no hay síndico aquí

"Poverty and other social inequalities come to alter disease distribution and sickness trajectories through innumerable and complicated mechanisms.

Take tuberculosis, with its persistence in poor countries and its resurgence among the poor of many industrialized nations. We cannot understand its markedly patterned occurrence - in the United States, for example, afflicting those in homeless shelters and in prison - without understanding how social forces, ranging from political violence to racism, come to be embodied as individual pathology.

Initially, poverty and racism increase the likelihood that one will become infected with Mycobacterium tuberculosis. The mechanisms by which this occurs include the prevalence of the disease among the poor and the fact that the poor are more likely to live together, often in the cramped, airless quarters that once characterized the 'lung blocks' of industrialized cities and now describe the urban ghettoes in which tuberculosis is endemic. Various institutions designed to serve or contain the poor have in many instances been the settings for amplified outbreaks of tuberculosis. Nardell and Brickner argue, for example, that homeless shelters have become the lung blocks of the late twentieth century. Poverty and racism surely increase the likelihood that one will end up in a shelter, just as these forces arrange the chances that one will wake up in a crack house or a prison.

Once infected, the poor are more likely to progress to active disease. Again, the mechanisms are myriad. Cell-mediated immunity, which keeps tuberculosis quiescent in most persons, may be compromised by malnutrition, HIV infection (or other concurrent disease), or addiction to drugs or alcohol. Addiction, in turn, is usually not comprehensible without an understanding of subjugation and racism, at least not if historical and population-based studies are to be believed. Even reinfection with M. tuberculosis might play a role in ensuring that tuberculosis infection will progress to disease; the risk of reinfection is strongly influenced by the social factors just described.

These same factors determine outcomes among those with active tuberculosis disease. Poverty and racism increase the likelihood of dire outcomes among the sick by restricting access to effective therapy or rendering it less effective if patients are malnourished or addicted. Poverty clearly decreases the ability of patients to 'comply' with demanding, lengthy regimens. Indeed, the advent of truly effective therapies only brings into starker relief the centrality of social inequalities, when unequal access to these therapies heightens the inequalities of infection and reactivation already described.

Thus do fundamentally social forces and processes come to be embodied as biological events."

- Paul Farmer, Infections and Inequalities

So really all of March is TB awareness month. It must be markedly obvious at this point what book I am currently reading (although I'm also embedded in The Bottom Billion, which takes me back to my IR days, and I was reading Reporting from Ramallah, but sadly I think I left it in Trinidad). I love this passage in particular because of the clear and concise way in which Farmer outlines some of the mechanisms by which social forces impact biological realities. An understanding of these mechanisms is essential for anyone who hopes to alter others' medical outcomes.

These pictures (from the same street on which the clinic is located) illustrate a bit of what Farmer is talking about:

Contra el hambre y la pobreza.

Against hunger and poverty.

No hay síndico aquí.

There is no mayor here.

(an arrow points to the ground below)

world TB day

*** HAPPY WORLD TB DAY! ***

March 24 commemorates the discovery by Robert Koch of the bacterium that causes tuberculosis, and it is an opportunity to raise awareness and assess the past year's work in the fight to eradicate TB.

I spent the first part of the morning in the clinic as usual. I talked for a long with time with a patient who told me out of the blue, after a long, jovial conversation, that he has HIV. The MDR-TB patient I mentioned in the last post could barely move today because of the gastrointestinal side effects of his medications. The sobering atmosphere of the reality of TB for so many was a striking contrast to the World TB Day event I later attended, organized by the governmental Ministry of Health and its TB Control Program. Representatives from the government, USAID, WHO, the Global Fund, and various NGOs gathered at a high-end hotel to pat each other on the back and discuss recent advancements in the agenda to end TB. It was an interesting morning.

Tuberculosis is one of the oldest diseases known to humanity, and is thought to have been passed to human beings by cows when people began to domesticate livestock (there is a very similar bovine strain that predates the human strain). It is caused by a bacterium with which about 1/3 of the world's population is infected. However only 10% of people will ever develop active disease. Immuno-compromised people, particularly those with HIV, chronic malnutrition, or other health problems (mostly related to poverty) are the most likely to develop active disease.

TB most commonly affects the lungs, but extrapulmonary TB - or disease in other parts of the body - can also occur. It was once known as "consumption," as typical symptoms include a long-term, productive cough, night fevers, fatigue, weight loss, and other signs of general wasting away. Perhaps the most dramatic and well-known symptom is hemoptysis, or the bloody cough that appears when severe infection goes untreated. However, TB is treatable with an intense regimen of antibiotics.

