Unprecedented!

Two PINCC campaigns are underway simultaneously, one in India and one wrapping up in Nicaragua!

Re: PINCC-India At work Again

An Indian child waiting for her mother to be screened

PINCC-India At work Again

From John Adams

June 29, 2011

Rhoda and John arrived back in India on June 26, and immediately began preparations for the two very important cervical cancer initiatives here in Puttaparthi (Andhra Pradesh) and in Mysore. It is a little strange to be in Puttaparthi, now that Sri Sathya Sai Baba has left the body (April 24). There are very few people around and the shopkeepers, porters, and others who rely on a steady coming and going of devotees are becoming desperate! The owner of Sai Towers Hotel tells us that his bookings are picking up again from about the middle of July, when Gurupurnima, a major Hindu holiday, takes place. By then, the tomb being built for Sai Baba's remains in the main darshan hall will be completed and the theme of "continuity" will ensure that all programs and rituals will be carried out as before. We all assume that the ashram, Prasanthi Nilayam, will become a major pilgrimage site for spiritual seekers of all kinds.

The Sri Sathya Sai Mobile Hospital gynecology section has already been certified in the PINCC VIA protocols and in use of Cryo and LEEP procedures. During this camp (1-5 July) Dr. Rhoda will be reviewing and helping the certified physicians to "brush up" on their knowledge and skills, and also begin the training for some additional SSSMH volunteer physicians. John will be inaugurating a quality assurance process for this program, so that they can self monitor and engage in continuous learning and continuous improvement.

On the drive down from Puttaparthi to Mysore for the third PHRII (Public Health Research Institute of India) cervical cancer camp, we will be stopping in Bengaluru to meet the CEO of Infosys. We hope to get his company's involvement and support in the "The Centre of Excellence for Cancer Prevention in Women" that we want to create through our collaboration with PHRII. During our stay in Mysore, we will also be meeting with the local Rotary club for the second time, seeking their support. We are also attempting to get the Rotary Wives Club involved to advocate for cervical cancer screening for all women in the area. Less than 5% of all Indian women (2.3% in the villages) ever have a single cervical cancer screening in their lifetimes.

While Rhoda is engaged in the third clinic with our Mysore trainees, John will begin rolling out our QA process here as well. (Contact John if you would like to see the items we are going to be investigating for quality assurance). This third camp is to be held at the JSS Hospital / Medical College -- our third venue in Mysore. By the end of this visit, we will have carried out PINCC clinics in a catholic hospital, a government hospital, and a private hospital. More networking for the future!

Also in Mysore, we will be meeting with the District Health Officer and other key stakeholders at the various Mysore medical colleges and teaching hospitals and will once again be hosting a Stakeholders' Dinner on our last evening in town. Our vision is to create a network of involvement that includes the local medical colleges, civic associations, and health-related government agencies.

Our volunteers on this trip are Dr. Rashmi Murthy, who volunteered previously on a PINCC Central America camp, and her mother Mytri Murthy. Dr. Shobha Krishnan, a professor at Columbia University, will also join us in Mysore. She has been engaged in VIA screening through her own program in northern India and also in Chennai. We are looking forward to also finding ways to synergize our programs with hers during this trip. India is so huge, and the need is so great, that we need to rapidly find ways to scale up before the cost of coming here becomes too high! 25% of all cervical cancer deaths in the world each year are in India (Globocan 2008), and there is at present no coordination of efforts and no center for rapidly building local capacities to address this huge challenge.

So all in all, we have a lot on our plates beyond running two PINCC-India camps. We will be much clearer by the time we leave about the future directions of PINCC-India! Progress reports will follow! Everyone who reads this -- please send good thoughts for successes!

Waiting room outside our exam rooms

At the hospital in Leon yesterday morning. Training is going great.

View from our hotel roof last night

This was before the spectacular lightning show that we had walking home from dinner in Leon!

