On Race

by Leana S. Wen, M.D.

Mr. A is a 23-year old black man with abdominal pain.

Mrs. S is a 48-year colored woman who was the restrained passenger in a rollover MVC.

Sammy is a 10-year white boy with fever.

OK, maybe it�s just me, but there�s something different about how these medical presentations start. I went to medical school in St. Louis, and once in a while, we did hear of someone referred by race. Maybe someone with sickle cell anemia; maybe someone with a rare inherited disorder. Maybe. But race is a common and almost unavoidable descriptor in South Africa.

And not just in the medical setting. I came to South Africa for the first time about three years ago, and the woman I rented a room from, a lovely Africaans lady in her late-sixties, raved about my �Oriental� skin. Her son was dating a beautiful woman, a �colored� woman. She was also telling me that she and her family were extremely progressive and opposed the apartheid from the beginning, even resigning from the Dutch Reform Church because of its initial position on apartheid. But how could she progressive, I wondered, when she used such terms to describe people?

Race in South Africa is fraught with a troubled past that the country is still grappling with. Under the apartheid regime, race was the sole determinant of what opportunities a person had. Apartheid ended less than twenty years ago, and remains in the consciousness of all but the very young. Interestingly, the way that South Africa has chosen to deal with race is to be completely open about it. Some of my other work was done in Rwanda, where the Rwandan genocide of 1994 is still very much in the public consciousness as well. Rwandans chose the path of not talking about race and who was hutu and who was tutsi. South Africa has taken a very different route by making race front and center of self- and public- identity.

As I came to see, my old landlady was hardly a remnant of some kind of old world tradition. I asked one of the young registrars how I was supposed to identify the consultant, and she directed me to find the �tall colored man�. My fianc� and I were looking for a DJ for our wedding, and the form to fill out asked for basic information: size of event, type of event, type of music requested, age of guests, and� the race of couple and race of guests. My South African fianc� didn�t blink an eye, but my American sensitivities were startled to say the least. Can you imagine such descriptors being used for hiring a DJ in Boston?

So what about this obvious display of race�is it a good thing? I don�t think I understand enough of South Africa to comment. I can say that the people here find the political sensitivity around race in the U.S. in particular but also U.K. and Europe to be excessive. Why not just get it out in the open and obviate passive discrimination, they would say. You�re probably thinking about race anyway. I would argue, though, that my American eyes see race perhaps as being less distinctive and less important of a descriptive. The last ten patients I saw in the U.S., for example, do I really remember them as a black man or a white woman? I�m not sure that I did, but I�m not sure that it would have been a bad thing if I did.

Curious to hear your thoughts, on this and other topics. Please email me, wen.leana@gmail.com.

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Becoming a Doctor in South Africa

Leana S. Wen, M.D.

Greetings from beautiful Cape Town, South Africa!

I am here for the month based out of the University of Cape Town/Stellenbosch University to work on a project examining the perceptions and experiences of the first group of emergency medicine (EM) graduates from the first EM training program in sub-Saharan Africa.

South Africa is a country that�s twice the size of Texas with a population of 50 million. At least 10% of the population subsists on under U.S. $1 a day. At the same time, it is a country where wealthy Europeans come on holiday and buy multi-million dollar vacation homes. In Cape Town, one can go from seeing dozens of the most expensive yachts in the world to tin shacks within a five-minute drive.

Healthcare in South Africa is relatively advanced. It is the training site for doctors from all over Africa; in fact, many American and European medical students come to South Africa to gain trauma and procedural experience. It is also a study of contrast. The private sector that serves less than 20% of the population exhausts over 70% of resources, and it�s possible to receive a very high level of medical service in South Africa. The public sector, on the other hand, is vastly over-burdened, and the lack of resource is most prominently felt in remote rural areas.

The training of doctors follows the UK convention: medical school starts immediately after high school and lasts for six years. Following a one-year internship, new doctors are assigned to do another year of community service, usually in a remote, underserved part of South Africa. This national service model exists in many other countries, and is a powerful way for doctors to give back to their country. It also instills and reinforces the idea of service as being integral to our profession. The U.S. has explored similar service-in-exchange-for-training models, including the novel concept of a national medical school devoted to public health and service to the community. http://www.cogme.gov/18thReport/default.htm. Unfortunately, the idea of compulsory service is not one that has taken hold in capitalist U.S. society.

Most doctors in South Africa practice as general practitioners or non-specialist medical officers. While GPs work exclusively in the primary care setting, medical officers can choose to work on any specialty service. Many graduates enjoy the flexibility of choosing to work in orthopedic surgery for six months, then internal medicine, then anesthesia�. It�s quite a difference from our training system where we choose our specialty while in medical school.

