Island in the Sun

You would be catching your breath after a flight of stair too, if those stairs were at 12,000 above sea level like they are in La Paz, Bolivia. I am currently in Bolivia to study mother-to-child transmission of Chagas disease.

Bolivia lays claim to having many of the world's highest things- La Paz is the world's highest capital at 11,800 feet above sea level (and FIFA even had a ban on playing soccer games at this altitude until recently), Lake Titicaca being "the world's highest nagivable lake" (technically not correct as small craft can go in several higher lakes, but Titicaca has a max depth of over 400 meters), etc.

After working at Hospital Universitario Japones for a week and a half, it was necessary to return to the Peruvian border to get some research equipment that our Peruvian colleagues were taking to the border for us. This trip was a great excuse to visit the famous Lake Titicaca (Copacabana and Isla del Sol) and the pre-Incan ruins at Tiwanaku.



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LaPaz, Tiwanaku, Lake Titicaca

Here are some photos from my trip from Lima to Arequipa, Peru (airplane) to Puno, Peru (bus) to La Paz, Bolivia (bus) to Santa Cruz (airplane)


download this album here:

Lima, Peru to Santa Cruz, Bolivia

The Great River Amazon Raft Race 2007

At noon last Tuesday I received an email: there was a raft race on the Amazon and a team needed an extra man. They were flying out the following morning at 5AM and I could step in if I could jump on fast enough.

Of course I jumped.

I flew to Iquitos the next day and crashed at the house of a team member for the night before starting what promised to be an adventure of epic proportions.

It is called the Great River Amazon Raft Race and brags about being the world's longest raft race at ~132 miles. The rules are simple: each 4 person team gets 8 logs and some jungle vines and makes their own rafts, then for 3 days they paddle down the Amazon River, stopping at a village called Porvenir the first night and a town called Tamshiyacu the second night.


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My team was Proyecto Dengue 1 (Project Dengue); it consisted of Amy, an entomologist who studies Dengue Fever and the mosquitos that spread it in affiliation with the US Navy and UCSD, Jackie, a grad student in entomology working with Amy, and Rod, a British physician who has been working on tuberculosis ventilation systems in Peru for a few years. Proyecto Dengue 2 consisted of 4 Peruvian field workers that work with Amy.

We collected big balsa logs from a boat then started whacking away at the ends of the logs with our little machete. Then a Mr. W, who lived across the river from the beach we were building the rafts on, showed up with an axe and offered to help us build our raft; after that he pretty much took over. Our unique design was to have a catamaran such that we could paddle in the center when paddling on the outside got tiring; Rod also very wisely thought to bring some lawn chairs, which we chopped down to size and then carved holes for and lashed them down in the back. I think it's fair to say that we had the most daring design.

Before the race even started, we had 2 people go to the hospital. One Australian gentleman who was in the race got stung by a stingray walking from the support boat to shore (the support boat was a double decker boat where we hung hammocks on the open top floor to sleep and below was storage); he needed to go to the hospital for anti venom. The second was a pretty British gal who had a nasty case of food poisoning.

Day 1: Saw what we thought was a kingfisher & lots of dolphins; the Amazon is one of the few places in the world with freshwater dolphins called Boto, some of which are a bright pink. We were thankful that it was cloudy, but I learned a lesson:

just because it's cloudy doesn't mean that the sun has gone away- the proof is that I burned the heck out of my feet, resulting in a fine "Irish suntan."

Overall spent about 7.5 hours rowing and we were all pretty hurting by the end. We stopped in the little village of Porvenir, which was basically a few community buildings surrounding a distillery where "Agua Arriente" or firewater was made from sugarcane- that stuff packs some punch I can tell you! We heard that another team had seen a poisonous water snake swimming along as well. It was great to get to know the stories of some of the international teams- there were representatives from at least Australia, the US, Canada, Mexico, Germany, Switzerland, Holland, and Tasmania (apologies if I'm forgetting some). There were the 4 funny guys from the US doing Peace Corps in Ecuador, the 4 Tasmanian river guides who said that this trip was as long as their entire island, the ringer team from Mexico-Germany-Canada-US who do competitive paddling and were clearly going to win for the international teams, the backpacker teams who met each other for the first time while building rafts, and others. It was relieving to hear from the Tasmanian river guides that the river was almost impossible to read and that they were going from competitive mode to enjoy the ride mode- made us feel better about ourselves, even though we finished a respectable 3rd place for the international teams on the day.

