natural medicine...working through my bias

I was not given a ton of instructions or guidelines about what this blog had to consist of to obtain credit for my international family medicine rotation, but at one point I was told to “reflect/process”, not just record what happens to me here.

This post is an attempt to process the things that I have seen related to healthcare that are quite different from western medicine.

In Peru there is a type of Tea for every single specific medical ailment. Take chamomile tea for upset stomach. Take black licorice tea for headaches. Take coca tea for altitude sickness and for digestion problems. Take lime tea for heart problems. Take peach tea for kidney problems. (Take a combination of 5 different teas to help with sleeping issues). It’s not that I dislike the emphasis on tea…I find it tasty and warm and soothing when I have a sore throat. But, my western-medicine brain finds it very hard for tea to solve these problems on a physiological level. How is lime-flavored tea going to reverse the pain of angina? How is peach tea going to treat a kidney stone? In the end, it seems semi-harmless to address all of these problems with teas, but what if drinking tea means someone stops taking their blood pressure medicines and their kidney failure worsens? Not so harm-less in that case.

Along the same lines, but a bit more absurd to me is the conversations I have had about “the herb de cancer”. Supposedly, if you have been diagnosed with cancer, you can use an herb (eat it or drink it in tea) and your cancer goes away. One time I was told a story about somebody’s aunt. She had been told she had metastatic breast cancer and only had 6 months to live. She refused surgery and chemotherapy and only drank the “herb de cancer” tea 3 times a day. And now she is still alive, 20 years later.

Great story, and I hope it’s true, but I highly doubt it. I’d like to see a control study where people with cancer drink “herb de cancer” tea and others drink black teas and a few years later we see whose still living 10 years later.

Now I know this makes me sound arrogant, quickly trashing these herbal and tea-based treatments because they are not scientifically proven. I know that there are many things that natural medicine remedies treat quite well, but in a society that relies so heavily on this approach to serious diseases, it’s hard not to be suspicious and concerned. This internal struggle I’ve had while witnessing a heavier reliance on natural approaches than I’ve seen in the US has reminded me of an amazing book I have read twice: “The Spirit Catches You and You Fall Down”. It is a very enlightening book that deals with a lot of the flaws that a western medicine approach has when it comes to treating patients that come from a vastly different cultural background.

At the end of the book, the author consults a Harvard Anthropologist about what he might have suggested the doctor do, to avoid the myriad of frustrations that developed....

Kleinman’s Eight Questions for Cultural Assessment 

1. What do you call your illness? What name does it have? 

2. What do you think caused your illness? 

3. Why and when did it start? 

4. What do you think the illness does? How does it work? 

5. How severe is it? Will it have a short or long course? 

6. What kind of treatment do you think the patients should receive? What are the 

most important results you hope the patient receives from this treatment? 

7. What are the chief problems the illness has caused? 

8. What do you fear most about the illness? 

These questions have been a good source of guidance for me...

The bottom line is this, there will always be things that I feel comfortable saying are right and wrong, regardless of how culturally sensitive I strive to be. 1) rubbing fecal matter on a wound is not a good idea. 2) bathing in urine doesn't do much 3) herb de cancer isnt all its cracked up to be (the secret would have gotten out by now) 4) depression is a real illness 5) child abuse (physical and sexual) is evil 

it was a crazy adventure

First off, I need to apologize: this will not be my most interesting post. Last week, I went on a 3-day trek with Clint Barnes (one of my closest friend’s older brothers) and two new friends. Due to a set of complicated circumstances, we needed to do the “Salkantay trek” a commonly done route…in the opposite direction. Usually most paths are walked in two directions, but this hike is not one of those.

Why? The normal direction consists of a difficult Day 1 with 700m of elevation gain to the pass, followed by 3 days of going downhill. Our route consisted of 1 day of relatively flat hiking, followed by 1.5 days of 2600m of elevation gain (over 8500 ft), finished with a few hours of downhill.

-In total we went uphill about 4x more than most people do when they do the Salkantay trek.

-We also carried our own packs, something we did not see a single group do (the tour companies use 10-12 donkeys to carry all the gear/supplies)

-We also did our hike in 3 days, instead of the allotted four days to go the easier direction

In spite of being the single hardest physical activity of my life…it was an amazing trip!

