DPP Volunteer Trip 2 – 2005

1-8 July

Day 1

I woke on day 1 of this Volunteer Trip very tired after little sleep.  The day before, our assistant had pulled out at the last minute.  This left me in a state of panic to find someone else.  I had spent 4 hours between 5pm and 9pm finding a replacement and confirming details when I should have been completing the last of the packing and organising.  Obviously, this meant I had to continue to work until 1am to be ready to leave for the Apurimac.  Not the best start to a trip you might think?  But my spirits were lifted and I had no doubt this would be a wonderful trip when the volunteers (from the UK) arrived full of enthusiasm and excitement.  These were 2 very special guys.

David Wilson, a 31 year old dentist in his Vocational Training year from Sunderland was the first volunteer to arrive in Cusco.  He had taken 5 days before the trip to acclimatise and explore the area a little bit.  David is a wonderful person with an infectious personality.  From his first email I knew we would get on well.  He is very excitable and ready for any challenge which he takes on with a smile – every time! 

Andy McLean was the second volunteer to arrive.  He miraculously organised his trip to Peru in about 2 weeks!  He arrived 2 days before our departure to acclimatise but managed to squeeze in plenty of “cultural exchanges” and laughs even before we left for the Apurimac.  He is the father of 3 beautiful girls and with this experience, is a natural with the kids.

We had our driver Fabian Palamino from the Ministry of Health.  It is always good to have him on the team with his Quechua tongue, local knowledge and love for the patients.

And our last minute addition to the team was Jeffery.  And what a great addition he was.  He was a friend of a friend who agreed to come with us at the last minute for a reasonable fee - and earned every penny of it!  He was our “sterilising man” and helped a lot with “crowd control” and educational talks amongst other things.

So at 8am we met at the office and got the truck packed up.  We headed off at about 10am in beautiful sunshine, full of excitement.  The drive was wonderful as always and everyone seemed to appreciate the beauty and scale of the landscape.  We got down the 24 switch-backs into the Apurimac gorge and then up the other side.  There, we chose our lunch spot overlooking the impressive road construction with the backdrop of the snow capped peaks of Salkantay and Veronica.

When lunch was finished, we got back into the truck to continue our journey.  But this was not to be….. 

The truck would not start.  It was a mystery.  The truck had been checked and serviced before we came on this trip and I was very surprised to have any problems.  Fabian did his best to sort things, but eventually we decided to try push starting it.  Now bear in mind, we were at about 3,800 metres above sea level!  That makes for hard work.  But to no avail.  A bus then passed us and 5 helpful men jumped off to give us a hand – but the other passengers soon insisted they get back on the bus and leave us to it!  During this time, one ambulance arrived behind the bus from Cusco and waited.  Shortly after, another ambulance came from the nearby town of Cotabambas with an emergency case going to Cusco – a one month old baby with Meningitis.  The ambulance could not get passed us so the doctor ran with the baby to the other ambulance (waiting behind the bus), the crew all changed, they turn the ambulance around and took off for Cusco.

The crew from the other ambulance told us they would return to Cotabambas and send us some help.  So we waited.  30 minutes later we heard the roar of something??.....  Then 2 huge Caterpillar tractors came around the corner.  They agreed to tow us back to Cotabambas.  By this time it was getting dark (6pm) so we are very grateful for the help.

Once in Cotabambas, we got dropped off at the “mechanics” house.  He and a few of his buddies proceeded to work on the truck for 3 hours.  Their conclusion was an electrical fault they cannot fix.  But they would resume at 5am. 

During our time waiting by the truck, we got talking to an 11 year old boy - Alex.  He was so nice and very intelligent.  I told him I was from Scotland and he immediately started talking about “Brave Heart” the movie.  He has seen two movies in his life and Brave Heart was one of them.  It was amazing.  He practically recited the entire script.  He told me how sad he was when William Wallace’s wife was killed and how he cried at the end when he dropped her handkerchief.  He remembered every scene and asked if things had changed in Scotland since then.  What a wonderful boy.  While speaking to him, I noticed he had a cleft lip and palate.  When I asked him about it, he told us that his mother had been struck by lightning when she was pregnant with him and that is how he got the split in this lip.  Truth or Myth??  Interesting.

With nowhere to sleep, I made some enquiries and found us 3 very clean beds in a ladies house.  We bunked down for the night (Dave kindly took the floor) with Fabian sleeping in the truck to take care of the equipment.  We slept well except Dave who was kept awake with a painful ankle that he sprained while pushing the truck.

