Amazon Medical Project Inc

Clinic Letters

Mid-January 2021

Poor 2020 … I don’t think there is a single person in the entire world who is unhappy to leave it behind us.  Hopefully, this new year will bring us a lot of change for the good.  We’ll see. 

Flights from the U.S. to Peru resumed in early November, but I was not willing to chance being stranded in Peru if the borders should close again.  For a while, Peru was doing pretty well.  All through the month of November, there were no COVID-19 deaths in Iquitos.  Now, there is a resurgence of COVID cases in Peru, and flights to and from Europe and Asia have been shut down.  Pam reports that in Loreto, our “department,” (equivalent to a state in the United States), over 80% of people who have been tested are positive for antibodies to the virus.  However, this still means that 20% of the population is presumably susceptible, and 20% of Iquitos’ population of six or seven hundred thousand is a lot of folks.  The Regional Hospital, now the COVID-19 hospital in Iquitos, is again full to capacity, with no ICU beds open.  So much for herd immunity.  (Although at least at this point, the hospital’s oxygen plant is functioning, and I believe that masks and gloves and so forth are in at least somewhat better supply than they were in the first months of the pandemic, when the shortages were dire.)  Also, a new variant of the virus has been discovered in Manaus (a large city in Brazil located on the Amazon River), and has been found in Loreto.  This is apparently because the hospitals in Manaus are so overwhelmed that patients are coming up the Amazon to Peru to try to find treatment. 

Everyone who comes into the country must have a negative test in order to be able to board the plane that will bring them to Peru, and must wear both a mask and a face shield during the entire flight and while in the airport.  Once arrived, anyone entering the country from anywhere in the world must go into quarantine for fourteen days, although there is now an option to be re-tested for the virus after six days in quarantine.  If that test comes out negative, they can leave quarantine.  Pam has heard rumors that the quarantine requirement might be waived if someone is at least twenty-one days past their second dose of coronavirus vaccine, but that is so far just a rumor.

Meanwhile, the clinic carries on.  As the year began, we had not gotten any vaccines from the government in months, there was only one vial of snake anti-venin left, we were just about out of DepoProvera (injectable birth control), and we are completely out of chloroquine, used to treat malaria, and have only expired primaquine, which is also needed to treat malaria.  Edemita made up a list of what we need, I typed up the appropriate requests, and she went to collect the supplies.  She succeeded in getting the DepoProvera, and the anti-venin, and most of the vaccines, but they were out of the tetanus vaccine, which is probably the single most important vaccine we use (and by far the most common).  And no one has any chloroquine, since at the height of the pandemic, it all got given (uselessly, as it turns out) to all the COVID-19 patients.  It didn’t help any of them, and now we’re going to have a rough time if we start seeing patients with malaria.  And the river is rising, as it does at this time of year, which marks the start of the malaria season.  We saw very few cases in 2020.  Hopefully, this will be another quiet year for malaria – and hopefully, before long, the government will have re-stocked and we can get more of what we need from them.  Edemita says the health authorities in Iquitos are saying they may get supplies in by mid-February, but in Peru, that sort of promise is often overly optimistic. 

Other materials are also again in short supply, given the surge of COVID cases.  Edemita says that the disposable masks bother her.  I suggested that she ask Carmen’s mother, who lives across the street from Eda’s house in Iquitos, and who has sewn curtains, sheets, and pillowcases for the clinic, to sew her up some cloth masks.  Eda’s response was that that would not be possible, since Carmen’s mother died of COVID-19 in May, one of many, many such deaths in those grim months. 

So, on we go, and where we stop, nobody knows.  I did succeed in getting the first dose of coronavirus vaccine this morning, though there is no guarantee that vaccine will be available when the second dose is due.  But it’s a start. 

Water BirdPhoto Credit: Bob Pelham


28 Marzo 2021 - Iquitos

Woke this morning to the sound of rain splashing on concrete.  Pam’s house in Iquitos has what we call the “piscina,” (swimming pool), which is not really a pool.  It is a six-inch deep tiled depression with an open atrium, where we used to bathe in rainwater collected off the roof, before there was a storage tank to supply water to the house.  The rain pours off the roof on all four sides around the rectangular opening, making quite the entrance. 

