5 oct 2009 - mission kashmir

From ladakh 2009

Anticipation, realization, reflection. Another adventure has come and gone, and I'm left with woefully inadequate photographs and rapidly fading memories as a full month has now passed since I returned to the routine and realities of residency in Rochester. The summer of 2009 took me once again to my homeland of India, but to an area I'd never been. Ladakh, high in the Himalayas, lies within the rugged, contentious, and astoundingly beautiful region of Jammu & Kashmir. For two days we traversed the Line of Control (LOC) between India and Pakistan en route to Kargil, the site of their last military conflict 10 years ago in 1999, before heading southeast into the Zanskar Valley. For the next month, I worked as an assistant lead physician, helping lead a group of 29 medical students and 7 other resident physicians and a dentist, trekking and setting up medical camps in remote villages in an effort to provide some level of medical care to this otherwise isolated group.

From ladakh 2009

My usual habit, when I travel, is to post periodic updates from cybercafes, as a means of documenting my impressions and (mis)adventures in as close to real time as possible. This serves both as an effective foil to my notoriously poor short term memory, and as a way for my friends and family to follow along. In Ladakh, however, this proved impossible. For 24 straight days and nights we trekked with packs on our shoulders and supplies on our mules and horses, sleeping in tents, without toilets, running water, or electricity. No showers, no shaves. No phones, no internet. No connection to the outside world whatsoever. There's a song by Weezer that I often would hum when I found myself trekking alone: "The World Has Turned and Left Me Here."

From ladakh 2009

Ladakh is a spectacular place, one I've always wanted to see, and it did not disappoint. High above the tree line, we were surrounded not by any vegetation but by soaring, snow-capped peaks nourishing, via descending tributaries, the mighty Indus River below. We trekked through glacier-carved valleys; the sun high overhead darkening our faces and arms; the dust from the trails matting into our scalps, layering on our skin, settling into our ears, onto our necks, and under our fingernails. We climbed, packs on our shoulders, negotiating hairpin turns, countless switchbacks, and gingerly crossing -- one-by-one -- wobbly, gap-toothed rope bridges spanning high above raging rivers below.

As we moved from the Buddhist heavy areas near Leh towards the more Muslim dominated Kargil, the transition was evident around us. Prayer flags gave way to prayer calls, as monasteries were replaced by minarets, bald monks by bearded mullahs. As we moved south from Kargil into the Zanskar Valley, Buddhist prayer wheels again emerged along the roadsides, as the onion domes of local mosques disappeared.

From ladakh 2009

The Himalayas, spanning 2,900 kilometers, represent one of the most spectacular manifestations of plate tectonics. Most geologists will tell you that the world's most immense mountain range began forming about 50 million years ago, when the landmasses of India and Eurasia, driven by plate movement, collided. About 225 million years ago, the Indian subcontinent was a large island situated well below the equator off the coast of Australia. About 200 million years ago, India began to forge northward, at a rate of around 9 meters per century. As both of these landmasses have roughly the same rock density, when they slowly but violently converged, neither could be subducted below the other. As a consequence, the only way to relieve the pressure between the colliding plates was via skyward displacement, forming the jagged, soaring Himalayan peaks that continue to this day to grow in height by about 3 cm per year.

From ladakh 2009

Every morning, I'd stand in awe of the sunrise over these mountains, warming us and illuminating the valley against the backdrop of a cloudless, blue sky. Every night, I'd gaze up at a celestial masterpiece, unmatched by any place I've ever been, however remote. I've never seen so many stars and meteors; so much of the Milky Way; or any of Jupiter's moons, let alone three of them with nothing more than a pair of binoculars. My neck sore from being craned skyward so long, I couldn't help but to consider my relative insignificance in the universe's unfathomably grand scheme each night as I lay in my sleeping bag.

From ladakh 2009

I'd wake up most mornings around 6am, my bowels reliably reminding me that it was time to emerge from my tent, and start my day with a shivering squat in the poop tent. I'd follow this with a modified bucket bath, stripped down shirtless in the cold morning air, washing my face, hair, and upper body, before brushing my teeth and warming up with a cup of tea. By then the sun would usually be just peeking over the mountains. Soon the shivers would be replaced by beads of perspiration, and the layers of outerwear would give way to coats of sunblock. This usually took minutes.

From ladakh 2009

The clinics we ran were mostly out of our tents. We'd send word to the villages of our plans in advance, if possible, but news of our arrival usually spread fast regardless. There is not any form of consistent medical care aside from some traditional healers, known as umchees. We would usually set up multiple tents, including one for triage, pharmacy, and the dentists. Our largest tent, which served as our dining tent at night, we'd divide into three separate parts and use to see adults and children. Usually we'd have one or two medical students, with a translator, get the initial presenting complaint, do a focused physical exam, and come up with a plan. They'd then present it to one of us residents, and we'd decide on the appropriate management from there. We saw a lot of infectious diseases, like skin and soft tissue infections, intestinal parasites, pneumonia, and tuberculosis. We saw countless cases of scabies, lice, and ringworm; chronic perforated otitides media; malnutrition; and visual complaints. Long winters stuck indoors made alcoholism a major problem, as well, and with it alcoholic gastritis and peptic ulcer disease.

From ladakh 2009

Our pharmacy was reasonably well stocked. We spent a lot of time in Leh before embarking on the trek taking stock of what medications we had available and what we would be necessary and sufficient to carry with us. Every patient, child or adult, symptomatic or not, was given a dose of the antiparasite medication Albendazole for deworming, and a 15 day supply of multivitamins for some nutritional support. Chronic disease management, as in most of the developing world, remains problematic. We could only offer temporary, stopgap measures for complaints such as chronic arthritic pain, heart failure, hypertension, and diabetes, for instance. Access and affordability remain major barriers in such remote, poor places. The regions where we worked and trekked through are accessible only by foot and for only about 3.5 months out of the year. The mountain passes that need to be crossed to get into and out of the region are snowed out the rest of the year, and there are no roads. The organization I worked with comes to Ladakh every August to run these medical camps, but for most of the rest of the year, access to care is unreliable at best, nonexistent at worst. And even when groups like ours come, they can only bring what they can carry on their person or on mules and horses.

