An Elective in Peru and Cuba: Peru

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used. 

The Inverse Care Law

The healthcare system of Peru is made up of a public sector and a private sector. The public sector is funded by two main types of health insurance – the Social Health Insurance (EsSalud) and the Comprehensive Health Insurance (SIS). While EsSalud is a mandatory insurance paid by the employers of all formal sector workers, SIS is an insurance funded by the government and international aid, which aimed to provide free or low-cost healthcare to those living in poverty and extreme poverty. Each of these insurances has their own healthcare facilities. While the EsSalud facilities provide more comprehensive and modern medical treatment, the SIS facilities only provide essential medical treatments with an emphasis on maternal and child health.

Before I arrived, I did not know how important the hospital I was placed in, Hospital Antonio Lorena, was to the people of Cusco. Cusco is one of the major cities in Peru, situated at 3500m above sea level, in the valley of the Andean mountain ranges. The city is the main commercial centre for the Quechua-speaking indigenous people of Peru; many whom still reside in the surrounding villages. In contrast to the Peruvians who live in the urban areas, who were literate in both Spanish and English and who were the beneficiaries of the EsSalud insurance, there was a high level of illiteracy, poor living conditions and transgenerational poverty amongst the indigenous people. Their rights were often neglected. There was no health insurance for this group and thus, no modern health care until the SIS was introduced in 2002. While there are many EsSalud hospitals in Cusco, Hospital Antonio Lorena is one of the two hospitals dedicated solely to the SIS beneficiaries in Peru.

When I arrived at Hospital Antonio Lorena, I was shocked to see the hospital buildings were made up of blocks of shipping containers. This was different from the photo of the hospital I saw online. The gate of the hospital was shut tight, with a big banner saying ‘National Doctors’ Indefinite Strike’. There were many doctors congregated outside the buildings, shouting, raising their placards and drumming. They seemed to be protesting about their low pay. There were another group of people outside the hospital’s gate, shouting, raising their placards and drumming as well, but they seemed to be protesting about an entirely different issue – ‘Save our Hospital!’ was written on one of their placards.

Fortunately, I could register myself for my elective. Initially, I planned to do three weeks of Emergency Medicine. Due to the doctors’ strike, I did not have much choice but was placed in Paediatrics for two weeks and Infectious Diseases for one week.

Later, I learned that the doctors had not been paid for months and this indefinite strike had happened a few times since last year. I also heard that the original Hospital Antonio Lorena was undergoing a major refurbishment. Therefore, this was just a contingency hospital until the work completes. However, doctors told me, even though it has been three years since the work started, the new hospital was nowhere near done and will probably take at least another three years to complete. I visited the construction site of the hospital, but there were no workers there at all on a Wednesday afternoon. What about the group of people protesting outside the hospital? I learned that they were probably the representatives of the poor. Instead of funding the refurbishment of Hospital Antonio Lorena, the local authority decided to channel the funding to building a new international airport in a nearby village to boost the tourism industry to Machu Picchu. The work on Hospital Antonio Lorena was therefore halted.

Unlike EsSalud or other social insurance schemes, SIS’s budget is fixed and does not adjust to the increasing number of beneficiaries. It also does not help that the General Government Expenditure for Health in Peru has remained stagnant at 4-5% GDP for decades. In the past decade, the government worked hard on the issues of inequality in access to health services. However, due to political corruption (a pervasive ‘culture’ from the ministers to the farmers, as the Peruvians put it), the opportunities to boost the personal economic situation took precedence over the welfare of the people. In this adversity, the poorest group suffered the most as they were left with almost no accessible health services. 

Fuelled by the poor access to health services, poor public health education and high illiteracy rate, the vulnerable rural population bears the brunt of nutritional deficiencies, maternal and perinatal death and communicable disease in Peru. These patients often present to health services, if at all, when the conditions are dire. In Paediatrics, I saw a 5-month-old boy with Kwashiorkor disease and globally-delayed development due to parental neglect; In Infectious Diseases, I saw cases of severe mucocutaneous leishmaniasis and advanced AIDS. In a short period, I saw many extreme pathologies which I thought only exist in textbooks. More appallingly, these diseases hardly exist in the metropolitan of Lima, just few hundred kilometres away. Based the Dahlgren-Whitehead rainbow we learned in our Public Health lectures, I knew that to resolve these heart-wrenching problems we will need to tackle the wider social determinants of health. However, in reality, how much influence do health professionals have over these factors? 

