* Meet Ana 

The day is winding down at about 3:00 PM. Triage is taking its last few patients before packing up the scales, tape measurers and blood pressure cuffs. Their assembly line of first eliciting chief complaint, taking patient vitals, and then measuring their heights and weights is winding down after a barrage of incoming patients. Up in the mountains, we generally receive an initial wave of mothers and their toddlers and infants in the morning, shortly followed by a stream of school children leaving class a little after noon with men leaving work at their tale. But at around 3:00 PM, we politely begin telling patients that there is no time for them to see the doctors. Being so high in the mountains requires that we leave around 3:30-4:00 PM so that we don’t make the treacherous descent down the mountain back to Urubamba in the dark (it’s unsettling enough in broad day light). 

 

However, a mother and her daughter are slowly making their way to the clinic as it’s closing. As our members prepare to tell them that they have unfortunately arrived too late, they note that they 18 year old daughter’s eyes are swelling with tears, her skin dry, scaly and cracked. Her expression is a reflection of the physical and emotional tension wrought on by a dermatologic disease externally manifested. As we bafflingly stared, we could not determine whether she was tearing because her eyes were also afflicted by the skin condition or because the social isolation due to her appearance was emotionally frustrating. Although our doctors could immediately identify her situation as Psoriasis with super fungal and bacterial infections, the people of Ampay only knew this skin condition as a congenital abnormality. On our first day of clinic, Dr. Morales explained that the congenital abnormalities, as explained traditionally by the people of the Sacred Valley, are understood as evil forces manifested in human disease. This evil spirit can impregnate a women which leads to an abnormal child. Our experiences in clinic did not reveal whether these beliefs and sentiments are strongly prevalent in the community at present. But regardless of such religious and traditional beliefs, stigmas associated with physical diseases are continuous throughout various cultures and ethnicities. And it was clear that this girl was a victim of such stigma. She was prescribed steroids, antibiotic and antifungal medication. When I asked the attending how this patient’s condition would be had she been born in the United States, the doctor informed me that her condition would be no where near what it is now. Perhaps a bit of dry skin, but their would be no lacerations that pierced her hands and feet and no scaly plaques that single her out in the community. 

*Names changed 

Meet Carlos*

What started with a complaint of lower back pain (a common problem the labor driven communities of the Sacred Valley face) turned into a medical crisis that highlighted the vulnerability of the human condition when isolated from resources many of us take for granted. This 26 year-old father of two explained that he had lower back pain that radiated to his legs, a pain he believed might have triggered the many syncopal episodes he has been experiencing for the past few years. Upon further questioning, he noted that he had ‘palpitaciones’ and radiating pain from his chest to his left arm prior to these episodes. Further probing revealed that he had swelling in his extremities and noticed a change in color in his fingers as well. It is interesting to note that while these symptoms scream cardiac disease among the general public in the US, up in the mountains of Camahaura, these symptoms did not signal an emergent condition to our patient. Here, public service announcements come in the form of traditional medicine, word-of-mouth and, sparingly, posters distributed by the government primarily targeting pregnant women. It’s no surprise that he was not alarmed by his cardiac symptoms and preoccupied with his musculoskeletal pain, a pain that is widespread amongst his community and prioritized as it can interfere with work and income.

We targeted the primary condition (possible congenital heart disease) by providing some information to the patient about a possible diagnosis. With just a history and physical, it is difficult to narrow down the differential diagnosis. However, we suggested that he travel to the nearest cardiologist in Cusco (about a two hour drive from his town) in order to have more conclusive tests performed. We were able to prescribe him ibuprofen for his back pain and sent him to our physical therapy station to learn more about proper lifting techniques and back strengthening exercises. Although we did the best we could in recommending he see a cardiologist, a local health professional explained that the likelihood that our patient will seek medical treatment in Cusco is slim due to his work schedule. Here, he explained, workers don’t take off of work to see the doctor until there condition is unbearable. Such a gauge inaccurately tracks the progress of cardiac disease as pain is a poor indicator of the insidious advancement of a congenital heart syndrome. 

*Names have been changed

Meet Juan*

In the district of Pisac, approximately 150 people inhabit the small mountain town of Ccotataqui. As our bus pulled up the bumpy dirt road into the courtyard of the school where we would hold clinic, a local official announced our arrival to the town via megaphone. While we set up our supplies for clinic, a crowd of women and children began to accumulate. We triaged these patients in order of their arrival, and sent them on to see the doctors. Although the line was long, we triaged effectively, and the physicians and their assisting medical students worked efficiently to keep patients moving through. However, around noon a group of men showed up from the fields. Their leader, Juan, explained that they were on lunch break from working in the fields, and only had an hour before they needed to get back to work. After a moment of deliberation, we decided to let this group cut the line. Although it seemed unfair to see these workers before the women and children who had been waiting all day, we knew that if we didn’t see the workers now, we would not be able to help them at all.

While filling out his triage form, I learned that like many of his fellow farmers, Juan suffered from the occupational hazards of lower back pain, eye pain, and a pterygium in one eye. When I asked the standard question <<Cuando fue la ultima vez que vio a un doctor?>> (when did you last see a doctor?), he responded <<nunca>> (never). After having his vitals taken in triage, Juan had an interview and an exam with a physician and medical student. He was then referred to the physical therapy station, where he learned back exercises, stretches, and practiced appropriate lifting techniques to reduce the strain on his back. Next Juan moved on to the eyeglasses station, where he was outfitted with donated sunglasses to protect his eyes during his long work days in the fields. Not only will these sunglasses help reduce the burning and tearing he experienced as a result of sun exposure, they will also slow the growth of his pterygium. After completing his circuit through our clinic stations, Juan thanked us earnestly for the sunglasses and advice. By working efficiently for the rest of the day, we were still able to see all of the patients waiting in line. Juan and his fellow farmers were so thankful for the chance to visit our clinic on their brief lunch break, we were happy to have been able to help them.

*Names changed