Day 2

I woke at 5am expecting to find the men working on the truck.  But unfortunately I was disappointed.  No-one appeared until 8am!  During this time I had been making phone calls to Cusco and talking with the personnel in the Health Post trying to come up with a contingency plan.  The plans were in place but I was not ready to give up on our truck yet!  At about 9am a truck drove into town with some mechanics from Cusco.  They had lots of great equipment and had the truck running before 10am.  It was a very simple electrical connection that had failed.  Simple to fix – when you know how!!  So we were off – what a relief!

The drive to our first village was 4 hours from Cotabambas.  I had radioed the Health Post to tell them our situation, so when we arrived there were plenty patients to be treated.  All the kids came running to the truck as we drove up to the building.  It was a great welcome and really beautiful with all the people in the native indigenous dress.  We were all quite over whelmed. 

We set up in the 2-room building and got to work straight away.  Both the guys seemed to be loving it but the language barrier was causing a bit of frustration.  So we decided we would have a basic Spanish/Quechua lesson that night.  We worked until about 6.30pm seeing all the patients who were waiting.  And I was delighted that we managed to do some fillings too.  It is a good situation to have 3 dentists because it allows one to be filling while the other 2 are still extracting.

There was one 16 year old boy who had decayed upper incisors.  Andy restored the teeth and thus restored the patients smile making an unimaginable difference to this young mans life.  Very rewarding!

After dinner and our language lesson, we sorted out mattresses and blankets and slept on the floor of the health post.  Jeffery slept on the birthing table!

Day 3

Andy and I were woken today by Dave’s sweet tones of “1-2-3, wide awake!”  He is definitely a morning person and is full of life no matter the hour!  With other people this can be annoying, but with Dave you cannot help but be infected by his enthusiasm!

We had a gentle morning as we waited for patients to arrive.  It was Sunday, so there were no schools arriving but rather a steady stream of adults and children.  Again, we had the good fortune to have the opportunity to do many fillings for people.  We filled about one in 10 teeth, the others being extracted.  This is a DPP record so far!

During the morning as patients awaited treatment, I gathered them together outside and we did our first Educational Talk.  My good friend, Marly Larabee, has made a felt education board which is an interactive game to educate patients on what foods and drinks are good and bad for their teeth.  This proved a great success.  With the bright colours and interactive component, the children’s attention is retained.  The presentation lasts about 20-30 minutes and is followed by a demonstration on how to brush teeth using our large plastic mouth model.  If I do the presentation, there is always someone to translate to Quechua – otherwise someone else does it in Quechua (usually a teacher to their students).  It was quite memorable as we did the talk in the bright sun in such a beautiful setting, surrounding by people in traditional dress speaking and interacting in their native language.  I think (and hope) we all learnt something.

We then gave toothbrushes to everyone.  It is very touching when even the smallest of children manage to say thank you in Spanish.  That is all I need.

Working until we saw all the patients, we finished about 5pm.  The whole team functioned well together and it was a pleasure to work with Andy and Dave.  Lots of laughs as well as exchange of professional opinion. We all felt satisfied with the amount of pain and infection we relieved as well as the amount of teeth we saved.  We packed up tired and happy.

Fabian drove us back to Tambobamba where we ate chicken in a “restaurant” (a pleasant change from pasta) and slept well in the hacienda.

Day 4

We really had a great day today!  We were up about 5.30am and ready to go an hour later.  We drove the one and a half hours to Choqueca.  The second half of the journey, the road is very bad – but no problem for the truck.  The road does not arrive at the Health Post though so we had 2 options.  To walk the last part and carry all the equipment, or four-wheel drive it down to the river.  A no-brainer!  We arrived at the river in the truck and I went to investigate what the situation was.

I had planned to work in the school because the Health Post was even more inaccessible and it would have been tricky to get all the equipment there.  But there was no-one around when we arrived.  So we waited about 15 minutes and then the Technician from the Health Post appeared.  She assured me she had communicated with the people of the communities and they would all come for treatment.  But there may be a problem with the schools – the national “Day of the Teacher” was to take place this week and this may mean the teachers would not be working.  We would have to wait to see……

We decided to set up in the school as planned and so started to unload the truck.  From nowhere, dozens of children appeared and helped us with the equipment.  It was great fun for them and a good help to us!

Then a strange sight came to my eye.  Up on the road, a white Beatle car appeared and 6 people piled out.  How the car managed to negotiate that road I do not know, but I was very pleased to hear that this was the teachers!!  We had a nice meeting where I explained who we were and what we were doing and asked for their help whenever possible.  They were very enthusiastic but I just had one question – “where are the children?”  The answer, of course, was obvious.  They were walking.  Some of them 5 hours to get to us!  Nice for the teachers to have a car though??...

