Food Scarcity and HIV in Uganda

The New York Times published an article today on Food Scarcity and HIV in Uganda. It's actually more of an opinion piece/narrative than a true news story. The author is a grad student in Public Health who is researching whether food scarcity and transport costs affect health outcomes in HIV patients. Duh!

As obvious as the answer to this question is to Mr Tuller or to me, I agree with him that it is important to study and publish the results. Otherwise Aid money will not help pay for food in patients who do not have enough to eat, much less for transport costs. How can we afford hundreds of dollars per patient per year for ARVs, but not a few dollars per month to help cover food costs?

Our program in Busia does not help patients with food costs and does not pay for transport to clinic. Most of our patients do not seem to be hungry, but I would say the majority of them have trouble scraping together enough money to get to clinic for scheduled visits. They often request less frequent appointments. This puts us in a difficult position; we would like to see new ARV starters weekly, rather than monthly, but often the patients cannot afford to get to clinic even once per month. On the other hand, the Kenyan Ministry of Health does not cover the full cost of medicines dispensed by public hospitals, much less the cost of food or transport. Some people would argue that Aid organizations should not cover costs for medicines, services, food and transport because such programs are not sustainable once the aid dries up. Complicated issues come up when you are dealing with poverty and chronic care. I think this is why MSF prefers to stick to natural disasters or conflict situations. It's less complicated when you can just come in during an emergency, help patch things up, then leave.

Lucy

is my new colleague and housemate. She is a nurse from London who has been with MSF on and off for the last seven years: Congo, South Africa, and somewhere else I can’t recall. I can’t help but contrast Lucy to the nurses at my old job in NYC who always seemed to be out on break. She is bright and hard-working (shown discussing PMTCT with Gabriella at left above). She uses funny expressions like "bips and bops," as in: "I'm going round to the office to collect the bips and bops I've left there." I think it means odds and ends.

Lucy knows more about tropical medicine and HIV than most of the doctors I’ve met in academic medicine. It makes me happy to think about the HIV negative babies who might have been born positive if Lucy had not been in charge of the Prevention of Mother to Clild Transmission program (PMTCT).

Top 10 Humanitarian Crises of 2007

I always love year end "Best Of.." lists, especially Jenny Davidson's annual best books list, and Brooklynvegan's collection of links to year's best indie rock albums. On the not-quite-so-lighthearted-side, MSF-USA publishes an annual top 10 most underreported Humanitarian Crises list.
The "top ten slideshow" is also worth a look. The picture of a the mother in blue from the Central African Republic is particularly electric.

Ebola

There is an Ebola Outbreak in Uganda. WHO reports that there have been 93 cases since early December, with 22 deaths so far. MSF sent teams from Barcelona and Switzerland to help with infection control. Kenya set up a tent at the border--just 3 km from our home-- to screen people entering the country from Uganda. We were called by a public health officer last week and rushed over, but it was a false alarm. I think I was the only disappointed member of the team. A case of Ebola! Now that would toot my horn.

Ebola is one of the filoviruses. It's clinical syndrome was detailed in The Hot Zone, a popular press description of the Ebola outbreak in monkeys in Virgina in 1989. I've read a few medical textbook descriptions of Ebola haemorrhagic fever which do not sound anywhere near as dramatic as the monkeys in the Hot Zone, who bled from every hole, crack, and crevice. Apparently the true clincal picture is much more akin to garden-variety septic shock, perhaps with a few scattered hematoma or petecaie thrown in. This leads me to wonder how a clinician practicing in Congo or Uganda would ever suspect ebola in the first place. Surely you can't go crying ebola over every fever, sore throat, headache and hypotension that walks into your waiting room.

According to Manson's Tropical Diseases, there have only been 20 or so Ebola outbreaks since the virus was first characterized in 1976. Manson says that primates probably are not the natural reservoir for filoviruses because they always get sick after infection, just like humans. A true natural host would have "latent infection," which means that the animal could harbor the virus without getting sick. There have been innoculation studies in bats that show asymptomatic viremia, which might indicate that bats are natural hosts. I guess I will stay away from bat infested caves if I ever get up to Uganda again.

Happy Hanukkah Hoboken

If I were in the States right now, I would be celebrating Hanukkah the way I usually do--front row center at Maxwell's in Hoboken for the eight annual YLT Hanukkah shows. Celebrating as the only Jew west of Kisumu just doesn't feel the same...

World AIDS Day 2007

Last year I posted a link to this picture on World AIDS Day. This year I thought I would post the actual picture. I don't exactly have permission to post this image, but I hope that Partners in Health (PIH) would not be mad, because I always use it to help patients in the spirit of PIH's treatment model of free health care for the world's neediest patients. We actually have posters on the walls of our clinic in Busia with this same picture along with explanations in Swahili of the benefits of ARVs for patients with AIDS.

The picture is of a Haitian man with HIV and TB who was (and presumably still is) a patient in the Partners in Health clinic in central Haiti. The left is a "before" image, when he was sick with HIV and TB. The right side is the "after" image, taken just six months later, after he was treated for TB and started on antiretrovirals (ARVs). I generally show this picture to patients before starting them on ARVS. I think it expresses the power of ARV treatment better than any speech I could come up with.

