We’re high up in the clouds rocketing 550 miles per hour on our way to Miami. After a brief plane change we will arrive down in Lima. The sky contains many shades of blue-gray and there are only a few cumulus clouds. A brief digital postcard, no stamps needed when you have Wifi access.
I have the aisle seat. My row-mates are a young couple whispering to each other. Dude is large and imposing, with his shaved head, red sweatshirt and shorts. Dudette is small and barefoot (her big ring indicates that they are married). She’s drinking a Sprite, wearing gray tights, a form-fitting pink shirt and has a silver heart necklace. His plane ticket on the tray table indicates that they are headed to Puerto Plata- maybe for a honeymoon? Probably not, they don’t seem that in love. More like lust. They curl together as the aircraft backs up from the gate. But Dude’s attention is divided. He arches his torso towards his wife but his neck cranes back at an odd angle, towards his shiny black phone. Because Dude seems to care more for his Samsung than he does for his Dudette.
The flight attendant asks the couple to raise their seats for takeoff. Dude seems a bit peeved. I try to make small talk to understand his thought process, but he’s not forthcoming. All he says is, “What’s the point? These rules don’t make any sense.” Halfway through the flight, Dude goes to the bathroom and comes back shortly thereafter. After sitting down, he reaches his palm towards his wife and hands a tiny syringe to her. I’m a bit surprised. Maybe he was injecting insulin, or maybe it was heroin, I’m not sure. But don’t want them to see me staring. It didn’t look like any insulin syringes I’ve ever seen (it was a bit wider). Seems pretty ballsy to go through TSA carrying drugs, but who knows. I do think the incidence of IVDU is higher than what most public health folks believe. We just don’t have quality epidemiologic data to prove it.
Why I am going to Peru
This is going to be an interesting 4-day trip (so short!) to Peru. The country has a long and complicated history, from the Inca Empire which dominated Peru, Ecuador, part of Columbia, northern Chile, northwest Argentina, and Bolivia, to a recent civil war and rapid economic development and globalization. Well-off neighborhoods like Miraflores are apparently where the wealthy jet-set tend to live (anticipating it will be somewhat like Newbury Street in Boston, with Pinkberry and Starbucks). Everyone also says the Peruvian culture is amazing, as is the food, although we’ll see how well I do with that. Much more important to me is the music, particularly trova. I downloaded a bunch of songs of Peruanos Jaime Guardia and Manuelcha Prado, with their pentatonic melodies, and Victor Jara (Chileno), Silvio Rodriguez (Cubano) with their sad voices, to get in the mood. Jaime and Manuelcha and Victor and Silvo are setting the tone for this blog post and this trip. But there’s clearly a generational divide when it comes to music. Many young Peruvians seem to prefer salsa, cumbia, and reggeton to trova.
The purpose of this trip, to remind you, is not to blog. Rather, it is to help get a study off the ground which aims to decrease TB transmission in hospitals using the “F-A-S-T” approach. TB is a still a deadly killer as I have written so many times on this blog. But Peru faces a larger burden of drug-resistant TB than most other Latin American countries.
In Lima I am meeting another infectious diseases physician from the Brigham. Thankfully my colleague has 15 years of experience in Peru, because I’m going there without many local connections. My goal on this trip is to listen, learn, and absorb. Socios in Salud has been working in Peru for almost two decades and this is a long-term relationship so I plan to “cerre la boca” (shut my mouth) and tread very lightly. How can I be most useful to our Peruvian colleagues as we try to get our F-A-S-T study off the ground?
Absorbed in memories—how the past blurs with the present
It’s funny to be on an international flight again. Living in Mozambique for one year and then working for CDC/PEPFAR for two years I spent so much of my life on Delta 200/201. Those were 16-hour marathons from Atlanta to Johannesburg and vice-versa. On 200/201, you saw the same people over and over again. The hunters in their fatigues carrying their rifle cases towards the airport. The NGO workers and humanitarian types (like me). The South Africans, black and white, on their Ipads. The same flight attendants, their eyes baggy after flight after flight. No one seems particularly happy, especially halfway through the journey, after we are served a tepid meal of sliced chicken.
So many takeoffs in my life, and they are always a time to be contemplative as we accelerate down the runway. On the ascent of 200/201 you always had to decide how you would spend your 16 hours. Half-watching the crappy Hollywood movies while trying to get some work done? Sleeping fitfully? Pondering the meaning of life? Either way I always emerge half-awake, searching for passport control in Johannesburg, still needing to catch another local flight to Maputo or Windhoek, checking to see if my clunky Blackberry is actually getting service, hoping there would be a way to get a bottle of Amarula at Duty Free on my return trip. Or I’d be overwhelmed by the Coca Cola and Delta advertisements at Atlanta Hartsfield-Jackson International Airport side, just trying to hail a taxi to get home before the jetlag really kicks in.
But I’ve barely left the city of Boston for the past year. First year of ID fellowship is busy, as anyone who has gone through it knows. You see consult after consult and are on (home) call all the time. There’s not much time for international gallivanting, especially with our new baby at home to help rear. The last time I actually left the United States was in April 2014, while still working for the CDC, when a EIS friend and I took “annual leave” from the Commissioned Corps of the United States Public Health Service (USPHS) and went to Havana, Cuba for a week. Some day I’ll tell you that story. Because it’s an interesting one.
And the last time I flew internationally for CDC work was in December 2013 to South Africa and Namibia. That seems like such a long time ago. I was still in the USPHS then, with my khaki Lieutenant Commander uniform crumpled under my desk in my cubicle, and a blue folder containing government travel orders for my “TDY.” Only if you have worked for the government do you understand the true meaning of “TDY.”