This however reminded me that I had neither poncho nor umbrella in the bag I had brought with me, and no spares at the house.  I am out of practice; in the rainforest one always has a poncho and/or an umbrella within reach, unless one has no objection to possibly being drenched. 

When I woke to the sound of the rain, there was a sheen of sweat on my face, despite the fan that had been blowing air at me all night.  I washed my face with soap for the first time in a year … no need to worry, here, about drying out my skin. 

Sky_Credit Yvette BarbariPhoto Credit: Yvette Barbari

29 Marzo 2021

Yesterday was Sunday, and the city was not bustling.  Normally, this is a day when whole families are out walking on the Plaza de Armas, and men and a few women are quaffing beer on the informal sidewalk cafés in front of people’s houses.  But we are still at Extreme Risk level for COVID-19, and the government has decreed that on Sunday, businesses remain closed, and no private vehicles are allowed on the streets, though motokars are permitted and it was easy to find those.  Pharmacies are allowed to be open, and restaurants have a small door where they serve carryout, but are not permitted to seat patrons inside.  Saturday night, which was the night before Palm Sunday, although the Iglesia Matriz’s doors and windows were adorned with palm fronds, the doors were closed and no crowds of worshippers were awaiting the evening Mass.

I took advantage of the day to meet with our clinic accountant.  He was down with COVID a few weeks ago, and for a while, I was seriously concerned, based on what I was hearing, that he might not pull through.  He has done so, and assures me he is improving daily.  But he lost ten kilos (more than twenty pounds), and he told me that in the hospital, he was in a ward with twelve beds, of whom eight occupants succumbed in the two and a half weeks he was there.  To be gasping for breath and seeing people dying all around you is hardly an enviable experience. 

31 Marzo 2021 - Yanamono

Well, I am home, and it is as always, and it isn’t at all. 

The Lodge is bereft of tourists, and has been for over a year.  I expected the dining room at the Lodge to be dark, and it isn’t.  Not all the lights in the chandeliers are lit, but there are several in each hanging group, which is good, since when there is only one tiny light (mine) in the entire dining room, it seems the mosquitos are drawn to it.  And there are lights along the pathways and the bridge, and some of the walkways to the rooms.  The generator only runs a few hours a day, but it is on for the evening meal, which Rider Santos, Mirlo and I share.  I can therefore sit in the dining room and write while Rider puts the finishing touches on tonight’s repast.  It will be simple – last night, we had rice, fried plantains, and fried chicken (and very tasty chicken it was – Rider is pretty good at the stove). 

I was concerned about the condition of the walk from my house to the dining room.  The whole path is badly overgrown, and as I went to let Mirlo and Rider Santos know I had arrived, I could only think Snake Territory.  They apologized, but the two of them are doing all the maintenance, and since no one has been using that path for months, it has not been a high priority.   

After supper, as I was walking back to the house, I had not gone five yards on this part of the path, when there was a swishing and a whirring, and an S-shaped slithering between and around my feet.  I performed a very delicate dance, doing my best to keep both my feet in the air simultaneously, but I felt movement against the sides of my feet, though I could not say whether it was the snake’s body or merely the weeds brushing against me as he passed through.  In a few seconds, he had crossed my path and stopped on the stream side.  We regarded one another warily for a few moments (after I had taken a very quick step or two backwards).  I could only see part of his body, but he had the correct coloration and diameter and apparent length for a jergón (fer-de-lance).  Furthermore, he was twitching the tip of his tail rapidly in the grass.  The fer-de-lance are in the rattlesnake family but do not have any actual rattles.  However, they do have the same habit of shaking their tale where the rattles would be, if there were rattles, so it seems very likely that this was in fact a fer-de-lance.  (When I related the encounter to Mirlo and Santos, and later to the clinic staff, all shook their heads ominously and concurred.) 

