Westward

I wanted to do something momentous to celebrate my last night in London, though in the end the most momentous accomplishment of my departure was somehow managing to get two suitcases weighing seventy pounds each down from the third floor, through two flights of narrow staircases, to the ground floor from which they could be rolled rather than carried out the front door. This whole affair begs the question of what exactly could be filling these two suit cases, because I arrived in London last fall with the exact same weight in two other suitcases - both of which I already hauled back across the ocean at various intervals filled with goods I no longer needed in London (eg. my heavy winter clothes which I sent back from Ohio with my mother in April).

Dusty and sweaty and unreasonably exhausted from my hurried attempts to pack most of a year's worth of accumulated junk, I still managed to clean up to a presentable state and make my way down to the church of Saint Martin in the Fields. There I listened to a last concert ensconced in the pews that during the day shelter a significant portion of the neighborhood's homeless population but at night, under the glow of a couple thousand electric candles, the stone edifice shimmers with music that was meant for air inside these walls the way that the echo of burbling water over cobbled rocks was meant for quiet forest glades.

Upward from the crypt of Saint Martin, past Trafalgar Square with Nelson's column now wrapped in scaffolding for some kind of restoration project. North on Charing Cross until it turns into Tottenham Court Road. Across Bedford Square by LSHTM's outlying buildings and towards Gower Street. Turn left on Gower, just short of the cut-off to the British Museum. Northward again until the dead-end into the traffic barrier at Euston. Down into the Euston Square tube station and back up on the opposite side at North Gower. A couple short blocks from there, past the hole-in-the-wall breakfast cafes on the left and the Crown & Anchor pub on the rights. A quick left turn, up the stairs to the third floor, down the hall and on the left. Tonight I am home. Tomorrow, a final journey westward toward America.

Last Outings - Primrose Hill & Regents Park

The neighborhood around Euston marks the northern end of central London - as evidenced, at the least, by the fact that the edge of the "congestion zone" (inside which drivers must pay a steep per diem fee for the privilege of sitting behind the wheel of a moving car) parallels the main east-west thoroughfare of Euston Road. North beyond this large invisible border lie the suburbs hardly distinguishable from the city itself, as well as such lesser known treasures as Regents Park (which houses the London Zoo within its expansive grounds) and the picturesque little canal-side neighborhood of Primrose Hill, where Sylvia Plath lived in her last dark days before her suicide in 1963. This corner of the city is named after the hill that dominates its core, a surprisingly steep little knoll whose rounded peak offers a startlingly expansive view of downtown London and - in the warm season - a crowd of onlookers jostling for the best view southward toward the city, where a quick look can pick out the unseemly British Telecom tower in the foreground and the London Eye ferris wheel on the distant horizon.

On the day that I visited, it was sunny and unusually warm, and the larger part of the London populace had emptied out of its stuffy apartments and spilled out in droves into the various parks. Even with thousands of picnickers, joggers, and rarely-indulged sun worshippers, the territory of Regents Park and Primrose Hill combined can accommodate them all and still leave room to find a quiet corner or a uninhabited patch of tall grass into which entire families could disappear and hardly be seen from the nearby paths.

I took a long loop northward through Regents Park, across the street toward the hill, up to the peak and around the crest, then back through the quaint neighborhood of boutiques and cafes serving afternoon tea. South again through the park, where the late spring flowers are blooming in neat, organized rows of pinks and purples and blues. Quick duck into Starbucks to indulge my favorite vice (a cold frappacino on a hot day), then back home to get some packing done.

Last outings - Kew Gardens

On a mildly sunny Saturday just before exams, I set out for the far southeast corner of London where the gardens and forest reserves of kings and queens past are now laid out in the vast and grassy tract known as Kew Gardens. The entirety of Kew Gardens is too much to see in one day or even a few days, but I set out with a map and a planned route around the various attractions that I promptly forgot about in favor of a prolonged meander along forest and glade and the more formal gardens of roses and lilies and rhododendrons.

Where the gardens were once the playground of the royalty - a place where the nobility could go to escape the dreadful humidity of London in the summertime and amuse themselves among the idyllic cottages and miniature zoos bursting with exotic animals - the gardens are now a repository for rare plant species both domestic and imported, which are nurtured and bred in the confines of protected greenhouses and gardens. Some of these are kept for display and conservation at Kew, but many other specimens are sent back to their homelands in which they are now rare, largely for the purpose of re-seeding endangered territories with authentic (albeit well-traveled) flora. (The location also bears the somewhat dubious distinction of being so close to Heathrow that the noise of the jets above is sometimes so loud as to drown out conversation, and one can watch the landing gear emerge from the belly of the aircraft and lock into place on their final descent into the English countryside.)

In one of the grand glass-and-steel Victorian greenhouses, tropical plants of all heights and girths wrap their way up toward the ceiling a couple dozen meters above. Below the canopy layer, low-lying herbaceous plants climb into the filtered light from above. And off in one nondescript corner an interpretive sign commemorates a pretty but unassuming little plant with purplish-pink flowers that you might just as easily walk right by among such a profusion of tropical color. This shrubby little specimen is the Madagascar periwinkle. If you boil down a hefty quantity the various stems and leaves and flowers, and if you cook them just right through distillers and condensers and other sundry toys you'll find in any organic chemistry lab, you might get a tiny droplet of a powerful substance that somewhere, some time in the last four or five decades, someone purified and altered and cooked down until it was in a reasonably unadulterated form. And then this anonymous someone got the whimsical idea to give the resulting concoction to patients with blood cancers - leukemia, lymphoma, and the like. Now the derivatives of this little figment of tropical island flora are known as the vinca alkaloids - vincristine and vinblastine - that are still among the most potent drugs used today against those cancers. If I remember right, one of these was among the many compounds that the doctors in Ohio used on my niece to drag her stubbornly persistent leukemia into remission this spring before her bone marrow transplant.

Which brings me, in a round-about way, to the reason why I'm headed back across the ocean so soon: my niece - my brother's elder child - is now a couple of weeks into her bone marrow transplant but has become very ill. So far as the doctors can tell, the transplant was successful and the cancer is gone. But somewhere between the radiation and the chemotherapy and the rapid growth of the new marrow, she has been left with a diffuse lung injury that is requiring intensive support and an expansive regimen of drugs to prop up her ailing physiology while the lungs heal from damage already done. My travel plans have been quickly altered to include a several-day stop through Ohio to see the family there and spend some time at my niece's bed-side before I move on across the country toward the west coast, via the bay area, and eventually to Portland.

But on this day, I simply enjoy a quiet outing to the park to walk among forested paths older than most American states, and raise a to glass of some not-quite-alcoholic brew to the quaint old gardens and forested grottos of one of Britain's most famous picnic spots - Kew Gardens.

Last outings - Templar Cathedral

Down by the banks of the Thames, but hidden up among a maze of old buildings, lies a blocky circular edifice that looks more like a fortress than a church. This is the Templar cathedral - known by its tube stop simply as Temple - a remnant of a far away time and a mysterious order of knights who amassed a great fortune then disappeared in the span of a few mere weeks. Several centuries ago, a faltering king of some long-gone version of a European empire ordered the entire order to be gathered and tortured til they confessed to horrific heresies such as (*gasp!*) spitting on crosses. Overnight the fabulous wealth of the Knights Templar (gathered largely by requiring joining members to donate their entire personal wealth to the order) was confiscated into the French king Phillip IV's royal coffers. Conspiracy theorists attribute this power grab to the church's attempt to retake the fabled Holy Grail which was suspected to have been in the Templars' possession when they decamped from Jerusalem at the close of the last of the Crusades. I'm a firm believer in the human race's ability to happily commit atrocities of a squalidly grandiose magnitude without any motivation deeper than pure greed, so I tend toward the more mundane explanation that the massacre of the Templars was merely a financial grab by a cash-strapped king with no other more lucrative objects of plunder than the local peasantry.