The downside for South African doctors is that for those who wish to specialize in an area, there are few specialty training posts (called registrarships). Also, even after the registrar completes their training, there are problems finding consultant�our equivalent of attending�positions. In my discussions with EM program graduates, the major concern seems to be that after their four years of training, they can�t find EM posts, and as result, have to go back to being a medical officer�the same position they held before their registrarship. Their training and skills are not put to use, and they wonder what is the point of undergoing such a rigorous and difficult training program. It�s a dilemma I�m sure we as US graduates can relate to as well!

I�ll be writing my thoughts on the practice of medicine and specifically EM in a separate post. Until then, stay well, and thanks for reading. Comments welcome at wen.leana@gmail.com.

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Weight Limit

Hasan Merali, MD

Khamer Spirit House

We set off early Tuesday morning for the village of Preambang. The dry season proves to be quite difficult for our ship as the water level is so low. On the way to Preambang the propeller got caught in a fishing net and our captain had to dive in to cut open the net with the kitchen knife. We will likely only be able to use this boat for one more week before having to rent a smaller boat that can handle the shallow water for the remainder of the dry season. Further along in our trip, two men in a fishing boat nearby were frantically waving for us to stop. Thinking that perhaps there was something wrong with the ship that needed immediate attention we cut the engine and waited for them to approach. They were selling shrimp......

In Preambang I saw something completely different....volleyball! There were a few patches of cleared land around the village and some children were having a game. They only have a couple of months of this, however, as soon the water level will rise and completely submerge any bits of usable land they have. There is a spirit house in the middle of the village soaring above all of the other houses. It is at least 12 m high above the water level and in the rainy season the lake will just touch the bottom of it. We spent a day and a half in Preambang seeing patients at the local school. Because of the level of malnutrition Dr. James and I decided to give multivitamins to all of the patients we saw. Unfortunately our supply ran out in the next village but we will be sure to bring more stock next week.

The second village we went to was Maot Khlar. We had been there briefly last week to see a woman with a burn on her hand but this time we came to do a full day clinic for the entire village. There are about 220 families living there. All of the children I see are less than 12 or 13. Anybody older than that is usually working out on the lake for days at a time fishing. The other thing we noticed was that there were very few Vietnamese patients coming to our clinic. When we inquired about this we found out that many of them are worried that they will have to pay money, or that they will have to show some type of registration/immigration card, both of which they do not have. Our captain/cook is Vietnamese and has slowly been working on this problem by trying to educate the Vietnamese people in each village telling them that we do not require any documentation or fees.

The morning was completely peaceful in Moat Khlar while we were seeing patients in the Chief's House (a floating platform with a wall on one side). In the afternoon, however, that all changed. Our director brought over 30 Malaysian Rotary Club members who have been involved in funding various projects in the villages including water filtration devices and schools. They were all eager to get off the boat and see what we were doing. One by one they dismounted their two boats and got onto the platform as it slowly sank lower and lower into the water. Finally, the platform reached its limit and as it touched the water, all of the creatures living happily under the floorboards in the space between the floorboards and the water suddenly emerged. Dozens of cockroaches, mice, and even scorpions suddenly began scurrying all over and onto each of us. I can normally handle these creatures well and they tend not to bother me but as several cockroaches were climbing up my leg, I quickly grabbed a broom and joined a few others in trying to sweep them into the lake. Lesson learned. On a positive note I think there is a good chance TLC will get more funding from the Rotary Club as many of them were in disbelief that this was actually someones home.

On a different note I wanted to write briefly about two other organizations that TLC has partnered with. The first is KIDS International Development Society. They are a Canadian based organization that work in South East Asia and are currently building a floating school for the village of Moat Khlar. It is being constructed in Siem Reap and will be towed to the village once it is complete. The second organization is the Angkor Hospital for Children in Siem Reap. I was fortunate enough to have a tour of this amazing facility a couple of days ago and I was quite impressed. This is where we refer any patients we see in the villages that are sick enough to need inpatient management or further diagnostics. They have a full inpatient unit, an emergency department and even a 6 bed PICU/NICU. They take medical volunteers (medical students, third year pediatric residents, attending physicians) as well as non-medical volunteers.

