Rememberences of Cali

Things I will miss, won’t miss, and will always remember (in a funny way, in a good way, in a bad way) about Cali….

-Mannequins with big breasts, mannequins modeling disposable contact precautions gowns
-Spanx for men and women, and all the signs advertising them
-More shoe stores than there are people in Cali
-Tight, shapely jeans
-Men being okay with doing aerobics at the gym
-Lack of personal space in the gym classes
-Traffic lights turning red and yellow together, as a warning they are about to turn green
-Inability of people to move out of the way on the bus to let people off before trying to get on
-Huge, cheap, prix-fixe lunches, small dinners
-Lulo, lulata, oblea, fresh fruit everywhere, arequipa
-Bakeries on every corner
-Open coal grills and arepas and hot chocolate on every corner
-Ice cream on every corner
-The ice cream man pushing the ice cream cart while it plays the song "Fur Elise" very loudly
-Pre-programmed voices running a long repeating loop of announcements, trying to sell fresh fruit on the street, very loudly, over and over again "Rica rica rica!!!"
-Identical coffee cups wherever I’ve had coffee, saying Café Colombia, with the Colombian flag
-Kids’ amusement parks at every shopping mall
-Cartoon characters for every fast food chicken restaurant
-Individual packets of one piece of gum you can buy on the street
-Friendly taxi drivers, friendly people in general
-Everybody greeting you, all the time, with an entire conversation
-Every single person always asking me how I like Cali and Colombia, when I came and when I’m leavnig
-Everybody doing everything “con gusto”
-Too much personal attention at clothing/shoe stores
-Slow hospital elevators
-Nurses wearing contact precautions gowns, caps, and face masks 24/7
-Pedestrians never ever having the right of way, not enough crosswalks
-Surprising lack of good enough cafes given all the coffee they grow here
-Every house with an open courtyard
-Parking attendants on the street
-Toilet paper doesn’t go in the toilet, it goes in the garbage
-All there is to do at night is go out salsa dancing
-Party buses
-Reliable 5 pm breeze
-The way the clouds look at dusk as they hover over the Occidental mountains, houselights flickering, Cristorey statue glowing green as he watches over Cali

Last set of pictures from Cali

Observations around Cali, and all my weekend trips...

https://plus.google.com/u/0/photos/106419429553511755451/albums/5947419406355448865?sort=1

Two Kinds of Clinics

On a pretty ordinary side street in Cali, a few blocks off of Calle Quinto, just behind the bullfighting stadium, there’s an HIV clinic. Unless you know it’s there, you probably wouldn’t even notice it. The only signage is a logo over the front door, two hands entwined in a show of support. Inside, it’s quiet and peaceful, with a spacious waiting room and a beautiful garden in the back. Doctors and nurses shuttle patients calmly between the waiting room and the few exam rooms.  Secretaries wearing identical clothes on each day of the week (Tuesday is khaki pants and white, flowered blouse day) efficiently register patients and collect medical records from the back. Most patients are greeted as longtime friends, which they are. Their thick medical records can attest to years of antiretrovirals, blood tests, and a few hospital stays here and there.  This definitely felt a lot more like Yale’s Nathan Smith clinic than any of the overcrowded, privacy free, bare bones clinics I saw in Zambia. Colombia’s HIV prevalence is the same as the US, about 0.6%, and many of the same people are affected: men who have sex with men, transgendered, economically disadvantaged women and IV drug users. Over the past two days, I’ve been fortunate enough to meet some of these people and hear their stories.

First there was Señora R., a short, quiet, middle-aged whose husband either died or disappeared many years ago, and she discovered her HIV positive status earlier this year when she landed in the hospital with neurological symptoms and was found to have toxoplasmosis. She made it through okay, and now here she was, ready to be initiated on treatment. She had a strange, peeling, bumpy and itchy rash on her face, arms and legs which had been present for months.  She had chronic diarrhea. She looked tired and drained, but fairly well put together. I watched the doctor explain to her that her CD4 count of 19 was very low, and that her viral load of 300,000 was very high. They went through each and every box of medication, five in total, and how to take it. Señora R just smiled slightly and nodded her head.  I think she understood, at least some of it. Going from 0 medications to 5, taken at different times of the day, is not easy. 

