Peruvian Customs...

My parents just left after a two week visit here in Peru. We had an amazing time around Cusco and the Sacred Valley, going to the jungle, and hiking the Inca trail to Macchu Picchu. While they were here I found myself explaining a variety of Peruvian customs Nansen and I have picked up over the last 7 months. Here is a list of examples:

On shopping:
Bargain on everything. This includes taxi rides, market purchases, and even while shopping in nice tourist shops. If you're buying more than one thing from the same person this is license to bargain even harder.
If you are in a nice store with actual price tags, offering to pay in cash (in effectivo) should drop the price 10%. This is before bargaining begins. If a store doesn't offer 10% for paying in cash they are playing hardball and/or trying to rip you off. This is an indication to consider going elsewhere.
If a Peruvian refuses to bargain with you it is for one of two reasons. One, they are actually offering you a fair price and you should quit bartering. Or two, they are being a jerk and you should walk away. It can sometimes be hard to know which situation it is, but trust your gut.
Things near the plaza and tourist attractions cost more. Inflation by location.
Peruvians hate making change. Always pay in exact if possible, or with the smallest bill possible. Give cents if you have it cause they hate breaking a sole too. This is becomes a problem because at some point you run out of coins and small bills. This is why its important to break big bills at shops and bigger restaurants whenever possible.

On eating:
It is totally normal to be served a dish that includes rice, boiled potatoes, and french fries. Peruvians love their starches. The corollary of this is that is makes finding a vegetable difficult.
Peruvian food is pretty bland in general. Even if you can't stand spicy food you're probably safe having a stuffed pepper.
Local restaurants use this green sauce. If its too local of a place the green sauce can sit out for days and get you sick. Best to only eat it if there are a significant number of other tourists in the restaurant.
If there are 50% or more tourists in a restaurant it is safe to eat anything, including raw green leafy vegetables.

On groceries:
Produce and fruits and really cheap. Meat is more expensive. Being able to go veggie for a while has the potential to save you a lot of money.
It is impossible to find really good cheese besides Andean cheese. Quit trying.
There is a huge variation in mark-up on imported American products (think granola bars, pancake mix, macaroni and cheese, pringles, etc). Shopping around for prices is important.
The one exception to this is M&Ms which are always the ridiculous price of s/3.50 (about a $1.50) a pack everywhere except Gato's, where they are s/3.00.
Baked rolls are ridiculously cheap at s/0.20 each.

On traveling:
Generally the more uncomfortable something is, the less expensive it will be. For example combvi's that cram 25 people in a space designed to seat 10 are cheaper than big buses with individual seats are cheaper than any form of transportation with the word "tourist" on it. Buses with bathrooms are the most expensive of all but totally worth it for long trips cause Peruvians have bladders of steel.
Some drivers will drive crazy fast to get there asap. Sometimes this is good, sometimes it makes you fear for your life.
Bus tickets do not need to be booked in advance for typical buses. 30 minutes in advance is often enough. This is not always true of really long buses and never true of buses catering exclusively towards tourists.
Cruz del Sur is almost always a rip. Although they do serve you tea which is nice.
Private tourist drivers are always the best and the safest. This is a fact, not an opinion.
Buses around Cusco have definite routes, but no map posted anywhere. There are also no scheduled times, the bus gets there when it gets there. All bus rides are s/0.70.
You don't tip taxis drivers.

On time:
Peruvians operate on Peruvian time, which after careful observation can be up to 2 hours later than the originally stated time. Only later, never earlier.
This is true of appointments with very specific times as well. These are more like suggestions than actual committed meetings.
Peruvians have a vague sense of days as well. "Come back Friday" can actually mean as late as several weeks later.
Always bring a book if you're meeting a Peruvian. It makes waiting much less infuriating.
The only time Peruvian time does not apply is with any kind of tour operator. In this case, things will run like clockwork and you better be on time. Real time.

Things we could appreciate a little more in the US...

Washing machines
Drying machines (even more so than washers, especially in the wet season)
Plastic baggies
Hot showers that don't electrocute you
Space heaters
(central heating and air are quite unimaginable)
Not needing to eat "scrap" pieces of meat- this includes back bones, chicken feet, neck, liver, heart, intestines, shoulder joints, hoofs, and whole heads.
Having enough pieces of silverware in the cafeteria
Dansko shoes
Thick carpeting
Dependable internet
Kleenex in doctors offices
Canned pasta sauce
Good mustard
Ethnic variety in food
Basil
Buses with a schedule and route
Cars with intact suspension systems
Drivers that use turn signals
Down comforters
Movie theaters
Store and restaurant info available online
Comfortable couches
Customer service
Availability of health care (I know we've got problems, but at least you don't have to walk hours to the nearest clinic only to have to drive hours into town, worry about whether the ER will be open or not, have to wonder if the doctors drunk or even around, or be told that life saving option is only available in one city in the whole country.)

