Category Archives: GROW Trip 2012 Blog
Woo! After a couple starts and stops, including a long hiatus in July, the 2012 UChicago GROW blog is DONE!
If you’ve enjoyed our adventures, learned from our experiences with TB care and want to support our partnership with ASPAT in the coming year, feel free to send a check addressed to “GlobeMed at UChicago” to:
5706 S. University Ave. RC001, Chicago, IL 60637
All donations are tax-deductible.
We’ll also be starting a newsletter with updates about the chapter and our partner, and insights on important global health events (for example, the International AIDS Conference that happened in Washington DC last Tuesday, or the Affordable Care Act). If you would be interested in receiving this newsletter and keeping up with our new adventures in the coming year, please leave your email in a comment!
In our 3 weeks, we have been amazed by our partner and their efforts, but this GROW trip is a stepping-stone to even bigger and better endeavors. Next year’s GROW internship will undoubtedly be longer and more productive, with even more stories to share and people to meet. Look forward to it!
Thanks for reading. ❤ Signing off for now,
Briana, Cindy & Lauren, your 2012 GROW Interns
We began our last day in Peru with a quick flight from Cuzco back to Lima. I have to say, I love flying Peruvian airlines. Although the flight was a mere hour at the most, the stewardesses took the time to serve us drinks, mini sandwiches, and dessert. American airlines have a lot to learn from Peru as far as food and beverages are concerned!
Once we arrived back in Lima, we basically had a twelve-hour layover between the Cuzco flight and our Delta flight back to Atlanta. We decided to kill some time by visiting the Parque de las Leyendas, Peru’s most famous (and potentially only) zoo. Our trip to the zoo marked our first visit to the San Miguel neighborhood. At this point, we have actually visited most of Lima: Miraflores, Central Lima, San Miguel, Callao and its various districts, San Isidro, and Pueblo Libre. We’re pretty proud of the exploring we’ve done!
The zoo was actually fairly similar to most zoos in the U.S., with one exception: Peru is actually home to the majority of the animals exhibited within. In fact, Peru is such a geographically diverse country that of the 31 climates that exist on the Earth, 20 can be found in Peru alone.
A map of the zoo. This was from the front entrance and thus intact, but the maps throughout the Parque were often eroded by the seasons and thus incomplete. Quite frustrating for our navigation. Incidentally, the zoo also boasted of a Petroleum Museum (“Museo del Petroleo), which you can see in the upper-right quadrant of the map. We decided to skip this undoubtedly mind-blowing cultural site.
This is an evil goat that Briana befriended and wanted to take home with her. Lauren and Cindy were convinced that it was the spawn of Satan.
Parque de las Leyendas was divided into three major sections (the coast, the jungle, and the highlands), and a couple of international exhibitions. We visited the coast and the jungle regions thoroughly, but were kicked out before we could see the highlands. It was only 5:30 by this point, so we still had a good seven hours before our flight. We decided to get food (quelle surprise!).
For our last night in Lima, we decided to try our first taste of Peruvian-Chinese food. To be honest, Peruvian-Chinese food tastes mostly like Peruvian food, with slightly Chinese sauces. We spent an enjoyable time sampling the food and watching a weird Peruvian game show, reminiscent of the U.S. show Wipe Out for those of you who watch game shows laden with physical humiliation.
After dinner, we returned to the airport to wait for our flight. Unfortunately, after an hour, we learned that our plane had been delayed, and would not be leaving until two in the morning. Fortunately, while buying coffee, Cindy ran into Melecio and his coworker Juan, who had come to see us off.
We spent several hours talking with Melecio and Juan, who were eager to hear about our experiences in Cuzco and tell us about their recent successes: ASPAT has officially been recognized as a valued partner by the Stop T.B. Partnership, a U.S. based organization. By 10:30, the two men were ready to head off to bed, so we said a reluctant goodbye. Melecio, Judy (who couldn’t be there due to her son’s illness), and all the members of ASPAT have done so much for us in the past couple of weeks. We really did have an incredible opportunity in meeting them and learning more about their work, and we were very sad to see them go.
As I’m writing this post now, we’re still in the Lima airport waiting for more news on our flight. With any luck, we’ll be able to board in an hour or so, and be back in the U.S. tomorrow morning. That being said, we would all like to take this opportunity to thank you readers for your patience with our slow updates, and for following all of our adventures in Peru. We hope you’ve enjoyed the ride as much as we have, and have learned something in the process!
This morning, we said farewell to Ollantaytambo and the Sacred Valley to return to Cuzco for our final full day in Peru. As I said in a previous blog post, Cuzco really is a beautiful city, clean and historically rich. Unfortunately, we knew that with only one day in the city, we wouldn’t be able to see all of its many fantastic sites, so we decided to concentrate on the most important couple.
