Dental Project Peru Trip 1

27^th May – 04^th June 2004

The first Dental Project Peru trip of 2004 was a complete success.  It was truly amazing.  For me, personally, it felt wonderful to be back in this magical part of Peru.  As we left the main road and the 21^st century behind us, I felt like I was returning to the place I was meant to be for that moment.  I was back.  And I could hardly wait to get to work.

Our team for this trip was made up of five people.  We had 2 volunteer student dentists come over from the UK.  Louise Thompson and Ruth Caldwell.  They are final year students at Sheffield University, England.  They had spent the month prior to this DPP trip doing an “overland” tour of Southern Peru and Bolivia.  They told us that being in a third world country had been all new to them and their eyes had been opened to beauty, poverty, extreme geography, different cultures and general “roughing it”.  But they had seen nothing yet!!!!......

Clark was an invaluable member of the team.  Clark is my boyfriend and fellow founder of Dental Project Peru.  It has been our joint vision to create this project and this first trip was the result of a lot of hard work and effort.  Therefore it was important that Clark could be a part of the team.  And a much needed member of the team at that! 

Our fifth member was our driver, Hernan.  The Director of the Ministry of Health for the Apurimac Region, Dr Oscar Garay, kindly offered to provide us with a vehicle and driver for the entire trip.  I was so happy with this offer as it saved us over $600 in costs.  The vehicle and driver arrived in Cusco on the 26^th of May.  At this time the driver was Hugo.  On the journey to the Apurimac we had mechanical problems and so on day 2 we changed driver and vehicle.  So we met Hernan.  He was a wonderful man who proved to be a lot more than just the driver.  He was keen to help as translator (Quechua to Spanish) as well as helping Clark with sterilizing and giving out medications. 

On the 25^th of May, Clark and I met Louise and Ruth.  It was great to finally meet after months of emailing.  We discussed the itinerary and what to expect from the Apurimac.  I think this was when the girls first realised that this trip was really going to stretch their comfort zones!  But we were all very excited about the coming 2 weeks.  We met the next day to buy the food for the trip and the medications.  It was during this day that we heard there was to be a transport strike the next day – the day of our “planned” departure.  This strike meant all roads entering and leaving Cusco would be blocked from around 7am.  We had to leave before this.  So we arranged to meet at 5am to get the truck packed up and get out of Cusco. 

So let me start from the beginning. 

Thursday 27^th May

It was still dark as we loaded all the equipment onto the bed of the truck that morning.  We had the full kit – generator, compressor, delivery unit, portable dental chair, forceps, hand instruments, sterilisers, water distiller, camp stove and 400 toothbrushes!!!  Not to mention all the gloves, anaesthetic, needles, medications, cotton, filling materials etc etc.  And then, of course, food for 5 of us for 9 days and 2 dental chairs!  Certainly a full load.  We left before 6am and managed to beat the strikers.  We were out of the danger zone and had just left the smooth main road onto the bumpy dirt track when the engine over heated and we had to turn back to the nearest town.  We spent the next hour observing 6 Peruvian mechanics trying to work out what to do with the truck.  The problem was the thermostat.  The outcome – remove it!?  There are times in this country when it is best not to ask any questions and just go with the flow – this was one of those moments (and would not be the only one of this trip).

The journey to Tambobambo in the Apurimac took a total of 10 hours and was very bumpy and dusty but one of the most beautiful, I think, one can ever take.  Once on this lonely road, there is nothing but fields and rivers and magnificent mountains.  The jagged Andes unfold in range after range as we contour around them.  At the top of one pass, we can almost see where we are headed.  It is only 50kms in a straight line, but takes 10 hours due to the fact that we have to go up and over and down and around these mountains – incredible!

At around 4pm we arrived in Tambobamba.  We stayed the night here and planned to head out to our first community tomorrow.  But we received some bad news.  Our driver, Hugo, had been radioing Pisaccasa – the community we were visiting the next day.  They did not know we were coming tomorrow.  Therefore, the patients did not know we were coming.  I was so disappointed at this news.  I had tried everything I thought possible to avoid this situation.  I had radioed the communities from Cusco.  I had written letters and got them delivered to the Health Posts.  I had written emails to the Director of the Apurimac who assured me he would get the message to the communities of the dates we would be treating in each village.  All this effort to ensure that patients knew when we were coming so we could treat as many people as needed treatment on these days.  But alas, this had not appeared to work.  What could we do?  Nothing.  Just go with the flow.  So we found a “hostel”, cooked up some noodles and then crashed out.  We were all exhausted.

