“Si, claro, Señor.”
Summoning up her not-yet-fluent Spanish, Susan asked Maria when she could start.
“Tomorrow. And I will take you to market in the morning. What time shall I arrive?”
“Nine o’clock,” said Susan. “We will try you for two weeks. Then, if all is satisfactory, you may continue. But if things are not going well in the first two weeks, you will have to leave.”
“I understand,” said Maria.
Maria would arrive promptly in the morning, and Susan would have her first experience shopping in the large central market of La Paz.
Our newly rented house looked out across the La Paz River. Across the valley spectacular red stone needles rose behind a few eucalyptus trees. The sight reminded Susan and me of Bryce Canyon in Utah, but on a smaller scale. And without the pine forests that surround Bryce; eucalyptus and sycamore trees are the only ones that survive at the above-tree-line altitude of La Paz.
That evening we enjoyed dinner with Gonzalo at a nearby chifa—a Chinese restaurant. Chinese food is the same all over the world, and it was an anchor point for Alice and Eric as they settled into life in La Paz. Later they would attend and make friends at the American Cooperative School.
We had arrived. We had made our initial altitude adjustment. We had found a place to live. We had connected with very helpful Gonzalo. We had hired Maria. Challenges and adjustments loomed, but we had no doubt that we would manage them. Life in Bolivia would be different from life in Cleveland Heights. Different, frequently surprising, sometimes challenging, always rewarding.
As dark descended into the valley of La Paz, Susan and I lay in bed, arms around each other, bodies together. “What do you think?” I whispered.
“I think this is great!”
8
“Buenos Días ¿Cómo te va?” Gonzalo greeted me. “How are you?” It was Monday morning about 9:30. I had arrived at the Instituto de Torax, and I was ready to get started on the projects I had planned for my year of working with Gonzalo in Bolivia.
“Yes,” I replied. “Buenos días.” Then I added, “Thanks so much for helping us get moved in. I think the house in Obrajes will be perfect for us. And weren’t we lucky to find Maria? Or for Maria to find us?”
“I think so,” said Gonzalo. “Bolivia is a poor country, and there are lots of people seeking work.
“Now we have some important things to do this morning,” Gonzalo continued.
“Good,” I said. “Let’s get to it. We need to make some specific plans.”
“Hold on.” American vernacular English came easily to Gonzalo after his year with me in Cleveland. “There are approvals we must get.”
“I thought you had done that. I thought all of our protocols had been approved.”
“Yes, they have been. But the important people have not met you. Until they meet you and approve of you, we cannot get started. You have to forget that you are an American. This is Bolivia. Personal contact means everything.”
“Okay. So how do we go about this? And whom do I need to meet?”
“Well, you have to call on people. Courtesy calls, as much as anything. There should be no problems, but we must jump through the various hoops. Did you bring your CV?”
“Yes, I have three copies here with me, and also copies of my diplomas and board certification certificates.”
“Good. If we need to, there’s a kiosk down the street where we can get additional copies made. So let’s start with the Director here at the Torax. Dr. Gomez. A fine man. You met him when you were here earlier. He asked about your arrival, and he wants to see you.”
“Yes, I remember him. When can we see him? Do you think we can find him now?
“That should be no problem.”
We had a pleasant chat over coffee with Dr. Gomez. I outlined our research plans. He had received copies of all of our protocols, which he might or might not have read. His English was marginal, so I tried to explain my ideas as best I could to someone who knew very little immunology. But he knew much about tuberculosis, and found my goals appropriate, if a bit ambitious, perhaps. He offered cooperation, and reassured us that the Torax radiology staff would be available to take chest films of those individuals for whom we might need them. He asked me to give a few lectures on tuberculosis to his staff and students during their rotations at the Torax. “Of course,” I said.
I doubted that there was much about clinical tuberculosis that I could say to the staff at the Torax. They could teach me, I knew. As for the medical students, Gonzalo told me that junior students in the medical school had an entire semester focused on tuberculosis and other chest diseases. During that semester, they had three hours of lecture each week while spending the rest of their time on the wards of the Torax and the pulmonary services of the adjacent Hospital de Clinicas.