We began our day (actually, it was mid-afternoon – Ollantaytambo is not particularly close to Cuzco) by visiting the city’s most famous ruins, the fortress of Sacsayhuaman (our readers may have heard of this site referred to by its common mnemonic “Sexy Woman”). Sacsayhuaman is famous for being the sites of one of the bloodiest battles between the Incas and the conquistadors: 20,000 Inca warriors were killed in the fighting, and Manco Inca was forced to retreat to his final fortress at Ollantaytambo (recall our blog post from yesterday). Of course, only one Spaniard was actually killed in the fighting – Juan Pizarro, one of Francisco Pizzaro’s brothers.
Very little remains of Sacsayhuaman now – it is thought that the site boasts only 20 percent of the original fortress. 30 percent was probably buried in earthquakes, and the other 50 percent was either destroyed by the Spanish or by various looters over the passing centuries. Here are some photos of the ruins of Sacsayhuaman:
The zig-zag pattern is intentional and is part of a representation of a puma’s head. In the days of the Inca Empire, Cuzco’s city boundaries formed the outline of a puma, with Sacsayhuaman as the head. Now, the city has overgrown its original boundaries, but the foundations of the giant fortress still exist.
The stones are massive, over 10 meters high, and this is with 20-30% of the wall still buried underground.
The view of Cuzco from the mountaintop containing the fortress.
Our visit to Sacsayhuaman done, the three of us returned to Cuzco proper to visit its famous Mercado Central for some more shopping. Then we took a taxi to Cuzco’s most famous site of all: Qoricancha, the Temple of the Sun.
The cobblestones of Mercado Central.
Like most other sacred Inca sites, Qoricancha is in ruins now, stripped of most of its beauty to provide the fabulous ransom than the Inca Empire Atahualpa offered to Francisco Pizarro in exchange for his freedom (for more on Atahualpa and Pizarro, see our blog post Happy Father’s Day from Peru!). But even partially destroyed and converted into a Catholic Church, Qoricancha remains a place of majesty. Again, pictures will serve better than words:
The inside courtyard of Qoricancha.
All the white stone walls used to have brightly colored and intricate murals painted on them – reminds me of the white marble statues from Ancient Greece, whose color and vivacity have also been lost to the sands of time!
The last of the gold in Qoricancha – guess it was too heavy to carry off as part of the ransom payment.
There were a number of art exhibits in Qoricancha, and this magnificent masterpiece depicting the layout of religious sanctuaries and shrines surrounding Cuzco (Qoricancha is the center, and all other sacred places radiate outwards from this sun) is a stellar example of modern Latin American painting.
Unfortunately, by the time we had finished at Qoricancha, all we had time for was a quick walk through Cuzco’s Plaza de Armas (a square which really deserves more time). At the end of the day, we returned to our hotel to pack our things for tomorrow, and our return to Lima (and eventually, the United States). It’s hard to believe that three weeks have gone by so quickly!
The Plaza de Armas.
On Sunday, the three of us woke up determined to explore Ollantaybamo, and the Sacred Valley around it. From our hotel, we could see Ollantaytambo’s most famous ruins, a fortress that hosted the Inca’s “Last Stand” against the Spanish Conquistadors (Cindy and I couldn’t agree on whether the battle qualified as a Last Stand, but I think it did, so that’s how it will be referred to from now on). If you recall from the previous blog post Happy Father’s Day from Peru, Francisco Pizarro was able to easily decimate the Inca by capturing their emperor, Atahualpa, and executing him. Pizarro then instituted Atahualpa’s half brother, Manco, as a puppet ruler. Unfortunately for Pizarro, Manco proved to be a less than compliant puppet ruler, and became the leader of the Inca rebellion. After losing a major battle at the fortress of Sacsayhuaman outside Cuzco (more on this in a later blog post), Manco retreated to the fortress at Ollantaytambo.
Pizarro sent his brother and a troop of 70 conquistadors (flanked with anti-Inca locals) to Ollantaytambo to capture Manco. As they approached the fortress stronghold, Manco and his men rained arrows on them from above. Then, Manco’s men flooded the plains below the fortress using a series of pre-made channels, trapping the Spanish horses. Pizarro’s brother (and his army) fled, chased the whole way by Macho’s victorious soldiers. Unfortunately for the Inca, the Spanish were able to rally, and returned to Ollantaytambo with more men, horses, and weapons. Manco fled to his final refuge of Vilcabamba (the lost city of the Incas which Hiram Bingham was searching for when he discovered Machu Picchu instead). Although the Incas continued to harass the Spanish, I believe the battle at Ollantaytambo was the last time they managed an organized resistance, which is why I consider it their last stand.
