The mission started with a brief orientation in Cusco, and it didn’t escape me when the medical director announced that patients could be seen by internal medicine, pediatrics, ENT, gynecology, and optometry. Psychiatry was strangely missing from the list, and when I pointed this out, he told me he had a special job for me: to run the pharmacy. While I was happy to help dispense medications, I had the sense that this population might have unmet mental health needs and suggested that it could be worthwhile to offer psychiatry as a specialty as well!
While the group came with an extensive supply of medications, vitamins, reading glasses, toothbrushes, and some wheelchairs, canes, and walkers, there were no psychotropic medications in the stash. I spoke with a local doctor who served as a liaison, and learned that he was familiar only with diazepam and alprazolam. Psychiatric patients were referred to doctors in Cusco, and local doctors did not prescribe antidepressants. For complex issues that required medical or surgical subspecialization, the referrals were even more complex: Patients traveled 18 hours by bus to be treated in Lima.
On the morning of our first clinic, I was given a small supply of fluoxetine (per my request) and alprazolam. Over 5 days we worked in three sites. On the first day, we were at the municipal center in Huarocondo, a little more than an hour outside of Cusco. Tents were set up inside the building, with the waiting room, triage, and pharmacy all stationed outside on the dirt. Inside, there was very little light, and like the other places we’d set up, no heat. My tent had a table and two chairs meant for primary school children, and I absconded with an adult-sized plastic chair for my interpreter. We had no access to medical records, no labs or radiographic equipment, and no clear place to send anyone for follow-up – this was true across all specialties, though the ENT who was working with us had come with suitcases full of his own equipment. Patients didn’t know what a psychiatrist or psychologist was, and some responded to questions about depression by saying that their blood pressure was just fine. Triage resorted to asking people if they felt sad and wanted to talk to a doctor about it.
The next 2 days, we worked in medical clinics in Ancahuasi and Anta, and while the conditions were more conducive to providing medical care, there was still no heat, the lighting was poor, and the buildings had not seen new coats of paint or furniture in many years. The clinics did not have psychiatrists, but they did each have a psychologist, and a couple of the people I saw had been seen. I was also told that fluoxetine could be obtained in Anta.
Courtesy Dr. Dinah Miller
Patients and their families wait to be seen by The Hands Across the Americas volunteer doctors outside a clinic in Ancahuasi, Peru.
Hundreds of patients came each day, and all told, more than a thousand patients were seen by nine doctors in those 5 days. My official psychiatry tally was 79, but my personal count was less – I imagine some people became impatient with the long line and left without being seen – I recorded visits with 8-15 people each day.
First, let me say that I was surprised at the lack of pure psychopathology; the issues were more reactions to tremendous deprivation, violence, loneliness, medical and developmental disorders, and chronic struggles. I saw only two adult men, the rest of the patients were women and a few children. No one I saw had ever seen a psychiatrist before, and no one had taken psychotropic medications (not even the diazepam or alprazolam, which I was told could be obtained), and in fact, very few were on any medications of any kind. No one had ever been in a psychiatric hospital. Poverty was rampant, as was domestic violence: Men beat their wives, parents beat their children, and there seemed to be no societal means to interrupt this. One bruised woman said her husband had been released from jail in a day, and several women spoke of living in fear for their lives; still, their families encouraged them to stay with men who were abusive or unfaithful. I was told that the statistic for spousal abuse in Peru was 60%, in Cusco it was 75%; I suspect it was even higher in these outlying villages. Families were fractured; employment was physically very difficult; and stress was extreme. Low mood and poor sleep were pervasive, but given the fact that I was unsure if people could get follow-up or even afford to refill medications, I gave out very little in the way of medications, and used the fluoxetine only for a few people where I felt their mood and circumstances were so dire that perhaps it would help – and it seemed unlikely to hurt. I was able to hospitalize one 18-year-old mother who was suicidal and said she had tried to hang herself, though she was released early the next morning before she was ever seen by a doctor; she did note she felt much better and was grateful for the help.