Dr. Muthyala Checks In From Arusha, Tanzania

Kilimanjaro, as seen from Mount Meru

20/12/2011

Today was a regular day on the pediatric wards at Selian Hospital in Arusha, TZ......

The day began with a Continuing Medical Education given by the palliative care teams at the hospital. In the middle of rounds, a nurse informed us about a very ill child that had been brought to the outpatient clinic.

We rushed to the clinic, where we found an infant apneic. At this hospital, the nurses have minimal pediatric or neonatal resuscitation training, so nothing had been done. Quickly we

began bagging the child, found otherwise good vitals, and obtained a history.

A one-week-old boy, born at home without any prenatal care, was doing well until a few days ago, when he began to have fevers and had a seizure today.

The family initially presented to an outpatient clinic, where the child was given oral amoxicillin (a capsule of amoxicillin was opened and given to the child orally) without any improvement.

The child had a strong pulse, good chest rise with bagging but was coughing. Bulb suctioning resulted in the removal of about 2-4 ml of pink fluid, which was thought to be not blood but the amoxicillin that the child was aspirating.

There was no oxygen available in the outpatient clinic, so the child was taken (while ambu bagging) to the pediatric ICU. Oxygen via nasal cannula was started, and the child began to breath spontaneously.

The child was found to be hypothermic and there is no incubator so the mother was instructed to place the child in direct contact with her own skin. After this his vitals stabilized.

We started empiric treatment for meningitis (without an LP or blood cultures, because neither is available or reliable at the hospital) but first taught the ICU nurse how to dilute a vial of 250mg of ceftriaxone into 150mg doses, and then instructed how to mix D5NS and D5W to make D5 ½ NS for maintenance IV fluids.

Then back to rounds.

Doing well here in TZ, have one more month before coming home.. Happy Holidays, everyone!

Brian

Brian Muthyala doing x-ray teaching at Selian Lutheran Hospital in Arusha, Tanzania

Dr. Tundun Williams - Weeks 2 and 3 in Ogbomoso, Nigeria

The literature states that the prevalence of G6PD deficiency in Africa is anywhere between 15-30%.

Risk factors for hemolysis include use of mentholated products in the first six months of life, illness, certain drugs (e.g., Primaquine, sulfa drugs, Quinine) and fava beans (the jury is still out with regards to whether Nigerians eat fava beans).

We screened children at schools, churches and small villages. The screen included asking simple screening questions and collecting blood samples from children under the age of 16 years old. Samples were processed back at the hospital lab.

By the end of the third week, we had exceeded our goal of screening 1,000 children.

Initial analysis of our data shows a prevalence of 10-19%; differences in prevalence appeared to be related to ethnic group.

Parents of deficient children will soon be sent notification letters telling them what to avoid and how to recognize symptoms of hemolysis. Lab personnel have been taught how to do the simple G6PD screening test. We hope they will continue to screen children long after we leave.

The Baptist seminary elementary school, one of the first sites we visited to perform G6PD screens.

Ajinapa village; more children to screen for G6PD

Adodo village. These boys were insistent on striking fighting poses.

Ilota village school

Our host, Dr. Daniel Gbadero, speaks to children at Ayegun Baptist Church.

At Baptist Medical Center Staff School. This is Samuel, looking very sharp in his school uniform (the bowtie is optional, and as you can see, is worn by only those young men with discerning taste). You wouldn't know it from this picture, but Samuel is a giggler. He was particularly amused when I asked him if he had ever had tea-colored urine.

When the generator was not running, the power supply was unpredictable. Here, Troy Lund and I are running hematocrits on a battery-operated Hemocue machine by lantern light.

We used the fluorescent screening method for G6PD deficiency. Patients who have adequate G6PD activity produce NADPH, which fluoresces under long wave UV light. The spots that do not fluoresce represent patients that are G6PD deficient.

Ogbomoso, a town of just over 1 million inhabitants, is located in Oyo State (in Yoruba-land), about 150 miles north of Lagos.

Photo courtesy Google Maps and Wiki Commons

Like all other Yoruba towns, there is a story behind the origins of Ogbomoso. It is said that a mighty warrior named Elemoso once habitually terrorized the inhabitants of present day Ogbomoso.

