Abaco; Poem - Draft 1

Worn white coral slides between my toes, as the morning floats by;
this is an imprecise hourglass. The wind- and water-
swept scape hides invisible cities.

A giant sea turtle floats by, beckoning me
into the shallow water with her aged flippers.
Her voice is quiet but clear:
"Marco Polo never arrived on these shores. Ours is a fragile Empire."

I'm not sure what Marco Polo has to do with anything, but I keep
quiet.

In respectful silence, I slip my hands into my swimtrunk pockets
and stare out over the ocean. The modest waves lap my legs
in agreement, adding a few plain-spoken but strongly cautionary
words aboutthe destructive power
of tourism dollars and expensive boats.

How has this lovely turtle learned of nature's potential fate?
Can we make it up to her or is it already too late? She catches
her reflection in my cheap aviator sunglasses and takes off down the coast,
paddling strongly and slowly, her head held high.

The sky has volume here. Clouds building over the clear
aqua sea. Small handfulls of water become flying vapor fotresses,
barreling through.

post and run

This is the same old story about TB and HIV in Africa, this time in the the world's foremost medical journal. Never has a broken record approach been so important. This week's New England Journal article is entitled "Tuberculosis in Africa — Combating an HIV-Driven Crisis" (click for full text).

Tomorrow I'm off to Florida and then the Bahamas to see family and friends. I must admit, I'm very excited for SPRING BREAK!! I'll even have a better sense of the med school landscape when I return. I'm reluctant to let my parents open those admissions envelopes, but I imagine that's what will happen. I'll be sure holler on the flip side.

It's official.

I just realized that in the midst of assembling all of these blog posts, I forgot to share some big news: I'm headed to med school in the fall! I received my first full-fledged acceptance last week, and am still waiting to hear back from a few places. There will probably be some wait list watching in the coming months, but the pressure is absolutely off. It's a tremendous relief to be nearing the end of this process -- an ordeal that has lasted nearly a year at this point. And so ends a very difficult and surprisingly rewarding period in my life. And I'll be sure to let you know where I'm headed when I figure it all out. More soon.

the Funny Pages

Alright - I'mma actually try and post some stuff up here this week. The absence of new material from this blog is sort of inexcusable. It's another week plus until I start to hear back from other med schools -- and when I might, uncoincidently, begin to suffer from a terrible case of some senior-itis related illness -- but I might as well use this time to get some material up here. Let's start here, with a recent Doonesbury comic strip from G.B. Trudeau. This shit is just plain old funny, and very reminiscent of some of the nonsense taking place surrounding the drug-resistant TB epidemic in South Africa.

The hospital I was working at in Durban was started by a Christian missionary. As a result, many of the physicians (and also patients seeking treatment at the clinic) hold strongly Christian beliefs -- and some believe in the very strict interpretation of the biblical description of Creation, making them young earth creationists. Every day these physicians treated patients with newly evolved drug-resistant bugs, yet they didn't believe in Darwin's principles of natural selection and modern evolutionary theory. Weird, right? In any case, here's Trudeau's take on an appropriate punchline:




from: http://www.doonesbury.com

You had to be a big shot, didn't ya? You had to open up your mouth.

Here are some highlights of a recent interview with Kevin De Cock (heh), the current director of the WHO's HIV/AIDS Department. Clearly the WHO is a giant bureaucracy, and the words of a departmental director won't ensure that any of the changes he suggests will be made overnight - but it is extremely heartening to hear such an important figure in the global public health arena discuss the complexities of these overlapping issues of health care, poverty, and infectious disease in such a well-informed and accessible manner.

I've also pulled out some of the sections where he explicitly talks about the current state of affairs in South Africa. For those who might be interested, the full text of the interview is here. And I've linked to some of the writing I did in South Africa that relates to the points made - usually more succinctly - by Dr. De Cock.