Amsterdam

is too good to be true: picturesque waterways, restored townhouses, tolerant Dutch people zipping around on their bicycles. I didn't make it to many of the museums-- too distracted by the endless bars, cafes, and coffeeshops. The average corner cafe has a wide-selection of Belgian beers on tap, smoked salmon and watercress sandwiches on thick brown bred, and homemade apple cake. Three or four of those establishments on a single block! With so many pubs to patronize, how can anybody be expected to get anything done? We ate (dad with college roommate at candlelit restaurant, at left below) and shopped (wide-eyed sister at bonbon-central, at right below).







I'm back in Busia now, dragging the odd feelings that come with rapid movement between sleek European capital and rural Kenyan village. Downtown Amsterdam vs. downtown Busia pictured below.

Holland

I'm on vacation in Amsterdam! I'm in heaven. I suddenly don't want to go back to Busia again. I'm going to stay in Amsterdam forever. More to follow.

Stephin Merritt on Project Song

I'm sick of thinking about global poverty. This article about Jeffrey Sachs pushed me over the edge. One billion people living on less than one dollar a day? I need to block that stat out until I can deal with it. Instead, I'm holed up in our office trying to forget that I'm smack dab in the middle of a community that fits that definition.

I'm entertaining myself with the new NPR music website. I'm not usually a big NPR fan. It's probably just a rebellion thing, because my parents always had it on in the car when I was little. But this new NPR music website is the coolest! They have music reviews, mp3s for download, musician blogs, live concert streams, and "project song" reports.

In Project Song they give a musician 48 hours in a fully equipped studio to write a song that is supposed to be based on a word and a picture. Stephin Merritt, the brilliant lyricist of the Magnetic Fields, wrote a song based on the word 1974 and the picture above left. You can watch a video of the creative process or hear the All Things Considered report here.

By the way, the Magnetic Fields have a new album coming out soon. They are also playing in NYC's Town Hall in February. I want to go if Lola or Yu will go with me.

New Look

I was just trying to change the margins for a quote on that last post, but the code in the template style box gave me a headache. I changed the whole template instead. I like the colors in the new template, but the margins are still wrong. The body text is too long and skinny, and the side bar is too fat. There's no going back though, this is my new look, at least until tomorrow. Does anybody know how to change the margins? Lola, where are you when I need you?

PLoS Medicine- Poverty and Global Health Issue

Check out PLoS Medicine's October 22nd issue on global poverty and human development:

We asked a wide variety of commentators worldwide—including clinicians, medical researchers, health reporters, policy makers, health activists, and development experts—to name the single intervention that they think would improve the health of those living in poverty. We also asked four individuals living in poor, rural agricultural communities in the Santillana district, province of Huanta, Ayacucho, Peru to give us their response to the question, “What do you think would do the most to improve your health and the health of your family?” (The four community members were Severino Rojas Poma, Mercedes Vargas Soto, Julián De La Cruz Chahua, and Martín Rojas Poma). Our October 2007 Editorial discusses this debate further.

Of note, now that I live outside the ivory tower, I appreciate PLoS's open access publishing. What's with medical journals charging $30 to download scintific studies that were funding by taxpayer money in the first place? This is just another hurdle for students, researcers, medical schools, doctors, and hospitals in poor countries that can't afford subscriptions to scientific journals.

PLoS Medicine believes that medical research is an international public resource. The journal provides an open-access venue for important, peer-reviewed advances in all disciplines. With the ultimate aim of improving human health, we encourage research and comment that address the global burden of disease.

PLoS Medicine (eISSN 1549-1676; ISSN-1549-1277) is an open-access, peer-reviewed medical journal published monthly online by the Public Library of Science (PLoS), a nonprofit organization. The inaugural issue was published on 19 October 2004.

Mama Chapati

sits right near our office every morning from about 6am to 10am.She makes these delicious things called chapatis, which are like a cross between tortillas and naan. When I walk past her on my way to work she shouts "Karibu Chapati," which I think translates to "welcome chapati," or maybe "you are welcome to chapati." My colleage at work said to to be careful of them, because apparently they "go straight to your hips." I buy one every morning nonetheless. They are definitely worth it.

Send your old digital camera to Sue Johnson

My friend, the lovely and talented photographer Sue Johnson, has been working with a photography collective in South Africa for the past 3 years. I met Sue in 1987, right after she left St. Cloud Minnesota for college. She had a perm then, and looked a lot like Meg Ryan back in the When Harry Met Sally era. she doesn't look like that anymore, but she still has huge blue eyes and amazing legs. She's married, with two small children who were both born in South Africa. Sometimes she collaborates with her husband Joe on his Radio Diaries documentaries. Haven't heard Thembe's Radio Diary about living with HIV in South Africa? Go immeadiately to www.radiodiaries.org

Back to the photography collective: It's a mix of young people and long-time street photographers. They have been documenting their lives in the townships, one neighborhood at a time. Click on the link above to see their work.

Sue says the group is growing and they need more equipment. They are looking for
used:

* used point and shoot or SLR digital cameras (3.2 Megapixels and up)
* Battery chargers
* Flash Cards or Memory Cards
* laptops
* hard drives
* firewire cables and power chargers
* photography books for the library

If you have any of the above equipment lying around since you bought a newer model, consider donating it to Iliso Labantu. E-mail Sue at sue@suejaye.com, and she will arrange to get your donation to South Africa.