The Spanish could not scale those really steep terraces.
Moving on, we walked to Ollantaytambo’s Plaza de Armas, where we boarded a local bus for Urubamba, which would eventually get us all the way up to Chinchero, one of the last truly indigenous villages in the area. Known to the locals as the birthplace of the rainbow, Chinchero is a beautiful little village with an awesome Sunday market. We spent several happy hours there, haggling with the locals and doing a ridiculous amount of shopping. By that point, it was mid-afternoon, and time for us to head off to our last stop of the day.
Moray is a remote site in the middle of nowhere. On the bright side, that meant that we were three of about seven tourists visiting the place, so we had most of it to ourselves. No one quite knows what Moray is or why it was built. From above, it looks like a series of phenomenally huge crop circles. We thought these circles would make the perfect location for a staged gladiator fight (preferably with the prize involving various freshly squeezed fruit juices. We’re all going to miss the juice). Pictures will be more useful than words here to give you an idea of what it looks like, and how large it really is:
The view from the visitor’s center at the entrance to Moray.
See? Huge crop circles.
And we mean HUGE. That is Lauren standing in the middle of the set of circles from the photo above.
How did we get from terrace to terrace, you ask? Good question, since each terrace is 4 to 5 ft tall. Every level has these stone steps jutting out from the rock at regular intervals – they’re thankfully much sturdier than they look.
Once we were done at Moray, we decided to go back to Ollantaytambo for the evening, where we ate a great dinner and attempted to make friends with the hotel’s spoiled cat. Tomorrow, we will be heading back up to Cuzco for our last day in the area, before returning to Lima on Tuesday. Until tomorrow!
Dear readers, you have now reached the portion of our blog that is purely travelogue. I hope you continue to enjoy our adventures, although we will not be focusing on ASPAT or the TB situation in Peru. Today, I will be covering the fantastic time the three of us spent exploring Machu Picchu, Sacred City of the Incas!
Cindy, Briana, and I woke up before sunrise this morning, excited to finally be seeing one of the world’s greatest architectural and archaeological sites. We boarded one of the early buses out to the ruins and drove through the dark up to Machu Picchu. By 6:30, we were in (and almost immediately lost, as always). We made our way quickly across the main site to the base of Mt. Huaynapicchu, one of four sacred mountains enclosing Machu Picchu. Huaynapicchu, the second tallest, is the most sacred of the four, as it was the residence for the high priest and the local virgins, who were responsibly for signaling the new day every morning.
Misty mountains in the morning!
The summit of Huaynapicchu stands at 8,920 ft, which means that the three of us had to ascend 1,180 ft up to the peak (I think I´ll call this distance ‘about a vertical half -mile’). The mountain was incredibly steep – at time, we had to bend over and ascend more or less on all fours. It made all of us feel thoroughly out of shape. To give you an idea:
Estimated time to summit and descend, according to the entrance: 1 hour.
Time it took us to summit: 1.5 hours.
Time we rested on the top: 1 hour.
Time it took us to descend: 30 minutes.
Total time: 3 hours, otherwise known as 3 times the estimate.
But even if we were slow, I think all three of us were really proud that we actually made it to the top. Even though we were exhausted, we all hobbled away thinking it was worth it – the views were fantastic. I’ll let our pictures do the talking:
We finally made it to the Summit! It was 8:30 in the morning and we were on top of a mountain. 😀
The descent was pretty grueling as well, although it took a lot less time than the ascent.
This staircase was so steep that we hung onto a rope while climbing down.
After Mt. Huaynapicchu, the three of us decided we needed lunch and a drink post haste. (I should have mentioned earlier – all the signs around the entrance prohibit bringing food or drink into Machu Picchu. Being law-abiding, we decided not to bring anything forbidden, and hoped that there would be some water for sale at the base of the mountain. There wasn’t, probably because we were the only people in the place that actually obeyed the restriction. The looming dehydration was pretty miserable on the hike). As rested as we were ever going to be, we hired the services of a local guide, Paolo, to take us around the main ruins.
Paolo, our guide, explaining to us why that corner of the ruins is sagging so gracefully.
Dude. Llama. The llama actually photobombed the 3 of us on that rock, it was epic.
A Brief History of Machu Picchu
Pachacutec, the ninth Incan Emperor, is perhaps the most crucial figure in Incan history. Pachacutec had the soul of a conqueror, and was responsible for the expansion of the Incan Empire from the areas immediately surrounding Cuzco to the greater part of Western South America. He was also responsible for the construction of the Capac Ñan, the Incan highway system, and may have been the man behind Machu Picchu as well. Little is actually known about Machu Picchu, as the Spanish never discovered the city, and so no records were kept of its origin or even its Incan name. After the destruction of the Incas, it passed out of history.
