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Clinic Letters - Late Enero, 2020

Jerry and I came back together to Peru, landing at the Lima airport a few minutes after midnight on New Year’s Eve, just as the fireworks were starting to go off. Red, yellow, green, white, starbursts, fountains of light, streaks of color, all filled the sky on all sides of us. It was quite a spectacular show.

We then came down to the Yanamono house, and the Lodge and I started in on the work at the clinic while Jerry read, people-watched at the Lodge, and accompanied Edemita’s husband Ari to monitor the progress on the new dugout canoe Jerry has ordered up. Last year, he watched as Orlando laid out the canoe’s outline, then chopped the wood away with axes and machetes to liberate the canoe from the log in which it lay.

This year, he wanted to see how they manage to remove the wood from the inside, so they had started work ahead of time. It was a long hike through the rainforest, but at least this year, he knew to wear boots, though he said it was a lot of climbing up and down hills, which is a challenge for his artificial knees. He made it to the worksite, though, and was again intrigued by the process. The outer shell of the canoe had been carved free from the log in which it resided. To guide the formation of the inner side of the craft, Orlando needed a chalk line. He, therefore, lopped off the bottom of an old battery with his machete and removed the oakum from inside. This, he mixed with some sort of solvent that yielded a gooey black liquid, into which he dipped a string, then snapped a straight line down the center of the canoe-to-be. From this line, he marked off perpendicular lines, then he and Ari began to remove the wood, striking unerringly at exactly the desired position with every stroke of their machetes.

Jerry again returned home not only muddy but peppered with hundreds of mosquito bites on his back. He was nonetheless grinning, ear to ear.

At the clinic, most things are well. Our Peruvian doctor, however, decided in mid-month that it was time to move on, so now, in addition to working through all the year-end reporting and the accounting for the last few months, and personally seeing all our patients, I have to find a new doctor, a chore I always dread. I think that the clinic is a very nice work environment, clean and well-stocked, and we work as a family and laugh a lot. Everyone gets paid on time, which is not always the case with those who work for the government, which is our main competitor for personnel. And the working conditions are much nicer than those in very remote areas with the petroleum companies, which pay well but take people deep into the jungle. Still, not everyone wants to work in a place where they are on call 24 hours a day, do not have internet day and night, and are separated from their friends and family in the city.

Someone has recommended a friend, who was born a few months after I first arrived here (!), and finished his medical training in 2016. He served his year of rural medical service in a community on the border with Ecuador, then went to a post in the Andes, and would like to return to the Iquitos area. I have yet to meet him but was able to interview him on Skype when I was in Iquitos, and we are going to give him a try. He is very young, but seems very enthusiastic, and laughs a lot, which I like. He will be starting in the first day or two of February, and I am excited about his impending arrival. I hope he shows up, and I hope he works well with the clinic.

Operation

Outdoor Laundry


Late Febrero 2020

It is still far too early to predict the height of our annual flood. Once the river decides it is time to get down to business, it may zoom up rapidly or may rise more slowly. Every day the television in the employee dining room shows huge landslides in the Andes, with one village after another being washed away by wildly surging rivers leaping out of their banks, and cars and trucks buried in mud, shoved up against walls by the roiling waters. All this water will eventually reach us, but I am not sure just how long it will take before it begins to show up, and the surging waters in a stream that is normally only a few feet across will not have the same power in a river two miles wide. But so far, the river has dropped since early January, and I am grateful to still have dry feet.

Our new doctor, Marlon, is so far working out well. He seems very young to me – Pam says he must have started medical school when he was ten. Partly, this is because he has a very young face; he will still look young when he is no longer so. Partly, it is because he is not yet thirty.

But he seems to have been well trained and is unfailingly cheerful, and interested in our patients. I have taught him a few old tricks, but he is also showing me some new ones. For instance, he tells me that the government’s interest in childhood anemia is based on research that shows that anemic children do not learn as well as well-nourished ones. Well, that doesn’t seem surprising. And it is something we can do something about. We don’t have a lot of in-house laboratory studies available to us, but one thing we can do is measure hematocrit, which is an indicator of how many red blood cells are actually in someone’s blood, i.e., whether the person is or is not anemic. The test requires only an inexpensive tiny tube, which we can get in Iquitos, and a centrifuge to spin the blood down, which we have. As a result of his interest, we are now measuring hematocrit in all of the kids whom we see for well child care, and I think he is checking it in a lot of others as well.

