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January 5, 2011

Time flies. It’s a tired cliche, but its truth is undeniable. And so, just like that, here I am in Quito once again.

It was way harder leaving home this time. Instead of the adventure of exploring a brand new country, I felt that all I had to look forward to this time was the daunting task of designing and implementing the research study that will be the sole academic activity of this whole semester. Time with family and friends was all too short. And my brief visits to campus revealed just how much I was really missing by choosing to spend my entire junior year abroad.

But the moment I stepped off the plane in Quito, all those negative thoughts vanished, and I couldn’t help but grin as I took a deep breath of the warm (relative to 10°F Minneapolis, at least) mountain air.

It’s good to be back.



December 11, 2010

Sat. 12/11 8:30 AM: Hello from Guayaquil! I’ll be “live-blogging” this crazy little Peru adventure. First step of the journey is complete: 7 hour bus last night from Quito to Guayaquil. Right now we’re waiting for our 26 hour bus to Lima that leaves at 11:30. We also just bought plane tickets from Lima to Cusco, only about $30 more (and 23 hours less) than a bus ride between those two cities. Machu Picchu, here we come!


Sun. 12/12 10:30 PM: Well, the 26 hour bus turned out to be a 31 hour bus, and the drivers seemed to be having a contest to see how many terrible movies they could show us: Big Momma’s House, The Bodyguard, some Jackie Chan movie where he has to take care of a baby he kidnapped (hilarity totally ensues), Mall Cop, Funny People, The Honeymooners… there may have been more, but they were probably so traumatic I’ve blocked them from my memory. Nevertheless, here we are in Lima! Grabbed hamburgers with our Colombian and Chilean traveling companions; now we’re spending the night in a hostel and waiting for our 10:10 flight to Cusco tomorrow.


Mon. 12/13 2:30 PM: Step 3 of the journey is complete; we made it to Cusco, despite staying up too late last night enjoying pisco with our aforementioned traveling companions at the hostel in Lima. It’s an absolutely beautiful city, and we’ve really enjoyed exploring it so far. Tonight we have a ridiculously overpriced train ride to get to Aguas Calientes, the closest town below Machu Picchu. I think we’ll follow the example of my good friend Pat and get up at 4:00 AM for the hike up the mountain, though hopefully it doesn’t rain on us (tough luck, Pat, we’ll see if ours is any better).


Tues. 12/14 4:00 PM. Mission accomplished. Machu Picchu was breathtaking beyond description, and the weather was perfect; it never rained, and we were even able to see some of the snow-capped peaks in the distance, before the clouds slowly swallowed them around mid-morning. I’ll probably have to wait until I’m back in Minneapolis (6 days!) to upload photos, though. Spending tonight in Cusco, then we’ll see where the road takes us from there.


Fri. 12/17 4:30 PM. Hello from Puno! We ended up sleeping in and taking a tour of Cusco and the nearby ruins on Wednesday, before catching an overnight bus to Puno, where we met up with 4 other MSIDers to do a 2-day tour of the spectacular Lake Titicaca. My internet time is almost up, so details will come later. Tonight I’m taking another night bus back to Cusco for one more day there, then I’ll catch my return flight to Lima, where I’ll spend one last day on my own before catching my flight from Lima to the States.


Sun. 12/19 4:45 PM: Today is a sad/exciting day. Sad, because I have to leave Peru tomorrow morning, and I can’t escape the feeling that there’s so much more I want to see and do here. Exciting, for the (hopefully) obvious reason that I’ll finally be home tomorrow night, though I also can’t escape the feeling that my time in Minnesota is going to fly just as rapidly.

Yesterday I managed to get to a few more archaelogical sites in the Sacred Valley; none of them were nearly as impressive or untouched as Machu Picchu, but it was still a great experience. My favorite site was Ollantaytambo; the terraces built into the steep mountainside were impressive in themselves, but it was equally cool to discover that the town has been continually inhabited since Inca times- all the houses are built on their original foundations so you can still see the original precise city planning.

All in all, this was a fantastic trip, though 10 days really isn’t enough time to appreciate Peru. In Cusco alone I never got to see Moray (a series of circular terraces the Inca used as an agricultural laboratory) or any of the museums in Cusco, not to mention the entire cities of Arequipa and Nazca. My flight got delayed by 5 hours, so I got into Lima late this afternoon, and I won’t have time to see much of this city at all. And talking to other travelers has made me really want to visit Bolivia, Argentina, Brazil, and of course Chile. And then to the north there’s Colombia, and all of Central America…

I’ve posted this on this blog before, but it bears repeating:

“It’s a dangerous business, Frodo, going out of your door,” he used to say. “You step into the Road, and if you don’t keep your feet, there is no knowing where you might be swept off to.”

