One Year. One Physical Therapist in Trujillo, Peru.

Combining passions of global public health with travel and cultural immersion... With the help of the Catholic Medical Mission Board, I was afforded the opportunity to live outside of Trujillo, Peru for one year's time (2010-2011). Check out old posts about my experiences as a PT working in hospitals, a school, an outpatient clinic, doing research/community based rehabilitation, and a little teaching too. And my experiences with an entire calendar year of holidays, cultural customs and new culinary experiences!

I make it back about once a year with university students/CMMB projects, so I will periodically provide updates :)

Wednesday, September 28, 2011


One of my biggest frustrations with the Peruvian culture lies in the reality of (lack of) safety. I’m not just talking about the lack of seatbelts or the common transit/pedestrian dangers of daily life. I’m talking about the daily dangers surrounding each woman – and likely not just Peru, but presumably all of Latin America. Now that I’m about to leave, I feel like I can comment on it a little bit (without hopefully freaking out my parents too much!)

It’s hard not to be a bit paranoid here. Whenever anyone asks me where I live, I get the gasp and the “Oh, no, you shouldn’t be living in that neighborhood, it’s so dangerous!” Parts of my neighborhood are notorious for murder and gang problems, but fortunately I live in a “nicer part of the ghetto” as it’s affectionately called. I chose to forego the comfort of an apartment in Trujillo for the many benefits of immersion– in order to truly get to know the community for work in public health, I wanted to become a part of it. It worked out well - my living arrangements have been excellent – complete with wireless internet, my own bathroom that now has hot water(!), great proximity to the clinic, and the best part of all… an AMAZING family!

Sure enough, once they began to recognize me as a long-term volunteer at the local health clinic, it was clear that my neighbors “had my back” and I really began to feel more like part of the community. True, I still get stared at all the time, but I certainly feel safer walking around my community. During the day, the main worries are robberies. Peruvians are constantly looking over their shoulders as they walk. Don’t talk on your cell phone outside of the house- someone will run by and snatch it. Don’t carry a purse unless you absolutely have to. Avoid certain streets that are notorious. Don’t sit near the door to the public transportation- someone may run up and grab your bag. Don’t use the bridge unless you have to- they wait to rob you there. Lock the house 3-4 different ways.

Many Peruvians in my neighborhood are terrified to leave their homes at night. I’ve become much less social at night, simply because it’s not safe to go out. If I want to go play soccer at 8pm in Trujillo, by the time we finish, the public transit will have stopped running and I’ll have to take a cab by myself back to La Esperanza at night. It was frustrating at first, but now I’m used to it and instead use night hours to either work from home, spend time with my host family, or read and drink tea ☺
La Esperanza is working to improve the crime situation
Trujillo and many other parts of Peru have had an escalating problem with what they call “extortionistas” – basically, groups of thugs who select homes or businesses and threaten them. They demand monthly payments and if they don’t receive the payment, they blow up the home. I’d heard of these groups before but didn’t realize how bad the problem was until about 6 months into my stay here. We were sitting around the table after dinner talking, when all of a sudden we heard a series of extremely loud explosions that were so close they made the house shake. We began running around in circles in the living room, unsure of where to go or what to do. They evacuated the sisters who had been in the back rooms and we huddled near the other side of the house, trying to figure out what was going on without leaving the front door. It was then that my family confessed to me that their neighbors had been having problems with the extortionistas. Just before I arrived in Peru, their neighbors’ house one street away was blown up because they refused to make the payments (fortunately, nobody was home at the time). The house across the street from mine is currently being threatened and the family has been making the monthly payments.

This news terrified me – it was suddenly a much more real threat. I began to worry that these people would see me entering my own home and start to threaten my host family since they have an obvious gringa living with them. Fortunately, nothing has happened, but it’s been a constant worry. On top of that, I’ve had many friends who have been mugged. I know people who have been kidnapped in taxis and taken out to the desert - and luckily somehow got away to tell. Safety is a real concern – whether you’re Peruvian or not.