We then set off next to INLASA, the Instituto Nacional de Laboratorios de Salúd (National Institute of Health Laboratories). This institute housed the national tuberculosis reference microbiology laboratory. We planned to collaborate with the laboratory, and Gonzalo had enlisted Dra. Juliana Perez, INLASA’s director, as a coinvestigator in our work. It would be important that the diagnosis of tuberculosis be confirmed by sputum smears and cultures. Juliana Perez was not only a competent bacteriologist but also an effective laboratory director. As with Dr. Gomez, I had met her—indeed had become friends with her—on an earlier trip to Bolivia. She was an attractive and intelligent woman. Her husband was an endocrinologist and one of Bolivia’s most highly thought-of physicians. Her son was a medical student.
Some of our proposed studies would involve cell cultures. Maintaining sterility and careful technique were critical to success in such endeavors. Work of that sort had never been done in La Paz, but I was confident the facilities at INLASA were adequate for our studies.
We found Juliana Perez in the tuberculosis bacteriology laboratory hovered over a microscope, reviewing sputum smears with her technicians. This laboratory, which was devoted to the bacteriology of tuberculosis, was clearly the largest laboratory in the building. That so much space was devoted to tuberculosis reflected the realities of infectious disease in Bolivia. She walked toward us and greeted us warmly.
Juliana Perez was enthusiastic about collaborating with us. She introduced us to all of the technicians working in her laboratory. Some of them would be helping us with our upcoming studies. We spent an hour and a half with her, and I left feeling that the bacteriology part of our research efforts would be in good hands. More than that, I felt comfortable with the idea of introducing cell-culture work into that setting.
It was shortly after noon when we left INLASA. Gonzalo and I walked down the street and found a small restaurant. Later I would pack lunches before setting out in the morning, but our household was not yet ready for me to do that. I ordered two salteñas and a Coke. Salteñas are the Bolivian version of small meat pies that are samosas in East Africa and pasties in Michigan’s Upper Peninsula. Gonzalo ordered the menú—the fixed-price meal. Like most Bolivians, he was accustomed to eating the largest meal of his day at midday.
After lunch we returned to Gonzalo’s office. We next planned to visit the dean of the medical school—the Facultad de Medicina de la Universidad Mayor de San Andrés. He would surely not return from his noon meal until 2:00 or a bit later. We passed the time chatting, largely reminiscing about Gonzalo’s year in Cleveland.
We set out walking through the large Hospital de Clínicas, the general hospital of La Paz, and then crossed Avenida Savedra to the nine-story medical school building. The dean’s office was on the fourth floor; s sign at the door of the single elevator told us it was not working, so we walked up the stairs. An attractive young secretary put aside her nail file to ask our names and the purpose of our visit. Gonzalo replied to her in Spanish too rapid for me to follow. But I did understand that he was introducing me as an important professor visiting from the United States. Soon we were seated in the office of Profesor Doctor Eman
uel Rodrigo, the dean.
Gonzalo introduced me, and I presented copies of my CV, diplomas, and certificates. He glanced at them and added them to the large pile of papers on his desk. “We are honored to have a distinguished ‘profesor catedratico’ here with us in La Paz,” the dean told me. “I understand you will be spending a year with us.”
“Yes,” I said. “Dr. Mamani has been an outstanding collaborator and coinvestigator. I am fortunate to have been able to work with him in the past, and I look forward to continuing our collaboration. Also, the scientists I have met at the Torax and INLASA are exceptional persons. I look forward to working with them.”
“Dr. Mamani has told me that you will be giving some lectures on tuberculosis at the Torax.”
“Yes,” I said. In fact Gonzalo and I had not had such discussions, although I expected it, and Dr. Gomez had made it clear that he wanted me to do so.
“And you lecture in Spanish?”
“As well as I can. And you can see for yourself that my Spanish is poor.”
“Not at all. You speak very well. Certainly better than I could do in English.” He shifted to English for that statement.
