A very good day in Ica

The Monday daytrip to Ica.

Goal: Meet with the head of the regional health system, bring all the materials for MODS, go to all the health centers where we want to collect data

5am. Breakfast. Start the 10 page NYTimes article on Haiti. Too depressing to finish.

Without coffee (4 hour car ride ahead of me, uncertain bathroom stop situation) I would rather starve all day than work up the motivation to make the lunches I planned to pack.

5.30 Shower.

Go over supplies: folders, photocopies of all documents that need signatures, money, hole punch, camera, diskettes, cellphone, computer, suntan lotion. Check.

6.00 Downstairs to wait for Dave, the MD I'm working for on this on project to come. Gossip with night doorman, Herman.

Herman: "Is there one Real Jefe [boss] of all the people coming in and out of Gilman central?"
Anne: "Me!"

We laugh hysterically.

6.15 On the road.

Alternate patches of dense fog. (Seeing fog in the barren desert still confuses me. Hot air, cold Humboldt current, and something I don't understand at all called thermal inversion.)

Discuss Arequipa situation, projects etc.

Listen to Johnny Cash (sing along) Interpol (don't know them) U2 (more singing).

10.00 Stop for coffee. Discuss outline of the paper I will hopefully write up from this project.

10.30 Meet Cesar, Gaby, Hugo at the medical school. For the rest of the day the 5 of us travel together.

Immediately meet Dean of the Medical Faculty. Exchange floral formal words bookended by handshakes and kisses. His office has many large soccer trophies.

10.55 Check email hoping a missing document that needs signing will have been sent. No luck.

11.00 Go to the DISA (the local health system headquarters) for the main meeting of the day with The Main Man. The Main Man we have been trying to meet with since September.

11.15 The Main Man is not there. He had to go to Pisco to sign some papers. Emergently.

Emergent paper signing. That's a new one.

Meet with the Younger Man in The Main Man's office.

He has one soccer trophy, same type as the Dean of the Medical School who clearly has a better soccer team. Schadenfreude.

30 minutes of words. Maybe because it is so oppressivley hot the man has forgotten to breathe.

In sum: You'll need to meet with about 3 different people who are impossible to meet with and then it will take at least two months and then everything might change with the election in April. I think it's a great idea!

11.45-11.46
Dejection.
Amazement that I can have such a strong visceral reaction to all of this.
Why do I care so much about any of this stuff?
What does it all mean that everything is always such a circus?
Why am I here?
Time to get over the melodramatic existential thoughts and get in the car.

11.45-12.00 Discussion about what all this means. Conclusion: All is not lost. While we're waiting for DISA support, we could still get MODS up and running.

12.00 Meet with head of the Regional Hospital. He says, "Great idea. We need this kind of test. Let me know anything you need. Sure I'll sign off on all your documents. We'll try and make this sustainable. Bye." A man of gloriously few words.

12.05 Unload microscope, MODS materials. Run back and forth to internet shop to print off corrected version of documents. Get signatures. Give the lab tech a sheet to record her work activities. Take photos.

1.30 Go to Sr. de Luren puesto de Salud. Meet with the fantastic Dr. Vicky - who I've met a few times now.

All six of us load into David's definitively 5 seater car and visit to 5 other health centers that serve people from Sr. de Luren - the pueblo joven (pop. 10 000) that had the MDR TB outbreak.

At each health center Cesar and Dr. Vicky introduce what we're all up to. We chat.

(I am choked when I try to explain the questionnaires in Spanish, but it gets a little better as the day goes on.)

Dr. Vicky knows everyone and asks amazingly detailed about individual patients at each center.

The Inka Cola - a golden colored peruvian soft drink that most non-nationals consider revoltingly sweet - we are offered at many of the places has never tasted so good.

Driving from center to center we sweat, get the car full of sand, and get lost a few times and laugh much.

5.30 The whole day has been inordinately smoother than any of the days in Arequipa thanks to Cesar, Gaby Hugo and Dr. Vicky.

