Medical letter: Rabies!

There has been an unexpected development in our town -- and outbreak of rabies among livestock.  Apparently there have been rabid dogs here before, but this is the first time that cows and horses have been affected.  It is a type of "paralytic" rabies, as opposed to the kind of rabies that we usually think of, where animals become aggressive and run around biting people and other animals.  Several families have had cows and horses die recently of the same kind of illness -- their legs become uncoordinated and they look "drunk," then over the course of a few days they fall to the ground and can't get up.  As the disease progresses upward in their bodies. they get spasms in their throat muscles and become unable to swallow, which is what causes the "foaming at the mouth" and water phobia that we normally think of in rabies cases.  Then the animals die.

The problem is in what comes next.  Because cows and horses are so big and heavy, if they lie down and die in a field, people often just leave them there and don't bury them.  Vultures and street dogs come and eat the meat, and people sometimes eat the meat as well, not knowing that it is a rabid animal.  People here are trying to make ends meet, and a farm animal represents a big financial investment -- so it is financially a very big deal for a family lose a cow, and many people feel like with that kind of a loss, they might as well feed their family with the meat.  If people butcher the animals, they come into contact with all kinds of infected body fluids.  I am also told that if the owner of the cow pays a couple of guys to butcher a cow, they often pay the guys with the cow's head (which people will eat).  Since rabies concentrates in the brain, handling or eating the brain of a rabid animal is the worst thing you can do.

There are also vampire bats here, which are probably the reservoir of the rabies virus.  Bats tend to be natural carriers of rabies, but they are somehow unaffected by it and don't die from it.  The bats come and bite the farm animals at night, which is very likely how the animals got rabies -- and they can bite people as well, though less often.  Apparently their bite is barely detectable, like getting pricked with a needle.

It has been interesting -- and heartening -- to watch the community and government response to this situation.  Once the local vet started to suspect rabies, the heads of two of the affected animals were sent to a lab (apparently all the way to Quito) to confirm the rabies cases.  Meanwhile, still waiting for the results, the local public health center got on top of contacting the affected families to start rabies prophylaxis treatment for the highest risk family members.  Once the cases were confirmed, the Ministry of Agriculture sent representatives out to hold a town meeting to educate the local livestock owners about rabies, what to look for, and what to do.  They sent out a mobile veterinary unit to start vaccinating all the animals in the area, and I suspect they were also investigating new cases.

With regard to dogs, the government has apparently been good about coming out and offering people free (but voluntary) rabies vaccines for their dogs once or twice a year (though not livestock, until now).  So most of the dogs that people actually own as pets are vaccinated.  However, there has been this big cadre of skinny street dogs in town that clearly are not owned by anybody.  Amazingly, they are just about gone, overnight.  The government workers must have come to round them up, or to feed them strychnine (we hear this is what they have done in the past).  Just like that, the streets are less crowded and noisy, and there are about 80% fewer dogs on the street that there used to be.  I feel bad for those pups, but in this situation, they really are a public health hazard.  To me, the human lives are more important.

So what do you do about bats?  We hear that one night the Ministry of Agriculture folks took a bunch of cows and put them in a circle in a field, and covered them with netting.  The bats came to bite the cows at night and got stuck in the nets.  They then captured the bats, painted some kind of poison on their backs, and let them fly back to their lair.  Apparently the bats lick each other, and so the other bats lick the poison off the previously captured bats -- each one can eradicate about 12-15 other bats. To they are reducing (though not eliminating) the bat population as well, in an attempt to control this rabies outbreak.

How does all of this affect us?  So far, not that much.  We are not eating any beef or red meat at the moment, and we are not touching the animals (including beloved Aspen the horse, who seems perfectly fine, but you never know).  We have not had any physical contact with sick animals, so we don't need rabies prophylaxis vaccines -- and hopefully it will stay that way!  We are just doing our best to stay out of harm's way.

Weekend outings

For the past couple of weekends we have ventured out to do some new things.  Much like at home, the weeks just go by in a blur of school and work unless you do things to mark the time.

Last Saturday we spent a little time watching a local women's soccer game.  In a Latino country where the men seem to dominate the sport, it was encouraging to see the ladies out there giving it their all!  Alas, shortly after this short was taken there was a big downpour, so I think their match was rained out.

That day (about 9 days ago) was the last day of rain we had -- we are having a hot and dry spell now.  (I suspect this is pretty different from what the folks back home are experiencing.)  So the next day we decided to try to combine our weekly grocery shopping outing with a trip to a swimming pool -- and we found an awesome one!  It's called Hosteria El Arenal, about halfway between Guadalupe and the city of Zamora, where we grocery shop.  We have figured out that we can take the bus there in about 20 minutes or so.

Emmett quickly figured out how to relax.

Annalise quickly figured out how to splash him.

This place has good food and cold beer (for the grown ups), and even a functional water slide!  Fun for the whole family.  This place definitely has potential for future weekend getaways.