Then there was J, a 35 year old transgendered female, and she looked so good that if I saw her on the street and didn’t know her past, I wouldn’t suspect a thing. She wore bright, multi-colored sneakers, tight, low rise, skinny jeans accenting her every curve, a fluorescent colored sleeveless vest top, unzipped slightly at the top just enough to reveal her ample breasts, bleached blond hair pulled back in a ponytail and a subtle hint of makeup. She spoke comfortably with her doctor. She’d been feeling good but eating a lot recently, and her weight was slightly up. Always takes her medications, she’s been on the same regimen since 2009. No concerns, no other questions. On her way. See you in a few months. 

Today I met  Señora L, who surprisingly, I had met before. In this city of 2 million people, what are the chances that a visiting student from Yale on an infectious disease rotation will see a patient at the hospital as a consult, and then see her again at a random, independent HIV clinic. But there she was, and she recognized me first. Even when I saw her in the hospital, she had a positive energy and pride about her. Today, despite her very slight stature, and the mystery surrounding her new recto-vaginal fistula, her lymphadenopathy and why her viral load is no longer undetectable, she continued to smile and speak positively with the medical staff. Her biopsies have already been done, there’s nothing to do but wait for the results, and she’s okay with that. Talk about continuity of care.

There’s a fabulous attending at the clinic. Although he is not technically ID boarded, he has been treating HIV patients for years, and their clinic is involved in occasional clinical trials. He has spent countless hours with us, presenting interesting clinical cases, talking through lunch hours and late into the evenings.  I saw pictures of a patient with disseminated histoplasmosis of his skin. I saw a case presenation of a patient co-infected with both mycobacterium tuberculosis and mycobacterium avium. Never have I seen anything like this before.  He could go on talking for hours, and he does. I think he does it because he loves it, and he wants to pass it all on. Although they don’t have the newest ARVs available here, they have many regimens that work well, and some of their patients have been coming to see them for over 20 years.  In Cali, HIV care is alive and well.

As Cali seems to be full of private clinics, I was able to visit another clinic today as well. This one, however, is a bit different. The doctors who run this clinic, “La Clinica de Alergias, Stem Cells Center” are a married couple that I met at the rabbi’s house. If we were in the US, they’d be living in Berkeley. They are wonderful and friendly and kind and like to talk about their healthy diets as well as their healthy souls. They invited me to stop by their clinic today. At 6 pm, just as it was getting dark, I found myself walking through glass doors into a peaceful courtyard, trickling little fountains, greenery, large pieces of artwork, luxurious couches, almost like walking into a hotel lobby or a private home. The mezzuzahs on the doorposts and Star of Davids on the metal railing of the gate let me know I was in the right place. They greeted me with open arms. “Remember that patient I was telling you about on Shabbat, the one with Crohn’s disease and the colostomy and rectal prolapse who was so sick before? She was just here. She’s doing much better now! It’s regenerative therapy!” I was hoping that my visit to the Stem Cells Center would leave me with a little more information about what exactly is their stem cell therapy, where they get the stem cell from, how they process them.  On their website I watched a video of one of their patients, an old woman with osteoarthritis who at first is walking very slowly and talking about her pain. The post-video shows her walking along more steadily, and answering that it doesn’t hurt a bit. Another success of the regenerative therapy, which they’ve been doing for 25 years.

I didn’t actually learn any of this though. Instead, I sat with the wife for a bit, talking about our families and backgrounds (her family is from Germany, they came after the war), and my impressions of Colombia (something every Colombian I ever meet asks me) and then about the Jews in Colombia and what their situation is like. Then she very generously offered to have their restaurant, Elements, cook me a fabulous fish dinner, although she and her husband could not join me, they had to work. So as I sat solo on the dimmed terrace of the Stem Cells Center’s Elements Restaurant, dining on delicious fish, fresh salad, and a glass of white wine, the evening Cali breeze blowing pleasantly, I reflected on the amazing hospitality I’ve experienced here in Colombia, on the many invitations I already have if I ever come back, and on what their stem cell treatments are exactly.  From looking at their beautiful and successful clinic, it seem that although some of this country is suffering, and the public healthcare system seems in danger of falling apart, somebody is able to afford to come to a clinic like this.