The people got fed up with being pillaged and decided to send a warrior of their own to defend their city.

This warrior fought with and beheaded Elemoso.

The alaafin (king) of Oyo heard of this feat and was impressed. He dubbed the warrior "Ogbori Elemoso" (he who beheaded Elemoso) and crowned him soun (regional king) of his hometown.

Over the years, the name of the town, originally Ilu Ogbori Elemoso (the place of origin of Ogbori Elemoso), has contracted to just Ogbomoso.

We chose Ogbomoso as the site for the G6PD deficiency study because of Tina (Slusher)'s long-standing ties with the Baptist Medical Centre, where we have guaranteed access to a lab.

Dr. Tundun Williams - Week 1 In Lagos, Nigeria

Lagos is home to over 7 million people who call themselves "Lagosians". They are kind of like the New Yorkers of Nigeria. They dress to impress, drive... how shall I put this...purposefully, and are all vying for a bit of the wealth that is for the making in this city which remains the business capital of Nigeria.

Lagos is inhabited by the uberrich, who live in sprawling mansions on gated estates, as well as the destitute, who make do in shacks that house up to four families and have one communal bathroom.

To say that the wealth in this city is unequally distributed is stating the obvious.

I spent the majority of my time this week at the Massey Street Children's Hospital, a government-run pediatric hospital in inner-city Lagos.

I soon learned that the action at Massey was in the ED, a two-room facility on the second floor of the outpatient building, which was located across the street from the inpatient department.

After nearly losing my life trying to cross the street while dodging public minivans (danfos), three wheeled cabs (maruwas) and motorcycles (okadas) on my first day at Massey, I mastered the art of road-crossing in Lagos, which consists of venturing forth at a time when the road is relatively clear and then holding your ground in the face of any oncoming traffic until you are given the right of passage. You must show no fear.

The in-patient building at Massey

The busy street between the two buildings at Massey

The doctors in the ED were glad to have me on board. Part of the art of practicing medicine in the developing world is learning to improvise, and improvise I did. I performed an LP on a 6yo with a 20-gauge needle (stylet, schmylet), used the elastic band on the bottom of a pair of gloves for a tourniquet and did many other things that would never have crossed my mind in the US. 

I saw several cases of very classic kernicterus, a case of cholera and malaria galore.

Since Massey is a government-run facility, basic supplies like gloves, IV cannulas, syringes and needles can be obtained for free from the hospital pharmacy with a doctor's written prescription.

If the pharmacy happens to be out of stock, however, patients are responsible for purchasing their own supplies and bringing them to the hospital. The cost of medical care can be mammoth and is one of the factors that prevents the average Nigerian from seeking timely treatment.

Inside Massey's ED

A toddler at Massey with left lower lobe pneumonia. The cuts had been made in his village when he started coughing and then complained of abdominal pain.

When I was not at Massey, I pitched in to help Tina (Slusher) with her sunlight phototherapy study. At the end of this week, I will head to the small town of Ogbomoso, where I will be spending the majority of my time.

Dr. (Henk) Vreman and his helpers setting up the sunlight phototherapy tent frame

Down time at an ice cream parlor

Andy Keenan: A Day At Selian

Fourth-year Medicine-Pediatrics resident Andy Keenan is currently abroad in Arusha, Tanzania, completing a month of peds and a month of internal medicine at Selian Lutheran Hospital. Here's his most recent blog entry:

Things are going great here in Arusha, albeit with unpredictable internet.

Selian is a small hospital just outside the village of Ngaramtoni, near the town of Arusha.

It is a semi-private entity that receives support from the Lutheran Church and the Tanzanian government. Among the hospitals in Arusha, it does not offer as much subspecialty care as Arusha Lutheran Medical Center (ALMC), but often acts as a referral center from small local and regional hospitals.

The hospital is made up of a number smaller buildings, with an administrative offices, outpatient/casualty, pediatric/adult medical ward, OB/GYN ward, surgical ward, radiology, and a number of other smaller buildings for support services and living areas.

Each day starts with chapel at 0815. Some people skip this, but it's a good way act as a part of the hospital staff, and you'll get some good Swahili practice. It's also a great place to find people in the morning.

