Culture Shock, Take Two

I arrived back to the US last week and am still getting used to my own culture again. Alaska gave me a nice welcome with -20 degree weather and a big bull moose grazing in the backyard. I think the two worlds I’ve lived in could not be further apart!

Home sweet Alaska...

 Aside from the obvious climate differences, I am taken aback by almost every aspect of daily life. The other day I stood for several minutes just staring at the choices in the grocery store. I keep saying hello, thank you and excuse me to people in Spanish. It took me 6 tries to check my voicemail the first time because I kept pushing the wrong buttons, and still takes me ten minutes to write a text message in English (well, lets be honest, that may be normal for me). Other big news - People here abide by traffic laws! There’s no swerving or hanging out of moving vehicles, and transportation itself here is so lonely- everyone with their own car and so many going to their destination alone. I can get all my laundry done in one day, and with a dryer! Tap water doesn’t have to be boiled, dishes go into this contraption called the dishwasher, and I can flush my toilet paper down! Doctor waits are minimal. TV and music are so foreign. And it’s so QUIET.

view of Anchorage flying in

I can’t shake the feeling that there are holes in my life after Peru. I miss everything-everyone- to the point of feeling a physical ache. I miss the symphony of roosters, buses rumbling by, horns blaring, bicycle peddlers, children shouting, latin music blaring, dogs barking. The organized chaos that is the public transportation system. Peruvian babies. The view of the ocean as we round the curve to Huanchaco and the bliss of riding a wave on a surfboard. Greetings from strangers on the street. Stray dogs. Slow walking pace. My neighborhood market. Freshly squeezed juice. The mass in Spanish. Picarones-arroz a lo pobre-lomito saltado-ceviche-papa a la huancaina-tallarines saltados-chifa-chicha morada-helado de lúcuma-aji-arroz con leche-hamburguesas y sandwich de pollo-yuca-mango-choclo-Cusqueña-pisco sour. (in no particular order!) But most of all, I miss my Peruvian family. My patients – the laughter of my peds patients and the stories of my geriatric patients. Neighbors, colleagues, co-workers and nuns. Peruvian and gringo friends alike. My friend and Spanish coach Maria. Pancake and taco nights with family. The shouts of my host cousins as they race upstairs to feed the dog. Night-time tea and laughter. I miss the culture, lifestyle, and though I feel so blessed to have had such a great experience, I can’t help but feel pretty bummed that it’s all over. However, it has been amazing to see family and friends again - 14 months is a long time to be away!

“Most of us live the greater part of our lives submerged. Certainly in my own case I can say that not until I left America did I emerge above the surface.” Awhile ago my friend shared this quote by Henry Miller, and it definitely mirrors my own feelings about living and working abroad. I don’t think I really “got it” until I spent a good chunk of time in a developing nation. Now that I’m back in the US, I find it’s hard to convey the exact experiences and feelings of life in Peru to others. It’s hard not to compare everything to life in Peru and bring it up in every passing moment. It’s also hard not to judge others, nor to be guilt-ridden and disgusted by parts of American culture.

Someone responded to Miller’s quote with, “The tough thing is to make personal changes as a result, without turning into a sour cynic about your own culture. ‘Enlightened’ people usually turn into judgmental people. Enlightenment with humility of a good thing.” So, two months post-life-in-Peru, I find myself faced with this challenge and still in a bit of mourning over my separation from South America. I hope that my new lifestyle and many of life’s lessons learned - the Peru “magic”- will somehow live on in my life.

on the descent to Anchorage

So, I guess this is my last post. I hope you've enjoyed hearing about my experiences and will carry some "Peru magic" into your life as well. Thanks for all of your support over the year! 

Y gracias de nuevo a mis queridos Peruanos- siempre contigo! (y hasta pronto!)

