Delhi Nov 2014: WHO meetings, friends and art galleries

In Delhi for the WHO meeting on global leprosy strategy and the 2015-2020 leprosy plans.

The Global Leprosy Programme had called about 30 people to Delhi, a mix of Indians, national programme managers and a few researchers for a meeting the next global leprosy strategy. We discussed a range of options. I hope that we shall be able to avoid the elimination target in future. The current plan is to divide countries into the big three “India, Brazil and Indonesia” with the largest numbers of leprosy patients and then a group B of countries with intermediate numbers and others with “Special situations.”

I enjoyed being in Delhi even though the winter is starting there. This means foggy days and cool nights. I visited the National Museum because my last visit was very rushed and I realized that there was a lot of good stuff there. I had a lovely time looking at the sculptures and miniatures. Fortunately there is an excellent audio guide given to the foreigners. Just as well because the labeling is very poor and gives little context to the beautiful stuff there.

My friends' children are now starting to get married. Raganadh and Kalyati. talked about their daughter Solanki"s wedding, they chose a Indian oil engineer husband living in Norway. They had about 1500 wedding guests in two sittings in Hyderabad, awesome. In my evening with Annamma John I heard about the preparations for her daughter’s wedding and we went shopping at Delhi Haat crafts centre and where Annamma bought presents for several different levels of the families. I bought some attractive pearl bangles and Kashmiri boxes to give to people at home.

I also had an excellent visit to the “Nature Bazaar” where people sell organic crafts from across north India. About 70 crafts people were exhibiting here with exhibits ranging from cloth to artwork and camel products. The quality of the work was impressive and better than most shops. I enjoyed browsing and bought soap from Aaorohi, silk scarves for £9 and birthday cards made from camel dung paper. The latter is part of a scheme for using camel products and so helping camel herders in Rajasthan find alternative work. The camel milk soap looked nice but I already had enough soap in my tiny suitcase. My Swedish friend Karin had a stall selling her organic cotton products (Songbird) that she has spent 6 years setting up. People admired the baby clothes and if one just said “how soft the cotton is “ and they immediately wanted to touch it and then bought items. A couple of French ladies came by doing Xmas shopping and they offered her a stall, at a French Mela in December.

I also read the proofs of Jasjit’s book about her mother’s life and death at 107 years and I commented on the medical aspects of the latter. The book captures mataji’s life well from growing up in the 1920s when she went to London to do a PhD, being a mother in the 30s and then retreating into a spiritual life for her last 20 years. The book will be published in January 2015 on Mataji’s birthday.

I always enjoyed being part of Jasjit’s household, she took me to a talk by a Chinamanda guru. I also walked the dogs in the park and enjoyed the garden.
When I was back in Delhi after the evaluation Bushan Kumar went one evening to a fabulous exhibition of “40 years of Indian Drawings” at the Indira Ghandhi art gallery. We arrived very late and had only 30 mins to see the collection. But the curator was curious about a foreigner who arrived late in an auto-rickshaw and took us round the exhibition, it was wonderful hearing her talk about the different piece and hugely enhanced them.

So I had a good balance of work and play in Delhi.

Evaluation Summary Session

Back in Delhi, hearing other states reports , discussing the recommendations.

It was interesting to be back in Delhi and to hear about other people’s experiences. Everyone gave their presentations from the states and common themes of undetected cases and no attention to the neurological aspects of leprosy, the medical colleges sadly provide a poor service from which patients default. The ASAHAS are also key people to the efforts in detecting cases and giving MDT. There is a huge urban/rural divide because there are no urban ASHAS. to fill in the health gaps in the urban areas. There has been a huge loss of leprosy clinical skills post integration. The people who are supposed to be running the leprosy service don't know about leprosy and have frequently been transferred from another service. Setting targets for elimination compounds this but this is a smaller part of the picture.

The hotel is uber luxurious, for lunch we had multi cuisine and one could nibble on Japanese sushi. Whilst I enjoyed it I felt uncomfortable and it did not seem a good use of WHO especially when they are short of epidemiologists in the country office.

We did small group work on aspects of the leprosy programme and Suarabh had an innovative analysis suggesting that we should just look at numbers of leprosy cases rather than prevalence bassed estimates people responded to this but I suspect that nothing will change. The quality of the group feedback was excellent and people had done good presentations, and a notable one on IEC was from a chap with a management background. We also discussed leprosy colonies, The health department doctors are offended by the colonies and talk of no more people going into them and closing them, actually the colonies are organic and all different. The national sample survey which would be very relevant to our evaluation is still not yet available and stuck on someone’s desk in the Department of Health, but it needs to be approved by parliament before it can be discussed with the contributors. It is now years since the sample survey was done and the suppression of results reflects badly on the programme.

The feedback meeting was huge with a full ballroom and the dias crowded with dignitaries. Krishnamurthy gave a long but not critical feedback and did not mention the absence of neurological examination. It also did not reflect the range of data presented on Tues from the states or the group work. Concern about the colonies was again expressed. It is possible that there will be new targets for leprosy, one is to detect all patients before disability. Saurabh and I had discussed this earlier in the week. It would be excellent of this could be the new target because it will circumvent the problem of having to detect fewer cases to be successful. I spoke to Sunil Anand afterwards who was disappointed at the lack of mention for a role for NGOs.

It was an interesting experience, I enjoyed being part of the team, It has been very sobering seeing the situation in Rajasthan and then getting the bigger picture for India. I feel that the loss of skills is associated with integration and that the skills from the vertical programme need to be revamped. I am hopeful that we might be able to have a new slogan and that would energise the programme.

Being a pilgrim and tourist

Visiting the Nathdwara Krishna temple and enjoying the Udaipur palace

We squeezed in a visit to a famous Krishna temple where an effigy of Krishna is uncovered to pilgrims 8 times a day so we sped across the Rajasthani countryside to reach the temple. We removed all leather items and went in without cameras, which was refreshing; every moment is being photographed here. I queued with a woman who came with her family and visited 8 times a day to cover all Krishna's waking, eating, cow-herding and sleeping moments when Krishna’s clothes are changed. She warned me that there would be “a dash” when the doors opened and so there was, we raced across a marble floor to stand in front of Krishna in blue, people cried out with ecstasy but I was unmoved. We then filed past a door where one could make a wish and then rejoined the men. I sensed that Ashok was disappointed by the crush, and I was glad that I had not made a special journey to see the effigy. The best part of the experience had been walking along the streets around the temple which were full of stalls selling interesting religious items.

After our work we visited Udaipur City Place, The city palace is awesome, a huge palace built of white marble and on the lake. The architecture is modeled on a Indian temple and the men's palace has weapons and courtyards with elaborate peacock mosaics and chittras with views over the lake; down in the zenana were silver treasures, the whole complex was an overwhelming collection of Indian Hindu wealth and culture, a contrast to the Muslim Mughal palaces in Delhi and Agra. We peeked around the hotel on the lake there and sat in the windows overlooking the lake. It was a light relief after our hard work in the field and we laughed and joked. We then watched sunset on the lake and the lights emerge on the uber expensive Lake Palace Hotel and the city. We ended our evening with a veggie meal in a garden where a Hindustani vocalist and tabla player played. Back in Jaipur spent the afternoon as a tourists visiting first the observatory and then the beautiful pink mahal

I was surprised by the rajasthani country side, I had expected desert but countryside I Typically N Indias, dry is but supporting small trees and greenery, cows and goats grazing. I also missed an opportunity to revise hindi, if I had revised my rusty Hindi before I l left I could have benefitted more from hearing the many conversations in the field in Hindi. I enjoyed many nice Rajasthani thalis.

Visiting Rajasthan with the National leprosy programme evaluation team

This post covers the 10 days I spent in Rajasthan in Nov 2014 doing the Indian Mid term national leprosy evaluation with other leprosy experts Rajasthan reports about 1000 new leprosy cases each year and so is regarded as low endemic in India and as having “eliminated leprosy as a public health problem”. Paradoxically if Rajasthan were a country it would be regarded as needing special input for its leprosy programme by WHO. We were in teams of 6 and other teams visited Andhra Pradesh, Assam, Haryana, Delhi and dadar Haveli, Harayana, Uttar Pradesh and Maharashtra. We had been briefed in Delhi and given a very detailed evaluation tool to asses different aspects of the programme. We were specifically told not to look for misdiagnosis.

I had interesting team members, Suarav Jain was the youngest and working with the WHO programme in Delhi on vector borne diseases and NTDS, he has worked on leprosy in Bihar, Surath Solanki is from Maharashtra and was previous head of health for Maharashtra, he is experienced in administration and health systems, Dr Thakur is also based at WHO and has worked in leprosy for years, he is an avid leaner, doing numerous online courses on his iPad. Dr Ashok Saxena is head of Dermatology at one of the big hospitals in Delhi and has experience with leprosy and yaws, the sixth member was Dr Vijaykumarn who worked for the Damien Foundation in South India and is now working part time for Lepra-India. Between us we covered a wide range of leprosy expertise. Ashok, Saurav and myself went to Udaipur whilst the other three went to Jodhpur. We had 10 hour train journeys in both directions and then a lot of travelling by vehicle around the beautiful Rajasthan countryside with rolling hills alternating with semi-arid conditions.

We visited a range of clinical and hospitals where leprosy patients were being treated so is a cross-sectional snap shot of leprosy work in Rajasthan. What we found was a small programme which is just ticking over, diagnosing and treating 1000 pts/yr and that there had been a serious loss of clinical skills in leprosy and a the programme was now low priority.

Pappu (32 yr), the patient we saw in a tiny rural PHC encapsulated many of the problems in the programme. The Primary Health Care Centre was a very poorly organised single room with a jumble of medicine boxes on the shelves. He had polio as a boy and then developed leprosy 18 years ago and developed neuropathic hands and feet with severe clawing of the hands and an ulcer on his foot, his leprosy had only been diagnosed this year and he had been started on leprosy MDT treatment, and so far too late. He had Borderline Tuberculoid leprosy years ago and these problems could have avoided with good disability management. it is a v poor reflection on the programme that he has such severe nerve damage. He had not had proper nerve assessment no-one cared about his nerve damage and he had not been told how to avoid trauma or even given dressings. Before we left someone had arranged for him to have a bandage for his foot.

This patient, Pappu then became the touchstone for our future discussions, how can we ensure that patients like him are detected sooner and have their disabilities managed to prevent further damage. We also saw a man with advanced Lepromatous Leprosy and nasal collapse in the same clinic and patients with undiagnosed erythema nodosum leprosum elsewhere. These patients show that there has been severe delay in diagnosis.

Visiting the Udaipur city leprosy clinic was depressing, the building was 180 years old and hidden behind the vaccine programmes building and with abandoned, decaying government vehicles there, one with branches growing through it. There were many Prevention of Disability posters clearly put up for our arrival and then used as wallpaper inside to cover the cracks. The staff here had not been trained in neurological assessment did not understand the WHO grading system for disability (including the District leprosy Officer). They had no records for how their MDT was being dispensed and were not using prednisolone to treat reactions and nerve damage. The day ended with a dramatic storm and water flooded down the walls and the posters peeled off, even though I had been assured 30 mins earlier that these old buildings were sound.

We also visited the medical school and district hospitals. They see lots of leprosy patients here with reactions and ENL but the records were poor and there was little communication with the leprosy programme. Elsewhere we found patients who did not have leprosy but were still on treatment.

Interviewing patients in the PHC was a positive experience because and they were obtaining their MDT close to home, often given by the Acredited Social Health Activist S. The ASHAS seemed bright and engaged, but they are also paid an incentive for diagnosing leprosy patients. When we gave feedback to the state officers and collectors they were very keen to promote health education about leprosy.

After 5 days in the field we met back in Jaipur. The Jodhpur team had similar experiences findings; they also visited a leprosy colony and found it functioning well and the inmates wanted better education for their children. We presented our account and recommendations to the state rural health mission chief medical man, which I did in English with Hindi comments from the other team members. He promised action especially on training, we then impressed a dynamic young Indian Administative Service man in charge of Information Education and Communication IEC) who immediately identified 3 lakh rupees in the education budget to be used for traditional and electronic IEC actives. Two goals for our team! We were a good team, Ashok and Vijay were good at information gathering, SJ and Thakur at analysis , me at presenting and Solanki at speaking the same language as the administrators. I hope that the budget will be really used for leprosy activity and not diverted elsewhere. We then went off for a celebratory lunch of Jaipuri chat and thalis with ladoos, hard dumplings instead of chapatis.

Other conversations about medicine and philosophy

We had other conversations during our long drives across the countryside
Saurav J and I had an interesting interlude when we visited the Vector borne disease state office, to discuss the mass campaign giving albendazole to treat and eradicate Soil Transmitted Helminths in Rajasthan, but they had sent their Albendazole request in far too late. They had requested syrup, easier to give but the drug has poor bioavailability in syrup and is not recommended by the vector programme. The Rajasthanis now had a surplus of syrup which they had given to other state centres to use. There is no Indian data the prevalence of helminth infections in India and so no way of assessing the effectiveness of this intervention. A national worm survey is being planned pre Mass eradication but there is a shortage of good lab technicians to do the survey. These are all interesting ethical and managerial programme complexities.

We also talked about the Indian Visceral Leishmanisis programme and patients are now being treated with a single high dose of Ambisome, 10mg/kg with a 95% cure rate. The case load is also coming down. Miltefosine is little used. The susceptibility of the Indian parasite to Ambisome is extraordinary and a benefit.
Ashok, is head of Dermatology at a teaching hosp in Delhi and has a faculty of about 35 and lamented that the younger dermatologists are not interested in general Dermatology, making money with cosmetic procedures is far more appealing. It is extraordinary to see a specialty being completely changed by money when skin problems are so common and often part of wider diseases. It will also be difficult to reverse this trend.

My Anglican priest godfather died whilst I was in Udaipur so I left flowers for him in a Hindu temple. We had many conversations about death and reincarnation and the Hindu philosophy on this. I remained unconvinced and comfortable with my atheism.

Argentina Overview

I had an exciting and stimulating time in Argentina first attending a pain conference in Buenos Aires and then travelling around the North West and up into the Andes. I loved the country outside Buenos Aires, I was amazed at its vastness, one flies over the pampas for hours. The Andes are the driest mountains I”ve been in, all the rain falls on the Chilean side. Driving up to Aconcagua base camp (Oct 13) was an experience in traversing different rock formations. Aconcagua is also bleak. I also went up to Purmamarca (Oct 16) where rock of seven different colours looms over the village. Higher up I experienced the harshest landscape I’ve been been inn- the San Antonio salt flats at 3500 m harsh, blindingly white, hot and lifeless. Here I posed for my photo of the year 2014, leaping above the salt flats.

I enjoyed the architecture of Buenos Aires, the French fin de siècle style but also the new modern developments down by the dockside. In Cordoba I enjoyed the cathedral and the evidence of the Jesuits whose schools have now changed into universities and the sociology students can walk around cloisters. (Oct10) I enjoyed the Spanish colonial town architecture in Salta, here the plazas became lively after sunset. Many of the town houses have now been turned into museums and one can appreciate the older style of living with a central courtyard with other courtyards leading off the central one.

Argentina is rich in museums. The Latin American museum of modern art in BA has a very enjoyable Latin American collection and also the trendiest coffee shop I’ve been in. In Cordoba (Oct 11) a 19 century house had been converted into a fine art gallery with the central stairs being an essential part of the gallery. Across the road was a modern art gallery. Salta(Oct 16) has one of the most unusual museums, The Museum of High Altitude archaeology where one can see the mummies of the Inca children who were sacrificed in a ritual that had multiple aspects, social bonding and being part of the Inca way of life, intercession for good luck and linking the living with ancestors. I suspect that the families felt that it was an honour to be part of this. I also enjoyed the museum of Andes anthropology, which comprised an female academic’s lifetime collection of Andean artefacts. The last time I was in the Andes was in Peru (2006) but I recognised the textiles, dances and rituals as being part of the same ethnic group. The most memorable museum was the Museum of Memory in Cordoba, set up by a group of mothers searching for their children; they have converted the torture centre into a museum where art and memory work together. In one room the possessions of the disappeared youngsters are displayed: LPs of 60s rock musicians and fashionable clothes, a motorbike, the names of the disappeared are on the wall in a poetic flowing piece, like a flock of vanished birds. I gazed at the cells, one is glassed off and I could imagine the torture going on there, It was immensely moving and the curators had used art beautifully to capture the different aspects of disappearing.

I enjoyed Argentinian wine at two very different vineyards, one very traditional with a small cellar and techniques similar to the 18th century. A Dutch investor had developed the other Salentien, and created a 21st century winery with state of the art temperature control, steel vats and the barrels for aging set in a modern surrounding. There was also an art gallery and sculpture outside. We enjoyed a gourmet meal in a modern Scandinavian style dining room.

My historical and political guide for the trip was superb Argentina Reader. History, Culture, Politics. Ed Gabriela Nouzeilled & Graciela Montaldo Duke Univ press 2002. This book combines history, social comment, speeches and stories from each of the main periods in Argentina’s history. From this I learnt what a violent past the country has and how human rights have always been a low priority. I also understand how important Peron was because he took on the cause of the workers and the Shirtless. He established state provision in Argentina and the health and education systems remain.

There are still interesting parts of Argentina to explore, the huge glaciers in the South and the sea life. Next time I would learn some Spanish before I went to improve communicating with people.

Salt pans and coloured rocks

Searing hot whiteness of San Andreas salt pans, coloured rocks of Pumamanca.

Went on an English guided trip up to the salt pans of San Andreas. My companions were a pleasant trio (Dutch, Italian, Belgian] from a neuropsychology lab in Brussels and working on pain. Our guide was a surly chap, he was late and then gave us almost no time at the beautiful village of Pumamanca with its amazing 7 colour rock with bands of red, brown, purple, and blue towering over the village. 
The scenery was stunning, huge dry rockscapes with. The rocks carved by the wind to look like organ pipes. There were huge valleys with rocks and streams weathering deep fissures in the rock. We went up to the huge salt pans, high but hot under the bright blue sky. The salt varies from being a few centimetres to meters deep and is excavated here. The salt pans form a huge icescape. Our driver got a buzz from a fast drive across the salt. It felt like driving on ice with only white saltscape in all directions. We stopped at a place where salt was forming in small square salt pans, tasted it and jumped up in the air above the icescape, We lunched in San Antonio de Colinas, a rather dour feeling industrial town at 4000 m, bleak and with few people around, I can' t imagine what it must be like to grow up and live there. We descended the rocky valley stopping at a huge viaduct over the river.

Our driver had every Argentinian stereotype; he was contemptuous of women, and laws and governments. He had worked in the silver mines as a machine operator 10 years earlier, then as a long distance lorry driver and flipped in and out of the tourist industry.

We ended the evening drinking in the main square in Salta; I stayed on to hear a local band play under the cadilla. Back to my hotel and packed for my early departure tomorrow.

Salta: Inca child sacrifice and Andean anthroplogy

Salta: Inca child sacrifice in 14century and Andean anthropology

Started the day with a long sojourn in a cool cafe reading about the appeal of Peronism which is rested on his appeal to the working classes, an ability to improve services for people combined with a sense of possibility and nationalism. I can see how it worked well here. The free government health services and free education system are still good, funded by taxes and valued by people.

My first museum stop was at the anthropological museum, Pajcha- Museo de Arte Etnico Americano, an exquisite private collection of an anthropologist who has been working in this region for 30 years. She had journeyed to Cusco traversing the Andean region collecting artefacts, beautiful textiles, brooches and clay figures. They were beautifully displayed over two floors of a house. She was interested in religious iconography and documented the changing depiction of Christ and saints who have acquired local characteristics. St James was very important here. I was taken around the museum solo by a very enthusiastic Keeper who pointed out all the cultural highlights out to me but did not leave me with enough time to browse.

Later I went to the Museum of high altitude archaeology (MAAM) which Andrew Rice would have loved. This is on the main square and is a big local draw. Locals discovered an Inca tomb atop a volcano and in 1999 excavated three children who had been placed there. There was an excellent exposition of the Incan way of life and how these children would have travelled to Cusco for a national celebration and then returned to their locality. They were probably drugged and then froze to death, their death appears to have been peaceful and they were then sat cross legged and entombed on the mountain too. It appears to have been a sacrifice that had multiple aspects, social bonding and being part of the Inca way of life, intercession for good luck and linking the living with ancestors. I suspect that the families felt that it was an honour to be part of this. It is not dissimilar to boys going into the church. There was an excellent video showing the different aspects of the excavation and a medical analysis, CT analysis has shown that the girl had obliterating bronchiolitis. The oldest was a 15 year old, then there was a 7 year old boy and a 4 year old girl. Fascinating stuff.

I had an afternoon of running around in the heat booking a trip to Andean villages instead of the non-existent Tren Los Nubes. Had a nice evening sitting in a open air cafe with pop music and people in their twenties.

Salta colonial plazas and museums

Exploring Salta, enjoying the plazas and museums, the tourist peso rate

I went to Salta, a colonial town close the Andes after a friend (Tom Lytttelton)had enthused about the city and to take the classic train los Nubes (train to the clouds) I flew to Salta via Cordoba, going over a huge salt pan in the mountains then great views of the Andes behind Salta.

Salta was asleep when I arrived, the streets were deserted. I was also in a fix as I had no pesos and the taxi driver and hotel did not accept my USD, and I fortunately found a cafe on the plaza where I could pay in USD, Argentina is running two exchange rates an official one of 8 pesos :$ and a tourist one which is published every day and is 14 pesos : $, this is an official rate not a black market one. The tourist rate makes everything here very cheap.

Salta has an interesting mix of architecture with a lot of colonial buildings. I wandered round the Mueos El Norte which started with Inca clay pots and went up to early 20c steam powered carriages. The museum had a series of linked courtyards.

Salta comes alive after 1700 post siesta and hundreds of peoples walk in the plazas, kids play and people relax and talk to each other. Such a contrast to BA.

Sadly the train to the clouds is not running, so I shall take a bus up to San Antonio which is a similar route but not so interesting.

Had supper on the plaza, salad and beer, I needed a light meal after the heavy gastronomy of the day before.

Mendoza : Art, wine ( Salentien estate) and landscapes ( Valle de Uco)

Pedro took us on a wine tour of 2 wonderfully contrasting vineyards. The first vineyard was a small family run operation. The grapes were hand plucked and then pressed in an ancient press. The wine matures and improves in barrels made of French oak. The vineyard technology had not altered for centuries and they produced a significant number of bottles some of which had the wine aging in them, others from the barrel. The farm house was a lovely 19 c building painted pink and with a lovely garden, the roses were scenting the air. It felt bucolic. Of course we tasted the wine, the reds were interesting but not outstanding and I bought olive oil to salve my conscience.

We drove across the plain and into the Valle de Uco area, with its landscape of vines and poplar trees with the mountains as a back drop. We experienced the ultra-modern Salentien estate, a Dutch industrialist has bought up the estate and invested heavily creating a modern 21 c wine producing operation with an art gallery. We had a gastronomic meal in a stylish dining room with huge open windows looking out to the mountains; I had conger eel risotto and a Sauvignon blanc. The wine factory was beautiful as well, with huge tanks laid out and downstairs even the barrels were tastefully arranged around a central area. Our guide took us into the tasting room which had a stone table and glasses and gave a tutorial on the differences between Pinot noir, merlot, Cabernet Sauvignon and Syrrah. The Dutchman is clearly producing very high quality wines and I suspect is marketing them as a high end product in Holland. There were also sculptures in the gardens and an art gallery with a collection of Dutch and Argentinian modern work. I was bowled over by the thought and planning that had gone into this development; it was a thing of beauty as well as a factory. This is niche capitalism creating beautiful working environments. I was reminded of the glass factory in Devonport where workers have a beautiful location.

We had a fabulous drive back going onto uplands that looked like the Brecon Beacons but then turning a corner and finding ourselves at the top of a huge dry Andean valley. We descended the twisting narrow road to a small village called Las Vegas. The village had trees with pink and green early spring leaves. A striking contrast to the dry valley and showing how a small amount of water alters the landscape. We also came close to the mountains and with snow lying on the ridges. I quizzed Pedro on the social provision in Argentina quite good and similar to the NHS in the UK. One can get emergency stuff done easily but one has to wait for non-urgent operations. The schools are not as good as they used to be. The biggest problem is low pay and many people have to take two jobs to make ends meet. We also saw some government sponsored social housing.

Ended the day with more wine on the very fine open air terrace at the hotel. It was a lovely day combining art, wine and landscapes. The contrast between this and the two wineries will stay with me for a long time.

Mendoza and Aconcagua: trekking in Aconcagua, and experiencing the driest mountains ever

Went with Andrew and Kathryn to trek towards Aconcagua with Pedro, a mountain guide. It was an amazing drive under a blue sky and with stunning views of different rocks. The mountain tops were streaked with snow but lower down there were rocks of different colours, yellow like sand lower down and then blackish rocks with carved patterns from heavy weathering. We passed a dried up river bed with many rock strata visible in the river banks. There were occasional small streams supporting trees and we stopped for coffee at an oasis like town with trees and water.

Aconcagua is 6969m and we trekked up from the tourist centre along a path that goes up to the base camp. We ascended through a bleak dry lifeless landscape, no trees. The only birds were a pair of condors gliding around and a pair of sparrows that emerged to pick at our lunch crumbs. We crossed a swaying rope bridge that had featured in the film "7 years in Tibet" ( filmed with Brad Pitt in Argentina). We also had fabulous views of the Aconcagua face with a glacier that stops abruptly. I saw how complex the mountain is with a black weathered mountain at the front, then a glacier and behind that two peaks with snow lying on them. We walked for about 2 hours, at an altitude of above 4000 not very taxing, the worst moment was when I had to run uphill to catch a plastic bag that was blowing away. I would have lost any eco- credentials if I had let a bag blow away in this pristine park.

Almost at the top of the pass is the multi-coloured "Bridge of the Incas" which is an extraordinary bridge built up from centuries if oxidised salts being deposited. We were very close to Chile, just a few hundred yards up the road.

We had a fine drive back traversing the dry landscape. It is the driest mountain I have ever been on.
Sat on terrace for a beer and then had supper in a restaurant on the plaza. Andrew loves mountains and was plotting an ascent. Kathryn had lived in Uruguay as a child and they will go to Montevideo later. That is the flattest land imaginable so Andrew had to get his mountain fix first.

Córdoba, town, art galleries, wandering

I enjoyed my second day in Córdoba. I wandered around the streets, explored the art galleries and enjoyed my trendy boutique hotel.

First stop was the Museo Freyer in a fin de siècle house and one walks in to a vast reception room with a staircase leading up out of it, it looks very conventional and only later did I realise that some funky modernisation had taken place. This included a staircase covered in black goat fur and panels of plain green light illuminating the front of the gallery. I was very pleased to see Argentine art here after noting the absence in BA. There were some Cezannesque scenes of the fields, portraits both of the rich and ordinary people.

I then wandered around the very modern purpose built Museo of art Moderne and enjoyed looking at some big pieces, one artist made his pieces out of coloured wool, another from overlaid slats. There was also a gallery of photos of Andean people. It was a bank holiday and everyone was out enjoying themselves and relaxing in the sun at the cafes. The cathedral was also busy with a christening going on there.

In the evening I wandered down to old Córdoba and checked out another art gallery, this time in an old town house, with the art works in the former living rooms and a staircase winding up to the upper floor. This had some interesting photos of landscapes and people.

Cordoba, museum of memory and Jesuit churches

Buenos Aires domestic airport is next to the sea and I enjoyed the beautiful sunlight on the sea before flying to Cordoba. I then flew over endless prime agricultural land flat, watered, green with large fields and farmhouses. No sign of cattle.

Cordoba looked rather poor as I drove in from the airport, small houses, low price shops, it feels like "poor America " on outskirts of town; in contrast the centre feels very Spanish colonial and much wealthier. I walked down to the plaza San Martin, and lunched next to a huge old 16 Carmelite monastery. All the churches here are heavily decorated with marble catholic statues which don’t excite me. The Jesuits were very active here and had large churches which remain but also libraries and colleges, this alone of learning was called the mañzana . The colleges that started life under the Jesuits then became baroque building s and are now university facilities of science and social science. I enjoyed the distance that they have travelled. There are still some lovely cloisters around and the social scientists can now walk around cloisters arguing about Argentine society. But I am irritated by the obvious wealth of ten churches and the poverty of the people around.

The most memorable part of the day was visiting "The museum of memory". This is set in a former torture centre next to the cathedral. It was set up by a committee of mothers searching for their children; they have now converted the whole torture centre into a museum where art and memory work together. In one room the previous objects of the youngsters who disappeared are displayed: LPs of 60s rock musicians and 60s fashionable clothes, a motorbike, one then walks through a room where all the names of the disappeared are displayed on the wall in a poetic flowing piece, they looked like a flock of disappeared birds. I gazed at the cells, one is glassed off and I could imagine the torture going on there, upstairs were more interrogation rooms. On the ground floor the central yard had been decorated with a display of light bulbs hanging from the ceiling and in another form one could hear the testimonies of the mothers, sadly not translated into English. The organisational aspect of the torture was captured by a room with a desk. The judicial investigation was also captured with a photo of the court hearing, middle aged people looking very serious. It was immensely moving and the curators had used art beautifully to capture the different aspects of disappearing. I have always been touched by torture and I found this museum very poignant and moving. The museum was more vivid for me through having experienced the disappearance of Alastair and I thought about him a lot afterwards.

Cordoba is lively in the evenings, lots of electro beat coming out of bars and I had supper next a band playing Andean music with guitar, drums and flute with a large appreciative crowd on the streets.

Buenos Aires: sophisticated or shabby?

A city that feels sophisticated to the Latin American traveller but shabby to the visitor from Europe.

I was surprised at how European BA feels; there is French fin de siècle architecture in the old areas in an attempt to smarten the city. 

The inhabitants are rather restrained, and don't feel Italian or Spanish, maybe that is the influence of the German and Polish migrants.

Queuing is the norm and the roads are orderly. 

The public transport system is also European with an oyster like swipe card for the buses and metro. There is an absence of litter.

The population looks very homogenous with no black faces, and only a few Indian ones. This is such a contrast to the multiculturalism of Brazil feels large middle class. The poor state of the Argentine economy is also palpable and the city feels poor, with many cheap shops; but also expensive designer one for the elite and the visitors. (E.g. Florida Street) the women not as fashionable as I had expected. I had looked forward to Spanish type food but Italian food predominates with pizzas, pasta and excellent ice creams.

Modern BA also has a trendy designer side, our hotel had concrete outside chairs which were also waterproof. There were seats in rooms with nylon strings that both looked cool and were comfortable.

I maxed out on Art museums. Started with Museo del bicentario i.e. 200 yrs. of argentine history and exactly coinciding with the independence war in 1812. It was set in the cellars of an old warehouse and illustrated the different periods Argentine history. Omer persuaded a guide to give us a tour in English. The exhibits were even handed but there have been several dictatorships in the 20 c, what makes the country so prone to dictatorships?

We went on a tour around Teatro Colon an early 20century flourish of gold opulence, awesome and clearly the place to be seen, evidence of older Argentine customs are present in the separation of the sexes on higher levels, and widows had their own area behind a grill were they could neither see nor be seen, but they could hear! It was an interesting building to see but I would prefer a modern Opera house.

Omer and I slipped out at lunch time to go round the Museo trabhat, a new building in the trendy dock. It was an interesting collection with beautiful examples of art across the centuries, set in a modern light wonderful space, we envied the secretaries at this foundation who had open plan offices looking down on the dock.

I also had an exhilarating afternoon at the Museo Modern Art Latino Americano with very modern design and interesting art and also a cafe with BA trendies sipping coffee.

This contrasted with the museum of Belles Arte in which 22 out of 24 rooms had art created overseas. The last two rooms had a few examples of Argentine art, including panels of a war in 1848 between Argentina, Brazil and Paraguay which showed the pre-battle beautiful white uniforms of the soldiers and the post battle devastation. I then wondered why so little modern art is displayed in BA. The Museo Belles Artes gave the impression of always looking back to Europe, but this would not apply to 20 century artists. Maybe I need to check out some other places.

I enjoyed being at the pain conference and learnt a lot. It was good to be presenting our interesting results in leprosy patients to the pain community, which we did in a workshop where Omer and I spoke together with Daniel Andrade a bright enthusiastic Brazilian neurologist. Omer has done ten detailed examinations of sensory nerves function in leprosy patients with and without pain sadly we have not been able to identify a unique propain. We can see that interesting profile that leprosy patients have a unique sensory loss . We also heard that other workers are also not identifying unique profiles for diff types of pain in patients. It is good to be adding our data to the data bank. There were also excellent presentations on treatments for neuropathic pain; this is also a challenging area where one doesn’t find unique responses. Also learnt about questionnaires for assessing pain. I also hope to collaborate with the Brazilians in the future.

My first impressions of BA are that it is shabby, quiet, unLatin, but also cosmopolitan and trendy. It has Italian food, French architecture and 21 century museums.

Dubrovnik Nudist beach on Lukom, panorama from cliff

Swam several times, took the ferry across the harbour to the island of Lukom. Tried the nudist beach there, I was looking forward to nude swimming but the beach was on harsh rocks that were too hot to lie on. There were no women there, and instead there were toned and tanned gay men. So I retreated to the woods and walked across the island. And had an excellent lunch of octopus and grilled veggies.

Back in Dubrovnik I took the cable car up to the old Napoleonic fort. I had gone to see the war photo exhibition about the shelling of Dubrovnik but I was enraptured by the panoramic view and I had a long, long coffee enjoying the view. The war exhibition was set in a series of five domed store rooms, lots of photos of the Serb shelling of Dobrovnik, incredible that they felt that they could do that given it's UNESCO status. But I was a bit war photoed out and preferred the view.

Had a nice place for my supper in Lapad but the food was nowhere near as good as the previous night at hotel. More ghastly crooners instead of jazz at night. last night, early start for the airport tomorrow. What a great holiday.

Dubrovnik: Walls of Stone, heart of Art

Swimming in the Adriatic, exploring the city, walking out to modern art gallery.

Had a relaxed start to the day with a fine swim from rocks at Lapad. The Adriatic is lovely to swim in, clear and warm.

I enjoyed walking around Dubrovnik and having long pauses for coffee at cafes with good views. This included a long view down one of the city streets and later on a view over the harbour. I visited the Franciscan monastery and looked at the old pharmacy, which was a rather static museum piece and needed a lot more explanation. The modern pharmacy just outside the monastery felt more alive with the various healing oils they were selling. I skipped the religious paintings and instead enjoyed sitting in the cloisters. Dubrovnik has an annual festival and this year strap line is "Walls of stone heart of Art". I felt as though I have experienced both.

In the afternoon I walked out to the modern art gallery, this was one of the galleries I had not seen on yesterday's museum blitz. I was almost the only visitor. The Croatian work was rather derivative, I could see quasi Renoir, Cezanne like works. Upstairs was a retrospective exhibition of a painter who is 90 and paints works that have a theatrical quality with figures interacting. His work was much easier to understand after seeing film about him. He had been to art college just after the war and was a member of the Russian academy of arts, a reminder of previous alliances.

In the evening I swam again and then had an excellent supper of sea bass with a mass of Swiss chard and potato at Hotel More in Lapad, recommended by Trip Advisor

Dubrovnik: Walls of stone, Heart of Art

The beauty of Dubrovnik as seen from its walls and the variety of life here in the museums.

I picked up a Dubrovnik 1-day card which was good for the walk around the walls as well as eight museums so I then had the challenge of finding and seeing all the museums.

The walk around the wall shows the beauty of Dubrovnik with the contrast between the white stone and the red tiles and beyond that the azure sea. I walked and photographed but was also glad to take a break in the maritime museum where the history of seafaring and Dubronik is displayed. They were very powerful in the 16-18 centuries but were then reluctant to embrace the new steam technology and so fell behind the other seafaring nations. They seemed to pick up at the end of the nineteenth century with the start of tourism here, so cruise ships have been around for a long time.

Dubrovnik took a huge hit from the 1992-3 war and apparently 83% houses were hit. What one can see now is that the red tiles are all very new and of the same age so indicating a massive repair programme. I rested at strategically placed cafes along my walk enjoying the views and rehydration.

In the afternoon I tracked down as many museums as I could. So I enjoyed the Renaissance architecture of the cultural historical museum, inspected the old cells and irons, chairs were big in this museum, with receptions rooms lined with elegant 19 c chairs and sofas and centrepieces of glass-sided sedans for getting around in the wet weather. Marin Drzic is billed as Croatia's Goethe and Shakespeare. His house was tiny and he risked execution for staging plays there in the town in the 16 century. The natural history museum was difficult to track down and initially looked very unpromising with ancient glass cases with stuffed birds. But they had used their money to create lively modern displays about sea life. The molluscs one was especially imaginative with shells hanging in clear plastic spheres in the centre of the room and looking like a piece of modern art. So I managed to see 6/8 museums and also have multiple coffee breaks in nice squares.

Back at the hotel I had a sunset swim and then enjoyed a jazz trio (sax, guitar, double bass) who were playing outside my hotel.

Dubrovnik feels lively, stylish with interesting shops and an interesting history because not colonised for significant period. Feels Adriatic and very different to Bosnia. And probably also inland Croatia.

Queues for Croatia and Dubrovnik

Walked around Mostar and visited a Turkish house to see typical Mostar life. The house was arranged a courtyard with a well now turned in an art piece with water running over five coffee pots soldered together. The largest rooms were upstairs. Here the women wove rugs at a loom, there was a large sitting area , a small bedroom, but leading off the area was an elegant domed room, again for guests with fabulous views of the river and mountains. A nice place to receive guests and drink Bosnian coffee.

I wandered through Mostar and saw the damage from the 1992-3 war between Serbs and Bosnians . The town was heavily damaged and although a lot of repair work has been done I walked along one street with a 19 c Hungarian facade clearly about to collapse. The destruction of the bridge was an iconic event . There is a film about the destruction and the rebuilding of the bridge, the early material of the old bridge is all in grainy film archive material, one then sees the soldiers of the bridge and the explosions that destroyed it. The bridge was later rebuilt and reopened with international celebrations and boys again dive from it, now for the tourists. In one of the guard houses I looked at a collection of war photos by a German photographer Wade Giddard. These black and white photos captured the different aspects of war and again were very moving. I wished that I could have stayed longer in Mostar.

We then had a 2 hour delay at the Bosnian-Croatian border because there were too few guards to process the papers of the coaches and lorries, one chap ahead of us had been questioned. We then saw a 4km queue on the Croatian side of cars waiting to enter Bosnia.That made our wait seem short.
We lunched at small promotory of Bosnian territory that reaches down to the Croatian coast.
 
When we reached Dubrovnik I raced into it with Joanna, Lori and Marikje. We sat in the main square drinking coffee and people watching. Dubronik looks like Venice with stone instead of canals, there are vast cathedrals with marble altars and baroque houses everywhere. The tourists were smart and affluent, such a contrast to Mostar .
 
Mostar was full of war but is also recovering, Dubrovnik feels very Mediterranean and touristy, but also a nice place to hang out for a few days.