I decided that it would not be wise to attempt to proceed forward past him alone.  He was a foot or so off the trail, but a snake can cover that distance in a flash, and I did not wish to annoy him.  I therefore turned to go back and bring either Mirlo or Rider.  As soon as I did so, the viper took off for the river.  He was in such a hurry to get there that he actually flung himself into the air, his entire body leaving the ground, then dove into the river and swam quickly away. 

I continued on home, alert for any additional creatures, but happily found none.  I did however resolve to make sure the trail got cleared before I had to venture another night crossing. 

Then, there is the river.  We are in flood season, and I feared that I would be consigned to my dugout to get to meals.  I love the dugout, the paddling is good for my aging arms, and the world is magic when it all stands in water, looming silently up.  But it is a nuisance to reach the dining room, realize I left my coffee cup or my pen at the house, and have to paddle back, negotiate the landing and the exit from the canoe, collect the missing items, and again risk slipping into the water either getting into or out of the canoe.  I am sorry to be so lazy, but frankly, walking is much easier. 

Thus, I am delighted to find that the river, although high, is still within its banks between my casa and the dining room; and although it is rising, it is doing so almost imperceptibly.  There have been many years when the water was well over my paths by this time, and still rising, so it is a blessing that this year, so far at least (though that can change abruptly), I am still walking, in early April. 

06 Abril 2021

Afternoon – The water came up another inch between breakfast and lunch. There is now three or four inches of water over the path at the base of the bridge over Yanacaño Stream. Unless we are at the peak of the flood, which is unlikely, I will have to use the canoa for meals when I return from my upcoming trip to Iquitos.

10 Abril 2021

In Iquitos, there are multiple evidences of the COVID-effect. All the stores have clearly marked Entrances and Exits, which are separate, so people are moving in one direction and not crossing one another’s paths. There are circles or X’s or lines or painted footprints showing people where to stand while waiting, and once you enter, you step into a shallow basin containing a piece of foam or rug soaked in bleach (or some other disinfectant). 

Walk Down

(Some businesses have failed, but those manufacturing alcohol, alcohol gel, disinfectants, plastic trays for shoe cleaning, masks, digital thermometers, and oximeters must be going great guns.) I stood on the sidewalk for ten or fifteen minutes before being permitted to enter the stationery store. Once admitted, someone aims a digital thermometer at your forehead or hand, and sprays your hands with alcohol. I don’t like the stuff, it just feels sticky, and of all the millions of cases of COVID-19, I am pretty sure that not more than a few dozen were caused by contact. Transmission is respiratory. Those masks and face shields do make a difference.

Then again, hygiene in general is good.  A few places even have a small sink and soap and water so you can wash your hands, and that, I like.  Even sitting in Explorama’s office typing on the laptop for an hour or two, my fingers get to feeling sticky.  Out on the street, even the air in Iquitos is grimy, so soap and water are welcome. 

Nearly everyone has a mask of some sort.  Some wear it below their noses, which is not terribly effective, and among young men, the common fashion is to loop it beneath their chins, which is even less protective.  There are a few people who are maskless, but they are not many.  And the hottest fashion accessory is a lanyard around the neck, from which dangles a small spray bottle of alcohol or hand sanitizer.  These are everywhere, sold on the street along with the sunglasses and earbuds and cheap wallets which have always been there. 

After running errands in Iquitos, I had an interesting trip downriver.  Edemita had recommended the ponguero El Gato, as being reliable and relatively rapid. 

The morning I was to leave, I went to Explorama’s office, rearranged the contents of the three modest bags I was taking, and called Edemita to let her know I was about to head for the Puerto San Jose.  Wait, she said, I will come and escort you. 

There are cement steps leading down from the sidewalk to the port, and she led me to the side which was sheltered from the rain.  There was then a series of eight or ten wooden steps going down, and though they were semi-steep, and wet, they were manageable, since there was a handrail at one side.  All the same, she insisted on holding my free hand and guiding me slowly and carefully down. 

