Busy Days. I've decided to call hospitals by the city zone rather than the actual health facility. Whether it is true or not, it makes me feel like I'm protecting confidentiality better since I'm talking about patients.

Yesterday in El Augustino saw a case of advanced case scrofula (oozing lymph node TB) the likes of which I had not seen anything close to before- in an HIV positive prisoner.

This morning in Lima Centro - follow up on past patients. No one is doing well.

This afternoon I spent in a sex worker's gynecology clinic in Callao- fascinating and busy. A lot of opportunity to pitch in and be helfpul.


Prostitution is legal in Peru. Voting, mandatory. Abortion, illegal.

Interesting combination.

Pesadillas and Haiku 73

Woke up early this morning at 4.30 to the sound of birds singing. A pleasant concept, but in reality a painfully early morning wake up. I immediately thought of Craig, the Fogarty Fellow in Mali, who fasted for Ramadan. Check out his account, which I thought was pretty fascinating; especially since this is the same guy who made his own poolside happy hour double-fisting beer at orientation: ie a more normal American dude than even most medical students.

Not living in a Muslim country myself, I guiltlessly tried to return to sleep, but couldn’t in part because of the memory of a dream I had about large spiders crawling all over me, and my itchy legs upon awakening. (I would count this as an improvement on the morning dream recalls I’ve had in recent weeks about driving off a pier in a car, crashing into the ocean in an airplane and having a small child while being pregnant with another. I’m not sure which is most frightening. I think I need to stop drinking mate de coca at night.) Remembering the cramped combi rides I took yesterday, I had to inspect for The Pulga. Fortunately, I was flea bite free and my mind for the next 45 minutes turned to a meditation of the combi, a well known source of The Pulga, and the two small buses I will take this morning to get to the clinic.

I reworked a Haiku I wrote on my favorite combi, the large as school bus and green as grass #73 –

Setenta y tres,

me encanta siempre.

El combi mejor.

I’m hopeful for a Peruvian combi equivalent of NYC’s Poetry In Motion to catch on here before I leave. I think I’d have a really good shot in the 4-7 year-old category. (Today I will spend 2.5 hours in transit getting back and forth to the clinic; in the first months I spent at least 2.5 hours every day on big green sally. Ample time for bad humor and bad poetry to gather a life of its own.) An entry is long overdue on the glories of this bus among buses, which in fact has its own hip little restaurant named after it in Barranco. I’ve been meaning to make a pilgrimage. Photos and entry dedicated to combis to follow.

Weekend waters and Blog identity

The pool that I swim in. At the Regatas Club. Thank you!!
A beach in Pulpos, named for all the octopuses that are fished there. It's a half and hour south of Lima in a car I've been told. Or 1.5 hours in a combi. The rocks are said to have the form of a whale. I see it.
Spent the night at Ingrid's house here this weekend. (See Thanksgiving photo.) An excellent escape from the city!
Chorrillos, where the pool is located. A sign with the name of the town is poking through the trees. This is about a 20 minute combi ride from where I live.

From a NYTimes article today- "Travel blogs came out of the travel space, not out of the blog space," said Martin Horne, the president of TravelPod ..... host to travel blogs. "In the big blog world it's blogging about anything. This is vertical specific blogging." I've situated myself in the amorphous blob blog space, according to this guy, by using blogger.com. Am I a horizontal blogger? Or a vertical blogger?

Happy Thanksgiving/ El dia de las gracias

Some of the party at the Thanksgiving dinner. From left to right. Anna, Rob, Ingrid, Ceci, Carla, Ernesto, Matt, Bruno, Sean and myself. More Peruvians than Americans. Matt and Anna cooked an amazing meal. And Sean brought a can of cranberry sauce from the states!

Had a great day at the clinic. Was thrown right in to seeing patients on my own with supervision. Saw anemia, zoster, PCP pneumonia, depression.