Day 2: This was the longest day at about 9.5 hours on the river. The coast guard actually had to go out looking for 2 late rafts after dark and so some towing. Now everybody knows that the Amazon River is long, but it really is an added challenge that it is so wide. In most places it seemed to be wider than the lakes I know from back in the US, and if I had to guess I'd bet that it was more than a half mile wide in most parts. This is frustrating because you have no point of reference to give you a sense of movement- you paddle for hours around these huge bends and can't tell if you're going forward or sideways or backwards. We were, luckily, able to take a somewhat narrower route in which the current seemed to move a bit faster and where the river was close enough that we felt we were trucking. We spent the night in the town of Tamshiyacu, where they had paved roads and the town actually put on a big performance with the school children in honor of us and then threw a party, which was great.

Day 3: We were all pretty tired by this point and the muscles were just feeling toasted. After 7 something hours, we reached the home stretch- an upstream paddle to the finish (the city of Iquitos is on a tributary of the Amazon River, which we had to paddle up). There were tons of local kids playing in the water to greet us (and snag a bit of a free ride) and a good turnout at the local boating house to see the end to this interesting endeavor. It was kind of abrupt to be leaving our little raft and the excellent company of Proyecto Dengue 1, but it was nice to give the arms and back a rest. It really hit me that the race was over when D, who was our support person and looked out for us, handed me a much appreciated cold beer.

This is one of those things you get to do once in your life, if you're lucky, and I feel very fortunate to have been a part of it.

Click on my photo below to go to my Picasa album, which has images linked to a map and high resolution photos.

The Great River Amazon Raft Race 2007

Quake aftermath

The aftermath:
7.9 quake
At least 337 Dead and the death toll might be much higher (e.g. 300 people were in a cathedral when it collapsed)
Supposedly 70% of a port city near the epicenter was leveled


It was on the front page of nytimes.com (this photo is from nytimes.com & I will take it down if asked)

http://www.nytimes.com/2007/08/16/world/americas/16cnd-peru.html?ex=1187928000&en=aca5b5d5be4d63cf&ei=5070&emc=eta1

Did you know that the west coast of South America (where Peru is) is the location of 2/3 of the world's large magnitude earthquakes?
So earthquakes are nothing new for Peru- who would have guessed it? There is an annual festival to commemorate a quake in 1746 when 5,000 people died (the Miracle Christ festival), and it is custom to wear purple in the month of October to commemorate the event.

This site has a great short history of quakes in Peru:
http://earthquake.usgs.gov/regional/world/peru/history.php

Quake in Lima

Today I was in my first earthquake, just 2 hours ago in the "gringo house" in Lima. The BBC says it was a 7.5 on the Richter.
Even more amazing, the phone company finally connected the internet in the gringo house!
But back to the quake.
It was strange but not at all scary. The house suddenly started shaking & the little wooden statue of an Incan playing a flute fell to the floor. The ground in the little square in front of the house undulated ever so slightly. The local people, or at least some of them, started panicking and one of them, a little old lady, clutched Gwen's arm and started speaking Spanish at a pace that would put the micro-machine commercial guy to shame.
A half hour or so later was an after-shock, and that was less strange because it was expected.
http://news.bbc.co.uk/2/hi/americas/6948888.stm
Anyhow, I'll try to fill out the story later, but for now I am heading out to drink Pisco (the local liquor, somewhere between sake & whisky) in the farewell party for a fellow gringo medical student.

Moyo

After spending the morning at the hospital in meetings for the project, Michelle and I took a walk to "Zoo Lake" and checked out a restaurant that Prof Dhai highly recommended. The park was nice, although I'm not totally sure that we were following all of the prohibitions listed in the sign. The food at Moyo was described as "modern African" and was excellent. Nothing too exotic but everything was delicious.

