lima.  This was particularly apparent with the sick kids we saw, 3 with significant and complicated osteomyelitis (bone infection) and one with a serious infectious encephalopathy characterized by fever, confusion, and rigidity.  (No, this time it was not rabies.)  One real surprise was seeing 2 cases of malaria, surprising because malaria is not found above 2000 m (about 6600 ft) in Peru.  Both were locals who had returned from the jungle.  In tropical medicine, the travel history is VERY important. 

The local staff accompanied us on our rounds.  They were polite and open but it was clear that to some degree they were struggling with our presence.  We wanted to understand their limitations and offer what we hoped would be useful insights and suggestions.  But they knew where we were from.  Our curiosity, incredulity, and compassion were not easily hidden and could have been (and probably were) misinterpreted as judgmental.  I know the feeling.

My favorite visit was to a catholic charity hospital.  They provide care for the poor in busy outpatient clinics and in hosptial wards with limited services.  We did hospital rounds on several patients there.  Most of them were receiving daily treatments with an expensive and potentially toxic medication for leishmaniasis, a relatively common parasitic infection in Peru that causes disfiguring skin lesions.  We also met one unfortunate young man in his 20′s with newly diagnosed, advanced liver cancer related to an ongoing hepatitis B infection.  (They were trying to arrange for treatment for him.  Hepatitis B vaccine is now required for all children.)  All of the physicians there are sisters.  It was an incredibly peaceful and clean environment maintained by an industrious and conscientious staff.  There were no televisions, video games or other noisy distractions.  It was clear that the men on the 2 wards were grateful for the compassionate but no-nonsense treatment that they were receiving. 

We also saw a man in his 40’s with a  very large Echinococcal cyst in his right lung.  This condition is caused by larvae that hatch from ingested dog tapeworm eggs.  Its size and location pose considerable risk for spontaneous rupture and death if not fixed.  The necessary surgical treatment is complicated and, for a poor farmer with little money and no insurance, prohibitively expensive.  One potential option was for him to apply for and receive hardship healthcare coverage to have the procedure and follow-up care done in Cusco.  To be eligible he would have had to return home and stay there until he was properly vetted and then approved.  The process is neither simple nor seamless and could have taken weeks and possibly more than a month to consummate.  The tropical medicine group has a fund it can use to help underwrite medical expenses in special cases.  It is generated in part by our tuition and also from donations.  Concerned because of the urgency of his situation (he was getting worse even while we were there), the Gorgas staff initiated the process to bring him to UPCH in Lima.    I don’t know the outcome yet.   You can read about the case at: http://gorgas.dom.uab.edu/2010cases/100315.html.

Healthcare Part 2

Peru seems to be making a really concerted effort to grapple with the large health issues that face their citizenry. One way is to provide healthcare coordinated through community clinics. The other morning we took a tour of one of them. The center serves a community of 33,000 people. It is one of about 10 other satellites in one of the regions in Lima. It in turn supports 10 smaller satellites. Their mission is to provide routine medical services (including obstetrics with 150 deliveries/month), emergency care, and education for the local citizenry. It is in a poor working class community surrounded by squatter’s homes on a hill, smaller in magnitude but similar, I would guess, to the favelas in Rio. As Peru’s prosperity has burgeoned modestly over the past decade, this community has as well.

The centers have targeted pregnant mothers, infant and child health, Tbc, HIV/AIDS, population control and sexually transmitted diseases. The clinic is the hub for providing public health information and support as well as prevention and treatment for common and important problems. Their approach to Tbc provides a good insight into how they work. If you read Mountains Beyond Mountains you know that Peru has had problems with Tbc, and especially the multi-drug resistant variety (MDRTB – multiple-drug resistance Tbc). Patients with high risk symptoms (e.g., persistent productive cough, fever, weight loss) are encouraged to go for an evaluation. Family members can ask for advice and clinic staff will make home visits. Once identified, Tbc patients are placed in a Direct Observation Treatment, short course (DOTS) program (http://www.who.int/tb/dots/whatisdots/en/index.html). This includes being placed on a database where information about attendance at the clinic is recorded. When they miss there is prompt follow-up. Scrupulous adherence to a medication regimen is essential for cure as well so to minimize the possibility MDRTB. HIV/AIDS and Tbc are bad for each other so all Tbc patients are tested for HIV; all HIV patients are screened and monitored for Tbc. Anyone testing positive for HIV is treated, the medications supplied by the clinic for free. They also check all family members including skin testing (PPD).  When appropriate, preventive and/or treatment medications are provided, too.  Children are particularly vulnerable to developing Tbc with 2 years of contact from someone that they are living with. Tbc in kids can be difficult to diagnose and they suffer with some pretty awful varieties. Kids are very important to Peruvians so they have tried to be proactive. This includes BCG vaccination at birth.  The real question is whether or not this has been effective. Peru has identified as one of the 20+ countries with real problems with Tbc and the emergence of MDRTB. It was one of 2 that has made substantive improvements within the past decade. Still, Tbc is a disease of poverty and poor nutrition. One need not travel far from the comforts of Miraflores to see there are still huge obstacles.

The clinic also screens all pregnant women, sex workers, and people with sexually transmitted infections (STI) for HIV. Birth control advice is offered and a wide range of options (excluding abortions) are available, including tubal ligations and vasectomies, all for free. The clinic also offers sex workers regular checkups, safe sex counselling, and treatment for symptoms of STIs by protocol, all free of charge.  This focus on STIs is important for Peru because unlike the US, HIV is spread here predominately by sex and not IV drug use. In the US there are people who would take great exception to public funds being used in these ways.  Despite the fact that Peru is a Catholic nation and is at least as conservative as the US with regard to sexual matters, many of these efforts thrive under the radar because they are directed toward the poor.

One additional observation. Historically, the spread of Tbc to healthcare workers was low until the late 1940’s. It has been going up since. The changes in hospitals over the past 60 years have no doubt contributed. Rather than open windows, modern hospitals now rely on closed ventilation systems. These systems are no match for the breezes that used to sweep in and through a hospital wing’s worth of windows. Ultraviolet (UV) light (aka sunlight), the bane of existence for Tbc, is in short supply in buildings with roofs, long hallways and few windows. Given that Tbc is spread by droplets, it should come as no surprise that resistant strains spread when people with TBC come into close contact, especially before their treatment has started taking effect. It would seem that bringing infected people together at clinics for DOTS would be a disaster waiting to happen. The solution? At least in the clinic we visited, Tbc patients wait outside on benches in a patio, bathed (at least metaphorically) by sunlight and a breeze rather than in a closed, cramped waiting room. This is not a great solution for Siberia but it makes sense here and in tropical and subtropical climates generally.

The clinic and its surroundings were clean and the patients and staff seemed positive and enthusiastic. Although this was prearranged, I don’t believe that we were just given a photo op. Quite frankly, their efforts embarrass me as an American when I think about what we do and do not do with our resources.  We have a president with a majority in both houses and still they squabble with special interests while the really important discussions about the fundamental issues of healthcare queue up behind what seems like a lot of nonsense.  Peruvians, with limited funds, have decided do something by addressing the problems that they perceive will have the biggest long term impact on the future of the country.  They have had to make difficult decisions, limited by resources.  In some cases, these decisions have resulted in interesting innovations.  Microscopic-observation direct susceptibilities (MODS), invented in  Peru, provides a faster and cheaper way to grow Tbc in culture and determine drug susceptibilities. 

No one knows if these are the right problems or solutions but Peruvians are trying and they seem to be making headway.  Many of the instructional staff here at Gorgas are seriously involved in the dialogue.  I am proud to be associated with them.