So This Weeks Talk is Called: Sexs, Drugs, and Resistance or why I came to Peru. About four years ago now, I was a first year medical student, generally impressed with the inside of the (dead) human body and its nearly non-sensical ability to construct a defense mechanism capable of recognizing (for decades on end) literally billions of foriegn entities. But generally unimpressed with Baltimore, with it's unflapable history of abject poverty and congenital racism. I missed California (where, lest I forget, I really truly always wanted to be). I met an older medical student who spent his first summer of medical school (the first and only break usually spent traveling, researching, or relaxing) working for an STD guru out in San Francisco. I thought I liked infectious disease and was sure I loved San Francisco. A phone and lunch time interview later, I had my most influential mentor of my young career. Jeffrey Klausner has the perfect job. By day he directs the world's best public STD clinic, formulates health policy to prevent disease transmission, works at an HIV clinic, and rounds at the SF general hospital. By night and weekend he hops from Peru to Africa to Thailand consulting and directing international studies. In between he has a wife and three kids, with soccer practice, school plays, and a two week per summer beach house in Mairn County. Hopefully he'll move on in about 6 years when I'm done with my training.
My first job for Jeff was to conduct a small study to analyze rapid tests for syphilis, an STD which usually requires a blood draw to diagnose. I spent a summer comparing these rapid tests (a finger stick much like a test for diabetes) to standard tests, and published an article showing they work very well (and acting as phil the syphilis sore in the SF gay pride parade).

About a year and a half later, I called Jeff asking him if he had any projects for me abroad. He sent me to Peru for a month, where, with a laboratory doctor, I worked to develop a new test for gonorrhea. Gonorrhea has been resistant to Penicillin for years, it has mutated a Penicilllin binding protein that Penicillin must bind to in order to exact its effect. So the choices to treat Penicillin in many places have decreased, to a newer Penicillin-like antibiotic (called a cephalosporin) which often requires an injection, or a new class of drugs, called Fluoroquinolones. Unfortunately, gonorrhea has recently become resistnat to fluoroquinolones in much of the world too, again through mutation of a protein that the antibiotic binds too. Mark Pandori (the laboratorian) and I developed a new test that looks specifically at the DNA (using PCR) to see if the bacteria has the normal (or sensitive protein) or the mutant (resistant protein). I came to Peru to test the new assay and see if we could find any Quinolone resistant Neisseria gonorrhea (QRNG). And we did! About 16% of the samples we tested were QRNG. That is important in Peru, because, unlike in the United States, were people are often treated after a specific gonorrhea test, in Peru people are treated clinically, which means that if a patient has discharge from the penis or cervis, a doctor gives them an antibiotic without a test. In Peru, because they are cheap and do not require injection, quinolones are usually used. This could be a major problem if 16% of the bacteria are resistant! We need to test many more samples to be sure, but for now, we have made an interesting finding.
In the meantime, I am doing some other similar work. Most notably we have also developed a new test that does a similar thing for Syphilis (looks to see if the syphilis is resistant to antibiotics) and a test looking for specific kinds of chlamydia that can cause specific symptoms and problems in gay men (or as they are called in scientific literature - MSM - men who have sex with men, to include those who may not consider themselves gay or who also have sex with women). All and all, it has been an interesting line of work. Ultimately, in Peru and SF, STD work is mostly working with MSM. Other sub-populations are much less affected. The social and political charactersitics of this work are facsinating and certainly add to the intrigue of the field. However, ultimately, as a straight male in the field, I do not think it is my fight. This year, working with TB, may have helped me shift my gears to diseases with less political complexity and more widesweeping impact on the poor, irrespective of sexual orientation.

