playful pests

Hail is unusual in Uganda. So when I first heard pounding on the tin roof in Jinja I wasn’t sure what was going on. “Ehh, the monkeys,” Okumu, the cook, would say half chuckling, half frustrated. They were running back and forth over the roof, playing, or fighting, or whatever.

It is not uncommon to find Okumu launching stones up into the trees hoping to get one just right. He hates them. They’re destroying the garden he keeps in the back and they’ve been doing so since I was here in 2005. Their crop of choice? Bananas. Seriously. According to Okumu they can eat an entire stalk in a day.

These are vervet monkeys. Aside from their playful behavior, and seeming immunity to human proximity, they are easily identified by their blue male genitals. What they are not immune to is the poison Okumu puts out for them when he’s particularly fed up. “Only a few more left,” he says, beaming. Okumu may be one of my favorite people in the world, but I’m rooting for the monkeys.

Exciting Developments in HIV Research

Michael and I were just discussing the recent New England Journal of Medicine article regarding reduction in HIV transmission rates. The study found that men at high risk for HIV (in this study, specifically men who have sex with men and transgender women who have sex with men) had a 44% reduction in HIV incidence when they took a standard antiretroviral drug as prophylaxis. It is extremely exciting to hear this news. Antiretroviral therapy has long been used as post-exposure prophylaxis (such as occupational exposure in the form of needle sticks) to reduce conversion rates, but this study suggests that preexposure prophylaxis is a viable option, as well. Obviously you'd have to take the pill everyday, and you'd have to be able to return to a physician for regular checks of kidney and liver function, etc. The men/women in the study also received counseling regarding safe sex practices--which should not be deemphasized in the least. Regular check-ins with a physician who is open to discussing high-risk lifestyles and ways of reducing risk is paramount in helping patients to make more educated decisions about their health. The study indeed found that enrolled subjects showed reduced high-risk behavior compared to before they began the trial. The authors note that the pill itself may be a daily reminder of the risk of HIV.

I found this last idea very interesting. There are many reasons why patients do not take their HIV medication. But some patients report that the pill is a daily reminder of their disease--and that idea depresses them to the point where they avoid their pills in order to "forget." In a personal aside, I had to take HIV prophylaxis for 30 days after I was exposed to HIV+ blood in the form of a stick from a dirty scalpel during my 3rd year vascular surgery rotation. I had to hang reminders in my bathroom mirror so that I wouldn't forget to take my pills before I dragged myself to the hospital at 4am. Regardless, I can definitely speak to the psychological toll of taking specific medications. Every time I took that pill, I was again reminded of my risk (which was very low--but, let's face it, no one wants that risk) and again got a deadening rush of anxiety and despair. I was fine in the end, and stronger for the entire experience, but I can't help but ruminate on the fact that I only had to take the pills for 30 days. Imagine the idea of having to be reminded of your HIV status for a lifetime. If the act of taking a pill can garner such strong emotion, perhaps preexposure prophylaxis is therefore a great way to remind patients of the potential dangers of unprotected sex--and therefore motivate them to always use protection.

The immediate negative backlash is, of course, the opposite of what the study showed. Much like one of the initial arguments against birth control, some may argue that this preexposure prophylaxis would lead to more unprotected sex as those who take the pill may feel that they are unlikely to convert even if exposed to HIV. I am not of this camp. Above all else, getting preexposure prophylaxis would mean that a patient is hooked into the "system." He/she will have a doctor who prescribes the med, performs regular serotesting, and counsels the patient regarding condom usage. Such sustained support and education, again, cannot be underemphasized.

Furthermore (I'm sure Michael has a lot to say about this), this is an option that can be made available to women in 3rd world nations who are not able to refuse sex or demand that their partner use a condom. This is an option that would give women the power to better protect themselves without having to engage their partner in the decision.

But I'm not done with my exciting HIV news! What completely amazed me is another article that I stumbled across while looking up references for lab.