The group dynamics were great from the start, and I truly feel like I made 3 new friends. Clint and Aaron had been in Lima the week prior to our trip, as they work for two different NGOs that do development work in Peru. Clint works with starting savings accounts for people in areas that usually don’t use banks and Aaron works for an organization that gives out loans/grants to private Christian schools in developing countries. Beyond the work they each do, they are just really genuine guys that I grew to look up to as the trip went on. If I could summarize why I found these guys so unique; it would be their openness and their ability to reflect and analyze themselves. I have heard many times that ‘knowing thyself’ is a very important thing. At times I have had bold friends and a patient wife who have had the courage to help me see the things in my life that I couldn’t see, and I know this has been helpful in avoiding sin and maturing. Anyways, being with Clint and Aaron was a refresher on how attractive it is to be around self-aware people.

I didn’t bring our nice camera on the trip, so I am hoping that some cooler/more impressive ones show up on facebook soon…but here are a few I took with my point/shoot

a millipede...gross/awesome

first day was flat and along the railroad track

clint barnes...crossing a sketchy bridge

travis, cool guy from austin, tx

brutal sun, big packs...

aaron roth, balancing across another sketchy bridge

JIMMY!!! the hero of our trip, jimmy was our guide on the inca trail 3 weeks ago, and he was the first peruvian in 2 days that gave us reliable advice! 

SALKANTAY!!!

the top...with my life in the fast lane t-shirt

Blog post about parenting and a child at an orphanage

Last week I was working with Dr. Nathan Wilson (pediatrician from Georgia, see older posts) and the patient flow was a little slow. We began to discuss the role of a pediatrician with regards to parenting. I usually cringe when someone gets on their soapbox about disciplining children (mostly because my brothers and I were certifiable terrors as little boys…and we all turned out decent). However, his opinions and perspective on the matter were valuable, so much so, I am going to share a bit of what we talked about. 

First off, he strongly believes that Pediatricians have a major role to play in assisting parents in the job they have to raise children. He thinks that one of the boldest and bravest forms of loving a child is by being willing to discipline them. Essentially he was saying that leading children towards God (through discipline) is a necessity for any Christian that has the chance to interact with kids, especially a Christian who is in the position to provide advice to malleable parents.

Duet 6: 1-2, 5-9

These are the commands, decrees and laws the Lord your God directed me to teach you to observe in the land that you are crossing the Jordan to possess, ² so that you, your children and their children after them may fear the Lord your God as long as you live by keeping all his decrees and commands that I give you, and so that you may enjoy long life....⁵ Love the Lord your God with all your heart and with all your soul and with all your strength. ⁶ These commandments that I give you today are to be on your hearts. ⁷ Impress them on your children. Talk about them when you sit at home and when you walk along the road, when you lie down and when you get up. ⁸ Tie them as symbols on your hands and bind them on your foreheads. ⁹ Write them on the doorframes of your houses and on your gates.

“so that your children may fear the Lord”

“impress them upon your children”

A big theme he centered on was the sinfulness of disobedience, which cannot be excused simply because a child is “a kid”. This is something that I had a hard time easily swallowing. Sure, if I see a 4 year old kid in a mall yelling bad words at his mom and throwing a tantrum, I might lean towards judging such a parent as failing at some point along the way…but even still, my natural inclination is to extend lots of grace to that parent and simply assume there is more to the situation then I realize. In my mind, there is a good chance the kid is just really nuts. To open up my mind a bit, he shared this passage with me…

Ephesians 6: 1-4:

 Children, obey your parents in the Lord, for this is right. ² “Honor your father and mother”—which is the first commandment with a promise— ³ “so that it may go well with you and that you may enjoy long life on the earth.”

⁴ Fathers, do not exasperate your children; instead, bring them up in the training and instruction of the Lord.

The call to children is to obey and the call to parents is to bring them [their kids] up in the training and instruction of the Lord. I am obviously not a parent, yet…but up until this point, I would have been completely ok letting this passage remain between parents and their kids. Not really wanting to get involved as a Pediatrician, but what Dr. Wilson argued is that when there is obviously a clear lack of anything resembling an obedient child, it is very important for a trusted Pediatrician with an established relationship to speak a word of wisdom into the situation. Remind the parent that their children are to be subject to them, not vice versa. Remind the parent that discipline/punishment with explanation is a loving act.  