It’s obvious that God’s watching over me during my time here. I am still amazed that I haven’t even been robbed (knock on wood!) I’ve had a few attempts but have managed to get out of each situation. I have a handful of taxi drivers that I know and trust – as for the rest, I only use taxis as a last resort – and almost never alone. I’d rather it take 30 more minutes but be on some type of public transit where the worst that could happen would be a robbery. I only get into certain types of taxis, and they have to pass the “face” test - Creepy? Bad feeling? Young? NEXT. Elderly man… okay! (Maybe we’ll get in a car crash because he’s half blind, but at least he’s less likely to kidnap me!)

My biggest struggle this whole time has been in how 2-sided my life is. I’m walking in Peruvian shoes for a year, but deep inside I’ve known that come October I’ll be whisked back to my safety net of top quality health services and few personal safety concerns. It seems so unfair that Peruvians, and in particular Peruvian women, have to live in daily fear like this for their entire lives. They are constantly worrying – Where can the kids play safely? Will someone rob the home? Sexual assault? Taxi kidnappings? Extortionistas? Muggings on the street? And it never ends. They say that with the new president Ollanta, Peru should start to crack down on crime…. let’s hope they’re right. 

But, safety concerns and all, Peru nonetheless feels like home now – a beautiful place and at it’s heart, beautiful people who I will miss deeply – come Saturday. Can’t believe the year is coming to an end!

Monday, September 26, 2011

Corre, Gringita, Corre!

With my new running buddies (and random bystander)
Yesterday, in honor of my last Sunday in Trujillo, I participated in the “Pedro Horna Montoya maraton” (actually a 10k) race. And get this - for the cost of 3 soles (one dollar) I signed up and got my t-shirt! I’ve been looking for races in Perú all year and was pumped to finally find my South America running experience!

It was a great final farewell in the city I’ve come to love and call home over the last year. I was amused by the little Peruvian touches – “a big medical work-up prior to race” was a blood pressure measurement; “be there at 8 and race starts at 11:30” was really be there at 11, race starts at 12. At the race start, I was literally left in the dust- all 150 participants took off in full sprint! (But then, a few blocks later, some people were walking.) I was the only non-Peruvian in the race and the crowds did not let me forget it. “Corre, gringita, corre!” (run, little gringa, run) and “MIRA a la gringa!” (LOOK at the gringa) were most common, but I also heard a little kid say, “Mamá… mujeres corren también?” (Mom, women run too?)

Whenever I approached a man in the race, he would look at me with wide eyes and take off sprinting full speed ahead for a few seconds to lose me. Given my lack of consistent training, I was in too much pain to care about the scene I was inadvertently making. At the finish line, I was sieged by a mob of Peruvian men who wanted to take a photo together. They informed me that I got third place out of the women (really not that impressive, considering there were maybe 25 of us) and that I won a prize! They called “Mary Bocker” up to the podium (and somehow they lost my first name in there somewhere!) and proceeded to give out medals, a certificate, and a cash prize – 100 soles (30 bucks)! Yeah! Aside from dodging cars, pedestrians and dogs, and the occasional inhalation of bus exhaust, it was a semi-normal running race – and for me, a very unforgettable day.

Thursday, September 22, 2011

Tough cases

Throughout my year of physical therapy work, I’ve faced a number of tough patient cases. By “tough” I refer to the fact that the economic status or cultural factors dictate the quality of care and ultimately the functional ability and quality of life of these individuals. The ones that are most heartbreaking always seem to be the patients of higher risk and less independence - children or elderly adults.

There seems to be this sentiment of learned helplessness when it comes to kids with CP (cerebral palsy) here – like “oh, he or she never started walking on his/her own, so there’s really not a lot we can do.” When I’m partnering with other local PT’s in treatment, especially in situations where it’s just for a short time period, I always feel like I have to tread carefully in my words and actions – I don’t want to offend anyone or come across as all-knowing, but at the same time want to maximize the type of care the kid is receiving.