Accha

Sunday the staff at CerviCusco did a campaign in Accha, a small village about 4 hours from Cusco. This involved getting up at 3:45 to get to the clinic by 4:15 to load the bus with all our supplies. We arrived in Accha at 8:30 and there was already a line of women waiting for pap smears. We saw 200 patients that day. Many had walked hours to come. My second patient had gotten up at 3 in the morning (earlier than me) and had walked four hours to get to Accha. I saw several patients who had some kind of tumor growing at their cervix. There were several more with very large prolapses who had no idea they needed surgery.

This is going to sound horrible- but women who have walked four hours smell really horrible. I saw more feet that clearly hadn't been washed in months that I care to think about. The city government had sent up tents in the main square for us, and do to privacy that meant no ventilation all day. I have never loved air freshener as I did that day. It made me really appreciate things like running water for regular showers, hot water, bars of soap, and sinks for washing clothes.

The most disturbing part of the day was when we were leaving. We had brought donations for the kids- pens, notebooks, crayons, coloring books, and stickers. Wendy, one of the nurses, started passing out pens and within seconds there was a swarm of people around us. Not just kids, but adults desperately trying to get their hands on a 5 cent Bic pen. Notebooks started an even bigger frenzy and we had to insist over and over that they were only for the children. At one point Wendy put her foot down and said no one was getting anything if there wasn't an orderly line. That was amazingly effective at calming the crowd.

It was a totally different experience for me. I have seen incredible poverty in India. People who live on pennies a day. I've seen Tibetan refugees who literally walked over the Himalayas with nothing but the clothes on their back. But I have never seen this type of desperation for an item that by no means is life saving. I've heard many people complain about how the campos people are lazy and greedy and just expect handouts. I know they weren't expecting these, but their intensity and cunning and getting more than one thing was startling. It was disturbing for me as well. I just hope that at least some of those supplies went to kids who really need and will enjoy them.

CerviCusco

So for the last few weeks I've been volunteering with a new organization, CerviCusco. Its a women's clinic started by some doctors in Georgia who were doing genomics research on cervical cancer. They now do thousands of papsmears every year on women in Cusco and the surrounding villages. I don't care much about genomics research, but the pap smear part is pretty impressive seeing as cervical cancer is the #1 most common cancer in Peruvian women.
When we go out to the villages we bring everything- brushes, lubricant, gloves, drapes, etc in suitcases. Sterilized speculums in canisters. Back-up plastic speculums. Folding tables for the patients to lay on (obviously no stirrups or anything). We use headlamps for lighting.
Many women come with general medical problems hoping we can help them cause there is no other doctor to talk to. Almost every woman over the age of 70 has significant osteoporosis- you can see it in their spines and shuffles. We write a lot of prescriptions for ibuprofen. For the majority of women this is the first time they have ever had a pap smear. They'll come back in two months to get their results.
Many women speak quechua and there aren't enough translators to thoroughly explain the procedure. We get by with a few essential phrases and a lot of hand gestures. At one point we needed a woman to move down the table and she just wasn't getting it. So I put my hands on my own butt and did exaggerated hip thrusts until she got the idea. She found my demonstration quite amusing. Better than being terrified by the weird gringa sticking a piece of metal into you.
In the campos and at the clinic I explain every day that cramping with your period is normal, that whitish discharge between your periods is normal, and that once you haven't had your period in over a year you are in menopause.
We had one woman who took three buses into town to be told she was going through menopause. She was afraid she had cancer because she hadn't been getting her periods. She reasoned this must because there was something (ie a tumor) blocking her period from coming out. We did an echo to confirm. She had to drink water to fill up her bladder to make the echo easier to read. She looked so uncomfortable from being bloated with water and needing to pee by the time we did the echo. She was really sad to hear she was in menopause because she really wanted to have more kids. The doctor told her to focus on grandkids instead. She was only 42.
A 19 year old girl came to us for her first pap smear. She was really nervous. She had been pregnant four months ago but had gotten into a car accident. A month later she had a miscarriage. Apparently this is a common type of story you hear to cover up an illegal abortion.
An 18 year old came to us for her first pap smear. She had been having sex with one partner, but without any type of birth control. I tried to explain to her to importance of condoms if she didn't want to get pregnant. Also that some guys might not always be so clean or faithful and therefore using a condom could also be a good idea in terms of disease prevention. She left looking totally unconvinced.
There was a woman who was referred to us from the campos because she was 38 weeks pregnant and the baby was in a transverse lie (not good). We did an echo and found that the baby had flipped and was now vertex (very good). We were able to show her the head and the profile of the face and the heart beat. We printed pictures for her to take back to her OB and to keep. We told her she was having a girl and she cried she was so happy and grateful.

Stress Abroad

Two thoughts occurred to me this week:

One is that the pace of life in Cusco is starting to infiltrate my pace of life. I realized that here, I don't even try to pack in stuff for a straight 12 hours before crashing. Some things are just fine waiting till tomorrow. I don't even feel guilty or weird about it. Its just how things are here. As a result I sleep better, don't need as much caffeine and am overall more relaxed.

I also realized that living in a foreign country produces this underlying low level of stress. You don't know the customs, the social norms, how to do things, where to find things. The latest example of this is tonight when I needed to buy a pair of scrubs tomorrow. In the states, even if I didn't know where to buy scrubs, I'd look it up online, drive there, pick some up, and be home in a maximum of 45 minutes. Here it took a bit of searching, a closed store, and two hours of waiting while a pair was hand-made for me. This totaled over 3.5 hours. This, combined with the uncertainty of if I'd find it or not was quite stressful.

Of course, my new hand-made, personally chosen color scrubs for my personal dimensions are pretty damn sweet. And the pockets are way better than any in US scrubs.

Opportunity

Nansen and I are doing our HIV/AIDS surveys at the universities in town. Yesterday we were at Universidad Nacional Andina del Abad de Cusco (UNSAAC). Its a public university, the largest in town, and very well respected. There is an entrance exam that every student needs to take and get a minimum score on for entrance. And apparently the minimum score is very hard to achieve. There is actually a special pre-University school students can attend after colegio (high school) just to prepare for the exam. Some students take up to years to prepare. Some students never get the score they need and end up at other universities. In addition to having a wide range of subjects and being well respected, UNSAAC is also free to anyone who gets in. This is obviously a huge deal for anyone from a middle to low income family.

Yesterday as I was waiting for people to finish their surveys, I looked around me. We were in the quad between the tourism, economy, and one of the engineering buildings. The buildings were all white, very modern, with scaffoldings enclosing external staircases. I could see in the windows of the tourism building and see classrooms with polished white floors, computers, and projection systems. Behind the building I could see the houses that are built into the hill side of the Cusco valley. These houses higher up and harder to get to and generally where poorer people live. They are constructed out of dirt adobe blocks. People cannot afford paint or tiles for the outside of most homes here. Clothes lines stretch across the roofs as almost no one here can afford a washed or drier. Things such as framing around windows, doors, and other niceties are also nonexistent. I thought about the houses in the campos I've seen. Dirt floors, sometimes only one room, wood-fired ovens for cooking. Barely electricity, much less televisions or phones.

Suddenly I understood in a different way what a really incredible opportunity UNSAAC must be for some families. Not in the way we talk about it at home- do what you want, make a little more money- but truly life changing. And not just for the student, but for their family as well. These buildings are like nothing else in town. Its easy to see how even just getting to study in one is an amazing advantage. Not to mention job opportunities and health insurance and the knowledge of how to look out for oneself in this complicated and quickly changing world. I wonder how many students in the US properly appreciate their colleges.

Speaking of appreciating our colleges: Oberlin just got named #3 healthiest college dining hall in the country! http://www.huffingtonpost.com/her-campus/healthy-food-dining-halls_b_1117652.html

Terremotos

Terremoto is the spanish word for earthquake. There's the Nazca tectonic plate that is along the coastline of Peru and it likes to move around and cause earthquakes, much the same as the North American plate does in California. Most of the biggest quakes happen closer to the coast, especially around Lima. Once in a while a doozy will hit in the mountains though. In 1984 there was a huge one that shook Cusco and the entire Sacred Valley. Buildings fell down, roads collapses, bridges crashed, and a lot of people died.

Some buildings in Cusco are constructed in a more traditional way- with adobe blocks made from dirt and dried in the sun. Others are made in a more European style with more solid concrete. In the spirit of Gandhi and Mandela and all those who have rejected that European = better; the traditional buildings actually hold up better during earthquakes. The adobe blocks have wiggle room and can absorb the shifting earthquake better. Other buildings collapse because they have no wiggle room. Obviously the poorest people get the worst of the deal because they just live in cardboard shacks which stand no chance at all.

The buildings of Hospital Lorena (multiple buildings because they couldn't build up at the time of construction 70+ years ago) are made in the newer, worse way. Therefore today we had an "earthquake drill." Everyone got called out of their work and had to stand between the buildings. They drove an ambulance up a sidewalk to use its loudspeaker system. Several people talked about the need for earthquake readiness for quite a while. There were several patients out there too- in wheelchairs and gurneys and hospital gowns.

I couldn't help but thinking as I was standing there that an earthquake drill is not inherently weird. But it would never fly in the US to call outside over half the staff away from their work. Especially in the morning when rounds are happening. Just another way different countries are different.

As we were waiting I was talking to the peds intern. He was quite surprised to learn we don't do earthquake drills regularly. We talked about where earthquakes are common in the US, and hurricanes and tornados and what drills we usually do in school. Fire drills are apparently unknown here, where at home they are the most common.