I´ll have to entice you a second time with promises about sex and disease for another week. Today I write from Santiago, Chile. About 1,200 miles and at least one and half worlds (in a development sense) from Peru. If I recall correctly you´ve done time down here. So perhaps this is old hat to you. But the differences between the two countries harken questions about humanity, equality, and yes, even, raw fish. I suppose a PhD would better suffice to truly comprehend differences in economic development. Chile is all first world roads, parks, achitecture, and a subway system that makes MTA feel obsolete. Peru is all lack of clean running water, tuberculosis (since last weeks lesson), and want want want. The border crossing is more drastic than San Diego - Tijuana. So whats the story. Probably mostly has to do with the lack of an indigenous population in Chile (whatever did exist was quickly decimated). Peru has always had millions of underattended, discriminated, and continually forgotten lower castes (darker shades to be precise). It is this 60% of the Peruvian 30 million who live by and large far below the poverty line, often out in the mountains where clean water, schools, and hospitals are still not being built for lack of a tax base (the governments wax exstatic about decentralization, but I suspect that just means more tax revenue diverted to their pockets - literally (See Alberto Fujimori)). Futhermore, Chile has exerted its dominance over the region in a series of wars (most notable in 1879 where it fought against the poorer Peru and Bolivia, took the Peruvian capital, and what was left of the Bolivian coastline for good - thus relegating Bolivia to a landlocked, portless, economically enslaved country which continues to this day to be by far the poorest in S. America.). It seems every profitable business in Peru (movie theaters, car dealerships, grocery stores) are owned by Chileans (only the phone company which literally disables communication is owned by the Spaniards). Visiting Chile now (to run my fourth marathon - which I did yesterday in a time of 3 hours 52 minutes - keeping me on ice for most of the day yesterday and preventing this email from being scribed until now), those differences are intense. It´s gorgeous. A valley embraced by mountain ranges on each shouder, hardly a vista exists without breathtaking repercussions. The streets are lined with sunny parks, people dress the business part and signs of abject poverty are rare. But it was not until I sat to eat a meal with some Chilean friends did I realize how all-encompassing Chilean continental domination was. I asked what the specialties were - the food and drink I cannot leave Chile without savoring. My hosts´ responses - Pisco Sours and Cebiche, to my agape amazement - the national drink and food of Peru!

So here goes.
So where do I begin?

How about from the end! I thought I'd fill you in on some of the work I'm doing down in Peru this year. This will be installment number 1, maybe the duller part: Combatting Consumption. I'll keep you on the edge of your seat waiting for part 2, Sex in the Peruvian City.

About this time last year, I spent a month in Peru doing some sexually transmitted disesae work (you'll learn more about this next week) and was offered a job to return for this year. Though I accepted the job, I have known for a whlie that I may not stay in the STD field forever (it's got some incredibly interesting elements of social and hard science, but ultimately I don't feel like it's my niche for a variety of reasons). There is a lot of good work go on in Peru, so I approaced some people at my school to learn about what was going on down here. There is a big research team led by a physician named Robert Gilman, who has been sweating it out in Peru for almost 30 years researching everything from childhood diarrhea to tuberculosis. One of his middle-managers, is now my boss down here - Carlton Evans, a charming English guy from Imperial College in England. We had a meeting last spring about possible projects and the rest is history, present, and future.

Tuberculosis is caused by a bacteria, called Mycobacterium tuberculosis. It is estimated that 1/3 of the world's population is infected with the bacteria. Generally speaking, tuberculosis takes two forms: 1) latent infection, in which people have a dormant form of bacteria in their lungs and 2) active infection where the bacteria actively reproduces in the lungs (most commonly, but can be in just about any tissue in the body) and causes symptoms: cough, fever, weight loss (which is why it was called consumption), and others depending on what other parts of the body are invovled. Overall, for healthy people - risk of advancing from latent to active infection is about 10% over a lifetime (but for HIV positive people it is about 10% per year). Despite recent advances in TB care (giving people medications face to face over 6-9 months to make sure they are cured), active TB rates and mortality due to TB are on the rise mostly due to the AIDS epidemic and emergence of new forms of TB that are resistant to medications. It is thought that the new cases are not due to increased transmission of TB, but instead due to activation of latent disease among those with AIDS.

TB is a disease that is relatively hard to diagnose. 90% of TB cases are diagnosed by smearing spit from a patient on a slide and looking at it under a microscope with stains specific for the bacteria (sputum microscopy). Unfortunately, this technique only finds TB in patients who really have it in about 30-50% of the time. The bacteria also grows very slowly (6-8 weeks by standard methods), so culturing a sample of someone's spit takes time, and can be expensive in poor settings. The group I am working with has developed a new culture method that takes about 15 days. It is pretty exciting, but still lacks all the requirements for efficient use worldwide.