An article in Blood (from Dec. 8th) is from a group of doctors in Berlin who claim that their patient has been CURED of HIV. The patient was both HIV+ and suffering from a relapse of acute myeloid leukemia (AML). For the AML, he was treated with a stem cell transplant, which is basically performed by ablating a patient's own blood cells and replacing them with donor cells. The interesting twist in this story is that the patient's cells were replaced with stem cells from a donor who lacks CCR5. Patients homozygous for the trait are resistant to most strains of HIV infection because HIV requires CCR5 to enter into and infect cells. It is a very rare trait. This patient, after a very grueling medical treatment, has come out on the other side as no longer HIV+. His titers are negative, biopsy material is negative, and, what's even more interesting, all of the myeloid cells in his body have been entirely replaced with the donor cells (which are CCR5 negative). His Kupffer cells (special cells in the liver), microglial cells (special cells in the brain)--everything and anything that HIV could possibly infect.

While lymphoablating someone in order to give them a stem cell transplant is not a viable option for regular treatment of HIV+ patients, this study definitely is a step in the right direction in understanding the role of CCR5 in HIV. HIV mutates constantly, and patients can be infected by more than one strain, so even if this man is indeed cured, there is potential for rebound of a virus that has mutated to no longer require CCR5 to enter cells. Regardless, what an amazing story for this man, and hopefully a giant step in the right direction for HIV research.

A juxtaposition of the field of medicine’s right and wrong.

On a moral compass, these two articles occupy opposite poles.

The former is a reflection of the privileges of being a physician, while the latter is an illustration of the abuse of such privileges. One is celebrated and the other is…prosecuted.

Excerpts from The privilege of caring: An open letter to medical students everywhere, by Barber Mueller, MD, FACS. Bulletin of the American College of Surgeons, 2006.

“…you will enter an elite and fascinating world”

“Rarely is ignorance of medical knowledge considered misconduct.”

“As a member of the health profession, you will receive many privileges from a society that expects you to serve it with trust and confidence.”

“You will be judged more on how well you care than on how well you cure.”

“You will be permitted to enter the homes of strangers – their bedrooms and bathrooms – and to touch the unclothed and the unwashed.”

“However, accidents do happen, misadventures do occur, and patients do suffer or may even die from (your) misjudgments…”

“…the greatest penalty occurs when a physician loses the purpose in life that comes with helping others less fortunate.”

“It is not a business; it is a calling and a life of caring.”

“Keep your aspirations high, your vision clear, and your eyes on the stars. But, above all, keep the faith.”

Excerpts from Doctor Faces Suits Over Cardiac Stents, by Gardiner Harris. The New York Times, December 5, 2010.

http://www.nytimes.com/2010/12/06/health/06stent.html

“…Dr. Mark Midei, had inserted 30 of (Abbot Laboratories’) cardiac stents in a single day.”

“Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler, and other fixings for a barbecue dinner at Dr. Midei’s home…”

“(Midei) had inserted stents in patients who did not need them, reaping high reimbursements…”

“’(Midei) may have implanted 585 stents which were medically unnecessary’ from 2007 to 2009. Medicare paid $3.8 million…for those procedures.”

“The Texas Medical Board last month accused a widely known cardiologist in Austin of inserting unnecessary stents…and last year a Louisiana doctor was sentenced to 10 years in prison for inserting unneeded stents.”

“ ‘Hospital patients expect their care to be based on medical need, not profits,’ said Senator Max Baucus…chairman of the Finance Committee.”

“When asked to review the cases himself, Dr. Midei found far less blockage than he had initially…The hospital suspended his privileges and eventually sent letters to all 585 patients. Hundreds of lawsuits against Dr. Midei followed.”

“Dr. Midei’s fall was as rapid as it was dramatic. In a June deposition for a lawsuit against him, he said: ‘I didn’t know what hit me. I was bewildered by what had happened.”

It’s worth mentioning that both of these articles caught my attention because of my dad’s influence. He sent the first article to me - and my brother - in our second year of medical school. It’s something I’ve held onto and that I re-read on occasion. And the last article? Well, given his opinion on the gross overuse of stents, it’s possible that, under pseudonym, he wrote this piece.

