Thursday, March 26, 2020

Coronavirus: Quick fixes or slow Italian slogs


Early in the 1980s Italian cars had seatbelts but if you wanted you could just let them dangle. The cops once pulled me over for wearing one, apparently because for someone at the wheel of a sporty Rabbit convertible this was suspicious behavior. When seatbelts finally became obligatory, Neapolitans responded by printing up t-shirts with a broad black stripe from left shoulder to right waist, to make it look from a distant police car as though you were had one on. 
Now the same national ingenuity has been put to work for a nobler purpose. Ten days ago a hospital in the northern Italian city of Brescia, hard hit by covid-19, was running out of the valves that hook up patients to ventilators, and the supplier couldn’t keep up with the demand. Two young Italian guys who owned a 3D-printing company brought a valve home, took some measurements, and 24 hours later had printed 100 fully-functional replicas. Their latest trick is turning snorkeling masks into respirators…
Italy is otherwise short lately on quick fixes – and on la dolce vita. Under the gentle Californian social distancing rules, we can’t eat in a restaurant but we can order out anything from Burmese to Ethiopian. We can’t go to a gym but we can stroll around the neighborhood any time we want or drive up to Tilden Park for a hike. We can’t have a friend over to dinner but we can meet her in a green space and have a chat, though at two meters one may avoid intimate subjects. We drove way across town to score a bottle of olive oil good enough for adoptive Romans.
The Italian stay-at-home, on the other hand, is more like house arrest – you can’t walk out the front door without written justification, which is frequently checked. Most of our friends in the now truly naked city of Rome can’t even take a pleasure walk. That privilege is limited to dog-owners, and then only within 500 meters of home. Parks are closed, you can’t drive except for health or essential work purposes, and in-person meetups are a no-no at whatever distance. All my informants agree that Romans, defying their reputation as scofflaws, are being amazingly compliant with the restrictions, and from conviction, not just fear of the patrolling cops and drones. There are no spring-break parties on Italian beachs.
Desperate measures are being taken – Italian medical students, who usually get little hands-on training, are being brought to work on the wards, courageous physicians from southern Italy have gone to the covid-striken North to fight the virus, and doctors have come out of retirement to lend a hand. Twenty-four of the 33 physicians who have died of covid-19 were over 65, including an 87-year-old woman psychiatrist from Brescia. Thousands of physicians and nurses have fallen ill with the disease.
Rome now has five dedicated covid-19 hospitals or buildings, two of them comandeered private hospitals, with a total of over 1000 beds.
Italy had to practically abandon the test-and-track-contacts strategy after a month cohabitating with the coronavirus, for lack of test kits and of personal protective equipment for the testers. Only people sick enough to require hospitalization are now getting a definitive diagnosis. Widespread testing is strongly advocated by the World Health Organization, and has proved invaluable both in Korea and in Italy itself.
Some aid is coming in from China. Chinese provinces have already donated 30 ventilators, 400,000 masks, 60,000 test kits, and 5500 protective suits to Italy, the Bank of China donated 100,000 masks and 50 ventilators, and a combination of donations and purchases brought another 100 ventilators and 2,000,000 masks. Two batches of Chinese doctors and nurses arrived bearing both their own experience and bags of convalescent serum for treating patients. It was rumored two weeks ago that China was making another 1000 ventilators, 50,000 test kits, and many million masks available for Italy to purchase, but that seems to have come to naught.
Part of that Chinese know-how is an artificial intelligence program supposedly capable of diagnosing covid-19 with 98.5% accuracy in 10 seconds by analyzing CAT scan images of the lungs…
It turns out, by the way, that I was wrong in my last post about the 500,000 test kits supposedly shipped on military planes to the US: they weren’t Chinese but Italian (from the Copan company in Brescia), they weren’t test kits but just swabs (those long Q-tips they stick up your nose), and they are, remarkably, not in short supply.
Incidentally, I keep trying to track the million masks and 500,000 test kits Jack Ma promised to the US. A first shipment supposedly arrived over a week ago, but I’ve found no word of it since. 
But there is now truly good news coming out of Italy: the rigorous countrywide social distancing measures are bearing fruit. In parts of the North the situation in hospitals is still horrific, 662 Italians died yesterday from covid-19, and in Rome the epidemic still hasn’t hit its peak. After just two weeks of nation-wide lockdown, though, the number of patients in Italy’s intensive care units is already plateauing, and the number of deaths are falling day by day – today the total death toll went up by only 8.8%, compared with over 30% a day before the lockdown. My updated graphs are below, and a New York Times article has made the same mathematical point. Deaths should start trending downward about ten days from now, trailing the ICU curve by a week or so. Exactly as optimistic virologists predicted.


