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Advancing Hematology Practices in Arequipa, Peru

May 18, 2022

June 2022

Leah Lawrence

Leah Lawrence is a freelance health writer and editor based in Delaware.

For the past two years, the global hematology/oncology community has been forced to adapt to the challenges of working and treating patients during the COVID-19 pandemic. For the hematologists in Arequipa, Peru, these challenges have been particularly great. As of November 2021, it was estimated that Peru had the world’s highest COVID-19 death rate.1 Before the pandemic, the Catholic University of Santa Maria and Carlos Alberto Seguin Escobedo Hospital in Arequipa, the second largest city in Peru, had 25 beds for patients with hematologic conditions. After making room for people admitted with COVID-19 infections, there were only seven.

(From left to right) Mauricio Postigo-MacDowall, Jose Malaga, Mariela Fuentes, Leslie Kean, Erin Sheek, and Alejandro Liendo.
(From left to right) Drs. Mauricio Postigo-MacDowall, Jose Malaga, Mariela Fuentes,
Leslie Kean, ASH staff member Erin Sheek, and Dr. Alejandro Liendo.

“Arequipa and these two hospitals are the referral centers for all of South Peru, so they are very busy,” said Jaime Andres Suarez-Londoño, MD, clinical assistant professor in the Department of Medicine at NYU Grossman School of Medicine. “They see around 500 adult inpatients with hematologic malignancies a year and have between 6,000 to 8,000 outpatient consults every year.”

 

Dr. Suarez-Londoño works with the hematologists and hematopathologists in Arequipa as part of a partnership between the American Society of Hematology (ASH) and Health Volunteers Overseas (HVO), a nonprofit organization dedicated to improving global health through education. ASH Clinical News spoke with Dr. Suarez-Londoño and others to discuss the ASH-HVO volunteer efforts in Peru and how the team there weathered the challenges during the COVID-19 pandemic.

Volunteer Efforts

The program in Peru was first initiated in 2008 and included several other sites in the country aside from Arequipa. From 2009 to 2013, 14 volunteers went to Peru to participate in the program. Administrative changes in EsSalud, the National Social Security Health Service in Peru, led to a discontinuation of the program, but in 2016, the partnership with the Catholic University of Santa Maria and Carlos Alberto Seguin Escobedo Hospital was reestablished.2

Prior to the pandemic, volunteers, who are usually hematologists or hematopathologists, would travel to Arequipa for two to four weeks. During that time, they could help in a variety of ways, such as providing didactic instruction, training, and consultations in clinic, laboratories, or through mentorship.

Many volunteers also spent their time rounding in the hospitals with the on-site hematologists or giving lectures. For example, when Dr. Suarez-Londoño visited Arequipa, he gave lectures related to leukemia, lymphoma, and transplant.

Volunteers also brought supplies back and forth between the U.S. and Peru, including books, microscopes, or other educational resources and tools to help the Peruvian team provide patient care.

The first time Michael A. Linden, MD, PhD, director of hematopathology at the University of Minnesota Medical School volunteered in Arequipa, he gave 14 lectures. He also spent time working with the pathologists there, looking at cases under the microscope or in the flow cytometry lab.

Knowledge Exchange

According to Dr. Linden, when it comes to pathology, the health system in Arequipa is less integrated than that in the U.S.

“If you have a patient undergo a bone marrow biopsy and aspirate you might have a clinical pathologist looking at a blood smear or flow cytometry study, a surgical pathologist looking at the bone marrow core biopsy, and a hematologist looking at the bone marrow aspirate,” Dr. Linden said. He and other volunteers have helped develop protocols to integrate all this information into a single report and to standardize diagnoses.

One of the anatomic pathologists Dr. Linden worked with in Peru is Mauricio Postigo-MacDowall, MD, of Carlos Seguin Escobedo Hospital. Several years ago, he served as Dr. Postigo-MacDowall’s host mentor at the University of Minnesota for two months as part of ASH’s Visitor Training Program (VTP).

In addition to learning new techniques, Dr. Postigo-MacDowall was able to see how the clinicians and pathologists worked together as a team.

“In Peru, we don’t have hematopathology training,” Dr. Postigo-MacDowall said. “That training was a huge help in hematology patient care.”

Volunteers have also shared protocols for standardizing chemotherapy administration, as well as helped in lab training, blood bank training, and transfusion medicine training to help the on-site team in Peru adapt as best they can with the resources they have available.

The ASH-HVO partnership has also provided the team with virtual access to meeting presentations and posters from the ASH Annual Meeting and Exposition.

“It is this type of education where the partnership with ASH has been vital,” Dr. Suarez-Londoño said.

Personal Connections

In addition to working together on-site, the team in Arequipa and volunteers in the U.S. hold virtual hematologic malignancy conferences to discuss cases together.

“When I was there in 2016, we started the equivalent of a tumor board that morphed into a monthly conference with the hematologists and hematopathologists,” Dr. Linden said. During these conferences, the team members present cases to each other and talk through diagnosis and treatment options.

For Dr. Postigo-MacDowall, this virtual conference has been very helpful.