Passing the Torch

My last week in Peru has been all about closure, and it’s been very emotional. I had my last day of work with patients at the clinic and bid old co-workers farewell at the Hospital. I taught my last course for about 50 people at the University. I had one last meeting with the support group for caregivers of children with Cerebral Palsy. I passed off the final plan for the community-based rehab project in La Esperanza. Participated in a parade with clinic staff. Met with my focus group of PT’s one last time. And bid the nuns - Hermanas del Buen Soccorro, host family, neighbors and friends farewell.

Anniversary parade!

The support group meeting again opened my eyes to new aspects of challenges faced by caregivers of people with disabilities. We talked about diapers and how costly they can be, as many of the kids/young adults go through 4-6 a day, not to mention time and money spent on frequent laundering of urine-soaked clothing. We also talked about the challenge of taking the kids to the dentist, and how difficult it is to find a dentist that has enough patience with their children. We discussed problems with the taxi drivers, who often discriminate and raise prices against the families of kids with disabilities. Again I am inspired by the incredible strength of these women and their daily perseverance. This creative and talented group of caregivers is developing some great leadership - I look forward to seeing where it will go and have high hopes that it will be around for my next visit to Perú.

My heroes - incredible women

We are fortunate to have some new CMMB volunteers joining us to form a team in the community based rehab project. One nurse, one psychologist, one occupational therapist, one physical therapist aid, one specialist in public health and one doctor make up the current core team who are planning the interventions for start date of January 2012. The project will begin in a high-risk zone called Nuevo Jerusalen, which sits atop a hill in living conditions that include sand for roads, no water or electricity, and many health disparities. “Rehabilitación con Esperanza” is based around the training and use of local community health agents (promoters) as “gatekeepers” into the spectrum of program services. The community agent volunteers will help identify potential participants in their neighborhood, determine their assets and health service needs, administer a baseline outcome tool, and be part of basic health education. Participation is based on a family approach; people with disabilities and their caregivers will have the opportunity for home and group therapy sessions with professionals across various disciplines, and will be expected to participate in support groups and educational sessions to fulfill the program criteria. The project will tie in resources from a local university and physical therapy students and staff from Regis University (Denver, CO) while also aiming to network with the local church and other organizations in the community. Long-term goals include self-sustainable projects in micro-lending, an assistive device workshop run by people with disabilities, labor and career training, and the improvement of access to medications, transportation and recreational opportunities, with an ultimate aim to foster change on the political level through connections with the Peru Ministry of Health.

Survey in action - Nuevo Jerusalen

I’ve learned throughout this process (and many other aspects of Peruvian life) the importance of patience – it’s certainly an understatement to say that community health is slow going. Last week I finished up a manual for the community health agents that gives an overview of what each profession offers, tools for starting support groups, and a set of care models for 12 of the most commonly encountered types of disability in the district. This will supplement another manual that trains agents in the basics of community based rehab across the lifespan. It’s been an amazing learning experience to start the project from the ground up – beginning with the survey created last November – and throughout the year, including very valuable input from the Peru Ministry of Health in Lima. Although I am sad that I will not see it all the way through, I know it’s in good hands.

Now for the difficult goodbye process. They don’t make it easy on you here- meeting with someone to “say goodbye” is apparently a three step process in Peru. Step one- meet, bring parting gift, give it to person and express your heartfelt emotions, and then as they depart – get invited to something else later on in the week to “say goodbye one last time.” Step 2- goodbye meeting #2, which ends the same way as goodbye meeting #1 – with future plans to again see that person. Step 3 – Finally meet one last time, while insisting that yes, tomorrow I will actually be leaving on my bus as planned. And Step 4 (optional) – Re-goodbye at bus terminal. It’s a bit overwhelming and tiring trying to express my emotions in Spanish so many times, but nonetheless reflects the beautiful heart and soul of Peruvians.

I really don't have sufficient words to express how I feel today and what this last year has meant to me. It has pushed me and given me so much personal growth - so much more than I ever expected. Call me cheesy but I don't care - my soul has found the other half of its home. I am filled with great dread to leave - but also great joy that I now have two distinct cultures and families in my life. 

