Long Journey Home, Nice People

Our lab shuts down for 3 weeks of holidays, so it’s vacation!  Luckily I was able to catch up with my sister and her kids in Orlando, then go home for Christmas with them.  So now, I am writing this on my 37^th hour of my 39-hour journey from Santa Cruz to Orlando (due to much bad luck and a missed Amtrak train).

In the last two days, a lot of people have paid it forward for me:  The taxi driver lowered the set airport fare for me.  The waiter told me he couldn’t substitute ham for chicken on a sandwich. then gave me both free of charge.  The station guard walked over to confirm I had correct change for my bus fare.  The man I flagged on the street gave me a 4-block ride to the Amtrak station (he wouldn’t accept my money, and unfortunately he drove a hair too slow).  The Amtrak station lady offered me free cookies and for one of her co-workers to drive me to a restaurant nearby.  The 2 different hispanic young men in a local restaurant in Miami both looked at me and offered a “Buen Provecho” (basically “enjoy your meal”), without even judging whether I could understand it or not.  My neighbor on the train offered up potato chips, her sandwhich, and a ride from the station if I needed one.  It's amazing how far a smile will get you.  I'll have to pay it forward, as well.

Grumpy from travel, I think of two things.  (1) When I asked my taxi driver, he said he has never left the province of Santa Cruz.  This is typical- no Lake Titicaca, no La Paz, and no salt flats in their lifetime, let alone another country.  (2) An 11 year-old girl we befriended once asked us “how long does it take to travel home?”.  She couldn’t understand our answer: ~18 hours (typical).  When her family moved across Bolivia from outside La Paz, it took 5 days of uncomfortable buses and terrible roads.  And if she ever wanted to return to see her old friends, it would take just as long.  But she will likely never have that opportunity.

Night out with Rosario

At the hotel where Evo Morales,
President of Bolivia, largely disapproved
of by Cruceñas, apparently stays

This is Rosario.  Rosario would likely define herself as a 61-year old mother of 3, a converted and strong Evangelical Christian, and a Cruceña (a person from Santa Cruz, more on this semi-feud later).  Months ago, I was making small chat with her while taking her EKG.  "My boyfriend is coming, so what kind of food should he eat here?" I asked.  Her eyes lit up, and she started raving about all the dishes here.  "You MUST come to a restaurant with me!  Yes yes come!  Here is my number, call me anytime and I'll pick you up."

So Jackie and I finally felt more relaxed with the project, and we figured we should call her up.  I've actually seen her in and out of her clinic appointments, gifting me with bread and earrings and a big smile every time.

I wish I could describe her better, but she is a riot.  She had her son pick us up, and they took us to a local restaurant with a wood grill and 50-gallon pots with the 3 typical dishes served for the night.  "No, not that, something less fatty and more meat!" she jokingly scorned the server picking out our meat hunk.

Los Tajibos is where the Queen of Spain stayed apparently.  It's decked out for the holidays, and starts at $205 per night.  Compare that with the hotel down our street (a nice area), starting at 250 Bolivianos, or $32

After dinner, she made her son drive us around town to all the fanciest hotels in Santa Cruz!  She also took us to the iconic restaurant here, but it is expensive so we just walked around it, snapping photos at her request and brushing off confused waiters.

Z is for Zebu

Oh no I might have eaten you! One day
I'll go veg, not for my new friend, but
for all the social implications the meat
 industry has on the world population

The zebu, or cebú in Spanish, is a friend of the cow family.  Originating from South Asia, he is known for his hump, his floppy ears, and his dewlap.  I looked "dewlap" up, it's the hanging flop from his neck.  Apparently, these beasts cost about 500 USD monthly in feed, which is about 1-2x the average monthly salary here.  I had some today at a grill with a family, the cut turned out to be pretty chewy but not bad.