Iron supplements are on my shopping list for Iquitos.

Linnea Housecall

The last few weeks have not been super-busy, but we have had some interesting patients. One had me worried. She is a five-year-old girl brought in by her mother for fever, and pain, and swelling in her thigh. It seemed likely that she was developing an abscess in her leg, for which we gave antibiotics. But mom brought her back a few days later, not improved at all, with the swelling having extended farther down, into her knee. She was still walking, but only very painfully. We told her mom she needed to go to Iquitos for more evaluation. I was concerned about tuberculous osteomyelitis (TB infection of the bone -- tuberculosis is relatively common here and likes getting into bones as well as lungs); or she could have a cancerous tumor in the leg, which would be very bad; or she could have any number of other illnesses for which we cannot test.

Thankfully, her parents did take her to the city, and her father brought her back yesterday for follow-up. The hospital in Iquitos did an ultrasound on her leg (the clinic paid the family back for this) and found a large abscess deep in her thigh – so our original diagnosis was correct, which is always nice to hear. Even better was that, although she was hospitalized for six days, and does not want to be anywhere near another doctor, the abscess was opened and drained, and they kept her long enough to be sure it is healing. When her dad brought her in, she had clean rags wrapped around her leg, but he said there is no more drainage coming out, and although her leg is still a little warm, and she is very shy of medical personnel, the small incision that had been made is now closed, she has no fever, and she can walk with only the barest limp.

Arriving finally at the place where the work was in progress, there was a log which had earlier been felled and sliced in half horizontally.  On its now-flat top, Orlando had drawn a straight line down the center, then carefully measured lines on each side equidistant from the center, marking an oblong with pointed ends front and back.  He now stood on top of the log, and began hacking the wood away from outside the lines.  Jerry said his aim was highly accurate, hitting the precise spot where he wanted to strike, each and every time.  Over the next few hours, Orlando and Ari gradually trimmed away almost all of the surplus wood on one side of the canoe, and began the process of hollowing out the center.  

We gave her a few more days of antibiotics.


Early Marzo

The rains have started here now, not a lot yet, but there are more and more nights with pattering on the thatch, and sometimes, heavier downfalls. One day I headed to the clinic, only to find my dugout three-quarters filled with water. There are several ways to deal with this. One can sit on the seat and scoop the water out with one’s paddle (Juvencio says his father thought that was bad form, and likely to wear away the paddle’s edge, but it has always worked pretty well for me). The drawback to this method is that some water always falls back on the seat, soaking my skirt. One can alternatively scoop the water out with a gourd or empty container, but that is a slow process.

Liliana, who used to live across from the place where I park, was an expert at emptying a canoe, and often helped me. She would rock it from side to side, and the water would slosh out over the edge until the canoe was nearly dry. When I try that method, it seems that I allow more water in over the gunwale than I let out.

But, if I give the canoe a push with my foot and let it slide back out into the stream, then tug abruptly on the chain wrapped around the front seat, a good quantity of water, already moving backward with the canoe, will continue to be carried by its momentum and will fly out over the back end of the canoe. When the dugout reaches the shore, some more of the water (at least sometimes) will splash out over the prow, though since the shore slopes upward, it’s hard to get much out in that direction. Still, I can then send the canoe back out into the middle of the stream again, and after I have done this a few times, there are only a few gallons left, and I can finish emptying it by either the scoop or the paddle method.

19 Marzo 2020

I have been traveling back and forth to and from Peru for thirty years, since my first visit to the country as a tourist in 1990. Then coronavirus came along, surging into international news just as I was about to head back to Wisconsin.

The first few weeks of the growing pandemic made little impression on us. But then, cases began to appear in Peru, and tourism dropped off rapidly, with many cancellations. In Peru, the school year ends at Christmas, followed by summer vacation (remember, we are south of the equator), then classes resume in March. Scarcely had they done so, however, when the president declared that all classes would be suspended until the end of the month. This raised a serious foreboding in my mind … what might come next? I was scheduled to fly out of Iquitos on the afternoon of March 17, then a little after midnight (technically, early March 18) would take a Delta flight from Lima to Atlanta. The timing of my departure was to coincide with the departure of a group of students visiting the Lodge. However, on Saturday afternoon, March 14, I found that the group had canceled their visit.

