College of
Human
Medicine

Ashley Hesson in Peru

September 2012

Ashley Hesson's story:

It took me about a week to understand exactly what we were doing in Peru. Oddly enough, the realization didn’t come to me in a hospital or at our hostel as we were packing supplies. Instead, it struck me in a classroom. I was scribbling notes on how to give an eye exam at an optometry school in Lima.

The instructor said, “Have the patient stand far enough from the chart, make sure they’ve covered one eye… Oh, and when you give them glasses, make sure explain how to use them.” 

My pen stopped. How to use glasses? You put them on your face. What is there to explain? The instructor went on, “Most of the people we’ll be giving glasses to have never had them before. You need to tell them to use them for reading or all the time…”

These people have never had glasses before. We were going to be giving glasses to adults who, for their entire lives up to this point, haven’t been able to see clearly because they didn’t have access to glasses.

I didn’t write a single word after hearing that. I sat there and thought about my own eyes. I’d had glasses since I was a year old. Following a series of eye surgeries to correct congenital strabismus, they’ve been a permanent feature on my face. If I’d never had glasses, let alone corrective surgery, school would’ve been impossible. I wouldn’t have been able to read, write, function— without my glasses, I would have been an entirely different person. I certainly wouldn’t be a medical student. I probably wouldn’t have made it to college at all. So much of my life as I knew it depended on my ability to see. Realizing this, I felt honored. I would be able to give people a gift that I had apparently been taking for granted.

Up to this point, I had been somewhat disappointed in the experiences we’d had in Lima. I came to Peru to do service, yet it seemed like we doing anything but service. Lima had a distinct character, but it was largely comparable to a major US city. It had poverty stricken areas, blocks where the houses appeared flimsy and the streets were dirty, but the same thing could be said of New York City. In terms of that analogy, our immediate surroundings- the neighborhood of Mira Flores- felt more like Times Square than Brooklyn. It had an exciting urban energy with an air of consumerism. Consequently, our time in Lima felt somewhat like a vacation. We marveled at the view of the Pacific Ocean and ate unfamiliar food. Several students compared our nightly expeditions to study abroad programs they’d done. Everything felt exotic, but comfortable at the same time. All of this was somewhat unsettling given our pre-departure discussions about medical tourism.

I knew that our first week was supposed to be the learning half of our “Service-Learning” experience and that we would not be doing any actual service. Nonetheless, I expected that our daytime, in-hospital experiences would provide some degree of culture shock. More specifically, I thought that the stark differences between Peruvian health care and US health care would mentally prepare me for the second week. They didn’t. In fact, the majority of the contrasts between US hospitals and the hospitals in Lima were, in my opinion, cosmetic. The hospitals in Lima were certainly designed differently than those of the US. Instead of long, indistinct hallways and indistinguishable floors, most of the Peruvian hospitals had small buildings with open courtyards. These courtyards were generally decorated with religious imagery. People stopped to pray at statues of Mary or in small, chapel-like areas.

The medical buildings were separated by function. Pathology was a distinct building from surgery, for example, in two of the three hospitals we visited. The third hospital was located in the center of Lima and, perhaps due to its location, it was more condensed.

As a whole, these hospitals did not exude sterility in the same way US hospitals do. They were more personal- unashamedly human. One could see this difference not only in the architecture, but in the way people interacted. Nurses and physicians hugged and addressed each other with first names. There were few curtains between patients. Little effort was made to keep information private or to allow for personal space. In short, there were fewer boundaries in Lima than in the US. I maintain, however, that these contrasts were largely superficial.

In terms of the medicine being practiced in Lima, it was comparable to what I'd seen in the states. Though my knowledge of head and neck surgery was admittedly basic, I heard the same terms and saw the same types of diagnostic imaging, etc. I was better prepared to compare the institutional organization of health care across countries.

Access to health care, for instance, was notably similar. People with money received the best care, both in terms of quality and access. Meanwhile the poor were relegated to lesser facilities with more logistic hoops to jump through. These similarities manifested in scenes that were reminiscent of ones I’d seen in the US. The long lines in the waiting rooms of Hospital Maria Auxilliadores could’ve been in the ER of the Erie County Medical Center, a major safety net hospital miles from where I grew up.

The sight of people being turned away was not new to me. Several of my fellow students had yet to experience these realities and were taken aback by the way patients were treated in Lima. From that perspective, our time in Lima was productive. It grounded us all in the status quo for health care in a major, modern Latin American city. It gave us a basis for understanding what we were about to see in the rural villages, a point of reference for what Peruvian health care could be given enough resources and infrastructure.

Once we’d begun our service in La Libertad, shortly after our time in the optometry school, my impression of Peru drastically changed. The loosely associated towns of Chicama, Chiclin, and Pampas were a far cry from anything that I’d seen in the United States. The houses were simple, made of mud brick or worn plaster. The roads were dirt. As we drove up to the more distant sites, we passed people riding mules and saw fields being plowed by hand. This was the Peru that I'd expected to serve, yet it was more striking than I could've ever imagined.

In a particularly sobering moment, looking out the window of our overstuffed van, I realized: people live here. People live their whole lives in Chicama. There really aren't words for that feeling; for the instantaneous change in perspective you get from seeing people live a life so unlike your own.

