4.17.2014

An East African Materia Medica

Serengeti



Introductory notes: the plants referenced here are ones I have been using in the highlands of north-central Tanzania, at an elevation between 7,500 and 8,500 feet from sea level. The climate is generally moderate, with mornings in the 50s and daytime highs in the 80s. It is the rainy season right now - the flora will be different in the drier months (May to October). Generally, one could find these species in a broad area from lake Victoria in the west, north past Nairobi in Kenya, out to the Ethiopian highlands in the east and down past the Ngorongoro crater in the south.
I reference plants that I have been able to positively identify, gather, prepare and apply myself. Preparation notes are included. Botanical names, as well as Swahili (Swa.) and Maasai (Maa.) names are included if known. Clinical outcomes and observations are from my herbal practice in the context of Wasso District Hospital over the course of about four weeks of work. Patient volume varies; on a typical day there will be five or six patients returning for acute wound care, two or three new acute wounds of varying severity, two or three chronic wounds or infections, and between two and six cases from the internal medicine wards (chronic asthma, diabetes, hypertension, peptic ulcer, HIV and its complications).
Patient diets are generally similar, and quite simple: rice and cornmeal are the chief carbohydrates, and beans the chief source of protein. There are some tomatoes, cabbage greens and carrots used, and occasional meat (goat, beef). Sources of fat (used in abundance) are questionable, consisting mostly of refined vegetable oils. In the context of the hospital, dairy products are virtually absent. One conspicuous factor is the ubiquitous use of soda (often up to six or more bottles a day) which is in large part at the root of the cases of diabetes and gastrointestinal ulcer - the latter also connetected to the near-universal Heliobacter pylori infection and the frequent, indiscriminate use of antibiotics.
This inappropriate use of over-the-counter (black market) antibiotics, as well as prescribed antibiotics in the hospital setting, have led to both gastrointestinal disturbance and antibiotic resistance, particularly in cases of cutaneous staphylococcus infection (but also typhoid and pneumococcus). This makes the use of herbal medicine all the more valuable and important. Wound management in acute cases usually involves simply a liquid iodine solution, though in chronic wounds I used herbal treatment exclusively. Aside from that, unless otherwise noted in discussing specific cases, treatment used was entirely herbal.




Achillea millefolium (Yarrow): truly a wound plant like no other. Luckily, there is a fair supply planted as an ornamental in the hospital garden. Daily preparation involves gathering a large handful of leaves and a flowerhead or two, coarsely chopping, placing them in a bowl and using just enough hot water to cover the herb. Then the mixture is blended and the juice strained and pressed. Yarrow juice is used as a wound wash for chronic ulcerations in cases of leprosy, diabetic foot ulcer, or unaddressed infected wounds. Apply liberally to gauze and use to scrub and irrigate the wound, cutting away necrotic tissue as necessary, twice daily. Saturate and pack gauze into deeper wounds if prurulent discharge is present (wet-to-dry dressing, iodine alternative, very effective).


Zanthoxylum chalybeum (Maa: loisugi): a bitter, pungent preparation is made by collecting the bark (outer and inner, after removing knobs and thorns), cutting into coarse strips, and decocting about one cupful of shredded bark to 1/2 gallon of water for 15-20 minutes. The decoction is yellowish-brown and can be used to irrigate wounds (mixed with yarrow juice) and internally for peptic ulcer and as a bitter digestive tonic, dosed at about 2 ounces of decoction twice a day before meals. One patient (who began his treatment with two days of goldenseal [Hydrastis] powder, 1/4 tsp. twice daily before food but then switched to this decoction) remarked that his after-meal symptoms of burning pain were completely resolved. He had previously tried a range of antibiotic treatments with no success.


Bidens pilosa: I tried this weedy plant as an alternative to yarrow for washing wounds, with limited success. It seems to lack some of the topical astringent hemostatic effect of yarrow. However, it is quite useful taken as a juice for internal use, particularly in cases where vitality is weak, there is anemia and/or fatigue, or the tissue (internal or external) seems in need of drying or toning. When these constitutional signs accompany infection, Bidens provides valuable systemic anti-infective support. This was particularly evident in a case of leprosy, where yarrow and usnea powder helped the lesions considerably, but failed to completely resolve the issue until Bidens was added. The aerial parts are harvested daily from specimens that have just started flowering (no seedheads), the leaves garbled from the stems, placed in a bowl and barely covered with cold boiled water. Then the mixture is blended and the juice strained and pressed. Patients take around two ounces of juice three times a day. The juice will keep at room temperature for 48 hours, but any leftovers should be discarded after that.


Usnea spp. (barbata / longissima): this hardy and cosmopolitan lichen can be identified by the white inner fungal cord (medulla) and the green outer algal cortex which can be "stripped" from the medulla as one might do with electrical wire. It grows at higher elevations, hanging off old tree branches closer to the hilltops, blowing in the near-constant wind. Here you can find it by the bagful. I have been using it primarily as a wound powder, particularly in long-standing damp lesions where I leave it embedded in the tissue for two days at a time before cleaning it out with yarrow/loisugi mixtures. It helps to form a nice matrix for granualtion tissue, while preventing infection and drying suppuration very effectively. In the leprosy case, it actually embedded itself into new skin, forming a sort of hybrid usnea-callous that closed the wound while also providing excellent protection from the pressure and friction that caused the lesions to re-open (Mycobacterium leprae can infect peripheral nerves leading to loss of sensation, certainly the case in my patient). My preparation method involved sun-drying the lichen until it was brittle (thereby increasing usnic acid content, too), then just cutting it for 15-20 minutes with a serrated blade until it became a mass of green powder and tangly white strands. The mass gets passed through a mesh strainer to leave only a fine, green powder which is liberally applied to wounds.
A note regarding leprosy: dressing the wounds is often counterproductive. They are moist and ooze quite a bit, and enclosing the discharge actually retards healing. Twice daily application of usnea powder to replace any that fell off during walking does the trick after a week to ten days, along with Bidens internally and good foot hygiene. Patient was discharged with a big wad of lichen to use and apply as a spit poultice (small amount at a time) should any further wounds develop. He had been in the hospital for six weeks before we began herbal treatment. Antibiotics had been used (internally and topically), along with bleach soaks, to little effect.


Argemone mexicana (Maa: langanum): a britsly Papaveracea with a bright orange latex and beautiful flower, it usually grows as a weed in planted fields. It is used by the Maasai as an immediate antiseptic and hemostatic treatment for minor cuts and wounds - really useful on trail walks. The latex, which flows profusely when any part of the plant is broken, tastes remarkably like celandine's. I regret not having had the opportunity to try it in cases of cholecystitis, though there was one patient who did come through minor theater with that condition. It was a very instructive abdominal exam, with all the classic signs in the right upper quadrant and referred scapula pain too. Ultrasound was inconclusive in her case. She was sent home and told to avoid fats before we got a chance to start herbal treatment.


Zingiber officinale (Swa: ntangawezi): this famous rhizome needs no picture nor description. It is readily available, still covered in red soil, at the weekly market in town. I purchased a big pile of it for the equivalent of about $2. While I made the occasional anti-nausea tea (for Westerners), the main use of this plant was as an anti-inflammatory circulatory stimulant to support the healing of chronic diabetic foot ulcers. I had two patients whom I followed with this treatment, along with caring for their primary wound and conducting daily foot and leg massages to promote lymphatic drainage. The procedure for preparation was simple: grate the fresh rhizome (about 1 TBS), add about 1 cup boiling water, let steep five minutes or so, then saturate a clean cloth with the infusion and apply hot to the foot. Before applying, I would take the leftover grated rhizome and apply it to the dorsum of the foot, then wrap it up. This happened twice daily.
A note regarding diabetic foot ulcers: one patient developed the ulcer after stepping on an acacia thorn which pierced her flip-flop and went straight through her foot, emerging from the top a bit lateral and proximal to her big toe. The resultant abscess had to be surgically opened, and a chronic wound developed. It was about the size of a nickel when I first saw it, and the whole foot was noticeably edematous. She could not walk on it. Daily bleach soaks and antibiotics had not really helped for the five weeks she'd been doing them. Within three days of using ginger and eliminating the bleach, the swelling began to subside and peripheral pulses returned. After about a week, the foot was almost normal in size, and the ulceration had reduced dramatically in diameter and depth (yarrow juice + usnea powder). Her course of antibiotics had ended a few days before. After two weeks she was walking pain-free, the ulceration was gone and fresh pink skin remained, and she was discharged with a big bag of prickly pear cactus pads.