The woman with likely PCP had no money for medicine and so was given cotrimoxazole (TMP-SMX -given for free for prophylaxis by the government program) though the doctor wanted to give her clindamycin because she was anemica. CD 4 count of 10, and pretty ill looking, he preferred to send her home with strict orders to come back quickly if she became shorter of breath. His experience with his patients with such low CD 4 counts was that if they came into the hospital, they got a nosocomial infection. Like MDR TB.

PCP= pneumocystis carini pneumonia

Nary a cranberry

The search has been on for a while and is now looking grim. One day left to find cranberry sauce. . .am celebrating Thanksgiving with friends tomorrow.

Pretty weird to see Christmas decorations sparkling in the sun as the days get warmer.

Had two interesting mornings of clinical work - yesterday at Bravo Chico's HIV and TB clinic from 9-2 and this morning at Dos De Mayo city hospital. Saw two cases of very similar-looking disseminated varicella-form rashes at each. Both patients had HIV and TB and had lesions at varying stages - both pearly papules and hemorrhagic vesicles- that were confounding the MDs. No answers, but it was interesting to see the approach to the differential diagnosis and physical exam.

Had another good meeting as well today. The projects are rolling.

I need to get the physical exam down in Spanish. It's been half mime-show/ half spitalian so far. My mastery of the imperative is fragile.

The New Yorker does the developing world

Good weekend here, except for the lack of sun. Saw a good Peruvian movie that’s supposedly making its way to the states: Un dia sin sexo. I thought I understood everything, but then again, I thought my landlady won a million dollars.

Of note: All of the women who come to the fancy swimming pool and gym where I too am now a lucky swimmer bring a full-on rolling suitcase each day with them. Makeup, change of clothes, hairdryer are all in tow. I think it’s a local style phenomenon- like in Palermo when _all_ of the women had matching bathrobes, flip flops and swim caps at the poolside.

Finally got around to reading this New Yorker article tonight: What Money Can Buy: Millions of Africans die needlessly of disease each year. Can Bill Gates change that?

http://www.sbri.org/news/New_Yorker_malaria.pdf

Some of the quotes were priceless:

Kent Campbell, a former chief of the malaria branch at CDC: “It has gone on for too long. I would love to believe that in the United States this effort is being driven by a decent desire to help, but I don’t think most Americans give a rat’s ass about the death of millions of African kids each year. I don’t think they ever have.” Cynical?

Bill Gates: “It just blows my mind how little money has been spent on malaria research. What has prevented the rich world from attempting this? I just keep asking myself, Do we really not care because it doesn’t affect us? Is that what it is?’’ Naïve?

I thought the overall evaluation of the impact and vision of the Gates foundation was well-balanced and insightful. A Lancet editorial is given a summative weight, placed at the end of the article: “The eradication of disease and the alleviation of suffering depends more on developing the skills of talented people than on technology.’’ (The Gates foundation has been criticized for focusing too much on cutting-edge technological responses to global health problems rather than things like buying mosquito nets – though they’re doing that now too.)

And I loved this line that described a British doctor working in the field: "Like any doctor who has worked both in the lab and in the village, he is well aware of the difference between efficacy and effectiveness."

Other interesting highlights/factoids:

• Ancient mosquito net use: Herodotus described Egyptians
  living in marshy areas who would wrap themselves in fishing nets
• The origin of the DALY (disability adjusted life- year) measure - the 1993 World Bank report

The section in which the author walks around with Tanzanian Dr. Mutabingwa made me think of Paul's blog entry about his experiences on the wards in Tanzania (see links section). However I was disappointed by some of the descriptions of Tanzania: "The rains were late that year" is kind of like the "'twas a dark and stormy night" of the developing world.

