Monthly Archives: June 2012

Bonus Post: The TB Edition

Cindy here. Sometimes I feel rather out-of-my-element here in Peru, since I don’t speak Spanish and Lauren+Briana have to constantly translate for me. They’re doing a great job of it, and apparently they enjoy my unending stream of questions, as it takes the pressure off them to think of questions and allows them to focus on translating. We have a good triumvirate going on. Still, there are many times where I feel useless and awkward (hopeful GROW-trippers who do not speak Spanish, take heed), so as a side project, I started researching TB as a worldwide problem and the equally global response to it. Tammy and the ghU team has covered some of these facts during a General Meeting, but I decided to include everything here for comprehensiveness.

Some basic TB facts and statistics.

TB is an infectious airborne disease caused by Mycobacterium tuberculosis. It is spread when a person with active TB coughs, sneezes or otherwise transmits their saliva through the air. TB infections are usually latent but can become active TB disease, where the bacteria eats away at your lung tissue or harms other parts of the body (such as the spine, brain, etc).

There are around 9 million new cases of TB each year and close to 2 million deaths. In fact, 1/3 of the entire world’s population is infected with latent TB, and most of these people are unaware of their infected status.

There is also extensive co-infection with HIV/AIDS: over 10% of TB patients are also infected with HIV, and TB is responsible for 1 in 4 deaths among HIV-positive patients. This is because TB is an opportunistic infection that transitions to active disease most easily in immunocompromised patients.

Millennium Development Goal: to halve the incidence of TB by 2015.

There are two additional goals developed by the Stop TB Partnership: to halve TB prevalence and death rates by 2015, and to eliminate TB by 2050 (defined as less than 1 case of TB per 1 million population per year).

Let me take a break here to say something about these statistics. They look nice and definite and are backed up by the World Health Organization (WHO), but I wouldn’t trust them to the letter: they are best estimates rather than verified facts about the state of the world. Peru, and probably many other countries, do not have the personnel to comb the population for active or latent TB cases. They wait for the patients to come to them. Because of stigma or lack of access to healthcare, many patients do not show up at the health clinics to be checked out. Furthermore, the governments of these countries may not receive accurate statistics from the clinics due to bureaucratic inefficiency, or the governments may have incentive to misrepresent the statistics in order to diminish the appearance of poverty. The WHO simply compiles these statistics from various national governments; it does not have the resources to verify them.

So on a fundamental level, we do not know the scope of the epidemic – and that lack of information is both consequence and cause of the problem of TB. Even more scary, despite our lack of a clear, comprehensive picture, TB is still a major public health concern.

Global Plan to Stop TB

The Stop TB Partnership addresses this state of things in its Global Plan, which has two focuses: 1) Implementation of existing diagnostics/interventions and 2) Research and Development.

The Implementation part of the Plan has 4 objectives, which I divide up into the areas of Infrastructure-strengthening and Targeting at-risk sub-populations. These 4 objectives are:

1. Directly Observed Treatments (DOTS) expansion and enhancement

2. Drug-resistant TB

3. TB/HIV

4. Laboratory Strengthening (referring to laboratory diagnosis of TB rather than R&D)

A lot of infrastructure needs to be constructed/strengthened: health clinics, hospitals and diagnostic labs need medicine, equipment and staff.

Two specific sub-populations are targeted: patients with drug-resistant TB (MDR-TB or XDR-TB) and patients co-infected with TB and HIV.

A short detour into the details of drug resistance.

MDR-TB refers to bacterial strains which are resistant to Isoniazid and Rifampicin, the two most important first-line drugs.

XDR-TB is MDR-TB that is resistant to additional drugs (a fluoroquinolone and at least one second-line injectable drug).

The current treatment regimen for regular TB takes 6 months. The current treatment regimen for MDR/XDR-TB takes up to 2 years, is less effective, more toxic and more costly (~$2000-5000 per patient, usually shouldered by the state).

The WHO estimates that around 0.5 million cases of MDR-TB occur each year and up to 150,000 deaths.

(End detour)

The Research & Development part of the Plan has 5 objectives, which basically boil down to we need to know more about this disease, biologically and epidemiologically, and we need to know more about the effectiveness of treatments, social projects and policy. These 5 objectives are:

1. Fundamental research (which will lead to the other 4 objectives…)

2. New diagnostics

3. New drugs

4. New vaccines

5. Operational research (i.e. are things working and how can we make them better)

I’m a big fan of biomedical research. Even though TB is curable, I think we need faster and more accurate diagnostic tests to detect both active and latent forms of the bacteria. We need more therapeutics against drug-resistant bacteria. A(n effective) vaccine against adult TB would revolutionize public health. I know that biomedical research won’t solve everything: there are still the problems of patient compliance and social stigma, which is why infrastructure-building and social programs are crucial to public health. There’s still the overwhelming poverty that inflicts a very large portion of the globe. But I believe that effective diagnostics and treatments (and, hopefully, a vaccine) will go a long way in preventing unnecessary deaths throughout the world. I believe that they will stop the impoverished from being so severely disadvantaged and disrupt the poverty-illness cycle, so that those who are motivated will have the opportunity to work hard and chase their dreams. That’s why I’m glad that the Stop TB Partnership has made R&D an important focus of their Global Plan.

