Pictures!

The Dutch neighborhood in Potsdam, the first Western suburb of Berlin. It was part of East Germany, but since reunification has turned into *the* place to live outside Berlin, with large homes, miles of forests and lakes, and many young families. It has a "Dutch neighborhood" because it wanted to attract Dutch immigrants way back when, when the city was a mecca of European immigration. Potsdam was also the home of some Prussian kings (see below), housed part of the Berlin Wall, and is connected to Berlin by the Glienicke Bridge, where the US and Soviet Union traded spies during the Cold War. Additionally (just when you thought this city couldn't get more exciting!), there is a little Russian village within Potsdam, called Alexandrowka, which was built in 1825 for a group of Russian singers. Several houses are still standing, and some are even still owned by the descendants of the original owners. Sorry I didn't get a picture, I was in a moving vehicle, but you can see pictures of it here. It is very cool in person.

Nothing says "Ich liebe dich" like potatoes on your grave. (Disclaimer: This is the "tomb" of Frederick the Great, aka Old Fritz, aka The Potato King [I am not making this up]. It's his "tomb" because he was not actually buried here [though apparently he wanted to be]. He's supposed to be the reason potatoes are so widely eaten in Germany. I'll spare you the details of that scintillating tale.)

I went to see the Berlin Wall in situ, if you will (and I know you will), at a place called the East Side Gallery, where artists have painted a long stretch of the wall with different murals. I would probably put this up there as one of the top three things *not* to be missed in Berlin, even though I just made it out there at the end of my trip. The different murals, by artists all over the world, are so cool.

Munich, etc

Updates from chilly Deutschland. Things are good here, I'm actually learning a little German, which is exciting. I wanted to post a couple pictures, largely because I don't want to be out-vacation-blogged by Natalie, which I will be ultimately because she a) is in Spain, and b) takes fantastic pictures, but I can at least attempt to keep up while I'm here... :)

I spent the weekend in Munich, which was totally worth the 6-hour train ride to meet my friend Anna, who lives as far away from Berlin as possible while still being in Germany. Munich was equally out of the way for both of us, so it was perfect! I got to experience the "real" Germany (right, Anna??) by drinking a mug of beer the size of a small person, getting hit on by drunk foreign men, and eating pastries soaked in gooey cream and sugar. I tried to wrestle Anna into a Dirndl, but she's surprisingly strong and resisted. So I don't have any pictures of that, alas.

Munich Lions

Anna demonstrating my newest vocabulary word: Schweinshaxe (on a boar outside Munich's hunting and fishing museum). Yum.

This is the Brandenburger Tor (Brandenburg Gate) in Berlin. (I think this picture came out pretty well despite being taken on my phone.) The gate is a major symbol of Berlin, being involved in so much of its history. It was finished in 1791, and the statue on top (the Quadriga) was taken to Paris by Napoleon after a Prussian defeat in 1806. The gate was one of the only structures in the area to remain standing after Berlin was bombed in WWII. The Berlin wall was constructed just west of the gate, enclosing it in (Soviet) East Berlin. It's a pretty impressive structure. I'll try to get back there with a real camera one day. :) On of the things I like about Berlin is that it's so clearly still being rebuilt. The Wall only came down 20 years ago, and there are still areas along where it ran where there's nothing more than weed-strewn lots with nothing there yet. There also isn't that much architecture that is obviously old, like the Brandenburg Gate, like there is in Paris, for example. It's a major capital city that's still becoming itself, in a way.

The other side of Germany

This weekend I had the (un)fortunate opportunity to visit Dachau, the Nazis' first concentration camp, located near Munich, in south-eastern Germany, about a 6-hour train trip from Berlin. It was a freezing, gray day, which suited the visit just fine. As I was told before I went, it's worse in person than you can even imagine. They have made a GREAT museum in the main building. For more information, and pictures from the camp, go to wikipedia's entry on Dachau.

The entrance - "Work makes you free"

View of where the barracks once stood (they've all since been destroyed, but two have been rebuilt as part of the memorial and museum), from near the crematorium. (I'm not posting pictures of the crematorium or the "oven," they're too creepy and gross.)

