Haunting, Parasites, Wine, Discrimination…

In the last two weeks, we’ve had quite a number of critical patients arrive at our little outpost. Among them, six patients arrived in a coma, two with malaria, two with typhoid fever, one trauma and one stroke. All awoke from their comas, but the stroke patient is recovering little and a young boy with typhoid fever died. The others look like they will recover. Two babies arrived with severe meningitis and both recovered completely. Three toddler-age or younger arrived with severe pneumonia, breathing more than 100x/minute, and all recovered, none of which at their initial exam I anticipated surviving.

Geraldo (photo) is 65y/o and also arrived in a coma with two weeks (!) of unremitting seizures at home, in good health prior. We treated his seizures and he woke up over 24hr, speaking complete gibberish and quite agitated, likely because the first face he saw was a big, ugly, white guy! We made a clinical diagnosis and began treatment for neurocysticercosis, a brain disease caused by pork tape-worm cysts, mentioned below. After two weeks of treatment, he is seizure-free, interacting normally and will go home soon.

Eduardo (photo), a beautiful and kind 56y/o man arrived in severe respiratory distress, from a small village, a full day away by motorbike. It appears he has had undiagnosed, untreated asthma for years in a country with few inhalers, and none in rural areas, even if he had been diagnosed. Most medication available in Angola was commonly used elsewhere thirty years ago. He responded wonderfully to basic treatment, but suffers from pulmonary hypertension (high blood pressure in his lungs) because of his long-standing lung inflammation, causing right-sided heart failure, called “cor pulmonale” with accompanying severe edema. His treatment is a bit challenging, but he has responded nicely and says it may have been twenty years since he has breathed so freely. He smiles a very warm greeting every day at our early morning talks and says he so looks forward to living, and sleeping (chronic asthma can make sleeping almost impossible), without breathing difficulties. He says he praises a God he’s never known, every day, all day. We are investigating the possibility of co-existing TB, as well.

We have a confused, extremely bright and quiet wanderer living among us, a young man, Neves, who showed up at our hospital about three months ago, and hasn’t yet shared his story.  He is a black man with dread locks who speaks no English, but calls himself an “Americano” (he’s Angolan).  It has been a delight to watch him hungrily devour the words of our morning talks about Jesus and see him sitting around all day reading a bible. The hearts of our team in accepting him and nurturing him have been delightful to behold.  He sleeps outside, eats people’s scraps, asks for nothing… I expect to see Him eating locusts and honey… 

Typhoid fever… Domingas arrived in a coma, after one week of severe fever at home. She was malaria negative and severely dehydrated. We initiated supportive treatment and antibiotics for typhoid fever and meningitis, both possible causes for her symptoms. With no real indication of meningitis, we focused on a typhoid cause. After about 48hr, she regained consciousness and tolerated liquids, but began stooling bloody water, indicating intestinal wounds, consistent with typhoid, which causes wounds in various areas of the body, commonly in the intestines. These wounds can erode through the wall of the intestines and allow stool to leak out of the intestine and contaminate the sterile abdominal cavity, creating overwhelming inflammation, which is nearly always and quickly fatal. For these several days, Domingas’ abdomen had shown no evidence of such a perforation of the intestines, though that she had intestinal wounds was clear. The following night, however, she began vomiting and the following morning her abdominal exam revealed all the physical signs of this overwhelming inflammation (peritonitis), indicating that she had experienced during the night a perforation of her intestines. We “just happened” to have MAF arriving that day to drop off Dr Collins, who was arriving to perform cataract surgeries over these current two weeks. We arranged for MAF to bring a cot and emergently transport Domingas to CEML for surgical repair of her perforated intestines. She arrived in Lubango in critical condition and survived immediate surgery at the hands of our faithful and tireless colleague, Steve Foster. Timing… Wind…

Sometimes I ask my Father to intervene and forget. Three years ago, we gave a truck driver from a city 3-4hr away $500 to pick up and deliver cement blocks. We must advance money often in trust for such deliveries and most of the time, the driver is faithful with our trust. This man we never saw again, though we sought and couldn’t find him and his boss knew nothing about it. The construction was delayed and I asked our Father to haunt him to return our money. As time went on, I forgot about it. Last week he showed up in Cavango and delivered half the money and said he would deliver the rest next month! He said his sister was treated at our clinic and recovered from a severe illness and He knew it was God who healed her. He said his heart was broken about the theft and this prompted his action. Our Father never ceases His pursuit of/for those He loves and He makes use of so many circumstances and people to draw each of us to Himself.

