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

More pictures up....

https://plus.google.com/photos/106419429553511755451/albums/5939242049883407137

Algo Mal, Algo Bien, Algo que aprendí

The daily rainstorm came late at night this time, the impressive lightning bolts brightening up the sky over Cali, while rain pounded the roof and drowned out the voices. Suddenly, the ten people enjoying Shabbat dinner were thrown into darkness, the only remaining light from the flicker of the dying Shabbat candles in the center of the table. The lively conversation continued, barely missing a beat. We dined on salads, chicken, brisket, vegetables, potatoes, homemade challah bread. It felt very much like a regular Shabbat dinner at home, way too much food, and even the same recipes and complete with Kedem grape juice. This was not a typical Colombian meal. But as the darkness settled, and stomachs filled, the conversation died down briefly. In the quiet darkness, one of the other guests turned to me and said, “Díganos algo mal, algo bueno y algo que aprendió esta semana, ” “Tell us something bad, something good and something you learned this week.” What a question!

Algo mal
I spent Thursday afternoon in the emergency room. Together with the residents and interns, I saw countless patients, some having just arrived and others having already been there for quite some time. Some of them were no different than patients I would see at home, and were getting the same care- COPD exacerbation in bed 3, getting steroids, albuterol etc. Chest pain in bed 4 has a troponin of 2, getting aspirin, Plavix, heparin, an echo and a cath lab activation. Bed 5- And here we have a gentleman who is unconscious, disheveled and dirty. He has several IVs and oxygen. This guy was found on the street, no personal information, no family information. Apparently he’s in renal failure and uremic, with a BUN of 150 and continued altered mental status. Is he going to get dialyzed? Not anytime soon. Why not? Well, setting somebody up for dialysis is expensive, and they need good support, and good continuity of care, and we have no idea where he’s from, or who his family is, and if he can pay. But he’s not even going to get dialyzed just this once? Apparently not, I couldn’t really understand this, and didn’t really get a good answer.  So he’s going to die like this? Maybe so.

Just 30 minutes later, a new patient appeared in the more critical section of the Urgencias.  He too was completely unconscious, with shallow and wheezy breathing. He was one of the most emaciated people I’ve seen, think National Geographic Somalia famine pictures. I could almost see his entire pelvis sticking through his skin. He, surprisingly, had a G-tube coming out of his stomach. Clearly, he’d been in the health system recently, although goodness knows what his story was. At home, I feel like there would have been a lot of action around this patient, immediately placed on the monitor, nurses taking lots of labs, a resident grabbing a blood gas. In this case, everybody seemed calm and kind of slower. This guy already had an IV placed at triage, but that was about it. One of the residents wired up a makeshift pressure bag with a blood pressure cuff to get some normal saline into him quickly. A finger stick showed a blood glucose of 29, and they gave him some dextrose, and then hung a bag of tube feeds and hooked it up to his g-tube. There were so many labs I wanted to send, but nobody seemed to be doing anything. The resident pulled me away to see the next patient. Perhaps the orders were already in? I really don’t know.

I know there are finer points I must be missing in translation. And in this case, not knowing the system, I was more of an observer. But it was hard to watch these very sick people get interventions so slowly, or perhaps, not at all. Yet somehow, we seemed to be seeing a lot of patients, all getting some interventions for their various problems.

I imagine the funeral home industry must be well aware of this level of mortality, as they have opened their storefronts directly across from and next to every large hospital in town. Some are even open 24 hours a day. Need to plan that funeral at 2 am? At your service! I could even tell that some of the funeral home businesses that are chains, as I’ve seen similar logos near different hospitals. Each has a large sitting parlor, with several coffins on display, as well as examples of flower arrangements. How discomforting must it be to see several funeral home signs while feeling ill and being wheeled through the door of an emergency room? Still, I guess it is good business model.