So by the time we were all set up and ready to start, the children had arrived.  Over 150 in total.  They all lined up and I did the screening.  They were such lovely kids.  But it broke my heart when one wee 5 year old came to me with no shoes on and dressed in rags.  She had walked 3 hours with her classmates – with no shoes!

Dave and Andy got to work once Fabian had taken the details of the children who needed treatment.  I have to say, I was very pleasantly surprised at how many healthy mouths there were.  I asked the teachers and discovered this was because the communities where these children were from were extremely rural with no “shops” or access to fizzy drinks or other refined sugar products.  So I found myself asking the question – “are these children better off being so rural and thus safe from the dangers of a changing society?” “Or do they deserve to be closer to a developing world where everyone has the basic necessities in life – like shoes?”  I look at these children and pity their options.

Once the children were screened we got everyone together – children, parents, health promoters and teachers to do the Education Talk.  We put our felt board up and immediately the children were intrigued.  I started the talk with Quechua translation but then handed over to one of the teachers when I realised how keen and excited she was.  What we do at these demonstrations is show the children (and adults) different foods and drinks made of felt and ask them firstly what they are and then whether they are good or bad for their teeth.  The children love shouting out the answers and then we choose a child to stick each food/drink to the board.  They love it!  The greatest revelation of the day was that the Coca leaf – indigenous to the Andes of Peru – is good for the teeth as it has a great abundance of calcium in it.  Over the past 50 years it has been given a bad name due to its exploitation in the manufacture of cocaine.  But the leaf itself is a valuable part of these peoples diet providing them with huge amounts of vitamins and nutrients that their diet otherwise does not offer.  So it was a bit of a shock for them to hear this leaf is good for them and they should eat/chew it after being told for so long now that the leaf is “bad”.  It is times like this that we must be culturally sensitive.  It would be irresponsible for us to try to change the way people live or give them information which results in confusion and misunderstanding.  That is why we must work together with the personnel of the Health Posts and the teachers.

After the Education Talk, I did the tooth brushing demonstration.  Again the kids love this as we use the big model and tooth brush.  And then it is time to distribute tooth brushes to everyone present.  But the new idea for this year is to give the toothbrushes to the teachers and have them be responsible for the children brushing their teeth at least once a day with their classmates under supervision in school.  The toothbrushes are kept in the classroom in separate little pots for each child.  The teachers all seem very keen to participate in this project.  I feel there is a higher chance of the children actually using the toothbrushes if we plan this way rather than making the child/parent responsible for oral hygiene.

After all this excitement it was time to join Andy and Dave inside treating the kids.  They had done amazing well and seen almost 50 kids already – and hardly any tears!!  I think they really enjoyed this day and got a huge amount of satisfaction from communicating and treating so many wonderful children.

We stopped for lunch once all the children were treated.  We should have stopped earlier as we were all very tired and hungry but we wanted to get the children all seen so they could start the long walk home!  So after our break we treated the adults.  The general state of the mouths was very poor and quite shocking.  We found ourselves doing multiple quadrant extractions and even some clearances. 

There was a 12 year old girl who had no dental pain but came to see us about her lower lip.  It was extremely swollen and suppurating.  There were round purple/black blotches, 3-4mm in diameter, about 6 in number.  At first Andy and I both thought it was Primary Herpes but there were no intra-oral lesions and the history did not match.  She had had this condition for about one year and suffered severe pain for the duration.  The technicians said it was due to the girl drinking “Agua Manta”. This is the marsh/bog water that seeps up from the ground.  It is very dirty and contaminated with bacteria and parasites.  But was this the cause or was it another myth?  It is hard to know and Andy and I were stuck to know what to do.  Our worst fear was it was some kind of cancerous lesion and we were desperate to rule this out.  In order to do this, we needed to send the girl to Cusco for tests.  So we stressed the importance that she return tomorrow with her parents so we could make the arrangements for her to be sent/referred to Cusco.  There was no more we could do without consent from her parents.  We hoped she would return…..she never did.

There was a 26 year old lady who came with dental pain.  During her treatment the technician pointed out she had severe arthritis.  Her fingers, wrists and ankles were very swollen and painful.  The poor lady had a new baby and a 3 year old girl.  She was clearly struggling with them.  Again, we tried to help in the small way we could.  We gave her an entire box of Ibuprofen and advised her to take them as she needed.  She was extremely grateful and thanked us profusely.  We were happy to help but it made me think, again, how there are so many factors that can make this difficult existence even harder.