“You do not do yourself justice,” I said. “I think you are more fluent than you credit yourself.”
“Well now,” the dean continued, “I understand you are an immunologist.”
“Yes, of sorts, although my primary specialty is pulmonary disease. But my laboratory work has carried me into the field of immunology.”
“Good. I want you to give a short course in immunology to our medical students. That field is sadly lacking from our curriculum. You should give a set of maybe six lectures. Teach our students the fundamentals of that important discipline. Our students need to know the science that underlies the pathology of diseases they will encounter and how that might affect the treatments they will offer.”
“I can do that,” I said. “I will need some time to prepare.”
“This is July. You should start in September. My secretary will arrange the schedule.”
Dean Rodrigo rose from his chair and offered his hand. Our meeting was over. After offering our thanks profusely, Gonzalo and I departed. “Well,” said my friend, “that’s a bit of good fortune. Your willingness to give a course—and the fact that he invited you to do so—have guaranteed us a free and clear path to carry out our studies.”
“I’ll need some help getting lectures into Spanish.”
“No you won’t. But if you do, I’ll help.”
We made our way down the stairs and out to the street. “That’s it for today,” Gonzalo said. “We have an appointment at the Ministry of Health tomorrow morning at ten. How about I pick you up about nine-fifteen? We should not be late.”
“Fine.”
“Can I drive you home?” Gonzalo offered.
“No. I think I’ll walk.”
“Are you sure you’re up to it?”
“Yes, I’m fine,” I replied.
“Okay, then. Tomorrow at nine-fifteen. No, make it nine o’clock.”
“Good.”
I turned and started down Avenida Savedra. Soon it wound its way steeply down to Obrajes. Trash lined the street. I walked past a wall upon which had been painted, “No vote basura.” Well, I thought, that represents Bolivia in a couple of ways. Votar is the Spanish verb to vote. Botar the verb to discard or throw away. Basura is trash. In Spanish, as spoken in Bolivia, there is no distinction between the pronunciations of b and v. So this might have been a political statement or a futile attempt to keep Paceños from dumping trash.
I turned up Calle Cuatro and arrived home—our new home, our Bolivian home. I opened the door to be greeted by the aroma of freshly baked bread. “Hey, Dad,” enthused Alice. “Maria baked bread. It’s great. Have some. She made small loaves. ‘Pancitos,’ she called them.”
I took the bread Alice offered; it was delicious. Then I told Susan about my encounters of the day.
Over dinner I learned about the market trip led by Maria. Alice and Eric found it exciting. “We bargained all the time. And most of the caseras—vendors—that Maria knew gave us ñapas—extras,” Alice reported. She was clearly pleased that she had learned two new words that had not been part of her Cleveland Heights Spanish lessons.
Susan had more to say about the market experience. “There was dirty water running in gutters, and the fruit and vegetable ladies were sprinkling it on their produce to keep it looking fresh. I’ve put what we bought into iodine water to soak, and we should carefully peel anything we don’t cook. I bought some ground beef for hamburgers. It looks awfully lean. I might have to put fat in the pan to cook it! You know,” she continued, “buying the meat was different. There was no bargaining over the price. However, Maria haggled and haggled about how many bones we had to take. Obviously, we don’t want bones with hamburger. But they added to the weight, and we would pay by the pound—kilo, I guess. This is going to take some getting used to, but I’m sure we’ll figure it out and that I will manage marketing.”
“Yep, I’m sure you will.”
Now adjusted to altitude, we all slept well that night. Altitude adjustment is a two-phase matter, I knew. The first part involves adjusting one’s breathing so that one is no longer hyperventilating and getting rid of too much carbon dioxide. Blowing off carbon dioxide leads to changes in pH (acidity) in the body. One’s tissues, especially the brain, tolerate that change poorly, and soroche results. That first phase of adjustment usually takes about thirty-six hours. The second aspect of adaptation to altitude involves increasing the oxygen-carrying capacity of one’s red blood cells. Partly this is done by increasing their number. Additionally, changes in cell enzymes make red blood cells more efficient in carrying oxygen and transferring it to tissues. Those adjustments take a few weeks.