Walk to Lukomir, Bosnia’s highest village A 4 hr walk to an old summer village, evening in Sarajevo.

We started with an hour long transfer past the village built for the 1984 Sarajevo Winter Olympics. Samir is very proud of these Bosnian landmarks.

Our walk started next to a group of old wooden mills driven by water.

We walked through the beech forest and then came to the edge of a canyon, then up and along a ridge to a small ancient village. The village had been there since the 14 c, outside the village were typical ancient tomb stones, these date back to pre-Ottoman times here and are pentagonal in cross section and weigh about 2.5 tons and nobody knows how they are made or what the represented. They are typical of the Bosnian, Serbian Croatian region and may yet be granted UNESCO protected status. The village comprised about 30 stone houses with wooden shingle roofs, but now many of the roofs are protected with tin instead and this is rusting and lacks the beauty of the wood. The houses are very simple inside, one woman cooked us lunch of a typical potato and cheese filed filo pastry like pie. we also drank coffee from tiny cups. The village is now abandoned in winter and the inhabitants move-down to stay with children who live in the outskirts of Sarajevo. I wonder what the children make of the move and how they cope with the arrival of sheep and hens. The village still feels very self-sufficient, there were potato patches, sheep grazing and hens pecking around. The women knit socks and I bought a pair of multi coloured socks with a geometric pattern on them which I can show off in winter. The men carve wooden items. The village is growing in different ways, some new houses are being built, a bar has opened and the mosque is being repaired and there were about 20 people there on the building site , inside and beyond the building was a working prayer hall with a mirab, green pulpit and carpets facing Mecca. The village is opposite an area of heavy forests but also quite inaccessible. We then drove back over the bleak rocky landscape. it was also v hot., it has been the first day when it has not rained.

In the evening we then walked down to Sarajevo for an excellent supper in an old brewery where the beer was better than anywhere else so far; it has been very bland and I also enjoyed a dark beer, the only one I have seen in Bosnia. Also had nicer beer than before. We ended the evening with Sarajevan ice cream.

Today’s contrasts were between the socialist architecture of the 1960s Olympic village and the stone buildings in Lukor. This village had the timelessness of high mountain locations. It was especially interesting to see this village because there were no villages in the Sujtska national park.

The beauty of Sarajevo contrasts with the horror of Srebrenica

We left the beautiful rocks and forest of the Sutkksa park, drove through a Middle European landscape with small villages and farms to awards Sarajevo. The many rocky canyons also illustrate the mountainous terrain. Sarajevo is bigger than I expected and lies in a valley; we had fine views of the red roofs of the houses the old centre of the town feels Turkish in the centre, with large mosques and old caravanserais. We also went round the ottoman library. A notice outside said that this had been destroyed in the 1993-5 war by Serbian criminals and 2 million documents destroyed and it has just been rebuilt with exquisite decorations but sadly no books. I also visited the spot where Archduke Ferdinand was assassinated with an old fashioned museum but I understand the event better and learnt that there were several potential assassins.

As one walks along the main Street in Sarajevo one can turn at one point and the vista changes from being Turkish to 19c Austro-Hungarian with high stuccoed buildings, shops, boutiques and both orthodox and catholic cathedrals. I also saw the synagogue.

The afternoon was sobering because I visited the gallery 11/07/95 which is a gallery devoted to remembering the Srebrenica massacre and the siege of Sarajevo. The Srebrenica massacre took place in 1995 and was done in a town that the UN had designated a safe area but the Dutch peacekeepers were unable to protect the people and the Serbs separated out the men and massacred 8000 with Ratko Mladic saying this was to avenge a previous Serbian defeat. There was a very powerful film showing the events leading up to the massacre mixing film footage and comments by people who lost relatives in the massacre. The task of identifying the dead is only partially done and despite even decades of work will never be finished. The photos of the events are in black and white and are high quality and well curated and create a powerful and saddening story.

I came out feeling sombre and sat in a cafe wondering how further massacres can be prevented. In am sure there are going to be massacres in Iraq.

In the evening we were sans guide for our meal so I found a cafe in the Turkish quarter that could take 13 and suggested to everyone that we went there, it avoided the problem of a large group being unable to decide where to eat. Sarajevo is heaving with people out enjoying themselves on a Sat night, maybe even more because of Ramadan. After enjoying an excellent ice cream in the throng we sat at an open air bar drinking beer and feeling as though we were in Vienna.

It was a day of contrasts, the Ottoman versus Austro- Hungarian aspects of Sarajevo, the horror of Srebrenica and festive throng on the streets of Sarajevo.

Climbing Mt Maglic (2886m) and lunch in Montenegro

This was the big hike, 9 hours circuit round M Maglic in Sutjeska Park. The omens were not good because we woke up to thick mist in the park and then drove up to the starting point. As we set off there was no sign of the peak we were ascending. We walked for an hour or so through scrubby forest. Then we started to ascend and had a long climb up. This also involved doing hand to hand climbing over rocks and three pieces holding onto a wire cable. Joann and I were right at the end, both struggling. When we reached the point below the summit we were in thick fog, so we let the others go up for a peak view of cloud. I knew that I needed to conserve my energy for the next six hours walking and I wanted to avoid any further climbing.

We then descended across rock and grass, with beautiful clumps of alpine flowers . After an hour's descent we stopped for lunch and the mist cleared to reveal a stunning view of high mountains with stone valleys, patches of snow and a steep drop down to a green lake. It was magical to have this suddenly revealed. We then had a very difficult descent across the scree, first time for me using two sticks and not a good place to learn, I also felt cautious and ended up dropping right back to the end of the group with Sujan, the other guide. The descent seemed very, very long, endless jumping over stones. We rested by the lake which is used as a summer residence by locals staying there fishing and living off the land. We then walked up and had another long descent, this time through forest, and came out at a sunlit valley but also full of mosquitoes. We crossed and climbed slowly out for the ninth hour of the walk which ended with a 45 min ascent . We were rewarded with stunning views of the light breaking up through clouds onto other mountains. Shafts of light piercing the clouds and illuminated the rocks and trees. Then had a hour slow bus journey back to the park hotel, I really could have done without that long transfer.

We had supper in a local restaurant, again a disappointing veggie option, same veggies as the main course with three slices of cheese and a semolina cone.

This was the biggest walk many of us had done and people are saying it will be their benchmark walk. The other long one I have done is the Larig Ghru through the Cairngorms but that was easier without these technical sections.

Pleasant group of people to walk with, though we don't encourage each other much, all a bit too individualistic. The youngest is a Dutch doctor who lives in London and is about to start training as a haematologist. There are many retired people.

The weather here is very variable, but there had been a pattern even from Berlin. The morning is bright and warm, then the cloud builds up and there is a storm and the evening is then cleared.

Walk in park, views of panorama and Maglić mountain

Our transfer took us up through the mountains through areas of rocky landscape with only short Mediterranean oaks trees as vegetation. The landscape flattened out into plains where sheep and goats grazed.

We stopped at the national park hotel, a large building from the socialist era. We drove on for an hour into the first meeting a logger (possibly illegal) coming down which required pretty good reversing skills by our driver.

We then set off on our walk and started through trees, mixed types we then crossed meadows full of Alpine flowers pinks, yellows, blues. We climbed up a ridge to a peak from which we had amazing views of the landscape, mountains, beautiful rocks sediments visible, walked along the ridge to the point where we had a close view of mount Maglić and also views of the forest, rivers that start up here and other mountains. It is a beautiful landscape, it is very deserted, very little evidence of human habitation. No nomads. Got drenched by a ferocious thunderstorm that penetrated most of our waterproofs.

Had a nice walk back across the meadow and then fantastic views of the ridge which we had just walked on.

5 hours walking

Bosnia, Dubrovnik and Trebinje

Took a taxi to the airport and saw the vastness of new Zagreb with endless socialist flats and more being built.

Zagreb airport is tiny. I had beautiful views of the Dalmatian coast with azure blue sea small cluster of red roofed house and long peninsulas. I could also see how rocky the ground was.

I took a taxi to Trebinje, our first town. More beautiful views, first of Dubrovnik and the bay, then of the landscape here, vineyards on the valley floors, small trees, dominated by bare mountains with their lines of sediment visible.

Trebinje is a lovely town which shows off the different styles of Bosnian architecture, there are old Ottoman gates, a bridge , an old town with a mosque, small houses , two churches and then a modern gate that leads into the Austria Hungarian part of the town with larger houses, and cafes around a plane tree filled square. In the evening this was filled with Bosnians with 80s music playing.
I had the afternoon to myself because I arrived ahead of the group. I really appreciated this and wandered around the town by myself enjoying the cafes.

The group arrived about 6.00; 16 of us and we seem a typical Exodus mix with a couple of couples and an abundance of single women. The oldest is a wiry man who lived in Islington all his life and moved out to St Albans and now comes back to London the whole time.

In Trebinje one could also see the socialist style buildings, I found a large medical outpatients and a very light airy modern post office.

Bosnia is visibly poorer than Croatia with poorer quality goods and not such a range, lots of local produce especially water melons.

Nice guide Samir who has been doing this tour for some time.

Surprised to see Cyrillic script on the road signs and hotel.

Zagreb: Walking round 19 c buildings, museum of broken relationships, live open air jazz.

I walked all over Zagreb, getting the feel of the town. It has a nice 19 c Austria Hungarian centre, lots of cafes and all the museums were closed on a Monday.

The cathedral is rebuilt neo-gothic , not very exciting, The other church has an amazing tiled roof with the Croatian coat of arms. I enjoyed the coffee and the cafes and bars were full of people meeting and talking. They are quite stylish but not aggressively so. I ended the evening in a fine open air jazz bar terrace and with hundreds of night lights on a wall and easy chairs for sitting. A young woman sang jazz classics accompanied by a key board player. Very relaxed.

I visited the Museum of Broken Relationships which is an extraordinary collection of objects that people have donated to mark the ending of various relationships. Romantic love and betrayal dominated and the objects which ranged from bits of pottery to magazines, a setting of the components of an Amstrad 64 to an axe. All had their stories. Many around the theme of love that initially seemed wonderful but then was not sustained, others of women betrayed by their husbands after decades of marriage, the axe belonged to someone who on being betrayed had chopped the betrayer’s furniture up into small pieces and handed it over. It was a strange sad collection, love is a universal phenomenon, betrayal is common, the stories were touching, sometimes the briefer notes were more poignant, one vase had by it: a business relationship that developed into an amorous one and both failed. In others the anger was still very palpable and the museum perhaps allowed people to dump their anger. I liked the philosophical exploration of the museum and was sad that it did not explore relationships between broken Balkan states for instance.

Interesting if rather mournful way to spend the afternoon

18 hour train journey Berlin, Prague, Vienna, Zagreb. Interesting, varied and exhausting

Started with a fast taxi ride across Berlin to reach the Berlin Sudkreuz station where I picked up the Prague train. I then found that this was the sleeper from Amsterdam and I slipped into a vacated compartment, stretched out and slept for 3 hours so catching up on my lost sleep from my very early start.

From Prague I was sharing a compartment with a Japanese music critic who lived in Vienna and a family from Montreal: a young couple who had an adopted Chinese girl. They were on their first trip to Europe. We all used our electronic gadgets; the critic was enjoying classical music on his phone and three of us had iPads. The Canadians were visiting friends and had brought caseloads of maple syrup. I enjoyed the very varied forest outside Prague and I remembered the steep and endless hills of Bohemia from cycling there in 1990. I enjoyed getting out at Prague and photographing the station. The scenery after Prague then flattened out into the Danube flood plain with huge wheat fields, all with ripe yellow plants.

I changed trains at an uninspired modern interchange, Vienna does have a huge new hauptbahnhof which looked like Reading station. But the train to Zagreb was elderly and looked as though it had been doing the Vienna Zagreb run for decades. Here I shared a compartment with 3 Americans and 2 Austrians, one a young chiropractor who got down at Graz and a middle aged woman who got down at Leibnitz. The scenery on the Vienna Graz section was breath-taking, we climbed up through forest with Alpine rocks and peaks, mountain cows grazed at impossible angles on the slope. We then had interesting views of rivers and churches in Slovenia.

The Americans were a couple and a young friend who were using all their holiday for a European trip. They were staying in hostels and moving on couple of days. The two men were engineers working on building gas and oil pipe lines and clearly loved their work.

The last two hours to Zagreb were very long and we had our tickets checked endlessly. Very glad to get here and to have a nice hotel to check into. The World Cup final was in the last stages as I arrived but I was too tired to watch but I did later wake up and had to check the score.

Dutch cousins in Brecon

Showing Welsh caves and mountains to visitors from the flat lands (May 2014)

It was fun having my cousins as visitors to Brecon May 2014, there were three generations, Noor, my cousin aged 69, Willemien (49) her daughter and her children Emma (11) and Martin (8). They flew to Bristol and rented a car, but brought their Dutch speaking Tom-Tom for navigation. Emma and Martin whooped with delight at seeing the mattresses on the floor and the sleeping bags had been organized for them.

We took my mother to Llowes to visit my father's grave followed by a pub lunch in the Radnor Arms. We sat in the summer house and it felt light and Scandinavian with views of the Black Mountains and the green fields and trees of the Wye valley. At the Brecon Beacons centre there were visiting falconers and Emma and Martin were photographed with kestrels and Harris hawks perched on their arms. Martin was bold in his choice of bird but his courage failed him when the fierce bird was perched on his arm.

At the Dan-yr-Ogof caves, we experienced geology in action; we walked deep into the mountain along a path that twists and turns through the active geological processes, there are live stalactites and stalagmites dripping and growing and one sees the force of water on rock in real time. The second cave is called the cathedral because it has vast caverns with deep streams and the so called curtains rock formations are illuminated. It is an extraordinary feeling being so deep inside the mountain and seeing the rocks being moulded. Outside the caves huge dinosaur models prowled on the hillside even though they were dislocated in time and place.

We confined the shopping to a visit to Hay on Sunday where they enjoyed the craft and art shops and the clothes shops. Hay is such a contrast to Brecon; Hay is like Hampstead whereas Brecon is a working county town. I also love showing people around Brecon, there are so many different things there are for them to enjoy.

Madrid Renaissance palaces and Modern architecture

After teaching in Madrid I dipped into the severity of the Spanish Golden Age and contrasted it with 21 c Madrid house.

I was over in Madrid for a weekend, first teaching on Miguel Gorgolas’ DTMH. The students are brave and cope with lectures in English. Many of them will then go for field work In Ethiopia so it is good practice.

After the teaching I had a day as a tourist with Miguel. We drove out on the Madrid plain to El Escorial which is surrounded by the oak trees, the small Spanish variety where pigs are fattened on acorns. El Escorial is an exceedingly severe building with long symmetrical sixteenth century fronts. They are very flat and severe. Inside we walked around the king’s apartments; I liked the tapestries designed by Goya, these had a humane feeling because they depicted life and events. Royal chamber pots were preserved for us to admire. The kings also had a large room for exercise- a renaissance gym, here they could walk around; the walls were decorated with maps of the known world, all surprisingly accurate, so the kings could muse on their possessions as they exercised. The royal family and its vast entourage also changed palace every 3 months which seemed a ghastly upheaval for everybody. We also descended to a chilly mausoleum where the Hapsburg tombs were displayed. Powerful even in death. I was glad to come out into the sunlight.

In the evening we fast forwarded to the twenty first century. We went to a science evening to promote at the home of a Jewish businessman. He had built a new house in the Madrid 7 years ago. It was ultra- minimalist with white concrete walls. No windows were visible at the front of the building but the back had large windows and a living room that opened out and became part of the garden. The swimming pool was next to the house with Hockney blue water and also appeared to be part of the construction. The house also had modern paintings and sculptures in the garden. We sipped wine, ate nibbles from black slate trays. A young Jewish woman scientist gave a talk about her research on melanoma that she was doing at the Weismann institute in Tel Aviv. She had moved there from doing a PhD and post-doc in the US. She was an excellent ambassador about science and talked clearly and enthusiastically about the work, the molecular biology that underlay it and how she was hoping that it would translate into clinical impact.