(It’s important to understand that covid-19 is a slow disease, so the effects of preventive measures take a long time to kick in. As a comparison, if influenza develops into pneumonia it takes only a few days. With covid-19 pneumonia develops gradually, over two or three weeks, and recovery is also much slower, so patients who need a respirator need it longer.)
I had hoped to be able to devote this piece to debunking putative covid-19 treatments, but after Donald Trump’s latest about-face I thought it was better to hammer home the Italian example instead. Just ten days ago, before I last posted, Trump embraced social distancing and those of us who believe in science started to breathe easy. Now he has back-tracked, floating on Sunday the prospect of getting back to business as usual, doubling down on Monday, declaring Tuesday that social distancing is a “cure worse than the disease,” and proposing that the country should be “opened up and raring to go” by Easter. 
The number of deaths in New York City has gone from 10 a week ago to 281 just now. Trump fiddles while his hometown burns – and proud of it. Just as he’s proud of having chosen Easter as a deadline not based on any scientific data but because “I just thought it was a beautiful time.
You don’t have to go as far as Italy to demonstrate the advantages of social distancing, by the way. The Imperial College study by Ferguson and his colleagues, the one that pushed Boris Johnson and – briefly – Donald Trump into advocating social distancing, thought “Stopping mass gatherings is predicted to have relatively little impact.” Unfortunately that may have been one of their few inaccurate guesses, judging from the counter-example of New Orleans. Its Mardi Gras was followed two weeks later by the very first case of covid-19 in Louisiana, and now, a month after Mardi Gras, there have been 1795 cases and 65 deaths. 
Experts agree that in the first growth phase of this pandemic, which the United States has barely entered, social distancing will take time to work – only now, after two months of draconian measures, is China cautiously daring to begin a return toward normality. Something like that time scale, however painful, will have to be applied here as well if we want to avoid going down the paths of China and Italy. A brillian new study shows that countrywide distancing measures are very effective in reducing covid-19 deaths even if they are not as draconian as China’s or even Italy’s. Fortunately city and state governments, the only ones to impose social distancing regulations thus far, can do so whatever the President says. But there is justifiable concern that the 60% of Americans who told Gallup pollsters last week they think Trump is handling the coronavirus crisis just fine will now feel freer to flaunt any guidelines put into place locally. 
The chance of a concerted national effort to contain the virus already lost three precious weeks between Feb 26, when Trump said “We’re going very substantially
down, not up
,” and March 17 when he “Felt it was a pandemic long before it was called a pandemic.” Now there may be no chance at all.
Bill Gates has already lost billions due to the shutdown of the economy. Here, contrary to his own financial interest, is his vicious paraphrase of the President’s new position: “Hey, keep going to restaurants, go buy new houses, ignore that pile of bodies over in the corner.” 
Or you may prefer The Onion’s version: “Trump Urges Loosening CDC Restrictions To Let Coronavirus Get To Work.”

Thursday, March 19, 2020

Diary of a coronavirus refugee: Schadenfreude and relief



Lockdown in Rome's Testaccio market (note 1-meter distancing strips) and San Francisco