Soweto

Today Michelle, Prof Ross & I took a tour of Soweto. The name "Soweto" takes the first two letters from "South Western Township"; it was set up as a temporary housing facility in 1904, housed migrant workers in large hostels in the 1940's, and has not changed substantially until the 1980's (electricity first was put in in 1985, and today many people still don't have it). Click here for the wiki on Soweto. The hostels were only made to house the working males, who would be away from their families for months, and so the structures to this day do not have indoor plumbing. Thankfully, they are being replaced by government-made housing.
Soweto has the reputation of being the place that the poor black people live; sometimes called "the heart and soul of South Africa," it is where the 1976 student uprising took place, where the Africa National Congress (ANC) party (the one formerly headed by Nelson Mandela and in power since 1994), and one of the squatter camps there is the home of the main character in the movie Tsotsi (Academy Award for best foreign film 2005).
Photos:

1. Tuck Shop is a general store
2. the tour company set up a preschool; they basically used a shipping container as the storage for the school
3. ladies doing the wash; you can't see it, but there are also pirate electricity wires running from the power lines- when the authorities cut them, more are up by the next day- not very safe but you have to respect the inginuity
   
4. tires along the road with Soweto in the background; during the anti-apartheid struggle, they had this thing called "tire necklaces"- when an informer on the anti-apartheid organizers was found, they put a tire over his/her neck, filled the tire with gasoline, then torched the person as a sign of what would happen to other informers
5. the tour stopped in to see a soccer tournament that was being sponsored by the English Premier League team Manchester United; Wits U is here in yellow; our tour guide played soccer for many years and told us that soccer in South Africa was generally the black sport whereas rugby was historically the white sport; these days sports are integrated
   
6. then we went to visit an unlicensed beer house & drink what the locals drink- homemade beer... it tasted rather sour
7. our tour guide with some of the local kids; our guide is from and lives in Soweto himself
8. a large wall painting inside of Regina Mundi in Soweto of Mandela, Tutu, Biko et. al.
9. outside Regina Mundi Catholic church; this church was very important during the anti-apartheid era as a sanctuary and meeting place for all of the forces; go here for more of its history
10. inside the church there are still bullet holes in the ceiling where soldiers shot both from outside the church into it and from within the church; our guide told us that they keep the bullet holes as evidence
11. our host for the church tour shows us how the corner of the altar was cracked off when a soldier hit it with the butt of his rifle... the MAIN ALTAR IN THE FRONT OF THE CONGREGATION
    
12. the famous Black Madonna, Our Lady of Soweto
    
13. at a shanty town
14. in the same shanty town; the remaining people are being moved into new houses that the government has constructed nearby
15. the Hector Peterson memorial; Hector was a student killed in the June 16, 1976 by the police during a student demonstration about requiring Afrikaans to be a required language in schools; here is the wiki on Hector; one interesting thing I learned was that Hector's family had changed their name to one that sounded more white in the hopes that their children would be classified under apartheid as "colored" instead of "black;" while Hector was classified as "colored," his sister was "black;" there apparently was a committee that determined what your racial apartheid classification was based on your skin tone and hair (e.g. our guide said that for the "pencil test" they put a pencil in your hair- if it stayed you were black, if it fell you were not)
16. Nelson Mandela's old house
    

Apartheid Museum, wine tasting, ostrich fillet

When you arrive at the Apartheid Museum, they give you a pass- if you're colored you get one pass and if you're white you get another. You enter the museum through different entrances based on your color. As was intended, that went against my grain. The museum was a chronological exposition on the history of South Africa, how apartheid came into being, and how it was ended.
I thought the museum's presentations were balanced; they gave enough information to understand the conditions that led to apartheid and how the system persisted for so long (being dismantled completely only in 1994).
Below are some descriptions from the museum. Steve Biko is the person for whom the bioethics center I am doing research at was named for; he was killed because he was denied medical treatment as a prisoner after severe beatings. A photo of Desmund Tutu, Nobel Peace Prize winner, is also below.
After the museum, Michelle and I ran into our neighbor Carl, a Princeton student here putting together a camp to encourage high school students to go to college. We went to a nearby suburb to meet with some of his co-workers for a drink. We met CJ & Bruno, two MBA students at Cornell & Wharton, respectively, and decided to go to a wine tasting at a nearby Hilton. It was a very good wine tasting- the Shiraz's and Pinotage's were solid.
To cap off the night, we went to Mandela Square for a late meal. I had ostrich fillet- which is more like beef than chicken; it was excellent. However, this Mandela Square was conspicuously extravagant. Although I didn't get a pass, as in the Apartheid Museum, it is true that most of the country can not afford to come to a place like this. On Sunday Michelle and I will go with Eleanor on a tour of Soweto to see what is through the other door. Although the doors no longer have colors as labels, the new doors have income as the criteria.