After being imported to Brazil, they have spread throughout South America (and through Africa, at that) due to their resistance to heat.  I got two answers from googling "How did the zebu get his hump?" :
(1) The people of India selected out cows with increasingly higher
      humps, which could better stabilize yokes and other carried goods.
(2) It serves to store water, and was subject to natural evolution similar to the camel.
Neither site seemed particularly reliable, so if anyone wants to write something with real sources about zebu, please enlighten us.  I cringe at the thought of spreading unverified information, but the theories were both plausible enough.

the glittery ones win the prizes at the fair!
bonus academic exercise: so what's the evolutionary purpose of a dewlap?

pellagra

Every morning we check through the paper charts of the 20 men and 20 women inpatients looking for heart diseases to recruit.  In one of the smaller rooms of two, we read of a case of pellagra by alcoholism, a severe deficiency of niacin (Vitamin B3).  Pellagra is uncommon in the world today, since it only comes from very severe malnutrition, seen in some of the poorest third world or today from alcoholism or malabsorption from intestinal disease.  In the US, it was common in the South in the early 1900s, where the diet was mostly corn, but since the development of fortified food throughout the world, it is largely prevented.  It's classically learned as being a dementia, diarrhea, dermatitis, and eventually death if untreated.

So after we finished with patients at 4:30, we decided to check him out.  We walk in, spot an old disheveled man with spaghetti sauce all over his mouth and clothes, and hone in on him.  We manage to get his name, but cannot follow a single thing after that.  Makes sense that this be the alcoholic man with pellagra dementia.  We look to the other guy in the room, our age with blisters on both arms, and confirm with him that the old man is incomprehensible even to Spanish speakers.  The other man was 25 years old, who worked in garbage removal, and explained that he had an infection that spread and now covered both forearms.

Time for the charts.  Turns out the old man had tuberculosis meningitis (think high protein, low glucose in CSF) - don't worry parents this isn't at all as contagious as it sounds.  It was the young, relatable man who actually had fell to alcoholism, been brought in by a friend, and was being treated for pellagra dermatitis which was now superinfected.  On his extremely swollen feet, you could see clearly delineated blistering sun burns where his skin was exposed to the sun through his sandals (classic photosensitivity reaction).

After I asked to take a picture of his feet, he held out his bandaged
arms for another picture.  You can see the impressive line demarcating
where his neck was exposed to the sun, causing the rash and blisters 

This was almost a week after hiss
admission.  

Jackie and I were both chatting about how bizarre it was that this guy had such an extreme of malnutrition without other diseases first.  We were flipping through the labs, a quick task as he only had the money to pay for 4 basic labs.  On his blood count, he had anemia as expected.  And we saw it- MCV of 116.  Of course he would be folate/B12 deficient as well!  We quickly stopped Everth, the resident with the cute smirk, and reminded him the patient should be supplemented with these vitamins as well.  Sometimes it feels like we don't do much for the patient care here, so it felt good to put in that two cents.

Funny Money

Front, note the tape barely holding it together.
Pantaleon Dalence headed the Supreme court in the
late 1800s, and is considered the father of Bolivian Justice

I actually haven't seen a fake bill here.  But nevertheless each shopkeeper, taxi driver, and everyday person who functions by exchanges of money knows how to check for one.  And since a good portion of the bills here are old and ripped in half, I'm constantly doing so too.  When I asked someone how to tell, they let out the secret: his mustache moves!

Here's 20 Bolivianos, worth $3.  I hoard these for my daily purchases, since with the 50 or 100 bills you often find people don't have change.