Schadenfreude = the uniquely German concept of enjoying other people’s suffering. 
I had a great gush of it on Monday, watching Donald Trump eat humble pie through clenched teeth, if you’ll forgive the mixed metaphor. After weeks of “We have it very well under control” and “One day – it’s like a miracle – it will disappear,” the current occupant of the White House, the same guy who two years ago closed down the American pandemic preparedness taskforce, had been forced to admit that coronavirus is a real threat and to recite a litany of guidelines for controlling the epidemic. Never one to be outdone by the competition, Trump went the Centers for Disease Control one better: the previous day they had advised no gatherings of over 50 people, he said no more than 10. 
Friends have written to me about hearing a nurse in Hawaii say the coronavirus story was “all hype,” a gym mate who thought covid-19 was “just the flu”… According to recent Kaiser Family Foundation polls, an incredible 46% of the US population trust what the President tells them about the coronavirus, and 44% think he’s doing a good job at handling it. That poll was taken between March 11th and 15th, before Trump made his 180º policy swing. What are those gullible Trumpers going to think now? Hopefully they’ll flip in turn, start taking the pandemic seriously, and stop being such a threat to themselves and others.
I must say, though, that my Trumpward Schadenfreude was far outweighed by relief. If the CDC had been allowed at last to make some concrete recommendations, with Trump backing them – if denial is no longer the Administration’s party line – there is now, I think, a good chance the US will escape the worst-case scenario.
Everywhere in the US the social distancing message is sinking in. Here in the San Francisco Bay Area, my current place of refuge, they have now instituted a “shelter-in-place” ordinance on the Italian model. Its rules are somewhat less rigorous – unlike the Italians, we’re allowed to go out for a stroll if we want, and can use our cars if we want to go shopping or hiking outside our immediate neighborhood. And thus far it’s much less rigorous in practice, relying on voluntary compliance rather than on the police cars that roam the streets of Rome in search of errant pedestrians. Between March 11th and March 18th, Italian cops had stopped and checked 1,226,169 people for compliance with the covid-19 ordinance, and given out 51,892 fines. Nobody’s been sent to jail yet, but sentences could theoretically be for up to 12 years.
Where the US is still failing abysmally is in applying the most important antiepidemic tool according to the World Health Organization: “test, test, test.” Anyone with symptoms of possible infection should be tested, their contacts should be traced and tested in turn, and everyone with positive tests plus everyone in each of their households should be quarantined (it’s now clear that the disease can be transmitted even before symptoms develop). As of early this weekItaly had tested 148,657 people; the United States, with a population five times greater, has only tested 41,552, and in a fashion more haphazard than systematic.
Alvin and I have been watching a lot of CNN, whose sole subject by now is the coronavirus. We’ve been shocked by two things: First, the endless direct-to-consumer ads for powerful prescription drugs with potentially fatal side effects, a criminal practice nearly unique to the US. Second, the way coverage of the pandemic has been virtually limited to the US – if it weren’t for a feelgood clip or two of Italians singing on balconies, you’d never know there was coronavirus beyond our borders.
Buried along with any foreign news has been the extraordinary aid that China has been giving countries badly affected by the pandemic to help cope. The Chinese government has started sending Italy everything from coronavirus test kits to ventilators, as well as teams of physicians and nurses experienced in treating the disease. And did you know that Jack Ma, the wealthiest man in China, has promised to give the United States 500,000 coronavirus test kits and 1 million face masks? They left Shanghai this Monday, and may have continued on to the US the same day on military aircraft, for eventual distribution by the CDC. His generous donation, by itself, may make a substantial contribution to stemming the American epidemic. 
By the way, Joe Biden was mistaken when he said at Sunday’s debate that the US had refused kits from the World Health Organization.
The Italian lockdown seems to be starting to bear fruit. Admittedly today’s coronavirus news looked bad: Italy has now passed China in total number of deaths. But that death rate, awful though it looks, is starting to rise less rapidly day by day than it was ten days ago, and the growth in the number of covid-19 patients in intensive care has similarly been slowing down (see my charts at the bottom).
The growth in confirmed cases has been improving less strikingly, but you can’t count on those data because they are so dependent on the amount of testing that’s being done.
Let me go back for a moment to the last Democratic debate. Another of Biden’s bad moments was a misguided attack on Italy, when he pivoted from a question about coronavirus into making a dig at Bernie Sanders’ Medicare-for-all. “With all due respect to Medicare-for-all, you have a single-payer system in Italy. It doesn’t work there. It has nothing to do with Medicare-for-all.”
I’d guess Sanders hadn’t been prepped for that particular line of attack, because he didn’t respond, as he should have, that if there hadn’t been a National Health System in Italy things would have been much worse. Aside from the well-organized medical response per se, all Italians knew from the get-go that if they needed testing or treatment they wouldn’t pay a penny out of pocket, so nobody hesitated to seek medical services. And the Italian welfare state helped greatly: all regular wage earners too sick to work, caring for a sick family member, or laid off because of closings knew they would keep earning their salary, or a good chunk of it, for many months. 
Italian medicine is terribly underfunded and undersupplied (it has 1/3 as many ICU beds as the US, and spends 1/3 as much on health care), and I haven’t hesitated to point out its uneven quality. But in this crisis the system has really come through, to the extent that resources allow it. The response was well-coordinated, physicians stay efficiently informed of the rapidly shifting national guidelines, private hospitals are commandeered to meet public need, and medical staff are giving their all and beyond; as of today, 13 Italian doctors have died of covid-19.  

It should be said, though, that many Italians who depend on the gig economy or are independent contractors, something around 17% of the workforce, are being left in the lurch and will suffer economically. My musician husband and I both fall into that category. All of Alvin’s gigs have been cancelled for the foreseeable future, and as a physician in private practice I obviously earn nothing as long as I’m in the US, while incurring unchanged office expenses. Even if I were home in Rome I’d likely be scraping together only some 10% of my usual income by giving a few paid phone and Skype consultations. Thank heavens for his Social Security, and for my small Italian pension!