I mostly wanted to write this post as a way to process/reflect on one man’s opinion. I also wanted to remark that it was surprising to me how universal and easy it is to recognize a child who never hears the word no and who lacks respect for their parent. Even in Peru, I’ve seen parents promise toys, just for letting me shine a light in their 5 year old son’s mouth. I don’t exactly know what sort of application I might take with me from this conversation, but I do know that it is a topic worth exploring as the topic of parenting will be unavoidable as a Pediatrician and hopefully very personal for Me as a future Dad (in a few years, hehe). 

On the flip side, I am going to describe the situation of a little girl that I saw in the clinic twice this week. A story not really dealing with the nuances of parenting/discipline, but rather a story about what happens with a complete lack of parenting all together. 

Arlet is 3-ish years old, her mom was abusing alcohol during the pregnancy and while breastfeeding. Last week she arrived at an orphanage here in Cusco. This little girl weighs 8kg (average 3yo: 15kg, 3% for 3yo: 12kg) ....8kg is the 50% for a 7 mo-old. So more than 50% of 7mo-olds weight more than this 3 yo girl! 

She also only can eat liquid foods, not because of something physically wrong with her mouth/jaw, but because she has never LEARNED how to chew. It's a habit she was never taught. 

She has had diarrhea ever since she arrived at the orphanage and she does not speak, not even words like mama or papa. 

As sad and heartbreaking as this girl's situation is, the two caregivers from the orphanage seem very loving and attentive, AND the little girl herself is a happy child. She likes to play, she laughs and she smiles. I wonder if God has gifted her with this disposition to weather these first few rocky years of her life, or maybe the joy on her face is a new development since arriving at the orphanage. Either way, it warmed my heart to see her so happy. 

I am thankful for the work of two orphanages here in Cusco who are connected with our clinic, they are vital places in this broken world. 

a few symbiotic reflections

Maren asked me the other day, do you know of any western doctors who have come to Peru and are working within the peruvian medical system?

The questioned stemmed from both the awful ER experience described a few weeks ago  and from the fact that the doctors with the lowest test scores coming out of medical school are assigned to the most remote/improverished health posts. On the flip side, it is nice that the Peruvian government sends Doctors to these remote health posts (locations I am sure no Doctor really desires to live), but its still hard to think its a good idea to have the lowest qualified doctors working in the areas where people are at-risk for many serious conditions and are hours & hours away from hospitals.

So, back to my answer: I don't think so. I feel bad saying this, but after those few hours in the public hospital's ER, I realized that it wasn't the competency vs incompetency of the doctors/nurses....it was the inefficiencies of the system. I understand refusing to work within this corrupt/broken system means that I have little chance of being apart of the solution, but I would find it utterly too frustrating to order an urgent medicine or a test, only to wait hours for the order to be carried out.

I've asked myself, if my goal/motivation for even considering being a doctor in a place like Peru would be to help poor/vulnerable people, then shouldn't I be willing to take an active role in changing the healthcare system for the better. And the answer surely should be YES, I believe every physician should play the role of advocate for their patients in the public/political sphere. However, I could much more easily see myself following in the footsteps of some of the American doctors I've worked with here, who are working in their own charity clinic, but also are actively engaged in training/mentoring/teaching local Peruvian medical students. Demonstrating a compassionate AND efficient patient care environment could go a long way to effecting the system as a whole, because these students they are working with are the future doctors of Peru, both in the remote areas and in the public hospital ERs.

This whole mental exercise lead me to broader reflections concerning one of the principal questions I came to Peru wanting to explore: What would it be like to me a missionary doctor? This past week I finished the same book that Maren read (and blogged about) a few months ago: Gracias by Henri Nouwen. This is an excerpt from a book that really convicted me to consider my heart when it comes to missions work.

the two most damaging motives in the makeup of missioners seem to be guilt and the desire to save.  Both form the extremes of a a long continuum, both make life in the mission extremely painful. As long as i go to a poor country because i feel guilty about my wealth, whether financial or mental, I am in for a lot of trouble. The problem with guilt is that it is not taken away by the work, hard work may be pushed underground or a while, but it can never really take it away. On the other hand the desire to save people from sin, from poverty, from exploitation can be just as harmful, because the harder one tries the more one is confronted with one's own limitations. If you depend solely on the success of their work, they would quickly lose their sense of self-worth. 

