Carnaval is now a distant memory (2 weeks ago), the paint and shoe polish have finally peeled off from behind my ears and between my toes, and all that remains is a tye-dyed t-shirt covered in splotches of purple, green, shoe polish, and every other imagineable color. It's already hard to remember exactly what transpired during that fuzzy two-day period, but it was colorful, loud, and fantastic. Imagine the most ridiculous party you've ever been to- mardi gras, new years eve, fraternity foam parties- and then put it in a blender with tequila, pop rocks, and explosives. and that's carnaval. neither this post, nor my pictures, will do it justice.
My Carnaval experience began on Sunday, when we were invited by Douglas to attend his aunt and uncle's carnaval house party. Decking myself out in some of my least favorite clothes (knowing this would be the end of their lifespan), we took off in the bumper to bumper traffic to make it the party. Most streets were blocked off for the parties, so it took about an hour to get where we were going (normally about 10 minutes away. It was even worse on the way home). Douglas's aunt and uncle, an adorable couple in their 70's with a child in San Francisco and an interesting history including prior work for a Bolivian engineering firm, invited us into their front yard/driveway with open arms. The hired band started to play, the giant bathtubs full of water and hose were all set up, and the cans of foam came out. Douglas's aunt innocently splashed me with a cup of water, and the chaos began. There was water spraying from everywhere- from hoses, from basins dumping water over my head, from squirt guns (big ones). There was foam (called nieve, meaning snow), silly string, and paint. The idea of the day is to douse everyone with everything, and while I was a little hesitant to spray down an elderly man with a hose full of freezing cold water I soon lost my inhibition when he completely drenched me first. One of the band members, who is also a friend of Douglas, passed around a flask full of Whiskey, and despite the fact that it was 10 am, my theory is 'when in rome!' So whiskey and beer were enjoyed, the music was loud, everyone was happy and laughing, and it was one of those moments when it's impossible not to feel like a 5-year old at Disneyworld. Complete innocent glee. Carnaval's not such an innocent event, though. It can be slightly dangerous (especially for gringos), and we were told to watch out for thieves and armed robbers. We were happy to have a 'homebase' from which we could enjoy the festivities, especially knowing that tensions are heightened in Bolivia right now and things could turn from happy to ugly pretty quickly. Curiosity getting the best of us, we ventured out into the streets to see what everyone else was doing. I've never felt more like a moving target- water balloons found their way to me faster than I could defend myself, paint guns colored my face, hands, arms, everything purple and green (I looked like a pastel spotted tiger with a purple tongue), and hoses point out from people's front yards into the streets. Social groups, called 'Comparsas,' marched through the streets playing music (one carrying a mock statue of Evo Morales, who looked suspiciously like a monkey, on the shoulders of George Bush). The Comparsas marched together with matching outfits (many spouting the politically charged statement 'autonomia'), and everyone was drinking, dancing, and generally just being hedonistic. Vendors sold beer, foam/nieve, silly string, paint/dye, bands played at every corner, and did I mention everyone was covered in color? One thing about this country is the color- everything is drenched in color and life. Cemeteries are covered in blue, pink, red, orange flowers, Crosses on the sides of road are full of color, homes are pink, yellow, green, orange, and the sky and trees are every shade of blue and green you could dream of. Carnaval was no different, and I've never been so colorful in my life.
I had one of those 'is this really my life?' moments when I was dancing in the streets amongst Bolivians who were celebrating the biggest celebration of the year, all of them laughing when they saw how wet and painted I looked, and happy to be sharing their party with a gringo.
We had 'take two' the next day, and this time the Carnaval celebration seemed a bit more aggressive. The paint wasn't diluted at all- it was pure pink, purple, and green paint- young men ran around rubbing shoe polish on our faces (personal space, anyone? come on), and everyone seemed more drunk and a bit more violent. It occurred to me that in another time (or even in the near future) the water guns could be shotguns, the ambushes of water balloons could be bombs, and the ease of organization of people in the streets could easily be applied to organizing revolution or civil war. The thought crossed my mind throughout the day, and it didn't help to see young children shooting water guns at specific targets (and it didn't help that I was one of the targets!). I was even more coated in paint, and this time it seemed permanent. It took about one week and 14 showers later to finally get the paint off, and recently we discovered some shoe polish still remaining behind Amanda's left ear. It was a little comfortable showing up for clinic that Wednesday with paint everywhere, and I would personally question my doctor if she had a blue beard. But the Bolivians understand what Carnaval was all about, and all it did was help to break the doctor-patient ice even more. Nothing gets done during carnaval- meaning absolutely nothing- and this explains why Chile was able to claim Bolivia's coastline in the late 1800's during Carnaval without the Bolivian people even realizing. The government withheld the information until the end of the 4-day party so as not to ruin anyone's weekend. All shops and businesses are closed, and I can only imagine the kind of care that goes on at the hospital during that time. Hospital admissions probably increase while staffing reaches an all-time low; disaster waiting to happen.
Post-Carnaval consequences are pretty interesting. Sumi, our attending, saw a clinic patient on the Wednesday after Carnaval (which ended tuesday) who presented with 'liver pain.' He said that he had drank liquor for 4 days street, had intense pains in his right upper quadrant, and generally fit the picture of alcoholic hepatitis. Ouch.
A week later, when we were in Copacabana, Carnaval was still going on. This time, the people dancing in the streets were all dressed in traditional Aymara Cholita clothing, with beautifully ornate shawls, dresses, and shoes. The water-dousing and paint-squirting was the same, and I was pleased to know that I was still a good target for water and paint in Copacabana and not just in Santa Cruz. The cultural part of Carnaval was a bit more evident in Copacabana, and it was fairly humorous to see indigenous men and women with very traditional clothing passing around bottles of beer and dancing wildly. Despite the hedonism the festivities had a slightly more religious point of view, and it was interesting to see the contrast. One of the most fabulously humorous sights of the day was a glimpsing a man dressed in shiny pants with sparkly rhinestones, looking a bit like a Vegas Elvis, and wearing an elaborate headdress, getting his shoes shined in the middle of the wild plaza.
That's about all I could possibly say about carnaval, except that I hope I experience it again!
Friday, February 22, 2008
Thursday, February 21, 2008
Delicious
With only one weekend remaining to explore Bolivia, we opted to seek out an Andean foothill retreat spot in a town called Samaipata. Catching a taxi in Santa Cruz, and squeezing 6 adults into a station wagon (no seatbelts, clearly, and sitting on each other's laps), we embarked on a 3 hour journey through the jungle, through rolling green hills, alongside mountains (scary ones, at that), and finally to the foothills and Samaipata. It's a sleepy town, known mainly for its easy access to the Parque Amboro (Bolivia's stunning national park). Our cab driver took us on a few detours on the way to Samaipata, and it turned out that apparently he's some kind of mail man who delivers eggs and some unidentified concealed goods to various locations along the way. It was both frustrating and humorous at the time, since we had to stop every 20 minutes or so while we sweated it out in the stinky station wagon. I suppose there's no right to complain when a 3 hour cab ride costs 3 dollars per person. I'm still not over how cheap everything is. Every time we go out for a 'really nice meal,' the max cost is 6 or 7 dollars a person. Looking at prices in stores and restaurants is like discovering my toes again for the first time, only every day. Pretty exciting.
We drove through the sleepy town of Samaipata, past kids kicking soccer balls in the dusty streets, past families sitting together in their open-door homes, and finally through winding dirt roads to a lush green paradise called 'Finca La Vispera.' After hearing about this paradisiacal retreat hotel/bed and breakfast/heaven from previous clinic volunteers, and becoming intrigued by the story of the two Dutch owners with their quaint mini-Dutch village, I couldn't wait to get there. I had no idea what I was in for. Greeted by Peter, the owner of the village and an ex-psychologist/ piano tuner from Holland who decided to follow his dream and open an organic farm in the middle of nowhere Bolivia, he invited us to sit down for a gratis pitcher of fresh tea from the herb garden. At the open-air cafe overlooking the herb garden, fruit trees, birds frolicking in the bird bath, and an infinite view of the mountains, I chose the 'flora and fruta' tea and watched in awe as our waitress scurried to the herb garden to pick each herb by hand. The lunch menu was one of the most impressive and delicious things I have ever laid eyes on, with each dish sounding more fresh and flavorful than the last. I chose the french onion soup and garbanzo wrap (very American food, I know, but when you can't eat fresh veggies and fruit for a month for fear of amoebas and giardia you want all of the crude veggies/legumes you can get when they're organic and safe). Again my jaw dropped as I peered out at my waitress picking out each onion, collecting fruits, and delicately creating each meal one at a time. It took about 2 hours for our meals to be ready, but I would have waited ten. And I had no complaints about looking out at the lush scenery over tea, fresh fruit juice, and good conversation. Fresh bread came out first, followed by our appetizer of fresh Gouda cheese with homemade Mango Chutney. Without exaggerating I can say that the chutney is one of the most exciting things I've ever tasted. Nutty, mango-ey, spicy, totally indescribable- and in perfect combination with the freshest, creamiest gouda cheese. The next dish was a fresh olive tapenade on Chapati bread, also delicious even for one who is not a fan of olives. The main event was breathtaking. Onion soup, created with 5 different kinds of fresh organic onions from the garden- so savory and fresh that you could taste the fact that the onions were just picked. Next came my garbanzo wrap, which was essentially fresh hummus (my favorite!) with fresh cucumbers, cheese, fresh dill... This was a lot of food, but with three hours, nothing else to do, and fresh ingredients, who could resist.
After an afternoon of palatal delights, it felt refreshing to walk the twenty minutes into town from our farm to explore the small village. We walked through the markets and through the empty streets for a few hours imagining how quiet and peaceful it would be to live there, and then ended our evening with a cheap bottle of Malbec to be shared in the gazebo in the town's plaza. The stars were blazing, moon was bright, and we walked back to our finca with a tipsy leap in our steps. The best part of the day was yet to come; we knew that awaiting us was a fierce game of scrabble in the open-air cafe/lounge and a lovely deep sleep in our individual mosquito-net-covered beds (it's amazing how much you appreciate sleeping space when you finally get it!).
Monday morning we awoke refreshed and ready for a full day, but first we had to try out the organic breakfast options (obviously!), some different teas and fresh juices, and cafe con leche. It wasn't disappointing- the omelettes were brimming with freshly picked vegetables- cucumbers, tomatoes, sprouts, sesame seeds, nuts, mango chutney... and the freshly squeezed orange juice was unrivaled. They even packed us lunches for our day out, and each lunch included a half cucumber, half carrot, apple, banana, fresh gouda cheese sandwiches, and some nutty/chocolately bread-cake. Checking out of our heavenly hotel was another one of those 'discovering your toes' moments--- for the room, all of the meals and packed lunch, for the beautiful premises, hikes, and views from the finca-- we paid about twenty dollars each. And on top of it, I bonded with the owner Peter and was told that he and his wife are looking for a replacement owner as they reach their later years. If I ever pick up and leave my job or the U.S., you'll know where I went. I'm certain that I will return to this place at some point in my life, so whoever's interested in visiting paradise with me sometime I'd be happy to go back.