Then there were five or six wooden steps with no handrail.  They were not especially steep, but they weren’t shallow, either, and of course they were wet, and I am not as sure of foot as I was thirty years ago.  She held my hand here, too, and we made it down safely, and then there was just a short plank leading to the boat, and a handrail on the prow, and lots of attentive young boat workers to help out.  

We arrived only a little after seven o’clock, but the boats have been filling quickly, and she fretted that the previous day’s boat had left at eight, rather than the scheduled hour of nine a.m.  The boat is maybe eight feet (two meters) wide, with a roof tall enough for me not to have to stoop.  Entering the boat, there is an open area where heavy cargo would soon be piled.  Then there were twelve or thirteen rows of seats, mostly two on each side of the central aisle, but in the front row, there were two seats on one side, and one on the other.  The seats were made of rebar bent into the shape of a chair, then strung with clothesline wrapped around and around and around.  They were not uncomfortable.  Eda suggested I take the single seat, and I did, and stowed two bags in the bins overhead, and the other by my feet.  In the back of the boat was a crude bathroom (a toilet bowl which would be washed by the backwash from the motor, but hey, at least there was a toilet, curtained off from the rest of the boat).  It was all pretty neat and clean and relatively new. 

Shortly, other passengers began arriving.  The pace picked up as time went on, and people and cargo accumulated.  Piled on the floor between my seat and the boat driver were sewn-shut bags of produce, a couple of large black bags containing dozens of bottles of gaseosa (soda pop), two and then three large planks of ice, and assorted other cargo.  A jaded young man, maybe sixteen to eighteen years of age, walked through carrying chickens by their tied feet, upside down and squawking, to the back, where they were stashed in the area between the motor and the bathroom.  At one point, a panting man came down the steps into the boat carrying a blue plastic chair on his back.  The chair was occupied by a venerable elder who was not much more than a frail husk.  When the chair leg caught on a protruding bag, he began to slide out of the chair and would have fallen to the floor of the boat, except that someone caught him, chest to chest, arms around the old man’s back, and gently lowered him into the front seat which Edemita had just vacated to allow for his entrance.  She bade me farewell at this point, and the son of the elderly gentleman solicitously placed a light blue surgical mask over his father’s mouth, nose and eyes, and there it remained for the rest of the journey.  The old man seemed content, though, and I later saw him lay an appreciative hand lightly on his son’s leg. 

Others entered the boat, offering bread and candies and snacks.  There were two who came through loudly announcing earbuds and cell phone chargers, so I assume these are items in demand.  There were a couple more vendors offering newspapers.  There was also a wooden boat which pulled up alongside, with a man shouting “hay juani, hay juani,” (juanis for sale, the balls of rice wrapped around a piece of chicken, a boiled egg, and a black olive, the fast food of Peru).   Many people brought bags of bread, some of which went into the overhead bins, some of which would provide sustenance for the passengers on the trip, and a few people brought along bags carrying food in thin styrofoam containers (which would later be thrown into the poor river).  Through it all, a loudspeaker announced the departure of various boats for various destinations, interspersed with a recorded exhortation from DIRESA, the regional health authorities, urging people to wear masks and maintain social distance.  “Ay!” shrieked the voice, “you don’t like wearing a mask?  Well, just wait until you can’t breathe with COVID, and then you will be crying.  Wear the mask covering your nose and your mouth, otherwise it will do no good (no sirve para nada).”  

The boat filled and filled.  The area between my seat and the boat driver became steadily more occupied until there was but a narrow aisle to walk.  Several LP tanks were lugged heavily down the steps into the boat, and a couple of crates of baby chicks, and a final influx of bags and people.  One of the last entrants was four cases of beer in their plastic crates.  These wound up being piled in a row along the left side of the aisle.  After all the available seats were full, the boat’s owner produced a cushion which he laid on top of the beer cases, and that provided seating for another four or five people. Around 9:15, the boat finally began backing away from the docking area.  The boat is long enough to be stable, so I did not fear for my life when other boats passed and their wakes crossed ours, and although we seemed to be moving at a leisurely pace, it took only an hour and three quarters to reach Las Palmeras, about the same time as an Explorama boat (although Explorama’s boats leave at predetermined times, so you don’t have to wait an hour or two while they fill up). 