Although a sense of guilt and desire to save can be very destructive and depressive for missioners, I do not think that we are ever totally free from either.

Thanks for reading yall...

quiz #2!

Another quiz time...here are your hints

-This disease exists here in Peru (and in other South American/ African countries)

-Most people (80%) of the people who contract this disease have a mild “flu-like illness” and that’s it

-The other 20% of the people who get this disease turn yellow

-The scary part: 3% of the people who get this disease will DIE and there is no cure, no medicine to stop these deaths, you simply cross your fingers if you get it and hope you are in the lucky group of the 97%

Ok, instead of withholding the answer, I am going to show some pictures that give the answer away

the vaccine itself, dont worry: they write dates backwards, the vaccine expires on Mar 12th, 2014 

someone looks pretty excited for a shot

someone else looks a little more nervous

my lovely medical assistant Maren, preparing her father's arm with alcohol

all the supplies

more skilled prep-work by maren...Nancy was the first person to go for the vaccine, super brave

In those pictures, you can see a vaccine for the mystery disease. And you can see the sketchy drug injections that took place in our hotel when our parents arrived to Peru. The YF vaccine costs $250/person in the states. Here we were able to buy the vaccine for $25 (1/10^th the cost!). However, the clinic that usually administers the vaccines was closed on Good Friday when our parents arrived here in Cusco, and we needed to give the vaccine ASAP, since it needs 10 days to work before you go to place with dangerous mosquitoes. So…an  “almost-wannabe doctor” wound up injecting his parents and in-laws. I don’t think it was necessarily “legal” as the vaccine needs to be administered by a doctor or nurse (I am neither of those) and it needs to be administered in an “authorized vaccination center” (which I don’t think our hotel is registered as). Anyways, it was a pretty funny experience,  we could all rest assure that we wouldn't wind up in the “unlucky 3%” and when we visited the jungle. 

a break from all the medical posts

This past week, I was invited to share my testimony with a group of non-christian Peruvian medical students. A few of the doctors that work at La Fuente came to Peru with the vision of reaching out to peruvian med students, and one of the Physician Assitants here (Mark) has a group of second year med students over to his house for lunch, a talk and hang out time every monday. Mark has 5 kids and after a big lunch, Mark or a guest talks to the students about Jesus for 20 minutes, and then the students stay and play Wii, ping pong, etc. Its a really cool ministry and I felt really luck to get to share with these students. Mark asked me to tailor my message to include a lot of stuff about my medical journey, in order to connect with these students.

In the end, the exercise of giving a testimoney of how God has worked in my life over the past 10 years was very worthwhile on a personal level. It is helpful and important to reflect on the different events God has used to change me.

Below is is an outline of what I shared.

1. How I became a Christian

-        -  As a child I my parents went to church and the only time I thought about God was when I got scared of “going to hell”, I didn’t really know much about God

-         -When I was 17 I worked at a Christian all-boys wilderness summer camp and it was here that I felt like I first met other people my age who were really excited about Jesus, they made God seem real

-          At the time, there were two bible verses that I encountered that really made an impression on

o   1 Corinthians 10:13- no temptation has seized you except what is common to man. And God is faithful. He will not let you be tempted beyond what you can bear. But when you are tempted, he will also provide a way out so that you can stand up under it

§  For me, in HS, I was tempted to drink alcohol, use marijuana, look at pornography and try to be physical with girls…this verse, and God being faithful to fulfill his promise and his help with these things was “proof” of God's power

o   Romans 8:38- for I am convinced that neither death nor life, no angels nor demons, neither the present nor the future, nor any powers, neither height or depth, nor anything in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord

§  This verse is so exciting! I am more loved by God then I can even imagine

2. How I became a doctor

-       -  I didn’t know any doctors (none in my family/none of my friends parents were doctors), but I decided I really wanted to be a doctor when I was 10 years old and remained obsessed with that dream through middle school, HS, and college

o   I thought that being a doctor was going to make me important and make me happy and I made choices as young as 12 yo to make sure that I’d be able to get into med school

