Back in La Paz

It rained torrentially overnight the sixth and seventh, and I awoke at five AM concerned that my day at Machu Pichu would be a wet one. Thankfully, the rain abated as I headed to the train around six, and mostly disappeared for the day. The train ride was pleasant for its view, though not so much for comfort.

The entire MP process is ultra-touristy, which I hear is a change from fifteen years ago. There is really no way into the site without paying for a guide, and a limited number of private enterprises appear to control travel to and from the site, as well as all the commerce located at stops along the way. My time in Bolivia has felt less plastic and regulated, and apparently Cusco has gone Disney in its desire to extract every dollar possible from the "experience." It seems as though hiking the trail is the only way to retain a feeling of discovery and untouched majesty from the Americas most impressive archeological site.

After spending about an hour with my tour group at the site, I realized that I was not going to hear anything about the site that I had not read on my own. To be fair, I have not seen anything quite like Machu Pichu. The acropolis in Greece never stopped being the center of a major urban area, and the architecture is unparalleled. Still, MP is so remote, and its location on a perch that constantly had clouds swirling around it made me think that it was just as impressive six centuries ago. The fact that it disappeared from the view of the rest of the world, and only remained known through the oral tradition of scattered indigenous groups, lends to its awesome affect on today's visitor.

So, after that hour, I decided to assert a little tourist independence. I took off on my own after the tour guide pointed out the nearby peak of Waynapichu, about 2000ft above the site, where there were barely visible remaining structures at the summit. I could see a few dots of tshirts at various points along the ascent. When I told the guide I was going to take off on the quick climb, he endeavored the group to send off the "intrepid american" with applause. It seemed like a tame climb, and it only took me an hour round trip, though I was drenched with sweat at the summit. My guess is that my twelve-pound weight loss on the trip has made it much easier for me to climb, but I look forward to a cheeseburger frenzy upon my return. Sadly, my view at the summit was mostly obstructed by the swirling clouds, though I did catch a few fleeting glimpses of the site.

I took the bus back from Cusco to Puno overnight Tuesday. The bus system in SA is atrocious, and it never ceases to amaze me how unprofessional it is. Our bus left two hours late, never with any explanation for its absence. It was raining so hard in Puno and the entire lake looked cloudy, so I decided to skip Copacabana and touring the lake by water, and I returned to La Paz. I am really worn out from traveling and can't wait to drink tap water. My travel has been very tame and much more luxurious than many SA backpackers, but I don't care. I think I am very ready for all the US has to offer.

It is raining in La Paz, and I would like to put the South American umbrella on the list of public annoyances that include American drivers with cell phones, and dog crap on French sidewalks. I have snags in sweaters and scratches on my scalp from those damn things.

My Spanish has improved to the point that I can react pretty instinctively and speak without thinking at times. This has its liabilities, too. When I arrived back in La Paz last night, I decided to take a cab from the bus station to my new hotel. It was only about a ten minute walk, but I figured a forty cent cab ride was worth it after fifteen hours of travel. When I got into the first cab in line outside the bus station, I told the driver where I wanted to go and mentioned that I knew it was close, and I gave him the cross streets. When I asked him how much, he said seven bolivianos. First of all, this is only 85 cents, but it was double what he should have charged me. I responded so quickly that the words were out of my mouth before I could think. I told him that he was probably charging me double for the short ride because I was a tourist and didn't know better. I said I would rather walk than let somebody like him have my money. I told him to stop and let me out. The price difference should have been negligible to me. He had approached me outside the station, however, and I know that he felt he could sucker me. Well, I hope he told the truth when he returned to the line of cabs and all of his buddies who he had pushed past to get my fare. Regardless, the walk felt good.

A couple of comments that I have been saving for no reason: American clothing is everywhere, which I may have metioned before, and I only encountered one kid with rheumatic heart disease during my month, which surprised me. Apparently there is a big market for re-sale of donated American clothing, a racket that would not make well meaning church groups and other donating agencies too happy. I must say, it is also humorous to see a Peruvian campesino wearing FUBU gear. As for rheumatic heart disease, which is an uncommon, though dangerous side effect of letting strep throat go untreated, I had expecte more. Perhaps if I were seeing adults instead of kids, it would have more time to develop.

This afternoon I am off to try to recover the $150 that I am owed from LAB for my undelivered La Paz to Cusco fight due to a continuing pilot strike. Apparently, it has been all over the news that there are no refunds in the works. I will see what I can do at the travel agency. They had told me last week to return this week. If I have no luck, perhaps I will try to get the credit card payment cancelled for the transaction. Then, I will skip the country.

So, I know it's Cusco

I seem to be addicted to writing Cusco, Cuzco, for no apparent reason.

I was just walking behind a demonstrably out of shape European couple, both smoking, and all I could think of was that they either lived in Switzerland or Austria at altitude, or they just arrived an hour ago. Nevertheless, there seem to be incredible soccer players and basketball players who have no trouble reconciling elite-level aerobic capacity with smoking two packs a day. These were not those athletes, however.

Cusco is ten times more touristy than anywhere else I have visited so far. I long for Bolivia, where I don't get hassled to buy tour packages all day long.

Catching up in Cuzco

I am having a perplexing time trying to arrange my posts in chronological order, and I give up, but the last several were from my final week at Hospital Materno-Infantil.

I am in Cuzco now, and will head to Machu Pichu tomorrow, then head back to La Paz via Lake Titicaca. I may not spend much time at Titicaca, depending on the weather. If it is sunny, then I will probably spend Wednesday on the Isla del Sol, arriving in La Paz late on

Last Friday, 2-3, was apparently TB day. I attended clinic with my preceptor, and our first patient was a six year old boy who was six months into treatment for TB. We also saw a seven year old boy with the same story. There was a thirteen year old girl from a wealthy family with no known TB contacts, who had what looked like TB granuloma in her lungs on her chest x-ray.

One nice 11 year old boy we saw had TB at eleven months. The TB was somewhat secondary, as his primary issue was an odd abdominal tumor that was made up of cells that resembled the lining of blood vessels or lymphatic channels. The tumor had been resected once, but was slowly growing again, demonstrated by his pot belly. The kid also had terrible swelling in his left arm, and less so on his right. The left arm looked almost cartoon-like, resembling Popeye's arm, and his hand was covered with patches of warts. The swelling was due to failure of his arm to drain fluid through its lymphatic channels. For no reason I can understand, the boy chose not to wear a compression sleeve that would keep his arm from looking so grotesque, as well as help the healing of the warts, potentially. He was there with his older brother, and both struck me as bright and able to understand the advantages of the sleeve.

I saw another thirteen year old boy who had a history of a huge parasitic cyst in his lung. This boy did have the surgery, unlike the other kid I saw a few weeks ago. This portends a much better chance of cure for the one who had surgery.

We saw another child with Down Syndrome, who I could tell already had heart pathology when I listened to his heart.

One five year-old girl presented with muscle spasticity and cognitive delay. She also had an odd bone-cartilage tumor on one of her ribs, but that is probably unrelated. I heard from my preceptor that the girl is a twin who was born second, and who spent an inordinate amount of time undelivered, according to my preceptor. This was her explanation for the nervous system damage we saw, and I could only wonder if the girl's devoted mother knew that there may have been a relation between her daughter's condition and how she was delivered.

Bolivia needs communities to fluoridate water, though the water supply infrastructure is so lacking that elimination of garbage, toxic pollutants, and feces from the water would be a better first effort. The need for dentistry and dental hygiene is overwhelming, with many in the middle class affected by lack of fluoride and dental care.

My ride to Cuzco by bus was one more bus ride than I cared to take, with glimpses of the lake the only saving grace. I was struck by how low clouds hang over the horizon when one is already traveling at 13000ft. With luck, my return to Copacabana will be more enjoyable as the Peruvian buses are rumored to be slightly nicer, and I will travel overnight...

More from HMI

When I woke up on Thursday (2-2), I had conveniently turned off my alarm in some mostly asleep state, and had fifteen minutes to get to the hospital. I was only about ten minutes late, and where my responsibilities are really only to show upand be interested, I considered myself successful. My lack of food, water, and coffee to jumpstart my day made my first two hours very uncomfortable, as an empty belly and dry body at 3600m is different than one at about 50m. Thankfully there was a mid-morning get-together that involved both coffee and food, as well as a dozen doctors. As a guest I was well taken care of, and only needed to sit and consume, and to tell people about ten times where I was fromand what I was doing--a routine I have down.

In many respects the Hospital Materno Infantil is very similar to a mid-sizedcommunity hospital in the US. It is newer and relatively aesthetically pleasing. Still, there are obvious differences, such as the number of beds in each room, the lack of computers, and the smaller number of treatment and diagnositic options.

One thing that HMI is not short on is Tuberculosis. I have seen at least forty kids with TB and more with probable TB during my time in Bolivia. On Thursday Is aw a sixteen year old boy from Potosi, the mining city I visited last weekend,albeit briefly, which happens to be located at 4100m. The boy was oxygen dependent now, and was about a week into treatment. As he coughed, and as I looked at his chest x-ray, my thoughts drifted to what was likely drifting towards me. Somewhere along the way people get old enough that their disease manifestation results in greater spread of TB bacilli. I think I am due for my TB screening in May, so we will see...I am optimistic and not too concerned.

The boy's lungs sounded awful, the worst I have heard on just about anybodye ever, now that I think about it. The chest x-ray looked even worse. With luck, removal of part of one lung, close to a year of treatment, and a temporary stay with family in Santa Cruz, around 500m, will help this kid out.

One habit I have with the kids who have TB who I see is to ask them if they take their medicine every day, and I really press on the point. I bypass parents, ast hey are very good at coming up with reasons to alter and limit treatment adherence and success (something there is plenty of in the US, too). My thinking is that if I have this conversation with some eight year old with TB, even if they tell me something untrue, at least their one memory of the American Doctor (I can't seem to get anybody to introduce me as a medical student) in his clumsy Spanish was that he seemed very serious about taking the TB meds every day. Relapse and resistance are to be avoided, and I guess I try to do my part.

I saw one of the infants with severe burns again today who I had seen two days ago in the burn unit of another hospital. He had been transfered due to his improved condition. I estimated that the kid originally had a burn of 25%, and now he was down to an unhealed area on hit buttocks the size of a pack of packof cards--still significant, but much better. I felt as though he still deserved to have pain medication for his dressing changes, and he was getting none. One of the older treatments for burns, mostly abandoned in the US, as far as I can tell, is to use dilute bleach as an antiseptic over the wounds. The kid obviously did not enjoy the dressing change, and the dilute bleach was not making him happy, either. The sliver of a silver lining was that he was alive, his face untouched, and he had enough pain to indicate there was nerve regrowth in the area.

