Iquitos. City of half a million people, surrounded by hundreds of miles of jungle on all sides. Photo by NASA.
World Citizen

On Iquitos, 3 months later

On a particularly sultry day in a hospital of the Peruvian Amazon, I found myself with the task of telling a group of parents that their babies, who had been waiting in the hallways for days without eating in preparation for surgery, would not be able to have their cleft lip and palate fixed. We, a group of American doctors and medical staff offering this procedure free of charge to a population without access to a plastic surgeon, had overbooked our week out of eager hopefulness and now had to cancel the cases that we couldn’t fit in before our flight home. Nobody else from our group could do this job – they didn’t speak any Spanish; nobody among our Peruvian counterparts wanted to do this job – they didn’t have the heart to deliver the news.

Lo siento, I said, limited by not knowing another way to apologize in Spanish, por favor regresa el proximo año. Please come back next year. Mothers cried, asking did I know how long a year is in the life of a baby. Fathers quietly and politely explained how far they had come, most families traveling for days in boats and canoes from deep in the jungle. I again could not say much more than Lo siento mucho. The Spanish phrase for “I’m sorry” literally translates to “I feel it (with you),” and I did.

I use the term “we” loosely, as I was not originally a part of this group, although by the end of the week everyone, especially I, had forgotten that. We met by serendipity during my last week in Iquitos, Peru, where I was working for a month in the Pediatrics department as an observer and experiencing the different levels of care (PICU, Pediatrics, NICU, Emergency room) for possible long term collaborations with American hospitals.  

My integration into the surgical mission was automatic – the group did not bring a pediatrician and collectively spoke no Spanish. After three weeks of clinical immersion in the most resource-scarce region of Peru, rejoining my fellow American practitioners, most of whom live and work within 30 minutes from my program back home, was a reverse culture shock. Suddenly, I had to transition from learning a new system (what anthropologists call participation-observation) to putting the tinted glasses of my own culture (American healthcare) back on and trying to bridge the distance.

I never would have signed up for this mission on my own. Shaped by my undergraduate background in anthropology, I was deeply wary of international medical missions – practitioners from wealthy nations air dropping into a poor region to deliver temporary medical care without regard or respect to the local context, leaving behind handfuls of antibiotics and no real change to the healthcare infrastructure. I was bothered by the questionable ethics of inflating one’s altruistic ego at the price of potentially disrupting a community’s efforts towards sustainable progress.

In other words, I would never have found myself facing the parents’ anguish that day if chance hadn’t intervened. Strangely, instead of feeling vindicated in my rejection of the genre, I realized something important  from being a part of something I did not previously believe in.  

Our oath begins “Do no harm,” which I think might be the most crucial and most difficult part of the pledge. But to scrutinize the opening even more, it begins with the word “Do.

Action and theory need to co-exist for progress to take place. I am reminded of my first struggle with this dichotomy when I traded pursuing a career in journalism/anthropology for medicine in order to follow up observation with more immediate action. In the area of global health, theory and cultural mindfulness form the foundation of Do No Harm, but the theoretical complexities led me to a mentality of inaction that was just as prohibitive. It is possible, and in fact necessary, for social science and clinical practice to build upon each other in global health. After careful participation-observation, there comes a point where one must jump in and do, even if the doing begins imperfectly. Otherwise, there is no path to improvement.

My Spanish is far from fluent. I looked up different ways to apologize later that day and immediately forgot them again. But the important part was to jump in and try, stumble and get back up. The surgical group is raising funds to turn the trip into an annual project and I hope to return with them next year. I am glad we did certain things poorly, so we can use this year to reflect, refine, refocus. And, of course, to practice Spanish.

3 thoughts on “On Iquitos, 3 months later”

  1. Dr. Fan, I wasn’t completely clear if this experience assuaged your concerns on the potential harms of medical missions. I’m a skeptic – just recently our organization asked for the donation of expired medicines to take on a medical mission – I thought this was an ethical no-no that had been debated and settled.

    1. Dr. Broselow – you are completely right, I did not commit to a resolution of my concerns. I think this will be an ongoing contemplative process, which is why I named the post “3 months later.” This may very well change in the future.

      So far my most importance realization is to stop seeing things in completely black/white terms to the extent of sitting out altogether. I used to want to reach a completely ethically comfortable place before taking any part in a mission, but after this experience, I realized maybe that place doesn’t always exist. Being part of the team allowed me to be part of the conversation for how to do things better next year, how to keep working toward a more culturally appropriate context in the future.

      This is of course not to say that I think we should jump into ethically questionable situations just for the experience. But if there is the intention to be culturally and ethically mindful, then I think imperfect execution can be a valuable lesson. At the end of my experience, I felt the objective value in the cases we did and the lives that were changed (although I tried to not focus on these stories too much because sometimes the sentimental persuasion makes us overlook the ethical concerns at large). If I only contibuted when perfection were guaranteed, then I might never do anything.

      So my lesson was to navigate the grey area we must wade through sometimes to make progress, and to balance skepticism with action.

      The situation you refer to is important to talk about. I agree with you, ethically questionable, and I am against it on principle. Here is the WHO’s take on it:
      http://www.who.int/bulletin/volumes/86/8/07-048546/en/

      But just for argument’s sake, should we throw away the medicine on principle when a life can be saved with, say, a course of antibiotics even at 90% efficacy? Is our responsibility to the patients in front of us or to a sustainable system? It’s not always completely black and white. I think the important thing is to continue engaging in the dialogue.

      1. Thank you for your thoughtful response. You have given me a lot to ponder. I look forward to following your blog, travels, and career.

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