Opuntia ficus-indica (prickly pear, Swa: freisha): an exotic cactus, the prickly pear has naturalized extensively across the Tanzanian highlands. Some specimens I've seen are over ten feet tall, bristling all over with long spines and tiny, fiberglass-like hairs that are perhaps even more of a hazard than the visible thorns. The fruits are starting to ripen here right about now, and can be used medicinally, but I harvested the wide pads by scraping them clean of spines with my knife's edge, then cutting the pads. Some clinical research looks at the fire-roasted pads (used as a food source in the American southwest), but I just went ahead and juiced them fresh. A little water is added to the chopped, cleaned pads (scraped, washed, and towel-dried), then they are blended and the juice is taken, at doses of about 1/2 cup full, twice daily before meals. I used this juice, sometimes spiced with a teaspoon of cinnamon powder if available, for managing elevated blood sugar associated with diabetes.
A note on diabetes: this is a relatively new disease here. None of the Maasai I worked with knew of any diabetics in their community. The cases were in overweight, non-Maasai community members, and staff members at the hospital. Once again, it seems to be a disease of relative affluence connected perhaps to that wonderful American export, the sugary soda, which is shared at almost every social gathering and can be a bit of a branded status symbol. Blood glucose levels are measured here as they are in Europe: in millimoles per liter, unlike in the US where the units are milligrams per deciliter. The conversion is based on the molecular weight of glucose (one mole of C6H12O6 is 180 grams), so 10mmol/L = 180mg/dL. That's a pretty high fasting level! The guideline is 6mmol/L, or about 104mg/dL, for a fasting blood glucose. One staff member at Wasso Hospital went from 10.4mmol/L to 7.8mmol/L in less then a week using Opuntia and cinnamon (and strictly avoiding soda). This result was a bit amazing to me, but isn't out of the realm of possibility (she was certainly pleased). Some confounding factors: I'm uncertain whether she had drunk any soda before her first test (would definitely have skewed the result, but even after a soda your BG shouldn't be 180); two different lab techs conducted the two tests (you might say lab work is objective, but I'm not so sure). Regardless, her BG levels have been a lot better in the mornings with the Opuntia juice than suggested by past test(s).


Aloe spp. (vera, alata, ferox. Swa: msubili): This succulent, rich in soothing gel, is a classic burn remedy. To be honest, I used it mostly for our family and other Westerners transiting through the guest house - but was also able to apply it on the more superficial burns I saw in minor theater. It is excellent to relieve pain and speed healing for superficial burns, but I'm not confident enough in its antiseptic power to recommend it on full-thickness burns after the top charred layer of skin sloghs off. However, with extensive burns, one of the major risks after infection is dehydration - and aloe can help a lot for that. One child who had been sweeping the floor of her home was extensively, though not deeply, burned when her wrap caught fire. Both arms and the back and front of her torso suffered partial thickness burns, and the evaporative fluid loss was high. The healthy skin on her legs showed pretty substantial dehydration, despite a lot of drinking. We used aloe five or more times a day (training her parents on how to apply it), and silver cream just twice over a week, and there was no infection and much less dehydration.
Preparing aloe is fairly easy. You cut whole leaves, then remove the spines on the sides of the leaves (taking care not to cut too deeply and expose the demulcent pulp). Then, simply cut cross-sections of leaf, peel off the green parts, and mush up the gel in a container. Apply liberally to the affected areas. One note: the stuff is remarkably bitter. Wash your hands after preparing.


Phytolacca dodecandra (Maa: ol'diangorras): I was excited to find the orange-red berries of this local species of pokeroot. It grows vigorously, more vine-like than its American cousin, and has a thick and juicy root. With some coaxing, I was able to harvest a fairly sizeable chunk. From this I cut wide slices, which were then pounded and the juice strained out. I used about 1/2ml of this juice on myself at first, then closer to 1ml twice daily for an HIV patient who had lymphatic swelling in cervical, axillary and inguinal nodes. She saw some improvement from this approach - not a dramatic reduction in swelling, but a marked reduction in tenderness. I searched extensively for cleavers (Galium), but was unable to find this species outside of the Ngorongoro crater rim. Needing a lymphatic, I opted to try this Phytolacca and was not displeased with the results. The flowers smell amazing, kind of like lilacs. The Maasai (at least those I spoke with) only know it as a poison plant and warned me against eating the berries.


Eucalyptus globulus (Swa: Makaratusi): These trees were planted by colonists, and now there are some huge specimens, usually along main roads but often in the more secluded (and less fumigated) corners of the villages, by streams. Many trees have been cut down, especially those next to cultivated fields, as they tend to suck up all available water and can contribute to crop loss during drought. Nevertheless, the leaves are abundant and quite fragrant, and I would place whole branches, slightly broken up, in pots of steaming water for patients in the pediatric ward who had chest congestion. The steam smelled nice, nobody complained, and some of the patients remarked that they were breathing more easily after taking big inhalations of the steam. This was especially evident in a case of chronic asthma, aggravated by the dusty conditions here, where eucalyptus steam inhalation provided almost immediate relief. Use a towel over your head for maximum steam concentration.


Olea africana (Maa: ol'orien): These strange looking olive trees live quite a long time, and have thick, gnarly trunks that end in a burst of spindly branches, loaded with leaves and olive-like fruits with little seeds that mature to an unpalatable orangeish color. I harvested the leaves to use as a treatment for hypertension. This condition is relatively rare (most blood pressures were in the 100/60 range) but more and more folks are experiencing higher blood pressures and atherosclerosis these days - even in the Maasai community. I'm not sure exactly why this is. Nevertheless, I'd give out bagfuls of fresh olive leaves, with the instructions to chop or pound a good handful and steep in a pint of hot water, drinking daily in two divided doses. Results took time - at least a couple of weeks - but I was able to see a small but consistent drop (5-10pts systolic) in blood pressures for those taking these leaf teas consistently.
The Maasai used the leaves for malaria and fever. Given their anti-inflammatory and potentially antiviral effects (extrapolating from research on the European cousin of this tree), these traditional uses make sense.


Commiphora africana (Swa: mturituri): I was introduced to this species as a remedy for colds: the resin that exudes from the bark of older trees is traditionally steamed and inhaled. Also, the root of younger trees is wonderfully fragrant and actually sweet - a remarkable surprise. But seeing as how I couldn't find enough resin, and eucalyptus was working well for chest congestion, I recommended the bark of this plant be chewed as a remedy for high cholesterol and atherosclerosis. I am extrapolating here from research on its cousins C. mol-mol (guggul) and C. myrrha (myrrh), and it is too soon to tell what kind of effect it may have had, but between that and the daily 3-4 cloves of garlic I am optimistic. One gentleman accosted me for a consultation on cholesterol and atherosclerosis while I was buying bar soap to do my laundry at the little shop across the street. He needed some exercise too - I suggested some brisk walking and less hanging out at the shop drinking soda.


Urtica massaica: Oddly, the Maasai didn't have a name for this ferocious species of nettle, preferring instead to give it a wide berth on the trail. The stinging hairs on this plant are stiff and potent even after drying, and can be two to three inches long on the stem. The plants grow to over six feet in height, out in the full sun. The sting persists for 24-48 hours, depending on how deep you're stung, and caused an immediate urticaria rash on my skin (U. dioica just doesn't do that for me). So I started using scissors to harvest the green tops, pre-flowering, and would juice them to a dark-green-black frothy fluid. Delicious. I'd combine it with the juiced berries of Cyphostemma (see below) to make a nutritive tonic for anemic patients. One cupful a day seemed like a good dose. Good nutrition, especially for moms and kids, is really important here: many are anemic, blood is difficult to obtain, and malnutrition is rampant.
Another use of this juice was for symptoms of allergy and upper respiratory congestion in Westerners unaccustomed to the dust and allergens of this environment. Half a cup of fresh nettle juice, once or twice a day, reduced eye itching and nasal congestion. Overall, it is a very nutritious, very drying herb.