After chapel, there is morning report in the same building. They usually briefly review the hospital stats (admits, discharges, transfers, deaths), and admissions from the night before.

More complicated admissions are discussed in some detail. This can get sometimes get pretty animated, and is usually conducted in English. It can be a good time to learn about management styles, and the staff here are generally interested in resident input, as well.

Occasionally MR is followed by a presentation by one of the attendings, interns, or other staff.

Usually after MR we'll go over to the radiology building to review x-rays. It's a pretty open format, and they will often ask us to read the films. I hear the term "micro nodular" a lot.

Rounding can vary widely depending on who is present, what you view your role as, and several other variables that I have not been able to define for myself yet.

Usually the team is made up of an intern, a doc who has finished internship and is working in that department (senior medical officer), and an assistant medical officer (somewhat similar to a PA here).

Like in the U.S., the level of knowledge for interns can depend on the time in their training cycle and interest in the given specialty. They are my main resource for how things get done in the hospital.

The senior medical officers are also an excellent resource. Many of them have an interest in eventually pursuing specialty training in their field, so they are great to work with.

The assistant medical officers (AMOs) have a wider range of clinical skills. I've been told that many were initially trained to primarily manage common infectious diseases, but that their scope of care has increased significantly.

Some AMOs are among the longer-standing medical staff of the hospital.

When a patient is admitted, they come through Casualty, where they are evaluated by an AMO (usually) or intern (occasionally), who starts the initial workup and management, with the ward or on-call intern to review after admission.

This is where you can find the age and weight. The weight is especially important, as there is not a functional scale in the Peds ward. Often under DOB it just says the year, which can be a challenge when coming from the Peds side and it just says 2011. With the prevalence of malnutrition it can be more difficult to eyeball the age based on the size and development stage.

After evaluating the patient, the orders and documentation are done on the fly. Usually the nurse is updated on any changes or discharges, and you move on.

After rounds, the schedule gets a little more variable.

Most of my regular duties are on the wards, which are usually done by 12:00 or 1:00. My team (intern) is on the hook for reviewing admissions until 1530 when I'm not on call. Some post-rounding options are clinics, ultrasound, heading over to ALMC, or working on research.

The bus driving back in to town usually leaves between 3 and 4 in the afternoon. Given the challenge with getting back in another manner, I have been arranging my schedule to allow for this.

That's a day at Selian!

A memorable week in Bolivia

Dear all,

I've now been in Bolivia for six weeks, and the last one was certainly memorable.

I'll get the negatives wrapped up fairly quickly:

1. 
   My driver's license was confiscated by Bolivian police because I wasn't carrying the hard copy of my passport when I traveled between Cochabamba and Oruro, but fortunately I reclaimed it after a tense encounter at the station.
2. 
   My wallet was confiscated by parties unknown in Oruro during the Carnaval festivities after I had foam sprayed in my eyes and was shoved from two directions. Unfortunately, the money was not reclaimed, but fortunately I was able to cancel my credit and ATM cards before anyone tried to use them. And fortunately Rachel was able to help me out via Western Union.
3. 
   I decided to drink juice of "canela" at Carnaval. When I got to the bottom of the glass, I realized that it just didn't taste right. Evidently my intestines agreed, and they protested vigorously for the next 6 days.

So my moral of the story is--"When you go to Oruro, bring your passport but not your credit card, wear a money belt, and consume only saltine crackers and Coca Cola."

Or just don't go.

Despite the above challenges, I am still enjoying my time here.

Before the Oruro fiasco, I accompanied one of the MAP teams to the village of Morochata, where I had previously failed to get to during heavy rains.

I observed and participated in a workshop where the staff of Morochata Hospital (functionally, a community clinic) learned about how to help parents take care of children with developmental disabilities.

The MAP team, "Aprendiendo de las Diferencias" (Learning about Differences), focuses on eliminating the stigma that often makes children with physical and intellectual disabilities second class citizens in their families and in society.

The team also wants to empower families to be the best caregivers and therapists they can be in order to maximize their child's potential.

During the workshop, I also demonstrated the maneuvers to evaluate for congenital hip dysplasia in neonates, though my model was a grown man.