18 Abril 2021

The water is now high enough that I can park my canoe parallel to my front steps, under the shelter of the roof over the steps.  The rains continue, many days and most nights. 

22 Abril 2021

Yesterday the clinic had a baby delivery, of sorts.  The mother-to-be, in her mid-twenties, was near the end of her fourth pregnancy, and arrived at the clinic around 05:00.  As the staff were triaging her, she announced that she needed to urinate, so they let her go to the bathroom.  Once there, she gave a mighty push, and a healthy baby boy dropped neatly into the toilet bowl.  They fished him out, cleaned and dried him, and the remainder of the delivery went without a hitch. 

Kid_Credit Sangita SundaramurthyPhoto Credit: Sangita Sundaramurthy

25 Abril 2021

Mirlo relates a wonderful tale of COVID resilience.  He fell ill himself last year in the first wave of cases, and his children and his wife also contracted the illness.  In theory, none of them should have left the house, but they need to eat, which meant they needed to go out for groceries each day.  There was a terrible shortage of masks at that time, so they were re-using the same masks day after day, and washing them at night.  Paper masks, however, do not take well to washing, and they were falling apart, and there were few masks available for purchase at that time. 

At this point, his wife came up with a novel solution.  She had a new brassiere, she said, and she brought it out and cut out the two cups, attached elastic straps, and thereby made two serviceable, and washable, masks for them. 

18 Julio 2021

It was once again an adventure coming downriver.  When there were tourists, it was so easy.  Now, it is a little more complicated. 

Juvencio and his wife Olga were in the city, and had mentioned that they had come in his own boat, so perhaps I could return with him.  He had said that the boat was lightly loaded, so there should be space.  The boat is open, he warned, no roof, and not very big, and the motor is a pequi-pequi, not an outboard.  Ok, I said.  We’ll manage.  Just come and get me. 

Pam was dubious, but I pointed out that Juvencio is an excellent boat driver, as well as being a very capable mechanic.  And I’ve never gone from Iquitos to Yanamono in a pequi-pequi, so it would be an adventure.  She asked whether they had life jackets, and I said look, I’ll take one of Explorama’s, and I promise to wear it the whole way.  She made me repeat the promise, then agreed that I could go, though she looked nervous, and mentioned that there is a lot of big water between Iquitos and Las Palmeras, and one pretty small boat. 

The boat was indeed small, maybe ten meters in length and barely a meter across in the center, the gunwales barely a foot above the water.  There was a small board seat across the prow, and another amidships, though Juvencio advised me not to sit on it.  Sit on the floor of the boat, he said, you will get uncomfortable very quickly if you sit on the seat.  Olga was already settling herself on the floor behind the seat, and Juvencio’s cousin Guido had the helm in back.  I sat on the floor in front of the center seat, grateful for the cushioning provided by Explorama’s life jacket as I leaned back against the board seat.  I pulled a t-shirt out of my bag and arranged it across my legs to cover them below my skirt, and tucked the tops of my ears under the hat I wear to prevent what Pam calls “boat hair.”  I had a jacket on, so all in all was pretty well protected from the sun, which was beating down with its usual tropical intensity.  Juvencio sat on the prow seat, and off we went. 

It was immediately clear that yes, this was a very small boat, compared to some of the others coursing the river.  And there were in fact some very large areas of water, not all of it placid by any means.  The first challenge was to navigate to the main river.  The Rio Itaya, which runs past Explorama’s dock, is not particularly large nor rough, but there were many boats racing in all directions, leaving waves in their wakes.  Juvencio gave hand signals to Guido, and Guido seemed to know what he was doing, and we made it to the mouth of the Itaya without difficulty. 

