Sirens and Lights

So I’ll blog instead.

A belated Halloween story: On Oct 31st, I was cleaning up the apartment for a pre-party dinner with friends. The doorbell rings, earlier than anticipated. Hm, I think. There, on my doorstep, is a tiny green dinosaur saying, “Halloween, Halloween.” Ah, yes. I’ve heard about this, the adopted Halloween traditions selectively practiced by some Peruvians these days. Then, I realize that I am in that dreaded Halloween situation of cute kid on doorstep and no candy in house. Resourcefulness and personal history direct me to skip past the apples and reach for the chocolate chip granola bars. Saved! I hand the bar to the 3 year old brontosaurus, feeling good that I hadn’t let down a kid on an American holiday of all things. Wide eyes look at the shiny blue wrapping and then up at me. From under the lime green, orange spotted hood, I hear, “No lo quiero.” [I don't want it]

Oh.

I look at his mom and we exchange matching looks of helplessness as I take back the bar. How sad! I felt like a Halloween failure.

Fortunately, I soon received the (mentioned below) reese’s and was able to make up for it with candy from across an ocean. “GRACIAS!” and, now, whenever I see little diego in the hall, i get many 3-year-old-esque inquiries about my comings, goings, plans and reasons for everything.

I feel redeemed!

The end.

This time on malaria.

I’ll hopefully have more to say later tonight, but I’m working on my presentation for tomorrow morning (man, I wish I was fluent in Spanish) for the rest of the night.

Wish me luck….

*Bargain for fares, obtain reasonable one, apparently reveal my foreigner status with my accented Spanish*

Taxista: So, where are you from?
Me: U.S.
Taxista: Oh, good. How long are you here for?
Me: 10 months. I arrived 4 months ago and will stay until the end of May.
Taxista: Oh, that’s a lot of time! Are you being a tourist for that time?
Me: No, I’m a medical student. I’m doing research for the year at Cayetano (university in Lima)
Taxista: Oh! I have this rash….
Me: Um….
Taxista: Do you think I need to see a psychologist?

*discussion on rash included listening to symptoms and talking about why his doctor wanted him to see a psychologist, and the importance of talking to physicians even though my answers made sense.*

gotta love medicine. and yes, I still secretly revel in actually having useful clinical knowledge with which to help people understand what their health care providers are telling them!

The best part though, was that this opened up a discussion that led to him showing me pictures of his children and discussing their educational goals, which then led to a discussion on how the public sector (including education and health) is run in Peru. While I’m usually reluctant to take just one person’s account of the strengths/failures in the system, I really like hearing how people perceive these services.

On education:
Taxista: Did you know that young students in Peru only go to school for 5 hours a day? I heard that in China they go for 10 hours, at least. Don’t you think that is how a developing country should act? How else will a country get ahead?

On health:
Taxista: Doctors here only work for 6 hours a day in the public sector and then spend the rest of the time in their private clinics. They say that medicine is too tiring to work more than 6 hours a day. I guess I can see that it is tiring work. But it is also work that people study hard for and enjoy. I’m not saying that they don’t work hard, but in my opinion, maybe they could think about that when deciding how much to work in public hospitals. What a luxury, to be able to do a job that one chose and actually enjoys!!

plane ticket buying is craziness…. today, i missed the perfect flight/cost combination by a matter of minutes…and couldn’t help but wonder if this just speaks to my longstanding goal to be more decisive in times that don’t require it (great in emergency settings in hospitals, bad when deciding on plane fares).

in other news, World AIDS Day will include, among other things, my first lecture in Spanish, to a group of medical students on the role of health professionals in promoting health and human rights. Nervous to say the least, but hoping some quality slides will make up for the flaws in my Spanish.

Disjointed as ever….but I’m heading out to support (dance) a friend who is DJing at a great place nearby.

