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Annual Report

Dear Clinic Supporters –

Patients Waiting

Even though I have had the data for the last week or so, for some reason I have been finding it difficult to settle down to writing the clinic’s annual report for 2019. The events of Spring, 2020 have kept pretty much all my thoughts occupied, even sometimes when I’m sleeping, and I’m sure that is true for many of us.

Peru has been hard hit by the coronavirus, and Iquitos has been hard hit. The situation is still developing, now, a month and a half after the first cases were diagnosed in Peru, there is no indication that they are slacking off yet. I remind myself that this will in fact pass, eventually, and hopefully we will learn some useful lessons along the way (and then, hopefully, will have the discipline and sense to apply those lessons), and we need to remember not to forget the routine, in the midst of the entirely new. And remember the new greeting – “stay safe” – and let’s all try to help our neighbors.


Now let’s talk about 2019

Last year, when things were still normal, we saw a total of 2,635 patients, a little down from the last two years. Most (nearly 90%) were people who had been to us before; there was the usual male/female ratio of about 40% women/girls, 60% men/boys; and children (that is, children up to the age of 14; after that we count them as adults) continued to constitute 37% of our patients. What is interesting to me is that the group thought to be 70 years of age and above has steadily increased over the years, and came up to a whopping 5.8% in 2019. This means we are seeing more chronic illnesses like diabetes and high blood pressure, but geez … in 1990, there simply were not elderly people along the river. Now, even in the Yagua village, there are people in their 80’s. I think we are making some progress.

Jon Helstrom Plaque Crew

We provided birth control to 266 women, and there is progress here, too. For the last 30 years I have asked each woman how many living children she has, and how many who are deceased. When I began doing this, the average age to begin having children seemed to be around 16, women in their 30’s had eight or ten children, and women who had finished their childbearing years had given birth to ten to fifteen, or sometimes more. Of all these kids, at least a quarter did not make it past the age of five, and a few more were lost, to snakebite, tuberculosis, leukemia, childbirth, etc., before they reached adulthood. Now, most of the women have families of three or four children, and some of them look surprised when I ask how many kids they have lost. Why, none! they exclaim. This makes me feel good, too.

Native Girls

We saw 72 cases of trauma. Out in this rural area, 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. We do see machete cuts, and sometimes lacerations from other causes, such as the splinter that bounced back when one of our neighbors was cutting firewood, cutting her above her eyebrow. 

Or the boy who ran into the goalpost while playing futbol (soccer), gashing his forehead open, and a number of other folks who simply ran into something hard, or slipped and fell and cut themselves. Collisions during soccer games provide us with a variety of contusions, abrasions, lacerations, occasional dislocations, and other owies. One seven-year-old actually sustained a fracture to his leg after being whacked by a flying soccer ball.

Burns are a hazard of life here, too. One adolescent managed to burn the tops of both his feet while in the process of making charcoal to sell in the city. To make charcoal, wood is piled into a sort of igloo, covered with weeds, and burned in a slow, smoky fire for a day or two until it is reduced to charcoal. This young man disturbed the pile, and part of it toppled onto his feet. He did recover, though.

Falls are another cause of trauma. One of these victims was a man who tumbled forty or fifty feet down from the top of the tree where he was harvesting sapote, a tasty fruit. He scraped past a number of branches on his way down, gashing his cheek open, and may or may not have dislocated his hip – he reported a large lump there, which was reduced by someone who rubbed it back into place, and he had a hard time bearing weight for a few days. Still, it is hard to believe that an actual hip dislocation would have reduced so easily, or remained reduced for the subsequent weeks of healing. He moaned that it was a bad day for him, but I reminded him that he was incredibly lucky to have survived at all, and with relatively minor injuries at that. We were all grateful when he came back a week or two later, bearing a gift of sapote for the clinic staff.

And there was a fourteen-year-old girl who was participating in a swimming match in Yanamono Stream, when she went under. I always say that for a child to drown around here, you would have to tie a rock to them, since they bathe daily in the river, and play in the flood waters around their homes when the water is high. They may not know breast stroke from backstroke, but they are at home in the water. Nonetheless, this girl failed to come up. Someone noticed, fortunately, and pulled her out after a minute or so, but once on dry land, she slipped and fell again into the water. This time, Elmer, one of the clinic nurses, happened to be on the spot and promptly pulled her out. She was stuporous when she arrived at the clinic, but improved fairly quickly. When she came back three days later for follow-up she was still a little short of breath, and complained of pain in her chest, but a few days after that, she was back to normal, and we have not heard from her since.