The next job was to pass through the large open area where the Rio Nanay runs into the Amazon.  The Amazon is wide and open at this point, and as the Nanay enters, the currents become complicated, and the water is usually choppy here.  Furthermore, there are again many boats, some of them quite sizable, navigating the same stretch of river.  Guido was clearly not thrilled at having to find a way through the many conflicting waves, but we did it, and we finally, forty minutes into our journey, passed the refinery, which was a relief. 

From there, we could see a storm forming ahead.  Iquitos, Ceiba Tops, the Lodge and the clinic are all on the river’s western bank, and usually we travel near that shore.  However, the looming storm was coming from the west, and grim banks of dark grey clouds were piling up from just downriver of us, all the way to Yanamono Island. 

We had gone only a little way beyond the refinery when the river suddenly sprang to life.  It is normally relatively smooth, but wind can make it choppy, and dangerous.  Within just a few moments, waves rose on all sides around us, irregular, triangular in shape, seemingly just leaping up from the river’s surface, and in no navigable pattern.  “El rio esta levantando,” Olga murmured.  “The river is lifting up.”  Guido looked alarmed, and began to turn the boat around in a U-turn.  I have been in boats on this river hundreds of times over the years, and I have never seen a boat execute such a maneuver.  But it was clear that it was the only thing to do.  There was no path through the waves, no way to run parallel to them or work around them, and attempting to head into them would swamp us in a minute or two.  Juvencio agreed, and we made the turn and fled the waves, racing back upriver diagonally toward the eastern bank. 

As we approached the bank, the water settled down, and we turned and again headed downriver.  Looking back toward the center of the river, we could see that the water had formed itself into ranks and ranks of rolling breakers.  They looked like the ones that come in to Lima’s beaches, from all the way across the ocean.  But these were marching in rows upriver on the Amazon, against the current and perpendicular to it.  I have never seen anything like these waves.  We were all impressed, and I was impressed that the three of them all laughed and joked about the danger. 

We stayed close to the east bank for the next hour or two, past Ceiba Tops, past Indiana, past the islands in front of Indiana, where there was a channel which again offered threatening chop, though these waves would have capsized us, rather than swamped us in a frontal assault.  It was interesting to contemplate the different ways in which the river might dispose of us, but Guido was able to guide the boat through by running almost parallel to the waves, and the difficult stretch of water was not long.  And we could see Yanamono Island in the distance. 

Finally, it looked as though the storm upriver from us was wearing itself out, and the waves in the main river were settling down.  Eventually Juvencio judged it to be safe enough to cross, and we did so uneventfully. 

And then we were just above Santa Rosa, and going downriver with ease, and in another half hour we were pulling into the clinic’s puerto. 

So now I can truthfully say I have come downriver from Iquitos to Yanamono, a distance of about 80 kilometers (50 miles) in a pequi-pequi, though I will attempt to avoid repeating the experience.  I envied Olga, who simply pulled her parka over her head, curled up on the floor with her back to the sun and dozed for much of the route. 

20 Julio 2021

It is truly a different world here.  There are no lawnmowers to be heard, only the sounds of boats of various sizes and sorts of motors chugging along the waterways (which is itself a difference from twenty years ago, when most of the boats were dugouts, and the motors were paddles).  There are the multitude of sounds from the rainforest, the birds, the insects, the frogs, the monkeys crashing through the canopy, the occasional falling branch or tree.  Underwear takes two or three days to dry. 

In the early morning, as dawn is breaking, I lie half-awake in my bed and listen to the whistles, chirps, grunts, crashing branches, whirrs, and crowing of the roosters from the village across the stream, and smell the smoke from the fires cooking breakfast. 

24 Julio 2021

I have now mentioned Adriana at least twice, so she deserves an introduction. 

I have been making noises for some years now about perhaps, maybe, some day, possibly  pulling back from the clinic and spending more time with Jerry.  In fact, with the pandemic, I was forced to spend more time with Jerry, since it was not possible to return to Peru for a little over a year.  I found I liked it – not the pandemic, but the time with Jerry.  It would be nice to be able to pass the baton, especially since, no matter what I do, one way or another, eventually I will be unable, or will not be around, to carry on. 