Cyphostemma serpens (Swa: mwengele, Maa: ol'kilenyei): this viney, trailing plant drapes itself over low acacias and on termite hills. It produces clusters of berries, which the Maasai harvest while still green to use as a food and especially as a tonic for children. The tuberous root can also be boiled and eaten, though I didn't try this. The fruits have an agreeable sour green flavor, and I expect they contain a fair amount of organic acids and perhaps even ascorbates - a great supplement indeed! So I'd harvest clusters of the berries and juice them up, often with nettles, to add into the diets of those needing a special boost. 1/4 cup of the blend for kids, 1/2 cup or more for adults, once or twice a day.
Traditionally, the Maasai add the fruit pulp to milk and feed it to kids to help them grow stronger.


The bitters: I used the bark of Acacia species for this purpose, primarily for myself, my family, and the Westerners with digestive complaints. I preferred loisugi for local folk, as it seems to be more of a tissue tonic for long-standing gastrointestinal inflammation. The acacias are bitter and, depending how they are processed, possess a varying amount of tannins which can be useful if there are digestive complaints accompanied by loose stools or diarrhea.

Acacia nilotica (Maa: ol'kiloriti): this is an excellent and useful tree though, like most Acacia species, it is viciously thorny. It has a characteristic shaggy, dark brown bark and rounded, yellow pom-poms for flowers. The Maasai go at the trunk with a machete, gathering the middle, soft, tannin-free bark layer. The outer bark is very astringent, and serves as an anti-diarrheal. The innermost layer is very bitter, and acts as a purgative. But the soft middle stuff - just right. At special dates two or three times a year, they boil handfuls of it in a goat stew which is eaten to "cleanse and renew the belly". It is moderately bitter, somewhat reminiscent of yellowdock root in flavor, and small sips (1-2 oz) of the decoction before meals improve appetite and regulate bowel function well.
I myself became quite fond of using the younger branches of this tree, adopting another common Maasai habit. Stripped of thorns, they make excellent toothbrushes and lack the inner purgative bark layer. So, after the morning run and before breakfast, I'd walk around chewing on a six-inch chunk of twig, swallowing the bitter and slightly astringent juice, and rubbing my teeth and gums with the juicy fibrous end.


Acacia drepanolobium (Maa: ol'munishui): nicknamed "whistling thorn" because of the big, dark, hollow galls that catch wind with a characteristic whistle, the Maasai use its roots as parturients to help expel the afterbirth. This is actually a big issue in the local community, with many women suffering prolonged post-partum hemorrhages that can be life-threatening. But I didn't use this tree for that. The inner bark makes another excellent digestive bitter, but it is a bit more pungent and almost numbing to chew, reminding me slightly of kava. Another traditional use is for sore throats, which makes sense (though no throats were sore at Wasso). I used an infusion of the inner bark, about 1 TBS per cup of hot water, with a little honey as a pleasant evening after-dinner digestif. Supposedly these trees, which can grow to 15 feet, are the giraffe's favorite food. I witnessed them browsing on some one afternoon. They have some tricky lips, getting around those thorns.
Walking through the bush, you move from green grass, yellow-barked acacias, red soil and a winding stream into denser forest with loisugi, vines, and epiphytes. Then you pass under a nilotica branch and find yourself on rich, black soil in a sparse forest of whistling thorns. There is a hiss in the air. The trees have a conical growth pattern and a grayish, mottled bark. This, along with the dark galls that look like black spruce cones, makes you feel like you just stepped into a grove of old spruce, towards the top of a mountain on the East Coast of the US. For a moment, the thorns look like needles. Then you see two Maasai kids, long sticks in hand, pushing goats through the thicket - and you're back under the hot sun.


Leonotis mollissima (Maa: ol'bibi): I first grew this plant back in Vermont, where I knew it as "wild dagga". I've smoked the leaves, and it is a mild euphoriant (very short acting). Here, it is an ever-present weed. If the bark of the whistiling acacia is a bitter with mild carminative action, leonotis is first and foremost a digestive antispasmodic, and a decent digestive bitter after that. It is a Lamiacea after all. I recommended the fresh leaves, two or three at a time, for intestinal cramps and spasms where it provides fairly rapid and welcome relief. It is similar to horehoud (Marrubium) in flavor and texture, and shares with it the presence of the bitter lactone marrubiin.


The aromatics: there are numerous scented plants everywhere. Most don't have specific uses, though the locals will rub them on their bodies as perfume, both to increase attractiveness and to repel biting insects. One aromatic plant, Hosnum suave, is eaten by hunters to improve focus during early morning hunts and also to disguise their body odor as the aromatic oils exude through their pores ("that's all the animal will smell", I was told). But there are a few that are, like most aromatics, used as diaphoretics, carminatives, and nervines - as pleasant beverage teas.

Ocimum kilimandsharicum (Swa: kirumbasi): spicy and rich in eugenol and camphor, this plant reminds me a lot of O. sanctum (tulsi, holy basil). It doesn't have quite as intense of a bite. Traditionally, it is used for fevers and upper respiratory infections where I have no doubt it functions as a mucolytic, diaphoretic, and antiviral (it is also rich in rosmarinic acid). I mostly recommended it as a tea, refreshing and carminative after meals, and also as a morning beverage for those who didn't want chai or coffee. It's stimulating and enlivening.


Lippia kituiensis (Maa: ol'sinoni): an indigenous species used by the Maasai for its carminative and diaphoretic effects, it is also called simply "wild tea", because its leaves make a delightful, airy, somewhat citrusy infusion that is excellent in the early evening after a day's work. I consider it a gentle local nervine, similar to lemon balm in its effects though less dry. There is ongoing research looking at its potential antimalarial activity.


There are many other interesting plants. Solanaceae: I harvested and dried Datura stramonium leaves, but was unable to convince an asthma patient that steeping them in Konyagi (some kind of distilled Tanzanian spirit that may start with fermented ginger root) was actually going to yield anything medicinal. Withania somnifera grows wild (I did point its root out to a gentleman who was interested in greater sexual vigor, translating the Ayurvedic name "ashwagandha" as best I could). Solanum incanum, the "Sodom's apple", is everywhere and used for everything from scrubbing pots (its gritty leaves) to dressing wounds (the fresh fruit juice), though I never felt drawn to using it. Lamiaceae: wild patchouli was an awesome discovery. Rosaceae: so many different kinds of wild hybiscus, red flowering, yellow flowering, delicate white flowering. Asteraceae: the important Artemisia annua and some of its cousins grow wild, a treasure against malaria. Very few if any plants are truly dangerous, if you're careful about where you step and avoid the thorns. Euphorbia candelabra, which drips a caustic white latex, may be an exception: it blisters the skin and causes temporary blindness.

In the end, I can only repeat what I've said before: plants are communion. If you get to know them, if you allow them to become a part of you by eating them, drinking their infusions, merging their tissue with yours like usnea in a wound, you become part of the land you're in. If you want to know a place, walk outside. Hold people's hands. Eat what grows. You'll never be the same.

So I leave you with one last plant.
Commelina benghalensis (Maa: engaiteteyai): this is a simple and common spiderwort, and grows in shady places. I'd find it covered in dew on my way back home, in the early morning. The Maasai ol'oiboni, or shaman-healer, uses it as a way to bless and protect those who have come seeking health. Dipping the fresh plant fronds in raw milk, he sprinkles the petitioner with the magical infusion, releasing negative influences and promoting wellness and growth. May your life be blessed. May no thorns find your feet. And may you have joy in simple things, wealth in those you love.


4.10.2014

The Dark Side

The Maasai are semi-nomadic. They set up living fences, made of thorny acacia branches covered in spikes that are rock-hard and often six inches long. These branches take root, sprout again, and create an impervious barrier for the "boma" - an enclosed compound with round mud huts and ample space for the cattle and goats to stay safe during the night. Cattle is wealth - the daily ritual of grazing, up the rocky hill slopes to reach the open grass, where the wind is strong and you can see forever, moves life here. And in the evening, when the shadows lengthen and the air gets cold, you hear the bells again and you see the boys driving the cattle back to the boma, long sticks in hand, flowing red and blue wraps covering everything but the bottom of their skinny legs.
The old-timers will tell you with disdain that only animals eat grains and vegetables. To the Maasai, food is meat, milk, and blood. The cows are often bled daily, their life-essence fed to the children. And the family follows the needs of the cattle: they will leave the boma, and move to an abandoned living fence, setting up a new dwelling where they may live for a few months. Though they do not eat plants, they do believe in plants as medicine: everyone takes "ol-chani" (special trees), though many don't remember why. These herbs are often simmered with goat meat, particularly at ritual holidays, and thought to purify, strengthen, and balance they body and spirit.