///

On the link between tuberculosis and HIV:

The recognition at the global level that these diseases are linked is a double-edged sword. On the one hand, the recognition is absolutely necessary; on the other hand, we must not forget that 89% of the world's tuberculosis is not HIV-related. But in Africa, the link between HIV and tuberculosis is particularly strong, especially in southern Africa, and a coordinated response to both is absolutely essential. When you add multidrug-resistant and extensively drug-resistant tuberculosis into that mix, it emphasizes the need for HIV and tuberculosis sectors to work together better.

Achieving this integration will be very challenging; there is not necessarily one model that works. Some parts of South Africa have done well in tackling the disease together, other parts considerably less well. As is often the case, individuals can make a big difference through their leadership, their own technical capacity, and so on. The HIV community has a lot of work do to. We are not doing particularly well, for example, in the screening of HIV-infected people for tuberculosis or in the implementation of preventive therapy for tuberculosis.

///

On the disturbing history of HIV denialism within the South African health ministry:

Last year, I spoke at South Africa's third national AIDS conference. An encouraging spirit of consensus between civil society and government about what needs to be done on AIDS seems to have emerged in the past year or so. The South African government's commitment to tackling AIDS was evident when the Deputy President spoke in a very robust way at the national conference about implementing their new national AIDS plan. And a new national council to oversee implementation is jointly chaired by the Deputy President and a member of a leading civil society group. The rate of treatment scale-up seems to be improving.

However, they still have an enormous job to do. The problems of tuberculosis and HIV in South Africa, individually and combined, are so great—South Africa's HIV epidemic is the biggest of any country in the world. About one in six or one in seven people with HIV worldwide is living in South Africa. It dawned on me while I was there that what happens in South Africa is more important for the future of the HIV/AIDS epidemic than what happens anywhere else in the world. It's also so different from the other African countries; it has such resources available—financial, human, and infrastructural—that you think if they don't manage to get it right there, what is the likelihood of us doing it elsewhere in Africa?

///

On the importance of women's empowerment in fighting the HIV epidemic:

Gender equity is extremely important for public health and for social justice. I think one needs to be careful before saying that there are macro-level explanations for the AIDS epidemic and that if we could only change that aspect it would all be fine. Botswana, for example, is a fair country in terms of the role of women and the respect for their rights, but it has one of the worst HIV/AIDS epidemics in the world. Some of the factors fuelling its high rate include rates of sexual partner change, lack of male circumcision, and high frequency of genital herpes. So you need to work on all these levels: behaviour change, biomedical interventions, human rights, and structural change.

However, for women's health in general, the issues of equity, economic empowerment, and human rights are all immensely important. And helping women to gain power over their sexual and reproductive choices is a key strategy to tackling the AIDS epidemic.

///

On the role of male circumcision in HIV prevention strategies (and the danger that circumcised men might take fewer precautions during sex):

The recommendations issued last March by WHO and UNAIDS were carefully worded to say that male circumcision is only partly preventive (its efficacy is 50–60%) against heterosexual acquisition of HIV. However, it's not every day that we are offered an intervention with a protective efficacy of up to 60%. Yes, I wish it were a vaccine rather than a surgical procedure that has cultural connotations, but it is what it is. The recommendations are careful in pointing out that it is not a replacement strategy, rather it is an additional strategy that must be added to the other advice of partner reduction, correct and consistent condom use, and so on.

There is obviously the danger that men may feel they are protected and will not use other prevention measures—although the guidelines strongly warn about this—but there is the same danger with any intervention that is not 100% protective.

///

On scaling up provider-initiated testing strategies:

First, knowledge of HIV serostatus is extremely low worldwide. Several studies in sub-Saharan Africa suggest that only about 12% of men and 10% of women had actually been tested for HIV and knew their HIV status. In mother-to-child transmission prevention programmes, only 10% of all women actually got tested for HIV. Tuberculosis patients are not being tested, so those who are HIV-infected are not accessing antiretroviral therapy or co-trimoxazole prophylaxis and have a mortality rate of 25% in 2 years.

This lack of knowledge translates into direct adverse effects—people won't get treatment early enough, they will present late with advanced disease, and the outcome is worse. Testing is the essential entry point to timely treatment. And from a prevention perspective, people who know their HIV-positive status tend to adapt their behaviour to avoid transmitting the infection. We are also aware that practice in health-care settings has been diverse. Many countries asked for guidelines for testing in health-care settings.