Today the temple is perhaps best known as the site of the climactic scene of the film version of The Da Vinci Code, where the director cast off any moral claim to the artsy high ground when he inserted a ridiculously cheesy CGI montage of spinning planets other cosmological symbols to clue Tom Hanks' blank-eyed character into the solution to the codex that held the encrypted location of Mary Magdalene's grave. Most visitors (self grudgingly included) now arrive at the site mostly out of a sense of historical pilgrimage - even despite the ludicrous book and film made on their collective grave, the tale of the Knights Templar and their downfall is perhaps one of the most intriguing mysteries of European history...up there with the hoisting of the Stonehenge monoliths on the list of things that have never been fully explained, either the how or (more interestingly) the why. The temple has taken shrewd advantage of this sudden interest in its esoteric past, charging a few pounds per head to attend a series of lectures enumerating the parts of the novel that might be founded in actual church lore versus those that are purely located in the dark historical recesses of author Dan Brown's mind.

In any case, the inside was closed to visitors on the day that I arrived at its door, so I was left to admire the unusual architecture from the outside and note the two-knights-on-horseback effigy placed at the top of a tall column that is among the unexplained symbols employed by the Templars. Inside I could hear a choir singing - rehearsing, I suspect, since the doors were firmly locked and no visitors were allowed inside. I took a few pictures, laughed to myself at the other visitors who were comparing notes on the film's adherence to the history of the church even though I was largely there doing the same, and quietly took my leave.

Last Outings around London

With my time in London growing rapidly shorter, I triaged down a shortening list of destinations and sights I wished to see before my departure back to the States: places I had to see before I left, places that are so easy to get to that it would be a shame if I missed it, and places that I just had to give up on without an endless summer-ful of weekends to spend roaming the British countryside. The former two categories stayed on the to-do list; the latter sadly had to be relegated to the generalized status of things to do next time I'm in Europe - as there certainly will be a next time. The next few posts cover those outings.

Hotel Tropicana, Part II

After two weeks on the HTD inpatient floor, I moved over to the clinic side, housed in an older building just down the road close to where the school is located. These clinic days gave me a rapid tour through the sorts of things one sees every day in tropical regions; whereas the inpatient ward houses only a dozen or so cases at a time, the clinic of course sees that many or more every day.

The clinic is split between the travel medicine side (mostly for people going abroad who want to get vaccinations and antibiotics lined up), the walk-in clinic (which takes anyone who has "been in a foreign country and has a fever"), and a series of specialty clinics for everything from leprosy to tropical eye conditions to dermatological complications of HIV. Each day was new and different, and on the quieter days I headed back over to the ward to go on rounds with them.

The leprosy clinic was an interesting one, particularly because it's a disease almost never seen in the US. Certainly there are no cases of leprosy that arise in the States; when cases are seen, they are usually in immigrants who bring it with them from the endemic region they come from. The same is largely true in Britain, but because of migration patterns from ex-colonies (particularly India and Pakistan). And the disease is very slow-moving and can go on for years causing quiet damage before it's caught, so even immigrants who have been in Britain for decades sometimes still carry active disease. Fortunately for leprosy patients (who suffer from chronic degenerative neurological symptoms that often end up causing slow amputation of the far extremities, fingers and toes and the like) in London, one of the foremost experts on clinical and epidemiological aspects of the disease works at this clinic. Hers is a name that is all over the leprosy literature (and she is known for openly challenging World Health Organization dogma about the conditions needed to eradicate leprosy - which she maintains are not based in any reasonable evidence, despite the fact that international policy on the disease is based on it), and it's always a surprise to see the same name tag on the door that matches the journal papers I'd just been reading.

On other days I sat in on the HIV clinics. While this is not a tropical disease per se, it seems that it has been linked into that clinic because of the heavy prevalence in recent immigrants from countries heavily affected by the disease. The disease has very different patterns in the developing world than in the developed world, and the expertise that the tropical medicine doctors bring is often helpful in dealing with some of the tropical aspects of the disease even in very temperate London. The clinic I sat in on most was a dermatology session, which consisted of a large number of skin biopsies interspersed between common and rare complications of HIV - everything from possible manifestations of Kaposi's sarcoma (once the most common outward sign of HIV in temperate regions, now decidedly rare since the advent of anti-retroviral drugs) to a fulminant case of human papilloma virus that had scarred a young man's face with thousands of tiny wart-like lesions. In this clinic I quickly learned to pick out the stigmata of anti-retroviral drugs; where once AIDS patients could be identified by their gaunt look and purplish lesions, now those same patients can be picked out by the metabolic changes caused by the drugs - especially the lipodystrophy that deranges the deposition of fat, stealing it from the puffy pads around normal cheeks and replacing it in regions around the torso where it should not be. That is just one of many reminders that while HIV has become a chronic disease rather than an inevitably fatal one, prevention is still a far better option than years of treatment.

The miscellaneous clinics in between included everything from ophthamology to the general post-travel walk-in clinic where anyone who had been out of the EU and has a fever can be seen on short notice. The eye clinic was a slow day, which gave the doctor a good opportunity to quiz me on everything under the sun that had remotely to do with eyes. I had warned him that I had almost no experience in ophthamology, so I was surprised that I could actually answer most of his rapid-fire questions. He did drag out a slit-lamp apparatus with a second lens to one side that allowed for me to see the same thing he could see in the patients' eyes while he described the findings. We only saw two or three patients, but they were interesting - one especially came over from the hospital ward to rule out a nasty little skin-and-eye parasite called onchocerciasis. Fortunately or not, he didn't have the particular infection - which was good in that he didn't have the kind of chronic eye inflammation that could lead to blindness, but not so good in that this left his chronic intolerable skin problems firmly undiagnosed. Since the end of my rotation was near, I was not around to find out if the skin biopsies eventually gave him a satisfactory answer or left him still with the mystery of his affliction.

I spent the rest of the time with the general tropical medicine providers, seeing more mundane cases than medical oddities. By happenstance one day seemed to be all about unhappy bowels and the uncomfortable individuals walking around town with them. It was in this clinic that I learned that the NHS brand of socialized medical care does not exactly protect the public from the depredations of private providers and labs out to make a buck on a gullible populace. One woman who had returned from exotic travels with a case of what looked a lot like post-gastroenteritis irritable bowels; she paid a private commercial lab to culture her stool (I suppose that's a mail-order transaction, though I didn't actually want to ask!), from which they gravely informed her that she had a colonization of Citrobacter and Blastocystis in her colon - and she came to us to ask for the appropriate treatment for such a terrible condition. The only problem is that Citrobacter is considered normal flora for the bowel, and eradicating it would not only be a lengthy and unpleasant affair, but would also probably leave her wide open for opportunistic bacteria that would take over in the absence of the usually bugs. The second bug, Blastocystis, is a matter of some controversy. Some think this is an important pathogen that might explain a large proportion of general bowel upset that usually falls under the catch-all of irritable bowel syndrome. The opposite camp points out that no one has actually been able to correlate the presence of the parasite with consistent symptoms. In any case, a whole cottage industry of private providers has sprouted up give the grave diagnosis and solemnly advice that patients immediately consult their the physicians for a course of metronidazole. This usually clears up low-level (and difficult to detect) giardia infections along the way, which makes it seem as if the lab was indeed correct that the Blastocystis was the problem. In any case, the lab makes its money, and any cases of cure reinforce their reputation for finding a mythological pathogen that mainstream medicine refuses to recognize - all this despite the stubborn little fact that not even those with a vested financial interest have been able to prove there's any symptoms at all from the bug itself.