Machu Picchu was formally ‘rediscovered’ on July 24, 1911, by the American explorer / Yale professor Hiram Bingham. Bingham had originally come to Peru in search of ‘The Lost City of the Incas,’ where Manco Inca and his followers made their last stand against the Spanish conquistadors. He set out from Ollantaytambo in search of this city, which he called Vilcabamba. Early on in his voyage, however, he came to a remote Quechuan village, and as was his wont, asked the locals if there were any ruins worth seeing in the area. These locals helpfully pointed Bingham to a site in the Old Mountain near their village – Machu Picchu, in Quechuan. The rest, as they say, is history.
*Note: Although Bingham set out to discover the lost city of the Incas, and even claimed that he had found it in Machu Picchu, no one knows for sure why Machu Picchu was built. It was probably never intended to be a refuge, and in fact, the actual city of Vilcabamba (now known as Espiritu Pampa) was eventually found further down in the jungle.
Stop 1: Recinto del Guardián, Guardhouse
This Inca guardhouse is situated at the top of the Inca Trail, and was used to monitor who entered Machu Picchu. It is thought that Machu Picchu was a city composed almost entirely of the Inca elite (even when it was being built, crews were changed out every month so that no one would know exactly how to get to the city and what it looked like).
Stop 2: Intipunku, the Sun Gate
Intipunku, the Gate of the Sun, is not actually located in Machu Picchu proper, but rather is at the top of the Inca trail, in an upper pass bordered by Mt. Machu Picchu, the tallest of the four sacred mountains mentioned earlier in this post. Of course, when the Inca inhabited the city, all visitors would have passed through the Sun Gate on their way down. It was considered sacred by the Inca because it was deliberately positioned so that on the summer solstice (December 22), it would align perfectly with the sun. The sun was held to be a god be the Inca, the most powerful god in the cosmos. In fact, the Inca emperor achieved his power because he was considered to be ‘the son of the sun.’ As a result, such astronomical manipulations were commonplace in Machu Picchu.
Stop 3: Roca Ceremonial, the Ceremonial Rock
Close to the Guardhouse is rock known either as the Ceremonial Rock, or, more imaginatively, as the Funerary Stone. Some historians believe the stone was used as a sacrificial altar, where the Incas could sacrifice llamas to their gods in return for good harvest and the like. The rock is carved into three distinct parts, representing the World of the Gods, World of the Humans, and Underworld.
Stop 4: Acceso Principal a la Ciudad Inca, the Main Gate
This one is pretty self-explanatory. It is also one of the few buildings in Machu Picchu that likely had a door or some form of security system, barring unwanted visitors from entering the sanctuary.
Stop 5: Templo del Sol, Temple of the Sun
The Temple of the Sun is one of the most famous buildings in Machu Picchu. The Incas probably used it as an astronomical observatory. Although there are many windows carved into the stone in the temple, there are two that are larger than the others, one directly in front and one off to the left side when looked at from above. On the winter solstice (June 21), the sun shines directly through the large front window onto a stone slab in the center of the temple. It shines through the large side window on the summer solstice (December 22). Because we visited near the winter solstice, we were able to see how accurate the large front window was. Very impressive!
Stop 6: Templo de las Tres Ventanas, Temple of the Three Windows
The Temple of the Three Windows, along with the Temple of the Sun and the Intiwatana, makes up Machu Picchu’s central plaza. The three windows represent the three worlds in which the Incas believed.
Stop 7: Templo Central, Main Temple
Called the Main Temple because of its size, the temple was probably used as a place where ritual sacrifices were performed. At the western end of the temple is a kite-shaped stone embedded in the ground pointing south and said to symbolise the Southern Cross (which the Incas considered sacred). When the sun falls upon the stone, the shadow cast resembles a llama – more specifically, a black llama (as the shadow is black). Thus, black llamas were frequently sacrificed here.
Stop 8: Intiwatana, the Astronomical Observatory
Although Intiwatana is called an astronomical observatory, it resembles nothing more than a giant sundial at first glance. In Quechua, the word Intiwatana translates loosely to ‘Hitching Post of the Sun,’ in reference to the sundial-like object in the center of the stone table. Inca astronomers aligned this ‘sundial’ so as to be able to predict the summer and winter solstices using its angle. As such, the Inca were always aware of what season it was (harvest, planting, etc.) which was probably particularly important in a country like Peru, which has a reasonably stable climate.