The Sunjo are agriculturalists. One of the biggest Tanzanian tribes, they wear rich greens, yellows and blues and till fields of maize by hand. The grain, white-kerneled and rugged, is ground into a cornmeal that is boiled into "ugali", a cross between porridge and cornbread. It is rich and somewhat cloying, and is mixed with stewed beans, peas, eggplant, tomato and squash. In some fields you can even see bean vines planted between the cornstalks, twining up in a surprisingly new world way.
Every week, they travel from Sunjo in the East down the long dirt road to sell their goods at the market here in Wasso. You'll find everything from sugarcane to ginger, beans and grains and fruits, recycled sandals and Adidas track jackets, cell phones and gasoline. The banter is cheerful, the faces more round, and the negotiation skills superior. And you find concoctions, "changu", generally dark liquids brewed from a range of unspecified plants. They are sold for stomach troubles (particularly worms and amoebas), malaria and fever, and to build the blood. I find myself a little reluctant to try the formulas, often sold in recycled water bottles with no label.

I've had the pleasure of helping all these folks over the past weeks, and the work had been largely routine. There were wounds from motorbike falls, cleaning knees and shins scraped down to the bone and dressing them, stitching if needed; cleaning and removing the stitches from massive vertical cesarean sections; dressing head wounds in children whose arms are as thin around as a young, green sapling; splinting and slinging the ever-present distal humerus fracture. Yet another young Maasai came in with a lion bite, this time to both of his hands (only his right was fractured, and severely swollen). We are still helping previous weeks' injuries heal, and most patients who come through the minor theater with trauma are doing well.
I have been following my own group of patients. One showed up at our little house asking if I was around and if I had any remedies for the "sugari", diabetes. I was able to point her to a local species of Opuntia, and to the bark of the cinnamon tree - not a bad juice blend. The Maasai elder with probable leprosy is almost completely healed, using only herbal therapy. One small lesion remains on the ball of his left foot, but we hope to have that cleared up by early next week (if he would just stop walking). When he's discharged, he says, he will gift me a goat. The woman with a diabetic foot ulcer is also on the way to complete recovery, despite my own skepticism that we could heal her wound using herbs. But with twice-daily hot ginger compresses, yarrow washes, usnea powder, my own "changu" (details forthcoming soon), and the strict avoidance of bleach soaks, we're seeing daily progress - including the return of a good dorsalis pedis pulse. Many have come in for other troubles, like their severely malnourished children, and lack the funds to take care of the open wounds they themselves have. One young mother, for instance, came to me while I was working out in the grassy space between the hospital wards. Her child was in the pediatric department with pneumonia. But she had a deep, somewhat infected wound on the inside of her big toe, incurred while chopping wood for the boma. She healed quickly - young, strong, and otherwise healthy - and free of charge. So all things considered things are going well, and I am again reminded how excellent herbal medicine is for wounds, as well as for chronic disease. You just have to apply it diligently and consistently.
So another big part of my daily rhythm is gathering plants and preparing medicine for my folks. I am using a lot of fresh plant juices, which are excellent though time-consuming to prepare. My mantra has been "ninaenda kuanda dawa sasa" (I go to prepare medicine now), while I disappear from minor theater during a lull. But I am so grateful to have this opportunity: exploring the land, gathering, making, and applying. I often harvest plants and stick them in my camelback during runs. We come back together as a family at the end of the day, and share simple (and greasy) meals. We sleep deeply. In many ways, this is the life.

This morning was no different. I joked (half through an interpreter) with the Maasai elder that it seemed that a side-effect of his herbal regime was strong morning erections - something he'd been missing. Good enough. I felt the near-scalding warmth of ginger tea on my hands as I wrung out a fresh compress before applying it. I smiled at the kids whose wounds I have come to know as I clean them and re-bandage them, usually about every other day. One of the most heartbraking cases has been that of a five-year-old whose entire right arm suffered full-thickness burns from a synthetic jacket that caught fire and melted onto him. I use aloe on the superficial burns on his chest, but we are using silver cream and vaseline gauze everywhere else. I have to remove and change the bandages daily, and lots of tissue gets removed with them. He whimpers quietly, under his breath, as his mom holds him in a big, white blanket. I can see his pain increase day after day, as more tissue sloughs off. But this morning, like every morning, I still got him to smile after I was done by puffing up my cheeks, sticking out my tongue, and crossing my eyes. White people are weird. These kids are so strong.

Then the first call came in. I knew someting was off when I saw Father Thomas, the hospital administrator and chief medical officer, run across the courtyard from his office. People don't run here, especially at work. Then the 4x4 ambulances started going out. All of them. I was told to gather supplies from the farmacy: gloves, tape, surgical blades, and to make sure we were well-stocked with gauze and bandages. I went right to it. Staff was briefed on the incoming multiple casualty event.
A week or so ago, a Maasai tribesman had been caught as he attempted to graze his cattle in a Sunjo field. This, apparently, was an act of provocation and the Sunjo tribesmen cut him down - killed him. In a story that repeats itself here like the seasons, the Maasai planned and executed an act of retribution. Every morning and evening, a small bus travels from Sunjo to Wasso carrying about a dozen people. This morning, it had been ambushed by Maasai with Somali (American??) machine guns, and machetes. There were mostly high school students on board, a Sunjo driver and some other folks. Apparently, one of the kids walked right up to the Maasai gunmen and attempted to explain that they weren't tribesmen, that they had no quarrel. He was shot in the head.
I ran to the front entrance of the hospital with two boxes of gloves. Someone put a robe on me. Then the ambulances started offloading casualties. We wheeled them into minor theater as they came in, car by car. Anne and Father Franco directed rapid triage - is he alive? I checked for breathing. Nothing. Radial pulse was weak and thready, intermittent. Then I noticed the exit wound on his skull. Soon there was no pulse - we had to move on. Another young man was dead on arrival - a massive slice across his neck had severed his carotid artery. He didn't even make it into minor theater. Anne and I started working on the driver - a large man, probably in his thirties. As I cut off his pants, I saw his foot was fully turned inward, tissue was everywhere, blood was coming quick from his lower leg. As I attempted to elevate his foot and apply pressure, it just flopped free, disconnected from the rest of his leg. He screamed in pain. So I got a splint and secured his leg in place, continuing to strip off his clothes. No other wounds. He pulled at me as I held his bloody jeans and told me "money, money in there". I packed gauze into his leg, trying to slow the bleeding a bit.
Meanwhile, a girl had a deep wound on the top of her head. She was marginally conscious, had a pulse and was breathing well. The skull had been compromised, but hopefully not too much. Father Franco was stitching her up, calling for more lidocaine and yelling "cut" periodically. I helped as I could with local anestesia and scissors, while staying with the driver. Another girl had a smaller head wound, and Teresa, a visiting OBGYN resident from Germany, was stitching her up. She seemed stable. Yet another woman had a gunshot wound to the right leg that had shattered her fibula. Other patients were being treated outside of minor theater, one with a bullet in his pelvis, another with an uncomplicated gunshot wound to his upper leg. They were ok.
Anne had to leave to act as one of three surgeons in major theater attempting to repair the shattered fibula. I stayed with the driver, applying pressure behind his knee in an attempt to restrict blood flow through the popliteal artery. He was going into shock, and we got fluid going into him through a deftly-executed IV (the nurse was so smooth, calm, precise - amazing). While squeezing behind his knee, I squeezed the bag of saline. The foot was pale. His lips were going pale. He was getting cold; we covered him as best we could. A unit of blood arrived, typed and matched from the sample taken from the IV port, and they were ready for him in the major theater. Anne, Father Franco, Dr. Peter and the team would be in there for hours.

I let him go and took a moment to breathe. The young girl Teresa had helped was resting in minor theater. Two other patients came in, walking on their own or with just a little assistance - I was so grateful to see this. I cleaned and dressed a simple, small head laceration (boy do they bleed though) in a woman who was seven months pregnant. How was her baby? Could she feel it move? Yes, everything seemed normal. No cramping. No vaginal bleeding. I shaved between her tight braids, cleaned and dressed her wound. She was shaken, but fine. Another man had a small arm wound that was most likely a graze from a bullet - lucky. No stitches needed.
Cleaning up minor theater felt like an honor and was a welcome respite. We worked slowly, methodically, in silence, mopping up blood and bleaching every surface. When we were done, I looked at the blue gown that covered me from my neck to my feet. Blood. I took it off, folded it, and put it into the bin where we dump contaminated laundry. I walked slowly back towards the entrance of the hospital, now under high security. Police with machine guns. People everywhere, crying. Blood trails on the concrete pathways. There must have been over a hundred people outside the front entrance of the normally quiet hospital.
After checking with Father Thomas I walked out, almost on autopilot, and crossed the parking lot to our little house. My daughter was waiting there, home from school for lunch. I just gave her a big hug for a long time.

All told, there were eleven casualties. Two died. Four had major wounds. Five had minor wounds. I will tell you, herbal medicine is fantastic, even for first aid. But the team at Wasso hospital worked smoothly and well today, exemplifying the best that technological medicine has to offer, even in such a low-resource setting, and I am so grateful. When I returned to the intensive care unit to visit the driver and the other three major casualties, all were stable - although I bemoaned the complete lack of narcotics, even a simple opium poppy tincture (next time I will bring an unlabeled bottle). The driver's pulse, which had been so strong and almost flooding when I first took it, was barely noticeable at the radius. In many ways, this is the life. The land is wild and strong. The tribal ways are pure and uncluttered by heavy modern baggage. But there is a dark side too.

3.31.2014

Wasso District Hospital - first week

The Wasso District Hospital serves a wide valley nestled between the Serengeti to the west and the foothills of the Rift Valley range to the east. The population here is mostly Maasai. They walk to the hospital down an access road, dressed in reds and blues, intricate jewelry made of seed beads in their ears, on their clothes, and on their heads. They are tall, skinny, and incredibly strong people from what I've observed cleaning and dressing their wounds.

There is an outpatient waiting area, an antenatal ward, and women's and men's inpatient wards. There is an excellent laboratory, where basic blood analysis (such as hemoglobin counts - many kids consistently come in with hemoglobins of 4 or 5, which is half to a third of normal) and the discovery of pathogens take place. I was able to observe motile bacilli from a stool smear, urinary bacteria, malaria parasites both free in the blood and invading a red blood cell. I saw the characteristic Trypanosoma bacteria, screw-shaped and large, responsible for sleeping sickness.

There is a pharmacy, fairly well-stocked considering we are a nine-hour ride from the nearest city; and kitchens for the patients, and a church. There are also some nice gardens throughout. Yarrow is one of the ornamental plants - a fact which I discovered immediately and with much excitement, to the puzzled amusement of the hospital staff.

Beyond the laboratory, there is a major surgical theater, where the chief surgeon and visiting doctors conduct operations involving the opening of body cavities, and also a small delivery room, x-ray and ultrasound suite. And then there is the minor surgical theater, where wound care, fracture reduction, and general examinations take place.

At our first morning meeting, I was assigned to the minor theater to assist where I could. My role has turned out to be three-fold: I handle minor wounds, abrasions, and general examinations. I assist in cleaning and applying final dressings and bandages to major wounds. And I am responsible for the patients deemed either too far gone, or simply the ones no one is interested in. Everyone is fascinated by herbal medicine and all too eager to see it applied, especially in the context of wound care. While the Maasai know many of the local medicinal plants, the tradition seems (at least here) to be broken, and treatments such as cow dung are used in home care instead of the medicinal plants and trees that are growing everywhere.

Here are some examples of cases from the minor theater over the last week:

- an infant child with an abscess on her scalp, opened and treated at home, came in with what was now a head wound about three inches in diameter. After thorough cleaning and dressing, the infection seems gone but the wound still won't heal - perhaps because the child's hemoglobin count is 3 and she is severely malnourished.

- a man has been coming in daily to have a major wound on the back of his leg cleaned and dressed. When he first presented with a raging case of cellulitis, over a liter of pus drained from the wound. Now, there are three large sites on the back of his thigh where there is no skin over the underlying tissue. Our basic procedure consists of removing yesterday's dressing, draining any pus, irrigating the wound with a large syringe we basically insert all the way under his skin, cutting any necrotic tissue, and packing the wound with wet-to-dry dressing. We are concerned that the skin is likely devascularized, but are monitoring closely for necrosis. He is on broad-spectrum antibiotics and metronidazole (as are most others).

- a woman with untreated diabetes stepped on a large acacia thorn, which pierced her foot basically all the way through. An abscess resulted which is now a non-healing ulcer on the dorsum of her foot. I was given the following instructions: clean and scrub the ulcer with bleach, and change the dressing daily. I remarked that it was unlikely this wound would ever close, especially with such a treatment. This comment was met with general shrugging. I am using warm ginger (tangawezi) compresses twice daily, which may be helping, but certainly feel really nice to the patient. Today we started herbal treatment to replace the bleach.

- a man in his 40s, who had lost a few toes to infection two years ago, returned with a 4"x1"x1" deep lesion along the side of his foot, with extensive infected tissue on the balls of both feet and his big toe. There is definitely staph, but the internist suspects Mycobacterium leprae (Hansen's disease, leprosy) as well. No one really wants to deal with him. His recommendation was twice-daily bleach soaks, along with broad spectrum antibiotics. At the hospital for over a week, his lesions hadn't really improved. He has eagerly moved to herbal treatment now, and we've seen excellent results over the last 72 hours.

- two men, from two different locales, came in with lion bites from two different lions. The first had been mauled on both thighs, bites mostly, and we suspect the lion was rabid as he had slaughtered over 70 goats before attacking the man. I assisted the surgeon by cutting away the ragged edges of the bigger wounds to allow for effective stitching, and irrigating and dressing the puncture wounds. The second man had tried to run from the lion, scrambled up a tree which proved too short, and had both his feet extensively damaged. I am not sure either foot will be salvageable.

There have been numerous fractures, including a compound femoral fracture in an incredibly strong four-year-old. The anaestehsia in these cases is an intravenous cocktail of ketamine, atropine and valium. Otherwise, general anaesthesia is rarely used. We use a fair amount of lidocaine on the bigger wounds requiring sutures, but otherwise it's just a shot of diclofenac IM for the pain. Most patients don't make a sound, though visibly distressed by the pain. It's incredible to me.


I am able to follow most patients independently with herbal treatment, which I discuss with their care providers who are more than willing to try anything which may work and which I can reasonably justify as safe. The nursing staff actually comes and asks me what I might consider beyond the ubiquitous bleach soaks. Everyone is on broad-spectrum antibiotics, mostly because the lab lacks the ability to culture pathogens to get any degree of specificity. Fairly often, infections don't really respond to internal antibiotics anyway: this has led many to suspect that there are resistant pathogens here, and I fully agree. So, here are some medicinal plants I've used for wounds in tropical sub-Saharan Africa:

- Rosemary (Rosmarinus officinalis) essential oil. Glad I brought 1/2 ounce of this, should have brought a lot more but wasn't anticipating how extensive a role herbal medicine could play in this environment. It is an excellent first-line treatment, I have been using it neat to clean out infected and partially necrotic wounds as I debride them. After the initial treatment, I move on and stop using the essential oil, so as to not retard good tissue granulation. Research indicates broad anti-pathogenic action from Rosemary, including against antibiotic-resistant bacteria (though this may be in part due to the organic acids, such as rosmarinic acid, which aren't found in the essential oil). I use 2 to 10 drops depending on the size of the wound.

- Goldenseal (Hydrastis canadensis) powder. Again, an amazing resource for acute wound care. I sprinkle the powder liberally after cleaning the wound, and when I go to clean the area that evening or the next day there is less inflammation, more granulation tissue, and rarely any pus. This has been especially evident in the case of suspected leprosy, where the lesions have gone from red, raw and bloody to pink and healing. An interesting side note: the patient being Maasai, he had a few friends along who wanted to try the goldenseal. As soon as they tasted a little of the powder, they remarked that its flavor was quite similar to a bark of a tree, "loisugi", that grows around here. After a little research, I discovered this was Zanthoxylum chalybeum, and it contains alkaloids nearly identical to berberine. The Maasai palate - an organoleptic testing device to rival any chromatograph.

- Yarrow (Achillea millefolium). I had brought a small amount of powdered yarrow with me, but was thrilled to find it planted here. The climate, though relatively constant, actually would lend itself to many other North American herbs I believe. I have been using this plant to create an alternative to the bleach soak/irrigation fluid: a decoction of goldenseal powder, 1TBS to 1L water, simmered for 15 minutes, to which are then added two handfuls of chopped yarrow flowers. The mix is steeped for another 15 minutes and used as a wash or diluted 1:3 as a soak.