Iliso Labantu -- The Eye of the People

Neighbors

These women sell roasted corn-on-the-cob at the side of the road near our house. They were delighted when I took their picture (at left above), and even happier when I gave them the hardcopy that I ordered from www.snapfish.com (at right below, with picture in hand). The woman in the middle called me "a nice mzungu." Now everybody on the block wants a picture.

Found on Office Floor

Actually, right at the office doorstep. James the guard chopped it in half with a stick (note protruding innards). James doesn't know what this type of snake is called in English, but he assures me that it is dangerous.

Fabulous

This is Christine, the administrative Assistant in our office. She wears fabulous outfits like this one every day. She's going to teach me how to tie an headress. Also, how to carry things on my head. I'm practically the only person in Busia who can't carry a 10 liter bucket full of water on my head.

Homesick

Western Kenya is interesting, but I've been thinking about New York this week. I miss visiting Aoibheann and her beautiful mzungu baby in Brooklyn (pic at left taken last May), then walking to Fort Green to sleep over at Lynnie's. I miss drinking whiskey with Lola while watching the Red Sox whoop the Yankees.

This ("X marks the Spot") made me miss the NYC nightlife. I've also been yearning for a visit to Economy Candy. And of course I miss my sister-- the hostess with the mostest--and her chocolate cake.

Flood Report

Here is an interview with Elena, our head of mission, about the flooding in South Busia District.

Floods in Budalangi

Since mid-August there has been flooding in the Budalangi region of Busia District. Part of a dyke near Mukabola health center gave way. The picture above shows people standing at the broken end of the dyke on day it collapsed. Apparently this happens almost every year at the end of the long rains. Year after year, the people in the area are displaced by flooding until the water evaporates and the dyke is repaired. Then they go back to their regular houses, or build a new hut if the old house was destroyed. According to members of our team who work at the health center, the water levels are higher this year and more people are displaced into makeshift camps. I'm hoping they build a stronger dyke this time around. They said the last one was weak becuase it was built by a "lady engineer."

Because MSF is a NGO dedicated to medical care in vulnerable populations, we are focusing mostly on health-related consequences of the floods. Gabriella, the doctor I work with from Argentina (pic in canoe below), goes out by bike, boat, and on foot to make sure the rural clinics have enough medicine and supplies. The logistics department also helped with building latrines and distribution of water tanks, mosquito nets, and water purification tablets. The pictures below show people displaced by the floods in their camps.

Chauma

I usually eat at home. We have a cook who makes a lot of delicious food. But every once in a while the New Yorker in me feels like eating out. There are only a few restaurants in Busia. Chauma is one of the best.

The only problem with Chauma is that it takes about two hours (minimum) from the time we order to the time the food makes it to the table. We've started going there at noon to order for an 8:00 pm dinner. When I saw the kitchen (pic at left), I understood why it takes so long. There are live chickens (not pictured) that run around until somebody orders chicken. Some of the mini-stoves burn firewood. The staff probably goes foraging for firewood after we order. The food is always delicious though!

HIV, Circumcision, and the Luo People of Western Kenya

The Washington Post ran a story on Friday about the high prevalence of HIV in the Luo tribe of Western Kenya. The article argues that it is due to the Luo tradition of shunning circumcision.

Over the last ten years, large clinical studies have shown an approximate 50% relative risk reduction of HIV with circumscion. I find this counterintuitive. It seems like the foreskin would act like a protective barrier. But this is not the case. A recent review of the subject in the British Medical Journal suggests that the penile foreskin puts men at risk for HIV when it is pulled back during sexual intercourse. HIV can freely enter the non-keratinized mucosa of the inner forskin layer. The outer layer of penile mucosa in circumcised men is keratinized, and therefore more difficult for the HIV virus to enter.

Traditionally the Luo do not circumcise young men, whereas most other tribes in Kenya circumcise boys on the brink of adulthood. The Luo Elders believe that circmcision robs manhood. Instead of circumcision, the Luo traditionally welcomed their young men and women into adulthood by whacking out six front teeth. The Luos I work with in Busia confirm this practice, but say that it stopped back in the 1950s. Many of their parents and grandparents are front toothless.

The Wasington Post's article exaggerates the benefit of circumcision, however. I do not agree with the article's assertion:

AIDS emanated from the jungles of Cameroon or Gabon but hit massive epidemic levels after reaching the uncircumcised tribes around Lake Victoria and, later, southern African tribes that had abandoned their own traditional circumcision rites. These differences help explain why West Africa, where circumcision is routine, has HIV rates much lower than in Southern or East Africa.

Who dreamed that up? How did it get past the editorial staff? It's true that the association between higher HIV risk and lack of circumcision has been shown in many studies, but the effect does not account for the magnitude of AIDS infection in sub-saharan Africa. Lack of circumcision is only one of many known HIV risk factors. Poverty, sexual practices, geographic mobility, prevalence of sexually transmitted diseases, and other complex socioeconomic factors likely all contribute to HIV risk. In the Luo communities, for example, both the fish-mongering economy and the tradition of wife inheritance also contribute to the high HIV prevalence. The practice of trading fish for sex is still a big problem in the fishing communities of Southern Busia district. I do not know much about wife inheritance. I will ask around.

Paper-Pusher

I've spent the last few days collecting data and churning out the reports. I did my weekly report for Aug 27th-31st on Friday. On Monday, I started my monthly report for the month of August. Now I'm working on the May-Aug Quarterly report. Every once in a while I break the monotony with a meeting about one of the reports, or writing a report about a meeting. Luckily I will not be here the last week of the year, when some poor sucker will bring in the New Year with a simultaneous weekly report, monthly report, quarterly report, and yearly report.