Stop 9: Central Plaza, Main Square
Likely the hub of Inca social life when Machu Picchu was a flourishing city. Because the plaza has particularly brilliant acoustics, the Inca king could have stood above the Central Plaza, spoken at a fairly normal level, and been heard by all of his subjects without the aid of a microphone. Our guide, Paolo, demonstrated for us – I was really impressed.
Stop 10: Templo del Cóndor, the Temple of the Condor
Our final stop was the so-called Temple of the Condor, names for a rock which has the outline of a condor with a clearly defined head and neck. The rock faced behind it contributed the condor’s outstretched wings. Condors were considered sacred by the Incas and seen as a messenger or embodiment of the mountain spirits or apus. Machu Picchu itself is supposed to have been built in the shape of a condor (representing the World of the Gods), whereas Cuzco was built in the shape of a puma (representing the World of Men). The Urubamba River, which links the two, is shaped like a serpent (representing the Underworld).
We were all very sad to leave Machu Picchu, but even so, all three of us were excited to return to Ollantaytambo to spend a couple more days exploring the Sacred Valley. We made our way back via train, and even found our hotel on the first try, despite the fact that the hotel doesn’t publicize its address on its website, and actually has a different name in real life than it does on its website and all its advertisements. Exhausted from a long day, we went to be early. Tomorrow, we will set out to explore Ollantaytambo and the surrounding Sacred Valley! Until then, good night.
The UChicago GROW team has conquered Machu Picchu!
Today was a travel day, as the three of us left Lima to spend the weekend in Machu Picchu. Machu Picchu, as most of you probably know, is not a particularly accessible place. Hardcore travelers hike through the mountains to reach it, traversing some 73 kilometers of Inca Trail from Cuzco before they reach their destination. We obviously did not have the time to spend several days hiking (we also do not have the legs, but that’s a different matter), so we had to reach our destination by every form of transport imagineable.
We began by flying from Lima to Cuzco, a quick and relatively painless flight. After arriving in the Cuzco airport, we took a taxi to our hotel to drop off our big bags, enjoying some of the sights of the city along the way. Cuzco is very different from Lima, much older and significantly more quaint. We enjoyed the comparatively peaceful pace of the city, and fell in love with the bright colors absolutely everywhere. The strangest sight? Possibly the rainbow flags adorning every free inch of space throughout the entire city. While we knew that these flags were the symbol of the Inca Empire, to the three of us, they symbolized gay pride – a comparison which the cusquenos apparently find less than flattering.
After dropping off our bags (and picking up our Machu Picchu entry tickets), we decided to take a bus out from Cuzco to Ollantaytambo, a small village about two hours away down in the Sacred Valley. En route, we enjoyed the scenery, which anyone who enjoys mountains would have absolutely loved. Briana and I both thought that the Sacred Valley had a very similar feel to Colorado, but immensely larger and more majestic (thus, the title of this post).
Here are a couple of pictures, for your viewing pleasure:
From Ollantaytambo, we boarded a train to take us most of the way to Machu Picchu. Fortunately, although none of us were originally seated together, some of our fellow traveling companions failed to show, so we were able to take up the better part of two seating areas. It was also rather fortunate that the train was very slow-moving, as it gave us plenty of time to take pictures out the windows.
Briana definitely prefers train travel to air travel.
Anyway, after a pleasant two-hour ride, we arrived in Aguas Calientes, the gateway to Machu Picchu.
Aguas Calientes has got to be the most touristy place on the face of the planet. Everyone who enters Machu Picchu has to do so through Aguas, so the tiny mountain town is filled to bursting with the 2500 tourists admitted every day into the ruins. It’s not even a town so much as it is one big shop. Anything that is not a shop is a hotel or a restaurant.
Cindy is not ashamed to embrace the tourism of the place.
Despite the ridiculous tourist industry, Aguas Calientes manages to have some charm, just by virtue of its location among the Andes mountains and right next to the Urubamba River. We got a quick dinner and went to bed as early as possible, knowing that we would have to be awake at four the next day for our biggest adventure: Machu Picchu.
Hello all! Lauren here. Once again, we owe you an apology for the extreme delay in posting the last couple of blog posts. Unfortunately, as I lacked Internet access for the better part of July, I was unable to write this part of the Thursday blog post, the complement to Cindy’s previous post, CERI: Cases and Camaraderie. Rest assured, now that this post has been written, we are entirely caught up with blog posts, and it is just a case of adding pictures to the necessary posts (Incidentally, I apologize for the lack of pictures in this post – drafting an agreement doesn’t lend itself to many photo ops) .
