The Dengue Diaries

California Dreaming

2006-08-20T01:11:00.000-05:00

My Nicaraguan sojourn is over, and I'm now back in the U-S-of-A. Due to incompetence on the part of a travel agent, I ended up with a 12 hour layover in El Salvador on Friday. My flight from Managua to El Salvador arrived at 7:30am, and my connecting flight left for San Francisco at 7pm. Too much time to spend sitting around the airport.

So I passed through the border control, paid $10 for a tourist visa, and hopped in a cab towards Playa Sunzal. The sand was black and the waves fierce, but all in all it was a pleasant place to spend the day. I lounged in a hammock, read my book, swam in the sea, walked along the beach. And I had an excellent lunch of grilled fish with garlic.

It was the best layover I've ever had.

Montelimar

2006-08-19T22:15:00.000-05:00

Montelimar was once the seaside retreat of former Nicaraguan dictator Anastasio Somoza. He built his house on a bluff high above the Pacific ocean with a commanding view of the wide sandy beach below. After the revolution the Sandinistas took over the property, and they invited party loyalists to enjoy the pleasures of Somoza's beachfront home.

Today Montelimar is an all inclusive resort owned and operated by a Spanish hotel franchise. They've got hundreds of hotel rooms, a wraparound pool (with poolside bar in the middle), a disco, and everything else one would expect to find at a nice resort.

Montelimar also happens to be the location of the annual Sustainable Sciences Institute retreat. Every year, 15-20 people who are working on the Dengue projects of Berkeley professor Eva Harris spend two days discussing dengue at one of the nicest resorts in all of Nicaragua. The meetings last much of the day and give the laboratory and clinical personnel a chance to interact with one another in a collaborative fashion.

On the second day of the retreat I was asked to give a presentation of the results of my Ultrasound project. So I presented some PowerPoint slides with the my statistical findings, and I stumbled my way through a report (in Spanish) of what I had been working on all summer. It turns out that thickening of the gallbladder wall is very strongly correlated with having dengue hemorrhagic fever. In fact, a thickening of the wall of 5mm corresponds to DHF with an odds ratio of more than 9. The main flaw in my analysis is that we only have 11 patients from last year with DHF, but Eva and the other doctors at the meeting were impressed with the findings and agree that it would be worth writing something up for publication.

Little Corn Island

2006-08-09T12:01:00.000-05:00

As the elastic fingers of globalization continue to reach further and further away from the United States, and each day we come closer to the day when McDonald's and Starbucks will be commonplace in Bangladeshi villages and on Ecuadorian hillsides, it's refreshing to discover a place that's still undeveloped.

This is the charm of Little Corn Island. It's located in the Caribbean Sea, 45 miles off the eastern coast of Nicaragua. Getting there involves first taking a boat or small plane to Big Corn Island and then transfering to a small panga (motorboat) for a 20 mile ride. The island is inhabited by fewer than 1000 people, mostly of African descent who speak a Creole language that's a mixture of English, Spanish, and Miskito (a Native Indian language). There are no cars. Just boats. Most islanders make their living catching fish and lobster.

Little Corn Island has beautiful beaches. White sand. Turquose water. Lots of palm trees. But there's no fancy beach resort here. No Club Med. Just simple beachside cabins.

I spent my days swimming in the 80 degree water, reading books, exploring the island on foot, learning to SCUBA dive, and eating delicious seafood.

The food was delicious. Of course there was seafood....On my first night I had garlic lobster which was fantastic. Miss Martha runs a little restaurant with excellent fried fish and beef tacos. But there was good food besides seafood, too. There's a Cuban couple who serve some of the tastiest grilled beef and chicken. One of the biggest surprises was the incredible Italian dinner I had at the home of an Italian woman named Paola who moved to the island from Rome over 10 years ago. To start off she cooked up penne pasta with brocolli and parmesian, then she brought out a freshly baked calzone made of imported mozerella. And dessert consisted of cream custard with cherry sauce. We accompanied the meal with a bottle of Italian wine. She buys all of her supplies from an Italian food importer in Managua (so to stock up on wine and cheese she has to take a 45 minute panga boat ride to Big Corn Island and then an hour-and-a-half flight to Managua).

The SCUBA diving was great fun. I was a bit nervious about it, but the four day course that I took was very comprehensive, and my instructor Audrey was an excellent teacher. After learning how to assemble SCUBA equipment, I practiced using the tank in the shallow water of the bay in front of the dive shop (most people do these skills in a swimming pool, but there are no swimming pools on little corn island). Then after mastering the necessary skills, I did four open water dives on the coral reef surrounding the island. The highlights included seeing many nurse sharks, sting rays, eagle rays, and even a hawkback sea turtle. Now that I'm certified, I can go SCUBA diving anywhere in the world.

A Mountain Retreat

2006-08-01T13:31:00.000-05:00

This past weekend I took a 3 hour busride to the town of Esteli in the northwest of Nicaragua. And guess what? For the first time in 6 weeks I actually felt cold! That's right. The posada where I stayed is located in a nature reserve high up in the mountains. To get there from the town I paid a taxi the hefty sum of 200 Cordobas (about $12) - the most expensive taxi ride I've taken in this country. But it was quite a drive! The road was not paved, and we drove uphill the whole way, snaking up through the mountains for what seemed quite a long time.

It was a simple guesthouse made of wood with flowers and coffee trees all around as well as fields of cabbage, lettuce, and other vegetables. I paid 110 Cordobas for dinner, lodging, and breakfast the next day. I woke in the morning all excited to hike up to the top of the mountain behind the lodge. But as I started walking, I realized that I was walking right into a cloud. So when I arrived at the summit, where there is supposed to be an incredible view all the way down to the Pacific coastal plain and the many volcanoes, I couldn't see more than 10 feet in front of my face. Oh well.

As I hiked downhill, I eventually emerged underneath the clouds and was treated to a fantastic view. Further down the trail was a series of sculptures carved into the mountain by a 70+ year old farmer. He was quite a character. He's been chiseling rocks into the shape of animals for more than 30 years and was quite proud to share his work with me. Furthern down the mountain was a beautiful 50 foot waterfall that made for an excellent swimming break. If you've never swam underneath a waterfall, I must say I highly recommend it. Very exhilirating.

