Satrom Gives a Tour of Elective Site

2nd Year Pediatric Resident, Katie Satrom, recorded a video presentation for the Annual Global Health Grand Rounds: While They Were Away: Resident Contributions Abroad 12-13 held on May 29, 2013.

Satrom Arrives In Cameroon

The following post was submitted by Katie Satrom, MD, second-year resident in the University of Minnesota Pediatric Global Health Track:

The view from my room

Greetings from Cameroon!

Dr. Tina Slusher and I arrived safely in Cameroon last week. We're working at Mbingo Baptist Hospital, which is a 250+ bed mission hospital in the Northwest Province. There are 45 physicians who work here, 600+ staff, and over 100 volunteers annually.

The pediatric ward consists for 20 general beds and another 6 oncology beds. There are also some children who are boarding in the surgical and ortho wards. In addition, there is a newborn nursery associated with the maternity ward and a very small NICU.

Currently 3 American pediatricians are working at the hospital. They are all recent grads who have committed to working here for 2 years. The hospital has surgical residents through the Pan African Academy of Christian Surgeons (PAACS) program and also a med-peds residency (although they only do 25% pediatrics).

The hospital entrance

Our daily routine consists of morning report from 7am-8am, followed by either rounding in the nursery or seeing some clinic patients. Inpatient rounds begin at 9:30.

The local residents do all of the pre-rounding, documentation, and most of the orders. Later in the afternoon, we will follow-up with any loose ends, see new admits, or spend more time in clinic or nursery.

Our role is more for supervision and teaching, as the local residents do not have much pediatric experience. I am learning a lot from the residents as well, especially about specific endemic diseases and also how to best use limited medical resources.

Drs. Satrom and Slusher with two nursery nurses and another resident, Erin Young

There are a lot of volunteers who are coming and going. Currently there is an American adult nephrologist who is here to help set up peritoneal dialysis. We have had two interesting cases of nephrotic syndrome on the wards, so he has been a helpful consult.

This week, Dr. Peter Hesseling, a pediatric oncologist from South Africa, and his team are here. They have a Burkitt lymphoma protocol to deliver simple, low-cost treatment for children that can be used in rural hospitals. Their team has treated more than 900 cases of Burkitt's in this region of Africa so far.

There is also a 2nd-year pathology resident from Mayo here for 6 weeks, so it's been fun to hang out with her. My husband comes next week to help with some engineering projects, so I'm looking forward to that!

Drs. Slusher and Satrom on rounds on the wards

My first day on the wards, I saw a new diagnosis of Burkitt's lymphoma, intussusception, cerebral malaria x3, acute bilirubin encephalopathy, TB peritonitis, H. flu meningitis, and bilateral retinoblastoma, just to name a few

This 26-week preemie was born here and was stabilized on bubble CPAP, and is actually doing quite well. Dr. Slusher and I check in on her a few times a day and have had to be creative when the power goes out for extended periods of time.

I've also been able to observe and help Dr. Slusher teach the Helping Babies Breathe protocol to the local nurses. One of these nurses is visiting from another city and will bring back what she has learned to teach others. It's pretty neat to watch them learn about simple neonatal care and to know how big a difference that can make in infant mortality if done well!

I'll try to write additional posts with interesting cases and pictures. The internet connection isn't great, so sometimes it's hard get online and especially to upload photos.

Katie

John Heimerl: 1 Month in Haiti

This entry was written by third-year Pediatrics resident, John Heimerl MD.

It has been awhile since I have last written on my experience in Haiti. Today marks exactly one month since I left Minnesota.



The Urgents remain busy. One day this week a girl was rushed in. A nurse pointed to her and asked if I could see her. My interpreter was a little late getting back from lunch, so I said yes in my limited French and Creole and was able to get the child's age and a little about her story.



I could tell she was febrile, breathing and responsive to pain. During my exam she began having brief seizures that lasted about one minute each.

Regan, one of my favorite nurses, was not available (he speaks fluent English), so after a few more minutes of intermittent seizures I asked another nurse to get me some rectal diazepam to give. The seizures immediately stopped.

I was then able to get more of the story and learned that the child is nearly two. She had been normal previously, until this morning when she was not acting like herself and was "getting worse".



My interpreter soon arrived and I was able to finish the history and get Regan to start with the orders. We got a bedside glucose (21mg/dL, which is extremely low), then gave rectal Tylenol, placed an IV, gave a dextrose bolus and obtained labs. When I left for the evening she was in a much better condition but still needing intermittent doses of diazepam for her seizures.

I learned the next morning that, shortly after I left, the family had taken her home to take her to a Voodoo priest, thinking her problem was that she is cursed.



I had a similar seizure presentation yesterday with a 11 year old who had been in an alerted state of consciousness or the past three days. She had been receiving some antiemetics and Benadryl at another facility and was sent to St. Damien's for further evaluation and management.

She was obtunded and, like the previous girl, was having intermittent seizure-like activity.

Her history was concerning--a severe headache prior to developing symptoms of slurred speech and difficulty walking, which then progressed to her current state. I ordered diazepam and asked them to draw up phenobarb. The nurse looked in the closet and reported they were out of both of the medications. After some searching she found some midazolam, which did the trick. (Well, it was that or the ceftriaxone.)