Without further ado, I am here to recap the part of Thursday, June 28 that Briana and I spent working on the M.O.U. with Melecio, while Cindy was off with Judy attending the CERI meeting.
For those of you who don’t know, an M.O.U. is a “Memorandum of Understanding” between a GlobeMed chapter and its partner, wherein the fundraising for the next year is estimated, and a project is roughly outlined. This past year, our goal was to raise $10,000 for ASPAT, to contribute to its goal of building modular homes for 8 patients who needed to be separated from their families (so as to lower the risk of spreading T.B.) and to provide 20 food baskets to patients in need. Although we were unable to meet our fundraising goal, those of you who have been reading the blog religiously know that we packed approximately 10 food baskets while we were in Peru, and provided the money to build 8 model homes.
This year, Briana, Melecio, and I decided that projects such as modular homes / food baskets were really only temporary measures: they alleviated some of the patient’s poverty, but obviously only for a short period of time (for example, food baskets are only provided for the first six months of treatment). After a long brainstorming session on the underlying causes of T.B., Melecio proposed that our project focus on educating patients and teaching them business skills. To that end, we once again decided to set our fundraising goal at $10,000, which will provide two rounds of three-day business seminars to 15 promising patients (culled from about 40 interviewees), and potentially some start-up money for patients to use to actually start their enterprises. With any luck, these seminars will be organized by next summer, when the GrOW team will be present to attend. Any additional money we might manage to raise will once again go towards food baskets.
Melecio has a more in-depth draft detailing exactly how much he thinks everything will cost (renting venues, providing food, paying lecturers, etc) which I don’t have on me right now, but he is planning on emailing it to us soon. Cindy, Briana, and I were all very excited to hear about this new project, which we think really has the potential to permanently change peoples’ lives for the better. We hope you all share our enthusiasm in the coming year!
Cindy here! This morning (Thursday, June 28th), Lauren, Briana and I traveled to the ASPAT offices together, where we admired some more of the jewelry that patients had made and that we’re bringing back to the US to sell.
After that, we split up – I went with Judy to Hospital Carrion, where the CERI meeting was taking place, while Lauren and Briana stayed with Melecio at the ASPAT office in order to discuss the MOU and next year’s project. I’ll leave those details to their own blog post, and in this one I’ll talk about CERI and what I learned there.
What is CERI?
CERI is a special committee of doctors who meet every so often (once every week or month, the frequency depends on the number of patients requiring their attention) to discuss the more complex TB cases from all of Callao and adjust their treatments if necessary. These more complex cases generally involve drug-resistance and/or patient non-compliance, and the team approach of CERI pools together the collective knowledge of the region’s pulmonary specialists and infection disease experts.
Thankfully, 2 of the doctors at CERI spoke English and were kind enough to explain the proceedings to me, so I didn’t flap around uselessly without Lauren and Briana.
Dr. Christian sitting next to Judy at the CERI meeting.
One of the two doctors who spoke English! I’ve forgotten his name and did not write it down, unfortunately. But he was awesome.
What does CERI do?
One of CERI’s main responsibilities is to prescribe new drugs or diagnostic tests to patients who might have drug-resistant strains. This is an interesting twist of Peruvian health care: all TB treatments and diagnostic tests are free-of-charge to the patient due to a recent initiative from the Ministry of Health. However, these materials obviously cost the government quite a bit of money, so to receive them, the more expensive diagnostics (i.e. the faster ones, and the tests for drug resistance) and treatments have to be approved by CERI and the Ministry of Health. Thus, even though the materials are free, they are not freely available to everyone*.
*This realization led to some interesting reflections on Jhosmel, the 3 year-old with MDR-TB in Hospital Carrion. His family had abandoned him, we thought because they couldn’t afford the treatment and hospital stay, but those bills are footed by the government automatically. Instead, they probably abandoned him because, even if he recovered, the resources (both financial and human) to help him develop into a productive member of society would be immense, as he can neither walk, talk, read nor write. Furthermore, they probably didn’t want to deal with the stigma surrounding a son with TB.
Everyone who deserves the more expensive tests and treatments seem to receive them, but often not in a timely manner. There are delays in transferring the paperwork from outlying health clinics to CERI. Lima’s hospital system has an electronic medical records program, but outlying health clinics do not have computers and thus their patient records and X-rays need to be shipped over to CERI by hand. It can be months before a case appears before CERI, whether due to nurse negligence or human resources being stretched too thin. For example, in the Centro de Salud Alberto Barton, there is one physician trained in TB care, but the physician-in-chief employs him to cover other procedures and he has little time to go through the TB cases and decide whether they’re severe enough to go to CERI.