I have been involved in two major projects here. The first is testing this new culture test on samples from the pleura, or sack around the lung, to see if it is better than standard methods to diagnose TB infection in this site. That study which was run by a Peruvian doctor here named Marco Tovar, has been completed and I just today submitted my manuscript today for publication. I am attaching that article to this email

The second, and more interesting project, is trying to improve the ability of diagnosing TB by use of a microscope. The main problems with all culture methods is that they require weeks to diagnose and incubators and centrifuges and other expensive equipment that poor places cannot afford. It is these same poor places where the terrible effects of TB are the greatest. We are trying to develop a simple and cheat method to increase the sensitivity of sputum microscopy from 30% versus culture to hopefully 80 or 90%. We are doing this by trying to filter the spit, catching the tb in filters, and looking at the more concentred sample under a microscope. This is in the beginning stages (I have been able to concentrate the bacteria on filters - which has been published many times since the 1940s, but like all things in TB, the wheel is constantly being reinvented), but am still working to make it a funcional tool and test it on larger numbers of specimens. I hope to be able to get there and design a study that will take place after I leave in May. If we can get it to work, the hope is that it will be used in poor resource setting as a simple technique to increase the detection of TB so we can treat more cases earlier and prevent further spread and mortality of the disease. A lofty goal (perhaps unrealistic), but it gets me out of bed in the morning!

September 20th.
I left my heart. In San Francisco, time is forever ephemeral – ten years in that city is ephemeral for me, like a double-take, like a beautiful woman walking past your moving car. Four short weeks after my liberating – jail breaking – flee from Baltimore, three weeks after finishing up my LGV and Az-R crash course from Mark Pandori, five short days after burning off my (I guess his) last rectal wart at the STD clinic with my two-handed liquid N2 ninja style, and two endless days following my clinical licensing exam (Q: “doctor, am I going to die?” A: “God, I hope so”)– I’m off to Peru. This blog/daily soul cough/diary is not about San Francisco. So I’ll leave the nostalgia at that. After I feebly recount the five shot/three whiskey/four beer night I spent on Polk Street with Kerwar, Thomas, and Lynch. Fuck I miss San Francisco already. (I miss Lydia too – but it’s different – Lydia gets periods (sorry babe)). Hungover after an ovation from my Not For Partner “roommate” I threw my five suitcases worth of life belongings back into three overweight containers and sped off to the airport.
The flight to Miami was mostly unremarkable. Except for the raging lunatic pacing the aisles, threatening the stewardesses (yes, you heard me – and Pac Bell Park too), and getting tied up like a shoelace by an air marshall (policias aires). Miami to Lima was equally mellow. Sat next to Hernando with the hearing impaired son he convinced to go to Florida International over Harvard/Stanford, and who, if you still believe him, was off to a 30 hour business “transaction” in Lima before returning to the states the next morning.
Paula (Bob Gilman’s assistant extraordinaire) had a taxi arranged (and even paid for). I got back to the Gringo House at about 6AM (flight got in at 4:20AM). Met Heidi of Bloomberg fame at the door. Took over a nice room upstairs to myself (keeping it warm for a CDCer (Mike Levy) who has been down here seemingly forever studying Chagas – remind me to look that up again). Hit the sack, met Gavin and Yvonne (couple from Thomas Jefferson), hit the door, hit the internet café, hit the Metro (Peruvian Wallmart) for towels and other non-perishables, hit the shanty counter for el menu (note to self: stop ordering pure), hit the bathroom, hit the books (subjunctive tense), met Gabrielle – charming ex-Hopkins MHSer, now hitting up Les Roberts old territory – doing some sanitation work in the Pueblos Jovens. MET THE SPANIARDS: with their haircuts, and their ice cream, and their phlebotomy???
I’ve got a full day of apartment hunting tomorrow. That it will end quickly. Also off to see Derek Fine’s friend, the country famous Peruvian rabbi (how do I get myself into these Jewish situations? Last time I supped with a national rabbi, I saw him the next week in the NYTimes next to the Pope, mostly unforgiving of the 20000000000 Jews killed by the Poles, only to celebrate when the Germans came (see Ukraine diary/daily soul coughing – which I think was the last time I did that) (then see any story I write about my grandfather).