I therefore hastily finished my house-closing and packing and headed for Iquitos. There, I was assured that although the number of passengers was way down, all flights were going as usual, which was a relief to hear. Nonetheless, I decided that I would attempt to get to Lima the next day, Monday, and try to advance my flight home.

I  spent Sunday afternoon packing and sorting, and had everything pretty much ready to go by the time I left to have a last supper at the Antica Pizzeria. Then it was home to my room at Pam’s house, shower, and bed.

But not for long.

Elmer

At about 10:00 p.m., my cell phone rang. It was Pam, and she told me that President Vizcarra had just announced that as of midnight Monday, barely more than 24 hours away, Peru’s borders would be closed. No one would be allowed to enter or leave the country until April 1.

Oh my. There was nothing to do at night, so I went to bed as usual. I popped awake at four a.m., donned my traveling clothes, headed to the airport, and was glad to be one of the first there, so I was near the head of the line, once LATAM opened its counter and began to check people in for the 8:00 a.m. flight to Lima. But I needed to change my ticket, which was scheduled for the following afternoon, and when I reached the young lady checking people in, she said, politely but firmly, I would have to wait. She wrote my name down on the standby list and told me to check back with her in fifteen minutes. My larger suitcase was in the area in front of the counter, not ten feet away from her, so I sat down on it, and waited. My heart was in my throat. I could not dare to hope that I might be able to get on this plane.

By 7:45, with the boarding area considerably thinned out, she finally fluttered a boarding pass at me. I leaped forward and clutched it greedily, then turned and raced toward the departure gate, leaving my large suitcase with a man I knew who worked at the airport.

Sloth

Photo Credit: Bob Pelham

Cooking Outside

Photo Credit: Amber Wobbekind

April 2019

To my surprise, the plane was half empty. A few more stragglers were loaded on after me, but there were still a good number of empty seats when we took off at 8:30. I am assuming that everyone at the airport at the time was on board, and was grateful that I had arrived early. As the day wore on and more people arrived at the airport, I imagined that later flights would be a great deal more crowded. But I was on the plane, my pulse racing, and an hour and a half later, we landed in Lima.

The airport there was busier than usual, with long lines of people seeking to change their tickets. Many of the restaurants were already closed, their tables upended and stacked on one another, their lights off and their counters empty. Once they sold their stock of food, there would be no point in bringing in more, since they would be closed for at least two weeks, starting tomorrow, when the country would go into lockdown.

I tried to find Delta’s airport office but could not locate it, then tried a telephone to the office, which rang and rang unanswered. There was no one from the airline in evidence, and probably wouldn’t be for many hours, as the airlines in Lima only open their counters three hours before their flight is to leave. With no way to contact Delta, I decided to try my luck with LATAM – perhaps I could purchase a ticket to Miami with them.


The line to their service counter snaked around most of the periphery of the area between domestic arrivals and the fenced-off area for international check-in. I put myself in the line. Every few minutes, the line would move forward a foot or two. We weren’t making fast progress, but we were progressing. Eventually, we were on the straightaway heading toward the actual LATAM service desk. I was impressed with the fact that despite the pressure everyone was feeling, people were generally calm and helpful, and friendly. Someone just ahead of me was talking with a young woman in a LATAM uniform. She said something about domestic flights, so I tapped her on the arm and asked if this was the line to get an international ticket. No, she said, those flights are all full. This line is just for domestic flight changes, there are no international seats left.

Oh boy. Ok, now my options are either Delta sometime tonight, or a miracle.

There was a sandwich shop that was out of sandwiches but did have bottled water, and outlets where I could plug in my phone. I bought water, plugged in my phone, then asked the young woman sitting on the next seat if she would mind keeping an eye on it while I went in search of some food. I wasn’t really hungry, though it was now mid-day, I figured it would be a long afternoon and evening, and I had better eat something. Most of the restaurants on the food court were now closed, except for a sushi place. I bought sashimi to go and took it back to where my phone was slowly regaining its strength.

Now, what to do? I was pretty much helpless until Delta opened its counters in eight hours or so, at which point I could appeal to them.

I decided to splurge. The Costa del Sol hotel at the airport is expensive – they charged a little over $200 for a room which I would be used only for a few hours. But for those hours, I had a quiet place of my own, with a bathroom, where I could take a shower and shelter away from the crowds, and even more important, charge my laptop and cell phone and improve my chances of remaining in contact with the people who were trying to help me.