Parking outside the hospital in Leon

No hitching post for the horsecarts, and no parking lot for the few cars. Main transportation: feet or two-wheeled vehicles (or buses).

Team PINCC on a day off on Sunday

At a nature preserve near the beach outside Leon. A much needed break!

Some of Team PINCC right now in Leon

Lunchtime in Leon! From left: Hayley Miller, Dr. Tara Hulbert, Dr. Pratima Gupta and Emily Riggs.

Guess what this is?

A bottle of orange soda left for the occupants of this house (which is in Leon en route to the hospital)? No! But if you said "a papaya", you're right!

Desvios, Puentes y 'Policias Acostado', Oh My!

SOMEWHERE BETWEEN JALAPA AND LEON, Nicaragua -- So I found myself yesterday engaged in one of the more adrenaline-pumping, sometimes-terrifying and certainly adventurous drives I've ever performed from behind the wheel.  With a vanload of innocent people relying on me to get them to their destination safely.  (Why me?  Because I volunteered to drive when our usual Nicaraguan driver was unable to join us for the trip. We later joked that he chose not to join us because he checked on the road conditions for the portion of the trip I'm about to describe.)

 

We got out of Jalapa later than expected, which meant we'd roll into Leon -- at least a 6-hour drive -- after dark. That's never good in an underdeveloped country, especially one where pedestrians (or groups thereof), loose livestock, bicyclists, motorcyclists, trucks and dogs all occupy major highways at unpredictable times and locations, and, depending on which of these you're talking about, without warning, lights, reflectors, consideration, caution or apparent concern.

 

The first part of the trip was predictable.  Jalapa to Ocotal is a known quantity.  It's a trying, winding road with the usual asortment of men on horseback, small children playing on the shoulder and -- best of all -- a series of "puentes," narrow bridges across rushing water where the approach is partly washed away, the ability of the bridge to carry our vehicle safely is questionable and the width of the bridge is just enough to drive across.  But it was during daylight hours; in other words, no big deal.

 

We got through without incident. 

 

Then we got to the highway (loosely termed) where you turn toward Leon.  Of the options to Leon, we had been told that this was the best one in terms of road conditions.  And the presence of major commercial trucks confirmed that.  In other words, if there was a better way to go, they'd surely be going that way.

 

Very quickly, we encountered a "DESVIO" -- known in the United States as a "DETOUR".  Detours where I live consist of a sign with an arrow followed by a series of signs keeping you on the right route.  Here, however, a DESVIO simply signifies that you don't go the way you thought you'd be going.

 

If it's dark (which it was by the time we saw our first DESVIO sign), you look to the right or left for a very bumpy, lumpy dirt road down in the gully alongside the highway where your vehicle MAY be able to pass if it's not raining.  And if there's no major truck (or herd of cattle) either coming the other way or stuck. 

 

We got used to this because we encountered at least a dozen of these always interesting one-way DESVIOS.  That's right: one way.  Nobody handles the duties handled in the United States by a person with a flag and radio, signaling someone at the other end to either stop traffic or let people pass.  Here, you take your chances.  Part way through, you may encounter someone coming the other way who also has taken their chances.  There's nowhere to turn around.  There's no way to back up. 

 

Once, the pavement abruptly changed from old pavement to new in our lane (with an 8-inch change in elevation) without warning.  Coming the other way, in my lane, was a huge truck.  When we got close to each other we both stopped.  The driver of the big truck leaned out of his window and motioned for me to drive off the edge of the new pavement onto the old pavement in the oncoming lane so he could pass.  I quickly thought this through.  He couldn't do what he was asking me to do because of the kind of vehicle he was driving.  So I veered gently down to the oncoming lane.  Fortunately for all of us, nobody was there.  The big truck passed and honked his air horn in kind of a "Spanglish" thank you.  I returned the signal, got back into my own lane and continued on to the next DESVIO sign I knew must lie ahead.  I wasn't disappointed.