Sunday, March 15, 2020

Notes from a coronavirus refugee

the Spanish Steps under lockdown

On April 14th, 2010, the Eyjafjallajökull volcano in Iceland spewed out a giant cloud of ash that grounded airplanes across Europe. That day my husband Alvin Curran and I happened to be in Valencia, a charming Spanish coastal city whose historic center you can walk across in an hour. Train seats to Rome were snapped up before we caught on, and it took three days until we managed to hop on a plane. Our first lesson in being a refugee: if you can’t leave, even the loveliest town is equivalent to Hades.
Ten years later here we are again, only worse. Alvin and I came to California on March 4th so I could attend the 700-strong medical conference I’ve been going to every year since 1988, where I was to give a presentation of my memoir Dottoressa: An American Doctor in Rome to my scientific colleagues, and fit in another three book readings around the US as long as I was there. Days later the coronavirus crisis hit in force, and we were sent scrambling. My conference was cancelled at the last minute, then my two presentations in New York, then all air travel to Italy. We decided reluctantly that it wasn’t wise to bring our over-70 bodies to our beloved New York – try social distancing on the subway. Instead we cast our net in search of refuge in the Bay Area, until at least the end of April when Rome-bound planes may start flying again. 
After offers of hospitality poured in from friends and relatives, we’ve landed in a comfortable “mother-in-law apartment” in North Berkeley donated by friends who usually rent it out on airbnb.
As soon as we’d unloaded our bags in that high-end refugee camp we headed off to the splendid Monterey Market, a few blocks away, to stock our refrigerator. Only after we got back to the apartment did it register, with horror, that after washing our hands a hundred times a day, and greeting friends with namaste instead of kisses, we’d just finished voluntarily spending an hour cheek to jowl with hundreds of Berkeleyites pushing past each other to score rice, blueberries, and kale.
In the meanwhile our adoptive country, Italy, is under rigorous lockdown, with everything from schools to restaurants to churches shuttered, and a three-foot distance enforced even between pedestrians on the street. 
Italians are great at handling emergencies, their national character being blessed with both resourcefulness and good cheer. The way Alvin and I got out of Valencia in 2010 was by sprinting across the airport on a tip from an Italian. Another time, when a cancelled flight left me and hundreds of others stranded at the New Orleans airport, all the Americans wandered around grousing. A party of Italians assessed the situation, decided there was no way to change it, and broke out some champagne. So it’s no surprise that quarantined Italians are socializing by singing from their balconies. For the national anthem, though, they needed help from a recording – nobody knows the words (watch half the Italian Olympic team fake it). 
housebound Romans sing the national anthem from their balconies
There are hints that the Italian lockdown may already be bearing fruit, with a slight slowdown in the rate of new cases. Austria, Denmark, France, Greece, and Spain have now decided to follow the Italian approach.
When oh when will the United States do the same? The occupant of the White House remains more concerned about the state of the stock market than about his citizens’ health (or even his own, he claims). You’d want to laugh at his wooden, self-aggrandizing, xenophobic Oval Office address about the coronavirus pandemic if its failure to provide any solutions weren’t so potentially lethal. 
Even the great Anthony Fauci is pussyfooting around. He does tell some version of the truth, that the epidemic is going to get worse before it gets better and that testing has been failing, but he offers virtually no guidance. The nation needs to hear from him who exactly should be tested, whether the US will accept the test kits they’ve been offered by China, how exactly to carry out “containment and mitigation.” When pressed Fauci said it wouldn’t be a good idea for basketball games to be played to full stadiums, but he didn’t suggest how large public or private gatherings should be, or whether schools, restaurants, or bars should be closed. He’s said nothing that I know of to promote the vital politicies of teleworking, universal sick leave, or free medical care for all coronavirus patients including the undocumented.
Fauci’s colleagues have suggested to the journal Science that he is “trying to walk a fine line, being honest to the public and policymakers but not so openly critical that he loses influence by being ignored or forced to resign.” I suspect this adds up to his still being muzzled by Pence for political purposes.
Even CNN, for all its justified criticsm of the President, has spread misinformation. I have heard their experts suggest variously that possible coronavirus patients head for Emergency Rooms (possibly spreading the virus around the waiting room), that people in self-isolation can go out to shop, and that family members of coronavirus patients don’t need to self-isolate (Justin Trudeau has stepped forward as a counter-example). And unfortunately Rep. Katie Porter, during her fantastic hatchet job on the head of the CDC, confused influenza tests with coronavirus tests. 
So far the decisions about concrete steps – limiting public gatherings, closing schools, encouraging people to work from home – have been left entirely to State and local governments and to organizations from the NBA to Amazon. Many more Americans will die from covid-19 whatever we do or don’t do, but if the United States takes rapid action as a nation, hundreds of thousands if not millions of lives can be saved. Anyone who is not yet convinced of the need to immedicately adopt aggressive measures should look at this brilliant piece in the NY Times. 