Statue outside the main building. The English says (it's a big inscription, but hard to make out in the picture): "May the example of those who were exterminated here between 1933-1945 because they resisted Nazism help to unite the living for the defense of peace and freedom and in respect for their fellow men."

The story of how I went to the opera wearing purple cowboy boots (and other adventures)

Greetings from frigid Germany! (Note to Germans: it doesn’t matter how many times you tell me “this is the coldest winter we’ve ever had!” or, “Normally it’s spring by now!,” it doesn’t make me feel better about the weather, or make me not wish I’d brought my down coat. Thanks.) Anyhoo, thought I’d write a short update of my travels up to now. I now know a tiny bit of German, and that tiny bit includes phrases like, “My hobby is rollerskating,” and “Klaus-Otto is married,” and does not include useful phrases like, “I’d like a small coffee with milk please.” Ah, well, it’s nice to know beginning language courses are the same throughout the world. :) I spent my weekend going to operas (they’re already in German, yet they put up German supertitles; I guess I never appreciated the Met’s individual screens where you can choose your own language until now) and going to Leipzig. Leipzig is a city about an hour and fifteen minutes from Berlin by train, famous for being the home of, at one time or another, Mendelssohn, Mahler, Schumann, Wagner, and Bach, who conducted the choir of the St. Thomas church for almost 30 years; as well as a pretty interesting role in the reunification of Germany. Leipzig also, as I learned when I arrived, has adopted the wait-until-it-melts method of snow removal, which made my choice of weekend footwear (suede pumas, as there was no snow at all in Berlin when I left) particularly unfortunate, since I was soon up to my ankles in snow and slush. As it was too cold to walk around and take pictures, I went to a few museums, then heard a concert at Bach’s church, which was advertised as a concert, but actually was more of a service, with standing, praying, a sermon (literally the only words I understood were “snow” and “March,” but maybe that’s because I was subconciously listening for them), the Lord’s Prayer in German, etc. (which reminded me of the fact that one of the first phrases I learned in sign language was “In Jesus’s name we pray, amen.” For an atheist I seem to gravitate towards religion a lot.) The whole concert/sermon was quite lovely, but I felt a little bad about disrespecting Bach in his house of worship by having my shoes and socks off, but both were soaked and cold. Afterwards I was wandering around and noticed that the Leipzig opera was doing Lohengrin, and decided to get a student ticket; but decided I couldn’t spend 5 (five! Thanks, Wagner.) hours in an opera with freezing feet and soggy socks, so I decided to buy some new socks. BUT the shoe store was having a major winter boot sale, and they happened to have some kick-ass purple cowboy boots (that’s right) in my size, half off. They also had some practical, black, staid shoes, but why buy practical shoes when you can buy purple cowboy boots? (Note: sorry for knocking the usefulness of my German – the entire shoe-buying transaction was conducted with a sales clerk who spoke no English, which is good, right? Even though it was mostly numbers. But still!) So that’s how I ended up at the Leipzig opera, seeing Lohengrin in ratty jeans (sorry, older and distinguished Leipzig opera-goers, and sorry, mom, I know I should dress better) and the aforementioned purple cowboy boots. Which, now that I’m back in Berlin, you’d better believe I’m going to wear with panache. :)

Bach, presiding over his church

A chandelier I liked in the opera house

The organ inside the Thomaskirche

FAQ: Buruli ulcer

Today's Global Health topic: Buruli ulcer. What’s that, you say? Never heard of it before? It’s OK, that’s why it’s one of the World Health Organization’s Neglected Tropical Diseases (more on that below). So consider this a public service announcement of sorts about Buruli ulcers.

Q: What is a Buruli ulcer? (Warning: google image at your own risk)

A: It’s an infection of skin, soft tissue, and bone that is caused by a bacteria called Mycobacterium Ulcerans. Mycobacteria are a unique kind of bacteria, and cause other serious infections (M. tuberculosis causes (surprise!) tuberculosis, and M. leprae causes leprosy). It’s called a Buruli ulcer because of a large study done on it in Buruli, Uganda in the 1960’s.

Q: Can I get it?

A: You can only get infected if you live in tropical wetlands. It’s most commonly found in Africa, but it can be found pretty much everywhere in the world if the climate’s right (It used to be called a Bairnsdale ulcer after Bairnsdale, Australia). No one’s sure how people get infected exactly, but at the moment it’s thought that you have to get bitten by a bug that carries the bacteria in its salivary glands. Yum.