 

Of all the DESVIOS we encountered, only one was so deeply rutted that the entire undercarriage of our van scraped along the center part of the dirt road with a pronounced sort of grinding sound, punctuated by abrupt stops and more pronounced sounds.  It felt and sounded really awful.  We envisioned u-joint parts, the oil pan and other essentials being ripped from beneath us. 

 

After many more DESVIOS, we finally concluded we were through the section being worked on.  Not because there were signs indicating "End Construction Zone," but because of the lack of any more DESVIO signs.

 

But now we faced a new phenomenon.  We called them "random strips of missing pavement."

 

These were sections where, apparently, new, huge concrete culvert pipes had been installed across the road, with the opening then filled in with dirt and rocks to be paved later.  No care had been taken to ensure the level of the unpaved space was anywhere near that of the highway. So, at 80 or 100 kph (that's kilometers per hour to those who have never left the mph world), you'd come to one of these strips and struggle to slow down enough to keep the car intact as you passed over the patch.

 

We got through all of these, as well.

 

Soon we were in total darkness, but with ominous lightning occasionally flashing in the sky to our right or just ahead.  Now came the really fun part.  Apparently, in Nicaragua, the place for people in tiny villages to hang out just after dark is along the side of the road. Once in a while, they hang out by themselves.  Mostly, though, they hang out in groups ranging from 3 to 20.  The custom I was most surprised at was the one where they hang out as close to the pavement as possible, or, in many cases, on the pavement where vehicles are traveling at what we in the U.S. would describe as "freeway speeds." 

 

Sometimes, they'd be sitting or even lying down perpendicular to the pavement.  One young man remained in this position, with his body from the waist up on the road and the rest of his body on the shoulder.  As I came speeding along, just about when the limit of my high beams brought him to my attention, he did a very slow and controlled situp -- just in time.

 

One of my favorite experiences, though, involved my encounters with people on bicycles, motorbikes, horsecarts and other vehicles with no lights or reflectors whatsoever. They weren't moving along on the side of the road.  They were in the road.  In the dark. Mostly, if they were people either on foot or on bikes, they wore very dark clothing.  Sometimes, I'd catch a momentary glint of a reflector strip on the pedal of a bike.  These made me feel lucky.

 

I also felt lucky to have Carol Cruickshank, our trip director and a one-time Nicaragua resident, as my co-pilot and navigator.  From time-to-time, she would quietly alert me to a barely visible pedestrian or bicyclist.  Carol's voice is almost always perfectly calm.  Her voice remained so as the rest of the passengers sat behind me in abject terror.

 

And then, once we got to Leon and my body had more adrenaline coursing through its veins than blood, I learned about "policias acostado."  In the United States, we call these "speed bumps."  Here, they're called "sleeping policemen."  If they're really large and challenging to drive over, they're called "policias acostados con su mujer," which means they're nearly twice as high.  I'll leave it at that since this is a family blog.

 

After nearly seven hours, we rolled into Leon without incident.  In fact, there actually were no true INCIDENTS on the whole drive.  Only the constant, nagging sense that an INCIDENT -- or worse -- would happen at any second.  There are a lot of seconds in nearly 7 hours.  What if we had a flat out there in the middle of nowhere and had no way to drive to a non-existent shoulder?  What if the oil pan had truly been pulled from the bottom of the engine on that one DESVIO where the center section of the dirt road was higher than the van's clearance?  What if a child on a bike had randomly chosen the moment we were careening past to cross the road? What if, what if, what if (fill in the blank)?

 

My mind reeled as to what may have happened but -- thankfully -- didn't.  We got to the hotel safely.  The longest, toughest part of our trip was finally over. 

 

-- Larry Shushan, PINCC volunteer in Central America

Success in Jalapa, Nicaragua

JALAPA, Nicaragua -- Seven PINCC-trained medicos yesterday were certified to perform screenings and treatments on their own, which is a tremendous accomplishment, both for the trainees and for PINCC.