September 23, 2006
Repente, yo impresso esciribir en espanol. Despacio. Ok, that was fun. Yesterday was a day for the ages, or at least for the diary. Dear Elena Saramiento showed me four apartments ranging from 280/mo for four walls and a chair to a 1,300/mo palace on the Malecon with flat screen and shag pad included. None were in my wheelhouse. All were livable. I also met Sly Silvio who came and left me feeling like Atlas was standing atop my shoulders. Finally, a rag-tag unfinished add-on in San Ysidro, with tons of promise where I hope to return this week. With tomorrow (Sunday) comes the Sunday El Comercio and an apparent tome of classificados.
So the clock rung 5pm, and I was drained, like a squeezed bar mat. Apartment hunting is only slightly more enjoyable than USMLE II CS, except I feel like the actor asking meaningless questions. I sauntered over to Casa de Benhamu for what I hoped would be a relaxing dinner. Thirty minutes later I was at the wailing wall (or should I say wailing gymnasium) while Sr. Benhamu lecturned his blessed is the lord you subservient believers in my mighty power for an hour with shaking and bowing and moaning all about. A veritable sea of black suits encircling goyish-gringo-guy in his baby blue sweater and white sneakers, lips sealed, uncomprehending either of the two languages spoken during the services (that’s one less than usual for me). So I stood when they stood, sat when they sat, undulated when they undulated, saluted, purred, laughed, coughed, and Amened when they did – or should I say, all about two seconds after they did. It may have looked a bit like a northerner at a line dance or one of those Russian dances when one guy drops while the other jumps. I smiled. They frowned. But the dinner was superb. Flanked by English speakers (Mrs. Benhamu and the doctor’s wife/jappy/mining company worker?) who were very pleasant and talkative And the food. Ten courses of appetizers representing sin and heaven and death and sorrow and humility and joy, fear, sleep, shoelaces, electrical sockets, car window wipers, and that Don Knotts. Followed by homemade challah (talked up a bit too much I must say (I can hear Kerwar now laughing superciliously as I demean a free lunch)), the first gafilteh fish I’ve ever liked with a beet/horseradish salad, and vereneki, kugel, roast beef, potatoes to round it out. Truly superb. I was content. Until I broke five rules of the Sabbath (used the elevator, wrote down someone’s number, told them I’d call them tomorrow to thank them, and called a cab home – actually got a ride from the nice couple next to me). AKWARD. Short of bringing along bacon double cheeseburgers, I don’t think I could have violated more rules.
Back to the gringo house, a couple beers with Gavin, some Michigan/Ohio State/Paul Farmer/wedding planning and to bed. This morning was not quite so smooth. I mapped out a 6 miler. Maybe 2 miles later I shit my pants. Literally. Truly challenging my pride to write this. Walk in the door about ½ mile after limping back home, resisting contractions – smelling literally like smeared feces to find none other than Gabrielle to welcome me and my malodorous back side. Fuck. Half an hour in the toilet-paperless bano where my underwear stayed for eternity in the basura, and another half in the shower washing the excrement off my body. I feebly tried to re-entice a friendship with one of those conversations that is so clearly avoiding the point. AKWARD. Luckily I left before we actually GOT to the point. I’m sure a few beers from now, the truth will be revealed. AKWARD!
The rest of the afternoon was quite enjoyable. I met Vicki at Hiraoke and took the Micro back to her pad. After navigating through the apartment offer mostly unscathed, I met her mother, sister, husband, and friend, dined on microwaved turkey hips and rice, and generally gained some espanol confidence.
September 28, 2006
The foreign experience, with all its idiosyncrasy, exasperation, and frustration is if nothing else the great pie slicer. Another slice of perspective with each new day. Circle de soleil, or Circo Etno, or El Vuelo del Condor – aka – the Peruvian circus and warm Pisco tasting festival was yet another slice of perspective. Truly unexpected to see Russians, Chinese, (Peruvians?), and god knows what else running around on stilts. Not so much soleil as I’d expected, and a little more ass discomfort than I would have liked, but memorable nonetheless (or would it be if I hadn’t written this). Less exciting (aside from Brian I must say) was the rest of the crowd. Krishna was all inquisitive looks and Harvard persona. The two Christina’s (the Othello board) were quite and mostly unnoticeable. Brian – the DO chap with the infatuation for stories of his girlfriend – was incredibly friendly and if nothing else, enthusiastic. So know Sean Hewens around (yet). I’ll have to drink by myself (or get Gavin to convince Yvonne to let him play once and a while).
I will refrain from complaining about the apartment hunt any more than to say it was only slightly more pleasurable than a hemorrhoidectomy and I’m glad it is over. Looking forward to the new digs on Saturday. Tarrata is in the heart of town, the better of the two finalists (thanks to Tammy for setting me straight – ranking the runner-up (subcapmeone) 3/10).
The last two days of work have been nothing short of incredibly soul cough worthy. Wednesday I headed up to Las Pampas for some body callipering and topless “el tigre” chanting with the incredibly uncomfortable Pampas jefe Lilia. Aside from the sexual harassment, I headed with Tammie to the home of a couple of the community workers (16 and 18 – Jkarold (spelled correctly) and Juan Miguel) – aka Los Dicipulos. These two guys have a nationally recognized Christian Rock Rap bank. Sounded incredibly good – and strangely timely/pertinent. They wrapped about and in front of Ollanta, leftist candidate who recently lost a runoff for president, and just barely failed to become Peru’s Hugo Chavez. Got to see their house (father was voraciously tearing through his psychology text) at the bottom of the sloping hills, littered with the tangled sprawl of half-homed architecture sloping up the hills. The area had recently been blessed with running water, a “sewage” system, and electricity. Arribe Peru!
This morning I met Carelton Evans at a swanky San Isidro hotel for strong coffee and some soul coughing on his part about his numerous TB dx projects. Pretty neat stuff. Would be thrilled to get to work with the guy. Thinks outside the box. Thinks a lot. Rubs his face while he’s thinking. Says something. Stops. Thinks a bit more. Hit up Telephonica for phone/internet installation (my freakin cell phone won’t behave – it’s what I get for being incredibly “frugal”) at the new place. Rosa offered to sign for it – makes life much easier. Then off to El Agustino slums to Dave Moore’s street children clinic. Two cab drivers refused to take me – demaisado pelligro. Finally, a chap from the area dropped me off. Dave Moore is somewhat of a god – or at least an idol. Brang down the kids for four years, going on eight for TB treatment/dx studies, street kid clinics, world famous mentoring, and generally saintly activities. Someone else I’d like to replace or assassinate and take over off (yes Jeff, if my plans for you are foiled). Anyway the clinic is Peruvian run and in its first stages – doctor, nurses, psychologist, physical trainer, etc. Turns out there are about 1,500 (seems low, no?) street kids in Lima proper. The psychologist and physical educator work every night to set up health and activities for them. They also organized a city wide soccer league (350 participants) now three years strong. It’s really good work. Pretty heart warming/wrenching. I sat back and watched today, rolled around with some scabbies, drew a couple horses, and put together El Winnie Rompecabeza. I hope to be back. The slum was something else. I thought Las Pampas were a unique housing experiment. God forbid an earthquake ever hit this shanty. The literally tens of thousands of interlocking brick buildings creep up the hills and over in the distance, hanging with unfinished mortar and scraps of here and there. Truly unique in my travels. Glad I had the chance to check it out, and hope it remains engrained in a usable part of my own rompecabeza.