Q: What’s it do to you?

A: The bacteria get into your skin and make toxins that cause cell death (How fun! No other mycobacteria do this). Because the toxins also suppress your immune system, you don’t get any “normal” signs of skin infection, like fever, pain, redness, or swelling, because all these symptoms of infection are actually caused by your body’s normal response to invading bacteria. Because people can have little more than a tiny bump or dark spot on their skin, they ignore it, and the infection is allowed to spread and cause serious problems. Untreated, it can cause severe deformity (again, the google image warning), resulting in permanent disability (the most common site of infection is the legs) and death.

Q: How do you treat it?

A: Antibiotics and surgery. Traditionally, surgery was the definitive treatment (to cut out all the dead tissue), but more recent studies show that if you diagnose the infection and start antibiotics early enough, they can cure nearly 100% of infections, with no need for surgery. But it’s a little tricky to diagnose it at an early stage, because there are no real symptoms that prompt people to seek medical attention, and there’s really no good diagnostic test for it, especially one that could practically be used in the rural, resource-poor areas where this infection is endemic.

Q: What’s a Neglected Tropical Disease (NTD)?

A: The World Health Organization has made a list of diseases that affect a large number of people worldwide, with high morbidity and mortality, yet receive relatively little funding and attention. The NTD’s affect one billion people, and together cause 534,000 deaths per year. From the WHO’s website: “Those most affected are the poorest populations often living in remote, rural areas, urban slums or in conflict zones. With little political voice, neglected tropical diseases have a low profile and status in public health priorities.” NTD’s affect 1 in 6 people worldwide. To compare that number to a disease that gets more press time, 1 person in 1,762 has Mutiple Sclerosis. (Ever heard of trachoma? Eight million people are blind because of it. Filariasis? Chagas' disease?) See their website for more info.

Such a pretty lake, but potentially so deadly: Lac Zilé, near Lambaréné, Gabon.

The story of Buruli ulcers in Lambaréné

Although I was doing adult medicine (and BU mainly affects children), I became interested in BU because of the several children who literally lived in the surgery ward, where they were under long-term treatment for the ulcers. All patients at the hospital were cared for by a family member, who was responsible for cleaning, buying and cooking food, giving medications, and many of the jobs that nurses in the US do for patients (even including taking and charting temperatures). Because these kids were there so long-term, they could not have a family member stay with them, so they were essentially on their own. We befriended three of the girls in particular (their picture is in another post), whom I would sometimes sneak away after rounds to visit, or would come over to our house on the weekends.

In the morning, one or two of the girls could be found sweeping the small stoop outside their rooms (all of the rooms opened into a main hallway inside, and had a door to the outside), or washing their sheets and spreading them out on the lawn to dry. I had difficulty picturing American tweens fending for themselves, cleaning their own hospital rooms, entertaining themselves, and finding their own food (even without one arm completely bandaged up). One evening after afternoon rounds, my attending and I passed the entire group of children, most of whom had Buruli ulcers, playing soccer on the large lawn between the surgery and ob/gyn wards. Most were running around, screeching and laughing and playing, enjoying the setting sun with their friends; only two boys sat watching from their wheelchairs, as neither had walked in several months due to surgical debridement for BU that spanned their legs from their hips to their toes. I was truly touched during the three months we knew the girls at how they created a normal childhood for themselves despite their disabling disease: constantly spending time together, choreographing dances to their favorite pop songs, and throwing birthday parties for their friends on the lawn outside the surgery ward.

One afternoon I left the three girls on our porch, and came home to find my camera filled with literally hundreds of pictures they had taken of each other, capturing their adolescence in a way no photographer never could. Looking at these pictures now (I couldn’t bring myself to delete even one) makes my heart break. They are only a few years younger than, but a lifetime removed from, the many young women that would come into clinic with the outlines of their skeletons visible and CD4 counts in the single digits, who would die overnight or the next day from AIDS. So what’s happened to these three girls? They were all discharged within one week of each other in late July, and I only hope they have stayed healthy since then.