Friday 28^th May – Pisaccasa

We left Tambobamba and drove the 2 hours to Pisaccasa.  It is so remote.  There is really nothing out there but small farms of potatoes.  But there has been an advancement – Pisaccasa now has electricity.  When I was here in 2002 there was none.  We were greeted at the Health Post by the two “Tecnicos”.  (Tecnicos are general health personnel.  They study 3 years at university learning the basics of medicine.  In many Health Posts, there is no Doctor, Nurse or Obstetrician and so the Tecnico fills these roles.)  They tell us that the village is not expecting us and everyone is in the fields.  It is the time of “Chakra” (harvest).  But they send out one of the Tecnicos who is going to pass the word around and hopefully some patients will come.

So we set up the equipment for the first time.  It is quite a relief there is not a huge line of waiting patients as there is a lot of improvising to do in trying to get things organised.  The two first patients are for fillings so the new Delivery Unit and Compressor get put to use immediately.  Then the patients start to arrive – and from that hour on, they do not stop arriving until 9pm at night!!  It was amazing.  All these patients had come from the fields to get treatment and pain relief.  We soon realised there were too many people to be doing fillings and we could only offer extractions if we were going to see them all.  But people were happy with this – most teeth needed extraction anyway.  At the beginning, there was only me extracting as the girls were still a little wary.  But I would ask them to check what patients needed and numb them up.  This seemed to work well.  But as the day went on and there were dozens of patients waiting, I asked the girls to start extracting some teeth they thought they could handle.  They were very nervous to start with but I was always around to advice them on technique etc or take over if things got a little tricky.  Throughout the day, their confidence grew slowly which was excellent to see.  One problem was the language barrier.  Neither of the girls could speak Spanish.  I would have to find out what the problem was from the patient and then Clark or I could translate for the girls.  And then there was the added complication that many of these people could not speak Spanish.  And that is where our driver, Hernan, became an invaluable part of the team translating Quechua to Spanish.  We had a system whereby Clark would register each patient as they arrived and take their details and form the waiting list.  After the patients had their treatment, he would then distribute and explain dosage of medications.  We all worked well as a team.

At about 7.30pm, I had a patient who had an upper premolar root which was proving very difficult to remove.  It took me over 30mins to finally extract it.  During this time the flow of treatment came to a stand still as the girls could not extract the teeth of 3 anaesthetised, crying, frightened young boys.  So after my own unnerving experience, where usually you might sit down and have a wee cup of tea and a 10 minute break, I then had to immediately calm and treat these poor boys.  The problem was a culmination of lack of communication and one boy crying and frightening the others.  Then Louise and Ruth became unnerved as their patients cried and they could not sooth or understand them.  But 10 minutes saw the tears dry up, the teeth pulled out and the system restored to normal. 

At 9pm we finally treated the last patient.  Then everything was packed up and we drove one hour to where we would sleep that night.  What a day.  A great learning experience for us all and an extremely successful day of treating over 35 patients.

Saturday 29^th May - Curca

This day was possibly the best day of the trip.  We drove one hour to the small village of Curca.  The road does not go to Curca and so I hiked down to the Health Post.  There I met the Tecnica, Alicia, whom I had worked with in Pisaccasa in 2002.  How nice to see her again and she told me she did expect us today – horray!  We discussed the fact that it was going to be difficult to get all our equipment down to the Health Post and so concluded that it would be best to set up surgery by the road and send the patients up to us.  And so we did.

We set up surgery on a small pampa/knoll on the edge of the valley.  There was no wind and the sun was bright – perfect conditions for outdoor dentistry!  It was so beautiful.  The panoramic, 360 degree view of the Andes was magnificent.  We could see for tens of miles.  Just amazing.  And people could see us from the fields and came for their treatment.  We were able to keep things hygienic and clean and set up our non-electric steriliser on the camp stove.  The people were curious and I am sure thought we were a bit strange but it did not stop them coming for treatment.  I treated one 76 year old lady.  What a cheeky character she was – no shoes, mouth full of coca leaves and full of wit.  She was like the local clown and had everyone in hysterics as she told her jokes in Quechua and jokingly made fun of us.  How wonderful to see such humour expressed from an elderly lady who had endured such a harsh environment for so many years.  30 minutes after she left, she returned with two packages of potatoes for us.  She had baked them in a traditional Quechua stone oven in the ground – and were delicious.