In case you’re curious, I did manage to do one book reading last Tuesday, to an audience of 50 at Moe’s Books in Berkeley, and on Saturday Alvin pulled off his scheduled house concert with Willie Winant to a similar-size group. Who knows when we’ll get to attend gatherings like that again.
Alvin Curran and William Winant in house concert, SL at Moe's


Thursday, March 5, 2020

Corona

The coronavirus with its spiky crown (artist's image)

Rome’s streets are empty, the supermarket shelves loaded with food. My fellow denizens, for once free of the tourist hordes, are enjoying their lives in a state of limbo, waiting for coronavirus to come crashing down around their heads before they start stocking their larders and hunkering down.
At least that’s what things were like yesterday. I can’t say about today, because I just arrived in San Francisco to begin a two-week book tour cum working vacation scheduled months before that damned virus jumped the species barrier deep into China. We were biting our nails until the last moment – would the Americans impose a 15-day quarantine on all travellers from Italy? – and felt some relief at getting away, like Boccaccio’s fictional pals who fled to the hills outside Florence to escape the Black Death. But the first New York Times headline I see on landing is California Declared a State of Emergency, and it’s entirely possible that all the events we’ve come for will be cancelled in the spreading panic. 
When Covid-19, coronavirus disease, struck northern Italy in February like a bolt from the blue, the authorities got their act together surprisingly fast. They isolated the worst-affected areas, set up national and regional telephone hotlines, called in medical trainees and retirees to man them, planned dedicated wards in infectious disease hospitals, instructed practicing physicians in telephone triage, and broadcast two concepts to the general public: people leaving an epidemic area should self-isolate for two weeks even if they have no symptoms, and if you have cough, body pain, or fever you should pick up the phone rather than heading for doctors’ offices or emergency rooms where they might infect the sick and vulnerable. 
Anyone with suspected coronavirus is tested in isolation in the emergency room, if they’re sick enough to be there, or in their own homes by a hazmat team sent by the Health Department to take the swab. Testing is free, preliminary results are available and public within hours, anyone who needs to stay home gets paid sick leave, and under the Italian National Health Service nobody pays a penny for doctors, Emergency Rooms, or intensive care.
Human beings being imperfect, implementation has had some hiccups. A Rome policeman developed a cough on February 28th after hosting a houseguest from Lombardy, the northern region where coronavirus disease is most rampant. Instead of calling his doctor or the hotline he went to an emergency room, where the ER staff left him to stew in the regular waiting room, where he infected at least 15 fellow patients in addition to his wife and children. Not clear who was dumber, the doctors or the cop.
Italy’s response capacity is also hamstrung by its chronic and ever-worsening underfunding. If even wealthy Scandinavia will have trouble rounding up enough ventilators and intensive care unit beds if a true pandemic develops, imagine where Italy will be with half the resources.
And how about on the other side of the Atlantic? How will the United States succeed in handling an epidemic that seems increasingly likely to hit big, either soon or in the fall? 
My guess is badly. As a haven of rugged individualism and for-profit medicine, the US is far less equipped than Europe to mount an adequate response.
To start with, a third of Americans have no paid sick time at all, and few have as much as two weeks. Which means that many people mildly ill from coronavirus will keep going to work, putting everybody around them at risk.
And as we all know, US is one of the few countries where access to medical care depends on access to money. Between deductibles and co-pays even insured Americans often find it hard to afford doctors’ visits, medications, and hospital care. Which means that many who should be tested for coronavirus are likely to skip it in order to avoid starting a chain reaction of medical expenses – some are even being charged for the test itself. Not to speak of the 27 million citizens who have no insurance at all, or the millions of undocumented immigrants who steer clear of hospitals for fear of hovering ICE agents, all primed to swell the pool of infected people who may soon be mingling with the crowds on American streets, subways, stores, classrooms, and baseball stadiums.
Even stocking up on medications in case of preventive quarantine can be impossible in the American context – insurance companies don’t allow it.
In Italy about 30,000 people have been tested for the novel coronavirus, versus only a few hundred people in the vastly larger US. The lag is largely because every test needed advance approval from the Centers for Disease Control; broader testing is set to start now. 
Italy is notorious for disorganization, and has neglected epidemic preparedness. But this time it’s bested the US, which has been unable thus far to enact some obvious measures for containing the coronavirus. The Italian authorities tell a Neapolitan businessman who was obliged to spend a day in Milan for a meeting that he should stay home for two weeks when he gets back. When I landed at San Francisco Airport today the border police chatted me up about my life in Rome, and wanted to know whether I was carrying any cigarettes, but didn’t even ask when I had last been in northern Italy. Scary.
Then there’s the politics of an election year. Our real experts on the science and the handling of epidemics, such as Dr. Anthony Fauci, are being sidelined and even muzzled, while the coronavirus task force is run by Vice-President Mike Pence, who as governor of Indiana suggested the best response to the state’s HIV epidemic was prayer. And while President Trump runs off at the mouth about how a vaccine is at hand and how the coronavirus is just another Democratic hoax. 
Obviously the situation in both my countries is evolving not just day by day but hour by hour, and much of what I’m writing today may be out of date tomorrow. But having scribbled these musings, mostly on the plane, I thought I'd offer them to you anyway. 