Algo bueno
Discovering the Jewish community in Cali. What a lovely surprise. I should know by now that if there is a synagogue in Lusaka, Zambia then there will be one in most major Latin American cities. But what a fortunate chain of events to meet the a member of the executive board at Universidad del Valle, who asked if I needed to be connected with a church (or a synagogue) who then did connect me to a woman at the large shul in Cali, who then arranged for me to come to Shabbat services, and to dinner at the Rabbi’s house. The synagogue is large and lovely, in a grand old mansion, with a very modern and comfortable sanctuary. The rabbi and his wife hail from Israel and Mexico. On a Friday night, the women dress up, in flowing large shirts, dress pants, high heels and large jewelry, while the men dress down in jeans and polo shirts. Little kids run around and under the seats, while the men chant, and the women chat. Surprisingly, all the melodies for kabbalat Shabbat were exactly the same as at home.  After services, the entire congregation does Shalom Aleychem, kiddish and hamotzee together. 

Shabbat dinner was like Shabbat dinner anywhere. Same melodies, same food. A group of fairly young people, mostly couples, talked about music and school and TV and having babies. Surprisingly, I found I could understand their Spanish so much easier than at the hospital. Were they speaking more slowly, more clearly? Is it the rapid chatter of residents discussing patients and attendings just a little more mumbled?

Algo que aprendí
Okay, here’s a bunch of things I learned this week…
Did you know that Star Fruit, also known as carambola, can cause acute renal failure and rapid death if you already have kidney disease? Star fruit has always been a favorite of mine, a special treat, appearing in our grocery stores only a few months per year, and fairly expensive to boot. Here, like so many Colombian fruit, you can buy them everywhere, cheaply, all the time. You better believe I’ve been enjoying them. Then I heard from a resident, oh, those can cause renal failure if you eat a lot of them. What, really? How much do you have to eat? I don’t know, a lot. This was further confirmed by my landlady, who does her own peritoneal dialysis four times per day and when she was me eating a star fruit said, “Oh, I really like those, but I can’t have any because of my kidneys.”  More online research on this matter has made me feel okay that I, with healthy kidneys, will not die from eating a star fruit but that my landlady should indeed not be eating them.  But still, now I’m enjoying them a little less. Worrying about the rapid onset of hiccups and nausea with each bite.

Colombians have more fruit than they know what to do with, so they do as many things as possible, to consume as much fruit as possible, each day. I already wrote about the cholado. Other fruit delicacies include:
-Salpicón- a drink you can think of a fruit cocktail. Cut up as many fruits as possible into tiny little pieces and add a small amount of soda water. Better yet, make it in a huge 5 bucket and then ladle it out to passersby seeking refreshment.
-Chontaduro- Okay. I don’t like this one as much, I guess it’s an acquired taste. This is also a fruit. It’s about the size and shape of a large egg, with a tough yellowish-reddish outside. There are carts all over the city with people selling chontaduro. All day, they stand there and peel them, and put them in bags. People walk up to them, buy a bag, top the fruit with honey and salt, and enjoy. The best I can describe it as almost like winter squash that has been just cooked enough, fairly starchy and almost tasteless. Not really my favorite.  
-Lulo- Another awesome fruit. I swore it was a persimmon when I saw the outside, but it’s much tougher, and tastes nothing like it. The flesh itself is usually too bitter and tough for people to eat as a fresh fruit. But, peel it, cut it up, run it through a food processor, strain out the pulp and seeds, and maybe add a bit of sugar (optional) and you have a fabulous fresh juice drink.

I have yet to try the champús, a drink of fruit, maize, cinnamon and cloves. I’m a little reluctant. Does corn meal really belong in drinks? I’ll let you know how it is.

Colombians also like breakfast on the go.  Although you actually can get your Egg McMuffin or Dunkin Donuts donut, far more popular and fun are the arepa vendors on every street corner. Every morning, they set up an entire coal grill, and when it’s piping hot, they grill arepas (corn cakes) along with sausages and eggs. Sometimes they even set up little stools next to their grills, for customers to sit on while they enjoy their arepa, egg and cheese sandwich, washed down with a little hot cocoa. Or maybe you just want an arepa with butter. They can do that too.  Warm and satisfying.

Colombians are excellent recyclers. They put our reduce, reuse, recycle campaign to shame.  Maybe your city has the blue box for your house, and you put your recycling on the curb every week. Maybe your school/office has some recycling bins? Here, every office/institution/hospital has an entire rack of bins at every garbage point – paper, plastic, compostable, other. Even on the street they have extensive recycling. Sometimes I have trouble figuring out which bin to put my item into, as opposed to not having any bins at all.