The effort to reverse the Inverse Care Law

While I was overwhelmed by the inequality I saw, a few doctors in Hospital Antonio Lorena showed me how they maintained professionalism and improved the lives of those who needed them most. For example, several paediatricians chose to stay in the ward and care for their patients instead of joining the indefinite strike with their colleagues, because they knew that no one would be saving those children if they choose to walk out indefinitely. Besides, even with the constraints of funding, they tried to deliver an evidence-based practice. When first-line investigations and treatments were not available in Hospital Antonio Lorena, the doctors were resourceful in seeking evidence-based alternatives for the patients to achieve comparable outcomes. Even with the little they had, they were relentlessly helping those neglected by their society. Therefore, at times when I am fixated with the disputes we have in the NHS, these Peruvian doctors’ attitude towards their patients reminded me to look beyond these dissatisfactions and to be a doctor who truly cares for the people. 

Unfortunately for the Peruvians, there were times when the second-line treatments and investigations were not available in Hospital Antonio Lorena. During these times, the patients could buy those services and items from third-party laboratories and pharmacies in town. This creates a strange picture which there were many pharmacies and laboratories situated right outside the hospital’s gate, and patients would bring along their cannulas, saline intravenous solution and drugs to the clinics and wards. However, this also means that these services, which are available only on out-of-pocket payments, are not available to those who just cannot afford to pay anything at all.

Conclusion

In conclusion, this elective gave me an experience which I did not expect at all. When I departed from Heathrow, I expected this elective to be an extension of the Infectious Disease placement we had in clinical school. However, it has taught me much more than clinical knowledge alone. This elective showed me what ‘lack of resources’ truly means; it is a harsh reality for millions in the Latin America.  It had taught me to appreciate every little thing I have been taking for granted in the NHS: the ubiquitous Hibiscrubs in Addenbrooke’s, the freedom to do audits and to access the latest scientific articles, the capacity to order fancy investigations, the support each of us has to groom us into a safe and competent doctor and so much more. It has also taught me that if an opportunity arises in the future, I could and I should contribute more to the developing nations either directly, by being a doctor for the people there, or indirectly, through doing researches which the results are easily accessible to the doctors in these developing nations.   

An Elective in Cuba and Peru: Cuba

This was written as part of my elective report 'What is a Hibiscrub?', so excuse the cringy formal/reflective language used. 

I did two weeks of General Surgery rotation in Hospital Manuel Fajardo and two weeks Obstetrics in Hospital Gineco-Obstetrico Ramon Gonzalez Coro. As expected, the biggest problem I had during my time in Cuba was the language barrier. Even though I could understand basic Spanish, the Cubans spoke at a breakneck pace and with a strong accent, which made it almost impossible for me to take a history from the patients. However, there were more surprises for me apart from the language barrier. 

The Lack of Resources

When my General Surgery supervisor brought me to the theatre changing room on my first day, I was surprised to be offered reusable surgical masks and head covers made of cotton fabrics. When I was changing into my surgical shoes which I brought from home, the other doctors were surprised to see the odd looking ‘flip-flops’ and offered me a pair of cotton shoe covers. I was at loss of how to use those covers until a nurse showed me how to tie them over my shoes. When I arrived outside a theatre room, a registrar told me to scrub in. ‘What is a Hibiscrub?’ she asked when I asked her where can I could get Hibiscrub from, a soap ubiquitous in Addenbrooke’s Hospital. She proceeded to show me how to scrub: first, by using a bar of regular soap for 5 minutes; after rinsing, apply an alcohol mix, which left strange white residues on my hands and caused the skin on my palm to peel.

