From left: Nora del Busto, M.D., Sister Anne, James Phillips, M.D., and
Mark Rego, M.D., pose outside the mental health clinic in which they work in
Photo courtesy of James Phillips, M.D., and Mark Rego, M.D.
In fall 2003 a Catholic nun named Antonnette Carbon started a small mental
health clinic outside of Ayacucho, Peru. Ayachucho is a remote city in the
high Andes. Its population is poor. Furthermore, Ayacucho was the cradle of a
terrorist movement during the 1970s and 1980s and of government reprisals
during the 1980s and 1990s. Thus, many of its residents were victimized by
both terrorists and the Peruvian military and consequently experienced
posttraumatic stress disorder.
Carbon, who hailed originally from the Philippines, had a strong background
in psychiatric nursing. She launched the clinic with just a smattering of
medication samples and a local nursing staff that was entirely voluntary. She
also had the help of a volunteer psychiatrist from Lima, Luis Matos, M.D.
Around this time, two Connecticut psychiatrists—Mark Rego, M.D., and
James Phillips, M.D.—happened to see an ad in the physician leisure
magazine Diversion. The ad said that the Peruvian American Medical
Society (PAMS) was looking for psychiatrists to join their mission in
Rego and Phillips had been wanting to do volunteer work in an underserved,
developing country for some time, although each had a private practice and
also a position at Yale University. Moreover, both Rego and Phillips spoke
Spanish fluently. "So we called the number in the ad," Rego said,"
and signed up."
So did Nora del Busto, M.D., a Peruvian-American child psychiatrist at
Wayne State University and a longtime PAMS member.
Ralph Kuon, M.D., a Peruvian-American cardiovascular surgeon from
California, had been organizing the general PAMS medical mission to Ayacucho
for the past 10 years and was the person who initiated the ad for psychiatric
involvement. He was delighted to have Rego, Phillips, and del Busto come on
In June 2004, Rego and del Busto flew to Peru with the PAMS mission. They
had a list of people to meet in both Lima and Ayacucho, but they really had no
idea of how the psychiatric team might make a mental health care contribution
"What we really wanted to find out," said Rego, "is what
happens if you get mentally ill in Ayacucho. We spoke with hospital officials,
government officials, clergy, anyone we could find, and the answer was,
Finally, they went to Carbon's convent. Rego started his inquiries in
Spanish, and Carbon replied, "Why don't we speak English—it will
make it easier!" And that is when Rego and del Busto learned that she
had started a small mental health clinic and decided that together with
Phillips they should invest their efforts in her clinic. Formally, the clinic
operates under the auspices of the local archdiocese, but there is no
religious dimension to the treatment.
Immediately following the Ayacucho visit, the three American psychiatrists
began sending monthly donations and psychotropic medications to the clinic.
They returned to Ayacucho in November 2004 and June 2005 and plan to visit
every six months for the time being. During these visits, they treat patients,
train staff, and conduct planning with Carbon. Between visits, they maintain
frequent contact with Carbon via telephone and e-mail.
A number of other individuals have been assisting the clinic as well. For
example, Matos "is really the heart and soul of the clinic," said
Rego. "He has devoted one weekend a month to the clinic since the
beginning, where he works virtually around the clock and is then on call seven
days a week by phone from Lima."
Nurses from Lima help out at the clinic as well. The Peruvian Ministry of
Health has started paying for the transportation and room and board for the
Peruvian psychiatrists and nurses when they work at the clinic. But they still
come on their own time. In addition, the Ayacucho nursing staff provides the
daily care at the clinic, some of them on a voluntary basis. Finally, a core
of volunteer nonprofessional individuals provides other support.
Various other groups and individuals are helping the clinic too. Carbon's
Order of Saint Columban made a sizable financial contribution to get the
clinic off the ground. American nongovernmental organizations, including
Direct Relief International, have assisted in shipping donated psychotropic
medications to Peru. The Milford (Conn.) Rotary Club, in conjunction with
Rotary International, is in the process of providing a grant for electronic
equipment, and PAMS, under the leadership of Kuon, has supported the clinic.
Finally, in addition to their own monthly contributions, the American
psychiatrists have conducted fundraising for the clinic.
The clinic was first established on the outskirts of Ayacucho but was moved
recently to central Ayacucho. Some 1,500 patients are in treatment. "We
have had to stop advertising," said Rego, "because when we
advertise, 60 people will show up for an evaluation."
"And one of the most important things," Phillips added,"
is that most of the local clinic staff are being paid reasonable
Not surprisingly, getting the clinic up and running has presented various
difficulties. For example, Rego said, "Getting medications to the clinic
has been a challenge. It is complicated because you are sending very expensive
pharmaceuticals, Customs is very complex, and there are a lot of laws
regarding health. However, I think we have finally found a solution that
works—a Catholic charity in Peru will be the recipient of the
Still another challenge, he added, is developing a working relationship
with a regional hospital in Ayacucho.
There are also certain difficulties facing the clinic staff in its
day-to-day operations. For instance, about 60 percent of the people in
Ayacucho who visit the clinic speak both Spanish and the local Indian
language, Quechua, but people who come from outside the city usually speak
only Quechua. The local nursing staff all speak Quechua, but the
psychiatrists, including those from Lima, speak only Spanish and thus need the
nurses as interpreters for Quechua-speaking patients. Carbon, fluent in
Spanish and English, is studying Quechua.
Not surprisingly, the American psychiatrists are receiving certain
psychological rewards from their clinic efforts and especially from their
treatment of patients at the clinic.
"It is gratifying to feel close to people whom you might think are
very different from you, but who have very much the same concerns," Rego
"There is something enormously satisfying about bringing psychiatric
treatment to a population that has had none," Phillips said. "And
when we work at the clinic ourselves, it is in a sense doing pure psychiatry.
In other words, people come in who are suffering, and you treat them. All
these layers of bureaucracy and insurance companies, all the stuff we have to
deal with in this country, are just not there. It's just you and the
"Even getting paid is not there," Rego chuckled, "which
makes it even purer! Patients need and appreciate our help, and it is a
Both Rego and Phillips said they are planning on helping the clinic
indefinitely. Del Busto followed the June visit to Ayacucho with a visit to a
small children's hospital in the Andean town of Puquio. She plans to divide
her efforts between Ayacucho and Puqio.
"The long-term clinic plan," Rego said, "and this may
take a very long time, with a 10-year outlook on this, is to build an Andean
mental health center that would be a referral center, a treatment center, and
a research center."
"I would say the same," Phillips added. "Everything in
Peru is sort of public psychiatry—the hospitals, the Ministry of Health,
and so on. Most of the Peruvian psychiatrists work for the Ministry of Health.
The clinic is unusual in that it is separated from all that, although it does
receive some financial support from the Ministry hospital in Lima. Our
long-term plans at the clinic would surely involve more collaboration with the