I live, she dies: Access to quality health care

(A version of this blog appeared in Global Post)          

I am thankful this season for good health care, and yet I am sad that many don’t have it. Here’s why.

            Three weeks ago, I flew to Manila, stayed a week, and then flew back to Washington, D.C. My calves felt extraordinarily tight during the whole trip, and when I went running one day in Manila I had to stop every three or four minutes. I have run marathons, but I couldn’t breathe after three blocks. (And that's where I left things in my last blog post. See below.)

            Back in Washington, I walked up three flights of stairs and again had to stop to catch my breath. I knew something was wrong so I opened my computer and typed in Google: “calf pain + shortness of breath + long flights.” Google told me what I feared: deep vein thrombosis, or dangerous blood clots that could migrate to my lungs and possibly kill me.

I drove myself to an emergency room, where 15 minutes later a technician using ultrasound found two clots in my leg; a doctor told me the clots were also almost surely in my chest. A nurse injected me with blood thinner, and after a few days in the hospital, I am now out of danger. I left for home and now recuperating.

            I am fortunate. I know this from years of experience of reporting about people who have poor or no access to quality health care, from rural areas of West Virginia to Afghanistan to Zambia. But today I feel this deeply, in large part because of an email that I just received from Rudi Thetard, the country director for Management Sciences for Health (MSH), a Cambridge-based non-profit that works globally to improve health care.

This summer, I met Rudi in Malawi and he had introduced me to Lucy Sakala (see Dominic Chavez's photo above), an HIV counselor at Salima District Hospital in Malawi, about a two hour drive from Lilongwe, the capital of the southeastern African country.

            Lucy was battling cancer and I wrote about her difficulties in getting treatment. Here’s what she told me in July about how she tells people that they are infected with HIV:

            “I tell people who just learn their diagnosis that they should live positively,” Sakala said. “I tell them that there are several conditions more serious than HIV, including some cancers. And I tell them I have cancer, and it’s difficult, but that I live positively. Then I say it’s so important for them to take their medications properly so they won’t have opportunistic infections, and that they shouldn’t fear much. They should listen to their health provider.”

            Those patients, Sakala said, sometimes “feel sorry for me, and their problem becomes a little lighter. But I tell them not to feel sorry. I tell them to live as positively as I am.”

            The story documented how Lucy couldn’t afford the cost for chemotherapy. MSH staff around the world donated $2,000 for her treatment.

            In the end, it was not enough. Rudi’s email was Lucy’s death notice. She died a week ago from her cancer, which had spread from her uterus to her brain, esophagus, and lungs.

            Here’s what he wrote:

            “Lucy has for the last year battled her own cancer whilst continuing to counsel persons who have tested positive for HIV.  Her death has been felt strongly by MSH staff in Malawi as we had all hoped that she would recover.

            “Her story echoes the story of many other cancer sufferers in Malawi.  Following the diagnosis of cancer she was able to start with a program of chemotherapy which had to be supplemented by radiotherapy.  It is at that point that that the doctor advised a course of radiotherapy which was only available in Zambia.  MSH staff (in Malawi and globally) contributed generously to the expenses she incurred in travelling to Zambia and she was able to complete a course of radiotherapy.  She returned to Malawi a few weeks ago and had to face a reality of a shortage of essential chemotherapy – these drugs have been out of stock since September in Malawi.  She died this morning and was only 28 years old, leaving a daughter and husband.”

            I told this story to Dr. Kevin De Cock, a pioneering global health researcher who is now director of the Center for Global Health at the Centers for Disease Control and Prevention in Atlanta.

            “This story of the 28-year-old woman is regrettably a common one,” he said. “But at the same time we need to step back with non-communicable diseases and say where we are: The world is just starting to recognize the global problem. Not a large amount of resources are being made available to for specific non-communicable diseases, such as cancer, hypertension, and diabetes. … Still, a great deal can be done through appropriate public health policies. This does not solve the problem of the sad story of this woman, but there is an awful lot we can do now.”

That is almost surely true. The reality today is that someone like me who was born in a middle-class family in a rich country has the means to access health care that can add years – maybe decades – to my life. Lucy Sakala, by virtue of being born in a poor country with poor health care, didn’t have that. Basic chemotherapy treatment was not available to her. And because of these facts, I live and she dies in November of 2011. It’s not right.

Manila: Xmas, shops, and ‘I want to marry that girl’

            HONG KONG – I’m now at the Hong Kong airport, on a layover, thinking about Manila and running and thinking about Manila and not running.

