Vacation

The pictures on the left side of the page are taken during my day-to-day life in Guatemala. The pics on the right are taken during my "vacation" this week in NYC. No wonder I am feeling particularly confused! Sad suspicious faces, whizzing subways, liquors to dull the pain of our very existence....

I also put "vacation" in quotes because part of the motive for coming to NYC was to pick up my prescription medication that I could not get in Guatemala. My beloved sister sent my refills via DHL, but the retards who work there got confused between my office address and the dead package office (they call it "customs"). We have been waiting over 6 weeks for a package they promised to deliver in 3 days. To my delight, I've discovered that there are several websites exclusively dedicated to railing on DHL and it's shitty un-service.

Anyway, I had to pay out of pocket to replace my lost medicine. Does $550.00 for a 2-month supply seem a tad overpriced to anybody else? It's not the like medicine really works that well anyway. At least the clinical trials don't show an overwhelming effect.

Let's just pretend for a second that I was one of the > 40 million Americans who does not have health insurance. Just for one medicine, I would have to pay over $3,300 dollars per year. But luckily I have health insurance, so usually I only have to pay a $20.00 copayment for each batch of pills. Who pays for the rest? All of you suckers! Your premiums are through the roof, aren't they?

You are not the only loser. We all get screwed, because the US is spending more than 16% of our GDP on health care, instead of investing the money in education, or the environment, or free frozen York Pepperment Patties for everybody. Wherever it is that nice governments like Canada invest their money. Pharmaceuticals account for the fasting growing piece of the health care cost pie. That money we spend is buying the fancy suits that fill the pharmaceutical reps' closets. The multimillionaire pharma CEOs are spending our money on god-knows what: another vacation in St. Bart's? more botox? alimony? How could they possibly spend it all during one lifetime?

Why am I up on a soapbox today, and what exactly am I railing against? I have no idea. I think I am only bitter because I have a headache and because I feel sick and confused on my vacation and because I spent a fortune at Duane-Reade. I think the coffee might be stronger in Guatemala. On the bright side, I am delighted to see my sister and many friends, including pregnant Aoibheann. Pregnant Aoibheann looks even more beautiful than not-pregnant Aoibheann, which is saying a lot.

Touched by the Sun?

Have you read Heart of Darkness? I read it in high school. Joseph Conrad. It is a book about a guy in the military who went nuts during a war and barricaded himself in a creepy fort up-river in the Congo. Or was it Cambodia? I get mixed up between Heart of Darkness and Apocalypse Now, which was a movie which ripped off the Heart of Darkness plot. "The horror, the horror" is all I really remember...

Anyway, here I am, practically in the jungle myself. The tropical heat all day long, all week long, all month long, month after month....I am a city girl--totally disoriented by all these flowers and trees and wide open space. There is no war here, but there are plenty of problems, especially if you are sick enough to get yourself into Hospital Naciónal, Puerto Barrios. Is it getting to me? Am I showing early signs of psychosis? I know I was not dancing on tables with half-naked men when I left New York....Or could it be the rum drinks that have turned the screw a little looser?

My first case of Leishmaniasis!

While we are on the subject of neglected diseases, I am happy to report that I saw my first case of leishmaniasis last week. It was only cutaneous leishmaniasis, but I was excited nonetheless. My patient lives in El Petén, the Northernmost Department in Guatemala. Most of Petén is undeveloped jungle, filled to the brim with sandflies anmosquitoesos and various other creepy-crawlies.

Most of you probably have the > 20 leishmania subspecies memorized. I was a bit rusty. I gave myself the Leishmaniasis for Dummies refresher course, which I will summarize below:

Leishmaniasis is a protozoan parasite. Molecularly, the parasite lifecycle and pathogenesis is similar to T. cruzi, which causes Chagas Disease (see previous post). The Leishhmania parasite vector is the female Phlebotomus dubosci sandfly, which is shown above right, enjoying a blood meal from a human host (picture courtesy of Welcome TDR image bank). In exchange for the blood meal, the fly passes the parasite back to the host, where it enters Macrophages. Infected macrophages either plant themselves in the skin, or travel through the reticuloendothelial system to infect various organ systems. But this may be beyond the scope of Leishmaniasis For Dummies...

Some leishmania species give patients ugly skin rashes (callecutaneousus or mucocutaneous disease). Other species cause more generalized constitutional ailments (visceral leishmaniasis). Full blown visceral leishmaniasis (VL) is called Kala-Azar, which is one of the DNDI Neglected Diseases (see Chagas Disease below). Kala-Azar presents with fever and weight loss, as well as diarrhea, body swelling, neurologicalgic disease, and rashes of all colors and patterns. The incidence of visceral leishmaniasis is high in patients co-infected with HIV. A 2006 study published by the journal Clinical Infectious Diseases cited that 70% of symptomatic VL patients were coinfected with HIV.