Just as it had struck me during the optometrist’s lecture when I was thinking about my own eyesight, I suddenly appreciated how different my life would've been had I been born in Chicama. Once again I felt privileged to serve, but also concerned. Would I really be of any help to these people? How do I look to them- with my glasses, my short white coat, and my broken half-comprehensible Spanish? Peru wasn’t a vacation anymore. By being there in my service capacity, I had a connection with Peru and a responsibility to its people, one that I could only begin to fulfill in a week.

My first experience was in a school. I was anxious. While the other students assigned to the school engaged in gleeful chatter about playing with kids and how cute they’d be, I wished I had more experience with children and reviewed my newly-learned dental vocabulary. As soon as we got there,  shouts of “Doctora!” rang through the schoolyard.

“Please don’t call me that,” I thought to myself, “I have no idea what I’m doing." Thankfully we were sequestered in a room preparing fluoride treatments for a bit. I felt confident with this task: put cotton onto a tray, squeeze fluoride onto the cotton, and repeat. I could do this. I was helping.

Soon, however, it was time to begin teaching the children how to brush their teeth. For the first few classes, I watched the Peruvian dentist. I thought that was going to be the routine: she would teach and I would do fluoride treatments. I was wrong. Without warning, I was handed a giant model of a mouth and told that it was my turn. It’s rather funny in retrospect. I had given lectures in front of hundreds of people as a PhD candidate. I had presented to the pillars of my field. Nonetheless, as I stood there in front of 20 or so three-year-olds, I was terrified.

At first, the words came out slowly. “Como nos cepillamos los dientes?” The kids shouted a dozen things at once, none of which were comprehensible to me in stereo. “Voy a enseñarnos!” They cheered and I picked up the pace. Before I knew it, I was completely comfortable. With each class, I refined my routine. I swelled with the feeling of accomplishment, but this feeling was tempered by the appearance of the children’s mouths. They had clearly never brushed their teeth before.

Would my 5 minute lesson, a small tube of toothpaste, and a single toothbrush be enough to prevent a lifetime of dental carries? After the classes, mothers came up to us to thank us. They also came to ask if we had toothbrushes for their other children. We had an exact count for the number of children we’d be teaching. We had to say no. It was difficult knowing that what we were doing was, without question, not nearly enough.

The adult clinics provided a similar experience, but with a different face. Instead of rooms of eager, grinning children, there were long lines of worn, expressionless adults. People stood for hours in those lines. It was painful to watch them. My white coat, a point of fascination with the children, felt like a two-ton weight with the adults. I was wearing a wall- a clear sign of separation and implied authority.

I was able to fulfill my role to some extent. I was able to take blood pressures and give eye exams, services for which people were extremely grateful. I was not, however, able to respond at-length to the patients’ complex and fast-spoken narratives. Every time I had to ask someone to slow down or admit that I didn’t speak much Spanish, I felt somehow illegitimate or mislabeled.

Furthermore, when I did understand stories about uncontrolled diabetes, chronic respiratory infections, or another long-standing conditions, I felt helpless. We might have been able to prescribe and supply one course of medication to treat hypertension, diabetes, etc, but we could not treat it in the way it needed to be treated- with long-term observation and consistent management.

To some extent, some treatment had to be better than no treatment. At very least, we could manage people’s acute problems and educate them about their chronic conditions. Perhaps the next aid group could provide them with another round of pills. Somehow they might patch together some semblance of care continuity. Despite my attempts at rationalization, I was left with the same question I had in the schools: how could this be enough?

In reality, what we did was not nearly enough to make a lasting impact on the villages we visited in Peru. There’s simply too much need. I had begun to realize this in the optometry school in Lima, but it was clearer to me after a week of service. It was most obvious in Chiclin. There were so many people crowding the hallway of our makeshift clinic that we had to climb out of the windows when it was time to leave.

We couldn’t even handle all of the people in front of us let alone those in analogous villages across Peru. In every town we visited, there were parents begging for vitamins for their children. We didn’t have enough to give them. It was heartbreaking. Through all of this, I developed a sense that the health care we delivered in two weeks really wasn’t the point. It couldn’t be. The point was to open our eyes to what medicine meant to these people. It was also to give us a sense of purpose and context for our own careers.

For me, going to Peru was more about understanding problems than finding solutions. It was about seeing everything from a drastically different viewpoint and learning to appreciate the challenges inherent to practicing medicine as a part of a global community.

I imagine that it’s somewhat like putting on glasses for the first time. It’s disorienting but you gain the ability to discern details and recognize contrasts that you’d never seen before. In my daily practice, I hope that this will help me empathize with my patients on a deeper level, especially those who are disadvantaged in the health care system.

More abstractly, I expect that my experiences will help me break down some of the barriers that are constructed by the institution of medicine, to nurture a sense of connectedness with my patients. At very least, I know my time in Peru has fostered a desire to understand more about the way health care is practiced in different settings. I think that through these experiences, one develops the attitudes and practices that collectively move medicine towards solutions to its many complex and overwhelming problems. 

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Ashley Hesson was a second-year medical student  when she participated in the College of Human  Medicine Service-Learning program in 2012.Ashley Hesson was a second-year medical student 
when she participated in the College of Human 
Medicine Service-Learning program in 2012.