It´s been busy at work for the past two days, as I´m going to the Atlantic Coast of Nicaragua tomorrow and am trying to finish up my project before leaving. I may not be able to update my blog for a week, but I'll try to post some good stories upon returning.

Boys Will Be Boys

2006-07-27T13:12:00.000-05:00

The photograph of a man riding a bike with a pig is admittedly hard to top, but I realize I have a couple other photographic gems that warrent sharing. For example, here is a picture I took of the family I hung out with at the Central Plaza in Managua at the Revolution Day celebration.

Notice anything funny in this picture?

Here's a close-up......

This boy isn't drinking Coca-Cola.

He's sipping a can of Victoria, the most popular domestic beer in Nicaragua.

And here's another pic of the same boy....

TDR Forms

2006-07-26T21:08:00.000-05:00

In this blog I tend to emphasize the fun and exciting stuff and gloss over boring things like working on databases or running statistical tests. But the truth is that I´ve actually been doing a lot of work this week. The dengue project that I´m working on, is part of a large, multi-center international clinical study of pediatric dengue. They are collecting data on children with dengue in hospitals in Nicaragua, Venezuela, Brazil, Thailand, and Vietnam. The study is being organized by The Program for Research and Training in Tropical Diseases (TDR), which was created as a joint venture between the United Nations Children´s Fund (UNICEF), The World Bank, and the World Health Organization. The mission of TDR is to support research in "neglected" tropical disease such as Malaria, Chagas disease, Leshmaniasis, and Dengue. These are refered to as neglected diseases because they primarily are diseases of the Third World, and drug companies have traditionally ignored research on these diseases because they know that poor countries don´t have the financial resources to allow them to turn handsome profits like they do on medications for such "Developed World" diseases as Cancer and Heart Disease. For more information on the TDR check out their excellent website with lots of information about tropical diseases: http://www.who.int/tdr/index.html

On Tuesday of this week, we had two visitors from the TDR who are monitoring the Latin America portion of this dengue study. Since this is the first year that Nicaragua has been a part of the study, there was a lot of work to do to get ready for the visit. Much of this work involved going over the data collection forms in the patient charts to make sure that we are collecting all of the information that the TDR is requesting from us. As it turned out, there were quite a few fields missing on our data forms, and somehow I got stuck with the job of modifying the forms to make them compliant. It sounds fairly simple, but it´s actually quite complicated to add a simple field like "Patient given Diuretics in last 24 hrs" because you have to shift everything else down to make room for the new field, and then the last line ends up running over the edge of the page so you have to then reformat another field to make it smaller and allow you some extra space so everything fits on the original page. When everything was all said and done, we had added so many fields that the font became so small you could barely read it. And then today the doctor in charge of the study in Nicaragua decided she wanted the form to be on two pages, which again sounds simple but required a full day of work to complete.

Now that the format of the data entry sheet is done, I´m looking forward to finishing up my study of ultrasound data.

This Little Piggy...

2006-07-24T18:44:00.000-05:00

Notice anything odd about this picture?

Take a closer look.....

That's right, folks. This man is riding a bike with a large pig tied to the seat. I know most bike seats are pretty uncomfortable, so the pig can only be an improvement. Perhaps the pig provides extra support for the lumbar region of his back.

I took this picture while I was on the Island of Ometepe last week, waiting for a bus. There I am, just sitting around, staring off into space when I see a guy riding a bike along the road - no big deal, as bikes are the main form of transportation on the island. However, it was only when the biker passed me that I noticed his cargo. And so I quickly grabbed my camera and snapped a photo.

You want to know the best part of the story?

The pig was still alive! I heard him squealing.

Birthday Bash

2006-07-21T12:54:00.000-05:00

Allan had his ninth birthday last week. Now, when I turned 9, I had a party with all of my friends from school. We all gathered in the backyard to play games such as red rover and capture the flag, and if I'm not mistaken there may have even been a scavenger hunt. So I was a bit surprised to find that Allan didn't have any friends over. Instead it was a family gathering. Uncles, aunts, cousins showed up to eat roasted chicken, rice and beans. Of course there was Coca-Cola to drink. And for desert we had delicious chocolate cake with lots of frosting that Allan's aunt smeared all over his face after he blew out the candles.

The traditional birthday song in much of Latin America is called "Las Mañanitas."

Las Mañanitas

Éstas son las mañanitas

Que cantaba el Rey David,
A las muchachas bonitas
Se las cantaba así.

Despierta, mi bien, despierta,
Mira que ya amaneció,

Ya los pajaritos cantan,
La luna ya se metió.

These are the morning verses

That King David used to sing,

To the beautiful young ladies,

He would sing them like this.

Wake up, darling, wake up,

Look, the dawn has broken,

The birds are singing,

The moon has already gone down.

When I was teaching in Mexico, the whole school would gather every Monday morning to sing this song to all of the children who had a birthday that week. I never really understood why they sing a song about King David on a child's birthday. Then today I did an internet search for Las Mañanitas and found that there's actually a third verse...

Éstas son las mañanitas
Que cantaba el Rey David,
Hoy por ser día de tu santo
Te las cantamos a ti.

These are the morning verses

That King David used to sing,

Today because it's your saint's day

We're singing them to you.

Now it makes more sense. Because back in the old days they didn't celebrate birthdays on the date on which you were born. Instead they celebrated the day that corresponds to the saint that is your namesake, which could be in an entirely different time of year.

And now, some cute birthday pictures:

The birthday boy smeared with frosting

Blowing out candles with Mom (Mari) and Brother (William)

Sandinista Pride

2006-07-20T17:53:00.000-05:00

Turns out that July 19 is the anniversary of the Sandinista Revolution here in Nicaragua. Even though the Sandinista’s aren’t in power now, it’s still celebrated as a national holiday, and the Sandinistas hold a huge rally in Managua’s central plaza. Not one to miss a populist political demonstration, I had to attend.

