Dr Madoc Flynn / Foundation Doctor / North East England

Madoc transports us deep into the Peruvian Amazon as he recounts his experiences with Project Amazonas on his medical elective in 2017. This thrilling expedition began at the Orosa river clinic providing medical care to the remotest communities. From there, Madoc swapped the jungle for city life in the local town of Pevas, where he saw first-hand the inequalities in healthcare that result from widespread economic diversity. To round up his elective, he then embarked on a two-week river barge expedition up the Pintuyacu and Itaya rivers providing further medical clinics; interspersed with local herbology lessons, football tournaments and caiman-hunting!

We slowed as our canoe navigated the maze of small inlets on our way to our home for the next few weeks. Within seconds my skin was already craving the cool wind that comes with the wider rivers and faster movement of the boat. Luckily, five minutes later we were unloading our gear; our shirts already clinging to our skin, permeated with a heady mixture of DEET, river water and unavoidably, sweat. Here we were, Madre Selva (Mother jungle in Spanish): a biological station, and our home for the next three weeks. The fruition of eight months of planning, four months of work shifts squeezed between study, and near thirty hours of travel time to get here.

Madre Selva is a field research station 150km deep in the Peruvian Amazon, located off the Orosa river and run by Project Amazonas; a USA/Peruvian NGO providing medical care and environmental initiatives. It is directed by biologist Dr Devon Graham, a Canadian transplanted to Florida, and my main liaison whilst organising the elective.

Me and my fellow medical students, Louis and Matt, quickly dumped our scanty belongings in our basic wooden hut and headed out to kayak along the river and take in our surroundings until sunset. After which we had been warned by Julio (the boat captain, handyman and general good guy to have around) that ‘the caimans come out and the water gets dangerous’. We floated down the river along the muddy water, past the riverside huts built on stilts to protect from the dramatic seasonal river level changes, patched with up-cycled plastic adverts for Peruvian beers. After the bustle of the city, even the cacophony of animal sounds and flapping leaves felt almost deathly quiet.

This soon became our routine; a morning boat ride to Project Amazonas’ Orosa clinic, return for lunch, then kayaking, hiking or swimming ’til the sun came down. Our surroundings continually took my breath away, and combined with the lack of phone signal and electricity (bar a couple of noisy generator-fuelled hours) made it one of the most idyllic places I have ever been. We were also presented daily with a huge variety of exotic foods and juices prepared by the excellent local chef David; making our basic set-up very homely.

On placement, we had the privilege of gaining access to remote communities; talking to their inhabitants, playing football and sharing beers. However, from speaking to the locals I quickly realised that life in the Amazon is hard. The same remoteness that makes it so incredibly idyllic is also the reason for many of the difficulties the inhabitants’ face. As well as being a great distance from the nearest healthcare centre, their subsistence lifestyle means that it is often not financially possible to travel there (unless the whole village pools their cash towards the petrol). This means that many tribes rely on a tribe shaman or natural healer. However, since Project Amazonas started, remote villages now have access to western healthcare which is easily accessible.

The clinic was simple, with no means of protecting the medications from the 30-35 degree heat and near 100% humidity other than cool boxes. The range of medications was also limited, falling short of the WHO basic recommendations. The inaccessibility of basic investigations in the Amazon means that a good history and examination becomes even more important. Luckily our seasoned doctor Luiz was a great diagnostician and was able to differentiate between parasitic, bacterial and viral GI infections almost purely by the consistency and odour of patient’s diarrhoea!

Patient presentations were surprisingly similar to GP presentations back home, namely; fungal skin infections, GI infections and anaemia; as well as some tropical diseases not usually found in the UK (TB, Malaria, Dengue, Zika).  Consultations in the Amazon typically involve the whole family; a cultural difference I found a rather pragmatic option as infective illnesses were often passed around families. I found some patients were shy of foreign doctors, however our fractured Spanish managed to ease many consultations!

Inevitably the time talking, drinking and hanging out under the stars in Madre Selva had to end, we stuffed our clothes, by now quite musty, into our bags and headed out. However, a two-hour private speedboat back to Iquitos (the closest city) turned into a six-hour ordeal with numerous stops, near capsizing and an eventual boat rescue by one of the charities own speedboats – a classic example of running on ‘Peruvian time’! Iquitos, which is the base for Project Amazonas’ operations within Peru is the largest city in the world that is not accessible by road. It is an odd dichotomy of a place, with old colonial grandeur from the rubber boom (it boasts a house designed by Eiffel of Eiffel tower fame) clashing with the water slums of Belen. Internet cafés and electrical shops in abundance, alongside alleys selling shamanistic potions and illegal river meats.