From ladakh 2009

The pace of the clinics varied from place to place. There were frantic days when we saw as many as 200 patients in several short hours, others when we saw no more than 30 or 40 the whole day and spent much of our time playing cards and quizzing each other on our medical knowledge, waiting for more patients to show up. On the busy days, the rate limiting step was often the number of translators available to speak Hindi and Ladakhi. A few of us could speak enough Hindi to get by without translators, but nobody knew Ladakhi, so without local translators, the degree of difficulty increased rather markedly. On the whole, however, we worked hard and were able to help most of our patients, at least to some extent.

From ladakh 2009

In our down time, we enjoyed our gorgeous surroundings and each others' company. We played a lot of cards and threw the disc around almost daily. We told stories, riddles, and jokes. With the cook staff and guides, who had brought a bat, ball, and wickets, we played regular, rather competitive cricket matches that would leave us winded given the altitude. At night, we'd stargaze, play more cards, and even had a pair of bhangra nights, dancing around a bonfire once we had descended back below the tree line at the very end of our trek.

From ladakh 2009

The Dalai Lama, in exile from Tibet, has resided in Dharamshala since 1959, which is about 700 kilometers away across rugged Himalayan terrain in the adjacent Indian state of Himachal Pradesh. He visited one of the first towns we passed through, Padum, about a week after we had been there. Though we didn't get to see him, his visit still had a profound effect on our trip. In the days leading up to his visit, we'd routinely pass scores of Buddhist villagers headed in the opposite direction as us, in hopes of seeing the Dalai Lama in what was likely his final trip to to the region. The number of patients we saw at the medical camps we set up during that 5-day period was undoubtedly lessened by the hordes that traveled to Padum.

In addition to the medical care we provided to the inhabitants of Ladakh, there was plenty to do within our own group. The altitude, the unforgiving sun, the dust, and the demands of the trekking took their toll. We struggled with dehydration, bronchospasms, and respiratory infections. Many in the group battled diarrhea and vomiting at different points, and one night in particular, over the course of six hours, no fewer than thirteen members of our group came down with gastroenteritis that threatened to cause severe dehydration. A fellow resident, Paul, and I stayed up the whole night, admitting members of our group into our 'sick ward,' which was just our large dining tent, where we could keep an eye on them and help them through the night with IV fluids, IM antiemetics, extra toilet paper, and buckets.

From ladakh 2009

We had to alter our schedule and stay back at that campsite for an extra day due to the severity and scope of the illness. Throughout the trek, as strong and fit as we considered ourselves, nature would continually humble us. The mountains -- formidable, aloof -- would overpower our naive ambitions. Foolish pride and false pretenses of invincibility were shattered by falling rock, melted by the scorching sun, suffocated by the thin mountain air. We would often be left lying weakly in our hazy tents, on dusty sleeping pads, begging for just one more cool breeze to relieve the heat. Then in the evening, as soon as the sun would disappear beyond the mountaintops, the chill of the night -- sharp, unforgiving -- abruptly set in. We would curl, fetal-positioned, into our expensive sleeping bags, on the same dusty sleeping pads, and shiver the night away in a fitful sleep, craving the sunlight that so recently had tortured us so. The hikes up the steep inclines would leave our hearts pounding, our lungs gasping for breath, our heads throbbing. The water we gulped from our filtered bottles evaporated off our sweaty skin no sooner than we'd gulped it down our parched throats. The mountains, at 14,000 to 19,000 feet, clearly had the upper hand. No amount of pricey equipment from The North Face could alter that.

At one point early on in the trek, while attending to an ill colleague with respiratory distress from bronchospasms, I pulled out a portable, fingertip pulse oximeter, which measures the oxygen content in your blood. We normally should have oxygen saturations between 96-100% in the ambient air we breathe, and I was reassured that my wheezy companion was saturating between 94-96% -- not bad for being at 15,000 feet elevation. At sea level, the oxygen content in the air is 21%. As we move to higher altitude and are thereby subjected to less atmospheric presure, the oxygen content drops. This is why we experience difficulty breathing at higher altitudes, and what is commonly referred to as 'thin air.' By my estimate, the oxygen content of ambient air at 15,000 feet should be about 13.5%, a significant difference from sea level. Out of curiosity, I stuck the probe on my finger before putting it back in the pharmacy tent, and was startled to see it read 83% and then 84% on two subsequent checks on different fingers. The pulse it measured correlated to the one I palpated on myself, and I rechecked my colleague's to find the same, normal reading. Since I was asymptomatic, I did nothing aside from giving my hemoglobin a pep talk. Apparently it worked, since 5 days later when I rechecked my oxygen saturation, it was 96-97%. My body got the message and likely produced more red blood cells (which carry hemoglobin, which binds oxygen) in the interim, making the adjustment to compensate for the changed environment (a process called secondary polycythemia). Physiology in action.

From ladakh 2009

Later in the trip, after crossing the Shingo La Pass, the highest point in our monthlong trek, I developed, for the first time in my life, a throbbing toothache. I tried taking Tylenol and then Ibuprofen, but it became increasingly painful, to the point of nausea. It didn't improve even after we descended 3000 feet over the next day and a half, and it became some of the worst pain I'd ever felt. After 48 hours, when my face started swelling, and my left nasolabial fold disappeared, I decided to start antibiotics for a likely abscess. At that point, though, the pain was almost unbearable, and I resorted to raiding the Pharmacy boxes, where I discovered an intermediate acting anesthetic similar to novocaine. Using a steel syringe from the dental box, I gave myself a series of dental nerve blocks, which despite giving me some left facial droop, finally alleviated the pain (albeit for only 3 hours at a time). It allowed me to sleep, though, and recover some strength. And fortunately, by the next morning, the antibiotic had worked well enough to relieve a significant amount of pressure, which got me through the last 9 days of the trek before I reached Mumbai. I'd never been so excited to see a dentist, even though I knew I'd need a root canal. After four dentist visits in Mumbai and two more back in Rochester, my root canal is finally complete. My dentists in both Mumbai and Rochester were astounded by the size of the abscess they saw on the x-ray and both theorized that it must've been tremendously painful. I confirmed their hypotheses.

All told, I gained a fair amount of stamina over the month, but lost some weight in exchange. Between the physical demands of trekking at high altitude and a few days of toothache-induced anorexia, I dropped 10 pounds. But fear not, I got a good start putting it back on with the help of my grandmother's cooking in Mumbai.

From ladakh 2009

full album of pictures: ladakh 2009

23 oct 2008 - post-mortem

The cottage where I stayed in Maseru, as a visiting physician for a month, is immediately adjacent to the clinic building. As I mentioned before, many patients arrive fairly early in the morning, and the clinic doors open at 7am, though the doctors, the rest of whom live at least a 10 minute drive away, aren't usually there until 7:30am at the earliest.