In my estimation there must have been hundreds of thousands of people who showed up. Buses poured in from all over Nicaragua, bringing Sandinista partisans adorned in Che Guevara T Shirts and waving red and black flags. The atmosphere was festive. Vendors were selling all sorts of food, beer, rum, even toys for the kids. There was a large stage set up on one end of the plaza, but for the most part people didn't pay too much attention to the speeches and dance performances up on the stage. Instead, families just hung out and had fun. Kids played while parents drank (sometimes excessively). It was a demonstration of pride: in Nicaragua, in Latin America, in anti-Imperialism. Thousands and thousands of people were waving their Sandinista flags enthusiastically, clearly proud to be celebrating the ideology of Sandinismo. But then there were lots and lots of people who were just there to celebrate for the sake of celebrating. How many people there at the plaza were planning to vote for the Sandinistas in October's elections? That remains to be seen.

For those who aren't familiar with Nicaraguan history, the Sandinistas emerged in the 1970s as a guerilla movement that was opposed to then-dictator Somoza. The Somoza family ruled Nicaragua for much of the 20th century. If anyone criticized the dictator, that person would be promptly "disappeared" and never seen again. For many years the US supported Somoza because he protected American business interests in Central America. Harry Truman is quoted as once saying, "He may be a bastard, but at least he's our bastard." But in the late 1970s, Somoza made the mistake of murdering a US journalist and lost the backing of the US government. Finally, in 1979 the Sandinistas were able to topple Somoza's government, and they promptly instituted a socialist regime in Nicaragua. However, by 1990 many Nicaraguans were dissillusioned with the Sandinistas, and they were voted out of power. Since then the Sandinistas have been an important political party, but have never recaptured the presidency. Every election since 1990 has seen Daniel Ortega, the Sandinista leader, lose to his opponents. This coming November there's going to be another election, and word on the street is that Ortega may actually win. Nothing is certain in politics, especially in Latin America, so it will be interesting to see what happens in November.

Island Life

2006-07-20T12:37:00.000-05:00

The island of Ometepe is comprised of two volcanoes rising up from Lake Cocibolca. Volcano Concepcion is still active, and on the ferry ride to the island I could see smoke rising from the top of Concepcion’s volcanic cone. Concepcion is surrounded by the islands more densely populated towns, and hundreds of people could lose their lives should the volcano erupt violently. Volcano Maderas is on the eastern, less populated side of the island. Maderas is no longer active, which makes it a popular destination for hikers.
I spent Friday night at Finca Magdalena, a hostel located in the middle of an organic coffee plantation at the base of Volcano Maderas. Then Sat morning I climbed the volcano with four Canadians and a guy from England. It took just under four hours to reach the top and another three hours to get back down. It rained for the first two hours of the hike, and the trail was completely muddy. But it was a beautiful hike. We saw howler monkeys in the trees above, heard the sounds of many different tropical birds, and even saw a 6-ft-long snake (that according to our guide was not poisonous). We walked through fields of coffee and cacao, and were surrounded by thick, green forest all the way to the top. At the summit of the volcano there’s a crater lake, but it was so cloudy and cold that nobody in our group felt like swimming.

Saturday afternoon I joined up with two of the Canadian guys I met on the hike and we decided to take a bus to the Monkey’s Island Hostel on the other side of Volcano Maderas. Sunday we rented horses and rode to a beautiful jungle waterfall that was a couple hundred feet tall. Previously, I’ve only ridden a horse as part of a group with a guide, so this was the first time I found myself totally in control of a horse. It was up to me to control the horse’s speed, tell him which direction to go, when to stop, etc. Other than the pain in my butt from all the bouncing up and down, it was great fun. And when I got back from the waterfall I cooled off with a swim in the lake. Lake Cocibolca is the only freshwater lake in the world with sharks, but apparently people aren't worried about shark attacks because everyone swims in the water.

The best part about Ometepe is the laid-back lifestyle. Dogs, pigs, chickens, cows, and horses roam free. Howler monkees scream from the trees above. Roads are mostly muddy, and are only passable by high clearance vehicles. Public transportation consists of old American Schoolbuses retrofitted with monster tires. Mountain bikes are the main means of transportation on the island, and wooden canoes are the main means of getting around in the waters offshore.

Giddy-Up!

Ometepe Beach

The Health Promoters

2006-07-18T09:57:00.000-05:00

Getting to Ometepe involved a two hour drive in Saul’s pickup truck from Managua to San Jorge, and then an hour-long ferry ride to the island. The trip was made ever the more difficult because Saul was bringing a large whiteboard to the Health Clinic on the island. The ferry from San Jorge arrives in the village of Moyogalpa, but the class was on the other side of the island in the town of Altagracia. Getting to Altagracia required a taxi, but finding a taxi that could take a large whiteboard was not so easy. Eventually we found a large van and were able to tie the board to the roof. Tying things to the roof of a vehicle is quite common practice here in Nicaragua (chickens, bananas, sacks of flour), and I’ve never seen anything fall from a moving vehicle. That is until Friday. Because after driving for ten minutes we heard a loud THUD and turned around to see the whiteboard on the road behind us. Remarkably, it didn’t crack, but the wooden frame splintered into many pieces.
The fall of the whiteboard turned out to be an omen for a long and unpleasant taxi ride, because soon afterwards it started raining, and then we found ourselves stuck behind a flag relay that consisted of a Nicaraguan child running with a flag for a few minutes and then passing the flag to another child who would continue down the road, etc. It apparently is a nationwide event in that the flag is carried by schoolchildren across the entire country, much like the Olympic torch relay. So we found ourselves going about 3 miles per hour in back of a 10-year-old boy who is jogging with an outstretched arm proudly holding aloft the Nicaraguan flag. And the police escort wouldn’t let us pass.
When we finally got to the health center in Altagracia, we then received the bad news that many of the health promoters had not been able to come to the meeting because the heavy rains had made travel impossible on the dirt roads of their villages. Just as Saul was ready to cancel the class, however, some of the promoters trickled in, and we were able to hold the class for the 10 people who showed up.
Inspiring, is really the best adjective I can think of to describe Saul’s class. The health promoters were mostly poor farmers without a great deal of education. Yet, he really connected to them in a meaningful way by emphasizing the interconnectedness of community health. That is to say, if your neighbors don’t have a latrine, and your family does, then you should be happy, right? Wrong. Because if your neighbors don’t have a latrine, they’ll go to the bathroom outside, and insects will land on the human waste and then fly over to your house and get you sick. So it’s to the benefit of all members of a community that everyone stays healthy and that everyone has clean water and a hygienic bathroom/latrine.