3. How I changed in University

-            - My relationship with God grew a lot during my time in university, I learned more and more about what Jesus really did for me (erasing my sins by dying for me)

-              -My faith in God grew from “a religion”, “a set of rules”, “a set of beliefs” to a way of life

-              -One really important verse for me was John 13: 34: A new command I give you: Love one another. As I have loved you, so you must love one another. By this all men will know that you are my disciples, if you love one another

o   I started thinking about what this verse might mean for my life, “loving other people” this is what was most important to God, and I started to question my goal of being a doctor

-              -Until that point, I had only wanted to be a doctor because of all the things it would do for me: give me a secure job, lots of money, respect in the community, it would interesting and fun

-             -I eventually realized that I needed to be willing to not follow my dream, if it was not the way God wanted to use me to “love others”

-             -During this period of considering giving up my dream, God wound up changing my motivation for becoming a doctor, but not changing the dream itself

o   Matthew 25: 34-40: Then the King will say…come you who are blessed by my father…for I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in. I needed clothes and you clothed me. I was sick and you looked after me. I was in prison and you came to visit me. Then the righteous will say, “ Lord, when did we see you hungry …when did we see you sick?” The King will reply, “I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me”

o   Psalms 37:4: "Delight yourself in the Lord; and He will give you the desires of your heart."

4. The story of how God has made my life look different in Medical School

-             -I have been able to pray for and with patients, I love the fact that as a doctor I can offer “physical healing” and as a Christian I can also offer them “spiritual healing”

o   This is the style of ministry that Jesus did, there are lots of stories where Jesus went to a town and he miraculously healed the blind, the crippled, the deaf the lepers, but at the same time he preached to the people about God and he told them about eternal life with God

-            - Being a Christian has also change the way that I look at patients- I try to see people the way God does (he loves them all the same)

o   For me, that has meant withholding judgment to a person who is an alcoholic or obese

o    Jesus showed love to the most evil people in his world, tax collectors who exploited the poor and prostitutes

-             -Even my choice to be in Peru right now, I believe that I followed the voice of God here, as a trial period to see if God wants to use me as a doctor not to make a lot of money or be impressive in the USA, but rather to use the gifts he has given me to serve others and tell them about Jesus

teaching about diarrhea

In one of my older posts, I talked a lot about an amazing trip Maren and I got to take to “el campo” with PROSIM. Under the same umbrella of PROSIM is a different ministry of the Mennonite Church here in Cusco. Once every month a “health representative” from each of the 12 Mennonite churches in the Cusco region comes to the city of Cusco (for some this is the same 8 hr bus ride we took to go to their towns). These representatives receive basic health training in a lot of different areas, and then they go back to their communities and act as community health workers providing things like basic first aid, basic medicines, hygiene education, and nutrition education. It’s a way for the church in those areas to help other people in their communities.

At the most recent PROSIM health representative meeting, I got to give a lecture on DIARRHEA. It was pretty fun preparing for, and ultimately really fun to present, as I taught the lesson in Spanish. Since I don’t think the majority of my readership speaks Spanish, I am not going to share with you the entire lesson, but I am going to make one quick plug for diarrhea.

Did you know? 2 million kids die from diarrhea (dehydration) every year in this world. That’s the #2 cause of death in kids (18% of all deaths under 5 yrs old) and those 2 million deaths are more than HIV/AIDS +TB + Malaira + Measles COMBINDED cause in a single year. But, only 5% of global health aid money/research is focused on diarrhea.  And here is the really frustrating and sad thing: The treatment to stop these deaths costs about 40 cents to create. 40 cents!!!!! With 40 cents a mother in a remote village can create an Oral Rehydration Therapy consisting of water, sugar and salt. This simple concoction can effectively prevent the vast majority of these preventable deaths from diarrhea.  OK, done my rant.

It was really cool to see “public health” in action at this meeting with these workers. The other lessons for the day were about drowning and choking.

See below some fun pictures from our day of teaching the health representatives

Dr. Derek Brubraker (our main host here in Peru), teaching about drowning

me 

everyone learning the Heimlich maneuver, very funny

we had two volunteers make the Oral Rehydration Therapy , and then we all drank it, it was not tasty

close up, more practice for what to do when a person is choking