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.