Now rosemary, goldensal and yarrow are lovely and quite effective, but I'm basically out of the first two and will quickly decimate the yarrow that's been planted around here, so I am experimenting with different local plants as sustainable alternatives:

- Loisugi (Zanthoxylum chalybeum). This relative of prickly ash (with a similar pokey, knotty bark) tastes almost exactly like barberry. Its inner bark is yellowish and decocts fairly well. I feel it is milder than goldenseal, and impossible to powder without a Vitamix, but good for the soaks.

- Bidens (Bidens pilosa). The fresh juice of this plant, obtained by blending the leaves with a little loisugi decoction, seems to lack some of the blood-stopping effects of yarrow but can still tone and astringe tissue and seems a decent antiseptic - plus, it's everywhere. I blend it and press the mash through a filter, then dilute it with warm water for soaks and washes. I'm really glad to be developing a relationship with this plant, which I had always really thought of primarily as a mild urinary remedy.

- Usnea (Usnea longissima, U. barbata). Had to hike up a mountain to find an appreciable supply of this, but after you get past 8,500 feet (the hospital is at 7,500 feet, so it's not really a bad climb) you find old trees draped with it everywhere. You can fill a big plastic shopping bag in about ten minutes. Plus, the view is amazing - from the Serengeti to Ol Donyo Le Nkai, Tanzania's only active volcano, it is a 360 degree panorama that includes Maasai villages, salt flats, and forest. Once back home, I dry the lichen out in the sun, chop it coarsely, then run it through the blender a bit. The result is a tangle of white threads, which I discard or eat myself, and a grey-green powder rich in usnic acid. This makes a great dusting powder to use after irrigating a wound, a decent alternative to goldenseal.

- Sida (Sida rhombifolia). There is a fair amount of this plant here, and I was hoping it would make a decent topical treatment, but after using a Sida tea for just one day on a couple of wounds, I failed to see the progress that I'd seen with the other plants. I was using a tea brewed with a touch of vinegar to maximize alkaloidal extraction. Perhaps it is just a mild species, or perhaps it should be drunk rather than used topically, especially in antibiotic-resistant cases.


This coming weekend, I may get a chance to go out hiking with two Maasai warriors who know the land, the trees, and the plants. I am honored that they are willing to walk with me. What saddens me is that, despite their knowledge of the flora, the knowledge of medicinal uses is largely lost, or so vague as to be useless. Fortunately, I am able to piece some of it together from botanical guides and medicinal plant books (the case of loisugi is a good example). Using this knowledge, I hope to be able to instruct some of the folks who come through the hospital on how to practice good self-care using local resources that are easy to find and effective.


Anne has a steady stream of gynecologic patients now that her presence has been announced. She is also participating in outreach clinics, traveling to villages and conducting prenatal, post-partum, and child wellness visits. I will leave it to her to share more.

Our daughter Uli is already fast friends with a brother-and-sister pair who live just down the road. She goes to school every day and then plays with them until dinner, then collapses into bed. I think she's having a good time.


The sun is strong, as are the rains when they come, strong as the people who live here who greet me with joy and run along side me on the red dirt roads. Every morning is rich with birdsong. In the evening, there is music, singing and drumming from the town up the access road. It's easy to slow down and forget that there are children and mothers who don't have anywhere close to enough food. But the folks here at Wasso hospital are doing their best to change that, little by little, and I admire them for it.

3.23.2014

Moving through Tanzania, Part 2

Our journey from the Ngorongoro crater took us out over a red dirt road, through the mountains that girdle the caldera. The land was mostly open, with shrubby acacias, ever-present nightshades (Datura and Solanum) and the occasional browsing giraffe. Once we came down from the mountains (the plateau below is still at about 5,000 feet elevation), we started driving west on a dusty, rocky double-track. Slowing frequently for road wash-outs, or the crossing of zebra and wildebeest, we made it to the southern Serengeti gate after a couple of hours.

At this point, we did not cross through the gate but rather left the road, taking a right-hand turn northward. Stretching before us was a vast, unbroken grassland. The grass on the Serengeti plain is short - no more than two or three inches - and interspersed with tiny red-flowering legumes and white-flowering composites. The effect is dramatic: an ocean of green, shading to reddish or whitish in different areas, with an occasional, rare acacia wherever there is a rocky outcrop and perhaps a touch of subterranean water. Thompson gazelles, small and swift, run in switchbacks. Impalas, which are larger and lack the distinctive black stripe, stand off at a safe distance and watch. Zebras and wildebeest migrate together, browsing, tending their young. Ostrich and the occasional flamingo (the black-and-white kind) show up now and again. No trace of human beings. No trace of road.

Our driver, Emmanuel,  pointed towards a mountain range to the northeast. We would have crossed this range had we taken a more northern route, straight from Arusha to Loliondo. But having taken this more southern track, we needed to head back up across the Serengeti plain. Emmanuel said, "We will find the way when we get to those mountains". And so we set off.

After a little while, we took a break to stretch our legs. Standing outside the land rover, looking out for a hundred miles, I was overtaken by the spirit of the place - a vast, complete, slow presence quite different from the familiar energies I feel in the mountains and valleys I've called home over the years. Even the Great Plains of North America, which may be the closest analogy, are still quite different. I felt at once infinitely small and exposed, and also welcomed, enfolded, not alone. Maybe it was the gazelles, maybe it was just because I love it, but I had to start running, just for a bit. Everything slipped away.

Eventually we made it to the mountains, and the road (if you can call it that). The rocks were more white, and we skirted the western edge of the range, up and down, across streams, through groves of yellow-bark acacia and flat-top acacia, all draped in usnea and interspersed with huge aloe plants and a new nightshade, Nicandra physalodes. The locals call it "shoo-fly weed", because it's everywhere and has a rank, insect-repelling scent. The flowers are beautiful: saucer-sized and reminiscent of a cross between a morning glory and the fancier Daturas. Maasai herdsmen drove their cattle, sheep and goats across the valleys. We started to see fields of maize here and there.

After about five hours of four-wheeling, Emmanuel pointed to a cluster of metal-roofed buildings a couple of miles away. "There is Wasso", he said plainly. We drove in through a strip of small shops and homes, then down a side road, across a small river, and into the compound that is the Wasso District Hospital.

3.20.2014

Moving through Tanzania - Part 1

We landed at the Kilimanjaro airport. It was late in the evening, and we walked down a staircase to deplane. On the tarmac, the air smelled sweet ("like honey", my daughter remarked). There were tons of stars.
We spent the next two days in Arusha, which is a large, crowded, intense town at the feet of Mt. Mehru. I ran up and down some red-dirt, bouldery roads and we collected provisions and things like a cellular internet connection for when we get to Loliondo. When mentioning our final destination to folks in Arusha, the general response was "Oh, really? Ok... for five weeks? Really?" I can't wait.


Arusha sunset

We left in a sort of stretch-land-rover, kind of big for the three of us and our driver, Jonas, but necessary for the piles of medical supplies Anne will use and donate. And don't forget the microscope packed into a huge suitcase and buckled into the front seat.

Nightshades are generally everywhere. Datura stramonium is ubiquitous, including its dried, upturned, spiny remains which litter the roadside and look a lot like the skeletons of animals that you can occasionally find on the grassland. In the city, Brugmansia is everywhere - but once you leave the concrete and cinderblock, a new, shrubby species takes its place. It has the characteristic purple five-parted flower and a golf-ball sized, yellowish fruit with the savory name "Sodom's Apple".

Brugmansia sanguinea
Solanum incanum



The road becomes - well - less easily passable. There are acacia trees, of many different species, thorny and branching across the savanna. Maasai villagers live in compounds made of small circular thatched huts, enclosed by living fences of sisal and Euphorbia. The children are out all day herding goats and cows.

Acacia nilotica is used for respiratory complaints - the fresh inner bark is chewed daily for asthma and the leaves are infused for pulmonary infections. It has a pleasant smell, and a bitter but kind of sweet flavor. Supposedly the young twigs are used as toothbrushes. Will try.

Acacia nilotica

The aromatic of choice around these parts is a native species of basil, immediately recognizable by its elongated seedheads and short, bushy growing habit that is remarkably similar to that of tulsi. It is Ocimum kilimandsharicum, and is delicious between the lip and gum. Traditional uses: fevers, skin infections, bug repellant, digestive issues. Seems about right.