Global Health

Hello everyone, loyal followers of the sporadic postings of PaleBlueDotBlog,

I'm currently taking a course in Global Health, and some of the topics are really really interesting. I didn't get a chance to post as often as I wanted to from Africa, so I'm going to try to post a few topics that come up in this course that I think are interesting. (Let's look at this as a chance to redeem myself for a dearth of postings from abroad about topics that would actually be fun [well, in my geeky opinion] to read about.) Hope everyone's good! :)

-L

Q & A: Rheumatic Fever and Rheumatic Heart Disease

Q: What are rheumatic fever and rheumatic heart disease?

· A: Rheumatic fever is a disease that can develop as a complication of strep throat. It is rare in the US (for reasons discussed below), but is relatively common in the developing world. Rheumatic heart disease is a long-term result of rheumatic fever (which sometimes you have to get multiple times) which can cause valve deficiencies, heart failure, and death.

Q: How do I know if I have it?

· A: You don’t. But symptoms occur several weeks after strep throat and can include fever, joint pain (without swelling), a heart murmur or heart failure, a rash, and involuntary movements. Kids make up 80% of the cases, and adults 20%. [For people who have taken medical boards and theoretically should remember this stuff: the major (Jones) criteria for acute rheumatic fever are: 1. Migratory polyarthritis, 2. Carditis, 3. Subcutaneous nodules, 4. Erythema marginatum, and 5. Syndenham’s Chorea*.]

Q: What causes it?

· A: I’d like to just say, “strep throat,” but that’s oversimplifying things. The most common cause of a throat infection (pharyngitis, if you will) is a virus, but the reason doctors always stabbing kids’ throats with long Q-tips is that they are worried about “strep throat,” which is infection of the throat caused by the streptococci bacteria. There are very very few strains of strep which can actually lead to Rheumatic Fever (and these are known as the rheumatogenic strains).

Q: So everyone who gets strep throat with one of these rheumatogenic strains of Strep develops Rheumatic Fever?

· A: Nope, that would be too simple. Rheumatic Fever comes about when someone’s body reacts (for unknown reasons) to the bacteria, causing the body to attack its own tissues (kind of like an auto-immune disease like lupus).

Q: What is Rheumatic Fever vs Rheumatic Heart Disease?

· A: Nope. Rheumatic heart disease is the long-term results of several bouts of (or a bad or long-term case of) rheumatic fever. If you catch and treat rheumatic fever (with literally years of penicillin), it is possible to avoid the heart disease. Rheumatic heart disease is a huge problem in the developing world. It is estimated that 15,000,000 children and young adults have rheumatic heart disease, and 230,000 die of it each year. It is especially bad because once you develop the heart disease, the only treatment is a valve replacement. As you can imagine, the majority of people who actually have rheumatic heart disease don’t have access to a cardiothoracic surgeon to pop in a new valve, as would be the case in the US. Also, dying from heart failure is a drawn-out and painful process.

Q: Why don’t we have rheumatic heart disease in the US?

· A: One hundred years ago, rheumatic heart disease was the #1 killer of children and young adults in the US, and now the incidence is nearly 0%. It would be nice to pat ourselves on the back about our great medical care and widespread use of penicillin in eradicating this deadly disease, but that’s not why it practically doesn’t exist here anymore. For reasons that are unclear, the rheumatogenic strains of Strep have practically disappeared in the US, except when they recur sporadically in specific pockets of the country (like Western PA). The incidence of rheumatic fever was already decreasing rapidly before we even started diagnosing it and treating it with penicillin.

Q: Does this mean we don’t have to test every single kid who has a sore throat for Strep?

· A: Probably, but who wants to open that can of worms? Also, why stop doing something you probably don’t have to be doing when it costs only a half a billion (that’s right, that’s a B) dollars per year??

*The word chorea describes a disorder of abnormal, involuntary movements. Chorea is a kind of ancient Greek dance (and also gives us the word choreography). Syndenham’s chorea is a term only used to describe the chorea of rheumatic fever (cause there are other kinds, like in patients with Huntington’s Disease). The other term for it (cause why only have one term in medicine when you can have two or three for us to memorize) is St. Vitus’ Dance, in reference to the “manic dancing that historically took place in front of [St. Vitus’] statue during the feast of Saint Vitus in Germanic and Latvian cultures.” (Thanks, Wikipedia!)