After a couple days operating on people in Iquitos, Peru, we realize we're going to need some more patients.
We started with about 50 candidates, with hernias, tumors or unidentified pains. But most were excluded for a variety of reasons. Some were too old or weak, and we feared complications with their hearts. Some never returned with the x-rays (relatively affordable at government clinics) we would need before operating. Yet others had conditions we were not equipped to operate on, like tumors of the ovaries or uterus.
A couple of us medical students headed out into the neighborhoods to find more patients.
Iquitos is divided into four districts, each with its own mayor and demographics. Belen is the poorest, situated on the edge of town. It literally extends into the Itaya River, a huge tributary of the Amazon. The houses are built on stilts or just float, tied to posts to prevent them from drifting away. The farther out on the river, the more questionable the construction gets: homes cobbled together with scrap wood and plastic. If you are truly poor, this is where you stake your claim.
We begin in the market, the largest in the city, and walk gradually downhill past stalls offering chicken, fish and monkey meat. There are clothes and shoes as well, but it's the meat that catches your eye, laid out on wooden tables and of questionable freshness.
Tarps strung over the street between the stalls lend red, green or blue hues to the scene. Through the open areas between these tarps, vultures descend to the street to squabble with stray dogs over scraps.
We're with Leovina Perez, a Peruvian counselor who works with the residents of Belen. We get a lot of attention from the vendors as we're still dressed in our scrubs from the clinic. As we walk between stalls a woman asks us what we're doing. When we explain that we are looking for people who might need surgery she asks us to examine her abdomen.
We step off the street through a door and into a concrete storeroom. She shows me her stomach while explaining the pain she has. Unfortunately, it is not a hernia, something we can easily fix in the operating room. It's likely a benign tumor of the uterus. Also known as fibroids, these growths can cause pain, especially during menstruation. We aren't equipped to perform gynecological surgeries during this visit but take her information so that Leovina can contact her if another surgical team comes through.
We turn and walk down stairs until we come to the edge of the water. It is the beginning of the dry season, and the water has receded a bit. The houses stand on their stilts about half a story above the waterline. From here you can get in a canoe or use makeshift walkways suspended above the fetid waters. Garbage is strewn about, collecting against the homes in the water. You can smell the human waste that gets deposited straight into the river. There is no sewer system or garbage collection. The current just carries it away — or so one hopes.
As I struggle to keep my balance on the narrow wooden planks I think about how much I do not want to fall in this water. Then I come across a group of children swimming, laughing and splashing each other. It's not exactly shocking. The reality is that more people live in similar makeshift communities around the world than live in American-style neighborhoods. Still, the water makes it seem especially unsanitary.
Leovina knows of a potential patient, so we follow her along the catwalk by rows of wooden houses. Eventually we come to the individual's home, where he waits with another man interested in surgery. Inside, a television is on next to a stereo with rather large speakers. It's one of the classic paradoxes of our times that we're here in the poorest area of Iquitos, yet some homes have satellite TV and we follow up with these patients via cellphone.
The home consists of a main room with two smaller rooms attached. Plastic sheeting lets light in through the ceiling. I can see the water through gaps in the wooden-plank floor.
After interviewing the patients I take them one at a time into a bedroom to examine them. One is suffering from quite a large hernia that he's had for 15 years. It hurts, he says and keeps him from working. He's in his 70s and I worry that his age increases the risk for surgery, but I tell him to come to the clinic for a final determination. The other man is younger, maybe 50, and has a smaller hernia that should be easy to repair.
We walk back via a different route finding more patients along the way. The walkways bring us to concrete streets, a recent improvement to the neighborhood. The receding waters have left behind large piles of wet garbage, which we pick our way around. The houses here are mostly concrete and brick. Various shops occupy their lower levels, but in the rainy season the water sits just below the second story. I am told that in very wet years the water can reach even higher.
It's tempting to call Belen a slum, but really it is a neighborhood like any other. Though the people are poor there are a range of incomes. Some people work in the market; others have jobs in the city. To call it a slum seems insulting to the dignity of the people who live here. They do the best they can with the little they have.
Leovina herself grew up here. People of Peru, the non-governmental organization she now works for, became part of her life when she was barely a teenager. Through this group she was provided with the opportunity to go to college. Today she counsels orphans and women in crisis centers run by the organization. Her story is a great example of how a helping hand can turn someone's life around — and that's basically what we're trying to do when we go out looking for patients.
The patients we found came to the clinic and most had successful operations. The reality, though, is that we couldn't get to everyone we wanted to help.
On our last day of clinic I had to go and speak with one of our patients from Belen to tell him we were not going to be operating on him. It was the older of the two gentlemen I had examined in the home above the water. We were leaving the next day and knew we'd already be operating into the night. As a medical student I know it will someday be my job to deliver bad news, but that doesn't mean it will ever be easy.
I felt personally invested in this patient. We had walked out into the neighborhood and found him, offered him hope, and now we were going to just leave? It seemed unfair, but the hard truth is that there has to be a limit. There are a finite amount of resources, and there are physical limits to how much work people can do. Someone has to be the last patient. We operated on the younger man because he had a lower chance of complications. It was a triage decision that underscores the fact that there is a lot more work to be done here.
I talked with Paul Opp, the director of People for Peru, about this. His organization gave logistical support to our trip and they host many other types of groups throughout the year.
Sometimes he'll hold a dinner for new volunteers and give each of them a coupon redeemable for a meal at a local restaurant. And the volunteer is told to give the coupon to a deserving resident of Iquitos.
It sounds simple enough, but the area of downtown Iquitos that runs along the Amazon River has many needy children begging and they recognize these coupons. It's easy to give away a voucher for a free meal. What's not easy is a situation with 10 hungry children begging you to feed them — and you can only help one.
Opp hopes this coupon experience will point up the enormity and difficulties of the task here. A city can't be changed overnight. But with groups coming in to help, at least some residents will get the help they need.
As for me, I can't wait to return.