The equipment in the theatre was all reusable: from cotton surgical gowns to the enormous pieces of green cotton fabric used as drapes, to the metal yankeur suction tube. The only things which were disposable were the swabs and sutures. The waste they had after any surgery was a little 2L plastic bag, as compared to the 2-3 large garbage bags we had in the UK. While in the General Surgical Ward, instead of the usual surgical site drainage bags we have in the UK, a white surgical glove connected to a plastic drainage tube with duct tapes was used in place of a drainage system.

Apart from disposable items, the hospitals lacked laboratory-based investigations, imaging equipment and medications. This used to be the reason why Cuban doctors were so good at diagnosing based on the clinical picture alone, instead of relying on imaging. However, I also witnessed the harsh reality of not having X-ray machines, CT and MRI scans readily available in clinical practice. An 80-year-old lady with painless jaundice was admitted during my placement. Although the doctors suspected that she had pancreatic cancer, they were unable to offer her CT scans to check for metastases. The only thing they could offer her was a staging laparotomy. I secretly hoped a palliative care doctor was referred for her, but judging from the lack of a CT machine, I wondered about the availability of palliative care here. During the laparotomy, they found multiple metastases and a blocked duodenum. She deteriorated rapidly after the surgery and died the next day.

Due to the economic sanctions, the Cuban surgeons had few disposable items and imaging equipment at their disposal. Although I was at awe with the creativity of the surgeons, there is a limit to their improvisation skill. After the death of patient with jaundice, I became more aware of our reliance on technologies in our daily practice in the NHS. These experiences made me realised the luxury we have always enjoyed in the NHS, both as a doctor and as a patient. For example, as a junior doctor, I would be able to order any investigations just with a few clicks on the computer without actually considering the costs behind them, and I can be sure that the results will return me soon. These experiences revealed to me the real costs of these investigations and treatment. Thus, I should be more mindful when using the resources available, using them only when there is a valid clinical reasoning behind each investigation, instead of doing it ‘just as a baseline’.  

The evidence-based practice?

Since the beginning of medical school, I learned about the importance of evidence-based medicine and how a simple study like Ignaz Semmelweis’ comparison of the mortality rates in obstetric wards cared by doctors and those cared by midwives had spared countless women and newborns from agonising deaths. As medical students, we were all told to wash our hands numerous times since day one of our clinical years to prevent spreading pathogens to our patients and ourselves. Despite so, I often washed my hands in the wards with the sole intention of avoiding reprimands from the infectious control nurses. In Cuba, I witnessed the consequences of not adopting this simple yet effective evidence-based practice. Due to the lack of proper hand-washing facilities nor gloves in the clinics and wards, I often witnessed doctors examining patients, one after another, without washing their hands in-between. As a result, surgical wound infections, wound dehiscence and large surgical hernias were familiar sights. It was strange to see these iatrogenic pathologies every day, yet no measures were adopted to improve the situation.  It was even more strange to see patients keep coming back to the same doctor to seek help and even thanking the doctor for his willingness to treat their complications! This would have earned the doctors lawsuits in the UK! 

The lack of resources might have curtailed any effort to do audits or research to improve the situation. However, I believe there is another factor dampening the research culture – the constant use of socialist-based propaganda to reassure themselves and the public of the current state of the healthcare system. After Fidel Castro’s successful use of propaganda to unite the Cubans in the Cuban Revolution, the government maintained an intricate propaganda machine, including all broadcasting facilities and publishing houses. The culture of using propaganda to unite the Cubans seemed to infiltrate the medical field. When asked about their health system, the Cuban doctors have only the highest praises and nothing less. Their unacceptance towards criticism was evident when a Colombian trainee doctor lamented about the state of the system to one of the elective students. The doctor later received very disapproving comments from his colleagues. Besides, as elective students, we were not allowed to conduct audits too. This surprised me as I learned from another elective student who was at the same time as I did that each primary care centre has a statistician and they were obsessed with collecting data! Several African medical students studying in Cuba told me that they were not taught to conduct any audits, partly due to the lack of resources, and partly since all statistics were heavily monitored by the government. The doctors were pressured to produce favourable statistics to protect the international ranking of Cuba healthcare system and Cuba hardly ever allow independent verification of its statistics. I have also witnessed how clerking sheets and observation sheets were completed in the hospital. The doctors filled in clerking sheets, which in theory would aid in taking an extremely comprehensive history and examination, without having interacted with their patients for more than 2 minutes; the 4-hour-post-partum observation sheets were filled in within the first hour postpartum. Although I would not generalise these actions to the culture of the whole system, they provoked my scepticism towards the stellar statistics reported to international organisations from Cuba.