I learned more of the story of the burn. While the mother was not at home, one of the older kids, perhaps six or seven years old, put the kid into a pot of a popular hot drink made from suger and corn, called Api. It is an awful story,b ut not an uncommon one for the many of the burns seen in Bolivia, and not that uncommon from some of the burns in the US.

Right before leaving for the day, we spoke with the mother of a kid who had been seen twice before at HMI, but who had not showed up for a follow up appointment in over a year, despite attempts to contact the family. The girl, who was not there, was fourteen. The family lived in Santa Cruz, which is likely a big part of the reason for the lack of follow-up. Her condition was that she had a supernumerary rib on the left side, which had led to a somewhat contorted appearance to her torso. It sounds like it was something the family had known about for a long time--the deformity, not the cause. The cause had been known for over two years after its diagnosis at HMI when she was twelve.

I have to admit, of all the things I have encountered in Bolivia, this one bothered me more than most. The girl could have had a surgery to remove it before she had grown, with growth as a nice, natural corrective process. Now she is an adolescent in Bolivia's most Brazilian city, with all of the cosmopolitan emphasis on superficial beauty. She is apparently overweight, has trouble with some types of physical activity, and I gather from my attending that the girl is not happy. The mother's only questions regarded how she should go about getting to Cuba for surgery. The family has money, and the procedure could have been done perfectly well in Bolivia, which has its share of talented surgeons for such things, and it could have been done long ago. I am glad I did not meet the girl, as I probably would have been very sad.

From Friday 2-3: One thing I have not mentioned is how friendly people are in Bolivia. I have never met a cold response when I have asked anybody for directions or information. Now, sometimes the info is suspect, but the people are always warm. It is always risky to generalize about people, but my interactions have been friendly as a rule. Hopefully I haven't jinxed myself to lose my backpack while traveling in the next week.

Speaking of traveling, there is only one airline that flies from La Paz to Cuzco, where I head tomorrow morning. As luck would have it, the LAB pilots arestriking, so my ticket is useless. Instead of a picturesque one hour flight, I have to settle for a picturesqe thirteen hour bus ride. At least I have somepractice, and the roads are better at this end of the country and to Cuzco. It will be a practice run for the same route my father and I take back from Cuzco Monday.My ipod is making terrible noises and is not working currently. This is not that big a deal in terms of music, mostly because I forgot headphones, don't want to buy them, and have all my music backed up at home. The problem is that my first 250 pictures from the trip are stored there. With luck Mac will find away to recover them when I get back to U Village in Seattle. All of my MacStore experiences have been good so far...

Hospital Materno-Infantil From Wednesday

Wednesday at HMI I attended the Peds department's version of grand rounds or a daily resident report. Several interesting cases were discussed. The first concerned a seven year old boy who had meningomyelocele, a pooching out of his spinal cord contents into a sac that sits partially outside the spine and towards the surface of his lower back. The corresponding nerves at this level of the spinal cord can get pinched or trapped and loose regular function. Like the infant I mentioned earlier, this is often (not always) preventable with increased folate in the pregnant mother's diet, and the class of defects, known as neural tube defects (spina bifida has the most name recognition), is perhaps the most preventable now known. Sometimes the pooching out of neural tube contents can be at the top end, which is far more serious, and usually fatal at or soon after birth. It is variably estimated that approximately two-thirds to three-fourths of neural tube defects are preventable with increased, early prenatal folate intake.

This seven year old had endless urinary tract infections, and he had no control over his urinary bladder in that he could not initiate urination. This required him to have either permanent catheterization of some sort, or temporary catheterization several times per day. Also, his ambulation was limited due to partial lower extremity weakness and paralysis. The case discussion centered on what type of permanent solution to his incontince merited trying next.

The next case discussion concerned a boy with Berger's Disease, an ailment where antibodies deposit themselves in an area within many if not all of the kidney's many microscopic filters. This leads to the loss of protein into the urine, and eventual kidney distruction. Unlike neural tube defects, which we see fewer of in the US due to the combination of prenatal care, nutrient rich diet, and pregnancy termination, Berger's Disease is rather common. It tends to be treated with steroids during atibody attacks, and aggressive lowering of blood pressure with one type of medication.

The final three cases all concerned malnutrition--two toddlers and an infant. Malnutrition is sadly common here. It provides an open door to all types of infection, and it hamstrings both the immune response and healing response.

The drug reps in the hospitals in La Paz (well, I have only seen them at HMI) are primitive relative to what transpires in the US. They have a few free samples to offer to the doctors in the hallways, but there is not nearly the full-court press I have seen back at home. My guess is that many academic and public medical centers in the US will go the way of the VA and eliminate industry representatives from peddling wares or influence in those institutions. I read that a prominent NY professional group recently advocated such a move, and my hope is it will resonate in the public medical schools, at least. Patients will then expect it elsewhere, I hope...Anyway, there are far fewer ad-laced instruments, pens, stethoscopes, etc. in the places I have visited in Bolivia. An interesting connundrum, however, is how such industry influence and largess plays out in a medical setting where resources are far thinner than in the US. I hope that Bolivia someday gets to the point that it, too, needs to de-worm itself from drug company influence. It does not have the luxury to even be the target of such influence, as I can see so far.

I have seen much more Down Syndrome here than in the US. Several mothers do not seem to be aware at first of what it is or that their child has a genetic condition. All of here in the program have encountered at least one mother with a child with Down's where the mother is clueless as to why her child won't walk or speak by two.

Patients and families seem to provide a lot of the basic care and interaction for some of the other patients. Adorable Soledad is from the Yungas, a jungle region north of here that is not always easily accessible from La Paz and vice versa. Her family was not able to have a member here with her for about a week due to mudslides and other problems that prevented travel from the jungle up into the Andes.

Hospital Materno-Infantil From Thursday

Adorable Soledad had a cardiology consult on Thursday. Her heart rate has beenbetween 120 and 140 pretty often, and she gets short of breath very, veryeasily. The big lymph nodes she has all over probably include the ones that sitin the area the heart occupies between the lungs. Previously I had asked my attending whether they had considered giving her a few days of steroids, as lymphocytes are exquisitively sensitive to them, and with luck her big lymphnodes would shrink some. My attending said that of course they had, but thatchances were very good that Soledad had been exposed to TB, which is rampantamong many Bolivian communities, including Soledad's. It was something that wasoutside of my previous realm of thinking, or at least was not something thatwould come to mind quickly for me. I suppose it will in the future. Nevertheless, her rapid heart rate still bothers me.

On the cardiology team was a fourth year med student from Colorado. He is herein La Paz for six months working on a high altitude pulmonary edema project, andhe hopes to become a general surgeon. His top choices include UW, which he mayvisit at some point. It was fun to speak English with someone in the hospitalfor once. Plus, he's left-handed, too.

Something we talked about in our lecture last night from the program medicalcoordinator, who works at the Hospital de Los Andes, is that there is a long-term effect seen in kids and adults here who had jaundice as newborns. It is far more common in Bolivia than I have seen in the US, and plays a role in some of the cognitive delay and retardation seen in some of the outlying and rural communities, I am told.

The Day After Groundhog Day

I meant to write yesterday, but had some trouble with blogger.com. It seemed to be down the three times I tried to post.

I've commented several times about the poverty I have seen here in Bolivia and feel I need to add some more context. I see a lot of poverty in the Seattle medical world, and I saw it in Alaska and Idaho, as well. The US has plenty of poverty and illness directly attributable to poverty, but there is also a large group of people in the US who suffer more than they might from acute and chronic illnesses due to complete lack of a mechanism to pay for care. In the US, it is as though a large majority of those without health care know what they need, or at least where they need to go and how often, but the only option available is the emergency room. Still, that ER option is a big difference. Another difference is that the caliber of poverty I see in Bolivia extends to malnutrition. With exception, it is not often to find an underfed person in the US.

Bolivia also has a more distinct separation between the haves and have nots. There are plenty of wealthy people in the urban areas, and both La Paz and Sucre have a significant middle and upper-middle class that has access to many of the same luxuries that similar classes do in the US and Europe, as far as I can tell. Still, the sheer volume of poor people here is the largest difference I notice from the US. With over two thirds the country living below the adjusted poverty line, wealth affects health.

Today was my final day in the hospital, and I was a bit sad to finish. I am very ready to return home, but I have learned something every day in the hospital in Bolivia, about medicine and more. For certain, my appetite is whet for a similar experience in the future when I have more autonomy, more command of the language, and (unlikely) more time. I would love to return to Bolivia, both to work and to travel, and I very much hope to visit other regions of the world as a physician. During the past few years I have met several physicians who have spent extended periods working in other countries; some of these people worked through Doctors Without Borders. I don't know, yet, if such a longer commitment is something I will be able to make, but is on my radar screen.

I have been very happy with the CFHI program. It is well-organized, locally, and centrally in SF. The faculty were excellent, and clearly have been selected with care for their collective ability to teach and desire to do so. Only two of the five with whom I worked spoke some English, another understood a minimal amount, and two more or less only spoke Spanish. This turned out to be fine for me, and my previous trips to Mexico played a big part. It certainly helps that I had four years at DHS and two terms in college, but speaking was a distant third priority to reading and writing. I also would not have undertaken such an endeavor any earlier in my medical training, as it helps to have only one language to translate. The couple here from SF seemed to feel similarly. Both are PA's who work in Oakland, and though they speak less Spanish than I, they seemed to take as much fom their time here as I did. I feel bad for the two other participants, who were learning the new language of medicine in a language they did not understand. Not that twenty-two is too young to travel or to have this type of experience, but I believe that I had ten times the trip they did.

My homestay family has been gracious to a fault. Much like I plan to keep contact with some of the faculty, I expect that I will see members of this family some time in the future, either in Bolivia or the US. A revolving door of nieces and nephews that came to Tio Jorge's every day for lunch, and especially one nephew living with Jorge, all served as full-time concierge service for me, making my transition and movement once here very easy. Language class was challenging, and much like flossing or buying renter's insurance, it was well worth it in the end. The combination of homestay, weekly medical rotations, and language class made for a valuable month.

...continued

...in a new cafe.

Some other things that have surprised me are the frequent use of cell phones in the hospital by doctors. Essentially, they have skipped the entire pager business and gone straight to the phone. Sometimes it seems very odd, and nobody, nobody fails to answer their phones, anywhere, including all folks in addition to doctors I have seen outside the hospital.

The disparity of resources between US health care, as well as general infrastructure that affects health, and what I have seen in Bolivia is more pronounced than I thought it would be. This is a very poor country, perhaps not by sub-Saharan standards, but certainly by Western measure. It really is a shame how much wealth was plundered here in the past thirty years and sent to already rich places at the expense of the already very poor.

The girl I mentioned in the previous post, Soledad, would not have been allowed to get as sick as she did if she lived in the US, anywhere in the US.

