Annual Report for 2022

Spring greetings to all the clinic gang in the northern hemisphere, and wishes for a temperate fall for those of you south of the Equator –

As it seems to do every year without fail, and to my perpetual surprise, yet another entire year has passed. This means it is time to let you all know what we have been doing with all the contributions that you have so generously sent to the Amazon Medical Project.

Photo Credit: Amber Wobbekind

Our patient census was once again significantly lower than it was pre-pandemic, and I think this is partly due to the difficulties of keeping a Peruvian doctor at the clinic, partly due to lingering pandemic effects, partly due to my own longer absences, partly due to the continued absence of tourists (they constitute few of our patients, but I think it’s one of Murphy’s laws that if you’re slow on one front, you’ll be slow on all), and it finally occurred to me that the population we serve may be dwindling. Las Palmeras continues to grow, but it has a secondary school, which most of the other nearby villages do not have, so there are lots of students from other villages who reside here. However, villages up and down the river are drying up. There used to be at least two small villages across the river from us on Yanamono Island, and they are gone. Las Palmeras Primera Zona, the ribereño community living along the river banks, had a good number of families when I first landed here in 1990. Now, almost all of them are gone. Even Armando Guerra and his family are going to move to Iquitos, and for the same reason that other families have done the same – they want better educational opportunities for their children, and once those children become accustomed to life in the city, they seldom return to the rainforest. In fact, all the children of all the local clinic employees have gone to the city, and there they now live.

Still, there are a lot of people who need our help. This year, we saw a total of 1745 patients, 1672 of whom received services, and 73 who took advantage of the opportunity to purchase medicines for their home medicine cabinets. Among these, females outnumbered males by about 1.6 to one, and adults (defined as people 15 years of age and older, since there are still a fair number who are parents by that age) outnumbered children about three to two. All these numbers are pretty steady from year to year. Almost 5% of our patients were 70 years of age or above, and we even had a few in their 90’s, which simply did not happen 20 years ago.

We provided family planning for 183 women, performed well child care for 263 kids (they get vitamins, if we have them, and dental fluoride varnish, a toothbrush, medicine for their intestinal parasites, and a basic medical exam, all for free), and vaccinated 202 people for illnesses ranging from tetanus to pneumonia to measles to hepatitis and diphtheria and whooping cough and influenza and HPV (the last means that in years to come, we will hopefully be seeing much less cervical cancer, which will be a tremendous improvement). Juvencio pulled teeth for a couple dozen patients, filled cavities for a bunch more, and made crowns or bridges to replace broken or lost teeth for a few more patients. This last service is slow work, but the recipients of his (largely self-taught) skills are very grateful.

We tended on average about five patients a month outside regular clinic hours, some of them genuine emergencies, others things like headache and diarrhea that would not have been emergency cases had they come during normal clinic hours; and we transported nine patients to a higher level of care. Several of these were women in labor (we almost never deliver babies any more at the clinic – most deliveries are normal, but every now and again something truly bad happens, and when it does, it may do so precipitously, so we try to get women to Indiana to give birth, so that if something does go wrong, they have a better chance of getting to Iquitos and surviving), and several others were women miscarrying and/or otherwise hemorrhaging. One was a young man who had gotten clonked in the head while playing the inevitable afternoon soccer games, and did not seem to want to regain consciousness; another was a man who had poked himself in the eye with a branch and came a few days later with a nasty infection of the eye (he recovered nicely, thanks to a good ophthalmologist in Iquitos), and several were cases of pneumonia. There was also one patient who was dying of cervical cancer. She was doomed, but her family wanted to make every effort, so we helped them to get to the city. When she died there, we bought a coffin so that she could be brought home for burial.

We see trauma due to a variety of causes. We generally do not have traffic accidents, since there are no roads, but we do have soccer games most afternoons, and inevitably there are a few collisions between players, or between players and balls, or between players and the ground, and a few twisted knees or ankles.

One young man bonked himself in the forehead with his own canoe paddle. There are also machete cuts, since these all-around tools are used for everything from cooking in the kitchen to chopping weeds. One man slipped and fell, landing with his hand on his machete, which cut deeply into his palm and through a small artery. Elmer and Edgardo and Juvencio combined forces, since there was no doctor in the clinic at the time, and closed the injury in several layers, and he healed well. A somewhat over-enthusiastic man who was helping to clear a field during a community work party swung his machete so vigorously that he caught the back of his wife’s hand on his backswing. Another man cut his foot with his ax while chopping firewood, and another cut his foot when he slipped down a muddy riverbank while carrying his machete. Several people stepped on rusty nails, which are a hazard when one is bathing and barefoot. Fortunately, we did not have any cases of tetanus following these accidents this year, but then, we are very conscientious about making sure such patients are vaccinated.

Trees are another hazard of life in the rainforest. One man was working in his crop field when a branch broke loose from an overhanging tree and came down on his head, lacerating his scalp. Then there was a nine-year-old who was collecting fruit from a mamey tree, and fell from a height of nine meters (thirty feet). Edgardo reported that a branch followed her down and landed on her back, causing significant bruising. Her father brought her to the clinic in his arms, as she was unable to walk. But amazingly, she evidently did not fracture anything, and after a few hours of rest and some pain medications, she was able to walk out on her own. Since we do not have sidewalks in the rainforest, and since we do have rain, there are plenty of slippery surfaces, and people sometimes slip and fall. I’ve done that myself any number of times, but fortunately have thus far escaped serious injury, but people do sometimes hurt themselves badly enough to come for medical attention.