The next stop was El Fuerte, a recently excavated site of Incan ruins. I've spoken before about the driving situation being a bit precarious here, but I had no idea how close you can really come to the edge- both literally and figuratively- while driving here. Our trip began innocently as our taxi station wagon started down the winding dirt road, but quickly and without warning the roads became more narrow, the cliffs more steep, and the anxiety ever more prominent. There was room only for one car on the road, but throwing caution to the wind (and giving each of us a panic attack) my driver confidently sped around each turn. He chose to drive on the edge of the road, with only a few inches between the tires and the end of the road (and did I mention there was a steep drop?) I suppose the reasoning was that the other side of the road (also known as the Right side of the road, where you're supposed to drive) was full of small rocks and pebbles from the mountainside above. Honestly, I would have been okay with a bumpy, pebbly-ride, but he wasn't interested in my opinion. We ascended the mountain, and thirty minutes later (an eternity, especially for Amanda who's afraid of heights and Erin who has transportation anxiety), we were almost there but came upon a sign that said 'narrow road, room for one car only'. I would personally say that the sign belonged about 1500 feet below, when the road began, but whatever. This part was really steep and really curvy, and our manual-transmission station wagon was having some issues. We would start driving, stall, and then slowly roll down, keeping in mind that we rolled down straight backwards on a curvy road, meaning that when you look behind you it looks like you're rolling off the cliff. Which we almost did. So the driver continued to attempt this, continued to roll backwards, and in a near state of shock Erin got out of the car and decided to walk the rest of the way. Matt joined her to be chivalrous (and also for personal gain, since he values his life as well). Sticking it out in the car, and seriously terrified, I watched him rev up the engine again and really step on the gas. Thankfully we got up the steep hill, got to the top, and immediately forgot about the traumatic drive when the glorious view from the mountain came in sight. I had a few minutes to enjoy the view of rolling green hilly jungle- and I mean every shade of green- while we waited for Matt and Erin to meet us up there. Our hike to the ruins soon began, and it was a refreshing and lovely hike. I was grateful for the use of my legs, grateful for my life, and a bit shell-shocked once again when I reminded myself that I was hiking to Incan ruins in the jungles of Bolivia. The ruins were really impressive, and the history was pretty interesting as well. When they were discovered (late 1800's I think) the team of explorers thought that the ruins looked like a takeoff site for alient spacecraft, and there's apparently a 'spacecraft'-like object that sits below the 'take-off' site. Bizarre story, and clearly persuaded by some hallucinogenics, but for some time a group of people believed that this was the very site where aliens first landed on earth and began the human race. The hike down was great (except for when we got lost and had to re-trace our steps four times until a Bolivian family took pity on us and showed us the way), and we loaded into our taxi (we hired a taxi for the day for all of our trips, from Samaipata to El Fuerte to the Waterfall and then to Santa Cruz-- all for seven dollars a person! no joke!)
Next stop was the Cuevas, a spot with a beautiful hike and a waterfall. We picnicked with our fresh (although now very warm) packed lunches while overlooking the waterfall, and then ran bravely into to the refreshingly ice cold water and experienced that life-affirming feeling of breathtakingly cold waterfall water on your face. The whole day was delicious- the sun, the fresh food, the hikes, the ancient history- no other way to describe it but delicious. We drove back to Santa Cruz, admiring the cows and sheep on the side of the road, and the peacocks (yes, there were quite a few peacocks. apparently peacocks spread their wings when they're in love, new fact courtesy of Alejandro the cab driver). Back through the every-shade-of-green jungle, through foothills, and then watching as the foothills flattened, and then through it all watching a sunset, with small-town kids running home from school (they leave school at 6 pm because they have a 3 hour siesta in the middle of the day)... we got back to Santa Cruz refreshed, in love with Samaipata, and ready to get back to work.
I have much to say about this week at clinic, as well as having to go back and really write about Carnaval, Freddy's nieto's baptism, etc... so I'll do it once I'm back in the states. I leave tomorrow morning (still not really sinking in), and I'll be back in Chicago late Friday night (but knowing my luck flying in Bolivia, I'll believe it when I'm there). All I have to say about clinic this week is that it was another fascinating but sad week. I diagnosed Chagas heart disease, a murmur in a 9year old girl, saw cutaneous leishmaniasis, was told my fortune by a young man with edema and JVD (which I was proud to be the first to find) -- and by the way my fortune was a little disconcerting, talked to a woman about her personal history of domestic violence and gave her enough diabetes meds so she can follow through on her plan to leave her husband and go to Argentina, and had another woman break down and cry about the sadness in her life (I guess I have that effect on people. On top of it, on our Tuesday morning exploration of Hospital Japones almost had me exploding in anger at some of the ways patients were managed. The diagnosis of the week was Hemorrhagic Dengue fever, and despite the fact that the 17-year old girl with low platelets and hemorrhage could have any number of forty different things, they assumed Hemorrhagic Dengue and since she's not getting better they're planning on withdrawing ventilatory support (basically pulling the plug). And on top of it, she and another patient are in a regular 6-bed room (which is all they have) on ventilators. No such thing as ICU for vent patients, just in the room with the rest of the patients. The vents are really old, and they use vent modes that we don't even have anymore in the states (pointed out by Erin who's starting her pulmonary/critical care fellowship this June. The flavor of the week last week at Hospital Japones was Ischemic stroke, despite the fact that the patients' CT scans were clearly showing multiple lesions highly representative of toxoplasmosis and the patients were young and HIV positive (giving them obvious risk factors for toxo or another infectious or malignant cause rather than Ischemic stroke). Medically it has been really interesting to see how the hospital runs, how different things are, etc. Don't get me wrong- I have been impressed by some things, especially how they make do with so few resources and so few tests- but it's frustrating knowing the capacity our hospitals have to care for patients (even though our system is far from perfect), and seeing these patients really struggling to get by. Another example- if a patient can't afford medications, for example if he's in shock and needs pressors to increase his blood pressure, but his family can't pay for it, he won' t get the meds. They'll let him die, because there's no other option. Ventilatory support only happens if the family will pay, along with emergency surgery (Appendectomy for example, which if not performed expediently the patient can die). But things are also fairly corrupt, which we learned a bit about this week. We're hearing a lot lately about unnecessary surgeries being performed, and just last week there were 2 appendectomies in the same small town by the small surgeon. There would be about a 1 in a million chance that both patients actually had appendicitis, and it seems as though the town's health leaders may be in cahoots (sp?) with local surgeons to get unnecessary procedures done. The clinic pays for the surgeries, and it's a complicated mess to get some of the emergency procedures approved by the higher-ups, so often times the town leaders have the authority to okay something. It's complicated and probably not making sense, but I've learned a lot about local politics here, the politics of running a clinic effectively (if not efficiently), and all sorts of things that make a 'free clinic' seem a bit less romantic.
I have so much to say, so many thoughts that keep piling up, and I hope I have conveyed the depth and significance of this past month. I leave the country with a bit of a heavy heart, but grateful for the interesting and beautiful places I´ve seen and the lovely people I met- patients, doctors, students, other volunteers, etc. Thank you for being interested in what I have to say, and thank you for being supportive and wonderful friends. Can´t wait to see you soon!
We drove through the sleepy town of Samaipata, past kids kicking soccer balls in the dusty streets, past families sitting together in their open-door homes, and finally through winding dirt roads to a lush green paradise called 'Finca La Vispera.' After hearing about this paradisiacal retreat hotel/bed and breakfast/heaven from previous clinic volunteers, and becoming intrigued by the story of the two Dutch owners with their quaint mini-Dutch village, I couldn't wait to get there. I had no idea what I was in for. Greeted by Peter, the owner of the village and an ex-psychologist/ piano tuner from Holland who decided to follow his dream and open an organic farm in the middle of nowhere Bolivia, he invited us to sit down for a gratis pitcher of fresh tea from the herb garden. At the open-air cafe overlooking the herb garden, fruit trees, birds frolicking in the bird bath, and an infinite view of the mountains, I chose the 'flora and fruta' tea and watched in awe as our waitress scurried to the herb garden to pick each herb by hand. The lunch menu was one of the most impressive and delicious things I have ever laid eyes on, with each dish sounding more fresh and flavorful than the last. I chose the french onion soup and garbanzo wrap (very American food, I know, but when you can't eat fresh veggies and fruit for a month for fear of amoebas and giardia you want all of the crude veggies/legumes you can get when they're organic and safe). Again my jaw dropped as I peered out at my waitress picking out each onion, collecting fruits, and delicately creating each meal one at a time. It took about 2 hours for our meals to be ready, but I would have waited ten. And I had no complaints about looking out at the lush scenery over tea, fresh fruit juice, and good conversation. Fresh bread came out first, followed by our appetizer of fresh Gouda cheese with homemade Mango Chutney. Without exaggerating I can say that the chutney is one of the most exciting things I've ever tasted. Nutty, mango-ey, spicy, totally indescribable- and in perfect combination with the freshest, creamiest gouda cheese. The next dish was a fresh olive tapenade on Chapati bread, also delicious even for one who is not a fan of olives. The main event was breathtaking. Onion soup, created with 5 different kinds of fresh organic onions from the garden- so savory and fresh that you could taste the fact that the onions were just picked. Next came my garbanzo wrap, which was essentially fresh hummus (my favorite!) with fresh cucumbers, cheese, fresh dill... This was a lot of food, but with three hours, nothing else to do, and fresh ingredients, who could resist.
After an afternoon of palatal delights, it felt refreshing to walk the twenty minutes into town from our farm to explore the small village. We walked through the markets and through the empty streets for a few hours imagining how quiet and peaceful it would be to live there, and then ended our evening with a cheap bottle of Malbec to be shared in the gazebo in the town's plaza. The stars were blazing, moon was bright, and we walked back to our finca with a tipsy leap in our steps. The best part of the day was yet to come; we knew that awaiting us was a fierce game of scrabble in the open-air cafe/lounge and a lovely deep sleep in our individual mosquito-net-covered beds (it's amazing how much you appreciate sleeping space when you finally get it!).
Monday morning we awoke refreshed and ready for a full day, but first we had to try out the organic breakfast options (obviously!), some different teas and fresh juices, and cafe con leche. It wasn't disappointing- the omelettes were brimming with freshly picked vegetables- cucumbers, tomatoes, sprouts, sesame seeds, nuts, mango chutney... and the freshly squeezed orange juice was unrivaled. They even packed us lunches for our day out, and each lunch included a half cucumber, half carrot, apple, banana, fresh gouda cheese sandwiches, and some nutty/chocolately bread-cake. Checking out of our heavenly hotel was another one of those 'discovering your toes' moments--- for the room, all of the meals and packed lunch, for the beautiful premises, hikes, and views from the finca-- we paid about twenty dollars each. And on top of it, I bonded with the owner Peter and was told that he and his wife are looking for a replacement owner as they reach their later years. If I ever pick up and leave my job or the U.S., you'll know where I went. I'm certain that I will return to this place at some point in my life, so whoever's interested in visiting paradise with me sometime I'd be happy to go back.
The next stop was El Fuerte, a recently excavated site of Incan ruins. I've spoken before about the driving situation being a bit precarious here, but I had no idea how close you can really come to the edge- both literally and figuratively- while driving here. Our trip began innocently as our taxi station wagon started down the winding dirt road, but quickly and without warning the roads became more narrow, the cliffs more steep, and the anxiety ever more prominent. There was room only for one car on the road, but throwing caution to the wind (and giving each of us a panic attack) my driver confidently sped around each turn. He chose to drive on the edge of the road, with only a few inches between the tires and the end of the road (and did I mention there was a steep drop?) I suppose the reasoning was that the other side of the road (also known as the Right side of the road, where you're supposed to drive) was full of small rocks and pebbles from the mountainside above. Honestly, I would have been okay with a bumpy, pebbly-ride, but he wasn't interested in my opinion. We ascended the mountain, and thirty minutes later (an eternity, especially for Amanda who's afraid of heights and Erin who has transportation anxiety), we were almost there but came upon a sign that said 'narrow road, room for one car only'. I would personally say that the sign belonged about 1500 feet below, when the road began, but whatever. This part was really steep and really curvy, and our manual-transmission station wagon was having some issues. We would start driving, stall, and then slowly roll down, keeping in mind that we rolled down straight backwards on a curvy road, meaning that when you look behind you it looks like you're rolling off the cliff. Which we almost did. So the driver continued to attempt this, continued to roll backwards, and in a near state of shock Erin got out of the car and decided to walk the rest of the way. Matt joined her to be chivalrous (and also for personal gain, since he values his life as well). Sticking it out in the car, and seriously terrified, I watched him rev up the engine again and really step on the gas. Thankfully we got up the steep hill, got to the top, and immediately forgot about the traumatic drive when the glorious view from the mountain came in sight. I had a few minutes to enjoy the view of rolling green hilly jungle- and I mean every shade of green- while we waited for Matt and Erin to meet us up there. Our hike to the ruins soon began, and it was a refreshing and lovely hike. I was grateful for the use of my legs, grateful for my life, and a bit shell-shocked once again when I reminded myself that I was hiking to Incan ruins in the jungles of Bolivia. The ruins were really impressive, and the history was pretty interesting as well. When they were discovered (late 1800's I think) the team of explorers thought that the ruins looked like a takeoff site for alient spacecraft, and there's apparently a 'spacecraft'-like object that sits below the 'take-off' site. Bizarre story, and clearly persuaded by some hallucinogenics, but for some time a group of people believed that this was the very site where aliens first landed on earth and began the human race. The hike down was great (except for when we got lost and had to re-trace our steps four times until a Bolivian family took pity on us and showed us the way), and we loaded into our taxi (we hired a taxi for the day for all of our trips, from Samaipata to El Fuerte to the Waterfall and then to Santa Cruz-- all for seven dollars a person! no joke!)