A Homemade Christmas

I could not ask for better mentors and associates in lab. I'm very lucky. Everyone always takes extra time to teach me how to do protocols, run experiments, and trouble shoot when things go awry. For the holidays, I therefore wanted to express my gratitude with some delicious homemade holiday goodies. I found a recipe for Monster Cookies on one of my favorite cooking/baking blogs: chocolate chips, peanut butter chips, oats, pecans, M&M's, and rice crispies. Sold.

So today I baked a HUGE batch of delicious cookies. I put the cookies in glass jars with flip-top lids and wrapped them with my favorite ribbon from Kate's Paperie. I love the look of glass jars, and they're the perfect way to wrap up baked goods. I'm still spreading holiday cheer...one stick of butter at a time!

an entrance exam

This is hilarious and brilliant at the same time.

So let’s say you live in a world with no birth certificates, and a place where most people – including yourself – don’t know their birthdays. Of course, that eliminates the possibility of celebrating yourself for one day every year, which is unfortunate. But it also means you never get grief for not remembering other people’s birthdays. Depending on your crowd, that’s not a bad tradeoff.

Some people here have to do things differently when it comes to age. Take for example Alon, the driver I described in a previous post about a week ago. We went to Rwanda the other day and he wanted me to fill out the immigration form for him because he was having trouble understanding it. So, we’re at the border and I’m filling out his form and I ask him what his birthday is. And he’s like “Oh, now, I can never remember that.” ‘Seriously?’ I thought. I wasn’t sure whether to laugh or to feel ignorant, or both. “Here’s my driving permit; it should be on here somewhere,” he said as he passed me his card. I had to pause for a second. It was another one of those times when I found myself thinking ‘we’re not in Kansas anymore.’

The above picture is not in any way related to this story (except that it was taken in Rwanda), but simply serves to illustrate the importance of checking your tire pressure before transporting a truckload of sugar cane.

I’m getting sidetracked. What is worth sharing is the way they decide whether to send a child up from nursery school to primary school. We’ve established they can’t use age. Of course, height doesn’t seem fair…plus they’d have to sort out differences between girls and boys. And it’s hard to use the Ugandan equivalent of an Intelligence Quotient test because there are so many languages used in Uganda, and English is introduced differently in each household. So what to do?

Answer:

The headmaster says to the child (spoken in Luganda or the child’s first language): “with one of your hands reach over your head to touch the opposite ear.”

Child: follows instructions (or tries).

I did this experiment a couple weeks ago with a family I’ve known since 2005 when each morning I passed by their house on the walk to school. The kids were happy to demonstrate.

Pass

Fail

It’s excellent. It assesses both cognitive and physical development. If they can’t follow these commands, they’re probably not ready to move on. If their head circumference is that much greater than their arm, then most likely, they’re younger than they’re acting.

It’s not perfect. But I can’t think of a better alternative. It's brilliant.

The Pope's Words on Condoms

Excerpted from “Light of the World: The Pope, The Church and The Signs Of The Times,” an interview with Pope Benedict XVI and Peter Seewald.

http://www.nytimes.com/2010/11/23/world/europe/23popetext.html

Much of this article is true. Go to the poorest, most dangerous, most desperate ends of the earth, and there you will find the Catholics. But it leaves much more to be desired in the way of support for contraception and safe sex practices.

As a Catholic working in a clinic with many HIV patients - not to mention in a country with the third highest fertility rate in the world - I've been thrust in the middle of this conversation. And yes, it is a conversation. Too often I find people in the Church unwilling to converse openly, honestly, and logically about this topic.