Drug reps are bringing OxyContin to Cali. I was invited to a session next week to learn all about his exciting development in treating Colombians’ pain. There is hope! I asked one of the residents if there are issues with pain medication abuse here. He hadn’t heard much about it. Don’t know how much of a good thing this is.

I also discovered that there's enough medication samples in the resident room to supply several patients for several years.

Colombian roads, El Parque del Cafe, and having HIV outside of Cali

There’s a road in Cali called Calle 5a. It’s the main north-south thoroughfare through Cali. You pretty much can’t avoid it. No matter where you’re going in the city, somehow, you will end up on Calle 5a. Parts of it almost feel like Storrow Drive in Boston, an elevated roadway, with exits to the main streets, graced by billboards and greenery. Yet in other parts it is indeed just busy street. And although there are recommended pedestrian crosswalks above, many people think it’s a good idea to try and dodge the traffic and cross, like the old man carrying several large boxes on his head, who we almost hit in our taxi last week. There’s also the men hauling huge rickshaws covered in fresh fruit down the middle of the road, kind of like getting stuck behind a horse cart. Calle 5a also becomes the Big Dig like tunnel I wrote about earlier. On a weekday morning, as early as 6:30 am, its lanes will already be congested with traffic, with motorcycles zipping along in their own private lane to the right. Don’t try and go above the speed limit though, because they’ll take a picture of you and mail you a ticket. But if you drive through the tunnel at 7 am on a Sunday, as we did last weekend, you’ll have it all to yourself.

Nora and I were driving through the tunnel with Jaime, our lovely attending and stand-in father in Colombia, who was taking us to the Parque Nacional de Café, near the city of Armenia, about three hours to the north.  The drive takes you on well-maintained highways and roads, slowly winding uphill, but only as far as the foothills. Interesting side note that although the highways are built by the government, they are then sold to private companies to maintain. Although there are several tolls, these seem worth the high quality roadway.  There are a few small cities and towns on the way, with businesses and churches and schools and dwellings that all look fairly comfortable. This is not the countryside poverty I’m used to seeing. 

In the rainy season, which it is now, everything is delightfully green and fresh.  Muscular cows graze lazily, as they slowly make their way up the sides of the dramatic and steep hills, and continue partaking in the juicy green grass. Apparently Colombian beef is tougher because the cows are forced hard to walk up hills, whereas Argentinian beef is softer because they graze in flat fields. So says Jaime.  Even the highway rest stop, where we stopped for some breakfast, was a delightful change from ours at home.  A large thatched roof protects an open space below, complete with full cafeteria, bathrooms with showers, and a convenience store.  Despite the gas station and rushing cars on the highway, there was something peaceful about sitting below a thatched roof, with a quiet breeze blowing through, and birds circling above, while we enjoyed coffee and arepas.

The Zona Cafeteria, the coffee region, is mountainous and green, with a slightly fresher climate than in Cali. The winding, bumpy road leading to the park is lined with small inns and farms, serving as a popular weekend escape for Colombians. The national coffee park is an amusement park, museum, performance space, getaway space and chance for the Colombian coffee growers to promote their product as the best coffee in the world. Juan Valdez watches over you from the minute you arrive, from the Juan Valdez café, to the coffee museum propaganda to the gift shops hawking his goods. There was a beautiful, shaded winding pathway down the side of the hill, from the entrance of the park, to the amusement park below. Along the path were coffee plants, and a bamboo forest, and a river. In the distance were mountains shrouded in clouds, with far away cities and farms in the valleys below.

After walking through the model coffee region town square, complete with food courts and gift shops disguised as authentic houses and buildings, we boarded the train from the train station. Along with 200 other people, mostly in their 50s and 60s, our train made its way at 5 mph to the other side of the park, while all the passengers cheered and waved at everyone we passed. Jaime told us, whenever you put a bunch of Colombians together, even if they don’t know each other, it’s going to be a party. Nora referred to the train as the roller coaster for the old people. Our train took us into the heart of the amusement park, and so how could we not partake in the excitement of the bumper boats.