Iquitos was simply meant to be a stop to resupply and wash our clothes in something other than river water before moving to our next clinic. Unfortunately Louis and I got the true jungle experience and ended up having to quarantine ourselves in our hotel with gastroenteritis. Given our swimming in the Amazon and eating every local food available to us, it was only going to be a matter of time. Thankfully in Peru all medications apart from opiates are available over the counter, so we sent Matt to forage the pharmacies and hunkered down. Once our all too personal experience of illness in Peru passed we headed off to our next clinic in Pevas.

Part 2: Pevas

The clinic in Pevas is a government clinic, 145km from Iquitos. The small town is known as ‘el terra de amor’ , the land of love, which is reflected in the warmth of its people. We were staying with a contact of Dr Graham’s, an internationally acclaimed artist Francisco Grippa, who helps the charity by housing volunteers in his sprawling wooden house and gallery, perched atop a hill overlooking Pevas.

Access to the government medical clinics and appropriate medication is free to any patients with public health conditions (TB, Zika, Malaria, HIV, pregnancy etc). Beyond these conditions, however, the issue of cost became a grey area, causing a lot of patients to avoid presenting for conditions that they anticipate to be costly. The clinic here was extremely busy, and much more of a challenge for us. However, it was a useful reminder to us of why NGO’s such as Project Amazonas are so vital in Peru. The government system has been battling hard to address the inequalities in healthcare that result from a widespread population with great economic diversity; one that is still hampered by the aftermath of frontier conflicts with neighbouring countries, as well as domestic social and political unrest. But, for the moment, NGO’s provide a valuable crutch to the national medical system.

Whilst there, we took advantage of being in a relatively populous area of the Amazon and used local contacts to organise a guide to take us around the local jungle and tribes. The next day a guy called Wellington turned up. Through the bulge of coca leaves in his mouth and a green-tinged grin we deciphered that he was to be our guide. Soon we were on board his dugout canoe heading to visit his tribe, the Bora Bora. Although western influence has certainly reached these remote regions there is still a strong tie to tradition. We were welcomed by a tribal dance in a traditional circular hut, built alongside more modern concrete counterparts. Dances represented the various deities and aspects of the peoples’ lives, complete with snakes, fish and jungle animals all being expressed through the pounding of staffs and guttural singing. Sadly, the financial strain of modern rural life has led to many tribes like the Bora Bora seeking money from tourists by selling cultural artefacts and crafts, which somewhat sullied the experience.

One of my motivating factors for going to Peru had been the indigenous communities’ deep understanding of medicinal plants and herbology. Whilst hiking we were stopped and shown the various fascinating uses of the plants around us. After a post-hike meal of fish wrapped in leaves and cooked in coals, we were onto the main event of the evening; caiman hunting. Although not something we personally agreed with on ethical grounds, in the Amazon it is a traditional part of the culture and the meat is regularly eaten by tribe members.

To spot a caiman you need three things: a boat, a torch and patience. By hour three we were starting to lack the third. As we entered the lagoon, we could see the torches of other boats out, blurred by the mist of the water. Yet despite all the other people there it was quiet except for the noise of the undergrowth. Wellington heard the distinctive call of the black caiman, halfway between a bark and the sound the water makes when you drop a large stone in it. Wellington replicated it as we drew nearer. Then we spotted them, two red lights reflecting back at us from our torch beams: the eyes of a caiman. As we drew closer Wellington inched his way to the front of the boat with his 3-pronged spear, lying on his belly as we closed in. In a moment that seemed both too quick and too slow he speared the caiman and shot out his arm to lift it by its tail and then swiftly clamp its jaw shut. “This is breakfast” he proudly proclaimed, binding the animal with rope so it wouldn’t get away. We sped back through the river, disturbing the calm reflection of the Milky Way upon the water.

Part 3: River clinics

After an emotional and rum-fuelled goodbye to the doctors and our host, Grippa, we took a boat to Iquitos for a quick pit-stop before heading out for the final leg of our adventure. We were about to launch on a two-week river barge expedition, following the tributaries to the most remote Amazonian communities. That evening we put on our least mildewy shirts and headed to meet our companions for the next section of our trip: a group of Florida international university students, a paediatrician, and Devon himself. The barge was equipped with a much better stocked pharmacy, had a full crew including translators and our friend Dr Luiz. I took a pharmacy internship to lower the costs of the trip and so was in charge of organising the medications.

