In the sixth of our Living With COVID-19 series, where we learn how fellow health workers are adapting and coping with the ongoing pandemic, we hear from Pedro Kikushima, based in Lima, Peru. Pedro is a family medicine resident who has suddenly been pulled into providing emergency medical services during the pandemic, and one of our friends within our collaborative network. Peru has been one of the hardest-hit countries in the Americas during the COVID-19 pandemic with an increasingly rapid rate of the number of cases (260,810 as of June 24). His words here describe how he has felt and what he is experiencing during this time.
When my tutor asked me if I was interested in writing about COVID-19 and healthcare in Perú from my perspective, I was excited and daunted at the same time.
The problem lays mainly in writing about healthcare in my country. I used to joke with a friend saying our healthcare was a monster of 9 heads, made in some lab during a rainy night. There are not 9, but it sounded funnier.
We have had a fragmented and deteriorated health system in place for a long time now and it came to be from the improvised decisions, and institutions we have had over the years. A quick search will show that Perú is among the countries with the worst corruption and education results in the region. You may imagine a completely backwards country, but at the same time we have been, in the past years one of the countries with the best economic growth in the region. It is a paradox, but not one hard to understand.
When coronavirus arrived at our country we were in the middle of one of our biggest political crises since the downfall of the terrorist group “Sendero Luminoso” and the end of a totalitarian government in the '90s. As an interim president assumed command, after their predecessor resigned because of corruption scandals, many of us expected the novel virus to be the “cherry on top”.
Unexpectedly our country's ‘higher-ups’ took a hands-on approach, and an immediate response to which most of us were unaccustomed to. On March 16, we had 71 cases nationwide, and a total lockdown was declared, police and military were sent out to enforce the lockdown, and all non-emergency, or hospitalisation services were suspended for 15 days.
The idea to flatten the curve, has since been advocated exhaustively, and the lockdown has been extended systemically. Economic measures, systematic sampling and other important measures were put in place. Nevertheless, the amount of positive cases and deaths has continued to rise. We are currently the seventh country with the most amount of cases worldwide. One can´t help but wonder, how did we get here?
I was just finishing my first year of residency in Family Medicine, when the pandemic arrived. I had even gave the introductory lecture for healthcare workers at the hospital where I was based. We continued with our routines, for a couple of days, but then it was decided we should stop our rotations and report to our base hospital. A couple of days later, I was told one of my last patients was a COVID-19 case, and told to go under quarantine. I got in touch with the ad hoc line, and was told someone would check up on me, but due to the scarcity of the tests and my youth, they would not test me.
The 14 days went by, a bit paranoid at the beginning, but all went well. Starting April, a fellow Resident, helped me coordinate with Hospital Angamos, from Essalud (one of the ‘9 heads’). I started going with two other Residents day on, day off partly because there was not enough protection equipment as back-up. Not being an emergency specialist, some of them showed a bit of mistrust with me, but during that month most got to know me and wee became team-mates.
In Perú we all have to become sort of GP's in name, and then apply for a residency. I knew most of the basics, but being in a hospital I couldn’t work completely solo most of the time. Funny thing is that many non-specialist GPs worked and are working with emergencies. They work solo, some of them are brilliant, some of them are just regular graduates.
Initially, I was tasked only with the morning visit of hospitalized patients, not really my main focus of specialization, but carried my duties with increasing fluidity. Some days, one of the ambulatory GPs was absent. They asked me to fill in. That, of course, was my forte. Soon enough, every time one was available, ambulatory consults were added to my routine. With the passing time, more colleagues were sent home, either for risk factors, or contagion.
Things progressed fast, and unknowingly I was seeing ambulatory care, hospitalization services, and sometimes those based at the symptomatic relief station. I even had to co-ordinate work (often supervised) in the COVID Tent, a kind of a non ICU improvised tent for oxygen-dependent noncritical cases. The adrenaline rush of those days, made them go fast, but I liked it.
The truth is, I was in as much uncertainty as the many patients who arrived. The escalation of treatment algorithms, the amount of workload, cases, deaths, and stress was seamless. Because of the problems first mentioned, the amount of self-medication, the pity treatments, and the fear of not doing enough, or of exposing non-COVID patients to undiagnosed cases, things got really hectic.
The incongruity between physicians even with my own emergency, was stressful. MINSA the head of heads of our 9 headed monster, unknowingly made said incongruity worse. We have had so much informality in our community it has even affected medical everyday practice, and the 9 heads fight each other. But between all that chaos every day, I have got to know some excellent colleagues even with the whole health system aflame, with the failed policies and the corruption scandals coming out even during the pandemic.
The mental health of the whole country was very unstable even before COVID-19. Due to the distrust in our own institutions, the scandals, and the inequalities, there was a sense of despondency and abandonment that was ubiquitous. During my days at the ambulatory care units, I got to confirm unofficially, that mental stress is as much of a problem as the amount of COVID-19 cases.
On a specific day, I have had to see 9 out of 10 patients in 4 hours of the emergency ambulatory services that arrive because of stress, depression and anxiety problems. Some very specifically, some with headache, heartburn, or palpitations. I have also observed that most non-specialist GPs and emergency specialists are ill-equipped to deal with such cases. It is not their fault though, it is a complex hospital, and we are in a health crisis.
The 9 heads keep fighting, money is funnelled from public funds, healthcare givers have no structural support system whatsoever, and the general population is left adrift. They are scared, unclear about their own health, and where to get help for their specific problems. Even diabetes, hypertension, oncologic and other chronic illnesses have, to a certain degree been neglected. So how does a country with so many problems at hand can manage?
I am left uncertain once more. People are starting to protest the confinement measures, crime has opened business once more. The repercussions of this time will probably last way longer than the pandemic. I can only hope, that at some point the 9 heads will get together, our institutions become stronger, and we as a country will learn from this all.