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more than 100

April 7th, 2015 No comments

miles or km for prescription refills. It really doesn’t make any difference which it is really since it means time, distance and diesel burned round trip.  If mail order pharmacy was a reality I might just indulge, but Germany is not exactly friendly on drug imports and I would have to get an APO box again. Instead, I get to drive to LRMC. I could take the train – minimum of 90 minutes each way followed by 20-30 minutes up hill from the train station.

That is right – put the hospital on top of the highest mountain in the area just to make sure that it is totally and completely off the beaten track. Add in paranoia on the part of the military which resulted in what used to be the front gate being redesigned into heavy metal most closely resembling a river lock followed by closing it to vehicular traffic. Why? I can speculate but it does keep incoming traffic away from the ER. Never mind patient transfer time from the Ramstein Flight Line has significantly increased…..  There is a pedestrian gate which I know to be open at shift change and is usually but not always open at other random times.

I thought about the train for about five minutes. That is about how long it took me to decide that half a day spent collecting refills was enough. If the pedestrian gate is not open then it is back down the hill, 5 km around the mountain and back up to the nearest gate which is as far away from the pharmacy as you can get and still be on post.  I drove the 115 km according to Google maps from my house to find that Gate 3 was closed. Gate 4 was now the entrance and Gate 2 the exit. None of this makes any difference to you unless you know the place.

The nice tech at the pharmacy pulled my refills and filled my new script on one counter trip which I really appreciated. Yes, I understand my refills – coming up on 20 years now. Yes, I am fine with Doxycycline – no I don’t need Primaquin, this will do me just fine.  Since I hadn’t had quite enough pain for the day I stopped at the immunization clinic. One needle (Zostavax) in the left arm, updated shot record and I was on the road to home.

 

 

Categories: Medicine, military, Travel Tags:

Botany, no fooling

April 1st, 2015 No comments

Never mind it is April Fool’s Day. What happens if you are a German traveling and fall in love with Uganda? You work hard, buy 72 acres of land near Fort Port and set up a guest farm. You employ people, you accommodate visitors. You can even provide German style salads with the meals (although better because everything is locally grown). Kluge’s Guest Farm is more fun to think about that River Blindness so I am not going there for the moment. Rather, if I could get any of the black and white col0bus to hold still for a photo I would be really happy. Otherwise it is like seeing a plumy tail striped like a skunk go flashing by in the canopy. I have hope…

a black and white blur, the best I ever got....

a black and white blur, the best I ever got….

Our program today ran well in spite of the two people with onchocerciasis thinking that there could not be a group of white doctors coming especially to see them. After all, it is the first of April.  Once we had that sorted out, the day went well.

the guilty fly

the guilty fly

But let me just leave it with: you do not want River Blindness. You do not want worm filaria traveling around your body, accumulating under the skin and seeking a home which they may well decide to find in your eyeballs. More cases every year than Ebola (but same with measles, malaria and a number of other miserable diseases).  But then there are those who have taken the mosquito netting and turned it into fish-netting to feed their families. The Health District is trying to get them to stop. My thought is it might be better to find an organization to get them fish netting so they have an ability to use bed nets for their intended purpose.

The rest of the day we spent on medical and herbal botany. I have been entertaining you with animals and birds. Now on to plants, flowers and strange looking seeds…

on to the plants!

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The Tooro Botanical Gardens grow plants and herbs  representative of that which is found in the Albertine Rift. They dry, process and sell herbs to supplement their income and run a nursery of plants for sale.  Our guide today specialized in these plants and explained the use of all. Some of it makes sense, some it pretty far fetched.  It just makes me wish that pharmaceutical companies spent a bit more time looking at the army of botanical compounds and a bit less time running panels of chemicals “almost but not quite identical” to known drugs. That is not how you discover something new…

Artemesia

Artemesia

two monkeys - would have been nice to have my zoom lens

two monkeys – would have been nice to have my zoom lens

organic lawn mower

organic lawn mower

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seeds on the bottle brush

seeds on the bottle brush

bottle brush - actually pretty soft

bottle brush – actually pretty soft

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passion fruit

passion fruit

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tree house

tree house

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Artesema dried and chopped. ready to be made into tea

Artesema dried and chopped. ready to be made into tea

Categories: Medicine, Travel Tags:

Mixed Challenges

March 27th, 2015 No comments

aka – poop, rashes and break bone fever.

Diarrheal disease is a fact of life. Not restricted to the third world, it is a major component of most potluck food poisoning, cruise ship Norovirus outbreaks, and numerous other infectious diseases. For the moment in the Kampala area, there could be typhoid involved (outbreak is well into its third month).