The Global Plan was originally written in 2006, but these objectives are from the 2011 update to the Plan. The update also estimates that the Plan will require $47 billion over 5 years to successfully fund all aspects and objectives, $37 billion for Implementation and $10 billion for R&D. Melecio says that the Partnership is having trouble gathering funds (probably due to the economic slump) and may not meet its goals for 2015. It’s still a pretty good plan for what needs to be done on a global scale to combat the problem of TB, which is why I felt it was valuable to do a post about it.

I don’t know how many of you have made it to the end of this post – I realize it’s pretty text-heavy. But hopefully you’ve learned something, and definitely comment or email if you have any questions! I’ve just learned most of this in the past 2 weeks, so I don’t know if I’m explaining it very well.

Here is a photo of a child so we can all smile and remember what we’re working for, in the end: the potential of the future. 🙂

I´m Currently Out of Creative Titles, Sorry!

I really have nothing to say about today (Monday, June 25th).  Briana and I were asked to translate ASPAT´s website into English, which was an arduous, occasionally painful task that consumed the entire day.  I do not have a future as a translator in front of me.

Lauren and Briana hard at work.

Cindy was there too, researching TB while Briana and I translated.  You will most likely see the fruits of Cindy´s research in one of our Bonus Blogs. Cindy also edited the translation for coherency throughout the day, allowing us to grab mental breaks here and there.

Anyway, that was all we did today, which doesn´t make for a hugely exciting blog post.  Tomorrow, I have no idea what we are doing, but it involves getting up early.  When I actually have a 9-5 job, I will make sure that I don´t live over an hour away from my place of business.  Transportation time really adds up.  With that said, it sounds like we´ll be pretty busy, so I´m sure that you will all enjoy the post when you see it!

Sunday with a Touch of Sacrilege

So last Sunday, the three of us had planned to check out Peru’s famous Museo Larco, but were sidetracked by the beautiful weather and our own general laziness.  But we knew we had to see this museum before leaving Lima, as it boasts one of the most famous collections of pre-Columbian erotic pots in South America.  Who could resist?

        

The museum grounds were absolutely dripping with flowers.

And the sky was a calm but distinguished blue.

We were attracted by all the flowers and went to explore the garden. In its midst was the “Erotic Gallery,” housing aforementioned pre-Columbian erotic pots, which is separate from the rest of Museo Larco.

Yup, pretty explicitly erotic.

Not just humans either!

I don’t know if the above are humans or animals or gods or whatever, but they look pretty blissed out.

After that gallery, off we went to the rest of Museo Larco, to learn all about the history of Peru – which I for one, knew nothing about.  Here it is, for our equally uninformed readers:

Peru has been inhabited for the past 10,000 years, and developed societies sophisticated enough to be called civilizations almost 5,000.  As such, Peru joins the ranks of societies such as Egypt, China, and ancient Mesopotamia, which evolved civilizations independently (as far as anyone knows).  Although the Inca Empire is the most well-known period of Peruvian history, in fact, they were in control of Peru (and other parts of South America) for a mere 150 years before the Spanish arrived.  Prior to the Inca, the Moche and Paracas civilizations dominated (while these were not the earliest Peruvian civilizations, little is known about previous societies).  Museo Larco focused primarily on the rise and fall of the Moche civilization, and the effects it had on the Inca Empire.

The Moche’s beliefs about the nature of the world parallel Chinese beliefs about yin & yang: both cultures believed in the essential duality of the natural order, represented by masculine and feminine elements operating in tandem (sun/moon, hot/cold, etc.)  Gold and silver were immensely valued in this culture because of their associations with the sun and moon – because the sun and moon are located in the heavens, they appeared to the Moche to be divine.  When their rules wore these precious metals, they were basically claiming divine ancestry.

They expressed their belief in duality elegantly, in a bowl made of both gold and silver.

    

They also wore a whole lot of jewelry. On the left are several nose-rings, while on the right are earrings.

Furthermore, the Moche believed in a three tiered world, consisting of heavens, earth, and the underworld.  Their beliefs about sexuality (epitomized by the erotic pot collection) are deeply intwined with their make-up of the world.

The World of the Gods

Represented by birds

The god Ai Apaec copulates, giving origin to life.  He inseminates the woman, the earth, and from this union, the first fruits are produced.  The union is performed at specific moments during the agricultural calendar, such as when the time for irrigating or planting begins.

The World of the Living

Represented by felines

In the earthly world, humans join to procreate.  The union between man and woman makes new life possible.  In this world, the animals also copulate, and in this way they insert themselves into the cycle of life.

The World of the Dead

Represented by serpents

The dead are often depicted as sexually active beings in pre-Columbian ideology, with the ability to interact among themselves and the world of the living.  The dead cannot procreate, of course, but are able to emit semen, a fertilizing liquid which  must be offered to the earth, which is inhabited by the living.  Living men and women also perform sexual acts that do not lead to procreation, symbolically linking the world of the living with the world of the dead.

Represented by serpents and by very skeletal human forms.

Moche tribesmen regularly performed ritual sacrifices to the gods to appease them and prevent catastrophic natural events.  The failure of various sacrifices to actually stop said cataclysms led to the fail of the Moche people, as the disillusioned tribesmen decided to combine with other, more powerful tribes, having lost faith in themselves and their gods.  From this fusion, the Inca tribes developed.  The Moche influence on the Inca is fairly obvious, and continued to be felt even after the arrival of the Spanish conquistadors.