Finger Amputation

There are also animal activities that sometimes affect humans, such as catfish spines which embed themselves in people’s hands or feet, depending on which body part happens to run afoul of the fish, and occasional scorpion stings. These are not lethal, but are reputed to be quite painful, although we now have antivenin for them. There were one or two tourists who managed to get bitten by piranhas (I always advise people to let the guide or boat driver take them off the hook), and one tourist who caught a fishhook in her arm. An adolescent from a village on the far side of the river got nailed by a sting ray, but was fortunate. These injuries often take a very long time to heal, but his appeared to be relatively minor. There were also several people bitten by ants or other insects. There are a multitude of different species of ants in this area, ranging from minuscule to over an inch in length, and virtually all of them either bite or sting, or both. Some are relatively mild, but some cause symptoms that are extremely difficult to ignore, though none are likely to be fatal. There was a dog bite to one of our trauma-prone neighbors (now six years of age, and sometimes I am surprised he has made it this far considering the number of accidents that have befallen him), and it became infected, which is another category of problem. He did recover, though. And we saw a couple of deeply bruised insect bites which might very well have been due to Loxosceles, a family of spiders who administer nasty bites (the brown recluse of the U.S. is in this family). No one had significant sequelae to these injuries, happily.

Other animal adventures include poisonous snakebites, of which we saw a half dozen in 2019, including the five-year-old daughter of one of the clinic nurses, who was bitten as she walked home from the village with her family after a celebration. She did well, as did the man who felt something on his arm, yanked it off, and found that it was a snake, which scraped its fangs across his arm on its way off. The other four snakebite victims also survived with no significant sequelae.

Boat PortPhoto Credit: Bob Pelham

Emergencies are another varied category of patients. Some of the “emergencies” were not truly seriously ill people, just folks with problems sufficiently disturbing to induce them to seek care over the mid-day break or in the evening hours. These are often people with headaches or back pains or fever or diarrhea.

There were, however, a number of people who required pretty urgent evaluation. One of these was a 69-year-old man who had tripped and fallen a week and a half earlier. He had either knocked himself out in the fall, or else perhaps lost consciousness for some reason and struck his head when he collapsed. Either way, he had given himself a good knock on the noggin. His family did not bring him in at the time, but as the days passed, he continued to complain of dizziness and nausea, and they thought he was having trouble speaking. When he arrived at the clinic, he was nonverbal, and did not respond to commands, so we took him to the posta at Indiana, from whence he was sent to Iquitos. A head CT scan there was negative, and over the ensuing days, he gradually improved. My best guess is that he probably had post-concussion syndrome.

Another of our neighbors was standing at the edge of his field, watching others take down trees, when someone miscalculated and a tree toppled onto him, knocking him unconscious. He too went home initially, but came to the clinic the following day with a terrible headache and a nasty bruise on his temple, so we took him to Indiana, and the authorities there sent him on to Iquitos, where his head CT scan also proved negative.

We transported a total of seven people to a higher level of care. In addition to the two mentioned above, there was a young man with appendicitis, a woman who gave birth at the clinic but sustained a large cervical tear, and another woman in labor. We used to deliver a lot more babies than we do nowadays, but then, transport used to be a lot more difficult. This woman’s labor appeared normal, but sometimes a delivery goes badly wrong without much warning, so the decision was made to try to get her to Indiana. She gave birth in the boat en route, and fortunately, all was indeed normal.

There are always a few patients for whom we can do little. We saw a 16-year-old young woman who had lethargy, headache, and yellow eyes (never a good sign). We gave her intravenous fluids and watched her overnight, but she needed more evaluation than we could provide. Her family took her to the city, but Edemita later heard that she died there – of what cause, we will probably never know.

And on Christmas Day, when Edemita was finishing up with inventory in the allegedly closed clinic, a 33-year-old man was brought in, carried on a stretcher as he was too weak to walk, with a daylong history of multiple episodes of vomiting and diarrhea. She says he was so dehydrated, his skin was wrinkled like prunes. Fortunately, he was otherwise young and healthy, and after she rehydrated him with IV fluids, and gave him medicines for the diarrhea and his nausea, he improved enough that he was able to return home that afternoon.

It wasn’t much of a year for malaria, which is fine by me, and we again saw a drop in the number of cases of pneumonia. Most of the children are now vaccinated against pneumococcal pneumonia, and many children and adults have been vaccinated against influenza. The result is that the formerly fearful death toll we saw among very young children has dropped markedly, which also meets with my approval. Now in fact, much of the pneumonia that we see is in that aging population I mentioned above, and just this year the government started giving them, too, the pneumococcus vaccine, which should help.

Bob Pelham - Northern Crested Caracara

We continue to see cases of diarrhea, but most are relatively mild, and just as with pneumonia, we no longer see many people dying of this scourge. Skin illnesses are common in a tropical climate, and include all sorts of fungal infections (ringworm, athlete’s foot, tinea versicolor, etc.), abscesses, herpes zoster (shingles), a few patients with psoriasis, warts and impetigo.

Juvencio continues to hone his dental skills, and in 2019 he relieved 50 people of decayed teeth, and filled cavities or restored broken teeth for 34 others.