I also talked to a Spanish neurobiologist about our work on the pain experienced by leprosy patients. I enjoyed the contrasts of the weekend, It is interesting going to Madrid annually and seeing different aspects of the city.

Spring in the Yorkshire Dales

Easter walks in The Dales experiencing springtime abundance.

At Easter weekend I walked again with Les and Vera, this time in their own county. We had a fine 5-hour circular walk that took us up over the moor top and then down into the Dales. We started at Arncliffe village and climbed up Old Cote moor. The landscape there is treeless, open and bleak, later on in the summer there will be heather but now the moors are dark brown. On the moor top grouse sped up from their nests squawking away. We then wound down into Wharfedale past an empty grey stone farmhouse. Down in the valley the fields were green and the curves of the river glinted in the sunlight. I was bitterly cold and had to warm my frozen fingers with soup in the pub in Kettlewell. We then climbed up out of the Wharfedale with beautiful views of the horizontal layers of rock sediment laid down millions of years ago. We then descended through Hawkswick moor to the valley. The sun had warmed the valley and it brimmed with spring abundance. The lambs were skipping around but keeping close to their mothers, both lambs and ewes were numbered so we could see when there was ewe-lamb mismatch. Black and white oystercatchers were pecking for grubs in the pasture and sand martins had arrived early and were swooping up and down on the river surface. In the village there were spring flowers in the hedgerows, daffodils, primroses. The contrast between the grey bleakness of the moor top and the warm spring valley was striking. It was like an Alpine descent when one moves into a different vegetation type.

Easter Day (Apr 20) was bright and breezy and we walked on Ilkley moor, again experiencing the vast openness and the greyness of the bracken. Further down the gorse was in flower and giving the view a cheerful yellow aspect. Up here kestrels were hovering and ready for action. The bracken was not yet out and the view was unadorned. My iPhone weather reading was “6 deg feels like 2” that felt accurate. We were home for lunch of salad and cheese shared with Eve and Aleandro. Then I returned to London to be on call on Easter Monday.

It was a fine way to celebrate the spring renewal.

Team Lockwood at a Leprosy Conference in Le Corbusier’s City. (Mar 2014)

Participating in the IAL meeting in Chandigarh linked into leprosy science and politics and nutured my many friendships.

India has the largest national leprologist meeting so an invitation to speak at the Indian Association of Leprologists (IAL) meeting in Chandigarh, (Mar 2014) was irresistible. I brought my London team, Steve Walker, Saba Lambert (currently in Addis) and David Chandler an MSc student who did a project on the household costs of having ENL, a leprosy complication, in West Bengal. We had to leave our Sudanese colleague Omer Haroun in London because he could not get an Indian visa even though he spent 7 months in Mumbai last year doing new work on neuropathic pain. Team Lockwood stayed in the le Corbusier designed Punjab State Guest house, a 1950s building with a compact design, huge lobbies and mature cedar trees in the garden, we took morning walks by the lake. Our Punjabi hosts organized an excellent conference with talks and excellent open-air parties. The meeting was held in the Postgraduate Institute of Medical Education & Research (PGIMER), one of India’s leading medical institutes where the dermatologists remain committed to the work on leprosy initiated by Bhushan Kumar, a previous head of the department.

The programme included talks from leading Indian leprosy workers including Dr. Vishwa Mohan Katoch, overseas visitors and people working for leprosy in India- NGOs, National and state leprosy programmes. The challenging question of the numbers of leprosy patients in India was mentioned in many talks but more discussion was needed about how to assess the problem now. India achieved “elimination of leprosy as a public health problem in 2005” and this was achieved after patient numbers dropped precipitately between 2003 and 2007. I gave a talk based on my BMJ paper in which I, Vanaja Shetty and Gerson Penna showed that setting targets leads to innovative ways of reducing patient numbers. (1) There was agreement that there is now reduced capacity for diagnosis, highlighted by the talks by Dr. Krishnamurthy and Dr. Sundar Rao.

A new tension is developing because in some districts there will be enhanced case finding which means detecting more cases and this is not compatible with elimination at a district level. I was struck by the presentation of the dermatologist Archana Singal from Delhi who presented data on the numbers of children presenting to her hospital clinic, and showed a significant disability rate in these children indicating that they had been diagnosed late. The Delhi state leprosy officer disputed her data and maintained that there were low levels of children with disabilities in Delhi. The state leprosy officer in Odisha showed that there are districts with high rates, and this is compounded by a huge shortage of trained personnel for the leprosy programme posts. There were two key presenters missing, Dr. Barua from the WHO Leprosy Unit failed to attend, also absent was Dr. Kiran Katoch, she has been closely involved with the Indian national Leprosy sample survey. This was done in 2010 but the results have not yet been published, Dr. Vishwa Mohan Katoch (head of the Indian ICMR) assured us that Parliament would have to discuss the results first. We missed their talks and the opportunity to discuss their findings.

An early morning visit to the Nek Chand sculpture garden was a cultural reward. We were the first visitors and we wandered alone through Chand’s amazing grottos, sculptures and admired his work with figures decorated with glass bangles and abstracts made of old light fittings.
The Punjabis are great partiers and every evening there was an open-air party with abundant booze including Indian style mojitos, food and Punjabis disco dancing. I danced freely and found myself on the conference You Tube next day. When I looked at the clips with my friend Annamma she commented that it must be nice to be so free which is a sad reflection on the trappings of marriage and society.

After the conference I visited Bhushan Kumar and his wife Sarla at home. They have a well appointed house with interesting Indian art and effigies of Hindu gods. Both their children are working in the US, I met their California based IT son with easy openness and an American accent. Bhushan and Sarla retired over 10 years ago but continue to practice. Kumar sees about 10 patients a day in small clinic at the side of his house. It is a real contrast to his days as head of department but also a nice way of using ones medical skills in a low key way.

I was last in Chandigarh 20 years ago and on that visit I then went to visit the Manali valley and drove up to the Rohtang pass. This time I appreciated the lack of traffic in Chandigarh and the organization. I was sorry not to be able to stay on and visit the other le Corbusier buildings.
I travelled to and from Delhi on the fast Shatabdi express. Indian Rail has embraced electronic ticketing and many people showed the travelling ticket inspector their tickets on their smart phones.
I stayed with Jasjit Man Singh in Delhi, she treats me like a daughter welcoming me with green tea even at 3am when I arrived from the London flight and being part of her family enriches my visits. Last time I was there (May 2013) her mother aged 107 was dying; Jasjit had spent years looking after her mother at home. Jasjit is now freer, less sleep deprived and more relaxed, and also on her own spiritual journey. She is an established writer and has written a book about her mother’s life. She writes vividly about her mother‘s early life including a spell as a PhD student in London, marriage to an Army doctor and building an unusual Art Deco house in Haus Khaz. There were family tensions at the end of her life between one son wanting aggressive intervention and others for her to die quietly at home. I suspect that such disagreements are common where ever there are advanced medical facilities.

I left my iPad in Delhi, a disaster because I use it so much professionally. Fortunately I activated my network and within three weeks my iPad had returned to London via Budapest thanks to Leprosy Mission meeting there.

Saba commented on how happy I looked in India, I enjoy being there but it was especially nice having my team there. We all participated in the IAL meeting with different contributions and each took our own lessons from the conference. Many of my professional friends are in the IAL and I enjoyed the warmth of these friendships as well as meeting my close friends .I also met up with many friends and Sujai and Suman Jain from Hyderabad. Sujai was showing photos of his newly adopted daughter aged 6 weeks.

This visit encompassed the politics and science of leprosy, the architecture of Chandigarh and the warmth of friendship.

Lockwood DNJ, Shetty V, Person GO. Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign BMJ 2014;348:g1136 doi: 10.1136/bmj.g1136 (Published 7 February 2014)