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?

Semana Santa

So it turns out that Semana Santa (Easter week) is a big deal here in Quetzaltenango. All the businesses close down mid-week and everybody heads to the central plaza. Artisans make murals out of dyed sawdust on the street.

There are many processions through the city. These parades have a stronger ceremonial feel than their North American counterparts, such as a 4th of July or Macy´s Thanksgiving Day parade. I suspect it has something to do with the religious element. I thought about asking the people standing next to me to explain what was going on, but that ugly Jews-killed-Jesus business always seems to come up this time of year. I kept my big mouth shut.

My observations: the processions are dominated by the purple-robed people. The elders line the crowd and clear the way for the statue-bearers. The statue bearers are younger purple people, charged with lugging the heavy statues of Jesus et. al. through the streets. White-clad incense bearers scuttle back and forth between statue bearers.

Then come the girls in bridal veils. In the procession this morning, the girls carried a sign that said "virgins." The virgins were followed by the buff statue-bearing ladies (not pictured). The band brings up the rear, playing somber religious numbers.

I thought the general tone was somber, but most of my fellow on-lookers appeared to be in high spirits. Ice cream was the most popular snack this morning. Last night there was a lot of elote-eating (corn-on-the-cob), which is served dripping with mayonnaise, ketchup, and hot-sauce. I scarfed down a few pupusas. Pupusas are corn tortillas filled with cheese, beans, and/or pig, with cabbage salad and spicy sauce on top.

They are a staple in El Salvador, but popular here in Guatemala too.

Goodbye Dreamteam...

This is the last pic I snapped of our Puerto Barrios team. From left, Jose Luis (doctor, Patagonia Argentina), Àngeles (logistician, Cadiz Spain), Conrado (nurse, Medellin Colombia), Nell (spaz, nomadland), Nuria (nurse and coordination, Canary Islands Spain).

I miss them already. Trying hard to detach on my vacation. Nuria´s head is blocking out my new beefy phisique.

Dysphoric No More

Over the past several months, I have been feeling increasingly certain that the username "Dysphoric" no longer suits me. This is a very good sign, ¿no? Sure, I want to paint it black most of the time, and I´m usually the most cynical voice in the conversation. But what about all the good times? How can somebody who has so much fun call herself dysphoric? I may just quit my often overwhelmingly sad day job and try my hand as an aging rock-star (pic at left on air drums during car ride to Coban, Alta Verapaz).

So, I kill you off, dysphoric. I now go by the name nomad. Funny-- all I had to do to feel better was escape the NYC psychiatrists for a year (no offense Susan, Tanya, Andrea...)

Vacation

I took this from the main plaza of Zunil, a contemporary Maya village near Quetzaltenango.

The green tree-like thing at right is part of the Semana Santa festivities. Everybody is carrying around palm-type leaves. I´m not sure why.

Below right is a mask shop in Chichicastenango.

New Atul Gawande Collection

Is there anything Atul Gawande can´t do? He works as a surgeon at one of the most prodigious academic hospitals in the world; he has published dozens of fascinating medical-related essays in the New Yorker, his second book is about to hit the shelves, and he is the father of three undoubtedly brilliant and beautiful children. All that, plus great taste in music! The New York Times discusses his second book and ipod playlist today.

If you have not read any of Gawande´s essays, I recommend that you correct that ASAP. His first collection, Complications, is widely available. Or, click here to read Naked, a short essay about the physical exam that was originally published in the New England Journal of Medicine in 2005.

I am on vacation, by the way. In addition to coveting Atul Gawande´s talent, I am catching up on book reviews online and exploring the Western Guatemalan highlands.

Takes My Breath Away

I will miss Guatemala's spectacular physical beauty...

But I will not miss the Tuberculosis Disaster here (yes, I know the X-ray is backwards).

Going Home

The Doctors Without Borders headquarters in New York sent me an email last week. I am booked on a flight from Barcelona to New York on Friday April 13th. I have to go from Guatemala to Barcelona "on my way back" to New York for a Debriefing with the MSF-España staff. I will debrief the week of April 9-April 13th.

I am going home! I will smother my loved ones with kisses. New York in the Spring: the music, the books, the art, the sushi, the smell of urine in the subway! All the languages and smells and different-sized people everywhere. ... the creative geniuses crowding the streets, bumping into the brainless bigots and mentally ill ....There are at least 15 single-malt whiskys I´m dying to try up in Angel Share, on 9th St., near St. Mark´s. Then I'll walk over to Moishe's on 2nd Ave and eat some Triangles and a Babka or two. I am super excited (no ironic tone here--I am told it is hard to tell).