 

But it's an especially significant development for the women of Jalapa and the surrounding area, because now there are trained medical personnel who know how to screen for the precursors of cervical cancer and provide immediate, effective treatment.  And Jalapa's clinic now has a gynecologist assigned there -- for the first time ever -- by the Department of Nuevo Segovia (the equivalent of a state in the United States).

 

Lives were saved while we were there, and lives will be saved in the future.  "Brigades" of medical teams will now be able to visit outlying areas -- trained and equipped by PINCC -- and screen and treat women.  It's a profound experience to contribute to this kind of progress because one knows that lives will be changed for the better.

 

Jalapa is the poorest place I've ever seen.  I acknowledge that I have not been to some of the world's areas most well known for poverty.

 

That said, however, I and others on the trip were deeply affected by our experience.  If you live in the United States, even the poorest areas we see have an infrastructure that provides basics -- from toilets to running water and from electricity to protection from most public health hazards.

 

In Jalapa, life is a grind, plain and simple. At first glance, it's quaint and charming to watch people ride around on bikes and horseback, or to see people walking from place to place -- except these people are using these methods of transport for lack of any other way to get around. There are almost no private cars, and public transportation is only from town to town, not within a particular town or village.  They're unprotected in the rain.  They're in sandals in the mud. And they have no protection from the blazing sun or suffocating heat.

 

Unlike patients we saw in San Salvador, where people of limited means showed vibrancy and interacted with energy, the people in Jalapa were blank, extremely stoic and flat.  There are few smiles. 

 

Dogs are treated like, well, dogs.  Not the way dogs are treated in the U.S.   Here, they wander the streets and look skeletal and desperate.  They're shooed away; sometimes even kicked.  They wander through the clinic and scrounge for crumbs.  I didn't see any that were "pets" in the U.S. sense of the word. Black vultures circle and, frequently, descend for a meal on the side of the dirt road.

 

Some streets are paved with interlocking concrete blocks.  Many are dirt.  Some are formerly paved streets whose pavement has been destroyed by the elements, vehicles and time -- apparently never to be repaired because there are no resources available.

 

As I said in a previous blog entry: One can only focus on the positive -- that people are being helped now and in the future because of PINCC's work.  But I couldn't wait to leave Jalapa, which I'm almost ashamed to say.  At least I had the option to leave.

 

-- Larry Shushan, PINCC volunteer in Central America

 

A much different kind of day

From the urban center of San Salvador, where clinics are relatively efficient, and patients and trainees are plentiful, PINCC's team has moved on to an extremely remote location in Nicaragua -- Jalapa. This is PINCC's fourth trip here.

At this clinic, where women travel sometimes for two days on foot or by bus from even more distant villages, there are more positive screenings and the need for more treatments.

Poverty is grinding and ubiquitous. The team is affected by what we see and experience. We went from celebrating success in the big city to sitting through hours of travel to come to a place where what we see is sobering (a huge understatement) and saddening.

Women wait patiently for screening exams, some of which are the first on their lives. Children wait with a patience unseen in the United States.

Here, where waiting is frequent and almost always lengthy, children occupy themselves without complaint or fuss. They wait for hours and say it's their duty to wait for their mothers. This phenomenon is utterly different from what we see in the United States. No video games, no books, no coloring books -- just waiting patiently.

Tomorrow is a new day in Jalapa. Today we saw 25 women. Tomorrow will bring whomever and however many it brings.

-- Larry Shushan, PINCC volunteer in Central America

Team PINCC heading for Nicaragua

...and so we say goodbye to El Salvador for this trip. We're heading for Jalapa, a tiny village in Nicaragua for PINCC's 4th visit. Then it'll be on to Leon, where we're training doctors to enable them to train others and to head to outlying areas to screen and treat women for the precursors of cervical cancer.

An amazing trip so far, with more to come.

Stay tuned ...