The international standard for treatment is known as Direct Observed Therapy, Short-Course, or DOTS. DOTS is a protocol for administering medicine that requires patients to take their pills in the presence of a health-care worker in order to ensure that they receive each dose. As with many bacterial illnesses, improper or incomplete dosing can create serious problems of recurrent infection and bacterial resistance, and the TB treatment regimen is particularly difficult to keep up with. Current challenges to the eradication of tuberculosis include the syndemic (or co-epidemic) of TB and HIV and the increasing rate of multiple drug-resistant TB (MDR-TB).

- TB incidence (or number of new cases annually) in the Dominican Republic is around 69/100,000, a rate surpassed only by Haiti when compared to other Caribbean and Central American countries. Other estimates, however, place incidence even higher, above 85/100,000.
- 45% of new cases occur in the National District, where the capital city of Santo Domingo is located.
- The DR is tied with Peru for the highest rate of MDR-TB in the Americas, and is one of the top 19 countries in the world in terms of MDR-TB incidence.
- About 6.8% of TB patients are also infected with HIV in the DR, but this rate varies widely according to region. In the poorest regions of the country, co-infection reaches up to 50%.
- The DR has rapidly expanded its coverage of DOTS health services, from virtually no coverage in 2000 to 85% coverage in 2008 (that is, 85% of the population now lives within 30 minutes from a health center administering DOTS TB treatment). It's an improvement, but the DR still has the sixth lowest coverage among American countries.
- The World Health Organization's target goals of 70% case detection and curing at least 85% of cases still have not been reached in the DR.

*** HAPPY WORLD TB DAY! ***

you'd think they would have found a way

Observing and talking to patients and TB health care providers every day in the clinic has been an interesting experience so far. It’s making me aware of one of the key reasons I’m so excited about medical school – as I wrote in one of my admissions essays, the individual, patient-doctor relationship adds an invaluable emotional component to bettering people’s lives that I think I will need to do my job well. It’s one thing to sit in an office all day and write policy (and don’t get me wrong, I’ll be doing that, too, insha’Allah!), but it’s quite another to have one-on-one relationships with the people whose lives your purport to improve. Given my personality, the latter is essential for me.

Some of the patients I’ve met stand out in my mind for various reasons. A couple of weeks ago, a trembling young man came into the clinic accompanied by another person who, it turns out, was accompanying him from the drug rehab program in which the patient is enrolled. He needed to have a TB test and had already completed an HIV test; grimly pulling the lab report from his pocket, he told us that he was HIV-positive. Perhaps it was the drug withdrawal or perhaps it was some other sickness(es), but he was in such bad shape that I saw not a hint of shame when he admitted this. He seemed to have acknowledged in what dire straits he had found himself, if only because his poor physical condition made it impossible to ignore or deny any longer, and was too agitated to pay much attention to the reaction of the nurse and community health worker on hand (who assured him that Jesus would take care of everything). What floored me is that the young man was 22 – my age. Suddenly the world did not seem quite so large anymore.

Another young patient (21 years old) came in today with his girlfriend and the positive results of a TB x-ray test (some people who have TB come up with negative sputum smears, but the diagnosis can be confirmed with a pulmonary x-ray). He seemed upbeat and otherwise healthy, and his girlfriend was clearly supportive, but I could tell that he was a little shocked at the intensity of the treatment he was in for – 4 pills every day for the next two months, taken in person at the clinic, and medication three times a week for four months thereafter (assuming he doesn’t abandon the initial regimen or turn out to have multiple drug-resistant TB – MDR-TB – in which cases the treatment will be longer and harsher). Although he could receive his medication at a hospital closer to his school, he opted to attend the clinic where I’m working – a staff member told me later that it was because he didn’t want to be stigmatized as a TB patient should any of his peers from school find out. Apparently he can escape to the clinic for his daily treatment during breaks between classes.

There’s the MDR-TB patient who has stopped and started his treatment countless times, ended up in the hospital for a month (at one of only two in the country that offer full treatment for MDR-TB patients), and has undergone pills, chemotherapy, and injections to fight the disease. Although the nurse who directs the TB program has told me that he’s just “disobedient,” and often yells at/about him and his noncompliance, he told me once in a low voice, when she was out of the room, that he kept having to stop the medications because chemotherapy is really, really tough. He couldn’t keep down any food as a result of the treatment (and taking the pills on an empty stomach exacerbates the side effects further still) and he felt ugly and miserable with a bald head because of the chemotherapy. He, like several other patients, is still crazy-skinny, but at least he’s been showing up lately for his medications.

