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Annual Report

Dear Clinic Supporters –

Map Photo Credit: Amber Wobbekind

Every year, I am astonished that yet another year has passed – already! – but 2020, as everyone knows, truly was one for the books. Thankfully, we are done with 2020 and into its successor, so it is time, to sum up, what we did last year.

Our patient count, not surprisingly, was down compared to recent years, with a total census of just under 2,100 patients. This was not due to a lack of illness. COVID-19 ravaged Peru, and Loreto, our “department” (state), in particular. The first cases started showing up in late March, and by April the situation was critical and remained so for several months. Not only non-medical personnel, but doctors, nurses, and hospital auxiliary staff fell ill at tremendous rates, and countless people died.


Now let’s talk about 2019

This was particularly true in the early months, when masks, gloves, and other protective equipment were in short (or non-existent) supply. Even oxygen was unobtainable for many people. Given the spread of the disease and the degree to which the Peruvian medical system was overwhelmed, the government decreed that all clinics, public or private, would be open only for emergencies and COVID-19 cases. Many had already closed on their own, simply because so many of their staff were incapacitated by the illness.

Most of our patients in 2020 required actual medical attention, but 215, about four times the usual number, simply picked up medications. This was again due to the pandemic – not only were we handing out medications for tuberculosis, occasional chronic infections, and other such diseases but during the months when the clinic was closed, we did an end-run for birth control, talking to women through the windows of the clinic, then leaving their family planning supplies on the steps for them to pick up.

Loro

Normally, we would weigh each woman, take her blood pressure, and often take a Papanicolau smear, but when we were prohibited from providing those services, we at least saw to it that as many women as possible (263, only three less than in 2019) were protected from unwanted pregnancies.

We saw an assortment of trauma cases, as usual. Out in this rural area, where there are no roads, we do not (thank goodness) have either motor vehicle accidents or the terrible catastrophes that sometimes occur in Iquitos factories, where there is no Occupational Health and Safety Administration to require protective measures for workers. There are always a few machete cuts and futbol (soccer) injuries. Collisions during the regular afternoon soccer games provide us with a variety of contusions, abrasions, lacerations, dislocations, and other owies. There are a few burns each year, although I think we may be seeing fewer of those since LED lights have taken over for most of the kerosene lanterns that used to be our only nighttime lighting.

Vendor with Baby

Then, people slip and fall, sometimes while coming up the stairs to their own homes, or simply sliding on the muddy ground. These accidents result in an assortment of bruises, lacerations, and/or occasional fractures. One four-year-old gouged a chunk out of his palate when he fell while sucking on a plastic straw as he was walking along. A nine-year-old got up in the night to urinate and fell off the back of his house onto a cement sidewalk, clonking himself in the head. And a man slipped while walking in the forest, and hit his head on a branch, causing an injury that subsequently became infected. Sometimes, the forest attacks.

One woman was whacked in the head when she was doing laundry in the stream near her home, and a branch broke and fell on her, knocking her unconscious. Another person was planting a shungo, one of the support posts for a home, in a hole; when he tried to add more dirt to the hole to fill it in, the not-quite-stabilized shungo toppled and cracked him in the head.


Animal adventures included a tourist (early in the year; after March, there were no tourists for the remainder of the year) who was bitten by a not-quite-domesticated monkey.

There was one person stung by an insula, the inch-and-a-quarter-long ant whose sting is said to feel as though you’ve been shot, and a man who managed to step on a piranha while fishing, thereby receiving multiple gashes to his leg, and a thirteen-year-old who stepped on a catfish whose spiny fin embedded itself deeply in the boy’s foot.

There were only three poisonous snakebites in 2020. The first occurred in May, to a two-year-old who was following his mother around her crop field and discovered the viper beneath a log. The next was in June, to a woman working in her field, who was bitten on the finger. The doctor was away at the time, but Edemita administered antivenin, and the woman recovered uneventfully. Then in October, a five-year-old was bitten on the foot. He spent four nights at the clinic since he had a lot of pain, a great deal of swelling, and persistent bleeding. Eventually, however, he did recover and return home.

Finally, there were a few person-to-person cases of violence. One man was punched in the nose by an irate (drunken) brother-in-law, and a thirty-four-year-old woman was poked in the eye, unintentionally, by her grandchild who was playing with a corncob as his grandma was shucking the corn. And there was a man who grabbed the blade of a falling chainsaw, thereby cutting his hand. Lucky for him, the damage was limited to several nasty and irregular slashes, with no amputations involved.