Next stop was the Cuevas, a spot with a beautiful hike and a waterfall. We picnicked with our fresh (although now very warm) packed lunches while overlooking the waterfall, and then ran bravely into to the refreshingly ice cold water and experienced that life-affirming feeling of breathtakingly cold waterfall water on your face. The whole day was delicious- the sun, the fresh food, the hikes, the ancient history- no other way to describe it but delicious. We drove back to Santa Cruz, admiring the cows and sheep on the side of the road, and the peacocks (yes, there were quite a few peacocks. apparently peacocks spread their wings when they're in love, new fact courtesy of Alejandro the cab driver). Back through the every-shade-of-green jungle, through foothills, and then watching as the foothills flattened, and then through it all watching a sunset, with small-town kids running home from school (they leave school at 6 pm because they have a 3 hour siesta in the middle of the day)... we got back to Santa Cruz refreshed, in love with Samaipata, and ready to get back to work.
I have much to say about this week at clinic, as well as having to go back and really write about Carnaval, Freddy's nieto's baptism, etc... so I'll do it once I'm back in the states. I leave tomorrow morning (still not really sinking in), and I'll be back in Chicago late Friday night (but knowing my luck flying in Bolivia, I'll believe it when I'm there). All I have to say about clinic this week is that it was another fascinating but sad week. I diagnosed Chagas heart disease, a murmur in a 9year old girl, saw cutaneous leishmaniasis, was told my fortune by a young man with edema and JVD (which I was proud to be the first to find) -- and by the way my fortune was a little disconcerting, talked to a woman about her personal history of domestic violence and gave her enough diabetes meds so she can follow through on her plan to leave her husband and go to Argentina, and had another woman break down and cry about the sadness in her life (I guess I have that effect on people. On top of it, on our Tuesday morning exploration of Hospital Japones almost had me exploding in anger at some of the ways patients were managed. The diagnosis of the week was Hemorrhagic Dengue fever, and despite the fact that the 17-year old girl with low platelets and hemorrhage could have any number of forty different things, they assumed Hemorrhagic Dengue and since she's not getting better they're planning on withdrawing ventilatory support (basically pulling the plug). And on top of it, she and another patient are in a regular 6-bed room (which is all they have) on ventilators. No such thing as ICU for vent patients, just in the room with the rest of the patients. The vents are really old, and they use vent modes that we don't even have anymore in the states (pointed out by Erin who's starting her pulmonary/critical care fellowship this June. The flavor of the week last week at Hospital Japones was Ischemic stroke, despite the fact that the patients' CT scans were clearly showing multiple lesions highly representative of toxoplasmosis and the patients were young and HIV positive (giving them obvious risk factors for toxo or another infectious or malignant cause rather than Ischemic stroke). Medically it has been really interesting to see how the hospital runs, how different things are, etc. Don't get me wrong- I have been impressed by some things, especially how they make do with so few resources and so few tests- but it's frustrating knowing the capacity our hospitals have to care for patients (even though our system is far from perfect), and seeing these patients really struggling to get by. Another example- if a patient can't afford medications, for example if he's in shock and needs pressors to increase his blood pressure, but his family can't pay for it, he won' t get the meds. They'll let him die, because there's no other option. Ventilatory support only happens if the family will pay, along with emergency surgery (Appendectomy for example, which if not performed expediently the patient can die). But things are also fairly corrupt, which we learned a bit about this week. We're hearing a lot lately about unnecessary surgeries being performed, and just last week there were 2 appendectomies in the same small town by the small surgeon. There would be about a 1 in a million chance that both patients actually had appendicitis, and it seems as though the town's health leaders may be in cahoots (sp?) with local surgeons to get unnecessary procedures done. The clinic pays for the surgeries, and it's a complicated mess to get some of the emergency procedures approved by the higher-ups, so often times the town leaders have the authority to okay something. It's complicated and probably not making sense, but I've learned a lot about local politics here, the politics of running a clinic effectively (if not efficiently), and all sorts of things that make a 'free clinic' seem a bit less romantic.
I have so much to say, so many thoughts that keep piling up, and I hope I have conveyed the depth and significance of this past month. I leave the country with a bit of a heavy heart, but grateful for the interesting and beautiful places I´ve seen and the lovely people I met- patients, doctors, students, other volunteers, etc. Thank you for being interested in what I have to say, and thank you for being supportive and wonderful friends. Can´t wait to see you soon!
Tuesday, February 19, 2008
Clinic, Chicken Brain and Chaos
Back from La Paz...
Wednesday (Feb 13) was all about transportation. When Erin and I finally got back to Santa Cruz from La Paz, we packed and piled into Oswaldo's taxi (Oswaldo is a taxi driver who is often hired to drive us to the airport, clinic, etc.). It was hard enough to get off the plane into Santa Cruz's scorching sun after being in La Paz's moderate/cool climate, but it added insult to injury when I approached Oswaldo's taxi and felt heat radiating from the dark seats. No air conditioning, of course, and obviously no seat belts. Who needs seat belts on a 3 hour drive when drivers in Bolivia have a death wish?
But anyway, we finally made it to clinic in enough time to finish up seeing the remaining patients. Most patients needed medication refills for their diabetes or high blood pressure. I saw a little 18-month old girl with a strange-looking rash on her behind (technical terms do not apply here). It looked a lot like Cutaneous Larva Migrans, which I can now say I've seen before and have some basis for comparison, but my attendings weren't convinced. I treated her for a fungal infection according to my superiors' opinions, but deep down I'm pretty sure she'll be back needing treatment for Cutaneous larva migrans. Thankfully, the patients in clinic have a pretty good return rate (almost too good, and I'll get to that), so we can generally find them if they need to return to clinic. Most of the clinic groups, organized by one group leader (who doesn't get paid for their work but reaps benefits like seeing the doctor whenever they want), have a scheduled clinic day once every 2 weeks. If a Wednesday patient needs medication refills, follow-up on labs or tests, etc., we can see them again in two Wednesdays. This is really nice since most of the volunteer doctors working in the clinic are here for at least 3 weeks, so there is often the potential for some continuity of care.
The rest of Wednesday was fairly uneventful. Matt saw a patient in clinic who was deemed pretty ill on the basis of his blood pressure, recent syncopal events, and heart rate. When a patient looks more sick than we're comfortable dealing with in the clinic, we talk to our clinic coordinator (usually Rachel, who was out of commission with Dengue fever) and set up appointments for our patients in Santa Cruz. This particular patient was sent to Santa Cruz for free to have an echocardiogram and figure out if he was passing out because of Chagas cardiomyopathy causing heartblock. We found out on Thursday that he got to the Santa Cruz cardiologist and subsequently decided that he'd rather see the doctors in Palacios (at our clinic) and went home. Nevermind that we specifically sent him away since we don't even have a working EKG machine, he really wanted to see the American doctors. I've noticed that a lot of patients make comments about preferring to see the American doctors (even if it's a med student!) over a Bolivian-trained attending. I haven't figured out the basis for this phenomenon, but part of it might be the 'art' of physician-patient interactions that we're taught in med school. Every med student takes a 'warm-fuzzy medicine' class (ours is called Patient-Centered Medicine) teaching you how to talk to patients, convey empathy, learn physical diagnosis skills, etc. The part about learning how to talk to people- which unfortunately some really do need to learn in a classroom because they didn't quite pick it up in their first 25 years of life- may be appealling to patients who aren't used to this. We introduce themselves, ask how they're doing, explain what we're doing when we're looking in their throat, examining their abdomen, pounding on their back. When we figure out their diagnosis and treatment, we explain it to them. I suppose most of us take these things for granted when we're at the doctor, but it truly is quite different when you see some Bolivian-trained doctors. Most of them get through patient encounters in about 5 or 10 minutes because they ask a few questions, decide on a diagnosis, and treat them. Cut to the chase (and jump to conclusions?) and don't dig too deep. That's the general impression of some of the doctors I've seen, but of course like anything there are incredible exceptions (like Dr. Douglas Villareal, the Endocrinologist who runs the clinic with Dr. Hou and Dr. Molitch). I worked with a Bolivian gynecologist who had a good bedside manner, but who unfortuantely ordered pelvic ultrasounds on almost every patient without doing a bimanual exam (this is an absolutely atrocious behavior- foregoing an easy physical exam step that can catch an ovarian mass and simply jumping to an expensive test!)
Clinic meals/sleep
Once we're done seeing patients we clean up our exam rooms and head over to the clinic's attached house to rest and start getting our dinner ready. Mid-day lunches are cooked by Mumi, and dinners are always a joint effort amongst all of the people staying atthe clinic. Mumi is a great cook, but once again I was jaded by my strong ability to find nasty things in my food (somehow I am always the one at restaurants who finds hair in my food or a bug nest in my broccoli). She cooked a chicken and vegetable soup last Thursday, and as I was eating my potato, enjoying the cold coke (which is heaven-sent on those hot clinic days), and chatting about the patients I had seen that day, I came upon a frightening scene. There on my spoon, amongst the carrots, broth, and potato, was a brain. I'm not kidding, not exaggerating, not trying to make an okay story great. This was a brain, with gyri, sulci, and a million little neurons (which probably aren't very functional given it's a chicken, and lord knows those are stupid animals). Unable to hide my disgust, but unwilling to offend Mumi, I quietly packed up the brain into a napkin and stored it next to my plate. I couldn't shake the feeling that gray and white matter were spilling into my broth, and when Mumi left the room I dumped the soup and opted to go hungry for the day. Having gotten over the memory of that frightful experience, I'll go back to talking about dinner at the clinic. We go grocery shopping on the Tuesday before clinic, planning ahead for the week's meals, and then every night we chop veggies, drink some cerveza, and cook some food (always with the lights off, of course, since the night we opted for electricity we also came away with 100 bug bites each). Dinner is usually over by 8ish, and everyone starts getting ready for bed around 9 or 10(latest) since the days are really draining and exhausting. It's also nice to get to bed early so you can fall asleep in ignorant bliss, only imagining but not seeing the little black bed bugs climbing through your sheets. Last Friday was an exceptionally fun night in clinic. It was Ginda's birthday, and we wanted to do something special to celebrate her dedication to the clinic. She works tirelessly organizing the patient groups from each different community, and it's a pretty thankless job. We bought her a vase, flowers, and Sumi&Amanda made her a cake, and Friday night after a dinner of bean stew courtesy of San Francisco Matt, we turned up the merengue music and had a dance party. It was quite a sight, with Mike being peeled from his seat to invite Ginda to dance, and then Matt teaching everyone how to moonwalk to Michael Jackson's Billie Jean. The 80's dance party commenced, and it was a good break from thinking about diabetes and bugs.
The sleeping arrangements are pretty humorous. There's once bedroom with 2 twin beds, a bedroom with 2 bunk beds (4 beds), a kitchen table that doubles as a bed, and 2 exam tables in clinic. We scoot together the 2 twin beds and squeeze three of us on there. The first week I volunteered to sleep on the crack between the beds (not comfortable, trust me), but we wisened up and converted to sleeping lengthwise so the crack between the beds hits the hips. Still quite bizarre and uncomfortable, but now the discomfort is evenly distributed. Our men usually take one for the team and sleep on the clinic exam tables. It's pretty gross when you think about it- we have all sorts of patients with scabies, fungal infections, and worms getting examined on those beds during the day and then the volunteers have to lay in those sheets for 8 hours. We make do, and thankfully no scabies (sarnas) or worms (bichos) yet. Let's all knock on wood and not think about it again. The shower does have hot water, which is fantastic, but sometimes in that heat you'd almost rather get doused with a freezing cold spray. I have to remind myself constantly not to swallow the water. I know the consequences for swallowing third-world water, and I'd rather have that remain a distant memory. The water is actually heated with an apparatus that resembles a torture device, and I'm under the impression that if I were to touch one of the wires above the showerhead I would undergo a lightning-fast, painful electric shock. I'll admire the wires from a distance and thank my lucky stars for hot water and no electrocution to date.