The best part of the visit may have been the show. Impressively choreographed and costumed, this 30 minute show had several large group dance routines, each highlighting the history of coffee in the region, as well as characteristic costumes and music from different parts of Colomiba. There was even a little aerial silks action a la Cirque De Soleil. As I sipped my Juan Valdez Café coffee, staring out at the green mountains, I was sad to be leaving.

Thus began another week in Cali, another week to get to know the hospitals here, and better understand the resources here, and how they work.  I saw a patient in the HIV clinic. It was his first visit. He carried with him a large manila envelope full of medical records from…The Mayo Clinic in Rochester, Minnesota. That’s right, my first patient in the HIV clinic was a Colombian who had been living in New York for 18 years, but then got deported after doing a yearlong sentence in prison in Minnesota. He was excited to speak English to me. I tried to keep speaking to him in Spanish. He told me about his children and their mother in New York. He told me how depressed he got after leaving prison and being deported. He stopped taking his medication altogether. That was two years ago. Previously his HIV had been very well controlled and he had never been hospitalized. Now he was finally presenting for care, with many months of fevers, weight loss, cough and shortness of breath. “I did a really stupid thing.”  We sent him from clinic to the Emergency Room to be admitted to the hospital. He would need a lot of workup and care. He had also traveled 2.5 hours to get to the hospital, from the port city of Buenaventura, where the medical care is apparently quite lacking and minimal, particularly for HIV+ patients. Later that day we passed by his stretcher in the ED, laying there with an oxygen mask, looking tired. I found myself thinking about his perspective on this experience. A Colombian, having previously been a patient in the US medical system, and now sitting in a Colombian ED, one of the largest, busiest, and most bare bones EDs in the city. Here, as in Rwanda, as in many other countries, patients may sit in the ED for days and days before being admitted to the medical wards. The ED is essentially a ward in itself, one stopping point in this long and somewhat inefficient system of getting patients upstairs and eventually out of the hospital. The up and the out take quite a bit longer here than they do at home. No such thing as 11 am discharges here. And you thought our EDs were crowded.

We saw another patient in clinic the same day. This one was a 16 year old girl who delivered a baby 2 months ago.  She found out about her HIV, and hepatitis B, during the pregnancy.  Holding her baby, who quietly stared up at the ceiling, as if all was not right in his head, she sat at the desk alone, no parent or partner to help her answer our questions. She didn’t really seem to have a solid understanding of any of it and it’s unclear what care her baby was getting. She too was from the city of Buenaventura.  Having met both those patients in one day made me very sad for what that city seems to lack in health resources. Both of them would have access to regular medications and care here in Cali. 

Not in New Haven anymore, or am I?

The more time I spend in Cali, the more I realize how close it is to being at home, and the world feels just a little smaller. This point was particularly driven home this evening, as I sat in a large movie theater, in Chipichape, the biggest shopping mall in Colombia, wearing 3D glasses and watching George Clooney and Sandra Bullock stare down at the earth in the movie Gravity (Gravidad). It was a bit surreal leaving the movie theater after an hour and half of floating in outer space in 3D, to find myself in a large food court, in an even larger shopping mall, with thousands of Colombians walking from Tommy Hilfiger to Zara to the huge tank of plastic balls with jumping children. I forgot for a brief moment where I was. 

Earlier this week, I went to a teaching a session at the hospital, La Ventana Cardiaca (the cardiac window), a weekly tradition for the residents. Each week, cardiology cases are presented, in full Power Point fashion. In front of a packed lecture hall, an older cardiology attending, stops the presenters every few words, to bring out a teaching point or randomly call on people in the audience to answer a question. When he likes the answer, he’ll ask the whole room to clap, which they will in one resounding single, “CLAP!” If he doesn’t like your answer, there may be some teasing or joking. Later in the week, we had radiology rounds, also with the expected PowerPoint presentation to the attending, and the usual random questions directed at the residents (Contrast or non-contrast? Blood vessels or nodules?)  I even got my assignment for next week, to present on the radiographical findings of aspergilosis. Lots of Spanish radiology translation coming my way.