In any case, after nearly a month with the tropical medicine teams, it strikes me that this is an area that I would like to keep one eye on, even as it's not the most common or lucrative profession in the decidedly temperate US. There is one stumbling block there, which is that the infectious disease training comes as a fellowship after an internal medicine residency. And since I want to go into family medicine - not internal medicine - that makes it a difficult path to follow. But I was also struck by the difference between medical care in the UK versus the US: in the UK, everyone with any access to the NHS can access the full breadth of the system - so a new immigrant with persistent pathogens left over from their homelands can go right to the specialist ID doctors who are most expert in those conditions. In the US, however, anyone without insurance (as is the case with most recent immigrants) usually ends up in the care of general practitioners in the community or government system of county clinics and the like. Most of the infectious diseases that I am interested in - TB, HIV, imported tropical pathogens - affect people who rarely reach specialized care unless their conditions are so bad as to require hospitalization. As such, with my intent to practice in the US, it makes more sense for me to train as a primary care generalist; were I intending to practice in the UK, I could quite well see myself going into the ID specialty.

And that was my month on tropical medicine - a perfect end to a year of tropical studies in the cold north lands of Britain.

Hotel Tropicana, Part I

For the last year I've stayed largely outside the world of clinical medicine and delved mostly into the realm of public health. Intuitively those don't seem like very different things, but they can be almost two entirely separate bodies of knowledge - as evidence by ability to expound at great length on the relative merits of various insecticide-treated bed net distribution schemes while I have totally forgotten all things clinical, such as which valve lesions cause which heart murmur. Late last fall, one of the infectious disease lecturers mentioned that just up Gower Street - only a few minutes' walk from LSHTM - is the old Hospital for Tropical Disease (HTD). I enquired as to whether the facility ever takes foreign medical students on rotation, and after some rapid maneuvering to get paperwork together, I signed up for the only spot that was available before the late fall - which happened to coincide with the three-week block I was due to study for the cumulative June exams. But I was very interested in doing the rotation, so I took the less-than-ideal dates and now here I am.

Because of the tendency for patients to come back from glorious tropical travels only to land in an HTD bed, the ward consultant this month (what in the US we would call the attending physician) politely but aptly refers to the eighth floor ward as "Hotel Tropicana." This particular consultant is a slightly wild-eyed Irishman whose lectures (both on the medical ward and in the CID course last fall where I first encountered him) are marked by an equal mixture of noir humor and photos of tropical skin disorders that inevitably turn out to be polaroids he took of his own arms and legs during his years in equatorial Africa. I've now heard his lectures on worms and other sundry parasites so many times that I can recount the original stories from the photos included in his standard Power Point presentation - the bucket-filling tapeworm that some poor gentleman spent most of a day winding out of his rectum while his very pregnant wife edged into labor; the migrating loa loa worm snaking across a patient's anterior eyeball while a very self-amused trainee doctor proclaimed that "the worm just came out to say hello-hello-a!"; and, more sobering, the newspaper headline from only a couple of years back that announced that Britain was trying to sell Tanzania a $23 million air defense system in a time when the Tanzanian government was spending about a dozen dollars per capita per year on health care.

The HTD itself is located on the eighth floor of a gleaming and spanking new building that is so close to my studio in Euston that if I lean far enough out the window, I can stare into the windows of the eighth floor where I see patients during the day. And from that floor, the rooms with southward-facing windows get an excellent view of London - with the cross-shaped and gable-roofed Cruciform Building (which houses the University College London medical school) in the foreground, and the London Eye (the enormous Ferris wheel that sits alongside the Thames) off in the distance, London looks like a carnival, even perhaps through the jaded eyes of the patients who are temporarily incarcerated on the hospital floors. The attached outpatient clinic is located a few blocks down the street toward the school. By the end of the month, I will have spent two weeks at each site, minus the two mornings in the last week that I will be obligated to make an appearance at school to sit through two three-hour exam sessions.

Two weeks ago now I started over on the hospital side, where a daily patient census sees more tropical diseases than a year back in Oregon. Most of these folks are travelers of some sort. Many are British nationals returning from vacations or work trips abroad; some are on their way home to other parts of Europe but get dragged off a flight into Heathrow barely conscious and hauled into the HTD for a few days of resuscitation before they are able to continue on home. Because most staff at LSHTM have international aspects of their jobs, there also seems to be a sporadic supply of lecturers and researchers floating through the ward who have picked up all manner of fever in the tropics; when one does show up, there is an uncomfortable shuffle to find a medical team who is staffed entirely by consultants and trainee doctors who aren't actually close personal friends of the unfortunate victim. Since there are three teams on the ward (tropical medicine, general ID, and HIV care), usually one or another fits the requirements - but not before most everyone on the ward has heard the intimate details of the patient's last dozen bloody bowel movements and other such unsavory personal details.

The remaining patients are largely native to Africa, Asia, or other exotic locales who have resident status in Britain. Some bring simmering infections with them on their immigration, which show up years later as, for example, the temporary seizures caused by a dying tapeworm cyst that has lodged itself in the patient's brain a decade or so earlier. Others return from short visits back home with some more acute condition; it was sadly pointed out during a lecture last fall that many of the ex-patriate Africans are admitted to the HTD after visiting home for the funeral of a close relative - and almost always, those funerals are AIDS deaths. A preventable disease, a treatable (though not yet curable) disease, and AIDS is still the leading killer of adults in most African nations.

But usually those returning to Britain are plagued with uncomfortable but far less serious infections - malaria at the top of the list, a whole host of enteric pathogens below that, and then some of the more obscure germs like a bacterial infection called brucellosis that one might acquire if one were to drink, for example, unpasteurized camel milk. Malaria is a very different disease for locals versus travelers in endemic regions; people who live with it all the time tend to carry a low level of parasites throughout the year, and if it doesn't kill them in childhood, they are virtually immune to getting ill from the bug as adults, as long as they are continually exposed. Immunity fades fast once they move to a temperate malaria-free zone like Britain, but most don't think of it as an adult disease and don't take prophylactic drugs when they go. There are several legendary horror stories about this phenomenon - people coming back to London so sick they can't think straight any more, but no one thinks to consider malaria until they turn up on an autopsy table. For this reason, just about anyone who walks through the door of the HTD with a fever automatically gets a blood smear to check for the parasites.

Aside from malaria, perhaps the most interesting cases to turn up harbor a vicious little disease called leishmaniasis. A few months back this parasite was making the news because it's endemic to Iraq and passed by biting sand flies - and more than a few Americans and Brits have returned from the various incarnations of the Gulf War with a teeming mass of these creatures carving out non-healing ulcerous wounds on arms and legs and various other exposed body parts. Most cases of leishmaniasis seen in London are not from the Middle East but from Central America - particularly Belize, by default of the fact that Belize is an ex British colony and thus a popular destination for British tourists. Some forms of the disease hit the gut, and that can be fatal. But one of the sorts found in Belize can have a less fatal yet almost equally unpleasant effect: some subtypes of the parasite stay in the skin, but some head for mucous membranes, where they invade and cause serious disfigurement of both the soft and bony structures, particular around the face. With one particularly unfortunate gentleman that we admitted this week, it was not yet clear whether the enormously inflamed lesion located on the tip of his nose was invading into the bone or not, but in any case he'll be coming into the hospital for a month of daily infusions of a ghastly antimony-based drug that almost universally causes heart arrhythmias and pancreatic damage - probably with a referral to plastic surgery on his way out the door.

In any case, the ward is never boring. Next week, onto the clinical side...