Go out with a bang they say. Well the mildly obese body habitused woman had her way with me yesterday. Dad came to town because I've been nice and he knew it. The man shed his customary curmodgeonly coat (almost definitely coerced by M2 as he calls her - the second Marilyn in his life), rented a car (sic), no AN SUV mind you, to help depossess me of my utterly valueless fortune of books, clothing, and bobble-head dolls. I was on call in the psych ED last Thurs night, admitting the average ordinary $500/night, 1 in 60,000, Baltimore drug abuser to the detox unit, and back again early to present to the no-show attending and go see neurofibromatosed type two demoralized, delirius patients Friday morning. I mention that only to stress my expectations: 32 hours of Darilyn between a late night on friday and another call sunday morning. My soothseying skills are not so hot (as my gambling history can attest to).
Friday night: John Stevens for shrimp (emmh), crab sushi, crab soup, and seered tuna salad
Saturday morning: Harvest for a delectable breakfast burrito, the BMA for the unexpected pleasures of the Cone, and her endless Matisses (they were apparently lovers - a point discussed when Lyd and I saw the Matisse BSO symphony production), Lexington Market for a whole new attitude towards crab cakes (when they actually contain observable crab) and raw oysters, Tapas Teatro - an old favorite with predictably dead-on sangeria, a 90 minute Al Gore lecture where I learned that global warming is not going to win him the presidency again, sleep, and a spot-hitting smoked salmon platter at Metropolitan to round out the wall to wall seafood theme. Packed up the truck and off they went, as I headed off to the loonie bin yet again, recharged, and replenished with probably toxic levels of serum mercury.