Back.  The bill has a distinct texture, and you can
pick at the corner to make sure it's one sheet

Small letters outline the Banco Central,
but it's honestly too small for my eyes.
I matched the 39337175 before
accepting these two halves

In the watermark is a face, the number 20 to the left,  and the
strip to the right. On the left edge, see the red box is shadowed
in the yellow outline, proving the sides match perfectly

This man is showing off the 100Bs bill.
Exhibiting wealth with 300 Bs, worth US $40

thanksgiving feast

Last week was packed with crazy long work days and Jackie just got back.  Saturday we handled emails, skype calls, and a meeting until 7 pm.  So afterwards we went off to the major grocery store to restock the house.  Though not wild here, turns out we managed to find a turkey!  After debating for all of a minute, we decided belated Thanksgiving must happen.  And so Jackie and I cooked our first ever Thanksgiving dinner on Sunday:

Turkey: bought frozen at the big supermarket (4.5 kg for about $30 USD), thawed overnight in the sink, stuffed with lemon and onion, cooked for 4.5 hours as directed.  However, our gas flame stove has no temp dial or control, so we ended up just leaving it in an extra hour
Green beans: boiled, topped with chopped almonds
Broccoli: boiled, with a cheese sauce my mom makes
Potatoes: mashed with plenty delicious butter
Camote: a version of sweet potato here, topped with butter, brown sugar, and a touch of cinnamon
Gravy: boiled extra turkey parts with chicken stock, flour, mushroom soup, and bay leaves.  No gravy mix packages here!
Stuffing: white bread, celery, onions, gravy, parsley
Rolls: pack of a twenty mini rolls bought at the supermarket for about $.60.  Will make next time if we plan more than 12 hours in advance.

Glad we could introduce the holiday to some Bolivians, who were a little scared at first by the stuffing and gravy ha. 
From left: Jacqueline (partner in crime), Jeong (MD from US on the project),  Lisbeth (lab manager),
Percy (administrator), Yours truly, Omar (recent MD grad on project)

I'm ever so thankful for the opportunity to be here- for the support of my school, family, friends, boyfriend, and even country.  I'm thankful for the people I work with, who are my only friends here but enough for me.  I'm thankful for the patience and kindness of everyone in my daily life.  I'm thankful for my health and that of my family and friends, especially as I see heartbreaking cases weekly.  I'm thankful for the ability to pay for more than enough food on the table, the bills, and many simple luxuries not afforded to many here.  May we all recognize our needs and our wants, which often pale in comparison to the things we already have.

I count!

We chatted over seltzer
about her role and the ID
she wears to avoid arrest

To sleep in this morning I threw a comforter over the window blinds and turned the AC down to 23 (really went wild Jackie, usually its 26!).  But just after 8 when the doorbell went "ding dong", I suddenly remembered the sound from all the commercials here and knew what day it was.  I jumped out of bed, threw on the closest pair of decent apparel (scrubs), and answered the door with a huge smile.  Census time!

For the past two weeks, the newspaper has had a front page countdown of this decennial day.  It's all over the television and the talk of the town.  But no shop even bothers to put a sign up "will be closed for census"- that's a given.  Today any Bolivian who leaves their house, without good reason, will be fined and jailed for 24 hours!  Hospitalists, EMT, police, and some other workers are exempt.

Literally, every single household is counted in one day.  All the university students are enrolled to help, setting off at 5 am to survey the grounds then begin knocking.  They get a screening (no criminals, etc) and a 12-hour instructional session.  Ha it almost seems the whole fiasco is just a way to count and ensure there will be enough future university students to help in 10 years.  But everyone knows the census data is used to distribute government money, so they must take it seriously.

"Living Censored" Now on my door!
(that's actually not the right translation)

It was actually rather quick and simple.  Level of education, house and utilities, employment, language, kids- no big surprises.  Surprisingly similar to our questionnaire for socioeconomics and risk of Chagas (we ask about house construction). Thinking of my patients, most live with 4-8 people and up, each one which needs to be surveyed individually.   My girl said my building, which has probably 60-70 apartments, is being covered by 5 students.

So, if in ten years, you want to see somewhere where one day is completely erased off everyone's schedules and daily life comes to a complete and temporary halt- come on down to Bolivia for census!