Thursday's clinic day was one of those 'fly-by-the-seat-of-your-pants' days, because an entire community failed to show up to clinic in the morning. We had a fair number of patients show up unannounced, and planned for the rest of the day to head to a distant town that never receives medical care. The village (whose name escapes me at the moment) is just far enough away that they have a very hard time getting to the Palacios clinic. I always like going to those villages, because on top of getting a better picture of their lives by seeing their homes and roads (and lack thereof), I feel that I'm doing more of a service to people who really can't otherwise get medical care. Travel clinic days are not without their challenges. First, we have to try and predict what we'll need and pack the appropriate meds in advance. This is especially hard when we often don't have the meds we need in the Palacios clinic, and we have to dig around amongst those to find the appropriate meds. Then there's the issue of clinic space. When we visit villages, they often set up the clinic in a local hotel or church. In this case it was a home, with only 2 rooms and no furniture, and a back porch with only a chair and table, and we had to divide up so that each room had 2 doctors seeing 2 different patients, examining patients on a chair, and then having one doctor outside on the back porch seeing patients. I was outside on the back porch, which was pretty interesting because immediately after seeing a child with fungal rashes all over his feet and advising his mom that he had to keep his feet clean and dry, I saw him running through the dirt barefoot past the barn with chickens, chicken poop, etc. So much of our 'medical advice' is just to make us feel better, because what are we really going to do about living conditions? It's equally frustrating and depressing. We tell patients to avoid 'bichos' by boiling their water and eradicate their scabies infection by putting their clothes in a garbage bag for two weeks and cleaning their sheets and clothes in boiling water. Too bad boiled water is a hot commodity, and most people don't have enough clothing and sheets that they can bag it all up for a few weeks while the scabies eggs die. No wonder patients leave the clinic looking a little disappointed; they typically only feel like it was a fruitful visit if they walk away with vitaminas, medicine for bichos (both of which everyone asks for, and I mean everyone). Unfortunately we have to ration our vitamins since they're in short supply, so we only give them to the patients who are obviously malnourished or anemic (based on pale conjunctiva). And we can't treat everyone for bichos, mostly because the azole meds are not without their side effects and you can't just give them out like candy.
Another barrier to travelling to see patients in their clinics is the basic fact that we have to travel. It's easier said than done. We pile all of us doctors, students, nurses, and coordinators into a car that fits an absolute maximum of 8, pack ourselves in like sardines, and then pile on meds, stethoscopes, water, tools, and whatever else has to accompany us. I have very short legs, and even I get leg cramps from squeezing into such a tight space. The back row gets the brunt of the bumps, and let me tell you there are a LOT of bumps on the way. The closest I came to a concussion on the trip was one particularly large protrusion in the dirt road where I flew from my seat and came about an inch from the ceiling. That same excursion out to clinic was particulary nauseating, as these car trips often are, and I was told by various sources in the car that my face was green and lips purple. At least it won me a spot in the front seat on the way back, but I'm realizing that I'd be perfectly content to stay in Bolivia forever were it not for the bumpy dirt roads. Call me a diva, but I like my roads paved.
Aside from those aforementioned challenges of bringing clinic to various villages, I really like the satisfaction of seeing a group of people who obviously need it. I happened to see mostly kids that day and was pretty frustrated by parents telling me that their child has a fever, nausea, vomiting, diarrhea, won't eat, and has been ill for weeks, and then seeing the kid chasing his sister around the room and giggling. I know that this problem exists in the states, where parents exaggerate about their kids' illnesses, but I understand why they do it here. The thought process goes like this (in my interpretation): 'the doctor is here today, and while my kid isn't sick at this moment, he will be in a month and I might as well stock up on meds while she's here'. It's not like they're using us, because they eventually will need the care we provide but just not right now; however, it's hard not to feel a little frustrated and used after a day of very dramatic 'ay dios, mi hijo esta enfermo, tengo hichazon, me duelen los rinones, tengo dolores de cabeza tan fuerte... necesito vitaminas, doctorita, y pastillas para los bichos...' This is a typical patient presentation, and it takes a lot of patience to explain to patients that vitamins won't heal them, we can't treat a patient who isn't at clinic and doesn't get examined ('my dad couldn't make it today, but needs such and such for this rash'), and that walking away without meds doesn't mean that we wasted their entire day. Thursday and Friday were frustrating clinic days for me, because most of my patients presented with vague complaints or no complaint at all (my favorite of all time was a mom complaining that 'my child's urine is yellow.') When I'm refilling someone's diabetic medications, doing a pap smear, evaluating an ongoing problem and checking for progress- those are all things that make me feel like I'm doing something. Their blood glucose is going down, they're taking better control of their health, they're being screened for cervical cancer- I like being a part of that. But the patients who show up with 'diarrhea about once a month,' occasional difficulty sleeping, occasional headache, I want to explain to them that this happens to everyone and they don't need to be alarmed. I suppose that part of the problem is that most of the patients we see have so little formal education (some of them stopping at 2nd grade), that they don't have enough information to know when to worry about a health problem and when to write it off. Interestingly enough, the patients on Friday were obviously a wealthier group of people, relatively well-dressed, clearly more educated, and in some ways a little less frustrating because they had a better understanding of their health. I could counsel them on their disease and they often understood completely and seemed motivated by the education. They had a different set of problems, clearly coinciding with their elevated wealth/education. Almost every one of my patients was obese, and I spent a majority of the day providing detailed weight-loss plans, healthier-eating plans, and trying to scare them into better controlling their diabetes (threatened one patient with the possibility of limb amputation and blindness because her diabetes is uncontrolled and she'll need to start Insulin at her next visit). I had to remind myself that I wasn't at a clinic in the states, because these particular patients and their issues were pretty familiar. Part of me feels uncomfortable knowing that some of these patients can afford to buy their own medications and may have access to other means to obtain healthcare, and yet still utilize the free clinic. The other side of me feels that their 'relative' wealth is still pretty minimal compared to the U.S. The clinic administrators are working out a method to figure out who really needs free care and who can afford to pay. We encounter these problems all the time at free clinics in the states, and while my bleeding heart wants to treat everyone and just hand out health care right and left, reason tells me there's a more efficient and just way.
Saturday would prove to be one of those days that shakes you, makes you re-evaluate and re-think what 'sick' means. It would end late, make me cry, nearly stop a clinic in its tracks, and leave me silent with my thoughts and questions for the two-hour drive home.
The day started like any other clinic day, with typical patient concerns, typical medication refills, counseling, histories, physicals. A 14-year old boy came in with the common complaint of headaches, and the day took an interesting turn when he actually had serious classic migraine symptoms (we get a lot of 'occasional tension headaches' just wanting some tylenol). His story was textbook, and then he had a few cranial nerve findings (deviated uvula) and nystagmus on exam. It's always interesting to get unusual physical exam findings since I'm getting used to benign physical exams. Also annoying because we didn't have enough of the meds that had been helping him, so we essentially have to move backward with him by not giving him the treatment he needs and likely re-imposing his symptoms. Then I jumped in to see one of Matt's patients, a 14-year old boy with Chorea (the physical movements you see with Huntington's Disease, but the movements can be caused by a number of diseases). He was a case of probably Rheumatic Fever, with Sydenham's Chorea being one of the Jones Criteria for diagnosis. Interesting to see this manifestation of the disease, and also really sad because the boy was getting frustrated by his symptoms. He would cover up the movements by acting like he was messing with his hair or playing with his shirt, when in fact his movements were involuntary.
My first patient after lunch turned out to be one I'll never forget. He was 54 years old, dressed in loose-fitting sweatpants and a dirty half-buttoned shirt, was missing the center top row of teeth, and wore a dark baseball cap. I called his name in the lobby, walked him into my exam room, and watched him as he struggled to find a comfortable sitting position. Without needing to dig deep to get his history, he spoke freely about an excruciatingly painful lesion on his penis. He said it started about two years ago as a tiny lesion on the glans penis, was told it was nothing to worry about, and then watched as it grew. He had been to multiple doctors, was told to get a biopsy, but always got scared and chose not to act on it. Curanderos (natural healers) gave him herbal remedies and he prayed, but at each suggestion of biopsy became too frightened about the possibility of having an operation on his penis. His pain had progressed so completely that he was unable to sleep, he could not wear underwear or anything that would rub, and had to wear loose fitting sweatpants for comfort. I had all the history I needed to seriously worry about cancer.
disclaimer: the following may be uncomfortable to read, especially if you have a penis.
We walked to the bed (a makeshift exam table), he sat on the edge of the bed, and pulled down his sweatpants. Covering his penis was a large piece of gauze, and I watched him wince as he cautiously removed tiny pieces of gauze. The gauze was full of pus, with a hint of a fruity odor(maybe a pseudomonas infection), and as it peeled off of his penis an ugly lesion revealed itself. Hiding his penis was a fungating, erythematous, oozing chaos of masses with multiple hard nodules. It was exquisitely tender to palpation. He pointed out the hiding place of his urethra, which was buried between two gruesome nodules full of cancer and infection. I choked back tears when I caught my first glimpse of the mass. Here was a man who carried himself with dignity, hid his pain, and walked like a man who was living, who in reality hid a secret and a death sentence lying just beneath his beltline. The tears were even harder to hide as I examined his inguinal lymph nodes to find multiple, solid, non-movable nodules bilaterally. His cancer had metastasized to his lymph nodes, and without a doubt to less obvious places. I told him to sit comfortably for a moment as I excused myself to get Erin's opinion and another set of eyes. We re-examined him together, and I translated for her as she told him he has cancer. Althouth it was coming first from her mouth in English and then from mine in Spanish, it was no less difficult to say the words. I wasn't the first one to tell him, and I'm sure doctors over the past 2 years had told him about their suspicions. But from the way he looked at me, it was if he had never heard the word cancer before. He had a look of begging in his eyes, as if maybe I could show him some mercy and pretend it was something else. We did offer him a glimmer of hope by asking him back this coming Wednesday (tomorrow, feb 20) for an RPR blood test to make sure it's not a brutal Syphilis infection. From the tone of my voice, from our exam, and from our conversation, he can't deny much. He took the hope I gave him, looked forward to seeing us again on Wednesday for the blood test (and I just pray he shows up tomorrow), and dressed himself with pride. He knows that his options are few. He doesn't want a biopsy because he knows that the results will undoubtedly imply further surgery. As a male member of a culture of machismo (latino machismo runs rampant here), the idea of losing a penis would likely be on par with loss of life. I mourn for the loss of his pride and his years. He's only 54 years old, separated from his wife, and with three teenaged children. The situation is tragic, and there's nothing else to say. Squamous cell carcinoma of the penis is something we read about in textbooks but hear about as a rare cancer, and here it is in this small village of Bolivia with nothing to offer but weak pain medications. I sent him away with an NSAID to help with pain relief and vitamins for the pending malnutrition that will soon wreak havoc on his body, and I felt defeated.
As we left the room, me clutching his shoulder and wishing him well and he promising to be back on Wednesday, he peeked out of the door and said 'a man has fallen!' I turned my head to the left to find a man seizing on the hallway floor. Hovering above him were Sumi and Erin, our attending and resident, and a crowd of clinic patients had formed a spectator's ring around him. The medical staff were already in the throws of administering a benzodiazapene (unfortunately we only had relazepam which takes 30 minutes to act, when really you need a fast-acting med like Ativan), his pulse ox was being checked, and things were relatively under control. The minutes felt like hours as we waited for him to stop seizing. The patients were beginning to panic, and the situation was chaotic. As everyone began slipping back to the patients waiting for them in the exam rooms, I became the patient's personal doctor on the hallway floor. Checking pulses and blood pressures, making sure he was gaining consciousness normally (knowing that recovery from a post-tictal, or post-seizure, state can take about 15-30 minutes), I sat with him and calmed him as he looked with fear from his vantage point on the floor. Over time, I learned from the woman accompanying him that his name was Daniel, he was 38 years old, and he was epileptic since birth. His epilepsy had caused some mental deterioration, his family had essentially disowned him, and he was accompanied to clinic by the wife of a friend because no one else cares about him. He had lived with his father at one point, but even then had been responsible for obtaining his own medications and caring for himself. Living alone, with no medical assistance, he dangerously seizes at home with no one there to keep him safe. This week alone he seized 4-5 times, all without witness but only known by the patient because of the confused state he finds himself in when he gets up off the floor. It's amazing he hasn't seriously injured himself up to this point, and it worries me that one day he will. Knowing what it's like to be part of a loving family, I grieve for this man who has no love and even more for his family that doesn't know how to give unconditional love.
