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.