I went to the burn unit of a separate hospital today with two of the HM-I doctors to see some pediatric burn patients. I was shocked that two of the kids we saw were not getting any pain medication other than acetaminophen, when they were clearly in significant pain. Also, there was little handwashing and little hadwashing opportunity. Families were allowed to provide much of the nursing care, often with very dirty, grubby hands. The windows were cracked, which perhaps helped the dozen or so flies I saw gain entry. It does not seem like the best way to deal with burns, but then again, resources are so limited that it is perhaps unfair for me to judge.

Hospital Materno-Infantil

Today I started in a nicer, fancier hospital that still sees many patients who are covered by the state insurance designed to help pregnant women and kids up to five. My preceptor is a fantastic woman who speaks German and English as well, and who seems to be the best known figure in the hospital. I spent the day bouncing between kids with congenital illnesses, infectious diseases, malnutricion, and sometimes all three.

The strongest memory of my day is of a two and a half year old girl with disseminated, cutaneous blastomycosis. It is a fungal infection, mostly uncommon in the US outside of a few AIDS patients and immunosupressed adults. The girl, who was a bundle of charisma and sweetness, was apparently much better than on admission two weeks ago. Still, she had a huge belly with prominent veins due to liver congestion from the huge lymph nodes she had throughout her body. She still had racquetball sized lumps under her arms, which were draining pus, and a similar, golf-ball sized one under her chin. She was very thin, and had healing skin eruptions all over, including her face. My hope is that they won't scar.

She needed a new IV line, and the process of placing it was much more barbaric than I have seen at Children's hospital in Seattle. I need to learn a bit more before I determine how barbaric it was, and it was unsuccessful at that.

I saw a seventeen year old girl with toxoplasmosis in her eye, which had returned after she failed to take any of the additional six weeks of medication she was sent home on a year ago. Her vision should be spared, and she is very lucky she didn't get pregnant while she was infected, as toxo can cause a number of awful birth defects.

Another eight year old boy had atopic dermatitis, only much worse than what I have typically seen in the US, save a recently immigrated Somali toddler a year ago.

An infant had spinal cord attempting to ooze out of a hole in his back, apparent cognitive delay, and no bladder or bowel function, all probably due to lack of folate in his mother's diet during gestation. This is why it is recommended that all women planning to get pregnant take a multivitamin with folate. It is one of the more dramatic preventive measures we have in medicine.

Time to go, as the cafe is closing...

Comfy in La Paz

I flew back to La Paz from Sucre this morning. Sucre is a lovely city, with nicer, warmer weather than La Paz. There is a stronger colonial influence, as well. It is smaller, but I found it very friendly. It reminds me a bit of Northern California, though a bit higher, much cheaper, and with more Bolivians.

I think I got really dehydrated (volume depleted is really more accurate) on my trip. Partially it was intentional. I spent a total of thirty-two hours on buses that lacked bathrooms. Anyway, I noticed this AM in Sucre that my pulse was between 100 and 110 at rest. This was sustained for several hours. It was a stark contrast from a rate of about 60 in La Paz last week, a rate at 12000ft of which I was very proud. Anyway, 110 is rather symptomatic volume depletion, and I don't think it was caused by anything else, for a number of reasons. Sucre is about 9000ft, and I noticed my easier breathing, so I don't it was altitude. I consumed about a liter and a half of fluid pretty quickly around lunch, and now I am back to 80, if anyone finds it as interesting as I do.

My trip to the Salar de Uyuni was delayed Friday, both due to my late bus arrival and the extensive rain the region had received, ostensibly. However, I think if I had a group ready to go on a day trip, or had offered to pay about $75, any operator would have jumped at the chance. I stayed overnight to wait, which I had not hoped to do. My preference had been to move to Potosi on an overnight bus after immediately visiting the Salar on a day trip.

Something I forgot to mention about Uyuni: it really is a frontier town. It was ugly, and in addition to salt and tourism, it also had a large army presence to protect from the hated Chileans. The Chileans are hated here for stealing the Bolivian coast during Carnival in 1879 or so. Uyuni is on the other side of the Salar from Tupiza, supposedly near which Butch Cassidy and the Sundance Kid met their fate.

The Salar was very impressive. It is a large salt flat at 12000 plus feet that remains from an ancient inland sea that dried up about twenty-five to forty thousand years ago, many millennia before Earth was reportedly created. There are mountains ringing the area, the Chilean Andes loom to the East, and a few volcanoes of eighteen to twenty thousand feet within the Salar. With all the rain the region had received, there was a layer of about four to twelve inches of water (ten to thirty centimeters for everyone but my father). This created a mirror effect that was so dramatic, I felt as though our Toyota Land Cruiser was actually a Chris-Craft moving across a perfectly placid lake.

As a comparison, the Salar is eight times the size of Utah's Great Salt Lake, which was once part of the huge Lake Bonneville (one and a half times the size of the 12000 square mile Salar), which happened to be two to three times older than the Earth is reported to be, by some.

So, the Salar is large, and very salty, too. Trucks drive out to the salt and dig it up for later distribution and sale. This was fascinating to watch when there was water covering the Salar, in a little boy digging in the sand sort of way. Men would pile up wet salt in piles four or five feet high, let it dry for a few minutes, then shovel the top of the pile into their trucks. I really wondered how difficult it is to maintain the Land Cruisers that drive through that salt water. They were rigged with tarps to prevent water from jetting into the engine from in front and beneath, though this seemed to be a meager effort with limited effectiveness.

My group of six spent much of the time on the roof of the vehicle, where we had a better view. There are curiously huge numbers of flamingoes that live in the Salar region. I saw a couple of flocks fly by, and evidence of their presence was apparent around the salt hotel, built of salt, where we stopped for lunch. I managed to avoid sunburn to most areas, despite being above 3600m, cruising on a giant mirror, and having little hair on my head. The only casualties were my feet, which had no sunblock and no shoes when I was walking around the salt hotel.

I have never seen anything quite like the Salar de Uyuni, and will eventually post pictures of the eerie mirror image one saw in each direction.

As for picture posting in general, it will probably happen once I return to WA.

I left Uyuni by bus after my day trip. The bus ride is one I will describe as one my mother would not take herself, nor would she have wanted me to take. We followed the same route back to Potosi (remember, there is a map link on the right of the site), but in a thunderstorm that provided marble-sized hail for the first half hour. The first twenty minutes out of Uyuni were uneventful, though it was obvious in a Conrad sort of way that we were leaving a sunny area for gathering clouds and lightning, with a siren-like trio of rainbows beckoning.

After twelve hours to make a six to seven hour trip (the same six to seven hour trip that took about nine or ten in the other direction from Potosi), I arrived in Potosi on Sunday morning, where all I wanted to see was closed or very inaccessible. What I most wanted to see were the old treasury building that minted all the Spanish silver coins, and to actually descend into one of the mines. At over 4000m, and deep underground with noxious gases, and heat up to 45C (113F Dad), it is supposedly much fun to join the miners for a bit of their day. This had partly occurred to me before and was why I hoped to avoid staying a night in Uyuni. So, as it was raining and tourism folks indicated it would be difficult to enter the mines, I decided to take another bus the three hours to Sucre, the other capital.

Twenty minutes out of Potosi, on a first-world quality highway (almost...), I was cruising downhill to Sucre. My neighbor on the bus was a man in his 70's, well dressed in a suit with a sweater, and completely unable to read his ticket or the seat numbers. Thankfully, he was still very mentally alert, enough so to figure out my explanation of where he should sit.

He had terrible cataracts, but there also seems to be a lot of other eye pathology in Bolivia. There are a few infectious causes of blindness that are restricted to the Amazon areas, as well as some childhood causes found in all poor areas. Also, presumably the radiation at altitude and uncontrolled chronic illnesses lead to other degenerative processes in addition to cataracts. I have seen many children and young adults with strabismus, a form of amblyopia (lazy eye)--far more than in the US. Plus, normal vision correction is more expensive and less common among Bolivians, primarily, though not exclusively amongst the poor...as I have observed in my brief twenty-three days here.

After about two hours travel time from Potosi, after having descended through some fantastic mountains in wonderfully sunny weather, to more fantastic mountains, the bus stopped. We parked on the side of the road behind several other buses, and quickly about one hundred people lined up to board the bus. It turned out that half a kilometer ahead (about a third of a mile Pops), there had been a huge landslide across the road. The expectation, which took all of us a little while to learn, was that we were to walk over and take stranded buses on the other side back down to Sucre.

My guess was that the slide was about fifteen meters high and fifty meters long. It had apparently happened in the previous half hour, perhaps due to the rain the previous night. A bulldozer was on top grading a path that people would later walk over to the other side. That is what I did, along with all of my bus mates. I actually stuck with my seatmate, the older gentleman, because I knew he could not walk across alone, especially with his suitcase. Interestingly, there were many people willing to help him, and many people willing to push by him and almost knock him over--an international bimodal tendency that seems distinctly human.

I have some wonderful pictures to show of the slide as well. I was surprised at how little crowd control there was. People were walking into the path of a moving bulldozer, across loose dirt and rocks that were unstable, and doing all of this at a precipice that drooped about 200m to a river. I don't imagine Americans being as aggressive about getting to the other side, partially because they would all be in their own vehicles, and also because authorities would not allow it to happen. Snoqualmie Pass on I-90 East of Seattle had a big avalanche block one direction earlier this Winter, which I did not get to see, otherwise I would certainly over-compare and generalize differences between the US and Bolivia.

So, I take from my trip the lesson that I needed much more time than I had. Tour agencies in Uyuni really cannot be counted upon to come through until one is actually on a trip. I knew this beforehand, but it was confirmed by my witnessing of collective experience during the two days I was there. Also, bus companies are somewhat similar, though to a much lesser degree. Bus drivers exercise a lot of independent itinerary control; very different from the couple dozen bus trips I have taken in Mexico. Road infrastructure is so terrible to the Uyuni region and to the Salar, that weather plays a prominent role. Also, this is the rainy season, and I underestimated its effect.

Flying Is Nice

My bus ride to Uyuni was interesting. It started with the discovery at the bus terminal in La Paz that due to the extensive rain in the Altiplano, the road from Oruru to Uyuni was washed out in two places. Conveniently, the bus folks even had a picture of a swimming bus from some previous washout. The kicker was that I would have to travel to Uyuni by a different route, through Potosi, which is where I hope to go tomorrow overnight. This would have been fine if I was not required to pay an extra sixty bolivianos. Now, this is $7.50, and really no big deal in the grand scheme. I explained to the people at the bus terminal, though, that I could just buy a ticket to Potosi and one from there to Uyuni for less. They agreed, and "let" me pay fifty extra instead, which felt like enough of a victory, $1.25, that I paid and got on the bus.