Lamu

I spent my vacation on the island of Lamu. Lamu is off the coast of Kenya, just south of the border with Somalia. Of all the bizzare places I have visited in the world, I think Lamu might be the most bizzare. Imagine:

2 mol Kenyan culture + 1 mol Oman + 1 mol Jamaica + 1/2 mol Bronx NYC, + 1/2 mol Saudi Arabia + 3/4 mol misc Europe ------> add heat ------>POW! -----> LAMU

I wish I could post pictures, but unfortunately my camara was stolen by a machete-wielding thief (more on this when the PTSD clears). I will try to use words to describe the island, although my pics would have been better.

There are not cars or bicycles on Lamu. The only forms of transport are donkeys and boats. There are supposedly more than 3000 donkeys in active service. They defecate anywhere they please. The boats--"dhows"--are made entirely of wood. Many of them are hundreds of years old. The masts are tree branches tied together with bits of rope. The sails are a patchwork of misc canvas pieces stitched together painstakingly over the centuries.

Like Zanzibar, Lamu is an ancient civilization that thrived--and probably peaked-- centuries ago, during the slave-trading days. Ancestors of the current residents came from the Middle East, Europe, and mainland Africa. More than three-fourths of current residents are Muslim. It is not easy to get a beer there. The women wear creepy ninja-burkahs; the kind with a narrow slit for the eyes. I took a good pic of a ninja-woman texting on her cell phone while she was riding a donkey through town.

There is a lovely beach 3 km from Lamu town. A bunch of Italians have bought up some of the beachfront property, but you can still walk for kilometers, bothered by nobody except for donkeys and bearded men with sharp machetes who threaten to cut off your head if you don't give them your favorite black bag filled with camera and seashells.

I will buy a new camera soon, so that I can post more pictures of Kenya on this blog. Lamu will live clearly in my memory though. I recommend a visit if you are ever in East Africa. Stay away from the Shela beach down past the castle.

Oh Please!

There was an editorial in the New York Times yesterday that questions whether the US really has the best health care system in the world. Does anybody actually think that the US is even in the running? What planet are these people from? If they are from planet Earth, which drugs are they smoking? How about the award for the Most Wasteful Health Care System in the World? That is an award we can actually win.

Tony Nyadundo Plays Check-In Club

I may not be the Brooklyn vegan, but I just might be the only person blogging about the Busia live music scene. Yes, we have our very own live music venue in Busia-- the famous New Check-In Club. We went on Wednesday to see Tony Nyadundo perform. He plays traditional Luo tribe music--more specifically the Ohangla-style music, which was historically played during beer hall parties. Apparently his newest album is called "Obama," in honor of the Senator from Illinois, whose father hails from the Siaya District, just south of Busia.

When I snapped the pic he shouted "Mzungu" into the microphone, then improvised a little ditty about Mzungus. There's no such thing as anonymity in Busia-town when you are saddled with white skin. Anonymity is one thing I miss about life in New York...

Bulwani

I spend most of my time at the Busia District Hospital in Busia town. After two months of begging, however, I finally got to go with the Rural Health Team to the Bulwani Dispensary.

Bulwani is a small village in the south of the Busia District. The trip to Bulwani from Busia township starts with a two-three hour drive over deeply rutted dirt roads. When we came to the end of the road, we stopped at a small dock area on the bank of a stagnant river. We boarded a motorized wood canoe. The boatman navigated our canoe slowly through narrow channels heavily covered with interlocking water weeds (pic above). We got stuck in the weed net a few times. The boatman jumped into the water and hacked away the weed cover with a stick. Thick vegetation lines the banks. Birds and butterflies parked themselves in the trees and fluttered overhead. We passed wood canoes loaded with locals gathering wood and fishing.(pic above.


After about a half an hour, we came to an open expanse of Lake Victoria. Free from the weed network, we sped across the lake for an easy half hour until we again entered a narrow passage.

The passage quickly tapered to a shallow trickle. When we could move no further, we jumped out of the canoe and continued on foot. The water dired up after about 200 meters. We walked on a dirt path that wound its way through small villages for about 45 minutes.

We passed a primary school. The students were playing outside. Within seconds I was surrounded by dozens of schoolgirls who all wanted to touch my weird white skin. A Mzungu must be a rare sight. I felt like a hybrid of red-carpet celebrity mixed with zoo-animal. I survived, however, and we finally made it to the dispensary. The one-way trip took more than four hours. And I thought Busiatown was the middle of nowhere!

World Music

I like the music in Kenya. The most popular kind of music in Busia is Zaire's Lingala. Lingala is energising dance music--lively vocals mixed with electric guitar, drums, and a a lot of percussion. Benga, the traditional Luo music from Western Kenya, also is also commonly heard around here. It's mostly drums and repetitive male vocals, with long pulsating electric guitar riffs. It's generally not as good as Lingala, in my opinion, but sometimes suits my mood when I feel like slipping into a trace.

Although I miss all the fun I had in Guatemala, I certainly do not miss all the high volume salsa, merenge, and reggaeton. I still listen to Buena Vista Social Club every once in a while and some of the Cuban music I copied from Conrado's collection. (OK, so maybe once in a while I dance around to Shakira's Hips Don't Lie, for old time's sake). Also Mano Chao, of course, who is in the top ten playlist on my ipod. Jenny Davidson linked to a good profile of Manu Chao on her blog.

