Dental Project Peru – Trip Report

Trip 1 – 18-25 June 2006

Simon & Caroline

Day 1

This was the first trip of 2006 so I was very excited.  But with the first of anything – comes a little bit of apprehension.  I was thinking “do we have all the equipment, materials, food, fuel, water, medications, toothbrushes……”  The list goes on and on and the night before was not the best nights sleep I have ever had! 

I met the volunteers the night before for dinner.  Simon Holguin is a 37 year old dentist from England.  His wife is also a dentist but with their 3 young children she was not able to accompany Simon on this trip.  I knew straight away Simon and I would get on great.  He is a very chatty and likeable guy and easy to talk to.  The other volunteer was Caroline O’Brien.  She is a 27 year old dentist from the South of Ireland but she lives and works in Cardiff now.  Unfortunately Caroline was not able to arrive in Cusco the required 2 days before the trip left to acclimatize.  This concerned me a little as I do insist volunteers take the time to get used to the altitude, but it could not be helped and she seemed fine when I met her the night before we left.

So we all met at 9am on Sunday morning.  The other team members were Lucho, who was coming along as our “assistant”.  He is a Peruvian guy who lives in Cusco but is originally from Tambobamba where we work!  So I was very excited to have him with us.  And he was equally excited as he had not been “home” for 6 years!

Our driver is Leo.  I have known Leo since I first went to the Apurimac in 2002.  We have stayed friends and I was delighted to finally be in a situation to offer him a position to work with us. 

So we got the truck packed up.  I checked the lists time and again and finally about 10.30am we set off. 

Clark and I had done a 4 day trip last month to get the word out to the Health Posts and communities that we were coming back.  We visited the larger centres and sent word to the smaller communities of dates and times we would be arriving.  So that was the first trip of the year but driving out today with the volunteers had a different feeling.  When we cross the different passes and see the different views I am always excited to share it with the volunteers and explain how amazing the landscape is in this part of the country.  It was a beautiful day and we could see the snow capped peaks of Ausangate, Veronica and eventually Salkantay.  These sacred mountains become more and more special to me with every trip.  It is clear to see why the Quechua people worship them!

We stopped for lunch on the Apurimac side of the Apurimac river.  We had gone down the 3000 metre gorge by way of the switchbacks and up the other side.  So a break for lunch was well received.  The view for a picnic has got to be one of the best!  It was relaxing sitting in the sun chatting between English and Spanish.

By 6pm we arrived in Tambobamba.  This is Lucho’s home so he was thrilled to be there.  He could not believe how much it had grown and changed in 6 years.  I agree with him – it is incredible the difference since I first visited in 2002.  His sister still lives here and so he quickly went to visit her.

We pulled up to Senor Antonio’s hacienda.  I love this place.  It is nothing fancy (to say the least) but it has beds and a flushing toilet.  But the best part is the courtyard filled with flowers.  Somewhat of a haven.  We ate dinner and were all happy to head off to bed before 10pm to be ready for our early start in the morning!

Day 2

We arrived in our first of 3 villages for this trip – Asacasi.  I can hardly believe the improvements that have occurred since last year.  They have improved the road so that it almost arrives at the health post!  We still had to do a bit of off-roading (or no-roading you might call it) but that is always a wee adventure!  And then when we pulled up to the Health Post I was amazed to see it renovated and looking shiny and new!  It was actually only finished a matter of weeks ago and still being settled into.  But as usual we had no problem with that – within an hour and a half we were installed as if we owned the place!

This was the first trip since the very first trip I have had no-one on the team who has been with me before and knows the system.  So I had to take a good amount of time to explain how we work things.  Simon, Caroline and I set up the surgery with the 3 dental chairs, the filling and extracting equipment as well as the dirty/sterilizing station.  Lucho was to be our “sterilizer” so I explained how we cleaned and cold sterilized things first and then showed him how the electric sterilizer worked.  Leo was in charge of patient records, medications and toothbrushes.  So I explained all this to him and by 11am we were ready to start!

A school of 130 children arrived just as we were ready to start.  So we got them all together and did the first Charla (dental education talk) of 2006.  Lucho helped me with it as most of the kids only understood Quechua.  It is so much fun.  The kids were really interactive and loved sticking on the different foods and drinks.  The teachers and parents gathered round and listened too.  This is very important as it is, after all, them that ultimately control the children’s diet. 

As I sat amongst the kids with their beautiful, well worn traditional clothes, all with their wee white hats on, I felt at home.  I feel somehow connected to these people and when I am with them I don’t wish to be anywhere else.