It was a relief to enter my own quiet space for those few hours. Pretty soon, I had everything plugged in and charging up, and had sent out a few e-mails to let people know where I was. I kept telling myself that if I got stranded, it would be ok. I would stay with Diana Bowie, my wonderful friend in Lima, and we could go to museums and such. However, when I called her, she had bad news. She was most welcoming and said of course I could stay at her apartment. But Linnea, she said, you do know we can’t go out?

Uh, no, I did not realize that. Diana explained that this was to be a true quarantine. People were expected to remain in their homes, except for forays out for food or medicine. There were already military in the streets, she said. And this would last until April 1, over two weeks away. (And that is assuming that by April 1, the president will decide that the situation is sufficiently under control to lift the restrictions, and who knows whether that will be the case?)

If I did not manage to get on the Delta flight out that evening, I would be staying in Lima. I would be far better off than many tourists. Diana is a wonderful person and a gracious hostess, and I was pretty sure we would be able to tolerate one another in close company for a few weeks, should that be necessary. Oh, but if only I could get on a flight out tonight! If only, if only ….

By six p.m., I was showered, checked out, and in line at the spot where Delta would open its counter in a few more hours. I was fairly close to the front of the line and exchanged occasional words with the neighbors in front of and behind me. The line slowly grew but was not nearly as long as normal for this flight. We heard that the flight which normally leaves at 12:30 a.m. had been moved up and would leave at 11:00, to beat the midnight deadline. After 11:59, no plane would be allowed to land or take off.

This meant that the counter would open around 8:00. Finally, the tape was pulled back and the first passengers were let through to the check-in counters. Unfortunately, when I reached the young woman who was looking at passports and boarding passes, it was the same story as it had been twelve hours earlier in Iquitos: they were only checking in people with boarding passes. Anyone who wanted to make a change would have to wait.

Gradually, slowly, the passengers with tickets passed through the lines, checked their bags and headed off. A young woman told those of us hoping to change our tickets that at 9:30, they would see if there were any seats left.

Nine o’clock became 9:05, then 9:10, then 9:15. I tried not to look at my watch but could not help myself. When the tape was opened, I was the first one through.

The young man who took my passport and reservation for the following night needed some assistance from a woman who appeared to be his senior, and I fretted as the computer delayed. Would all the available seats fill as I stood there?!?

But then, he handed me a boarding pass. A boarding pass! I could hardly believe it. Go straight to the gate, he said, but I had no idea of doing anything but. I ran as quickly as I could for the stairs up to the next floor, ran to the turnstile where they put your ticket on a little machine whose light obligingly turned green, ran for passport control, which had only a very few people coming through – we were now past 10:00, and most flights had already left – and finally, ran to the departure lounge and found a seat. I called Pam with my newly recharged phone, and called Diana Bowie, and told them of my triumph. My hands were trembling and my voice was shaking as I did so. But I was in the departure lounge, and I was going to be able to get onto this plane, and I could hardly believe it.

They began boarding, and I found my seat, put my carry-on into the overhead compartment, and sat down, relief flooding through me.

The plane was full, and many people had bags that were a little large for the overhead compartments. The pilot came on two or three times to say that he was ready to go, but we could not move until everyone’s bags were stowed and everyone was in their seats. He reminded us that 11:59 was the deadline. There would be no extensions nor reprieves.

Once again, finally – everyone was in place, the plane moved back slowly from the gate, then stopped for a few minutes, then started backward again, then stopped again, then began to roll slowly forward. And it rolled, and rolled, and rolled, and rolled. We must have gone to the runway at the very apogee of the airport.

Then we stopped. I could see a parallel runway that was the takeoff lane, and one plane took off. There was another plane ahead of us, and I waited for it to turn onto the runway, but it just sat in place, for a minute after agonizing minute. Finally, an incoming plane landed. Ah! – ok, now, the other one will go. But no. It still sat, and eventually, another plane landed, and then a third.

By now, it was 11:20. There was still a little time, but this was cutting things close. How ironic it would be if after all the day’s adventures, and have gotten a seat, the plane just missed the deadline for departure.