More on MDR

I wish I was at the International AIDS Soceity Conference in Australia this week. They have a special HIV-TB track, where I could submerge myself in the alarming world of HIV-TB coinfection research. I've been thinking about MDR and XDR tuberculosis a lot lately, and actually worrying about it. This is quite unusual for me--I not a big worrier when it comes to things like germs or terrorism or death or other things that normal people worry about.

For those who need something else to keep them up at night, might I suggest a review of the HIV-TB coinfection literature? For lay readers, I recommend an article I stumbled on in the Yale Alumni Magazine . For doctors and scientific-types (that means you dad), the Nature Medicine March 2007 Focus (vol 13, no. 3) is loaded with good stuff.

For those who are too tired to click a link, I am copying John Bartlett's literature review of Neel Gandhi's XDR-TB 2006 Lancet paper below [Gandhi NR; Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa; Lancet 2006;368:1575].

The purpose was to assess the prevalence and consequences of multidrug-resistant tuberculosis (MDRTB) and extensively drug-resistant tuberculosis (XDRTB) in KwaZulu Natal, South Africa.

Methods: The authors increased surveillance for MDRTB with sputum cultures and drug susceptibility testing in patients with suspected tuberculosis. The analysis included genotyping of resistant strains and susceptibility testing for first and second line drugs.

Results: Sputum cultures for TB were done on 1,539 patients; this showed 542 (35%) were positive; of these, 221 (40%) were MDRTB and 53 (24%) of the MDRTB were XMDRTB. These results are summarized in the following table:

Total tested 1539
Culture pos 542
MDR M. tuberculosis 221
XDR M. tuberculosis 53
No prior treatment 26 (55%)
HIV pos/no tested 44/44 (100%)
Hospitalized < 2 years 35 (66%)
Mortality 52 (98%)
Median time to death 16 days
Genotype KZN 39/46


Analysis of the 53 cases involving XMDRTB showed only about 50% had received prior therapy for tuberculosis, 2/3 had been hospitalized within the prior two years, and all 44 who had HIV serology were positive. Of particular note was the observation that 52 of the 53 died and the median time to death among these patients from the time of the sputum sample was a median of 16 days.

Genotyping indicated 39 of 46 strains were in the KZN family.

Conclusion: The authors conclude that this study shows the presence and potential serious consequences of XDRTB in resource-limited areas with high rates of HIV, and they emphasize the need for "urgent local and international intervention".

This is an extremely disturbing report that was presented by Dr. Gandhi at the 2006 International AIDS Conference in Toronto; in this report he finished by warning that this strain of TB could undo all of the achievements to date in the international effort to treat and control the HIV epidemic in the developing world. KwaZulu Natal is a rural province in South Africa in which about 80% of patients with active TB have HIV co-infection; mortality rates in those with co-infection are reported as high as 40%/year despite treatment for TB. The authors of the present study note that the rate of MDRTB was only 1.7% when surveyed in 2000-02, but had increased to 9% in 2003-06. XDRTB is defined as MDR (resistance to INH and rifampin) plus resistance to at least three of the six second-line drugs. In the US, these account for about 4% of the MDR strains and up to 15-19% in reports from Korea and Latvia (MMWR 2006;55:301). This susceptibility pattern renders these strains virtually untreatable (Hopewell PC Lancet Infect Dis 2006;6:710). The authors of the report summarized above emphasize four needs:

There needs to be better surveillance to determine the full extent of MDR and XDR tuberculosis in the areas with high prevalence rates of HIV.
Treatment programs need to be strengthened to improve the rates of treatment including access to second line drugs. Infection control practices, especially those within health care settings, need to be enhanced with inclusion of protection of health care workers. There needs to be simpler and more aggressive testing to detect TB and drug resistance in resource-limited areas.

In a more recent editorial comment by Mario Raviglione and Ian Smith (N Engl J Med 2007;356:656) call attention to the unique features of this epidemic that emphasizes the important points noted above. This includes the fact that most of the patients in KwaZulu-Natal province had never been treated, most had been hospitalized suggesting nosocomial acquisition, and all who were tested had HIV infection. XDRTB has been reported in at least 17 countries. Their conclusion is that the "global threat of XDRTB has great significance for the public health field" and "its very existence is a reflection of weakness in tuberculosis management".

The lab

My work here in Kenya involves very little clinical work. I suppose "Public Health" is the best way to clasify it. Maybe "Program Development" is a good subcategory, or "Monitoring and Evaluation,' perhaps? I don't exactly know. Unfortunately medical education in the United States short-changes public health, in my opinion, so I'm kind-of trying to figure out this job as I go.

My job responsibilities include lab supervision. How do you supervise a lab? Hummmmm...... nonetheless, I've capitalized on my ignorance by asking the lab techs to teach me about what they do. How fun! Catherine (pic above) is my lab mentor. She has taught me how to do gram stains, and AFB stains for TB, and blood smears, and malaria smears, and CD4 counts, etc etc. Perhaps I should have gone into hematology, or even pathology! I managed to snap the weird looking pic above through the microscope. It shows a sliver of my healthy-looking red blood cells. No neutrophils are visible, but let me assure you that they all have lovely segmented nuclei.