The aim was to get as far up the Pintuyacu and Itaya rivers with the low dry season river levels and then work our way back along treating all the communities on the way. Clinics were held in the main communal house or school of the villages, with stations for registration, consultation, pharmacy and eye testing. When a patient came in they would be registered, height and weight taken, basic observations recorded, and prophylactic course of mebendazole administered (due to the high prevalence of parasitic illnesses within the populace). Vitamins would also be given to all children. We ran parallel clinics with the doctors and presented cases back to them to decide on management plans. Although we had an ample supply of medications, it was impossible to treat long term conditions effectively. Due to the high humidity we were not able to dispense stockpiles of medications as they would spoil before they could be used.

These remote communities only have access to healthcare twice a year from charities and outreach clinics, or must raise the money to make it to Iquitos to receive medical attention. Therefore, it was not surprising that saw a fair amount of drug seeking behaviour. Nearly every villager would present with symptoms they knew to be due to a medical condition. However, it was hard not to empathise with their predicament when they reside so far away from medical care.  One week before we arrived at one village a baby had died as the parents hadn’t been able to afford the cost of going to the doctors so had used a shaman to try and treat their baby’s malaria.

The conditions we saw in these communities were much more varied and developed. We saw Neurofibromatosis type 1, spinal cancer, malaria and TB, as well as a Cushing’s syndrome due to a patient self-medicating her arthritis with steroids her son had bought her. The other challenge we had here was that Dr Luiz unfortunately got ill and we had to ship a replacement doctor out. However, the practice of medicine in Peru is often less evidence-based than in the UK. Although our replacement doctor was a great diagnostician, he used many unorthodox treatment regimes and incorporated many of his own health beliefs into his practice, for example that IV/IM medications were more effective than oral preparations. We discussed the merits of different treatments, however as students, we ultimately had to respect our colleagues and the foreign practices in Peru.

Our clinic days generally ran from 8am until we had seen all the patients. We would then move on to the next community and moor up for the evening. Due to the increased number of clinicians we often managed to finish early in the afternoon and had enough time to socialise with the locals before moving on. No matter how far we travelled, there was one universal constant amongst all villages; a football pitch in the centre of the village, and the fact that we got beaten every…single…game. Although getting skinned by 8-year-old girls was humiliating, it was fantastic to get to know the locals as people rather than just as patients. This also made the goodbyes even harder. On board the barge, we had the opportunity to spot pink dolphins and sloths from our hammocks as we chugged along. And once all the medications had been prepped for the next clinic, we had time in the evenings to unwind by swimming or stargazing. It was the perfect end to our time with Project Amazonas.

All too soon we were back in Iquitos, parting with both colleagues we had spent seven weeks growing close to, and a place that had almost become home. Although we spent a few weeks afterwards hiking in the Andes, visiting Machu Picchu and all the other tourist destinations, the weeks spent working with Project Amazonas are my most treasured memories of that time. The warmth the people showed in inviting us into their communities and trusting us with their health was humbling. The fulfilment of working in a challenging environment where your presence really makes a difference to others is unparalleled, and I can’t recommend it enough to anyone. But you already knew that, why else would you be on this website…

Further Information

Where / Peru ( Iquitos, Madre Selva biological station, Pevas, Pintuyacu and Itaya rivers)

When / June – August 2017

How Much / Roughly £4000 including flights, insurance, living costs, donations to the charity and spending money. Biological station cost $100/week. Boat trips dependent on trip destination and length but can be subsidized by internships.

Contacts / If you would like to contact Project Amazonas or send a donation, simply head to their website. Dr Devon Graham, devon@projectamazonas.org (Project Amazonas charity director), Dr Madoc Flynn (Author and Elective Student) madocflynn@hotmail.com

Top Tips

• Think about how involved you want to be/how much medical work you actually want to do.
• Act early. Get in contact and show your interest early with organisations you are interested in.
• Think about what will progress your career in the future/skills you want to improve (e.g. Spanish in my case).
• Give yourself a generous budget so you know how much you need to raise, and the time scale.
• Remember to apply for bursaries and funding early.
• Most importantly try and go for your dream elective and find the way to make it happen, you only get to do it once so make the most of it.

About the author

Madoc is currently working as a Foundation Doctor in the north east of England, following his graduation from Newcastle University. He is an avid traveller: he was born whilst his parents were travelling and he hasn’t stopped since; 36 countries and counting. He loves rock climbing, hiking and any outdoor activity, and hopes one day to work as a medic on expedition or in a humanitarian setting.