For me, Colombia continues to be a country of contrasts and extremes. I wonder if the stem cells could help the HIV patients?

Highlights from last weekend, on Lago Calima, a lake created by a dam about 2 hours north of Cali, world renowned for kite surfing and wind surfing.

A view of Lago Calima, and the kite surfers

 Kayaking with Jaime

Hummingbirds taking a snack at "Dieciocho", literally, it is Kilometer 18, on the road outside of Cali, where the weather is much cooler up on the mountain, and people stop at restaurants. My stop involved hot chocolate with cheese dipped into it (sounds awful but is yummy).

A Weekend on the Farm

Last December, when I chose to come to Colombia for this six week rotation, I could not have imagined that attending a 35^th high school reunion would be part of the experience.  But somehow, through the natural course of hospitality and invitations that I have come to appreciate so much here, that’s exactly where I ended up this weekend. 

It started with the invitation to the finca. A finca is a farm. For Colombians, this could be an actual productive farm, and there are certainly many in the region. A finca is also the word used to refer to a country/weekend home, and it seems that many middle and upper class Colombian families have the good fortune to have a finca.  Visits to the finca are usually a family affair, and families here are large and close knit. As a Colombian you will socialize often with your extended family, and will spend many holiday weekends together, often at the finca. It also seems to be tradition to invite visitors along to the finca. This past weekend was a holiday weekend, which seems to happen often in Colombia. I asked several people what the holiday was, and none of them seemed to know, but just that Monday was a holiday, and so it was a good weekend to go away.  Clara, Jaime’s wife, invited me to her family finca, outside of the city of Manizales, and I enthusiastically accepted.

Manizales is about 3-4 hours north of Cali, halfway between Cali and Medellin.  Along the way, you will come across many actual fincas, regions known for growing one item. The sugar cane region, the maize region, the pineapple region, and finally, the coffee region, the Zona Cafeteria, one of Colombia’s most famous regions. In the sugar cane region, massive and endless fields of sugar cane end at large processing plants, ingenios, where they make sugar, a cane liquor called Aguardiente, and sweet, creamy sugar cane candies. The longest and largest trucks I have ever seen, hauling trailers and trailers full of sugar cane, chug along slowly back and forth along the main roads. In the pineapple region, there are fruit stands where you can easily pull off into the side of the main road, have them load a few pineapples into your trunk, and hand you a cup of freshly sliced pineapple through the window. Up in the hills, in the coffee region, you can admire the beautiful coffee plants, planted every which way along the hillsides, and then stop at a rest stop atop a mountain, and sip a fresh coffee, a tinto, while taking in the green hills around you.

This lovely, fruit filled and green drive brought me to the city of Manizales, in the mountains, sometimes even above the clouds. A small city, a university town, a city with the coolest public transportation I have ever seen. Where else can you take a cable car up and down the mountain, as part of the regular public transit system?  Hanging there, over the entire city, mountainside and valley, I wanted to stay in the cable car and just keep going around and around, up and down. The original cable car in Manizales was built to transport coffee down the mountain. There are still some remnants of the original wires going over downtown. Manizales seems kind of like Seattle, often cool and rainy, and it definitely did rain while I was there, a torrential downpour made little rivers in the narrow streets. But the sun came out just in time for a stop on the promenade that runs along the edge of the mountain. As I indulged in an oblea,  a Colombian treat of very thin, almost crispy crepe/waffle like dough with a caramel-like spread between the two layers, I looked out at the clouds, at the green mountains, and to the valley below, towards the finca where I was headed.