The patient takes Tegretol as his anti-epileptic, and has for years, but when his medication runs low he tries to ration it to make it last longer. I can't imagine the feeling- gambling with a seizure disorder by taking a half-dose of meds in hopes that it will last 2 days longer. We're going to try to get him to a neurologist in Santa Cruz for some serious medication re-adjustment. But we can't make someone care for him, and I wonder what will happen as he ages.
Wednesday (Feb 13) was all about transportation. When Erin and I finally got back to Santa Cruz from La Paz, we packed and piled into Oswaldo's taxi (Oswaldo is a taxi driver who is often hired to drive us to the airport, clinic, etc.). It was hard enough to get off the plane into Santa Cruz's scorching sun after being in La Paz's moderate/cool climate, but it added insult to injury when I approached Oswaldo's taxi and felt heat radiating from the dark seats. No air conditioning, of course, and obviously no seat belts. Who needs seat belts on a 3 hour drive when drivers in Bolivia have a death wish?
But anyway, we finally made it to clinic in enough time to finish up seeing the remaining patients. Most patients needed medication refills for their diabetes or high blood pressure. I saw a little 18-month old girl with a strange-looking rash on her behind (technical terms do not apply here). It looked a lot like Cutaneous Larva Migrans, which I can now say I've seen before and have some basis for comparison, but my attendings weren't convinced. I treated her for a fungal infection according to my superiors' opinions, but deep down I'm pretty sure she'll be back needing treatment for Cutaneous larva migrans. Thankfully, the patients in clinic have a pretty good return rate (almost too good, and I'll get to that), so we can generally find them if they need to return to clinic. Most of the clinic groups, organized by one group leader (who doesn't get paid for their work but reaps benefits like seeing the doctor whenever they want), have a scheduled clinic day once every 2 weeks. If a Wednesday patient needs medication refills, follow-up on labs or tests, etc., we can see them again in two Wednesdays. This is really nice since most of the volunteer doctors working in the clinic are here for at least 3 weeks, so there is often the potential for some continuity of care.
The rest of Wednesday was fairly uneventful. Matt saw a patient in clinic who was deemed pretty ill on the basis of his blood pressure, recent syncopal events, and heart rate. When a patient looks more sick than we're comfortable dealing with in the clinic, we talk to our clinic coordinator (usually Rachel, who was out of commission with Dengue fever) and set up appointments for our patients in Santa Cruz. This particular patient was sent to Santa Cruz for free to have an echocardiogram and figure out if he was passing out because of Chagas cardiomyopathy causing heartblock. We found out on Thursday that he got to the Santa Cruz cardiologist and subsequently decided that he'd rather see the doctors in Palacios (at our clinic) and went home. Nevermind that we specifically sent him away since we don't even have a working EKG machine, he really wanted to see the American doctors. I've noticed that a lot of patients make comments about preferring to see the American doctors (even if it's a med student!) over a Bolivian-trained attending. I haven't figured out the basis for this phenomenon, but part of it might be the 'art' of physician-patient interactions that we're taught in med school. Every med student takes a 'warm-fuzzy medicine' class (ours is called Patient-Centered Medicine) teaching you how to talk to patients, convey empathy, learn physical diagnosis skills, etc. The part about learning how to talk to people- which unfortunately some really do need to learn in a classroom because they didn't quite pick it up in their first 25 years of life- may be appealling to patients who aren't used to this. We introduce themselves, ask how they're doing, explain what we're doing when we're looking in their throat, examining their abdomen, pounding on their back. When we figure out their diagnosis and treatment, we explain it to them. I suppose most of us take these things for granted when we're at the doctor, but it truly is quite different when you see some Bolivian-trained doctors. Most of them get through patient encounters in about 5 or 10 minutes because they ask a few questions, decide on a diagnosis, and treat them. Cut to the chase (and jump to conclusions?) and don't dig too deep. That's the general impression of some of the doctors I've seen, but of course like anything there are incredible exceptions (like Dr. Douglas Villareal, the Endocrinologist who runs the clinic with Dr. Hou and Dr. Molitch). I worked with a Bolivian gynecologist who had a good bedside manner, but who unfortuantely ordered pelvic ultrasounds on almost every patient without doing a bimanual exam (this is an absolutely atrocious behavior- foregoing an easy physical exam step that can catch an ovarian mass and simply jumping to an expensive test!)
Clinic meals/sleep
Once we're done seeing patients we clean up our exam rooms and head over to the clinic's attached house to rest and start getting our dinner ready. Mid-day lunches are cooked by Mumi, and dinners are always a joint effort amongst all of the people staying atthe clinic. Mumi is a great cook, but once again I was jaded by my strong ability to find nasty things in my food (somehow I am always the one at restaurants who finds hair in my food or a bug nest in my broccoli). She cooked a chicken and vegetable soup last Thursday, and as I was eating my potato, enjoying the cold coke (which is heaven-sent on those hot clinic days), and chatting about the patients I had seen that day, I came upon a frightening scene. There on my spoon, amongst the carrots, broth, and potato, was a brain. I'm not kidding, not exaggerating, not trying to make an okay story great. This was a brain, with gyri, sulci, and a million little neurons (which probably aren't very functional given it's a chicken, and lord knows those are stupid animals). Unable to hide my disgust, but unwilling to offend Mumi, I quietly packed up the brain into a napkin and stored it next to my plate. I couldn't shake the feeling that gray and white matter were spilling into my broth, and when Mumi left the room I dumped the soup and opted to go hungry for the day. Having gotten over the memory of that frightful experience, I'll go back to talking about dinner at the clinic. We go grocery shopping on the Tuesday before clinic, planning ahead for the week's meals, and then every night we chop veggies, drink some cerveza, and cook some food (always with the lights off, of course, since the night we opted for electricity we also came away with 100 bug bites each). Dinner is usually over by 8ish, and everyone starts getting ready for bed around 9 or 10(latest) since the days are really draining and exhausting. It's also nice to get to bed early so you can fall asleep in ignorant bliss, only imagining but not seeing the little black bed bugs climbing through your sheets. Last Friday was an exceptionally fun night in clinic. It was Ginda's birthday, and we wanted to do something special to celebrate her dedication to the clinic. She works tirelessly organizing the patient groups from each different community, and it's a pretty thankless job. We bought her a vase, flowers, and Sumi&Amanda made her a cake, and Friday night after a dinner of bean stew courtesy of San Francisco Matt, we turned up the merengue music and had a dance party. It was quite a sight, with Mike being peeled from his seat to invite Ginda to dance, and then Matt teaching everyone how to moonwalk to Michael Jackson's Billie Jean. The 80's dance party commenced, and it was a good break from thinking about diabetes and bugs.
The sleeping arrangements are pretty humorous. There's once bedroom with 2 twin beds, a bedroom with 2 bunk beds (4 beds), a kitchen table that doubles as a bed, and 2 exam tables in clinic. We scoot together the 2 twin beds and squeeze three of us on there. The first week I volunteered to sleep on the crack between the beds (not comfortable, trust me), but we wisened up and converted to sleeping lengthwise so the crack between the beds hits the hips. Still quite bizarre and uncomfortable, but now the discomfort is evenly distributed. Our men usually take one for the team and sleep on the clinic exam tables. It's pretty gross when you think about it- we have all sorts of patients with scabies, fungal infections, and worms getting examined on those beds during the day and then the volunteers have to lay in those sheets for 8 hours. We make do, and thankfully no scabies (sarnas) or worms (bichos) yet. Let's all knock on wood and not think about it again. The shower does have hot water, which is fantastic, but sometimes in that heat you'd almost rather get doused with a freezing cold spray. I have to remind myself constantly not to swallow the water. I know the consequences for swallowing third-world water, and I'd rather have that remain a distant memory. The water is actually heated with an apparatus that resembles a torture device, and I'm under the impression that if I were to touch one of the wires above the showerhead I would undergo a lightning-fast, painful electric shock. I'll admire the wires from a distance and thank my lucky stars for hot water and no electrocution to date.
Thursday's clinic day was one of those 'fly-by-the-seat-of-your-pants' days, because an entire community failed to show up to clinic in the morning. We had a fair number of patients show up unannounced, and planned for the rest of the day to head to a distant town that never receives medical care. The village (whose name escapes me at the moment) is just far enough away that they have a very hard time getting to the Palacios clinic. I always like going to those villages, because on top of getting a better picture of their lives by seeing their homes and roads (and lack thereof), I feel that I'm doing more of a service to people who really can't otherwise get medical care. Travel clinic days are not without their challenges. First, we have to try and predict what we'll need and pack the appropriate meds in advance. This is especially hard when we often don't have the meds we need in the Palacios clinic, and we have to dig around amongst those to find the appropriate meds. Then there's the issue of clinic space. When we visit villages, they often set up the clinic in a local hotel or church. In this case it was a home, with only 2 rooms and no furniture, and a back porch with only a chair and table, and we had to divide up so that each room had 2 doctors seeing 2 different patients, examining patients on a chair, and then having one doctor outside on the back porch seeing patients. I was outside on the back porch, which was pretty interesting because immediately after seeing a child with fungal rashes all over his feet and advising his mom that he had to keep his feet clean and dry, I saw him running through the dirt barefoot past the barn with chickens, chicken poop, etc. So much of our 'medical advice' is just to make us feel better, because what are we really going to do about living conditions? It's equally frustrating and depressing. We tell patients to avoid 'bichos' by boiling their water and eradicate their scabies infection by putting their clothes in a garbage bag for two weeks and cleaning their sheets and clothes in boiling water. Too bad boiled water is a hot commodity, and most people don't have enough clothing and sheets that they can bag it all up for a few weeks while the scabies eggs die. No wonder patients leave the clinic looking a little disappointed; they typically only feel like it was a fruitful visit if they walk away with vitaminas, medicine for bichos (both of which everyone asks for, and I mean everyone). Unfortunately we have to ration our vitamins since they're in short supply, so we only give them to the patients who are obviously malnourished or anemic (based on pale conjunctiva). And we can't treat everyone for bichos, mostly because the azole meds are not without their side effects and you can't just give them out like candy.
Another barrier to travelling to see patients in their clinics is the basic fact that we have to travel. It's easier said than done. We pile all of us doctors, students, nurses, and coordinators into a car that fits an absolute maximum of 8, pack ourselves in like sardines, and then pile on meds, stethoscopes, water, tools, and whatever else has to accompany us. I have very short legs, and even I get leg cramps from squeezing into such a tight space. The back row gets the brunt of the bumps, and let me tell you there are a LOT of bumps on the way. The closest I came to a concussion on the trip was one particularly large protrusion in the dirt road where I flew from my seat and came about an inch from the ceiling. That same excursion out to clinic was particulary nauseating, as these car trips often are, and I was told by various sources in the car that my face was green and lips purple. At least it won me a spot in the front seat on the way back, but I'm realizing that I'd be perfectly content to stay in Bolivia forever were it not for the bumpy dirt roads. Call me a diva, but I like my roads paved.