And we always have what I think of as Animal Adventures. There was a nine-year-old whose family brought him for treatment after he was stung by a scorpion (we now have antivenin for scorpions, at least sometimes – sometimes the government does not have it in stock). He did well with that, but his grandparents who are raising him mentioned that he also has occasional seizures, so we had him evaluated by a neurologist and are now treating him for epilepsy (not related to the scorpion). There are occasional dog bites, since dogs are mainly used for hunting and for protecting their owners and their homes, which means that they are sometimes aggressive toward strangers. There was a forty-one-year-old man who was stoic enough to wait all night before coming to the clinic in the morning for us to remove a barbed catfish spine that had inserted itself deeply into the soft tissue between two of his toes. There was a twelve-year-old who had larva migrans, which is a long, skinny worm which gets under the skin and weaves a path there, and a couple of people who were stung by sting rays. These injuries are often very slow to heal, but fortunately this year’s victims did improve. And there was a woman working as a teacher in a remote district downriver, who was reported to have been stung by an insect called chicharra machaco (Fulgora laternaria, or lanternfly). These guys have a bizarre air-filled bladder in front of their true faces, which gives them the appearance of having a very large head. Eda tells me they get as large as 25 cm., which is a pretty big bug even for the Amazon, and that they have a venom which is similar to that of the vipers, and can be lethal. The woman received antivenin at the local medical post (apparently the antivenin used for poisonous snakes is thought to be effective against the venom from this insect), but when she arrived at her home in Las Palmeras, she fainted and was brought to the clinic. She had a small lesion on her forearm that was painful and erythematous (red). The staff gave her IV fluid, medicines for pain and for nausea, and after resting a while, she felt quite a bit improved.

According to what I can find on researching the topic, it seems that this insect’s actual size is up to about ten centimeters (four inches), which is large for an insect but not quite as large as twenty-five centimeters, and that it is incapable of biting or stinging, and has no venom. I’m not even going to try to convince the clinic staff of any of this however, as they have heard these tales all their lives and will just regard me as a gullible and unknowing gringa. Whatever happened, at least our patient recovered.

We only treated two poisonous snakebites in 2022. One was a woman who was bitten on the foot as she walked to her crop field, the other was a seventeen-year-old who came down the steps from her house on her way to bring in the laundry, and stepped on the snake as she reached the ground. Both did well, with no complications. There are fewer cases of pneumonia and diarrhea than there used to be, thanks to vaccines against pneumococcus and rotavirus, and to widespread efforts to help people get access to clean drinking water. We did still see 84 people with diarrhea, often accompanied by dehydration, and 36 with pneumonia. And we had another outbreak of COVID-19 among the clinic staff, causing us to close for a week or so in late July. Fortunately, everyone is vaccinated now, and besides, they’ve all had COVID at least once or twice already, and all recovered pretty quickly on the latest go-round.

Another category of illness is skin afflictions. One of the nice things about the rainforest is that the humidity means one does not need lotions and moisturizers. On the other hand, the constant moisture does predispose to fungal infections of all sorts -- athlete’s foot, vaginal candidiasis, ringworm, jock itch are all common. Many children are not vaccinated against chicken pox, so we see a few cases of that each year. Scabies are common (and usually affect multiple family members), and periodically, we see people with herpes zoster (“shingles”). And of course, there are a few babies with heat rash, as well as a few people with rashes due to (usually unidentified) viruses.

Then, we have our Interesting Patients, those who present with unusual or challenging illnesses. They keep our professional lives interesting, though the patients themselves, if they had a choice, would probably rather be dull and boring.

One of these was a twelve-year-old who came in with an ominous swelling beneath his eye. Infections in the face can be serious problems, but when Edgardo opened the lesion, quite a bit of blood issued forth, and no pus. It turned out that he had been struck in that area a few days earlier, and I think he just had a hematoma, a collection of blood which had leaked into the soft tissues. He did well, once the lesion was drained.

There was a ninety-year-old woman who came in late one afternoon, when the doctor was away and I was in Wisconsin. She had fever and abdominal pain, and the staff were concerned that she looked gravely ill. Juvencio managed to get a phone call through to me, and I suggested doing a urinalysis – older people frequently get urinary infections, and the symptoms are not always as clear as they are in younger folks. She appeared sufficiently ill that there was concern that she might die during the night, but it was late in the day when she arrived, and trying to evacuate her to Indiana in the darkness would have been risky (not to mention extremely uncomfortable, since Juvencio reported her belly was exquisitely tender, and a bouncy boat ride would have brought her no joy). He explained the risks to the family, they agreed to stay overnight, we gave antibiotics for a presumed urinary infection, and in the morning she was much improved, and wound up not having to go to a higher level of care after all.

And there was a man in his forties who had been seen in the clinic earlier in the day by our Peruvian doctor, who diagnosed “allergic dermatitis,” who in the late afternoon complained that he couldn’t move his left side. He happened to be passing by in front of my house, so I went out and did a quick outdoor consult. Since he was walking normally and could grip my hand, I concluded that he was not in fact paralyzed on that side. I poked around his shoulder muscles, and they were hard as rocks, so I suggested to his mother that she administer massage therapy, and promised him I would give him muscle relaxants if he came to the clinic the next day. However, in the morning, it turned out that both I and our Peruvian doc had completely misdiagnosed him. His real problem was “mal de gente,” or witchcraft, and his family had taken him to Iquitos for professional treatment.