I had a run that I would rather forget. At dusk one night, I ran inside a gated Makati neighborhood – an exclusive part of the city -- and then rather foolishly went out the next morning at 6 a.m. A few minutes into the morning run, I wasn’t running. I was out of breath. So I walked. I started up again, and I stopped again, covering four blocks. My run-walk continued for a half-hour.

I’m not sure if it was the Manila humidity, the air, jet lag, or general fatigue from my life of too much travel, but it didn’t matter. I had one choice. No more running for a few days. And when I don’t run, a couple of things happen. One is that I have time.

So I explored Manila in a different way, just not in my running shorts.

It was hard to avoid experiencing how the city was gearing up for Christmas, even in the second week of November. My five-star hotel, the Makati Shangri-La, produced a “lighting of the (fake) trees” ceremony in its giant entryway.  The hotel brought out a choir of women all dressed in red floor-length gowns who sang from the top of a curving staircase. They hired a woman who wore a flowing golden gown and who belted out Christmas tunes as she walked down the stairway. She burst into a Motown song at one point, and the Filipinos in Red shook like they were from African-American sisters from Detroit.

The hotel also erected a two-story-high artificial Christmas tree, which stood in the middle of a forest of artificial one-story trees. And running around them were a bunch of elves, or girl-thin women dress in red skimpy outfits with caps on their heads.

A crowd witnessed the spectacle, of course. Who wouldn’t want to see this? Everyone had some sort of camera, either real ones or those on phones or other devices. (People were forever taking pictures in this hotel, even in the elevators, of themselves.)

Later, when I talked about this scene to a Filipino friend who had come to take me shopping (I had to find time for that), she said, “We’ve been celebrating Christmas since September! This is a late party!”

Shopping followed. Bernie, the mother of a friend in DC, took me to a shopping mall an hour’s drive away. Inside was a kind of an upscale flea market featuring knock-off brand clothes and bags, pearls, coral jewelry, hand-made bags, and Santa-and-elf figures. Plus a lot of Jesus statues.

(Did I mention the Philippines was “100 percent Catholic”? It’s not, of course, and in fact the Muslim population is large in certain areas, but people like to joke (sort of) about it.)

Bernie is a shopping pro. All foreigners need Bernie to take them by the arm. We had a short strategy session beforehand (I was looking for over-the-top pink/oranges/reds polos for my suddenly fashion-conscious 17-year-old boy; jewelry; anything locally made) and she marched into the place. I struggled to stay two steps behind.

We wandered into a maze of little booths selling thousands of strands of pearls and coral beads. We waded deep into the booths selling polos on major discounts. We found woven handbags, including some with coconut shells, and silk ties going for $5. “Give him your lowest price,” Bernie kept telling them.

When they lowered their price, Bernie would say, “No, I said, your lowest price.”

So we bargained and bought presents at their “lowest price,” and I filled a couple of bags, and felt like Christmas was here, even if it wasn’t.

But the best non-running moment was a third excursion – to a massage parlor. I went with my two companions on this trip. (The purpose of this trip, by the way, was to report on how the Philippines has attacked the ancient disease of tuberculosis.) Toward the end of the week, the three of us, all guys, found an upscale massage place and treated ourselves to an hour of massage.

It was heavenly.

When it was over, as I changed back into my clothes next to Riccardo Venturi, an Italian photojournalist who is working with me, I asked him how it was.

“Oh,” Riccardo said, “I want to marry that girl.”

“That good?”

“If I don’t marry that girl, the girl I marry will have to know how to massage like that girl.”

 We laughed. He said it was his first massage.

“First professional massage,” he said, correcting himself. “Shall we come again?”

“Sure.”

“Tomorrow night?”

We later went out for a beer, a San Miguel, which everyone in Manila calls a “ladies’ beer,” probably because it’s so light. I enjoyed the ladies’ beer, the massage, the lowest-price shopping, and the elves and the two-story-high fake Christmas tree. This was not a running trip, perhaps for the best.

A first-time run in Manila and rule No. 18

The flight here was horrendous. Thirty hours door-to-door. One 16-hour flight in the middle, during which both of my legs cramped up. It meant I was really looking forward to my run this morning in Manila.

I’m staying at the Makati Shangri-La, a five-star hotel surrounded by malls on all sides. There’s a triangular-shaped park a few blocks away – I can see it from my 14^th floor room. It doesn’t look so big, but it may be my best bet. A doorman pointed me in the right direction and also talked about going into a neighborhood “past the park.”

                

That’s the trouble, and the opportunity, when it comes to running in a place for the first time. I have been to Manila once before, in 2008, but I stayed in a section of town along the bay, about five or six miles away. It might as well be another country for this city of 12 million.