I keep seeing Bolivians with “rip curl” hats, an American surfwear company. They are so ubiquitous that I initially assumed they were actually garb for a local soccer team, until I looked more closely. There is so much American clothing in Bolivia, as I think I mentioned before, that I wonder how much is direct sale and how much is donated. Obviously, a park district somewhere in Ohio probably does not market directly to Bolivians, so t-shirts of that ilk are likely donated.

The ride to Oruru was pleasant, giving me a wonderful view of the Altiplano around La Paz. At times I felt like I was riding through central Washington, based on the arid steppe appearance with sharp mountains in the background. It took about four hours, which was about what it normally takes.

A side note: I have this little notebook in which I write down brief notes to remind myself what to write about later. It is something I use in the hospital too, when I don’t know something, so that I can look it up when I get a free moment. The problem is, I am starting to feel like Bob Graham, who is famous for documenting everthing that occurs in his days in one of thousands of little notebooks.

The next leg, to Uyuni, was different. It was entirely unclear which bus service I would be taking to Uyuni, nobody seemed to know where or when the bus would arrive one I found the correct company. Then, I kept thinking I was missing my bus when someone would yell about boarding a bus to Huanuni, which I could never distinguish from Uyuni. When the bus did arrive, I felt like I should be a third-string goalie on a 50's semipro hockey team, crusing from Bemidji to Minot. It was raining, but half the luggage still went on top of the bus. I am not carrying much, just a small backbapck, which lets me keep my things close to me on the bus.

Something that would never occur in the US or Europe are modern day stowaways. Yet, that appears to be very common on some Bolivian bus routes, based on my ride to Uyuni, as well as the sheer numbers that boarded other buses. It is partly due to overbooking, but also due to the fact nobody checks tickets on some lines. I spent sixteen hours on the bus to Uyuni with people sitting or sleeping in the aisle, including a young couple who seemed to sprawl violently into legs and under the seats during the night. It appeared that there were about fifteen extra people on the bus that seated forty, which I suppose is not as bad as it could have been.

I met an Argentine guy, 29 as well, waiting to board the bus in La Paz. We spoke briefly, then not again until we reached Oruru. As the only two people from our bus from La Paz now riding with another outfit to Uyuni, our seats were next to each other. It was nice to meet a fellow foreign traveler, though he was still speaking his native language. I wish he had been from Spain or Mexico, because Argentine Spanish is ridiculously hard for me to understand. As I have heard before, and now again with this guy, every word seems to be a combination of “shushing” sounds, tv static, and indulgent rolling of one’s “R’s.” So, I felt like I had regressed in my ability to listen and communicate.

It rained from Oruru to Potosi, or so. I slept much of the trip, amazingly. Once we left Potosi the quality of the roads diminished markedly. Again, I don’t know how I managed to avoid motion sickness, but it might be that the busride was too rough to get sick. The final four hours before reaching Uyuni, the road was single track dirt through the mountains and across some intervening plains. Alpaca roamed everywhere, often on the road, so sleep became difficult with the bus horn sounding every five minutes at precarious turns or when alpaca were in the way. We crossed several washed out areas of the road, lending some credence to the bus company story. A few times, I figured we would have to get out after the bus sunk too deep in the mud or water, but the driver seemed to have a much better idea than I about the capabilities of his vehicle.

Having bussed around Mexico on multiple occasions, I must say that the Mexican system is ten times better than the Bolivian. In Mexico, busses run on time, they are relatively clean, the first and premier class busses have bathrooms, and the system tends to be very easy to use. It is not often one has the opportunity to wish for the luxuries of Mexican infastructure, so I will take advantage of this rarity now. Nevertheless, I made it to Uyuni, albeit six hours later than I had hoped.

Uyuni is a small town that has dual purposes of serving as a jumping off point for tourism to the Salar, as well as a labor town for the Salar salt mining. I must admit that compared to the weathered backpacking crowd, I probably seem like William F. Buckley, Jr. My idea of a place to stay, if I am not camping with my car nearby, is one with electricity and running water, though it not need be hot.

It was too wet on the Salar today to attempt even a short day trip once I arrived, which was what I had hoped to do. Now I plan to spend the night, rather than take an overnight bus to Potosi. With luck, it will be a bit drier tomorrow, otherwise I will probably leave on a morning bus, though I really don’t want to miss it having come all this way.

Finally, a Potosi correction: it was the largest Latin American city at some point in the 18th or early 18th century. Silver was discovered in 1544, and the city did not take long to become a huge mining metropolis.

Alalay

Thursday morning I went to the largest of the Alalay sites, a ten year-old compound that houses up to 110 kids, has its own water system, and is located about forty-five minutes to an hour from La Paz. In the little town of Huajchilla, this site is by far the most desireable for the kids. The rooms are nicer, with only three or four to a room, both boys and girls live there in separate facilities, and the weather is warmer and nicer. Sadly, due to a mixup, almost none of the kids were there, so I only met a few and did nothing medically. Huajchilla is at about 9000ft, which was noticeably nicer for me. I felt much stronger and more energetic than I had earlier that morning.

The ride to Huajchilla was my first time travelling through the Zona Sur, the wealthier, warmer, lower-lying section of La Paz. I took a cab to meet Dr. Galvarro, and then we took a minibus, one of those Toyota toaster-looking minivans, for the remaining forty-five minutes of the trip. Somehow, we had seventeen people in that thing for a good portion of the drive. I don't know how I managed to avoid the motion sickness that usually plagues me in such conditions.

With few kids to see, I headed home a bit early to catch the bus for my weekend trip.

Last Day of Class

I finished my Spanish classes today. I paid for fifteen, two-hour sessions at the Centro Boliviano Americano. This is a standard part of the month-long program. I ended up using eleven of them, and to be honest, I was very ready to finish. They have helped my ability to communicate, but I was pretty tired of homework and two hours of one-on-one conversation in a second language. I am skipping the final two days of class to travel a bit through the Altiplano.

Tomorrow afternoon I am taking an overnight bus to Uyuni, a remote town somewhere nearer to the Chilean border, and the gateway to an odd dinosaur of a salt lake at 4000m. I plan to spend one night in Uyuni, then head to Potosi, which was the largest city in the Western hemisphere 460 years ago, thanks to silver mines that Spain devoured with slave labor. One can still visit the tin and zinc mines there, descending into what I imagine are well-regulated facilities. After one night there, I plan to head to Sucre, the other capital. All that travel will be by bus, and I plan to fly to La Paz from Sucre. The weather looks to be rainy, which is not what I want, but it's my best time to travel.

Today I went to one of the other Alalay homes in La Paz. Just down the street from the girls' place I visited Monday, this one was larger, nicer, and all boys. There weren't too many medical requests when the doctor and I arrived, so I ended up playing soccer in a large room inside the house. Though at an altitude disadvantage, my team of two won very handily over all comers on the other side. Of course, I am twice the size of most of the kids, including the fifteen and sixteen year-olds. I passed on the few tricks I knew, which really are few, as I tend to be less of a skill player than most.

The home reminded me a bit of my three-week experience in the adolescent unit of the Alaska Psychiatric Institute, the state's largest inpatient psych facility. Though the kids can always run away, for those who don't, the experience involves development of the standard code of social conduct that most of us adhere to without much thought. Many of these boys have lived on the streets by the most base rules of human nature, so the rigid environment of communal living can be a big adjustment. I sat in on a discussion between the staff psychologist and several of the boys, that centered on behavior that was preventing some of them from attending an upcoming trip to Cochabamba, one of the larger cities to the Southeast of La Paz.

All of the Alalay homes take trips with the residents to areas of Bolivia every few months, often to visit and maintain contact with the boys' families. A recent trip was to the Yungas about a week ago, and the few medical complaints to which the doctor and I attended were related to the travel. Several of the boys had dozens of insect bites to their arms and especially their lower legs. Four of the boys had significant skin infections from the wounds, infections that I probably would have treated with an oral antibiotic if I could have done so. Our treatment involved unroofing the areas of infection, cleaning them with peroxide (which I believe to be a waste of time), treating them with mercurochrome (which I opt not to do, as kids don't need more mercury poisoning them), and then covering them with bandages. The best advice I could give was for the boys to shower more frequently, and to really clean the areas with hot water and soap as much as possible, ostensibly to allow the areas to drain better. They have access to hot water showers, so in theory this could be achieved.

I have noticed some physical findings with these kids that aren't as prominent in US kids. Many have old scars from burns, often kerosene, on their arms and even faces. Today I spent some time sitting next to a kid with an amputated finger, though I did not ask about the story behind it. Many kids who I see sitting on the street with their parents, who are selling items, have numerous warts on their hands and even faces. The kids in the Alalay homes have warts frequently, and some have more than a dozen. I helped one kid today by covering many of the warts on his hands with a thick tape, knowing that if by some chance he keeps the tape on (or replaces it) for two weeks, he'll have as good if not better a chance of eliminating the warts than if he had access to nitrogen or acid.

La Paz began a street fair yesterday called Alasitas. It is some blend of many cultural influences that has as its basis the thanks and hopes for abundance. Innumerable street dealers sell miniaturized versions of just about everything. Buying these things and then gifting them to another person is the way that one ensures receipt of abundance in the coming year. For example, buying a miniaturized dollar ensures riches, a chair brings new furniture. It is apparently just a La Paz thing, it lasts for two to three weeks, and it is extensive enough that there are several street closures.

It continues to rain.

Second Day at Alalay

Today I went to El Alto to see one of the other Alalay homes. It is similarly bare bones, but a big step up from the street. The home today was just for boys, and many more of them had spent time on the streets in comparison to the girls I saw yesterday. In fact, one of the new boys, who gets an entrance physical, courtesy of me, had lived on the streets from age eight to eleven. I suppose he qualifies as someone forced to grow up a little faster than his peers. I took a picture of him with one of the volunteers and the cat of the house, and he was intent upon receiving a copy.

These past two days have been a bit more difficult emotionally, as the kids I am seeing happen to be the poorest and worst off in a country where 70% live below the poverty line in a country that is already one of the poorest in the West.

I have not commented much on the physicians with whom I have been working, but generally I have been impressed. Currently the doctor who serves Alalay splits his time between private pediatric and adult patients, and then offers almost half of his time gratis to Alalay. He has all of the wonderful personality traits of a pediatrician, and recognizes that half of his job is being a father to the kids.

At Hospital Del Niño, the primary physician is a pediatric infectious disease specialist, who has spent some time in Cincinnati during his training. He is the only primarily indigenous doctor I have worked with, and has a similar ease with kids. He clearly enjoys the interaction with American program participants, and offers as much cultural teaching as he does medical didactics. One of the arrangements HDN has for patients requiring surgery is a relationship with the Cincinnati Shriners’ hospital.