More photocopies. Goodbyes to Gaby and Hugo who are going to help set up paperwork at all the clinics.

Apologies that we haven't eaten anything all day.

On the road with Cesar and Dave by 6.

Cesar is reeducated and I am educated in British rock with selections from groups with names like the The Jam, The Happy Mondays, Cocteaux something and Sioux somethingorother. Am clearly not the best student.

We stop for the famous Ica roadside olives around 8 and eat them the rest of the way.

10.30 Home, hoarse voice. Have dinner with the folks who are home in the apartment.

Apologies for the posting delay Mark!!!

The application & anticuchos

The application got done around 8.30 with 5 forms, multiple copies of the project proposal, extra letters, signatures from 5 people and we still need to to get two more people to sign. Who knew it was so involved? I certainly didn't.

Will know Monday while I'm in Ica if we got everything right. But it'll be hard to do anything about it there.

I went out to a down-home Peruvian Parillada with some friends after leaving the lab in Barranco. Somehow the anticuchos- the smoky peruvian meat specialty, of heart (typically cow) wasn't seeming that appetizing. They really do taste good. They just look very recognizably like heart to me.

Clinical work and general update

Had another Peruvian stomach bug that required antibiotics for the second time here last week. That put me out of commission for a solid couple of days.

Everything's picked up all the sudden since as of Monday we're trying to get an IRB approval in to Cayetano by Friday with various documents and letters in Spanish. It is impossible to be fully prepared and think of everything, but I keep trying which has kept me at a high level of anxiety. Kafka novel level of intricate beauracracy.

Couldn't get to clinic today because of the proposal deadline. Last Thursday and Tuesday were intense as usual. Saw a patient with Kaposi's Sarcoma and a Hgb of 3- likely the combined effect of AZT and Vincristine.

On Tuesday there was a patient with excruciatingly painful scrofula - huge superinfected lymph nodes full of TB on his neck. The young MD I go to the floor with ordered another X-ray because the patient was having trouble breathing- "Socios in Salud are helping you, right?" This is the Peruvian branch of Partners in Health that helps abjectly poor patients out sometimes financially.

He said the MD very evenly, through teeth clenched in pain: "I have three children. There are many people in my home who are sick. Let me die and please, give them what Socios in Salud is giving to me." He's 28, never been treated for TB or HIV.

The MD said as much to him, and said there was hope for improvement. "Tiene che tranqualizate. Calmate." The way he told him to calm down in Spanish was perfect. Everything he said to him was perfect. One of the nicer clinical moments I've ever had. By the time we left the patient was laughing.

Am going to Ica Monday. Maybe tomorrow night, if they're doing more of the survey tomorrow, but I won't know until tomorrow. After that, Arequipa at the end of next week.

The weekend will be spent getting all of the paperwork and materials together to give out questionnaires to the health centers serving Sr. de Luren.

photos, a prisoner, and teeth whitening

Bob Gilman's apartment, where I'll stay when I'm not travelling for the rest of the year.
The golf course in San Isidro over which the apartment looks. The fog rolls in and out and in clearer hours you can see the sea and islands off the coast.

Hospital in El Augustino

Today I spent a lot of time on the internal medicine floor in the room that all of the HIV patients are in. Some have likely MDR TB, and half heartedly put their masks on when we enter the room.

I wonder if the mask I have still works at all after it's been crushed in my pockets and bags. The green CDC approved ones have been hard for me to find.

Waiting the MD to join me, I talk to one of the patients who knows me from last week. The man with the chronic diarrhea. I notice for the first time that he has handcuffs around his ankles. He tells me someone else from jail in the hospital bolted over the weekend, but not him. He's served 23 months for selling drugs and is getting out of jail at the end of the month. He's feeling much better and will be discharged soon.

I ask him what happened to the young woman in the next bed, the one who was yellow and literally skin and bones. "She died Saturday," He said. "Anyway, you know, she was dying." I nodded. Extremely sad.