Hippos

near the shore of Lake Victoria, about an hour away from Busia. I realize this looks more like Tourists Without Borders, rather than MSF, but in reality we actually work too. I'm trying to refrain from writing about our work. It's hard.

Isolated

I thought I could live without constant internet access, but it turns out that I cannot. Our internet connection is broken half the time and too slow for my impatient side the rest of the time. No TV either. Has anything happened in the world since May 29th? I feel cut off from the world. If anybody feels like sending me their already-read New Yorkers or Economists, I would be grateful.

It will probably get here if you write:

Isolated
c/o MSF-Spain-Kenya
Busia, Keyna
Africa

Or send it to the MSF-Spain Headquarters in Barcelona, and they will send it with the next visitor.

Rafting the Nile

Over the weekend I went white water rafting on the Nile. Several companies based in Jinja Uganda run raft and kayak trips starting from the Owen Falls Dam, which is where the Nile exits from Lake Victoria. The dam destroyed Ripon Falls, which is the site that John Hanning Speke deemed the source of the nile in the 19th century.

Digression: Speke originally "discovered" that Ripon Falls was the source of the Nile in 1862, after a 2.5 year schlep on foot from Zanzibar to Sudan. [I put discovered in parenthesis, because some local people get annoyed with this language; they say their ancestors knew that Lake Victoria/Ripon Falls was the source of the Nile long before Speke was a ovum in his mother's ovary.] Speke’s journey is described in detail in Alan Moorehead’s epic The White Nile. Thanks to my parents, I have all 1000 pages of Moorehead’s The White Nile and it’s prequel, The Blue Nile, here with me in Kenya. I know more than I have ever dreamed of knowing about the golden age of British exploration in Africa.

Back to my weekend: We left for Uganda at 6:30 am on Saturday morning. Including border bureaucracy, the drive from Busia to Jinja took more than three hours. Luckily, the rafting company was busy with 30 peace corps volunteers who chose to raft the same day. After signing waivers and forking over more money than the average Ugandan makes in many months, we divided into rafts of 6-8 people and started down the river (pic at left is with Sharon, a midwife from the United States, right before getting into our boat).

According to the Lonely Planet East Africa Guide (and Nile River Explorers promotional material), this 30 kilometer stretch of the Nile has some of the biggest rapids in the world. I'm not expert enough to confirm this, but I can safely say that the rapids are supermassive. Our boat flipped several times, spilling all seven of us into the Nile. Even if the raft stayed bottom down, at least one of us was likely to fly out of the boat on the class IV and class V rapids. On these occasions, we were washed down the river with the current until a kayaker on “search and rescue” duty fished us out and towed us back to the raft. Each time I ended up in the river, as I sputtered and gulped down Nile water and clawed my way to the surface, all I could think about was….. Schistosomiasis!

Despite the near-drowning episodes and the annoying overheard peace corps conversations, it was a great day, and I would do it all over again given the opportunity. We rode back from the take-out point through rural Ugandan villages in an open-backed truck, The kids waved and shouted "How are you Mzungu?" The rafting company supplied BBQ and beers at Bujagali falls afterwards (see pic at right).

Found on Living Room Floor...

I'm pleased to add this photo to the highly acclaimed "Found on Living Room Floor" series...

Thank you people!

Tras un mes mirándonos mutuamente las gotas de sudor deslizarse sobre nuestros rostros en la nueva oficina instalada en la casa de los expatriados, Nuria y yo nos vamos tristes por la partida, pero contentas por lo vivido en Puerto Barrios. ¡Gracias gente!

Is It Time to Move North?

I was disappointed when MSF-USA told me I could not blog anymore due to security risk. Then Olivier sent me the link to the MSF-Canada website, where they are posting blogs from many of their volunteers, and my disappointment turned into irritation with MSF-USA. I should have known it was a MSF-USA thing, rather than an MSF-International policy. Technically I´m contracted by MSF-USA, although I´m working with the MSF-Spain operational section. I suppose I´m offically beholden to MSF-USA´s rules. I wonder if I could contract with the MSF-Canada office next time...Although then I wouldn´t have health insurance when I get back to the US after my mission. Í would have to buy my medicines to de-worm myself out-of-pocket and add my name to the roster of 40 million uninsured Americans.

Dunga

Busia Town

is basically a roadside village, 3 km away from the border between Kenya and Uganda. Boda-Bodas--bicycle taxis--are the primary form of transportation in town. "Taxi" makes them sound more civilized than they actually are.They are actually just old rusty one-speeds with a small cushin behind the driver´s seat for the passenger. They shuttle people up and down the highway between the southern part of town and the group of shops near the border.

I need to schlep the three kilometers between the hospital and our office a few times a day. I used to take the boda-bodas when there was no car available, but even with my eye's clenched shut and my hands gripping the driver I was scared. Now I prefer to ride the old tanker bike that has been passed through generations of Busia ex-pats.

Becuase the boda-boda business is one of the more important sectors of the Busia economy, bicycle repair shops/stands line the highway. This bike repair business, located under the mango tree near our house, repaired the bike I've been riding.

Innocent Muzungu* Attacked by Ratty Sheep

I was walking home from the office on Sunday, minding my own business, when a sheep looked up from his grazing, and shot me the evil eye. Before I knew it, he head butted my left thigh with enough force to knock me down in the mud. Gabriella, an Argentinian doctor who weighs no more than 90 pounds, came to my rescue. She was also head butted, but somehow managed to stay on her feet. The pics above are of the perpetrator and victom (note the sheep's-head shaped bruise).