Luckily, I have a "little" distraction to ease my heart-ache … Before my re-insertion into American culture, I’ll be making a detour down towards Patagonia! ☺

Random side note - Thank you Steri-Pen for sending me a new water-cleaning tool! It’s working great!

Y Perú – MUCHAS GRACIAS POR TODO! Nunca me imaginé tan increíble seria la experiencia y nunca te olvidaré. Muy agradecida por todos los Peruanos en mi vida y esta oportunidad bonita que he tenido en el año pasado. Siempre contigo… No es Adios, sino mejor HASTA PRONTO!

Con mucho cariño, La Gringita

Cuidado!

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!

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.

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.

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!

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.

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.

QUÉ RICO!

Today I savored one of my favorite Peruvian foods, yet again... CEVICHE! Now that my days left in Perú are numbered, I have even more of an excuse to splurge on my favorite local culinary dishes. :) (Not that I needed one.)

Ceviche de Pescado:

White fish marinated in lime juice

Aji (spicy pepper sauce)

Cebolla (sweet red onion)

Choclo (big corn kernels)

Yuca (cassava - starchy tuberous root)

Camote (sweet potato)

Yes, the fish is technically raw, but it's cooked a little from the lime juice. Peruvians swear it's a great hangover cure. I think it's great for any day - and best accompanied by a big pitcher of chicha morada (juice made from purple corn). If you ever visit Perú, you MUST try this dish - (and on the northern coast! It's not as good in Lima!) 

RIQUÍSSIMO!!

A first of (hopefully!) many

Centro de Eventos Los Corregidores - Trujillo

August 13-14th, 2011, one of my big work projects here in Peru finally came to life! CMMB and Regis University hosted the “Primera Conferencia Internacional de Actualización en Terapia Física” – the first annual international physical therapy conference held in Trujillo, Perú, created to develop a sustainable collaborative relationship between the US and northern Peru in the field of physical therapy. Secondary aims were to provide quality, affordable continuing education including access to evidence-based updates and criteria in patient management, and to strengthen the unity and leadership within PT’s in northern Perú.

Presenters from the knee group

Morning lecture session

If you haven’t seen prior posts - I began planning the event back in December 2010. Nancy Mulligan, faculty at Regis University, was on board immediately and was extremely instrumental in organizing a group of students and Kristin Carpenter (affiliate faculty) to come down and help with the event. She also helped spread the word, and Alec Kay (Anchorage, Alaska) and Ommar Ortuvia (Houston, Texas) committed to volunteering as presenters. We felt it was important to have a team of both Peruvians and Americans involved, so we sought out local leaders Ana Herrera (Lima, Peru), Pedro Rojas (Trujillo, Peru) and Pedro Romero (Lima, Peru), to present as well. The event just kept gaining momentum – and before I knew it, I had people calling around the clock from cities near and far to find out how to sign up!

With Dr. Leon (Ministry of Health) and Dra. Llanten (CMMB)

Participants from Chiclayo, about 3 hours north of Trujillo

No matter how much you plan ahead here in Peru, there are always last minute changes and frustrations. I was lucky to have a whole bunch of volunteers involved and great support from CMMB, or event planning would have been a lot more stressful! We certainly experience a few little momentary “setbacks,” such as…

- 1 week before the event, our restaurant/bar lined up for the reception of 200+ people tried to back out, even though we’d already paid the deposit. We received an invoice for event costs from the event center that was different than our calculations. Claudia’s luggage was lost, which had a number of different materials for the event. We had problems with a speaker of one organization who needed a new official letter in order to come from Lima. Customs in Lima almost confiscated the entire 4 bags of conference equipment donations.

- A few days before the event, the custom-made event bags for participants were still not in Trujillo - 1 week after they said they would arrive.

- The day before the event, I received a call that one of our Lima presenters had missed her flight! And one hospital that was supposed to lend us a large quantity of treatment tables for labs suddenly was suddenly unwilling to give them to us, despite a written contract. One of our other presenters was MIA and didn’t show for the welcome dinner.

