Three days in the Amazon

Day #1 – I'm writing now from within the ghostly protection of my mosquito net, by the light of a candle. It is dusk. We're in the Amazon. Monkey roars, bird twitters, frog chirps; the occasional shriek of a macaw. There is something so other-worldly about being in the rainforest – even on merely a tourist expedition – a certain untamed wildness about these places that commands respect and caution.

A long story to get here, briefly to catch you up, my parents came on Friday, I showed them around Cusco, and we went to chabad. Expect for Hanna who wasnt feeling well. By the time we got back on Friday night, there was vomit on the coverlet and Hanna was burning up. Shabbos day we went to chabad, walked around, came home and rested and stayed in debating what to do about Hanna. She was still vomiting large quantities of fluids and couldnt keep anything down. We were all slated to go to Manu, the wildest part of the Amazon that is reachable in a few days, but with Hanna sick as she was, we werent going anywhere. Instead we put off the trip one day and waited her out. In the meantime we horseback rode in the Andean hills, over the cloudline, through golden grasses, eucalyptus groves, ancient Incan ruins, and mysterious tunnels and caves. A lovely day, but when we came home, the TV wasnt on, Hanna wasnt complaining about there being no food in the house, she was still pretty sick. What to do. After a lengthy debate, I sent Mom and Dad to Manu – someone should see it, and I felt resourceful and familiar enough with the area to entertain us for a few days while they were gone. So 5am Monday they left. I spent the day organizing our own trip to Puerto Maldonado, the more accessible (fly in fly out) part of the Amazon. That I did it was a feat of luck and persistence in itself, but by this morning when we were supposed to leave, Hanna was still not feeling well. Then the tough call, is she just in post-illness fatigue, or is she really still sick in which case this was serious and we couldnt go. I was ready to resign myself, but in a surprise move Hanna wanted to try – the idea of warm humid weather and getting out of her hotel room was enticing – so we went.

The flight itself was amazing. In only 35minutes we flew over the colossal Ausangate range (which if youve been following the blog, you know all about), and witnessed an impossible terrain change. Until the Ausangate range, it is dry dry arid foothills for miles and miles. After the range, it is instantaneously lush and tropical. The classic mountains-block-the-rain-from-passing weather phenomenon, but to the extreme, with the Amazon on one side and high altitude deserts on the other.

We deplaned onto the airfield, hit with a wall of heat and humidity. It is only 80 degrees here right now (winter) but the powerful sun and 100% humidity make an instant sweat. It was really interesting, a very true and not so touristy rainforest experience. See, people actually live here. A rainforest community. And so it is not pristine or beautiful at first. It is thatch-roof shacks, rickshaws, barefoot kids, and stray dogs. It is chickens running in the streets and papaya plantations. Everything looks about ready to fall down, and certainly not water-tight which makes me wonder about the rainy season here. Once we passes a car in the river. I thought the guy had been trying to drive it through and gotten stuck, but the I realized he had just stopped the car there to give it a bit of a wash. There is so much dust here; the condensation on my waterbottle ran brown. We drove along a dusty dirt road for an hour.As we rattled along, little brown monkeys dived off the side of the road to escape the bus, the rainforest looked disorganized, scarred in places, with vines growing up and down and every which way, such that youre not sure which direction the forest is growing. Weeds, vines, groves of fine feathery bamboo punctuated with giant flat ovals of banana leaves. There are trees here that look like Dr Suess came up with them; thin white perfect branches with no leaves at all, just tipped with bright red poofs at the ends.

After an hour on the dirt road, a boat was next. This is the accessible part of the Amazon, I remind you. Stepping on the boat, you go through a snow-globe of tropical butterflies. Attracted to the banks of the river by salt deposits, literally hundreds or thousands of butterflies create a cloud of flickering florescent colors and patterns. Theyre like pests here – people waving the butterflies off their faces, wincing as their covered in them – which is funny because had we seen any single one of them in the park at home, we would run for the camera. My favorites were little white ones with intricate black spirals on the outside of their wings, like dizzy zebras, and then when open, a luminescent tropical blue band set against black tips.

The boat ride was relaxing, an hour and a half up river, stopping to see a herd of caybata, he large rodent in the world, munching happily on the banks. They look like a cross between a hippo and a guinea pig. It was interesting they paid no attention to our boat, but when one of the tikitiki motorized canoes passed, they bolted. They know who hunts them and who leaves them alone. We saw big white birds with blue faces and lots of egrets, logs of sleeping long-nose turtles and one big caiman (crocodile family). Local gone miners on sluicing rafts waved as we went by. But the boat transporting Amazonian wood did not – the guide pointed it out to me, and said it was illegal, but with poor law enforcement, nobody cared – such is life here. Poaching anacondas for their good-luck heads, crocodiles for their delicacy meat and skin, turtle eggs for soup, nevermind the PBS drives to protect the endangered animals, the reality is here, with now law enforcement people do what they want.

We got to the lodge by 4pm, drank our very welcome starfruit juice. And I promptly took a cold shower (running water here from the river, but clearly no warm water). Hanna is doing really well. Sleeping when she can on the airplane, bus, boat, and now in the room. She is feeling pretty good and recuperating, and actually has a pretty good attitude about the whole trip, "thats a huge guinea pig. These mosquito net canopies are kind of cool." We're going out caiman-watching tonight, and we'll see what tomorrow has in store.

Day #2 – Last night we cruised up and down the river in the boat, listened to the night sounds of the jungle and saw lots of tiny caimans. This morning, 4:55am wake-up call for the hike. Breakfast was 5:30 and we were on the trail by six. This was really the Amazon, how do I know? Because it was uncomfortable. Alive and uncomfortable. First, Ive never seen such diversity of mosquito. Usually they all look the same, you know? But here there were big ones, small one, black ones, white ones, striped ones, and medium-sized polka-dotted ones, to names a few. And they were everywhere. We were like the pied pipers of mosquitos, bringing along a bouncing joyful trail of them as we walked. I could see the rainforest only through a cloud. They hovered, alighted, and sucked when possible. However, I had a wicked good protection strategy: 1. Cover up with clothes that cant be bitten through (no cotton or thin materials). I wore a gortex jacket with the collar flipped up to protect my upper body and back of my neck, and nylon rain pants that traveled into knee-high rubber boots. 2. Hat with a brim. Ive noticed that mosquitos always hover around the top of my head and face, so wearing a hat with a brim has them hovering around that instead, off my face. 3. DEET. Sure its carcinogenic, but so is barbequed food , and you dont see me saying no to a BBQed burger, do you. All over my clothes and hat and jacket, apply liberally (but not yet to skin). Key places to get are edges – hat brim, jacket collar, sleeve cuffs, waistband if exposed. 4. Baby oil for the skin. Good old Johnson&Johnson baby oil over neck and face and hands if you think they might peek out. All this for the excellent result of trudging 6 hours through the rainforest without a bite.

We didnt see much wildlife except the constantly spectacular tropical butterflies and their spiky neon predecessor catepillars, but the flora and fauna was incredible. By 9 we had reached a jungle lake, were they served juice and crackers (just want to note, a juicebox! What a joke! As if that was going to be enough fluids. They had told us to bring water but some people didnt). There was a platform over the water, and we could peer through the cracks to see little pirahnas feeding on the sardines underneath. We took out canoes and watched the birdlife on the water, rainforest chickens with blue faces and 4ft wingspans, colorful tanagers and circling vultures.

The truth is, just walking though the jungle is like being in a fairyland; with the calls of the birds, and the smell of hot earth and living greens. The floor is periodically littered with impossibly purple or red or pink flowers. They nearly glow, and with every step hundreds of iridescent butterflies take flight, as if they were the flower pedals come alive. Giant glowing powder-blue, and tiny transparent outlined wings which allow you to see the jungle through them, they look more like fairies than insects. Then there is the steam that rises from the earth creating a mist around the fauna. When a beam of sunlight penetrates the canopy, you can see the rising droplets and the falling nectar. Its like being on another planet. Every few steps we would walk by a tree or a plant which gave birth to a branch of modern medicine. The salicylic acid tree (aspirin), the quinine tree (anti-malaria), and when the guide offered me a medicinal stick to chew (but not swallow), I took it happily asking what is this for? In a few seconds my tongue started tingling, went numb, and the numbness spread throughout my mouth rapidly; anesthesia, she laughed.

Then it was time to head back. We took a different trail home and it was tough going. First, my mosquito strategy started backfiring as the temperature climbed. Black gortex-nylon-rubber is not the best choices for keeping cool, and drops of sweat ran down my back, but Id rather be hot than open my jacket to the hungry mob waiting just outside. I ran out of water. Of course, because I had brought only 1.5L (Im sure Avi is so annoyed), and I drew out the last drops over the final hours. Then, there was the mud. So much mud. It was, in some place, feet deep and made of heavy clay and as the day heated up, it steamed furiously as we slogged through it. As if alive as well, it grabbed my boots and determinedly clung to them as I tried to pull them back onto my foot. It was tough going, hot and mosquitoy and fighting the jungle that tried to hard to suck us in and eat us. The best feeling ever was when we saw the man-made steps out of the jungle to the lodge, and got a tall cold glass of passionfruit juice.

Hanna slept through all of this: The night activity and all through the morning hike (good thing, Im not sure she wouldve enjoyed), got up briefly to pick at lunch and went back to sleep within 5 minutes. So she hasnt seen much, but shes here, and shes not complaining, so its a start. Tonight, night hike (not sure about that after todays), and then tomorrow, home. This has been great but a little lonely with no one to share it with, and quite so authentic that Im ready for a break from the hot humidity and the cold water – how nice to think of cool mountain air and a warm shower.

Now its siesta time, the heat of the afternoon, though some of the staff are out playing soccer. There are moneys in the trees overhead and a macaw on our window sill. Otherwise, the steady hum of the cicadas indicates the heat, and I am just going to sit for the next few hours and watch the jungle baste.


Day #3 – So Hanna couldnt handle the night hike, so I arranged to redo the caiman watching she had missed the night before. But she didnt have energy for even that. So she went to bed, and I went again on the tour. It was really fun – I hadnt realized how much I enjoyed it the first night. The air on the boat in cool and wet with no bugs at all. The stars are brilliant and both Jupiter and Mars are visible in the sky, along with the famous Southern cross. The night calls are incredible, and there is a 10 minute meditation where they turn off the motor and you just drift along the river silently listening to the voice of the night. The caiman spotting itself is cute. Someone stands in the front of the skiff with a bright flashlight (hooked up to a handheld generator for power) and scans the shores for the two red caiman eyes to flash back. Then we sort of sneak up on them, as much as 10 people in a motorized craft can sneak, and inevitably they look at us for two minutes and then scuttle into the water. They are surprisingly fast when they decide its time to go.

I went to bed at 8pm as always here, to the perfect sound of the million cricket choir, and was awoken this morning at the standard jungle wake-up time of 5am, to nearby throaty roars in the jungle. After Costa Rica, I know enough to not think these are jaguars, but rather, huge Howler Monkeys, which to me is about as scary. By seven we were back on the boat, speeding home towards Infierno port and then the bus and then the plane. As far as Im concerned, the water is the only place to be in the jungle. As the sun rose, it gave color to the black forest changing it back into its iridescent green. The clouds began to dissipate and the furious blue charged out. I could have stayed on that boat forever, skimming the flat water between walls of Amazon.

Back in Puerto Maldonado was the reality of being a person trying to live in the jungle. The chickens and the poverty and the little motorscooters and the lazy shacks; an ugly city of the edge of such pristine beauty. It is interesting, the people here are somehow different from the Peruvians I have met so far. There seems much less joy here. First, everyone who worked at the lodge seemed sort of beaten down, doing it for work and not for pleasure, which while the reality most places, was not my impression of Peru in general. Like the taxi driver who took us up to the ruins in Cusco; he stopped off to show us his favorite spot with the best view of the city. That could have been another fare he was missing, but he enjoyed talking to people and showing them his city; things like this have been my experience here. In Puerto Maldonado, people seemed to have problems, they work 7 days a week, all year, including Christmas, and though they get one month vacation, the tourism business is just too much, and theyre burnt out. This is what they said to me. It reminded me of medicine, and I thought how everyone needs a break, no matter where they are or what theyre working in, people are only made to work so hard before they start missing the things that make life fun and meaningful. Another example is our guide who was 24 and had a 7 year old son. She had tried going to school in Puerto Maldonado, but the classes were poorly taught and the teachers always on strike, plus she needed money, so back to work she went. She is a woman of the jungle, and left only for 1 years before she couldnt stand being away from it anymore. This is how it is, the jungle is in their blood, and yet in a way, a dead-end. She dreams of studying environmental law, but previously there was no law school in the jungle. A new one opened so maybe she'll try it, seem how it is, a possible new path.

Today is a fast day and a travel day, since there is not much I can do besides sit in a boat-bus-plane-van-train which without exaggeration is the plan for today. Tomorrow, we'll be positioned for a different cloud forest and a different tempo; Machu Picchu.

Ancient deep tissue wisdom

My parents are here! And the hotel offers very cheap massages on the day of arrival. So at 3pm we all filed downstairs into the high-end spa for our massages. We were given the option of Relaxing or Deep Tissue. I should have known by the fact that Deep Tissue was in a whole separate classification -- set in opposition to Relaxing -- that this was not going to be fun. I have a vague idea that it would be painful, but clearly not enough to stop me from trying it.

The problem with deep tissue massages, for me, is that without a lot of meat or fat on me, the only thing deep to my tissue is bone. Wincing the whole first thirty minutes, I kept thinking, I cant survive this. Certainly not without crying out. It was a bone-crushing rub. The masseuse actually got up on the table so that she could throw her whole weight behind her elbow which was being pressed again and again over my scapular ridge. I wasnt a believer then; mumbling mentally about this being a pseudoscience. I thought my back and body might go easier than my neck and shoulders, the muscles being bigger there, but turned out that my muscles were just pinged against my ribs like a xylophone. And there was no love in it either. This wasnt a Bethany massage. It was borderline angry, just shy of sadism (not so shy actually, but I want you to keep thinking that Im a pretty normal person).

Then around minute 40, a transition happened. I started to enjoy it. I cant tell if my body had just warmed up, or if the masseuse was getting tired and so pressing less hard, but whatever it was, I started to really relax into it. By the last 10 minutes I was actually smiling instead of gritting my teeth, and when I got up, I was a new woman. A lot like the stretchy mother in The Incredibles, and very happy. Crazy but true, in one hour, I went from skeptical to sold on the ancient wisdom of deep tissue massage.

Ahhhh

Luxury. Im staying in a hotel. With wifi, television with English channels, movies, a bathtub, and hot matte de coca in the lobby. Its inexplicably rainy and cold here in Cusco, and Im planning on taking the day off from here on out. A hot bath, matte de coca in bed, with a movie and internet. What a great day.

La Ultima Dia

What an AMAZING last day. Wow. Storybook. Cant go into it all right now, will have more time tomorrow afternoon. Basically, the morning we drove way up into the mountains and blitzed out 125 patients in 3 hours. It was insane. But I had the time to sit and talk privately with a woman who lived with the stress of her father being an alcoholic. Not violent, but she was so worried about him and didnt understand his disease. That was probably the most effective thing I've done in Peru. Then at 1pm we headed to Lamay, the clinic was packed by Jackie, and we ran out for a 2pm meeting with the Mayor.

It was some meeting; it was a diplomatic banquet.

In the top of the municipal building, they had decorated the party room with streamers and balloons and flowers. Everyone was there -- the elders of the community, the clinic workers, municipal workers, and of course the Mayor and his wife. They served us vegetable soup (still dumbfounded why anyone would opt not to eat meat), and beautiful fresh fruit, and we sat and talked and enjoyed. There was Bach on in the background. Everyone felt like they were going to be asked to waltz. Then Guido got up to talk. He spoke about all the back and forth in the year before, and how excited everyone was when we got here. But more than that, he said how impressed he was by the compassion and attention and sensitivity that each doctor and student displayed towards the poor people that we treated. And of course how excited he was to have a partnership that will continue on into the future to effectively improve the health of the people of Lamay. Then he presented us all with two large plaques, written on leather and pinned to a framed background. They are of course hilariously Latin American and so wonderful. Then each of us got a "certificate" which we assumed was a piece of paper, but here apparently means a hand-painted wooden plate personalized for each person. Incredible. We all hugged and laughed and some more people gave speeches and I even cried a little. We gave small gifts to Guido and Lucia (who always made us lunch), and formally gave the microscope to the clinic... with a red ribbon and all, like in a perfect dream. So much friendship and good will. I cant wait to come back next year. They all stood in the street and waved to us until the bus was out of sight.

The Ultimate Penultimate

Strike days are always the best because we spend time with people in the community, and thats the most important work. For example today in the market we met up with Yanett, she invited us to her house. We ate cake and drank papaya juice in her kitchen and spoke with her parents about healthcare in Peru. She brought various herbal remedies from her extensive medicinal garden, and they promised to teach me each and every yerba when I come back.

But tonight was the best night. For me, the best night in Peru. Nothing in particular happened, but it was the culmination of all our efforts here in a feeling of family and good will and excitement over improving the future.

First we had our regular Tuesday night meeting, with presentations of patients (from epilepsy to GERD), with some extra reflection. The reflection ran along the lines of, what did we give these people, what did we accomplish, etc. And we came to a very important insight. Yanett's family was saying to us what we so often hear in the US: The last generation of doctors just dispensed pills, we need someone to listen to our problems, to care, and to tell us we'll be OK. Raphael Bendezu, the Peruvian doctor here, also offered a similar insight, saying that listening to these people and reassuring them or directing them within the medical system is the most important part of the medicine we do here, and indeed medicine in general. The very fact that people like us -- who seem impossibly wealthy, educated, and glamorous -- spend time holding hands, kissing cheeks, bandaging wounds, teaching and explaining, and treating the poor country people with the respect they deserve, is a new experience for them. And can do as much for their state of mind as temporary fixes like albendazole or tylenol. As Raphael said, much of what we see here is a product of poverty, which is a bigger problem than just us (worth tackling, mind you, but slow to change), but a caring and knowledgeable ear can do wonders. Especially when coupled with meds, supplies, and community action to improve the system. A special moment was when we reflected, maybe we did more to help than we thought.

During this meeting, Senor Guido (the mayor) showed up to seek us out, and refused to interrupt the meeting, waiting instead for us to finish. It was amazing, but he was like a changed man tonight. In the past, very reserved, austere, tonight he was all smiles and kisses. Kisses! He knew our names and our plans and was thrilled about the ideas of a mobile clinic and a womens shelter. More than thrilled. He was like a giddy schoolboy making faces and jokes. Jokes! I kept looking around like, is this really happening? He met with everyone and then stayed for dinner where the table talked regular social talk, trying (unsuccessfully) to explain American Football. It was an exciting energy, that we did great work, the mayor and community were our friends, more than that, like family, and we were planning for a future together -- a future dedicated to improving people's lives slowly but surely.

Dinner was the next phenomenon. We bought a huge cake to surprise the staff, and when dinner was over, everyone gathered and ting-ed our glasses and Anna stood up and said thank you so much, we feel like family here. Then Alida hustled the staff to sit down and we all served THEM cake and they laughed and ate and asked for our emails, and there was such a special warmth all around. Even Edwin had a piece of cake (one wont hurt). It was the perfect end. Guido and Edwin, the staff, some random stranger who became our friends after we fed them cake. Everyone was working together, using their power and lucky positions in life to help people less fortunate. Of one mind, and one heart. Sound cheesy, but thats how it felt in the room full of friends.

If nothing else, we built wonderful relationships with incredible people. Relationships to last a lifetime. This really was something to be proud of.

Strike!

This is Alida, Gita, and I at Hearts Cafe, an NGO we're making connections with in Ollantaytambo

Yep. It had to be that our penultimate day was quite Peruvian in that we cant leave the town. STRIKE!
This happens about once a week or once every other week. The strikes here are tranquilo, calm, with people parading, megaphones, and road blocks made of huge boulders that people roll into the road. No violence. Unless you try to cross the lines, then they slash your tired, throw stones, and maybe beat you up. But if you just walk over and dont provoke them by crossing union lines, tranquilo. So despite big plans to do a huge outreach program in Matinga, we are taking a forced administrative day in Urubamba. Its Ok. We need it. And tomorrow will just be crazy busy with all the stuff we couldnt do today!

Los Peruanos

Do you know, I love working in Peru. I really do. And there is one major reason for that; the Peruvian people. Unlike the stereotype some people have of South American countries -- siestas, fiestas, corrupt governments, manana-manana attitude -- Peru is quiet the opposite I have found. The Peruanos have huge hearts. They are dedicated to their people, and work often back-breakingly hard to support their families, friends, communities. They give charity at every level. They go out of their way to help a stranger as they would a friend. They laugh a lot, enjoy their chicha beers, are connected to their culture; know the old dances, language, philosophies. Values of community, physical work, connection with Mother Earth (pachamama), spirituality, centeredness, are so prominant, that people put aside more superficial values of money, fame, and success without thinking twice. The children are happy and playful, even with runny noses. Taught to work hard, the kids here are loved deeply, nursed and carried against moms safe back for years, but expected to be independent and to pitch in. One man explained to us the Ancient Incan morality as the famous phrase: Dont be lazy, Dont lie, and Dont steal. Its really these values that we see in the modern people.

So why is this coming up now? Besides every single day receiving an education from the Peruvians in generosity, selflessness, priorities (family, friends, community), today bore a special example.

We have been talking a lot amongst ourselves about the needs of the community here that we can work on in the future. A mobile clinic is a pretty straightforward goal which would be helpful. A more long-term one would be to establish a shelter for women and children subject to domestic violence. As I have mentioned in a past blog, we see many women bad situations (though my guess is that the numbers are comparable to the US; others here believe it is more pronounced because of cultural acceptance. Research question!). We saw this as a need, but it is most important what the community sees as a problem. Clearly we can only help out a community effort since a) were not so big and powerful b) were only down here one month a year and c) most importantly this needs to be a grassroots effort owned by the community (just aided by us) as this is the only way it will be embraced and sustainable. So today we had a meeting with Dr Sotomayor who works at the Lamay clinic day to day and spoke with her about our idea for a womens and childrens shelter but made it clear that we only are suggesting this as a possible course and her feedback would determine our course of action. She got really excited (for the first time as far as I have seen), and said she has been thinking about this need but never had any money or specific external push that could get it going. And she rounded us up and took us in the ambulance to the site that she has been plotting to use for this purpose. It is the old clinic. Abandoned for three years, in cobwebs and peeling paint and broken windows, we all looked at it and saw a brightly painted safe and healthy shelter building. She even showed us (though we couldnt get in because the bars on the front were rusted together), where the guard would sit, how the fence would run, she had this all thought through and just needed a little help to get it going.

This is how the Peruvians are. Forward-thinking, hard-working, and community oriented. When we think of an idea, they had thought of it already last year, but they just dont have the resources to do it. It is so rewarding working with them because they have all the elements and drive to better their own lives, they just need a little money and attention and energy to do it. And those are the only three things that we can really bring with us, so its a perfect partnership.

Pampallacta

Great day serving a very poor mountain community. Sang 80s music the whole ride home, for the ultimate in incongruity.

Today, clinic and Pisac festival.

Transportation

So we all listen to eachothers phone calls, conversations, etc – this is how it is when you share a lobby for internet calls and one bedroom with three other students. Tonight it happened to be hilarious, because I listened to Anna describing our daily commute to her boyfriend over the phone, and I realized, the mundanities need to be recorded. So from her mouth to my blog, here is an average commute home.

We ride the public bus one hour each way to and from Lamay. None of the public busses match. They are all different colors, are labeled incorrectly with the names of random places, are different sizes, but they do share the feature of never stopping entirely. They just slow down at stops while everyone walks/runs alongside and jumps in the open door. Then, as Anna was saying, at rush hour, people are just crammed in like sardines in a can. There is no courtesy and whoever gets on first sits. After that, you are just kind of smushed into your seat by pregnant women with babies wrapped in colors against their backs, old men with shoes fused to their feet, old women with all manner of grain, grass, potato, or livestock in their manta (cloth wrapped against the back to form a pack). Everyone smells like corn-meat-smoke and fields and B.O.

Theres two people work the bus, the driver and the guy who takes the money. The latter just walks around knowing who paid what and where everyone is going and so how much they owe. One of the eternal mysteries is how he keeps track. We cant figure it out. Apparently the guy who takes the money is also the guy who shows the registration (stored under a felt blanket on the dashboard) to the police when we get pulled over at a random checkpoint checking if we have too many people on the bus (We do. No one gets off though, the bus just pays a fine and continues on). While this standardness is going on, we just stand blankly, with everyone else, waiting for the bus to start up again and take us home. An old guy in the pile of people is grunting vamos vamos; sir the driver got off to talk to the cops. Ah. Vamos.

Then the bus spends a lot of time in the left lane. Sometimes for a cow, sometimes to pass a mototaxi (see below), but sometimes its just not entirely clear that the whole lane-distinction thing matters. Theres not much in the way of traffic, but going around mountainbends in the middle of the road does create a just-dont-look feeling in the pit of your stomach. Especially knowing that the bus coming the other way has about the same level of regard for lane-lines as yours.

Between Urubamba and Cusco, the way we go when we run our errands there, is only one city, Chinchero. In Chinchero, entertainment always boards the bus to keep us occupied until Cusco. A mentally retarded man singing Peru's top 40 hits (asking a sole for the privilege of listening), or a slick-talking salesman selling superfood and eucalyptus balm (he convinced me, I almost bought it).

Within Urubamba are the mototaxis. I frankly dont even write about these things because Ive gotten so used to them, theyre ubiquitous. The are motorbikes that pull a nylon box in the back that you ride in. I didnt realize the first night that we were here – until Satoko tried to get in the front seat with the driver – that there was no front seat, unless you straddle the bike with the driver. Strangely they are covered in decortaive stickers – it looks like a 6 years old girl picked them out. And they especially love batman stickers. I thought they just loved any stickers and that there must just be a wealth of batman stickers here since that is what at least 50% seem to go with, thematically speaking, but then today I saw one with no stickers but "BATMAN" handwritten across the top, so go figure. Maybe they really just love batman.

Once we get off at the bus station, there is the sigh of "were almost home," but first there are a few more obstacles. If its evening, you have to hop two fences to go the short way, or you have to walk all the way around the hill, to get to the road. Then is an uphill climb filled with swerving mototaxis. Then is the dark unpaved part of the road, and around the bend is the mad dog who tried to bite anyone in a group smaller than three. Then is the secret hole in the middle of the street that drops into the stream – perfect size for an ankle twist. Then finally, you ring the bell and the huge door swings open into Edwins paradise. THEN, youre home. Home, sweet, home.


Smushed on the bus!

El Hogar en Anta

Today was some organizing in the morning. We met with Mayor Guido about future directions in the clinic (see the write-up below), and planned the next few days. Tomorrow, the town of Pampallacta, a health fair, with en emphasis on womens health. Friday, half day in the clinic, and a cultural break to visit Pisac's festival of the Virgen del Carmen. Monday we return to Pampallacta to work with the children, specifically. Tuesday we go with Yanette to another region to work in Matinga. Wednesday is the last day in clinic, and then everyone leaves for the US.

Alida was great enough to write up some of our big discussions as to where this project should go next year. Here is an excerpt:
As you may have expected with our actually being and working here in person, seeing the communities first hand has led to an evolution of our ideas and perspectives on the needs of the communities here. The biggest unmet medical need that we have been seeing continuously day in and day out is a combination of women's health needs and domestic violence. Together with the Mayor of the town and the clinic in which we have been working, and with the indispensable help and guidance of Dr Falcone, we have begun to plan a women's health clinic and domestic violence shelter. Currently there is no shelter that allows women to stay with their children in the entire region, there may be one in Lima, but we are unsure of even this. The idea we are developing is to use a part of the clinic building that was built for women's health issues, but is currently not being used. The women would come in to get women;s health care, such as PAP smears, birth control, counseling education etc. If it comes up that there are domestic violence issues (as we have seen in patient after patient here as the root of many presenting chief complaints) the women would then have the option of being admitted into the shelter. A rehab program for alcoholism and education program is being developed in the community currently by the mayor and this, we believe, would be a perfect compliment and addition to the effort. The center would be staffed by local health care workers, a social worker and a nurse, and we are planning to write grant proposals to support a health professional student working at the center for a semester each term. Along side of this project we will continue to run the July rotation for the CCF and CWRU students who would like work in the medical clinic as an elective clinical rotation. We are also planning to write a grant to support the project itself, but this will be to supplement to the money provided by the government.

Well written, Alida. Thats just one of our many exciting schemes... theyll come out one by one, dont worry. Poco a poco.

Now back to today. In the afternoon after lunch with Lucia and finishing our patients, we drove through the most fantastic countryside up above the glacial peaks through golden cornfields, past surprising mirror lakes, to an isolated little city where we visited the orphanage that Peruvian Hearts supports. It was lovely and the girls were of course adorable and vivacious and each unique and different. We gave check-ups, socialized with the children, and all around enjoyed yet another interesting experience of being welcomed into a Peruvian community.

Birthday!

Today was the best possible birthday. First, it was a work day, and Alida and Elizabeth and I went to Cusco to get the Lamay clinic money account dealt with and pick up meds for an outreach program we're doing. It sounds boring but it was perfect. Normal, but meaningful, and really gives you the perspective that you need on your birthday. As we were driving on a bus through fields of plowed corn, varigated yellows and browns, with the Andes music piping surrounded by Peruvians who smell like meat smoke and maize.

I want to write about the whole day, but we have to be out of the lobby by 10pm so Ill post it tomorrow.

Tonight, we had dinner at Edwin's and then they served jello for desert (which clearly had gelatin and so I didnt eat), and we were prepping to finish dinner with out mattes, when the lights went out and a fire cracker popped and they came in with two cakes complete with candles and a wish (to come back next year, shhhh). One was from Edwin and the Group, the other was brought by Yanette, a Peruvian friend we met here who we're working with to coordinate care to very distant mountain towns. I was so surprised I blushed all through the dark and then served everyone two pieces of cake a piece. Wow, guys. Best birthday ever.

Everything is good!

Busy, we leave at 7:30, commute an hour, work until 4-5, home at 6, dinner then meetings/studying/reading on what I saw during the day. But tomorrow Ill blog, for SURE. :)

Shabbos Rest

I got up for breakfast at 8am, saw the Fikes off, and went back to bed. I was too stuffy to sleep but I moved my sleeping bag out to the huge porch and spent the day resting fitfully in the warm shade, reading my book and the parsha, falling asleep, sitting up to drink some tea, laying right back down. At about 3pm, I thought it was high time to get up. I took a cool shower to try to wash the sick sweat off, and felt much better, I made motzei, ate lunch, and continued to read and rest. Bill Fike taught me this awesome home-remedy for congestion that saved me today. One teaspoon of salt in 8oz of warm water, put it in a syringe, and flush it up one nostril until it comes out the other nostril. The salt pulls the fluid out of the boggy nasal membranes, and opens everything up. It made all the difference. So I pretty much was only conscious for the end of Shabbos, but I have to describe to you what it is like to watch the sun set from my porch overlooking the Andes:

