doi:10.1136/bmj.320.7228.173 
 2000;320;173-175 BMJ
  
Hans Veeken 
  
 criminality
Lurigancho prison: Lima's "high school" for
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supervision of an established consultant experienced
in the particular technique … or will they? For techni›
cally complex operations, especially if the consultant
performs them infrequently, there will be a natural
reluctance to allow even an experienced trainee to
undertake these procedures. This may be particularly
so in the new era where surgeons’ results will be avail›
able to the public and consultants are responsible for
the results of their trainees. Trainees may thus not have
the opportunity to perform a particular procedure
until they have been appointed to a consultant post.
How, therefore, do they start? Furthermore, how does
an established consultant learn a new technique
without having a learning curve?
Alternatives or ameliorations
There are few options. Strict regulations in the United
Kingdom prevent surgeons practising a new operation
on animals. The surgeon may visit an established con›
sultant to watch an operation, but, as a visitor, will not
be allowed to perform it. A better option, therefore, is
for a surgeon to invite a more experienced surgeon to
the unit to act as assistant—but not all surgeons will be
in this privileged position. Perhaps the royal colleges
should appoint peripatetic experts who would travel
around the country. A further alternative is to attend a
specifically designed course as we did, and therefore
the onus must be on the surgical colleges to provide
these facilities. As a minimum, we would suggest that
consultants undertaking a new procedure should have
another consultant surgeon capable of performing the
operation as their assistant. By these methods we
believe confidence can be given to patients (and in the
case of children, their parents) and new procedures
introduced into surgical practice with limitation on the
amount of morbidity and a low mortality.
Informed consent
The other major issue is of informed consent. The
GMC insists that surgeons must quote their own mor›
tality figures. How many cases does a surgeon need to
perform before he or she can begin to quote an accu›
rate statistical risk? We have had one death, but it would
obviously be ridiculous to quote a low mortality. As
health professionals, we understand the concept of
small sample size and confidence intervals, but how do
we explain these to a patient or parent? Can we stratify
patients by risk and quote different risks for patients
undergoing what is apparently the same procedure?
The recent GMC inquiry into events in Bristol seemed
to suggest not.
Competing interest: None declared.
1 Senate of Surgery. Response to the General Medical Council determination on
the Bristol case. London: Senate of Surgery, 1998.
2 Stelzer P, Elkins RC. Pulmonary autograft: an American experience.
J Cardiac Surg 1987;37:429›33.
3 Elkins RC, Knott›Craig CJ, Ward KE, McCue C, Lane MM. Pulmonary
autograft in children: realised growth potential. Ann Thorac Surg
1994;57:1387›94.
4 Kouchoukos NT, Davila›Roman VG, Spray TL, Murphy SF, Perrillo JB, et
al. Replacement of aortic root with pulmonary autograft in children and
young adults with aortic valve disease. N Engl J Med 1994;330:1›6.
5 Ross Procedure International Registry. Sixth annual Ross colloquium.
Boston: Ross Procedure International Registry, 1998.
6 Gula G, Wain WH, Ross DN. Ten years’ experience with pulmonary
autograft replacements for aortic valve disease. Ann Thorac Surg 1979;28:
392›6.
7 Stelzer P, Weinrauch S, Tranbaugh RF. Ten years of experience with
modified Ross procedure. J Thorac Cardiovasc Surg 1998;115:1091›100.
(Accepted 13 July 1999)
Lurigancho prison: Lima’s “high school” for criminality
Hans Veeken
“It is the largest prison in Lima.” Juan, the coordinator
of my visit to Lurigancho, says. “There is room for 1600
prisoners, but much more people are being kept
inside.”
“How many?” I ask.
“Well, the authorities do not even know. Let us
assume that there are 6000 people, which at least is the
number given by the prisoners themselves—who are
accurately keeping count of the number. You shall see
that the prison is overcrowded and the prisoners
themselves are the boss.”
My visit to Lurigancho prison in Lima is on behalf
of MØdecins Sans FrontiŁres to see if it can help the
prisoners. It sounds strange: prisoners running a
prison their way. Once inside the gates I see a prisoner
leave his cell, lock the door, and nonchalantly pocket
the key. He is going out for lunch within the prison. In
Lurigancho the prisoner is indeed the boss.
A western style fortress
Lurigancho is located on the outskirts of Lima and
comprises around 20 pavilions surrounded by a
carefully guarded wall. With its watchtowers the prison
looks like a fortress in a western. The prison operates
on a simple informal agreement between the prison
Summary points
Around 6000 prisoners are interned in
Lurigancho, which should only accommodate
1600 prisoners
Inside, the prisoners are “in charge”
HIV is a time bomb for the prison and local
community
The prisoners are a core transmission group
for HIV
Prostitution, tattooing, and drug misuse are rife in
Lurigancho
Education and debate
MØdecins Sans
FrontiŁres, PO Box
10014, 1001 EA
Amsterdam,
Netherlands
Hans Veeken,
public health
consultant
hans_veeken@
amsterdam.msf.org
BMJ 2000;320:173–5
173BMJ VOLUME 320 15 JANUARY 2000 www.bmj.com
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authorities and the prisoners: the prisoners are not
allowed to leave the closely watched precincts, but
when inside the prison walls they can do whatever they
like. In this way the prison authorities do not have to
bother about the prison’s organisation. Inside, about 20
unarmed warders oversee the prisoners. The prisoners
take care of everything—law and order, cleaning, food,
education, but they cannot control the numbers of
inmates as the authorities continue, despite the
overcrowding, to admit prisoners. Currently, there are
about 6000 prisoners in Lurigancho.