Aside from those aforementioned challenges of bringing clinic to various villages, I really like the satisfaction of seeing a group of people who obviously need it. I happened to see mostly kids that day and was pretty frustrated by parents telling me that their child has a fever, nausea, vomiting, diarrhea, won't eat, and has been ill for weeks, and then seeing the kid chasing his sister around the room and giggling. I know that this problem exists in the states, where parents exaggerate about their kids' illnesses, but I understand why they do it here. The thought process goes like this (in my interpretation): 'the doctor is here today, and while my kid isn't sick at this moment, he will be in a month and I might as well stock up on meds while she's here'. It's not like they're using us, because they eventually will need the care we provide but just not right now; however, it's hard not to feel a little frustrated and used after a day of very dramatic 'ay dios, mi hijo esta enfermo, tengo hichazon, me duelen los rinones, tengo dolores de cabeza tan fuerte... necesito vitaminas, doctorita, y pastillas para los bichos...' This is a typical patient presentation, and it takes a lot of patience to explain to patients that vitamins won't heal them, we can't treat a patient who isn't at clinic and doesn't get examined ('my dad couldn't make it today, but needs such and such for this rash'), and that walking away without meds doesn't mean that we wasted their entire day. Thursday and Friday were frustrating clinic days for me, because most of my patients presented with vague complaints or no complaint at all (my favorite of all time was a mom complaining that 'my child's urine is yellow.') When I'm refilling someone's diabetic medications, doing a pap smear, evaluating an ongoing problem and checking for progress- those are all things that make me feel like I'm doing something. Their blood glucose is going down, they're taking better control of their health, they're being screened for cervical cancer- I like being a part of that. But the patients who show up with 'diarrhea about once a month,' occasional difficulty sleeping, occasional headache, I want to explain to them that this happens to everyone and they don't need to be alarmed. I suppose that part of the problem is that most of the patients we see have so little formal education (some of them stopping at 2nd grade), that they don't have enough information to know when to worry about a health problem and when to write it off. Interestingly enough, the patients on Friday were obviously a wealthier group of people, relatively well-dressed, clearly more educated, and in some ways a little less frustrating because they had a better understanding of their health. I could counsel them on their disease and they often understood completely and seemed motivated by the education. They had a different set of problems, clearly coinciding with their elevated wealth/education. Almost every one of my patients was obese, and I spent a majority of the day providing detailed weight-loss plans, healthier-eating plans, and trying to scare them into better controlling their diabetes (threatened one patient with the possibility of limb amputation and blindness because her diabetes is uncontrolled and she'll need to start Insulin at her next visit). I had to remind myself that I wasn't at a clinic in the states, because these particular patients and their issues were pretty familiar. Part of me feels uncomfortable knowing that some of these patients can afford to buy their own medications and may have access to other means to obtain healthcare, and yet still utilize the free clinic. The other side of me feels that their 'relative' wealth is still pretty minimal compared to the U.S. The clinic administrators are working out a method to figure out who really needs free care and who can afford to pay. We encounter these problems all the time at free clinics in the states, and while my bleeding heart wants to treat everyone and just hand out health care right and left, reason tells me there's a more efficient and just way.
Saturday would prove to be one of those days that shakes you, makes you re-evaluate and re-think what 'sick' means. It would end late, make me cry, nearly stop a clinic in its tracks, and leave me silent with my thoughts and questions for the two-hour drive home.
The day started like any other clinic day, with typical patient concerns, typical medication refills, counseling, histories, physicals. A 14-year old boy came in with the common complaint of headaches, and the day took an interesting turn when he actually had serious classic migraine symptoms (we get a lot of 'occasional tension headaches' just wanting some tylenol). His story was textbook, and then he had a few cranial nerve findings (deviated uvula) and nystagmus on exam. It's always interesting to get unusual physical exam findings since I'm getting used to benign physical exams. Also annoying because we didn't have enough of the meds that had been helping him, so we essentially have to move backward with him by not giving him the treatment he needs and likely re-imposing his symptoms. Then I jumped in to see one of Matt's patients, a 14-year old boy with Chorea (the physical movements you see with Huntington's Disease, but the movements can be caused by a number of diseases). He was a case of probably Rheumatic Fever, with Sydenham's Chorea being one of the Jones Criteria for diagnosis. Interesting to see this manifestation of the disease, and also really sad because the boy was getting frustrated by his symptoms. He would cover up the movements by acting like he was messing with his hair or playing with his shirt, when in fact his movements were involuntary.
My first patient after lunch turned out to be one I'll never forget. He was 54 years old, dressed in loose-fitting sweatpants and a dirty half-buttoned shirt, was missing the center top row of teeth, and wore a dark baseball cap. I called his name in the lobby, walked him into my exam room, and watched him as he struggled to find a comfortable sitting position. Without needing to dig deep to get his history, he spoke freely about an excruciatingly painful lesion on his penis. He said it started about two years ago as a tiny lesion on the glans penis, was told it was nothing to worry about, and then watched as it grew. He had been to multiple doctors, was told to get a biopsy, but always got scared and chose not to act on it. Curanderos (natural healers) gave him herbal remedies and he prayed, but at each suggestion of biopsy became too frightened about the possibility of having an operation on his penis. His pain had progressed so completely that he was unable to sleep, he could not wear underwear or anything that would rub, and had to wear loose fitting sweatpants for comfort. I had all the history I needed to seriously worry about cancer.
disclaimer: the following may be uncomfortable to read, especially if you have a penis.
We walked to the bed (a makeshift exam table), he sat on the edge of the bed, and pulled down his sweatpants. Covering his penis was a large piece of gauze, and I watched him wince as he cautiously removed tiny pieces of gauze. The gauze was full of pus, with a hint of a fruity odor(maybe a pseudomonas infection), and as it peeled off of his penis an ugly lesion revealed itself. Hiding his penis was a fungating, erythematous, oozing chaos of masses with multiple hard nodules. It was exquisitely tender to palpation. He pointed out the hiding place of his urethra, which was buried between two gruesome nodules full of cancer and infection. I choked back tears when I caught my first glimpse of the mass. Here was a man who carried himself with dignity, hid his pain, and walked like a man who was living, who in reality hid a secret and a death sentence lying just beneath his beltline. The tears were even harder to hide as I examined his inguinal lymph nodes to find multiple, solid, non-movable nodules bilaterally. His cancer had metastasized to his lymph nodes, and without a doubt to less obvious places. I told him to sit comfortably for a moment as I excused myself to get Erin's opinion and another set of eyes. We re-examined him together, and I translated for her as she told him he has cancer. Althouth it was coming first from her mouth in English and then from mine in Spanish, it was no less difficult to say the words. I wasn't the first one to tell him, and I'm sure doctors over the past 2 years had told him about their suspicions. But from the way he looked at me, it was if he had never heard the word cancer before. He had a look of begging in his eyes, as if maybe I could show him some mercy and pretend it was something else. We did offer him a glimmer of hope by asking him back this coming Wednesday (tomorrow, feb 20) for an RPR blood test to make sure it's not a brutal Syphilis infection. From the tone of my voice, from our exam, and from our conversation, he can't deny much. He took the hope I gave him, looked forward to seeing us again on Wednesday for the blood test (and I just pray he shows up tomorrow), and dressed himself with pride. He knows that his options are few. He doesn't want a biopsy because he knows that the results will undoubtedly imply further surgery. As a male member of a culture of machismo (latino machismo runs rampant here), the idea of losing a penis would likely be on par with loss of life. I mourn for the loss of his pride and his years. He's only 54 years old, separated from his wife, and with three teenaged children. The situation is tragic, and there's nothing else to say. Squamous cell carcinoma of the penis is something we read about in textbooks but hear about as a rare cancer, and here it is in this small village of Bolivia with nothing to offer but weak pain medications. I sent him away with an NSAID to help with pain relief and vitamins for the pending malnutrition that will soon wreak havoc on his body, and I felt defeated.
As we left the room, me clutching his shoulder and wishing him well and he promising to be back on Wednesday, he peeked out of the door and said 'a man has fallen!' I turned my head to the left to find a man seizing on the hallway floor. Hovering above him were Sumi and Erin, our attending and resident, and a crowd of clinic patients had formed a spectator's ring around him. The medical staff were already in the throws of administering a benzodiazapene (unfortunately we only had relazepam which takes 30 minutes to act, when really you need a fast-acting med like Ativan), his pulse ox was being checked, and things were relatively under control. The minutes felt like hours as we waited for him to stop seizing. The patients were beginning to panic, and the situation was chaotic. As everyone began slipping back to the patients waiting for them in the exam rooms, I became the patient's personal doctor on the hallway floor. Checking pulses and blood pressures, making sure he was gaining consciousness normally (knowing that recovery from a post-tictal, or post-seizure, state can take about 15-30 minutes), I sat with him and calmed him as he looked with fear from his vantage point on the floor. Over time, I learned from the woman accompanying him that his name was Daniel, he was 38 years old, and he was epileptic since birth. His epilepsy had caused some mental deterioration, his family had essentially disowned him, and he was accompanied to clinic by the wife of a friend because no one else cares about him. He had lived with his father at one point, but even then had been responsible for obtaining his own medications and caring for himself. Living alone, with no medical assistance, he dangerously seizes at home with no one there to keep him safe. This week alone he seized 4-5 times, all without witness but only known by the patient because of the confused state he finds himself in when he gets up off the floor. It's amazing he hasn't seriously injured himself up to this point, and it worries me that one day he will. Knowing what it's like to be part of a loving family, I grieve for this man who has no love and even more for his family that doesn't know how to give unconditional love.
The patient takes Tegretol as his anti-epileptic, and has for years, but when his medication runs low he tries to ration it to make it last longer. I can't imagine the feeling- gambling with a seizure disorder by taking a half-dose of meds in hopes that it will last 2 days longer. We're going to try to get him to a neurologist in Santa Cruz for some serious medication re-adjustment. But we can't make someone care for him, and I wonder what will happen as he ages.
On a happy note, this week had some really beautiful moments. We had a brief rainfall on Thursday afternoon and subsequently an incredibly brilliant arcoiris (rainbow). It was actually a full rainbow, a complete half-circle, and it was stunning.
With us at clinic was a 21year old Bolivian guy named Humberto, who helps translate and volunteers ocassionally. He's studying English in Santa Cruz. We spoke at length about his experiences growing up in a small village (he's from Yapacani, one of the villages we serve), and especially his experience as an Autonomista in a village of Masistas. He's articulate and politically outspoken, and it was fascinating to hear the perspective of a young Bolivian on the current intensifying situation. All in all, from devastating patient encounters to flowers and rainbows (said with sarcasm but also quite literally), the clinic experience has been very complete. I head back to clinic tomorrow, so hopefully I'll get a chance soon to write about the incredible time we had in Samaipata and some updates on the clinic patients.
Sunday, February 17, 2008
COCA
Day 3 in La Paz would turn out to be quite a long one. and then it would become day 4. but I'll get to that in a bit.
First it's critical that I write about what the city actually looks like during the day, since I've talked about the night sky, the day trips outside of the city, and everything but the city itself. On the morning of our first full day in La Paz, we walked out of our hotel and within blocks (really steep blocks, putting san francisco to shame), we were in the heart of the Artesania district. The textiles, ceramics, and artwork were all exploding with color, and I could have spent weeks there planning out how to decorate my next apartment. And on top of it, it was all incredibly cheap. Little cholita women were selling their goods, and there were also some young girls (probably around 9 or 10) selling goods. One of them had a baby sibling sitting on one of the shelves on a big stack of fabric. I pointed to the baby and asked 'cuanto cuesta?' She didn't get the joke, and then I think she was scared I was going to try and steal her little brother.
We meandered through the Witch's Market, through countless stalls selling Llama fetuses, herbs, and whatever remedy you need- love potion, 'medical' remedies, who knows what else. The llama fetuses were pretty nasty, but the idea behind it is that you're supposed to bury it in front of your new house for good luck. I'd rather not, thanks.
After satisfying my every last shopping desire and buying an original piece of beautiful art (worth rearranging the layout of my apartment art), it was time to educate ourselves. We slinked into a back alley and followed the arrows to the Coca Museum, paid our 10 bs to enter, and immersed ourselves in the culture of Coca. The museum was actually quite fascinating. I'm amazed at how important Coca has been in the history of Bolivia. Legends include MamaCoca as one of the Incans' first and most important ancestors, and Coca has been a mainstay of religious/spiritual occasions throughout Bolivia's history. Coca is presented to a future father-in-law to ask for the daughter's hand in marriage, it is offered to houseguests in the same way we offer guests a drink, and it was given freely to slaves to increase their productivity and allow them to work for days without food. Coca is also an enormous point of contention in today's political environment. Evo Morales, the first indigenous President of Bolivia, is a former cocalero (grew up cultivating Coca) and is a very strong supporter of the Coca industry. He defends its cultural/spiritual role and believes that taking away the coca industry will detract from a huge part of Bolivian culture. The U.S. obviously has very different interests and would prefer that the substance that is so easily transformed into Cocaine would not be so widely cultivated and exported to the U.S., but the Bolivians blame U.S. cocaine consumers and not the actual coca leaf.
I could go on and on about the museum- it was really fascinating. This week in clinic I did a little experiment and asked my patients if they use coca. I had a lot of young male patients who work in the sugar cane fields, and each man that I asked said that they use coca to help get them through work. Instead of having coffee with meals and taking Starbucks breaks, they chew coca multiple times a day for productivity.