Several cases that were reviewed today involved patients whose samples had undergone drug-susceptibility testing (i.e. drug resistance testing) and were shown to be resistant to one or more drugs. However, they had been kept on those drugs for weeks or months after the test results had come through, because CERI had not yet approved the change in treatment. Centralizing the decision-making is good, since it ensures that those making the decisions have the necessary knowledge, but bureaucratic inefficiencies can lower the effectiveness of centralization.
The review process stayed pretty similar for all 20 patients: look at their chart for compliance, check out their X-rays and test results for severity of the disease, adjust treatment if necessary due to drug resistance or presentation of side effects. I won’t go into details about individual patients. However, I did manage to discuss other problems facing TB prevention and treatment with the doctor acting as my translator, and he had some interesting insights.
1. One site of extreme TB contagion is jails throughout Lima and Callao. The health system cannot guarantee the safety of doctors and nurses who venture into the jail, so what usually happens is that the health workers train police personnel to go around the jail and carry out the National TB program, i.e.the collection of sputum samples for diagnosis and treatment monitoring. Despite the training, the police personnel do not have the same level of expertise as doctors and nurses and may not catch every new case of TB, so the health system is worried about the scope of TB infection and transmission in jails because they don’t really know how severe the problem is.
2. All health policy is made by the government, usually the regional governors, and these policies determine the treatment prices and programs offered in the area. Lima and Callao thankfully have free diagnostic tests and treatments, but there can be a lack of program continuation from governor to governor. The doctor stressed the importance of educating the government and getting them on board with what the health system needs, which is a niche that is filled excellently by ASPAT in Callao.
Despite these problems, the TB program in Peru has still improved immensely. Before 2000, the doctors had to send sputum samples to the Atlanta CDC to test for resistance, and this process could take up to 6-8 months! Now, the process is whittled down to a few weeks to 1-2 months, which is not perfect but at least a step down the right path.
At this point, Melecio appeared with Lauren and Briana, and all of us listened to a presentation on the effects of introducing the MODS (microscopic-observation drug susceptibility) assay to Callao. MODS uses a new liquid-culture technique to test for drug resistance. Apparently, the new test has not done much to diagnose more people, but it has halved the diagnostic time, so that they can be treated sooner.
After the presentation, the entire GROW team and ASPAT went out to lunch with a bunch of the doctors and nurses working in the TB unit of Hospital Carrion! We went to a cevicheria (Lauren and Briana did not eat much, as they do not enjoy seafood) and enjoyed the camaraderie and jokes of the hospital staff.
It was a fun lunch. =)
After getting food (by now it was 4 or 4:30), Melecio, Judy and the GROW team hopped into a taxi and drove to a government office to meet with a Coordinator from the Ministry of Health. She gave us a powerpoint presentation on the role of the government in the TB program, including the organization of the government diagnostic labs and the street festival the government had sponsored a few months ago to raise awareness and educate citizens about TB (it seemed similar to the children’s festival the GROW team had stumbled upon during our first weekend here). We were all tired by this point – we had spent over an hour in the waiting room, whiling away the time by teaching English to Melecio and Spanish to Cindy, and by the time the presentation was over, it was close to 8 in the evening. We probably didn’t process as much of the presentation as we could have, but it was gratifying to see the close relationship between ASPAT and the Ministry of Health official. Perhaps next summer’s GROW team will work more closely with the Peruvian government!
As I´m sure you´ve noticed, the posts have been getting shorter and shorter in the past couple of days. Why, you might ask? Honestly, it´s because as exciting as our days might seem to us, I´m aware when I´m writing the blog that readers are hearing a lot of the same events detailed time and time again (particularly in the last two or three days). Today (Wednesday, June 27th) is no exception: we attended another educational seminar (led by Judy, this time) and like yesterday, the talk was on nutrition. I do plan on talking a little bit about the differences between Judy’s seminar and Melecio’s, but on the whole, I will keep this short so as not to be repetitive.
As has been mentioned before, Judy is a much more aggressive personality than Melecio, so her approach to the seminar is much more upfront and confrontational than his is. She is tirelessly enthusiastic – quickly memorizing the patients’ names and then calling on them personally to answer her questions when no one wants to volunteer an answer. I think in some ways, people feel less confident around her (because they can´t just give answers when they think they know them), but at the same time, she is more fun (she’s always willing to laugh at herself and tease the patients).
Judy at the front.
There were fewer patients today, and several of them were young enough to still be in middle or high school (which made us wonder why they weren’t in class – Winter vacation perhaps?). The youngsters, combined with Judy’s presence, really increased the energy of the charla!
Bruce, the teenage boy, was very happy to give a correct answer to one of Judy’s questions! See below.
Judy teased him about his cuteness.