The man with the unwitnessed convulsions was tearful today. He had eaten prunes and had diarrhea. He appears physically to be the healthiest patient I have seen either in the clinic or the hospital, which unfortunately doesn't mean much since he doesn't think so and seems depressed . We talked with him and a psychologist is coming by soon.

Another hospitalized patient had right flank pank, fever and anemia. I didn't get the whole work up, but the suspicion is abdominal TB.

Another abdominal TB suspect was a new patient I examined and interviewed with wasting disease. I thought of a wafer when I saw the aid lift her from her wheelchair to her bed with such ease.

I heard more dirty lungs, and saw more patients with cryptococcus and more candidiasis in the clinic.

I managed to switch from asking quiero tomar su pulso to the apparently less brusque sounding quiero tomarle el pulso with the aid of my pocket medical dictionary.

A dental student with us today and I looked through my spanish-english medical dictionary on a down moment. We decided I wouldn't be needing the part in the dental section in this hospital: Estaria interesado en un tratamiento que le pondria los dientes mas blancos? Would you be interested in a treatment that could make your teeth whiter?

Clinical days: from Leishmaniasis to agonal breathing

Hospital in Central Lima:

Saw a case of andean cutaneous leishmaniasis wednesday morning, which is endemic to the patient's hometown, San Lorenzo de Quiche (or Quito, can't remember now). She had two lesions, one on the face and one on the forearm, that were black and necrotic in the center. Each was about the size of a quarter. One was superinfected. Otherwise, she looked and felt well. The diagnosis is biopsy with Geimsa or Leishman stain. I didn't know that the parasite (called the leshmania parasite) is intracellular and only a little bit larger than bacteria. The vector is a sandfly. The treatment is pentavalent antimonials (no idea what that really means ) and antibiotics for the bacterial infection. The differential diagnosis was cryptococcus, anthrax, TB, if I'm remembering correctly.

We then heard about a a case of likely lamivudine-induced anemia (which apparently is unusual) and a case of neurcryptococcus.

Hospital in El Augustino:
Yesterday I went back to the HIV clinic for the morning. I found a combi that avoided the market of trash that the other combis pass through, which made for a more pleasant ride.

The HIV clinic opened in 2004 in June, when antiretrovirals started being offered in Peru. They have enrolled 318 patients for ARV treatments, had 5 suspensions of treatment, 12 who abandoned, and 21 deaths. There are 278 currently on antiretrovirals.

Yesterday was a heavy day. Maybe being in the States so recently made the poverty, illness, and barriers to improvement (economic, social, and political) seem unusually hopeless.

One woman wanted a letter verifying that she had been ill and unable to work so at she would not have to immediately pay a school tuition fee for her son. She wanted the letter to say that she had cancer instead of HIV. The doctor agreed that telling that she had HIV could create problems with stigma for her son, but that he wouldn't lie. They brainstormed a few solutions and he sent her to the office where he thought they would be able to adequately justify her illness without giving the diagnosis.

I went to the internal medicine floor with the infecitous disease consult MD. We looked in the room of a patient with neurocryptococcus who the MD said was going to die soon. I didn't get the whole story since we moved on quickly. The patient was stripped to the waist, and on nasal oxygen coming from a tank that looked like a torpedo. His back was arched and heaving with each breath, at least every second. A cachectic woman placidly sipped from a cup, watching him across the room. It was a disturbing scene.

Then we went into a room with 4 young people in beds. The first was a woman about my age. Yellow. I realized I had never seen a very young person wasted and dying. She looked, for example, extremely different from the child cancer patients I had seen on my pediatrics rotation. Her eyes closed, I thought she might already be dead when we first walked in.

She had abdomenal distention and yesterday, the MD told me, when they had done a paracentesis to look at the fluid, it was milky. It should be clear. She previously completed treatment for TB, and currently has no fever and no pain, just fatigue, diarrhea and abdominal distention. And AIDS and cachexia.

