Halfway

I'm feeling more accustomed to the school schedule now - class, studying, quizzes for the first time in years. Just in time for the mid-term exam yesterday! Hard to believe we're already halfway through our time in Peru. I continue to be amazed at the sheer volume of material presented, but I understand tropical medicine much better now than I did a month ago - though I still have a long ways to go! We saw our second leprosy patient this week and our group immediately made the diagnosis - whereas we had no clue with the first case a few weeks ago. It's amazing how the brain can absorb so much information in such a short period of time! Isn't God's creation interesting?! Below follow pictures from the last week:

 Reviewing the CT scan from a young teenage girl (with a four month old baby at home) with symptoms suggestive of TB &/or AIDS. The CT scan suggested a hydatid cyst (echinococcus) in her lungs. Pathology (below picture) showed choriocarcinoma (very rare cancer associated with pregnancy). Certainly wasn't the expected diagnosis. Thankfully she's receiving excellent care including chemotherapy at this specialized hospital in Lima. She joyfully shared with us how she was in a coma shortly after she was admitted to the hospital for 2 weeks but miraculously recovered. I couldn't help but think we wouldn't even be able to diagnose her condition, let alone treat it in Burundi.

 Obviously she's still very sick. Please pray for her healing and for the team caring for her. Also pray for her mother who's quite worried and for her baby boy being cared for by relatives at home. 

 The highlight of the week was visiting the children's hospital in Lima. Though adults can be interesting :), I was reminded again of how much I love pediatrics! The kids smiled brightly and loved the stickers we handed out - toddler language is pretty much universal - no translation needed. :) We spent our time in the infectious disease ward - which was quite nice as you see in the pics - and saw patients with typhoid fever, chicken pox, pertussis, parasitic liver disease, TB, pneumocystis pneumonia, and AIDS.

 This case was quite heartbreaking. She's one year old and weighs the same as a newborn (3.5kg). She's been severely neglected and was just diagnosed with advanced AIDS (her mother refused to take medication during pregnancy to prevent transmission to the baby). She's evidently improved significantly during the month she's been hospitalized, but her long term prognosis is bleak. She is a precious child of God who waved at us and said "ma-ma". The injustice of the world is hard to fathom sometimes - how this little girl could end up in this state without anyone seeming to care. 

Isaiah 49:15-16: “Can a mother forget the baby at her breast and have no compassion on the child she has borne? Though she may forget, I will not forget you! See, I have engraved you on the palms of my hands."

 

Our group at the children's hospital pictured with our attending there and a couple new friends :)

 Random sight on the side of the road - not quite sure what the chickens are stuffed with. I guess I don't need to wonder where my daily chicken and rice for lunch comes from anymore!

 

 Mmm, intestinal worms...

 Learning about cholera from one of our favorite professors

 Hospital Cayetano 

 Studying for the midterm during a class break

 Classmates, Peruvian med students, & another favorite professor

 Celebrating after the mid-term exam with a Saturday brunch overlooking the ocean - awesome!

 The studying break continued through the weekend and I actually tried surfing for the first time Saturday afternoon. I'd like to say I'm the surfer actually riding the wave in the above picture, but, no, I spent most of my time paddling in the water and only stood up once - very briefly! But I had fun - and today I have lots of sore muscles to prove it!

 I bought maracuya (passion fruit) on my way home. I'm loving Peruvian fresh produce - especially maracuya, mangos, and avocados! 

 One of the best ways to end a day - frozen yogurt with two of my roommates!

Travel medicine

Half my classmates at a small clinic we visited this week to learn about their tuberculosis, HIV, and vaccination programs

Pricking each other in class this week to practice making malaria smears

When I signed up for this course, I expected to learn about tropical diseases like malaria and worms and other parasites. I hadn't thought of tuberculosis and HIV/AIDS and malnutrition as being "tropical diseases", but in retrospect, they're hugely relevant to tropical medicine - and most cases do, in fact, occur in the tropics. So I'm thankful the course is emphasizing those important, clinically relevant topics for those of us practicing medicine in developing countries. Several of my classmates intend to work at travel medicine clinics in their home countries. If you've traveled overseas, you know that vaccinations, malaria prophylaxis, etc. are required/recommended for various countries and you may have visited a travel clinic for your yellow fever vaccine. If you returned from your trip to Timbuktoo with a fever, you could have seen a doctor at the same clinic for evaluation/treatment from a specialist who knew what diseases you were at risk for based on your travel history. So part of our course is learning how to practice travel medicine. I initially thought this portion was not relevant to me as I don't intend to work in the States with travelers anytime soon, but surprisingly, I've been realizing more and more that it's quite important. And actually travel medicine was a big part of my job in Kenya - I just didn't call it that!