-- Larry Shushan, PINCC volunteer

Former PINCC trainees now doing the training

One of the most rewarding things about this trip so far has been seeing El Salvadoran doctors I watched being trained two years ago by PINCC now training their own colleagues. That means PINCC is accomplishing its objective of creating sustainable programs to stop cervical cancer.

Here, Dr. Julio Rosales trains doctors and nurses after a long day of working with about 4 dozen patients at the San Jacinto clinic in central San Salvador.

PINCC donates biopsy tools to El Salvador Ministry of Health

PINCC Board President Deborah Shefler (in red) signs documents with Vice Health Minister Violetta Menjivar marking the donation of gynecological biopsy tools for use in San Salvador clinics. The PINCC medical team of volunteers moves on to Nicaragua in the morning after spending five days of work saving lives and training local doctors and nurses in three San Salvador clinics.

One has to focus on the positive

NEJAPA, El Salvador -- Three trips to Central America with PINCC, and I still struggle with this inevitable conflict of emotions: Cervical cancer is always found during a trip, and as the guy handling all the paperwork, I am aware of all the details. This time, it was two in one day (out of 60 women) -- one that's certain, the other probable. Always sad because this cancer is totally preventable. (Some American gynecologists see it maybe twice in their whole careers, by the way.)

On the other hand, how many lives were saved because the medical team (PINCC volunteers and Salvadoran medicos alike) successfully identified pre-cancerous lesions that were treated and which otherwise would have gone unnoticed and untreated until it was too late? Nearly a couple of dozen, and it's incredibly gratifying to be part of a team doing this work.

One more work day here, and then on to Nicaragua for two weeks in two communities.

-- Larry Shushan, PINCC volunteer in El Salvador

Scenes from our day at Zacamil

Salvadoran doctors training Salvadoran doctors and nurses

By Larry Shushan, PINCC volunteer

SAN SALVADOR -- Today in San Salvador, we saw the tangible results of PINCC's sustainability-centric focus: after years of partnership with the national health infrastructure in this small Central American country, the training and certification of local doctors is going beyond merely enabling them to perform cervical cancer screening and treatment on their own. Now, Salvadoran doctors are doing the training, creating an incredible multiplier effect from PINCC's work here.

In this photo, doctors at the Zacamil clinic are training other doctors and nurses to recognize lesions on the cervix that become visible when vinegar is applied. Flashcards and discussion are used to prepare for actual visualization, followed by practice on patients. The experts -- already certified by PINCC -- supervise the work of those not yet certified.

At Zacamil, 140 women were seen in two days. Several tested "positive" for pre-cancerous lesions, then treated on the spot with cryotherapy, a technique using a special tool that freezes the lesions, effectively destroying them. The single treatment has a 95 to 98 percent cure rate, essentially eliminating the risk of the deadly disease for the rest of a woman's life.

Some of the doctors and nurses who saw 60 patients today

At the Zacamil clinic in San Salvador, where Dr. Melissa Miskell of PINCC (center) is leading this phase of the trip. Yesterday we saw 89 patients at San Martin, and more than 15 local doctors and nurses received training there in screening and treatment techniques to prevent cervical cancer.

Today at Zacamil

I sit in a tiny room at a beat-up metal desk typing patient information into a laptop while a woman is examined on the other side of the partition. 

It's tedious, repetitive work requiring utter accuracy.  I sense a stare: To my right, just outside the metal-barred open glass-slatted window is a sweet, smiling face with big brown eyes that watch my every move. The face belongs to a Salvadoran girl of maybe 10, whose mother is on the exam table. The eyes epitomize innocence and shyness being overpowered by curiosity about the unusual white-haired American man performing mysterious work with fingers on a keyboard. I try to imagine how to connect without a shared language and beyond just returning the smile. 