-J.R.R. Tolkien, The Fellowship of the Ring

A) Quito B) Guayaquil C) Lima D) Cusco E) Puno

That’s It?

December 9, 2010

I spent last summer counting down the days until my departure for Quito. As I got on the plane, thinking about how quickly those days had passed, I felt a flash of sadness, because I knew the time in Ecuador would pass just as rapidly as the time spent waiting for Ecuador. I once wrote on this blog that I hoped I could make the most of my stay here, because “before I know it, I’ll be landing back in MSP, and it will be winter again.”

Well, in 11 days I’ll be landing in MSP, and it will indeed be winter (Mom & Dad, please bring a winter coat when you come pick me up from the airport). In the several-weeks-old spirit of Thanksgiving, I’m just grateful that I still get another 4 months here. Though, I’m equally grateful I finally get to go home. I’m excited to see my family, as many friends as possible (email/facebook me! Let’s hang out!) and have a break from the stress that MSID has been recently. And eat peanut butter, and go 2 weeks without eating a single plate of rice. Woo!

Here’s your obligatory apology for not posting in a while (I moved it a few paragraphs down, just to change things up). You haven’t missed much, really. The internship is over. The last two posts capture the best of it; the only times, in fact, that I ever did get to go out to a community. I spent almost all of my time volunteering in the public clinic, which, while still a great experience, was considerably slower than the hospital. I’ve also spent the past 2 weeks stressing out about the research project I have to design for next semester. I barely understand what public health research is, and I have almost nothing in the way of support while I’m in Tena, but I’m supposed to design and implement a study by myself (across language, culture, and skin color barriers, no less)? It doesn’t help that everything I want to do is probably wayyy too ambitious, anyway.

So yeah. I’m looking forward to being home for a bit. But first: Peru! Still haven’t bought my bus tickets (looking at a couple options, I am the king of procrastinating), but I’ll leave on a 32+ hour bus ride to Lima either tomorrow or Saturday night. The really depressing thing is that’s only about 2/3 of the way to Machu Picchu, which I’m dying to see. Even if I have to spend literally half of my time in Peru on a bus to do it, it will be worth it.

Since I will be living out of a backpack for the next few days, you probably won’t hear from me much. This will probably be the last post from this semester, except perhaps for when I post my Peru pictures. Thanks so much for reading; it really means a lot to me to see that you’re interested in what’s been going on. I promise some really awesome posts next semester, k?


November 24, 2010
“And it’s okay if this world had a billion saviors
‘Cause there’s so many things to be saved.” –Cloud Cult


I met a couple of my heroes today, on a medical excursion to the nearby village of Alto Ongota. Both of them are government employees, incidentally.

Alto Ongota

#1 was the elementary school teacher. As he described the situation in the village to me, with its multitude of problems and unsatisfied needs, his eyes had a spark that hinted at the intelligence behind them. He spoke with sincere interest about the two important impressions he tries to leave with his students. First, he described the curriculum’s (his) attempts to instill in the students a sense of identity and cultural worth, fighting Ecuador’s colonial hangover by teaching the children to be proud of their indigenous heritage. Soy de Alto Ongota, soy Quichua, y tengo orgullo. Then he described how important it was for them to know the richness of their environment, and understand the impacts of the deforestation going on around them. As he pointed out the little car in which he commutes the gravel road to and from Tena every day, I couldn’t help but wonder: “What is he sacrificing to be here?” Or maybe, due to the government’s savvy decision to pay teachers more for working in rural and economically depressed areas, it’s not such a sacrifice after all.

#2 was the dentist on the 3-person medical team. White skin and professional degree firmly establishing his place at the top of the social order, here he was in a storage room-turned-makeshift-dentists’-office, using a portable kit to drill away at the cavities that riddled the teeth of every single kid. At a rate of 4.5 minutes per kid, neither the smile nor the line of sweat ever left his face. And just like that, 25 children, who would likely otherwise never see a dentist, got a cavity filled; something that cost me $80 (just for the filling, after insurance) the last time I had to get it done in the States. He’s originally from Quito, so you know he’s sacrificing something- rarely do you see someone migrate from the city to the Amazon; the opportunities gradient runs strongly in the opposite direction. Maybe working in a government clinic in Tena was simply the only job he could find when he graduated. Or maybe he just likes to see poor kids smile.