Then the plane ahead of us moved into the runway and left, and we moved into the cross lane. I could see one plane behind us, but there did not appear to be anymore.

Again we waited. Again an incoming plane landed.

And then, finally, we turned onto the runway. The engines revved, the plane moved forward and picked up speed, and at the final of the day, we took off.

As the plane lifted into the sky, the pilot’s voice came over the intercom: “Ok, folks,” he said, “we’re going home!”

And the whole plane erupted in applause and cheers and shouts of USA! The USA!

After that, the rest of the trip home was a piece of cake.

Ongoing Operation

28 Marzo 2020

Well, the world has changed. Edemita reports that the day after Peru shut down, there were 25 or so patients at the clinic, most with simple colds but all deeply concerned that they had coronavirus. Since then, however, the patient census has fallen off, perhaps because of a rumor that there are cases of COVID-19 in Las Palmeras.

Nonetheless, the clinic is quickly running short of Tylenol and other fever reducers, not to mention gloves and masks. Edemita and Elmer went into Iquitos to stock up on more medicines and face masks, and found the entire Plaza de Armas closed down, and were stopped by the police. They talked their way out of being arrested, and at Pam’s suggestion, Dr. Marlon wrote them a letter on clinic letterhead saying they are authorized to purchase medicines for the clinic, so that should help.

Several folks from the regional health authority came to Las Palmeras and visited the clinic. They told the clinic staff that they should not treat anyone except emergency cases. I think this makes sense – no point in potentially exposing the clinic staff to the virus just to treat someone’s headache, or exposing the person with a headache to the clinic staff who might have been exposed. Still, it is going to be hard on the women who need family planning. I suggested to Eda that they consider talking to the women from inside the office. The women can stand on the sidewalk in front of the clinic, with everyone at a safe distance from each other, and the staff can then leave the birth control pills on the front steps, to be retrieved once they are back inside.  
And now, movement in Iquitos is restricted to the hours between 5:00 and 10:00 a.m., which means that everyone is on the streets at the same time, which doesn’t seem to me to make any sense, since everyone will be crowded together. Further, since the markets are closed and the supermarkets don’t open until 9:00, there is hardly time to stand in long lines, buy groceries, and return home by 10:00 a.m. And few Peruvians have either pantries or refrigerators, so the purchase of groceries is a daily chore. 

Things are much easier in Wisconsin. Still, I fear the economic fallout once this is all over, and unless someone succeeds in coming up with a cure, it may not be over for some time yet. Especially if we all continue to venture out regularly. 

I wish us all luck.
Frog

30 November 2020

Oh dear … Edemita just called, to ask if one of the nurses can take his vacation in April. Why? Because he is feeling bad and is coughing. She put him on the phone, and indeed, he is coughing mightily, and gasping for air in between racking coughs. Does he have a fever? … only a little at night, he says. 

I told her to take him to Indiana immediately and get him tested. Then, he needs to remain in isolation until they have the result. Furthermore, though no one else at the clinic is yet showing symptoms, and may have all dodged the virus, they have now been exposed – continuously, for the last two weeks – to our infected nurse, and should remain isolated themselves for two weeks. But that would mean the clinic needs to close and not see anyone. 

Hoo boy. 

06 Abril

Another phone call this morning from Edemita. She reports that so far, there are no cases of COVID in the village. They, therefore, had a general meeting and agreed to postpone all fiestas, and even futbol games, till the pandemic quiets down. They are also closing their borders … no one from other villages will be allowed to visit. She says other villages up and down the river are doing the same. 

Sadder news … three nights ago, late in the evening, a woman who was 39 years old and at her 39th week of pregnancy came in, unresponsive, with a blood pressure of 200/180. She has two precious children and had pre-eclampsia with both of them, so no one knows why she and her husband did not anticipate this and seek earlier medical help. The clinic staff gave her magnesium sulfate, and blood pressure medicines, and diazepam when she began convulsing. As soon as they could, despite it being well after dark, they loaded her into the clinic boat and took her up to Indiana, notifying the doctor there as they were going (there is no cell phone reception at the clinic, but at the river’s edge, or on the river itself, if you’re lucky, you can often get a signal), so the crew at Indiana was waiting for her, and took her straight to Iquitos. There, a Cesarean section was performed, but neither she nor the baby survived.

