George Thomas – Medical Elective in Quishuar, Peru – LED Report

In summer 2022, Leeds medics George Thomas and James Peaty undertook their medical elective at the  health post LED supports in Quisuar, in Peru’s Cordillera Blanca. Here’s the report George prepared for us:

We really enjoyed our time at the clinic and want to thank the LED charity for giving us the opportunity to go and the local people around the clinic for being very welcoming. We went to the clinic in Quishaur near Huaraz for around a month. This clinic supports the health of the people in the area surrounding Quishaur.

At the health post: George and James with Claus and Lary

The clinical part of the elective was very varied. Primarily it consisted of us working at the clinic. We would see people with the permanent nurse, Lary, for consultations in the clinic and go on home visits. Often it could be difficult for local people to get access to glasses, so on one occasion we also went to a neighbouring village to do an eye clinic. Furthermore we did lessons in English with the local school where we tried to incorporate teaching about health.

Eye Clinic

Often there was different health problems to what would be normal in the United Kingdom where both of us are currently at medical school. People would more likely to have late presentations of diseases which could make them more severe. Different medical conditions were also more prevalent for instance parasites were more common. At the clinic we had less access to the resources that would be expected in the UK for instance investigations such as bloods or scans therefore it was very important to work as a team doing the medical fundamentals of history taking and exam well. It was very useful for our training to be able to see conditions which would be less common in the UK and focus in on the core fundamentals of medicine.

The Clinic, Quishuar

The language barrier could also pose a challenge as both our Spanish is not the best. We have to thank both Claus, a local mountain guide, and Lary, the nurse, who we couldn’t have done without who helped with translation from Quechua to Spanish. Though by the end our Spanish had improved a lot and we also have to thank them for that!

It can be difficult for local people to get access to healthcare in the area around Quishuar therefore throughout my time there we realised the importance of clinics such as the one we were at to give medical support. It was a very humbling experience going to such a remote clinic and getting to help treat the local people. I was continually surprised; especially by some of the older people there, by how tough they were and their ability to carry on living quite physical lives with sometimes severe medical problems. Even so the local people were always very generous to me and James. One memorable experience was after a consultation one of the patients very kindly gave us some Guinea Pig which we had never tried before.

Home visit

After the clinic we also had the opportunity to do some mountaineering in the region with Claus, a local mountain guide who also helped translate at the clinic. This was my first chance to do mountaineering and I really enjoyed it. It was challenging at times, for me especially so when I was trying to sleep at altitude. I was a bit out of breath and only managed to fall to sleep what felt like just before I had to wake up. We ended up going up Mount Urus and Mount Ishinca. It was a really great experience and has made me keen to do more in the future.

We both want to again thank Val and everyone at LED for what was a great experience at the clinic and we really appreciate the help from everyone who made it possible for us to go!

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An Elective Volunteering in a Rural Peruvian Health Clinic

In summer 2022, Leeds medics James Peaty and George Thomas spent their medical elective period at the health post LED supports in Quisuar, in Peru’s Cordillera Blanca. As well as providing healthcare from the clinic in Quishuar and undertaking home visits for local elderly people who weren’t able to come to the clinic, James and George also ran a mobile eye clinic to distribute reading and distance glasses away from Quishuar and provided English lessons for local children in Quishuar. Here’s James’ report.

Aims and objectives

The key aims of the elective were to:

  • Experience healthcare provision in a developing country.
  • Experience healthcare provision by an international charity.
  • Contribute to healthcare provision in an area of need by fundraising for and purchasing a laptop as well as transporting glasses donated in the UK to be handed out on arrival.
  • Learn a new language using audiobooks and Duolingo.
  • Conduct English lessons for local school children.

Background and Organisation

I first heard about the elective form a friend, Hugh Harris, 3 years above me on the MBChB program at Leeds. He along with 3 other University of Leeds Medical Students had volunteered at the clinic based in the village of Quishuar in 2019. Through Hugh I was able to contact Val Pitkethly, the founder of the charity, Light, Education, Development (LED), that supports the clinic. After a short application process that involved submitting a CV and meeting with Val to discuss practicalities and get more information my elective partner, George Thomas, and I were accepted onto the elective.

The clinic itself is based in a mountain village on the eastern side of the Cordillera Blanca range in central Peru. It serves the people who live at the highest elevation at the western end of the province of Lucma who are furthest from the government run clinics that sit on either side of the range.

