Colombia: Thoughts on My Mind

I have spent the past five weeks working with the infectious diseases specialists at the Clínica León XIII hospital, an affiliate hospital of the Universidad de Antioquia. Though I had a hunch when I applied months ago that it would be educational and an interesting use of my professional time, I could not have known what a rich experience it would be to focus on infectious diseases down here. I chose the specialty both because Ob/Gyn mentors of mine had told me it was a helpful auxiliary field for an Ob/Gyn (given that sexually transmitted infections, urinary tract infections, and the prevention of vertical transmission of numerous bacterial, viral, and parasitic infections between mother and fetus all fall under the purview of our specialty) and because I figured I would see a different burden of infectious disease down in Colombia than what exists in the United States, where parasitism and infection with neglected tropical diseases are rare. What I could not have expected, however, was the sheer depth of exposure I would experience regarding both tuberculosis and also acquired immune deficiency syndrome (AIDS).

Relevant detour: one of the earliest and strongest influences on me to become a doctor was the life story (as written in Tracy Kidder's Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World) and writings of Dr. Paul Farmer, an infectious diseases doctor and PhD anthropologist at Harvard Medical School. He started a non-profit organization named Partners in Health in Haiti (which has since expanded to Peru, Russia, Rwanda, Liberia, and a few other sub-Saharan African countries) based on the principles of working with the local Ministries of Health, strengthening health systems in all their facets (creation of clinics and labs; training of technicians, nurses, and physicians; supply-chain management to acquire needed medicines; and so forth), and predicated upon the ideology that all of us on this planet, regardless of the wealth or opportunities we were born to, have a right to the best that medicine and biomedical science have to offer. He has written much about co-infection with tuberculosis and human immunodeficiency virus (HIV), a fatal yet prevalent combination that is completely lethal if untreated but that is completely survivable if properly treated. Treatment for each, however, requires the daily use of multiple medications. Throughout time, people with power and influence in the spheres of global health have argued that it would be too costly to treat these diseases among the poor, or that a “different perception of time” would prevent poor people in non-Western nations from being adherent to the stringent medication regimens, and so forth. Dr. Farmer has always seen all of that as the self-mollifying garbage that it is, the excuses of those not plagued by these illnesses or of those with easy access to their treatments for why others must suffer and die needlessly from them when the treatments for them currently exist on this planet. These readings of his have been fascinating but always something theoretical for me, or something remote. My time in Colombia represents my first foray into a world where different infections afflict people than what we experience in the United States.

Over the past five weeks, I have met many people with tuberculosis. Tuberculosis is an infection caused by a special type of bacterium called Mycobacterium tuberculosis. The disease has a fascinating history: for example, it was responsible for a quarter of all deaths in Europe in the 18th and 19th centuries and was often associated with being artistic, given that such famous people as the poet John Keats and novelists Emily Bronte and George Orwell all died of it. According to the Center for Disease Control, a quarter of the world’s population has been exposed to tuberculosis, which lingers in tiny, aerosolized droplets in the air when an infected individual coughs or sneezes. Most people with a robust immune system are able to control the infection once exposed. Unlike other bacteria, the tuberculosis bacterium is not completely killed by our immune system but can live inside some of our white blood cells, so our body instead essentially recruits other cells to come in and wall it off so that, even if not dead, it can't spread or cause further harm. For most people, the disease never escapes its cage of cells, and they live a normal life. About 10% of people exposed to tuberculosis in their lifetime will see it reactivate, which it typically does with a vengeance, destroying the lungs to the point that people cough blood, lose lots of weight, and have clothes-drenching night sweats. It can also travel essentially anywhere in the body once it reactivates and can infect the spine, the protective surroundings of the brain, and more. Among people with HIV, the rate of reactivation is almost 10% per year when the HIV is untreated, far higher than the 10% lifetime risk for those without HIV.

In the United States, we hardly ever see a case of tuberculosis. I had never seen a patient with tuberculosis prior to my time in Colombia. For our medical board exams in the US, we are required to memorize the four first-line drugs used to treat it and the main side effects of each (for example, isoniazid can cause peripheral neuropathy, rifampin turns sweat, tears, and other bodily fluids orange and increases the hepatic metabolism of other drugs but is otherwise benign, and so forth) but it is all theoretical and abstract. In Colombia, on the other hand, this first-line prescription regimen became simply second nature. I saw not only pulmonary tuberculosis, the most common manifestation of the illness, but also tuberculosis of the kidneys, tuberculosis of the intestines, tuberculosis of the bones, tuberculous meningitis. It was wild.

