Jhilam Biswas, MD

Nearly 70,000 residents of Ayacucho, Peru, were violently killed  during the campaign of the Sendero Luminoso (The Shining Path). A Peruvian  communist revolutionary movement, the Sendero Luminoso employed guerrilla  terror tactics to fight the government of Peru in the 1980s.The brutality  inflicted on this community continued for 12 years, until the leader of the movement  was captured in 1992. As in other war-torn areas around the world, combat has  come at a steep psychological price. Confronting the trauma experienced through  horrific crimes to their loved ones, many women in this small Andean region at  10,000 ft cope through knitting, doing craftwork, singing, journaling, and sharing  stories of the past and present.

Pictured from Left to Right: Dr Biswas, Dr Bullon, and Dr Abdool. 

As doctors from abroad, we were privileged to join a healing group  called La Asociacin Nacional de Familiares de  Secuestrados, Detenidos, y Desaparecido del Per (or, ANFASEP, the  National Association of Families of the Kidnapped, Detained, and Disappeared of  Peru). This  organization offers war victims an opportunity to confront the trauma, to show  support for each  other, and to commemorate the lives lost by holding  memorial services. The ANFASEP meets in the Museo de la Memoria,  a museum established to chronicle this civil war. The women whom we joined there sat in a  circle with neon-colored yarn in hand and thick double braids beneath their  hats; they told us the stories of their sons and husbands who were lined up and shot  in the plaza or a remote field.

These members demonstrated the importance of collective grieving and are working to incorporate it into their culture. ANFASEP is  one example of the many interconnected communities we experienced during our  weeklong commitment at the clinic in Ayacucho, the poorest region of Peru. As  PGY-2 and PGY-4 residents in the Harvard Longwood Psychiatry Residency Program  in Boston, we followed our attending, Antonio Bullon, MD, high into the Andes  to the mental health clinic where he devotes his time every 6 months. We  discovered that this trip was structured in a unique way that led to an  experience that was culturally enriching and educational. We hope that our  description will help other psychiatrists as they plan global mental health  trips of their own. The main themes include:

•A  structured clinic dedicated to mental health treatment
 •Real-time  attending supervision for residents
 •Clinical staff  committed to patient follow-up when doctors are not available
 •Didactics  for Ayacucho staff regarding management of mental health crises when doctors  are not available

The clinic we worked at in Peru was called Comision de Salud Mental  de Ayacucho (or, COSMA, the Mental Health Commission of Ayacucho). Antonette  Carbon, a Filipina nun with a psychiatric nursing background, started it in  2003. It became her answer to the trauma she witnessed in this community after  the decades of war that ravaged the area. 
 Although no psychiatrists live in Ayacucho, Sister Antonette was  able to recruit Dr Luis Matos from Lima and a group of psychiatric nurses from  the local nursing school. Soon, psychiatrists James Phillips, MD, and Mark  Rego, MD, from Yale University learned of the clinic through the Peruvian  American Medical Society (PAMS), and joined Sister Antonette in the clinic  every 6 months.

A few years ago, Dr Bullon of Beth Israel Deaconess Medical Center,  a native Peruvian who went to medical school in Lima, met Dr Phillips at an  American Psychiatric Association Conference and learned of his work. Dr Bullon  also committed to work for this small but powerful health institution. The  clinic is made up of Peruvian residents who work in the clinic 1 weekend a month  and American psychiatrists who join the clinic for 1 week every 6 months. In  our week at COSMA, we visited with nearly 50 patients; made home visits;  trained staff members on mental health topics, including bipolar disorder,  alcohol abuse, and psychiatric manifestations in organic brain disease; and  visited community nongovernmental organizations (NGOs) focused on alleviating war  victim stress.

Before our arrival, COSMA provided us with an explanation of plans  for the week via e-mail, setting expectations for our trip. From the time we  arrived, not a minute was wasted. Brother Alfredo, who has taken over Sister  Antonette’s work in managing the clinic, gave us a warm welcome tour and  directly took us to a case conference the nurses had prepared to provide more  insight into a particularly complicated patient.

Together with psychiatric nurses, we visited homes of patients the  staff thought would benefit from the mental health system. The nurses would  listen in on our sessions so they could provide continuity for the patients after  we left the country. In the evenings, Dr Bullon arranged for a member of PRAXIS  Ayacucho, a group that helps investigate war crimes, to take us to local NGOs  involved in helping war victims heal from trauma. It was through this connection  that we met the group members of ANFASEP.

The structure of the trip ensured that we received maximum exposure  to Peruvian mental and social health and contributed to the success of our  trip. However, none of it would have been possible without the mentorship we  received. Our attending’s experience and leadership were essential for our  global health trip. Dr Bullon helped translate, supervised our patient care,  and consistently offered us a cultural and historical context to all that we  saw. Each night, we would debrief the interesting and problematic situations we  encountered, and Dr Bullon would offer insights. His understanding of Peruvian  society and geography created a fertile ground for deeper reflection. Most  importantly, he was excited about teaching and left no question unanswered.

Our team was organized so that Dr Bullon saw patients with the 2nd  year resident while the 4th year resident saw patients with a translator. With  practice over the course of working 12 to 14 hours a day for 2 to 3 days, we  were able to interview and treat patients in an unfamiliar culture. The nursing  staff’s knowledge about their patients and their dedication to keep them safe  served as a crucial component to continuity-of-care. They freely shared their  concerns and questions from what they had observed in the patients over time.  This proved invaluable to our treatment of patients with whom our interaction  was only a brief 30- or 60-minute snapshot in time. We worked with translators,  even when translation required a 2-step process (from English to Spanish to  Quechua, the language of the Ayacucho region). Within a few intense workdays,  we began to understand the meanings behind facial expressions, body language,  and tone of voice, which allowed us to relate to our patients as psychiatrists. This  process introduced new profundity to an already rich experience.

We had the opportunity to lead didactic sessions on topics  specifically chosen by staff as part of our work in Ayacucho. These sessions  were conducted with an audience of onsite nurses, social workers,  psychologists, and members of the community. The 2-hour sessions were held  weekday afternoons and included a presentation of topics described above,  followed by a question-and-answer period. Both staff and community participants,  who were able to provide insights on diagnostic and treatment strategies that  might be helpful within the region, enthusiastically attended these didactics.  The clinic in Ayacucho represented a gateway to an integrated care structure,  finely attuned to the needs of the community, despite the limits of medical  services in this area.

As our time in Ayacucho drew to a close, we could not help but  reflect on the resourcefulness of the clinical staff, the resilience of  Ayacucho’s people, and the richness of our learning. During many moments in  patient interviews, it was easy to forget that we were high in the remote  Andes, far from the comforts of Boston. We learned that American psychiatric  training has wide-reaching cultural value. The cultural dynamics certainly  highlighted the influence certain beliefs have on the way patients present.  However, the universality of psychiatric presentations, such as psychosis, OCD,  mania, addiction, and depression, reminded us that psychiatry is a field of  organic disease and that the field must have a secure place in world health  initiatives.

We would like to thank Dr Zeina El Chemali, who  leads the Peace in Medicine Initiative, for her generous support, mentorship,  and funding of our project. Dr El Chemali is Director, Neuropsychiatry Clinics  and Training, Departments of Psychiatry and Neurology, at Massachusetts General  Hospital, and Assistant Professor of Psychiatry at Harvard Medical School,  Boston.

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During their time in Ayacucho, these visiting psychiatrists learned that American psychiatric training has wide-reaching cultural value. 

Author | Jhilam Biswas, MD

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