There is much more to say about Leishmaniasis, but I will spare you the details. I refer interested parties to the UpToDate Monograph, CDC, and WHO websites. Also, while browsing the internet for a pic of the sandfly that carries the parasite, I stumbled across the WHO TDR website, a most useful resource. WHO TDR is short for "The Special Programme for Research and Training in Tropical Diseases (TDR)." According to it´s mission statement, TDR is "an independent global programme of scientific collaboration. Established in 1975 and co-sponsored by the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP), the World Bank and the World Health Organization (WHO), it aims to help coordinate, support and influence global efforts to combat a portfolio of major diseases of the poor and disadvantaged. " Cool, ¿no? The best part is Welcome trust´s image databank, which has over 13,000 images related to TDR target diseases.

Chagas Disease

Chagas is a disease caused by a protozoan called Trypanosoma cruzi. You haven´t heard of of Chagas? Maybe because it is only a big problem in poor areas of Central and South America. Chagas was deemed one of the "neglected diseases," along with Kala-Azar (visceral leishmaniasis), and sleeping sickness (aka Human African Trypanosomiasis), by the a non-profit called Drugs for Neglected Diseases (DNDI). DNDI was founded by seven organizations in 2003. They work with scientists and pharmaceutical companies to develop better diagnostic tests and treatment for diseases that primarily affect poor people. Poor countries cannot afford newly patented expensive drugs. Who wants to waste time designing drugs for a feeble market?

Anyway, MSF-Espana has done a lot of work on Chagas. There are on-going projects in Bolivia, Ecuador, and Olopa, Guatemala. The four bad-ass women who run the Olopa project will hand over their project to the Guatemalan local health authorities and close up the office in November 2006 (see friends from Olopa, below).

The skinny on Chagas: T. Cruzi is passed via the reduviid bug "kissing big" (see pic above left). These insects live in the cracks of poorly constructed wood houses. At night, the bugs suck blood from sleeping children, thendefecatee on their skin. When the kid scratches his itchy bug bite, the parasite is passed from the bugs fecal matter into the patient´s blood stream through small breaks in skin.

Chagas is particularly difficult to diagnose because it has a long asymptomatic stage. After the initial bug bite/feces inoculation, the parasite passes from the blood stream into muscle and nerve cells. The acute disease is generally a mild flu-like illness that goes undetected by the patient and/or doctor. After the innocuous acute phase, the parasite load in the blood stream falls, and the patient feels well. Several decades pass.

Twenty to thirty years after the initial infection, about 50% of Chagas patients become ill with the chronic phase. The most common manifestations are cardiomyopathy (heart failure) and megacolon (gastrointestinal disease). By the time a patient becomes symptomatic in the chronic phase, Chagas is almost impossible to treat.

In some United States tertiary referral hospitals (e.g. a certain Northern Manhattan medical center), some patients with Chagas are candidates for heart transplants (if they are lucky enough to have Medicaid or other health insurance, of course). I saw exactly one patient with Chagas in my 10 years in at the northern manhattan medical center. Several months after a heart transplant saved this patient´s life, her new heart failed. The medical team suspected that the parasite load increased while the patient was on immunosuppresant drugs, then the parasite swarm infected her new heart! I cannot remember whether this theory was ever proven by heart biopsy.

For more info on Chagas (including pics of Olopa), check out the MSF-Espana website "virtual Chagas tour."

Olopa

These are the famous women of Olopa. They are a common topic of conversation in our household, given their immense beauty, intelligence, sensibility, humor, and general all-around awesomeness.

Ángeles is on the left, swigging a beer. She is the logistician. Most MSF logisticians are male. They need to know how to fix the truck, install sanitation systems, deliver water to refugee camps, etc. Montse is in yellow. She is a doctor from Barcelona. I can´t understand her accent, but word has it that she is very funny. Gemma is in the pic below with Conrado (in disguise in my hat and glasses). Gemma drives the truck around to remote villages to draw blood samples and teach the locals about Chagas.

The women live together in a combined house/office in Olopa, a mountain village too small and poor to make most maps of Guatemala. Olopa is 2.5 hours from the nearest highway. It does not have any restaurants or hotels, but there is a small store and another business or two. The locals wear sombreros and carry machetes.