This morning the child was awake, had a completely normal exam and was asking for food. Amazingly, the same seizure intervention had two distinctly different outcomes.

On Urgents ward with Nurse Geno and my interpreter, Hilaire.

On my most recent day off, I was able to tag along with a Chicago photographer and journalist as they made a couple of stops on their way to Cité Soleil, the largest slum in Haiti.

The first stop was Operation Blessing, a well-financed NGO that is in the process of building a fish farm, with plans to expand these low-impact ponds to other locations. Apparently Paul Farmer has worked on the planning process for the ponds.

I had seen tilapia farms in Zambia, but those were small scale. This was the other extreme; the operation was impressive. Each pond contains 25,000 fish fry, there is a filtration system and a separate water well that supplies fresh water to the tanks.

The most amazing aspect of this operation is how minimally invasive it is to the land here. Operation Blessing hopes this project will be the first of many tilapia farms that will help provide both fresh protein and jobs to Haitians.

The fish pond at the fish farm.

Operation Blessing also operates an orphanage that houses several hundred children. They also recently have gotten into the exotic fish business.

The halls of the orphanage operated by Operation Blessing, home to several hundred orphaned children.

Aquarium at the fish farm operated by Operation Blessing.

Our next stop was a school financed by Artists for Peach and Justice, which teaches music to the impoverished youth of Cité Soleil. We were delivering a new batch of donated instruments. The children were appreciative of their guitars and xylophones. They are in the process of forming a marching band, so they are awaiting the delivery of some brass instruments this month.

Young musicians at the music school operated by Artists for Peace and Justice in Port au Prince, Haiti.

On we went to Cité Soleil. We were to tour the new trauma hospital that Nos Petits Freires (which operates St. Damien's, where I'm rotating) is forming; a different NGO that had been providing medical care following the earthquake had left a gap in services when they recently closed their trauma facility. The building was mostly empty, but a small clinic had been set up.

Cité Soleil Hospital

On the way to the hospital, one of our traveling companions warned us to be extra cautious because fuel had run out across Haiti. So, while there would be fewer vehicles on the road, others might be stranded and might make take "drastic actions" to get more fuel. I did notice fewer cars on the streets, but aside from the long lines at the gas stations and some hospital staff not being able to get to work on subsequent days, I didn't see any other sign of the fuel shortage.

Cité Soleil is a slum with inadequate housing and water. Wikipedia claims that, "the area is generally regarded as one of the poorest and most dangerous areas of the Western Hemisphere and it is one of the biggest slums in the Northern Hemisphere". NPH and other groups (including Sean Penn) are working to build new quality construction in the area. We saw a couple of these $7,000 cement structures. The NGOs are planning to eventually move all inhabitants to these houses which have running water and toilet facilities.

New permanent houses built by NGOs in Cité Soleil.

The remainder of Cité Soleil consists of corrugated steel roofing fashioned into a house. These structures do little to prevent rain water from entering, and when we visited, the city was in the process of drying out from the previous night's rainfall. Children were playing in stagnant, foul-smelling water. Pigs were foraging through the piles of trash. (Cité Soleil happens to be situated at the end of all the gutter runoff for Port au Prince, so during the rains the trash in these ditches makes its way to Cité Soleil).

We walked a short loop. Our guide had chosen the loop so the rental truck could always be within site, to ensure we could keep an eye on the equipment that was left. This, however, was not necessary as everyone welcomes the new hospital in their community. Children flocked to the professional photographer. Teenagers engaged us in conversation, usually culminating in a request for financial assistance for school. One nice boy asked if I could help him with his English. When I told him I would be there only for a few minutes, he returned shortly with an English book, and we practiced his pronunciation.

On Valentine's Day I was asked to work an overnight shift in the hospital. The hospital director would be available by phone should any crisis arise. So I worked till noon then had the afternoon off.

At 5PM I returned to a busy Urgents. Most of the children had minor complaints. Around 6:30 a nurse asked me to examine a child who they were giving manual bag mask ventilation to and who had no heart rate. We coded him for the next fifteen minutes, and it was only after I pronounced him dead that I recognized his malformed ear. I had admitted this child for pneumonia my second day in Haiti, and he had subsequently returned home appearing much better. And he returned within a month in respiratory failure.

Fortunately that was the only death of the night. It remained busy till midnight, and then I was able to return to my house and lay down for a few hours.



That gave me yesterday off, so I was able to catch up on some sleep. In the afternoon we delivered a portable oxygen system, provided by a group called Urban Zen, to a chronic patient named Peterson. He has been in the hospital for over a year and remains on an oxygen concentrator.

Urban Zen fundraised the $4,000 dollars for the device, which ultimately will allow him to go back home and to school. We had him practice putting it on and using the device. He enjoyed walking down the hospital and to the street, where he would yell at people so they noticed he was not confined to his room anymore. The internal and two external batteries will give him 7 hours of continuous use. He has a ways to go, as his legs were tired from the exercise after just going a few feet.

I will have to check on him today to see how he liked using the machine last night.

Peterson and his new oxygen machine

Till next time....

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