The day went without any problems.  We had the one seat operating continuously all day.  There was no great rush or urgency, just steady patients from 11am to 4.30pm.  People just came and sat around us.  Kids played and everyone waited patiently.  We were accompanied by 3 dogs, 2 baby chickens and had lots of sheep close by.  There was even a little black piglet who kept trying to get into the picture.  It was just all very surreal and calm and beautiful. 

I did most of the treatment as Louise and Ruth still seemed to lack some confidence.  But to be fair, we were working on top of a mountain in the blazing sun, in the high Peruvian Andes, surrounded by a collection of animals and children, treating Quechua speaking Indians.  Not your average day in the Dental Hospital!  A weird and wonderful experience.

At 4.30pm the sun went behind the mountain and it was freezing cold in minutes.  My last patient was a wee girl who was shivering uncontrollably.  After the treatment I held her to try to warm her up – she was so thin.  This reminded me, that despite having this wonderful day with these happy, friendly, grateful people, in these magnificent surroundings – the reality is that life is hard here.  There is little food and children are skinny and in pain.  How difficult that is to accept.  I only hope that we being here will help in a small way to relieve some suffering.

We drove to Mara to sleep that night.  There was not really any accommodation so improvisation was in play.  Clark and I slept on the floor in the Birthing Room while the girls shared one of the Hospital beds and Hernan had the other one.  We set up our stove and cooked up some food in the Birthing Room – it was a strange situation (just as I had suspected) and Louise and Ruth could not really believe where we were.  But we were all exhausted again and soon fell asleep.

Sunday 30^th May - Mara

Market Day in Mara.  They were expecting us and hundreds of people had come from communities around.  We were set up and ready to go by 8am.  This was our busiest day but yet it passed with relative calmness.  Or at least it did for me, Ruth and Louise.  We were situated in one large room in the Health Post and Clark and the Tecnica dealt with patient registration and medication outside.  They had the responsibility of “Crowd Control” – not an easy job.

We set up 3 dental chairs and we all worked right through from 8am to 8pm.  This day did a lot for the girls’ confidence.  I gave them a lot of responsibility but was always present in the room with them.  They would make their diagnosis and anaesthetise their patient and I would check it just before they started the extraction.  Often they could not complete the extraction and I would finish it.  But I encouraged them to ask for my assistance rather than take anything on they were not confident with.  Together we saw over 160 patients!

The majority of these patients were “Campesinos” (indigenous people from highland communities).  I was pleased to be able to reach these people as I feel that it is these people who need our help the most.  These people have no money; they survive on their crops of potatoes and whatever they can trade these for.  The majority of them have never seen a dentists before (unless they saw me last year!?).  The level of dental health was atrocious and the amount of dental infection was huge.  We saw numerous mouths with only rotten, abscessed roots – no teeth as such.  There was a huge amount of rampant deciduous caries, rendering children as young as 3 with multiple infections and pain. 

We were lucky at this Health Post to have the full support and efficient help of the staff there.  Even the Mayor of the town visited us.  He was very thankful that we had come and invited us to breakfast the following day.  At 8pm we saw our last patient (who was a little girl that screamed louder than any patient I have seen before and drained the final ounce of energy I had left in my body).  It was cold there – but we all slept soundly.

Monday 31^st May - Ccocha

Breakfast with the Mayor was how we started the day.  We were served boiled potatoes and eggs – which we thought was very nice.  But then the sheep’s stomach was the next course and we struggled a little with that?!  We discussed at length the possibility of me returning to Mara for a longer period of time (perhaps a week) as the need for treatment is so great.  The Mayor offered to provide a vehicle and driver if we could supply the petrol.  A very generous offer.  I hope I will be able to take them up on this offer, but there are just so many places in the Apurimac that need treatment.  We finally headed off after lots of handshakes and hugs.  Ccocha was our next destination.

This was a smaller community with a Health Post staffed by two Tecnicos again – no Doctor.  The road was very rough but the views were magnificent.  When we arrived, there were already patients waiting.  We set up quickly (we had a good system by now) and got straight to work.  We started with two chairs – one for me and the girls worked together on one.  But as the people started to arrive we needed to all be working.  “Crowd Control” was a problem here.  There were dozens of people waiting but they were all so curious to see what was happening and scared they missed their turn that they would be pushing to get in the door and shouting.   The stress levels were definitely higher today.