Monday, February 24, 2020

Nilotic Jeopardy: Finale

our escort paddling across the Nile
When my Italian ex and I were visiting the Sudan in 1979, word had it that one of the few tourist destinations in the South was the Nimule game park, within range of the regional capital Juba, and that foreigners couldn’t go there without a permit. The number of interlocutors, rubber stamps, and banknotes we went through to obtain one in Khartoum made Italian bureaucracy seem like child’s play.
When we eventually made it to Juba and handed over the hard-earned permit to a government official, he tore it up. The guerilla war of the black South against the Arab North had nominally ended seven years earlier, but for all practical purposes Sudan was already two countries joined at the waist (their divorce finalized in 2011). Another round of stamp-wielding bureaucrats, another wad of dough, another permit.
Our next problem was how to get to Nimule. At that particular moment, this was a non-trivial issue. All of Juba’s fuel was trucked in from Uganda, and the border had been closed for months, so gasoline was a mirage. But perseverence – and perhaps bribery, I can’t remember now – succeeded in landing us a jeep complete with a driver, a hanger-on, and some kind of liquid in its tank. 
The first minutes of our Nimule safari provided an unexpected sartorial lesson. From our daily treks to the market we thought we knew the local costume: a draping of cloth or animal skin ample enough to cover the vital parts, topped off by a necklace of glass or blue plastic beads. But when we crossed the river heading southeast out of town, around 9 am, we encountered some market sellers who had cleared their merchandise early and were changing out of their work clothes. We stopped to watch. Each removed his piece of drapery, folded it, placed it on his head to double as a support to balance his market basket, and walked off still wearing his necklace but otherwise stark naked, penis swinging.
Between the nearly impassable rocky road, one flat tire, and several mechanical breakdowns, it was dark before we were deposited at the official Nimule lodge 120 miles away, a sub-basic establishment perched on a small hill just outside the game park entrance. 
At dawn we tromped into the park on foot, in the company of a guide with a rifle slung around his neck whose stride was twice mine and who never let up for a moment. After a couple of debilitating hours without seeing a hint of wildlife, we reached the bank of the Nile. The river was wide but full to the brim, and frighteningly swift. Andrea, the guide, and I piled into a dugout canoe with two paddlers, and a small boy climbed into another one, alone. The river was rushing by so fast that the oar-wielders had to angle their canoes’ noses upstream at a good 70º and then paddle like mad, in order to reach the bank just opposite our starting point . . .
 . . . but, as it turned out, not quite. When we emerged from the fast-moving part of the river to where the water was still and full of rushes, about 50 yards from shore, the guide motioned for us to take off our shoes and wade the rest of the way. As a doctor I knew this was a bad idea. Still water full of rushes means one thing in Africa: bilharzia, a/k/a schistosomiasis. Wade in that water and the snails clinging to the rushes will pour out myriad tiny parasites whose life’s mission is to crawl through your skin, work their way into either your urinary tract or your intestines depending on whether they’re named Hematobium or Mansoni – in Southern Sudan both types are rampant – and destroy your kidneys, liver, brain, or all three, causing agonizing pain as they go. We begged, we pleaded, but the boatsmen refused to take us closer to land. I’m sure they had no idea what we were complaining about, since for them schistosomiasis was just part of normal life – in that area, it still is. So it was wade in the water or give up on seeing any of that game we had come all this way for. In the end what we did was take off our shoes but leave on our socks, then splash through the stagnant water as fast as we could, trying to outrace the little buggers.
Yet another entry to add to my incubation period countdown, and a long one: you can’t be sure you’ve escaped schistosomiasis until you’ve made it six months without symptoms.
As far as wild animals were concerned the expedition was a total wash: all we saw was a single family of warthogs. At least we got an adrenalin rush out of them, when mama pig, papa pig, and a pack of piglets dashed precipitously, tails in the air, out of a hidey-hole under our noses so close that the guide pointed his rifle. 
How come a game park had no animals? Our hotel manager let us in on the secret: they had all been killed and eaten by guerilla fighters during the war.
The reverse Nile crossing was uneventful, as would have been the hike back to the lodge if we hadn’t run prematurely out of water. It was still the middle of the day and I lagged farther and farther behind Andrea and the guide, exhausted and shriveling in the sun. At the foot of our hotel’s little hill I admitted defeat and lay down in the dust, curled up in the rudimentary shade of a thorn tree.  
For a half hour or so with nobody coming to my rescue I worked on gathering my dehydrated strength. When it it started to look like I had been permanently abandoned to my fate, I struggled up the hill on two and four limbs, only to find my husband swigging beer with the hotelier and claiming, unpersuasively, that he had been about to go fetch me. Too dazed and sick from heat exhaustion to properly express my fury, I instead vomited a couple of times, drank a vast quantity of water, and passed out on the mattress. Andrea had the nerve to complain, years later, that I’d been a wimp.
Next day at dawn we headed back to Juba. The vehicle crept along without much mishap until well after nightfall, when it died some six miles outside of town. Despite our protests the driver wouldn’t even make a stab at fixing it – we suspected he had his own nefarious reasons for staying put. But the wheels were totally in his power so our only option was to set off on foot. Musically, at least, that hike was memorable – the silence of the moonlit night periodically broken by drumming that would reach us from a far-off Dinka cattle camp, fade away, then return as another camp came within earshot. 
back from Nimule, dusty and famished
Back at the hotel, hours into the night and well past dinner hour, we plunked ourselves down at a table hungrily anticipating the dozen gristly bits of mystery meat that every day of our stay thus far had been the restaurant’s unvarying entree, morning noon and night. But what arrived on our plates this time was white instead of the usual grey-brown. We were thrilled – fish!
One bite banished the thrill. The white morsels weren’t fish at all but chunks of fat, left over after the restaurant ran out of meat. If you don’t count a cup of milky tea, we went to bed without supper.
Nowadays, they say, the Nimule game park is easier to reach, and teeming with elephants. But apparently unexploded landmines and the like make it an even more dubious destination today than it was four decades ago, when the worst thing we risked was a case of schistosomiasis.