The last day I worked at the clinic, I woke up at 7am and got into the shower after brushing my teeth and shaving. Shortly after, I heard someone banging frantically on the bathroom window from outside, and I knew immediately what it meant. I jumped out of the shower, put on a pair of jeans and a t-shirt after quickly drying off, grabbed my stethoscope and ran outside, where one of the clinic nurses was still banging on the window.  She saw me, ran over, and breathlessly confirmed what I had suspected -- a very sick patient had just arrived at the clinic.

We ran over and I got to the treatment room just in time to see a pale, cyanotic, three month old infant gasp his last breath. Although my first instinct upon walking in the room was to think (and almost say aloud), 'we need to intubate this kid,' it was not an option. We simply don't have the equipment to do it. There are no ventilators in Lesotho, so as a consequence, nor are there any laryngoscopes or endotracheal tubes. I helped the nurses already there with positive pressure ventilation and chest compressions, but looking at the child I knew from the outset that it would be futile. He had stopped breathing, was pulseless, and we couldn't intubate him.  There was neither IV access nor epinephrine to push.  After about another minute, I did the only thing I could at that point: I called the code. Time of death: 7:24am. 

The infant's mother crumbled to the ground sobbing; one nurse looked sullenly away as another quietly covered the child's face with a white sheet; I stood staring down at the lifeless body, stethoscope dangling over my left shoulder, interlocked hands resting on top of my wet head, and took a deep breath. No one said a word; there were no words to say.

We break the silence by uttering soft reassurances to fill the uncomfortable void, but they are ineffectual, inconsequential. An infant has died, one of several this month. And though we may become desensitized to many things we see with regularity, this cannot be one of them. I stand over the tiny corpse and consider this indisputable demonstration of our limitations, this unmistakable demand for humility, and bow my head.

29 oct 2008 - south african travels

as i'm short on time and bandwidth, i'll have to rely on pictures being worth their reputed thousand words for now.  i'll catch up with the text (admittedly far less interesting than the pictures, let's be honest) later, more for my purposes than anything, mainly to feed my egotism as a closet writer.

in short, though, the mountains left me breathless in semonkong, where i also abseiled down a 204 meter waterfall (the highest commercially operated abseil in the world); the clinic continued to challenge and astound me, though i did feel i made a contribution, learned a tremendous amount, and recognized within myself a sincere desire (and perhaps even a need) to return for a longer period of time; i saw unforgettable numbers of (unforgetting) elephants at addo national park; i hiked many kilometers of rugged coastline and lush forest along the indian ocean in tsitsikamma national park, both intentionally and unintentionally (i.e., i got lost on one of the hiking trails); i went kloofing in wilderness, hiking, swimming, hopping rock to rock, and even jumping off a few cliffs into the river below.

tomorrow will take me to stellenbosch, the heart of south african wine country, and then onwards to capetown for a few days before returning stateside.  feel free to peruse the photos for now, and (who are we kidding) there will probably be more from me later.

much love from south africa,

sachin

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more photos:

high in the mountains in semonkong

elephants galore at addo

rugged coastline besides lush forests in tsitsikamma

kloofing in wilderness

taking in the views in cosmopolitan capetown

15 oct 2008 - resources and resourcefulness

I resumed work at the clinic on Monday, and have found a nice rhythm seeing patients on my own, trying to pull my weight. Most of the patients show up pretty early in morning, having often travelled from long distances to make it to the clinic. They are registered in order of arrival, and after going through whichever combination of pharmacy (for pill counting), triage (for vital signs, height and weight), social work (for adherence counseling), and lab (for blood draws) they had been slotted for from the last visit, are called back by us into a room as we finish with the previous patient. The waiting room is teeming in the morning, and gradually thins out as the day goes on and patients are seen and leave. There are no assigned appointment times, it’s essentially first come, first served.

Working in a country in which I do not speak or understand a lick of the local dialect has been a new experience for me, one that’s required some adjustment. For one, like most of the other PAC doctors, I rely heavily on the translators for my history and counseling. The translators at the clinic are all involved in some way in the care of HIV positive children or are positive themselves, and are remarkably good at what they do. Each one has their own personality, and often will launch off on their own into counseling, scolding, explanations, and exhortations. It’s not unusual for me to ask a simple yes or no question through the translator (e.g., ‘are you breastfeeding?’) and 10 minutes later, after an animated discussion between the patient’s mother and the translator, complete with yelling, arguing, and finally perhaps some laughing, I’ll get a clearly understated answer (e.g., ‘she is now’). And for all the experience, insight, and cultural fluency they have that someone like me could never even approach, it’d be foolish not to trust them and encourage them to take ownership like they do.

That said, I miss the closeness I’d have with the patients if I spoke, even semi-fluently, the language. It’s certainly a skill I could hope to acquire to some extent with some work, but it’d likely be a clumsy, broken form that would still miss the subtleties and nuances of the interview that only a native speaker can really distill out. By far my favorite part of the time I spent working in Mumbai in 2006 with children from various slums in the city was the relationships I formed with them—the conversations we had, the questions we asked of one another, the jokes we shared, the Bollywood songs we sang together. I can do that with neither the children nor their caregivers here, and it undeniably takes away from the clinical experience for me. My favorite part of being a pediatrician, after all, is talking to kids.

Balancing that, however, is the remarkably challenging, rewarding, and indeed humbling nature of practicing medicine in a setting like this. It reminds me of why I went into medicine in the first place, why I wanted to train in a combined program in Internal Medicine & Pediatrics, and what your limitations are as a physician. It’s an overwhelmingly clinical, conceptual, and collaborative undertaking. You rely on your physical exam, your knowledge of pathophysiology, and your colleagues for second opinions and input. There are protocols and guidelines for organizational purposes and structure, but these often have to be adjusted on the fly, reinterpreted based on your clinical judgment, or abandoned altogether given the circumstances. Problem solving and innovative adaptation is crucial. Not only are resources limited, they are often intermittent (like the internet). Last week the CD4 machine wasn’t working; the week before, the lab couldn’t run a Hepatitis B surface antigen test; for the past month, and until at least mid-November, the lone ultrasound technician in Maseru is away attending to a family emergency. So we managed HIV and antiretroviral therapy without CD4 counts; transaminitis and ascites without a Hepatitis B test; and hepatomegaly and abdominal pain without an ultrasound.