An Island Adventure

2006-07-17T18:54:00.000-05:00

Just got back from Isla de Ometepe early this afternoon. It was quite a journey. From the hostel where I stayed last night, it's a long, slow bus ride over muddy dirt roads to reach the town of Moyogalpa where the ferry departs. The ferry ride to San Jorge is an hour, and from there it's a 20 minute ride to Rivas from where you can get a bus to Managua. I got on the bus at 5:30am in front of my hostel. Didn't get back to Managua until 1pm. Quite a trip.

But it was much fun - monkeys, volcanoes, swimming, horses, waterfalls, lots of pigs, and a good amount of rain.

I don't have much time to write now, but hope to update the blog with details by tomorrow.

Blood Draw

2006-07-11T15:04:00.000-05:00

The Pediatric Dengue Cohort Study is prospectively following a group of over 3000 children who live in Managua. Part of the study involves an annual blood draw from each of the children enrolled in the study. So all during the month of July they have set up a "blood draw factory" at the Socrates Flores Health Center. I spent yesterday observing the operation, and must say that I was quite impressed with the organization and sophistication of the endeavor.

Each of the children enrolled in the study has a photo ID card that they present upon arrival at the health center. An attendent enters the child's data into a laptop computer, and then the child's thumbprint is scanned via an electronic fingerprint reader that is connected to the computer. This allows verification of the child's identity. The child then takes a seat and when his number is called by a nurse he proceeds to one of the six blood drawing stations that have been set up in the room. After his blood is drawn, he gets a lollipop and the nurse enters his information into a Palm Pilot to confirm the success of the blood draw.

In all, over 220 children had their blood drawn yesterday. It's a huge operation, but the army of over 20 nurses kept things flowing smoothly. The majority of the children were quite stoic and endured the needle poking with minimal complaint. But every now and then a child would scream upon sight of the needle, thus putting uneasy all the children in the waiting area. Many kids I talked to were proud to tell me "No llore" (I didn't cry) or "No duele" (It doesn't hurt).

The goal of this cohort study is to study the prevalence of the Dengue Virus and Dengue Antibodies in the community. In the long term, the idea is to use this information to help create a vaccine.

Granada

2006-07-09T19:49:00.000-05:00

“Ni la misma Granada de Espana is tan Linda y extrana como esta de aqui”

- Tino Lopez Guerra (1940)

After staying out till 4am on Friday night, I woke at 11:30 Saturday morning a bit groggy, but thanks to a bucket of cold water (the tap water wasn’t running) and some gallo pinto (rice and beans), I was ready to do some exploring. In the short time I’ve been here I’ve learned that Managua is a fun place at night. It has the best movie theaters, restaurants, bars and dance clubs in the whole country. However, during the day Managua is a hot ugly city with not much to do. So after consulting with my guide book, I decided to spend Saturday afternoon in the colonial town of Granada.

I took a “Microbus” or van from Managua to Granada. The drive was about an hour including numerous stops to pick up or drop people off en route. I’ve learned that there really don’t seem to be direct buses here in Nicaragua. If there are empty seats, the bus will stop to pick up anyone who flags it down. And the ticket taker will scream the name of the buses destination to anyone standing on the side of the road in hopes of drumming up business.
But back to Granada. It really is a beautiful city. Granada is on the western end of Lake Nicaragua (more commonly known here as Lago Cocibolca), and most guidebooks say that it’s the most beautiful colonial town in Nicaragua. It was founded by Spanish settlers in the 16th century, and was the seat of power for William Walker, an American who briefly ruled Nicaragua in the mid-19th century. When he was forced to flee Granada in 1856 he burned the city to the ground, and most buildings today date from the late 1800s when the city rebuilt after the devastation left by William Walker.

Granada is not so different from colonial towns I’ve seen in other parts of Latin America (San Cristobal, Mexio; Antigua, Guatemala; Trinidad, Cuba; Cuenca, Equador). But after being in Managua for the past two weeks, Granada’s brightly painted houses with sloping tile roofs seemed like architectural paradise to me. I spent a couple hours just wandering around the cobblestone streets, visiting the many churches and taking pictures of houses that caught my attention. I went to the museum in the old convent of San Francisco. The convent dates back to the 16th century, although it was destroyed a few times by fires and earthquakes, and so the present building is only about 150 years old. Inside the museum was an interesting exhibit of pre-Columbian stone statues as well as a display of art by contemporary Nicaraguan painters.

Energetic Eva

2006-07-09T19:44:00.000-05:00

Eva Harris first came to Nicaragua for a couple of months after graduating from college. Now, twenty years later, she runs one of the largest Dengue research programs in all of the Americas. She has a research lab in Berkeley, but she comes to Nicaragua once a month for 4-5 days to check in with her team of over 25 Nicaraguan doctors and laboratory investigators. She was in Nicaragua this past weekend, which gave me a chance to check in with her regarding my summer project. Plus, I learned that when Eva visits, everyone goes out and parties. I don’t know how she does it, because she works around the clock and never seems to sleep. Yet, on both Friday and Saturday nights Eva was the most energetic of everyone on the dance floor. The music gets into her and she can’t stop moving, even after the rest of the group was exhausted and ready for bed.

Saturday night there was a big fancy dinner in honor of Samantha the project coordinator for Eva’s studies here in Nicaragua. After over 4 years, Samantha is leaving Nicaragua to go back to the United States and eventually attend medical school. The dinner was quite moving, as many people gave praise-filled speeches about Samantha. She has been instrumental in making this program work, so her loss will definitely be felt. Part of the reason that Eva came down this weekend was to interview replacements for Samantha’s position. The three candidates came out to the bar with us on Friday night, and I believe Eva will pick one of them in the next week so the person can start working as soon as Samantha leaves at the end of July.

