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.

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.