Some of the signatures we collected at the health centers where we presented our letter of introduction from the head of the Arequipa TB program.
In the song and dance that became our traveling MODSimplementationwillyoufilloutourficha show, there were certain gestures that smoothed the path: signing the presentation letter, for one. Everybody really seems to love pulling out their personal stamp and signing the form. Everyone also seemed to love when I pulled out my laptop to collect contact information.
The structure was this: get to the top person as soon as possible, while they're reading the presentation letter, get the person actually filling out the form in there at the same time so you only have to talk once, explain that there's a new test being implemented, that we're going to analyze how it works. When you've got them on your side, pull out the ficha/ questionnaire- this is a scary moment. You comfort with something familiar and pull out the document that they've all seen before that gets filled out for every sintomatico respiratorio (TB suspect.) They seem doubtful- give more information about the science, tell them about the patient benefits. Ask them to sign the presentation letter - this makes them comfortable again. Throw in that a talk is being organized in 6 weeks that they will all be invited to and, subtle pressure, all of the data from each center will be presented. Then ask them how they think it will work in their center - now we've got them talking amongst themselves. Stress that they need one person to be responsible and while they're talking, pull out the computer - the big gun- and starting copying names from name tags. The computer seems to signify this is all to be taken seriously. Get phone numbers. Repeat the ficha application process. Stress that I will be back in six weeks. Kisses goodbye that are much warmer than arrival. Run to the next place preparing the number of questionnaires and labels in the car. Repeat.
The closed doors of the Islay clinic, when it was already dark. The frustration of bad planning.
Adorable kids just out of school.
Sand dunes in Puchun. Both of us got burned waiting in the sun for the collectivo to pass on the way back. No phones, nothing for miles around.
I think the only time I had this much adrenaline running through me for so long was making my way back to the US after 9/11.
We're trying to evaluate the eventual fidelity of the centers to the MODS implementation plan and the reach of the test. In order to do this, we want to get a baseline prevalence of TB symptoms and multi-drug resistant TB risk factors in all of the TB suspects that come to the clinics - before the test is really getting used. We'll then compare that to results in the regional laboratory and data collected after the official start of the implementation of MODS. This translates to getting to the 15 centers with the highest TB incidences NOW in 4 days, before the test is officially used at the end of January.
We didn't want to only visit places in the city of Arequipa and so we came up with an overly- ambitious schedule. Yesterday we got up at 4 to go to Camana (3 hours SE, and 1800 windy meters down to the coast) and got there by 8am. We met with the director of the hospital who was passionate about his work, and had made tremendous changes in the hospital since he's been director for 1 year. We saw the first of our questionnaires filled out by the nurses there.
We tried to meet the head of the regional health system, but he was busy all day. He supposedly was going organize transport throughout the Camana Ret - the net literally - but this didn't work out.
In between meetings we ran to make photocopies, adjust our ficha (form), and to buy binders and folders to store them. At each center, the trick was getting to the right person quickly and steering the conversation in the right direction. Hurrying is not something that happens here. I felt like I was running up a sand dune the whole time, against the flow of the land I was in. Relaxation = inertia.
Or the bigger fear relaxation = almuerzo = 3 hours in the middle of the day lost to eating the traditionally large peruvian lunch.
Then to La Pampa via a cramped collectivo taxi- the MD in charge there was smoking a cigarette in the back when we arrived and we had a moving conversation with her. The doctors and nurses at all these places shared stories of their individual patients with us. Visiting doctors in the field in their small outposts, many without computers or telephones, hearing so many doctor's and nurses unload in so short a time, was intense. We heard their frustrations with the system, their feelings of helplessness, their dedication to improvement, their successes and failures with patients that they felt so personally. Luz and I were both near tears several times. A lot of sweat (in the desert), a few tears (admittedly), and thankfully no blood.
From La Pampa, we drove 30 minutes through a river valley with irrigated rice fields into an oddly beautiful series of huge dunes with clusters of reed shacks built on them. The health center folks in Pucchun were not enthusiastic at first, but seemed to catch on. It was not the most inspiring of our visits, to be honest, even though I loved the setting and the kids running around outside the clinic.
From there, we caught another cramped collectivo taxi - 7 people, several bags and searing sun for a half hour- back to Camana. We debated paying 200 soles for a taxi to take us direct to Islay in Mollende, the next stop. I definitely should have opted for this- but it seemed like an obscene expense in the face of the poverty we just saw, and I faltered.
To contrast - this is how much several of the homes in Ica I visited this past sunday in the Sr. de Luren shantytown earned in a month, the equivalent of about US $60. In any case, we get on a bus that promised us it's an hour to an hour and a half to Kilometer 48, where we would take another bus or a taxi onto our next stop, but it in fact is two and half hours away.
From kilometer 48 we were promised by another bus that it was 30 minutes to Islay.