Me and my sunburnt thighs.

I'll briefly apologize for the temporary break in the blogging action, but I must admit: I'm not all that sorry. Nearly ten days ago this trip grabbed Nate and I by our respectively sun-drenched wrists and sort of dragged us around for a while, eventually leading us to the beaches of Uruguay (which is - I add editorially - not such a bad place to end up.) And now a brief summary of the reasons this trip was awesome:

climbing on stuff
jumping off of stuff
swimming in stuff
waterfalls!
growing beards
lots of delicious Argentine meat and beer
wearing a shirt as infrequently as possible

And now I'm home, watching my sunburn slowly settle into something resembling a tan. I also had what was perhaps my final med school interview today. The school was a very impressive looking place, but perhaps didn't feel like the absolute best fit. I did, however, run into one of my good friends from South Africa who is coincidently beginning her travels along the interview trail just as mine are coming to a close. It made the whole day better to spend it catching up about life in Durban - sharing stories of friends and activities 8,000 miles away.

There's an off chance that I'll be invited for another interview before February is out, but I won't be holding my breath. I'll be so relieved when this whole process is over. In general I'm very positive about how things are going - and I think there's a decent chance that I'll end up in New York City come August - but it has already been more than a year since I began the earliest preparations for my application. That's a really long time to be worrying about the same thing.

And now I'll leave you with two excerpts from an article in The Lancet, depressingly titled, "Crystal meth boom adds to South Africa's health challenges":

"The Medical Research Council (MRC) estimates that there could be as many as 200 000 tik (a South African nickname for meth) users in and around Cape Town. About half the people receiving treatment cite tik as a primary or secondary substance of abuse—far ahead of alcohol. But among the under 20-year-old age-group, this figure rises to 70%, according to the South African Community Epidemiology Network on Drug Use (SACENDU), which is funded by the MRC and the government. In 2002, it was less than 1%. About 90% of patients are coloured, according to SACENDU's November, 2007, update.

Antidrugs activist Naelah Scott says tik has heightened the reign of terror exercised by notorious local gangs as they battle for turf and for their slice in the lucrative drug pie. Chinese triad gangs were initially blamed for bringing tik to South Africa in exchange for endangered abalone shellfish, a delicacy in Asia, but now the trade is believed to be firmly in the hands of the locals. Scott says that the gangsters use minors to do their dirty work, knowing they cannot be prosecuted, and entice schoolchildren with free samples and presents to get them hooked. She accuses the local police station, which is plagued by allegations of corruption, of turning a blind eye to the crisis and allowing the drug lords to operate with impunity."

Pretty heartening, right?

Puerto de Iguzu

Yesterday I got on a bus. Today, after nearly 22 hours on the exact same bus, I arrived at the Argentine-Brazil border where we'll spend the next two days exploring the national park and getting sprayed by a giant-ass waterfall. From the montanas to la jungla in less than a day. Not bad work, but my legs and back haven't taken it lightly.

These long bus rides give you a lot of time to do some serious reading, writing, and thinking. Books I've read so far this week: The Namesake, Lahiri; You Shall Know Our Velocity, Eggars; and today I finishied Diary of a Bad Year, Coetzee. I haven't actually done very much writing, only sketches of things I want to write. I have to finish a poem, a short story, an introspective blog post, and a let-me-into-med-school-NOW letter in the next two weeks - so I don't think any of my notebook scribblings will be going to waste.

Gots to run. Later, all.

In the driving rain (unedited notes from el autobus)

The warm drops pelt against the windshield of our overnight bus to Cordoba. The sound is almost deafening, like TV static turned up too loud. I am also kept awake by the two concurrent electrical storms: the one beyond the windshield and the one inside my brain.

Some of the things I think about:

I imagine myself looking back on this trip with Nate - effectively my brother since we arrived at college that warm August of 2001 - sitting around a table rehashing all of the wonderful things we have experienced together.

And about how Obama pulled out the Iowa caucus, and what that might mean for the future of the Estados Unidos. And science, public health, and everything else rest of the world.