After taking in more of the city, seeing the Museum of Contemporary Art (where Erin actually purchased a painting off the wall since they're all for sale), it was time for my own coca experiment. I removed the coca leaves from their plastic bag, placed about 7 in my mouth, moistened them until they were in a little ball, and then let them soak at the side of my mouth. Little grean leafy pieces kept escaping down my throat, which is not the correct coca chewing method, and it was obvious from my technique that I was a rookie. I let the coca soak for about 40 minutes until I just couldn't take the strange numbness in my lips and tongue and the nasty green pieces running loose in my mouth, and that was the end of my coca experience. I guess I felt a little bit stimulated, as if I had just had some espresso, but nothing crazy. It actually helped some of us with our altitude sickness a bit (because I forgot to mention all of coca's medical benefits including dilating the bronchioles and therefore increasing oxygen exchange and improving altitude sickness), but that was the extent of it.
The rest of the day we hung out, enjoyed the view from our hotel overlooking the whole city, and then went to the airport. This could be a long story in itself, but since I'm leaving in about 2 minutes for Samaipata (3 hours outside of santa cruz, can't wait) I'll make it brief. When we changed our flight, Erin's flight was somehow not changed and they didn't have any room left on the plane. The weight limit was already exceeded, and it's hard enough for planes to fly out of La Paz because the air is so thin and it's hard to take off. We argued with the AeroSur people for hours trying to get her on the plane, pulling the 'she's a doctor and she has to get to her patients tomorrow' card (which really was true). I was pleased at my ability to articulately get mad in Spanish (especially while a little hopped up on coca and beer), but we were out of luck. The whole situation was a little shady, and people who showed up for their flight 20 minutes after the flight's scheduled departure time got on instead of us. When things were looking futile, I changed my flight so I could stay with Erin. We knew that neither of us should stay in La Paz by ourselves, and she doesn't speak Spanish so it made sense that I stayed. The whole thing was a mess but funny in the end, and not surprising when you're traveling in the 3rd world. Another night drive through La Paz was fine with me. After finally getting booked on a flight for the next morning, and then making it back and forth to the airport for the 10th time, of course our flight was delayed. When we eventually got on our flight, it was worth the wait just to leave in the daytime and experience how it feels to fly through the Andes. I can't even describe how close we were to the Andes-- close enough that Erin felt the need to grab my arm and tremble. I had a different take on it and whipped out my camera to get some of the most gorgeous pictures I've ever taken. It was stunning and horrific at the same time.
Clinic this week was really interesting and sad, but hopefully I'll have time to write about it when I get back from Samaipata. Ciao!
First it's critical that I write about what the city actually looks like during the day, since I've talked about the night sky, the day trips outside of the city, and everything but the city itself. On the morning of our first full day in La Paz, we walked out of our hotel and within blocks (really steep blocks, putting san francisco to shame), we were in the heart of the Artesania district. The textiles, ceramics, and artwork were all exploding with color, and I could have spent weeks there planning out how to decorate my next apartment. And on top of it, it was all incredibly cheap. Little cholita women were selling their goods, and there were also some young girls (probably around 9 or 10) selling goods. One of them had a baby sibling sitting on one of the shelves on a big stack of fabric. I pointed to the baby and asked 'cuanto cuesta?' She didn't get the joke, and then I think she was scared I was going to try and steal her little brother.
We meandered through the Witch's Market, through countless stalls selling Llama fetuses, herbs, and whatever remedy you need- love potion, 'medical' remedies, who knows what else. The llama fetuses were pretty nasty, but the idea behind it is that you're supposed to bury it in front of your new house for good luck. I'd rather not, thanks.
After satisfying my every last shopping desire and buying an original piece of beautiful art (worth rearranging the layout of my apartment art), it was time to educate ourselves. We slinked into a back alley and followed the arrows to the Coca Museum, paid our 10 bs to enter, and immersed ourselves in the culture of Coca. The museum was actually quite fascinating. I'm amazed at how important Coca has been in the history of Bolivia. Legends include MamaCoca as one of the Incans' first and most important ancestors, and Coca has been a mainstay of religious/spiritual occasions throughout Bolivia's history. Coca is presented to a future father-in-law to ask for the daughter's hand in marriage, it is offered to houseguests in the same way we offer guests a drink, and it was given freely to slaves to increase their productivity and allow them to work for days without food. Coca is also an enormous point of contention in today's political environment. Evo Morales, the first indigenous President of Bolivia, is a former cocalero (grew up cultivating Coca) and is a very strong supporter of the Coca industry. He defends its cultural/spiritual role and believes that taking away the coca industry will detract from a huge part of Bolivian culture. The U.S. obviously has very different interests and would prefer that the substance that is so easily transformed into Cocaine would not be so widely cultivated and exported to the U.S., but the Bolivians blame U.S. cocaine consumers and not the actual coca leaf.
I could go on and on about the museum- it was really fascinating. This week in clinic I did a little experiment and asked my patients if they use coca. I had a lot of young male patients who work in the sugar cane fields, and each man that I asked said that they use coca to help get them through work. Instead of having coffee with meals and taking Starbucks breaks, they chew coca multiple times a day for productivity.
After taking in more of the city, seeing the Museum of Contemporary Art (where Erin actually purchased a painting off the wall since they're all for sale), it was time for my own coca experiment. I removed the coca leaves from their plastic bag, placed about 7 in my mouth, moistened them until they were in a little ball, and then let them soak at the side of my mouth. Little grean leafy pieces kept escaping down my throat, which is not the correct coca chewing method, and it was obvious from my technique that I was a rookie. I let the coca soak for about 40 minutes until I just couldn't take the strange numbness in my lips and tongue and the nasty green pieces running loose in my mouth, and that was the end of my coca experience. I guess I felt a little bit stimulated, as if I had just had some espresso, but nothing crazy. It actually helped some of us with our altitude sickness a bit (because I forgot to mention all of coca's medical benefits including dilating the bronchioles and therefore increasing oxygen exchange and improving altitude sickness), but that was the extent of it.
The rest of the day we hung out, enjoyed the view from our hotel overlooking the whole city, and then went to the airport. This could be a long story in itself, but since I'm leaving in about 2 minutes for Samaipata (3 hours outside of santa cruz, can't wait) I'll make it brief. When we changed our flight, Erin's flight was somehow not changed and they didn't have any room left on the plane. The weight limit was already exceeded, and it's hard enough for planes to fly out of La Paz because the air is so thin and it's hard to take off. We argued with the AeroSur people for hours trying to get her on the plane, pulling the 'she's a doctor and she has to get to her patients tomorrow' card (which really was true). I was pleased at my ability to articulately get mad in Spanish (especially while a little hopped up on coca and beer), but we were out of luck. The whole situation was a little shady, and people who showed up for their flight 20 minutes after the flight's scheduled departure time got on instead of us. When things were looking futile, I changed my flight so I could stay with Erin. We knew that neither of us should stay in La Paz by ourselves, and she doesn't speak Spanish so it made sense that I stayed. The whole thing was a mess but funny in the end, and not surprising when you're traveling in the 3rd world. Another night drive through La Paz was fine with me. After finally getting booked on a flight for the next morning, and then making it back and forth to the airport for the 10th time, of course our flight was delayed. When we eventually got on our flight, it was worth the wait just to leave in the daytime and experience how it feels to fly through the Andes. I can't even describe how close we were to the Andes-- close enough that Erin felt the need to grab my arm and tremble. I had a different take on it and whipped out my camera to get some of the most gorgeous pictures I've ever taken. It was stunning and horrific at the same time.
Clinic this week was really interesting and sad, but hopefully I'll have time to write about it when I get back from Samaipata. Ciao!
Thursday, February 14, 2008
Isla del Sol and Llama jerky
Bundling up with my newly purchased alpaca wool scarf and hat, the four of us (matt, erin, sumi, and myself) boarded the top row of our boat to head from Copacabana to Isla del Sol (Island of the Sun). The trip took us past tiny islands with scattered homes, through the sparkling blue waters of Lake Titicaca, and finally 2 hours later to the Isla del Sol. From what I have read and heard (not all to be believed since it came from the mouth of an 8year old boy who heard legends passed down from his elders), Isla del Sol is one of the most spiritual places for the Inca people. It was basically the birthplace of the Inca civilization, beginning with the birth of Manco Capac who was the son of Inti the Andean deity (who was the god of the sun). The island represents the birth of the sun and light, and it´s a place of pilgrimage. Now I can say I´ve been to two religious meccas in the past 2 months! We arrived at the island and were told we had to be back on the boat within an hour. One hour to explore the island´s gardens, fountain, and incan ruins was clearly not enough, but we made a dash for it and started climbling the steep incline of the island´s shore. This was the point in the trip when we all felt pretty bad about ourselves! We made all sorts of excuses about being at an altitude of 14,000 feet, and the difficulties our muscles were facing in trying to get oxygenated, but it was pretty embarrassing to see little kids running up and down the steps without even breathing heavily. Being born and raised a flatlander in Chicago imposes its limitations, and I may have to accept that I won´t be running any marathons in the Andes.
The ruins themselves were fairly underwhelming, and I apologize if that makes me sound like a travel snob. Something about the ruins didn´t seem ruinous- they looked a little bit too restored to transport my imagination back to the time of the Incans. They were beautiful nonetheless, and the best part was paying the little 8-year old 20 bolivianos to sneak us to the ruins before the boat took off without us, and then watching him run down the side of the mountain through potato gardens to stop the boat from leaving. It was money well spent, since he threw in a few history lessons about the island and saved us from missing our 1:30 bus back to La Paz. The bus ride back was gorgeous again, but the beauty was somewhat tainted by the many crosses on the side of the road and the dead cow being viciously consumed by vultures. The ominous images in the forefront, juxtaposed with the shining Andes in the background, left me with images forever engraved.
Back in La Paz, we found a hotel (right next door to Alcoholicos Anonimos) and we took off to explore the city. And by the way, somewhere in the midst of all of this we changed our flight to give us an extra day in La Paz. Walking past the Plaza San Francisco, past vendors selling meat carved directly off of pig heads (I know one or two of you that would just love this. head cheese is it called?) and past a beautiful 17th century church (gaudy of course to remind the peasants what they would find in paradise), we made our to way the Prado which is the main cosmopolitan paseo in La Paz. We had dinner at a place called ´Pronto Dalicatessen´, and the Dali theme resonated not only in the decor but in the dishes. I tried a dish called ´spaghetti evo,´made with a coca-infused sauced and sprinkled with llama meat (which tasted an awful lot like beef jerky). Our wine was a Bolivian wine made with grapes grown at very high altitude in the Andes. A perfect end to a great Andean day.
The ruins themselves were fairly underwhelming, and I apologize if that makes me sound like a travel snob. Something about the ruins didn´t seem ruinous- they looked a little bit too restored to transport my imagination back to the time of the Incans. They were beautiful nonetheless, and the best part was paying the little 8-year old 20 bolivianos to sneak us to the ruins before the boat took off without us, and then watching him run down the side of the mountain through potato gardens to stop the boat from leaving. It was money well spent, since he threw in a few history lessons about the island and saved us from missing our 1:30 bus back to La Paz. The bus ride back was gorgeous again, but the beauty was somewhat tainted by the many crosses on the side of the road and the dead cow being viciously consumed by vultures. The ominous images in the forefront, juxtaposed with the shining Andes in the background, left me with images forever engraved.
Back in La Paz, we found a hotel (right next door to Alcoholicos Anonimos) and we took off to explore the city. And by the way, somewhere in the midst of all of this we changed our flight to give us an extra day in La Paz. Walking past the Plaza San Francisco, past vendors selling meat carved directly off of pig heads (I know one or two of you that would just love this. head cheese is it called?) and past a beautiful 17th century church (gaudy of course to remind the peasants what they would find in paradise), we made our to way the Prado which is the main cosmopolitan paseo in La Paz. We had dinner at a place called ´Pronto Dalicatessen´, and the Dali theme resonated not only in the decor but in the dishes. I tried a dish called ´spaghetti evo,´made with a coca-infused sauced and sprinkled with llama meat (which tasted an awful lot like beef jerky). Our wine was a Bolivian wine made with grapes grown at very high altitude in the Andes. A perfect end to a great Andean day.