I had the opportunity to spend a day in the Shriners’ hospital in Spokane, so I have a minimal familiarity with their system. Though I could not get the Shriner-folk to give me an exact figure regarding how much of their charity budget goes towards patient care, hospital operation, or capital investment, I was still impressed with the charitable nature of their cause. The Cincinnati Shriners’ take several Bolivian children each year and provide vital surgeries such as congenital heart disease repair, some cancer treatments and surgeries, and orthopaedic procedures for hip dysplasia or limb-length disparities. When children are sent to the US for procedures or treatment, there is usually a Bolivian MD who travels with them, and Dr. Velasco has visited repeatedly.

The first week I spent with a Peds ID guy who is the husband of the program director. He happens to be a prominent parisitologist, so he was a wonderful resource for my malaria, TB, and worm questions. He provided a lecture to our group last week about Chagas' disease, which is probably the number one cause of heart disease in Latin America.
The view on the return mini-bus ride from El Alto this afternoon was spectacular, though still cloudy enough to obscure Illimani and Illampu, the two 6300 meter-plus behemoths. At some point I will hire a cab for an hour or two to take me around so I can collect the requisite touristy pictures. La Paz is situated in the most striking manner I have seen for a city, save a few of the Alaskan ports, but it is difficult to compare. I think that Seattle and Vancouver are my two favorites, but La Paz is so different...I wish I could share pictures sooner.

I have not found much smoking in the Altiplano. I may have mentioned this before, but it makes sense to me, both in economic terms and because it's so fricking high. There is the rare person I see smoking in the street, usually a middle-age, well-dressed male. Nevertheless, there is a woman smoking across from me at the internet cafe, and I am looking for things to throw at her. The smoking bothers me, but her inability to understand the use of the "inside voice" while on her cell phone is even more irritating. The only other place I have encountered smoking is at the club I visited the past two Saturdays, requiring me to air out my clothes for the next three days.

I make a lot of generalizations, and I recognize that is what they are, but I don't know how else to pass on my thoughts. The Altiplano is generally at a high altitude. I suppose I am soon entering a profession that catalogues generalizations in the approach to patients. I have found a couple of places with computers that have USB ports, but I’m having no luck getting them to recognize my iPod. So, my next step may be to burn them at the Kodak store, if they can do such things.

Homeless in Bolivia

Thankfully, I am not, but much like tens of thousands of kids in the USA, there are kids who live on the streets in La Paz and El Alto. Today I spent the morning with a doctor at a private charity that houses homeless kids. I'll spend the next week with him as he tours the different homes that serve a total of 150 or so kids at any one time. The charity, called Alalay, has four distinct housing setups, as far as I can tell. Today I went to a rented building that houses 20 girls, though currently there are only 10 there. Turnover can be high, as life with the strict rules of shared housing can be difficult for somebody used to life on the streets, where rules are different. The oldest was sixteen years, and the youngest eighteen months.

The doctor is a pediatrician, who ends up being a father figure for many. As he stated to me later, and as I observed very quickly when I arrived, the limited staff really are parents for these kids. The typical story, though for sure there are many, is that the parents are drug addicts, or that the mother dies and there is no father present, leaving the kids to fend for themselves. La Paz has an extensive network, or collection of street youth, many of whom can be found after ten PM in the same plaza where Evo spoke publicly and thousands gathered yesterday. Most, from what I hear, end up on the street after a family somehow disintegrates. At Alalay, some kids are abused, some abandoned, and it seems few actually run away, which is more common in the US.

As a segue from the apparent infrequent occurance of runaways, in the US all of the homeless teens with whom I have worked, especially in shelters prior to med school, ran away as an assertion of independent action in the face of some sort of abuse. It has been mentioned to me repeatedly that kids in Bolivia grow up later, or mature later emotionally. Though there are many in the US who live with their parents into their late 20's or later, Bolivia does not seem to have the going away to college or out into the world to work types of separations. Families are very close, and aunts and uncles seem to be extra parents, with young adults skipping around to different family members' homes for lunch or dinner. I tend to think that, sadly, though this cultural familial support is sorely lacking in the US for the most part, the tendency for kids to lack independence keeps them in harmful situations.

Some examples of this growing up later trend are obvious in clinic, where every fourteen year-old has their parent in the exam room the entire time. Other kids, such as the thirteen year-old with the lung cyst I saw last week, have no opinion on whether they want the only potential cure, which is surgical removal of the cyst and part of the lung. The boy's father does not want the son to surgery because the father does not have the money to pay for it. It is a terrible excuse, because the Hospital Del Niño arranges donors for such procedures. In reality, the father does not have the explanatory model that allows him to understand his sun will probably die in a few years without the surgery, and will have an increasingly uncomfortable life until then. What shocks me about this is that in the US the child would probably have some idea, some comprehension of the ramifications of going home to die from a curable illness.

Other eleven and twelve year old kids, including those I see in my extended host family, strike me as much younger emotionally than their American counterparts. I don't think this is necessarily bad, just different. Still, it is striking sometimes because of the adolescence to which I am more accustomed.

One girl I saw today had a second digit growing from her thumb. It was shocking to see, as it looked essentially like her thumb branched into a big and small thumb. The supranumerary half-digit could have easily been removed with a minor surgical procedure, so tempting that I started thinking about how I would do it myself. It's not that I would do such a thing, but it could probably have been achieved by most family docs in clinic, if there were some expectation for reasonable follow-up and cleanliness of the wound. What moved me most was how odd and awkward such a deformity could be for a child and how unfair it seemed that she not have it remedied.

Seven of the ten girls currently staying there had just recovered from chicken pox, including the youngest. I'm glad I have had it, considering I had spent an hour chatting and playing soccer with them before I noticed some of the healing lesions when we moved to the clinic space. Perhaps in a few decades, or few years depending on how infastructure changes now that the vast majority of natural resource wealth remains in the country, kids will get immunized against varicella as they do in the US. This is obviously pretty far down on the list, though, of what needs to be done.

As another intentional segue, Evo Morales' inauguraton, or possession, as it is referred to here, was very emotional to be a part of yesterday. Admittedly, I am not too invested in who gets elected in Bolivia, nor do I have firsthand knowledge of the country's political history that I have been learning. Still, there is so much pride apparent in the faces and attitudes of many. I think most of the country cried when Evo cried after taking the oath, including those who did not vote for him (and not solely out of sorrow). Streets were all closed, people packed the public squares near where Congress sits, as well as the huge public square where Evo spoke publicly. Fireworks went off all around the city at nine PM, something my host family says never happened with other presidents.

Evo's VP gave a rousing acceptance speech, almost entirely extemporaneously. Not to be outdone, Evo himself spoke for almost two hours after taking his oath, largely extemporaneously, partly in Quechua, and even singled out the corruption of one of the past presidents sitting in the audience. I have to admit, it has been a few years since I have heard a head of state speak comfortably at length and about cocepts he understands, without notes, prompting, or earpieces.

I have learned quite a bit about coca. It turns out that there are really two coca markets, or coca crops, in the country. One is almost entirely used for traditional, indigenous purposes, with nowhere near the kick or abuse potential of cocaine. The other is all cocaine. Evo pledged to keep the first, and eliminate the second. We shall see. Though Bolivia exports quite a bit of cocaine, perhaps even to people in Texas in the 70's and 80's, it pales in comparison to Colombia in terms of contribution to the illegal US market.

Another thought about Bolivia and its poverty is that there is an incredible lack of infastructure. Many people have never visited certain parts of the country, though it is not that large, for lack of roads to get there. Many of the roads are awful in the first place, apparent even though I have spent most of my time in the urban enclave of La Paz and El Alto.

One last thought: stop lights and street signs often appear to be nothing more than decorations, not even hints at how to drive. Downtown La Paz has a small semblance of traffic order, partially due to traffic cops in the intersections, and partially due to mass action once the cops signal a change. In El Alto, or elsewhere in La Paz, it seems like the only rule is "look out and try not to hit stuff or get hit." Amazingly, this seems to work. Perhaps the lack of in-dash GPS, satellite radios, and talking on the cell phone while driving contribute to better attention spans.

A final, final note: I spent much of yesterday in front of the TV, watching all the dignitaries arrive (some curiously absent, including Fidel, who said he had to work) and watching the transfer of power from the supreme court president (who returned to his job leading the court today) to the new president. The entire time I have been here a big deal has been made about what Evo will wear, sparking the fashion economy I mentioned before. He ultimately wore a suit, sans tie, with a subtle indigenous scarf. It reminded me of how we talked of no issues for two weeks during the 2000 election other than Gore's supposed use of a focus group to choose attire. Anyway, style-coverage provided a nice detour from substance, which probably describes politics anywhere.

I finally went to the Plaza de San Francisco once it was clear that Evo was on his way there. Nobody seemed to know in the days leading up to the inauguration just how the day was going to unfold. It was very un-American, where we generally have an idea about where and when to show up for things. I heard reports as diverse as ten AM and six PM for times that Evo would finally be outside. Some of my program-mates went to the plaza around nine AM, only to return home having missed the transfer and speeches, and then missing Evo's public appearance, as well.

I have been out both Saturdays with some variation of host family entourage to hear a couple of Bolivia's hottest bands play at an intimate club in La Paz. Both times were fun, more later...

Evo Day Minus One

So, it really has been all-Evo all the time for the past week. His inaguration tour comes to La Paz tomorrow, and all the four-star hotels have had riot police out front for a few days, so I assume that's where some of the big wigs are staying. Somebody told me that the president of Slovenia was at Tiwanaku today, so Tracy should be happy to know the Slovenes are well-represented, though I don't know if he was really there. With luck, I'll take some fun pictures tomorrow. I have found a place with USB ports on their terminals, so perhaps some picture posting soon.

I can't remember if I wrote about hip dysplasia before, and I am too lazy to look back, but it is worth mentioning again. Hip dysplasia occurs when a baby's hips fail to develop normally, usually do to the way the infant is swaddled or restricted during the first few months. It is something that a kid can grow out of during infancy, but it is tougher to correct once the child is more than a year or two old, and at some point during childhood (I scored in the mid-70's during my musculoskeletal anatomy course) hip dysplasia becomes significantly difficult to reverse, guaranteeing arthritis, immobility, or worse later in life.

There are tons of indigenous babies with hip dysplasia. There is a cultural tradition of swaddling newborns and infants with their legs straight, rather than the natural frog-legged position that allows normal development. I probably saw two dozen infants with dysplasia in the past two weeks, far more than in the US, where it gets treated aggressively early on when it occurs.

There does not appear to be much central heating in La Paz. My room gets down to 50 to 55F at night, if I can believe Tracy's travel alarm clock. It feels like 45, so perhaps it is correct. My solution has been to add a second comforter to the three blankets and one comforter already there. In actuality, it makes for nice sleeping, though sometimes I wear my hat.

Yesterday we saw a very bright, healthy 3 and a half year old girl in clinic, born to reasonably well off parents. She was deaf, and her family could not afford the hearing aides she needed to hear. She signs very well, but one wonders how her language and hearing development will be affected by waiting too long for the aides. Her father was very aggressive, though friendly, in questioning me if I had visited as part of a foundation or some charitable organization that could provide the devices.