I felt like there was something missing in the description of the overcrowded hospital, and of the patients. Too much distance from the subject maybe? "Women dressed in robes, their heads obscured by flowing scarves, lined a long, low breezeway connecting the main wards. Each woman had at least one child, bundled in swaddling, sitting by her feet, or nursing. None of them cried; the children seemed like statues while their mothers waited wordlessly to see a nurse." Jeff, Paul? Is this a familiar scene to you? To me there's a certain vibrancy missing that I felt at hospitals and clinics in Kenya. But maybe I'm the one missing something. Who am I, as a blogger who doesn't even spell check to criticize?

I nominate Big Red, pen name Bryan Walsh, Time Asia reporter to write the next New Yorker article on global health issues; his short piece about a refugee clinic in Thailand was great: http://www.princeton.edu/~paw/archive_new/PAW05-06/04-1102/features3.html

Big Red also describes silent patients in a crowded waiting area: “Only the recovering children can be heard crying in the Mae Tao Clinic’s makeshift pediatric ward, and they sometimes are drowned out by the fat rain drumming off the tin roof. It’s the quiet ones you have to worry about, the toddlers struck down by cerebral malaria. They lie in their mothers’ laps on the cement floor, draped in fabric, skin shrunk to their skulls, breathing shallow. The mothers make no noise, and neither do the handful of fathers, who stand helplessly against the wall with their hands behind their backs. There’s nothing anyone can do, except listen to the advice of the nurses who pick their way through the packed ward. The comparatively well-off ones wait inside makeshift mosquito nets, and seem to watch us as if through a cage, like a zoo turned inside out.”

Red wasn’t thrilled with the piece; he felt he couldn't “synthesize the experience in the right space and syntax” he told me. But I was really moved, probably because I know the author. Maybe it’s also because he captured in writing how I would have seen the waiting area, more so than the New Yorker author, Michael Specter.

****

Had a good cap to my evening at the Sports Bar on the corner, a watering hole for all sorts of characters. Met up with an expat friend who was there for the Monday night football. When I walked in, my friend was talking to a businessman who is building a luxury casino in Lima. Luxury as in you can have plastic surgery done there. Maybe I’ll finally get my broken nose fixed!

Learning to count

I'm resisting the temptation to delete the previous post!

A real-time recording of a language mistake - The landlady won mille as in 1000 dollars, not one million.

Como el burro que toco la flauta.

My landlady one a million US dollars in a Marriott Hotel lottery last night!

She still can't believe it happened.

Flat

Stood guard while Dave Moore (the doctor I'm working on the TB projects with) performed the fastest tire change I've ever seen on the side of an unsavory Lima road. I'm not sure whether I was standing guard or announcing - Hey gringos with car trouble! The whole thing was, fortunately, extremely uneventful.

Been a few more elaborate robberies of people I know recently. Nothing violent, but nothing fun either.

The flat happened right after Dave introduced me to his friend, a Peruvian ID doc I'm going to start shadowing twice a week at city hospital called Hipolito Unanue- also known as Chico Bravo. I've been going weekly to grand rounds and walking rounds at another hospital called Dos De Mayo, but it will be nice to see patients one to one. I'm excited!

Had some other meetings today, and the projects are coming along slowly but surely. . .

"Mobile porcupine"

My dad thought this shot of a young Puya Raimondi should go up on the blog and so here it is. He calls it "mobile porcupine."

A otro perro con ese hueso . . .

You might be saying when you I tell you this is an albino biringo,
but see and believe!

Yo tengo una tia que toca la guitarra. . .

An ancient hairless Peruvian dog found often at ruin sites. (Though not usually so well-dressed.) The biringos are one of the uglier creatures I've ever encountered, and to me are all the more endearing for it. Their body temperature is supposedly very high at 40 degrees C and therefore they are reputed to be good pets for asthmatics.

The big question: What have you been doing in Peru?

The Fellowship

I am currently on a year’s leave from Mount Sinai Medical School to pursue a Fogarty Ellison Fellowship in Global Health and Clinical Research in Lima, Peru at a research training center that is run collaboratively by the Johns Hopkins School of Public Health and Universidad Peruana Cayetano Heredia. (see link for more info.)

