Shortly after finishing my second year of medical school I have come to Iquitos, Peru. With a population of nearly half a million, it is the world's largest city inaccessible by road. Iquitos is located along the Amazon River, so the only way to get here is by boat or airplane. And cars come at a premium.
The main mode of transport is the motokar, a motorized versions of the three-wheeled rickshaw, with loud two-stroke engines and no emissions controls. Rush hour sounds as if you're surrounded by an angry swarm of lawnmowers. The exhaust can be stifling in the hot, humid air.
The organized chaos of the traffic is striking. Lines on the road mean little. Motokars and motorcycles, many with broken headlights or wobbling wheels, weave back and forth. We move around the city on these vehicles, clutching our bags as the "motos" pass and re-pass one another, near misses at every turn.
There are 15 of us here with the non-profit organization Pacific Northwest Surgical Outreach (PNSO); one general surgeon, four nurses, four medical students and a variety of support staff. Most have been on trips with PNSO before to South Sudan, Guatemala, Haiti or Nicaragua. What we all have in common is a desire to teach or learn throughout the week and do some tangible good for the poorest members of this community.
The clinic is just off a dirt road near the airport. It's relatively small, with a long waiting room that runs along the front wall, two dental rooms with chairs, a storeroom and an obstetrics room with a table on which we'll operate. The concrete walls inside are painted a bright, cheery orange; the ceilings are tongue and groove wooden paneling.
Standing in the operating room I can hear bats squeak in the space above the paneling. All along the edges of the floor are piles of dust and droppings from the termites slowly demolishing the panels above. After all, we are in the Amazon jungle.
Patients begin to arrive at 8 a.m. to be screened and scheduled for surgery. We see a number of benign, superficial tumors, but the majority of cases are hernias. A hernia is a defect that allows an organ or tissue to protrude, notably in the area of the abdomen.
Women can have hernias but they're more often seen in men. As the blood vessels to the testes pass through the abdominal wall, they leave behind a weak spot where the contents of the abdomen can push through into the scrotum. This is what doctors are feeling for when they ask a man to, "turn your head and cough."
In the U.S. a surgeon would usually fix this problem at an early stage — say, at the first sign of pain. Here in Iquitos we see very large, often very old hernias. In some men, the scrotum is distended to the size of a softball. Many of the patients have been living with the pain and disability for over 20 years. The operation is available in Iquitos, but the $800 price tag has kept it out of reach for our patients.
I talk to a young man, Juan, who has had his hernia since he was six. Now he is 29. The hernia has worsened over the last few years, and he can no longer play "futbol." His friends don't want to hang out with him anymore because they think he's no fun. They don't know that he's just terrified the ball might hit him in the groin.
Examining him, I imagine even walking must be painful. This is a real disability for Juan. In a community where manual labor is often the only type of work available, he can't run or lift heavy objects.
After examining and interviewing Juan, I conclude he is an excellent candidate for surgery. "We can fix this," I say. "Can you come back tomorrow?"
Juan's broad smile reminds me of my original motivation for studying medicine. After spending my 20s and early 30s as a photographer and filmmaker, traveling and climbing around the world, I entered medical school at 35. It is a cliché, I know, but I wanted a way to change the world.
For me, it seems easiest to change the world by helping one individual at a time. Juan has a problem, and we're going to fix it. I'm happy for him and he's happy too. I walk him back to his wife in the waiting room. Outside, the sun has dropped quickly behind the horizon as it does in the tropics. I step through the front door of the clinic and listen to the drone of crickets as Juan and his wife hail a motokar and buzz off into the darkness.