On the other weekdays, I have continued to see patients at the clinic in Chilimarca. Thus far, I have seen over 260 patients, including many well child checks, respiratory and diarrheal illnesses, musculoskeletal injuries, and even a case of Bell's palsy.

Miguel, my last preceptor in the clinic, is no longer working there as of last week.

Instead, a new doctor named Gustavo started on Wednesday. However, on Friday he, too, was unable to come to clinic because of a renewed transit strike (giving me the opportunity to see 26 patients on my own, including 17 well toddler checks in a 2-3 hour span).

At this point, I have no idea whether the strike will still be on tomorrow. The issue is that the drivers want to raise the fare, but the people don't want the fare raised.

The drivers have a valid point--the price of gas is going up, the price of everything else is going up, they aren't able to make money at the current rate.

The people also have a valid point--they don't want to pay more.

Thus, the literal impasse--complete with road blockades on the weekdays.

Personally, this hasn't affected me as much because I live right next to the clinic. But it is wreaking havoc on schools, offices, clinics, etc.

The plan for Monday is to attend the weekly MAP team meeting and then get oriented at the Center for Children Who Have Been Victims of Sexual Abuse (CUBE). We will be doing health maintenance there later in the week.

With luck, transit will cooperate; otherwise, I may stay behind in the clinic. For the next couple of weeks, I'll be doing more rotating around the various MAP programs, pitching in where I can.

This past weekend, I went to the village of Tuini Grande, which, despite its name, is very small.

It is a very rural area past Morochata in a rugged and hilly landscape that is beautifully green (thanks to the last two months of rains).

I participated in a workshop about sorting trash into organics, combustibles, and toxics, and the MAP capacity-building team is going to go back in 2 weeks to help the community organize a clean-up and waste assortment effort.

We stayed at the home of Asunta, a health promoter I've written about previously.

She is a pretty amazing woman who does just about everything--gardens and farms, raises chickens, runs a knitting workshop, oversees efforts for water filtration and latrine use in her village, and provides health care to the children and adults in her community.

I can now also attest that she is an excellent cook, which was extremely necessary since we hiked 3 hours uphill to her village yesterday from the nearest accessible road.

(Incidentally, within the first 10 minutes of that hike, my left leg went knee deep into the mud, suggesting that I should spend more time looking at the ground than the gorgeous scenery.)

I continue to be impressed and humbled by many of the Bolivians around me who are working so tirelessly for their communities.

In some small way, I hope to approximate their energy and approach in the future. I am doing well, and owe that mainly to the help of my neighbors Emilio and Ada, who ensured my safe return from Oruro, loaned me money until Western Union came through, helped me get my driver's license back, and have been nothing short of guardian angels.

Big thanks also to my supportive family back home. Unfortunately, today's friendly internet cafe computer lacks a USB drive, so I am unable to share with you my most recent batch of photos. I will try to send them soon.

Much to my delight, Rachel gets here in one week and she'll spend several days seeing each of the programs here (clinic, school, CUBE, Capacitation, Learning about Disabilities) before we embark on a week of vacation around La Paz and Lake Titicaca.

Thank you for reading along.

I wish I could better capture my day to day life here. The last couple of weeks were good for me in that I am not romanticizing my experience as much as I was initially, but I still very much appreciate the opportunity to be here and to see an integrated model of health promotion in a resource-poor setting in action with all its incumbent challenges.

Being here has definitely been a transformative experience for me, and I hope to be a better doctor and friend when I return.

Best to all,

Brian

John Heimerl Completes His Elective In Zambia

Wow, I am now down to my last few days in Zambia. It is amazing how fast time goes!

This past weekend the farm hosted a Tiny Tim and Friends social and graduation. Each month, children newly enrolled in the program gather to celebrate those who have been in the group already for six months.

The day is filled with education and activity and culminates with a graduation ceremony.

Over 80 children attended. I had the opportunity to take some good pictures during the event, and as soon as a camera was noticed I was surrounded by children asking to have their picture taken.

The farm also started building for the animal enclosures that are being planned for the farm.

This is the future site of the chicken house. The farm also plans to keep goats and ducks in the future.

Also on Saturday we visited Our Lady's Hospice.