The Boss Men

My overall boss is Bob Gilman from Hopkins, an MD who lived in Lima for 18 years with his family and now splits his time between the US and Peru. It’s hard to sum up the career or charisma of a man who can talk about immune fluorescence with the same facility as global economics or the American variety walnut tree. Most of his work is in clinical diagnostics and infectious disease. For my medical friends, I think he put the string test on the map with his work in typhoid. Needless to say, I feel lucky to be on his team.

Two other wonderful doctors from Imperial College mentor students and work closely together and with Bob at Cayetano. Carlton Evans is known for his work in micronutrients and tuberculosis and David Moore for tuberculosis diagnostics. Again, I feel lucky to be working with MDs who are such admirable people as well as doctors.

Orientation

The fellowship began in July with a three week orientation in Bethesda, Maryland on the NIH campus that brought together fellows from the host countries (mostly foreign MDs) and the 27 medical students slated to work at each of the 18 sites. Course work ranged from ethical research to epidemiology to economics. Guest speakers ranged from the US surgeon general to a member of the French equivalent of the NIH.

Lab Rotation
After the orientation, I took my second board exam and then arrived in Lima on August 28 - unusually late for the fellows but necessary for personal reasons. I arrived on a Monday and began my lab rotation that Wednesday. Bob has all of the students who work for a year with him (6 this year, not including those who are here for shorter periods) spend 4-6 weeks rotating through the different laboratories at Cayetano.

The first month I spent mornings in language classes and afternoons in the lab. I rotated through Parasitology, the Helicobacter Pylori Group, the Immunology Group, and Tuberculosis learning a lot from many patient Peruvians. One of the first words I learned in the lab was “torpe,” Spanish for klutz. My lab rotation stretched across 5 and a half weeks as my language classes cut seriously into lab time.

I also visited different projects to see how various projects ran. I went to health posts and/or out with field workers in the shanty towns of Ventanilla, Callao, Villa El Salvador, and San Juan de Miraflores. I traveled to Ica, a city 4-5 hours south of Lima to hear David give a talk about a rapid and cheap new diagnostic test the Tuberculosis group developed (with Luz Caviedes at the head) called MODS – microscopic observation drug susceptibility assay. David was invited by a young MD, Cesar Munaiko, who is organizing a campaign against tuberculosis in Ica. They had an unusual outbreak of drug resistant tuberculosis a year or so ago. Here arise many questions (that my mother asked) that I hope to address later, like what the heck IS MODS? What is tuberculosis, anyway?

The Research Projects: 1 big, 2 small, 1 back up

My main project came out of the car ride back from Ica: to do a formative and summative process evaluation of the implementation of MODS in Ica. From what I understand at this point, process evaluation is often used in quality improvement studies and to analyze the effectiveness of behavioral interventions. We want to apply this critical approach to the implementation of a new diagnostic test in a resource poor setting. The goal, in my mind, is to come up with a few practical things: 1. A simple quantitative and descriptive method that health care providers who implement MODS in resource poor settings without huge numbers can use to ensure that their plans are carried out optimally 2. some sense of which components of the intervention are effective, for whom the intervention is effective and under which conditions it is effective.

In theory, I love this project. It focuses on bridging the gap between innovation and clinical practice. How good is your invention if it never gets to the people who need it?

It seems both intimidating and challenging to not be able to find a model in the literature for what we want to do.

I also plan to do a short lab project comparing the effect of two types of centrifuges – one very expensive, one not -- on MODS. I’ve also spent some time tinkering with different microscopes – or rather commandeering different microscopes so Luz Caviedes and her amazing Peruvian lab team can play around with them.

When there’s down time, I’m working with data on children’s poisonings that one of the other Fogarty Fellows, Joe Donroe, collected from 5000 homes in one of the poorer slums. The goal is to come up with an intervention addressing the problem of kids drinking bleach and kerosene.