One man arrived with a very swollen left side of his face.  His lower left wisdom tooth had decayed and abscessed to such an extent that the abscess was draining out of the side of his cheek.  This man was in a serious amount of pain.  His eyes were weepy and he was very weak.  He had been in this pain for 2 weeks.  The Tecnica had previously given him a course of antibiotics but the treatment he needed was extraction of the tooth and draining of the fistula.  So this is what I did.  The poor man endured an incredible amount of discomfort but his gratitude after the treatment showed how terrible the previous two weeks had been for him.  To treat this one man alone made this whole day worthwhile – not to mention the other 126 cases of pain we relieved that day.

The stress levels rose considerably when there was a young girl with an upper first molar that Ruth could not extract.  The girl was anaesthetised but screamed throughout the treatment.  I took over and after 30mins, lots of sweat and tears and Clark almost fainting – the tooth came out.  We all needed a wee break after this but that was a luxury we could not afford. 

The saddest patient I saw the entire trip was in Ccocha.  He was not my patient and his problem was not dental.  He was a 3 year old boy with an enormous distended stomach.  He never spoke or cried – he just watched us all day.  He had a severe case of worms – his enormous stomach was packed full of worms the size of earth worms.  There are so many inside him that some escape through his mouth and nose while he sleeps.  I spoke to his father who asked me for medication or for us to treat his son but, with great sadness, I had to tell him I was not able.  We think the boy had got the parasites from drinking the local water which is contaminated.  Most people have been taught to boil the water before drinking it.  But he is just a little boy and drank from a stream as he did not know any better.  He has previously received parasitic medication but this has not worked.  So now the Tecnicos do not know what to do.  Since being back in Cusco I have spoken to a Paediatrician who has suggested a number of different treatment choices but all are uncertain without a full examination of the patient.  It is such a difficult situation due to geography and lack of resources.  But one day soon, I hope to return to Ccocha to see how we can help this little boy.

After this long and hard day (especially for Ruth who was a little ill after her sheep stomach breakfast) we packed up and headed back to Haquira to sleep.

Tuesday 1^st June – Llac-hua

We were up early and back on the bumpy road to Llac-hua after picking up two extra passengers (an obstetrician and nurse who wanted to visit this community too).  With the extra people the truck was a lot less comfortable with 4 of us squeezed in the back!  I was looking forward to getting to Llac-hua as I had heard the Tecnico there had had some basic training on tooth extraction from a German dentist.  For most of the day he closely observed me and then for the final two hours I encouraged him to extract some teeth.  He was quite nervous at first and asked a lot of questions but soon he was working himself and I was very pleased at what I saw.  He seemed to know his limitations and did not try anything too tricky.  His anaesthetic technique was good and he was quick!  He had been given a few extraction instruments by the German dentist and when I asked to see them he proudly unlocked them from a cupboard.  He was missing a few essential items and I took note of these in order to complete his set.

This town had a very nice feel to it.  The patients were polite and well mannered and showed their appreciation and gratitude.  All the school children came and we gave a good tooth brushing demonstration which they all paid close attention to.  An interesting observation was that there were more Orthodontic extractions needed in this town than any other.  The main problem was bucally displaced upper canines completed secluded from the arch.  These are not easy teeth to extract!  But with Orthodontic treatment not an option here – we had little choice.

My last patient in Llac-hua was a 12 year old girl.  She had a palatally displaced upper left lateral incisor situated directly behind her upper left central incisor.  Her speech was impeded by this tooth – she spoke with a very pronounced lisp.  She desperately wanted it extracted.  But on examination, I saw that her upper left central incisor had a carious cavity.  I was faced with the problem – if I take out the displaced tooth that will help her speech but is she going to loose her central incisor due to caries and then be left with no front teeth?  Although it was after 9pm and we were all very tired and finished for the night, I decided to extract the displaced tooth and then fill the central incisor.  This was the only choice of treatment.  And it was the right choice.  The patient understood what had been done for her and showed her appreciation with a big hug and smile – nothing more is needed.

Wednesday 2^nd June - Patan

I woke this morning with a lot of things to consider.  We still had two days of treatment in two separate villages.  The village today – Patan – was relatively small but the last village – Huancasca – was the size of Mara and there was sure to be over 200 hundreds patients needing treatment.

The first problem was we had used all of the anaesthetic, painkillers and antibiotics – we had no stocks left.  The only way we could continue the treatment was if I could buy more stock from the Health Post in the town we were sleeping.  I went to see what they could sell me.  They only had enough for one more day, so I had no option but to cancel our last day in Huancasca.

The second problem was we had a flat tyre.  We discovered it when we came down in the morning.  There was a spare, although it was very bald.  The road to Patan was notoriously bad so I decided to leave the decision of whether we could go or not up to our driver.  He said we would be ok – so I trusted his judgement.