Dr. Tim rounds there each week and sees the more complicated patients they are having difficulties with.

We saw three adult patients. One had suffered an acute intracranial hemorrhage following an eclamptic seizure, another was suffering from dementia, and the last was also suffering the devastating effects of a stroke. There were 28 patients at the hospice.

Our Lady's Hospice will be the site of the first pediatric palliative care center in Zambia.

TTF will start with 4 rooms at the hospice and then expand in time.

The project will allow for proper palliation and access to opioids when needed. Currently, terminally ill children in Zambia are either sent the University Teaching Hospital or are sent home with minimal pain relief.

The new palliative care center will be staffed with a specifically pediatric- trained nurse on site to care for the terminal children.

The training is intense and will take two months in Uganda.

There are big things on the horizon for TTF and the children of Zambia.

I will be traveling back to Minnesota on April 5, so this will conclude my blog updates from Zambia. Thanks to all of you for viewing my photos and posts while I've been here.

Cheers,
John

Dr. Yablon's 4th Week in Bolivia

This blog post was authored by Brian Yablon, 4th year resident in the University of Minnesota Medicine Pediatrics Residency.

Well, I now have four weeks under my belt here in Bolivia, and I'm very glad that I made this a two- month rotation. It would be too difficult to leave right now, as I'm just getting into the swing of things.

I've been journaling nearly every day, but I won't subject you (or myself) to a public airing of all my thoughts. What follows, then, is a synopsis of my recent activities and a bit of editorialized reflection.

My second week here (which I've already written about) was a hodgepodge of activities, touring around the various projects here with the American visitors from MAP International headquarters, spending afternoons in the clinic. Touring around to the different projects has afforded me the opportunity to get a bird's eye view of the program that I don't think I otherwise would have had.

We were all gathered here to bid farewell to Jose Miguel and Stella, coordinators and spiritual heart of MAP Bolivia. They are traveling for the next 3 months on MAP business and will be based out of Baltimore during that time. We had a big party at Marienela's house to say goodbye (and eat, a common theme).

The past two weeks have been more down to business, with full days (8 am to 6 pm) in the clinic, with a noon-to-2 pm lunch break (during which time I've been eating with the school kids at the Comunidad Educativa para la Vida, where I'm a local celebrity).

This is where I eat lunch. There is a lot of noise and the kids rarely desist from running up to me, touching me, asking me questions, etc. I have since learned to stop carrying my camera to the cafeteria if I want to eat.

These are some pics of fun around the schoolyard, some kids posing and some au natural.

Clinic has been complicated by a couple of situations.

First was the abrupt and unexpected resignation of the clinic doctor (Pedro) during my second week. Second was the nationwide transit strike ("paro") that has been in effect for 7 of the last 8 weekdays, keeping the new clinic doctor (Miguel) from being able to get to work, since he lives more than an hour away by public transit and has no private vehicle.

Thus, it came to pass that I have been the only doctor in the clinic for most of the last two weeks. Our lab tech and pharmacist (Maruja) was also stuck at home because of the strike, which has lead to even more empiric treatment than usual.

From Tuesday through Thursday, a very nice pinch-hitter doctor named Erica was in the clinic to divide the work with me; in addition to her medical knowledge and skills, a key asset is a motorized scooter that enables her to commute to Chilimarca.

The news for Friday was that the strike was over, so Erica did not come in. Unfortunately, the strike was still on, so Miguel again could not come to clinic and I was again the only doctor (among the four of us--Pedro, Miguel, Erica, and I--I am the oldest).

During this time, the mornings have been filled with well child visits from the neighboring school.

We have been systematically working up from the daycare to the third grade so far, and are doing fourth through eighth grade this week.

Afternoons have consisted of acute visits and follow-ups. My personal record was seeing 31 patients and writing 31 notes last Thursday.

These groups of kids are waiting not quite patiently for their well child checks. Every morning sometime between 9 and 10 o'clock it's been akin to getting cluster-bombed with healthy children. Many days, I've been the only doctor around to see them.

These are three second grade girls who were reluctant to leave the exam room and go back to school, especially without a photo or three.

Teo, the clinic nurse, runs the show; she is unwavering in her dedication to her work and very on top of things.