Daily Life

I’m pretty much in charge of my own schedule, but also very much subject to others’ availability. In the beginning, I probably spent about 40% of my time in transit in this sprawling city and the rest in lab or language class. Needless to say that no matter how many surprising street scenes Lima has to offer, no matter how profoundly I enjoy taking the little buses called combis around (seriously), that much commuting quickly loses its charm. Fortunately now I’m not at the lab every day.

I have a great place to run and a fantastic running partner. I had the best visitor for two weeks I could have ever hoped for. I have recently acquired a gorgeous place to swim thanks to the guest pass of one my Peruvian friends. I have a lot of extremely nice Peruvian and international colleagues and there are more social events going on in a given weekend than one could possibly keep up with. My home situation, after some initial difficulties, is suiting me perfectly. I’m settled in. I’ve had the opportunity to see fascinating and beautiful new things.

I’ve been hesitant to write about what my daily life is like because it is so variable. I’ve been hesitant to write about my projects because of how they come along in fits and starts.

I have tremendous anxiety about not having a single finished product by the time I leave here, about not having done much more than set up some projects that would likely fizzle out if I left. I have been surprised that I was even capable of feeling as frustrated as I have at times. Example: Traveling 10 hours in a day on the bus to get some documents that could have easily been emailed to me.

There are the frustrations of relying on others for work and then there are the frustrations of being work for someone else because I can’t speak the language well. I am taking private lessons still but I can’t learn Spanish fast enough. I can get around the city, and make casual conversation, but it’s another thing, for example, to give a comment about something medical in front of a group.

It’s also hard to know when to throw yourself into something and when to throw in the towel.

Again, I could not ask for better mentors and I’m in constant conversation with the boss men about this; they are incredibly supportive.

More photos from Huaraz

May 31 1970 in 15 minutes half of the 30,000 people living in Yungay were killed by an aluvion - combination avalanche, waterfall, and landslide - produced by a 7.7 earthquake on the Richter scale. The palm stalks and church facade are from the original city. Walking above the interred city was eerie.
Can't remember the name of this lake. Pato, or duck, was somewhere in the name. Loved the colors.
Pastoruri glacier.
Higher up on Pastoruri glacier, 5400 meters.
Snowstorm rolling in over the mountains around Chavin.

Photos from Huaraz

The Lanzon, still in its original site, in the underground labrinth. A 4m high, carved white granite, dagger-like rock stuck at the intersection of four narrow passageways. Designed with a series of vents, the underground tunnels are so well-ventilated that the air is not musty.
Laguna Chinancocha (female in Quechua) one of the Llanganuco Lagunas is 28 meters deep at 3850 meters in Parque Nacional Huascaran. The gorgeous color, not photographed to justice here, is from the depth and the algae.
The Puya Ramondi only grows in few places in the world at 3800-4200m. It grows up to 12m and is a member of the pineapple family. They bloom at the end of their 100 year lifetime just once. (May is supposedly the best time to see this.)
The San Pedro cactus blooms twice a year and we were lucky. A burro is hanging out at the base. This cactus is featured in a lot of the Chavin artwork and is a source of mescalin.
A tenon. One of the large keystones that used to project from the outer wall of the Chavin ruin. They look like really big nails (can't see that at this angle though), the head of which is carved into different faces. This one, according to our guide, is supposed to show the effects of mescalin: dilated pupils, eyes rolling up in their orbits, and saliva or a hemorrhage running from its nostrils.

Chavin and the Pastoruri Glacier

Went to the mysterious Chavin de Huantar ruins. The culture is from about 1000 BC - and is possibly amazonian in origin. They were the center of the Andean world in their time, sophisticated in hydraulics, mathematics and agriculture. The blue granite structures are beautiful and hardly worn. The whole place was covered in 1945 by an earthquake, like Yungay and then reexcavated. Greenery was lush. Underground labrynthe led to a very striking Lanzon - stone carved cult object. The central ¨Falcon Door¨ was also well preserved with images of male and female human and animal figures in white and black stone. The female figure was especially notable for the vagina dentata image - something we spoke about a lot as a literary image in english classes in college. The image of the Cruz del Sur - the Andean cross with a hole in the middle of it symbolizing the umbilicus of the world was a repeating theme.