Friday, February 7, 2020

Dottoressa events in the USA



I want to be sure all my blog readers know about two free public presentations in the USA in March of my memoir Dottoressa: An American Doctor in Rome. If you have friends within range of either of them, consider letting them know.
In Berkeley: Tuesday, March 10th, in conversation with Katharine Michaels (writer, restorer of old stone farmhouses in Italy, widow of Susan's literary mentor Leonard Michaels). Time: 7.00 pm. Place: Moe's Books, 2476 Telegraph Avenue
Event page at Moe's Books website.
Event page on Facebook.

In New York City: Monday, March 16th, in conversation with Alexander Stille (author of Benevolence and Betrayal, Excellent Cadavers, The Force of Things...). Time: 6.30 pm. Place: Italian Cultural Institute, 686 Park Ave (between 68th and 69th St.). An announcement will soon be appearing at the Institute's Events webpage.

There will also be an event on March 13th at the American Psychosomatic Society conference in Long Beach, CA, hosted by Bill Lovallo, but that’s open to conference attendees only.

Monday, February 3, 2020

Nilotic Jeopardy: The Prequel

drawing by Suzanne Dunaway

Even before I went bottoms-up on Nile water (see Nilotic Jeopardy, Part 1), the medical dangers of southern Sudan had literally landed on my head. Our plane from Khartoum touched down in Juba, my ex and I took a taxi to our hotel, the cabbie opened the trunk, I leaned in to pull out a bag, and bang! down came the lid on my cranium. Blood all over the place. That’s normal for a scalp wound, and it’s a welcome form of self-cleansing. Plus it offered Andrea plenty of gore to stanch in addition to the dirt to scrub painfully away and the ragged bits of torn skin to try and disinfect.
But as soon as the immediate emergency was over, a larger problem sunk in. Every roadway – even in Italy, even in the United States – harbors vast armies of tetanus (a/k/a lockjaw) spores, with their general headquarters in the feces of those charming creatures that bear Carabinieri on their backs in Rome and pull carriages through Central Park in New York. In subsaharan Africa, e.g. Juba, animals are ubiquitous and the contamination on every outdoor object is a hundredfold, a thousandfold greater. 
Like most physicians I’m sloppy about my own health, so I hadn’t bothered to get a tetanus jab preparatory to the trip. To count back to my last one, I needed all my fingers and all my toes. More than ten years and you’ve likely lost your immunity, so there we were, only just landed, condemned to start our sojourn in southern Sudan tracking down a booster shot of tetanus toxoid, the vaccine we all get as kids followed by boosters every ten years, and some immune globulin (serum), the antibody soup you’re supposed to get shot up with if you have a contaminated wound. 
Andrea and I dedicated our first full day in Juba to the hunt. First we tried the public hospital, a crumbling structure whose furniture consisted of nothing but bed frames armed only with springs, no mattresses. They were jammed into every available space, each holding two patients arranged head to foot, and were surrounded by encamped relatives. I explained my issue to the head doctor but he didn’t seem to know what I was talking about. 
The year before, visiting a mission clinic while we were travelling in Kenya, I saw that the only tetanus medication they had was serum harvested the old-fashioned way, from horses. That product had been a miracle of modern medicine in 1911, but it had an unpleasant tendency to give severe and even fatal reactions, so the medical world heaved a collective sigh of relief when a more benign, more effective version of immune globulin, derived from human blood, arrived in the late ‘60s to replace it. But here in Juba, a beggar and not a chooser, I was starting to think if someone offered me that toxic horse serum I’d kiss him.  
