Peru

Into the Jungle

Aside from losing my luggage for a week, Peru was amazing. Just an overview on South America. There is a tremendous amount of natural beauty, tradition, and diversity packed into every single country.

In search of something more exotic, I headed straight for Iquitos, better known as the Gateway to the Amazon. There are only two ways to get to Iquitos: by plane and by boat. It turns out that due to the relative isolation, lack of demand, and the minor problem of asphalt melting during the extremely hot summer months, there hasn't been much traction on building a road. As much as I would have to loved to hitch a ride on a barge, that would have taken two days and that was a little beyond me.

I arrived in Iquitos really pissed off, mostly because my bag got left in Ecuador, and as it turns out, was broken into (for an used phone that I had brought to donate later in Kenya), and my bag of granola had been ripped open so all my clothes were covered in bits of dried fruit and oatmeal. Of course, I only discovered all this later after I hate spammed LATAM on Facebook before getting someone competent to file a complaint with. Minus that absurdly annoying inconvenience that cost me a few days of thumb twiddling rather than going deeper into the Amazon, I highly recommend going to Iquitos.

Iquitos had a particularly interesting history. The town grew as a result of the rubber boom when, you guessed it, Europeans, came to the region. In the late 1800s and early 1900s, these Europeans became fabulously wealthy. Many stayed and started families, introducing new European ideas, culture, and architecture to the area. There's even a building in town called Casa de Fierro supposedly designed by Gustave Eiffel!

Really nice mosaic tiling. Built by indigenous tribes for lavish Europeans.

Casa de Fierro: not quite as good as the Eiffel Tower

When the rubber boom moved on to Southeast Asia in the 1940s, the Europeans slowly left too, only to be replaced by a wave of Chinese immigrants, who similarly stayed and married with locals. It was extremely surprising to find Chinese-Peruvian fusion restaurants, colloquially known as chaufas, all over Loreto (the name of the region).

One aspect of note: Iquitos is hot and humid. To make it worse, there is literally no breeze. Ever. As such, cars are rare sites in Iquitos. Everyone has a motorcycle or takes motos to get around the city. These are basically like three wheeled motorcycles with seating for two or three in the back. Imagine a rickshaw or tuk tuk, except the driver is seated on a motorcycle. Motos are everywhere. It sounds like a biker gang has taken over the city. All day. Every day. The good thing is that because there are so many, they are quite cheap, so sometimes I would just ride to a random location for 50 cents just so I could have a nice warm breeze.

Sunset on the Amazon

The Itaya River as seen from Iquitos (basically an Amazon tributary)

While I was waiting to get the majority of my stuff, I visited a couple of animal reserves and had the opportunity to meet with some doctors based out of Iquitos. My guide for the time was the absolute badass nature guide, Erikson "Eagle Eyes" Salas. This dude has been working for National Geographic, is an avid bird watcher, and basically knows everyone that is anyone in Iquitos. With his help, I visited a rescue center where many "exotic" animals are brought after being found while being smuggled out of Iquitos. Many of the animals are babies whose mothers have been killed, so returning them to the wild is a death sentence. Instead, they are brought here, and if possible, are released when they are mature.

A true Super man

Macaws talking Peruvian politics, unsurprisingly a bit of a shitshow

Caimans: The alligators older, but just as ugly relative

Baby Manatees!

Nicknamed the Military Parrot

Flash Flash Hundred Yard Dash

3 toes instead of 2 

Fun fact: I hate butterflies

But I like taking pictures of them

My visit was a good precursor to my time in the Amazon afterwards, as it made me aware of the innumerable threats faced by the environment and communities in this region of the world. At the same time, I was particularly interested in what medicine and medical technology looked like in this region. For many remote villages, that are upwards of a week away from Iquitos, and all treatments are local, and frequently from the plants and trees that grow throughout the region. Medicine men and shamans are frequently interchangable terms in the region, as many illnesses have spiritual causes. Erikson's father was a shaman trained in the Brazilian Amazon and spent a couple days explaining some of the more popular treatments. According to him, there were upwards of 1000 plants that he knew about. Whether that is true or not, he definitely was knowledgable and interesting. Some names are only in Spanish, but in all fairness, this is the only place of the world some of them are found.