We also had an entire inpatient service of people with HIV and AIDS. At least half of the patients were men who have sex with men, a demographic that continues to suffer disproportionately high rates of HIV infection. All of them had not been adherent to antiretroviral medication regimens which, if someone with HIV takes religiously every day, means that their life expectancy and health throughout their life can now essentially be equivalent to those of their non-infected peers. When HIV, which refers to being infected with the human immunodeficiency virus, destroys enough of a certain cell type of the immune system, we begin to define the disease as AIDS. Once someone has AIDS, many infections that you and I fight off daily without even being aware start to afflict them. There are constantly little fungi floating around in the air that your and my immune systems combat easily, but a weakened immune system cannot, so these patients can get a host of bizarre fungal infections of the lungs, the brain, and the mucous membranes. Viruses to which most of us have been exposed at some point in our life are able to come out of quiescence and cause infection and cancer. Parasites that are in our food and water that you and I combat with ease linger in patients with AIDS and cause diarrhea that persists for months and leads to general bodily wasting. In short, AIDS is a horrible way to die, as the body loses its ability to fight off the many predators that we face on a daily basis and are blissfully unaware of. I saw some remarkably ill patients over the past month, patients who looked like a layer of skin pulled tightly over their skeletal frames, patients with fungal infections of the mouth, with syphilitic pustules on their skin, with Kaposi sarcoma tumors on their hands and feet. My exposure to HIV and AIDS on the inpatient service down here in Colombia made me think of the experience of doctors in the 1980s and 1990s who watched hordes of (mostly) men perish in hospitals of these infections before there were any effective treatments. It was painful and sad to experience. I kept thinking over and over, "the problem is these patients' abilities to adhere to their medication regimen. That is where we need to be spending our time and money now--devising systems to help people take their pills each and every day. That is what is failing these patients. It's not lack of treatment options like it often is for cancer patients to this day. And it's not even lack of medications like it still is in some parts of the world. It's us needing to find a way to make sure these drugs get into our patient's mouths each and every day." 

Improving my Spanish has also been quite the challenge. It is easy to rest on your laurels and pat yourself on the back with regards to foreign language skills when your basis of comparison is other second-language learners sitting with textbooks in a classroom. Reality hits with a humbling strike when the basis of comparison is native speakers who, by definition, have perfect grammar, flawless accents, and a broad vocabulary. Moving to Spain in 2011 was the first real “wake-up call,” when you realize that your book learning and getting good grades in Spanish classes mean you will probably understand 15% of what you hear in a Spanish-speaking country. In Spain, I learned a lot of useful colloquial vocabulary and conversational phrases that have helped me to hit the ground running here in Colombia. I’m in an interesting period of language acquisition defined for me by alternating optimism and pessimism, where I’m both frustrated by how much more I have to learn and also really grateful for how far I've come along. I purchased a beautiful copy of Cien años de soledad, the magnum opus of Gabriel García Márquez, a Nobel-prize-winning author from Colombia, and it has brought me so much pleasure to read his work in the original language and to remember with many of the words I read when and where I first learned them. It’s a trip down memory lane with stops as far back as Mrs. Chamberlain’s high school classroom, many stops in Spain, and now quite a few from Colombia, as well. My efforts to learn Spanish extend deep into my past and represent an important part of my identity. I am so grateful for Mom and Dad for encouraging us all to study Spanish and for my best Spanish teachers, most notably Señora Chamberlain, without whom the spark of passion may never have been ignited. Though speaking like a native is probably something that no one can do who wasn't exposed to it as a mother tongue during the incredibly young ages of infancy, I still aspire to improve my command of Spanish throughout my lifetime, my residual gringo accent be damned.

I have also become very engrossed in understanding the violence and corruption that defined Colombia for decades of its history. Because I come to Colombian history with essentially zero background knowledge (except for some extrapolations about the country due to its status as a former Spanish colony), it has proven difficult to understand this violence since the sources I’ve chosen for my learning presume a background understanding of groups like the paramilitares, the guerrillas, and the political system of Colombia, all of which is new for me. One thing that has been simpler for me to understand is the narcoterrorism of Pablo Escobar and the other narcotraffickers of Colombia, whose stories I have been learning about from sources as diverse as doctors I work with, Netflix’s series Narcos, documentaries, and a book called More Terrible Than Death Than Death: Drugs, Colombia, and Massacre. The picture is a gruesome one. The basics of the drug trade boil down to this: Colombia is both an incredibly fertile country as well as one with broad swaths of un-monitored, hidden forest perfect for establishing laboratories where the coca leaf that is natural vegetation here and in neighboring Latin American countries can be converted into cocaine. In the United States, the world’s largest single economy and a very wealthy country relative to Colombia, cocaine receives top dollar for many reasons, including that it is a party drug of the wealthy who can pay for it and because of the fundamental law of economics whereby limited supply, due to its illegality in the United States, increases price. This means that, if you are a Colombian who can establish a pipeline of cocaine manufacturing where it is cheap and largely un-monitored (Colombia) and get it to where it is desired and well paid (America), you can make a killing (with the pun intended for both cash and human life). Pablo Escobar was that drug trafficker par excellence. Through underlings, he flew literally tons of cocaine into the United States each day at the height of his drug empire. Cocaine came in hidden pockets in suit jackets, in the seats and wheels of cars, in plastic bags being slowly passed through the digestive tracts of unassuming people who had swallowed them to get through security. Pablo Escobar flooded the United States with the cocaine that our foolish consumerism demanded and then used money-laundering tactics and bribery to legitimize the truly unbelievable wealth this made him, from writing the money off as from taxi sales to straight-up burying the physical money in the earth since saving it in a bank would have raised too much suspicion. 