And then there’s another, older man, who always seems so beaten down when I see him enter the clinic. The nurse’s impatience with him also doesn’t seem to be helpful, and whenever I ask how he’s doing he usually just shakes his head and shrugs. Yesterday he told me that it’s a 30-minute walk from where he lives to the clinic. Today he said that knee pain has been making the journey even more trying. I hope to talk to him in more depth soon, and I wonder if he has a family, a job (from which he may have already been fired for missing work due to his treatment and/or discrimination against TB patients), or other obligations that make the daily, hour-plus ordeal of getting his medications even more costly.

I was relating some of these stories to a friend the other day, who remarked, “but you’d think they would have found a way to make TB treatment easier by now!” Yes, you would think so, given that TB is one of the oldest known diseases afflicting human beings. The global health care economy, though, like the rest of the global economy, is market-based, and pharmaceutical companies supply what’s in demand, which in turn dictates research priorities. Unfortunately, TB almost exclusively affects people who do not have enough money to demand anything. There is research on TB occurring around the world - but unfortunately it's not the type that can relieve many of the logistical and physical hardships of TB treatment. If poor living conditions and malnutrition were not such critical factors in TB epidemiology, if Mycobacterium tuberculosis, like cancer cells, did not discriminate according to the size of its victims’ bank accounts, perhaps we would have found a way to make treatment easier by now.

 "Our society ensures that large numbers of people, in the United States and out of it, will be simultaneously put at risk for disease and denied access to care. In fact, the spectacular successes of biomedicine have in many instances further entrenched medical inequalities. This necessarily happens whenever new and effective therapies - from antituberculosis drugs to protease inhibitors - are not made readily available to those in need. Perhaps it was in anticipation of late-twentieth-century technology that Virchow argued that physicians must be 'the natural attorneys of the poor.'"

- Paul Farmer, Infections and Inequalities

Trinidad

I just got back from the Fulbright Regional Enhancement Seminar for the Caribbean, which was in Trinidad & Tobago (though I didn’t get a chance to visit Tobago). Although the seminar was only four days, it felt like I was there for weeks.

Trinidad was amazing. It was wonderful to encounter spicy food (much of it South Asian in origin), streets clear of trash and grime, less fume-choked air, and men who whistled, hissed, and catcalled at much lower rates than in the DR. The academic portion of the four-day program consisted of presentations given by each of the 15 Fulbright Students stationed in the Caribbean.

We were also able to explore quite a bit of Trinidad in the short amount of time we had. I heard live Calypso; found organic toothpaste and Ecover glass cleaner (this stuff makes me excited because it's difficult to find healthy, environmentally friendly products in the DR); swam in our hotel pools (so nice to do laps in the morning!); took a road trip to the island’s eastern coast; where we went to the beach and saw a leatherback turtle lay eggs; saw a script reading of the new play written by an American Embassy official (she’s an amazing writer as well as a diplomat); went to a ridiculous club and partied, Trini-style, till 3am; hiked through the rainforest to a beautiful waterfall and swimming hole; walked around downtown Port-of-Spain; bought chocolate, tea, and spices that are impossible to find in the DR; stocked up on the latest soca and soca chutney music, and finally caught up with some of the English hip-hop, dancehall, and reggae I’ve missed out on in the DR.

Throughout all this, I really enjoyed spending time with my fellow Fulbrighters, who are an amazing bunch. Being reintegrated into the larger scholarly community of Caribbean Fulbrighters was an invigorating experience. Most of us have multiple interests, such as public health and creative writing, so there were many facets to the “enhancement” I underwent at the seminar. By the way, several of my poems, a Spanish translation I did of one of them, and a photograph of mine have been accepted for publication to a literary journal back in the U.S. (34th Parallel). I’m so excited and encouraged!

As for research, I’m reshaping my methodology to a more qualitative approach, and I hope to devote a month to data collection at each of three field sites where I will work (the first being the clinic mentioned in the previous entry). Please, let’s not even discuss data analysis and write-up yet. Trinidad was a vacation disguised as a seminar, but when you put a bunch of Fulbright students together, even a vacation is deliciously academic, yet relaxingly chill.

oh, God

March has been busy, hence this is my first blog entry this month. I began the community portion of my research last week by journeying to Sabana Perdida, a marginalized collection of sprawling neighborhoods just north of the Ozama River (which is joined by the Isabela River and eventually dives south to meet the ocean). It is just east of Villa Mella, the area where I used to work with SOMOS. It was under the suggestion of one of the NGO staff members I interviewed that I began with a clinic in Sabana Perdida, which is one of the sites for the NGO’s TB program. The clinic serves a population of just over 14,000 people and offers tuberculosis, HIV/AIDS, emergency, and general health services. It’s a small, cramped compound with a large, outdoor waiting area, but it boasts laboratory and x-ray services, and a passionate and committed staff.