Doctor Saul

2006-07-08T18:55:00.000-05:00

Saul and his Wife

Back in the spring, when I was trying to figure out what to do for the summer, one of the doctors at the med school put me in touch with a friend of his who was involved with an organization called Doctors for Global Health. I spoke to the director of the organization on the phone, and was quite interested in their community-based work. However, I chose not to work with DGH because I wouldn’t have been able to apply for Stanford funding if I did a community health project that didn’t involve research. Then, a few weeks before the end of the school year, I got an email from a fifth year medical student at BU who had spent a year volunteering with DGH in Nicaragua. He gave me the contact info of a doctor he had worked with who lived in Managua. I gave the doctor a call, and he invited me to attend a traditional Nicaraguan folkdance performance with his wife and another American medical student who was volunteering for the summer with his organization.

Turns out Saul is quite the rebel doctor. He grew up in Guatemala and was a medical student there during the Civil War of the early 1980s. Like most of the idealist university students at the time, Saul got involved in the cause of the anti-dictatorship guerillas. But when the government started killing students for their political involvement, Saul had to flee to Canada. He was just months away from finishing his medical degree. He lived for three years in Canada, and during this time he secretly returned to Guatemala in order to finish medical school. By this time the Sandanistas had come to power in Nicaragua, so Saul decided to put his medical skills to use in a country where the Socialists had emerged victorious. Except for a three year stint in the early 90s when he went to El Salvador to help the guerilla fighters, he’s been in Nicaragua ever since. And he’s devoted his life to providing medical care to the poorest of the poor. He’s now the head of a Nicaragua-based organization called APS (Atencion Primaria a Salud). APS runs health clinics and also trains health promoters to attend the medical needs of people in remote areas where there are no doctors.

"Che" picture on Saul`s Truck

I met Saul at his clinic around 5pm on Thursday evening (Carreterra Norte, from Siemens, one block up). Turns out there were some problems with his truck, but after a bit of pushing we got it to start. Then we swung by his house to pick up his wife as well as a medical student from USC who is volunteering with APS for the summer. The dance performance was in Masaya, a colonial city that’s a forty minute drive from Managua. It was quite the spectacle. Dancers in elaborate costumes and some very lively music. When we arrived it was raining hard in typical tropical fashion. But soon the rain stopped and we sat outside and watched the show. It was a fun time. They invited me to come the next day to attend a health promoter training, but I already had a meeting scheduled at the hospital, so I’m going to go with them next week. I’m looking forward to it.

A hazy picture of the dance performance

Independence Day

2006-07-05T14:24:00.000-05:00

Sara threw a party at her apartment last night in honor of July 4th. It was an excellent July 4th, celebrated with chips and guacamole, roasted chicken, hot dog casserole, Nicaraguan beer, and a bit of Jose Cuervo. The crowd was quite diverse and included Americans, Nicaraguans, Japanese, and one Korean. The cast of characters included: William and Mario, the two informatics guys who work on the Dengue Project; Nana and Emmy, who both work at the Japanese embasy; Miyumi, daughter of a Japanese diplomat father and a Colombian mother; Robert and Justin, two American guys who run clothing factories (aka "sweatshops); Sara 2 (to distinguish her from MPH Sara), who will be starting med school at the Univeristy of Oklahoma in the fall; Two pre-med volunteers from a program that gives free medicines to needy Nicaraguans; Willy and Indira, the cute newlyweds who live next door to Sara and are both architects....

And then there was Alex. A Korean man who runs a textile factory that does embroidery. Alex knows basic Spanish vocabulary but almost no grammar. However, he didn't let his language difficulties get in the way of his telling stories. It quickly became apparent that Alex was the evening's feature entertainment.

He told us:
- about his wife who lived in Korea who he missed very much.
- that they had only been married since January
- that he had left to work in Nicaragua soon after the marriage
- that his wife would be coming to live with him in Nicaragua in August
- that he had taken up drinking out of loneliness because his wife wasn't with him.
- that he wanted children
- that he was sad he couldn't make children since his wife was far away.
- that he was exercising so he wouldn't be fat when his wife came
- that he was learning to cook so he could cook a romantic dinner for his wife.

In short, Alex was hilarious. And thus was spent a wonderful July 4th evening.

Haircut

2006-07-04T19:19:00.000-05:00

I got a haircut this afternoon for 25 Cordobas, which is equivalent to $1.50. I had been meaning to get my hair cut before coming down to Nicaragua but was too busy. Then I had my surfing accident which left a mark on my forehead all last week. Now that my head is healed, I was ready for the haircut.

Turns out there's a barbershop just one block from the house where I'm staying. And I thought the barber did an excellent job. He used electric clippers on the back and the sides, used scissors on top, and then he shaved my sideburns and back of my head with a real razor. I was a bit concerned about disease transmission as I watched him shave someone else while I was waiting my turn. But then he showed me how he uses a brand-new razor blade for each customer to prevent the spread of SIDA (as AIDS is called in Spanish). I was impressed with this public health awareness, especially when the barber is charging so little for each haircut and the cost of new blades for each customer must erode his bottom line.

I also played Monopolio this afternoon with Alan. The game was funny because the street names were in French but the cards were in Spanish. I'd say we were about tied when a gust of wind came along and scattered our money all over the patio - thus putting an end to the game.

World Cup Drama

2006-07-04T11:19:00.000-05:00

Yesterday afternoon around 2pm I was running some statistical tests on the dengue database when I realized that the Italy-Germany World Cup Semifinal game had started. So for a half hour I monitored the progress of the game via the internet. The first half ended with a score of 0-0, and things were shaping up for a dramatic second half. So I looked at Mario, the informatics guy, and he was thinking the same thing as me: "Vamanos!" we said to each other, and we hopped in a taxi to take us to a bar where we could watch the rest of the game.

When we got out of the taxi and walked into the bar, I noticed that it seemed eerily quiet considering there was a World Cup Semifinal Game going on. There were very few people, and it was dark inside. Then it hit me: "Ah, se fue la luz!" The power had gone out! Dejected, Mario and I decided to try elsewhere. After walking for about 10 minutes we finally found a bar with electricity, air conditioning and 2 projection TV screens! We plopped ourselves down on a couple of stools, and with a cold brewski in hand, we were soon comfortably immersed in the drama of the soccer game.