The pathology is also unique to the developing world. We see and treat countless cases of TB and Pneumocystis pneumonia, routinely deworm kids, ponder all kinds of diffuse, overwhelming rashes, which often seem like caricatures of zoster, scabies, and ringworm, and encounter in a normal day more moderate to severe malnutrition than I’ll see in my career as a physician in the U.S. We saw a bow-legged boy suffering from severe nutritional rickets just two days ago, something we only see in pictures in medical textbooks at home.

What’s even more difficult than seeing these conditions, though, is the realization that we often don’t have the resources to treat them. Malnutrition, often due to food insecurity, is perhaps the most sobering example. We have high calorie supplementation packets that we can offer to moderate to severely malnourished children, in hopes of avoiding hospitalization, but for most, we simply can’t provide food for them. The sight of an 8 year old girl who is at best the size of a 3 year old is virtually the norm here. And in another example of one of the many vicious cycles that pervade the lives of the underprivileged, malnutrition of course leads to a much greater vulnerability to disease. When your immune system is already weakened by HIV, it doesn’t take much of an insult to start a downward spiral.

Having access to antiretroviral therapy (ART) for children in this setting is a paradigm shift, and even a few years ago was unthinkable, so does represent a major advance. I initiate several children daily on ART, and the improvement in their health can often be dramatic over the course of mere weeks. But it’s a strange dynamic, since we don’t even have permetherin for scabies, let alone a CT scanner anywhere in the country. And I can’t help to wonder if this is a sustainable solution; I may be proven wrong, but I don’t think it is. How many years can you, as a government or NGO, afford to treat an HIV positive newborn with antiretrovirals when over thirty percent of the population is infected? HIV has become, for all intents and purposes, a chronic disease in the developed world. But chronic disease management, requiring lifelong medications, are almost without exception a prohibitively costly undertaking in the developing world. Can you realistically hope to procure antiretroviral medications for one third of your population for decades (if the program is successful at prolonging lives), even when they’re made by generic companies like Cipla for as little as $300 a year, when your per capita spending on health care is closer to $25 annually ($24.10 for Lesotho based on a 2001 WHO estimate, compared with $6,100 in the US)? And especially in this global economic climate, it’s not practical to rely too heavily on outside sources of funding to help.

This is of course why the most cost effective, lasting impact is in prevention, public health, and population based strategies. Prevention of mother to child transmission is a major area of work, and rightfully so, as with proper medication regimens starting at 28 weeks gestational age and lasting through between 1-4 weeks of life for the newborn, vertical transmission can be drastically reduced. An HIV vaccine remains for now the frustratingly elusive, holy grail of the international health world, largely because the HIV virus is so adept at evolving to evade efforts to contain it. In the immunological cat and mouse game, it exemplifies the power of natural selection, almost in real time, rapidly developing resistance to new strategies (pharmacologic, immunologic) designed to eradicate it. It’d be fascinating if it weren’t so devastating.

This weekend we’re headed to a town high in the mountains in Lesotho called Semonkong. It’s a treacherous drive up there, but it’s supposed to be a stunning place. There is an outreach HIV clinic there where we’ll spend two days working, but also will have some time for adventures like abseiling down a waterfall and trekking. I’ll keep you posted. Thanks for reading.

Much love from Lesotho,
Sachin

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More photos from Kruger & Lesotho:
http://sdshah.com/photos/southern%20africa_oct_2008/lesotho/

12 oct 2008 - kruger and back

This past weekend four of us went to Kruger National Park, in Northeastern South Africa, which was an ambitious road trip from Lesotho, especially given that we had only one full day to spend there. But it was undoubtedly worth it. Kruger is Africa’s most famous wildlife reserve, and it’s easy to see why. Roughly the size of Portugal, it’s filled with the big five of lions leopards, elephants, rhinoceri, and cape buffaloes, in addition to countless giraffes, hippopotami, warthogs, kudus, impalas, and a lot of other animals I couldn’t begin to name. We left early Friday morning for the 10 hour drive through South Africa, and aside from a 1.5 hour wait at the maddeningly inefficient border crossing from Lesotho, the trip was fairly uneventful. I expected it to be more difficult to get there given the convoluted route we had to take, but with a good South African road atlas and an attentive navigator, it was pretty easy.

We had booked a lodge just outside the park, and it turned out to be fantastic. Two stories, four bedrooms, wet bar upstairs, beautiful terrace, and a price that made you triple check the listing when you saw the place. We woke up early (4:15am) again Saturday and took an all day safari in a jeep through much of Southern Kruger with a fantastic guide named Heinrich, recommended to us by the guy who owned the lodge where we were staying. We spent the day in an open jeep, scouring the bush and open savannah for animals, and saw essentially everything but a leopard or cheetah. Though it was supposed to only go until 1 or 2pm, Heinrich went two hours over to take us to a spot where a group of lions often hang out, and the gamble paid off when we were able to see a pair of lionesses and two young males lounging in the shade. We were dropped off back at our lodge at 4:00pm just in time to get in our car and head back inside the park for a night safari, which was less personal and in a bigger jeep, but during which we saw a number of elephants, giraffes, rhinos, and buffalo right in our grills.

After scrutinizing the landscape all day for animals that have evolved to blend into their surroundings, I began to see creatures everywhere I looked. The view from the moving jeep was a motion picture: dry driftwood would morph into a giraffe with its head craned; from the tall grass would emerge a herd of zebras; a mound of dirt in the distance would become a lumbering rhinoceros. Heinrich, with eyes like a hawk, saw virtually everything, and was masterful at picking out for us the subtlest movements in the peripheries.

The park was unusually dry, and so normally rushing rivers were left only as parched beds of sand; and barren, leafless branches replaced the usually lush, green foliage. It did make spotting animals easier, especially since they all had to go at some point to one of the few remaining, well stocked watering holes. For the same reason, it made hunting easier for the predators, as was evident by the halting, cautious way the impalas, especially, would gingerly approach the exposed watering holes for a drink. For their sake, I hope it rains soon.

So after 14 hours of safari on Saturday, we went to bed early and slept in Sunday morning, then left after a big breakfast for the drive back. We went back through Swaziland, earning the added passport stamp by traversing this beautiful, mountainous, and greener (though still afflicted by the drought) land filled with acres of pine trees, rolling hills, and hairpin turns. We made good time back to Lesotho, and the border crossing back was painless.

