Camiri Camiri Camiri

The group, including Carlos the
Peruvian entomologist

So our project worked off of 2 sites for their congenital Chagas R01 (wrapping up now) and will try and restart the new cardiac R01 in both: Santa Cruz the huge city and Camiri. Camiri is a town in the dry region of the “Chaco” climate, basically a lowland desert bordering the Amazon where Chagas disease bugs are very prevalent. It was built on the oil industry, and is about 4 hours outside Santa Cruz on a 2-laned, 2-direction highway which supposedly has a name that no one knows.

Driving into the communities. Jackie later laughed "Did you
notice the fact you were drawing blood, and sitting on a log?"

For a different data set, we went down to help catch vinchucas (Chagas vectors) in the communities 2 hours outside Camiri, similar to last year. It’s a different land. Power lines run the road, on which we saw only 3 other cars all day, and we were stopped from going to some communities because of the rain. School children walking to and from lunch just gawked at us. The younger generations all speak Spanish, but most also speak another indigenous dialect (Guarani, Aymara, or Quechua, from Incans). We came to help draw blood, to then be used for stimulation assays to look at effects of people chronically bit by the bug; 1 in 1000 bites actually transmit the disease, but most all people have Chagas meaning they are bit quite a lot. Anyways it’s such an opportunity to see the simple but rich life people live out here, and I wanted to share. Heck, maybe someday you'll find my living out here with my mangy dogs and my piglets : )

The bathroom which the trufi (shared van) from Santa Cruz to Camiri stops at. The ride is about 4.5 hours for $7,
and Jackie and I bought out the row of 3 in the back so as not to squeeze. The bathroom costs 1Bs, or $0.20, and
comes with adequate amounts of folded toilet paper (flush with the water seen in the tub). At night, the speckled sky
here is absolutely stellar and out-of-this world : )

MIERCOLES!

If you have taken basic Spanish, you probably know it’s a day of the week (Wednesday, at that). So we were driving two hours into the communities on the dirt roads which had areas that were a little too muddy to risk.

MIERcoles!  Llovió mucho aca! our driver said. “Wednesday, it rained a lot here!” was the direct translation. Which was confusing because it was Wednesday and not raining, and rain from a week ago would have dried…

That’s when Jackie pointed out that Carlos and his family talk about Miércoles a lot like that. Instead of saying mierda, or “shit”, they switch it up at the last moment to say “Wednesday!”. Like saying “Shoot!” or something of the sorts.  Anyways, I think it’s very cute, and will certainly be talking about Wednesday a lot more : )

Match Day!

So after a year of applying to residencies, writing essays, getting letters of recommendation, flying around the country to visit 19 fantastic schools ranging from Seattle to San Diego to New Orleans to Boston... came Match Day.

To make sure each and every residency spot gets filled, there is a match system. Which means that each person makes a list of places they was to go, and each residency program makes a list of residents they would like (consisting of those 10-30% of applicants whom they invited to interview). Then it goes through an algorithm for 4 weeks, and everyone gets an envelope that says the name of their future residency (which is 3-7 years, depending on residency). So for me, I was looking for internal medicine residencies with a primary care program, hispanic population, good dating city, global health opportunities, and of course a rigorous training.

Our school hands out our envelopes at 12 pm on March 21. However, since we are in Bolivia, we get an email at 1 pm. Jackie and I went to the butterfly reserve/resort getaway outside of the city for the day with our friend Enzo. At 12 pm, Jackie began checking Facebook, and we squealed with joy as friends posted their happy futures online for us to see. At 12:55, Jackie got an email that let her know she was going to her #1 choice- Yale!  I wasn't ready.  My life comes in waves of huge changes. I sat for about 5 minutes just tearing up, knowing everything would change. Then I jumped in the pool, came out, dried my hands and checked my iPhone.  My assignment? Primary Care (part of internal medicine) at University of Pennsylvania! I was thrilled. My fear was replaced with relief and happiness. And then I had a freaking awesome day in Bolivia. Life isn't perfect, and I still have a long way to go to settling down one day. But things aren't terrible for the moment I suppose : ) 

Thanks to everyone for the love and support to get me this far. I'll need more of that to make it through intern year, but I know where to find it... Or do come visit Philly in the next three years!

Leaf cutter ants! It's like they hold up
signs saying "I'm here! Don't step on me!"