I have played the board game, Risk, a few times with a couple of the mid-20´s cousins occasionally visiting. It is just as much fun in Spanish, and it reminds me of many junior high and high school evenings, playing all night in the basement. We haven't been able to finish a game, yet, but it's still enjoyable.

Thursday

I forgot to write about one patient we saw in clinic yesterday. He was there for a one-year follow up for TB meningitis. The boy was from a community in the Yungas, a region that is exactly what it's name suggests, the jungle. About two-thirds to three-fourths of Bolivia resembles Brazil and the Amazon. I have to take people at their word about it, since I probably won't have time to visit. The kid and his mother took a day and a half to reach the hospital in La Paz, all for a five minute visit.

What was interesting about the visit was that most of the history was offered by the mother, but the wonderful doctor with whom I am working this week chose to direct all of his comments to the boy. Basically, many of the doctors speak directly with the children about the treatment of TB and the importance of taking all of their medication. The reason is that once a kid has reached the age of ten or eleven, and if they are in school, they quite often have an explanatory model of illness and medicine that is more consistent with the goal of the therapy. A common trend for adults in rural areas when they have active TB illness is to stop medicine as soon as they feel better, if they even seek medical care at all. This can lead to development of drug-resistant TB very easily, and drug-resistant TB is a nightmare. Also, the incomplete treatment often leaves patients contagious, yet with a drug-resistant bug this time.

The boy was incredibly faithful with his medication. He had TB inside his brain, which requires twelve months of treatment, longer than the standard six to nine months patients get when they have pulmonary TB. One of the reasons everybody outside the US and a few european countries gets immunized with a TB cousin at birth is that it reduces the risk of extra-pulmonary TB, like the TB meningitis the boy had. It did not don on me to ask him whether he had been immunized at birth until after he left. I asked the boy how he was doing with taking his drugs, and he replied that he had missed two days in the ten months since he left the hospital. I suppose being 12 and spending two months in the hospital will make one faithful. Anyway, he looked great and will probably do very well.

Immunizations are another topic I have found fascinating. Of all the things humankind has to offer for improving health, I feel that only two and a half are really worth mentioning. Immunizations are tied for number one with not defecating in drinking water. The half are antibiotics, treating pneumonia and TB. After that we have not done too much to improve our lives and lifespans, relative to those two and a half things, as I see it. Of course, that means that I am dedicating my life and career to something that is a world of incremental improvements. I suppose the improvements on the individual level are much more than incremental, so perhaps that is how I can rationalize my choice. That, and the great hours.

Anyway, immunization is a big struggle for many in Bolivia. Kids still die of neonatal tetanus, diptheria and pertussis as infants, hepatitis, meningitis and pneumonia from a type of bacteria called Haemophilus influenzae, and many get the nasty extrapulmonary forms of TB. There are vaccines for all of these things, and they are all free for all kids up to 5 and for many more later than that, and they all make a difference. In my handful of clinic days, we have seen a bunch of kids who have not been immunized againsts the things killing their neighbors. There is a lot of distrust of doctors and medicine, perhaps much with good reason. Still, it hurts to see kids with hepatitis who should not be getting it. Dr. Valasco, with whom I am working this week, has told some great stories about the nursing vans with WHO employees and local doctors getting pelted with rocks. More about him later...

Another thing that strikes me about the sick children I have seen is how sick they get before coming into the hospital. A dental abscess, or a pocket of infection around a tooth, that would normally get treated pretty quickly in the US, turns into a raging bone infection in the jaw after months of waiting. Sadly, there is a girl with just such a problem at HDN right now, and my hope is that IV antibiotics alone will cure her, but I am doubtful seeing the jaw X-ray. Kids with meningitis are brought in once they are comatose, which sometimes happens too rapidly for even the most hospital-friendly of patients to outrun. Still, I have seen more meningitis in two weeks, two days even, than I did in Seattle and Anchorage.

It is all Evo all the time here now. The radio and TV are filled with talk about and pictures of him. Entrepreneurs are racing to make their own versions of Evo-attire, which is being labeled "Evo-fashion," though it strikes me as a misnomer.

I forgot to write about one patient we saw in clinic yesterday. He was there for a one-year follow up for TB meningitis. The boy was from a community in the Yungas, a region that is exactly what it's name suggests, the jungle. About two-thirds to three-fourths of Bolivia resembles Brazil and the Amazon. I have to take people at their word about it, since I probably won't have time to visit. The kid and his mother took a day and a half to reach the hospital in La Paz, all for a five minute visit.

What was interesting about the visit was that most of the history was offered by the mother, but the wonderful doctor with whom I am working this week chose to direct all of his comments to the boy. Basically, many of the doctors speak directly with the children about the treatment of TB and the importance of taking all of their medication. The reason is that once a kid has reached the age of ten or eleven, and if they are in school, they quite often have an explanatory model of illness and medicine that is more consistent with the goal of the therapy. A common trend for adults in rural areas when they have active TB illness is to stop medicine as soon as they feel better, if they even seek medical care at all. This can lead to development of drug-resistant TB very easily, and drug-resistant TB is a nightmare. Also, the incomplete treatment often leaves patients contagious, yet with a drug-resistant bug this time.

The boy was incredibly faithful with his medication. He had TB inside his brain, which requires twelve months of treatment, longer than the standard six to nine months patients get when they have pulmonary TB. One of the reasons everybody outside the US and a few european countries gets immunized with a TB cousin at birth is that it reduces the risk of extra-pulmonary TB, like the TB meningitis the boy had. It did not don on me to ask him whether he had been immunized at birth until after he left. I asked the boy how he was doing with taking his drugs, and he replied that he had missed two days in the ten months since he left the hospital. I suppose being 12 and spending two months in the hospital will make one faithful. Anyway, he looked great and will probably do very well.

Immunizations are another topic I have found fascinating. Of all the things humankind has to offer for improving health, I feel that only two and a half are really worth mentioning. Immunizations are tied for number one with not defecating in drinking water. The half are antibiotics, treating pneumonia and TB. After that we have not done too much to improve our lives and lifespans, relative to those two and a half things, as I see it. Of course, that means that I am dedicating my life and career to something that is a world of incremental improvements. I suppose the improvements on the individual level are much more than incremental, so perhaps that is how I can rationalize my choice. That, and the great hours.

Anyway, immunization is a big struggle for many in Bolivia. Kids still die of neonatal tetanus, diptheria and pertussis as infants, hepatitis, meningitis and pneumonia from a type of bacteria called Haemophilus influenzae, and many get the nasty extrapulmonary forms of TB. There are vaccines for all of these things, and they are all free for all kids up to 5 and for many more later than that, and they all make a difference. In my handful of clinic days, we have seen a bunch of kids who have not been immunized againsts the things killing their neighbors. There is a lot of distrust of doctors and medicine, perhaps much with good reason. Still, it hurts to see kids with hepatitis who should not be getting it. Dr. Valasco, with whom I am working this week, has told some great stories about the nursing vans with WHO employees and local doctors getting pelted with rocks. More about him later...

Another thing that strikes me about the sick children I have seen is how sick they get before coming into the hospital. A dental abscess, or a pocket of infection around a tooth, that would normally get treated pretty quickly in the US, turns into a raging bone infection in the jaw after months of waiting. Sadly, there is a girl with just such a problem at HDN right now, and my hope is that IV antibiotics alone will cure her, but I am doubtful seeing the jaw X-ray. Kids with meningitis are brought in once they are comatose, which sometimes happens too rapidly for even the most hospital-friendly of patients to outrun. Still, I have seen more meningitis in two weeks, two days even, than I did in Seattle and Anchorage.

It is all Evo all the time here now. The radio and TV are filled with talk about and pictures of him. Entrepreneurs are racing to make their own versions of Evo-attire, which is being labeled "Evo-fashion," though it strikes me as a misnomer.

like Seattle, but with more Bolivians

Apparently the onus is upon the person without an umbrella not to be hit by one, when walking along sidewalks in La Paz. I never thought I would live in a place where I feel tall, and in the Yucatan I felt huge, but now I see some of the pitfalls my taller brethren must face. All of the umbrellas are held by semi-clueless, or more likely semi-careless older adults about four and a half to five feet tall. I have had some close calls, and I'm not alone. The other tall folks seem to be on the look out for the umbrella sniper as well. All of the trees along the sidewalks and in the plaza have limbs cut to a height of about 5'8". Whereas I am 5'10" on a low-gravity day after a long night's sleep, I do quite a bit of ducking.

It has been raining off and on Seattle-style for about a week, it seems, and the last two days have been more or less constant drizzle. I have been forced to don my blaze orange raincoat, my other jacket no longer doing the job. Interestingly, there are not too many people wearing bright, fluorescent attire. I must finally stand out.

Spanish class is helpful, but a daily, two hour, one-on-one assault on my pride. So difficult are some of the exercises that I have resorted to all the tricks I know to pass the time. Today I asked about fifty questions about Bolivian superstition and tradition, based on my encounter with the woman last week whose three year old son had died of a combination of surprise, and what I think was hepatitis A. Apparently, close to a third of childhood deaths get blamed on surprise. My Spanish professor told me the story of how her older brother died at six months old, and how her mother to this day feels it was due to the surprise caused by fireworks set off outside by neighborhood kids.

One of the more interesting traditions is that of sacrifice to the goddess Pachamama. For small homes, burying an alpaca or llama fetus usually satisfies the belief and brings security to the home. For large buildings in the cities, it often necessitates the sacrifice of a person. I questioned my professor thoroughly on this point, but she was adamate that the practice occurs. She has struck me so far as rather erudite and extremely knowledgeable about the Aymara and Quechua-speaking people. Apparently La Paz is one of the more superstitious cities, despite its international appeal and relative modernity. It used to be that construction workers would get drunk after work, and some poor sop would get drunk enough that his coworkers might bury him on the construction site. Nowadays, vagrants appear to be the people who get sacrificed to Pachamama.

Today in clinic at Hospital Del Niño, we saw a one-month old girl with Down's syndrome. She had horrible jaundice and her lab values indicated significant hepatitis. It is not certain whether the hepatitis is infectious or not, and that is something that will be determined now that the baby has been admitted to the hospital. What was most interesting was that the mother has not accepted that her child has Down's. Her greatest concern was that her girl was not crying much, nor taking much milk. It appeared to me that the woman and her husband were relatively well off based on their dress, but the woman did not seem to understand that her baby had Down's syndrome, not something temporary. There were two social workers in the exam room as well, and the doctor is wonderful at negotiating the different explanatory models of illness that patients have. Nevertheless, it seemed as though this couple, the mother especially, had a long way to go before they understood the condition with which their daughter had been born. Sometimes, like this one, it hurts that I can't offer as much verbally as I could in English.