A tuber of Jergon Sacha: boil, squeeze the tuber, drink, repeat 3xs, natural antivenom

Palisangre: Boiled, Prevent infections after mother gives birth

Chuchuasha: A bark, again boiled, water is then drunk, 1 Liter, for anemia in mothers

Ecoja: Male or female fertility, 3 bottles=years of potency!

Murare: Drunk with sugarcane for 8 days, arthritis and rheumatism

Huacapuranas: for uterine or vaginal pus 

Cashew rojo: Burn the leaves, grind, and cover affected regions: skin cancer/lesions

Cortez de camperona: Mix with hubo  for cellulitis

Una de gato:Super common, mix roots with acai, boil, and drink the mix for 90 days, diabetes

Raiz de huacai (acai): roots cut before they touch ground are best, boil and drink for diabetes

Renaquilla: Strangler vine, cut up, boil, Drink 2 oz morning/evening: reduce scar formation

Paico or wormwheat: Lombrices (aka helminths/worms), drink 4 (2 for kids) spoons of liquid for 3 days, no sugar or alcohol at the time, laxative

Anatto or Acheote: UTI, renal, prostate probs, hemorroids, drink only this for 15 days, no hot food/alcohol  

Verdulage:mash leaves, drink extract for 2 weeks: liver problems and kidney stones

Sabilla (Aloe Vera): blend with water for 1 month: Leishmaniasis, skin problems, ulcers 

Medical store in Belen Market: Amazonian consumerism

There's actually a whole street of medical stores...

The second aspect of being a Shaman is the spiritual role of healer. At the center of this process is the use of ayuhuasca. This plant is a recent fad amongst Westerners, but there are many that swear by it. While shamans use ayuhuasca for the enhanced sensory perception that it endows upon the user, many patients using it for the first time find its more immediate effects most notable. Ayuhuasca is a purgative. Within the first couple of hours of taking ayuhuasca for the first time, violent vomiting and diarrhea are common. As such, it is a common treatment for GI issues, although some have said it has cured terminal cancer or untreatable skin problems. After the first couple of hours, the psychedelic effects manifest, due to the DMT-like compound that is supposedly found in the plant. As such, it is also used for patients with spiritually-associated conditions such as sleep problems, anxiety, and other mental health concerns that are believed to be caused by a spirit in this part of the world, similar to Guatemala.

I had the opportunity to witness such a cermony for a patient who was having trouble sleeping. While it was completely dark, being able to listen and record the ceremony was an unbelievable and intriguing experience. While I did not partake in the ayuhuasca (didn't really have a strong urge to purge), the sounds, smells, and feelings from the ceremony are not something I will ever forget. He prayed for my safe travels and health across air, water, and land, and the ceremony was in Portuguese primarily because of his training. Listen to a portion that I recorded here.

As a Westerner and scientist, I certainly had reservations. Evidence-based medicine requires, well, evidence. Controlled experiments that explain what is happening is occurring because of whatever factor you introduced into an otherwise identical situation. When generations of communal, but largely unwritten, knowledge collides with a new influx of medical knowledge developed by others (read Westerners), I was curious as how the two would interact.

Iquitos was the perfect place to explore this interaction. As Iquitos has become more interconnected with the rest of Peru, it has grown and drawn many indigenous tribes into closer contact. There is more money, more opportunity, and a greater variety of goods available in the city. The old way of life of bartering is being replaced by an organized economy where money is king. This means that people who until recently primarily sought a shaman or used plants available around their communities are now in proximity of hospitals and pharmacies as well as the traditional markets of Belen. Talking to locals, you meet many who swear by the medicines of old. They are "more natural" and more familiar to many, especially older people. The younger generation however, is quick to recognize the potential of Western medicine, especially for diseases that have mosquito and fly transmitted diseases that have plagued the area such as malaria, dengue and leichmaniasis.