It is easy to say that contraception is immoral because it somehow depreciates the act of love between a man and a woman. And abstinence is great! Indeed, it's the only sure bet. And being faithful? Well, no one can argue that. But what do you tell a woman who comes to you because her husband has beaten her for becoming pregnant. She is "faithful" - and so is he, for that matter. But she's one of three wives. Polygamy is legal in Uganda. And because she is the third wife in line, she lives in a hut next door to his first wife and their children. As it is in many polygamous families, the husband will not allow her to have any form of gainful employment, partly because staying at home will eliminate the threat of another man meeting her, and partly because it means she will remain entirely dependent upon him. Her role as "wife": cook the meals, clean the home, care for the children (none of which are hers), and sleep with him whenever he says. But there's a catch. She can only stay in that hut and eat the food he pays for if she does not become pregnant. The matron, or first wife, will not tolerate her husband having a child with another woman, even if he is married to her. And one more thing: she is not to use any form of contraception because, according to him, "it's against the Church's teachings". So what is she to do? She's a 33 year old woman who ovulates. If this man is sleeping with her (is it fair to call it rape at this point?) 5 times a week, it's only a matter of time. So to prevent her from being kicked out of the house - and becoming homeless - we at the clinic put her on the pill. She came back the following week with cuts and bruises all over. There was no need for her to describe what he had done when he found the pills. It was literally painted on her face.

Now she has come to us again, this time 3 weeks late. She's always had a regular 28-day cycle, so it doesn't take an obstetrician to diagnose this one. Again, she is covered in bruises, and as promised, he kicked her out. Poor, beaten, unemployed, uneducated, homeless, and pregnant.

Forget HIV-infected male prostitutes. We're not talking abortion here. This is something entirely different. Until the Church can ensure that sex between every man and every woman is an expression of love, it must not condemn the provision of essential medical care. But that's just my opinion.

Death by Brown Butter Pumpkin Cake

Besides standard, pre-made cookie dough shenanigans, I have never been much of a baker--until now! When Michael left for Africa, I decided to start making use of my new oven (the last one caught on fire--not my fault!--it was literally the oldest oven/fire hazard still functioning in the state of Connecticut). I love playing with recipes, repeating them with new additions, and basically finding the JUST RIGHT mix of ingredients to make the perfect dessert. I am a lab researcher--and baking fits perfectly in with my love for experimenting and testing hypotheses. Yes, I really am as nerdy as I sound. Ask Michael. He agrees.

When a girlfriend forwarded me a recipe for Brown Butter Pumpkin Cake, I started salivating while reading the ingredient list. Pumpkin+butter+cream cheese frosting. How can you go wrong?? With a holiday party approaching, I thought I should whip up this delicious little number for my gracious hostess.

I've never made a cake with so many steps, and I was a tad nervous about browning butter--but WOW what a difference in taste it makes. It's also not as hard as it sounds. You literally just boil the butter until it's brown, pour it into a small bowl, and then freeze the butter mixture so all the sediment is stuck to the bottom of the bowl when you scrape off the top. My whole apartment currently smells like toffee. It's scrumptious. I was also a little nervous about the amount of butter this recipe called for--literally sticks upon sticks. I'm channeling Paula Deen tonight.

These were my cake layers while they were cooling. I recently discovered parchment paper (you can see it peeking out), and it has changed my life. Don't do what my girlfriend did and confuse wax paper for parchment paper. Wax melts. Whoops.

Unfortunately the recipe called for too much frosting, so I had to eat a couple (or 5) spoonfuls just so it wouldn't go to waste... When all was said and done, this was my final product:

Looks delicious, no? It was a big hit!

Christmas Time in the City

The holiday season is here! Every year on December 1st, I pull out the decorations, mull some cider, hang my twinkle lights, and blast Christmas carols. This year, after decking out my apartment, I headed to New York for a holiday party weekend with my best friends from college.

One of my favorite things about the holidays is getting together with all of my friends to catch up on life...something that we rarely get to do because of the fact that we are spread all across the nation, and we all have ridiculously busy lives. But the holidays are a great excuse and good motivation to spend some quality time together. I am so blessed to have my girlfriends!