..I’ll ever find it normal that Christmas goes along with shimmery, jewel-toned ocean blues and reveling in the warm warm sun…

I guess I won’t be finding out this year, ’cause I’m coming home for Christmas! Let me know where you’ll be and maybe I’ll be able to see you. I won’t be around for New Year’s, but before that, I’ll be home with the family!

1 month and counting ’til I move again… this time with the benefits of apartment hunting in a city I actually know, from my favorite lunch stops, bus routes (there’s no official guide anywhere…madness!), friends’ houses and all. It’s exciting to think about, a new beginning even in my year of new beginnings.

Today was full of random amusing conversations, but those will have to wait for a bit…. I’m about to fall asleep on the computer!

Sweet dreams.

by how often we have to hear a story before we are moved to make a change. There’s an article in the Times magazine about relationships between the pharmaceutical industry and physician representatives. It’s a 7 page personal account by a former physician-lecturer for a drug company discussing his introduction to this world and subsequent revelations and decisions to leave the industry to publish his own reportedly unbiased report on psychiatric medications. It’s interesting and well-written (especially if you’re unfamiliar with the system), but ultimately a twist on the facts and stories we’ve known for years…that these interactions are often less than 100% factual and have the potential to hurt patients.

In medicine, almost all of us have heard this story, the data on the influence the sales pitches have on physicians’ prescribing habits following meals/gifts, and the stories of patients tribulations as a result (frequently changing medications according to what samples are available, less than purely evidence based prescriptions being doled out, expensive medications written for instead of comparable affordable-but-less-marketed versions).

It’s an uphill battle with the strength of the drug lobby in the U.S., but I still find myself (naively, I know) frustrated by our apparent inability to let the facts define our policies.

http://www.newyorker.com/reporting/2007/06/11/070611fa_fact_danticat

things that get me through the data-crunching….

…thanksgiving x 2 was tonight…and i’m way too worn out to post, between the meal, some emotional stresses and lots of work these days… but i wanted to add how thankful i am for all of the support i have, both here in Lima and elsewhere. it cozy, warm, comfy in a i swear it’s baby alpaca blanket sort of way…reassuring.

thankful for….

too much food (part of it made by a bonafide pastry chef)….cheeks that hurt from laughing so hard… and adorably amusing children running amok.

hopefully, will get to talk to the family in Vegas before bed, and life will be good!

happy thanksgiving, everyone!

(name that song!)

Happy Thanksgiving in advance to everyone, especially my family that is celebrating my mom’s birthday (delayed) in Vegas at the moment! I’m not only attending two Thanksgiving’s this year (which, by the way, matches the sum total of Thanksgiving’s involving traditional food in the entire rest of my life), but am actually cooking dishes for both of them! While tomorrow’s cooking plans aren’t that exciting, as of Friday I will (hopefully) officially know how to bake a pie.

I’m sure the NIH is glad they provided me with funding with which to have enough time to actually learn how to bake a pie! Well, here’s a post to say that I am thankful…

_____________________________________

In all seriousness, I’ve gotten back into clinical activities this week. Most of my experiences in Peru have been of the out-patient sort, and I suppose they have allowed me to forget how awful it is to see children really suffering– well beyond the sheer agony that is an ear exam when you are 6 months old. One of the pediatric infectologists invited me to spend time with him on the HIV service at the biggest children’s hospital in Lima, which serves as a reference hospital for the rest of Peru. Many of the children are from provinces quite far from Lima, many with HIV complicated by another infection, and often with malnutrition. I can’t imagine how isolating it must be for the parents and children alike, not only in the unknown of the hospital environment, but so far from home as well, sometimes while grappling with a heavy new diagnosis. And yet, the children clearly need to be here. So few of them look their actual age, and the range of consequences of even uncomplicated HIV infection still strikes me, even though I know to expect it.

