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.

An Elective in Cuba and Peru: The Ultimate Packing List

When we first booked the trip to Cuba and Peru, we didn’t realised the huge contrast in climate between the 2 countries. Cuba, a hot and humid country, just like Malaysia, but probably at the peak of the hot season; Peru, a dry and cold country, at the peak of the Southern Hemisphere winter in June-July. We did not realised these differences until 1 day before our departure when I was busy moving out of my rented house + packing for the trip when Kevin checked a Salkantay trekking website which said, ‘The temperature may drop before zero degrees.’ It was then when I removed a Cuban hat (it was a souvenir from my friend, Han Rong, a few years back) from my luggage, frantically dug my winter coats from the boxes I have packed and squeezed it into my exploding luggage. So unless your trip involves travel to an extremely hot country, then an extremely cold country, which requires you to have equipment for 5-days long trekking and equipment to work in the hospital as a medical student, the following list shouldn’t bother you too much:

General

• Winter coat
• Thermals
• Sweaters/jumpers
• Beanie
• Gloves
• Swim suits
• 2-3 casual shirts
• 2 jeans/casual pants
• 2 trekking trousers or exercise pants
• 3-4 set of working clothes
• A nice dress – for nice dinners or to go to nice places
• Enough underwear to last you for ages…
• Sport shoes
• Flip-flops
• Work shoes
• Souvenirs for our hosts
• Plastic bags and zip-loc bags   

For working in the hospital:

• Stethoscope
• A thin, short white coat ‘batas’ – not the type we used in the UK for dissection or biochemistry lab
• Surgical scrubs
• Surgical slippers
• A small Oxford handbook/medical pocket book

For Salkantay trek (5D4N):

• Sleeping bag – one which can protect you from -10 degrees + wind during the night in the snowy mountains
• Extremely durable, water-proof trekking shoes – one which fits perfectly, else you’d get blisters
• Small bag pack
• Water bottle
• Snacks – can be bought right before the trip
• Walk stick (optional) – I didn’t had one
• Hat – to protect against the strong UV in Cusco-Machu Picchu 

Toiletry bag

• Shampoo – toiletries were not provided in any of our accommodation throughout the trip
• Body Soap
• Facial cleanser
• Insect repellent
• Lip moisturiser
• Face and Skin moisturiser
• Waterproof sun screen SPF 45 and above
• Alcohol hand gel – you’ll need it for hospitals and for eating out
• Tooth brush
• Tooth paste

First aid bag

• Lots of plasters
• Antiseptic cream
•   Paracetamol
•  Antihistamine
• Activated charcoal
• Loperamide (antidiarrhoea) – not advised to take this but for just in case
• Mountain sickness drug – we had acetosalicylic acid + caffeine, instead of acetazolamide as we don’t want to take diuretics during hiking for obvious reasons!
• Courtesy of our Occupational Health Department, we actually had sutures, SteriStrips, swab and cannulas with us in our first aid bag too. (LOL. I have yet to suture outside the theatre!) 

Tip: I also brought my ever-handy Longchamp handbag and a cloth recycle bag so I could use them when walking around in town. 

This seems like crazy amount of stuff, but these was just enough to get us through the journey, without having to buy a lot more on the way. We forgot to bring gloves, so I bought a pair for about £1 in Cusco.

We managed to packed all these into 1 big luggage (25kg) and 1 rug sack. And we're all ready to go!

An Elective in Cuba and Peru: The Preparation

Hello! I am currently in Cusco, Peru, starting the 6th week of my elective. I've decided to write this series of blog posts, instead of just my elective report, to allow more space where I can express myself in greater details, and to share my experience to whoever/future medical students who may appreciate this. 

For those of you who are not very medical profession-inclined, a medical elective is something (very fortunate) medical students do towards the end of their 5/6-years of medical school. During the electives weeks, we are allowed to go, literally, anywhere in the world, where there are medical professionals willing to give us supervisions during our practice. The main purpose is for us to see the world, instead of just hiding in our mountain of books and to learn about other health care systems and medical practices around the world. I think it's a particularly important part of opening our minds, especially for the medical students who have been studying and living in their own country for their whole lives. 

Our goals for our elective

The preparation for this medical elective started about 2 years ago when we first started our 4th year. Kevin and I decided to do our electives together and instead of going back to Malaysia or Singapore (where most Malaysians and Singaporeans would prefer to go for their electives), we decided we would like to do something different, something 'once-in-a-lifetime' because after all, when we start working next year, when will we have 2-months long holiday to do whatever we want again? So instead of choosing where we can learn 'proper first world medicine' eg in Australia, UK or US, we tailored our elective so we could experience cultures and healthcare systems which would be wildly different from what we have experienced. And maybe for once, put ourselves out of our comfort zone. As for proper medicine, that can wait... we have at least 40 years of working life ahead! :p 

Where should we go?