Not that I need an incentive to visit NYC! The holiday season is by far my favorite time of year in New York. I love the decorated windows, the Rockefeller tree, the hustle and bustle as tourists frantically shop, and that New England nip in the air. The majority of my friends who actually live in New York are savvy enough to avoid midtown during Nov-Jan simply because of the insane crowds--but I couldn't resist going to see the Rockefeller tree. I've made it a point to visit every year since I lived in the city...it's simply magical. You can't help but be awed by its size and feel all warm and fuzzy inside. A perfect NYC weekend to kick off a joyous holiday season...!

Meet Alon

This is Alon, my driver, and this is his car which reliably takes me to and from the clinic. Before I took this picture I asked him playfully how his morning and afternoon had been. He replied in a solemn manner, "Not good." I immediately got serious, thinking he was going to tell me a relative had died. He continued, "I haven't yet taken my lunch."

He can be a pain in the ass sometimes. 'That makes two of us', I wanted to reply. As always, there were many more patients than can be seen in a day, and he had spent the last 6 hours napping in his backseat. And he way over charges me. But I still like him. He teaches me loads of Luganda (the local language), he's usually on-time, and he's really serious about his two little girls going to good schools.

I bought us both a late lunch and we ate sitting in his trunk with our legs dangling over the dirt road. I tried hard to pretend like I cared about his ranting about Manchester United and how they had crushed their last opponent. I wanted to tell him about ND's win over Utah, but realized it would take 30 minutes just to give him a frame of reference. But we just beat USC for the first time in 8 years. He may be getting a short lecture on American football tomorrow...

A Ugandan Thanksgiving

Despite being far away from home, I had much to be thankful for this Thanksgiving.

I started the day by opening a package from Annie whose contents were kept a secret from me until now. Inside the package were literally dozens of individual letters from the important people in my life: friends and family. High school friends, college and med school friends, cousins, aunts and uncles, Gran, mom, dad, Brendan, and Kate, and the organizer of it all – Annie. It was the perfect way to begin a Thanksgiving Day.

In fact, so inspired was I by the letters I received, that I decided to do something special to celebrate. So Okumu and I walked up a hill into a village to seek the owner of a turkey. As we weaved between the houses it became obvious by the reactions from the children passed along the way, that this was a path not many mzungus had taken. The children were even more excited to see the mzungu walking down the hill – this time with a big, dirty, squalking turkey in his arms. They began following and before long, I was leading a sort of parade with my trophy held precariously in my arms.

After laying down a bed of matooke (banana) leaves on the ground, we slaughtered the bird and plucked it naked. Okumu did the rest in the way of organ extraction while Matt (an overseas lay missionary also from Sorin) and I began calling local religious houses looking for a functioning oven. Ovens aren’t used much here, so when they break nobody bothers repairing them. About 7 km away was Brother Alan’s house and he had an oven.

We were off. I had two plastic bags: in one hand was the bird, in the other were a few Nile Specials to keep us busy during what was sure to be a long baking process. Okumu was the general in the kitchen, while Matt and I made the stuffing and tried to stay out of the way. By 8:45 – only 2 hours late, which, on African time, is basically early – we were on the way back to Bugembe with our prize. Matt was in the front seat with the turkey on his lap and a cutting board beneath so as not to burn his thighs. I was holding the gravy which was spilling out with every bump and pothole we hit, and Okumu was next to me with knife and thong in hand. So - worsecase scenario - the car would break down and we’d still have everything we needed to celebrate Thanksgiving in the middle of the road.

Fortunately, we made it back to Bugembe and the rest of the overseas lay missionaries – Terry, Whitney, Damion, Joella, and Derrick - were waiting to receive us in their house to begin the festivities. They had made all the peripheries: potatoes, cassava, vegetable salad, and apple pie. Luckily, we were also joined by Mike Otremba, my Yale colleague who is in Uganda filming a documentary. He arrived from Kampala minutes before we cut the turkey. We circled around, shared what it was we were thankful for on this day, Brother Alan said Grace, and we enjoyed a Ugandan Thanksgiving.

And it all began that morning with the inspirational words from the people I love most. Indeed, we have much to be thankful for.

-Michael