I remember a toy my grandchildren gave me to share, a simple number puzzle square like I had as a kid -- a toy whose language isn't exclusive to my world or hers.  I grab it and walk it out to the girl, who is overjoyed by the attention and the gift. She beams and quietly says 'gracias.'  When she is leaving, she first stops by and waves goodbye with the puzzle, still smiling ear to ear.

-- Larry Shushan, PINCC volunteer in Central America

This is Deborah Shefler writing from San Salvador, having just completed our third visit to Medisol, a well organized clinic in Lima that is a big fan of PINCC. We were able to certify 3 gynecologists in VIA, cryotherapy and LEEP, and 2 midwives in VIA and cryo, so the trip was a success just from that perspective. We screened 220 women!

The Medisol clinic is in a stand alone building in a poor, run down section of the huge city of Lima (I heard variously 8 to 10 million). We stayed in a very safe touristed area full of glittery shops and outdoor restaurants called Miraflores, in a simple but beautiful little flower bedecked hotel, Hostal El Patio, PINCC discovered a couple of trips ago. It´s a budget gem.

It´s about a 40 minute drive from Miraflores to the area where we worked. The contrast between Miraflores and the clinic area is stark. Nothing glitters, the shops are tiny and basic, the building construction is one to two story brick and concrete, and the streets are full of little microtaxies rather than buses and cars. I quickly realized that the microtaxies are essential because they are the only vehicles that can make it up the steep streets of the neighborhood. This area is filled with seemingly ad hoc slums that ascend the hills in switch back fashion. There seems to be at least some electricity, but the plumbing is unclear. By the time you get to the top of the hill the housing is more like camping out. The city is full of these ascending slums. I´m told that in recent years the government has invested in infrastructure in these areas.

I spent a few days in Lima before the group arrived. I stayed in 3B Barranco, a fine small and inexpensive hotel with a friendly staff. The best experience I had was the world class Larco Museum. http://ping.fm/CauKV Check out the beautiful objects, particularly the ceramics, which are extraordinary. Also check out the restaurant, which is quite posh but not expensive. It was filled with French tourists while I was there. I had a pisco sour and a peruvian sampler. Delicious all. It is a private museum with exquisite, well maintained grounds, colorful flowers abounding, quiet ambiance. Some of the art is astounding, particularly the ancient Moche pottery, which was mostly found in perfect condition in tombs. The pre-Colombians in Peru practiced a cult of the dead, something like in Egypt. The pottery therefore depicts all aspects of ancient life, including the pornographic.

I also went to the national cultural archaeological museum, http://ping.fm/yFzsd Very extensive museum of everything about Peru. Again, the Moche ceramics from the north are worth the visit in themselves. It's among the most inventive, beautiful and entertaining art work I've ever seen. It's the vessels with the curved handle and spout coming out of the top of the handle. But what we've seen in the states is nothing compared to the work on display here and in the Larco. Unlike Museo Larco, little of this museum was in English, but I got along fine. Finished with a delicious grilled fish with sauteed veggies in a big, open air restaurant.

There was (supposedly) no alcohol served in Peru for several days leading up to last Sunday´s run off election. Also, it is compulsory to vote in Peru. Some people predicted the election would be very close and the results not available for some time, given the remote rural situation of many voters. But that turned out not to be the case and one candidate conceded within a day. It seemed most people in Lima preferred the more conservative candidate, the daughter of a former president now in prison, but she was defeated by someone who has sometimes identified himself with Hugo Chavez.

I drove through some of the nicer parts of town in taxis, particularly San Isidro and Miraflores, which is next to Barranco, where I'm staying. Lots of attractive stucco housing, some colonial buildings, Spanish churches, flowers everywhere, lots of walls and attendants, low buildings and luxury high rise towers with expansive views of the ocean. These parts of town look well taken care of and very clean. There was some graffiti, but few signs of poverty.