Tuesday, February 12, 2008
At the Copa, Copacabana- Day1
Arriving at midnight in La Paz gave me just enough time to see how beautiful the nightscape is and to experience firsthand what it´s like to be at the same altitude as the clouds. Stayed in the Adventure Brew Hostel (clearly a gringo abode!) where they brew their own beer. After taking in an excellent view of La Paz and unfortunately getting to the bar just in time for it to close, we found our assigned bunk bed (they actually assign you a number, felt like I was in elementary school getting a locker). I was in the bottom bunk next to a Dutch or German guy (goodnight was not enough information to determine his country of origin) and was interested to see that he felt comfortable sleeping shirtless amongst strangers. I opted to take the high road and sleep in clothes. Sunday morning we took a cab to the bus terminal ´near the cemetery´ and hopped on a public bus headed to Copacabana. With no idea what we were getting ourselves into, we climbed aboard for 20 bolivianos (about $3) and soon discovered that the windows didn´t open and the seats leaned back all the way onto the lap of the person behind you. At least we had our own seats, right? Well, the bus took off through La Paz, got stuck in severe early morning traffic, drove through the bustling markets with Cholita women selling everything from fruits to cell phone covers, and finally ascended up to El Alto.
Here´s the thing about La Paz: the rich people, who make up a very tiny portion of the population, live in the center of the city. As you get further out from the center, and ascend higher up the sides of the crater, the people are poorer. El Alto is at the top of the crater´s edges and is home to the urban working class poor. Many are indigenous people (cholitas and cholos) who wear the traditional Aymara outfit including a bowler hat, big puffed-out ankle-length skirt, sweater, and fabric shawl on the back carrying goods or babies. The cholitas have long black hair parted in the middle and braided down their back. The hair, clothes, shoes, etc. were all dictated to them by the Spanish conquistadores in the 16th century, and the women continue to wear these clothes today even if they no longer live in the campo.
Getting back on the bus to Copacabana... we stopped in El Alto and, despite the fact that we considered the bus to be full (most seats were taken, thus full by american standards), a large group of Cholitas, children, and some men lined up to get on. They started boarding, and just kept on boarding until the aisles were full of people standing together, packed in like sardines. I felt guilty having my own seat until an adorable little 4-year old named Jocelin decided to share it with me. This adorable little person, with dark skin and even darker huge brown eyes, a reddish hue on her cheeks, a rainbow hat, and a sweater with a ´piglet´hood was standing with her Cholita mother who was dressed beautifully in indigenous clothing. I noticed Jocelin staring at me, and then Sumi (who I was sitting next to), pointed out that Jocelin had not stopped looking at me for a solid few minutes. I could picture the cartwheels happening in Jocelin´s head. I´m sure she had never seen anyone like me with fair skin and reddish hair (I even asked her if my skin and hair looked different/funny and she said yes), and she probably thought I was some kind of alien. After making faces at each other, she became quite cuddly and affectionate and soon passed out on my lap.
The bus ride itself was marvelously picturesque. On my right I watched in awe as we drove parallel to the snow-capped Andes, with small towns, cemeteries, and various emaciated animals in the forefront. On my left was the Altiplano, a geographical wonder in Bolivia, and eventually when the view of the Altiplano subsided I was given my first taste of the beauty of Lake Titicaca. I could never decide which direction to look-- to the mountains on my right, the brilliant Lake on my left, or the little child on my lap. Eventually we reached the point in the trip where we (and the bus) had to cross a small portion of Lake Titicaca. We disembarked, paid 1.5 bs, and boarded/packed into a rickety wooden boat with a motor threatening to implode at any moment. Our bus also boarded it´s own version of a boat- a wooden plank without any obvious motor that somehow (and I´d rather not know the details) supports its weight on the excursion to the other side. After watching in horror as the bus rocked back and forth on the crystal blue waters of Lake Titicaca, and picturing the traumatized people who opted to keep their 1.5 bs and stay on the boat, we all made it safely to the other side. I saw the Bolivian version of the navy, which exists only to protect Lake Titicaca since they lost their coast to Chile in the 1850´s during an exceptionally distracting Carnaval celebration. At this point we had to show our passports since Copacabana is a stop-off point for people headed to Peru (Lake Titicaca is bordered by Bolivia on the east side and Peru on the west, so you can just take a boat across the river to peru). Before boarding our bus again, we saw a magnificent display of men and women dancing in traditional Aymara festival attire, which basically consists of the Cholita´s style of dress with much more color, celebration, and sparkle. They were dancing through the streets to a marching band, and through inquiry I learned that we had jumped right into the middle of their Carnaval celebration. This was our 2nd of 3 total Carnaval celebrations in Bolivia... I still have much to say about Carnaval in Santa Cruz.
The long and winding road alongside the mountain gave us a stunning view of Lake Titicaca, and after dropping off a few families at various points on the road (it looked like they were getting off literally in the middle of nowhere, but I assume they were walking somewhere deep into the mountain to get home), we made it to a small city called Copacabana framed by two large hills with a backdrop of Lake Titicaca. I felt obligated to eat trout for lunch since trout has been their pride and joy since it was introduced into the lake in 1939. Apparently the city lives on their trout sales, because they do everything possible to sell you trout. At one point we sat down at a lakeside cafe to order 4 beers and instead got 4 trout. Trout isn´t quite as refreshing as a Pacena beer on a sunny day, but to each his own. After our Trout lunch we explored the city and followed the sounds of crashing drums and people screaming to find our 3rd Carnaval celebration. In the city´s plaza, bordered by a gorgeous 1600´s church, small tiendas selling coca-cola, fruit, and a traditional south american popcorn called Kasanqala (which tastes like stale caramel corn in my opinion) we found hundreds of people dressed elaborately in sparkly indigenous outfits, modified clown/rodeo suits (only a picture will explain this one), and kids running around spraying people with water and foam. Being every kid´s favorite Carnaval target, and in Santa Cruz a perfect canvas for kids and adults alike to cover me in paint and shoe polish, I was again doused with water. We had dinner at a hostel overlooking the city and the lake, and planned for our big day ahead at the Isla del Sol. The day felt like a full weekend, and we ended our day at the Hotel Rosario in the matrimonial suite for only $20 per person. Why not splurge when a hot shower and a big bed costs less than most meals in the states!
Here´s the thing about La Paz: the rich people, who make up a very tiny portion of the population, live in the center of the city. As you get further out from the center, and ascend higher up the sides of the crater, the people are poorer. El Alto is at the top of the crater´s edges and is home to the urban working class poor. Many are indigenous people (cholitas and cholos) who wear the traditional Aymara outfit including a bowler hat, big puffed-out ankle-length skirt, sweater, and fabric shawl on the back carrying goods or babies. The cholitas have long black hair parted in the middle and braided down their back. The hair, clothes, shoes, etc. were all dictated to them by the Spanish conquistadores in the 16th century, and the women continue to wear these clothes today even if they no longer live in the campo.
Getting back on the bus to Copacabana... we stopped in El Alto and, despite the fact that we considered the bus to be full (most seats were taken, thus full by american standards), a large group of Cholitas, children, and some men lined up to get on. They started boarding, and just kept on boarding until the aisles were full of people standing together, packed in like sardines. I felt guilty having my own seat until an adorable little 4-year old named Jocelin decided to share it with me. This adorable little person, with dark skin and even darker huge brown eyes, a reddish hue on her cheeks, a rainbow hat, and a sweater with a ´piglet´hood was standing with her Cholita mother who was dressed beautifully in indigenous clothing. I noticed Jocelin staring at me, and then Sumi (who I was sitting next to), pointed out that Jocelin had not stopped looking at me for a solid few minutes. I could picture the cartwheels happening in Jocelin´s head. I´m sure she had never seen anyone like me with fair skin and reddish hair (I even asked her if my skin and hair looked different/funny and she said yes), and she probably thought I was some kind of alien. After making faces at each other, she became quite cuddly and affectionate and soon passed out on my lap.
The bus ride itself was marvelously picturesque. On my right I watched in awe as we drove parallel to the snow-capped Andes, with small towns, cemeteries, and various emaciated animals in the forefront. On my left was the Altiplano, a geographical wonder in Bolivia, and eventually when the view of the Altiplano subsided I was given my first taste of the beauty of Lake Titicaca. I could never decide which direction to look-- to the mountains on my right, the brilliant Lake on my left, or the little child on my lap. Eventually we reached the point in the trip where we (and the bus) had to cross a small portion of Lake Titicaca. We disembarked, paid 1.5 bs, and boarded/packed into a rickety wooden boat with a motor threatening to implode at any moment. Our bus also boarded it´s own version of a boat- a wooden plank without any obvious motor that somehow (and I´d rather not know the details) supports its weight on the excursion to the other side. After watching in horror as the bus rocked back and forth on the crystal blue waters of Lake Titicaca, and picturing the traumatized people who opted to keep their 1.5 bs and stay on the boat, we all made it safely to the other side. I saw the Bolivian version of the navy, which exists only to protect Lake Titicaca since they lost their coast to Chile in the 1850´s during an exceptionally distracting Carnaval celebration. At this point we had to show our passports since Copacabana is a stop-off point for people headed to Peru (Lake Titicaca is bordered by Bolivia on the east side and Peru on the west, so you can just take a boat across the river to peru). Before boarding our bus again, we saw a magnificent display of men and women dancing in traditional Aymara festival attire, which basically consists of the Cholita´s style of dress with much more color, celebration, and sparkle. They were dancing through the streets to a marching band, and through inquiry I learned that we had jumped right into the middle of their Carnaval celebration. This was our 2nd of 3 total Carnaval celebrations in Bolivia... I still have much to say about Carnaval in Santa Cruz.
The long and winding road alongside the mountain gave us a stunning view of Lake Titicaca, and after dropping off a few families at various points on the road (it looked like they were getting off literally in the middle of nowhere, but I assume they were walking somewhere deep into the mountain to get home), we made it to a small city called Copacabana framed by two large hills with a backdrop of Lake Titicaca. I felt obligated to eat trout for lunch since trout has been their pride and joy since it was introduced into the lake in 1939. Apparently the city lives on their trout sales, because they do everything possible to sell you trout. At one point we sat down at a lakeside cafe to order 4 beers and instead got 4 trout. Trout isn´t quite as refreshing as a Pacena beer on a sunny day, but to each his own. After our Trout lunch we explored the city and followed the sounds of crashing drums and people screaming to find our 3rd Carnaval celebration. In the city´s plaza, bordered by a gorgeous 1600´s church, small tiendas selling coca-cola, fruit, and a traditional south american popcorn called Kasanqala (which tastes like stale caramel corn in my opinion) we found hundreds of people dressed elaborately in sparkly indigenous outfits, modified clown/rodeo suits (only a picture will explain this one), and kids running around spraying people with water and foam. Being every kid´s favorite Carnaval target, and in Santa Cruz a perfect canvas for kids and adults alike to cover me in paint and shoe polish, I was again doused with water. We had dinner at a hostel overlooking the city and the lake, and planned for our big day ahead at the Isla del Sol. The day felt like a full weekend, and we ended our day at the Hotel Rosario in the matrimonial suite for only $20 per person. Why not splurge when a hot shower and a big bed costs less than most meals in the states!
Sunday, February 10, 2008
starry,starry night
Landed in la Paz last night after a 3hour delay /aka bolivian time. the flight was interesting b/c once we left santa cruz you couldn't see anything, not one light, until we flew over cochabamba *the one city that falls between santa cruz and la paz. Everything else was campo, and now that i can picture Palacios and some of the rural areas I have an image of how different bolivian life is outside the city.
Coming into la Paz, the city lit up and really looked like a reflection of stars on a starry night. it was absolutely stunning. The stars were dramatic, and the whole picture was like stars reflecting on a clear pool of water. hard to describe, but gorgeous. Driving from the airport to our hostal was also one of the most spectacular views i've seen. La Paz sits inside a crater, and we drove down about 1500 km into the crater through winding roads. At each turn the view became more dramatic, with lights guiding the way down into the crater. we've already made the decision to change our flight and stay another day... there's too much to take in here and 2 days won't do it justice. more to come.
Coming into la Paz, the city lit up and really looked like a reflection of stars on a starry night. it was absolutely stunning. The stars were dramatic, and the whole picture was like stars reflecting on a clear pool of water. hard to describe, but gorgeous. Driving from the airport to our hostal was also one of the most spectacular views i've seen. La Paz sits inside a crater, and we drove down about 1500 km into the crater through winding roads. At each turn the view became more dramatic, with lights guiding the way down into the crater. we've already made the decision to change our flight and stay another day... there's too much to take in here and 2 days won't do it justice. more to come.
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