After the hospital fiasco we set off to do the rounds of all the half-dozen private clinics in town. One chief medical officer after another said nope, no booster, no horse serum, no human serum, no nothing. As a traveler and a scientist I could muster some anthropological interest in our odyssey, since it was giving us an inside view of every medical facility in one of the major cities of a country one fifth the size of the USA. But as a patient I saw no plus side. 
Finally at the last clinic, run by missionaries, I hit the jackpot. Or at least I found someone who knew exactly what I was talking about. An earnest Dutch doctor kindly explained that tetanus toxoid, the booster I needed, was completely unheard of in southern Sudan. But he said if I wanted he could get me some immune globulin. And this immune globulin wasn’t even that toxic kind they used to make from horses – it was of human origin, like the products used in Europe and the US. Except for one slight difference, my saviour confessed: the serum he had to offer was not a sterilized commercial product but a concoction hand-produced in Juba from the blood of local people. 
It took me a minute to realize what this meant. Unprocessed serum from south Sudanese blood could be – would be – loaded not just with antibodies but with germs. Nowadays the most-feared culprit would be HIV, but this was years before AIDS (or hepatitis E, or West Nile virus, or Zika fever) had appeared on the scene. Nonetheless even in 1979 the list of blood-bourne diseases was already long. The biggies were malaria, syphilis, and hepatitis types B and C (then known as “non-A non-B”); a somewhat less serious category included brucellosis, toxoplasmosis, Chikungunya, and Dengue fever; and an obscure-but-deadly blacklist featured trypanosomiasis, babesiosis, leishmaniasis, and Ebola. For a south Sudanese patient who had never had a tetanus shot and had already been exposed to most of those other infections the risk from the serum might have been worth it. For me? Not on your tintype.
The outside incubation period for tetanus is six weeks. Though a few days later I downed my unfortunate chalice full of Nile water, initiating a countdown as I waited for myriad diseases to strike, lockjaw may have been the scariest – even with modern medical care, it’s still frequently fatal. Fortunately, the six weeks passed without my jaw ever giving a twitch.

Thursday, January 30, 2020

Dottoressa in Pieces
































Dottoressa: An American Doctor in Rome will be one of the cut-up books featured in an exhibition at the Visioni Altre gallery in Venice, Fresh Cuts / Tagli Freschi / Exploding Red Piano Keyboard by post-Fluxus artist Coco Gordon. This installation will be on display from 1 to 13 February 2020, culminating in a SuperSkyWoman performance by the artist, 3 Dances for Paper Piano, on the 13th at 5 pm.

says the artist:

Coco Go aka
SuperSkyWoman's
Fresh Cuts: Tagli Freschi

Cage, Duchamp, Fluxus da fondo a caso, da capo, tutte precedente esperienze gestiti: fare, stare, sentire, strappare, tagliare, scoprire—nascondere tra tagli spioncini, Il lettore esplosivo, trasvolgente, integrativo, honorato, riaperto, ritornato, risognato, ricambiato, rimprovviso, risupposto, ri-in gioco—richiavato nel suo pianoforte Rosso allungato a 6 metri, tesi a lungo cinque gambe cinque piedi per la collaborazione invitata alla Galleria VisioniAltre 
Mostra 1-13 Febbraio 

Invented this form. I began cutting my best loved & lived books in 2018 as a project to let go of them,
surprising myself by exploding outward, following clues of the books themselves to retain the essence I felt of them.

In 1981, I had cut centers the shape of fruits out of old paperback books & placed mushrooms at the centers
then filled my red paper piano keyboard with a proactive healing aim to stop clear-cutting forests.
This first pass of flowering out & opening the insides to view, is for honoring Fluxus friends.