After the Charla I started to do the screening of the children outside while Simon and Caroline started treatment inside.  This year, I have printed “cheat sheets” and put them up on the wall of the surgery to help the volunteers with the basic dental questions in Spanish and Quechua.  Simon and Caroline were trying but the language barrier does pose a problem.  So after a while, Simon and I swapped so he did the screening and I worked with Caroline inside and was able to help her with translation. 

The language barrier can be a problem whilst doing the screening too as this is when you have to establish if there is pain, where the pain is and whether extraction in necessary.  But Lucho helped Simon and they got on fine.  Doing the screening is great cos you have contact with all the children and get to see so many beautiful wee faces.  Simon seemed to enjoy it.

The day continued well.  We stopped for lunch and then continued afterwards until there were no more patients (about 6pm).  We worked well together as a team and even managed to get some fillings done.

When the sun went down it got bitterly cold.  Asacasi sits at about 4,300 metres and is very exposed.  We all bundled up and sat and had dinner in the Residencia of the Health Post.  It is actually very nice as it is also new.  And it was big enough for us all to sleep side by side on the floor.  The poor Tecnica – Soledad, must have wandered what had happened when she got into her bed (the only bed) in the Residencia with 5 strangers lying on the floor around her!

She is a lovely girl.  She on her Serum (training) year and has been placed by the government in Asacasi.  She is from Tacna which is in the very south of Peru on the border with Chile.  The climate is very warm there and the town lies at almost sea-level.  So this has been one big shock for her!  Every month, the Health Post workers are allowed 5 days off.  So Soledad makes the trip home to Tacna.  It takes her 2 and a half days of traveling day and night to get home.  She arrives in time to spend the day from early morning to evening with her family before having to catch at least 5 buses back to the Apurimac.  What a life!

Day 3

We all woke to a beautiful clear morning in Asacasi.  Our alarm clock was typical Peruvian music being blasted out of the Health Post building.  The music is a kind of wailing-shrieking agony which pierces your ear drums and gives you no option but to get out of bed to try to escape it!  But they must like it – so who am I to complain……..

I love watching the people start their days.  Although by the time we were up at 7am most people had been up for 2 hours.  But seeing people (men, women and children) head off to the fields with their different animals is a reminder of how simple life can be.  No commuter traffic, no morning rush hour, no worry of being late.  Life is tough here but tough at a slow pace.

I was quite concerned this morning as Caroline was a bit poorly.  She had not slept well at all and had been very cold in the night.  She vomited while trying to eat breakfast and was very pale and clearly lacking energy. These were classic signs of her body trying to adjust to the high altitude.  Unfortunately the lack of acclimitisation time in Cusco was taking its toll.  I encouraged her to take it easy, drink plenty fluids (especially Coca tea) and keep me up to date with how she was feeling.  All credit to her – she got to work and was pulling those teeth out with no delay.  I was very grateful for her efforts as we had a lot of patients to treat. 

One patient in particular sticks in my mind today.  He was a 10 year old boy named Juan.  He had had his wee head shaved very close to his scalp and so immediately looked different from all the other boys.  He was so very very scared.  He needed his lower right first adult molar extracted as it was very badly decayed and infected.  Simon was trying to give him the local anesthetic as I was trying to comfort him.  But both tasks were proving impossible.  The tears were literally bouncing out of his eyes which were opened so wide.  As I touched his hands to comfort him, he was trembling and freezing cold.  He was so scared he could hardly catch his breath.  My heart was going out to him and I raised my right hand to stroke his head and try to reassure him.  As I raised my hand he flinched violently away from me and looked into my eyes with fear.  My heart almost broke.  He was not only scared of the treatment but now thought I was going to hit him.  How could anyone hurt this wee boy?  What happened to him at home for him to think I would harm him?  I could feel the tears coming to my eyes now and all I wanted to do was give him a big hug.  We were past the point of reason now and I could not bear to force him to have the treatment.  We let him go and I watched as he left.  Sometimes the raw emotions of children leave you exhausted and broken.

But then there is always another child who pulls you out of that and gives you hope and reminds you that you are doing a great service for these people.  A little six year old girl named Marisol came into the surgery and jumped up into my chair.  Before I even had a chance to speak to her she opened her mouth as wide as she could.  She needed an abscessed lower left deciduous molar tooth extracted.  I treated her and the entire time she stared into my eyes.  She was completely still and trusting – never once taking her beautiful big eyes off of me.  She was so brave, never once showed any sign of distress or fear – I was very grateful for Marisol that afternoon.