- During the event, our person to give the opening remarks did not show. The presenter who missed her flight made it, but late, so we had to shift some things around. There was one chaotic coffee break mix-up, where one group was accidently let out at the wrong time. One day, the MC’s didn’t show – so I spoke for them.

ETC ETC! But- “asi es la vida” here in Peru. (And of course these types of things happen anywhere.) 

Afternoon lab session

Presenters of the cervical spine group

All in all, the setbacks were minor and the success was huge. We had nearly 200 participants who were split into two groups- neck pain and knee arthritis – two of the most common outpatient conditions seen here. We included “labs” both days to practice techniques, a rare opportunity for Peruvians. The labs were a bit chaotic, and the lectures were a bit heavy with material- but from an organizational perspective, we learned a lot and got some great feedback on how to change the event in future years. 

Presenters and Regis students teaching labs

                                                

Participants received DVD’s with powerpoints and videos of lab techniques, and their bag (came just in time!) complete with therapy equipment. The event included different breaks for networking opportunities, a cocktail and appetizer reception Saturday night, and a catered lunch Sunday with a dynamic discussion led by Peruvian PT’s from my focus group. We discussed some of the challenges facing rehab. providers – with a high caseload and short time with each patient, how can we incorporate more exam components into a new patient session? How can we as PT’s be more involved in the prevention aspect of healthcare? And how can grow more unified and organize ourselves as a community of PT’s in northern Peru? We came away with a list of 125 people who are interested in creating a national organization of PT’s, aids and students, similar to the something like the APTA in the U.S., who also voiced interest to work together to improve opportunities for persons with disabilities.

Enjoying the reception Saturday night

No cocktail night complete without a spine manipulation! (I swear, this was not staged!)

Saturday we invited leaders of local academic institutions to a lunch discussion over potential teamwork with CMMB and Regis University in a community based rehabilitation project. I’ll elaborate on this project later, but it was a very positive conversation and I plan to do everything I can to strengthen this relationship between now and when I leave.

Networking lunch on Sunday

One of the big challenges of the event was that it included 18-year-old students in their first semester of studies, all the way to 50+ year olds who have been practicing in the field for decades. Thus, within the participants we had a wide range of skill sets and experiences. A big emphasis in the event was the practice of basic exam skills. We also had to tread carefully in treatment with the teaching of manual skills over such a short time frame. From my experiences, I can affirm that Peruvians tend to focus almost entirely on modalities in physical therapy treatment, so we tried to address this delicate topic throughout the event by saying “Hey, since you have such limited time with each patient, how about this exercise or manual technique over the machine – more bang for your buck.” At the same time, the whole idea was to share knowledge and ideas – a two-way process – and I hope that we were able to do this without coming off as all-knowing or superior in the presentation of materials. 

more lab practice time

The event design and organization certainly had many flaws, and realistically 1 two-day course cannot change clinical practice drastically. It may be putting a “band-aid” on an evidence-based knowledge gap that is rooted in flaws in the curriculum of the local academic programs – but I like to think it’s more like one of those awesome “liquid” band-aids – the ones that fill in the cracks to create a clear, breathable seal. I know it’s not the complete solution to changing practice patterns in Peru, but I believe that it’s an important piece of the puzzle on many different levels. 

Coffee break during event

As I jumped back and forth between auditoriums to observe groups throughout the weekend, and through many conversations during the event, I was really touched by the very positive responses across the board. People came up to me in tears to thank the team of volunteers. I saw glimpses of hope and sustainability – changes in comfort levels with hands-on skills, changes in critical thinking skills, and changes in social networks. I overheard discussions on how the PT’s plan to teach their peers and co-workers what they learned at the event. I think that the event was an important tool – be it a baby step - in changing clinical practice- but I believe that it also managed to bring more unity within the PT community. And I have high hopes that it is the beginning of a strong collaborative relationship between the US and Peru.