Unfortunately, the whole neighborhood witnessed this ugly attack. Several neighbors approached us on our way home and appologized on the sheep´s behalf.

*Muzungu is Swahili for "white person," as in "how are you Muzungu?¨(frequent greeting by neighborhood children).

Please remove all liquids and store in a transparent 1liter resealable bag...

It looks like I´m not going to be able to blog much here from Busia. We do have the internet, but the connection is precarious and ssssssssllllllllllllooooooowwwwwww. I´ve aged significantly waiting for this page to load. I´m not even going to try to post a pic, as I´ll reach retirement before it uploads.

Anyway, I just want my friends and family to know that I made it here safely. It took five days to get to Busia from New York, including overnight stops in Barcelona and Nairobi, lost luggage, and cancelled flight. My final itinerary was New York--London--Barcelona--Amsterdam--Nairobi--Kisumu--Busia. I took NYC subway, airtrain, five planes, Barcelona Airbus, and several car/taxi rides. It probably would have only taken four days to get here in the days before the retarded no-liquids-allowed business slowed travel down to a snail´s pace. [Yet another reason to hate George W. Bush.] I had a heated discussion with security about whether bug repellant counts as a true spray. The security tech thought the only spray permitted is deodorant.

Anyway, I made it here eventually. I am adjusting slowly. More details if I find a better internet connection someday...

Las fiestas Gallo del pueblo

La semana pasada fueron las fiestas de Puerto Barrios. Y con el patrocinio de Gallo, la mejor cerveza de Guatemala, cuyos dueños poseen la mayor parte de la zona 2 de la ciudad capital, incluyendo una iglesia que alquilan a precio de oro para las bodas, bautizos y demás acontecimientos sociales de la elite económica guatemalteca, se colocaron unas casetas donde se ofertaba, además de la bebida amarilla, churrascos y tortillas. También había atracciones como la noria, el barco vikingo o los carros locos, todo aderezado con mucho ruido y luces de colores.
Pero uno de los acontecimientos más esperados de la feria fue el jaripeo, al que tuve el gusto de asistir. Como podrán observar en la foto de la derecha también estaba patrocinado por Bebidas Centroamericanas SA, y su producto estrella, ¡¡la Gallooooo!! –cientos de veces nos hicieron escuchar esta frase; cada artista, cada bailarín, cada presentador que salía la repetía-. Las chicas y chicos Gallo amenizaron la primera hora del espectáculo con música, baile y un concurso cuyo premio era una camiseta (playera) con el logotipo de... ¡¡Gallo!!
Después, tras una oración -con el sombrero a lo cowboy entre las piernas en señal de respecto-, comenzó la monta de toros. El que más duró encima del toro fue uno de chiquimulilla que tardó ocho segundos en caer a la arena.
Al salir del foro, nos vimos delante de un escenario sobre el que tres chicas vestidas con logotipos de Gallo bailaban. Y después, me fui a tomar unas gallos.

Curiosidades

Ayer vi un programa de televisión muy interesante de una cadena española. Normalmente en España pasan este tipo de programas muy tarde, ya en la madrugada, pero por la diferencia horaria, lo pude ver a las 10 de la noche desde Guatemala. El programa que pasaron ayer trataba de responder a la pregunta de si existen diferencias culturales en la forma de sentir. Llegaron a la conclusión de que todos somos desde el punto de vista genético exactos, por tanto, nacemos con las mismas emociones, independientemente del lugar o contexto en el lo hagamos. Si bien, las diferentes culturas dan mayor importancia a unas emociones que otras. Es decir, todos sentimos las mismas emociones, pero no tenemos la misma capacidad de identificarlas, porque en nuestro entorno no se le ha dado relevancia o porque no tenemos la palabra en nuestro idioma. Hay muchos conceptos que están codificados en una lengua y no en las otras. Por ejemplo, aunque no me dio tiempo de apuntar todos las palabras que iban apareciendo en la pantalla, y casi me mato subiendo y bajando los escalones buscando desesperada algo con lo que escribir, pao heo heo, en Hawai es una palabra que significa “volver de la pesca sin peces”; queesting, en holandés significa dejar a tu amante entrar en tu cama, debajo de las sábanas, para tener únicamente una charla; sgriob en escocés es “el picorcillo del labio superior antes de tomar un trago de whisky”; y una muy buena es senzuri, la palabra japonesa para la masturbación masculina (literalmente “cientos de frotaciones”). Shiko shiko manzuri es la versión femenina (literalmente “10.000 frotaciones”).

Después de algunas semanas de debate interno sobre mi futuro en el mundo humanitario, al ver este programa resurgió de las cenizas uno de los motivos por los que acabé siendo cooperante: la curiosidad.

No Blogging Allowed!?

I went downtown to 29th street at 7th Avenue in Manhattan again today for my pre-mission New York briefing. This one was much shorter than the last one. The bad news: MSF New York says "no blogging allowed." Well, it was not quite as cut and dry as as that, but still a major disappointment.

The communications department told me that blogs are "too live." They say some blogs were getting overly specific about daily activities and routines, and they think it has turned into a security risk. I can understand this concern in unstable settings, of course, where there is risk of violence or attack on humanitarian workers. But what about in places like Puerto Barrios, Guatemala? Does it really hurt to describe the pig-grilling routine for our goodbye parties?