The main activity undertaken by the population served by the clinic appeared to be small scale farming and labouring jobs and the main form of housing was mud brick houses.

The local shop and a mud brick house in Quishuar

The clinic building consists of 4 rooms; the kitchen and nurse’s quarters, a waiting room, the consulting room and the bedroom. Running of the clinic is funded by the charitable donations mainly form the UK but also worldwide thanks, in part, to an international network built through Val’s mountain guiding clients.

There is a permanent Peruvian nurse stationed there throughout the year but all other medical staff are volunteers. Volunteers were mainly doctors and 5th year medical students from the UK but doctors from other developed nations had also staffed the clinic on a temporary basis in the past.

The consultation room of the clinic, Quishuar

Type of work performed

The clinic functioned as a basic source of primary care. To fulfil this function the clinic was equipped with basic examination equipment including all the equipment necessary to perform observations, a few books including the BNF and Oxford handbook of clinical medicine and a large stock of various basic medications ranging from antimicrobial agents to proton pump inhibitors.

In the clinic our history taking, and examination skills were well practiced. Diagnosis based exclusively on these was essential as the only tests we had access to were urine dipsticks. Communication skills were also tested as none of the patients spoke English and many did not speak Spanish but instead only the Incan language of Quechua. Thus, all communication had to go through the translator working with us.

Other functions that were performed by the clinic included: distribution of glasses, English lessons for local children and home visits for local elderly people who weren’t able to come to the clinic. My elective partner and I were involved in all these functions. For example, one weekend we packed up enough for an overnight camping trip and drove across to an adjacent valley, hiked up to a village with no road access and set up a field clinic distributing glasses to the anyone who required them.

My elective partner George using a Snellen chart at the mobile glasses clinic.

I had bought the glasses, which included both reading and distance prescriptions labelled as various strengths, in a shoe box from the UK. In the box there was also included a Snellen chart and reading materials of different sizes to help us determine, using a bit of trial and error, what strength of glasses each patient required. Over thirty people turned up to this mobile glasses clinic in both the evening and the morning of the next day. In the end we ran out of distance glasses.

English lessons were conducted after the children had finished school 3 days a week. We taught a small group of keen, primary school age, students basic things like the colours, animals, how to say their name and types of food in English. We also included games, songs (such as head, shoulders, knees and toes) and education about basic hygiene, sun safety and healthy eating. We tried to use as many visual aids as possible and to work form a rough plan.

Lesson materials and plan used for English lesson.

Other tasks we performed while at the clinic included taking stock of and helping order medications, alphabetising medications, taking stock of equipment and helping purchase or replace equipment. We also helped purchase and set a laptop for the clinic that we had fundraised for by running the Leeds Half marathon.

Case report

During the elective I was fortunate enough to be exposed to clinical cases that were fundamentally different from cases I commonly saw in general practice in the UK. An example of this was a 5-year-old child bought in by his mother due to a month-long history of gradually worsening diarrhea and epigastric pain particularly after eating. He had also developed a chronic cough in the last month. On further questioning it was noted that because of the stomach pain the child wasn’t eating as much as normal. The key positive finding on examination was that the boy was underweight for his height and age measuring at the 50th centile in height for his age but only at the 2nd centile for weight.

On discussing my findings, I was told that this was a classic presentation of worms. One study done on the prevalence of parasites in rural Peru found that half of the participants (aged 3 and above) had at least one intestinal helminth or protozoan detected by microscopy. The most common parasite detected was Strongyloides stercoralis which infected 24.5% of the population studied. This nematode can produce symptoms of pneumonitis, chronic malabsorption, diarrhea and abdominal pain thus accounting for the child’s presentation.

I was informed that the standard treatment for this infection was Albendazole. Although the Oxford handbook of clinical medicine recommended Ivermectin as the first line treatment of Strongyloides stercoralis without access to stool microscopy or blood tests it was impossible to be sure of the causative organism. Albendazole has been shown to have good efficacy against a range of roundworms including others common to rural Peruvian populations like hookworm. So, using this broad-spectrum drug was more likely to be effective in treating this child.

In addition to pharmaceutical management, I learnt that it is important to educate patients on basic hygiene and protective measures to avoid re-infection. Many parasites are picked up by the faecal oral route but hookworms and Strongyloides stercoralis can also burrow through the skin. Studies have shown that those who do not wear shoes when leaving the house, and particularly when defecating are more likely to become infected with Strongyloides stercoralis. Therefore, education about regular handwashing is highly important but shoe wearing is also likely to reduce rates of nematode infection. However, this is easier said than done in an area where houses have dirt floors and there is poor access to proper sanitary facilities. Living in close proximity to parasite carrying livestock may also increase risk of infection.

Extra curricula activities

During my elective I was able to significantly improve my Spanish through a combination of immersion, Paul Noble audiobooks and the Duolingo app which I had been using to practice daily since January 2022.

Conclusion

Overall, I believe the elective met almost all of my aims. I was able to fully experience what it is like to work in an international charity and to contribute to healthcare provision in an area of need by: fundraising for, helping purchase and set up a laptop for the clinic; taking and handing out glasses donated in the UK to those who cannot afford them; and helping with the day to day running of the clinic. Furthermore, I significantly improved my understanding of Spanish and taught English to local primary school aged children.

I would have liked to experience the Government run hospitals and clinics to get a full experience of how their health system works. Although this was originally planned it did not end up coming to fruition.

Additionally, this elective had many learning points. These included: learning about diseases, like parasitic worms, that I hadn’t come across in the UK; learning what it means to live in a developing nation and how health needs in a developing nation are different from those of developed nations such as the UK; and the practicalities of healthcare provision in a resource poor environment.

LED Projects 2021 – The Year So Far

Having held our 2021 Fundraising Event recently, we thought it would be a good time to provide a round up of the projects LED has funded and delivered so far this year.

In Peru

  • Continued to keep Quisuar health post open and stocked with the help of our nurse, and provided transport of all medicines to the area 

In Nepal

  • Funded food distribution in Tilje and communities on west of Manaslu area with the help of Somi Gurung
  • Food distribution with the help of Tsering Darkya in Samdo 
  • Food and medical supplies to Langtang and Rasuwa Solu with the help of The Partners Nepal 
  • Food distribution in various villages of Rasuwa with the help of Bhudi Tamang 
  • Food distribution with the help of Dr Kami Temba and Yangji Sherpa in Khumbu 
  • Tree project reforestation in Langtang area through Ang Rita of The Partners Nepal 
  • Continued help with Bung old people’s home
  • Completed the solar light distribution project for Tsum and Manaslu area funded by the donation from The Derek Moore Foundation with help from Tsering Darkya, Ang Chhering Sherpa and Bhudi Tamang 
  • Delivered medical supplies for health posts and completed a much needed health survey in cognitive development of children in areas of food shortages for a medical project in Tsum and Manaslu area, again with help from Tsering Darkya, Ang Chhering Sherpa and Bhudi Tamang 
  • Follow up food distribution in Rasuwa 
  • Help for communication / online classes in Khumbu area enabling school students to continue their education during COVID
  • Medical supplies to health posts in Khumbu area via Himalayan Trust 
  • Thame teacher funding, with Dr Kami kindly organising this for us 

Thank yous

A huge thank you to Melky and Antonia Bedon in Peru for their unstinting help and support in getting all supplies to Quisuar for its continued running and for overseeing all issues with the health post.

A massive thanks to all helpers in Nepal and especially to Tenzing in Pokhara for unfailing organisation and help to get the funds once in Nepal to the right people and places for all of the projects to work.

Special thank yous to Bhudi, Ang Chhering, Tsering Darkya, Dr Kami, Yangji Sherpa and Ang Rita Sherpa.

And to everyone who helps with their very generous support, Thank you – Tuche – Gracias

https://www.justgiving.com/lighteducationdevelopment

Our Medical Elective in Quisuar, Peru

In August 2018, Leeds medics Rachel, Alice, Heather and Katie spent their medical elective period at the LED Health Post in Quisuar, in Peru’s Cordillera Blanca. During their four weeks they also ran mobile clinics in surrounding villages, delivering school supplies en route. Here’s their report.

Elective Report

Over the summer of 2018 we as four 4th year medical students spent our medical elective period at the health post in Quishuar, a remote village situated in the Cordillera Blanca mountain region of Peru. The team consisted of ourselves, Tula a permanent nurse at the post and Juan, an interpreter and guide. The health post aims to provide basic healthcare to the 75 families of Quishuar and sometimes to surrounding villages at a reasonable cost of 5 soles per consultation. We aimed to contribute to the running of the health post, promote health education and also teach English to the local children.