Back in Maseru, we dropped off Dan, a medical student from Virginia who’s also been working here, and headed down the mountain on the road back towards our cottage. Here we were forced to stop by a pair of cars that were at a standstill in front of us, and were summarily greeted by a pair of men with guns in their hand who gesticulated for us to pull over to the side of the road. Convinced we were about to get mugged and perhaps carjacked, we did as we were told. A third man, who spoke English, came up to us at that point and began explaining that he was a policeman (a dubious claim, as he was not wearing a uniform, and there was no police car in sight), a man had just had his car hijacked there moments ago, and they were stopping people to check them. Then, somewhat inexplicably, after exchanging a few more words, he waved us through and let us go. I’m still not convinced they were really cops, but I am also at a loss to explain why he let us go without mugging us if he wasn’t. I suppose it’ll remain a mystery, but in any case we were pleased with the outcome, and it capped a weekend of adventure.

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5 oct 2008 - into africa

I've come for the first time to Africa this week, to spend a month working with a group called the pediatric AIDS corps (PAC) in Lesotho (le-soo-too), a small nation contained completely within South Africa's borders. One of my fellow Med-Peds residents from Rochester, Nina, has also come, and we made the trip over together. After a quick flight from Rochester to DC, it consisted of a 16 hour flight from Dulles to Johannesburg, a 22 hour layover, and finally a short, 75 minute flight to Maseru, the capital of Lesotho, on a 20-seat South African Air propeller plane. Our bags even made it on the first try.

Lesotho is a small, poor country, nestled in the mountains, and called southern Africa's 'kingdom in the sky.' It's a beautiful, mountainous nation inhabited by the Basotho people, who are historically farmers, cattle herders, and traders.

The PAC is a project run out of Baylor University in Houston, and has a number of locations throughout Africa. The clinic here in Lesotho is impressive. It's a new, glassy, spacious building with the first floor devoted mainly to a waiting room, a pharmacy, offices for social workers, a treatment room for higher acuity care, and patient care rooms. The second floor has administrative offices, a computer lab, and a lecture room. It's certainly the nicest clinic I've seen in a developing country, and in fact compares favorably to most of the clinics I've worked in at home in the US. Each patient care room has a computer, and the clinic runs an electronic medical record. In theory, there is supposed to be wireless internet throughout the building, but so far since I've been here it hasn't been working (one of the inevitable reminders that I am still in a developing country). There's a small pharmacy that stocks most of the medications we prescribe, and technicians there that assess adherence to anti-retroviral therapy (ART) each visit by counting how many pills remain in the bottles the patient and their caregiver bring back each time from the quantity dispensed at the previous visit. Anything less than 95% adherence, which has been shown to markedly increase the development of resistance to ART, is unacceptable, and aggressively addressed with a full assessment and further adherence counseling, as there are very few options for these patients once the virus develops resistance to the therapy. The first line regimens have to last years; there are limited second line regimens, and little to offer in this type of resource poor setting after that.

The disease burden here is intimidating, and produces some astonishing figures. A full thirty percent of the nation's population is HIV positive, and as a consequence maternal to child (vertical) transmission impacts an extraordinary number of newborns. Fifty percent of infants here infected with HIV die within their first year of life. Infant mortality rates in Lesotho exceed 130 per 1000 births, and HIV accounts for roughly 45% of those infant deaths. Also found here is the fourth highest incidence of tuberculosis (over 600 cases per 100,000 people) in the world, which is no coincidence given the burden of HIV in the population.

There are a large number of adult clinics for HIV/AIDS care in Lesotho, but hardly any other options for Pediatric HIV care. Through funding from the Ministry of Health and the Clinton Foundation, primarily, the clinic offers antiretroviral therapy (ART) to children with HIV, which is a medically complex and organizationally daunting endeavor given the unique challenges (e.g., minimal scientific data specific to HIV positive children, the necessity of weight based dosing, complicated regimens reliant on surrogate caregivers in the face of countless parents dying from the very disease they have passed on to their children) present in pediatric populations. Bristol Myers Squibb, the pharmaceutical company, also contributed a significant amount of money for the clinic building (which bears its name), and apparently contributes to the salaries of the Pediatric AIDS Corps (PAC) physicians who are here full time, but seems to have no involvement (based on my initial, cursory inquiries) in the funding or selection of the ART medications. Further investigations on my part are pending, stay tuned.

The clinic will offer HIV testing to anyone, child or adult, and though they see primarily pediatric patients, for those caregivers with multiple children enrolled in the clinic, pregnant mothers, and select other adults, care is often offered here when the time and transportation requirements of going to multiple sites for medical care is prohibitive. Prenatal care is also a part of the repertoire of care often offered at the clinic, care that centers around the administration of drug regimen designed for the prevention of mother-to-child transmission (PMTCT) of HIV, which ideally starts at 28 weeks gestation and continues up to several weeks postpartum for both the newborn and the mother.

The children we see are often extraordinarily sick. They are severely malnourished, immunocompromised, and afflicted, as a consequence, with a host of opportunistic infections like TB, Pneumocystis carinii (or jiroveci) or bacterial pneumonia, diarrheal diseases, candidiasis, dermatological diseases, meningitis, and severe sepsis. We seem to average at least 1 or 2 lumbar punctures (spinal taps) daily in clinic for lethargic infants that almost certainly have bacterial meningitis. We coded a little girl last week (twice), before stabilizing her and transferring her to the hospital. Maseru's government hospital, called Queen Elizabeth II, is not a place we like to send our children unless it's absolutely essential. It's a third world hospital – understaffed, overburdened, and crawling with cockroaches – and the outcomes of the patients sent there do not inspire confidence. That said, there are undeniable limitations of even the most aggressive outpatient management of serious medical problems (and the envelope is certainly pushed here) which quite simply require inpatient management.

Maseru has thus far lived up to most of my expectations from previous times I've spent with NGOs in developing countries. Rural and urban sites in India have to date served as my frame of reference and, in reality, there has been a lot about what I've seen here that is familiar from the places I've worked in India before. The poverty is pervasive, visible everywhere, and inescapable. Ubiquitous are the sheds with plastic bags or blue tarps for walls tied between crooked wooden beams supporting corrugated tin roofs; or else the short, squat, one room houses of brick situated haphazardly along the roadside. The overwhelming majority of Maseru's population lives in structures like these; they peddle vegetables and collect scrap metal; with a once thriving textile industry essentially destroyed by competition from China and a national unemployment rate hovering around 50%, they are migrant workers without jobs. The air is smoky from the cooking fires; hazy from the heat and pollution of the daytime; dusty from the wind blown roads.