Furthermore, Cuba is also a country with an inadequate and heavily-censored internet connection. Although I was unsure if this was due to the US embargo or it was part of the government’s effort to prevent Cubans from assessing outside culture and information, I witnessed how their healthcare system suffered from their isolation from the international medical community. During my four weeks in both hospitals, I have attended several teaching sessions and teaching ward rounds with the local medical students. However, during those sessions, I did not see any professors quoting any evidence from any scientific journal during their teaching. When questioned about their clinical reasoning, anecdotal pieces of evidence were often used to justify their actions. However, how are the Cuban doctors supposed to assess the latest NEJM when the internet costs USD 1.50 per hour, but an average Cuban doctor earns merely USD 60 per month? Besides, most Cubans who have never been outside of the country were unable to understand simple conversational English.

Throughout my time there, I worried about the quality care received by the patients and at times, secretly blamed the doctors who did not wash their hands for the infected surgical wounds. On hindsight, perhaps the cause of those infected surgical wounds was more than the bacteria on the doctors’ hands, rather a cumulative consequence of the environment they were in. 

We had to wear white coats! (and I really wore the sunglasses on the way to hospital)

An actual Caribbean beach, where we spent hours doing nothing but chill

They said the friends you made during the hardest time in your life will last. I think so too. 

My new friends in La Habana (and the ones without which I couldn't have survived the hospital)

Salsa - the Cuban way

A must.

Learned about the dual currency, and learned how to use them to our benefit. 

Those stains are not blood.

Empathy, or the lack thereof.

 In my final term of the year, I am finally in my first ever Medical Rotation. And I started this when the Junior Doctors are on strike. Great. Honestly, it's great, because I get to do most things the juniors do, under the supervision of consultants, who usually don't even acknowledge our existence in the wards. So, it's so great for our education!

_____________________________________________________________

I was in Neurology clinic this morning. My first ever encounter with clinical neuro. It was really strange yet very interesting at the same time. The patients came in with epilepsy, migraine, headaches etc, just like how I read in the textbooks before. However, the strangest part of the whole morning was this consultation...

The patient had been experiencing difficulty walking and blurry vision, twice in 3 years time. Before she came in with her family, the consultant and I had a look at the MRI scan of her brain. 

'Look at those plaques.' It wasn't great.
'Does she has a diagnosis yet?' I asked, 

'No.' Then she walked out to get the patient in. 

I thought, No...this is bad.

The patient came in with her young family, all cheery and happy and agreed for me to be present while the consultation went on. She smiled. I forced myself to smile back. I thought, this is really bad. Does she knows? Is she suspecting? Will she walk out of this room the way she walked in?

The consultant smiled and carried on doing examinations, as if she does not know anything. Everything went on smoothly until the examination ended and everyone was back at the desk. I felt very strange throughout the whole time. I kept asking myself, how would I feel if I were in her shoes? Young family, strange symptoms happening to myself, confused, probably desperate for an answer, nah, I hope it's just something trivial. 

'Remember you had an MRI scan?' the consultant said. 

'Yes, how was it?' she replied. 

'From your history, your examination and your scans...It seems very likely that you have Multiple Sclerosis.' 

The air was cold, dead silent then. Even the baby was not making a sound. 

She started tearing. I grabbed some tissue for her immediately, having observed how the nurse reacted the last time I saw a consultant broke bad news to another patient with breast cancer. The consultation went on with her prognosis and treatment options. The patient went out slightly more composed, but I could see she was very fearful at the end. 

