Sirens and Lights

Prose. Haunting, startling, simply graceful or otherwise. (does anyone use e-books? i’m curious about them.)

Long, meandering conversations. Chris, David, Angela, Tanya. The fare-collector on the bus yesterday (I got on the wrong bus…another story). With patients when I have them (waiting for formal approval to start at the new hospital), long or short.

My pen. And this thick block of bond paper. Disorganized, yes, but filled with ideas and musings.

Little victories in Spanish (or any other language).

Simple brilliance (indexed.blogspot.com). This might fall under “procrastination,” but the clever inspires me to apply myself.

Accomplishments. Not in the accolade way, but in the to-do list way. Set goal, accomplish it. Motivation for the next.

Beautiful days. Is that weird? In a city as gray as Lima, my productivity is emerging as suspiciously linked to the presence of the sun. I think this may be a weakness.
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Contrary to how it seems, there are usually about 4-5 topics I want to write about on a given day….though I rarely seem to be able to give the ideas the justice they deserve. Here’s one:

WHO’s new make medicines child size campaign.

“Finish each day and be done with it.
You have done what you could;
some blunders and absurdities have crept in;
forget them as soon as you can.
Tomorrow is a new day;
you shall begin it serenely and with too high a spirit
to be encumbered with your old nonsense.”

Ralph Waldo Emerson

“It doesn’t matter if you do it perfectly. Just go out there and try to do something. As long as you always act according to your set of values, it will be meaningful.” 2 years ago, I spent a day lobbying with PHR on the African Health Capacity Investment Act. A breakfast conversation with a fellow student was overheard by one of the physician activists, a very well-respected physician-researcher. He added those words to our conversation, effectively concluding what might have been a longer discussion on all of the possible paths out there. I still think of his comments sometimes (and have to admit it was a rather silly reason for why I chose to spend this year in Peru, since he’s very loosely involved in this program).

Lately, his words have to come to mind more frequently than usual. I’ve been thinking a little about how weird it is for me to want to go home so badly. The 5 month mark is always a little hard for me with regards to missing my family, but I don’t think I’ve ever seen so much value in leaving the place I’m working. Walking in the sun today, meters above the intensely aqua summertime Pacific, I wondered a little if I’m becoming a little less idealistic or passionate about where all of this energy is going…or if the research path is as fulfilling as I had hoped it to be. It’s tough to evaluate, since 5 months is so little time with regards to seeing the outcomes of research. Still, I keep wondering if this the best way to go about, for lack of more original phrasing, reducing health disparities [at least for me]. And by that, I mean, is this work really a meaningful contribution, is this the best way I can contribute based on the skills I have?

I know the thought process is most useful when I am actually doing something, something that fits in with my values, and so I’m grateful that I’m here and have set aside a year to commit to a few of these options. It’s the only way to seriously test out the theories, to at least try to sort things out and make some kind of contribution. Doing is better than speculating, no? Though, I have to say, it’ll be nicer if i ever get to some answers!

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Excuses….

6 days! I’ll be home in 6 days! While I am mildly terrified of the cold in the Northeast these days, it’s exciting to think of reconnecting with everyone before coming back here for the rest of the year. I usually do well with deadlines, and so these last few weeks have become crunch time for in anticipation of the holidays (everything more or less closes after Dec. 15 in Lima).

and I’m back to my usual ways. Nighttime, to me, will always be when I get caught up in my own thoughts and confront all of the lovely existential thoughts that can build up in a day. Usually, I relish the quiet darkness, the glow of my ceiling stars and computer screen my only anchors to the world. Tonight, however, is different. Outside of my room, there is water running and there are conversations going, light is seeping unfettered beneath my door, scattering across floor of my room. My roommate is moving out tonight, and my soon-to-be new roommate and I are discussing our new place on chat while I edit a presentation with another friend. I can feel myself clenching my jaw, a frustrating recently developed manifestation of restlessness. The night is not calm. Too much to think about, maybe.