There are many residential enclaves, however, tucked away in corners of the city that represent the pockets of wealth, and stand in stark contrast to the other Maseru. As in all developing countries, the dichotomy between the few 'haves' and the many 'have nots' is perhaps most evident in how the former group lives. These residences are often situated on one of the several mountainsides checkering and surrounding Maseru and offering spectacular views of the city and, most strikingly, the daily sunsets. I've already seen many of these areas as well, as most of the fairly cohesive, interconnected expatriate population resides within them. The small number of wealthy Lesotho families and expats (most of whom are working with various NGOs in the area) live quite comfortably, and if I were to come work here for an extended period of time, this is how I would live, too.

Aside from the other PAC doctors, I've met a Fulbright scholar from St. Louis studying the nation's history, a number of Brits working for a sports outreach NGO, a Welsh woman volunteering at the city hospital, another American working here with Partners in Health setting up solar power and satellite based internet access for remote villages in the mountains, and quite a few other expatriates doing (mostly) interesting work. They speak varying degrees of Sesotho (se-soo-too), the main dialect spoken here, know the city and country remarkably well, and have made comfortable homes for themselves.

There's also a fellow Princeton graduate, fresh from the class of 2008, and all around good guy, named Stuart, who's doing a yearlong post undergraduate public service fellowship program called Princeton in Africa. He's working with the clinic organizing various outreach activities and, as he has a car here (practically speaking, essential for anyone here long term), serving kindly and without complaint as our informal driver. It's not unsafe to drive here, most drivers are well behaved and things proceed relatively orderly, though it is advisable to avoid driving at night. But it's remarkably better than driving in India, for instance, where sheer chaos reigns amidst the congestion, two features that are happily absent here. I think there simply aren't enough cars on the roads to wreak that kind of havoc, perhaps speaking to the absence of a middle class. Urban traffic volume in a developing country probably does represent a surrogate marker for the emergence of that nation's middle class. Maybe. We're staying in a cottage next to the clinic, which while convenient for getting to work, is otherwise very isolated from where everyone else stays, and leaves us dependent on (mostly) Stuart's kindness to come pick us up and drop us off, which, fortunately for us, he does so willingly.

The PAC doctors, who are a tight knit group, have welcomed us warmly and wholeheartedly into their fray, a social network that includes most of the city's expatriate population. There has already been a birthday dinner party (enchiladas), guys only poker night (at which I won 750 Rands, which is the equivalent just under $100), Friday happy hour (at the swank Lesotho Sun hotel), trip to a local music and arts festival (in a town called Morija), and a Sunday brunch (banana pancakes) followed by a lazy movie afternoon (Kung Fu Hustle).

Despite rumors to the contrary, I'm doing just fine without internet, and passing my free time with downright equanimity. Between the busy social calendar and the frequent cooking, there is not an excess of free time. When I do have it, though, I'm reading, apart from all I can get my hands on about HIV care in resource limited settings, 'Don Quixote' at present, and taking breaks by playing hearts on my internet-less laptop (I shot the moon three times in one game last night en route to victory).

Four of us are trying to get a trip together to Kruger (huge, famous national park in South Africa, and the best place to see wildlife) this weekend, which would be at least an 8-10 hour drive, so we'll let you know how we do. More later.

Much love from Lesotho,
Sachin

15 apr 2006 - growing pains

mumbai is the epitome of an overpopulated city. it continues to push the constraints of its geography, yet manages somehow to always find room for more people. the slums are the smoke and mirrors with which a finite area--its capacity long since exhausted--is made to accomodate still more. people are crammed beside each other and stacked upon each other in what precious little space there is. while population density estimates are often wildly disparate, simply dividing population (~18,000,000 by a 2005 estimate) by land area (437 sq km) puts mumbai's density at ~40,000/sq km. many of the slums have a much higher density, though i won't hazard a guess to try to quantify exactly how much more. i also personally think the population is greater than the official estimate given the difficulty in accurately counting the number of slum residents, a demographic that makes up ~40% of mumbai's population. manhattan, by comparison, has a population density of ~25,000/sq km. finding consistent figures for population density of other populous cities of the world is very difficult, but they are almost without exception significantly less than mumbai's. in any case, superlatives aren't necessary to make my basic point: there are a lot of people here in a small amount of space.

i promised more stories and less commentary this time. here are a few selected details about some of the children i spent time with this past week.


nargis is a 14-year-old girl who came up to me on three separate occasions asking for an examination. she complained of body aches all three times and wanted medicine from me. i found nothing significant on her exam (all three of them) and explained to her that her body aches because every morning she has to go fetch water for her house in several heavy containers and drag it back about 2.5 km. all three times i told her that i really couldn't give her any medication for that, and all three times she frowned at me and walked away.

shyam is a 14-year-old boy who is tall for his age and could be called lanky. he is in fact skinny--too skinny--and he told me he wants to gain weight and build muscle mass as he lifted up his shirt and showed me his sunken pecs. i told him he needs to eat more (he is malnourished) but i don't know if it's possible.

elsie is an 11-year-old girl with asthma. she has never previously been told she is an asthmatic, though she's been having almost nightly symptoms for years. we classify asthma into four groups: mild intermittent, mild persistent, moderate persistent, and severe persistent, based on the characteristics and frequency of attacks. by history she falls into the moderate persistent category, and she was wheezing when i listened to her during my exam. so i bought her a bronchodilator to use when she has attacks and spent some time the next day showing her how to use it properly. i noticed a reluctance on her part to take the inhaler from me and show me that she understood how to use it, but i didn't think much of it. about 20 minutes later, though, i found her outside in the hallway crying. she didn't want the inhaler because it made her different from everyone else. i explained to her that she could keep it hidden in her pocket or under her pillow at home, and that no one had to know she has it. but i'm still not sure she will ever use it.