But, my excitement is not without ambivalence, I´m afraid. I will miss my fabulous teammates/housemates, who have been half temporary siblings and half best friends. What will happen to our clinic? To our patients? Also, as my remaining time here in Guatemala shrinks, a few ugly little thoughts nag my brain. For the last 8 months I have had to shamefully admit my citizenship to people who think of the US as a land of bullies, war-mongers, and money-grubbers, rather than the Land of the Free and Home of the Brave. Now I´m going back to commune with the bullies and money-grubbers. "The people are different than the government," I´ve said. Well, some of us are kind-of OK. Right? I think so. Whatever the truth may be, I need to rest my overworked shame receptors for a bit. They are so tired...

My life has changed while I have been away. I don´t have an apartment or house in the US, for example. And, oh yeah, I don´t have a job either. Freedom! Opportunity! Fear of Health Insurance lapse! United States--here I come.

Working Hard in Guatemala

With Ángeles, on the shores of Laguna Ipala, a crater lake atop volcano Ipala in Chiquimula, Guatemala.

Logistics

Expertise in logistics is one of MSF´s greatest strengths. Efficient logisticians get supplies to disaster sites quickly after an emergency. They also are in charge of security, administration, and finances in the field. Most of all, they are problem solvers, the handy-types with common sense (Lola Evans, you were born for this job!). If the lights go out, go find the logistician. What?? There is no Fluconazole? Tell logistics I need it by tomorrow.

Logisticians come from diverse backgrounds, training, and education. Some of them are ex-military, some are engineers, some mechanics, and others are water or sanitation experts. Mary Ángeles (at left, in black sweater), our current logistician in Puerto Barrios, says that the most important quality in a logistician is curiosity and willingness to learn new skills. She also says it is the best job if you are a woman who happens to like men, as the male:female ratio is about 6:1.

These pics are from the logistics conference that Angles and Rafa attended in January. There were 25 men and four women. They had workshops on car fixin, water chlorination, antennas, and how to play tug-of-war with your vehicle. Note Rafa´s butt in pic below right, just in front of the rear wheel).

Fungal Pneumonia

Marvin, ELAM, and Cuban Doctors

The

Marvin (pic at left) is the new doctor I am working with at the Hospital Nacional Puerto Barrios. He will take over as the Infectious Disease clinic doctor when MSF leaves Puerto Barrios. Over the next couple of months we will see patients together. I am teaching him everything I know about HIV.

Marvin was born in Coban Guatemala. He went to medical school in Cuba. He was in the first graduating class at the Latin America School of Medicine in Havana Cuba (also known as ELAM). After he graduated in 2005, he returned to Guatemala to work.

ELAM is a fascinating place. It is one of the largest medical schools in the world, and certainly the most diverse. There are currently about 10,000 matriculating medical students from more than 25 different countries (the majority are from Latin America). The school trains students from poor countries who do not have access to medical education. All students are given free tuition, room, and board for six years while they study medicine in Havana. They are encouraged to return to their home countries to practice medicine after they graduate.

There are currently about 100 ELAM students from the United States. The students are recruited and screened by the Interreligous Foundation for Community Organization (IFCO). Most of the North Americans at ELAM are from underrepresented minorities in US medicine.

There happens to be an article just this week in Slate about ELAM and Cuba´s system of medical education. It reports that Cuba has more doctors per capita than any other country in the world. Another recent article in the Economist discusses Cuba´s tradition of exporting doctors to sites that need medical help after natural disasters and emergencies. The article says that about 1 out of every 3 Cuban doctors practices outside the country at any one time.

How is it that Cuba can afford to train poor American minority students while the US can't manage to do so? How can Cuba manage to send thousands of doctors abroad to take care of the poor after International Emergencies and Humanitarian crisis, while almost all of the doctors in the US are too busy trying to pay off their medical school debt (average debt of graduating medical students in the US is currently somewhere around $100,000)?

Mancos, Tuertos, and My Weekend Strike

My Spanish is improving at an infinitesimally slow pace. The process of learning a language in my old age has made me appreciate the importance of words in a whole new light. I never realized how important it is to my well-being to have just the right word to express my idea or feeling at any particular time. The converse, of course, is the frustration of not having the right word, and having to choose the next best available choice, which is often does not convey anywhere near the idea I want to express. What´s the point of talking at all?

But, as I get better, I am starting to think that Spanish is a better language than English. I´m no linguist, obviously, but Spanish seems to be more organized, for one, with more rules and less randomness than English. You can make verbs from the nouns, and nouns from the verbs. You can increase and decrease the size of things simply by tacking on an ito or issimo to the end of your adjective. And there are many important words that have no English translation. For example:

Manco- A person with one arm
Tuerto-- A person with one eye
Cojo-- A person with one leg
Also, Madrugar (to get up at the crack of dawn), is a handy word for an unpleasant concept.

Despite the above advantages, it has been hard to live in a world where I don´t have the slang I need and I can´t throw around bad grammar just for fun, like I do in English. I tire of sounding stupid and being misunderstood. I am on strike this weekend, actually. No more Spanish for me until Monday. I need my rest, as I had to madrugar today to round at the hospital. There is a tuerto on my service who needed some attention.