Last month I went to check out a school for kids with disabilities, where I encountered an 8-year-old boy (we’ll call him Jose) who has CP and is in a wheelchair. The director invited me to spend a few hours working with the other PT’s in the rehab room. Generally, from my observations across a number of different facilities, care for kids with CP involves supine passive range of motion and massage. Sometimes hot packs. (Yeah, I know... The problem is, this is what they are being taught in school.) The PT wheeled Jose in and began the range of motion routine. We began to talk and he expressed a desire to be able to walk around like his friends. He has spastic diplegia it was evident to me right away that he had sufficient strength and balance for ambulation with an assistive device. When I brought this up with his PT, she said that they had never tried walking before and that the walkers provided by the school were too big for him. I suggested we give it a go at the parallel bars and the next thing I knew, to his PT’s surprise, he was ambulating with min-contact guard assist in the parallel bars. It was a beautiful moment- his entire demeanor changed, his eyes sparkled, and he had the biggest grin. We also practiced balance and coordination tasks; Jose had a great time with the games. The walking was slow going, but it was obvious that if they practiced in PT every day, he would make the gains necessary to safely ambulate with a walker on his own some day.

THIS is what drives me nuts here- this recurring theme of learned helplessness by people in rehabilitation. To me, it seems like common sense – if someone has the goal to walk, practice walking! If the assistive device isn’t perfect- seek another temporary solution and find a way to get something custom made for the home. Practice FUNCTIONAL activities! But it seems that many PT’s here are hesitant for some reason - and the patients are not often pushed to their functional capabilities. It breaks my heart, time and time again.

This is just one of many examples. And it’s not just the PT’s. The parents often share this sentiment and it’s very hard to motivate some to get involved with their child’s home exercise program. I know it’s partly cultural and partly institutional – there’s a definite need to change the education system to reflect more evidence-based practice across the board, particularly with the pediatric population. Just another observation into physical therapy practice in Peru – and one that I wish I would have worked harder to change in the last year.

On a more positive note, last week we had our first support group meeting for parents of kids with cerebral palsy. It’s been a little vision in the back of my head all year (better late than never, right!) The group has 9 members and its’ goal is to provide a self-sustaining regular source of companionship, support, education and social activities for caregivers of kids with disabilities. The clinic has offered discounted and free health services for the group, who will meet bi-monthly. Members agreed to pay a tiny amount at each meeting, with the idea of a small community micro-lending type fund that can be borrowed for medical emergencies or used for the end of the year Christmas party. The mothers are also planning to take turns in childcare so that other group members can have a free afternoon each week to run errands or have some alone time. The group will have occasional guest speakers from different health professionals, but will be led by the mothers, with the bigger focus in creating a social outlet and a grander sense of community.

These are some of the toughest, most incredible women you will ever meet. They are truly amazing. They all have several children and on top of that fight tooth and nail for the rights of their disabled child. They talked about how the community reacts whenever they go to public places, how their children are constantly rejected from the public and private schools, how they struggle to find quality medical care and specialists, and how they are barely scraping by financially. Every day is a struggle, in even the simplest of things. Imagine trying to navigate the public transit system here (Moto-taxi? Small fast-driving van with 20 other people?) while having three toddlers, one child or teenager with CP, and one giant un-collapsible wheelchair in tow. They have to resort to taking taxis – but even the taxis often reject them when they see their child and wheelchair.

Needless to say, it was an emotional meeting, but also a joyous one. It’s very frustrating how un-accepting the culture is of people with disabilities, but hopefully now these 9 women will feel less alone in their situations. I hope that when I visit next year, they’ll still be meeting and will have grown to be a great community resource here in La Esperanza.