In clinic we also saw a family that I could imagine seeing in the US as well, one where the mother has come to the doctor with a set diagnosis in mind, and little will sway her from it. A mother was convinced that her children had worms. Her reasoning was that her kids no longer wanted to drink milk, and that her three year old daughter had lost her potbelly from six months ago. Now, the eight year old boy made it clear he just didn't like milk anymore. Bolivians drink very little milk, and kids tend to follow parent habits. Both kids looked as healthy as can be, three year old kids grow taller and lose baby bellies, and kids with worms often have GI symptoms. These kids had no diarrhea, no weight loss, no nothing. Nevertheless, the mother was convinced. So, in an example of overtreatment that I witness plenty of in the US, the mother's conviction was treated with two lab slips for stool samples for her kids.

On the inpatient side, the girl with likely TB is still not better. Everyone, including me, has heard telltale signs listening to her lungs that something is going on in her left lung, in addition to the right, where the TB appears most likely on X-ray. The X-ray shows two foci of something infiltrating, and TB doesn't often present with multiple foci in the lungs of kids. Absolutely everybody, including my preceptor and all of the residents, thinks that her sustained rapid breathing and fever are probably due to pneumonia on top of TB. Everybody, except the chief of medicine, that is, thinks empiric therapy with an additional antibiotic is warranted. Now, the attending has more experience than anyone else, and he is very right that one of the TB drugs should cover many pneumonia bugs. Nevertheless, where I am currently growing up in the medical world, I think we would try something empircally now that she has had a fever for two weeks. Time will tell.

Hospital Del Niño

Feeling much better after my cipro-immodium combo, I spent this morning at a new hospital, Hospital Del Niño. It is a large children's hospital in La Paz. It serves a slightly more diverse crowd than the hospitals in El Alto, mainly, there are a few paying patients, but the majority still are kids who are covered by the national insurance program. This week I am with another program participant, a 29 year-old PA from San Francisco who is here with his wife, also a PA, for two months. Russell is a splendid guy, who needs no explanation of anything medical, and has a better command of Spanish than my co-participant from last week.

In three hours this morning, I saw some very sick children. Three had bacterial meningitis, and one had possibly TB meningitis. As I am learning, TB in children is in many ways more difficult to manage than in adults. TB period is difficult, because though we have had effective treatment for over 50 years, 2 billion people have it and a few million die from it each year, including half a million children. Nobody really knows how many children survive primary infection and with what deficits, perhaps many to develop the disease again later in life, spreading it to others along the way. What makes TB tough in kids is that it usually is not in the lungs, or at least not in cavities in the lungs that allow for easy aerosolization of the bugs. It's nice to examine somebody who is not coughing tons of TB into one's own lungs, but it also makes it virtually impossible to isolate the TB bacilus for diagnosis.

Kids tend to present with TB in the bones, like the spine, in the brain, or in lymph nodes. When it does present in the lungs, it tends to be spread out more diffusely, in a pattern that resembles millet seeds on X-ray, hence it is often seen in kids in a form known as miliary TB. In my week plus I have now seen at least a half-dozen kids with TB. Kids get TB usually from an adult at home with active TB in the lungs. Kids also tend to do very poorly, with many dying, and those who don't having a difficult time with treatment, not because they tolerate it poorly, but because they are not old enough to treat themselves. Childhood TB is a big problem in Bolivia, as I am finding out.

Russell and I saw a very friendly, handsome, though very slender 13 year-old boy who looked too healthy to be stuck in a children's hospital in the developing world. One quick look at his chest X-ray revealed that 90% of his left lung, or what should have been his left lung, had been replaced with a huge fluid-filled cyst. The cyst was caused by something called Echinococcus, a worm that people occasionlly acquire from contact with dog feces. The worm tends to set up in the liver or lungs, forming large, impenetrable cysts, resistant to anything but surgery. Many dogs and other animals carry this worm in Bolivia and other parts of the developing world, as well as parts of Alaska and Canada. It strikes people of all economic class in Bolivia, as it takes very little time for a domestic dog in a wealthy home to acquire the worm if the dog leaves the house for any amount of time.

What is very sad about this kid is that he has been completely healthy, with no problems whatsoever for most of his life. This cystic disease was discovered when somebody was listening to his lungs about two weeks ago and could only hear one of them. This cyst did not form overnight. Some people claim the cysts tend to grow at a rate of about two to three cm, or an inch, in diameter each year. This thing has probably been growing since he was three. A careful auscultation of the lungs, listening with a stethoscope, at an earlier time might have saved him much of his left lung, allowing it to grow somewhat more normally. It is very easy to do cursory exams on healthy people with who have no complaints, and this is likely what happened with this kid, if he even had many exams at all in his thirteen years. Now, after a dangerous surgery to remove the huge cyst, taking care not to let it rupture and spread an overwhelming amount of worm forms throughout the body, the kid will spend the rest of his life at 3500m with one lung. The ID doctor who is precepting Russell and me has suggested we take a picture of the X-ray, which I will do tomorrow. I was floored when I saw it, so with luck I will be able to get a good copy of it to share later. Sadly, though not as common as TB and siphilis, Echinoccocus cystic disease is still seen frequently in La Paz.

Today I also saw two kids in the same room, both with bad liver disease, one from EBV (the cause of mononeucleosis) and the other from CMV (an EBV cousin). I didn't realize such complications ever occured, and it is something the folks at the hospital here had never seen themselves. I am still skeptical that these were the two actual causes, but it seems like a thorough workup for common and uncommon liver disease was done for both of them.

I have two quick comments about my hospital experiences so far. There appear to be many wet nurses for infants, beyond the mothers who stay with their kids in the hospital. The second thing is that I see a lot of family in the hospital, usually mothers, who provide some of the basic care for the kids. This isn't that different from what I see in the US, but there is more of it. Oh, a third thing, I was shocked today when I visited the burn ward at the hospital. Knowing the dangers of infection to a burn patient, I was taken aback by the number of people coming and going from the unit, the lack of areas to wash hands, and the flies inhabiting the unit. Apparently many of the kids are there for kerosene burns, often acquired while parents are at work and the oldest, non-working child is at home. Many of the burns the infants and toddlers present with are clearly abuse, as well. Sadly, this is not that different from the US, where bad things happen to children, as well.

The altitude is no longer bothering me, so apparently I needed seven or eight days to acclimate. I don't expect to run while here, and even locals seem out of breath walking uphill. One might think that the Bolivian soccer teams would be invinceable at 13000ft. Apparently, even though the opposing professional teams huff and puff in La Paz, they still seem to stick it to Bolivia's best. Of course, one would also think their Brazilian and Argentine competition would be pretty good while moving very little, as well, which seems to be the case.

MLK

We have much to be appreciative in the US, especially when it comes to our standard of living, which I think has been hard-earned. Waiting for the elevator tonight, as it half-opened and then closed and disappeared for five minutes, I was struck by how nice it is to live in a litigious society at times. We have an expectation that things will work and will be safe. That does not seem to be the case here. Even in a nice apt building, it has been rare that more than one of the two elevators has been functioning at any one time. People seem to take the five person limit VERY seriously, and I don´t care to know why.

Functioning elevators was hardly the legacy I hoped to assign to MLK, JR, but on the day we celebrate him, I thought I would mention one of the distinctly American things for which we should be both proud and thankful. Largely, the US is a country where things work, and we have an expectation that people are looking out for us (in a good way). We have a society that has worked together to make a smooth way of daily living for most of us, and at times we forget it. Well, I like the fact that people obey street lights and that street lights work in the US. Here it scares the crap out of me sometimes.

More from Monday

I see that Chile has elected a new president, a woman, doctor, and Pinochet torture victim, no less.

I have been following some of the medicare prescription coverage woes from afar. My first inclination is to think that the mess is just another example of the administration's incompetence with all things governable, and that this is more of the same. I know that part of the problem lies with the dozens of private insurers that actually provide the coverage and their dislike for actually providing something in return for money. But the more I think about it, it seems like this is an attempt to discredit medicare and any sort of large, government-run health program by making it so horrible. What a great idea. Provide something that sounds like health care, provide it for seniors who vote, provide tons of taxpayer cash to individual insurers, and make public health coverage look terrible, all at the same time. Obviously, this is not a federal venture, but the hope is that it appears so to the majority of us. Were medicare actually buying medications itself, bargaining itself, and supplying through its current enrollee coverage system, rather than the dozens of private plans, methinks we would not be reading about twenty states having to take over the provision of and payment for the medications that medicare is supposed to be covering.

By the way, I know that I'm not really supposed to use immodium if I have a fever, but it's tough not to use a little bit...

Atahualpa's Revenge

Well, I made it seven days before my intestines fell prey. I awoke Sunday morning feeling a bit off. By two PM I was starting to feel chilled, and by five PM I had on a fleece over my sweater, my fleece hat, and had taken some tylenol and cipro. The diarrhea has not been overwhelming, but clearly something is amiss. I waited until after a few trips to the bathroom before taking any immodium, thinking I would allow more of the unwelcome guests out the old-fashioned way.

Of course, I have tried to pick out where I went wrong in my dietary habits the past few days. My first guess was Friday for lunch at a little ma and pa type of place outside the Hospital Los Andes in El Alto. Perhaps it was the tomato on the sandwich, or something unseen in the kitchen hidden in back. My next thought was the sprite from the fountain at a nice restaurant on Saturday evening, though it seemed unlikely. The ice in my glass of coke at a bar on Saturday evening is a good bet. I don´t know what to make of the eggs sunny side up that get fed to me at home, but the family and the cook seem very in tune and adept when it comes to cooking with my wimpy gut in mind. One thing that I don´t know how to get around is that we eat reheated food that doesn´t seem to ever get to the fridge. Food made at noon stays on an extra plate for me to have as dinner at eight or nine or later. The prominent rice component also gets me worried, so I microwave the food pretty well, knowing that only staph toxin should remain as a potential enemy. Tap water is used to clean glasses, so if they aren´t completely dry, then I suppose that is another possible culprit. The water heater used to boil water for coffee and consumption is limited by the elevation, so it only gets to about 88C or 188F for a few seconds. I would feel better with 30 seconds at 100C, but I tend to be a bit of a worrier.

Anyway, I decided not to go in to the Hospital Del Niño today, nor to language class this afternoon. There´s something reassuring about being close to home...

Saturday Morning

Saturday is interesting in La Paz. It still seems to be a regular workday for many, with stores open until noon or so. It seems to be a big cleanup day, with hundreds of younger soldiers on the sidewalks scraping up trash, which there is not much of in the first place downtown.

I think that in addition to waiting in line for documents to work, it seems that one of the biggest reasons I keep seeing the several block long lines each morning and afternoon outside various public record buildings is to get kids necessary documentation to attend school. Apparently it is not possible to begin mid-year, from what I hear.