On more than one occasion, especially early on, she has corrected my diagnoses and orders (i.e. "that's not varicella, it's scabies" or "that's not bacterial enteritis, it's amebiasis," with quotation marks not actually reflecting what Teo said, since all of our conversations are in Spanish).

These photos are from the second Sunday I was in Bolivia (Feb 13), when Teo and I did well child checks out in the community of Chilimarca and gave mebendazole to deworm 72 people.

Teo and Maruja also help me out a lot with the patients who predominantly speak Quechua. These are the patients who either politely nod or just stare when I am talking (responses I am also familiar with back home, but in a different context).

I've been spending a lot of time reading the Red Book, Harriet Lane, and some Spanish literature, and I definitely have been learning a lot both from the patients and from independent study.

Yesterday, Maruja was back at work despite the strike. We had two patients back to back with diarrheal illnesses. The first one had fever, pus, and small flecks of blood. I ordered a stool study (which I delivered to Maruja and proceeded to look at with her under the microscope). I said, "I think she's going to have amebas." Thirty seconds later, "Yes, here are the amebas."

The next patient had watery, foul-smelling diarrhea. The mother hand-delivered the freshly collected specimen, and I remarked to Maruja, "I think he's got Giardia." Thirty seconds later, "Yes, here is the Giardia."

There's something very gratifying about synthesizing what you've read and seen and using it to improve the way you treat patients in the clinic.

Being able to look under the microscope regularly is also a huge plus, and something we really miss out on in American medicine.

I would hate to leave you without a sense of some of my extracurricular activities.

Four friends I went hiking to Pairumani Park with during my second weekend. I went back to the park because of the incredible views.

Marivel, one of the new first-level health promoters, wearing Bolivian garb and picking flowers after our hike to Pairumani Park.

I have been itching to run, so last Sunday I ran around the large lake to the southeast of Cochabamba with one of my Bolivian neighbors.

His family then invited me to tag along with them for the day, which soon became what I can only describe as a gluttonous expedition, hitting up several markets from Chilimarca to Cochabamba, stopping at family members' homes to "say hello" (which meant being served hot, two-course meals), all before heading to the peach festival in Cliza, where the first sight was of dairy cows being milked into a glass, after which some hard liquor was added, and the drink (ambrosia) was sold.

This was the first time that I emphatically put my foot down when food or drink was offered to me in Bolivia.

My purple paper necklace commemorating that I am an honorary "compadre", despite my lack of fathering or baptizing prowess. There was a party on Thursday, Feb 24, for "El Día de los Compadres", a rough equivalent of our Father's Day but much more of an excuse to consume copious amounts of food.

I've made plenty of mistakes, and eaten things that I generally avoid in the US (e.g., meat), but drinking raw milk at a Bolivian fair just seems like I'm begging to be a question on the tropical medicine boards.

No matter, there was still pigeon to be eaten, but fortunately the group did not purchase a plate of the local delicacy, guinea pig (several of which were cutely running around in an enclosure earlier in the day), due to the expense.

There were more heaping plates of food, potentially mixed with queso blanco, and fermented peach juice (chicha de durazno) which reminded me why I swore off Peach Schnapps in college.

All told, a day that started out as an opportunity to exercise turned into a gastronomic marathon where I easily packed in 7,000+ calories.

This weekend, I embarked on a trip to Morochata, a village in the mountains several hours away, where we were to participate in a health promotion workshop.

We left at 4:30 am, got a ride to the neighboring town in an off-service taxi, then boarded a van theoretically bound for Morochata.

This was our trusty van. Even it wants to go to Morochata!

In each of these journeys through mountain exchanges, there is an energizing--or terrifying--amount of uncertainty. There was pelting rain, as there had been for the last 2 weeks, and after about an hour of driving around blind mountain curves on slick and narrow dirt roads, we abruptly stopped.

There was no passage on the bridge over a raging brown river because of the torrent.

Baffled, I stepped outside with my camera and immediately sank almost 6 inches into the mud.

My boot when I stepped out of the van. From this I deduced the reason we had stopped.

This is where we were stuck just before a bridge, seen from the van and then from higher ground.

This is me stuck. I'm from Minnesota.

These are my Bolivian friends stuck. They are very cold.