Two things can make a serious difference to whether you shrub off the illness, lose a day of your holiday to hang out near a toilet but other wise recover or potentially are headed to life threatening illness. The particular disease you have been unfortunate enough to acquire is the first and the individual is the second. Extremes of age, marginal to poor nutrition, intercurrent disease, immune compromise can turn what should be mild discomfort and a need for an extra roll of toilet paper into potential death.

Not to be too morbid, from that discussion we are going to be moving on to rashes. Now, rashes are not my favorite thing. I can identify the simple infectious diseases (measles, chickenpox) because I grew up while they were still prevalent. Poison Ivy is obvious as is acne and warts. But for the rest of it? Hey, it is dermatitis (skin irritation, eruption…) and there are the standards (if it is wet -> dry it; if it is dry -> wet it, etc). Since I know so little (and remember even less – it is a great opportunity to learn.

The last disease of the day is Dengue which comes in four major flavors (I mean serotypes). It is viral. There is no immunization. There is only supportive treatment. Many call it “the worst case of flu” they have ever had. Just in case you are feeling comfortable about being “there” while I am “here” may I simply remind you that the mosquitos are well established in the New World as well as the Mediterranean Basin.  It has been around for a while.

In the last several years (not seen here that I am aware)  Chikungunya (viral) is now an issue.  Given that people travel, even sick people travel it shouldn’t be surprising to note that the disease is rapidly spreading across the Caribbean and Central America. Whether hitch hiking mosquito or human vector – this is another disease which has escaped its original habitat. Packed its suitcase and is off to see new countries and infect new populations.

Anyway – morning was dermatology, afternoon was adult ward rounds divided in the middle by lunch.  The less said about luncheon challenges the better. Mine was excellent, but it took a bit of an effort to get the staff to understand that we didn’t have the whole day for lunch.

Hanging out with the Marabou Storks (but not one)

Hanging out with the Marabou Storks (but not one)

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Hospital Laundry - as managed by patients families

Hospital Laundry – as managed by patients families

and no clue why a batch of pelicans. Mbarara is not exactly on water

and no clue why a batch of pelicans. Mbarara is not exactly on water

Categories: Medicine, Travel Tags:

Crossing the Equator

March 26th, 2015 2 comments

Which reminds me – I picked up The Sugar Barons on the most recent Tantor Audio Book sale. For $4.99 I can listen to non-fiction and learn something about the sugar trade and the Caribbean from the 1650s on ward.

Leaving infectious disease behind for the day, a discussion about occupational health and safety is in order. As it turned out – no tour was on offer at  Kakira Sugar (the largest manufacture here in Uganda).  The photos are from outside the compound as picture taking is not allowed on the compound much less in the clinic or on the wards. The fields are easy – the alternative hauling (dude on the bike is blurry – sorry about that).
Sugar Cane in the fields, areas of cut and ares just planted a few months ago

Sugar Cane in the fields, areas of cut and ares just planted a few months ago

man on a boda loaded with sugar cane

man on a boda loaded with sugar cane

We left Jinja at a relatively early time in order to avoid traffic, if that might ever be even remotely possible. The field trip this morning (starting to feel like a happy elementary school child without the burden of parent chaperone.  Kakira is one of the major sugar producers in the country. Not only do they have plantations and factories – they have an incredibly huge compound with all the amenities of your average overseas military post.

Besides the headquarters and administrative areas there are shops, post office, barber shop, schools, clinic and hospital. Extensive housing is on the ground for workers of a certain level. Housing is also supplied for the contract workers: cane cutters, truck drivers. Given the geographical location in the world (see today’s subject line) growing and harvesting sugar is a year around proposition. Unlike a long time ago when I lived in the neighborhood of Crystal Sugar which ran shifts around the clock for the few weeks after harvest of the sugar beets. 

Since I  mentioned cane cutters – you have probably already figured  that the cane is cut by hand, loaded into the trucks by hand and, for that matter, sorted off the trucks by application of significant amounts of human labor. It is a good job in a country where employment is difficult to find, especially that which includes the provision of free medical care. The downside for the cane cutters – besides the risk of injury is living in extremely crowded barrack type situations away from their families for extended periods of time. 

And then we got on the bus to start our 320 km trip to Mbarara. Not that the traffic was horrible or the roads a challenge. Our driver said we did well to make it back to the North Kampala by-pass in about three hours (100km).  

Once past Kampala our pace picked up and the traffic decreased.