Presenters, translators and event focus group

After the event, I had a couple of nights of 10+ hours of sleep and got back in the rhythm of nice, long, relaxing evenings in with my host family. I couldn’t believe how physically and mentally exhausted I was! However, despite 10 months of work, complete with challenges and periodic frustrations, it was all completely worth it. So, after a 48-hour recovery period, I couldn’t help myself - I started looking at the evaluation forms and – call me crazy – planning for next year. ☺ Any PT’s out there interested in coming down for the Segunda Conferencia Internacional de Actualización en Terapia Física - August 2012?

MUCHAS GRACIAS to team Perú-USA!

A change of pace

I’ve just finished a whirlwind couple of weeks with a group of volunteers from the US. Regis University sent down 6 students and 1 affiliate faculty as part of a service-learning type trip working in conjunction with some of CMMB’s projects. We started planning it all back in – whew, December I think?! So it was great to finally have the group down here and put them to work. And work hard – they did!

Sunday evening myself and another CMMB volunteer met the group in Lima. On Monday we toured the hospital ESSALUD – Almenara facility with Lic. Ana Herrera. Ana has been one of my biggest mentors during my time here in Peru. During her career, she has transformed– literally from scratch – an underfunded outpatient clinic into a great resource of evidence-based PT practice for Peruvians. She is one of the few Peruvian PT’s I’ve met who focuses on manual therapy and exercises over electrotherapeutic modalities. Creativity is one of her great strengths, as is evident from a number of home-made therapy exercise devices. Ana is constantly seeking out literature on her own in order to stay up on the latest treatment techniques. She gave the group a tour of her facility and an introduction to a number of challenges inherent in the current healthcare system.

From there we headed to INR – Instituto Nacional de Rehabilitación – which is known as Peru’s one-of-a-kind model for quality rehabilitation services. INR has applied a community based rehab program in their community near Lima. Things I like – a team approach within different medical specialties, state of the art equipment and lots of space for PT services, workshops for job training, and an onsite center where people with disabilities have been trained to make prosthetic devices.

However, I’ve gotten to know the center and staff through visits and various meetings in Lima, and I do see some weaknesses with their approach. For one, they’re not very open to sharing – ideas, resources, documentation, etc. They insist that they must “validate” every form or resource that they create – a process that takes on average 2 years. For example, they wanted to “validate” and then implement an infant developmental milestone chart with the ministry of health. Instead of turning to charts that already exist, they created their own, and then spent 2 years “preparing it.” Now it’s supposedly “implemented” in all of the ministry of health facilities- though I have yet to see the same chart in any of the health facilities I frequent. Not the best use of time and resources. Another weakness is that their system is not very replicable for Peru – they train outsiders to refer people to their facility in Lima – but what Peruvian can really afford the trip to Lima and all the associated costs? There’s certainly a huge problem in Peru with most of the healthcare resources centered in the capital, Lima. I find all of this very interesting since I’m currently working on my own community based rehab project plan – but, I digress…

After lunch Monday we spent the afternoon with Dr. Luis Leon, the executive director of integrated healthcare for Peru Ministry of Health. Dr. Leon has been a huge supporter of CMMB’s work in Peru and I’ve been lucky to spend a lot of time in meetings with him throughout my year here. We skyped in Nancy Mulligan, professor at Regis University, who put the students’ trip together. The group learned about the current healthcare system in Peru and the disability statistics, and the goal of universal healthcare by 2015. Dr. Leon proposed a sustainable relationship with Regis in the form of academic support. Specifically, he asked Regis to create protocols/a review of the current best evidence across ten different common pathologies here in Peru! An exciting opportunity – more on this later.

That evening we headed by bus to Trujillo, and Tuesday morning we toured Colegio Santo Toribio, a school for kids with disabilities in a poor community near Trujillo. The school follows the Montessori approach and focuses on empowering kids with independence and functional skills for activities of daily living with the ultimate goal of integration within the community, job skills and employment. In addition to academics, they provide physical therapy, meals, skill workshops/training including a bakery business, carpentry, and jewelry making. The school has a several-year wait list and a very compassionate, talented staff.

