7.15.13 Part 2

         Curiously, although there are many more men here at the clinic getting treatment, today there were almost exclusively women. When I asked why the prevalence of HIV in men who come to the clinic is 20% and the prevalence is only 3% in women, they said that it is simply because women take better care of themselves. I would guess that it probably is self-selection in who comes to the clinic. The men who are here are mostly men who engage in high risk behavior, or are have been referred here because they already know they have HIV. But the majority of female patients are here because of sexual violence (too many) but others were just here doing the responsible thing and getting their free routine testing. But this whole phenomenon baffles me.

This isn’t just in HIV testing, it can be seen across their health care field. Why don’t men come to get routine check ups just as much as women do? Why don’t men go to their years check ups with their Primary Care Physicians (PCP) as often as women do? Women are also more likely to get the flu shot than men.

Why? Is it culture? Does it come from men’s macho attitude? Or, is it more biological? Do women have an instinct to take care of themselves so they can care for their children? Perhaps it is just spilt over from their nurturing instinct. We end up nurturing ourselves, too. Do men have ancient instincts to hunt and fight and give up their life for their tribe? Does this necessarily give them the attitude that they are invincible? Is this attitude the necessary attitude of the victorious tribe and has it thus been selected for over hundreds of years? Do men think that they just won’t get the flu? Or, do they believe that they will be able to fight it off if they do? Both, it turns out. Just look at the diction that we use. One “fights off” the flu or they “succumb” to it. If you succumb to it, you didn’t fight well enough; you weren’t a good enough warrior.

Additionally, the word flu is used so liberally that it has lost its connection to the influenza virus. Whenever we have a cold that puts us in bed we colloquially and even medically sometimes categorize it as the flu. Even at Brown’s “esteemed” health center they categorize every case of the sniffles as the flu – without doing any sort of test to confirm that diagnosis! They hand out diagnosis like candy and this lessens the fear that people should have the flu. When, after a couple of days you kick your “flu” you say “oh that wasn’t too bad; I don’t need to worry about it.” I can “fight” it on my own. I have a “strong” immune system.

How do we overcome this? Well, an angle for the flu is to protect those around you. There are people who cannot get the flu vaccine because of allergies to eggs, or severe immunosuppression. This angle plays on their protector mentality. Do all men feel this way? No, of course not. But, I would argue that those who believe themselves to be “invincible” also generally have strong protector instincts.

But back to the lab. It was pretty slow today. We had only done 14 tests by 10:30. One of those was positive – a 25 year-old male. So now, a councilor will tell him that he has HIV and then they will come back for two more tubes for CD4+ and viral load.

At 11, a man came in to get the test. It was the first time that he had ever gotten blood drawn and he was being a baby about it all. She asked if this was the first time that he had gotten the test and he said yes, it was because he was only getting the test due to a rape. He was walking and a bunch of guys came up to him. He thought he was being robbed so he gave them his wallet but they gang raped him instead. “It hurt so much for me, it was very painful.” By the end of the story he was crying. The nurse went with him to take him to the doctor so that they could treat him.

Then in came another victim of rape with a little card that indicates that she was raped and reported it to the police. She had a big bruise on her arm and the nurse asked if that was from the attack. The girl looked down and just noticed it from the first time. “I guess it appeared overnight,” she said. It was really all swollen up; she had to have been hit very hard. It just makes my stomach turn. I can’t handle it at all. I suppose no one thinks it’s pleasant, but boy does it hit me hard.

Then there was a frail old man who was also crying for some reason. It was this tiny tiny old guy whose dad dies or something like that I don’t know, I didn’t really understand but I wasn’t paying close attention either. It just didn’t affect me like it would have affected me last year or even yesterday. I suppose it’s that professional distance that you get but it made me upset. I saw a skinny sick old man sobbing and felt nothing. It was scary. Made me feel like a robot, like a monster.