Travel medicine is a specialty that focuses on prevention and treatment of diseases and conditions acquired during travel. And I treated travelers (short and long term) all the time - especially with as many visitors as we welcomed at Tenwek. I answered questions about malaria prophylaxis and diarrheal diseases and vaccinations - both specific to travel and routine childhood immunizations. I cared for patients with fevers and pregnancy and altitude sickness. I was stumped by many a rash - scabies, bedbugs? And I even made house calls! Thankfully, other doctors were available as consults in Kenya when I was unsure, and praise the Lord no one was critically ill. I'm grateful to be learning all this relevant information now to apply to travelers coming to Burundi in the future.

So when a visiting professor asked this week how many people in the class were practicing travel medicine, I raised my hand. Burundi Travel Clinic, open for business!

Am I at the right course?

First, some pictures from the last week:

Rounds on an outpatient with chronic strongyloides diagnosed due to a high eosinophil count

Classroom - we spend 3-4 hours here each day

Parasitology lab. We have lab Tues through Friday afternoons for 1 1/2 hours - so far we've mostly been working on identifying malaria and other parasites in various specimens.

We made a new friend during a break from lecture - she's been named Loa Loa - ahh, medical humor

View from the hospital on a hazy day - it rarely rains in Lima but it's frequently overcast. It's a strange mixture of humidity and dryness - the mountains are actually quite brown with almost no vegetation.

Hospital rounds looking at a CT scan from a patient with neurocysticercosis. We round daily for 2+ hours either on the tropical medicine ward or on patients with tropical diseases elsewhere in the inpatient or outpatient settings nearby. It's amazing that the course faculty continue to find at least 3 interesting patients for each of six groups to round on 5 days per week. We're learning a ton!

We do see some interesting sights from the bus on our commute each day. This is the central square in Lima.

Colorful slums on a nearby hill

And here are all but one of my housemates pictured with our landlord (in the middle) - an archeologist with fascinating artifacts throughout her house. I really enjoy hanging out with all my housemates.

Today I enjoyed exploring the neighborhood a bit and found a cafe to study at with this view just a ten minute walk from my house!

 OK, so on to the title of the blog: 
 

As I mentioned last week, my classmates for this course have all traveled extensively throughout  the world and most have experience living and practicing medicine at least a couple months in a developing world context. Consequently lunch and break time discussions frequently include such topics as poverty, limited resources, cultural barriers to healthcare, medical education in various contexts, global health disparities, etc. A guest professor this week stirred up more such discussions and led me to ask the question, “Am I at the right course?” His lecture topic was tuberculosis transmission and he presented data from several sources that though TB has been extensively studied and excellent, effective programs exist for treatment in most parts of the world (including most developing countries such as Kenya and Burundi), decreasing rates of TB incidence have not correlated with the effectiveness of these programs. One World Health Organization reference from 2009 states, "Although TB control programs have averted millions of deaths, their effects on transmission and incidence rates are not yet widely detectable." 

The studies show that the only thing that decreases the rates of new tuberculosis cases in a country is improvement in poverty and development in that country. The programs obviously accomplish a lot in treating those who are diagnosed with TB and who have access to the medications. But for the most part, TB is a disease of poverty and the best way to eliminate TB would be to eliminate poverty. And actually, the same could be said for many of the tropical diseases we're studying.

 So, should I be attending a global development or micro-enterprise course instead of a tropical medicine course? Should I be working on a macro scale trying to reduce poverty rather than on a micro scale treating worm infestations that will only return due to a lack of clean water or sewage systems? Obviously I hope Burundi will improve from it's current ranking of fourth from the bottom on the United Nation's Development Index. But I also hope they will have more doctors than 3 per 100,000 people - that obviously is a factor in development and poverty as well.

So for now I'll work on that goal - training medical students and caring for the patient in front of me with the resources and compassion available to me (including the resource of specialized training in tropical medicine). Hopefully others are working on the problem from a different direction. We know poverty and disease won't completely be eliminated in this world, but (as I mention frequently:)) God is making all things new here and now and we look forward to seeing that more and more in Burundi and elsewhere. Your thoughts and comments are welcome!

First week in Peru

I arrived uneventfully in Peru and am settling into life here. So far I love it! This trip sort of snuck up on me with so much energy being directed towards Burundi, but that means I'm pleasantly surprised at the joy of the week as opposed to having expectations built up for a while. The following pictures tell some of the story of my new surroundings and studies:

 Rounds on the tropical medicine ward occur daily. Peru is unique in that many different ecosystems exist quite close to one another - jungle, coast, mountains, jungle highlands, etc. - this leads to a lot of different tropical diseases in one place. In just five days on the wards, I've seen at least five diseases I'd never seen before - leprosy, leishmania, paracoccidiomycosis, balantidium coli, & echinococcus vogeli.