The challenge is to find someone who can take over my multifarious and not always doctorial duties.  There have been numerous groups trying to do good in the Amazon rainforest, and among them is one which has visited Explorama several times.  


One of the organizers of this group undertook to advertise for someone to come and work with me at the clinic, and Adriana was the result. She is from Puerto Rico, thus has grown up speaking both Spanish and English, and well understands the Latino temperament.  Her Spanish is far beyond mine, and she often picks up on details or nuances which sailed right past me.  She obtained her medical degree in Puerto Rico, as well as her residency in Emergency Medicines.  During the latter, she worked in hospitals without electricity after Hurricane Maria. 

Then she went to California and completed a fellowship in Wilderness Medicine, and has achieved her board certification in Emergency Medicine. 

So far, her qualifications sound pretty good.  But in addition to all that, she is an ebullient, highly intelligent, abundantly cheerful person, and is rapidly adapting to paddling a dugout canoe. 

She came for several weeks early in 2020, leaving not long before coronavirus exploded onto the scene.  She is now coming for another three weeks, and will in fact remain for a week or so after I leave, so she will really be getting her feet wet this time around. 

28 Julio 2021

For the first seventeen years that I lived in my Yanamono house, from 1993 till 2010 when I relented and let them put in plumbing, I had an outdoor shower and latrine, fifty feet or so behind the house.  As I age, I find an indoor bathroom to be a great blessing.  However, last night, when I took my final pre-bedtime visit to the bathroom, a problem arose.  I flushed, and the water just kept gurgling out of the reserve tank into the toilet bowl.  This is not good.  A running toilet can quickly empty a pretty large water tank, and I did not want to cause that problem. 

I lifted off the lid of the tank, and peered inside, using my flashlight, since although I do now have running water indoors, I do not have electric lighting.  I could see nothing obvious to explain the leakage.  Perhaps there was calcium build-up around the ring where the ball valve rests, so I ran my finger around the ring hoping to wipe away any obstruction.  It was kind of slimy, and really, who wants to spend a lot of time inside a toilet tank?  It is not quite like being inside the toilet bowl, still, it is part of a toilet.  However, then I noticed a floating body … a largish beetle had managed to get himself inside the tank, and had drowned there.  I suspect his body had lodged between the ring and the ball valve, preventing the valve from closing, so I got out a forceps that I keep for occasions where there is something I want to pick up but do not really want to touch, grabbed and removed him, and the toilet is now functioning as it should. 

Ah, the challenges of home ownership. 

Late Setiembre 2021

I am now back to Wisconsin and Jerry.  Back at the clinic, Juvencio, Edemita, Elmer and Edgardo are carrying on without a Peruvian doctor.  Our last one left at the end of June, and we have had no luck in finding a replacement for him.  Unfortunately, since there is no internet anywhere near the clinic, it is tough to get a young, modern doc to come out and stay. 

We do have a doctor prospect for October, and he is a good one, the young man who worked with us for a couple of months last year before leaving to do his year of national service.  Sadly, he has no ambitions to serve long-term with the clinic, just wants to have a job for a few months before he starts residency, probably in March or April.  Still, I can hope – maybe he won’t get the residency, or it will be delayed, and he will stay longer. 

Juvencio & Edemita

 On the cheerier side, even without a doctor, the clinic carries on, and the nurses are doing a fantastic job especially considering that the only doctor they have to back them up is me, and I am not always reachable.  The cell phone signal at the edge of the river is spotty, and sometimes the wind drowns them out, or the rain sends them scurrying for cover.  But they do call sometimes to consult with me about certain patients – Doctora, what diagnosis should we give to the forty-one-year-old woman who stopped taking birth control months ago, and is now bleeding vaginally, and has a positive pregnancy test?  Doctora, what should we do with the woman who has abdominal pain that just won’t go away despite IV fluids and antibiotics?  How about the adolescent with persistent fever and a negative malaria smear, whose eyes are now turning yellow?  (He turned out to have Hepatitis A, but it took a while to get that diagnosis, because the doctors in Iquitos who saw him seemed to be focused on dengue fever and it took several tries before we could convince them to order tests for leptospirosis and hepatitis.) 