The porch is a natural, earthen, red. It is quite large, and retains the heat of the day, so walking on it in bare feet allows you to soak up the sun through your soles. As the late afternoon comes, there is a brief, cool breeze, the changing of the guard, and as quickly as it came, it dies down. Beyond the green haven that my porch inhabits is lots of brown and yellow fields. The end of the corn husks being toted away by wheelbarrow. A peasant, knee deep in mud, churning it with his feet into smooth material to make the bricks of the mud huts. An escaped goat wanders along the road, munching happily on the other side of his fence. The daytime sounds of children's play, cows offended by the milkers, lots and lots of dogs barking at each other. Long shadows reveal the undulations of the mountains, each wave casting darkness on the next. Then the light drops away. An evening bird sings its night song as the children are called in by their mothers. It is suddenly cool and blue. The mountains looks flat, like disney-world facades which I could push over with a nudge of my toe. Jagged dimensionless silhouettes against a duskblue sky. The world falls quiet, with only the indistinguishable sounds of a nearby brook and the breeze. Everything is so still, you can hear the footfalls of the last people walking home on the dusty road. Tall, feathery eucalyptus trees rustle and sway, as if on their own. A yellow light comes on here or there in the huts. One star. Right in the middle of the sky. The twilight is heavy, it is difficult to see through, as if mist or dust formed a screen around the porch. And then it is night. Clear, perfect night. Thick heavy but perfectly transparent blackness, punctuated only by the stars.

Busy, busy

Sorry I havent written in the last few days. Weve been so busy.

Really quick update. Yesterday was a strike so we went on a hike to the nearby glacier, which, as it turns out, is not too nearby. We were lead by two kids from a local orphanage training to be mountain guides, and a local social worker who runs these sort of programs for the whole area. After hours of bushwhacking and scrambling up the sheer edges of the Andes, we had to turn around. But we learned from our guide about natural local medicines and the needs of the towns nearby and are actually working with her to make health fairs to deworm he kids and teach about nutrition and such. More on this later.

The strike is off today and were leaving at 7:30am to start work there so until then!

Week 2

So I have to start with this evening because there is some strange energy in the air tonight. First, it got cloudy today. Very unusual. Big dramatic stormy-looking clouds. And I even felt a few droplets materialize before they decided not to rain. Then we rode a van home, only half of us, and Alida and I got dropped off in the main square to hit an ATM, but though it was there yesterday, it was literally uprooted and there was no money to be found. So on the way home we used our last soles to buy pasta, avocado, and milk. We walked home in the dark, arms full of groceries, and delayed in the courtyard talking to Edwin about hiking the nearby glacier (we're anticipating another strike Weds and Thurs). When we came into the lobby, I waited for Alida to get her key, and from the darkness emerged the silhouettes of a couple. A very hassidic couple. My friends who run the chabad house, Ofer and Yael, came out of the shadows with a... "Rachel!?" The Rabbi and his wife are staying at Edwin's hotel. Not only that, they are old friends with Edwin and his family. They came out for a visit, etc. And they were throwing a BBQ next door. A BBQ. With kosher meat. After many meals of banana and peanut butter and yogurt and granola and the occasional avocado ("palta"), a barbeque sounded too good to be true. Amazing. Plus, I made plans to stay with them in Cusco over Shabbat, assuming the strike is over.

What a small world. I came to Peru when I saw Ana Dodson on TV one morning; she had adopted her town Lamay, whose Mayor is Guido, who worked with a higher political figure who connected him with Edwin, who funds projects for the town but who really lives in Cusco where he was connected with Ofer and Yael through the Chabadnik's uncle who apparently worked with the President of Peru, who of course knew Edwin as well, so they became friends. And I spoke no Spanish so had to come a month early to Cusco during which time I became friends with Ofer and Yael while learning to talk to Edwin and Guido, and now, with my arms full of avocado, delayed 1000 times, I was standing in the lobby at the exact right moment to intersect with both the Rabbi and his wife and Edwin. Go try and tell me that is random.

Anyway. We had a big meeting last night in which we reviewed the goals and accomplishments of the clinic thus far and planned for the next week. Today went smooth as butter. We saw 100 patients, of which a number of them (like 20 maybe) were only for glasses. If youre interested, this is what we're talking about and thinking about:

Meeting after week 1:

• Broad goals for next week
a. Sustainability
i. Interfacing with current clinic setup better
1. Discuss with Carla – set up meeting time
a. Emphasize that this is their show
b. Learn more about the community
i. Community Education how?
ii. What would you like us to teach?
iii. Domestic violence issues, engage religious leaders in community, group: living hearts, ask Guido for advice
iv. Do they have literature etc that we could work with in Public health campaigns
ii. Outreach: Pampallacta
1. Set up with Edwin details
2. Monday of the last week health fair
iii. What else is needed to keep this sustainable
1. Microscope, ultrasound
b. Better organization of clinic
i. Smooth running of clinic
1. The Cap: 80 - 100 medical
2. Separate glasses from medical by numbering system
3. Set a schedule daily
c. Educational componant
i. How to make Docs positions meaningful
ii. Improve 4th yr experience
iii. Improve 2nd year experience
1. Triage in the morning
iv. Other necessary seminars/study sessions?
1. Stagger second year students

To bear in mind:
Part I of their hopes for our participation is to see if we can help get them fitted with the missing pieces that will allow them to work with the Federal government and be self-sustaining.

Part II is to help the clinic gain the confidence of those not only in Lamay, but the thousands of underserved who live in the deep rural mountains and receive no medical care at all.

Shabbos

Today was quiet. Everyone left in the morning for Cusco except Jackie who stayed back with me to rest. I had breakfast at 8:30-9:30, then walked with Jackie to drop off the laundry downtown. Back at 10:30, I read then napped until like 1:30pm. Got up groggy, folded my stuff and cleaned the room, ate a banana with peanut butter, an orange, and a chocolate for lunch, with a little bread to wash and bench. Then we walked around the little town of Urubamba again, Jackie bought a cloth, and we came home, drank some matte, ate melons, and watched the sunset.