Reading the news on the UN report, these images were in my head. It’s phenomenal that the estimates have been consistently too high, that this disease is not destroying as much of the world as we had thought. Yet, the consequences of HIV when untreated, or sometimes even when treated, are truly devastating. In medical-ese, it’s cardiomyopathy, hypotonia, malnutrition, respiratory infection, developmental delay, encephalopathy, tuberculosis, contact isolation, failure to thrive. In real words, it’s a ten month old who can’t yet sit up, struggling to breathe and placed on oxygen. 33.2 million frightens me when I think in these terms. And, the reality is that in many parts of the world*, it is still a leading killer of adults and children alike.

* As a note, Peru’s HIV rate is similar to that of the U.S., and the government provides free treatment. HIV rates are still high in certain populations in Peru, mostly men who have sex with men and commercial sex workers.

Today, I went to visit a small group of young doctors that are working on health and human rights education for medical students and health professionals in Peru. Rather by chance, I’ve spent a lot of the last few years working on very similar topics in the U.S. through the American Medical Student Association and at my own medical school. It was a path I never really intended to get onto, but I suppose everything happens for a reason! After a discussion with this small group in their office, I ended up being offered a chance to speak at World AIDS Day at one of the medical schools on the role of health professionals in promoting human rights. I’m not sure yet if all of the details will work out, but it’s nice being able to channel some of my past experiences into programming here in Peru. Also, they’re considering adapting some of the curricular materials/plans we’ve developed through AMSA into a program here for medical students with an interest in human rights. While I think the framework has a lot of potential in many places, in post-Truth Commission Peru, I think it’s a useful approach, and one that has been applied successfully in the past.

It’ll be interesting to see the report when it comes out…

The United Nation’s top AIDS scientists this week plan to acknowledge that they long have overestimated both the size and course of the epidemic, which they now believe has been ebbing for nearly a decade, according to U.N. documents prepared for the announcement.

AIDS remains a devastating public health crisis in the most heavily impacted areas of sub-Saharan Africa. But the sweeping revisions amount to at least a partial acknowledgment of criticisms long leveled by outside researchers who disputed the U.N.’s portrayal of an ever-rising epidemic on the march across the globe.

The latest estimates, due to be released publicly on Wednesday, put the number of annual new HIV infections at 2.5 million, a cut of more than 40 percent from last year’s estimate, documents show. The worldwide total of people infected with HIV — estimated a year ago at nearly 40 million and rising — now will be reported as 33 million, with the numbers of new infections falling.

Having millions of fewer people with a lethal, contagious disease is good news. However some researchers have contended that persistent overestimates in the U.N.’s widely quoted reports long have skewed funding decisions while also obscuring potential lessons about how to slow the spread of HIV. Critics also have said that U.N. officials overstated the epidemic to help gather political and financial support for combating AIDS.

http://www.washingtonpost.com/wp-dyn/content/linkset/2006/10/13/LI2006101301077.html?hpid=topnews

So today was the peru-brasil qualifier match for the 2010 World Cup…we bought our tickets last week and I rearranged my work schedule to make sure I’d be able to attend relatively guilt-free. the day turned out to be one of the nicest in Lima so far this spring, with actual blue skies and sun…all signs pointed to a great day.

A bus ride and a few bandanna purchases later, though, we found ourselves in a confused crowd being quickly surrounded by police in riot gear, on horses! They had shut down the gates to enter the stadium through the West entrance and weren’t letting any more people in, with or without legitimate tickets– apparently the section was full, since so many counterfeit tickets were made. Argh. We ended up sprinting for the next gates (the stadium is separated into 4 sections based on orientation- N, S, E, W- and you can’t cross between sections inside the stadium), and managed to slip in just before they slammed those shut, too. Along with 10 others, we spent the next 40 min or so (lovely how that works out to be almost the ENTIRE first half) pleading our case before the guards… after another brief brush with the riot gear, we finally found ourselves clear across the sold-out stadium from our original seats, sitting in the steps in the aisle between seats, arguing with the “evacuation” team until they finally left us alone… Peru scored a goal in the second half, to match the one scored by Brasil in the first (we missed the latter)…

It was great to be part of the crowd even if I’ll probably always be rooting for Brasil when it comes down to it. Concerts, sporting events…. I’m always mildly awed by being in stadiums, with all of the passion and energy that people have visible in this circular sea of frenzied movement. Even though there’s always the risk of it all being channeled into riots or the like, I can’t help but revel a little in the eruption of shared excitement for one single event, like a goal by an underdog team, manifested in synchronized joy: the wave, chanting, flags, confetti, contraband red flares and hugs all around.