31 Octubre 2021 - Yanamono

It’s a long time since I have been here at this time of year.  The river is still very low, though rising now, and in fact is at just about the same level it was when I left in August.  However, in August the water was dropping, and the banks were muddy and barren after having been submerged for months.  Now, the greenery has had the opportunity to re-grow, and the banks are crowded with shrubs and grasses and vines and small trees, all vigorously and ferociously green.  The sounds of the rainforest at night, though, are the same as always. 

01 Noviembre 2021

It is a holiday afternoon, so I am slung in my hammock, finishing up a good book and preparing to dig into the accounting again.  It is storming outside, with lots of thunder and lightning, and a light rain just starting, and I have been hearing scratching noises at the back corner of the house.  I finally decided to look and see if a tree branch is close enough to be rubbing against the house, because if so, it needs to be taken down before it becomes a bridge for snakes, termites, or anyone else with whom I don’t want to share my quarters.

It turns out, there is no branch.  When I peered through the screen at the back corner, I found myself looking into the placid eyes of a three-toed sloth carefully inching itself down from the far end of the pulley line where I hang laundry to dry. 

Sometimes, it is really fun to live in the rainforest. 

02 Noviembre 2021

Meanwhile, patients continue to come into the clinic.  Some are beyond our help, like the woman in her early 50’s who has been menopausal for the last five years but began bleeding vaginally three or four months ago.  She reports that the bleeding was intermittent at first but has steadily become more persistent.  This is a history I dread hearing, because I know what I am usually going to find, and I did.  When I did her pelvic exam, there was a lot of blood in the vaginal vault, and her cervix is pale, crumbly, and irregular.  On bimanual exam (one hand gently on her abdomen, with a couple of fingers inserted in the vagina to find her cervix), her cervix is the size of an orange, hard as a rock, probably fixed to the abdominal wall, and very irregular in texture. 

When you can diagnose cancer just by looking, it is almost never a good sign.  And this woman has not had an easy life.  She had seven pregnancies, lost two to miscarriages, then of the five babies she delivered, only two survive.  The other three all died in infancy, of “fever” or “black vomit.”  Her husband was killed a dozen years or so ago by a lightning strike direct to his head.  And now she has this. 

Linnea with Patient

I gave her a letter to take to the post at Indiana, which should give her a reference to the health system in Iquitos, but the clinic staff tell me she has yet to go.  She is pretty traditional, and I expect she will spend her efforts with the brujos (witch doctors), rather than seeking modern treatment.  This seems sad to me, although I have to admit, the likelihood is that, treatment or no, this is probably going to get her; so why should she not remain in her village, receiving the kind of care with which she is comfortable?  

The pandemic has been terribly hard on Peru, and on its economy.  However, the country is working hard on getting its citizens vaccinated, and so many of them were ill with COVID that there is surely some degree of natural immunity as well.  The country was ravaged by the illness, with the highest per capita death toll in the world.  By an easy margin – Peru lost 5,971 people per million to COVID-19 (a total of over 200,000 people, in a country with a population somewhere around 33 million), while the next highest death rate was 3,809 per million, in Bulgaria -- but now, new cases are practically non-existent.  And the health authorities are vaccinating pretty much all adults, and starting to work on children, and even some booster shots have now been given. 

So, with luck, there is hope. 

Signs of the season: it has been a while since I was here in November, but even though we are hundreds of miles from any evergreens, artificial Christmas trees, bedecked with winking multi-colored lights or hung with shiny round ornaments, are popping up in stores and hotel lobbies.  Tinsel and glittery holiday decorations are draped over stands in the markets.  And pretty soon, Santa with his sleigh and several reindeer, outlined in lights, will be lit up again on the roof of Ari’s Burger on the Plaza de Armas.