We saw an average of about one “emergency” a week, although some of these were thus labeled only because they arrived during hours when the clinic was closed – headaches, back pain, diarrheal illnesses, etc. sometimes manifest themselves over the mid-day break or at night.

Other cases truly are emergencies. Our first emergency evacuation of the year came in early March when a nineteen-year-old woman came to the clinic in labor at a time when I was in Iquitos. The staff took her to the posta in Indiana, where she gave birth. Ironically, she had had the very same problem two years earlier.

Senior in Bed Photo Credit: Amber Wobbekind

The next two emergencies were also obstetric patients. One came to the clinic in labor, with a foot presentation – that means the baby’s foot, not his head, was the emerging part. The clinical staff at Indiana were able to turn the infant around in utero, so she gave birth at the Indiana posta medica, instead of needing a Cesarean section in the city. Another woman, however, was not so fortunate. She had pre-eclampsia with both her earlier pregnancies and arrived at the clinic in full-blown eclampsia, which means she had very high blood pressure, was having seizures, and was comatose. We took her to Indiana, the government medical post there got her to Iquitos, and she underwent Cesarean section, but neither she nor the baby survived.We also took several other women in labor to Indiana, where they gave birth without difficulty. We probably could have tended them at the clinic, but one never knows whether there will be unanticipated problems, so we tend to err on the side of getting these women to a place where, if necessary, they can be transported to the city. One woman came in when there was no doctor on hand, and birth was imminent, and Elmer and Edgardo successfully delivered her baby.

In May, in addition to multiple patients who came during regular hours, we had several patients who arrived during the mid-day break with what was presumably COVID-19. They kept the clinic staff busy, but fortunately, none of our COVID patients died.

Another emergency case was a two-month-old girl who had been born at home, whose mother reported that she had had fever ever since birth. The family had taken her to a government clinic, but she was given only paracetamol (Tylenol). Her parents then brought her to us, we gave her antibiotics for presumed sepsis, and she responded well.

HallwayPhoto Credit: Bob Pelham

We saw very little malaria, only three cases all year, but it is possible that there were people who simply did not come in for diagnosis and treatment, given the difficulty of getting from one place to another, and the lack of available services, during the height of the pandemic (which occurred at the time when malaria is normally also at its peak). Still, we did not hear of many cases of malaria from other healthcare providers, so it probably truly was a low-incidence year.

Cases of community-acquired pneumonia have been on the decline for several years now, as more and more people are vaccinated against pneumococcus and influenza. There were quite a few cases of what was probably COVID-19 pneumonia, during the months when the disease was ravaging the entire area. These were diagnosed as “probable COVID-19,” rather than “pneumonia.”

In a tropical climate, where warmth and humidity flourish, skin problems are common. Scabies often affects whole families, since the parasites move from one person to another through shared bedding. There are all sorts of fungal infections, from athlete’s foot to diaper rash to jock itch to vaginal candidiasis to ringworm, and we see a few cases of herpes zoster (“shingles”) each year, as well as occasional genital herpes. Warts occur, and impetigo, and sometimes contact dermatitis, when someone’s skin is exposed to an irritant that results in a rash. And people are frequently seen with urticaria, or hives, which are an allergic reaction. We saw a few cases of chickenpox, but I think they were fewer than usual, which is hopefully a result of the campaign a year or two ago to vaccinate children against this illness.

Diarrhea used to be very common and was a frequent killer of small children, but there have been many projects to provide clean drinking water, and this seems to be finally having a beneficial effect. We saw only 99 cases of diarrheal illness all year, about half what we saw in 2019.

Juvencio pulled decayed teeth for 36 people this year, and filled cavities or restored chipped or broken teeth for another 44. There probably would have been quite a few more, if the pandemic had not changed the landscape so abruptly.

We were able to vaccinate only 173 people in 2020. Normally, we vaccinate children against diphtheria/ tetanus/pertussis, pneumonia, diarrhea caused by rotavirus, polio, measles/mumps/rubella, and in recent years there have been a series of campaigns to vaccinate against influenza, in people of all ages. Girls are eligible for the Human Papilloma Virus vaccine from 9 to 12 years of age, which will hopefully save many of them from cervical cancer in the decades to come. Adults continue to be vaccinated against tetanus, and as noted, also against influenza. The pneumococcal (pneumonia) vaccine is now targeted to adults over the age of 60, as well as for small children, and that’s a help. However, the government’s pharmaceutical warehouses were closed for several months at the height of the pandemic, and the result was that vaccines were not as available as usual, plus the fact of the clinic closure simply meant that fewer people came for this service. We will hope to be able to do better this year, although so far, we have gotten only some of the vaccines we requested, and the government’s efforts right now are geared toward the COVID-19 vaccine – including armed police and military guards around the sites where the vaccines are to be distributed (which is probably a reaction to the scandal involving several high officials in the government who secretly got themselves and their families vaccinated several months ago).