Certainly makes up for missing half of the game, though it still really is ridiculous for those who didn’t ultimately make it in with official tickets.

To go along with the article in NEJM about the cost of medications, another recent article in BBC looked at a study published in PLoS on the savings earned through willingness/ability to negotiate with drug companies in Brasil, a middle-income country with the somewhat unique strength of being capable of producing their own drugs locally in domestic laboratories. The study found that between 2001 and 2005, the Brasilian government saved over $1 billion and were able to reduce prices on 4 out of 6 antiretrovirals used to manage HIV. Unfortunately, the price of generic drugs produced in Brasil also rose during that time. Though the reasons for that are unclear, the government did acknowledge this by issuing a compulsory license for efavirenz and importing it from another country rather than producing it for a higher cost themselves. The article mentions concern that this will affect their bargaining power over prices from drug companies for drugs without generic forms, as it demonstrates reduced capacity to produce drugs themselves….but I think that this is a good decision for the moment. Much of the respect for this program comes from its focuses on increasing as much access as possible and acknowledging that there are cheaper alternatives even accounting for importation. And hopefully, someone will be moved to explore (and fix) the reasons for these higher prices.

It’s impressive (though it shouldn’t be) that Brasil continues to offer this type of support for affected individuals in the country, even as the number of people needing coverage (and therefore cost) has risen. Brasil’s infection rate is similar to ours in the U.S., and it says a lot about their [still expanding] program and commitment to fighting this disease. This “commitment” represents 2% of the government’s total health expenditure, and covers 180,000 of the 600,000 people with HIV (I’m not sure how many of the HIV+ people need treatment). These cost findings should be motivation to countries with similar resources, and hopefully offer a potential direction to other countries. As the article notes, and as is quoted below, the results of this policy indirectly extended to savings for many around the world in remarkable ways.

Brazil’s model has affected ARV prices around the globe. First, Brazil’s model set an important precedent for price negotiations and tiered pricing schemes for other developing countries. Second, Brazil’s treatment policies have helped create a market for generic ARVs; in turn, generic competition has facilitated Brazil’s price negotiations and lowered global ARV prices. Third, other countries have also used compulsory licenses in order to import drugs and reduce drug prices….Despite declining patented ARV prices, Brazil’s total HAART costs more than doubled since 2004. Cost increases reflect, in part, the progression of Brazil’s AIDS epidemic ten years after introduction of free and universal access to HAART: more people began treatment, the standard of care evolved, and new drugs became available for both treatment-naïve and treatment-experienced patients. However, the incongruous rise in costs from 2004 to 2005 warrants further scrutiny. Brazil faces rising costs for many locally produced generic ARVs, particularly AZT/3TC. Brazil’s AIDS treatment model nevertheless resulted in sustained lower prices for four of the six ARVs consuming the largest percentage of Brazil’s HAART budget, saving Brazil over US$1 billion from 2001 to 20

Background:

The World Health Organization (WHO) estimates that globally, 2 million AIDS patients in developing countries were receiving highly active antiretroviral therapy (HAART) in December of 2006, a more than five-fold increase since 2001. However, this number is only about 26% of the estimated 7.1 million people needing HAART.

Evolution of Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to AIDS Treatment Nunn AS, Fonseca EM, Bastos FI, Gruskin S, Salomon JA PLoS Medicine Vol. 4, No. 11, e305 doi:10.1371/journal.pmed.0040305

(placeholder until tomorrow morning, as I’m having website issues at the moment….)