A fine afternoon of theater

A couple of decades ago, an American actor named Sam Wanamaker got the idea in his head that on the unmarked site of Shakespeare’s long-disappeared theater beside the Thames River, the city would do well to erect a replica that could serve as a permanent home to the playwright’s legacy. Not everyone was so enthusiastic as Wanamaker, and it took several decades for the project to come to life. By the time the first play was staged in the new Globe Theater in 1997, Wanamaker had long since passed away, but because of his passion and persistence, London is now blessed with a venue authentic to every minute detail to the stage that Shakespeare originally wrote his plays for. On that muggy river-side site where such literary genius was put to stage and paper, the Globe emanates a multi-layered history – a contemporary construction mimicking an original Elizabethan edifice where a long-dead writer recounted legends of the Roman empire that had petered out a millennium earlier.

I had visited and taken a tour in mid-winter, when the skies are far too rainy and the air far too chilly to stage outdoor plays. I made a point of putting this on my list of things I must do before I leave London – and with the date of departure coming ever-nearer, I decided this sunny Saturday was as good a day as any to skip out on studying and go see a play.

The theatre is set out in the original style, with thatched roof over heavy wooden rafters, three tiers of stacked seats viewing the action from almost every angle possible, and an open floor plan where those who want something even cheaper than the cheap seats can pay £5 for a standing-only space that is close enough to the action that spatters of fake blood are a regular hazard. I know myself well enough to know that while £5 for an afternoon’s entertainment sounds like a great bargain, I can’t stand still for that long (especially after a week on my feet in the hospital wards) before I get cranky and just want it all to end. Instead, I bought the cheapest seated ticket (“restricted view,” the box office warns of these tickets) and installed myself on the top-most deck in a corner from where I found myself looking straight down onto the stage from a vertigo-inducing thirty or forty feet up.

I’d never read Titus Andronicus and had only heard that it is one of the “darker” works that Shakespeare ever wrote, which is of course a mild euphemism for the gore-soaked bloodbath that actually characterizes the story. I do believe that I can only think of one Hollywood film that out-gores this stage play, that would be Quentin Tarantino’s Reservoir Dogs. Except that Reservoir Dogs was perhaps even subtle and understated compared to Titus Andronicus. One reviewer cautiously described the script like this: “This is a great play. We're talking fourteen dead bodies, kung-fu, sword-fu, spear-fu, dagger-fu, arrow-fu, pie-fu, animal screams on the soundtrack, heads roll, hands roll, tongues roll, nine and a half quarts of blood, and a record-breaking 94 on the vomit meter."

And in the hands of the very expert actors and directors at the new Globe, it was a fabulous show.

From my vantage point, I got to see it all. I quickly realized that I had chosen my seat with unintentional wisdom. For one, being just above the action meant that I could see some of the stage tricks and sleight-of-hand manuevers – heh, no pun intended – such as the quick turn of a prop that provided the murderous Aaron with the disembodied hand of his victim just as the axe hit the ground. But even more than that, being so deep up inside the rafters meant that I was shaded from the dizzying early-afternoon heat of a muggy summer day next to the Thames. The two hundred or so folks who were standing on the theatre floor were not so lucky, and somewhere in the middle of the second or third act, the first spectator went down. Just as the beautiful maiden Lavinia was dragged off stage to the accompaniment of a screaming soundtrack and then thrust back onto the stage in red-stained rags and with a prodigious slug of stage blood pouring down her chin, a young woman in the standing audience passed out, flat on her back, right there in the theatre. Within seconds two ushers were by her side, and in less than half a minute an attendant in a starched white uniform pushed through the crowd with a wheel chair. The girl came to, hauled herself up into the waiting chair, and was rolled out the side door before the title character had finished his soliloquy.

But then the real carnage began. The audience started dropping like flies. Inside the next fifteen minutes, three more spectators were wheeled out of the theatre – and that was just in the limited section of the theatre that I could see. In fact, two were wheeled out almost simultaneously, meaning that that the staff must have had at least two wheel chairs and two attendants ready to go at any given time. Moreover, one of the fallen was not even standing on the floor, but was seated (fortunately) in the first row on the lowest balcony. Another two dozen or so staggered off toward the doors propelled under their power and only trickled back in after dousing heads with cool water and fortifying themselves for another couple of acts back in the theatre. None of this would have been even remotely entertaining if it had seemed to me that any of them were seriously hurt, but since all of them picked themselves up off the floor with only minimal help, I figured no one was throwing a fatal clot into their brains or anything. As it was, since the action on the floor was producing a higher body count than the action on the stage, most of the remaining audience probably missed out on a good quarter hour of the play watching the real-life casualties. And that was all before intermission.

In any case, I was quite happy to be seated in the shade. While I have a pretty high tolerance for all sorts of gore – staged or otherwise – I also know I have a fairly low tolerance for standing around in the heat. If I didn’t know that already, I got a quick and sharp lesson on it last year when I scrubbed into an obgyn surgery one evening and nearly passed out into the patient’s open c-section incision. To be fair, I was on my fifth consecutive shift of night call and I had some ghastly virus that wasn’t the flu but sure felt like it. But from that I know my limits for standing still in sweaty conditions, and I could be fairly sure that I would be among the casualties down below if I hadn’t had the foresight and the cash to pay for a seat.

The remainder of the play was ever-more gory but produced no further emergencies among the audience. By the time intermission came along, the worst of the mid-day heat had passed, and those who were left standing were probably the heartiest of the bunch anyhow. Three hours after it started, the play ended with some half-dozen or so primary characters sprawled out in various pools of blood (some their own, some not), and a final monologue installed a minor character as the next emperor of Rome, and the figurative curtains came down. A good time was had by all.

Oh yeah, that school thing...part four

For the final two courses of this year, I took a course in HIV/AIDS and another one in maternal/child health. The first one was directed by a very well-known physician and researcher whose credits include - among dozens of other more scholarly works - a mention in the back of John LeCarre's novel The Constant Gardener as a technical advisor on the novel.

The course opened with a viewing of the movie version of And the Band Played On, which is probably the most thorough account available of the early years of the AIDS epidemic in America. The book was written by a San Francisco Chronicle journalist named Randy Shilts, who died of AIDS no more than a few months before the first anti-retroviral drugs appeared on the market and forever changed the face of HIV from a death sentence into an unpleasant but treatable chronic condition. In the ensuing discussion, it was discussed that in one sense, the world is very lucky that the virus hit the gay community first - not to justify any of the vile hatred that was inflicted on homosexual men in the 1980s (and still today), but because the gay community was quite probably the only minority group in America who was vocal, well-organized, and politically committed enough to overcome the fatal inattention paid to the disease in the Reaganite era of small government and declining interest in public investment into health. Without the hard-fought battle to find a treatment when the president of the USA wouldn't even say the word AIDS on television, whole classes of anti-retroviral drugs we have today would probably not exist. And as the disease makes its inevitable shift from a condition of the well-traveled to a condition of poverty (with prevalence in some African nations running up to a jaw-dropping 20% in adults), it becomes ever-more clear that the world owes a debt of honor to the early AIDS victims on whose graves the struggle for attention and research and progress against the disease was built. Without them - especially activist groups like ACT UP and the Gay Men's Health Initiative - medical science and government agencies would probably still be twiddling their thumbs while the disease becomes Africa's top killer.

The course moved on from there through the various aspects of HIV & AIDS, from the disease pathology to its global epidemiology, from treatment challenges as the virus grows resistant to antiviral drugs to sociological approaches to reduces the stigma of HIV that so often hinders prevention and adequate treatment. One of the more original and amusing talks was given by a advertising executive who had taken up the cause of producing effective campaigns that use very slick and market-tested radio, television, and newsprint spots to bring public health messages into the media spotlight in developing nations. On the topic of leprosy - thought by some Hindus in India to be a duly deserved curse from the gods - one ad sent a leper to the house of the gods, who joked about how only a silly fool would think the disease was a god-given curse when they could get pills to cure it from the local health department. In another one, an attractive young woman asks the viewing audience if they think they might have also been intimate with the gentleman she contracted HIV from; at the end, she tells the viewers, "All I want to know is...did you give HIV to me, or did I give it to you?" Some of the ads threw interesting spins on homophobia - in one spot, an angry father tells his son's boyfriend to leave and never come back; just when you think you know the punch line, the father turns to his homosexual son and comforts him with reassurances that someday he will find a man who treats him well enough to be worthy of his love. Other than that, the most memorable ads were a series of condom promotions from various parts of Africa, which set up very steamy scenes between one beautiful woman and one hunky guy, which inevitably ended with hunky dude using a handy condom (always be prepared!) to fix quotidian problems such as a leak under the hood of a car.