Cristian the dentist

Unrelated anecdote: I learned something today. I need to work on keeping from jumping to conclusions, especially when they come to me all pre-formed. When I first arrived at the community this morning, I went over and inspected the latrines (a pretty crucial weapon in the war on diarrhea) right away. I found them in a sorry state of affairs: overgrown with grass and weeds, the absence of trampling at the entrance an obvious sign of disuse. Clearly, I thought to myself, sanitation still isn’t a cultural value for these people; they must prefer to do their business in the jungle. If I had then thought, Poor dears, it wouldn’t have added much condescension to my little internal monologue.

Only later did I discover the new bathrooms behind the school buildings. They really were bathrooms, not just latrines, with bright white flushing toilets, and clear signs of use. Only there wasn’t any water with which to flush them- the village is dependent on a water source that is only replenished when it rains. Apparently waterless days like today are not uncommon.

Moral of the story: the way we think about hygiene is just one of the many privileges of our affluence. It was easy for me to look down on the people of Alto Ongota for what I perceived as their neglect of the latrines, but that’s only because I have had continuous access to soap, abundant water, and a functioning toilet for my entire life, not to mention an upbringing (cover your nose and mouth when you sneeze!) that has drilled into me, time and time again, the importance of hygiene. See, poverty has this hideous way of comprehensively disadvantaging a person: after a lifetime spent without developing hygiene habits, using the new latrine is not going to be a pressing concern on your mind, no matter what that man in the blue Centro de Salud polo is saying in your second language. If you have to work all day in the field under the tropical sun to cultivate enough of the tasteless yuca to feed your kids, are you really going to waste your little fuel on boiling water for them? And the benefits of good hygiene are likely to be invisible to you, anyway- will you notice if your kids get sick with slightly less frequency (if it changes at all, since dozens of factors remain uncorrected)?

And if there’s no water to wash your hands anyway, does it really matter?


November 12, 2010

Tested my FWD today, by accompanying a team of 2 doctors and a nurse out to a village called Calvario (the name may or may not be correlated with the huge blazing-white cross visible on the cliff across the valley, a strange sight when everything else in view is swallowed by the jungle), about 30 minutes from Tena. Well, it would have been 30 minutes if one of the bridges hadn’t been closed to vehicle traffic so they could replace some of its termite-eaten planks. Fortunately, instead of having to hike the rest of the way, we managed to hitch a ride with the guys bringing the wood down from somewhere up in the hills (the only vehicle I saw on the road all day, though that may or may not have been because people knew the bridge was out). It was a bumpy, uneventful trip- except for when the trailer decided to suddenly unhitch itself. After arguing in Quichua for a while, our hosts re-attached the trailer, secured it by lashing it together with rope, and we continued on our merry way- three in the cab, myself and two others hanging off the back of the jeep, and three riding on the trailer.

Our task for the morning was to inspect the situation of the water storage/treatment jugs that had been previously distributed to the community in an effort to reduce the prevalence of water-borne parasites and, of course, diarrheal infections. The protocol is as follows: fill the big blue tank (clearly labeled with the Ministerio de Salud Pública (MSP) logo of which I’m becoming so fond) to the top with water, add two bottle capfuls of bleach (which, being photosensitive, must be stored in an opaque container, otherwise it quickly becomes useless), secure the lid tightly, and let it sit for half an hour before using. Simple enough, right? Welcome to community health.

Out of the 16 houses we visited, 7 were unoccupied, the family likely at school and at work in the chakra. Of the nine homes we did inspect, only one had been storing the bleach properly- the rest had it sitting around in clear plastic water or Coke bottles (in one case, sitting on a shelf in the sun!). Nobody had an opaque container, so we had each mother wrap a bottle in a black plastic shopping bag, and filled it part way from the bottle we carried. In none of the homes did we find the jug with the lid firmly secured, probably due to poor design- we could only seem to get them shut properly with two people pushing on it, imagine a Tupperware with a poorly fitting lid, one side popping out as soon as you secure the other. One tank had a broken lid, another was filthy, and the only evidence we could find of the tank in one house was a shard of blue plastic in the dirt. One woman was in the process of washing hers as we approached- likely having been forewarned of our visit by her neighbors. She properly added the bleach we gave her, but had contaminated the jug’s spigot on the slimy concrete slab underneath the faucet (another design flaw- the mouth of the spigot is flush with the bottom of the jug, so that it touches the ground unless placed on an elevated surface like a shelf or countertop [Edit: I got the chance to examine one of the jugs in the clinic the other day, and I had remembered this point wrong: the spigot does indeed have a couple centimeters of clearance]).