 In the classroom and on the wards, I've already learned a lot about the diseases present in Africa, too. It's overwhelming the amount of information there is to learn - and humbling to realize I certainly mis-diagnosed and chose the wrong meds for several patients in Kenya. Hopefully the Burundian patients and medical students will benefit greatly from me taking this course! Our days are long (7:15am-5:30pm - including the commute to the hospital) and tiring, so it's hard to find the time needed to study all this material, but the topics are so interesting! And I'm so thankful for my years in Kenya which certainly taught me a lot and prepared me to learn more about these diseases.

Outside one of the hospitals we work at in Lima - definitely a tropical, summer location!

 On arriving in Lima, several girls in my class and I met and agreed to be roommates for these two months. We live in this cool house in a nice part of Miraflores (suburb of Lima) just a couple blocks from the Pacific ocean. I love having five housemates from four different countries. We've enjoyed getting to know each other this week and it's great to walk together to the various activities for the course.

 Yesterday (Saturday) we began collecting data for the high altitude portion of the course by traveling up to 4,000m (13,000ft) and checking our oxygen saturation at various points along the way. Our tour guide - one of the doctors from the hospital - explained all about the different tropical diseases present in the regions we passed through - not your typical tour!

 The bridge on the upper right in the picture is famous because the railroad is the highest in the world (3800 meters) & because 7,000 railroad workers died while building it from Oroyo fever which they got from specific biting flies who live in the region. The disease was later named "Carrion's Disease" (and is a form of bartonellosis for you medical readers) because in 1885 a medical student named Daniel Carrion was studying the disease and actually intentionally gave himself the disease thinking he would develop Peruvian warts and could then describe them. Unfortunately he developed a febrile illness and severe anemia instead and died a few days later. Don't worry, the mosquitos don't start biting till 5pm, and we were long gone by then! And I don't intend to ever begin experimenting on myself!

Classmates at a mountain waterfall/river

Train

Incredible scenery that varied quite dramatically as we ascended from sea level in Lima to 13,000 feet in the Andes

Coca tea thought to be beneficial for altitude sickness

Our Incan feast being cooked in the ground

Delicious!

I love experiencing new things, seeing beautiful sights, enjoying interesting conversation with classmates who have extensive experience in the developing world, & learning about new languages and cultures and diseases. Thanks for following my journey with me!

Peru

I first heard about the Gorgas Tropical Medicine course in Peru during my med/peds residency days at UAB when I rotated through the infectious disease department. I thought it sounded fascinating and actually added it to my list of what ended up being thirteen things I wanted to do after residency! A friend of mine that completed the course as part of his infectious disease fellowship and then ended up working at another mission hospital in Kenya described the Gorgas course as "the best educational experience of his life since kindergarten". Well, as God continued to confirm that long term medical missions in a tropical location (sub-Saharan Africa) was His calling, I revisited the idea of the Gorgas course and applied last year. God provided the finances through my locum tenems job in Birmingham and now I'm off to Peru on Friday.

Formal intense tropical medicine training will prove very beneficial both in caring for patients in Burundi and in teaching medical students there. This course, which is a partnership between the infectious disease department of University of Alabama at Birmingham and the Institute of Tropical Medicine in Lima, is unique among tropical medicine courses in that it is one of the few actually located in the tropics. We'll round on patients in Lima, Cuzco, and Iquitos during the course and hopefully seeing actual patients will help me remember the various diseases. My studying brain is a little foggy from disuse these days. This course is also known for being quite intense - condensing information taught in as much as three years at other courses down to two months. I'm looking forward to learning a lot!

One of the aspects of the course that really interests me is my classmates. The roster shows 34 students from 12 different countries and 5 different continents. From those I've interacted with on email, most seem to have traveled extensively and practiced medicine in various settings in developing countries, primarily through non governmental organizations. I look forward to getting to know them all and hearing their stories.

I recently heard a good quote, "Am I approaching people with curiosity or with certainty?" I like this as all too often, I make quick judgments of people rather that being curious about who they are and what their back story is. Pray my curiosity will remain intact as I meet my new classmates, professors, patients, and neighbors in Peru. Also, pray for my Spanish! I used to speak conversational Spanish, but Swahili seems to have occupied the front foreign language spot in my brain for the last couple years, and I'm guessing that's not going to help in Peru! The course is thankfully taught in English, though.

OK, next blog post location: LIMA!