I was not quite sure what to feel. I was constantly battling between 2 different point of view within myself, throughout the consultation:

From the medical point of view, the consultant knew from the beginning what was happening and what will happen. She will get the diagnosis, then she will treat it the best she could and the MS should be under control, given she had RRMS. Job done. At one point, I almost could not understand why is she crying. I thought, don't have to cry, you are not going to die, at least, not that soon. There's a cure, MS is super common, I just saw several patients with MS before you. You will be fine. 

Then I put myself into her shoes: Omg, I am freaking scared, with all the news and things happening to people with MS! Will I shrivel up, stop breathing and die? Will I be wheelchair-bound? What will happen to my baby?! I want to watch him grow! 

I realised how my perspective and state of mind change as I learn more about Medicine. We see so many very very ill people coming in day in and day out, it's just seems normal to be very ill. The same for death - a dead body was pushed pass us on a trolley the other day and we continued to talk about the patient we were about to see as if nothing happened. A life just passed away, for goodness sake....

But...we don't live with those diseases and we have never experienced most of those diseases before, it is very hard to imagine how does it feel like. 

During our Clinical Communication Skills session, we were told to empathise with our patients, whom we have never met before and many with diseases which we never even heard before. I really don't know how medical students like us, 20-something years old, who barely have enough life experience or children of our own, can truly empathise with our patients. We can offer our utmost sympathy, but to empathise?

As for now, to expect us to offer empathy, as it is defined, will take more time, more experience and more deliberate effort to put ourselves in others' shoes in our every day life. 

Stage: Consciously incompetent.

I will not be surprised if a patient decides to shout at me or hurl a filled vomit bowl at my direction one day. I mean, if I am feeling sick as hell, confused, half deaf, half blind, half naked, hungry and old, the last thing I want to experience is having an utterly dumb medical student, who has no idea what she is doing, to repeatedly stab my arm with a needle, while 'attempting' to take my blood but ended up with nothing so the nurse has to stab me again.

It's my second week in the ward now. I am still very happy to be part of the 'student doctor' team! Unlike the pre-clinical years, I am experiencing completely new, unique things every day and I am meeting new people every single day! When I wake up in the morning, I have no idea who I will meet and what I will see in the hospital, but I am excited to be there and to learn.

The thing is, I am also slightly frustrated at the moment. If you know the 'conscious competency' learning model, I am currently at the consciously incompetent mode.  (When I was told pre-clinical students are unconsciously incompetent, I didn't believe it. But it's probably true.) 

For instance, when I listen to a heart, I know it's abnormal, but I can't tell what's wrong with it. Then I learned that any heart sound that you hear aside from the 'lub-dub' is a murmur. So I spent ages trying to figure out what kind of murmur that is, but I still have no idea where on earth does it come from or whether it's a stenosis or a regurgitation. I feel even worse when my patient starts quizzing me what murmurs does he has when he knew his diagnosis. What a joke. (If I manage to make the patients feel better this way, good then. At least, I am somewhat useful. :/ ) 

Even frustrating is the fact that I can't remember much from my pre-clinical years. All the anatomy, all the pharmacology, all out of the window. There are instances that I recognise a drug name, but have no idea what does it do; there are instances when I don't even remember seeing that word before! Eg. I don't remember reading about 'brachiocephalic veins' until I re-read my notes from first year this morning. (Apparently, they are pretty damn huge and important veins, which obviously everyone knows) So much for doing the most expensive anatomy course in the world...

It's almost like I have complete amnesia sometime during the past 3 years that I almost have no recollection whatsoever that I learnt those stuffs before! Or probs, due to the concussion i had on my head a month ago...hmmm

I have to learn the millions of new stuffs out there while trying to remember the millions of facts from the past. Not that I don't want to learn them. The fact is, I really hope I know all of those things now. I really hope that I will be as capable and as smart as the qualified doctors now. I really hope I am that bit more competent now so I can be useful on the ward and actually help my patients, instead of doing practice examinations on them when they should be resting. No wonder many of them wants to charge us students for each examination we do on them (I can assure you they are joking). 

I really don't mind spending that bit more time to learn, if that's what it takes to get me there.
Oh brain, work please.