Gonzalo arrived in his van in the morning promptly at 9:00, and we headed up into town to the Ministry of Health. After warming a bench until about 10:30 we were ushered into the minister’s office. He was a pleasant man, a physician, an obstetrician, an expert in neither public health nor any of the major health problems of Bolivia. Politically well connected, I supposed. But he seemed genuinely interested in the health problems of Bolivia, at least insofar as I could judge in this brief meeting. He sipped on a mate de coca from time to time. (A mate is a small pot typically containing an herbal tea.) Gonzalo reported to him on our meetings of the previous day. He nodded and then welcomed me to Bolivia. Fifteen minutes later we were again outside and walking to Gonzalo’s van.
“You’ve passed,” Gonzalo said. “We’re all set. We can begin. Well, not quite. We have one more hurdle. We need to clear things with the military.”
“Have you made contacts there?” I asked.
“Yes, but you need to get their approval. Our person there is Col. Alberto Surez. He’s a good man, I think. He seems generally interested in the project. And he is well enough positioned to assure that everything will go smoothly for us.”
“Okay, let’s go.”
The army’s general headquarters—the cuartel general—was located just down the street from the medical center. We presented ourselves to the soldier stationed at the entrance and soon were ushered inside. We passed what looked like a World War II tank. “Bolivia’s tank corps,” Gonzalo said softly. Soon we were seated in the colonel’s spacious attractively appointed office. We explained our proposed studies, repeating what Gonzalo had told the colonel earlier. He asked a few questions and then told us he would be glad to help in any way he could.
“At last we can begin,” I told Gonzalo as we left.
“Right. And let’s hope the work goes as smoothly as all these approvals did.”
9
What were the studies Gonzalo and I had planned and hoped to carry out during my year in Bolivia? They fell into two categories. First, I had ideas for simple, rapid tests for the diagnosis of tuberculosis—tests that could be carried out easily by minimally trained people and that would not require a labora
tory. I thought we could find break-down products of tubercle bacilli in the urine of patients with TB. The amounts would be tiny—miniscule—but finding tiny amounts was one of the strengths of immunoassays. And immunoassays were what I was good at. If one could develop a urine test recognizing tuberculosis that was as reliable as a microscope-dependent sputum examination, it would greatly simplify the diagnosis and management of TB in remote areas such as those of Bolivia. And in many of these remote areas of Bolivia and similar remote areas in other parts of the world, tuberculosis was rampant.
Immunoassays can be done in a variety of ways. I thought I could set up one on a strip of paper-like cellulose acetate that could be dipped into urine. If the immunoassay found products of tubercle bacilli, a color would develop. Color, tuberculosis; no color, no tuberculosis.
Back in the Wearn Building I had put Jennifer to the task. She and I had made repeated experiments with the detection of small amounts of tubercle bacilli products, and had been pleased with our results. We had inoculated rabbits and mice, and we were pleased to have success with our assay in their urine. Going on from that, we had had success in testing the urine of four tuberculosis patients in Cleveland and some healthy medical students. The time had come to take our assay to Bolivia.
Gonzalo and I planned to try out this test in Bolivian soldiers, and that would mean continuing to collaborate with Colonel Suarez. Employment for young men in Bolivia was hard to come by. Enlistment in the army was popular among Bolivian men after finishing secondary school. Health screening of recruits was cursory, and young men seeking to enlist were highly motivated not to disclose any symptoms of illness. Moreover, it is the nature of tuberculosis to have its peak incidence among young adults, especially so in high-prevalence areas.
We planned to try the simple test on a company of soldiers, and then bus them to the Torax for chest X-ray examinations to determine if they had tuberculosis. Based on what we knew of tuberculosis in Bolivia, we thought we would find many soldiers harboring TB—at least five percent, maybe ten percent. Gonzalo and I were enthusiastic about this study. We felt its results might be of considerable importance. We felt we could do this study quite easily with no more than an ordinary collection of unanticipated problems.
Escape Through the Andes Page 4