Holding pattern

The only thing to report is that my fellow research student from Harvard has arrived- Michelle. Besides that, we are waiting on ethics committee clearance from Harvard before we can begin talking to patients.
Here is a picture from the main library and another from the main campus quad of Wits.

As the ship goes down

I was asked to clarify the research question I'm here to study... following is my explanation if you care to get into more details (sorry, no photos for this post!):

Well, I did over-simplify the question a bit for the blog.
The question is really: do people want more access to the first-line drugs, or would they prefer less access to the first-line but guaranteed access to second-line drugs if they become resistant to the first line? This is a little more complicated. When an HIV infected patient needs to go on anti-HIV drugs, we start them on "first-line" drugs (same as you start your first-string players in a game); if they fail because the virus mutates or there is a side effect we can give these patients our "second-line" (which may also fail, but if you don't put them in you forfeit the game).
It turns out that the second-line drugs are ~10-20x as expensive as the first-line drugs. In the US we say "who cares? we can pay so second-line for everybody that needs them". However, in Sub-Saharan Africa, only 1 in 10 people who need drugs get ANY drugs. This is the reason that HIV is a chronic disease in the US but a death sentence for 9 in 10 HIV infected persons in Sub-Saharan Africa.
So, why the heck am I working at a Bioethics center? Well, we have a question about distributing severely limited resources that will determine who lives and who dies. This decision has a very strong moral dimension.
Imagine that you're the captain of a ship (the Titanic 2) that just got hit by an iceberg; it is going down in the freezing Atlantic and your first-mate sheepishly admits that not only are there barely enough life rafts for 1 in 10 passengers... some of the life rafts are also way beyond their life expectancy and so they will certainly sink. Since the supplier Rafts-R-Us never bothered to label which ones are old and which new, we do not know which will sink and which will float. Although an obvious solution is to randomly distribute what rafts they have and accept that some will drown when the bad rafts spring a leak, another solution would be to put an extra life raft aboard some of the rafts in order to give those lucky enough to get on any raft a second chance in case the first raft starts to sink.
This analogy fails because doctors claim that they have an ethical responsibility not to let their patients sink if they get on a raft. Docs would say that all rafts should have a backup; they say this because their contract is with the individual patient and letting the individual patient drown would be abandonment, even if such a policy would overall end more lives.
But what if the passengers were all gathered on the slowly tilting deck of the sinking ship while the band played and unanimously said that they wanted the rafts to be distributed one way or the other? That is what we want to know- 1) whether there is consensus among patients about distributing their drug life rafts and 2) what should we do with that information- does it negate the physician ethic of non-abandonment because you are giving the patients what they would prefer?
Oddly, nobody has ever asked HIV-infected folks in Africa, where HIV has been doing the most devastation, what they prefer as the ship goes down.

In the Zone

"The Zone" is a huge indoor/ outdoor mall/ market in the Rosebank neighborhood. Eleanor (Prof Ross) again kindly offered to spend her afternoon to take me there. There is everything from up-scale jewelry stores to a flea market- of course I wanted to go to the flea market! There were crafts from all over Africa- I especially was a fan of the masks.
There were also several performers of various sorts about the market- click here to hear a 36 second mp3 clip of the wooden xylophone folks pictured below.
The last photo is of Hillsboro, which I can now say I drove through! It's not the best of neighborhoods, but on a Sunday afternoon we figured that it would be fine for a drive-thru. When you see a picture of Johannesburg with a big tower, it is the Hillsboro Tower.