One of their rituals was skull trepanation. It sometimes even left the person alive, as you can see on the right where some bone regeneration has occurred around the hole.  This was done to the wealthy, to separate them from the ranks of the common people.  The things we do to ourselves in the name of wealth and power!

After exploring the museum and learning all about the Moche, we stopped for a quick snack, and then headed back to the hostel to rest up for another long day with ASPAT.  Stay tuned!

The Tale of Cindy and Briana

As mentioned earlier, the three of us were split up among Judy and Melecio on Saturday to cover more Centros de Salud and visit more patients throughout Pachacutec. Cindy and I teamed up with Melecio and made a trip out to Centro de Salud Ciudad Pachacutec.

Here, the head nurse of the TB unit of the center informed us about an MDR TB patient, Marcos, who had abandoned his treatment regimen. After talking with the nurse for a few moments, Melecio acquired his address, and on bumpy ATV ride we made the short trek  out to the patient’s house .

When we reached the house of Marcos we soon learned from his wife, Ana, that he was away on a trip for work. They lived in a small, poorly lit house with only two indoor rooms and one bed. While Marcos and Ana shared a room, their two sons of 4 and 2 1/2 years old slept on small chairs outside of the bedroom. After observing their sleeping conditions, Melecio emphasized the problem it caused with the prevention of  the spread of TB to other family members of the household. Sleeping in a small, shared, poorly ventilated room offered no separation for the TB infected person of the household, so receiving a modular housing unit for Marcos was of utter importance. However, the catch was that Marcos had to return to a regular treatment schedule in order to receive the housing unit, as well as a nutritional food basket, and protect his family.

Marcos had abandoned his treatment due to adverse side effects from the pills and because of his job. Without being home regularly, it became difficult to attend the health center for treatment. Despite this, Melecio stressed the importance of continuing with the treatment plan and gave Ana ASPAT’s number for future reference. Unfortunately, Ana and Marcos didn’t have a working phone or any other means of direct communication, so getting in touch with this family might turn out to be slightly difficult in the future. But, even though we hit this small obstacle, Melecio wouldn’t let that prevent us from helping Marcos. He suggested the idea of contacting ASPAT through the doctors and the nearby health center. Although this seems slightly inconvenient and improbable given the fact that Marcos currently cannot make it to the health center even for his treatment, I’m hoping that our visit with Ana and ASPAT’s future visit with Marcos will change their attitudes.

The Tale of Lauren

While Melecio, Cindy, and Briana were off having fabulous adventures of their own, Judy, Lisette, Juan (+ barker), and I (hereafter referred to as “Team Combi”) went to visit the Centro 3 de Febrero.  After some initial confusion, we met with the head coordinator of the TB program, Dr. Vanessa, who told us that it would be best if we could catch local nurse Laney as she was doing her rounds, so that she could take us to see the remaining MDR patients in the area.  We were soon able to find Laney and her assistant, who were extremely grateful to be able to take the combi to see the rest of the patients.  Trying to find specific addresses in Pachacutec (and really, Ventanilla in general) is a dubious prospect – just look at the pictures of the area to see what I mean!  As per usual, we got lost a fair bit.  Judy spoke for everyone on Team Combi when she mentioned how much nicer it was to be traversing Pachacutec’s many sand dunes in the car, rather than on foot the way we had at Centro Mi Peru ( although actually, Melecio, Cindy, and I always waited at the bottom of the hill for Judy to confirm that the house in question really was at the top before bothering to begin climbing).

Pachacutec

Judy and Laney

I will now do my best to detail our interactions with the patients being served by the personnel at Centro 3 de Febrero, keeping in mind that all our notepads went with the other team.

JHONATAN

Age: 18 years old

TB: MDR-TB

We stopped by Jhonatan’s place at around 10:30 on a Saturday morning, so naturally, we ended up rousing him from his sleep.  At first, he was very reluctant to let us in (citing the fact that he hadn’t had time to clean the house or make himself presentable), but Laney and Judy overpowered him.  Judy truly becomes a force of nature when confronted by patients, and Laney herself fulfilled the stereotype of “really fierce old lady” so the two of them were quite a sight to behold.

Jhonatan’s family consists of himself and his grandparents – his own parents having abandoned him when he was diagnosed with TB.  Although Jhonatan’s grandfather collects a pension, and both the grandmother and Jhonatan himself have jobs (Jhonatan as a member of the cleaning staff in a restaurant), the family is still so poor they have no real way to isolate him should he abandon treatment and become contagious.  Currently, his ‘bedroom’ is merely an extra cot laid out in the family’s main living space, a fact which clearly concerned Judy.

Meeting Jhonatan was very different from meeting patients in Callao, or even in the slightly less poor areas of Ventanilla.  It was immediately obvious how stigmatized the disease is and how ashamed patients were to be associated with it (a theme that I noticed in all of the patients we interviewed in Pachacutec).  Jhonatan was extremely reluctant to have Judy take his photo for her records (although I do think this was at least partially due to the fact that he had just woken up), and despite Judy and Laney’s reassurances, did not seem to want to receive any aid if it meant declaring his name and TB status to the general public.