  

 

Steak dinner for 8 and a bottle of wine? $120
Great group to celebrate with? Wouldn't trade it for the world
Carlos, Jackie, Enzo, Anne, Vishal, Lulu, Emi, Leny

Steak... and in Bolivia,
it's free range!
(I'm a wanna-be-vegetarian!
... maybe starting in Philly?)

Happy Match Day!  Enzo finishing up med school here, Jackie off to Yale, and me off to UPenn!

Dengue

The Bolivians say "watch out for the
ones with striped legs", or Aedes
(this battle of mine was a lose-lose situation)

In the large room where most of the internal medicine male patients lay, a few nets dangle from the high ceilings (remnants of old European style hospital wards which utilized sunlight and air to treat tuberculosis). That's right, it's dengue season.

Dengue is carried by Aedes aegypti, the primary vector, seen here and recognizable by the stripes on its legs (which are surprisingly apparent while it's flying too). Fun fact, only female mosquitos bite as males don't need as much nutrition for reproduction. As well, Dr. Seuss started his career doing cartoon mosquitoes warning soldiers about malaria.  Back on track...

Anyways the Aedes mosquito often breeds in wet containers, and thus is associated with living in areas of poor trash disposal. It was found in Puerto Rico that broken septic containers can breed immature forms in rates of hundreds per day. The mosquitos live mainly in subtropical areas, and outbreaks have recently been seen in the Florida Keys.

Don't worry, even if I get dengue, I will likely survive. Most people get a mild illness including fever. The biggest risk comes from getting infected with the same serotype (of 4) twice, i.e. something to do with the immune reaction. There is no current vaccine. The risk is hemorraghic dengue, which for pimping you can use the tourniquet test as people can drop their platelets rapidly and fatally. As long as people are in the hospital monitored, they do fine. The main risk is letting people who live in the countryside go, as they may not have access to quick healthcare if their blood counts unexpectedly drop.

When an intern (our friend actually) fell sick with a fever (UTI), the head of medicine became concerned about dengue and the vector control in the hospital. So the next day, they announced the exterminators were coming. In the U.S. this would take about a week of entire staff cooperation, moving patients carefully from one ward to another in a well-orchestrated plan. Here? Just wheel the patients into the fresh air outside the ward, sit the interns next to them, and have everyone wait outside for a few hours enjoying the fresh air. It was quite nice : )

I sold my first painting today!

It was to Victor's friend and work partner, who sells Victor's work from a nicer shop (rather than Victor's workshop). He always comes in and jokes about buying my work too haha. I had a draft of a painting I didn't like, so I was fine to part with it for 5 Bs. He asked for a signature, so I charged 7 Bs in total.  That's an entire dollar for my first sale! 

Meet Jose, my first client! : )

Continuity

Jackie, Maria, Lourdes, and I. Verbal photo consent and
big hugs given. And a request to upload this to "Face"
(what they call Facebook). We loved Lourdes's shirt!

In medicine, we talk about continuity. Continuity of care. Patient panels. Transitions to outpatient. Oooo primary care!

Anyways, so Jackie and I came back to do follow-ups on select patients (about 80-100 people). This week we are calling them back to take blood samples, a new EKG, +/- an echo. We don't pay them, as it very quickly becomes an ethical question if by offering payment we are only getting the poorest because they have to versus their willing participation. So we offer crackers, a free blood pressure measurement, and free use of the scale (which, per prior post, costs 1 Boliviano).

I hope to work one day where I can work with patients over time. Seeing these folk come back has been such a joy : )

This one guy was funny. After a very awkward visit of little conversation (most chat a bit with at the conversation starters), I prepped him to leave while Jackie was in the room. He sat there awkwardly then ventured in Spanish, "Where's Yackie?". Jackie's face lit up. "I'm Jackie!". "No, I knew a Jackie, she used to work on this project, it wasn't you." We were confused. He continued, "and there was another doctorita, part Asian, like one parent came from Japan or something".  "That's me!" I said. "No, no, it wasn't either of you. I wonder what happened to them".  Hahahah. Odd...

dinner table conversations

So currently I am living in the project office/apartment with other transient project workers:
-->Anne Palumbo, an ID doc who gave up her work in Illinois to get her MPH and is planning on joining MSF (doctors without borders) next year
-->Lulu Messenger (Louisa, but her mom thought that wasn't professional for her birth certificate), a soon to be doctorate in biochemistry who specializes in Chagas disease (as she sits here in her pajama shirt with a trypamastigote on it hahaha)