11 Abril

Now, Peru has curfews throughout the country, and according to one decree, no one is allowed on the street without a mask on. No more than one member of a family is to be out at any one time. Men can come out on Mondays, Wednesdays, and Fridays, women on Tuesdays, Thursdays, and Saturdays. No one is allowed out on Sundays. Pam says every night the Peruvian president comes on television and has a fireside chat. He does not rant, he does not criticize anyone, he does not loudly proclaim how great he is. He explains, simply and clearly, what measures he has taken, and why. Sounds good to me. 

12 Abril

Another phone call from Edemita. I had been worried because Juvencio had e-mailed a couple of days ago to say he and his teenage son had fever and pain, then he said Edemita had developed the same. Oh great, just what we need! 

But today she called and said that everyone in the village has the same symptoms, and although they all have fever and aches, no one is in respiratory distress, and it sounds like both she and Juvencio are improving. 

We will learn from this. We will be much better prepared, and much quicker to respond, when the next microbial threat appears on the horizon (as it will, sooner or later). Our government leaders may be slower to learn, valuing their political survival above the nation’s survival. But the bulk of us will learn protective behaviors, we will think of more than just what we need to live today (maybe go back to planting gardens, even), and will be quick to isolate when the next emerging pathogen rears its ugly head. We will be more conscientious about hygiene, and although our social interactions may move toward less touchy-feely-ness, we will find new ways to connect and support one another, through hard times. 

We are going to be in for a long run. 

Mid-Mayo, 2020

There was an interview in Time magazine with a doctor who had treated patients with the Ebola virus in Africa, and he pointed out that many people did not take that highly lethal virus seriously – until they saw people dying from it. Only at that point, did the disease become real for them. 

We are seeing the same phenomenon in the U.S. with coronavirus. In areas with a low prevalence of disease, many people simply do not believe it is a threat, and they chafe seriously under the restrictions placed on them to prevent the spread of an illness they hardly believe to be real. On the other hand, in areas where the illness has ravaged many, there is a great deal of fear, because people see what the virus can do. I have been spared from having to treat any actual cases, but it is apparent that this virus makes people feel terrible. The milder cases endure racking body pains, high fever, sometimes vomiting and/or diarrhea, and all the misery that comes with fever including weight loss due to lack of appetite. But the respiratory problems cause people to feel as though they are drowning, which is a horrifying sensation, made worse by the need to isolate these patients so they don’t infect those caring for them, and by the fact that this virus takes a long time to resolve.

The Peruvian borders are still closed and will remain so at least through 24 May, and the quarantine will probably be extended beyond that. 

Peru has been hit hard, with over 67,000 cases reported so far. Almost three-fourths of these are in and around Lima, the capital, which has a population of eight or nine million. But Iquitos has been clobbered, with over 1,780 people infected officially, but from what I am hearing, I believe the count is much, much higher. If it were possible to test everyone in the city, I think I think it would be found that almost everyone has been infected. The city has a population of at least half a million, probably closer to six or seven hundred thousand, and the population density is high. Everyone goes to the market every day for their food, and the markets are seething masses of people passing among long, narrow tables with narrow aisles between them. Maintaining distance is impossible. 

At our clinic, I was hearing for several weeks that everyone except Dr. Marlon had terrible pains, high fevers (Edemita reports that hers was as high as 108o F/41 o C), and dry cough, lack of appetite, loss of the sense of smell, and sometimes diarrhea. Most of the residents of Las Palmeras, the nearby Yagua village, had the same. It sounded pretty suspicious to me, but they were convinced it was some other virus, because (fortunately) no one had severe respiratory distress. 

However, in late April, medical workers from the government clinic in Indiana came and tested Edemita and three other village residents, and all the tests came back positive. This implies that everyone else had COVID, too. The good news from the clinic is that all the residents, and the clinic staff, are now recovering, and there have been no deaths among them. 

The bad news is that the infrastructure of the region, never sturdy, is falling apart. Edemita went to Iquitos to try to find medicines, and the shelves of all the pharmacies were empty. 

Not only is there scarcity, but price gouging is common. Paracetamol (acetaminophen) normally sells for S/1.0 for a blister pack of ten tablets. A couple of weeks ago, the price had risen to S/7.0 or S/8.0, and Edemita says now it is S/18.0, and when pharmacies have any, they will sell only one pack, which will not go far to help the multiple people who come to the clinic. Masks are extremely scarce, and costly – I thought she had wisely scored eight boxes of them a couple of weeks ago, at S/25.0 each, but she says no, it was eight individual masks. In normal times, a box of 25 masks costs S/50.0. 