On the preventive medicine front, in addition to the family planning program, we have our well child program, which offers a free medical exam, worm medicine, vitamins, dental fluoride varnish, and a toothbrush to any child up to twelve years of age whose parents bring him or her in along with their vaccine records. This also gives us a chance to catch up on their vaccines, and sometimes to persuade their moms to start, or return to, family planning.

Finally, there are the patients who don’t exactly fit into a category but who are challenging to us professionally, and/or are unusual. I have mentioned before that COPD, Chronic Obstructive Pulmonary Disease, is more common among women here than in developed countries, since they spend half their lives cooking over open fires. Generally, no one has the access or the money to buy several packs of cigarettes a day. However, there are a few of the older men who regularly smoke mapacho, the locally grown tobacco, which is hand-rolled into cigarettes with no filters. One of these men came to us with COPD symptoms, but is unwilling to give up his mapacho, because he is sure it is good for him.


We don’t see a lot of psychiatric illness, but there are occasional cases, such as the seventeen-year-old who was brought in for “fainting,” multiple times over a number of hours. He was also reported by his worried mother to be talking crazily, waving his arms, and generally behaving in a very peculiar manner. He had not experienced anything that sounded like convulsions, nor loss of urine, nor biting of his tongue, so it did not sound like a seizure episode. When I talked with him, he explained that he had finished secondary school and applied to the navy, but had not been accepted, and was at his wit’s end trying to decide what he was going to do with his life, and how he was going to do it. I could not solve that dilemma for him, but was able to reassure him and his mom that he does not appear to have any physical health problems.

Another time, a tourist was brought in with a panic attack. Ayahuasca has become a significant tourist attraction in the area, with occasionally uncomfortable results. Ayahuasca is the hallucinogenic mix of herbs used traditionally by shamans to divine the cause of illness and receive guidance from the spirits of the forest as to how to treat. As part of the culture, I believe it is perfectly appropriate. When tourists come for an ayahuasca experience, however, they are basically either looking to get high, or seeking instant enlightenment. I have no quarrel with getting high, but the expected side effects of the mixture include severe vomiting and diarrhea, which seems to me like an unappealing advertisement. Worse, there is no standardized concoction, and some of the mixtures offered to tourists may not be exactly up to pharmaceutical standards for purity and/or safety, which might explain why this man became so unhinged after taking the drug. At any rate, we treated him for his anxiety, and he survived.

Amber Wobbekind -  Macaws Birds

We see a variety of infectious diseases, including some nasty soft tissue infections. A six-year-old girl presented to the clinic with swelling, pain, warmth and redness over her lower back. We suspected she was in the process of developing a large, deep abscess (called tropical pyomyositis, meaning deep infection of the muscle), gave her antibiotics both intravenously and orally, and she had gratifying improvement. And a two-year-old girl we had seen earlier returned to us. She had come in to the clinic late at night a few months earlier, with chicken pox and what looked like an infected face. The clinic staff thought she looked very ill at that time, and took her to Indiana. The doctors at Indiana agreed and sent her to Iquitos, and the folks at the hospital there thought the same, and sent her on to Lima. According to her mother, she was in the children’s hospital there for weeks, and underwent multiple surgeries. Her face has now healed but the scars are obvious, and it looks like a lot of the underlying tissues just dissolved, so I suspect she had necrotizing fasciitis, the “flesh-eating bacteria” which cause tremendous tissue destruction. Her face is not quite normal, but she is not horribly disfigured, and appears to be neurologically intact, which is reassuring.

And, perhaps my favorite patient was a blast from the past. This woman is from Indiana, 25 miles upriver from us. When I was first working here in the early 1990’s, I spent some time working at the Indiana medical post, in order to establish my street creds (there was no other doctor there at the time, so even though I spoke little Spanish and had no Peruvian legal standing to practice medicine, they seemed happy to have me).


I would spend the night at Explorama’s Inn (now Ceiba Tops), then walk to Indiana, work at the posta medica, come back to the Inn for lunch, then return again to Indiana in the afternoon. Along the way, people would sometimes stop me to ask for medical help. One day, there was a woman sitting on the edge of the sidewalk as I passed by. She had a piece of gauze taped over the top of her foot, and when she removed it, I was horrified to see a quarter-sized area where the skin was completely gone. I was even more horrified when she peeled the gauze farther back, showing how half the skin from the top of her foot had dissolved. The tendon leading to her fourth toe was clearly visible.

I explained to her that she had what is called a tropical ulcer, and needed hospitalization, intravenous antibiotics, and oh, yes, a skin graft once the infection was under control. Nothing doing. Such fancy treatment was just not an option for her. Instead, I gave her some new-fangled oral antibiotics that a drug representative had given me before I left Wisconsin, and amazingly, her foot healed. She was left with a significant scar, but she healed.

I did not see or hear from her for well over 25 years, then in February, she showed up at the clinic, mostly just to say hi and to introduce her husband. The scar on her foot has receded a bit over the years, and although her foot is not beautiful, she can walk normally.

This is the sort of patient who makes me glad I chose to practice medicine.

Amber Wobbekind - Mono Boat