2 Bodas, five passengers, multiple packages but no chickens

2 Bodas, five passengers, multiple packages but no chickens

Our rest stop was at the equator (see photo) and consider this probably the only pix of me that you will see for this trip. My partner in crime is Canadian. In fact, I am not sure that I mentioned it – but we have four Germans (usually living in Germany), one Canadian and me living in Germany, one Ugandan living in the Caribbean for greater than 30 years and a Canadian living and working in Hong Kong.

standing at the monument

standing at the monument

Apparently end of the month is low economy for the Police; I counted over 25 radar stops along the way. Usually located about .5 km out from town or a few hundred meters after where everyone is hitting the accelerator it seemed at least that they were not interfering with commerce. I missed catching the fish and fish standards but there were plenty of opportunities for anyone to buy vegetables, chick-on-a-stick, catch a Boda or buy any number of things in town.

Stands in town

Stands in town

Bodas for hire

Bodas for hire

typical main street in the many, many towns we drove through

typical main street in the many, many towns we drove through

fruits and vegetables

fruits and vegetables

houses, animals and kids line all the roads

houses, animals and kids line all the roads

sun headed down before we arrived

sun headed down before we arrived

Categories: Medicine, Travel Tags:

Fever is/

March 25th, 2015 No comments

aka – it isn’t alway Malaria. Although when you are in Africa for more than 8 days it could be a good guess.

This morning we went to the Buikwe Subdivision Hospital where fever was the symotom under consideration. There was an excellent lecture about Ebola (last outbreak in Uganda was 2012 and not the same variant as in West Africa). This is also an areas where Trypanosomiasis (sleeping sickness) is endemic. Ward rounds: in a room about this size

yes, exactly this crowded and no better furnished

yes, exactly this crowded and no better furnished

(except with bright animals painted on the wall) where we saw several older mothers caring for their babies on the pediatric ward. Older means 18 with your first child or 26 with your fourth/fifth and most with a child over the age of 12 months were visibly pregnant. We saw sickle cell and cerebral malaria. Unhappy babies and ones that could peak out a smile.

To Build a House

To start – the room I currently have. Please note the frame on the bed. It makes it easier to drape the mosquito netting and have it work while leaving enough space to turn over.

#21 Upstairs

#21 Upstairs

 

The population density in the rural areas is amazing. If you live in North America, Western Europe or Australia, you know that few people leave outside of the major areas. In North American, rural areas are characterized by long stretches of empty, a few scattered towns and houses surrounded by out buildings and land. In Europe it is most often small tows surrounded by extensive fields under cultivation. In Australia, you are either along the coast or literally “outback” somewhere that no one usually goes.

Uganda has 85% of its population in rural areas. It isn’t just the houses and shops lining both sides of the road at what are probably towns even tho there are no town names, road signs or route numbers. I can understand the concept of “Plot Number” but do not appreciate at all what it might tell me about location. People are continually in motion. There are children all over the place: in school yards, walking along the roads, playing in front of the house, working in the fields, sitting with their mother as she sells vegetables from a road side stand. There is absolutely no question that children form half of the population.

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From the Buikwe Subdivision Hospital where we saw babies, discussed African Trypanosomiasis and Ebola we took a drive to both have lunch near Lake Victoria and see one of the local fishing villages (small smelly fish which require drying….). While we were at it, we set a TseTse fly trap to see what we could capture. These critters are first cousins to horse flies and we all know how great it feels to be bitten…

simple and effective trap. the flies come to the dark colors, then always fly "up" when they take off, becoming trapped in the netting

simple and effective trap. the flies come to the dark colors, then always fly “up” when they take off, becoming trapped in the netting

For those of you who haven’t met them – tsetse flies are nasty biting flies capable of happily transmitting parasites from infected mammal to uninfected in pursuit of blood – a favorite food. Since they are so effective in disease transmission, they have been well studies in the lab, as well as extensive vector control programs. (Trapping, release of irradiated males…..)

One wonders about their place in the food chain. Effective disease vectors, still something else had to have been eating them. I couldn’t find any information at all about what species, a bird perhaps, used to find this fly a nice juicy treat. Not that I want disease back. The effect on humans, livestock and wild animal populations was devastating but some critter somewhere has lost their lunch.

I started thinking about where all these children and their relatives live. You may have a landlord who owns the land, most of the time you are responsible for your own shelter. Round houses with mud dabbed walls and thatched roofs are out. Not only are they impossible to live it, but they provide an absolutely wonderful vector habitat.

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So you want to build a house. First you either make your own bricks or buy them from someone who is in the business. Made from the local iron rich red clay they are stacked in a standard form and the outside is coated. A fire is then started inside and is maintained until the bricks are hard enough to build with. Age them a bit along the side of the road.

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When you have time/money, draw out the walls, then start the layers after leveling your dirt floor.