Pablo Escobar

Prior to my reading, I was ignorant of the extent of Pablo’s violent machinations to maintain his power and wealth. When good-hearted, honest politicians spoke out against the corruption of Colombia and its involvement in drugs, Pablo hired people to assassinate them. Politicians were shot in their cars by motorcyclists as they drove. Politicians were blown up in their cars when they turned the ignition and inadvertently tripped the fuse on a planted car bomb. When Pablo learned that Colombia’s supreme court was accumulating evidence against him and his drug trafficking, he hired a group of leftist radicalists to storm the Supreme Court with guns and tanks, resulting in the conflagration of the edifice, the destruction of the evidence against him, and the death of half of the top justices. I cannot even imagine this level of corruption. We (rightfully) fret in the United States over the Senate failing to approve the appointment of one Supreme Court justice, as happened to Obama's pick Merrick Garland. In Colombia, the supreme court was lit on fire and half of the justices murdered to prevent the truth about Pablo Escobar from coming to light. He ruled in this country for a couple of decades with a combination of sheer terror tactics through these types of murders, through bribery of whomever he could bribe (and with his yearly earnings in the billions, the reach of his bribery was vast), as well as by appealing to the utterly indigent here, whom he reached through political speeches and by gifting them things like soccer fields and literal hand-outs of cold, hard cash. My favorite doctor that I work with named Dr. Diego Molina told me that, among the extremely impoverished, Pablo was considered a saint, and the day of his death was a tragedy for them, as he was one of the first people to consider them worth attention and resources.

I am hyper-aware of the fear of glorifying Escobar, which has begun to happen in disturbing ways. I was considering taking a “Pablo Escobar” tour of Medellín until I read online that the tour has a strangely pro-Pablo vibe and that it often includes speaking with some of his family members and former accomplices, many of whom are still alive. I was dissuaded and didn't attend. There are Pablo Escobar shirts that I’ve seen around, too, that have his face on them. People must be ignorant of what they are representing when they do this: Pablo has the blood of countless innocent people on his hands. In 1988, a Time Magazine article dubbed Medellín the most dangerous city in the world. In 1991, at the height of the violence, the homicide rate was 381 out of every 100,000 people, which is an unthinkable number, a statistic that makes Detroit or Baltimore or New York City look like Sesame Street in comparison. Any type of glorifying him or excusing him is a deep insult to all of the good and innocent people who lost their lives and lived in terror because of what he did in order to live like he did. He is not uniquely guilty. In fact, it is American consumption and America's methods of handling its "War on Drugs" as well as our exportation of arms that created a Pablo Escobar in the first place, but Pablo Escobar is no one to be admired.

I’ve also become aware that Colombians find it very frustrating that the image that North Americans have of them is largely centered around the Medellín Cartel and Pablo Escobar. This has come up in small ways, from a friend asking me not to read about narcotrafficking during my vacation to Bogotá and Cartagena when I told him about the book mentioned above that I'm reading, to two other Colombia friends telling me how much they hate the Netflix show Narcos because of how it further perpetuates this face of their history. I sympathize—how frustrating would it be if you were primarily known for your weaknesses, for the worst part about you, with everyone either not knowing or ignoring what makes you great? For that reason, I also want to remind everyone all that Colombia has given us. We import most of our coffee from this region whose fertile soil, high mountain climes, and proximity to the equator create an ideal climate for the cultivation of this bean. We also import the majority of our flowers and our emeralds from Colombia, as well. Colombia has given us Gabriel García Márquez, the Nobel-prize winning author of some incredible short stories as well as the stunning novels A Hundred Years of Solitude and Love in the Time of Cholera. Love the hit song from Zootopia "Try Everything" and its positive message to keep trying in the face of failure? You can thank Shakira, a Colombian from Barranquilla. Love watching Sofia Vergara make fun of her husband Jay and her son Manny on Modern Family? She’s another native of Barranquilla, Colombia.The country has more aviary biodiversity than any in the world and is the only South American country with both Caribbean and Pacific Ocean coasts. In short, Colombia is a remarkable country with much to be proud of and much to celebrate. 

Gems from Barranquilla

Thanks for reading my thoughts on some themes that have recurrently occupied space in my mind this past month. My next (and probably last Colombian) post will be far more entertaining, focusing on my trips to three small pueblos in Antioquia as well as Bogotá and Cartagena. They will be photo-laden and more anecdotal.