Many of the presentations were similarly interesting, but the course leaned heavily on the lecture format to the exclusion of direct participation and discussion - and six hours a day of straight lecture is enough to put an audience to sleep no matter how interesting the topics. I also started to realize during this course that LSHTM as an institution seems to hold dominion over a finite and somewhat limited breadth of topics. And while I find all the areas covered to be rather interesting, toward the end of the year I started to get a feeling that I had heard it all somewhere before. Indeed, when I went back to look through the lectures from the fall, some of the speakers and hand-outs were indeed identical to those covered in this class. I suspect that is partly because my track - Control of Infectious Diseases - is somewhat narrower than other like Public Health in Developing Countries; I also understand that a balance has to be struck to cover the basic CID topics in the fall for those who don't take those particular classes in the spring. Nevertheless, a certain saturation point has been reached in what LSHTM has to offer.

That saturation point has also been reached for that enormous annoyance known as group work. Someone once said regarding group work that a group is only as strong as its weakest member. I disagree. I think a group is only as strong as its most anal-retentive member who is willing to stay up for hours just before the assignment is due to clean up the messes left by those inevitable weaker members.

We had two group assignments for this course. One involved four teams of 25 people each arguing various aspect of HIV resource prioritization in a debate on the last day. The size of the group was the first problem, given how hard it is to get half a dozen people to meet at an agreed-upon time, much less a couple dozen. The second part of the problem is that with no appointed leader, most people just didn't show up and about ten of us ended up putting our part together the day before the presentation. Ours was as good (or bad) as any others, which indicated to me that we weren't the only team with these same problems.

The other group project consisted of writing a country profile together, then using that document to write individual plans for how one might use a given amount of funding to fight the AIDS problem in that nation. Largely because no time was allowed in class to complete this assignment (and also because the "country profile" was more like a book report than anything more original or useful), this was one of the most painful group projects out of a year of many painful group projects. I ended up putting together (ie. re-writing) a set of contributions that did not speak well for the literacy of the participants. One was not in complete sentences, just half-factoids in broken-up phrases. One was yanked wholesale from a website on South Africa, with just enough words changed around to make it borderline plagiarism rather than overt plagiarism. One was cited by highlighting each paragraph in a color to be matched to a color in the reference list; this left me scratching my head as to whether the paragraphs were original works or block quotes from one source or another. It took me one long weekend afternoon trying to sort all that out before I blew a gasket at the group via email and demanded that some of this stuff get fixed before I had to work with it. In the end, I coped with the short-comings by re-writing each paragraph then spot-checking for plagiarism by googling random phrases to make sure they would not show up in the software that universities now regularly employ to check for plagiarism. I know fairly certainly that this was not intentional on the part of the group members I worked with, which left it as either laziness or incompetence. The worst part of these experiences is usually the fact that by now most of the groups contain people who I am well acquainted with and otherwise like very much. I'm sure the unpleasant after-taste this left in my mouth was mutual from their end, but with very little patience left so close to the end of the year, I couldn't really bring myself to be apologetic.

The other class I chose to take was entirely outside the realm of infectious disease, and because of that it was a breath of fresh air. The course had some very lengthy and complicated name that was a dressed-up phrase for maternal/child health (MCH, as the parlance goes). Because there was very little overlap with infectious disease (aside from a few topics such as neonatal sepsis and vertical transmission of HIV from mother to child), the bulk of the information and the lecturers were refreshingly new to me.

Most striking about the course was the simple statistics they presented early on - the rates of maternal, infant, and childhood deaths in developing nations are ten-fold - sometimes even a hundred-fold - increased over the rates in nations like the UK. For a wealthy nation, the US doesn't score so hot either - far down the ranking in terms of industrialized regions, though still nowhere near the bottom-out rates in southeast Asia and sub-Saharan Africa. The causes of maternal mortality are particular tragic both in how preventable they are, and in their terrible impact on the dependent families these women leave behind when they die in birth. Hemorrhage, eclampsia, and a handful of conditions that are so routinely treated with total success in the developed world are still killers of moms and babies in areas where even low-tech birth interventions are unavailable.

One of the most disturbing elements brought up in lecture was the tight correlation between restrictive abortion laws and maternal mortality. In the 1990s, a morbid and tragic experiment in human behavior took place in Romania. For about a decade before the fall of communism in Europe, Romania's population was falling and strict laws were instituted against any and all abortions. During that same time, improvement in the care of birthing mothers dropped the maternal mortality rate from perinatal causes in Romania to the low level commonly associated with developed nations. But at the same time, the overall maternal mortality rate failed to budge at all, as it was propped up by the mortality experienced by women who died from unsafe abortions. A few years ago the abortion laws were lifted, and the all-cause maternal mortality sank within months to a level comparable with any wealthy nation. In other words, during the years of abortion restriction, the vast majority of the women who died due to pregnancy-related causes died because of unsafe abortion. All of which points to the ultimate lie of the anti-abortion contingent, for whom "pro-life" only applies to fetuses in utero, and not the adult women who carry them. Access to safe abortions IS a pro-life stance, if one considers the life of the woman as part of the equation.

In any case, this class also had its own fair share of group work, and strangely enough, this was perhaps the smoothest and most productive group project of the year, as well as being the last one. This was probably because ample in-class time was dedicated to the project, so there was less stress of having to stack the project on top of all the other class commitments. I chose the group that was looking at ways of reducing maternal mortality from hemorrhage.

In wealthy settings, when a woman shows signs of post-partum hemorrhage, a quick shot of a drug called pitocin is administered. This is the synthetic version of the hormone oxytocin, which causes the uterine contractions that drive labor. In a direct intramuscular dose, pitocin cause the uterus to contract tightly (and nearly instantaneously), stopping most of the bleeding that kills women who experience this problem. It's fairly painless with few side effects, and usually the mom & baby go home with no further effects. But pitocin is expensive by third-world standards, it requires administration with a needle, and it has to be kept cold and away from sunlight if it is to keep for very long. In nations where most births occur outside of hospitals with no skilled attendants, pitocin is hardly a practical way to slow the death rate from post-partum hemorrhage, and so the mortality rate from this complication remains unacceptable high.

At the moment, two different interventions are being considered to reduce mortality in regions where pitocin isn't available. The first is a strange looking apparatus called a non-pneumatic anti-shock garment. It's mostly a big piece of fitted neoprene that is wrapped around the legs and belly of the woman in shock and cinched tight with velcro straps. This pressure on the lower limbs and the belly can both slow the bleeding from the uterus and drive the remaining blood out of the limbs (which don't particularly need it on an immediate basis) and back toward the heart, brain, and kidneys, which can't live without it. There are tales from Africa (even documented in the literature) of women coming into hospital with no pulse and no signs of consciousness who literally come back to life after being wrapped up into one of these garments. There are downsides though - the outfit is a little expensive for a poor community to invest in (about $150, though it can be re-used a few dozen times), and for women who give birth way out in the sticks, there probably isn't enough time to get them to a clinic that might have one of these things before they bleed out. Some people even think that investing in these sorts of things is a way of slowing progress toward investment in the gold standard treatment, which is still pitocin.