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Maybe sometime in the future you will be able to afford to pour cement inside to have a solid floor.  If you have money, you can buy supplies – including your bricks and mortar from a commercial store –

 

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Continue building your walls, leaving space on one side for doors and windows. Make one side of the roof higher than the other so it slants and the water will run off and away.  (Gutter could collect rain water, but then still water could also provide a breeding place for insects).  If you don’t have money for the roof right now, you can always start raising crops inside the buiing. (which means that like Death Valley in the Balkans – trees inside a currently unoccupied house doesn’t mean war, someone died or the house was bombed.)

When you have a bit more money add the tin roof. Even better, you can have windows and a door rather than cloth curtains.

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The white X you see on some of the buildings is from the Transportation/Highway Department. Sometime in the future this is going to become a paved road and probably two lanes. The houses in question are going to have to be taken out to build the road….

and ending with birds

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Categories: Medicine, Travel Tags:

Leprosy

March 24th, 2015 1 comment

Doesn’t that stir up thoughts of Gothic castles, strange asylums and nuns nursing the damned in the slums of Calcutta?

Otherwise known as Hansen’s Disease, it is caused by one of the mycobacterium family (TB ring a bell for anyone?)  Similar to TB, causes granulomas and can be treated with a long course of a couple of particular antibiotics. It doesn’t cause parts of the body to fall off, but does severely damage nerves which results in the patient having decreased ability to feel pain. Recent research in genetics has lead to the assumption that about 95% of the population is naturally immune.
The other five percent? They can become infected.

We drove along between klick after klick of sugar cane fields between Jinja where we are staying and Buluba where the St Frances  Hospital is located. Founded in the 1930s and mostly funded out of Europe (esp Germany and UK) it was initially solely dedicated to the care and treatment of Leprosy. It’s role has evolved over the years as antibiotic regimes have proven to stop the progress of the disease. Unfortunately, neurological loss is normally permanent. In a culture that values village and family times, most patients are not welcome back home. Even though the treatment is outpatient now, occasional medication reactions but mostly lack of support have a significant number of patients remaining for an extended period of time. No matter how much education you provide, some superstition remains. Medication is provided by the government free of charge and it also pays for care.  There are a handful of patients who consider St Francis home and the nuns who run the hospital their home (all over 75 years old).  M. leprosae is not an opportunistic infection, so there has not been any increase with the spread of HIV. 

The infra structure needs help, the generator only supplies those area which require power. We saw a number of patients with leprosy as well as babies with malaria, a toddler with tetanus and several other diseases not routinely found in North American or Western Europe practices.

When you think about it – the characteristics of leprosy with all the associated myths might well have played into nightmare, fantasy, fear and the belief that the living dead really exist.
Zombies anyone?

Water Birds and Sacred Ibis

On a much lighter note, the weather held without rain so we went ahead the planned short boat exploration of Lake Victoria. What follows are pictures of water birds, shore birds and, of course – the source of the Nile (which is the longest river in the world. Yangtze is the third and the Mississippi is the 4th. Blanking on the thirds – but thinking it is the Amazon…) a couple of lizards and one monkey determined to ignore us.  With the skyrocketing population, this area has been extensively fished. Fish farms are now in operation along the shore. Each “container” is stocked with small fish which are fed and will yield about 1000 fish at full growth. What is obvious is that several of the bird species think this is just a special version of “fish in a barrel” created especially for them.

We ate dinner before returning to Jinja.  Since it was too early in the day for the fruit bats I am afraid that I can’t provide you photos of them. 

The origin of the Nile

The origin of the Nile

headed OUT

Source of the Nile

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I'm ignoring you

I’m ignoring you

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Vegetarian Kebab Platter

Vegetarian Kebab Platter

Categories: Medicine, Travel Tags:

Starting with HIV

March 23rd, 2015 1 comment

As you might guess, HIV is a major issue in Uganda as it is in other sub-Saharan countries. The plan for the morning is a review lecture followed by ward rounds at the Joint Clinical Research Center in Kampala.

Established by the Ugandan Government, the Center works in collaboration with UCSF, Johns Hopkins, NIH, ITM (Antwerp & Hamburg). Much of the funding comes from PEPFAR & EDCTP.

 

forget your standard thoughts of US or Ger man hospitals.  There are two wards where we made rounds: one for the men, one for women. The windows are open with light and fresh air coming in. The nurses here know how to manage IV medications as there are no fancy electronic pumps.  The ward is squeaky clean.  Some family are present helping.  Opportunistic infections are the reason every is here. Malnutrition is a fact of life.