It turned out to be a classic duel. No score through the first 90 minutes, so they went into overtime. Nearly everyone in the bar was rooting for Italy, but it felt like a lost cause because the Italian team kept coming close to scoring but could never close the deal. Finally, with two minutes left before a penalty shoot out, the Italians scored and the bar went wild. Then, a minute later Italy scored again to seal the deal and secure a spot in the finals on Sunday. The dramatic conclusion made this the most exciting World Cup game that I've seen this year.

Signs of Progress

2006-07-03T15:31:00.000-05:00

As I've noted previously (see Nicaland entry), the Gringos are coming to Nicaragua, and signs of Gringo invasion can be found in the most unlikely places:

#1. Notice the Visa Sign behind the Hammocks

#2. The sign on this "house" says it has just been sold

Joc Dog Boys

2006-07-03T15:17:00.000-05:00

I went to the beach town of San Juan del Sur again this weekend. I tried surfing again, and this time I was fortunate not to sustain any surfing injuries. So I feel like I'm making progress.

While walking around San Juan on Friday night I came across a couple of boys with hot dog carts. There carts were right next to each other and there seemed to be a bit of a rivalry between them: according to the letters on the side of their carts, one was selling "Hot Dog," and the other was offering "Joc Doc." I thought about doing a taste test to see whether Joc Docs taste better than hot dogs, but on second thought decided that such an act could have adverse gastrointestinal consequences.

I'm surprised he's not crying!

Sitting on the Street

2006-07-03T15:14:00.000-05:00

The main pastime in the evenings here in Nicaragua is to hang out on the sidewalk. It gets hot and stuffy inside, so people take their chairs and place them outside. I spend many an evening sitting in front of the house with Mari and her sons William and Alan as well as Mari’s brother-in-law. We sit and talk and watch the people walking past. It’s quiet here in the evenings and most of the traffic on our street is from people walking to the tienda on the corner to buy cigarettes, candy, soda or beer.

Americans build houses with backyards so families can gather in back of the house. That way children can play in a protected space and parents can barbeque out of sight of the neighbors. In Nicaragua (and Latin America in general) the paradigm is reversed: it’s rare to find a house with a backyard. Instead people gather in front of the house, in view of the neighbors. It’s much more inclusive this way.

Plus, we’ve been having power outages almost every evening for the past week. When the power goes out at night, people have no choice but to go outside because no power means no fans. And without a fan it’s nearly impossible to put up with the hot, stagnant are that’s trapped inside the house at night.

The moment the power goes, everything goes dark, and there’s a collective groan of frustration emitted by the adults of the neighborhood that’s intermingled with shrieks of excitement from the children. People grab flashlights or candles and head for the streets to pass the time and wait for the power to return. Luckily, we’ve gotten power restored within an hour or two most nights, but on night last week the power stayed off all night, and William and Alan moved their mattresses to the patio so they could sleep outside. where it’s cooler.

La Mascota

2006-06-30T11:17:00.000-05:00

The official name of the hospital where I work is “Hospital Infantil Manuel de Jesus Riveras.” But that’s a mouthful to say, and so it is instead referred to as “La Mascota” which means The Pet. There must be a story behind this name, so I’ll have to do some investigation to figure it out.

“La Mascota” is one of the best public children’s hospitals in Nicaragua, and children from all over the country come here for treatment. The doctors are knowledgeable and well-trained. It is a teaching hospital, and serves as a major training center for the medical students who attend the public university in Managua. On the infectious disease ward there are two senior residents, four interns, and six medical students who work under the supervision of the attending physicians who are infectious disease specialists. Each morning the entire medical team visits each of the patients on the ward. They call it “La Visita.” Each patient is presented to the group by a medical student or resident who gives a summary of the patient’s history and physical exam. Then the attending physician questions the child or parent to fill in any gaps in the history and afterwards briefly examines the patient. The final step before leaving each patient is to come up with a plan of what needs to be done for the patient. The entire Visita usually lasts about an hour, and writing up the orders for tests, external consults, discharge summaries, etc. usually keeps the interns and residents busy until 3pm or so.

Everyone arrives by 7:30am. The medical students leave by 11am. The attending physician leaves around 1pm. The interns leave at 3pm. And the residents stay until evening. Night call starts at 6pm and involves one resident and one intern. They call it doing a “Turno” and it comes every four nights.

I’ve been going on the Visita each morning, and then afterwards I work on the ultrasound data analysis project on my computer. Sometimes before the visita I’ll take a history and physical of one of the patients but thus far I haven’t worked up the courage to present any patients to the team. Once I get more comfortable with how things work then I’ll present a patient.

Shock

2006-06-29T11:58:00.000-05:00

One of the children hospitalized for dengue went into shock today. His blood pressure was low, his heart rate went up, and his extremities were cold. What happened was that his blood vessels were leaking fluid so he didn’t have enough blood in his circulation to maintain a healthy blood pressure. The doctors gave him fluids by IV, but his blood pressure failed to respond. The only option left was to put a catheter into one of his large veins (a.k.a. a “central line”) in order to both increase his blood volume and give him medicine that would increase blood flow to his vital organs.

His parents were both in tears as the resident informed them of the procedure that needed to be performed. Within minutes, a surgeon arrived in the infectious disease ward, and they began the procedure. I observed from the back of the room as a resident and two nurses held the boy firmly in place to keep him from moving during the procedure (which was done under local anesthesia, so the boy was awake for much of it).

After injecting the anesthesia, the surgeon made an incision to the right of the groin and then set about to locate the femoral vein (which leads in to the Vena Cava – the route by which all blood returns to the heart). However, the procedure did not go smoothly, as the first catheter did not go in correctly and had to be removed. A second surgeon then arrived on the scene and after much effort was able to succeed in inserting the central line. The entire process lasted over an hour. It was made the more difficult by the fact that every now and then a nurse would relax her grip of one of the child’s limbs and he would kick or flail his arms. There was a collective sigh of relief when the whole thing had successfully terminated. Poor kid. He´s only three years old.

Boys Playing on the Street

Nicaland.com

2006-06-27T14:58:00.000-05:00

One of the biggest surprises I encountered on my trip to the beach this past weekend was the preponderance of real estate signs – in English. Seems that the Gringos have run out of cheap coastal properties to purchase in Costa Rica, so they’re now buying land in Nicaragua. Many of the real estate signs are Century 21 or REMAX.