kajal is a 13-year-old girl who refused to tell me her age. 'i don't tell my age to anyone,' she replied when i asked. 'i need to know,' i said. 'nope,' she said. i persevered, and finally she relented by writing it in pencil on the table and then quickly erasing it. i usually walk over to the slum in which the children reside and then ride the bus with them to the akanksha center to which they go for their after school program. on tuesday, kajal comes and sits next to me on the bus with a big smile on her face. 'i have your number!' she proclaims triumphantly. 'what do you mean you have my number?' i ask. 'i have it!' she says, beaming. 'which number?' i asked. 'i don't have it memorized yet,' she says, 'but i have it written down at home.' 'where did you get it?' i asked. and she pointed to the luggage tag on my messenger bag, in which i carry my stethoscope, flashlight, and some medications and dressings. 'that's my number in the u.s.,' i tell her. her hand goes up to her mouth in a look of shock. 'what's your number here?' she asks me, and demands i take out the mobile phone i carry with me. she then proceeds to take my pen from my shirt pocket and write down my mumbai number on her hand (that never happens to me). she hasn't called me yet (that's more familiar territory).

jyoti is a 12-year-old girl who lost her father last june to tuberculosis. she has two younger brothers whom she looks after with a lot of love. her mother, parvati, is actively involved with akanksha, and comes to the center most days with the kids from their slum and serves as a sort of liaison between akanksha and the other children's parents. jyoti has trouble with her vision at night and itches all over her body most nights, too, both signs of vitamin a deficiency, which many of the children have. she's goofy, she loves to play with my medical equipment, and on several separate occasions took my stethoscope and flashlight and tried to examine me. she concluded that while my eyes and throat looked fine, i did not have a heart.

jeetendra is a 13-year-old boy who's a fantastic cricket player and a genuinely good kid. he is the humble captain of his cricket team, comprised of kids from his slum, and last month led them to the championship of a tournament between the teams from multiple slums around mumbai. thursday when we were playing cricket outside while waiting for the bus to come take us back to the slum, he smacked a ball so hard it literally split at its seams into two, ending the game (there was only one ball). jeetendra first came to me complaining of some chest pain on his left side which appeared to be a muscle strain in his rib cage. 'just take it easy with the swings for a few days,' i told him, then got distracted with some other kids and wasn't able to complete his exam. the next day i found him and said let me just finish with you, and that's when i discovered the striking difference in size between his right and left thighs. the quadriceps muscles on his right leg had wasted away almost completely, and he had significant weakness there compared with his left leg. the process had taken place over about a year, he said. he doesn't wear shorts anymore, he told me, because he's embarrassed by it. i suspected this was a consequence of polio, and after reading on it that night, i think he has something called post-polio syndrome, in which the virus (which he must've had and survived when he was younger, though he couldn't recall) reactivates and affects focal muscle groups innervated by common nerves. there isn't an effective treatment from what i could gather, all you can do is hope it is self-limited.

pankaj is one of the children i'll never meet. by all accounts, though, he was beloved by his peers. he was a 13-year-old boy who died a few months ago when he was hit by a train after he unwittingly ran onto the railroad tracks while chasing a kite near his home. pankaj also loved to play cricket and so the other kids from his slum, in tribute, spent two days clearing a parcel of land that had essentially become a dumping ground, turning it into a cricket field. they proceeded to designate it 'pankaj's cricket club,' etching his name into a stone wall at its edge, in a touching monument to their deceased friend.

as i've said before, these children give me extraordinary access into their lives. they trust me. they show me their homes and communities, introduce me to their parents, and share their dreams with me. they show a fondness for me that i can't help feeling that i don't deserve--not so soon. but in truth, i reciprocate their adulation and become attached to them quite quickly myself. as a result, i find it exceedingly difficult to leave each center and move on to the next.

i've posted some more of my favorite pictures from the past two weeks at the following locations. check them out, as they are worth much more than my words could ever convey:

more mumbai photos (smaller files for slower connections & smaller monitors)

more mumbai photos (larger files for faster connections & larger monitors)

much love from mumbai,
sachin

8 apr 2006 - the audacity of hope

i've been in india a week now, for those of you who didn't know i was here (sorry). i came to help a nongovernmental organization (ngo) called akanksha (www.akanksha.org) that works with slum children here in bombay. read about them on their website (which is excellent, i'd really encourage you to read some of the kids' quotes under the 'i am here for me' part, they're beautiful) if you're interested, they do incredible work providing educational opportunities for these kids. akanksha runs programs after school at spaces near each of the slums in which the children reside. often they bus them from their slums everyday before or after school to the nearby spaces and then spend ~3 hours on additional educational and extracurricular activities.

there are lots of problems, as you might imagine, that come with living in the slums. sanitation, hygiene, clean water, for example. access to health care is also a big one. i'm here to modestly assist on that front, as i'm doing medical checkups on all of the kids in each of as many centers as i can get to in the time i'm here. i'm unfortunately on my own, though, as there is no supervising doctor, and we are very resource poor. i have my stethoscope and a penlight in need of new batteries. i usually take the kids to the corner of the classroom and talk to them a while and then do a basic physical exam. for the girls, i usually take them to a stairwell landing upstairs, and have them lie on a mat on the ground to complete my exam on them -- it's as much of a private space as we have. i'm seeing a lot of dermatological problems like impetigo and pyodermas, malaria, ascariasis (worms), anemia, lice, ringworm, vision problems, diarrheal diseases, the occasional TB, and a host of others. for the diagnoses that i am confident about that are treatable with meds, i'll write the name of the drug, the dose, and duration, and either the teacher, the social worker, or i will go to the chemist (pharmacy) and buy them for the child. it's pretty informal here, if you want mefloquine for malaria, just ask for it and they'll give it to you, no prescription necessary.

i'm hindered, of course, by my inexperience, but i'm doing my best. the kids that absolutely require lab tests (a girl that i think has malaria needed a peripheral blood smear yesterday), and those that are more complicated or serious, i send to the government hospital. but the parents hate taking their kids there and often don't, so i try to do as much as i can, because they trust me. that means i make some presumptive diagnoses that i can't prove with lab tests that would normally be routine at home, but that i have a high clinical suspicion for. i am able to connect to a really powerful medical reference resource called 'up to date,' which i have access to remotely from my medical center's computer network in detroit, and i'm relying on it for a lot of guidance -- it's basically my attending right now.