I am a master.
I feel gloriously unchanged (though now I know what a lowess plot it is).
Grandpa, grandma, and sis made the trip down from the apple. You'd think it would be nice to kick with the elders for a few hours, learning about the haulocast and the cold war, etc. But the problem is - they aren't related. The only reason they'd ever be in a car together is because their children married (procreated, twice, and quickly divorced) thirty years ago. Now they are forced together in the most unlikely of places - the back seat of a geo metro. And they don't like each other (or anyone else for that matter). Even worse, they can't hear each other (or anyone else for that matter). So Becky says they both talked the entire way down, unawares of the others line of reasoning, and my poor sister was left to navigate the waters of two unintelligible conversations simultaneously. Needless to say, she was ready for some R/R and a large plate of Hana sushi when she finally made it to Charm City.
Grandpa, in a nutshell:
Grandpa: Can I have a menu please?
Waiter(Karate Kid headband and all): Sure, here you go.
Grandpa: Danke
Waiter: (blank stare)
Grandpa: What's a matter, you don't understand?
Waiter: No, I'm Japanese.
Grandpa: But you don't speak German?
Waiter: No, I'm Japanese.
Grandpa: But you signed a pact with Germans.

NyTimes today:
House Passes a $2.7 Trillion Spending Plan
By EDMUND L. ANDREWS
Published: May 18, 2006
The measure calls for increasing military spending by 7 percent, to nearly $558 billion in 2007, a figure that includes $50 billion for military operations in Iraq and Afghanistan. The package would essentially freeze or cut spending on most domestic discretionary programs, including education, energy and national parks, and it calls for trimming $6.8 billion over five years from entitlement programs like Medicaid and farm subsidies.

Is it possible that one can be a moral person and "fiscally conservative." How do these ideals fall short of outright gluttony? I must surround myself with republicans. I need to become a mole. Become immersed in the enemy. There is no education without challenge. My fucking public health education. Surrounded by bleeding hearts and bandanas. And the token republican. Kyden "Oklohoma" Creekpaum. Sooner. Sooner be dead than caught helping a welfare recipient. Man thinks Walmart is second only to fire in the endlessness of its value to mankind. I need to find some smart republicans. Sooner than later.

 

I was bummed enough. Coerced from my high school girlfriend prematurely - back to my second term of college after an ephemeral winter break. Plus there was that whole thing with my ruptured appendix and soon to be hematoma, etc. No driving - doctor's orders. I was outside Cleveland. What did he know anyway, he gave me a second waistband to take out an organ the size of a peapod. Mid-day darkness. the flakes opacified the windshield. The car directly in front of me swerved. off to the side of the road with a sudden thud. I tried braking. No use. Eventually the silver bullet, an 85 cutlass siera, followed his fate. I hiked back the 60 meters to his car. He futily reved the car to 70 rpms. We shovelled. We shook. He left. I had a lunch ticket to sin for at least a week.
I got the call from Shayna three days later. I can't remember the name of the company. Evidently I had caused an accident, steering someone off the road in a mad fury in the midst of the worst blizzard since the last one. I couldn't help but remember that Goofy, Jeckyl and road-rage Hyde cartoon they show you for speeding. I called Dad. Told him the truth. He didn't believe me. But was happy to tell the insurance company to fuck off. Never heard again. There should be laws against that. I guess there are. Fraud it's called. Maybe it should be called a bad samaritan law.