Monday, February 24, 2020

Nilotic Jeopardy: Finale

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

Friday, February 7, 2020

Dottoressa events in the USA

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

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

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

Monday, February 3, 2020

Nilotic Jeopardy: The Prequel

drawing by Suzanne Dunaway

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