Just before dark, we were finished.  We started the mammoth task of packing up.  Everyone helps and the truck is packed up and strapped down within an hour.  Or at least it is strapped down if we have ropes……  During the day, our ropes had disappeared from the back of the truck.  It was probably kids wanting to play with them and we should not have left them there.  But it did pose a slight problem of how we would make it back to Tambobambo with all our equipment!  So after asking around, someone in the village appeared with a length of llama-wool rope.  It was the prettiest rope I had ever seen, all natural llama colours.  Luckily it was extremely strong and we secured things well enough to make it to town.

As I jumped into the truck, I noticed the truck had been “signed” – literally.  What often happens outside while we are working is the children waiting for treatment have great fun climbing on and playing around the truck.  I can never get annoyed with this as this big hunk of metal is quite the novelty for them.  The dust that gathers on the truck proves a lot of fun for the kids to draw on with their fingers.  The problem is when all the dust is gone.  Then they often continue to draw and scribble on the truck with stones.  But I had just had a brand new paint job done on the truck so when I saw “Juliana” scratched on my door in big letters, I have to admit to being a wee bit upset – but what can you do…….

We arrived safely back in Tambobamba where we ate a great meal of roasted chicken and bought some new ropes.

Day 4

With all the equipment secured to the truck, we left Tambobamba with Choqueca as our next destination.  This is always an interesting village because the road does not actually arrive in the village which makes the Health Post, which is right on top of the mountain, completely inaccessible.  The first year who walked into the Health Post carrying all the equipment – not a favorable choice!  Last year we worked in the village school which is at the bottom of the mountain and not too far from the road.  But working in the school depends on getting permission from the School Director.  Working there for 2 days disrupts classes as we accommodate both of the 2 existing classrooms.  My fingers were crossed in hope that the new Director would be kind enough to let us use his building.

When we arrived there were already children lying up and teachers bellowing instructions to them in Quechua.  As I approached, I recognized Profesor Juvenil.  He used to work in another community but had been moved here and been made Director.  He greeted me with a big hug and thanked me for coming back to Choqueca.  He had been informed of the visit and already made arrangements for us to use the classrooms.  Hooray!!

So we unloaded the truck and the eager children were more than happy to help carry the equipment over the field and river and up into the school.  I had a good feeling about this visit…….

As usual, we got set up but unfortunately there is still no electricity in Choqueca.  So we were unable to offer fillings as the drill/compressor require power!  But before we knew it there were over 200 children lined up outside waiting to be examined.  The Tecnica – Elsa – was very well organized.  I have known her for 3 years now and she knows how to make things work.  She had organized all the school communities to come the first day as the second day a big sports day event for all the local schools was being organized in Tambobamba.  So we had all the kids to see in one day.  Luckily the teachers were very helpful and we managed to treat all the children that day.

The communities of Choqueca are very far reaching and rural.  This, for us as dentists, is a good thing.  It means there is usually no “local shop” in the village.  These small shops appear in villages that are close enough to larger towns that people can bring produce to their home to sell.  This produce includes, among other things, fizzy drinks, sweeties and beer.  Although people in these villages have very little money, these products are marketed to them at just an affordable price.  For example, a bottle of coca cola will sell for maybe 40 centavos (6p or 10 cents).  The sweeties are less than a penny.  And so villages with shops generally show worse dental health in the population than the further away communities.  And so, we were generally pleased to see a lower rate of rampant caries in many of the Choqueca community children.  But there are always exceptions……  And these exceptions kept us very busy.

Before doing the screening we did a great Charla with all the children.  Again Lucho helped with the Quechua and the kids loved it!  Afterwards, we did the screening and treatment.  The kids were so brave and not one shed a tear.  One of the hardest things on these trips is if the first child in the dental chair cries – then there is a good chance most of the kids to follow will cry too.  This can cause us serious headaches!!!  But these children were wonderful and a pleasure to treat.  They were also very respectful and polite.  We really felt we had made a difference with these communities.

There was one boy we saw with the worst case of Impetigo on his face I have seen to date.  It spread from the bridge of his nose to his chin, down the left side of his face.  I was curious to see it appeared light green on the crusty surface.  Through broken Quechua, I found out that the boy’s father applied Tooth Paste to the lesion daily!  Not sure if that is a registered treatment but what other choices did he have.  The wee boy was great.  He did not seem too troubled by the lesion despite having it for 2 months!  It is quite a common occurrence in these villages and so the children don’t seem to get bullied or teased when it is “their turn”.  But he did say it could be painful at times.  We gave him strong doses of antibiotics and some painkilling medication.  After consulting with a Paediatric colleague in the past, she advised to do no debridement treatment as this made things worse as the patient could not keep the lesion clean.  So there was nothing more we could do.  But we hope it will clear up soon with the medication.