Everything is for sale
The prisoners can only survive by providing for them›
selves, which means they need help from their families
for money to buy essentials and food. A strict hierarchy
operates within Lurigancho. Those prisoners without
money have to work for the wealthier inmates. This
ranges from washing clothes to sexual services. Most
things are available in Lurigancho, and they either
enter the prison overtly or are smuggled in by visiting
relatives. For a small fee the warders willingly turn a
blind eye, but for more money they will bring things in
themselves. “Look, 100 g of cocaine can be smuggled
in, which is mostly done by women who hide the
cocaine in their vagina,” a prisoner says. “But a whole
kilo cannot be brought along that way and must have
been smuggled in by the warders themselves.”
Private space
We enter the pavilion where some 800 prisoners
reside. For privacy the prisoners have mostly
partitioned off parts of the halls with blankets. The
inmates either take over these sleeping places when
prisoners are released or they rent them from other
inmates. Prisoners without money have no place of
their own and sleep in the corridors or outdoors. The
pavilion is overcrowded. I feel uncomfortable as I
become aware that I am at the mercy of 6000 criminals.
I am glad to be wearing my MØdecins Sans FrontiŁres
T shirt and hope that the red logo will offer some kind
of protection. The “delegado” of the pavilion shows us
around. I see a public telephone hanging on a wall.
“Yes,” Juan says. “There are even prisoners who have a
mobile phone—and look, over there is a television and
a refrigerator.” Everything, absolutely everything, is to
be had in Lurigancho, as long as the prisoner can pay
or has connections.
Some foreigners are interned. I decide to pay a visit
to a compatriot. Maybe I could pass on a message to his
family. The delegado asks for the support of a
“llamador,” prisoners (recognisable by a uniform) who,
for money, locate fellow inmates. The Dutchman, who
had secured a private cell, peeks through the door but
is too drowsy to speak. I leave it at that.
Credibility: piranhas to sharks
Most of the prisoners are young, and the average stay in
Lurigancho is one year; some, however, have been inside
for 10 to 20 years. Most have not been put on trial. “You
get the picture, they will learn the art in here,” Juan says.
“The street is said to be the school of crime. Well, in that
case Lurigancho is a high school. Beginners will get to
know enough contacts and gain enough experience to
take a step further in the wrong direction.” For the most
part the prisoners come from the poor segments of
Lima. Poverty and the struggle for survival have
prompted a life of crime. This usually starts with petty
theft such as stealing from markets. Children about 12
years of age work in small groups and are called
piranhas. Once they have learnt the basics, these
children progress to robbing people in the streets and
stealing cars. They may eventually become armed
robbers and kidnappers—a status prestigious among
criminals both inside and outside prison. Criminality is
such an essential element to these people that they will
never really belong to the criminal class until they have
been locked up in Lurigancho.
1
The law of crime, drugs,
alcohol, and prostitution applies within the prison.
Medical care
A doctor and his assistants run the outpatient clinic in
the mornings. The assistants are often prisoners. Medi›
cal care is free, but in practice prisoners have to buy
their way through every door they pass to reach the
clinic. Inside the clinic, drugs and supplies are scarce.
HIV
HIV is a time bomb for the prison population. Unpro›
tected sex is standard. On visiting days, prostitutes have
sex with about 40 men each. Sexual relationships
between men, frequently under the influence of drugs
or alcohol, are also commonplace. Along with
tattooing, the intravenous use of drugs, and contact
with the local community the scenario for HIV
transmission is obvious. Prisoners constitute a core
transmitter group for HIV. Currently, nearly 40
patients positive for HIV are quarantined on their own
floor. “Naturally, isolation isn’t a good thing,” a
transvestite admits, “but here we are better off than in
any other pavilion. Here we are being left in peace.”
Three years ago he and three other prostitutes were
picked up by the police. The police checked them for
HIV. He was the only one with no money. For three
years he has been locked up, without a trial. Another
patient has a few weeks to live at the most. “Two weeks
ago,” Juan explains, “he was taken to the hospital, his
hands cuffed. He was beaten up during the ride. They
could not help him in the hospital, because he had no
JOSÉ
LUIS
PÉREZ
GUADELUPE
When inside Lurigancho prison, prisoners can do whatever they like
Education and debate
174 BMJ VOLUME 320 15 JANUARY 2000 www.bmj.com
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money. He was transported back and again beaten up
by the warders.” The doctor tells me that he has asked
for the man to be released; the request is still under
consideration. The man will die in prison.