At first light, about 6 a.m., I found the park easily and started running around it. It took me seven minutes for the first lap. That meant it was too small. I want to run 40 to 50 minutes a day here, and I can’t imagine running around this park six or seven times a day. It’s leafy, it doesn’t have any traffic, but who wants to run in circles?

                

So after two trips around, I branched out.  I crossed a busy road for a smaller one and ran straight for a  half mile until I came to a line of cars waiting to get into a gated community. I ran past the guards without saying a word, appearing like I was staying at the place. That’s one of my rules of running, No. 18: Never ask permission to go into a gated establishment unless a) It’s an African game park; b) it’s a military installation; or c) You are in a country run by a dictator.

This was none of the above, and I had found a small version of running heaven in the middle of  a crowded humid city. I ran along the perimeter, passing large homes, men sweeping the streets with long-handled, heavy-straw brooms, and an occasional walker. One walker, an Aussie, was kind enough to tell me how to stay on the perimeter all the way along by talking a tiny alleyway that led to a bridge that led to a small pass-through, and then, he said, I would be able to run 2.5 kilometers (about a 1.6 miles) around. 

The run took me 45 minutes. I arrived drenched in sweat at my five-star hotel, found some free tea by the front desk, and hustled to my room. For a first-time run in a city, it was top-rate. I wouldn’t be running in seven circles every morning. I had found my gated community – not quite like my inner self, but not bad.

               

An oasis in Nairobi

After spending a few days in western Kenya on a trip for a group that advocates for more global health research, I returned to Nairobi last night for just 24 hours. I went out with some friends to dinner and a nightclub, where we saw things we had never seen before. There was dancing that left little to the imagination, a big woman who gyrated her hips in such wide circles we were awestruck, and gumby-like men dancing with gumby-like women.

I didn’t expect to run this morning. But I did, joined by my colleague Michelle and her friend Natasia. The day was beautiful. Blue skies, 70 degrees, a light breeze. We drove to an oasis in the middle of the city, the Arboretum. 

Nairobi is traffic hell. A six mile ride can take two to three hours.  Buses and minibuses emit black smoke. But in the midst of these horrible road scenes is a protected forest with dirt pathways. One path around the circumference is two kilometers, or about 1.25 miles.

We set off under a canopy of mostly eucalyptus trees, an invasive species brought in years ago from Australia. The path was wet clay and soon we were running with inch-thick mud caked to our running shoes. But it felt great to be in a forest in Nairobi, almost euphoric, and we went down hills and up hills and along a roaring brook.

A monkey ran in front of me and scampered up a tree. It joined a family of monkeys and they all looked down on us as we ran under them.   We ended up running four laps, eight kilometers or five miles. We saw several other monkeys, red birds, orange birds, yellow birds.

I had to get back and pack my things for the plane ride home. I’m taking chunks of Kenya with me, clay caked to the bottom of my shoes. I packed them in plastic bags, and know that when I clean them at home I will get a good whiff of a side of Nairobi that I didn't expect.

Hippo Point, and Kisumu's wildlife

Runners love routine. They may have a variety of routes, but most run just a handful. I think it’s because sticking to a routine means there’s one less thing to think about. And there’s a lot to think about on a run.

So running while traveling often adds a degree of difficulty; it means finding a new route. I just traveled to Kisumu, Kenya’s third largest city. It is in the western part of the nation, sitting on the shores of Lake Victoria. I had spent a few weeks in Kisumu a couple of years ago for research on my upcoming book, A Twist of Faith, and that meant I already had a running route.

I headed out to Hippo Point at first light. You can’t go earlier here. A motorcycle or bike or car or truck might hit you. There are also deep holes the size of car tires in the sidewalks. You could fall in and never crawl out. You can’t go much later either. Then the mixed traffic is a nightmare to navigate. Just when it seems safe a biker is flying right at you.

After a mile on the main road, I headed toward Lake Victoria. All downhill and dirt. My memories of the run started coming back to me: the old Sunrise Hotel, which now looked empty; large flowering bushes in front of large homes behind security walls; and the Kisumu Impala Park. A small herd of impalas, most with antlers, stood right by the fence and I stopped a few feet away. They were a little jumpy, but curious, too.

I ran around the park and came to the front gate, which was open, and I ran in a few yards. A sleepy park officer stopped me. He wouldn’t let me enter. The park has a leopard and a hyena in cages, and only the impala and a zebra or two wandering around. Next time.

Less than a mile down the road was Hippo Point. All the way, I ran through swarms of dragonflies. There were tens of thousands of them, hovering like helicopters about 15 feet in the air all the way to the ground. It felt almost like I was running inside a black cloud of insects. They maneuvered around me, not touching me once. I didn’t enjoy it, though.