New news and old news

Just saw the Brown homepage put up a little news blurb about the study we just published in the American Journal of Public Health ( brown.edu under "News" or
http://www.brown.edu/Administration/News_Bureau/2006-07/06-175.html ). The photos are of Dr. Pugatch, a Hasbro pediatrician who has been my clinical research mentor.
Also thought to share a magazine article "15 Reasons Mister Rogers Was the Best Neighbor Ever". And here is the video referenced in the article of Mr. Rogers testifying before the Senate about PBS funding here.

The Blind Pig

The Blind Pig is the graduate student pub at Witwatersrand; it's an excellent watering hole that is great for meeting international folks from all over the world at. Click here for the Blind Pig web page. On the web page, the Pig boasts to have members "spanning the entire age spectrum (pretty much) and all major genders."
It reminds me of Brown's Grad Center Bar, except that the Pig is above ground. After spending the day working in my apartment, I met Solomon at the Blind Pig and we watched a tennis match and then the Brazil-England soccer match (ended in a 1-1 tie).
About that strike- well, according to the papers it was as huge as expected and they're calling it the "biggest strike since apartheid". The only report of force seems to be some stun grenades for people blocking access to a hospital in Cape Town. Article here.
On Sunday I'm off to the flea market!

Map of my little world inside Joburg

I made a little Google map of where I am to give folks a lay of the land.
http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&msid=110176479543937992356.00000112e35056fa42f96&t=k&om=1&ll=-26.187367,28.037109&spn=0.018678,0.029182&z=15
Double-click on pins or lines for a description; click and drag a part of the map to pan around it or click on the arrows in the top left; zoom in & out with the +/- controls on the left.

Joburg on Strike

I am working from my apartment tomorrow because of the difference between 6% and 57%. Let me explain. Public workers (about 1 million of them in South Africa) were offered a 6% increase in salaries whereas government officials increased their own salaries from upwards of 50% (President Thabo Mbeki himself got a 57% increase in salary). An article on the strike is here. The folks I work with actually said was that I should not leave my apartment tomorrow because 1) I probably would not be able to get into the Wits medical school building because the public workers are going on strike, which includes the guards and 2) it might not be safe as strikes & marches can explode into bloody conflicts with the police (in a past strike 200 Wits student protesters were arrested and there were many injuries due to police force).
So tomorrow I'll try to catch up on 2 other projects I'm working on & on my Spanish-version Harry Potter reading (in prep for Peru!)

Constitution Hill

Today I went with Solomon (a faculty member of Wits in the Social Work Dept. who immigrated from Eritrea) to look at Constitution Hill. This hill is a public testament to post-apartheid South Africa: on one side it has turned the old segregated prisons into museums- focusing on how under apartheid the blacks and whites were not equal under the law and the brutal conditions for black prisoners; on the other side is the Constitutional Court- the highest court in the land that upholds South Africa's post-apartheid constitution where a person's color does not matter before the law. The second photo is the inside of the constitutional court where the Justices preside (they call them "Justices" and not "judges"). Click here for a 1 minute MP3 of my tour guide's explanation of the South Africa Flag. The next 2 photos are quotes from Nelson Mandela, who began his many-year political imprisonment at this place. The wall photo is from "Number 4", the jail that was for black prisoners. Amazingly, even Ghandi spent time at these jails- he had initially come to South Africa to serve as a stretcher bearer during the Boer War (now called the "South African War" to acknowledge the role that black South Africans played in it), and then afterwards as an advocate for Indians and proponent of peaceful resistance (Indians were also second-class citizens under the old government, and in jail the Indians stayed with the "coloreds", but they did not have it as bad as the blacks). The young chap with the smart mustachio, believe it or not, is the man who would become the Ghandi that we know in the US. Lastly is the cover of today's newspaper- getting rid of apartheid did not solve all of the society's problems, but it was clearly a huge step to fixing some of the most glaring.
People & terms:
-Nelson Mandela
http://en.wikipedia.org/wiki/Nelson_mandela
-Apartheid
http://en.wikipedia.org/wiki/Apartheid
-Mahatma Ghandi
http://en.wikipedia.org/wiki/Ghandi