The woman sitting across from me talked, through two translators ( Quechua to Spanish to English) about how sad she had been since the death of her husband last year. “I eat alone,” she said, and my Spanish translator, a native Peruvian, explained the cultural significance of such a phrase to me. Eating alone is not a good thing; sometimes it’s how people are shunned. The woman talked about her adult children and how little contact she had with them, a continual disappointment in a poor rural area where the younger generation often flocked to the city and the hope of a better life.
She was in her 60s and dressed in the traditional attire of the indigenous people of the Andes: a high bowler hat, layers of sweaters, a long skirt, and woolen stockings. Her long black braids remained ageless in a land where somehow hair does not turn gray, but her bronze skin was leathery from generations in the sun. Her problems – grief and loneliness – are universal issues, and while she had moments where she longed for death, she felt her animals, and her cow in particular, needed her now.
Months ago, a friend – an internist – asked if my husband and I would join him, his wife, and some other families we knew on a volunteer medical mission to Peru. Hands Across the Americas is an organization founded by Jennifer Diamond and it has sent 27 medical and surgical missions to Latin America to serve those with limited access to medical treatments. I hesitated when I heard the request, and in case I wasn’t entranced by the idea of spending a week addressing the mental health needs of indigenous people in remote Andean villages, he added that another friend of ours, Patricia Poppe, a native of Peru and an expert on health communications at the Johns Hopkins School of Public Health, was eager to show our group of friends around her homeland before we all joined the mission. With this, I was sold on the whole adventure. I will spare you the details of our wonderful vacation, but will share with you, instead, what I learned about psychiatry in the Andes.
The mission orientation began in Cusco, Peru’s second-largest city and a way station for travelers headed to Machu Picchu. The tourist district of Cusco is a beautiful and fascinating city that reflects both Incan and pre-Incan Latin America and the heavy Spanish influence brought by the 16th- century conquistadors. While the city is beautiful, and the worlds have intertwined over the centuries, it remains a land where there is tension between the different cultures.
At just over 11,000 feet, the air is thin and visitors get easily winded just walking the hills. The villages we worked in were all about an hour outside of Cusco. They were impoverished and dilapidated, with some of the homes still constructed of bricks made from mud and straw. Dogs and farm animals roamed the streets. July is midwinter there, and it’s the dry season, so everything – and everyone – was covered in a layer of Andean grit. By the end of each day, we were as well.
I wish I could say that I wasn’t anxious about the work, but I was. What can a psychiatrist do in a single visit, much less a single session that requires one, and occasionally two, translators, in a population where I had no knowledge of their culture or resources? I didn’t know what types of patients I might see, if using medication would be reasonable, or if follow-up of any kind would be feasible. In the 27 missions of Hands Across the Americas, I was to be the first psychiatrist.
Four years earlier, a psychologist, Dr. David Doolittle, had gone with another psychologist, and when we spoke on the phone, he was very enthusiastic. He told me that this had been one of the best experiences of his professional life, and he was pleased to hear that mental health would continue to be a part of the agenda.
Finally, I should add that despite my hesitation about how helpful I might be as part of a medical team offering one-time services, I did have a similar experience in a different setting; In 2005, I volunteered for 2 weeks with the Substance Abuse and Mental Health Services Administration’s Katrina Assistance Project, and while I wondered then if my efforts were helpful to those I was trying to serve, I walked away feeling that I personally had gotten a great deal from the experience. I decided I would go to Peru with limited expectations and one simple agenda: I would try to be helpful.
The mission started with a brief orientation in Cusco, and it didn’t escape me when the medical director announced that patients could be seen by internal medicine, pediatrics, ENT, gynecology, and optometry. Psychiatry was strangely missing from the list, and when I pointed this out, he told me he had a special job for me: to run the pharmacy. While I was happy to help dispense medications, I had the sense that this population might have unmet mental health needs and suggested that it could be worthwhile to offer psychiatry as a specialty as well!
While the group came with an extensive supply of medications, vitamins, reading glasses, toothbrushes, and some wheelchairs, canes, and walkers, there were no psychotropic medications in the stash. I spoke with a local doctor who served as a liaison, and learned that he was familiar only with diazepam and alprazolam. Psychiatric patients were referred to doctors in Cusco, and local doctors did not prescribe antidepressants. For complex issues that required medical or surgical subspecialization, the referrals were even more complex: Patients traveled 18 hours by bus to be treated in Lima.