From there we visited a part of La Esperanza called Nuevo Jerusalen, where the living conditions and sanitation are poor and people face daily challenges with things like crime, lack of water, and no access to healthcare.

In the afternoon the group (ahem… mainly Kristin!) ☺ led staff of Clinica Madre de Cristo through an exercise class! We had some technical difficulties with the video equipment, so we ended up winging it and doing a cardio circuit followed by stretching and abdominal stabilization exercises. The Regis group stayed at the convent attached to the clinic and the nuns invited everyone to a delicious welcome dinner that night.

Wednesday we headed up to Puesto de Salud Bellavista, where we split into groups to do physical therapy initial assessments with a group of older adults. We offered to see 20 people… which, not surprisingly, turned into 43 people signed up and waiting in line! I think the students were a bit overwhelmed between the language barrier, facility, time constraints, and other cultural factors, though it was a good learning experience for all. The hardest part for me was seeing a number of heartbreaking, complicated cases and feeling a bit helpless, seeing as how these people would not likely have any follow-up care due to financial constraints. One can’t help but compare the situation here to the US and how much different their quality of lives could be if they were on another side of the world.

That afternoon we toured Hospital ESSALUD Albrecht with one of my colleagues. We were able to see the emergency room, post-surgical, and maternal health parts of the hospital. We toured the outpatient PT part of the hospital, which in this case was in a 3-story home near the hospital! It was quite the contrast from what we saw in Lima, and the students observed first-hand the strong reliance on massage, ultrasound and other modalities for PT treatment here.

Thursday we headed to a community called Cambio Puente, outside of Chimbote, about 3 hours from Trujillo. CMMB has a public health project there targeting mothers and children under the age of 5. Partnering with the Sembrando Infancia team, we went out in groups doing home health visits. It was an eye-opening experience, as many of the homes have dirt floors and no bathrooms, water, or electricity. The students were deeply moved after seeing patients who were neglected or not provided with resources to reach their full functional capacity.

Friday we finished up some preparations for the continuing ed conference and then went to another CMMB-sponsored event – a Community Based Rehabilitation congress. The event included a number of presentations, and at the end a discussion on how to move forward together as a team between the different non-profits and leaders of the Ministry of Health present. For me, the discussion was a bit frustrating – as there was a lot of talk but no concrete changes or big action plans. This is one of my big pet peeves with Peru – everything appears so formal on the outside, but where is the progress? Peruvians almost never say “no” initially to something – so many things end up falling through. I hope that this group of leaders will show more initiative and that it won’t be empty promises. Nonetheless, it was a positive event and a week packed with activities for the Regis group!

The students shifted into hands-on teaching roles for the weekend, in the 1ra Conferencia Internacional de Actualizacion en Terapia Fisica. [I’ll save comments from the International PT Conference (Sat-Sun) for my next post.] After the conference, we had a couple days to relax and surf in the beach town of Huanchaco. 

I had a great time sharing Peruvian communities and culture with the group (not to mention wining and dining them at all of my favorite restaurants!) We were lucky to have an extremely energetic, dynamic group of students who were open and flexible, asked great questions, and didn’t complain - even after 16-hour work days! All in all, the trip was a huge success and I’m excited about the potential for a sustainable relationship between Regis, CMMB, the Peru Ministry of Health and other local academic institutions.  

Special thanks goes out to: Kristin Carpenter who came down with the students, Nancy Mulligan for all of her invaluable planning, Hermanas del Buen Soccorro for offering lodging and transportation, and Cathleen Daly & Claudia Llanten who helped with the group activities.

Now I’m having some serious group withdrawals – I keep looking for our bus (and drivers…), gazing around instinctively like a mother hen to make sure we haven’t lost anyone, cracking jokes in English over my shoulder to strangers, and fantasizing about what dessert we will have next.

Thanks Regis students for coming down - MUCHAS GRACIAS a Megan Daly, Jenna Neff, Laurel Proulx (Lor-ell..Proo!), Megan Kelly, Erin Carpenter, and John Zapanta! (And, Gracias.. A..Dios!)