Today went to Pastoruri glacier and climbed to 5400 m (about an hour fom 5000m). Now that´s breathless. Had a nasty headache on the descent - altitude. Saw the towering Puya Raimondi plants that only grow in a few places in the world and only between 3800 and 4200m, I think. Saw oxygen bubbling into springs. Pretty amazing to think I´ve only seen a small part of this area.

Stuck to the tourist route in Huaraz. I hope I have more time in May, after the rainy season, to come acclimatize and then do a long hike in the Cordillera Blanca.

Heading home on the night bus.

Huaraz

Beautiful! went to some glacial lakes today. lagunas llanganuco in the national park. 28 meters deep and very very blue. Hiked around the lake for about an hour at 3800 breathless meters. Saw a city that had been buried by an earthquake in 1970. walked over the buried city. Called yungay. could see the tops of palm trees poking out. morbidly fascinating. in 15 minutes 25,000 died. Saw natural rock saunas called vapor caves in Carhauz. The hotsprings there too were an exciting idea, but it kind of would've been like taking a bath in a public bathroom. skipped it.
Tomorrow to the Chavin culture ruins. The next day to see Puya Raymondi plants, oxygen bubbling up through some streams and to hike on a a glacier.
Had an Andean wheat soup tonight and some fresh trout. Their known for their ice cream and it´s good-pisco sour is a flavor. Air is clean, sky is blue and the mountains are spectacular -cordillera blanca and negra.

photos to follow...

Salir de Guatemala y meterse en guatepeor.

So the Peruvian government pays for HIV antiretrovirals - HART or TARGA - but not for the meds when HIV patients get opportunistic infections.

Saw two HIV patients on rounds this morning, one young woman and one middle aged woman infected with cytomegalovirus who cannot pay for gancyclovir, the treatment. If they are put on their antiretroviral treatment they will have a high chance of having an immune reconstitution syndrome - their fighter cells increase in numbers and react against the infection and create inflammation. One patient recently who could pay for a partial course of gancyclovir was then put on her antiretrovirals and the inflammatory reaction that her reconstituted immune system mounted against the infection caused her intestine to perforate (something which kills you unless you are immediately operated on.) (She survived her operation.)

So, you don't take your HIV meds unless you take the gancyclovir and get rid of the cytomegalovirus infection first. And if you can't pay for the gancyclovir, you are sent home to die.

They are working on finding organizations to pay for the medications for these two patients, but the patients will more likely either die waiting in the hospital, or deteriorate to the point where they are sent home.

The doctor conducting rounds stated how much this emotionally affected the housestaff, but how now things were much better in the past when they basically sent many more people home to die.

I didn't get a chance to ask how much it costs.


The translation of the subject. Literally: To leave Guatemala and arrive in worse cornstalks. Or out of the frying pan and into the fire.

Happy Halloween

Viviana, Hilary and Mike - who all work at Cayetano - at the Party.

The Gringo House- where many peruvian and international students working at Cayetano land for a few months- threw a party tonight. Salsa music, dancing, smores, and of course, pisco sours.

The highlight for me was talking to a visiting Dutch MD who seemed like an unlikely party attendee - a few weeks early, he had told me he liked boring Dutch literature, because it described the cold, cozy boring Dutch life he liked. Tonight, with the same halting English and hushed monotone he quite earnestly told me a story about dressing up in women's lingerie for a Halloween party in North Carolina, and then getting a flat tire and having policemen help him out.

The 31st is also the day to celebrate Criollo music in Peru. Tomorrow is a holiday. I'll be catching up on work after a few days of travel last week.