3 other young people in the same room with HIV. One with vision complaints and a positive tinta china (india ink I think) and a low ADA- I guess this helps distinguish TB from neurocryptococcus. She was being started on amphotericin, which costs 70 soles an ampule (about 22 dollars) and she would need an ampule a day for 2 weeks. The other two patients in the room - two men - had chronic diarrhea, and the other had unwitnessed convulsions with loss of continence. The doctor asked the healthier patients how the sickest young woman had slept through the night. She slept well, they said, but she isn't eating anything. The yellow girl nodded the skin clinging to shape of her skull in agreement.

Then back to the clinic for some more patients. Then to the pediatrics floor. First we saw an 8 year old being started on antiretrovirals who was adorable and playful. His grandmother was with him. His mother had died a few years ago. Then we saw a 3 year old with HIV and sagging skin and diarrhea, crying inconsolably. He was from an abjectly poor family. His mother said she could hardly get him to eat, even if she brought him whatever he wanted. He cried miserably for the 30 minutes we were there. I was on the verge of tears. Leaving the room, I thought, pedriatrics could break a person.

Visiting MD
There's a young US MD here visiting for a couple of days who lives and runs projects in another part of Peru. She's one of those people you meet and think, now there's a version of what my future could be like. She told me of her failed attempts to implement various tests. Hard to imagine my project will have a different fate but will continue to suspend disbelief.

Welcome back to Lima -luck and a pickpocketer

Despite the lost luggage, the cancelled contract of the person key to my project in Arequipa, and the slimly avoided pickpocketing, it is surprisingly good to back.

It is summer in Lima and I feel like I've come back to a different city. The climate is sultry and .... SUNNY! I woke up to the depressingly gray garua, but in a few hours Lima was transformed - light pouring over everything, everyone in sandals on the way to the beach.

I moved from my old apartment today into one of the rooms in Bob Gilman's. Because of all my anticipated travel, I didn't (don't?) expect to be in Lima much.

I took a break from unpacking to swim at Regattas and when I got down to the beach it was teeming, shockingly so. It looked as if you could walk in the water on heads for the whole length of the city.

I had to figure out different buses coming from my new home and didn't realize there was such a crowd until I was already in it being pushed along.

I was overly cautious because this was the first time I've carried a backpack in Lima and also because there were more groups of young boys ( half naked on their way to or from the beach) than I'd ever seen in Lima. Sunday on summer vacation I guess. I carried my backpack in front of me and told myself, Be prepared to not be too upset when it happens. You have entered a high risk body-grabbing environment.

I heard someone spit and felt something wet hit the back of my pants but just kept moving. A woman tapped me on the shoulder and said, "Senorita! Sus pantalones!" I thought maybe someone was trying to point out something sticking out of my back pocket and reached one hand behind, and realized my pants had no back pocket. "Senorita," she insisted, tapping again. "Sus pantalones stan completamente sussio!" (Your pants are completely dirty) I quickly glanced backwards and when I turned back, a man holding a child's hand had his other inside the front pocket of my backpack, between the fingers of my other hand.

"HEY!"

The man dropped the used phone card he already had in his hand and looked as if he had walked in on someone in the bathroom, very apologetic and nearly embarassed.

When I saw that look, I didn't even feel angry. I was confused, I thought there was clearly some mistake. I quickly moved out of the crowd and only about 5 puzzling minutes later, did I register exactly what had happened. Maybe it was the childs face Fortunately all I had in the pocket was a used phone card, and he didn't even take that.

The nimbleness of the would-be thief's fingers was impressive. I wonder if he said to his wide-eyed son beforhand, "See that gringa? Let me show you how this is done...."

I made some mistakes here and the situation could have been avoided, mistakes, (ahem- for the reader or two who loses sleep over me being here), that I will not make again!

Feliz Año Nuevo

Mt. Sinai Medical School overshadowing the dustbowl in the East Meadow.
Santa Claus, in his traditional Christmas Eve visit to our family gathering, decides my cousin has been good this year.
Wreath maintenance.
The monolith that is the Annenberg Tower at Mt. Sinai reflected in the Jacqueline Kennedy Onassis resevoir.
Grand Central Station decorated for the holidays.