On the morning of our first clinic, I was given a small supply of fluoxetine (per my request) and alprazolam. Over 5 days we worked in three sites. On the first day, we were at the municipal center in Huarocondo, a little more than an hour outside of Cusco. Tents were set up inside the building, with the waiting room, triage, and pharmacy all stationed outside on the dirt. Inside, there was very little light, and like the other places we’d set up, no heat. My tent had a table and two chairs meant for primary school children, and I absconded with an adult-sized plastic chair for my interpreter. We had no access to medical records, no labs or radiographic equipment, and no clear place to send anyone for follow-up – this was true across all specialties, though the ENT who was working with us had come with suitcases full of his own equipment. Patients didn’t know what a psychiatrist or psychologist was, and some responded to questions about depression by saying that their blood pressure was just fine. Triage resorted to asking people if they felt sad and wanted to talk to a doctor about it.
The next 2 days, we worked in medical clinics in Ancahuasi and Anta, and while the conditions were more conducive to providing medical care, there was still no heat, the lighting was poor, and the buildings had not seen new coats of paint or furniture in many years. The clinics did not have psychiatrists, but they did each have a psychologist, and a couple of the people I saw had been seen. I was also told that fluoxetine could be obtained in Anta.
Hundreds of patients came each day, and all told, more than a thousand patients were seen by nine doctors in those 5 days. My official psychiatry tally was 79, but my personal count was less – I imagine some people became impatient with the long line and left without being seen – I recorded visits with 8-15 people each day.
First, let me say that I was surprised at the lack of pure psychopathology; the issues were more reactions to tremendous deprivation, violence, loneliness, medical and developmental disorders, and chronic struggles. I saw only two adult men, the rest of the patients were women and a few children. No one I saw had ever seen a psychiatrist before, and no one had taken psychotropic medications (not even the diazepam or alprazolam, which I was told could be obtained), and in fact, very few were on any medications of any kind. No one had ever been in a psychiatric hospital. Poverty was rampant, as was domestic violence: Men beat their wives, parents beat their children, and there seemed to be no societal means to interrupt this. One bruised woman said her husband had been released from jail in a day, and several women spoke of living in fear for their lives; still, their families encouraged them to stay with men who were abusive or unfaithful. I was told that the statistic for spousal abuse in Peru was 60%, in Cusco it was 75%; I suspect it was even higher in these outlying villages. Families were fractured; employment was physically very difficult; and stress was extreme. Low mood and poor sleep were pervasive, but given the fact that I was unsure if people could get follow-up or even afford to refill medications, I gave out very little in the way of medications, and used the fluoxetine only for a few people where I felt their mood and circumstances were so dire that perhaps it would help – and it seemed unlikely to hurt. I was able to hospitalize one 18-year-old mother who was suicidal and said she had tried to hang herself, though she was released early the next morning before she was ever seen by a doctor; she did note she felt much better and was grateful for the help.
Despite tremendous stresses and limited access to care, the suicide rate in Peru are quite low at 3.2 per 100,000 (as compared with nearly 14 per 100,000 in the United States), and despite the fact that some of the patients I saw had considered it, most said that their children or animals needed them, and there are religious prohibitions.
At moments, I wondered what I could possibly offer. One woman came in with a 5-year-old child with Down syndrome strapped to her, and another, older, developmentally delayed child in tow. There were other children at home, and while many women noted that their husbands beat them while they were drunk, this woman said her husband was calmer when he was drinking; he beat her when he was sober. I asked her what would help, and she said she needed money. Feeling I had nothing else to offer, I did something I have never done in my years as a psychiatrist: I gave her money. I hoped that she would spend it on something that might provide a moment of relief from her anguished life.
For the most part, it was interesting work, and often, it felt useful to make psychological interventions, to validate the distress the patients felt and to reorient them to seeing their own strengths. The people talked of holding their problems close, and of a relief and ease that came with sharing their difficulties.
In the end, I did feel helpful for at least some of the patients some of the time. At the very least, I felt appreciated – in one clinic, we were greeted by the mayor and a band – and patients expressed their thanks to both me and my cadre of interpreters, sometimes profusely. In the end, it was an adventure, from the vacation with 16 people to Lima, the Sacred Valley, and Machu Picchu, to my foray into high-volume, single-session psychiatry in a culture so vastly different from my own.
Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).