I went out to hand out consent forms and across the balcony I saw our BFF. He actually came! He came to get his results, hoping they would be positive. I sat down with him on a bench and he said that they were going to kill him. “Who is going to kill you,” I asked. “The asdfghjkl family,” he said. I didn’t quite catch their name so I didn’t ask anymore. He reiterated though, “one of the biggest crime families in Mexico City is going to kill me.” He didn’t have much time left, he said. I asked him to do me a favor and tell all of his friends to come to the clinic to get tested and to get free condoms. He said no he couldn’t. When I asked him why, he only responded that he wasn’t going to. “But,” I pleaded, “don’t you want to spend your last few days here on earth doing good?” Begrudgingly, he said that he would.

They called him into the office for something and I said that I had to go back to the lab but when he was done that I would be in the lab and he should knock on the door to come talk to me more. But he asked me to wait for him. I said that I had to go. But he just looked confused. So, I asked the nurse if I could leave for a minute. I waited for him to be done and we talked for a little while. Then, the nurse asked him to come with her so I went with her to Octavio’s office. So we went there and I asked if I could keep talking to him for a minute, as we hadn’t finished our conversation. I hadn’t gotten a chance to ask him to be patient with the doctors like Octavio asked me to do and I hadn’t said goodbye either.

They said I could so I kept talking to our BFF. He said he was part of a cartel and that he was going to go to the safety of the United States. To Tucson, Arizona, he said. From there he would make his way to LA. I told him that was a great plan. Then he went off for a little while about my eyes and from there got lost in another God speech about how God will look after me and how whenever I need him he will come to protect me. Then he talked about how I looked like his daughter. I told him to be careful for his daughter’s sake. If the rival family wants to hurt him, they could go after his family. He had to be careful for her sake. Then he said that I mean more to him than his daughter and launched into another speech that lasted for a while. I only got 20-50% but I think it was mostly prayer, some stuff about my eyes and angles and God and what a terrible person he is. The usual.

Finally, I said that I just really had to go and he said that he would wait until my shift was done so that we could talk for 15 more minutes. I said I couldn’t talk to him outside of the hospital. He begged me to, “just 15 more minutes.” Then he grabbed my hand and tried to take off a silver ring with a rose on it that my mother gave me. I pulled away and he said he just wanted to look at it. But I said no, my rings stay on my fingers. It was a present from my family, I told him. “And the other ring?” he asked. “That one is from my boyfriend,” I said. “We’ve been together for 5 years” I lied. That set off a new level of supplication about how he had fallen in love with me bla bla bla.

Finally I started to realize how good he was at reading people and pushing their sympathy buttons. He craved the attention that I was giving him and he knew just what to say to get me to stay a little longer. It wasn’t malicious, he had just been told he was a terrible person his whole life and then I came along and told him that his past didn’t matter and I told him that the clinic will always be there for him and that. He said that he only came to see me and that he wasn’t going to go to his doctor appointment. I said he had to go to the doctor. Although it might take a while, I said, the people who were going in front of him were all rape victims and needed to be attended to as quickly as possible. He seemed to understand that and respect those people, but still wouldn’t go. Ultimately, I just had to say I really had to go, that I wished him all the best and that I couldn’t stay after work to talk to him.

The more I think about the urgency with which he spoke, the more I worry that he will be outside the clinic waiting for me to walk home. I really hope he isn’t. I worry that he’ll have a goon follow me home. I guess that sounds paranoid, but I’ll surely be looking over shoulder the whole way.

Oh I forgot when I told him that I couldn’t meet him after work, he pulled a bottle of rum or something out of his pocket and downed what was left – about a full cup. You aren’t allowed to drink at all in the clinic or be in the clinic drunk. It was then that I realized he just would never change. I realized that he was a murderer. Yes, he craves love and attention just like anyone else but he just didn’t have the boundaries and if he weren’t to get his way he would, at best, retreat into his world of cartels and drugs. At worst, he would come find me and get retribution for his perceived wrong. Let’s hope it’s the former!

It was pretty slow so at 2:30 I decided to go back. The whole way home I was looking over my shoulder, making sure our BFF wasn’t following me. Then, I went to a restaurant by my house and finally got chicken soup! It was glorious.  I also got some little taco things that I ate later on that night.