Now, there is no oxygen available. The Hospital Regional in Iquitos has been dedicated to COVID patients, with the Hospital Apoyo de Iquitos, the other public hospital in the city, tending all others. Unhappily, the Hospital Regional’s oxygen processing plant is down, and people are dying for lack of oxygen.

Furthermore, the Hospital Regional is understaffed, with many of the doctors and nurses down with the illness themselves. The staff is overwhelmed, and bodies are piling up in garbage bags since the one crematorium in the city evidently cannot process them fast enough. The Clinica Stahl, the city’s best private clinic, is closed because so many of its staff have the illness. 

Most people seem to agree with the Peruvian president’s measures to suspend most activities, but there are problems nonetheless. Lines for anything stretch for blocks, and people who live in the villages out along the river have to come to the city for kerosene, medical care (if they can get it), and food to supplement the crops they grow (not to mention gasoline to power the boats that get them to the city, since there are no roads). They then return to their villages, infected. 

At the Clinica Yanamono, the staff is seeing only emergency patients. We currently have one patient from a village downriver who came in with what appears to be COVID-19, who was having difficulty breathing, then improved and went home, only to return a few days later, again in trouble. Our oxygen tank was nearly depleted, and Dr. Marlon feared for her life if it ran out, so he and Juvencio took her to the medical post at Indiana, on a night-time run. They kept her only until the following afternoon, when they brought her back to our clinic. It seems that she improves one moment, then relapses the next, and we now have no oxygen left to give her. 

There are a few rays of hope. The Ministerio de Salud, the Ministry of Health, has just sent an oxygen plant to the Hospital Regional, and a priest has raised funds to bring another, though I do not know how long it will be before that one is up and running. Edemita did succeed in getting at least a few medicines when she was in Iquitos a few days ago. And the city must surely be nearing the peak of its curve, given the numbers of people already sick. 

Still, there is little I can do except offer comfort and guidance when the clinic staff calls me, and I have found this frustrating. 

Late June 2020

The clinic is plugging along. 

In April, we saw only 73 patients in the whole month, and of the 73, only 25 were treated as patients. The remainder simply picked up medicines, some for fever control, others for the treatment of their previously diagnosed tuberculosis (no new cases, as TB testing was suspended for the last two months since the medical posts were so busy testing for coronavirus). Most of the patients were for family planning, which we delivered by curbside service. There were a few patients with fevers and occasional traumas, but most people just stayed home and coughed and hoped to get better. 

In May, there were a total of 70 patients for medical care and another 36 who picked up more medicines. Seventeen of the patients were for birth control, and there were a startling fourteen emergency cases. Most of these were people with COVID-type symptoms, although there was also a man in his sixties with a stroke and a woman who had been washing her laundry in the stream when a branch broke loose from an overhanging tree and bonked her on the head, knocking her unconscious. 

In mid-May, Diana Bowie and some people she knows in Lima began to organize a project to bring medical supplies to Iquitos. They focused on basic medicines like acetaminophen (paracetamol) to control fever, and protective gear for the health workers – there are several hundred doctors in Iquitos, and the last I heard, twenty of them had died of COVID-19, including one who worked for our clinic a few years ago, and the numbers of nurses and professors who have succumbed are too high to enumerate. In the first of DBPeru’s shipments, the Clinica Yanamono received gloves, masks, and protective aprons, and many more supplies were delivered to the Hospital Regional. Now, there is another shipment including medicines and more supplies, for the Clinica Yanamono as well as the government medical posts in several villages downriver. 

And the hospital in Iquitos got a new oxygen plant, and the last time Edemita was in the city she was finally able to fill our oxygen tank. 

The clinic has now resumed seeing non-COVID, non-emergency patients, and it seems clear that nearly everyone in all of Loreto has been infected. 

The country’s borders remain closed through the end of June, with domestic flights slated to resume in early July. The rumors about international flights vary from the possibility of flights starting in August, to no flights through the end of this year.