Currently (WHO statistics) – HIV disease accounts for 17% of the annual mortality over all and about 7% in those under the age of 5. Life expectancy at birth is 57 years. If you make it to age 60, you have on the average another 16 years ahead of you. The death rate/100,000 population from HIV/AIDS has dropped from 440 in 1990 to 169 in 2013. The accuracy of either statistic is in serious question. 85% of the population is rural. Death registration is no more accurate I suspect than birth registration and cause of death is going to be as much political as medical.

Our early afternoon has a lab and discussion of opportunistic infections. We drive to Mobria for a field trip on medical botany. Pictures will be forth coming, but the 2 hour hike through the forest was a blast. The plants are blurring in my mind, the red tail monkeys were a hoot and there was something called a blue ttracto ??? flying from tree to tree and expressing extreme displeasure at our presence

road construction delayed out arrival to Jinja till about 2000.  The rain kept most vehicles and people off our interesting back route alternative

 

 

Categories: Medicine, Travel Tags:

And on to the next adventure

March 22nd, 2015 No comments

22 March

Entebbe – Kampala – Jinja – Kampala – Mbarara – Queen Elizabeth National Park (QENP) – Fort Portal – Kampala – Entebbe

The Uganda Route

The Uganda Route

In this case, the Park is a short stop on the way of most mornings and afternoons being tied up with either Tropical Medicine lectures or patient rounds.

Genereal Background on Uganda

Statistics

Total population (2013) 37,579,000
Gross national income per capita (PPP international $, 2013) 1,370
Life expectancy at birth m/f (years, 2012) 56/58
Probability of dying under five (per 1 000 live births, 0) not available
Probability of dying between 15 and 60 years m/f (per 1 000 population, 2012) 389/360
Total expenditure on health per capita (Intl $, 2012) 108
Total expenditure on health as % of GDP (2012) 8.0
Latest data available from the Global Health Observatory

The mean/median age is ~16 with 48% of the population under the age of 15 and 4% over the age of 60. Obviously, childhood mortality (average family size 5.6 children) is more of a concern than is Alzheimer’s. 15% of the population is urban and birth registration covers perhaps 30% of the children. About 1/2 of births are attended by a qualified attendant. The risk of dying from maternal related causes is 27% for women between 15-49. Makes one understand some of the historical reasons behind the tradition of multiple wives: in these African countries, men don’t raise the children.

Categories: Medicine, Travel Tags:

Its been more than 40 years

May 25th, 2014 No comments

Reflections happen every once in a while. Sometimes deliberately and other times triggered off by a simple event, object or gesture. So it was for me this morning while sitting in the Star Alliance Lounge at Heathrow T1. I have been here before.  In fact, I distinctly remember being here for hours while waiting for a flight. Plugged into power and catching up for hours. I can’t find a post about it (searched Heathrow, Lufthansa and Riesling for the lovely wine that captured my attention six hours into the wait – after 1700 as well) but I can even remember where I was sitting.

However, it wasn’t any of that which caught my attention. Rather it was hunting down the women’s restroom.  There are two restrooms clearly marked in the Lounge; one men’s and one women’s. But I can remember when this simply wasn’t the case. This is allegedly a business class lounge which used to mean business travelers since no one who didn’t have a company paying the high tariff for the seat would travel in business. Especially not if you are from Minnesota – it wouldn’t seem like a sensible use of funds. Except for one time during my college/professional school/residency years on the rare times I flew – it was cattle car. Once, for whatever reason having to do with exhaustion, a kind check-in agent and a strike of fate, I wound up with a free upgrade. It also might have had to do with being well dressed and traveling alone. In any case, I was directed toward the lounge. There were no women’s restrooms; business travelers are men, right?

Seemed to be just the way of the world in the early 1970s. I can remember being on a surgical rotation at one of the U of MN affiliated hospitals. The surgeon I was with sent me off to change so I could scrub in on his cases that day. There were three changing rooms: Doctors, Nurses, Orderlies. Female med students, who it turned out were a rarity at this hospital for excellent reasons, don’t fall into any of those categories. When I failed to show up in the expected five minutes, one of the orderlies came to find me. Why wasn’t I changed? Where? The nurses had already told me that their changing room was for nurses (note the lack of male nurses in that time frame. And the fact that nurses are assumed to be female. It is 2014, and most of the time we still caveat nurse with “male” for the 20-35% of the professional who aren’t female. The assumption is not quite so obvious that doctors are male only due to the overwhelming numbers of young women entering med school in the last 10 years).  Said orderly thought the whole thing was funny, explained that the place had a reputation which is why they almost never had women rotating through there on surgical clerkships and found me “the closet.”

That is right – a closet. Not the nurses changing room with lockers, not the orderlies with one of the guys standing guard at the door. And certainly not the doctor’s changing room where the male med students were more than welcome to change. Today? I would have just let the chips fall where they may and used the doctor’s lounge but I was not at all willing to rock the boat back then.

When asked why I was late I explained about the changing rooms. The surgeon was astonished. Obviously this was not something that had occurred to him as an issue. I suggested that if he could not get this resolved that I could change preceptorships so as to go to other hospitals. How would I do that? Talk to Mamma Pearl (Assistant Dean of Students) about this hospital not being “ready” to have female med students……

Fast forward to 2014. There are men’s and women’s changing rooms, restrooms, locker rooms (unless of course you are a Dutch military deployed camp. Then it is uni-sex with locks on all doors, stalls and showers. Everyone is an adult, everyone gets privacy).

In most shopping centers there are family restrooms. There are set-ups to change diapers which didn’t exist when mine were young. Some of the airport lounges even have a “child room” which I think is de facto recognition that whether or not you want small children in the executive lounges adults are going to keep brining them. The goal then is to keep them separate enough from the rest of the travelers that no one gets hurt…

Drifting around from topic to topic I guess. But I have managed to get caught up on all of my audiobook downloads, two novels I hadn’t gotten around to finishing and some nice munchies courtesy of Star Alliance.  Their timetable download turns out to be a PC app but booking a round the world flight is easy and relatively cheap compared to a couple of round trip FRA-SFO round trips.

Who knew?

Wonder if finding clean bathrooms and changing rooms is going to continue to improve?

 

Categories: Medicine, Travel Tags:

Marseilles

August 12th, 2013 Comments off

To many, Marseilles is that French city which is the gateway to Provence; just a stop on the way to more interesting places. Of course there is a somewhat famous cathedral, winding streets, little outdoor cafes and the obligate castle.

To me it is that place in 2011 where we disembarked from the MSC Lirica in a commercial area a complicated and deadlocked highway system from downtown. If it hadn’t been for the Eldest and her hauling out her French, smiling at a taxi driver we might not have made our departure. Note that Maus and College Guy were along, both of whom speak a more than adequate French but didn’t want to play. Mine is fine for reading, but I don’t speak taxi.

It is also home to several colleagues at the Institute of Tropical Medicine, the National Arbovirus Reference Center and the Army Health Service. Marseilles, as I am now reminding you – is a port. France like many of the other European powers was want go to sea, Plundering Africa was fairly high on their list which explains all those French speaking locations that don’t belong to the Belgium King.

So it was interesting to explain to fellow travellers that not only is it the second largest city in France but it remains very immersed in maritime culture.

We docked in the commercial harbor; the old being strictly pleasure craft and the small tour boats. Learning from past experiences, I took the ships water shuttle.

Along both sides of the inner harbor is an interesting mix of eateries, tourist shops, bars, cafes, marine supply & chandlery, sea going agencies, and more than one antique store dedicated to ships artefacts.

Oh yes, museums.

What turned out to be the hardest again was finding stamps, especially since the country in which I live is aka Germany ( soft g) as English has crept in even in this bastion of national superiority and purity.

Pictures soon – they seem to make the phone server nuts.

Categories: Medicine, military, Travel Tags:

Enough sense to

May 21st, 2013 2 comments

You would think after all the time I have lived in Europe I would have better sense. I even told you that I had managed to uncover, while cleaning up the bedroom and packing, the two lovely umbrellas purchased in Naples.

So explain to me why, in spite of the fact that it rained yesterday, I didn’t think to take one along today? Perhaps it was because it rained yesterday while I was inside the MECC and so missed the entire experience of rain in Maastricht. Seeing is believing. Since yesterday I neither saw nor experienced the rain I didn’t think of it this morning. All of this is the long explanation for why I wound up dashing the 1.5 km back to the hotel from the Convention Center.

The lectures today were interesting – topics ranging from malaria through immunization programs to pulmonary embolus risk after flights – all of which took second place in my concern compared to getting my new red leather jacket (from Istanbul) wet.

So may I just leave you with

An. atroporavus is perfectly happy indoors

An. atroporavus is perfectly happy indoors

Categories: Medicine, Travel Tags:

History of

May 20th, 2013 Comments off

One of the things that has delighted me over the years is the history of medicine lectures that start each morning at ISTM conferences. Usually presented by a fairly well know but local academic these have been relevant, entertaining and educational.

This conference is no different. Today’s topic, presented by Professor Hillen from the Netherlands is From House of God to Academic Hospital – a History of Medicine in Maastricht.

the original hospice - for taking care of the poor

the original hospice – for taking care of the poor

I think most of us forget that “organized” delivery of care was since earliest times in western Europe, the right, responsibility and mission of religion and religious orders. Not being any different than other cities – Maastricht, with the original city being founded in Roman times saw early the establishment of hospices to care for the poor under the religious umbrella.

From there it is not much of either a physical or intellectual jump to see how care evolved through the centuries with areas being set outside the city walls both for leprosy and later for plague.

special clothing, not just scare, but to keep out the smells of the plague

special clothing, not just scare, but to keep out the smells of the plague

From these humble beginnings developed one of the first guilds of barber surgeons, later medical schools in the region till today as a academic center. I have more pictures, but these were the ones that delighted me the most.

Tomorrow we will hear from Dr Marc Coosemans, a Belgian entomologist about the history of malaria in the region and we will finish on Wednesday morning with the History of the Dutch East India Company.

Much of the rest of today was taken up with more discussions on malaria, vaccines and fast and furious section on trauma and injury in travel.

Categories: Medicine Tags:

Pre-Conference Courses

May 19th, 2013 3 comments

When I registered for this conference it seemed to me I had two choices: travel on Saturday and use Sunday for look around and education or travel on Sunday and be rushed. Since this turned out to be the two week holiday for most of southern Germany, being smart about travel seemed wisest.

 

really shaggy sheep grazing

really shaggy sheep grazing

So here I am, registered, educated and fed. Not a bad deal.

The session I attended turned out to be extremely interesting. Titled Responsible Tourism the three speakers covered a fairly wide range of topics. The first discussed the economic impact of tourism for good and bad on the developing world ( with a strong aside about who actually makes money and how/why/what travel health professionals can accomplish. The idea of the human zoo comes to mind…. Visit a local tribe and see….

The second speaker, more than a little disorganised covered the two way street of disease impact on both travellers and local populations ( hint – the new world only furnished syphilis. The old world provided measles, mumps, chicken pox, smallpox, …..)

The final speaker was the most interesting and organised. She discussed the whole emerging money making field of volunteer tourism aka voluntourism . Specifically she discussed Gap years, short term feel good projects and the more than real negative impact that many of these program’s have. As a group we had a rousing discussion of the different segments of this population.

Even more fun was the opening ceremony complete with The Night Watch

 

The living Night Watch

The living Night Watch

 

 

And an excellent speaker who discussed what was really portrayed in many of the Old Dut h Master’s Paintings.

The lighter side of old Dutch Masters

The lighter side of old Dutch Masters

I forgot to take pictures of the exquisite food preparation. You will just have to use your imagination.

Categories: Medicine, Travel Tags:

Getting to Maastricht

May 18th, 2013 Comments off

It was just short of 2000 last night when I had a blinding flash of the obvious. I didn’t have to pack liquids in my suitcase. I was taking the train. Yes, I know that it should have been in my mind early on but you have to remember that I normally take the train to the airport so train in my mind is normally an intermediate form of transportation, not the definitive one. In this case it meant that I could toss my toothpaste, sunblock and hand lotion in my backpack without fear of loss at the first security point. What security point? I am taking the train. Or rather – trains.

Today I am headed to Maastricht in the Netherlands for the ISTM Conference on Travel Medicine (19-23 May).

Just in case you cared – by road it is 343 km which means Google maps estimates driving time around 3:10 ( I will spare you the 23 steps of the driving distance). By public transportation (now also there complete with numbers of changes) the estimate is around 5:19 from Google.

Heidelberg
Heidelberg Hbf
Train IC
Train IC 2216 towards Stralsund Hbf
8:25am – 11:15am (2 hours 50 mins, 5 stops)
Köln Hbf
High speed train ICE
High speed train ICE 16 towards Bruxelles-Midi
11:43am – 12:16pm (33 mins, 1 stop)
Aachen Hbf
Train RB
Train RB 11912 towards Heerlen
12:32pm – 12:59pm (27 mins, 6 stops)
Landgraaf
Walk
Walk to Landgraaf
About 1 min (7 mins to make transfer)
Landgraaf (Platform 1)
Train Stoptrein
Train towards Maastricht Randwyck
1:06pm – 1:44pm (38 mins, 10 stops)

Maastricht

Maastricht
The Netherlands

This is what the Bahn had to say:

Heidelberg Hbf Sa, 18.05.13 ab 08:25 5 IC 2216 Intercity
Bordbistro
Köln Hbf Sa, 18.05.13 an 11:15 5
Umsteigezeit anpassen
Köln Hbf Sa, 18.05.13 ab 11:43 6 ICE 16 Intercity-Express
Bordbistro
Aachen Hbf Sa, 18.05.13 an 12:16 9
Umsteigezeit anpassen
Aachen Hbf Sa, 18.05.13 ab 12:32 1 RB 11912
RB 11962
Regionalbahn
Fahrradmitnahme begrenzt möglich
Heerlen Sa, 18.05.13 an 13:06
Umsteigezeit anpassen
Heerlen Sa, 18.05.13 ab 13:16 4 32044 Regionalzug
Fahrradmitnahme begrenzt möglich

In actuality, it is going to take me slightly more than 6 hours because  I have to take an alternate method from Koln on since all the seats are sold out on ICE 16 and I need to take a regional instead.

obviously, I am over the border into Holland

obviously, I am over the border into Holland

It doesn’t bother me – I save money and enjoy the the Bummelbahns. Besides, it leaves me more time to knit.