RICARDO

Age: Unknown

TB: MDR-TB

Continuing with this theme of reluctance, we have our next patient Ricardo, whom we did not actually meet.  When we arrived at Ricardo’s presumed address, we found it occupied by a family who were extremely surprised to be receiving a visit from ASPAT, having no idea who Ricardo was or why he would have said he lived in their house.  Apparently, many patients in the area report false addresses when they first begin going to the Centro 3 de Febrero, because they are so ashamed of their TB status and don’t want health workers dropping by and ‘outing’ them as TB patients to their neighbors.

UNKNOWN FEMALE PATIENT

Unfortunately, I don’t think I ever heard this woman’s name, or if I did hear it, I’ve forgotten it completely.  Regardless, I just included her for the chance to show the above picture.  People here are always on the defensive when it comes to opening their doors – maybe no one knocks unless they’re delivering unwelcome news.  This woman, apart from being reluctant to open the door, refused to let us in because she felt too sick from the medicine to talk to anyone.  I believe Judy will follow up with her at a later date.

YOLANDA

Everyone is very confused.

Age: 30 years old

TB: MDR-TB

Centro 3 de Febrero clearly has a problem with its record-keeping in general (probably due to a lack of staff), as we learned in the case of Yolanda.  We approached her house, which was empty except for three young children, and asked if Yolanda, a 15-year-old girl, lived with them.  The oldest boy looked very confused, so Judy asked if he lived there (yes), and if he had a sister (yes).  Was Yolanda his sister?  No, he said, Yolanda was his mother, and his sister was younger than he was.  At this point, I think Judy, Laney, and I were all wondering how on Earth 15-year-old Yolanda could have a son who looked as old as this boy did (10 or 11).  Judy asked to speak with Yolanda, and was told that she didn’t live in this house.  She lived somewhere else, and he could show us.

We wandered through more of Pachacutec until we ran into Milcha, the boy’s father, who was more forthcoming in his explanations.  Apparently, Yolanda was not a 15-year-old girl but a 30-year-old woman, and the mother of the two children.  The address that the Center had was Yolanda’s mother’s house, where the children were living with their grandmother and uncle so as not to be exposed to their sick mother.  Milcha took us back to his and Yolanda’s real house, and was very willing to talk about his situation.  He seems to understand how serious TB is (although Yolanda might still be in denial, but she wasn’t there so this is all hearsay), and is doing his best to prevent it from spreading to the children, which Judy approved.

Milcha, very concerned

When we left Milcha, Laney explained to us that there has been such a large problem with TB and other diseases in this particular area because it is so close to a hidden cemetery.  In fact, when we climbed up a series of small sand dunes, we were able to see the cemetery, probably within 50 or 100 feet of Milcha and Yolanda’s place.  Even this was better than the situation a few years earlier, when the dead were left to rot in the street.

DENIS

Age: 39 years old

TB: MDR-TB

Our final patient of the day was Denis, a friendly man who was as difficult to find as all of his counterparts.  At first, we visited the address on record, which turned out to be someone else’s shop.  The little boy running the shop recommended trying the other side of the street, which we did.  At that house, we found Denis’ niece, who said that Denis wasn’t living in the home with them, but rather managing her shop at the top of the hill (naturally – I’m so glad we had the combi with us!)  When we arrived at the shop, we did indeed manage to find Denis, who told us that as he is completely indigent, his niece had kindly taken him in, allowing him to manage and live in the store while he is ill.  Denis reluctantly allowed Judy to take his photo and his name, but appeared enthusiastic about any potential aid, so he doesn’t have to live off of his niece’s charity forever.

Our visits done, Team Combi headed back down the sand dunes, dropping off Laney and her assistant on the way.  After yet another round of getting hopelessly lost, we picked  up a group of women and children on the way to the center where we were to meet Melecio, Cindy, and Briana, who gave us directions in exchange for the ride!  Thus concludes The Tale of Lauren.  To learn what happened once the teams were reunited, read Pachacutec: A Study in Irony.  To learn what happened to the other 2/3 of the GROW Team, read The Tale of Cindy and Briana  

Pachacutec: A Study in Irony

Pachacutec was the ninth Inca leader of the Kingdom of Cuzco, and is most famous for transforming said Kingdom into the empire Tawantinsuyu, better known as the Inca Empire (side note: Machu Picchu was probably one of his many fabulous estates).  He was responsible for the era of conquest that expanded the Inca dominion from the valley of Cuzco to nearly the entirety of western South America, the decimation of all competing enemies, and the construction of the Inca system of superhighways that allowed their widespread empire to function smoothly.  In Quecha, the local indigenous language, the name “Pachacutec” means “He who shakes the earth.”  And if he were alive today, I am certain he would be offended if he could see the region named in his honor.

The modern-day region Pachacutec’s one claim to fame is that it is the poorest region in Ventanilla, itself an extremely poor region in extremely poor Callao.  We went out to visit with Melecio and Judy, and the for the first time, other members of ASPAT!  One of the members, Juan Jose (referred to as Juan ever after) apparently drives his own combi (a type of Peruvian bus).  Combis are a sort of tw0-man opersation: one man drives the bus, while another man stands at the door and advertises the route.  I started calling this man “the barker,” and the term caught on among this year’s GROW team.  So anyway, Juan and his barker stopped by to pick us up, and we got our own private combi out to Pachacutec!  We also picked up another young member of ASPAT, a girl named Lisette, who can only work weekends because she’s at university during the week.  I think she’s being trained by Judy to do patient evaluations on her own.