It hasn't happened to me too often here, but it's an acknowledged practice that bus drivers and their cobradores (the people who collect the fares) will sometimes flat out lie about their routes and travel times in order to collect more fares. The bus driver saw us talking to the taxi and just lied. It is in fact a minimum of 1.5 hours. When I realized this after talking to several passengers, I uncharacteristically expressed my irritation to the bus driver and told him that we were now going miss an important meeting at a health center because of him. To his credit, he flew through the fairly weird landscape - a cliff hanging road winding through mountains covered in sand dunes. Luz and I were both struck by the unearthliness of the landscape- neither of us had ever seen anything like it. Still, we lost the chance to meet in person with 3 centers there because of this delay and did not make the best impression with the person who was waiting for us there. If we had taken the taxi we would have certainly arrive 2 to 2.5 hours sooner and made the appointment.
Here's where the exhausted tears came in. We also hadn't eaten all day
since 4 am except for a roll on the fly from one of the sellers walking through the bus.
We had gotten bad advice. We were told that Islay was 2 hours from Camana and that we could go to both places in one day, but in fact this is entirely untrue. Islay is at best 2.5 hours in a speeding taxi and at worst 5 hours. La Joya is at Km 48 and we could have done Camana and La Joya in a day. But had been advised not to on Monday. Very frustrating.
We got to Islay at 6, banged on doors, made phone calls, and finally met with a secretary and a doctor for 45 minutes before running back to catch the last 7.30 bus to Arequipa.
We could have stayed in Islay overnight and seen centers in the morning but this would have meant losing 6 centers in Arequipa with the highest rates of positive smear patients. We decided to cut our losses and return. We grabbed juice and crackers in the bus station getting there in the nick of time and returned to Arequipa at 10.30. We stopped to get photocopies on the way home and made ourselves get something to eat - Chifa, the peruvian version of chinese food.
We made phone calls on the bus ride back to Arequipa to organize the following morning. After getting into bed around 1, I got up at 6.30 to go get more money from the bank and grab breakfast and replace the supplies we used at our friend's home. An american student who has been here for 2 years gave us the keys to her apartment.
We got to the hospital at 8 am and conferenced with the Dr. who is the head of the TB program there. The lab tech had organized a friend to come meet us who is from one of the zones we actually weren't very interested in surveying, and in what was likely another strategic time-loss error, we spent an hour instructing her how to distribute the fichas to 4 of her health centers. I should have said, no thank you, and moved on. But I didn't.
This was again frustrating. The internal disputes between personnel created delays for us. Their efforts at non-collaboration and coordination with one another cost us. Each camp helped us organize conflicting schedules. Not quite realizing what was going on until after the fact I was unable to appropriately avoid being sandbagged by all this.
Between the hospital's laboratory and and the TB program director's office there is a small circle of grass where sheep occasionally graze that might as well have being the Atlantic Ocean. I hesitate to even record the pettiness of some the personal conflicts here, but the utter absurdity is summed up by stating that in this particular setting, public health decisions are impacted by whether or not people are invited for birthday cake.
We made it to 2 centers in Red Este before trying to give a talk at a meeting of MDs from all over back at the hospital at noon. We came back at the appointmented time, and were told to wait. I don't know where my newfound assertiveness in Spanish came from, but I insisted we be given a time when to return rather than sit around. We got another health center in the meantime and came back at the appointed 1 pm.
We immediately were given time to speak at the meeting organized by the head of the TB program. The second thursday of every month, drs with MDR suspects come and present cases at the regional hospital. I actually spoke in Spanish in front of about 25 people and I think they actually understood me. I told them who we were, and what was being implemented and what we were evaluating. Luz explained the science of the project. I understood and responded to questions. Granted, I had just said the same thing at least 20 times in meetings in the past two days, and Luz was there to translate the trouble spots and jump and explain, but that felt really good. I feel like my spanish improved in leaps and bounds in 4 days.
From there we said goodbye to the folks at the hospital - not without hearing more political gossip than we ever wanted to know and hit 3 more health centers, unbelievably.
Our flight was at 5.30 and on the way to the airport at 4 I said we ought to skip the last one. Luz said, Okay, but it's not my idea a and so I reluctantly accepted trying to go to the last place. It worked, much because of Luz's savvy and fast speaking skills.
I'm nervous about how the questionnaires are going to be applied in the places where I didn't actually get to speak to the nurse filling it out, and have a lot of phone calls to make in the morning, before I meet with Dave at 9.30 to debrief, then go to two holiday lunch parties for work on opposite sides of town, make some last minute errands, pack, and fly home.
I learned some important lessons for the next time we do this. I would definitely do things differently; like pack a lunch for one. Luz was absolutely amazing to work with. I learned so much from her in the past days. More than how clear of a teacher she is, she's the kind of person you would take anywhere in the world with you. She was damn pleasant considering all of the circumstances.
The woman is driven and bright and sensitive- a consummate Peruvian professional.
I felt like if the past four months here were worth anything, it was to prepare me for these past four days. I go back in 6 weeks to visit all the centers.