Thankfully this flight to Lima is only about 5 hours, not 16. Bump bump, just a bit, but not too bad. We’ll probably survive. On Delta 200/201 I used to walk back and forth from the restrooms to the cabin, trying to move my legs and imagine who were the other passengers on my flight. A Repubican Senator from Nebraska going to shoot a few animals in a Zimbabwe game park. A USAID contractor enjoying his per diem. An entrepreneur from Cape Town. I need to push by my row-mate and walk around, just a bit of movement to avoid DVTs. I never did attempt the amazing Dr. Charlie van der Horst workout of “calisthenics, crunches, push-ups and lunges in the aisle of the plane.” Too self conscious, sadly. Why?
Will we die?
Airplanes are claustrophobia inducing and exhausting, but the main thing I sometimes struggle with is catastrophic thinking. Sometimes when we hit turbulence, I imagine, what if something is going wrong? Things go wrong in medicine every day— even at our best hospitals— medication errors, surgical site infections, etc, and certainly things go wrong in aviation as well. Of course it is exceedingly unlikely that all our engines will fail and we will plunge into the ocean, and I rationalize that I am at much higher risk of being mowed down crossing the street in Boston than I am crossing the continent. But accidents do occur in aviation just like they do in medicine. For example, Dr Jonathan Mann, one of my role models, plunged into the ocean with his wife in 1998 (Mann was an AIDS advocate and health and human rights pioneer). And Comair 5191 went down just a few miles from my high school. Am I headed for the same fate? Hope not, as our aircraft shifts back and forth. How can those of us who work in infection control learn from the relatively safe systems that aviation has developed? Eli Perencevich has written about this (“What can infection control learn from aviation safety”). But the parallels are not clear.
There are some benefits to flying. When there’s no wifi or cell phone service, an airplane is one of the few places, except for the middle of the woods, where I can really focus and do some deep thinking without any interruptions, except for obese passengers bumping the back of my seat and flight attendants offering drinks (“algo para beber?). No pager. No text messages. No crying baby. Well, I miss the crying baby already.
So I do have mixed feelings about flying. It’s not only the exhaustion from travel or occasional catastrophic thoughts. It’s not just the burning of dinosaur oil, melting the Arctic, and rising sea levels. It’s not only being away from my wife and 10-month-old son Joe although that’s obviously a major downside. And it’s beyond my hesitancy about neocolonial medicine. The issue is a bit more existential—where am I really going in this life? Physically, and metaphorically? Sweeping back and forth to some faraway country where I know few people? What are the benefits of flying overseas for work and what are the downsides? What will I achieve before my time is up?
Who is a writer?
And why did I spend two hours on this flight writing a blog post that will probably be read by 5 people? Although I did spend the first hour of this flight writing out some goals longhand in a notebook, I could have accomplished real work-related tasks that are piling up on my to-do list. Yet I felt compelled to blog rather than do real work. Why? Do I want friends, colleagues, and strangers to know what I am thinking? Am I writing this post for myself or for you? Am I actually a “writer,” as I like to increasingly think of myself? What is a “writer,” actually? Or am I just a narcissistic procrastinator?
Now my thoughts turn to David Sigelman, the father of my close friend and college roommate Ben. David was an extremely energetic, socially conscious middle-aged pediatrician in Springfield Mass. With his wife, Pat, he was always doing something active, like kayaking, biking, or hiking in the Himalayas. For several years David had worked high in the Andes, in the Altiplano of Peru, helping build greenhouses to reduce the burden of malnutrition among the local people. His work really was done in the “Last Mile,” similar to Raj Panjabi and colleagues in Liberia.
I considered David to be one of my mentors during college because I barely knew any physicians and hadn’t yet applied to medical school. He always had a wry smile and useful career/life advice. He also played the viola de gamba.
But on one surprisingly normal day in 2004, I received a sudden, horrifying call from Ben. His voice was cracking. His father had suddenly and unexpectedly died from high altitude pulmonary edema (HAPE) while at in the Andes of Peru. There had been a race against time to get David down to a lower elevation, because that’s the treatment for HAPE, and yet he had died. His memorial service in Northampton, Mass a few days later was so tragic, with the audience of friends/family singing “Get come together/ right now” and yet, so uplifting. You can listen to the entire ceremony on his memorial website, www.davidsigelman.org.
David really cared, and that is what was most important. Had he lived, he would be so proud of his Ben’s daughter, his granddaughter, Ida, who was born in November 2014 in San Francisco, only few hours after from my son Joe in Boston.
So my first visit to Peru is bittersweet, yet following in David Sigelman’s footsteps makes it clear that time really is precious. We must do the best we can and have a positive attitude while doing it. I will do my best to live up to David’s example…
Talking about airplanes plunging into the ocean and friends asphyxiating in the Andes probably classifies this as a morbid blog post. Maybe I should include the hashtag #morbid. Although I’ve tried to make it a bit uplifting, it’s hard. Perhaps the haunting music of Jaime and Manuelcha and Victor and Silvo over my earphones is responsible. There clearly are many ghosts in South America.
And what about humor? I’ve resolved in the past to try to imitate Dr. Paul Sax’s writing style (Paul is an ID physician at the Brigham and blogger extraordinaire, for Journal Watch). Paul is hilarious, in person and in print. Perhaps I could write just a bit funnier blog posts, but that’s tough—it doesn’t seem to come naturally. In person I think I have a decent deadpan sense of humor (at least my wife laughs at my jokes– occasionally). But in writing, for some reason, I come across as quite serious. Maybe I need to watch more Stephen Colbert. Or perhaps my humor is not best expressed through prose, but rather through defacing photos from the in-flight magazine.