Our supplies are always limited, and I often enter our inpatient wards at night or in the morning and see two patients sharing a single mattress on the floor.  Our inpatients currently and consistently outnumber our mattresses and many sleep outside on the ground near an open fire….

We’ve initiated an anti-parasite program for our region, where any person can pay less than one dollar and receive two medications, taken once annually.  One (Albendazole) will treat a pork tape worm that causes intestinal worms and/or a sadly common disease that, if it grows in the brain, results in mental changes and/or epilepsy.  The other (Praziquantel) kills a parasite that can reside in the intestines, liver or bladder (three types).  The most devastating type in our region attacks the bladder, commonly causing bladder cancer and/or renal failure after years of consistent inflammation. We see so much early death from this parasite, and lost a 40y/o dear friend to this disease three years ago, and once/year dosing in early adulthood will prevent the long-standing inflammation that leads to these fatal consequences.  

The pork tape worm can be ingested in uncooked meat or via feces on food or in water.  If ingested in meat, it migrates to the intestines and develops into an adult, egg-producing machine, and the microscopic eggs are defecated onto the ground. If eggs are ingested (unseen in water or on vegetables), they develop in the host and migrate to virtually any tissue and encyst.  We see many patients with hundreds of cysts under their skin, which are pretty harmless. We had a patient earlier this year survive a ruptured gall bladder (repaired by our surgical colleagues at CEML after emergent transport by our MAF pilots) from these cysts in the organ’s wall, weakening it until rupture.  I’ve seen two patients with a cyst containing a small worm on the sclera (white part) of their eye.  When they migrate to the brain, they cause the above neurologic symptoms and are often debilitating or deadly.  With inadequate cooking over open fires, river/pond water for drinking and wandering animals where vegetables grow (no fences here), these people are ever vulnerable to this and so many parasites.

The latter parasite, called Schistosomiasis, has a fascinating life cycle, where the parasite resides in stagnant water (where laundry is done) and enters the host through the skin of the legs and feet.  It migrates to the intestines, liver or bladder, depending on the type, grows to adulthood (remaining very small) and causes inflammation where it attaches to its host.  From there it produces thousands of eggs, which are released into the environment in either feces or urine and infect snails (!) living in the stagnant water.  It morphs into larvae, which are released into the water, to infect sheep (the definitive host) or humans, where the adult can reside for years.

We’ve put up a 1200m adobe fence around the hospital campus, and we offer a reward for killing dogs, goats, pigs and cows (all harbor various parasites and deposit them on the ground in their feces) that wander onto the premises.  We then slaughter the animal and cook it (well) for consummation by the patients and their families.  Protein of any kind is severely lacking in the whole human population in this region, especially in many of our patients, and they love the free meat.  Win-win!

Interesting cultural tidbit tangent…  When one lives in an area without electricity, it is easy to appreciate what life was like in Jesus’ time.  We have been talking at length in our morning meetings and with our staff about disease transmission and how to avoid picking up illnesses from each other and from the environment, including CV19 and others more dangerous.  We’ve emphasized the common public health admonition that “if you don’t peel it, cook it or boil it, don’t eat/drink it”.  Most animal products bought here at the open markets are salted and/or dried.  Mankind learned well before Jesus’ time that drying and salting food protected and preserved it, while cooking and boiling sterilized it.  Mankind also learned eons ago that alcohol was a preservative for liquid and this caused me to think this week of one of the many, silly disagreements we hear among some “theologians”, this one regarding wine.  