Friday, September 16, 2011

Proyecto Wiñay

A few weeks ago Trujillo welcomed visitors from Anchorage, Alaska! Two nurses from my church in Anchorage came down to help us out with Proyecto Wiñay – a public health program here in La Esperanza (sponsored by CMMB and Caritas) targeting children under age 5. The projects’ main aim is to prevent and treat malnutrition and includes cooking workshops for moms, educational sessions, health services, anemia & parasite testing and treatment, and an agriculture project – to name a few components. The use of community agents – local leaders – is key to the programs’ huge successes in the year and a half since it began. 
I enjoyed learning more about the project and getting our hands dirty up on “el cerro” – a sand-covered mountainside that’s home to many squatters living in makeshift shacks – no pavement, electricity, bathrooms, and an infrequent water supply. Many of the homes are held together by pieces of plastic, tarps, and woven straw. Though the people are living in a difficult socioeconomic environment, I encountered many really happy people and a great sense of community. 
That being said, crime is a big problem there, so we had to do everything in small groups. We visited with families in the project for a week, conducting a survey and doing one-on-one health education on topics including hand-washing, anemia/diet, and signs of alarm in infants and young children. Later the nurses led educational sessions on maternal lactation – they did a great job! 
I experienced a mixture of emotions throughout the week. By now (and I hate to say it, but) I’m pretty unfazed by poverty and un-sanitary living conditions, and we conducted a survey earlier this year in the same neighborhood, so I felt pretty comfortable. It was fun to walk around and get to know the families through home visits. Because of the sand, most cars can’t make it all the way up there, so it was quieter too – almost peaceful.
But I’ll keep some images in my head forever – policemen riding around on horseback, neglected-looking young children answering doors to say that their parents were not home, a sobering memorial service right next to a loud and rowdy soccer game. One lady came up to us and mentioned rather nonchalantly, “You know the guy who owns the corner store, who has three kids? Well, he was shot this morning with 7 bullets, right in front of his home!” And then she went on to talk about the weather, like it was no big deal. (Later talking to someone else, the story changed to “ten bullets,” but the attitude was still the same – just another day in the life.)
I was grateful for the change in scenery and a glimpse into another one of CMMB’s projects. It’s clear that Proyecto Wiñay is a great source of light and hope for a community of many challenges and needs. The project, led by the incredible efforts of Hermana Maria, is certainly understaffed and really needed the extra hands that week. Thanks Maria Roldan and Carla Bazan for helping out with translating! And we’re all so grateful for volunteers Genna Fox and Julie Reloza, who were hard-working, flexible and did an excellent job in everything that came their way– MUCHAS GRACIAS! THANKS so much for coming down!

Tuesday, September 6, 2011

Helping vs. Hurting

“No das pescado… enseñales a pescar” – “Don’t give the people fish… teach them how to fish” – Peruvian expression

I recently read the book “When Helping Hurts” by Steve Corbett and Brian Fikkert. Many parts of the book have paused me to reflect on volunteer work I’ve done in the past, and on my actions here in Peru in the last year.

Did you know that in 2006, Americans spent 1,600,000,000 dollars on short-term missions?! Often without the volunteers’ awareness, short and long-term mission trips can cause more harm than good in developing nations. Often we have these big expectations and want to GIVE so much - but on our own terms. From my experience, #1- you always get more than you give on a short-term trip, and #2- to be effective, you really need to get a solid understanding of the culture and the community, your role and what is considered “success.”

One important distinction is relief vs. rehabilitation vs. development. Back in college, I signed up for a trip to New Orleans for a few months post hurricane-Katrina. We spent a week gutting homes in what was then a “ghost town” of a city, for persons who were older or had health conditions that prevented them from helping with the manual labor. It was an incredible experience and when the opportunity came up the following year to go back, I jumped right on board. However, the 2nd year’s situation in New Orleans was much different- there was better infrastructure and many people had returned to the city. The work had changed from gutting homes to repair and we spent a week helping rebuild a church. While we left feeling pretty good about ourselves that second trip, I often wonder if we did more harm than good. Where were the church’s community members and why weren’t they rebuilding? Why did we provide relief when we really should have been working on rehab. and/or development?