And finally, a photo of sunflowers growing at the health clinic, just because.
Anyway, we are fast approaching the end of our time with Melecio, Judy, and the rest of ASPAT. Tomorrow is our last day, as a matter of fact!
Cindy will be off with Judy to attend a meeting of CERI, a committee that evaluates patients on a case-by-case basis to see if they are deserving of emergency measures to save their lives. If you recall Daniel, the XDR-TB patient mentioned in some of our previous blog posts, he is an example of a patient who might be brought to CERI’s attention. Apparently Cindy and Judy will be joined their by Dr. Christian (who has been mentioned in various previous blog posts). He ostensibly speaks English, so he can translate for Cindy. I will be very interested in hearing Cindy´s impressions on the CERI meeting, so look forward to an exciting blog from her!
While all this is going on, Briana and I will be meeting up with Melecio to outline the ASPAT/GlobeMed partnership and set goals for the next year. This part of the blog post might not be as interesting for casual readers, but the GlobeMedders among you should be sure to pay attention! I assume at some point the five of us will reunite for more adventures, but I really have no idea what they are. Until tomorrow, buenas noches.
So it’s July 9th, almost a week since we came back to the United States. Lauren’s currently vacationing with her family in Hawaii, Briana’s home in Chicago and Cindy’s home in Maryland. We fell behind with blog posts during the last week of our trip – partially due to lack of Internet, partially due to fatigue – but we promise to put all of them up this week and finish this blog! Here we go. =)
Today (Tuesday, June 26th), Briana, Cindy, and I actually managed to reunite with Judy and Melecio at the appointed time, mostly due to our extremely knowledgeable cab driver (it is a breath of fresh air to get a taxi driver who knows what he´s doing and can get us to a location on his first try). Of course, Judy has been telling us we need to get there half an hour earlier than we really need to, anticipating our faux-Peruvian tardiness, so we were actually half an hour early, and poor Judy hadn´t even managed to get her son off to school when we showed up. We chilled in the ASPAT office and read over some of their educational pamphlets – apparently, the stereotype of Latinos exlaiming ‘caramba’ and ‘viva’ at every vaguely appropriate opportunity is not just an American one. You learn something new everyday.
Speaking of learning new things, today we observed our first educational charla, courtesy of ASPAT! For those of you who don´t know, educational charlas are pretty much exactly what they sound like they’d be: educational seminars given at local hospitals (or health clinics) to inform TB patients on such topics as nutrition, prevention, TB risk factors, the importance of completing a full treatment regimen, and so on. Today´s charla focused on teaching patients about their nutritional needs.
Before the charla, we passed out folders containing the educational pamphlets that we looked at this morning!
In spite of the fact that Melecio and Judy have probably given this particular talk hundreds of times before, they still managed to bring an inspiring amount of energy and enthusiasm into the room (it was actually more of a patio). The patients ranged from the young to the very old. I believe the youngest boy was 14, and the oldest man was in his 80s. At first, I wasn´t sure how successful the charla would be. Many of the activities required people to write: Melecio would put up a large poster with a question on it, such as What does food do for us? and ask the patients to write their answers on smaller pieces of paper. Unfortunately, at least two of the patients were illiterate – something I wouldn´t have thought to anticipate, and which obviously increased the difficulty of spreading awareness, as many of ASPAT’s promotional materials and pamphlets require patients to be able to read.
But perhaps the lack of literacy actually inspired more camraderie, in the end, as those who could write helped their struggling neighbors. The longer the talk went, the more enthusiastic everyone became, telling Melecio about the food they´d eaten that past week, asking him about acceptable substitutes for food they didn´t like, and just generally wanting to learn as much as possible about how to get better.
Melecio talking to the patients at the charla.
The patients and Briana listening intently.
Melecio helping a patient to write so that she can participate in the charla (note the GlobeMed logo on the back of Melecio’s shirt!).
Judy looking very serious – perhaps listening to a patient’s opinion on their nutritional and dietary needs?
Judy and Melecio both at the front – they make a very good team!
Judy ended up concluding the talk by asking if anyone would like to volunteer to be a coordinator for the health clinic, providing emotional support for the other patients and making sure that everyone took their medicine on time. One of the most enthusiastic participants, a middle-aged woman named Sarah, volunteered to help out. She said that she was tired of being judged for having TB when she had always been compliant with the treatment and taken preventative measures because other TB patients failed to be as vigilant, so she would be glad to help other people comply. More importantly, Sarah has two young children that she doesn´t want to see infected, and she is willing to do anything to minimize the spread of TB for their sake.
This is Sarah – congratulations! We´re sure you´ll be an excellent coordinator.