The kids had an awesome time.  They are working hard, trying to get used to their new school and learning Spanish -- so they deserved some real fun.

This past weekend we went further afield, to a town called Vilcabamba.  John's birthday is this week, so we thought we would have an actual getaway and explore the area a little more.  It took us about 5 hours to get there on multiple buses.   We stayed at a place called Hosteria Izhcayluma, which is run by some Germans, and is crawling with tourists from Europe, Australia and the US.  It was kind of a trip to walk in and see so many white faces!  All the staff there are multilingual so we didn't even really have to speak Spanish (though we mostly did).

Vilcabamba is in a valley south of the city of Loja, and is itself home to many expatriates who are apparently attracted there by the really nice climate (warm and dry, but not too hot).  It's kind of a funny enclave of bohemian, yoga and meditation oriented folks -- as opposed to most of Ecuador which is very Catholic and homogeneous in its religious practices.  For example, the church in the middle of Vilcabamba is very prominent on the town square, as is the case in most Ecuadorean towns.

But then we saw this mural of the Buddha on the wall of the Vilcabamba Meditation Center (the first time we have seen any such thing in Ecuador).

The hotel itself is a really nice place, very relaxing, with hammocks everywhere.  The kids quickly disappeared into them, rarely to be seen again.

We did manage to get out for a nice hike, and saw some pretty countryside.  The climate in Vilcabamba is much drier than in Guadalupe, where it is greener and more humid.  It also reminded me of the hiking we have done in Western Washington, where the vegetation is SO different from here.

And last but not least, I think I may have found Dr. Pepper's long lost Latino cousin:

A foal is born...

Yesterday evening Kate and I went for a walk.   As we walked through the mission property we learned that a mare was giving birth.    I quickly retrieved Emmett and Annalise to witness this wonderful event.     We learned that the foal's legs were stuck and the mare required some hands on help from Clementina.    The clinic nurse, Amanda, told us that the foal needs to latch on to the mare for milk within an hour to survive.   This was the mare's first foal so this experience was a first for both horses and us.    The delivery occurred on a grassy hill which left the foal in a precarious position to maneuver herself to latch on.    Nature requires her to stand and find her way to the nipple on her own.   After watching the foal struggle in the high grass on slanted ground for 35 minutes, it finally latched on.  This morning the foal appeared vigorous and strong as you can see in the picture below.

Clementina watching the foal shortly after she had to reach in to the womb to help deliver the foal.  

This was a graphic introduction to the wonders of the afterbirth for Emmett and Annalise.   

Everyone had a front row seat.  

This morning the foal appeared vigorous and strong and the mare appeared to have recovered. 

Family members of the horse's owner inspected the foal this morning. 

A picture taken after dark shortly after the foal learned to stand and had not yet found the nipple to feed.  

   

Tales from the Clinic

My professional life working in the mission clinic is always unpredictable (I see as many people as show up that day, usually somewhere between 3 and 18 people), sometimes pretty mundane, and sometimes quite interesting.  The interesting moments can take many shapes and forms.  

This morning I saw a very cute, very old (89 yrs old) tiny Shuar indigenous woman in the clinic.  She walked slowly with a long walking stick, and I suspect she could barely see because she needed to take my hand to guide her into the exam room.  (Plus, she was wearing 2 different earrings, which I doubt was a purposeful fashion statement.)  This lady lives all by herself.  She had a couple of ailments, mainly related to arthritis -- people work incredibly hard here, and painful joints are very common.  I gave her a couple of prescriptions to help her feel better.  Later when I went by the clinic pharmacy to ask about something, I found out the old woman had paid for her medications with 2 baskets that she had woven.  The kind clinic staff had agreed to sell the baskets for $2 each to recuperate the cost of the medication.  Needless to say, I promptly bought both of them.

Another day, I saw a middle aged woman as a patient who struck me as a little strange almost at once. She had various complaints, one of which was a history of anemia that she said had never been treated. I saw in the electronic record that she had been seen for anemia in the clinic a while back.  It took me quite some time to sort out all of her various complaints.  We were able to get a quick estimate of her blood counts (a spun hematocrit, for those of you who "speak medical"), and sure enough she was a bit anemic.  The most common cause of anemia is iron deficiency, followed by vitamin B deficiency -- since I didn't have any way of determining what she needed, I prescribed her both iron and B vitamins, and recommended that she take both of them every day for 3 months.  Then she should come back and we could check if her anemia was better.  She seemed really happy with that plan.  When I went by the pharmacy later, nurse Amanda (who has been here for 15 years and knows everybody), told me that this lady bought a grand total of 4 iron pills.  No wonder her anemia never gets better...  Amanda also told me that this lady actually sells jars of snake oil out of her tote bag (a piece of a cut up snake in a jar of oil), and tries to get the patients to buy her snake oil (literally!) instead of buying their medicine from the pharmacy.  Even the kindly priest in charge of the mission has tried to chase her out of here.  Amanda also told me that this lady sometimes borrows young indigenous Shuar kids and takes them to the bus station to pass off as her own, to help generate sympathy and help her beg for money.  It takes all kinds, I guess.