Fundraising

Before departing for Quishuar, we raised funds to allow us to purchase some resources to contribute as well as donate to the charity that is responsible for building and supporting the sustainability of the post, Light Education Development (LED). LED aims to provide sustainable solar lighting, basic education and fundamental healthcare to remote communities in the developing world. We were inspired to start this following the walk to Dufton Pike in May 2018 where we met many of the people involved with the charity. We thoroughly enjoyed the day and saw first hand the commitment to the cause from so many people which was inspiring.

What makes Quishuar unique?

We found the Quishuar population had an inflated view of medical management, almost always preferring tablets over conservative or surgical management. We thought this may be due to a combination of lack of education surrounding common health problems and accessibility to alternative means of treatment, being so far away from a hospital (12 hours by car and significant expense) or other supportive services.

In terms of clinical practice, there were several differences to note that became apparent whilst working alongside Tula. This was most obvious with regards to the management of infections; we would often think that antibiotics were unnecessary, but it seemed the norm to readily give out antibiotics even when there was little evidence of infection. This was difficult to negotiate at times due to differing opinions as to what the problem was as well as the language barrier. Our antibiotic stewardship awareness is evident as we were much more cautious, however this may be less appropriate within a community where antibiotics are not so readily available and therefore resistance is far less likely.

Furthermore, there was an issue with non-returning for follow-up. It was unclear as to the main reasons for this, but we found that the knowledge that people are unlikely to return resulted in a change in our management, often distributing more medications at once and giving more long-term explanations of advice in order to pre-empt this problem.

Common presentations

One of the main problems was chronic dehydration, commonly manifesting as headaches and in many women, “urinary tract infection” symptoms. When asked, most people reported drinking only a glass or two of water a day and there was little understanding of the relationship between poor hydration and kidney problems/headaches. We tried to make the most of this situation, taking the time to explain this to patients during consultations. The language barrier made this challenging at times, with the level of patient understanding difficult to gauge but we got into a habit of asking every patient about drinking habits and advising them to drink 2L of water per day.

Giardia and worms were the two most common gastrointestinal presentations seen; often entire families came in with the same symptoms. We had a low threshold for treating these conditions as we had been advised they were common and recurrent, and quickly treated with a short course of medication. Hand hygiene was an important topic to raise here, as most people worked in agriculture and kept animals in and around the house, a major source of these infections.

A condition that we found particularly shocking was “pterygium” an ocular condition caused by sun damage. Therefore, one of our main education drives was sun protection; encouraging people to wear their hats low over their face and to purchase sunglasses if they could. A recommendation for future groups would be to collect sunglasses and provide them to the community to provide protection to as many people as possible.

Additionally, we saw several people with permanently scarred corneas as a result of untreated corneal ulcers. A case that was particularly upsetting was a young man who presented with a frank cornel scar, hoping for his longstanding blindness to be cured. His expectations were so far removed from what was possible making it a difficult conversation to have, especially as he was insistent on receiving medications to cure his condition. The frustration was only heightened due to the preventability of his condition. Whilst a corneal transplant was discussed (the only curative treatment here), it would never be possible for this patient to explore the options due to his financial position which was difficult to accept having only experienced the free services offered by the NHS in the UK.

Education

During our time, we had the opportunity to teach local children English in our afternoons. These sessions were well attended and we worked through different themes such as: weather, food and sports. The children were enthusiastic to learn and a joy to teach. Some would travel from neighbouring villages and all would work hard – even after a full day at their schools! On our last day we organised a mini-Olympics which was well received and got every child equally involved as they practiced their English through team sports. All the work that the children completed was handed out to them with a certificate, which we hope will keep them motivated to continue to work hard. We also taught about health education, the key topics being sanitation, signs of infection and when a doctor is required. We believe that this along with the water advice is invaluable to the community and it was great to take the opportunity to organise this. Another session we managed to organise was sex education with 20 attendees, aged between 14-17. This session was held with the help of Juan and lots of questions were asked at the end, demonstrating the engagement and interest in the topic. We hope there is scope for it to become a yearly event to help tackle high rates of teenage pregnancy and STIs. Our

Reflections

We can safely say that this was a unique and unforgettable experience on so many levels; both from a medical and personal perspective. From our dancing welcome party to our first taste of guinea pig we had so many new experiences in such a different environment and we all felt that we improved our medical skills as well as our Spanish speaking skills. The health post is evidently a very highly regarded epicentre in the village that contributes not only medically but also socially to the people of Quishuar.

A few highlights

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Interested in volunteering with us in Peru or Nepal? Use the Contact LED form on www.lighteducationdevelopment.org or message us on facebook.com/LEDCharity to find out about opportunities in 2019.