I secretly love days like this, that start too early after just a little too little sleep…an early morning to wrap up a project, setting the pace for the day…busy, but calm, with just enough moments to enjoy coffee or a quick lunch in the sun with friends (yes, SUN in Lima!)

I presented one of my research proposals to the peds HIV network this morning, and am happy to report that it was received well. It’s been a crazy week between this project and another one, Spanish and research classes, among other things. In a year that is fairly undefined, successes are exciting! In a way, I feel like it’s taken longer than I would have expected to settle into a routine that is satisfying, which is a comment other people have made doing this year, too. Paradoxically, I think it’s because of the sheer number of options of things to be doing, from research and clinical work to pursuing all of our own personal reasons for wanting to have this time to focus on non-clinical work.

Honestly, I’m still not sure how I’m going to judge if this year has been meaningful in any real way, but I do think that feeling as if I was productive during the time in something beyond learning to salsa…well, it would certainly help!

Ok, there’s a book sitting next to me along with a Reese’s peanut butter cup…so I’m going to stop thinking out loud, and get to that.

p.s. Sunday- going to the Brasil v. Peru 2010 World Cup qualifier!!!

There’s a commentary in this week’s New England Journal of Medicine that is focused on the difference in both treatment regimen and affordability of these regimen in high- versus low- or middle-income countries. I think it’s a pretty clear description of many aspects of the situation.

“Unfortunately, many medications remain unaffordable in low- and middle-income countries. In the public sector, medicines are often provided free of
charge, but essential drugs may be unavailable.2 If they were less expensive, governments could provide them to more patients and international drug aid would benefit more people. In the private sector, medicines are more available but not more affordable. One way to estimate affordability is to calculate the number of days the lowest-paid government employee would have to work to purchase a 1-month treatment regimen.2 The affordability of standard
treatment for coronary heart disease in the private sector varies from less than 2 days’ wages in Bangladesh and Sri Lanka to about 5 in Brazil, Nepal, and Pakistan to more than 18 in Malawi (see Figure 2). The affordability range of standard asthma and diabetestreatments is similar.3″

(link for citation)

I felt slightly guilty as swirled my spoon around my soup. I was at lunch at my favorite vegetarian place with a pair of the nicest people I’ve met so far, a Peruvian-American couple living/working in Lima. I’ve been here for about 3.5 months so far, which means there are only about another 6.5 or so months left before I leave. As I’m working on learning to live in the moment given my own difficult history with goodbyes, I can understand my new American friend’s hesitation.

As an expat in a place with many expats, it’s usually inevitable that you’ll befriend a few fellow escapees, yielding to the siren song of the magnetic anglophone connection. Without a strongly developed common language (or 2 halves of 2 different languages), it’s tough to have a certain kind of meaningful conversation, especially if one usually, say, speaks at a breakneck speed– that is, if you are lucky enough to find someone with mutually intriguing views on the world and entertaining/comforting senses of humor. And even if you are fluent in the local language, like the friend above (she’s married to a great guy she met when she first starting working in Peru), sometimes the friendships just happen, a side effect of academic/professional circles and chance.

The danger with this, of course, is that most expats eventually leave. Whether it’s on to newer opportunities or a return to older ones, expat friendships usually come with an expiration date. And as my friend’s husband commented, when you’re trying to settle into/live a life, it’s a lot of unsettling every single time someone you’ve come to trust or are close to (relatively speaking) leaves. I can only imagine how hard it must get each time…

I’m not sure where I’m going with this, and by that I mean both the post and the thought….I’m not sure yet exactly what form my efforts and therefore life will take. I do know how important close relationships are to me, however, and how much I despise goodbyes.

I suppose for now, I’ll just look forward to more lunches at the veggie place and be happy that I’m apparently worth investment.

a bag of mini-reeses

a new book

a bagel

febreeze

Add that to the webcam that showed up at my door courtesy of my brother, and I am happy.

Thank goodness for the expat community that convinces their friends/family to deliver goods for people they will never likely meet for more than 3 hours…. and for the friends/family for being indulgent enough to be couriers for strangers!