I saw a similarly long line of people at eight yesterday morning in El Alto. After passing the hospital where I had spent the first part of the week, El Alto came into better focus for me. It seemed to be an endless maze of one and two story brick buildings, many which seemed either in disrepair or abbreviated contstruction. Many lacked windows, many had rubble in front or in the first floor. Occasionally something hanging in the window, like lace or some decoration indicated it was a home. Between blocks were streets which seemed very alley-like. Many had rocks and garbage scattered across them, and the few drains in the streets were plugged with garbage, leaving a nice flowing layer of muddy water running over most of the streets. At times it felt like a long-abandoned city, except for the fact there were people living there and walking along the sidewalks.

Traffic lights appear to be suggestive at best in El Alto. The drive involved much creative merging. The hospital to which we were headed was on the opposite side of the airport from where I had been to begin the week, about a 30 minute drive from downtown La Paz. The clinic was filled with about 150 people in a space the size of an elementary school classroom when we arrived. There were a few patient visit rooms, but the majority of the building seemed to be a space for waiting. There was a small pharmacy, a tiny room with an X-ray machine from long before I was born, and a room with several beds next to each other that served as the labor and delivery area.

My time was spent doing well-child (or not-so-well child) checks. Malnutrition is a huge issue in Bolivia and El Alto especially. Half the kids we saw were iron-deficient, based on exam. Many of the infants were dehydrated and listless. There seems to be a cultural tendency for mothers to feed infrequently, perhaps due to their own infrequent meals. Perplexingly, when a child has diarrhea, parents stop giving liquids, which often results in stopping the diarrhea, if the child survives the volume depletion. I saw a ten day old girl who probably weighed about two and a half pounds, usually the sized infant one only sees in the neonatal ICUs of developed countries. She had been born at home and had yet to visit a clinic or hospital. Surprisingly and fortunately, she was doing well and feeding without trouble. I have a picture whenever I find a USB port.

One two year old boy came in who was malnourished, had a chronic cough for two months, and the past two days had been coughing blood. His chest X-ray, story, and the prevalence of TB in the community makes it very likely he had TB. He looked so sad and resigned. Treatment is available, but sometimes it is difficult to get parents to recognize what needs treatment and what can be treated if they seek care. Some interesting beliefs still have a strong hold amongst Bolivians. There is still the idea that one can die due to surprise. On mother with a two week old infant said that her three year old boy had died ten days ago from a surprise or shock he had weeks earlier. The fact that she told us he was completely yellow with diarrhea makes it more likely it was Hepatitis A, another prevalent disease here.

Some kids are remarkably healthy, but many are not. Two programs to provide free care to kids were started over the past five years. One is a national program that covers pregnant mothers and kids from birth to age five. Surgeries for congenital diseases, such as heart defects or cleft palate, are not covered. Much of the routine care, immunization, and general kid illnesses are, however, and already doctors say they can see the effect of prenatal care and routine immunization. Nevertheless, kids still die of neonatal tetanus and other preventable maladies. The other program is specific to El Alto, that covers kids from six to eighteen if they are going to school. That, I think, is one of the main reasons parents are in line to get documentation for their kids. It's an interesting self-fulfilling program. One needs immunizations to be in school, and to be in school to get free health care. So, the byproduct is more healthy kids and more attending school, one would hope.

More later...

El Fin De La Semana

...
As I am spending a moderate amount of time in the internet cafes of La Paz, I have noticed how popular the msn chat and messenger features are amongst teens and young adults. For some reason, which is probably some standard mix of poverty and corruption, phone calls can be expensive here. International calls are very expensive, but even local calls and cell calls are very expensive for Bolivians, even many in La Paz, as far as I can tell. Anyway, the internet is cheap. It costs about 25 cents an hour, and though things load slowly, it is a reasonable way to keep up with friends and family in other cities or areas of La Paz.

I'm still searching for a cafe with computers with USB ports, and will heighten my intensity tomorrow morning so that I can finally post some pictures.

Instead of going to my final day at this week's hospital, I went with the program director, the wife of the doc with whom we were working in El Alto, to another El Alto hospital. Her husband was not going to be in today, so she took me to one of the hospitals that is otherwise not on my list of places to visit. It was much deeper into El Alto, and it was much smaller and resource-deprived than Boliviano Holandes, where I had been this week.

The drive this morning was interesting itself. It has been drizzling and showering (we know the distinction in Seattle) off and on the past 72 hours. La Paz is built upon several rivers, which now run wild under the city. La Paz sits in a sloping valley between the higher altiplano, where El Alto and the airport are. As one heads South and descends in altitude, one finds more wealth. Downtown and where I stay is about midway. When it rains, water runs down the sides of the bluffs from the plateau above. Typically this results in a combination of running water and eroded rocks in the middle of many of the streets, as well as some interesting up and downhill driving on slick cobblestones and pavement. As one approaches El Alto, garbage, well picked-over by the roaming packs of dogs, seems to blend into the water-rock milleu.

La Paz is surpisingly clean to me, though I do see the crews of people out picking up garbage and cleaning the streets at night and in the morning. El Alto is different. I could seem a good (bad) amount of garbage in alleys and gutters my first few days, but Hospital Boliviano Holandes is really at the entrance to El Alto proper. El Alto used to be part of La Paz until recently, so the distinction is not too clear. As one begins driving up the few hundred meters towards the high plain of El Alto proper, it gets very poor very quickly. Boliviano Holandes is only a half-kilometer or so past the crest of the high plain.

Where I went today was rather different. I have seen many very poor areas of Mexico, and I think of some of the poverty I saw in a few of the Arab communities in Israel, and what I saw today in El Alto still caught me off-guard. When one drives up into El Alto, there are a lot of billboards with public service messages about the danger of garbage. Now I know why. My time in the cafe, however, is coming to an end. I'll share more about the entire day when I get more time, perhaps tomorrow morning.

One quick note about mate with coca. I am changing my mind a bit. I have felt much better the past two days, even regaining my appetite, which until now has been ridiculed for how little I have eaten. The mate really does provide a boost of sorts, and I seem to go several hours without being hungry. I don't notice my heart rate change, but I do notice that I don't get as short of breath. I guess I was just too out of sorts to notice any amelioration my first few days.

Tuesday

I forgot to explain more about the program and the clinic details yesterday. I am in one hospital this week with only one of the other four students. She turns out to be from Kirkland, across the lake from Seattle. She speaks about as much Spanish as my father and mother combined, and is applying to medical school. It is tough to have to be the interpreter, as well as to explain all the medical stuff. The faculty member in the hospital is very knowledgable, very engaging, and clearly well-trained, but he's a sub for the usual guy who speaks English. So, I find it rather more intense than I expected, and I get a little dizzy at times when I speak more than three sentences in a row. One can imagine how much that limits me.

I will finish at this hospital Friday, and move to another next week. In all I visit three hospitals for a week each, and then a service for homeless kids in La Paz, as well. I'll be alone the next three weeks, which is just as well, I guess.

One interesting thing is to see the thousand or so people standing in line every day for blocks and blocks outside my building as they wait to get into the public record building. It seems as though nobody has birth certificates or other things they need in order to work, rent a place, or who knows what. My guess is that people are expecting the coming of many social services upon the arrival of Evo. I must admit, though I don't know what the future with Evo holds, it can't be worse for the poor folks. At least they could be screwed by one of their own. Nevertheless, I don't think that will be the case. I am a bit amazed at how much oil and gas wealth left the country in the 80's and 90's, but don't really know enough to comment more at this point. We don't seem to balk at the Saudis funding their entire state and none of them having to work, so I suppose why can't another state at least push its standard of living beyond the poorest outside of Haiti in the West, which is where I think Bolivia stands. Anyway, I do find it interesting to see the pride in the indigenous folks with almost nothing who seem very proud that Evo will take power soon. What I see in the papers and hear on the radio is that he's moving to establish big ties with China, and also India and Iran. My feeling is that the first two will infuse a bunch of money in order to buy energy outside of US influence.

I saw two newborns with congenital siphilis yesterday, one with a brain infection from genital herpes (which the mother had to get for a first time in her 7th or 8th month), and one of toxoplasmosis-caused swelling of the brain. I don't think I would see any of those in the US, except if I were a pediatrician in an urban area for a dozen years. It's sad for the kids, but a learning experience for me. It's an odd dichotomy when I think about it.

Cafe is closing...

High in Bolivia

I arrived safely, and other than seeing the mountains, didn't notice the altitude for at least fifteen minutes or so. As far as tea with coca goes, I tried it three times before I knew that the mate had coke in it, so it was less impressive than I imagined.

My host family is technically a fifty year-old guy, but all of his nieces and nephews visit constantly, and one 22 year-old nephew is staying with him, so I have plenty of company. Nobody speaks English, but all are friendly. I don't know what tires me more, the altitude, or having to think and speak in spanish all day. I rarely see my program-mates.

The altitude really is striking. I wake with my pulse in the mid-60's, which for me is a bit higher than normal. It is really odd to be walking but have the empty feeling in my abdomen and pounding heart I get normally after sprinting several times. My first day I felt frequently like I had just stood up quickly, even while sitting. Anyway, I felt great today until I went to the hospital, in the very appropriately named, El Alto community, which used to be part of La Paz and for all practical purposes is, except that it's about 1000 to 1500 feet higher. I can't even go without my hat for two minutes midday. The sun is so intense, even when it feels cool, that even the well-haired natives cover their heads.

The view from my room is incomparable, in a good way, but I have to find a computer with a USB port...so stay tuned.

As for the program, it is very organized. The hospital I went to today I will speak about more in the future. I am by far the most experienced medically, and I speak better than the other four students. That is good for me, as it will help me get more from this, I think, and I'll be able to share and contribute more in return. The tough thing is that my ten hours per week of Spanish lessons are one on one, rather than in a group, like the other four. It was the most tiring two hours I have had in some time.

Everybody seems to be excited about the inauguration of Evo Morales on the 22nd, though many in La Paz did not vote for him. Rumor has it he'll wear a poncho and a silly hat...which is how I feel with my yellow and green floppy beach hat.

Photos from Tulum, QR, Mexico

This was the sunrise Tracy and I saw on 12/30/05...


...and the sunset the previous evening.


The astute dionysian may notice the Leon on the table, and the not-so-astute will notice the monster coconut drink with straws. Tracy and I had the opportunity to drink several of the Mexican beers we rarely see in the US, like Leon and Montaje, both brewed in Oaxaca. I had trouble finding the elusive Montaje Especial, but I will continue to look.

With luck I can apply my limited computer ability while in Bolivia and Peru and keep posting things. I'm still in FL, and leave tomorrow afternoon.

First Post

I wish I could remember where I first heard someone talking about waxing the buick.