The other intervention is a drug called misoprostol, a synthetic prostaglandin that contracts the uterus much like pitocin. It works more slowly, but has the big advantage that it comes in the form of a pill so no needles are needed. And, the pill can last for years if it's kept in the kind of air-sealed packet that lots of over-the-counter medications come in. Women can take the pills on their own at home after the birth to prevent any problems that might come on, or the pills can be given just as the problem starts to keep it from getting worse. Some trials have returned good results when community health workers hand out the pills to anyone who might be pregnant (both those who show up at a pre-natal clinic and those who the health workers find out in the rural areas who never make it to a prenatal clinic at all), with strict instructions about how and when to take them. This intervention shows great promise because it can work in rural regions where most women give birth far away from medical facilities - ie. the same regions that are most difficult to place other interventions in. The downside of this is that because the same drug can also be used quite successfully to induce first- and second-term abortions, there is a large contingent of politically active people out there who do not want it distributed anywhere. Again, this sort of stance shows what the "pro-life" slogan really means: the anti-abortion people are willing to sacrifice the lives of birthing women - women who are trying to carry their babies to term and raise healthy families - in order to restrict other women from having access to a pill which not only induces abortion, but shows far safer outcomes than illegal abortions. Because of this problem, the drug has never been tested or formally registered for any obstetrical use, so optimal dosing regimens have not been firmly established. In fact, misoprostol was invented as an ulcer drug, and there is some concern that because there are many better ulcer medications available now, the companies that make this product will cease to market it at all.

On the last day of class we presented this information and our hypothetical recommendations that this be implemented in several African countries alongside studies to make sure that this approach was producing good results for the investment required. Of course, we were immediately shot down by one of the instructors - an attending physician who has worked extensively in African crises from outbreaks of Ebola to outbreaks of civil war - who asked us, "What about the second twin?" We puzzled over this for a moment, then realized what he meant: where pre-natal care is minimal, it's often not known whether a woman is carry a singlet or more babies until the birth gets going - and a substance taken routinely to contract the uterus after birth would certain clamp down on the blood supply to any remaining babies in the womb - twins or triplets. Back to the drawing board for us, eh?!

And so ended my last class at LSHTM. Now all there is to look forward to is exams!

Oh yeah, that school thing...part three

After a week's break between terms, the second five-week blocked started. This was split between a course in Medical Anthropology for Public Health and a course called Epidemiology and Control of Communicable Diseases.

I've always found anthropology to be a mixed bag, at least in the couple of classes I took in it during my undergraduate years. On one hand, the idea of trying to understand phenomenon of human behavior from within its cultural context seems like the few legitimate ways to try to make peace between factions throughout the world who are constantly at each other's throats - and it has a role as well in trying to make medicine less of a top-down do-as-I-say profession and more of a partnership between providers and patients who often seem to be a cross purposes. But I also find it frustrating that there's a tendency in anthropology to over-explain things, to ascribe grand meaning to details of other cultures so minute that we wouldn't ascribe meaning to the equivalent in our own cultures. Well, that and the fact that apparently no self-respecting anthropologist can write anything in less than fifty pages. I think the official term for that latter phenomenon is "thick description" - trying to capture every nuance and detail and variation rather than the trends and generalizations that epidemiology focuses on, for example - although half the time I feel like it's just bad editing. (And the final irony is that the exam for this class required four essays in one hour - which seems to be in ironic opposition of anthropology's tendency to require at least 10,000 words to describe the variation on how people drink their coffee in the morning.)

The class did cover some interesting territory though. Each student presented one journal article and a relevant example to their respective seminar group; I focused on an article by Paul Farmer, the Harvard-trained doctor who opened up one of the only TB (and later AIDS) clinics in rural Haiti. His thesis was, ironically, that anthropology as a discipline has a lot to answer for over some of the omissions and biases that it indulges in. For example, when it became clear that Haitian immigrants in the US were a major risk group for HIV infection in the early 1980s, anthropologists got on the case and conjectured how it must be bizarre blood rituals associated with voodoo beliefs that sparked the epidemic in that group - without an iota of evidence to say this was true. In retrospect, it was almost certainly the international sex trade in the dirt-poor capital city of Port-au-Prince that caused the initial cases, and from there it spread like wildfire via trucking routes and the near-constant military movements that marked the era of coups and counter-coups after the fall of the Duvalier regime in 1986. Farmer went on to accuse anthropologists (quite rightly, I believe) of entirely ignoring the factor of poverty in determining how people behave, instead searching for arcane cultural reasons why so many Haitian do not, for example, finish TB treatment regimens when even the TB patients themselves know that non-compliance to prescribed medications causes worse disease later on down the road. The thesis ended with perhaps the most important factor for understanding why TB control has failed so miserably in places like Haiti, Russia, and the entire African continent: "Those least likely to comply," Farmer says, "are inevitably those least able to comply." Very well said.

The other class - Epidemiology & Control of Communicable Diseases - is one of the foundation classes for my course in Control of Infectious Disease, and it was required for most of us in this track. This class largely covered the conceptual and mathematical approach to describing, predicting, and controlling infectious disease (in case that wasn't obvious from the title!). The course director was an American-born professor who had a very effective stage presence in lecture, which somehow devolved into an arrogant and assinine persona in the smaller seminar sections. He managed to make arcane subjects like "stochastic micro-simulation of disease transmission" not only palatable but even kind of interesting, using a physical model full of colored marbles to mimic the probability that one sick kid in a school will run into another kid and pass on a germ. At the same time, he managed to alienate just about every seminar group he taught, which ended up in a fiasco that I can only describe as The Day I Told Off The Course Director. About fifteen minutes into one session, I raised my hand and was called on to contribute during the discussion (the first time I'd said anything); I got about half a sentence into what I was going to say when he threw a dismissive little wave in my direction and told me he didn't want to hear what I had to say. I do believe that first my jaw dropped and then my eyes rolled (me? rolling my eyes? never!). I take full responsibility for what happened next, though I should also mention that I was a few weeks into a new medication for chronic headaches, and I was still pretty loopy while I was adjusting to it. Anyhow, we broke up into small groups; when he came by the group I was in, I told him I thought that was the rudest thing I'd ever seen a professor or any other supposed professional do in public. He sorta dropped his jaw, muttered something I didn't catch, and walked away. During the break, I was walking out of the computer lab to go back to class when I ran straight into him. He apologized with a fair amount of grace, but I was still pretty loopy (and totally not prepared to run into him) and all I managed to get out of my mouth was something like, "Uh...errrm...uh...ok...uh...thanks, man." It was not my finest moment, but it apparently made for a great piece of gossip, since I heard back about it from about half of my classmates in the next day or two. Apparently I wasn't the only one who was itching to tell him off, and if anyone thought I was wrong, I sure didn't hear about it. That was however a moment in which I was profoundly glad that a) all assessed work is turned in with an identification number and not a name so that graders don't know whose paper they are grading, and b) that this class is entirely graded by a multiple choice test at the end of the term so there is zero arbitrary input into final grades.