I signed a lease today. I’ll be home in 2 weeks. It will soon be the halfway point of my time in Peru. I’m almost done my first big project for the year. I’m ready for a new beginning.

From my little corner of Peru, it seems like so much is changing these days, and not just in my life. Engagements, graduations, residency applications and decisions to pursue new degrees. Watching my friends move to each of their respective new steps is making me think about my own priorities, work, relationships, passions. More specifically, it’s reminding me of how much can change in a year, and how much I wanted things to change this year. I had specific goals, even if I knew better than to be inflexible in them. Yet, the challenges of this year have been unexpected, and in some cases things I had thought I had already conquered. And so here I am, 4 months into this year, feeling like I’m really just hitting my stride…and the more positive I am these days about my abilities, accomplishments and skills, naturally the more I’m wondering about my own priorities (for at least these next 6 months). Tanya wrote a similar post today, about recognizing what her priorities really are, and being surprised by them. Her take is different than mine, but I think that the ideas are similar….selective sacrifices (as my med school describes rotations, they’re not electives because you have to do them, but at least you can choose which ones you do/make).

My thoughts are meandering, so maybe it’s time to stop writing. I guess I just wanted a reminder to myself that I’m in a good place right now and to cherish the luxury that this is. For now, what that means to me is to work hard on my projects/Spanish, to read and to write as much as I can, and to keep looking forward to being able to enjoy my family and friends in 2 short weeks that could not possibly pass quickly enough.

and because i’m still mildly predictable:

Google horoscope take on this
You may daydream of escaping the humdrum existence. Your imaginative wanderings can point you in the right direction and lead you to successfully break out of your current boredom. Your routines will likely change for the better no matter what you do now. Don’t force any issues because you could alienate others. Instead, just set your course and take the first steps of your journey today.

World AIDS Day was on Saturday, as I think some of you already knew. Like many around the world, Lima was alive with events which were amazingly well-organized and -attended, if poorly advertised (I only knew about them because the people in my office all do research on HIV and thus informed me of the going-ons). As I mentioned in my post on soccer games, there is something really inspiring about rows of seats filled to capacity with people determined to celebrate life with as much enthusiasm and energy as the fire marshals will allow. Even more inspiring, though, are the individuals who come stand before this massive crowd to share their losses, successes, suffering and joys, all in an effort to reduce stigma and provide hope….and (this is Latin America) to encourage everyone to enjoy the party! I attended the event with one of my closer friends here, who happens not to be involved in medicine in any way (beyond her friendship with me). Navigating the AIDS-quilt-like display and stopping at booths filled with young adults hosting mock game shows on HIV, sexually transmitted diseases and prevention, she reminded me of the potential for education at events like these. The relaxed environment and non-judgmental attitudes of the young experts made what may have begun as a wander through the museum turn into an interesting opportunity for people to have all of their questions and doubts answered, and to learn about risks and preventions. If we all brought a friend….

I ended up giving a talk on education in human rights at a Latin American human rights conference on Saturday morning. The talk was in Spanish, and so I made it through as best as I could (with my speech written more or less verbatim on the slides just in case– I would recommend this for foreign language presentations, though obviously not otherwise). Despite the fact that I know I made mistakes, I was happily rewarded at the end with a lively discussion on education in health professionals, priorities and suggestions for the future. And, I am now working with the panel moderator, a young Peruvian doctor who has investigated and written on human rights issues in Peru for the last few years, on writing about human rights education in Latin America. In all seriousness, I believe in the power of good programming to foster young minds decidated to developing informed, innovative solutions to some of our worst problems. Who knew running for Global Health Education coordinator for AMSA 3 years ago would lead to education being my most comfortable and impassioned niche at this point? The folks at my high school summer program on teaching would be proud…

Ok, worn out after a crazy day of hospital, public health school, clinical research class and dancing. ‘Night.

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…

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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