Another difficulty facing short and long-term missions lies in our individualist (vs. collectivist) culture and the need for rapid, measurable results. Corbett and Fikkert agree that “the North American need for speed undermines the slow process needed for lasting and effective long-run development.” During grad school, I went on a weeklong “alternative spring break” trip to a small desert community in Mexico. For the last decade, students from Regis University had been going to the same community once-twice per year to help build a community center. The progress was painstakingly slow. Most of the men in the community worked 2+ jobs to make ends meet and thus were unable to continue the building once we left without the manpower of the Regis group. The year I went, day 1- we played soccer with the kids and began to plan a health fair, because we were waiting on the actual building supplies to arrive. The manual cement mixing was slow and thus in one week, all that we accomplished was laying cement and getting the roof up. As volunteers, we started out feeling a bit frustrated. I was blown away by the fact that the community was that patient- every year they saw the center grow a baby step closer to completion, but not by much. But what I learned above the patience of the people was the importance of community in the process. To the locals, the groups’ coming meant so much more than construction, health fairs, and a few physical therapy home visits – to them it was all about the feast of a goat, Catholic mass, swimming in the river, playing with the kids, various meals and celebrations together, movie night, a fantastic dance party, and soccer games – community building. It’s not about the product- it’s about the process. And say Corbett and Fikkert, “development is a lifelong process, not a 2-week product.”

The book elaborated on these concepts – development/rehab. vs. relief, processes vs. projects and products, and the importance of empowering people and ensuring local collaboration/participation. Avoid paternalism and don’t do things for people that they can do for themselves. Many lessons I’ve learned here in Peru mirror some of these notions. Another - “I was still amazed to see people in this Kenyan slum who were simultaneously so spiritually strong yet so devastatingly poor.” Though across continents, I see this day in and day out in the people of Peru, too.

So now I look back on my year here in Peru and wonder, did I do more helping or hurting? One of the underlying issues is the idea that providing continuing education is a good idea, but it’s really only putting a band-aid on the “problem.” Why didn’t I focus my energy this year on changing the curriculum of the local PT schools? Is continuing education really worth it? This is something I’ve struggled with as I’ve begun thinking in the lines of public health projects, too. How do we act at the root of the problem, vs. helping the symptoms?

When I first arrived here, I began to learn about the different types of health problems faced. Based on statistics from the WHO in 2008, the number 1,2 and 4 causes of death in Peru are non-communicable diseases. In my community, I noted the poor diet, the low physical activity/opportunities for recreation, and began to see a lot of patients affected by conditions like stroke. In my first month here, I began to envision this project targeting non-communicable disease – exercise classes, educational sessions, an incentive program teaming with the local health clinic, etc.

Right around the same time, I became connected with a number of PT’s here and became very impacted by the lack of continuing ed opportunities and the huge thirst for knowledge. This ultimately shifted my focus for the year. I often wonder how successful a different type of program would have been. I think that ultimately the most important aspect as a volunteer abroad is to listen to – what do the people need? What do they want? What are they most likely to participate in? And how can we build on the skills and strengths that already exist? Reality is, I would be up against a large number of cultural challenges in creating the first project targeting non-communicable diseases– had I jumped right in quickly without really knowing the community, I could have hit a dead end really fast.

That being said, I know that many of my actions could have been better thought through this year. I think that 2 projects – the regular continuing education classes and the planning and execution of the international event - went well and included important cultural factors and community participation. Ultimately I saw the event build relationships and networks, community togetherness, critical thinking, hands-on skills and introspection of physical therapy practice here in Peru. While it doesn’t directly target the cause, as I mentioned in a prior post, I think continuing ed is an important piece of the puzzle.

I’ve been lucky to have 3 short-term volunteer groups of healthcare providers visiting this year. I think that in general, their experiences were well-planned and really tried to get at the sustainability potential in short-term missions. The volunteers were working with community members and people on-site who already knew the ropes, which assisted in their effectiveness. Each group participated in teaching and also had activities planned to visit sites and learn more about the healthcare system here. The opportunities to develop relationships and continued collaboration with the Peru Ministry of Health, a local university that has a PT program, CMMB, etc. were all valuable outcomes of the trips and the beginning of exciting new relationships.

However – when I reflect on my other projects this year, I don’t feel they encompassed as many of the qualities suggested by the authors. Take, for example, the survey of people with disabilities. Here in Peru there are constantly people begging for money – in the streets, at the clinic, even my neighbors and people I know well. There’s a big problem here with free handouts and I don’t think Peruvians and tourists alike realize how much they are perpetuating the process by giving the beggars money. I fear that the survey hurt more than it helped by setting people up to expect free hand-outs from the project. Also, the questions were functional, yes, but some were worded negatively toward “what can’t you do? What do you lack?” vs. the approach of “What are your assets? What do you bring to the table and how can we help develop them?” Ah yes, hindsight is 20/20.