'The world is your oyster!' we were told once during our elective preparation session in clinical school. We will have plenty of opportunities in the future to go to places in Asia, US, UK and Australia, whether for medical practice purposes or research purposes. To be able to complete our elective in prestigious universities in the US (eg Harvard, Stanford, Yale, John Hopkins) would be great for our knowledge and CV, however, when we checked the elective prices for those universities, our eyes popped. Is the price worth it? What will we gain from paying that ridiculous amount of 'registration fee'? 

So we decided to park 'US elective' aside. And we were left with mainly Latin America, Africa and the Middle East. I have been hoping to see Machu Picchu and Kevin loved Latin America when he first came here a few years ago. So Latin America it is! 

Peru was the top of our list. But spending 8 weeks in 1 country seems a bit dull to us, so we've decided to choose another country for half of our elective. Our main alternatives were Bolivia and Cuba. And somehow, charmed by the photos of 'Capitolio' and the old American cars of Cuba on google, we've decided to go for Cuba.

I took this. Not from Google. Proud of that. 

Ok, so our touristy interests aside, these are the things you should consider when choosing an elective destination:

• Safety - in general, and in clinical practice
• Costs
• Availability of supervisions in specialty of your choice
• Language

A good starting point on what to consider for your elective - the MDU's booklet

Contacting our hosts

When we did our research on which hospital to go, we had no idea on which hospital actually caters/welcome elective students. Besides, some hosts were notoriously bad in replying to emails. Fortunately, we found 2 very brilliant, organised and responsive organisations that provide elective packages which met our interests: 

• For Cuba - Cuba Medical Electives, which has sadly closed now. However, you're encouraged to search for other hospitals in Cuba from Atillo
• Medics Away - who also provides elective packages to many other countries in the world. 

With their help, we managed to secure places in hospitals of our preferred destinations without much fuss. I will talk more about hospital, accommodation, food and tourist attractions in detail in another post. 

Many people opted to organise their elective independently. While feasible for developed countries and countries which you've already known the hosts, it may be a bit hard to know exactly what is suitable. We've tried another Peruvian elective company, Mundo Verde, before Medics Away. However, after spending 1 year trying to arrange our elective and not getting any response from them 2 months before our elective, we've decided to switch to Medics Away. Fortunately, Medics Away is very very responsive and made arrangements for our whole elective within 1 week's time. 

Language classes

Important when you are trying to understand what your patients are talking about!! 

Most parts of Central and South America speak Spanish. I knew zero (really!) Spanish before year 4. I was fortunate as I was able to take a Beginner's Spanish course, with a slight medical twist, as part of my student selective component (SSC) in my clinical school. After the course, I've decided to learn Spanish on my own by doing grammar books and watching medical Spanish series (Centro Medico). I was nowhere near as good as Kevin, who did 4-5 years of Spanish course, of course. And I knew I will have a hard time following what's going on in the hospitals, but I had to learn! Just imagine, after these 2-months of elective, I will be able to understand a whole new language! 

There are several Central American countries which speak English eg Trinidad and Tobago and Belize. These are popular choices among my peers. Otherwise, you're always welcome to visit Malaysia or Singapore! We speak English and we are quite 'exotic' too! (lol) 

Funding

I shall not dwell much on this as there are plenty of ways to earn your way to your dream elective. From bursaries and grants of Royal Colleges and specialty societies to University Grants, you can easily search for fundings from google. I was fortunate enough to be able to pay my whole elective from my savings and Kevin's college paid for most of his trip. 

I will talk about our specific budget in each country in the other blog posts. 

Flight 

This is a major cost to consider when planning your elective and best booked early. We booked our flight 8 months in advance and managed to spend only approx. £900 per person (London-> Havana-> Cusco -> Lima -> London), with 30kg luggage allowance. 

Vaccination 

This also another major factor/cost to consider. We visited our University's Occupational Health to disucss about this 6 months before our trip as they tend to get really really busy as summer approaches. I spent about £250 getting vaccinations for Rabies and Yellow Fever, and prophylactic tablets for Malaria. The Rabies jabs come in 3-doses and require at least 1 month to complete, and it lasts for 10 years once completed. As for the Yellow Fever vaccination, it supposes to cover your whole life. 

That's it for the advance preparation we had. I will talk about our Ultimate Packing List next!