We waited for about 2-3 hours as more traffic backed up on both sides of the bridge until finally a "mud plow" came through from the opposite side to save the day.

This is a mud plow. It's like a snow plow gone dirty.

Success!

The camiones (flatbed trucks that carry lots of people to and fro) started across, but given the several- hour delay, the terrible road conditions (which were likely to get worse and worse the closer we got to Morochata), and the almost certainty of being stuck in Morochata if we got there, we abandoned course, hitched a ride with one of Tania's friends in a municipal vehicle (everyone knows everyone!) back down the mountain and got out at a random spot to hike to a hot springs.

This impromptu hike involved crossing 2 muddy rivers by walking on tree trunks (a total of 4 crossings round trip, most terrifying in the heavy rain with the furious waters).

This is a rickety "bridge" that we all somehow managed to hike across twice without being killed.

This is a view of the scenery from the hills outside Quillacollo, a little before we got to the hot springs. On the way back, we bought lunch here (picante de pollo) from a woman who brought a pot of her home cooking out into the woods.

Ada and Tania either like the view or are glad to have a moment's rest.

Ada and her husband Emilio run the health promoters program that builds communities' capacities to defend their own health. Tania started working with health promotion and capacity-building a couple of months ago. She lives in Quillacollo, and I was a guest at her evangelical church a few weekends ago. They unknowingly and un-ironically sang me a welcome song to the exact tune of the Jewish song "Aleinu Shalom Aleichem". I felt like I was in the middle of a Cohen brothers' movie.

When we got to the hot springs well over an hour later, my 3 Bolivian friends waited outside for me to enjoy a half hour of extremely hot (as advertised!) water from a thermal spring before we hiked another hour back and then hitched a couple more rides back to Chilimarca.

Thus, I have not had the pleasure of seeing Morochata, but I have bathed in the buff in a scalding--yet refreshing--Bolivian spring.

This is my beet-red face after taking a steaming hot 30 minute private hot springs bath. I had previously told my companions that I didn't bring a swim suit. They explained that once I was in the private room, I needed to dress "like Adam and Eve". Unfortunately, no fig leaves were present. Fortunately, no people (and hopefully no cameras) were either. Incidentally, the water was ridiculously hot and I drank my entire water bottle after leaving the bath.

Such is life.

Being here has given me a lot of time to reflect, both on medicine and on life in general.

In a lot of ways, we are very lucky in the United States.

In our clinics and hospitals, we have quick and reliable diagnostics, an array of medications and other treatments to choose from, state of the art buildings and facilities.

Yet all of this can sometimes serve as a distraction--get the second test to confirm or negate the first one, change from medication X to medication Y, refer to specialist Z, build a new hospital or two or three--from the main reason most of us went into medicine, which is to make a human connection with our patients and to promote their health.

Here in Bolivia, resources are scarce, patients economically self-ration their care even more than in the U.S., there is no medication Y or specialist Z, and yet it is that human interaction of the clinic nurse or doctor talking with patients and their families, working through problems or just being of comfort, that really takes center stage.

Likewise, our American culture pushes us to keep climbing the academic or socioeconomic ladder, often driving us away from family and friends (I don't live within 1500 miles of anyone in my family), in the pursuit of things that are really external to our health, wellbeing, and happiness.

It isn't news to anyone who has travelled outside of the U.S. or western Europe, but absolute income does not correlate with happiness.

Definitely, income disparities are a marker of societies with other ingrained inequities that strain social relations and worsen everyone's health and wellbeing.

But being accustomed to having less, using less, treading less wantonly on the environment does not in any way mean less health or less happiness.

One lens for looking at Bolivia (or much of the world) would show that it is a place with LESS than the United States.

But another lens, and one I have had the good fortune to look through, reveals that Bolivia has a lot MORE of some very important resources--nuclear and extended family ties, community and social bonds, respect for indigenous cultural traditions, transmission of knowledge and skills across the generations, and lithium.

Don't get me wrong--I am very glad to have access to clean water, reliable transportation, and state of the art medicine. But we in the "overdeveloped" world have a lot to learn about the parts of ourselves that we have let atrophy in the name of progress.

Hope all's well,

Brian