We headed back to Tambobamba to sleep.  After dinner we all wanted a nice warm cup of tea, but we had left the extra fuel for the stove at Choqueca.  The team took a vote and decided we wanted tea enough that we should siphon diesel from the truck.  Fabian took on the job and the poor man was pleased to have his tea, finally, to get rid of the horrible taste of diesel that had almost choked him during the siphoning mission!

Day 5

Another good day in Choqueca.  We had a relatively long lie until 7am and then drove back to the town.  The first patient arrived about 9.30am – a young campesino farmer who had suffered terrible tooth ache for months.  He was very relieved to be rid of his two infected teeth.  The patients arrived steadily throughout the day which kept us busy but not stressed!  No schools came.  It was the first day of celebrations for the “Day of the Teacher” (which apparently lasts almost a week!!).  So there were few kids but plenty of adults.  Again the level of caries and infection was very high and there were a number of patients that I had treated the year before who had come back for more treatment this year.

A lady brought 2 Guinea Pigs for lunch!  I must admit, I have had enough to last me a lifetime but Andy and Dave were both keen to try it.  So they scoffed it down and quite enjoyed it!  But there was nowhere near enough meat on it so tuna sandwiches were the second course.

Children from Choqueca itself were present all day.  They played outside and peered through the windows intrigued at what we were doing.  We finished early and had the chance to play with them outside in the sun.  Andy started the fun by blowing up a glove which then became a balloon.  The kids loved it so much, they all got glove balloons.  The next thing, of course, was to fill the balloons with water which was even more fun!  But then the finishing touch was when Dave found a marker pen and transformed the balloons into faces of all sorts of shapes and expressions.  We all really appreciated this relaxed time playing with the children.  Often on trips, we are so busy we literally arrive in a village, treat the 100’s of waiting patients and then get back in the truck and leave because it is so late and we are so tired.  This was a special day.

As we were leaving, all the kids were clambering on the truck.  I thought it was funny when the Technician told them we would drive away with them to another country.  All the kids immediately jumped off the truck in fear of being transported to some strange place.

We arrived back at the Hacienda, and after a mini-adventure getting into the locked grounds (??!!), we had plenty of laughs at some of Dave’s stories before getting some sleep.

Day 6

The drive to Pisaccasa was beautiful.  I really like this village, it was one of the first I visited on my own in 2002.  But when we arrived we were disappointed to see the Health Post was locked up and there was a note on the door to say the Technicians had gone to the nearby town to do “paperwork”!!!

I was quite angry because they knew we were coming on this day so why, of all days, would you decide to do your paperwork??  I was annoyed because I had done the first “Preperation Trip” in May in order to avoid this exact type of occurrence.  But with no other option, we waited!  But then that seemed futile as a couple of people started to arrive for treatment.  We had to find out when the personnel would be back to open the Health Post.  So Fabian, Dave and I walked down to where someone told us there was a radio.  The walk down was nice – very beautiful (but we had forgotten we had to walk back UP! Remember we were at almost 4,300m!).  We spoke to some villagers and eventually a young man came and opened a mud hut and led us inside to find a radio!  Amazing!  So we radioed the Health Post in Mara and spoke with Irene (the illusive Technician from Pisaccasa).  She realised our annoyance and promised to get back as soon as possible.

When we got back up to the locked Health Post more people had arrived.  They too were annoyed at Irene leaving.  So what should we do?....

We unpacked the truck and set up the dental chair outside and started work.  It was a beautiful sunny day and it felt great to work in the sunshine.  We got through a few patients before Irene arrived in a truck.  She was very coy and apologetic.  After the barrage of abuse she got from the waiting patients, I did not feel it necessary to release my anger on her too.

Before too long, we were set up and organised inside.  Then began the two days of hundreds of patients in Pisaccasa.  The people came from all the 7 communities.  It was interesting to see their different dress, some very traditional and some surprisingly modern and clean.  We worked great together as a team.  We had a number of difficult Orthodontic cases.  One in particular was a 6 year old boy with mixed incisal dentition.  His upper left adult central incisor was in cross-bite (ie. Placed inside his arch on this palate), as were his two lower adult central incisors. (placed in towards his tongue).  We spent a long time in discussion deciding the best treatment for this wee boy.  We felt our only option was to give him the best chance of moving these teeth out of cross-bite.  This required extraction of 10 teeth! (8 milk teeth and 2 adult teeth).  We were certain the wee boy would cry and be upset.  But Dave treated him without the slightest objection or tear.  We were all amazed.  What a wonderful little boy (and dentist!).  It is also remarkable how much trust the parents put in us.  We explained to his mother, through Quechua translation, what we were going to do and why and she had no doubts about letting us do it.  Bearing in mind we were taking 10 healthy teeth out of her son, I think this was quite a leap of faith for her.