Science, similarly, has responded in different ways. My visit to Instituto de Investigaciones Amazonia, or IIAP, was basically like meeting a whole group of people that are doing exactly what I am interested in, except in Spanish in the Amazon jungle. Dr. Elsa Salgado was a sweet woman who I met at her home instead of the office due to a power outage. Over a pot of tea, we discussed her background and pursuits. A chemist by training, her job is essentially to study Amazonian plants used by shamans using modern techniques in order to characterize, identify, and isolate the active ingredients. However, with time, she found her role evolve into what is better described as a ethnobiologist or ethnopharmacologist. In addition to using chemical anaylsis techniques including mass spectrometry, gas permeation chromatography, and much more, she spends her time talking to shaman to identify plants used for treatment.

In doing so, she identified a critical gap in the exist infrastructure: the codification of shamanistic knowledge. The introduction of Western evidence-based medicine has resulted in a decline in growing urban areas. In addition, not all shaman are created equal. Whereas doctors in Lima and Iquitos might diagnose a patient with the same condition and subsequently prescribe the same medicine, the same cannot be said for shamans. Shaman don't run blood tests or use a rapid diagnostic test to identify a patient with malaria. Rather, they are more subjective. Finding a shaman you can trust is half the challenge. As such, she has undertaken the monumental task of aggregating this information in a way that is aligned with the movement towards evidence-based medicine. As she said, she is a chemist by training, but an anthropologist by necessity.

Elsa succinctly explained my entire purpose for pursuing the Keegan Fellowship. There are plenty of engineers in the world. They understand, design and optimize machines and processes. But people are anything but perfect. They do irrational things and are finicky, fragile, and easily manipulated. Having an end goal in mind is important, but the journey one takes to get there looks resoundingly different if I am working in Peru as opposed to the United States.

Elsa works represents a bridge between old and new. To get perspective on the new, I headed over to Clinica Ana Stahl, one of the largest hospitals in the province, to meet with Dr. Yuri Alegre. Dr. Alegre served as director for health resource management for the whole district, and as such, had much insight on the tenuous transition from old to new. He highlighted the robust offerings of the hospital, although noted that the distance and cost of coming to Iquitos when patients were sick in remote settings was a challenge. Similarly, the only PET and MRI scanners were in Lima, so patients sometimes could not be fully scanned before diagnosis. Given the high rate of motorcycle accidents, this could be frustrating at times. Because of centralized allocation of many resources, rapid diagnostic tests for patients with malaria wouldn't always be available. However, treatments for suspected cases of malaria, dengue, and Chikungunya were all treated pretty much the same way: rehydrate the patient and then based on further manifested symptoms, follow a more specific treatment plan.

As the gateway to the Amazon, Iquitos recieved a significantly higher proportion of patients from indigenous villages. Despite the growing use of mobile clinics and telemedicine, there were many instances where patients needed more immediate treatment than could be arranged if they came all the way to Iquitos. Injuries such as maiming and snake bites had to be treated using the resources on hand, namely those available in the jungle. Sangre de grado, or Dragon's blood, was used as a coagulant and antiseptic and catava could be used for snake bites. As it turned out, these were plants like those prescribed by shamans.

Dr. Alegre does not believe in shamans and similarly requires more proof about plants before he would ever prescribe them to patients. However, roughly 70% of his patients often seek these options out on their own, and there is little he can do to stop them, aside from warning them of the potential risk of unregulated treatments. For every potential miracle treatment, there are countless others selling snake oil.

Dr. Alegre also highlighted the recent introduction of education and nutrition programs which he hopes will make a difference. Getting over the language barrier is step one, with many of these previously isolated tribes speaking languages other than Spanish. With the process of urbanization, however, this is changing rapidly. As fishermen come to the market to sell their goods, learning Spanish has become necessary. Similarly, young children are taught Spanish in government schools that have been established in previously isolated territory. In addition, the presence of a robust vaccination program was particularly impressive. Coupled with mobile clinic trips to isolated communities, there were impressive efforts underway to vaccinate the youngest generation most at risk for complications from diseases such as dengue.

Why is his hand so big?