One other really interesting and eye-opening case was a guy who was bit by a snake in his right arm about 5 months ago.  If you are easily grossed out, you might not want to read further.  This man was working out in the fields, and was bitten by a venomous snake.  He went to the local hospital 45 minutes away, where they shipped him to the bigger city hospital in Loja, about 2.5 hours away.  As best I could gather (there is really no way to get my hands on written medical records), the bite was infected and he stayed at the hospital for weeks on IV antibiotics.  They then shipped him to an even bigger hospital in a bigger city called Cuenca, about 2.5 hours further on from Loja.  There they did surgery to get rid of the infected tissue, and to do skin grafts over the open wounds.  He is still doing wound care treatments.  He came to see me because he cannot straighten out the fingers on his right hand at all -- he can close the fingers (grip), but he can't open them.  He has such a big divot out of his arm that I suspect the muscles that straighten out the fingers are mostly gone.  We are going to try get an MRI of his arm (which feels like a Hail Mary, as I have absolutely no idea how we are doing to get such a thing as an MRI from here) to see what is left.  It's a cautionary tale, for sure, and has given us an even healthier respect for staying away from snakes.

Who knows what tomorrow will bring -- that is true of family medicine in general, but particularly out here in the far reaches of South America.  

Everyone is invited to the annual fiesta honoring La Virgen de Guadelupe (the biggest party weekend of the year!)

Guadalupe: shopping destination

It has been a quiet week in Guadelupe.    Yesterday we travelled to Zamora for our weekly grocery  shopping.    Today is Sunday and we are relaxing before 11:30 mass.   Emmett will be reading at mass today, so we will arrive early for him to meet with Fr. Jorge to practice.    As usual in Gaudalupe, our neighbors awakened early today.  Roosters started crowing at dawn and our neighbor started hammering and using an electric saw at 7 am.    Now,  Latin rock music is playing in our neighborhood, which is a pleasant change.   Kate is shopping for fruit and baking ingredients.    In addition to the stores pictures below, many of the houses on the main street sell buns, candy, ice cream, snacks and some fruit and basic cooking supplies.    Later today Emmett and I likely will watch Gaudalupe's adult soccer teams play neighboring town teams on a large outdoor soccer field (mostly dirt with no seats for spectators)

Annalise winning a bet that she couldn't keep a spoon on her nose while tap dancing (gently) for more than 30 seconds

Neighborhood boys playing with a homemade cart in the concha.

mother and her colt across the street from our apartment

Guadalupe liquor store (which does not stock wine)

The woman who sells empanadas next to the concha which Annalise and Emmett frequently enjoy

tienda where we buy milk, eggs and pantry supplies

tienda/internet cafe where they sell some buns  and has a television for the occasional viewing of an Ecuador national team match

tienda where we buy much of our produce, meat and chicken.  

tienda where we buy ice cream and water jugs

Anniversary celebration at Inti Pakari school and Emmett's encounter with a toxic caterpillar

Emmett and Annalise's school, Inti Pakari, celebrated its 14th anniversary on Friday.   The day included dancing, singing and a sacred ceremony with burning incense and a blessing with oil.     Below is an opening circle of flowers, sugar cane and fruits, which was the focus of the ceremony.    To me, the ceremony recognized the blessings of our natural world and how we all belong to a holy and interdependent earth.  Speaking of interdependence and healing, Emmett encountered a toxic Giant Silkworm caterpillar.  As he was walking back from climbing a tree, his arm brushed up against a leaf with the caterpillar underneath.    He immediately felt pain on his arm and developed hives where the caterpillar touched him.   I had heard of these caterpillars, "Lonomia", which can be very dangerous with larger exposures due to their anticoagulant toxins.   Emmett had a stiff upper lip but clearly was in pain.   None of the adults seemed too alarmed about the incident.   Fortunately, one of the dads evidently knew about a local remedy for Emmett's exposure to the toxins.   He gathered the caterpillar and extracted a gelatinous green sack and rubbed it on Emmett's arm.  Emmett immediately felt better and the hives subsided. 

Annalise and schoolmates making noisemakers out of old bottle caps for the cultural dance 

A Saraguro elder at the school 

Many of the mothers and grandmothers helped cook lunch at the school

Emmett climbing a tree shortly before brushing up against a leaf with the giant silkworm caterpillar 

a local man extracted a green gelatinous sack out of the caterpillar to rub on Emmett's hives

The caterpillar, which was about three inches long. 

The ceremony at school. 

Annalise received a blessing of aromatic oil, which then she rubbed on her face. 

Cultural dance 

Annalise having soup with her classmates