Another ever-present feature is the termite hill. These fantastic structures, which my daughter aptly calls "castles", are at times six feet tall. But perhaps the most exciting experience comes from encounters with the wildlife. There are lots of zebras and warthogs, baboons and monkeys in the forest, and hippos in their wading pools. We even saw three giraffes. But the elephants - wow.



By the end of the day we made it to Ngorongoro crater, a huge wildlife preserve that we will explore tomorrow on our way up to Loliondo. It is a circular caldera, remnant of a four-million-year-old volcano, part of the tumultuous geology of the southern Rift Valley. Over ten miles across, it yawns yellow-green from our vantage point on the rim - over 1,800 feet up. The entire crater sits at over five thousand feet of elevation. They don't let you do any running on the roads here because of the leopards and lions. Bummer. Not really.



11.10.2013

Catalysts in Herbal Medicine

 The following is a summary of the talk I gave at the most recent NEHA retreat. It was great to meet new folks and have a chance to relax with old friends in the countryside of the Hudson valley.

So you've found the perfect plant for yourself, or for a friend. Its actions fit the symptom profile, its indication is specific. To maximize its effectiveness, it might be useful to combine it with a synergistic catalyst, an herb (or herbs) capable of directing and aiding the remedy through the body.
But why not just use the single herb alone? Why is it even necessary to add a catalyst? To understand the answer, it's useful to take a little step back and explore some concepts from the art and science of alchemy.

I have always associated alchemy with late-Middle-Ages Europe - a time when the extraction of precious ores from mines deep in the Alps was taking place alongside explorations in the new art of distillation. But truly, alchemy (from the Arabic "al" and "khemeia", literally the metal-transmuting) far predates this time, even in the European tradition. And in China and India, mystics, sages, and healers were discussing the alchemy of immortality for many hundreds of years before the Greeks ever dreamed of turning lead to gold.
Nevertheless, though he may not have been the first, Paracelsus articulated the concepts of alchemy in Europe in the late 1400s perhaps better that anyone before him. He drew on a personal history that involved his father's ore-smelting operations, as well as research into the hermetic arts whose roots date back to the Egyptian kingdoms. His practice was well-grounded in nature, focusing on plants - but, by employing the high-proof spirits that had just recently been discovered in Europe, he stressed the usefulness of extraction and alchemical potentization, primarily through reliance on the hermetic concept of the "vital force".
Hermes (the fleet-footed messenger of the gods whose name is the source of the term "hermeticism") became known as Mercury in the Roman pantheon. In acting as intercedent between the gods and humans, he became known as a sort of embodiment of the basic animating power that sustains all life - as sort of "carrier wave" from the divine to the physical. This idea is echoed in the Christian conception of the trinity, with the "holy spirit" acting as a bridge between the divine and the material. These doctrines actually rely on old Platonic conceptions of reality, whereby the "astral" (divine, idea-driven) world flows into the material plane (world of form) through the animating power of the vital force. Thus, by the time of Paracelsus, mercury became the alchemical shorthand for life-force itself. And it was the goal of every good alchemist to capture and harness this force, as it was seen as the key to all healing, and perhaps to immortality, too.
Paracelsus realized that a growing plant, source of all true medicine, would need to be sacrificed at least in part in order to help the sick and needy. He sought a way to capture and harness the living vitality of that growing, green being, that it might be infused into his medicines and thereby into his patients. In order to achieve this, Paracelsus emphasized separating the components of the plant - primarily the airy, volatile aromatics from the fixed, bitter and salty constituents - and then tying them together again with high-proof alcohol (we still call this stuff "spirit", an echo of its mercurial, vital nature). "Solve et coagula!" he urged his students: "dissolve and recombine!". In so doing, though the plant is no longer living, the extract is nevertheless alive, bio-available, and more potent than the simple dried leaf might be.

And that's really the crux of the matter: catalysts in herbal medicine, whether they be processes or substances, turn a remedy from a simple infusion to one capable of conveying the powerful, life-changing experience of interacting directly with a living plant out in the wild. All herbalists have experienced this interaction, and I'd wager most gardeners have too. This is a healing experience itself, and modern research is beginning to realize that garden therapy, forest bathing, and just simple time spent outside on the plants' turf can have profound healing implications. The most potent remedies I've ever made - the ones where folks tell me later that quick, profound changes follow their use - were made from plants I harvested in a state of semi-transcendent flow, where the edges of "me" began to bleed into "herb" and vice-versa. This experience is a catalyst in and of itself. It's what helps the action of a remedy "stick". It's what makes it different from all the mass-produced stuff in pills out there on the shelves of stores and pharmacies. It's what makes real, effective herbal medicine - as opposed to just a weak substitute for a drug.

So one way to add a catalyst to botanical remedies is simply being an herbalist. We are catalysts ourselves, in that we help to bridge the gap between plants and people (like some sort of green mercury). I'm not sure every herbalist really thinks about this quite so much, or realizes its importance. When you think about it, you see how crucial it is to cultivate ourselves as practitioners, to develop a healing presence. The herbalist (or doctor) is far from being simply an impartial observer! So we must consider practices such as mindfulness training, ceremony and ritual (even if it's just a moment of focus and hand-washing before meeting a client), and cultivate self-awareness to maximize our potential as catalysts. We are lucky that the discipline of herbal medicine includes such exercises and emphasizes self-development and relational understanding: to use old Taoist alchemical language, you refine the mercury through gardening and wild-harvesting. And a practitioner with a well-refined mercury will always achieve better results, believe me. Even with the smallest doses of remedies. Plant-spirit medicine may be the ultimate expression of this reality.

Next, we have the possibility of adding an actual substance to a formula or even to a single-herb extract. The first type of catalytic additive I would call a personal "signature" catalyst - a few drops of a special, highly meaningful preparation that you blend into every product you make. These are more likely energetic catalysts, somewhere between pure plants spirit medicine and the more material formula-additives we'll look at next. Their nature can be highly variable, depending on the herbalist, the client, the season, or whatever variables might come in to play. The key is that they be meaningful to you, and act as an undeniable physical reminder of a powerful living-plant connection you've made. Some choose to add a few drops of an elixir made from the fresh rosebuds of an old, wild rose from their family's homestead. Others will craft flower essences, or labor for a whole season over spagyric extracts of a personal plant ally, or painstakingly collect vials of morning dew from the leaves of Alchemilla, the Lady's mantle, to add to their simples or formulas. Deb Soule adds the essence of Heal All to many of her blends. I was able to run some spring water over a yarrow plant that grows on the top of the fairy hill of Queen Maeve, in Ireland, and I will add a single drop of this water to some formulas once in a while. You get the idea.