So our conversations can get incredibly intelligent and far beyond my scope. Here are a few random ones that came up:
--> What would make toxoplasmosis activate and kill beavers (likely from oyster contamination with cat fecal matter) when they should have a healthy immune system? (versus humans, many who are infected but only immunocompromised i.e. HIV people and fetuses have an issue with it)
--> The worldwide patterns of neurocystercercosis and reasoning
--> The validity and regulations on the American Red Cross blood donor screening
--> If we were to raise awareness of Chagas, the disease of 8 million, which is a bigger worldwide financial burden than cervical cancer, often cited the number one neglected tropical disease (all the funding of Gates and WHO goes into the trio of HIV, malaria, and tuberculosis), it would be getting Angelina Jolie to adopt an orphan with congenital Chagas

My long walk!

a friend who found me quite
interesting, as I found him

Santa Cruz de la Sierra is a city that was build in an annular, or ring-like, structure. There are 8 concentric rings, though most of my life is in the 1st-3rd. Yesterday, I decided to walk around the entire first ring in the blazing heat. Took about 2 hours with the aimlessness, the course totaled ~4.5 miles. I gauged myself by the landmarks I knew and by watching the angle between my shadow and the tangent I was walking slowly move full circle. Some highlights:

• A small elderly man standing by the side of the street with a spring scale. I weighed myself for 1 Boliviano (15 cents) and the man sized me up, read the scale, and said "you are perfect!" with a big smile : ) He was wearing a hat from some wooden bridge in Oregon.
• Two notable shirts in English: (1) A huge USA flag with the big words "AMERICA FOREVER TRUE" and (2) a cheap generic screen print saying "Please Excuse My Dear Aunt Sally". The second one made me laugh hours later, when I finally remembered the elementary school mnemonic.
• I got a blister from my new sandals I bought at the market. Went into the next pharmacy, asked for a bandaid. Decided to get 5 bandaids, just in case. Total cost? 1 Boliviano. What a pleasure to buy PRN, and not need to buy in bulk!
• As I was holding the bandaid wrapper, I thought "I may never find a trashcan". Before I finished that thought, I saw a bin! I happily ran over and tossed it in, and was confused when I saw it go bouncing on the cement. Was my perception off and I missed? Nope, the suspended trashcan just had no bottom haha.



Julio y Emi written in a tree
(v-a-n-d-i-l-i-z-i-n-g)

• "Jackie!!  Jackie Jackie!!!" I heard someone cry behind me. He must be talking to me, I thought, as there is no other Jackie nearby. I turn around and see a man, Gustavo, who used to go to dance class with us.  Anyways he chatted happily as I awkwardly dripped sweat.

Advertisements here used Cumbia,
Electronica, and Bachata. This one
was my favorite : )

Alternatively, there are shared taxis constantly driving around each of the rings, picking people up as space allows and dropping them off. For about 30 cents (2 Bs) you can get anywhere on the ring! I asked a driver once, he said the full circle, stops and all, takes about 45 minutes. Cool system.

What would you do?

Short Story: An 18 yo with somewhat suspected tuberculosis pericardial effusion in the ER at 9 pm. We saw a moderate fluid collection on echo when untrained people did it (namely me, who then made the CT surgeon do it too).  A tap was considered, that is sticking a needle into the space between the sac covering his heart and his heart to remove fluid- risky to puncture the heart and/or lungs or infection. I was told by the CT surgeon that I would be the one doing the tap, not to be afraid, and that he would help me. But I said no, thinking it was not safe and not knowing if it was the indicated procedure. Anyways, it is probably the only time in my medical career where I will have the opportunity to do a semi-emergency pericardiocentesis. And I turned it down. And am proud of myself : )

To start, I typed out the entire detailed story, which delves into so much of the hospital culture and patient care, but couldn't bring myself to publish it here. It involves understanding politics, the lack of resources in this particular hospital, and the limitations and stresses placed on the physicians and patients. To do it justice, I'd be happy to sit down with everyone and delve into it all. Just not here.

Carnaval- Santa Cruz!