7.15.13

            Today was my first day in the laboratory where they do test for HIV, Hep B, C, syphilis, CD4+ (the muy importante immune cells that HIV attacks), and viral load (how much HIV do you have inside you?).

            Nathalie told me to wear bata blanca all white scrubs in the lab. So on Monday I got there at 8:15ish and the two nurses I recognized from getting results previously for counseling. They were seated in a little room next to the room where they do their test. I walked in and introduced myself as Nina and asked if Nathalie had given them a heads up that I would be spending sometimes with them in the laboratory. They introduced themselves a Sol y Guadalupe. They were eating breakfast and so I sat down while they finished that and gossiped about some family dispute.

            Finally at 845ish they meandered into the room where they draw blood. They explained the process: patient goes to counseling, gets registered, comes to lab, they take a tube of blood and run a bunch of tests, give the results back to counseling, and counseling gives the patient the results. They take the paper from counseling, have the patient say their name and present identification to make sure everything matches up with the computer. They then put it on a piece of paper and again into the computer. Then they take the tube, print a label, label the tube. Then they show the patient that their name is on the tube and check it with the ID. Then finally they take the blood. From the tube of blood they take out a drop and put in on a fast HIV test.

            The fast HIV test is a type of immunoassay – similar to a sandwhich elisa that looks for anti-HIV antibodies.  It only takes 15 minutes to do, but this test does have the limitation that one must have had the virus for over a month and a half in order to have amassed the sufficient amount of antibodies.

            Antibodies are one of the ways that your body fights invaders They mark the invader as bad news bears so that other cells can come eat them and they cover the bad guys so that they can’t attack to stuff (like your CD4+ cells). Every person has a gazillion antibodies already in their system to almost every foreign body you could imagine. This is so that a person can begin to respond to an infection the moment it enters your body. But, it takes a while for your body to make enough of the particular splinter-fighting antibody, or chicken-pox-fighting antibody, or in our case HIV-fighting antibody to be detectible. This means that you have to have had HIV for at least a month and a half to have anti-HIV antibodies in your system. So if you got HIV yesterday and take the HIV test today you’ll come out negative even though you’re infected with the virus.

            Once they do the fast assay they send the tube of blood for Hep B, C, and syphilis on every patient that comes through the doors. If the fast test comes out negative, they also send that blood for and antigen test. This looks for the virus itself and thus can detect HIV more rapidly than the antibody test. For example if you got HIV 2 weeks ago, you won’t have high enough levels of HIV fighters (antibodies) but you will have a bunch of HIV in you. This helps to close the possibility of someone getting a negative result and still actually having the virus. If the rapid test was positive, then we take two more tubes of blood and measure the number of CD4+ cells (immune cells that protect you that HIV attacks and demolishes) and your viral load (how much HIV do you have?). This way they can tell that same day how badly you have HIV.

            The women here are curt but efficient. They work very well together and do the blood test, get old results for counseling, and do the rapid HIV test. They are making and effort to learn my name and one of them gave me an info sheet on the test that they use. I think it comes with each box, but it explains the mechanism of the rapid test pretty well... 

MORE TO COME :) check back tomorrow!

7.12.13

I got into the clinics a little later today around 9:30. Even though I got up at 6:30 I just wasn’t feeling leaving bed. So I didn’t. Until 8:30. It was glorious. I read all the news – disturbing, as always. I meandered in at 9:30 and no one blinked an eye.

            Today was fun, though right now that means that we had a bunch of form to files. It was really disheartening thought. They were all of the sexual violence cases, where they got the HIV test and then went to the doctor to get the morning after pill. There were hundreds of forms. It was terrible to think that every small paper was a woman/man violated. Ick. It made my stomach turn. So I spent all morning doing that. The afternoon in comparison was boring. You know you’re bored to tears when filing hundreds of rape cases is the highlight of your day.

            At the end of the day Nathalie came by and said I could go to the lab on Monday so there should at least be some blood there. Better than rape forms.