And why does she exclusively refer to her past in the plural. The key, I know, lies in the allieterative Brian, Boyfriend, Brooklyn; the repetition deepened by the Ex- in front of each of the triumverate.

My handwriting is falling apart. Nate is waking up next to me and the electrial storms are now fading. It's time for me to wrap up this missive. We'll have arrived in the morning. Damp, tired, but optimistic about a new day and all of the yet unmade memories in front of us on this trip.

The rain drives us onwards.

Imp't note:

I'm pretty sure all of this writing, or this impulse to write, is fuelled by the limitations of leading my public life en Espanol these past few days.

I can bascially only express myself in the present tense. Trapped in the words of a 6 year old, my brain sends out a clarion call to express - to capture the complexity of tense, sentence structure, and content that my native tongue allows for.

Hopefully, my Spanish will get better - but these 3am scribbling fests are worthwhile too. Goodnight, en serio.

El Tango Argentino

Last night, Nate's family friend and su novio took us out to one of the oldest milongas (tango clubs) in all of Buenos Aires, the Sunderland Club. We sat for a giant dinner of delicious Argentine steaks - which were perhaps even more delicious than the ones I had with my family at Peter Luger's in the Bk last week - at half past midnight. After washing it all down with a couple of bottles of delicious locally grown Malbec, we moved into the converted gym next door where the party was already in full swing.

I can't really do the dancing justice in the few minutes I have this morning, but it was increible. The argentine tango is dramatic, sexy, and transcends all age barriers. The grace with which the dancers move across the floor is stunning. The young, the old, the beautiful, and the not-so-beautiful sliding across the floor with confident turns.

Generally, the women seemed to close their eyes, preferring to be led entirely by feel. The couples' heads are tucked in - almost as if to kiss - as they fly around the stage. The basic moves of the dance are deceptively simple - but there were a few inexperienced dancers out there who allowed us some insight into how hard the whole business actually is.

I caught a couple good pictures, which I'll try to put up eventually. This was the sort of experience that really makes you want to try it yourself (more than partially because good dancers seemed entirely irresistible to the beautiful women dotted throughout the club). Maybe we can try and get some basic lessons before this trip is over.

Today or tomorrow we're headed out of Buenos Aires. Our first stop: Rosario, one of the other major cities in Argentina. We'll use this as a jumping off point to head further north and west into the Andes, where we'll probably do some good hiking and visit Che Guevara's birthplace.

Alright, it's time for me to hit the shower before heading out for the day. Nate managed to get in touch with an ex-girlfriend of his who coincidently has been living in BA for the past year plus., The world is getting smaller and smaller, kids. Happy Sunday, and I'll write more when I can. Peace out.

Live from high atop Buenos Aires

I know, I know - it's been a million years since I've written anything. And even longer since I've written anything of substance. But here I am, on the 20th floor of an apartment building in Buenos Aires, Argentina sharing a few of my thoughts and gross generalizations. I'm just starting out on a 18-day trip with one of my closest homeboys from college.

BA is a big and beautiful city. Lots of parks, tree lined streets, old buildings with decorative wrought iron balconies, newly constructed skyscrapers, and interesting stories behind them all.

It is notable that I once again find myself in a place where I'm not marked as an outsider. The Argentinians are snobbish about their European decent - marking them, in their minds, as superior from those descended from the indigenous peoples who make up the bulk of the population in other Central and South American countries. As a result of this caucasian bent - and my outrageously manly stubble - everyone here assumes I'm a local. My mediocre spanish betrays the reality of the situation.

It's 12:22 in the am, but Nate and I are about to head out for some late night drinking and dancing. The sun doesn't set here until 9 or 10 (it's verano in el hemisphero del sur, silly) and Argentinians are known for their night owl tendencies.

I've liked writing this post a lot. Hopefully I'll be able to find some more time to write as Nate and I begin our travels up into the Andes, back across the country to Iguazu Falls, and finally into Uruguay where we'll lie on the warm Atlantic beaches and ogle the local beauties. I also have my camera, so you'll get to see some of my pictures eventually. Adios.