The only occupants of one house we visited were the grandmother, who only spoke Quichua, and her 5-year-old grandson, whose bloated abdomen displayed a textbook case of intestinal worms. Through the grandmother’s feeble attempts at Spanish, and the grandson’s translation, we determined that the mother was currently in Tena at the hospital because of some condition with her head. When we asked to open the water jug, we discovered it was being used as a vat to ferment chicha (the traditional alcoholic drink made from ground yuca, a somewhat distant relative of the potato).

And there you have it: my first ever real community health experience.

Semi-unrelated anecdotes from the day:

1) During our walk through the village, we came across the pre-school, which didn’t have an MSP jug but the teacher said she boils water for the kids. I’m inclined to believe her, if only because there was a functioning stove with large metal cauldrons. We also went over to the primary school, where most of the 36 students who attend 1st through 7th grade were out in the field, training for the Tena youth athletic competition this weekend by running barefoot in the rocky grass.

2) At one house we visited, I counted 23 beer bottle caps in the dirt between the gate and the front door.

3) I learned some indigenous medicine: apparently if you have a stomach-ache, you should boil tobacco in some water, and rub the solution on your belly to make it go away.

4) We didn’t have a ride back down the mountain, so we ended up walking in the sun for about an hour. On the way I counted 19 species of butterfly (though that number is likely inflated if males and females of the same species have different morphologies), including the spectacular Blue Morpho, and others with combinations of neon colors I never would have imagined to exist in nature .

5) I fell in love with the countryside. I wish I had brought my camera (will not duplicate that mistake); I’m too poor of a writer to adequately describe the breathtaking views of forested valleys, or the way life seems to spring from every inch of soil, saturating the earth with green in the never-ending struggle to survive and reproduce. Living in the city, it’s easy to forget the ferocity of that conflict, or the frailty of our own existence, but we are all part of it every day, all the same.

Four Wheel Drive

November 10, 2010

Hello from the Amazon! Things are kind of crazy for me right now- I’m in the process of switching from “working” in the hospital to “working” for the Ministry of Public Health in their community health programs. Why the sudden switch, almost halfway through my time here? That’s the subject of the rambly bit below. But before I lose you all to Acute Boredom Syndrome, I just wanted to share how excited I am for what my life is about to become. As I was walking with the director of the regional branch of the MSP to his office, he described to me how their teams head deep into the selva, to remote villages only accessible by canoe and on foot. Then, he suddenly turned to me and asked: “¿Eres cuatro por cuatro?” (Literally: Are you four by four? Roughly: do you have 4-wheel drive?) Having misheard him, I was about to explain that I don’t have any sort of vehicle, when I realized he was asking about me: am I equipped for offroading. That’s all I needed to hear to decide if I was making the right choice in leaving the hospital.

DISCLAIMER: I’m now going to subject you to some of my world-famous incoherent reflections, this time on the subject of the role of personal gratification in medicine. “A la mitad del mundo, Inc.” takes no responsibility for injuries or loss of personal belongings.

I started out having a blast in the hospital, getting to see and do really cool stuff. But that’s part of the problem: I didn’t come here to do cool stuff. It’s an unbelievable rush to help a real doctor stitch a patient’s hand back together, reconnecting severed tendons in the process, or watch an infant take his first breaths, but again, that’s not why I’m here. I’m here because little kids are dying for no good reason in this crazy messed-up world, and I want to know why, and what needs to happen for that to change.

After the second night in the ER, I found myself being strongly tempted by the field of trauma surgery. It’s a very attractive and gratifying way to deal with your ambivalence, going into pretty much any form of specialized medicine. You see a problem: a 7-year-old boy screaming with pain from a broken femur. And you can fix it. You can fix him- all you need are a few screws, an operating room, and a few years of specialized training and expertise. And voila! You have played God: a broken leg is now healed by your own two hands.

Infectious disease, I think, has a similar pull for me. A patient comes in with lungs full of TB, or hideous pustules all over his skin, and, if you can be just clever enough to get the antibiotics right, you can heal him.

You can be a cardiac surgeon, and extend by 20 years the life of someone who previously had less than a snowflake’s chance in Hell of seeing her grandson’s wedding. You can be a hero.