Clara’s finca goes by the official name of El Limonar. It says so on the front gate, the linens in the house are all embroidered with it, and if you order delivery from the little town, all you need to say is, “deliver to El Limonar” and they’ll know where to go.  It’s located about 45 minutes down the mountain from Manizales, in a little village which seems to be nothing but fincas. The town clears out during the week. Unlike the rainy and cool top of the mountain, it is hot down there. Perfect weather for lounging by the pool all morning. Together with Clara, her two brothers, one sister, their children, three dogs, some roosters and chickens, we passed a lovely weekend.  Weekend highlights:
-Attending Clara’s brothers’ 35^th high school reunion:  Yes, somehow I got invited to this too, which was happening right down the road from the finca. I spent the afternoon and evening, socializing, dancing, and dining with the class of 1978. Everybody seemed quite happy to dance with me, despite my poor sense of salsa rhythm and some tried to speak with me in English. Awkward moment of the evening was when one of the classmates, who had since become a politician and wrote a book about his life, was trying to sell copies of his book up on stage in front of everybody (Come on, you know you want a copy, pretty please??)
-Watching the Miss Colombia pageant (otherwise known as La Reina) on TV with Clara’s sister.  Despite being dressed up in some ridiculous regional traditional costumes, Colombian woman are definitely beautiful.
-Being rudely woken up from my peaceful afternoon nap, lounging in the hammock on the back porch, by a rooster squawking right next to me. He flew from the ground floor all the way up the second floor balcony, and decided to start cock a doodle doing at 3 pm, ongoing, for 30 minutes. Nearly jumped out of my hammock.
-Being part of a Colombian family. How amazing to be welcomed in like that, and to be treated as one of their own. For all the good and bad and quirkiness of any family, how special is it to count on weekends like this.

 Foothills leading to Manizales, the beginning of the coffee region

 Scenic point along the road with Clara and her cousin

 The finca, El Limonar

 Produce stands along the road

 El Limonar

 The rooster who woke me up

 View from the back porch

One last snippet of the weekend worth mentioning was the stop we made on the way home.  Clara wanted to stop at a friend’s house to see the progress of some construction that had been happening. This house is located in one of the poorer neighborhoods in Cali, a neighborhood unlike one I had seen thus far, but one that I imagined must exist somewhere. Narrow streets, with barely enough room for one car to drive through, lined with very small, one and two story simple homes. The main, intersecting streets bustled with traffic and small tiendas, and drainage canals down the middle of the street formed a river of sorts, with rickety wooden planks placed over them to cross in places. Fewer trees than other parts of Cali, dustier. The police had cordoned off a section of one street where there had been a shooting, and Clara took the opportunity to tell me about gangs in Cali. Despite all of this, there was running water, and electricity, and most of the roads were at least somewhat paved. I thought back to the compounds of Lusaka, the makeshift houses with corrugated roofs and no doors, the muddy dirt roads, the barefoot children. This wasn’t quite that.

Back in Cali, the strike goes on. It’s been nine days now that the public hospitals all over the country have been without residents and with hardly any doctors. There was another march and protest today, organized by the residents. At the hospital, the medicine wards have almost emptied out, as they aren’t admitting new patients. The emergency room is emptier in some ways, but those who really need a hospital bed are stuck down there waiting for days longer than they normally would. Surgeries have come to almost a standstill, with only those most emergent happening. The HIV clinic was cancelled last week, I wonder where those patients got their medication refills? In contrast, at the city’s numerous small, private hospitals, which do not serve any patients with state insurance, several of which I have visited with the infectious disease attending over the past week, life has continued as usual. The sick continue the usual journey through emergency room, ward/ICU and hopefully better and home. They continue to ask for consults regarding toxoplasmosis, post-operative peritonitis, liver abscesses and multi-resistant gram negative organisms (Is it just me or does BLEE sound so much funnier than ESBL? Some things just sound funnier in Spanish.)   How striking that the people being most affected by this strike are those that are sickest and most in need of this healthcare? Although I suppose that’s the point the striking healthcare workers are trying to make.  Tomorrow the professors (attendings) are having at meeting at Universitario del Valle to discuss the strike and next steps.  I hope they make some good choices. 

Beginning of the residents' march, as seen from the 9th floor of Hospital Uribe. If you can't tell, that's a large white coat they are carrying at the beginning of the march.