A quick internet search for real estate in Nicaragua will yield quite a few hits such as www.nicaraguarealestate.com, www.nicaraguaproperty.com/, www.nicaland.com/

And the prices are good. You can’t buy beachfront property in Florida for less than a million dollars, but here the same parcel of land costs a fraction of the cost. We met a lawyer from Texas who decided to move down to Nicaragua to make a living selling real estate to foreigners. She surfs in the morning and works in the afternoon – not a bad life.

Getting Around Managua

I’ve already mentioned that Managua is not the most accessible city. There are no street names or numbers, so if you don’t have a good sense of where the main landmarks are, you’re absolutely helpless. And that’s how I’ve felt for my first week here. I tell the taxi driver the directions for where I want to go, but I have no way of knowing if he’s actually taking me where I’m supposed to be going. Yesterday, I took a taxi back to the house from the Health Center, and I told the driver to take me to a house “Two blocks south, and half a block up from the Bar Los Rostros.” He took me to an unfamiliar street, and told me that we were at the location I had requested. I told him that this wasn’t the street, but I had no way to know where we had gone wrong, so I paid him the fare and decided to find the house on my own. After circling the block, I realized how I had gone wrong: the house was one block south of the Los Rostros Bar, and I had told the taxi driver two blocks south.

However, there are some landmarks that I am beginning to recognize. Whenever I go to the Health Center the taxi will pass by Stadium Denis Martinez. When I go to the laboratory, there is a Pizza Hut along the way. Plus there are the Redondas (traffic circles) that serve as major landmarks. Any time you go from one side of the city to the other you end up on one of the major roads, and these roads all intersect each other at traffic circles – usually with a statue in the middle.

For my first two days I was driven everywhere by drivers who work for the Dengue Project. This was great since I didn’t know my way around the city and was worried about being robbed. But the problem was that I’d have to wait to go at a time that was convenient for the drivers. By my fourth day, I got tired of waiting for them to pick me up and started taking taxis. They cost about $1.25 to $1.50 to go almost anywhere in the city – but that’s if I pay the Nicaraguan price rather than the Gringo Price. Before getting into a taxi I ask the driver, “How much to X neighborhood?” And usually he’ll quote me 30 or 40 Cordoba (2-3 dollars). But since I know it shouldn’t cost more than 25 Cordoba, I’ll tell him so, and sometimes he’ll drive away (probably out of pride/spite) and sometimes he’ll agree. From my experience thus far, it’s about 50/50.

A Surfboard Encounter

2006-06-26T14:52:00.000-05:00

I went to the beach yesterday with Sara, a public health student from Berkeley who is also working on our dengue project for the summer. Sara is working with CIET, an organization that promotes community health by mobilizing community members to educate their neighbors. In this project, CIET is working with various neighborhoods in Managua to help promote the eradication of the dengue vector, the A. aegypti mosquito.

When I arrived at the bus station at 7:30am on Sunday, I asked for the bus to San Juan del Sur. I was then physically pushed onto a bus by a group of four men who work for the bus company. I told them that I was waiting for a friend named Sara and they told me she was already on the bus. However, the problem was: 1) this wasn't the direct bus and 2) Sara wasn't on the bus.

Once this was sorted out, I got off the bus and found Sara. Then we found the correct bus and had a pleasant ride to the town of Rivas. Once the bus was en route, a man came around to collect money from passengers. When he came to my seat I handed him a 100 Cordoba bill, and he then gave me back a ticket and also gave me back my 100 Cordobas. So in the end I got a free bus ride.

From Rivas its a twenty minute drive to the beach. Sara and I planned to take a bus, but while we were waiting for a bus to come, taxi after taxi came by to offer to take us there for 100 Cordoba. We waited a bit and then asked a shopkeeper how much a taxi should cost and he told us 25 Cordoba per person, so after a bit of negotiation, we found a taxista to offer to take the two of us for 50 Cordoba.

However, there were complications with this taxi ride:
1) Sara had brought her surfboard and the taxi did not have a roof rack. Turns out we were able to fit the board diagonally from the backseat to the passenger seat.
2) He had a big dent in the back right corner of the car. When we asked him about the dent he told us that just the day before a group of Gringos had crashed into his taxi from behind.
3) The road was full of some of the worst potholes I've ever seen. It was like navigating an obstacle course at times. We'd periodically slow down and swerve left, right, left, center, left, right, to try to avoid the worst holes.
4) En route, the taxista found a local woman with two kids who wanted a ride to San Juan. So the three of them squeezed in alongside the surfboard that was already taking up most of the back left seat and front right seats.

Nana
We got a ride from San Juan del Sur to the beach with Nana, the Japanese Surfer Girl. Nana works at the Japanese embasy in Managua, and surfs every weekend. First Japanese surfer I've ever met. The beach was at the end of a twisty dirt road, and it was beautiful. There was a simple shack selling food and drinks, but otherwise it was just sand and surf. The waves were big and the water full of surfers, mostly foreigners.

I spent a couple hours just swimming in the warm water, but then this guy Robert offered to let me try his surfboard. However, it was a short board which is really hard to balance on, so I was unable to stand up. Then in the afternoon, a girl who had rented a long board was leaving and she agreed to let me use her board for the rest of the day. I tried my best, and was able to stand up maybe 4 times, but it was exhausting. The hardest part was trying not to get knocked over by the waves that I did not want to ride. Eventually, a wave caught me unawares, and I banged my head on the surfboard. It didn't hurt much, but it left a nice little cut on my forehead. I like to think of it as a war wound. I may not have dominated this battle, but I'll be back on the lines, fighting the board and the sea. It's a fun sport, especially when the water is warm.

Soccer and Butterflies

2006-06-24T14:36:00.000-05:00

This afternoon was the training session for the annual blood draw for the cohort study of dengue transmission. A large group of nurses came to the health center to learn about the project and to practice drawing blood and labeling the vials. It's quite a sophisticated operation - each time they take a sample, they record the details electronically in a PDA(Palm Pilot). The whole thing is going to start in early July, and teams of nurses will go out into the community and take blood samples from all of the children who are enrolled in the study. This year, they are trying to make things easier for the nurses and they will encourage the parents to bring their children to the health center. However, those who do not come to the health center will receive a visit from the team of nurses to their houses.