“We have some unusual cases that give us a lot of diagnostic problems,” Dr. Postigo-MacDowall said. “There are many that do not present in the way a textbook would say.”

According to Mariela Fuentes, MD, director of hematology at Carlos Seguin Escobedo Hospital, the ability to access information and exchange knowledge, as well as the level of experience, have all improved since the ASH-HVO partnership began. In particular, she noted that the hematologists were able to improve their skill level through better training and networking opportunities.

For example, acute B-lymphoblastic leukemia is one of the most common hematologic malignancies in Peru. Dr. Suarez-Londoño said that through the partnership, work has been done to change some of the local protocols and to provide transplant training.

“They now use asparaginase-heavy protocols, and we helped them be able to identify patients that need transplant versus those who do not,” Dr. Suarez-Londoño said. “We have made progress.”

Dr. Suarez-Londoño said he can see a difference in the realm of pathology during their virtual meetings, where he has noticed improvements in the quality of the aspirates and slides.

Some Challenges Remain

While some areas have improved, there are still challenges to overcome. For example, there is still a need to improve blood banking and transfusion protocols, Dr. Suarez-Londoño said.

“They have a shortage of blood products because of the transfusions required for patients with COVID,” he said. “It has been a challenge for the blood bank to keep up.”

From her perspective, Dr. Fuentes said that many challenges remain for the team in Peru. For example, the limited space availability during the pandemic resulted in the bone marrow transplant unit being closed. Additionally, the workforce in Peru remains insufficient.

“Our greatest needs are human resources,” Dr. Fuentes said.

Prior to the pandemic, the programs had six adult hematologists and two pediatric hematologists.

“During the pandemic, hematologists who worked in pediatrics decided to transition to another pediatric service and did not support the care and treatment of adult patients. This created a shortage of hematologists,” Dr. Fuentes said. “After some time, two hematologists were hired to manage patients with COVID, and they also worked in hematology and cared for patients with hematologic pathologies who came for emergencies.”

Available equipment and infrastructure also remain a challenge. The seven available hospital beds are insufficient in the face of patient demand, Dr. Fuentes said.

“We do not have a space to check out bone marrow aspirates, and we only have access to two microscopes,” she added. “Our schedules do not include hours for bone marrow reading, forcing colleagues to review these slides during their free time.”

In addition, there is work to be done to shift the mindset of some in Peru.

“If you have a hematologist who for years has been involved in diagnosing bone marrow aspirates and looking under the microscope, and now you are asking a hematopathologist to be involved, it is definitely a shift in the way someone thinks about approaching a case,” Dr. Linden said. “It takes time for hematologists to gain confidence in the hematopathologists, and vice versa.”

In these challenging times, though, the partnership between the ASH-HVO volunteers and the team in Peru has remained.

“We found that we can do a lot of things remotely,” Dr. Linden said. “Dr. Postigo-MacDowall can send me a message via WhatsApp or start a Zoom on the fly and we can look at cases together. There is still a knowledge exchange that is possible.”

Future Needs

Looking to the future, Dr. Fuentes said the needs of the team in Arequipa remain much the same: greater human resources, greater education and training capabilities, access to more equipment and infrastructure, and more accreditation.

Dr. Postigo-MacDowall emphasized the ongoing need for access to technologies that get the most accurate diagnosis and prognosis in every patient.

“We still need more access to diagnostic testing,” Dr. Postigo-MacDowall said. “I would like to train in more advanced techniques such as FISH or cytogenetics.”

No matter the ongoing needs, Dr. Fuentes said that the program can always count on support from HVO and ASH volunteer doctors.

“With great effort, and through coordinated work between the various groups, we will be able to strengthen the partnership,” Dr. Fuentes said. “We will provide quality services and rigorous monitoring of all our processes and indicators, and we will not risk losing this achievement.”

Find Yourself in Arequipa

“Arequipa is a safe and beautiful city,” Dr. Suarez-Londoño said. “There is nothing better than feeling like the work you are doing is having a direct impact not only on just one person but on a multitude of people.”

When the program is again open to volunteers, Drs. Linden and Suarez-Londoño both encouraged people to sign up.

Dr. Linden said that even in just a few short weeks as a volunteer in Arequipa, he felt a sense of closeness and camaraderie with the talented team there.

“Although they are so busy, the pace feels slower,” he said. “They spend time together, bring in cake on people’s birthdays, and get together for lunches. There is a sense of closeness with colleagues and their families that is not as common in our day-to-day lives here [in the U.S].”

To get involved or learn more about the HVO programs, visit hematology.org/global-initiatives/health-volunteers-overseas. As Ghandi said, “The best way to find yourself is to lose yourself in the service of others.”

References

    1. Beaubien J. Peru has the world’s highest COVID death rate. Here’s why. NPR Morning Edition. Published November 27, 2021. Accessed March 1, 2022. https://www.npr.org/sections/goatsandsoda/2021/11/27/1057387896/peru-has-the-worlds-highest-covid-death-rate-heres-why.
    2. Fuentes M, Malaga J, Postigo M, Linden MA, Harris S. The development of the American Society of Hematology Health Volunteers Overseas Hematology Program in Arequipa, Peru. Blood Adv. 2017;1(suppl):90-92.

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