Anyway, I discussed the issue a bit more in depth with my HR officer. She said there have also been problems with patient confidentiality. Any American MD who has survived HIPPA knows better than to post pictures or identities of patients. We came to the conclusion that if I blogged only about 'personal things' it might be OK to keep Whatonearthamidoinghere alive. Of course, 99.9% of my 'personal things' are of no interest to anybody. I don't think a list of my souvenir purchases or a detailed description of my new suitcase-on-wheels is worth posting.

I will discuss the issue a bit more with the Head of Mission, who has the final say, I was told. Hopefully I will be able to post a few pics of Kenya and my team. In any case, I will stay away from project specifics and the inner workings of MSF here on blogger. It looks like I will have to save these juicy details for my private journal and hippocampal grey matter.

Busia, Kenya

Tomorrow I am leaving for Busia, Kenia, by way of Barcelona. I am going to work on another project with MSF/Doctors Without Borders. Busia is in Western Kenya, right on the border with Uganda. It is right near the shore of Lake
Victoria. The closest town on the map is Kisumu, which is actually two hours southeast of Busia via car.

I do not know much about MSF's history or current work in Kenya. I do know that the Busia project is another HIV/AIDS project. Like Puerto Barrios, Busia is hot and humid. One of the biggest differences from Guatemala is the prevalence of HIV/AIDS in the area. In Busia, about 15-20% of the population is infected with HIV; Izabal Guatemala has about 1% prevalence. I know nothing about the people I will be living with and working with in Kenya.

I do not know if I will have access to the internet, and if so, how much. My guess is that I will manage to post pictures and bits on this blog every once in a while. Stay tuned...

What on Earth Are We Doing Here?

Dear Confused Friends:

That last post was written by my friend Maria de los Angeles Navarro, the Puerto Barrios logistician. [Pic at right is of Angeles looking effortlessly beautiful, as usual.] A few of you might not have understood what she wrote. She uses words that are difficult for those of us with language learning disabilities and/or hypoplastic left temporal hemispheres. Nevertheless, I hope she keeps writing entries from Guatemala. It gives the blog more of an international flavor, don't you think? And we would also keep up on the progress of MSF's work in Guatemala, not to mention gossip from Barrios. Hopefully I will find a few other willing blog contributors from the MSF staff I meet in Spain or in Africa.

Sincerely,

--Housesitting in luxury Soho loft, and readying myself to go to Kenya

The last party-La última fiesta

Hace ya más de un mes que se celebró la fiesta de despedida de Nell. Y esa fue la última fiesta de despedida que se celebró en Puerto Barrios. A diferencia de la fiesta de Sole y Rafa no hubo ningún cochino muerto. La ausencia del cerdo se compensó con mucha ensalada, guacamole y papalinas, litros de ron y unos chorizos a la brasa como único producto de origen animal. La foto de la izquierda corresponde al momento en que la fiesta se animó después de que todos habían probado el mojito especial y a alguien se le ocurrió poner música punta. De tanta gente que llegó, entre compañeros, trabajadores de los centros de salud y hospitales, y amigos de amigos, no cabía un alfiler. Como en todas las fiestas que se precien hubo alguna pelea, algún estropicio, bastantes borrachos y mucho baile. Hubo música para todos los gustos, cuando en un acto de ludicez a Nell se le ocurrió poner rock!! No tan estúpida, eh? Aunque no se salvó de bailar un merengue a lo guatemalteco. Hasta las cinco de la madrugada tuvieron que escuchar nuestros vecinos el jaleo -aunque creo que alguno se animó y se vino a echar un bailoteo-. Al día siguiente con los ojos pegados todavía despedimos en Litegua a Nuria, Jose Luís y Nell que se iban de vacaciones de semana santa. Más tarde Conrado se fue para Livington (punto). Y el fin de semana se presentó para la que suscribe como un entrenamiento de lo que vendría después. Osea, ahora. Empecemos a recoger el tinglao que se acabaron las fiestas.

Man over machine...

I have a lot to report. Since my last post, I've bounced from Quetzaltenango to Guatemala City, to San Jose Costa Rica, to Madrid, to Barcelona, then to Frankfurt, and finally landed here in New York. I've debriefed in the MSF offices in Guatemala, Barcelona, and New York. I've officially survivied my first mission!

Unfortunately, my camera and laptop are not as lucky. Both are sick with viruses, I presume. I cannot post pictures, and I can't even open my computer without beeps and and flashes and warnings that my system is vulnerable. I was on the phone with the Dell Software Tech for SEVEN hours on Sunday. It was an heroic effort, but when we said our goodbyes she said "your machine is deeply infiltrated." I'm writing now on a borrowed computer. This is just another example of human triumph over machines, I might add (remember the Matrix?). I am in great shape, but the gadgets couldn't survive the demands of their first mission with MSF.

More details and pics when the gadgets are repaired or replaced...

Más Semana Santa

I stumbled onto an even more bizarre procession today in the Maya village of Zunil. This one featured young men dressed up as Marvin the Martian, complete with blond wigs, sunglasses, and multicolored cap feathers. No rayguns. This ceremony hardly looked like Catholicism to me, but when I asked an old lady about the occasion, she said "Semana Santa."

The truth is that I am a little tired of Semana Santa (everything is closed; very stressful for a New Yorker), but I could not resist posting these pictures. The colors are spectacular, no?