7.11.13

           Today was my first day back at the clinic since I was sick. It was pretty slow in consejaria (counseling, where I work). But, I did get to talk to a Canadian girl who has been here a while. She is a social worker and is just trying to understand HIV treatment. In Canada she works for a refugee organization that is trying to start up some HIV something somethings. Ok I guess it’s not just the language barrier. I really don’t listen to anything people are telling me. Sorry about that.

            Mexico is fairly accepting of homosexuals but doesn’t teach homosexual health in schools. Four or five years ago they made gay marriage legal in the capital Districto Federal. People from all over the country come here to DF to get married because the marriages must be honored throughout the country. But, there is still a lot of discrimination and anti-homosexual violence that exists. For example, homosexual couples generally don’t show affection on the streets – holding hands and kissing in public is “not a good idea.” But, the clinic is a very accepting and safe place, with guards everywhere so couples feel safe and can hold hands and cuddle as they wait for their results. Well, technically potentially devastating results, but its still really sweet.

            While I was waiting for a bus to take me to the prostitute park (see below), I got to play with an adorable kid. She was only 5, but she was so excited about everything. I showed her the different parts of the clinic, explained the plant reproductive system (in Spanish nonetheless) and then we played The Ramp Game for about an hour. The Ramp Game consisted of her running up and down a ramp. There were variations, of course. She walked on the edge of the ramp, she did it on one foot, she ran, she crawled, etc. It was a great game. My part was to watch. I was really good at The Ramp Game.

            Finally, at 2:00 we went to La Almaneda, a park that is known for its male prostitution. Male prostitution in terms of the clinic means males having sex with males. Our goal was to bring people back to the clinic to get tested, to give out condoms, and to bring anyone who is due for treatment. When we arrived at the park, prostitution was everywhere. If I had just gone to the park as a tourist, I would have never have known what was going on. Octavio, the employee of the clinic who went with me, pointed it out slowly. A group of young 20-something boys siting on a bench, probably prostitutes. Really old guys sitting together? Clients. In fact, the clientele seemed to be almost exclusively old men. It was especially obvious when a young guy was standing too close to an old man, talking. They are most likely bartering over the price and what the prostitute will and won’t do for that price. Once the details are ironed out the couple goes to a hotel and does the deed.

            The majority of prostitutes in the park were homeless. La Almaneda was the lowest of the different prostitute places in the city. Here, a man can buy a night with a man for as low as $15 USD or $150 pesos. Sometimes the guys can get up to $50 USD nights, but these usually include more acts. (I didn’t ask which ones).

            We handed out condoms to anyone and everyone – even the clients. But the lube that we brought with us, now that was special stuff. We gave away 2 tubes to Octavio’s regular study participants (There is a study about paying people each year if they stay STD free that many of these men participate in. This study is the reason I’m here, but its pretty dormant at the moment.) Octavio saved out last tube of lube. After we had walked around the prostitution part of the park, we made our way to a restaurant where a bunch of guys were sitting around a table drinking beer. It was one of the men’s birthday and Octavio had saved a tube of lube for him. It was probably the only birthday present he would receive but his face just lit up when he saw it. To these prostitutes, lube is gold. “Without lube oy yeah it hurts like a bitch, but with lube its just another job,” said one man. From a public heath perspective, lube is very important a) to keep the condom on so that there is not an accidental exchange of fluids and b) so that the anus doesn’t tear and become infected.

            As we rounded the corner, I saw our favorite murderer, prostitute, robber, and rapist! I was so happy to see him alive and well that I ran up and give him a big hug! He picked me up off the ground and said how happy he was to see me. I yelled at him jokingly and asked why he hadn’t come to the clinic to see me and to get his results. He shrugged and said that he was going to start living a good Christian life soon. Good, I said, but why didn’t you come to the clinic? He answered that he did come but that I wasn’t there. I brushed him off and said that I didn’t believe him. I turned to his friend and asked he was going to come to the clinic for his results of the Hep B, C, and syphilis test. The friend answered that he was so I said the friend had to bring our BFF with him. But, we’ll see I'm not very hopeful that either of them will show up. Hopefully next Thursday we will be able to come with a big van so that we can drive them to and back from the clinic.