KIDS International Development Society: http://kidsdevelopmentsociety.org/index.html

Angkor Hospital for Children: http://www.angkorhospital.org/

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Primary Care at The Lake Clinic, Tonle Sap Lake, Cambodia

Floating Villages

Hasan Merali, MD

Moat Khlar Village, Tonle Sap Lake, Cambodia

I am sitting out on the front of our boat, TLC I, as we enter a small channel with reeds on either side. After a seven hour journey on Tonle Sap Lake with just the horizon in every direction, it's nice to see some signs of life. As we go further down the channel I spot some small huts in the distance. This is the floating village of Moat Khlar. As we draw nearer to the huts, I see that none of them are connected. Each small hut floats alone separated by at least 3 meters from the next structure. Some homes are bigger, and sturdier, while others only seem to have enough room for one person and are slowly sinking. My eyes are drawn to the children sitting at the edge of their homes, feet dangling in the water, smiling and waving at us.

The team was at this village last week for a clinic and they wanted to follow up with an elderly woman with a severe burn on her hand. We pull up to a larger home, the chief's home, and wait as he sends word to the woman that we have arrived. About 15 minutes later she comes with her daughter. Dr. Sambun, TLC's primary physician, examines the wound. It appears to have healed well since last week, despite the fact that the woman spread pig fat on her wound against his advice. Her hand is cleaned and a dressing is applied. We are thanked by her, and the chief of the village and then set off. About 2 hours later we arrive in Pichakarei. The sun is just beginning to set so we anchor the boat, eat dinner, try some fishing with no luck, and rest.

The next day we are up with the sun setting up our clinic in one of the floating schools. There are 5 desks in an open room. The first desk is for registration, three physician desks and a desk that is the dispensary. Luckily the two other physicians I am working with, Dr. Sambun from Cambodia, and Dr. James from the UK are both family medicine doctors. This is perfect for the pediatric resident who has not done any adult medicine for nearly 2 years! That day we worked from morning to night with only a short break for lunch. I saw countless children, making recommendations, giving advice and prescribing medicine all with the assistance of my translator, Sri Mom. As a first year resident, it was certainly nice to have Dr. James and Dr. Sambun sitting just a few feet away so I could ask them questions and get their opinions on the many cases I was unsure about. I also found the 'Oxford Handbook of Tropical Medicine'' and 'Where There Is No Doctor' to be invaluable resources that Dr. James and I were constantly passing back and forth. Overall, I was struck by the amount of malnutrition and dental problems these children have. I want to spend more time learning about their diet to see if we can possibly make some recommendations that will make a difference to them.

In the evening we quickly place a sheet and a mosquito net over the bucket seats in the boat to sleep on. It is only 8 pm, but with complete darkness, quiet, some jet lag, it is easy to fall asleep. When I wake up the next morning we are already on our way home since it is such a long journey back to Siem Reap. I wish we were able to see more patients, but I understand the limitations of the boat with so much travel in such an isolated region. Next week we have a longer, 4 day journey planned, and I can't wait to be back.

The Lake Clinic: http://www.lakeclinic.org/.
Short Documentary: http://vimeo.com/9875870. 

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42 GOATS

42 GOATS


E.E. Freeman, MD PhD



We pull over on the dusty track. The health technician opens her door. I look around expectantly, but all I see are a few cacti. She points up the scree slope, and I see a small goat track winding it�s way through the cacti. I follow her up the hill, a thirty minute scramble between rocks and shrubs, and then suddenly we pop onto a plateau, and there is a long mud hut, a roof of sticks, a small garden, and a goat pen.



An old man, wool cap and rubber boots in place, is lying on a sheep skin next to the hut, looking out over the valley. He does not see us, so we call out to him, but he does not hear, and remains still, pondering his view.



And suddenly there are kids, and dogs, and hubbub. �Welcome, welcome,� a tiny shrunken woman hidden behind years of wrinkles greets us. �This is the doctora, she comes from the University to check on the uta [common name for Leishmaniasis],� the health technician explains. �Well well,� the old lady replies, �we have plenty of that here. You are most welcome.� She gestures at a vacant spot on a sheepskin. She lines up her grandchildren, each of them with large scars across their faces. �We all have uta here,� she explains. �Even me - � she gestures at a scar on the tip of her nose. �All of my children, all of my grandchildren, they have had the uta.� One of the young boys, the only one with red, active ulcers, has a thick white cream on his cheek. �What is that?� I ask. �Egg white to help with the swelling,� his grandmother replies. The health technician chimes in, �this little on was treated at the university three times, but he failed treatment. We are out of ideas, and his mother is sick of trying to bring him down to Lima when nothing helps.�



What is it about this place, that every single member of the family has been affected by leishmaniasis? The grandmother is more than happy to show me around. She shows me her garden, her favorite herbs she uses on the children�s faces to help with their wounds, her many goats, 42 to be precise. I look at their dogs, hosts for the leishmania parasite, checking their noses and their fur. I am still without an answer, other than that this farm must be the perfect combination of elevation, plant, and animal life for both the sandly and the leishmania parasite to thrive.