But look at this figure:

That, my friends, is UNICEF’s breakdown of the causes of child mortality worldwide. If you include neonatal deaths, diarrhea, a condition that should never be fatal (except perhaps in the most extreme cases), accounts for a full 17% of the total causes of child deaths, some 1.7 million every year.

And all you need in order to save them is some water with sugar and salt.

So what do you do? Diarrhea isn’t exactly the most glorious disease to treat- I almost lost my lunch in the hospital the other day when I examined the contents of one kid’s diaper. It’s also boring as hell in the hospital- kid comes in with dehydration, so you give him a rehydration solution, either by mouth or intravenously depending on the severity of the case. Then you watch him for the next few hours as the signs of dehydration slowly start to disappear, load up his mother with some zinc tablets and more packets of ORS, tell them to keep giving him food, and send them on their way.

Nobody should die of diarrhea. And yet they do. So what do you do?

You sit and think. You look at health statistics. You figure out what the strongest determinants of diarrheal infections are- poor sanitation, poor personal hygiene, etc. You discover that the poorest 20% of children in Ecuador are almost five times more likely to suffer an episode of diarrhea with severe dehydration than the richest 20%. Their likelihood is two times greater if their mother calls herself “indigenous,” rather than “mestizo,” and three times greater than the children of “white” parents in Ecuador. You haven’t found the relevant data yet, but you have a hunch that the mortality rates of diarrhea are far higher in remote rural areas, where educated parents are rare and access to medicine is limited, and water quality is inadequate, at best.

You’re still stuck though. What do you do with this information? How do you get packets of ORS into the hands of every community and into the mouth of every kid? How do you teach every mother how to check for signs of dehydration, that you’re not just wasting water by giving it to a vomiting child, and how to make adequate solutions of sugar and salt if ORS is unavailable or the kid won’t drink it? How do you fight social problems like paternal neglect? How do you end the grinding structural violence, the economic power systems that leave people without running water, or toilets, or electricity and fuel to boil water to drink?

And you can devote your life to this, and likely never see the results of your work. Gratification in public health is delayed, if it comes at all. The best you can hope for is a non-event: “nobody died during that cholera outbreak,” or slight changes in regional health statistics that may or may not have anything to do with your interventions at all. And after all, the grinding poverty and oppression and structural violence will still remain. Is this what you really want to do? Can you do anything else, though? It has to be done.

So you switch into four wheel drive.

Where’s David?

November 1, 2010

Here’s a brief recap of all that has happened since my last post, oh so long ago:

Finished up my last week of classes. Woo! As I was leaving I managed to snag from Cimas a Spanish copy of Where There Is No Doctor, the friggin’ gold standard of rural community health.

4-day spur-of-the-moment trip to Bogotá, Colombia. Um, what? I’m still struggling to believe this happened. Bogotá is an amazing city though, and I definitely want to get back there someday, and hopefully see more of the Colombia if possible. I can’t help but feel sad that such a beautiful country with such wonderful people has such a terribly exaggerated reputation of drug trafficking and violence. To be honest, I felt far safer the entire time in Bogotá than I did in Quito. Here are some pictures!

Downtown Bogotá from the mountainside

The Plaza Simón Bolívar

We paused our bike tour for a llama break.

Moved to Tena. It is hot. No internet at my house; TGFIC*. Needless to say, my communication with the outside world is going to be somewhat inhibited during this time.

A 25-hour shift in the hospital. Not even going to try to describe all the crazy things that happened during this. Now I know the feeling my dad was describing when he would say he was “post-call,” though to be honest I got way more sleep than any of the actual doctors/residents/nurses that night.

Went on a super-intense hike through the jungle. Also swam in a lagoon, drank chicha, and danced to indigenous music played by my host father’s friend and like 15 of his grandchildren. The perks of living in the Amazon. More pictures!

The overgrown hiking trail. Pura selva.

Climbing up waterfalls. Nbd.

Some flowers or whatever.

[Update: the full album is here]

That pretty much brings us up to now. It’s hard to believe that tomorrow will mark 3 months since I first stepped wide-eyed off the plane in Quito, and even harder to believe that my program ends in less than a month and a half. Current plans are to travel to Peru immediately after, and fly to Minnesota from Lima on the 20th of December, so if you’re in the greater Twin Cities area any time between then and the 3rd(ish) of January, let me know!

*First person to guess this acronym gets… I dunno. Sumthin.