            After I said goodbye to my friends we kept walking. Because we didn’t have the van this time, we had extra time. We strolled through the rest of the park. Octavio explained that they had just expanded the park a lot and where as before the guys could wander throughout the whole park and do their business wherever they pleased. But after the remodel of the park, the cops now keep them to one corner of the park only. I asked how the police could possibly know/enforce that policy. He said that the police just don’t let them sleep on the benches in the middle of the park, but they don’t bother them when they set up shop in the corner. It’s an unspoken between the guys and the police. We walked through the touristy part of the park for a while until we got to some big monument for something or another.

            On the car ride over I said that I had been cooped up in my apartment so I hadn’t gotten a chance to get to know the city very well. I asked Octavio if he would show me what was what. He became a regular tour guide. Better than a lot of the other ones I’ve had in the past, in fact. We turned down a side street away from the park and he said that he was taking me to a modern art museum. “Great!” I replied and into the museum we went.

            We didn’t buy tickets so we couldn’t see the whole thing but they let us in the lobby. The majority of their pieces have modern detailed takes on old, traditional Mexican art. There was a big sculpture with little seed beads covering it. The sculpture was enormous and from far away, well actually even pretty close up, you couldn’t tell at all that it was covered in these tiny tiny beads. It was a huge sculpture at least 5x5x3ft big. An incredible amount of work must have gone into it. Then, there was a poncho with an indigenous pattern but, it was made by placing thread on top of other fabric. Again, a painstaking interpretation of traditional art. The gift shop had really beautiful, colorful stuff but it was all way over-priced. Regardless, there was just really breathtaking stuff there It was some of my favorite art that  I’ve seen. Fun, vibrant, visually pleasing, awe-inspiring, pieces that require talent and vision. Yeah. Good stuffs.

            Then we started the long walk back to where our car was waiting. On the way, we met another group of male prostitutes. They had an adorable little puppy with them. We stopped to chat and they asked about me. I promised my mother that I wouldn’t tell anyone that I was from the states so I lied and said I was from Eurpoe. Where in Europe, they of course asked. I should have a) changed the subject or b) told them I was from England, but certainly not c) panicked and chosen a random country whose language I did not speak, say France. France, I said. Why France? I don’t know. Honestly, it was the only country in Europe I could come up with. Then one of the boys asked me what my fame was… in French! Thank god I got what he was saying and replied that my name was Nina. I was very scared that he would try to keep talking to me in French or about France, so I went and played with the puppy held by one of the guys/girls.

            This was another mystery that I never did unravel. There were two adolescents from the group that we ended up taking back to the clinic with us in the car. I think I caught them saying “oh we are just two girls, two best friends,” but when asked if they were males having sex with males, they said yes. They also weren’t dressed like girls. It was ambiguous (both their clothing and the situation). As far as I can tell, they were physically boys that considered themselves girls that dressed like boys to attract their gay, males clientele. But, again the whole thing was cloudy.

            Anyway we brought the two of them back. I was in the back with them and they kept trying to ask me questions about France and I had to them. But, I kept asking that I wanted to know about them. Then, they of course would say “ok, what’s your question.” I didn’t have any questions! So where DO you live when you don’t score a client and thus a hotel room? What do you DO? Oh yeah. You’re a prostitute? Hobbies? Really, what could I ask? I stuck to really bland questions like where are you from, how long have you two known each other, etc. They were super open thought and talked about their clients. Sometimes they would have 5 or 7 clients in one day they said! The one said she/he had been with 700 men that past year. That’s a lot. Even if that number is inflated, talk about being at risk for VIH (in Spanish HIV is VIH) They said that sometimes they would book clients for a whole week or clients would take them on vacation with them. They talked about the famous people who had hired them, and how, for the most part, they enjoyed their work.

            Finally, at 5:00ish I went home for the night. It was a long first day back.