(scroll down for photos of Juan Jose and Lisette, taken during lunch)

There are a number of health clinics in the Pachacutec area, although it is a large enough region that many patients still cannot easily access the clinics on foot.  To increase our efficiency we decided to split up and hit up different clinics.

To read about the adventures of Cindy and Briana (who accompanied Melecio), read The Tale of Cindy and Briana!

To read about my adventures (I accompanied Judy), read The Tale of Lauren!

This particular blog post will resume when all teams had completed their respective missions and met up again with one more stop on the agenda: another visit to the family of Daniel, the XDR-TB patient from the blog post Making Friends and Influencing People.

For those who don’t remember, Cindy and I met Daniel’s mom and dad two days previously, where we learned that Daniel had been removed to the Hospital Carrion to be isolated.  Judy and Melecio visited him to evaluate his situation and learn more about his story, which we have recorded here (part of this story was recorded in the earlier blog post, but this is the full version as far as I understand it).

Daniel is 25 years old and is a crack addict.  He was diagnosed with normal TB while in prison as a teenager in 2003.  He took the treatment for two months before being released, after which he returned to his previous habit and failed to complete.  Naturally, the TB returned a year later, and he was resistant to one of the two primary drugs used in TB care, so he was put on another plan for eight months.  He quit again after five.  Again and again, Daniel tested positive for TB, always resistant to more meds.  Now he is extremely drug resistant.  If I understand correctly, Daniel is co-infected with TB and HIV, which means that even some of the most aggressive TB drugs usually used to treat XDR patients will most likely fail in his case.  If he is not approved for surgery (assuming he is strong enough for surgery), he will probably die.

Daniel spoke with Melecio and Judy about his regrets, particularly about his failings as a father to his two young daughters (ages 7 and 6).  He wishes he were able to do more for them, feeling keenly the poverty that prevents him from being able to buy them necessities, let alone little treats like candy.

We spoke with his parents, who weren’t optimistic about the situation.  It was very difficult to talk with Daniel’s mom, who is struggling to be strong for her son while coming to terms with the prospect of watching him die.  Melecio and Judy reiterated that they will do all that they can for their family, and emphasized the importance of hope and faith.

I was very impressed with how Judy and Melecio handled the situation, particularly because Judy is only 25 herself.  She presents herself as such a mom that people much older than her seem to find it easy to trust her and rely on her.  I am also impressed with their ability to move on from situation to situation.  They very much live in the present, moving from a disquieting visit to a delicious lunch seemingly effortlessly.

Lunch was really good, and it was nice for the three of us to get to meet Juan and Lisette, and talk with Melecio and Judy more.  We began teaching Melecio English, mostly by having him point at the different parts of the meal and letting us tell him the English word.  He is bewildered by the fact that the word for “potato” is “potato” but the word for “french fry is “french fry” (in Spanish, “french fries” are called “fried potatoes”).  If anyone knows the reasoning for that, drop us an explanation in the comments!

Juan Jose and Melecio

Judy and Lisette

After lunch, the group went back to Callao and Miraflores respectively, and Briana, Cindy, and I basically went to bed at about 8:00 (which is why you are getting this blog post late).  Clearly, we were not meant to get up at 6:00 multiple days in a row.  Until tomorrow!

The Calm Before the Storm

Today´s blog post will be pretty short compared to our earlier ones.  Briana, Cindy, Judy, and I intended to visit three or four different health centers around Hospital Carrion, but due to the fact that there was apparently an important election today to appoint doctors and nurses from the area to a Federation of Doctors, many of our contacts were out voting.  So we met far fewer patients than anticipated, and have decided to add a Saturday visit to our schedule, which will no doubt be intense.

Anyway, after the depressing posts about yesterday`s patients, I thought we could start with something a little different today: a success story!

MIGUEL

Because we weren’t supposed to take photos in the health clinic, we don’t have one of Miguel, but here are some shots Cindy snuck of the health clinic (La Perla) before they told her to stop.

Age: 23 years old

TB: MDR-TB

Miguel is 23 and has been in treatment for his MDR-TB for the past 6 months (meaning he´s made it through the interval with the highest rate of failure, and is now on fewer meds).  He isn´t sure how he caught TB in the first place, but in the months before his diagnosis, he was pushing himself very hard, working a job during the day and attending classes at night.  Obviously, he wasn´t really sleeping properly, and as he didn’t have a lot of money, he wasn´t eating very much either, which weakened his immune system (maybe Miguel was a UChicago student in a past life).  He lives in a poor area, and passed many trash collectors on his route, which is where he thinks he contracted TB once his immune system was weakened.

Fortunately, Miguel sought treatment right away, and began receiving food baskets funded by the World Bank.  Now he has been able to return to his job and his night classes while eating enough to keep him healthy!