Without knowledge of history or global realities, and with life experience limited to always having electricity and refrigeration, one could surmise that the wine mentioned often in the bible was non-fermented.  If this were true, they would have had to make it daily or, because of lack of refrigeration, it would spoil from bacteria after only a few days, and cause illness to the drinker.  Whereas, if it was fermented wine, it could last for long periods in clay jars, without going “bad”.  The taste of fresh wine in unsealed containers is better than that of old, but neither will cause illness from bacterial growth because of the preservative nature of the alcohol.  At the wedding feast recorded as Jesus’ first miracle, the wedding’s host remarked that Jesus’ miraculously-made (and fermented) wine tasted better and this was note-worthy because typically at cultural feasts at that time, the new wine was served first and the old last, as a matter of custom and honor, because the bland, old wine could better be enjoyed after “a few” cups of the new. The culture in which we live in Cavango has changed little since Jesus walked, bathed, slept, fished, ate, drank (fermented wine), and battled parasites on this earth, and one can visit Cavango and get a very real idea of what it was like 2000 years ago – more accurate and less touristy than visiting Israel!  Let us know when you might visit!

Perspective… A beautiful, knowledgeable, local community pastor/small-business owner from a city visited us this week and told us that he’s been following the US news and said, “Those rioting in the US against “discriminatory” treatment by those in authority, in the most free and “privileged” country in the world, would never survive here, the proudly claimed continent of heritage for many ”. He smiled as he highlighted some stories of almost daily abuse by authorities, which have nothing to do with race, gender or “sexual preference”. “Everyone here is, and always has been, abused by those with power, and we face daily hunger, widespread unemployment, early deaths of our children, no health care vs typhoid fever, parasites and malaria… and we stick together in community and support each other without riots, murder and destruction…” One man’s trash, another’s treasure…

It is hard to describe to our neighbors living outside of the palace… as they return barefoot to their stick/mud huts, corn mash, and grass mats after working with their hands all day in their fields under the tropical sun… the destruction, criticism and discontentment within the palace (US), centered on people mistreating people, the right to kill one’s unborn child, the right to unrestrained sexual behavior/preference, the inequality of US wages (all are globally and historically extravagant), and EMS five minutes away and a doctor and pharmacy on every corner are not sufficient health care access…

Fully half of the world’s population live on less than $5.50/day (!!!!) and median, annual income in the US is $63,000. Many in the developing world literally sacrifice their lives to see their loved ones enter the US, a culture that ungratefully riots around concepts like “privilege” in an environment where every citizen is immensely privileged, comparatively, beyond measure, in so many ways even beyond the innumerable financial opportunities for those willing to work. The US culture, for example, respects and honors individual freedoms more than any culture in history, significant and crazy-unique privilege by any comparative standard, and this is a reality neither in Angola, nor in the majority of the world.

Those in this impoverished culture rarely struggle with discontentment, as they have no expectations of rights, happiness, or ease. What is becoming the trademark characteristic of my own country is virtually never in evidence among my neighbors here, who are thrilled to make $2/day (!) to work on our hospital project (better than the local wage), are abused, mocked and disregarded by those in power in their own country and of their same race, and who have no hope for cultural advancement. They sleep on the ground near an open fire, under a grass roof, get wet when it rains, have no shoes, eat the same corn grits cooked over an open fire of scrounged up dead wood twice daily – every day, see none of the rest of the world, have never taken a “vacation”, love and lose their children, have no plumbing, electricity, furniture, transportation, books, internet, tooth brushes/paste, toilet paper, phone service, and never complain and are not discontented! Thirty years ago, when I was working in northern Haiti, a missionary friend relayed a story to me about how the locally hired hospital cleaners, who lived contentedly in huts with dirt floors, had difficulty understanding their boss’s frequent discontentment with the (imperfect) cleanliness and appearance of the hospital’s “beautiful” cement floor…

The godless direction of the mainstream US culture is revealed in the priority given, both within the church and outside, to our own greater well-being, prosperity and rights and/or perceived lack of the same. It is this focus which is the source of our discontentment. Jesus encouraged a radical “other” way and He invited, those willing, to a passionate other-health and other-prosperity focus, financial and otherwise. As He entrusted His care to His Father, He encourages us to “seek first His Kingdom” and to “care not” for our personal concerns, entrusting them to His capable and loving care…

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