Agosto 2020

As noted earlier, the clinic re-opened to non-emergency, non-COVID patients in June. There were only about 160 patients in the entire month, and of those, 31 came for birth control, and eight for our Well Child care program (we had seen almost no children through April and May, though there was one two-year-old who managed to find a poisonous snake whilst he was playing around with sticks, while his mother washed laundry in the river). There was a 51-year-old woman who got bitten by a poisonous snake while she was working in her crop field and several people who probably had COVID-19, a few cases of diarrhea, and no serious emergencies. Several people came for dental procedures – Juvencio pulled a fair number of rotten teeth and repaired several others (I am sure he wore a mask, but do not know whether he had a face shield). 

July brought 177 patients, plus another nine people who just picked up medicines or purchased toothpaste. There were 26 more women for family planning, 13 people of various ages with diarrheal illnesses, and an assortment of other ailments and illnesses, including a couple of collisions sustained in soccer games – forget social distancing, futbol is back on the calendar. 

And August has brought a tally of patients closer to our normal numbers. 

Meanwhile, Dr. Marlon has been offered a contract at a government clinic, at a huge salary (at least temporarily), in the city where his girlfriend/fiancée is doing her year of rural service in dentistry. He, therefore, left in mid-June. I can hardly blame him, at double the salary and being able to work side by side with his girlfriend. But it is going to be tough to find a replacement for him, especially since he was not only a very good doc but also a genuinely nice person, and I think did a lot to help keep clinic morale up, which is always useful, but especially now when I am unable to be present. 

There is always the possibility that his gigantic salary will not pan out. It would not be the first time the government has failed to pay its employees, and Peru’s economy is currently in even worse shape than that of the U.S. Where will they get the money? 

Well, we’ll see. 

In Iquitos, it sounds as though the city is pretty nearly back to normal, except that everyone wears masks. Over 90% of the population tests positive for coronavirus antibodies, so, as I expected, it does seem that virtually everyone was infected, which probably means the city has achieved the coveted status of “herd immunity.” Then again, no one knows for sure or knows how long the immunity against the virus will last. Also, although the pandemic may have burned itself out in Iquitos, the illness is still spreading in other parts of Peru, and the president just decreed that the country is going back to lockdown on Sundays – the typical large weekend gatherings of family and friends, in the plazas and dances and futbol fields, are banned at least for a while longer.

And there is still no word on when international flights might resume.

I asked Edemita about the mercados, the open-air markets where most of Iquitos has always gotten their daily groceries. She says that the mayor of Belen had the main market there demolished, as the markets were major centers for contagion. For a while, everyone was buying their groceries at the supermercados, which are like US grocery stores, but the lines! she moans. One stands in long lines to pick what one wants, then stands in more long lines to pay, then stands in yet more long lines to collect the purchases. She says that the vendors want to move back into the Belen market, and some are selling on the street out of bins and boxes and benches, others are setting up shop in large open areas behind schools, or wherever they can find a space. And prices are high – Eda says as much as S/38 for a chicken (currently over $10) if you can even find one. 

What a time. And if we think the US economy is having a difficult moment, Peru’s is far worse.

Noviembre 2020

No one who has lived through 2020 will ever forget it. The courageous workers who put their own lives on the line to care for others who were ill, the school kids all around the world who had to turn to online teaching, or in the case of rural areas in places like Peru, simply have had no formal education at all for many months, the older ones who graduated in drive-by ceremonies, the workers who have lost their livelihoods, everyone who spent months in cramped spaces, unable to pursue many of their usual activities, and of course the many families around the world who have lost loved ones, all have much food for thought. One hopes that the younger people who made it through this terrible time will be able to look back later and know that the experiences of this year made them stronger.


They tell me that life in Peru is beginning to get back to normal, though everyone now wears masks in public places. All those years that I wondered why the Chinese tourists were all masked – well, now we know. They had more awareness than I did, about the risks floating around in our air. Domestic flights were resumed in July, and international flights to cities within a four-hour travel time started up a month or two ago. Flights to the United States just began this week, so tourism remains in a deep, deep hole.

As everyone now knows, it is difficult working from home. The staff scans the patient registers and other documents and sends them to me, but it is not the same as being able to look at the original documents, then going to the file cabinet to pull out a patient file and see what the story was. The clinic staff is all hanging in and carrying on, and we have a lot of phone calls and e-mails and WhatsApp notes back and forth between Peru and Wisconsin.

Well, one day at a time.

If anything changes drastically, I’ll let you know.