We also normally see quite a few children for Well Child Care, in which we offer an exam, worm medicine, vitamins, and a toothbrush at no cost, but for most of the worst of the pandemic, children were not brought to the clinic in any significant numbers, so we only saw 118 kids for this service.

Every year, we see an assortment of obstetric problems. There was a sixteen-year-old who came asking for worm medicine and vitamins, and I asked, as I always do, whether she would like to use birth control. She agreed, even though she claimed she was not sexually active. We did a pregnancy test, and it came back positive, at which point she admitted she had miscarried a few days earlier. We got her started on family planning. A woman in her early forties with psoriasis stopped using her birth control because she thought it made her skin worse and became pregnant. Abortion is highly illegal in Peru, but of course, is available if you have the resources or are sufficiently desperate, and I suspect that was the route she took because the next time we saw her she was no longer pregnant, which was frankly just as well – she already has grandchildren. Another woman, in her thirties, with four living children, the youngest of whom was ten years old, stopped her birth control pills because her husband was working far from home. She did not remember to start taking them again before his return, and she also became pregnant. Another woman came in with vaginal bleeding. She adamantly denied that she could be pregnant since she was in her mid-forties. However, she had not been using birth control, and after the doctor had diagnosed a miscarriage and performed uterine curettage, she finally admitted that she had lost the fetus a couple of days earlier.

MonkeyPhoto Credit: Bob Pelham


Then, there are always patients who fall into no particular category but do make life interesting for us. One of these was a thirty-eight-year-old who had a fever, headache, and general malaise for a week or so then developed a mildly itchy rash from his waist down to his feet. We cannot test for it, but he probably had dengue fever.

Mini PharmacyPhoto Credit: Kelly Riddle

A five-year-old girl was brought in by her parents because she had swelling in her thigh. We suspected an abscess and gave her antibiotics, but when they returned two days later, the swelling had extended to her knee. We were unable to find a localized collection of pus, so we told the family they needed to take her to the city and get an ultrasound of her leg, for which the clinic paid. The study showed that she did indeed have a deep abscess, and she was hospitalized for several days for treatment. When she came to the clinic afterward for follow-up, she was extremely wary of doctors in general, but her leg was much better.

A thirty-five-year-old man had stepped on an unidentified sharp object a year earlier and had a chronic draining ulcer. He said he had gone to the hospital in Iquitos when it first appeared, and they had diagnosed an abscess, but gave him no treatment. Dr. Marlon cleaned the wound out and we started him on antibiotics, but this was unlikely to be a simple infection – those heal in much less than a year. He came back three weeks later, reporting that a “piece of bone” had come out of the wound, so we told him he needs an x-ray of the foot and a consult with the infectious disease folks in Iquitos. Tuberculosis is a likely diagnosis, but there are multiple other possibilities, and we can’t sort them out.


One woman presented with a botfly larva in her arm, with quite a bit of associated swelling. Edema reported they made several unsuccessful attempts to remove it, but finally suffocated the larva with a non-porous wound dressing, after which they finally succeeded in getting it out. They also removed a small piece of a plastic toy that a toddler had stuffed up his nose, but it took three of the clinic staff, plus both his parents, to hold him while they worked on him.

In December, a woman in her seventies came in with obvious cancer in her breast. Breast cancer is relatively common in the U.S. but uncommon in Peru. We have seen only a handful of cases in all the time I have been here. The staff tried to tell her she needs to go to the cancer program in Iquitos, but she did not want to do so. She would much rather just have us give her an injection and cure her on the spot.

Unfortunately, when cancer is sufficiently advanced that it can be diagnosed just by looking at it, it is unlikely that any program will be able to help her. She is probably doomed.

Still, most of our patients survive, and we will hope for the best in 2021, including the disappearance of COVID-19, and the widespread delivery of vaccines against this terrible virus. We’ll see.

Bill Plaque