Actually into the jungle

I didn't just want to stay in Iquitos. It was time to continue on and explore Amazonia, the name for the entire Amazon River basin region across Peru, Brazil, Ecuador, and Colombia. Due to stupid LATAM, I didn't have as much time as I would have liked, but the time I spent was absolutely amazing! My guide was Jorge, who was absolutely amazing. In addition to his tremendous knowledge of medicinal plants, he had worked in England and Tanzania, and had tremendous perspective on every question I asked. In Peru, the majority of the Amazon is found within Pacaya Samiria Reserve.

As I was there during the dry season, I didn't get to see any big snakes or many of the birds (I can live without seeing an anaconda), but because the water level is low, you can actually get out and walk through the jungle. During wet season, the water level rises 15 meters on average, so while you may see more wildlife, it will be done exclusively from boat because 90% of the land is underwater. Here's just a small sampling of my time there.

That time I swam in the Amazon and saw some pink dolphins and wasn't eaten alive by piranhas

The path doesn't exist until the man with the machete says so

Even then, it barely exists

Red Piranha that I caught while fishing

Big ass tree

Typical community along the river

Unsurprisingly, no electricity. Surprisingly, solar powered stereo system that blasts music that can be heard downriver

I've been skirting around the topic for a bit now, using terms like previously isolated and urbanization. Well, as it turns out, these are basically euphemisms for the destruction of the Amazon, which is happening alarmingly quickly. There are a number of contributors. Logging is the obvious one. Cutting down trees, often illegally, undermines conservation efforts, leads to soil erosion and, loss of biodiversity. Cracking down is hard because Amazonia spans 4 countries and policing is costly and difficult. With logging comes commercial agriculture. Growing soybeans, trees for palm oil, and the million other things that 7 billion humans eat is a lucrative endeavor, and what better way to cut cost than cut down a bunch of forest and claim the land as yours. Its not like the jungle is going to grow back so there's not much to be done after the fact, especially with wealthy and powerful invested parties lining the pockets of the ruling elite.

Government policies have not always been the most useful either. A recently completed transoceanic highway from Peru to Brazil passes through and has devestated portions of the surrounding jungle. Illegal mining operations have popped up and the supposed benefits of a road for transporting cargo have been undermined by the lackluster quality of the roads themselves.

Finally, locals themselves have a role to play. Subsistence farmers have routinely burned down swaths of land, and along with animal husbandry and climate change, areas that previously would be fertile year in year out are less so now. The rains come later and are more unpredictable. In addition, locals similarly participate in illegal logging operations because of the lack of alternative economic opportunity.

One alternative that the government is pushing is farming for aguaje, a purplish fruit with an orange interior that grows in the palm trees. In addition to being delicious and extremely nutritious, it provides a reliable and sustainable source of income for communities in the jungle.

Just an aside. The fruit we eat in the states is tasteless crap. Ecuador and Peru had some of the most amazing fruits, many of which I had never heard of. We call acai a superfood, they just call it food. Try camu camu, maracuya, aguaje, and so many more. 

I had a chance to meet a farmer and was able to climb the palm trees how they do. Basically they use a system of ropes, their body weight, and some counterweights to climb. I actually was pretty good at it and was almost to the fruit about 30 feet up when Jorge told me that scorpians that also like to eat the fruit. I got down very quickly after that.

Chacos: the exclusive shoe for aguaje palm tree climbers. Toe strap adds some necessary stability

Aguaje

We also went looking for some caimans one night. They are nocturnal hunters and the easiest way to spot them is to shine a flashlight along the shoreline looking for the reflection of their eyes. Then, the boat driver turns off the engine, and Jorge tries to sneak up on them. They are notoriously difficult to spot and very easily spooked so definitely a process. Also totally insane. You just plunge your hands into pitchblack water hoping to come up with a relative of the alligator. Kids, don't try this at home.

That's how he jumped into the river...Bear Grylls would be proud 

Sophia. Smart and sassy 12 year old and absolutely hilarious. Made Iquitos feel like home

Iquitos is an extremely interesting city: a mix of old, new, misunderstood, mysterious, unique, and beautiful. I was sad to leave, but I was heading to Cusco for a few days to check off the number one thing on my bucket list: Machu Picchu!