La salud no lo es todo pero sin ella, todo lo demas es nada

The title of this entry, "Health is not everything but without it, everything else is nothing," was one of the many signs hanging in front of the hospital yesterday morning. Since last week, the number of flyers, posters and T-shirts have been growing all over the hospital, all in anticipation of protest day.  At 9 am yesterday, roughly 5,000 doctors, medical students and hospital personnel from multiple hospitals in Cali marched down the main road in town and then held a protest.  The same thing occurred simultaneously in numerous other cities around Colombia. They were protesting planned health reforms by the government. These reforms, from what I can gather, involve outsourcing of management of the public hospitals, and decreased pay for doctors and other hospital employees. There is a lot of fear that if the public hospitals are no longer truly public, that many people will lose access to care. In a local news article I read today, the government seems to be denying that any of these things will happen with the proposed reforms, and that the public are misunderstanding the legislation.  Regardless of what the truth is, the residents are currently in strike mode. That’s right folks, residents are actually walking off the job. Imagine that. All of the residents currently on consult services are not consulting. The residents and interns on the medicine wards saw their patients and wrote their notes very rapidly this morning, checked in with the attending briefly, and then left to go to the protest. The attending was kind enough to stay on the ward and watch the patients while everyone else went. 

 Health is not everything but without it, everything else is nothing. Outside the front of the hospital.

 Flyer put up around the hospital. Big text says "El Hospital Universitario del Valle, don't outsource it, don't privatize it, don't sell it, defend it. The small cartoon, which is hard to read, says, "I'm sorry but we can't authorize this exam" and shows a skeleton coming to the doctor.

 From the newspaper: Before they called me death, now they call me EPS (EPS is the health sector of the government).

Unlike everyone else, the emergency room doctors were working.  Working in the emergency room’s  medicine ward two days in a row means seeing many of the same patients.  The medicine ward in the ED is somewhat of a transitional medicine ward, and some patients stay there for days.  It seems that the patients are at two extremes. Those who are incredibly sick and unstable, awaiting an ICU bed, and those who require just a bit of intervention and can then go home. The 19 year old boy with the asthma exacerbation requiring steroids and frequent albuterol was sitting on the same stretcher, wearing the same albuterol mask and the same clothes, 24 hours later, as if he hadn’t moved at all. His mother gave me a little smile, I’m not sure that she had moved either.  Next door, in the critical room, the woman in heart failure with a ruptured chorda tendineae of her mitral valve continued to wait patiently for the cardiothoracic surgery consult to come. Were they running behind because of the protest? It’s unclear to me. Her daughter saw me walk in, and introduced me to another family member as her doctor from the United States. While honored, I also felt shy, and sad. I had also seen her once briefly the day before, and I had no news for them, and no control over when the surgeons might come. I certainly did not feel like her doctor. But I smiled and checked in with them all.  I looked over at the jaundiced, emaciated man on the stretcher across from her. He has been sitting there every day for the past week, looking tired, ill, miserable, and near death. According to his chart he has end stage AIDS, chronic diarrhea, and malnutrition. I am not sure what he is waiting for, what is keeping him in the ED. I imagine he would be more comfortable on the medicine ward but perhaps there are no beds.

Suddenly, paramedics roll in to the middle of the room. On the stretcher is an overweight, well-groomed, middle aged woman who appears to be non-responsive. They start talking quickly to one of the nurses. A family member holding the woman’s hand is bawling. It seems that this woman may have ingested something, and when her family found her she would not wake up. Over the phone, another family member at home read off the name of a bottle of some chemical, an insecticide, that had been next to her. Impressively, the ED attending was immediately on the phone with a toxicologist, and five minutes later, that very same toxicologist appeared in the ED to see the patient. There is 24 hour toxicology consult available, in person or over the phone, with a poison control line too that anybody can call. Our consultant did not seem overly worried about this woman, as her vital signs and physical exam were all within normal limits, but it was a good opportunity to discuss organophosphate poisoning and treatment. She soon regained consciousness and seemed back to herself. I’m not sure how much longer she had to sit before being worked up and discharged.