Aside from that run in, this class offered a rare view into the classic material that the school - indeed, tropical medicine as a whole - is all about. Toward the end of the term, with the basic concepts under our belts (as well as a hectic three-day stab at a simulated outbreak investigation), they brought in a series of lecturers on the major diseases that still plague the tropics and anywhere else that poverty is rife: malaria, TB, AIDS, and a handful of smaller ones like meningitis and polio. In the last couple of days came a series of guest speakers and debate presentations that tackled the issues that have defined tropical medicine ever since the field started to its shed history as an instrument of imperial dominion (largely focused on how to keep white settlers from dying in droves when they shipped out to colonize Africa and Asia) and began to turn toward the health of the populations who actually come from the tropics and have endured the additional blow of colonial rule over the last couple centuries: disease eradication in face of successes like smallpox and rank failures like malaria; health priorities in the face increasing inequalities across the planet; and emergent epidemics like bird flu that threaten an ever-more tightly globalized world. This profound redirection has shaped the field of tropical medicine today - and forced a hard shift away from imperialist intent and toward the days when celebrity causes-du-jour include debt relief and the wealthiest couple in world (all bow to Bill & Melinda Gates!) hand out funds by the millions for programs to improve the health of the people that imperial rulers once sought to exploit. It's a transformation that is far from complete and promises no smooth road in the decades to come. But there are signs that new priorities are emerging and that LSHTM and the network of similar institutions around the world do have something to contribute. Most profoundly, the halls of this little world of academia that used to be dedicated to supporting the exploitation of the tropics now house an increasing number of individuals from those regions - students, doctors, community advocacy workers - who are training to bring improvements back to those regions. While I find the topic fascinating and hope to keep global medicine at the forefront of my career, I am also under no illusion that my education will profoundly affect the health of people in poor nations. But the training provided to citizens of those tropical nations may yield profound impacts far greater than the majority of the student body that comes from the US, the UK, and the rest of western Europe. Their presence and their voices are what signify the profound possibilities of real improvements in global health, more than the Gates' and all the celebrities that Bono can recruit to the cause. It's a quiet shift, and often ignored, but it's those students who forge the hope that the field of tropical medicine can be more than just a way to provide first-world travelers with the right drugs to head off malaria when they vacation near the equator.

On the evening of the last class, the course director arranged for a gathering of all who wanted to come at a pub in the Soho section of London, not too far from the school. The pub is called the John Snow, after a long-dead gentleman who is credited with being the first to use on-the-ground epidemiological sleuthing to identify the source of a cholera outbreak that was plaguing London. In the days when the idea that microbes caused disease was still only brewing in the imaginations of a few future scientists, Snow mapped out the cases, tracked the water source for each household, and zeroed in on a particular water pump on Broad Street. He demanded that the local authorities simply remove the pump so that no further water could be obtain from the contaminated ground it drew from; with no other viable suggestions on the table, the authorities acquiesced. The pump handle was removed in September of 1854; the outbreak petered out, and modern infectious disease epidemiology was born. Soho is now a fashionable part of town, but if you look you can still find the site of the Broad Street pump, where a small plaque and a statue remember the outbreak. From the second-floor window of the John Snow, you can see the memorial and raise a pint to the grandfather of epidemiology.

Oh yeah, that school thing...part two

From January to May, we take three five-week blocks chosen from a variety of classes that have more or less to do with infectious disease. In the first block, I took a course called Primary Health Care in Developing Countries, and another called Conflict & Health.

The first one I chose largely because there wasn't a whole lot else on the list that I was terribly excited about taking, Mostly, I was avoiding the continuation of the epidemiology/statistics series, which would probably be very helpful but is not something I can see using enough to put myself through the unpleasantries of the actual course. Primary Health Care seemed like an apt enough course, being that this is probably where my intended career will take me anyway. Or so I thought.

The idea behind the PHC concept is something of a strange one. In nations where health infrastructure is minimal if at all existent, alternate systems of health care workers with minimal but specific training in local problems have been developed. In China this is called the "barefoot doctor" movement; other regions have different names for it. In theory, this is a good idea; it doesn't take four years of medical school to recognize the periodic fevers of malaria in places where most the population gets it more than once, and it doesn't take a doctor to hand out chloroquine at the appropriate time. And for simple matters like that, this sort of system works - if it has sufficient support to keep facilities and drug supply lines running.

But the whole concept has taken on the aura of religion. What started as a quick-and-dirty way to provide basic care in severely marginalized communities has managed to take on a following of true believers, among them the instructors of this class. Community-based health care is not seen as a service or a stop-gap until professionalized medical infrastructure can be built, but as a golden path to liberation - a way that a community can rise up out of poverty and achieve heath, wealth, and, apparently, the pursuit of second-rate medical care.

Which is, indeed, where I start to object. The evidence for the PHC actually improving health outcomes is minimal - or, if it is out there, this course directors failed to cite any of it. Far from presenting evidence on what sorts of programs have yielded better outcomes for the people involved targeted by these programs, the focus lies on how well a program adheres to the concepts of PHC - a rather circular bit of logic that neatly skirts the question of whether PHC actually provides reasonably improved medical care and health outcomes.

On top of that, there is an open hostility toward the "biomedical model" - that is, the notion that drugs and hospitals and health professionals are the key to improved health. In some part, this is true - much of the burden of disease in developing nations is tied up in conditions of poverty, and demand a system-wide solution that includes the alleviation of crowding and other such factors that drive the transmission of disease. PHC presumes to help out in that field including community development schemes as an integral part of the program.

But there's a couple of problems with all this. The obvious one is that health care provided by untrained or minimally educated local workers is bound to meet with unsurmountable technical limitations. Periodic fevers may look like malaria, but pneumonia also presents as acute fever, and these two are somewhat difficult to tell apart where both are common; additionally, they require two very different drugs which have absolutely no effect if the diagnosis is the reverse of what the local care provider guesses it might be. There's no way to fix this without at least a stethoscope and a microscope to run blood slides on, but that would take an investment in training and equipment that the PHC crowd looks down on. Apparently, they find it disempowering to inflict such technology and diagnostic precision on people.

The second objection I raise is that this system is touted not as a stop-gap until a modern health care can be installed, but an ultimate goal. Funny that wealthy nations - those with enough cash to create whatever kind of health care system they want - do not choose to venerate untrained locals over doctors, hospitals, and established clinics. And I have a strong suspicion that the course directors themselves - including one Brit and one American - do not go to half-trained community health workers when they get sick. I feel quite sure that they engage exactly the kind of system - one with university-trained professionals and well-equipped laboratories and well-stocked pharmacies - that they deplore in the developing world. It comes off as a kind of reverse snobbery: putting on a pedestal the kind of second-rate system that they have no obligation to depend on when push comes to shove.

This underlying attitude breeds some weird responses to health care professionals themselves, which probably made up a majority of the sixty or so students in the class. One doctor from Africa finally asked in exasperation what exactly her role should be in such a system. The American course director exclaimed that of course health professionals have a role! They should be serving in outreach and training positions. This struck me (and a number of others) as very odd. As a future doctor, I am not educated in either of those activities, and though I think either might be fun or interesting, it would be a total waste of my education to become a doctor only to do outreach activities, which do not take a four-year investment in expensive education to perform. In my opinion, doctors in these systems should be doing the things that community health workers should absolutely not be doing - things like cesarean sections and treatment of malignancies and management of complicated patients and surgical fixes to trauma.

There are other problems too, much of it rooted in a strange aura of naivete about what actually goes on in the developing world. One of the course directors once declared that no government ever objects when community development advocates try to build these kinds programs - which makes me think these people never read a word about Central America in the 1980s, when any sort of community development was violently quashed in nations like Guatemala and El Salvador under the guise of stamping out communism. Another time the same instructor mentioned that aid projects should be careful never to overwhelm the local capacity that has been built - an assertion that, if carried out, would mean that vital projects like mass measles vaccination should wait until each community can get it together to do it themselves. In other words, the desires of first-world PHC advocates to see a certain sort of work be done according to their dogma outweighs the objective of keeping kids from dying of measles. PHC can also be a victim of its own success - where straight-forward problems like malaria have been brought under control by community-based health projects, all that's left is the really ugly stuff that community health workers can't deal with: cancer and diabetes and neonatal sepsis and post-partum hemorrhage and the like.