I walked alone down the main drag in Barranco several times, feeling very safe. This area used to be a town in itself, but has been absorbed into greater Lima. It's a middle class neighborhood. No international chains, only local businesses. Not even Starbucks, and nothing even close to Benetton. Some shops are quite small and simple, like in Morocco or Turkey. The nicest businesses are white table cloth restaurants, and some look nice indeed. It is safe for me to walk here after dark, and indeed you see lots of police and guards, certainly around all the banks. If you eat before 8 or so, you'll be eating alone. Street food looks good but not sufficiently tempting to take a chance. Streets are relatively clean, much better than India but there is some litter. Traffic is relatively courteous, with lights, sidewalk slots for persons with disabilities, and pedestrian crossings. Sidewalks are normal and walkable, much better than in India, at least in these areas. No hassles whatsoever on the street. In fact, it felt like not a single person bothered, or even looked at me. People are conservatively and simply dressed, with young women almost universally in tight jeans. ATM worked perfectly. Super market well stocked.

I spent a day with a prearranged guide named Arturo, visiting downtown Lima. There are two squares in particular that are world class. The buildings are consistent in size, period and color, and exquisite, clean and well maintained, mostly from late 19th century. The oldest church is 17th century. Lima is a relatively new city. Someone from Spain would be right at home with the civic and ecclesiastical architecture. The weirdest thing is the catacombs under St. Francis church, which is now a museum. It's really an ossuary, full of piles of bones separated by type, femurs, tibias, etc. It's completely anonymous, just bones, all looking exactly alike and undifferentiated in any way.

We took public transportation, a first for me, so I got to see more parts of the city, for better or worse. We took a bus with a dedicated lane, a massive public works project that is only a couple of years old. I'm told it's like a system in Mexico City. It goes above and below ground and was a big deal project here that took several years to complete. On the other extreme, I got my first look, from afar, of one of Lima's infamous slums, little houses built up a steep hill.

Had ceviche, sliced raw fish in a lemon, yellow pepper sauce about the consistency of lemon juice. It was served with corn and sweet potato, and delicious. This was my third fish dish in a row. Fish is the thing to have here. Chinese food is big here too, on virtually every block, but it is made with Peruvian ingredients so should be a little special. Peruvian ingredients generally means potatoes (there are hundreds of types here, in all colors and sizes), rice, and corn (also all colors and sizes). Cooked veggies are a little hard to come by.

Arturo is a nice, 34 year old single man who is thinking about getting married (or not) and having children, or not, or moving to the US, or not. His father lives in NYC, but he seems more attracted to Miami or San Diego, where he'd like to have a travel agency. He says that Peruvian young people generally do not get married, they just live together and have children. His brother did get married, but that's because he's a Jehovah's Witness. This is strange because although people tend not to get married, they are religious, overwhelmingly Catholic. There's a real dichotomy in my experience here. The museums are all about pre-Colombian pagan polytheists, and the architecture is all about Spanish colonialism. It's interesting to compare how the ancient civilizations imposed order, and how the Catholic church and its secular political/military arms did something similar. Two different ways of accomplishing oppression.

On Sunday I took my last walk in Barranco. It is an up and coming neighborhood with small luxury high rises that I didn't see on my prior evening walks. Everything, however, is behind formidable doors, gates, bars and walls. I transferred by taxi to the Miraflores neighborhood around noon and checked into Hostel El Patio. There are big markets or bazaars nearby that are full of little shops, like the souks in Istanbul or Morocco. Some of the stuff is really nice, particularly the alpaca items, which are highly recommended.

Once the whole group of 8 had arrived, we met for 2 hours to go over what we'll be doing for the next week. Carol is very well organized and has seemingly thought of everything. Indeed, the week went smoothly, showing what planning and experience can accomplish.

Deborah Shefler and I arrived in Lima last night, with two medical suitcases, after easy but full flights. Lima is showing off with beautiful weather today and it is lovely to be here.

Saludos, Carol

Carol Cruickshank, CNM, PINCC Program Director

PINCC is getting ready for our June trip to Latin America.