As the day went on, more patients arrived with the paramedics, others are wheeled off to the ICU, portable ventilators and heart monitors in tow, and others continue to just sit. All around them, the hospital thought it would be a good time to start taking down the curtains between the beds for washing, drilling other unidentifiable objects into the walls, and polishing the floors. It was a very active place for a place that sometimes feels like very little happens.  

I sent a text to David, the Colombian resident who is on the infectious disease service with us, to ask him what time we would be starting today.  He wrote me back in English, “Hola, please call Dr. Segura for going to Hospital Uribe , ‘cause we are in strike.”  I had not realized this would be a multi-day strike, I thought it was just the protest.  So this morning, together with the other visiting resident from Ecuador, we made our way to the Hospital Uribe ourselves, without David, to meet up with Dr. Segura the ID attending, who was not on strike today. When we arrived in the ED there, I could tell something was different. The rooms, waiting rooms and hallways were overflowing with patients, much more than usual. While there did seem to be large gaggles of residents and interns there, I think there was a back log from everyone having been at the protest the day before.  This hospital is semi-private, unlike the hospital where I normally work, Hospital Universitario del Valle, which is entirely public. I think the resident staffing there is going to continue to be very bare bones today. While hopefully nobody will die because of it, I think patients will continue to wait. I’m also not sure how long this strike is expected to last.

Would we as residents in the US ever strike? I can’t imagine it. We have lobby days where we can go to Hartford or Washington. We have the AMA and the NPA to make our voices heard. But the idea of walking off the job, saying, I am not going to go to work at the hospital today, and coming up with a system of bare bones coverage for the wards, with the full support of our attendings, is something I cannot fathom. Let alone the potential harm to the patient, but what health or labor issue would make us mad enough, and brave enough, to do something like that? As the Ecuadorian resident said to me over lunch today, You guys don’t celebrate Labor Day do you? By Labor Day you mean the long weekend where we go away to the beach and wear white for the last time?

They may not have beach homes here in Cali, but it seems that most wealthy people from Cali, which includes many doctors, do have country home. I was fortunate enough to be invited to Jaime and Clara’s country home last Sunday. Only one hour out of the city, it is truly a welcome retreat from the rush of Cali. The small, usually sleepy town of Ginebra is actually well known for its annual music festival. One week per year, all of Colombia descends on the town to celebrate classic Colombian music, “the music of our grandparents” as Jaime said, “before people listened to Salsa and Rhumba” (kind of make me think of Dirty Dancing). They have so many friends that want to come that often, people will be camping in their front yard. The amazing thing about living in a tropical county is that you can build your house to be partially outside. In their case, the entire middle part of the house is a big courtyard, some of it covered but some of it entirely exposed. Shrubbery, small trees and flowers grow freely upwards toward the sun, fed by rain that falls directly upon them. As we were eating lunch at the dining room table, protected by a ceiling, a hummingbird flew directly up to the shrubbery beside us to sip from the flowers.  What a peaceful and tranquil retreat, something so special to be able to enjoy for so many years.

Nearby their house is Hacienda El Paraíso, known as one of the most romantic places in Colombia. The story is a true one, and was made famous by the Colombian writer Jorge Isaacs. In fact, you can see a picture of him and the hacienda on the 50,000 peso bill. When he was young, a girl named Maria came to stay at his family’s hacienda. He fell in love with her, but she soon became ill and died. Jaime told me that every teenager in Colombia read this book and feels the romance of the story. There is something even more magical about being able to walk the very hallways and courtyards of this estate, of seeing the actual rose bushes where he offered her a flower, of sitting beneath the tree where they sat. The hacienda itself is situated on the cusp between valley and mountain, in a shaded, impossibly green and flower filled spot, with endless sugar cane fields in the distance. You can definitely feel the romance in the air. 

Photo of Maria on the wall at the Hacienda del Paraiso. 50,000 peso bill shows the writer and his inspiration

 View of the Hacienda, and the same depiction on the bill.

The countryside as seen from the hacienda