Miguel and Judy spoke a great deal about ASPAT (he was clearly very interested), and about Miguel´s plans for the future, which involve graduating from school, where he studies graphic design, and opening up his own t-shirt business.  Judy told him to call her anytime, she and ASPAT would really like to help him with finding some start-up funds.  After Daniel and Jocelyn from yesterday´s post, it really was great to meet someone like Miguel, who´s been so compliant with the treatment and has so many plans for his future.  We wish him the best of luck!

At this point, I think the three of us have learned a lot more about the types of patients that ASPAT is seeking to help.  I divide patients into three groups, sort of like in triage.

Group 1:

Patients like Miguel, who are for the most part self-motivated and completely compliant.  ASPAT might help these people with their future plans, give them a little bit of short term help to make it easier for them to finish treatment, or even seek to incorporate them into the team.  But on the whole, this group of patients doesn´t receive much help while they are sick, because they don´t really need extra encouragement to comply.

Group 2:

Patients like Raul, who would like to comply with the treatment, but fail because they feel torn between their families and their treatment plans.  These people receive the most support from ASPAT, both in the form of food baskets and emotional guidance, and use up the majority of the ASPAT´s resources.

Group 3:

Patients like Jocelyn, who are beyond help.  ASPAT doesn´t bother to waste resources on people who don´t want treatment, and who are incapable of taking the treatment due to circumstances of their own.  In these cases, ASPAT just tries to improve the situations of the innocents suffering from the patient´s failures (in Jocelyn´s case, her children).

Anyway,  Miguel was the only patient we actually met today.  We stopped by several other health clinics, but personnel was usually absent.  Tomorrow, we´ll be heading out bright and early once again (oh joy!) to Ventanilla, this time to Pachutec, the absolutely poorest region to evaluate patients at the health centers there.  Stay tuned!

Bonus photos: Cindy has been pretty excited about all the graffiti she’s seen in Lima on this trip, so here are a few shots of the strange and vivid art that has decorated Lima’s public walls.

Bonus Post: Peru´s Educational System

As promised, here is our quick bonus blog post on Peru´s educational system!

According to Melecio, education in Peru is pretty terrible (which is not surprising in a developing country).  Chile, Peru´s neighbor to the south, is considered to be 20 years ahead of Peru in educational terms.  So what makes Peru so bad?

(1).  Technology, or the lack thereof

When Melecio graduated high school in 1999, there was only one computer in the entire school, and it was considered a luxury that they had it.  Students weren´t allowed to touch it, of course, but it was still a thrill to gather around and watch other people touch it.  Throughout most of the 2000s, computers remained scarce.  Until four or five years ago, the only way to use a computer was to go to an Internet cafe, and no one had personal computers at their homes.  Computer literacy was very low, and people could barely type.  That´s changing now, but computer usage and other technological developments that could be used to improve education are still lacking in many parts of the country.

(2).  Lack of Teacher Qualifications

Lack of human resources seems to be a theme in Peru.  Because there aren´t enough certified teachers, underqualified people are allowed to take on the position, despite the fact that they really have little to no understanding of their assigned subjects.  The problems here are obvious.

(3).  Methodology

Because so few teachers have a firm grasp of their subject, education is confined mostly to the realms of memorization and book learning (in the sense that a lesson may be comprised solely of a teacher reading to the class out of a textbook).  There is no emphasis either on investigating or problem solving, so students aren´t encouraged to think for themselves.

To address the problem, the Ministry of Education implemented a series of national exams to raise the level of education and compare the various districts. Of course, because each district sets its own standards and has been taxed with actually implementing the reforms, the quality of education continues to vary depending on how corrupt the municipal government is and how poor the region is.  Only 2 districts in all of Peru actually were actually up to standard on the most recent series of tests (Arequipa and Tacna) in both reading and math.  Lima was in 15th place.

That´s all for this bonus post, be sure to check out today´s post, The Calm Before the Storm, for more updates!

Making Friends and Influencing People

Today, Cindy and I got up at 6:00, and fortified by some delicious Dunkin Donuts, made our way back out to Callao to meet up with Melecio and Judy (Briana, unfortunately, was feeling a little ill, but after taking a day to rest, is now doing much better).  We just have no luck with taxis here – when we got into the cab, the driver asked me if we could get to Callao by driving along the beach.  Yes, definitely.  With that out of the way, he wanted to know if I´d be able to direct him to our destination once we reached Callao (for the record, this guy had a GPS on him).  Unlike loyal readers of this blog, he didn´t know about my abysmal sense of direction, but even so, all I could do was sit there and think,

You wanted to charge us 35 soles for this trip (which we did not pay), and you need the foreigner tourists to give you the directions?

I managed to communicate to him that he should definitely not rely on me for any of his directional needs, and instead put him on the phone with Judy, who managed to get us to the rendezvous station safely, if late as usual.  Then, it was back out to Ventanilla with Melecio and Judy!

Today we visited a different health clinic than yesterday, which meant going to a different area of Ventanilla.  This area initially felt a bit nicer, but quickly got just as poor as yesterday.  Most of the settlement, we found out, was built on the equivalent of an enormous sand dune.  Walking through the area was like being at an extremely depressing beach, if the beach somehow happened to be uphill both ways (I don´t know how this happened.  Somehow everything was “just at the top of the hill!“).

A hill advertising Jehova.

The Health Clinic Mi Peru.