The Andean Highlands

After the stickiness and humidity of Iquitos, it was refreshing to arrive in Cusco where the temperature was a comfortable 65 degrees. While Peruvian, the people of the highlands and the jungle are totally different. The language, history, culture, clothing, health problems, etc. Tracing lineages is also revealing of the tremendous differences in these communities. Again, stupid LATAM cut short my time in Cusco but it was insightful and fun just being an aimless traveller. After visiting Machu Picchu (go in the afternoon and avoid the morning fog fyi), I took the long circuitous road home, stopping in Ollantaytambo and weaving my way through the sacred valley and over to Vinicunca aka Rainbow Mountain. The Incas basically are engineers extraordinares. I couldn't help but marvel at the amazing durability and foresight of their designs. Their urban planning, clever agricultural techniques, and even their water drainage systems left me impressed. Looking at the crapshoot that is urban sprawl in the developing world, I couldn't help but think that the Incas were way ahead of their time. Then, the stupid Spanish had to come and ruin it. 

Here's just a bunch of photos.

On the way to Aguas Calientes

Ollantaytambo, honestly better preserved than Machu Picchu. GO HERE

Incan grainery aka collca

Sacred Valley

Cusco

On the way to Rainbow Mtn

Llama

Vs Alpaca. Difference is the snout length

Llama with a red bow!

On the way out: Lima

My last stop before heading out was meeting with researchers at NAMRU-6. Basically, the US Navy funds scientific research across the world in different areas of strategic interest. In other words, if the US military might get involved in a conflict where a particular disease could prove strategically crippling (think Vietnam), then NAMRU is doing research to find better treatments or a vaccine. In Peru, they are based in Iquitos and Lima. While I didn't get to visit in Iquitos, I spent a day at the facility in Lima. Because the facility is technically on a Peruvian military base, I wasn't particularly keen on pissing off the wrong people walking around with a camera.

There, I met with doctors working on a malaria vaccine, along with a whole host of similar mosquito-transmitted or environment specific diseases. Basically, the facility serves as a research and commercial accelerator. While there is currently a malaria vaccine in clinical trials by GlaxoSmithKline, NAMRU is also working on one because the current iteration is effective only 60% of the time. 

Basically, the biggest cost in developing any drug or vaccine is the basic research that underlies it. Companies can spend almost 10 years and billions of dollars bringing a single drug to market from the stage of drug discovery through clinical trials and commercialization. The biggest time and money sink is the first step: identifying mechanisms of action and subsequently candidate molecules that could illicit a desired effect by leveraging this mechanism. 

Think Edison's quote when asked about his search for a suitable filament for the lightbulb:

I have not failed. I've just found 10,000 ways that won't work

That's basically the research that goes on across universities, research institutions, and pharmaceutical companies. All those hours spent in the lab looking to explain how some specific protein-ligand interaction causes some electrochemical cascade that causes your allergy to peanuts eventually pay off, but think of the hundreds of not thousands of manhours, expensive assays, tests, equipment and reagents that had to be procured before someone finally had that eureka moment.

Now, because pharmaceutical companies are grubby profit-seeking soulless bastards (according to some), they don't waste time working on treatments for diseases that mainly affect poor people. Poor people cannot afford to pay the exorbitant fees that Westerners dish out for the newest cancer immunotherapy, for example. In addition, companies tend to focus on chronic conditions like arthritis or diabetes because they disproportionately affect wealthy people as well as require continuous treatment, providing companies with lifelong clients with fat pockets.

On the other hand, the hundreds of millions of people that get malaria will eventually get better (or die, but let's be positive). Companies can do one of two things: charge high prices for such medications to offset the shorter time period they are necessary (which they can't because they're poorer) or not waste precious and expensive resources with pursuing such interests. The latter unfortunately happens a lot. Hence the umbrella designation of neglected tropical diseases.

Enter NAMRU. They bear the initial burden, and then pursue public-private partnerships to bring a drug to market that costs less for the company. Sure, they don't make as much, but they didn't pay as much on the front end anyway, plus its good PR. A win-win for humanity and corporations (Corporations are not people).

I also spent some time exploring Lima. Here are just some random pictures again.

Plaza Mayor and the Presidential Palace

Seen during my old creepy Church crawl

The crypt

Catedral de St John

Cool urban art

Uncool urban art