On Thursday evening, the Center for Infectious Diseases here in Cali held a meeting , which brought together adult and pediatric infectious disease specialists, to present interesting clinical cases.  Aside from the discussions about treatment of free-living amoeba infections, the hot topic of the night was…multi drug resistant bacteria and ICU acquired infectious with otherwise rare bacteria. They highlighted case reports from as far away as India and China with these specific infections. If I had the time I would actually love to do an epidemiological study of the infections and resistance patterns happening at Cali’s hospitals. The ICUs I’ve seen are impressively modern compared to what I was expecting, and although I see nurse’s wearing gowns, hats, gloves, masks, it does not seem quite as routine as at home. The rooms do not have those huge signs, “STOP. Gown and glove before entering this room!” I wonder if that makes the difference. I wonder if the prescribing practices of the ID attendings in this city matter more. How do you not use meropenem as your standard, first step, broad-spectrum antibiotic for sick patients in the ICU when you know that so many infections here are so resistant? We face similar questions at home.

Last night also felt like a very typical night of hanging out with other residents and yet, it was so much more exciting. Put a bunch of residents together anywhere, and the conversation will be the same: work schedules, difficult patient cases, fellowship and job applications. But last night, these conversations took place during the walk over to Tin Tin Deo, one of the best Salsa dancing clubs in Cali. Cali is particularly known for Salsa, and I think that every child is born knowing how to dance it like a pro. Walking into Tin Tin Deo felt timeless. Dimly lit, with hanging Chinese lanterns, black and white photos of great Salsa singers look down upon a large space, lines with small tables on the edges, and well-dressed couples dancing salsa in the middle. I’m sure it looked the same in 1950. The music is not live, but the energy is very real. Great salsa songs from the decades play continuously throughout the night. Each song has a very definite beginning and end. The dance floor clears after each dance.  Some people return immediately for the next dance, others take a break to sip some Club Colombia beer, or perhaps a shot of Aguardiente, a Colombian rum with an Ouzo-like flavor. I asked the residents, “do they teach this to you in school when you are kids?” No, they just know how to dance, and dance they do. The higher the heels on the high heeled shoes, the better they can dance. One particular woman, dressed in an elegant yet sexy red top which was low cut in the back, a short denim skirt, and 4 inch heels, danced beautifully for hours with multiple dance partners. The men were lining up to ask her to dance. I managed to dig up some basic steps I had learned years ago in Cambridge, at the weekend Salsa lessons and dancing, and was further helped by a Colombian dentist who came out with us that evening.  I probably did okay for a first night of salsa dancing in Cali, but I’ve a long way to go to 4-inch-heel chica.

Today I got to explore even more of Cali. After a grueling class at the gym this morning, which involved 30 minutes of spinning, and then another hour of a track style workout- outdoor running, sprinting and jumping up stairs on the edge of the mountain, I couldn’t possibly imagine moving again. But somehow, after a good Colombian power lunch, I got up the energy to spend the rest of the afternoon winding my way through artisan boutiques, the colonial streets of the San Antonio neighborhood, and its hidden courtyards. Every street in San Antonio is as first somewhat plain, old shuttered houses with solid wooden doors. But then you may come across a bohemian store selling jewelry and clothing made from recycled materials, or a vegetarian/vegan restaurant, or an art gallery. The most amazing home furnishing store I have ever been to was an unassuming corner house. But inside, a hidden garden and fish pond served as the centerpiece around which antique and modern tables, chests, lanterns and ottomans graced every corner of the house. I would live in that house if I could.

One more word before I close, on food. The people of Cali are quite proud of their traditional foods. I had the pleasure of trying some of these this week.
 

Cholado- Take all the tropical fruits you can think of, crush them up with ice, pile them into a glass with layers of fruit syrup and sweetened condensed milk, top with a wafer cookie. Sweet yet satisfying. Our resident happy hour on Thursday involved ten residents enjoying cholado at a street side café a 5 pm Cali traffic rushed passed. Pretty happy hour if I do say so myself.

Pandebono- Bread with cheese inside. How could you go wrong? Almost like a Bialy, only better. Every corner panedaria has them, and the smell of fresh, hot , baking pandebonos permeates the streets at all times of the day.  

 David knows how to enjoy his Cholado

 Fountain above a fish pond in the interior design store

 More hidden fountains and courtyards of San Antonio

 San Antonio street