Anyway,we arrived at the Center Mi Peru, where we met up with our guides for the day: Dr. Anita and her assistants Milagros and Jully.  None of these women had ever worked with ASPAT before, so Melecio began explaining the goals of the organization, particularly those specific to this health center.  Dr. Christian, the regional head of TB treatment in Lima, has been working with Melecio to implement a system where 2 or 3 recovered patients from each health center take responsibility for the rest of their community, encouraging them to take their meds and providing something of a support group where they can all air their grievances and compare their treatment experiences. (For more on Dr. Christian, see Callao, Here We Come! ) Did Dr. Anita think such a program would be successful in Center Mi Peru?

Dr. Anita and Nurse Jully, both skeptical.

No, as it turns out.  Center Mi Peru is famous for its noncompliant patients: 1.5 % of their cases of MDR-TB stop treatment before completing a full course.  Those who do successfully complete treatment often just want to resume normal lives and forget about their struggles with TB.

We were all concerned about this high rate of failure.  As it happens, the area that Center Mi Peru treats has a very high population of drug addicts, which is generally weakens their immune systems to the point where they catch TB.  TB medicine can´t be administered while the patient is simultaneously consuming street drugs for fear of drug interactions, and obviously, most of the addicts are not willing to make use of rehab centers or the like to overcome their problems (indeed, rehab centers don´t appear to exist in this part of Ventanilla).

With that said, I´m going to segue into talking about the patients.  Most of the TB patients here also have jobs (they take meds on an irregular basis so that they can still work, which might make them feel better but in terms of increasing drug resistant TB strains, is just about as bad as abandoning treatment completely), so they weren´t at home.  There were two patients who made an impact on Cindy and I (and ASPAT, of course), although once again, we were unable to meet them personally.  Instead, we spoke to their families.  Here are their stories:

DANIEL

Here is a photo of Daniel’s parents.

Age: 25 years old

TB: XDR-TB (Extremely Drug Resistant TB)

Daniel was first diagnosed with normal TB in 2003, and took the treatment for two months before failing to complete.  Naturally, the TB returned a year later, and he was resistant to one of the two primary drugs used in TB care, so he was put on another plan for eight months.  He quit again after five.  Again and again, Daniel tested positive for TB, always resistant to more meds.  At this point, he has made himself completely drug resistant, and there is no possible cure for him.  We learned from his parents that he has been sent to the Hospital Carrion to be isolated.

Melecio and Judy think that surgery might be possible to save Daniel`s life.  They will evaluate him, and if the two of them, Dr. Christian, and Daniel´s doctors all concur, they will send him off to CERI, a Peruvian commission that evaluates extreme patients on a case-by-case basis to see what, if anything, can be done to save their lives.  If Daniel`s TB is not too advanced, they will be able to remove the infected part of his lung and send him on his way.  Unfortunately, if the TB has spread throughout the lung, he will not be able to have surgery (all this is contingent on the assumption that he is even strong enough to survive surgery).  If he cannot receive the surgery, he will die.

JOCELYN

Jocelyn’s mother.

Juanito, Jocelyn’s eldest son.

Age: 19 years old

TB: MDR-TB

Jocelyn is one of Dr. Anita´s problem patients.  Although she has been diagnosed with MDR-TB, she is, to the best of my understanding, a crack addict (crack appears to be the drug of choice in these parts).  The health workers are never able to reach her, as she sleeps until 3 or 4 in the afternoon, presumably wandering the town at night in search of her drug source.  She has two children: Juanito, a little boy who is 3 years old, and Ivan, a baby of about 1 year.  We met both of them, and they are absolutely adorable.  Juanito spoke with Cindy and me, and showed us his toys.  He seems very bright and eager for attention.  The boys and their mother live with Jocelyn´s younger sisters and their mother.  The mother works while the two younger girls are at school, leaving Juanito and Ivan at home all day with no one to feed them or take care of them until Jocelyn`s sisters are able to get there (the sisters are maybe 12 and 15).  It´s an appalling situation.  We spoke with Jocelyn´s mom, who is clearly overwhelmed dealing with her drug-addicted daughter, her younger girls, and her grandsons all on her own.

Melecio and Judy promised to send the mother food support for the next three months for the babies, on the condition that they are kept away from Jocelyn.  Both feel that the best outcome of the situation would be for the boys to be taken into the custody of the state, and I believe they intend to begin this process as soon as they possibly can.

More photos of Ventanilla:

What is driving away from us is a “moto,” a motorbike turned taxi that is pretty comfortable – but may flip over if there is too much imbalance of weight. Disclaimer: we haven’t seen firsthand a flipped over moto on the road, but the situation seems possible.

As bleak as the patients´stories have been today, I think Cindy and I truly had a good time.  Milagros and Jully, the two assistant who accompanied us, were really engaging, fun people, and told us all about how they think we should both become doctors and then move to Peru to run a clinic and teach everybody English.  Milagros actually did speak a little English, and told us she´d learned a bit in school, but had gotten out of practice.  We taught her a little English, and she and Melecio taught us a bit of Quechua in return!  (Quechua is the local indigenous language.  I am assuming that both Melecio and Milagros are indigenous, since it´s not particularly common for non-indigenous Peruvians to learn Quechua, but don´t quote me on that).

So, here are the two words of Quechua that we know:

Ari = Yes.

Si = Ten.

