42 GOATS

42 GOATS


E.E. Freeman, MD PhD



We pull over on the dusty track. The health technician opens her door. I look around expectantly, but all I see are a few cacti. She points up the scree slope, and I see a small goat track winding it’s way through the cacti. I follow her up the hill, a thirty minute scramble between rocks and shrubs, and then suddenly we pop onto a plateau, and there is a long mud hut, a roof of sticks, a small garden, and a goat pen.



An old man, wool cap and rubber boots in place, is lying on a sheep skin next to the hut, looking out over the valley. He does not see us, so we call out to him, but he does not hear, and remains still, pondering his view.



And suddenly there are kids, and dogs, and hubbub. “Welcome, welcome,” a tiny shrunken woman hidden behind years of wrinkles greets us. “This is the doctora, she comes from the University to check on the uta [common name for Leishmaniasis],” the health technician explains. “Well well,” the old lady replies, “we have plenty of that here. You are most welcome.” She gestures at a vacant spot on a sheepskin. She lines up her grandchildren, each of them with large scars across their faces. “We all have uta here,” she explains. “Even me - ” she gestures at a scar on the tip of her nose. “All of my children, all of my grandchildren, they have had the uta.” One of the young boys, the only one with red, active ulcers, has a thick white cream on his cheek. “What is that?” I ask. “Egg white to help with the swelling,” his grandmother replies. The health technician chimes in, “this little on was treated at the university three times, but he failed treatment. We are out of ideas, and his mother is sick of trying to bring him down to Lima when nothing helps.”



What is it about this place, that every single member of the family has been affected by leishmaniasis? The grandmother is more than happy to show me around. She shows me her garden, her favorite herbs she uses on the children’s faces to help with their wounds, her many goats, 42 to be precise. I look at their dogs, hosts for the leishmania parasite, checking their noses and their fur. I am still without an answer, other than that this farm must be the perfect combination of elevation, plant, and animal life for both the sandly and the leishmania parasite to thrive.



After my walk around the farm I return to the sheepskin. The old man sits next to me. He’s been deaf for allegedly two months, though I guess it is longer. The local health technician started him on ampicillin, just in case it’s from an ear infection. A bilateral ear infection in an elderly man with no other symptoms? Instead I talk to the old man about getting his hearing tested, maybe getting evaluated in the city, but he grins and shakes his head.



“How old are you?” I probe.

“Six grandchildren!” he motions across the sheepskin proudly, grinning.

“No, you deaf fool! How OLD are you? How OLD? That is what the doctor is asking!” his wife yells.

“I’m a deaf fool? You can barely see!” he shakes his fist at her, her eyes cloudy from cataracts.

“What can I do with him, what can I do,” she shakes her head, not unkindly.



His children came for him one day, up from Lima in a car, which is a feat in and of itself, to bring him down to the hospital for an exam, but he refused to go. “I’m 81, why would I go to Lima? I’m old, I’m meant to die here. No need to waste anything on me. I don’t have too many years left.” So he stayed. She was scheduled to have her cataract surgery done in Lima, but she heard about a woman across the valley who went blind after eye surgery. “It’s safer not to.” So she stayed. And here they sit, on their farm infested with sandflies, with a beautiful view across the Andes and their 42 goats.



My biology student hands me a pad and a pen. “You should write it down. They’ll listen to you. You’re a foreigner and a doctor.” I write in huge letters in Spanish: “GO TO LIMA FOR TREATMENT.” They laugh at me, and I laugh with them. They will be sitting here on their sheepskins, of that I am sure, watching the clouds roll in, tending to their farm, until death comes to take them. It does not matter what I write.

Utilization of empiric treatment for leishmaniasis in endemic communities of Peru

LEARNING LOCAL
E.E. Freeman MD PhD



I do speak Spanish. Or so I thought, until I tried explaining my purpose here in Peru to my taxi driver on the tortous drive between Lima's airport and my apartment. "I work with leishmaniasis," I explained in my best Peruvian Spanish accent, "from the bite of a sand fly." He stared at me blankly. Perhaps I was not pronouncing leishmaniasis correctly. "LeishmanIASIS?" Nothing. "LEISHmaniasis?" Still nothing. "LeishMANiasis?" Nope. "Well, it's a parasite transmitted by the bite of a sand fly. We don't have it here in Lima. It's at higher altitudes." That would have to do. Perhaps he'd never heard of it? I found that slightly hard to believe, given the high prevalence rates of Leishmaniasis in Peru, and given that most Limenos travelled into the sierra (mountains) or selva (jungle) at least at some point, whether to visit family or at least touristically. There was, of course, the more likely possibility that in common parlance Leishmaniasis had another name. I would have to wait until clinic tomorrow to figure that one out.



"Uta," as I later discovered, was my missing word. Uta, derived from the phrase "the bite of the rat," presumably because the ulcers can look like animal bites, comes in two forms. Wet uta is an ulcer from leishmaniasis, whereas dry uta is a flat lesion from an inject bite without parasitic involvement. Now, when people ask why I'm here, I explain that my research is on La Uta. This is followed by an instant flash of recognition, and stories about family members or friends who have had uta, and what they did to treat these notoriously difficult ulcers.



Tomorrow I head into the field, to visit endemic communities affected by uta. I'll be visiting patients in one of the Leishmaniasis Research Group's phase II clinical trials, as well as gathering background information for future investigations on empiric treatment of Leishmaniasis with battery acid, hot chili peppers, and the like (an unfortunately common practice). The plan is to sleep on the health center floors in these remote communities, visiting our patients during the day when the sand flies themselves are at their least active, trying to minimize our own risk.



I'm in charge of packing for the expedition, which includes our driver, a Peruvian physician, a Peruvian biology student, and myself. The medical supplies didn't worry me. I already had our Leishmansis smear slides, lancets, and gloves packed up. "There's no where to buy food up there," warned my Peruvian physician friend. "So make sure you pack enough food for everyone for several days. You never know when you'll get trapped by a river. Our driver likes coffee and eggs, otherwise he'll get grumpy. Oh, and don't forget a small food token of appreciation for the nurses in the rural health posts that will be hosting us." My confusion must have been obvious. "Marshmallows!" she chuckled. "They love marshmallows!"



Local knowledge triumphs again. Off I go, several bags of marshmallows tucked into my backpack, to study "the bite of the rat."