At the point, hippos are said to come into the shore here, but I did see any. Instead, several fishermen readied their boats, and two gigantic black ibises cried out high in one tree.

The run is an out-and-back, and so I ran through the army of dragonflies, past the beautiful impala, up the hill, and on to the main road, where I avoided bikes, motorcycles, cars, trucks and large holes in the sidewalk. All is well in Kisumu.

Birthday run in Kenya: Crows and first steps

I turned 52 today. I arrived in Nairobi after a 19-hour flight from Washington. After I walked into my hotel room in downtown Nairobi, I laid down on my bed and surrendered. I slept for two hours, and knew I had to get up. It was late afternoon. I had to run.

Birthdays are important and birthday runs must happen without exception. There is something in the joy about being able to run, period. There is something about staying fit, no matter your age. But best of all, there are the sight aches and pains in legs and joints afterward that remind you that nothing happens without effort.

I ran to an old Nairobi standby: the Nairobi Club, an institution that started in 1901 and still has the feel of being in a place at the turn of the 20th century. You can almost imagine British colonial aristocracy sitting on chairs around the edge of a large green, oval-shaped field, politely cheering on the cricket teams.

Around and around the field I went, eight times in all, two minutes, 30 seconds a lap. African crows swooped over my head. A family of olive thrushes hunted for food nearby. The most impressive sight, though, was of a determined father and one-year-old son as the boy tried to walk on his own.

The boy had the look about him of a miniature Mr. T, the old TV show character. He was chunky for a one-year old, and his hair was cut in Mr. T's trademark thick Mohawk fashion.

Every lap I saw the boy walk a little farther. The father laughed and laughed, and encouraged him with each step. He even smoothed out the bumpy grass a half-step ahead of the boy. Still, the boy keep tipping, sprawling, nose-diving into the grass. Still, he pulled himself up and kept trying. He even laughed at his falls. I couldn't tell who was more determined: father or son. It made me think back to earlier birthdays, my 33rd, 36th, and 38th, when we had one-year-olds learning to walk and how completely astounding that whole experience was.

There were some parallel moments today on the Nairobi Club's cricket fields: a boy learning to walk, a birthday boy shuffling around him. A boy taking all the time in the world to learn to walk, a birthday boy taking forever to complete a few laps. It brought back memories of earlier time when first steps were the most glorious thing in the world.

A prayer for Stella

One of my favorite runs in the world – on par with running on tiny bridges over the Nile or on paths deep in the Vermont woods – is Central Park. And the best time to run it is fall.

It’s especially true on a morning like this: 54 degrees at 7 a.m., clear blue sky, a hint of a breeze, sun lighting up the Dakota building like a front-lit pearl.

I’m staying in a hotel on Park Avenue, around 38^th Street, which is a little far to do my regular Central Park loop, which takes me around the reservoir, up to 96^th Street area or so, and then back again. But I did it this morning, even with a late-ish 7 a.m. start. It required more dodging than normal, especially on the return, but the run was not too cold, not too warm, just right. And with the sun lighting up the NYC midtown skyscrapers, I felt I could have stopped for 10 minutes and just stared.

But I kept going – around the reservoir, around a loop in the park, out of the park down 5^th Avenue, until I came to the St. Patrick’s Cathedral. I decided I should poke my head in. It’s a magnificent gothic structure and very quiet at 8 a.m. on a Monday. I wandered down one side of the church and came to an area for Polish saints, which had rows of lit and unlit candles in front of beautiful old drawings of the saints.

I am a lapsed Catholic, but I do remember the importance of lighting a candle and saying a prayer for a loved one, or a departed loved one. I immediately thought of my wonderful neighbor, Stella Donovan, who had a bad fall several months ago, breaking her upper fibula, near her hip. She has only been home for short periods since and it’s unclear whether she will move back into her home full-time.

So I said a prayer for Stella, and I took one of those long wooden sticks (skinnier than a chop stick) to light a candle for her. It was easy to light the stick, but I dipped it into each candle holder without any luck. It turned out that there was either no more wax in the holders or that the wick was buried in the wax. I didn’t really want to dig into any of the candles, so I stood on my tippy-toes, and did some candle hunting.

In the meantime, a priest started saying Mass. I was on my second fire stick. I was a little concerned I would have one of those Inspector Clouseau moments when I would reach, reach, reach, and tip over the whole box of candles, setting curtains ablaze, or something like that. Luckily, I found one holder with a teeny wick and a teeny pool of wax, and I got a little fire going. I said another short prayer for Stella and then I was off, stiff-legged down 5^th Avenue, happy to have an unexpected moment to think about someone I loved.