I feel totally prepared to conquer the indigenous markets in Cuzco now.  Expect a very interesting blog post about that experience in a week or so!

Lauren and Milagros! There are photos of the whole group, but Cindy’s phone died so the photos are on Judy’s camera. We promise to post all of the updated photos here later.

We also talked with Jully and Milagros about our perceptions of Peru, which they were very interested in hearing, and then about the U.S. (because they´d learned about in school).  I explained that Cindy and I attend school in a city called Chicago, but that I actually live in the northeast and Cindy lives in the capital.

Milagros: Oh!  NEW YORK! (Very excited)

Me:  Um…no.

This would be a perfect segueway into the conversation Cindy and I had with Melecio about the Peruvian education system, but this post is already really long, so I guess it´ll have to be a teaser instead!  Expect a bonus blog post about Peruvian education sometime in the next couple of days (by which I mean, by the end of the weekend).

After we walked by everyone´s houses, which took several hours, we dropped Dr. Anita, Milagros, and Jully back off at the center, posed for several photos, and exchanged contact information.  I´ve noticed that we´re definitely more of an oddity in Ventanilla than Callao or other parts of Lima (or at least, I am – Cindy apparently looks native from a distance), so people consider it more of a thrill to meet us – especially the kids.

Once we´d said our goodbyes to the trio, we headed back with Melecio and Judy to Callao, and ultimately, to Miraflores.

I have no idea what we´re doing tomorrow, but I know we´re going to be able to sleep later, which is always exciting.  Until then, good night!

Bonus Post: Extended Interview with Esther

Hello, it´s Lauren once again.  To make up for being late with Tuesday´s post, and because I´m on a blogging roll that may never be replicated, we´ve decided to offer you yet another bonus post!  This time, we´re going back and filling in the blanks  in our initial interview with Esther, as promised in last Friday´s post, Callao, Here We Come!  To refresh your memory, here are the topics we promised to cover:

(1) A discussion of the make-up of the staff at Hospital Carrion’s TB Ward

(2) Esther’s guide to overcoming a sense of impotence at the enormity of the problems that TB poses

(3) The difficulties of performing triage

(4) How the lack of mental health facilities impacts TB patients

(5) The role of ‘indifference’ on the part of doctors, patients, and families

So without further ado, let´s dive right in.

Point 1.  A discussion of the make-up of the staff at Hospital Carrion’s TB Ward

The TB Ward at Hospital Carrion boasts 6 staff members: (1) doctor, (1) nurse, and (4) technicians.  These 6 people have a caseload of about 30-40 people, making the staff to patient ratio about 1:5 or 1:6.5.  This is not the worst ratio that exists in Peru, (sometimes there are only 2 nurses for 500 patients), but even so it´s not a particularly good ratio.

There are only 12 total TB Wards / health clinics in Callao.  2 are for children, and the other 10 are for adults (2 each in Ventanilla, Bepeca, and Bonilla, 2 in San Jose, and 2 in Hospital Carrion).  At least twice as many clinics are needed to adequately house all of the patients.

(2) Esther’s guide to overcoming a sense of impotence at the enormity of the problems that TB poses

Obviously, because resources are so limited and there is a real lack of staff, Esther often feels impotent and unable to help.  She has learned to focus on the impact that she does make so that she doesn´t feel overwhelmed by the enormity of the problems.  By focusing on the small and the specific (individual triumphs and stories), she is able to get through the bigger problems one step at a time.

(3) The difficulties of performing triage

Because the money and resources only go so far, Esther is always having to perform triage.  The hospital mainly takes those who can be cured, of course, but even so, many times Esther knows that certain patients could really benefit from different treatments or diagnostic tests that they´ll never receive because other patients have a greater need.

(4) How the lack of mental health facilities impacts TB patients

Many of the patients that Esther sees have been abandoned by their families.  As a result, they feel worthless and dirty.  It is also fairly common for these patients to have been mistreated at other health clinics.  Upon their admission to Hospital Carrion, they are often very angry at the world in general, and unwilling to comply with the doctors´orders.  They have no one to really talk to who can help them come to terms with their situations or their diagnoses.  Of course, this lack of mental support makes it difficult for the doctors to help the patients recover physically, and so the cycle continues.

(5) The role of ‘indifference’ on the part of doctors, patients, and families

No one wants TB, and there is a  huge fear of being infected.  These are understandable, but unfortunately, have resulted in situations where families abandon the sick, doctors have no respect for their patients, and patients themselves feel like they must have done something to deserve the disease.  Because so many people consider TB a poor person´s illness, doctors and patients alike can consider it an inevitable result of poverty…with the implication that those who have it are somehow unclean (whether simply due to their poverty or due to associated HIV infections, drug use, alcholism, etc.)  Patients are on the defensive (I don´t have HIV/I`m not a drug user) but they too believe that they must have done something wrong to contract TB.  With all this negativity surrounding the disease, no one makes a real effort to help the patient get better, and so, once again, the TB spreads.

Well, this was just a quick expansion of our interview with Esther.  I´m sure you can see some recurring themes throughout the blog posts.  Hopefully, you understand more how devastating the social attitudes have been to the recognition of TB as a threat, and you have enjoyed reading this bonus blog post as well as our newest post, Making Friends and Influencing People.  Until tomorrow!