As part of the training I agreed to participate as a volunteer for a role playing exercise. I thought this meant that the nurses would pretend to draw my blood and would learn
how to label the vials and enter the data in the PDA. What I didn't know was that I had actually volunteered to have my blood drawn. It went fine. They used brand new, sterile Butterfly needles (the same kind that I used my first week of medical school when I learned how to draw blood). And when the needle entered my vein I didn't feel a thing. It was actually the most painless blood draw I've ever had.

Afterwards I went to a local bar with William and Mario (the two guys who manage the database) to watch the World Cup match between Mexico and Argentina. It was a good game, and Mexico played well, but in the end they couldn't come up with a second goal, so their World Cup dreams came to an end. Argentina moved on to play Germany in what should be an excellent game.

El Cine

2006-06-23T14:16:00.000-05:00

Went to the movies tonight and saw a German film called "Downfall" about the last days of the Third Reich. Quite sad but also interesting. It showed Hitler and his top commanders in their bunker in Berlin as the Russian forces were advancing on the city. The film was in German with Spanish subtitles.

The movie theater was brand new with stadium seating and very comfortable chairs. Plus the theater had the nicest, cleanest bathroom that I've seen since I've been in Nicaragua - that is to say, it had toilets that flushed, faucets that worked, soap in the soap dispensers, toilet paper in each stall, a clean tile floor. Really quite amazing.

On the other hand, the bathroom at the Health Center where I've been working doesn't always have running water, so after using the toilet you have to pour a bucket of water in to make it flush. And of course there's no soap. Not the best way to prevent the spread of disease.

Managua

2006-06-23T14:09:00.000-05:00

Two days in Nicaragua. Where do I begin? I’ve lived in Mexico. I’ve traveled in Peru, and Ecuador. Compared with Nicaragua, these countries are rich. According to Wikipedia: Nicaragua has a GDP per capita of $867, placing it in 127th place amongst all the countries in the world, and placing it just behind Bolivia and Honduras as the poorest country in Latin America. http://en.wikipedia.org/wiki/List_of_countries_by_GDP_(nominal)_per_capita

They ration the water here in Managua. In the neighborhood where I’m staying, the city water only comes out of the faucet between 7pm and 7am. To cope, people fill up large basins with water at night so that they'll have water to wash with during the day. This morning I woke at 7:20am, after the water had been turned off, so I had to use a bowl and pour water over myself from a water basin that they leave in the bathtub. Same goes for using the toilet - you get one free flush once the water has been turned off - but after that flush there won't be any water to replace the water in the tank, so after that you need to dump a bucket of water in the toilet to make it flush.

There really are no street names in Managua. I read this in the guidebook but didn't believe it until I got here and saw for myself. Instead, people give directions based on landmarks that are found in each neighborhood. People don't use the four cardinal directions, either. Instead, they say: Al Lago (North), Arriba (East), Abajo (West), y al Sur (South). For example, here’s the address of the house where I’m staying: “Barrio Campo Bruce, del Bar Los Rastros, una cuadra al sur y una cuadra arriba, frente a la casa de dos pesos. (The Campo Bruce Neighborhood, One block south of the bar “Los Rostros” and one block up, across from the house with two stories)."

Seriously, those are the directions that you would give a taxi driver and would also write on a letter if you wanted the mailman to deliver it correctly.

The house in which I'm staying is simple but they have the essentials: a refrigerator, stove, oven, microwave, TV (with cable) and a stereo covered in plastic. There’s no air conditioning. My room has a window, a double bed with a very soft mattress, a wooden dresser, a TV (with cable including HBO), and on the wall: a picture of Jesus.

Maribel lives in this one-story house with her sister Flor and her two sons: Alan (9) and William (14). Flor works at the National Laboratory at the Ministry of Health, and that is how she knows Eva Harris, the scientist at Berkeley who runs the Dengue program here in Managua.

Last night the power went out just as I was going to bed. This was problematic because the fan stopped blowing, and without fan it was HOT in my room. Then because I had trouble sleeping I woke up after 7am and had to pour myself a shower.

So far I've split my time between three different sites: The laboratory at the Ministry of Health, the Hospital Infantil Manuel de Jesus Rivera, and the Health Center Socrates Flores. In two days I've gotten a chance to meet the various doctors working on the multiple dengue projects that are all affiliated with Eva Harris at Berkeley. These include:

1) A Cohort Study of over 1000 healthy children who live in Managua. They are followed long term and are evaluated by medical staff anually to see who develop dengue and to try to better understand risk factors and dengue transmission.

2) A Clinical Study of all children referred to the Hospital Manuel de Jesus Rivera with suspected dengue. These children are treated and their information is all recorded electronically in a database. There is also a Lab Component in which the viral genomes and host antibodies are analyzed by PCR and serology and are also sent to Berkeley for further analysis.

3) A Community Health Project that sends health promoters out into the community to work on mosquito control and educate the population about how to avoid Dengue.

My involvement in this project is to help analyze data that was collected during the past year from the clinical study. Specifically, we're interested in learning how Ultrasound could better be utilized in children with Dengue.

Arrival in Nicaragua

2006-06-21T16:00:00.000-05:00

Left SFO at 1:30am and arrived in Managua at 10:30am this morning after a brief layover in San Salvador. I'd say I got about 3 hours of sleep, so needless to say I'm exhausted. I was picked up at the airport and then I dropped my bags off at Flora's. Since then it's been a whirlwind tour of the Ministry of Public Health, the Children's Hospital, and the Health Clinic. Now I'm sitting in the office of the health clinic waiting for someone to get me a cell phone - then, once I have the cell phone I can go back to Flor's to take a much needed nap.

Lake Tahoe

2006-06-19T02:18:00.000-05:00

I'm up at Lake Tahoe with my parents and grandmother, relaxing after finishing my first year of medical school. In two days I'll leave for Nicaragua. Should be an adventure.

Here's a pic of the lake that I took with my new digital camera: