I’m in the heart of the Peruvian Amazon, with my friend Patch Adams and Gesundheit!, and Bola Roja, the Peruvian clowning organization, who have been coming to Iquitos for the last 6 years to organize a grass-roots approach to public health delivery. These clown trips have become an instrument of change in the city’s poorest slums; they have helped integrate the healthiest parts of the community into a network of agencies who continue to do the hands-on health care work.

The poorest area of the city is in Belen, a community that lies in the Amazon floodplain. Every year during the rainy season, Belen homes are flooded out. The people build rudimentary bridges, and commute in canoes and rafts. The people have no access to sewage or potable water, and the rest of Iquitos dumps its waste there is well. The water (in which the children swim happily) is filled with sewage. All the ravages of poverty and powerlessness are here; violence, crime, alcoholism, child prostitution, sexually transmitted diseases, teenage pregnancy, and drug use are all rampant.
When I’m down here I conduct a mental health clinic with Amazon Promise, a non-profit, NGO that provides healthcare to indigenous people. This year the mobile clinic was held in a one-room flophouse, where for pennies someone can lay down his or her mat on the floor, and for a quarter you get an enclosed space. There is a rudimentary pharmacy dispensing some drugs but they carry no psychiatric medications other than Valium.

The huge room is filled with sick and crying children, adults who are getting sewn up, and infected wounds are everywhere. Somehow this noisy circus is organized and works. I sit in one corner for some bare semblance of conversational privacy, with the patient and my wonderfully sensitive interpreter, Rosa.

The first patient Pablo was a 17-year-old young man who suffered daily episodes of momentary spells, in which he couldn’t remember anything the teacher was saying; or if playing soccer he’d suddenly blank out and not remember what to do with the ball. These spells happened on a daily basis for the last year, he didn’t feel them coming on, and they could last from moments to half an hour. Pablo said he fell and bumped his head 3 years before and wondered if that might be the cause of his current problem. He seemed a bit lethargic and withdrawn, but denied sleep problems or suicidal ideation. Neurological examination revealed no gross abnormality and there was no family history of seizure disorder.

Pablo hadn’t told anyone about his symptoms, only that he was not feeling well and it was not pursued further. I asked him if there was anyone he trusted to share his truth, and he said he’d already told us more than he had anybody else in his life.

I told him that if he could talk to just one other person about what he was feeling, or afraid of then his symptoms would improve. Pablo insisted he had no one; so I told him that before I left, I’d leave him a gift from Rosa and me so that he could talk to us whenever he wanted to again. I bought him a fluffy lion and a note along that said that he had heart of a lion, because even when he was hurt he remained strong and fearless. But his skin was soft and furry, so that a few could get close to him. I thanked him for letting me be able to touch him and hoped through this lion we would touch again.

Gloria, a woman was in her early 20s wanted me to see her seven-year-old son Pablo because of his recent onset epileptic seizures. Gloria went on to say that she believed she had contributed to his problems because for many years she told Pablo that she didn’t want him. She would tell him he reminded her of his father who had abandoned her before Pablo was even born. Gloria lived with another man who fathered her second child (now a 3-year-old son), and was currently 6 months pregnant. A month ago her second man abandoned her; Gloria was working as a waitress and added that in order to feed her children she also worked as a prostitute. Tears were rolling down Rosa’s cheeks when she translated Gloria’s words.

My training in psychiatry has not prepared me to deal with these kinds of social problems. Her overwhelming survival needs were not going to be met by insight-oriented psychotherapy or psychiatric drugs. I felt so helpless in providing any meaningful support, an at the end of our 45’ together could only say, her son would always love her, and to be the best mother she could so he could love her even more.

Before leaving she thanked us, for what I wondered and then added, thank you for listening to me. Here in Belen, just being paid attention to and knowing you’ve been heard is enough to relieve suffering.