Luckily, I’m still finishing components of the plan for “Rehabilitation con Esperanza,” so I have the opportunity to right some of these mistakes and hopefully leave a well thought out model behind. In this manner I hope to ensure participation by mobilizing the skills/resources of the community and only bringing in outside resources when local resources are insufficient. Thus, the project will ultimately act off some of the authors’ helping principles – as in my favorite Peruvian expression, instead of fishing quickly to produce mass quantities, to slowly teach people how to fish.

Sunday, September 4, 2011

The Positives

When it comes to negatives and positives, it’s a no-brainer that my personal experience over the last year tips the scale in the positive direction.

The Negatives…
Of course, poverty levels and poor sanitation, dangerous public transit, crime, and faults in the healthcare system are obvious negatives common in South America. But on a personal note in regards to my own daily life here, the negatives include…

Dog attacks – 2
Bout of unidentified 3 to 5-day fever illness – 6
Food poisoning - 1
Near pedestrian-car collisions – too many to count
Flea attacks – 2
Parasites – yup
Cockroach incidents – 3 especially scarring moments
Bed bugs – yup

Other than the occasional cheddar cheese craving, there’s not a whole lot that I’ve found I really miss anymore as far as “things” go. I feel pretty adjusted to powdered coffee (or no coffee), no sense of personal space (in fact I think I will miss this!), long conversations after dinner, hand-washing clothes and dishes, the smells, bugs and rats, the slowness of daily life. Constant mugging-prevention precautions. Frequent power and water outages. Less frequent bathing/hygiene. Answering to "gringita" and various versions of my name ("Ahm-bar.") Latin music (In fact, I will really miss this!) New ideas of what is “loud.” LOTS and LOTS of white rice; my host moms' spiciest aji. "Peruvian time" - lines, waiting, and everything starting late. Crazy public transportation rides (which have interestingly enough helped with my motion sickness- I can now read in moving vehicles!) Being gawked at when doing any sort of physical activity. (Well, being gawked at whenever I leave the house). Daily male harassment on the streets. Having to eat unidentified parts of animals. Peer pressure to dance (with 5 foot tall men) in front of everyone at family events. Being charged three times the rate, simply because I am white. These things all make up bits and pieces of my daily life that I now come to savor and expect – I’m enamored with the culture. Which leads me to …

The Positives…
I feel very blessed to have so many wonderful work opportunities and professional connections here. As someone recently pointed out, I’ve had the chance to have a unique glimpse into such a broad spectrum - not only the poorest of the poor, but also the national political level through work with the Peru Ministry of Health. I’ve networked through hospitals, physical therapy clinics, physical therapy academic institutions, public health projects, schools for kids with special needs, different groups of religious congregations, different levels and groups within the ministry of health, groups of physical therapists from all over Peru, Regis University and PTs in the US, various other non-profits, health outposts, and rehab equipment specialists.

Socially I’ve had the time of my life - meeting people from all over the world. Having the chance to use vacation days to explore other parts of Peru. Learning how to surf and attempting to master another language. Learning all about so many different aspects of Peruvian culture and experiencing holidays and special events. The incredible culinary experience, regardless of the side effects (will have a stomach of steel when all is said and done!) The personal growth – spiritually, professionally, and in leadership. So many amazing experiences leading to the expansion of my comfort zone boundaries and the shift of my worldview - something I'm already having a hard time putting into words, but something that's ultimately had a huge personal impact.

By the far the greatest positive of all has been the people – the heart of Peruvians. My “second family” – the host family that have treated me like one of their own. The incredible co-workers and support from the clinic, the school, the physical therapy community and the Hermanas Del Buen Socorro. Peruvian friends and neighbors. My patients. My friends at Espanglish and Muchik surf shop. And the different little networks of gringos I've stumbled upon. 

I do not know how on earth I will say goodbye in less than one months’ time. I think it will be one of the hardest moments of my life.