Ode to Papaya (attempt 1 of many)

I love papaya!  I really, really love papaya!  It's sooo delicious.  And so fresh.  And although a few months before I was horrified by the almost repugnant aroma inside, now it just smells sweet and tempting (when I first starting getting to like it, I had to hold my breath sometimes while eating it as not to smell it).  The little slimy peppercorn like seeds used to freak me out, but they just make me laugh and excited to feast.  Poor Jackie has to listen to this monologue every other day, and even poorer Jackie hasn't converted to a papaya lover!

Oh papaya, I already can't stop thinking about how I'll miss you.  Buying one the size of my head for $1-2.  Then sometimes eating it all by accident while cutting it.  Great in a blender with just about anything.  More vitamin C than oranges, and a laundry list of other vitamins and minerals (including calcium!).   Tons of carotene (think "carrots"), which I'm sure will some day soon cause my palms to turn orange. I could write about you forever, papaya.  I'm sorry it took me so long to write this post about you.

More fun facts: Unripe papaya contains the enzyme papain.  This is used as a meat tenderizer, and has also been used to induce abortions and help Harrison Ford's ruptured disk in Temple of Doom.  Unripe papaya also oozes latex, strangely enough.

makes me so happy : )

a long day in the life of research

Today was my first day at work without Jackie (she is off traveling the Andes in Chile!).  So it was a very long day since only our nurse helped collect patients in the morning, but it had a lot of meaningful/interesting interactions.  For anyone wondering what my days are like, here's an example of a hectic one:

6:40 wake up, breakfast with a cup of coffee
7:25 am take bus to office
8:35 interview first patient.  60 year old healthy man, first time getting his blood drawn and his pressure taken
8:50 go to cardiology clinic to drop of EKGs for the cardiologist to read.  End up taking a patient of his back to our office to include in our study.  She came in because she just developed a terrible dry cough from Enalopril (hypertension med), but she may have Chagas heart failure as well.
9:40 listen to a long spiel from the lady's daughter how I should go to their church
10:30 return results to a 71 year-old patient, who I diagnose with Chagas.  I am in my scrubs and she is wearing a headscarf, a purple hoodie, a jacket, and gloves!  have a very circular conversation with her about nothing in particular
10:45 start a third patient interview
11:25 check patient charts in the inpatient ward
12:05 leave for lunch because the patients get lunch and I don't want to bother then
12:15 drop off photocopies
12:25 order soup and baked chicken at a lunch place (they serve an option of two meal plates)
12:28 eat soup as always to start.  get a plate of fried chicken
12:29 remind waitress I ordered baked chicken
12:32 watch 3 other customers get baked chicken
12:34 waitress tells me there is no more baked chicken.  asks if I want fried chicken.  I say no way, mainly out of principal.
12:40 go around looking for another thing to eat.  end up eating junk.
1:15  check email at the project headquarters with internet.  find out Nate and I are both registered for the 2013 NYC Triathalon!
1:45 return to photocopier - they did my copies wrong.  no surprise there.
2:15 resume interviews with two of the inpatient men.  one has Cheyne-Stokes respirations on exam (sounds like a wind storm came and went during cardiac auscultation)
3:45  tell two interns that they don't have Chagas.  our boss allows us to run some free tests as favors, including to hospital staff or family members of patients
4:05 get asked to do an EKG for free on another man.  turns out he is crying because no one visits him, and he thinks I can understand him (I cannot, as he speaks rapid, soft Spanish through tears, but I will stand there)
4:30 get called away to give more results.  tell another two ladies that they have Chagas, and changes in their EKGs so they both get a cardiology referral
5:00 go visit a laboratory because Fernando, the guy who helps me draw blood sometimes, asked me to come by.  met some people at the laboratory who want to collaborate with us.  Fernando asks if I have to return to my family in the states.  I say "of course!" then he clarifies by "family" he meant "kids"
5:40 finally get things together and finish the EKGs on the men
6:15 finish inputting basic data into notebooks
6:25 print out the EKGs and give them to the inpatients to put in their chart
6:40 run into an old patient, who tells me about how he wishes more people would visit and bring him bananas and crackers.  make a mental note to bring a banana for him.  I try to chat with him (we talked about the hospital dinner was)
7:10 arrive back at the office headquarters.  Input more data, organize some of the completed questionnaires
8:40 go to dinner with our boss from Johns Hopkins who is in town.  talk about the project
10:20 leave dinner, find a cab driver who absolutely adored having a foreigner.  he chats and wears a huge child-like smile the whole ride back
10:40 looked over a scientific paper on Chagas.  Ate some chocolate.
11:15 started a blog post
11:35 posting blog post
11:45 still editing blog post?  why?
12:00 lights out!