While doing the screening I immediately recognized a patient from last year.  It was a young girl who had swollen, pigmented lips.  I examined her in 2005 and the patient history suggested a reaction to drinking “marsh water”.  This, at least, was what the teachers and patient thought.  But seeing her today I knew immediately that this was not the diagnosis.  It could not be an infection or reaction that had lasted over a year.  I was now thinking it was some kind of autoimmune response or allergy to an ongoing exposure in her diet.  Last year I had urged the teacher to tell the parents to take her to Cusco for tests.  This had never been done due to lack of resources and so we were no further on than a year ago.  As this was the first day of our visit, I asked the girl to come back tomorrow with her parents.  I would then have the opportunity to speak with them and even give them funds to take her to Cusco.  I was hopeful they would come – they never did.

Our last patient of the day was a very elderly lady.  (She did not know her age but we guessed over 80).  She had walked for hours – with no shoes - to come for treatment.  She was an extremely animated character and we all loved her straight away.  She told us a graphic story (in Quechua) how she had the “devil” living in her mouth and we must get rid of it!  She said she had not slept for months and we had been sent to Choqueca to treat her.  She had a grossly carious mouth but was very sure the devil resided in her lower left molars.  So we took them out.  We knew she was anesthetized but she wailed as we extracted her teeth.  Immediately afterwards she thanked us and went on her way. 

We were finished by 4pm and made the group decision to go back to Tambobamba to sleep rather than stay in Choqueca.  We would have had to sleep on the school’s floor and we were, again, at very high altitude.  But the decision maker was the “toilet”.  It has been built since my last visit but has to be the worst “facilities” of all the Health Posts I visit – and believe me there are bad ones.  I don’t think it is necessary to go into detail here but just know that all 5 of the team would not wish the experience on anyone!

So we tidied up the equipment, locked up the school (that had no glass in the windows) and I crossed my fingers that the equipment would be there when we came back tomorrow!

Day 5

We got up at 5.30am in order to be back in the village by 7.30am as we had been told that was when patients would start to arrive.  The first patient arrived at 11am!!!!  Oh well, nice to catch sunrise at least…….???!!!

It was a cloudy morning and so it was freezing cold.  We kept well wrapped up and after a cup of tea Caroline, Simon and I decided to warm up by walking up the Health Post.  I personally love the village of Choqueca.  It is situated on the side of a mountain and is one of the prettiest locations.  The walk up the hill takes the breath out of you as you start at high altitude and just get higher!  But we took our time and were lucky to have the opportunity to take in a typical morning in the life of Choquecians.

We saw a family sorting and bagging up their harvested grain.  The entire family helped from the little 4 year old to the very elderly grandmother.  A man sat at the side and stitched together the bags with a sharpened bone.  They were unphased by our presence and let us be silent by-standers.

We then came across a beautifully dressed young lady with her mother.  The younger lady was weaving a belt and so we sat with her by her hut and she told us about what she was weaving.  Speaking to her, she had a great sense of humor and when she laughed she really let go.  She loved to see her photo on my digital camera although her mother was more reserved.  As I admired her weaving she offered to sell me other ones.  She showed us all the different animal figures she had weaved into it and explained their significance.  This was a really special experience and at the end we did buy some of her work and will have it is a great reminder of Martina.

When we eventually got to the top of the mountain and to the Health Post, we found the Tecnica, Elsa.  She was with a new mother and her baby of only a couple of days.  The baby was all bundled up on her back.  She let us see him and was so proud to show us.  I spoke to Elsa and she explained there would be less patients for dental treatment today because of the Sports Day in Tambobamba. 

We headed back down to the school and treated patients as they trickled in throughout the day.  I took out one patient’s two lower wisdom teeth plus another molar.  He had been in such agony with them for so long I felt it was worth coming even if we had just seen him.