Another concern was that Clark had been quite sick during yesterday with the start of a cold and had gotten much worse driving back last night.  He had a fever and was very congested.  I did not want him to come with us to Patan today as it is at an altitude of 4,000 metres and is bitterly cold.  I insisted he stay in bed today.  That left the team a man down but we knew Hernan would help out.

I realised the fourth problem as we were packing the truck to leave.  Our camp stove had been stolen.  There had been some men sleeping in the same building as us and (we later discovered) two of them had stolen the stove during the night from the back of the truck.  The stove was our source of power for our non-electric steriliser.  Although the village we were going to today had electricity, this steriliser would have also been used to cope with the load of instruments requiring cleaning.  But I decided we would have to cope with our other steriliser alone.

So despite all these problems telling me that perhaps we should not go today – we set off.  Our first stop was to collect the same Obstetrician and Nurse as yesterday and take them to Patan with us.  But they had invited alone another person which made the journey very cramped again.

In Patan we set up surgery.  The Health Post was very small and dark and made of adobe.  It was very cold up there.  We mainly treated children throughout the day and then the adults came later in the afternoon.  The children were amazing.  They were the bravest, most polite, sweetest group of children I have ever come across.  Not one of them cried or screamed or showed any resistance to the treatment.  They were an absolute pleasure to treat.  Ruth did have one wee boy, however, who vomited.  The poor wee soul.  We don’t know if he was sick or scared but before Ruth even started to take his tooth out, he was sick.

There was a 10 year old girl who had a cleft lip and palate.  It was really quite severe.  Her lip had been repaired because the government pay for this treatment.  They do not, however, pay for the operation to repair her palate – and therefore the girl had never had this operation.  Thus – she had no palate.  Her oral cavity and her nasal cavity were completely open to one another.  They were basically one in the same space.  I do not know how this child coped with eating, drinking and speaking.  Her teeth were all malformed and displaced.  And on top of everything else, she had a painful abscess.  How hard life can be for these small children.

Our day was made more difficult by the fact that our “extra mystery passenger” took our vehicle and Hernan and drove to a village 90 minutes away.  She was doing work for the Ministry of Health but there was no request for the vehicle or discussion or respect for the fact that Hernan was an important member of our team who we could not spare that day.  Not to mention I paid for the petrol!  We had planned to stop work at 4pm as it gets too cold after that.  But we were stranded there until 6.30pm waiting for this lady to return.  We were so cold by the time they returned; we headed straight back down to the village with no further delay.  Clark was feeling better and had cooked us dinner.  We soon heated up and spent the next few hours talking about how wonderful the trip had been, how much we had all learned, how we could see what a difference we had made out here, the great need for treatment and how exhausted we all were.  We slept very well that night again.

Thursday 3^rd June

It was time to head back to Cusco.  It was sad to leave the house we had been staying in.  We had made good friends with Dino, the caretaker.  He had a beautiful garden and the views from here were magnificent.  But we got packed up and headed off.

The drive back was awesome.  We took a different route but were treated to just as many amazing views.  The journey was somewhat eventful.  About half way, we decided to stop to eat.  Hernan said he knew a good spot.  When we pulled up he pointed to an old woman in the field with her sheep and cows and said that was his mother.  It turned out that he had not seen his parents for three years and here we were just bumping into them on this journey.  We all sat and ate and spoke (through translation) and we told Hernan’s mother what a great asset he had been to our team.  She seemed quite proud of him.  We gave her all the food we had left – which she was very pleased with.  Plus, some antibiotics and painkillers for some ailments she had.  Then just as we were about to leave, his father came into sight.  We all met and it was quite emotional – it seemed a fitting reward for all of Hernan’s hard work with us.

About two hours after that stop the suspension in the truck broke.  The roads were so bumpy and rough that it got the better of us.  We hobbled to a flat area in the bottom of a gorge where Hernan patched it up as best he could (with the usual Peruvian materials of a strip of rubber and a piece of metal wire) while getting eaten alive by mosquitoes.  But then we were off again in the setting sun.

Ten hours after we left Dino in Haquira, we arrived back in Cusco.  We were all a bit shocked to see so much traffic and light and people.  During our eight days in the Apurimac, we had seen only one other car on the road!  And it was silent when you lay in bed at night.  It truly is like a different world out there – and I have been lucky enough to return there and share it with some very special people.  I am thankful for this and look forward to the next trip.