But most of all, this approach demands that the poorest people in the world - those who work the hardest, those who have the least food to eat - take on the additional burden of running their own health care system. This is not something we ask wealthy people to do; wealthy people walk into a clinic or hospital built by some kind of health care system, they pay their bills through insurance or pocket cash or nationalized funds, and then they go about their lives. They are not asked to pitch in to build the clinic and create income-generating projects to finance the doctors' salary before they can access any care. And yet the PHC philosophy believes that it is entirely appropriate to ask the most poverty-stricken people of the world to do this themselves.

That was one class. The other one, Conflict & Health, was just about the most opposite in philosophy and subject matter. On one hand, the approach to the problem of providing health care in conflict zones (or "fragile states," as the current lingo goes) is the reverse of PHC: in camps for refugees and internally displaced people (refuges who are still within the borders of their home nation), there is little effort giving to building community capacity and more given to just getting people fed finding enough water and housing to provide a bare minimum of life quality. But more than that, this class covered the spectrum of approaches (from top-down aid to community-based efforts), noting the advantages and disadvantages of each and allowing for discussion for where different tactics are most appropriate for the provision of care to those most in need. Philosophically this was much more palatable than the narrow and dogmatic approach of the PHC class. And it made for some interesting discussion about what relief work is about these day - humanitarian workers used to have a somewhat protected status, and they could feel pretty safe even on the ground in some very conflict-ridden areas. Not so anymore. Because of the publicity and attention that arises when aid workers are affected, in places like Iraq and Afghanistan they have become intentional targets for any faction wanting front-page coverage in the western news media. There is much discussion about how this has evolved in Iraq, because with the recent incursion, the military has specifically encourage aid agencies to participate in the rebuilding - which certainly makes aid workers look like they are in collusion with the invading military. In other regions the situation is even worse - in Chechnya, it is estimated that fully one half of foreigners who land on the ground are kidnapped. Fifty percent. Any agencies wishing to do aid work there go in under heavily Russian military guard - which keeps them somewhat protected, but puts them squarely in the position of seeming to approve of or even aid the violent faltering Russian control over the region.

In any case, the two courses together made for an interesting (if not uncontroversial) look into health care in the developing world.

Castles & gardens

Sunday morning I got going early (after a carefully ordered breakfast of poached eggs, which were mercifully more palatable than the scrambled version yesterday) and made my way back to the castle. By the time I made the nearly hour-long walk from Leith downtown and the up the hill, the line in front of the castle was already building. But it seemed to be moving fairly swiftly, so I waited it out and finally got inside the fortress walls. This reminded once again that while I've been traveling these last few months, it's always been during the cold low season - which is quickly giving way to warm season when throngs of visitors seem to all want to go to the same place I want to go. Go figure.

I made my way into the walled battlements, where cannons of various vintages guard over the city below. The castle has been around for centuries, and it's current incarnation as a tourist magnet (at ten pounds fifty a pop) is probably its most successful endeavor, given its reputation more as a target to be conquered rather than an asset to be defended. Along the main street are signposts outlining the history of the castle, of sieges and counter-sieges and grand battles between the English and the Scottish that seem to have been going for so many eons that it almost makes me wonder how either knew where one nation ended and the other began.

Inside the castle walls are a series of museums and monuments largely dedicated to the glory of the Scottish military tradition - that unique brand of fightin' man that wears plaid skirts into celebration and battle alike. Part of this whole display has that whole ring of a proud people who refused to be ruled (or at least refused to be ruled without some effort at revolt) by outside forces. But when it spills over into glorious celebration of, say, the role of Scottish regiments in the first and current Gulf Wars, the charm really starts to wear off. No matter how many times the same story is told, it never fails to amaze me how those who are most attached to their own autonomy and home rule are also so quick to trample on the same desires of others to that same end. Is this what William Wallace (memorialized so indelibly and inaccurately in the movie Braveheart) would have wanted when he rose up against British rule? Maybe it was, who knows.

The remainder of the display mostly covered the variety of gear worn by Scottish soldiers over the centuries and over the different clans. One thing I was surprised to see was that there was one clan variously known as Docherty, Doherty, or Dougherty - same as the Irish name. Though Scotland and Ireland are just a narrow channel away, I never knew that there was significant crossover between the two - but apparently there were enough Irish in Scotland for long enough that they have their own tartan, their own clan identity.

Interspersed among all that was the bits of history here and there of the endless wars that seemed to virtually define Europe for everything but the last 50 years. For some reason, I find the stories of the pre-historical to the Roman era to the middle ages fascinating, but somewhere around about 1700 the whole of Europe seems to have devolved into a revolving series of battles in which no one was particularly right about their actions, and if someone was right in one battle, they were inevitably creating unholy terror the next time around. France, Britain, the various incarnations of Germany, and half a dozen other nationalities seemed to have just spent a few hundred years reaming each other without mercy, eventually landing on the upward end of steep learning curve that was the two world wars. Not that Europe or America has established an entirely enlightened foreign policy since then, but at least there seems to be a general consensus now that if you're going to wage war between mighty powers, you might as well do it on someone else's territory where you're own civilians aren't trying to go on living with the front lines passing through their front yards. Not that this has made for a benign policy toward the rest of the world - it's just that with this history, it's all the more amazing that Europe has been able to come together in the European Union, drop the national currencies that hinder trade across the continent, and even open up the physical and legal borders so that citizens of any of the EU countries can travel and work in any of these other nations that once went to decades-long war against each other. It's almost kind of inspiring.

Chewing on the political philosophy of the EU, I wandered out of the castle complex and back down the royal mile. I figured lunch was pleasant enough yesterday at the Hollyrood Palace's cafe (with the additional benefit that they didn't throw me out even after I'd been sitting around for a couple of hours, resting my feet), so I went back there again, and again put my feet up and ate a sandwich and salad - though this time I skipped the beer, as I didn't want to get any overblown ideas about, say, re-attempting the hike up to Arthur's Seat again. Feeling slightly more energetic after lunch, I decided (once again, what was I thinking?) to make the walk out to the Royal Botanic Garden, which was most of an hour in a completely different direction. Along the way back across Prines Street, I stopped for a few minutes into the National Gallery. I didn't stay long - I always give it about 45 minutes or so before I get bored with museums, which is why it's great that the museums in Britain are free, so that I can go back again without having to shell out several pounds to see a few paintings.

I made it to the gardens around five o'clock (still hours to go before sundown!) and wandered around through neatly trimmed lawns and immaculately kept trees. An enormous greenhouse at one end holds several specialized gardens from areas of the world far hotter than Scotland (though perhaps no wetter), so I wandered through miniature desert and cloud forest and tropical swamp until just about closing time. It was still fairly early - too early to go home to the hotel, but again there didn't seem to be too much Sunday-night action in this part of town. I started to head back up (don't laugh!) to the mall again. There wasn't much else playing at the movies that I wanted to see, but I figured there must be something I could sit through if it meant getting off my feet for a while. I started walking in that direction, but stopped at a bus stop to see if one might happen along like the schedule said. It didn't, so I started walking again, but finally saw it going by and ran to catch up. And a good thing too, because I don't think I would have made the rest of the walk to Ocean Terminal. I did finally get there (dinner at Starbucks, yup) and put up my feet to watch Mission Impossible III, which was actually (and sadly) far better than the flick I watched last night.

The next morning it was back to London for me, on the first train I could get out of Waverly - which was, unfortunately, on the long route to London. Despite the crowded holiday train, it passed through some beautiful country. Lots of small towns and open green fields, and one stop that sounded familiar - Lockerbie, which was just a dot on a map until late 1988 when a Pam Am jet with a bomb on board exploded over the town, killing almost a dozen people on the ground as well as 250 or so on the plane. Beyond that landmark, the scenery passed imperceptibly from Scotland to England. Four hours later the train pulled into Euston Station, just a couple blocks from my flat, and I was home again.