Last night was GREAT. On the way home from work, everyone was like, "do we have to meet tonight?" and I was like, "Yea... for pizzas and drinks and unwinding and talking not at all about the clinic" and everyone went "yay!" So we all went down to a pizza place for post-week 1 beers and pizzas relaxation and bonding. Everyone ordered 15 pizzas for 15 people and it wasnt even enough. There were at least 2 rounds of pisco sours (the local drink), and cervesas all around. It was great; so much good energy, everyone happy at the good work that week, high morale, feeling like we did something. We all laughed and told hilarious stories and got to know each other better. We toasted each other and ourselves and one week of incredible success at Clinica Lamay.

Smooth

A quick note before the morning begins. We are working hard here. Really hard. With a 30minute commute up and down the valley in an old bus, a 8-5 work schedule and really no breaks, strangely I feel like Im on a rotation. :)

Id say so far this week has been a smashing success. Yesterday we were infinitely more organized, seeing 80 patients in the same amount of time we saw half that yesterday. The level of teaching for the fourth years has been great -- we see patients on our own, present them with an assessment and plan, and have the doc look over the physical/history and do some one on one teaching. Everyone agrees they are learning a lot. The first years were paired with four years for a while yesterday. I taught Matt how to do basic things like take blood, give an injection, as well as STD differentials and such indicators. Today they will be paired to a doc directly, since now we have more doctors here (2 more arrived last night).

Yesterday we officially diagnosed the Leishmaniasis from the day before (unusual at this elevation but she had just come from the Jungle), as well as domestic violence, renal failure, UTIs, standard gastritis and diarrhea, hypertension, palpitations, quite a few hernias (inguinal, umbilical, ventral), and a very sad neurological birth defect. It was a full full day. Hilariously, the goiter shown below wasnt even a complaint, I stumbled across it on physical exam (how could you not), but she said she had it for 20 years with no problems, so there you go.



Today we round out our excellent week with a final day of 8-5 and then the weekend off to explore Cusco, the market in Pisac, and for some, Machu Picchu.

The Start

So yesterday the strike was on so we took the beginning of the day to sort medications, hold talks on derm, ID, and related pharmacology, and then we took a relaxing afternoon for group bonding over lunch, buying necessary foods in the market, and seeing the town. In the evening, medical Spanish practice sessions, and an early bedtime.

---

This morning there were no lazy clouds, only immediate blue skies and excitement. Everyone was down to breakfast and hour early and ready to go. I tried to prepare everyone (and above all myself) that it is likely to be a slow organizing day since the radio announced we were coming Thursday not Wednesday. We shouldnt be frustrated if it is as quiet as it was when we visited on Monday afternoon, we need the down time to prepare. I neednt have worried.

We were planning on getting organized in the morning, and starting to accept patients at 1:00pm. By 8:45am there was a line.

As we watched people trickle in steadily, it became obvious that the longer we waited to see people, the longer we would be at the clinic, and by 9:15 I was taking stitches out of a womans whose bull had impaled her. It was only her leg, but there was an entry wound and exit wound and it was infected and ulcerated of course, and why are the stitches still in three weeks later. Plus, do you have any idea of the kind of logistics necessary to treat even the smallest thing? First, just a place to sit. She sat in a spare dentistry chair. I squatted on the floor. Second, light. We left the door open for the hallway light, and I used my penlight to spot the stitches amongst the scab and the healing tissue. Third, water. That wasnt going to happen. Even if it was running somewhere in the clinic, its not clean anyway. Lots of iodine and alcohol. Then there is the issue of providing excellent treatment with limited medications and procedure options. Its really tough. There is always the "this is what the evidence says" and then the slightly different "but this is what we have in the medroom" talk. The woman took 45minutes. There were 10 people in the waiting room when I came out at 10am.

A local nurse was helping us organize, and at one point in the afternoon I commented to her, "this is really a lot of people" and she corrected what she thought was a Spanish error "you mean a FEW people." I looked at her, "no, a lot." She looked at me for a long moment and then decided to laugh, "Doctorita, espera." Just wait.

We had three people in triaje (triage) taking chief complaint, history of present illness, and vitals. Then passing them on 4th year students who filled in the gaps and did an exam, developing their assessments and plans and then staffing them with one of our three docs. Nearly every one requires the docs to consult each other. What did we see? Before we started there was a general question of whether we would see lots of common issues or many rare ones. The answer is both. We saw diarrhea and fever, lots and lots of back and leg pain (herniated discs, compression fractures, radiculopathy), depression and anxiety, hypertension. We saw brisk GI bleeds, severe gastric ulcers, corneal edema (possible slow cranial bleed), domestic violence, gaping sores on the mouth... maybe leishmaniasis. About 40-45 patients in all today, which means triagers and doctors saw about 15 each, examiners/students about 8 or 9 each. Remember that for each patient we do our own labs, we are our own pharmacists. No one stopped for lunch, everyone had to be pried one by one from their post to eat a banana and orange and drink some water.

We stopped taking new patients around 3pm and the waiting room was empty by 4:30pm. We were all shell-shocked and reeling, and got home after dark an hour later. Some went straight to eat, others straight to shower. Our nightly 1- hour debriefing session was delayed until 8pm (in fifteen minutes), while people collected themselves. There is so much to talk about tonight, it is wild. Tomorrow's goal is to be more streamlined, because Im afraid that really the masses will start pouring in.