Speaking of same – I finished the simple cotton scarf to go with one of the hats knit in March.

Allegedly the hotel has WiFi.

1600 Update

Yes the hotel has wifi – no charge! I am ensconced in a most comfortable room after having trucked across the city (ok, only 1,4 km) to get here. I am about to go out and wander around including finding some supper, but first wanted to finish up this note.  Now I have to just decide what is next on the project list for those between lecture times….

Categories: Knitting, Medicine, Travel Tags:

No BBQ

May 15th, 2013 Comments off

The middle day of these conferences always seems never ending.  To top it off, the weather is cold and there is supposed to be a BBQ tonight. I am sure that you can just imagine how excited I am. Not.

In fact, it seems pretty much a given that I am skipping most of the social events. Since I am no longer in the situation that attending these kind of things constitutes mandatory fun – I see no reason why I should pay to attend something where there will be little to nothing I am willing to eat. Oh, yes, and beer – not particularly interested in that either.  Originally I was going to go and meet friends for dinner, but that has been postponed which leaves me an evening to myself.

I can’t say that I am disappointed after having spent the day first listening to a succession of gloom and doom scenarios for which various assorted detection, diagnosis, triage and treatment  ideas and protocols were put forward. I will admit to a certain bit of cynicism after working in the field for so many decades. Plus, I find a basic fallacy in everything that is proposed.

Please tell me how many of the terrorist attacks (Afghanistan, Boston, Twin Towers, you name it) have been single point events and how many have involved more than one nasty item.

Exactly. Unlike the bio-defense people who know that the most likely thing to happen is going to be more than point source, not instantly detected and a rapidly spreading problem – these lovely people are still happily in the “one oops” one time pinpoint release/explosion/meltdown/whatever mindset. I suspect that there is most likely much more intelligent planning going on somewhere behind classified doors to which, thank goodness, I am no longer privy.

So – with an evening to knit (grin)

the hat needed a matching scarf

the hat needed a matching scarf

Categories: Knitting, Medicine, military Tags:

One Health

February 17th, 2013 3 comments

Even though it is a major initiative well past first blush of implementation, I would be willing to bet that almost none of you have heard of  One Health.  The idea – establishing close links between human and veterinary medicine make absolute sense. People affect the environment (wildlife as well as climate in their roles as anything from pet owners to farmers, developers, explorers and tourists) while animal health is key to both the food supply as well as infectious disease.

I have borrowed the following map to give you an idea of some of the newly emerging problems. Some diseases are shared between animals and peoples with one or the other serving as host. Others are a simple, inadvertent spill over into the other population.

map

It is a concept whose time is probably long over due. Established in ~ 2007-2008 it has spread well beyond the founding at University of Iowa (yes Virginia, there is actually life and good works in the middle of the corn belt) and has seen buy in at governmental, NGO, grass roots and private foundations.  The CDC has jumped on the band wagon, using the concept to further progress in Med-Vet interface as well as flu surveillance while the EU has to a large extent gone in the direction of biosecurity.

In any case, the idea is that professionals from a wide spectrum of backgrounds work together on common interests and grounds with the idea that the interface should provide some synergy and accelerate progress on some of the more complicated challenges.

If the whole thing leaves you thinking “blinding flash of the obvious” please remember that we make progress to a large extent through research. Academicians make their name by becoming expert in a very specialized field. That tend toward highly specialized interest starts before graduate school, is further guided through PhD research and encouraged by the whole publication process. Multi-disciplinary is not a familiar concept to most.

In practical application it means that slaughtering off large numbers of poultry infected with H5N1 (HPAI) is not really done for the benefit of the farmer (who loses the flock prior to being able to slaughter and sell the birds) but it prevents spread to others and  humans. At the same time, the impact of the loss of protein to the population will have implications for human health well beyond the small risk of infection spread.

It means that surveillance of West Nile Virus needs to include entomology (the mosquitos), local bird flocks (wild life management), horses (vet services) and human case reporting (encephalitis). Any single one of these will neither give the whole picture nor the extent of the disease impact from either infectious load or economic cost.

See! I do listen as well as knit….

Categories: Medicine Tags:
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