Figure 1: many young partygoers buy
a 4-day pass to party in a big lot

Santa Cruz is a bit of a mess during Carnaval. Some love it and buy a 4-day pass to party in a lot with unlimited alcohol (Figure 1). Some form a comparsa, or basically a party group where you pay anywhere from $30-$100 to $1000+ for some of the crazier ones to join a group with matching outfits and their private parties. Most people I know actually stay in and just call the city’s celebration feo, or ugly, because of how dirty and drunk everything gets. It used to be water and foam, but now grocery stores sell $0.25 bottles of ink that people love to tint the water to spray any person or car that ventures out during the 4-day celebration (Figure 2).

Figure 2: the bus. sidewalks,
storefronts, and even faces are
still stained the days after.

Our group of researchers left Santa Cruz for a quieter getaway city over the weekend, and came back Monday. On Tuesday, I was invited to celebrate a c’halla with my painting teacher, a yearly Incan offering made on the last day of Carnaval, before Lent begins (odd mixing of cultures, isn’t it?). A small nest is made of various symbolic things, from incense to llama wool to fake bills, and burned (Figure 3). To celebrate it all, everyone sat around, grilled, and enjoyed mercilessly spraying anything daring enough to leave the house during Carnaval (video). As my taxi driver said of a pedestrian starting a fight after being soaked, “If you don’t wanna play, don’t leave your house! It’s Carnaval!”

Figure 3: c'halla burning to
bring good fortune to the shop.
everyone offered some drink
to Pachamama, the earth

p.s. Can you tell by all the figure references we have been writing a scientific manuscript? Science got this trick right, along with the whole metric system thing.

Socialism and Corruption- I don’t know what I think of all this…

I'm quite naive in politics, and not sure I ever will ever understand by just watching the Daily Show and willfully hoping that everyone just supports everyone.  But what is interesting is watching Bolivia work. I’m living the historically richest, elitist province of Santa Cruz, which has struggled under the socialist rule of President Evo Morales, the first indigenous man to be elected to office in La Paz. Maybe one day I’ll write about all the people I know who almost broke off to form Nacion Camba with half the country, and still have dreams of it.  It’s tough because Evo has spent his 9 years in office pushing recentralization, and nationalizing some large industries.

The other day I had breakfast at a hostel I was at, and I met Kent Eaton (UCSC politics professor) who was here for research, as he knows much of the research is done in La Paz, whereas Santa Cruz is a fantastic place to study the dissatisfaction and anti-government movement, which almost led to civil war in 2008. He pointed out one of the main problems with Evo’s rule is the lack of checks and balances existing, and the fact that Evo mostly controls the judiciary branch as well. My friends talk about how he pays off all the big businessmen here to kept hem calm. Besides the corruption, Evo was actually recently praised in the NYTimes article for perhaps the best economic management in South America.

Kent only had time to do one unofficial interview thus far, and it was the taxi driver who drove him back from the airport.  It went something like this: “No way, I don’t like Evo at all. He is stealing all the money from Santa Cruz and not giving it back to us. Yeah. But thanks to him, my brother is able to have reliable phone service for the first time.” Through nationalizing things like the phone system, Evo has pushed for the many still living in rural poverty to have access to paved roads, electricity, and phone. Since the opposition is to divided, Evo is set to win the election this year, but it'll be interesting to see the lead up...

Ghost Stories

from the Witchs' Market is La Paz (stole this picture from
online, as the shopkeepers don't tend to appreciate the tourist
gaping and snapping photos of their livelihood sometimes)

We spent the other night discussing ghost stories with Carlos and Enzo, and apparently La Paz has a lot of haunted places. If you’ve ever been to La Paz, you’ll know it’s the section of Bolivia really rich in a pagan culture.  Vast majority of the people are Roman Catholic, however many still ascribe to the beliefs of Pachamama (mother earth) as well.  You can walk through the Witchs' Market and see offerings to these gods- the mountains and the earth. These include dried baby llama fetuses, sullu, which hang from almost every stall entrance. They are buried into the ground as an offering before constructing a new building or a new house. So apparently, a lot of ghosts haunt some of the larger buildings built, when some superstitious owners offer a sacrifice more proportional to the building's size- a human. According to the guys, there are stories of those in La Paz who will still do this, and recently a journalist found out about a few too. They find homeless men, get them very drunk, and them bury them alive in the foundation. Fact or fiction?