so that's the means by which i am getting to my end of interacting with these kids. they are inspiring to their very core. they live in the most difficult of circumstances: small, cramped, makeshift homes of concrete floors and corrugated roofs no larger than many of our bathrooms or closets. they are shoehorned into spaces that are chosen based solely on their availability in this teeming, overflowing city -- alongside railroad tracks, on pavements beside main roads, under bridges and overpasses. they are subjected to dirt, pollution, heat, disease, and hunger. they must drink unclean water and defecate by the railroad tracks. they must withstand abuse--verbal, physical, sexual--from society and often their own parents. many fathers have left their homes, having squandered what little money they had on alcohol and gambling, leaving them with only their mothers or as orphans. they are shunned by the government, condescended to by society, and written off by virtually everyone. they are regarded as worthless nuisances, parasitic products of the bottom rung of society. they are looked down upon as poverty's contemptible procreation.

in reality, the slum dwellers make the city run. they are the rickshaw drivers, the vegetable vendors, and the servants. they collect the trash, sweep the floors, and deliver the tiffins at lunch time. without them, the city would be brought to its knees. they deserve a place to live and a certain standard of living, both of which they are mostly denied. many of the adults have given up, they have been defeated by a life of suffering and hopelessness.

yet the children persevere. if only you could meet them, believe me, your heart would be buoyed by their spirit. they are young, and they have known no other life than that of the slums, but with the help of akanksha, they believe in themselves. they desperately want an opportunity, and they dare to dream big, of improving their lives, of achieving and advancing themselves through education. how they personify the audacity of hope.

they are beautiful, they are curious, and there are many that are incredibly gifted. take 14 year old hina, for example, who came up to me the first day and asked me if it was hard to become a doctor. i asked her if that's what she wanted to do, and she smiled with self assurance and said, 'yes, that is my dream.' i watch her sometimes at the center, the way she furrows her brow in concentration when she thinks, when she seeks to understand; the way she explains complex concepts to her peers, and the passion she has for learning. i believe she will be a doctor some day, but more importantly, she does, too. these children will be given an opportunity--thanks to akanksha, especially--small though it may be, and i believe (i hope?) many of them will seize upon it and succeed, despite intimidating odds and a deck stacked squarely against them. this, to me, is a fairer application of the concept of personal responsibility.

i've already grown close to many of them. they accepted and embraced me immediately, and they make my day everyday. they've given me tremendous access into their lives, as well, and i'll share some stories and photos from my time with them in my future writings.

their city, bombay, is full of contradictions, of a stunning juxtaposition of poverty and wealth; there are no protected pockets, no sheltered areas. the staggering dichotomy between the haves and the have nots is evident everywhere you look. it is the legless beggar sitting below the louis vuitton display window, asking for money, at the taj hotel by the gateway of india in colaba in south bombay. it's the barefoot, naked, 5 year old ragpicker boy, scavenging for anything of value in a pile of garbage beside the railway station as a wealthy, 17 year old girl with gucci jeans, driven by her driver in her air conditioned toyota qualis suv, passes by. the poverty is so pervasive, that most mumbaikars (residents of the city) don't even see it. they look right past. it's not a criticism, it's an observation. i don't know how you could do much else, quite honestly, given the scope.

i have been placed in a flat near one of the slums (called dharavi), in a part of bombay called sion. it's centrally located, buried in a crowded, easily disguised maze of lanes. but i've grown accustomed to the area and have carved out in my mind the pockets of recognition that get me home each night, despite often coming from different directions. i ride the local trains to all the slum sites, and i'll be sure to write about riding the central line, for instance, during rush hour here sometime. space, including personal space, is at a premium always. it's been great learning and exploring the city for myself. staying with family, as i normally do when i'm here, shelters me from most of what i've been seeing and doing here this time. but i also get to spend time with my extended family when i'm free, as most of them live right here in bombay, so it's the best of both worlds.

so that's my intro. i'll write mostly stories and anecdotes in my future posts, but wanted to start with a frame of reference. i hope you're all doing well, and that life is good.

much love from mumbai,
sachin

i got my md

"i got my md"
sung to the tune of "when I'm sixty-four," by the beatles
by sachin d. shah

when I grow wiser, no longer scared,
pass all my exams.
will I ever get to sport a long white coat,
bedside manner, otoscope.

when I'm on call in the ICU,
another month q3.
will I regret why,
will I forget why,
I got my MD.

1st year resident,
but now the bank wants back,
all the cash they lent.

first I will master, the interview,
flesh out HPI.
attempting to be thorough I will spend whole days,
on OPQRSTA's.

starting a family, so far in debt,
light is hard to see.
will I regret why,
will I forget why,
I got my MD.

every year we buy another copy
of the new first aid, for a hefty price.
USMLE.
we passed step 1 & 2,
all that's left is 3.

working the trenches, at my wit's end,
running out of gas.
wondering why I put myself through all this pain,
need more sleep, I'm going insane.

when i'm an intern, scuttin all day,
almost work for free,
will i regret why,
will i forget why,
i got my MD.

the orange

The Orange
by Benjamin Rosenbaum, in the Spring/Summer 2002 issue of Quarterly West

(from Harper's Magazine - 'Readings' - Nov. 2002)

An orange ruled the world.

It was an unexpected thing, the temporary abdication of Heavenly Providence, entrusting the whole matter to a simple orange.

The orange, in a grove in Florida, humbly accepted the honor. The other oranges, the birds, and the men in their tractors wept with joy; the tractors' motors rumbled hymns of praise.

Airplane pilots passing over would circle the grove and tell their passengers, "Below is the grove where the orange who rules the world grows on a simple branch." And the passengers would be silent with awe.

The governor of Florida declared every day a holiday. On summer afternoons the Dalai Lama would come to the grove and sit with the orange, and talk about life.

When the time came for the orange to be picked, none of the migrant workers would do it: they went on strike. The foremen wept. The other oranges swore they would turn sour. But the orange who ruled the world said, "No, my friends; it is time."

Finally a man from Chicago, with a heart as windy and cold as Lake Michigan in wintertime, was brought in. He put down his briefcase, climbed up on a ladder, and picked the orange. The birds were silent and the clouds had gone away. The orange thanked the man from Chicago.

They say that when the orange went through the national produce distribution system, certain machines turned to gold, truck drivers had epiphanies, aging rural store managers called their estranged lesbian daughters on Wall Street and all was forgiven.

I bought the orange who ruled the world for 39 cents at Safeway three days ago, and for three days he sat in my fruit basket and was my teacher. Today, he told me, "It is time," and I ate him.

Now we are on our own again.

the best of peru

the lost incan city of machu picchu, high in the andes

my favorite photos from my travels in peru:
http://sdshah.com/photos/best_of_peru_jan_2006/