Medicine in the Amazon

Nancy DeTora, MD

Sometime in my forties, I accompanied my son’s eighth-grade class to the Ecuadorian Amazon, not realizing that it was the start of a 22-year adventure. After flying into the capitol city of Quito and spending a day in the Andes Mountains, we took a short flight to Coca--an outpost military station--then traveled in a motorized boat for 60 miles down the Rio Napo. Finally, after a hike and a ride in a small dugout canoe, we finally arrived in our home for the week, Sani Isla. Sani Isla is an indigenous Quechuan community in Ecuador with 400-500 residents. They live in family units along the river in traditional thatchedroof huts with a kitchen fire pit and a gathering space. Furniture consists of split log benches around the perimeter. There is no electricity or running water, and there is a “bathroom trail.” At bedtime hammocks are pulled down from the rafters for sleeping, and bathing and laundry are done in the river. The community is not a monetary-based society and the Residents are hunters and gatherers. Tourism is the main source of income for the village, and profits are shared by all in the village.

On our third trip to Sani, we brought the students into the community to meet other school children and experience the local culture. During the soccer game (which instantly became a tradition) I took a walk and ended up in a kitchen area where some women were cooking lunch for the community children. I realized that they all had many burns on their hands and forearms, so I shared some ointments I had with me to help soothe and heal their burns. That was the beginning of the community clinic.

With the help of our guides, we consulted with the Sani elders and the shaman and were granted permission to establish the clinic. Our initial team included Helen Blazis for Spanish translation, Blanca the amazing community midwife, Quechua translation, and me. Together we developed a successful working system for triage, treatment, and pharmacy.

Once the clinic was established, I would spend the year prior to each trip gathering supplies, which included suture sets, antibiotics, skin and eye ointments, ibuprofen and Tylenol, electrolyte powder, antacids, antiparasitics, anti-diarrheal meds, and vitamins. Sani does not have electricity, so the only diagnostic tests I could bring were urine dip sticks and pregnancy tests. I always appreciated donations from medical offices back in the United States, and I even received donations from my patients. On many trips, I was fortunate to have other health care providers and parent volunteers. Even on the trips I could not participate in, we were able to assemble a health care team and supplies for Sani.

Clinic day was always busy, starting by 8 a.m. and finishing long after sunset. Year after year, increasing numbers of families from Sani and surrounding

communities came to the clinic. Initially, we saw mostly children, but after a year or so, more women began coming to the clinic with OB/GYN issues. The next year, we had everyone--men, women, and children, and all body parts. I was truly humbled by my patients’ trust.

The most common issues we encountered were aches and pains, gastritis, grippe, machete injuries, conjunctivitis, soft tissue infections, and pneumonias. The most worrisome issues in the jungle environment were the pulmonary illnesses and soft tissue infections, since those issues can quickly become life-threatening. Some of the other issues were congenital heart disease, tumors, menstrual/ fertility issues, benign prostatic hyperplasia (BH), cutaneous Leishmaniasis, Type 2 diabetes, tuberculosis (TB) (very common in the jungle and the leader in mortality). We were always working on wound care and dental hygiene. We also tried to provide other educational information on topics like puberty and STI prevention. With improved communication technology I was able to bring along specific meds for individuals with specific needs. The youngest patient we saw was two hours old, the oldest an 85-1/2 year-old gentleman.

Throughout our time at the clinic, we were regularly reminded that we were not providing medical care in the luxurious clinical setting we were used to in Massachusetts, but rather in an extreme environment with Indigenous population that had very limited health care rights. The people of Sani were only allowed to go to indigenous clinics and were required to pay for their care before being seen, even though they are not part of a monetary society. They could access the occasional government doctor or oil company doctors, who both charged for care. The oil companies even held them hostage for money or oil rights on their property. We were lucky in that if we needed to transport someone, the village would provide some funds for transportation and care.

I wanted to include a few notable stories from my time at the clinic in Sani:

Around 2005, my friend Rosa started having syncopal episodes after the birth of her last child. She made her way through the indigenous health care system, where she was diagnosed with cardiac syncope and sent home. One day while at the river doing laundry, she had an episode and drowned.One morning a petite older woman was led into the clinic with respiratory distress due to massive ascites. She also had large purpuric lesions from her umbilicus to her toes, but had no history of jaundice or parasites.

In order to determine if this was tubercular, we were able to transport her to a medical facility with support from the community.A somnolent nine-month-old arrived at the clinic febrile and in severe respiratory distress. We worked on fever reduction and improvised an Albuterol treatment. By some miracle a doctor and transport boat arrived and the baby was able to be hospitalized and lived.

One evening, a man was brought to the lodge with a machete injury. He lacerated his entire posterior thigh--vertically, thank goodness. We stitched him up by flashlight, gave him supplies, and “signed him out” to the lodge manager, who would later take out his stitches.

On my last trip to Sani, a three-month-old infant with sepsis and apnea was brought in. We had to keep tapping her to keep her breathing. We worked on fever reduction by Tylenol and sponging, but at one point I thought she was going to die, so we moved to a private area and kept sponging. We were able to get her transported upriver and the only news I received was that she was still alive when they got there.

Now to end on some lighter notes:How do you take care of an anaconda bite? First, you have to get the anaconda off of the patient’s hand! During birdbanding research at a friend’s hut an anaconda was brought in for us to see. There was a bit of missed timing, and my physician colleague was bitten. We left the anaconda issue to Luis, who showed us how to thoroughly clean the snake bite with soap and clean water. The entire family watched closely.

One day, while examining a toddler, there was a roar and then an earthquake. The structure we were working in quickly emptied but for Dr. Gail Ryan, my child health partner. She continued to examine the toddler with her stethoscope, not realizing that the shaking was from an earthquake, not the toddler kicking the table! We were all fine.

Clinic day was always a big celebration that included a soccer tournament. One day, a young man (who happened to be the oh-so-important goalie) was gently and slowly led into my exam room, explaining that he had small a tumor, squeezed it, and “tumor juice” came out. I was worried about the jungle version of Burkett lymphoma, but as he came out of the shadows I was so glad to see a pimple and a facial cellulitis!

Our adventure in Sani continued for 22 years, paused for the time being due to the COVID-19 pandemic. Throughout the years we tried to provide good medical care and knowledge. We also received knowledge and great appreciation from the incredible people of Sani. It was a gift I gave to myself. +