Locked in cages
The rest of the morning I accompany Manuel, an
orderly who treats patients with tuberculosis. Tubercu›
losis is diagnosed in around 30 patients a month. The
patients stay in a special pavilion. Manuel is greeted
with shouts. “The pills, boys, the pills . . .” all of them are
screaming. Imperturbably, Manuel sits himself down.
“First, everyone ought to put on his shirt,” he says.
“There must be order,” he explains to me. A patient
called Alvarez is not there. “Cuchillo, Cuchillo . . .,” his
fellow inmates are shouting, “come on, man, your pills.”
I realise that Cuchillo means knife in Spanish. Cuchillo
turns up and, even without a knife, looks impressive
with all his tattoos. He takes a cup of water and
swallows the handful of pills in one gulp. The next
patient first counts his pills: one is missing. He asks
firmly for another brown one. Without flinching,
Manuel puts an extra vitamin pill in his hand. A
prisoner walks around with a drip. He asks me if it is
good stuff. On the bag is written metronidazole. I
explain to him that metronidazole is not suitable for
him. Laughing, he says “I just for once want to clean
out the mess properly,” and he takes to his heels, drip
and all, afraid I might take it away from him. I know he
will find someone to insert the needle for the infusion.
In town, saline or glucose infusions are used to “regain
strength.”
Self regulation
Manuel and I set out for the pavilion where prisoners
are locked up for misbehaviour, mostly fighting. The
prisoners deal out punishment to fellow inmates—even
capital punishment, I am told. In this pavilion nearly 20
prisoners have been locked up in a 10 m
2
cage with
thick bars, two wooden beds, and an open toilet. They
cannot possibly all lie down at the same time. There is
no daylight and only limited water. The prisoners,
clinging to the bars, all talk at the same time. In the dim
light I can see about six cages, but I don’t have the
nerve to walk further along the corridor. This pavilion
is inhumane, dark, and reeks, and it reminds me of a
zoo. We briefly talk to an American prisoner. He has
served 18 months of a 10 year sentence and talks about
his stay with steely composure. Resignation is probably
the only way to survive. The move to this pavilion, how›
ever, is too much for him. “I’m here for a week now.
Nobody tells me how long I have to stay. We get bread
and water in the morning, some soup, and that is it. I
have blood in my stool, but am not allowed to see a
doctor. It is inhuman. We have no rights—animals are
treated better.” He earns some money by repairing
televisions and radios. It turns out that Manuel is treat›
ing a patient with tuberculosis in the same pavilion;
I hope that his sputum test is negative.
In the afternoon I am accompanied by a nurse who
is doing a survey of the hospital. She plans to interview
a sample of prisoners who have been randomly
selected. She informs several delegados which prison›
ers have been chosen. I see a panicky look in the
delegados’ eyes when they realise their cook has been
picked. “How are we going to eat that day?” one
delegado says. “We shall appoint another one. He will
also do,” another delegado says blandly. The other nods
in assent, glad they can solve the problem so quickly.
The nurse explains the procedure again, and the
delegados resign themselves to the cook taking part.
Our boatswain
Later that day Juan tells me the story of Carlos, our
boatswain, who is working on a project in the jungle.
Three months ago the police picked him up during a
routine check along the road. His identity card had
been found in a bag during a house search two years
ago. The bag had contained cocaine. According to
Carlos, the identity card had been stolen, and he had
papers to prove that he had reported the theft.
Nevertheless he was sent to prison, where he has been
locked up now for several months, without trial. His
lawyer says that he could be sentenced to 10 years in
prison. Suspects have little rights in the war against ter›
rorism and drugs in Peru.
After years of lobbying, MØdecins Sans FrontiŁres
has had the unique opportunity to see inside a
Peruvian prison. Most people’s reactions about the
organisation’s motives have been predictable:
MØdecins Sans FrontiŁres should use its scarce
resources for worthy causes such as needy children.
From an ethical point of view, this does not seem right.
Crime and punishment in Peru are problematic issues
and it seems appropriate that MØdecins Sans
FrontiŁres should help the prisoners.
Competing interests: None declared.
1 Guadalupe JLP. Faites attorantes: una etnografia del penal de Lurigancho.
PhD Thesis. Lima, Peru: Facultad de Teologia Pontificia y Civil de Lima,
1994.
One hundred years ago
Unqualified practice
Sir, › One gets very tired reading almost every week various
suggestions for the General Medical Council to adopt this, that, or
the other reform. As far as safeguarding the interests of the
practitioner the General Medical Council’s utility is nil. When the
employment of unqualified assistance was prohibited, surely the
profession had a right to expect that the Council would see that
discarded unqualified assistants did not indulge in independent
practice. Such, however, is not the case.
Here in the town where I practise we have a man who was for
years an unqualified assistant here, and who now not only
practises medicine, surgery, and midwifery with impunity, but who
has successfully run the gauntlet of a couple of inquests. Now, I
ask, where is the use of having a qualification when such a state of
things is allowed to exist?—I am, etc.,
April 4th. M.D. Dublin.
(BMJ 1900;i:933.)
Education and debate
175BMJ VOLUME 320 15 JANUARY 2000 www.bmj.com
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