After my walk around the farm I return to the sheepskin. The old man sits next to me. He�s been deaf for allegedly two months, though I guess it is longer. The local health technician started him on ampicillin, just in case it�s from an ear infection. A bilateral ear infection in an elderly man with no other symptoms? Instead I talk to the old man about getting his hearing tested, maybe getting evaluated in the city, but he grins and shakes his head.



�How old are you?� I probe.

�Six grandchildren!� he motions across the sheepskin proudly, grinning.

�No, you deaf fool! How OLD are you? How OLD? That is what the doctor is asking!� his wife yells.

�I�m a deaf fool? You can barely see!� he shakes his fist at her, her eyes cloudy from cataracts.

�What can I do with him, what can I do,� she shakes her head, not unkindly.



His children came for him one day, up from Lima in a car, which is a feat in and of itself, to bring him down to the hospital for an exam, but he refused to go. �I�m 81, why would I go to Lima? I�m old, I�m meant to die here. No need to waste anything on me. I don�t have too many years left.� So he stayed. She was scheduled to have her cataract surgery done in Lima, but she heard about a woman across the valley who went blind after eye surgery. �It�s safer not to.� So she stayed. And here they sit, on their farm infested with sandflies, with a beautiful view across the Andes and their 42 goats.



My biology student hands me a pad and a pen. �You should write it down. They�ll listen to you. You�re a foreigner and a doctor.� I write in huge letters in Spanish: �GO TO LIMA FOR TREATMENT.� They laugh at me, and I laugh with them. They will be sitting here on their sheepskins, of that I am sure, watching the clouds roll in, tending to their farm, until death comes to take them. It does not matter what I write.

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Utilization of empiric treatment for leishmaniasis in endemic communities of Peru

LEARNING LOCAL
E.E. Freeman MD PhD



I do speak Spanish. Or so I thought, until I tried explaining my purpose here in Peru to my taxi driver on the tortous drive between Lima's airport and my apartment. "I work with leishmaniasis," I explained in my best Peruvian Spanish accent, "from the bite of a sand fly." He stared at me blankly. Perhaps I was not pronouncing leishmaniasis correctly. "LeishmanIASIS?" Nothing. "LEISHmaniasis?" Still nothing. "LeishMANiasis?" Nope. "Well, it's a parasite transmitted by the bite of a sand fly. We don't have it here in Lima. It's at higher altitudes." That would have to do. Perhaps he'd never heard of it? I found that slightly hard to believe, given the high prevalence rates of Leishmaniasis in Peru, and given that most Limenos travelled into the sierra (mountains) or selva (jungle) at least at some point, whether to visit family or at least touristically. There was, of course, the more likely possibility that in common parlance Leishmaniasis had another name. I would have to wait until clinic tomorrow to figure that one out.



"Uta," as I later discovered, was my missing word. Uta, derived from the phrase "the bite of the rat," presumably because the ulcers can look like animal bites, comes in two forms. Wet uta is an ulcer from leishmaniasis, whereas dry uta is a flat lesion from an inject bite without parasitic involvement. Now, when people ask why I'm here, I explain that my research is on La Uta. This is followed by an instant flash of recognition, and stories about family members or friends who have had uta, and what they did to treat these notoriously difficult ulcers.



Tomorrow I head into the field, to visit endemic communities affected by uta. I'll be visiting patients in one of the Leishmaniasis Research Group's phase II clinical trials, as well as gathering background information for future investigations on empiric treatment of Leishmaniasis with battery acid, hot chili peppers, and the like (an unfortunately common practice). The plan is to sleep on the health center floors in these remote communities, visiting our patients during the day when the sand flies themselves are at their least active, trying to minimize our own risk.



I'm in charge of packing for the expedition, which includes our driver, a Peruvian physician, a Peruvian biology student, and myself. The medical supplies didn't worry me. I already had our Leishmansis smear slides, lancets, and gloves packed up. "There's no where to buy food up there," warned my Peruvian physician friend. "So make sure you pack enough food for everyone for several days. You never know when you'll get trapped by a river. Our driver likes coffee and eggs, otherwise he'll get grumpy. Oh, and don't forget a small food token of appreciation for the nurses in the rural health posts that will be hosting us." My confusion must have been obvious. "Marshmallows!" she chuckled. "They love marshmallows!"



Local knowledge triumphs again. Off I go, several bags of marshmallows tucked into my backpack, to study "the bite of the rat."

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