My first task has been to observe the daily operation of the TB program, which is housed in a tiny, well-ventilated office in the clinic. From around 8am to noon every day, 10-30 TB patients and “sintomáticos respiratorios” (those experiencing suspicious respiratory symptoms that warrant a TB test) filter in and out of the office for treatment or testing. Some of the patients receive nutritional supplements, and all medicine, provisions, and services are provided free of charge.

I’ve been getting up before 7am (so weird!) in order to make it to the clinic by 8, which is sometimes a tricky prospect based on traffic and when the guagua (beat-up bus) decides to leave in the morning. For several hours I hang out in the TB office, engaging staff members and patients in informal conversations and taking notes on everything I see and hear. My plan is to build up rapport with the patients (who are obligated to show up 2-4 times per week to receive their treatment) in order to ultimately conduct qualitative interviews with them. I will extract data from these conversations and disaggregate it according to gender. My hope is that the information gleaned will help TB programs and their implementation at all levels – from the formation of policy by donor agencies to the local health workers in target communities.

Recently, I’ve also been dealing with the challenges of religion and personal health in this country. It just so happens that the nurse who runs the TB program in Sabana Perdida is a zealous Christian. She begins clinic days by reading from the Bible and making us say a prayer. As a non-Christian (I consider myself spiritual but not religious, and if I had to pick a religion to convert to right now, it would be Islam. I am nowhere near Christian.), this makes me uncomfortable.

The Dominican Republic is an historically Catholic country, but the Catholic church here is more a social and political institution than a religion. No policy gets passed without the approval of the DR’s archbishop, a notoriously conservative man who has been known to attribute child exploitation in the sex work industry to “the way young people dress,” and who has been an instrumental proponent of the recent (and highly controversial) changes to the constitution, which include the banning of abortion under any circumstances, including cases of rape, incest, or danger to the mother’s life.

But the Dominicans who talk about Jesus on a daily (no, minute-ly) basis are primarily Protestant. There has been a notable explosion of evangelical Christianity in recent years. On one hand, I find that taxi drivers who listen to Jesus songs are less likely to hit on me and/or attempt to overcharge me, so I don’t mind it per se. But when someone randomly starts proselytizing (my taxista the other night asked out of the blue if I was aware how much Jesus loves me), it makes me uncomfortable. Thus I sometimes find it difficult to spend so much time with the TB nurse in Sabana Perdida (and the main TB community health care worker, who is almost as zealously religious). I am all for faith, and if subscribing to an organized religion is the best way for people to experience faith and meaning in life, then more power to them. But when I asked the nurse if she took prophylaxis to protect herself from contracting TB from her patients, and she responded, “Prophylaxis? No, but there is a medicine called Jesus Christ,” I almost threw up a little bit. Multiple times I have been randomly approached by strangers on the street hoping to preach to me or hand out written materials about Jesus. Others' religion doesn't make me uncomfortable; but when I'm drawn into it against my will, it does (at the bus station today, this guy could not understand why I didn't want one of his pamphlets about Jesus). My four-year-old roommate has begun to make signs of the cross and announce “may God bless us” at random times as a result of the indoctrination he receives at his nursery school.

As for personal health, take a guagua ride across Santo Domingo and you’ll see what I mean. You can’t go anywhere in this city without breathing fumes constantly. It almost makes my throat hurt. Produce here is treated with pesticides not legal in the United States (and back home I purchase only organic food), and the meat and dairy industries are even more environmentally harmful and hormone-heavy than that of the U.S. This makes me sad, because I cannot go running without feeling like I have probably developed cancerous lung lesions, and it’s sometimes difficult to feel good about what I am eating, even though I cook almost all my food from scratch. Since I’m here for only three and a half more months, I know that the overall effect of these factors will probably be negligible in the long run. But it’s just gross.

On the other hand, the lovely gym located two blocks from my apartment recently moved to a new location; while it’s slightly farther away, it’s still within a ten-minute walk. The new place is a large space on the sixth floor of a building. The view is incredible and luckily most of the fumes don’t reach that high. In addition, Crudo, the small café/store a few doors down from my apartment, was started by a local doctor who shares some of my concerns. He owns an organic farm right outside the city, and everything served at Crudo is organic. I can also find imported, organic green tea, pistachios, and other products. Apparently there’s going to be a yoga retreat to his farm for semana santa (Easter week). So I have a few health havens.

This weekend I’m taking a break in Santiago, the Dominican Republic’s second-largest city, and the coming week is our Regional Enhancement Seminar for Fulbrighters in the Caribbean. This means that on Tuesday I’m off to Trinidad and Tobago! It’s going to be weird to be in a Caribbean country where no one speaks Spanish or (Haitian) Kreyòl (which I’m still trying to learn!).