Everyday People

Here are some people I met or saw this weekend:

-Two children, about 8 and 13, sitting on a tarp selling toys on the street (I had just seen a commercial advising against endorsing child labor)

-A taxi driver who lived in Japan for 18 years and spoke Japanese to me (unfortunately, I can hardly speak a sentence in it anymore).  He even has been to Tsu, the city where I worked!

-A lady holding her baby awkwardly while walking in front of me.  I sped up in front of her to confirm my suspicion-  her shirt was pulled down to walk and breastfeed simultaneously.

-An 11 year-old girl who watched me read the newspaper.  I tried to explain Obama to her, then I tried to explain taxes to her (the article was about Obama's plan to raise taxes for the rich).  Then I gave up and we just looked at inappropriate dresses together (there is usually a bizarrely sexy photoshoot of teen girls for their quinceañeras).  I avoided the Victoria Secret fashion show spread.

-Two grown men, total strangers to each other, sharing the front seat of the shared taxi we were riding in.

-A lady who gave me a $3 pedicure and then was confused by my $1.50 tip, until she understood it was a tip and gave me a huge hug

-A 50 year old obese woman walking around a store in her bra finding the right size shirt for herself
-A lady selling illegal DVDs and Bluerays on the street.  I asked her for a phone card, and she had me sit there and guard her stack of movies and her piece of chocolate cake while she ran to get me a card from a few blocks away.

-My beautiful niece and nephew on Skype!  Daniel was playing good guy/bad guy with Ojichan ("grandfather" in Japanese, aka my dad) and taking cheap shots at his crotch ha.  Malea was being her silly giggly self, and decided to name our houseplant "doodeedoodabat"

Vampire Family: Malea, Daniel, and Misa
visit to the senior citizens' home in South Carolina

-

Sandy

The snippet in our paper about NYU Langone
Hospital evacuating

First, our sympathies go out to everyone who found themselves/home/family/work in the line of destruction.  NYU was devastated, with NYU Langone Hospital evacuated by candlelight- a big kudos to all the staff and volunteers.   Our three teaching facilities (including Bellevue and the VA) will be closed for at least weeks.  It sucks, but may all my classmates have patience and flexibility for this last year, and still enjoy it fully before starting residency…!  Nate went out everyday reporting, and you can feel the drastic shift in attitude in his jolly pre-storm story about businesses staying open, followed by a harrowing visit to Breezy Point.  His favorite is pitching a day in the field and calling it work – he’ll be following an organized vets volunteer group.  He told me no one knows making order out of mass chaos better those coming back from deployment. 

As for here, the front page of our paper showed NYC, and coverage continued daily.  The Bolivian government shipped 60 tons of rice for aid off to Cuba, who suffered the harsh tropical side of the storm.  As you could have guessed, Bolivia went unscathed.  When I told everyone “I’ll be safe”, I could not have imagined that I would ever be more secure here than back in NYC.

Let's Eat!

A few pictures from the last week:

Grilled sabalo at the fish market, and a lot of fish bones

Or we make our own strawberry jam with fruit from the market

Sometimes I just eat potatoes and cheese

Home-made Margs

This was delicious!  Good end to a night!

Made a simple stir-fly with ginger, sesame and soy