Saving teeth was our mission for Pisaccasa.  And I think we succeeded.  We managed to save one in every 8 teeth for treatment.  We were all so pleased about this.  We would take it in turn to do the fillings as each one can be quite taxing with the limited resources and tricky working conditions.  Andy even did some nice “cosmetic” crown lengthening on an upper lateral incisor.  The result of which was the prominent canine of this young patient became less prominent and he no longer wanted it extracted. Nice job!

We were so busy with patients this day, I asked Jeffery to do the Education Talk with the waiting patients.  He did and he loved it – as did they!

We did stop for a quick lunch break this day.  Apart from that we worked straight through – apart from the 5 minute break Andy had to take.  He had one patient who had a particularly pungent odour!  A few deep breaths of clean fresh air were necessary in order for Andy to recover without fainting or vomiting.

We bedded down in the same room we had worked in that night.  Fabian and Jeffery got the birthing tables again (not sure who got the better deal there…..).  We slept well after a very busy day.

Day 7

We awoke in Pisaccasa at 6.30am.  For the first time on the trip, the guys agreed with me that it can get cold.  They laughed at me most of the time with my 6 layers on while they were working in T-shirts.  But waking at 4,300m is pretty chilly.  Dave in particular wore more layers than usual. 

Our first patient arrived at 8.30am and from then until 5.30pm we worked constantly only stopping to eat a quick lunch, including potatoes cooked for us by a local lady.  The patients came in a constant flow throughout the day, but once again no schools came with their teachers as the teachers seemed to still be celebrating their national day of honor!  But a lot of children did come either alone or with their parents.

I am pleased to say that the change from one day in each village (as we did in 2004) to spending two days in each place (as is the plan for this year) seems to be an excellent idea.  It really allows us time to do more fillings and spend time doing the Education Talks too.  Also, having 3 dentists on each trip is the way forward.  Again, this allows so much more restorative work to be done.

A 15 year old boy presented with a lower molar for extraction, which I did.  But his main complaint was the two large swellings on his lower lip.  He requested we remove them.  After agreement between the 3 of us that these were large Mucoceles, (benign swelling of minor salivary gland), our treatment of choice was excision.  Andy had a lot of experience with this type of surgery so I followed his lead and we removed both the lesions.  The result was excellent and the young boy was delighted to be rid of these unsightly swellings.

We had a few tricky extractions.  With this being our seventh day working, we were all very tired and our strength was diminishing towards the end of the day.  That is always when the toughest of extractions present, and become tougher with the circumstances.  But we completed them all successfully and we all continued to learn from each other.

One of the most difficult aspects of this work is when you cannot complete the treatment the way you would ideally like to.  I think Dave in particular felt this.  A typical example of the frustration is when a patient presents with a mouth full of decayed and infected teeth but will not allow us to extract all that require extraction.  Even after explaining the risks of leaving these teeth or roots (ie. Further pain and infection) if the patient expresses the desire to keep the teeth – we must respect this.  This decision is often motivated by fear but although, as a dentist, we want to provide the best treatment to each of our patients, the bottom line is - these are people and we need their consent to carry out treatment on them. The communication barrier often makes this situation frustrating as we imagine we could explain the situation and make the person understand the need for treatment if only we could speak their language.  But at the end of the day, we must respect their wishes, even if this means our treatment is, in our eyes, compromised.

It was getting dark when we finally saw the last patient of the trip.  This is always a strange feeling because we are happy and relieved to be finished the work and looking forward to going home – but at the same time we know we will not be of service to this people again.  (Or at least not until next year!!......)

We drove back to Tambobamba to eat and sleep – very weary and very content.

Day 8

The trip home.  We left early so that Andy and Dave could have a few extra hours enjoying Cusco before their flight back the next day.  The drive was beautiful and we all just appreciated the scenery and each others company for the last day. 

Despite our “teething problems” at the beginning of the week, I have to say this was a wonderful trip!  This was due entirely to the people that made up our team.  Each person brought a great personality and a lot of hard work to the experience and it was my pleasure to work with them.  I hope we can do it again some time!!......