During my trips with Dental Project Peru, I often get asked for money by people.  This often puts me in an awkward situation because I always want to help the people but feel it is important not to be seen as the Gringa that always just hands out money.  Everybody out there could do with a few extra Soles but that is not what I am there for and it is not a healthy habit to start.  And so with each request, I try to check out the story and situation and only give to those who have genuine emergencies or extreme circumstances.  Hilario, a gentleman from Choqueca came to me and asked if I could help him get his daughter back.  She was 4 years old and 8 months.  She had been born with a deformity in her hip and a few months ago Hilario had finally got the money together to take her to the hospital in Cusco.  Once there, they did tests and said she needed to have an operation in Lima.  He used the rest of his money to take her to Lima.  Once there, the hospital said she had to have the operation in Arequipa.  He had to find work in Lima in order to pay to take her to Arequipa.  The weeks passed and eventually they arrived in Arequipa.  There, his daughter had her hip operation.  The actual operation was paid for by the government.  While she was recovering he had to leave her in Arequipa to come back to Choqueca to take care of his animals.  And now, 2 weeks after her operation, he did not have enough money to go back to Arequipa to take her home.  He pleaded with me to give him their bus fares.  It was not hard to convince me.  But I wanted to check it out.  So I asked the School Director and he told me the story was completely true and Hilario was a very good man.  I already knew that from meeting him, but now I had no doubt in giving him the money.  I hope he brings his daughter home and she fully recovers from her operation.  We will see next year!

After packing up we drove back to Tambobambo with a beautiful sunset accompanying us.

Day 6

Our last village on this trip was Pisaccassa.  We left early to start the 2 hour drive and it was unfortunately very cloudy and cold.  The clouds hanging over the mountains gives the landscape a mystical feel – I love those mountains whatever the weather!

I was so pleased to see my old friend Irene at the Health Post when I arrived.  I first met her in 2002 when I came to the Apurimac on my own.  She thought I was a crazy Gringa Doctora then for being by myself – and I am not sure if her opinion has changed!

We got set up and worked through the day, mostly with adults, until 6pm.  As the day went on it got colder and cloudier.  Then the rain came and it was so heavy that we could hardly hear ourselves speaking to the patients with the rain hitting off the metal roof.  It was so cold, we were working with hats and scarves and fleeces all day!  If there is no sun, being at 4,300 metres is very chilly!! 

The patients came steadily all day and we got quite a few fillings done.  There were less children as it was Sports Day in Pisccassa – what bad luck to have such miserable weather on Sports day.

Midway through the day I had a strange request from Irene.  She asked if Leo could take her in the truck to a nearby community to do an autopsy on an old lady who had died.  If there was anything untoward about the death, she would need to take the body back in the truck.  How could I refuse?  As they were preparing to leave, however, the sons of the deceased lady brought her body in.  What a sad day for them.

When we finished work that night, we all put on all the clothes we had and stayed together in one room playing cards.  It was a cold night!

Day 7

We woke up today to one of the most beautiful sights yet on a DPP trip.  It had snowed in the night and the views were breathtaking!  Although Pisaccassa sits at 4,300 metres, it does not snow very often.  This was the first fall in over 6 years.  So we spent the first hour of the day just taking in the beauty while we waited for patients to come.  I figured the snow would either stop them coming or more would come because they could not work in their fields – the latter was what happened!

So we had a busy day.  It was good because we managed to do a fair amount of fillings too.  Most of the patients were adults as it was Saturday and the teachers don’t bring the kids on the weekends.

In the afternoon we were all getting tired.  The last day of the trip is often the hardest as 6 days of work takes its toll.  But unfortunately this is usually when you get the difficult case.  A lady was having her lower left wisdom tooth extracted – but it broke!  It was a very difficult extraction.  I took over and tried to extract the roots for a further 45 minutes.  The poor lady was so brave.  In a normal clinical setting other measures would be taken, but in this situation you have 2 choices – persevere and dig it out or give up and leave the roots in place.  I hate to leave roots as these can cause the patient severe pain and infection in days and weeks to come.  So I always persevere.  But I was very close to giving up, when finally (with some extra last attempt force) I got the remaining roots out.  What a relief – for me and for the patient!  So by then, I was truly exhausted. 

Later in the day, I heard that there had been a terrible accident and the Doctor from Haquira (closest hospital) had been killed when his ambulance had gone off the road and down a 300 metre drop.  It was so sad to hear as I had met him just a few weeks before.  He was a very nice and enthusiastic man who was just out of medical school.  It was a harsh reminder to me how dangerous these roads are and that we must take the utmost care at all times.

At 4pm we had seen all the patients and were packing up for the last time.  It is so satisfying to know that we, as a team, have given a small population in the Andes a great service of pain relief and education.

We headed back to Tambobamba.

Day 8

Homeward bound!  We got up early and left Tambobamba by 6.30am.  The views were, again, incredible as the clouds were just lifting and we had wonderful views of the high peaks with a fresh covering of white snow.  We stopped a lot to take photos and enjoy the surroundings.

By 2pm we were back in Cusco and Caroline and Simon were kind enough to help me with the mammoth clean up that afternoon – many hands make light work!

This was a great trip and I was privileged to work with such a great team.  Being back in the Apurimac after 8 months was great.  I big part of my heart definitely stays there.