Coming to Iquitos was a good way to end things. We took the final exam on a Monday so the last week was focused on reviewing and tying up loose ends, discussing case histories, touring an entomology/malaria research center and seeing patients. The pace was less intense, allowing for a little touring each day during siesta hour.
Although it didn’t seem all that hot getting off the plane, within minutes I was drenched with sweat. This is the jungle and it is summer here. One of my classmates said that it smelled like Bangkok. Although I have never been to SE Asia, it certainly fulfilled my image. There were motokarts (the frontend of a motorcycle grafted onto a rickshaw frame) chaotically whizzing around, lush and exotic greenery and plenty of people. Iquitos, a city with more than 500,000 inhabitants, is bounded by the Amazon, Nanay and Itaya rivers. It is purported to be the largest city in the world not connected to the outside world by a road. Kind of like the Sitka, AK, of the southern hemisphere. The 100km (60 mi) long road to a small settlement called Nauta does not count. If you want to visit, you need to arive either by water or air. It is a hub for resupply for mineral exploration so it includes all of the expected trappings of the drug and flesh trades. My vision of the jungle in SA is prejudiced by the movie Fitzcaraldo. In fact, some of the scenes were filmed in the floating community of Belen, a part of Iquitos. Unfortunately, I never escaped far enough away to see any really isolated spots.
The hospitals and clinical settings were the most primitive of the course. Lab testing and radiographic imaging were limited. There were also fewer medications to choose from. People are also poorer here so even those modalities that were available were used less often because of personal financial constraints. We were more likely to make a diagnosis solely on clinical grounds here than at any other place that we visited. This was also the only place where I was approached by family members, either for money for medication or some personal intervention on behalf of a family member. (I am certain that it was the white coat, scrubs and my gray-haired, gringo look.) In one instance, several of my classmates arranged to buy some medications for a very sick kid.
We saw several cases of significant starvation. The terms kwashiorkor and marasmus have been supplanted by levels of starvation that reflect the presence or absence of edema (swelling). Chronicity, energy supplies/diet, the relationship to recent infections and other factors play into the clinical manifestations. We no longer believe that severe starvation (with edema) is caused by a protein deficient diet. In turn, the fix is not dependent on and the condition can be made worse by a high protein one. Two of the kids we saw were moribund. It was a sobering experience, especially seeing that these kids were not doing well for potentially fixable problems despite being in the hospital. It was the most helpless that I felt during my stay in Peru. I am not naïve. I realize that the starvation that we saw occurs on a much larger scale other places in the world.
So, was this course really worth it? Yes, without a doubt
- The medicine is interesting and I believe relevant both for WMA and my medical work here in the US as well as abroad. We are seeing more immigrants from tropical areas and many of them take trips home.
- Being a student again allowed me to see and experience the educational process from a different prospect. That it was fairly intense only heightened my awareness.
- It is no surprise that I enjoy a challenge and Gorgas was that. It was a challenge to be a student who is 62 yo studying with a younger and better informed crowd, in a different country in a field where I was woefully unprepared. I hope that I can continue to read, learn and hone my general conceptualization and practical skills.
- It turns out that there are other learning opportunities in Peru, Africa and SE Asia. I look forward to more study and practical application.
This blog turned out to be fun for me. I will work to continue it when I travel and will express my opinion or relate an experience now and again in between trips.