As a second option, from a more "rationalist" perspective, we have the possibility of adding biochemically (and energetically) active substances to a formula in small amounts (usually 10% or less of the blend). As a Western herbalist, I will focus mostly on catalysts from that tradition - though other approaches of course exist. A huge part of the art of Chinese medicine involves formulation, with complex blends often involving multiple catalysts and synergists. But for this discussion, consider the addition of one herb, often a powerful and strong-tasting one, to your formulas to enhance the overall potency, "revitalize" it in the Paracelsian sense, and also improve its effectiveness by aiding in the emulsification of extracts (such as Kava, or Reishi mushroom, which can have problems when blended with other extracts), or improving the overall flavor.
There are three general "classes" or approaches involved in picking a catalyst for a formula, and of course they can overlap. The first is energy-based: using a small amount of a powerful herb to either balance the overall energy of a formula, or to make it better suited to a particular client. The second is physiology-based: adding an ingredient that helps "direct" the formula to a particular part of the human being. The third is action-based: reinforcing the action of a blend with certain herbs particularly suited to that action.
Energetic catalysts, from a Western point of view, involve heat and moisture. This is a relatively simple idea: if you want to warm a formula, cool it, or balance out the overall energy of other ingredients, this is the approach to use. It often makes the blend easier to take, and safer, too (especially for long-term use). Warming catalysts include cayenne, ginger and rosemary; more cooling ones for me mean strongly bitter plants such as gentian, artichoke or lavender. I usually turn to a little bit of licorice, a time-honored harmonizer of herbal formulas, for an overly dry formula or constitution; conversely, agrimony and lady's mantle are nice to add to gloopy demulcent blends.
"Directing" a formula to a particular organ system is seen as a way to maximize therapeutic effectiveness. Traditionally, certain catalysts were thought to have this ability - and the rationale for this belief seems to rest either in the excretory routes for the catalyst's chemistry, or in its direct effect on the organ system itself. So, for instance, juniper can be added (in small doses) to urinary formulas to increase their effectiveness, partly because the volatiles in juniper are excreted largely through the kidneys. Other volatile oils, such as those in thyme or mint, are lighter and bubble out of the bloodstream through the lungs. Specific pulmonary antispasmodics, such as Lobelia, are added to reinforce the action of chest-congestion formulas. Cayenne and rosemary, classic low-dose circulatory enhancers, enhance the activity of other cardiovascular herbs. In the gastrointestinal system, bitters such as gentian serve as reliable catalysts in tiny amounts, though ginger might be of use too. And for the nervous system, classic "brain" aromatics such as rosemary, sage, or even lavender (for a more calming note) might be indicated as catalysts.
Action-based catalysts reinforce the overall goal, or action, of a formula. I tend to focus on major areas of activity, rather than each individual action: for example, if crafting a formula that's designed to address tension or tone in the nerves and muscles, there are a few ways to go. The first type of catalyst is an aromatic plant: such as lavender, rose, ginger, or mint (a pinch of mint goes great in many nervine teas, an enlivening trick I first heard from master tea-formulator Rosemary Gladstar). Another type contains alkaloids that have a profound rebalancing effect on neuromuscular tone: Lobelia is a safe choice, but it's interesting to note that the solanaceous plants (such as Atropa or Datura, sources of atropine, or Solanum dulcamara, source of solanine) were used by Eclectic physicians in drop doses to relax excess tension (1-5 drops) or stimulate a sluggish constitution (5-10 drops). This is the perfect dose range for a neuromuscular tone catalyst.
If your formula seeks to address immunity or inflammation in the body, consider adding a saponin-rich herb as a catalyst. These phytochemicals seem to have a biphasic effect, at first interacting with the immune tissue in the GI tract and "waking up" innate immunity, and then helping to control overall inflammation once their non-polar backbones are absorbed into the systemic circulation. Licorice features prominently here, again a great example of a catalyst that's energetic, immune-active, and also sweetening. But try horse chestnut too. It's dose is small, yet it has great effects on overall inflammation and immune balance. Extra bonus: saponins act as emulsifying agents, helping to keep plant constituents in solution (especially if you're mixing high proof and low proof extracts - so try a little licorice in your kava / crampbark blend).
If attempting to address imbalance in the digestion and metabolism (which includes the liver), I've had some success using bitter herbs such as gentian, absorption-enhancing pungents such as black pepper, or specific hepatic "activators" like Schisandra or agrimony. They cross the line between action-based and physiology-based catalysis - but remember, there's a lot of overlap between energetics, actions, and organ function.

In conclusion, adding a small amount of a very specific herb can help custom-tailor your formula and increase its effectiveness, re-awakening some of the vital power that may have been lost after harvest and processing. If we mindfully blend catalysts into our simples or blends, we reinforce the heart-centered experience of being with a whole, living plant in its own environment. We can also thereby help set our remedies apart from the growing pile of pills you'll find on store shelves. If you were a client, what would you choose? A remedy mass-produced and packaged in a plastic jar, or a blend where one of the ingredients was picked especially for you, has an incredible story it carries with it, and makes everything more effective? By using catalysts with intention, we go back to the root - back to the future.
So as it turns out, as herbalists we have a responsibility as go-betweens, as mercurial catalysts, not only in the garden, not only with our clients. Using catalysts to make truly vibrant, powerful medicines, we can stimulate change in our greater community, and perhaps in the minds and hearts of those seeking an alternative to technological medicine. Herbal medicine is from the heart, it's personal, it's vital. It is a catalyst for cultural change.

10.31.2013

Guest post: A view from Kampala, Uganda

This post is from Dr. Anne Dougherty, MD. She is almost in the middle of a six-week project at Mulago Hospital in Kampala where she is providing support and training to the OB/GYN staff. I will let her words speak for themselves.

Resigned helplessness – that is what the resident’s face said as she answered questions following her presentation.  The patient was a young woman who was transferred from an outside hospital for “confusion and severe anemia.”  On arrival at Mulago, the patient was tachycardic and tachypneic.  Her mental status was altered.  Her abdomen was distended and rigid.   She was bleeding per vagina.  A pregnancy test was performed and was positive.  My assumption at this point is that the patient has a ruptured ectopic pregnancy and is in danger of bleeding to death.  An IV was placed and normal saline was dripping into her vein.  No additional labs or studies were obtained.  This all happened at 1AM.  At 9AM – eight hours later, the resident stood before the department at morning meeting and related this story.  There was no more to the story than what I just told you.  For the last eight hours, the patient had lain in a bed on the ward where a single nurse watched over 40-50 patients with a single IV running crystalloid @ 125cc/hour.  The resident was asked, what did the ultrasound show?  Did you locate the pregnancy? What was causing the surgical abdomen?  Did you draw coagulation studies?  I was struck that in the telling of the story, the resident did not mention that these might be things that she considered.  When asked why such studies were not obtained, she simply stated that it was 1AM.   As if the main referral hospital in the country should close at a certain hour.  Well, as it turns out, it does or at least that is the perception that then becomes a reality.

A horrible inhumane experiment was performed with dogs in which they were placed in a cage with an electrified floor.  There was a high barrier in the cage over which the dogs could not jump.  The first few times the floor was electrified, the dogs tried desperately to get over the barrier, but as time went on, they would curl up in the corner until it was over.  The dogs continued to do this although the barrier was lowered such that the dog could jump over it.   This is not to say that humans are dogs, but it does demonstrate the effect of repeated negative events on the desire to keep trying, to keep striving.

I have seen repeatedly that when even a small challenge is presented here at Mulago, the answer is often, “it is impossible.”  And yet I know that it cannot be as I see some are able to overcome the challenges.  Today, while performing a series of exams on patients with suspected cervical cancer, I ran out of exam gloves.  I asked the “sister” (that is what the nurses are called) if she could get more gloves.  She said, we do not have any more and just stared at me.  She said the person who was supposed to go to the supply annex last night to restock did not turn up and so we were low on supplies.  Not being one to take no for an answer, I persisted.  Well, I said, where can we get them from now?  She said, give me a minute.  In a short time, the “sister” returned with a new box of gloves “borrowed” from another unit.

One of the things about cultural exchange is that you really have to leave yourself at home.  That is, you need to surrender your sense that “this is the way things have to be done.”  As long as you continue to compare here to there, it is easy to be irritated by the way things proceed within the foreign culture and ultimately become very frustrated.  And in that frustration you miss the cultural exchange.  In medicine that can sometimes be difficult.  When you have a patient in front of you who could be helped with a few basic diagnostic tests and swifter treatment, I feel another force at work that is complicated to separate from my own cultural context.  The feeling of responsibility I have to the patient while embedded in my cultural context feels like it stems from an inner part of my being and is so painful to let go even temporarily. And yet, that is really what you have to do here at Mulago or you will be crushed by the tragedy of it.

I am not sure that I understand entirely where the resigned helplessness comes from.  It is likely multifactorial.  Being subjected as a colonial territory plays a part.  Follow that with decades of struggle and war while surrounding countries began to get their independent “legs” under them.  Add in poverty, food scarcity, unemployment, resource shortages and a dejected passivity develops.  I am also quite sure that western world “charity” contributes.  Interestingly though, when you learn the stories behind some of these Ugandans and the life challenges that they have overcome, you are left with paradox.   Ne woman told a story of moving out of her stepfather’s house because he would beat her mother when she showed affection to the woman and her sister.  She moved in with a relative who took her on as household help (a common practice here), but the woman wanted to go to school.  So she moved onto the streets where she tried to earn some money during the day to support her sister and herself and then went to primary school as an adult. She taught herself English while living on the streets.  As a cleaner at Mulago Hospital, someone discovered that she spoke English and promoted her.  She worked her way to a stable job as an administrative assistant.  She continues to go to school and is now married, expecting a baby shortly.  Amazing.  And her story is only one of many.  So many Ugandans have witnessed horrendous violence either at home or at the hands of the government.   Most have been in a home without enough food to feed the whole family.  Many have inherited entire families of 6, 7, 8 children when parents pass away from HIV related illnesses.  They will work against all odds to send those children through school.  The strength and wherewithal to persevere through such trials is more than the average American in 2013 would tolerate I think. And yet that same woman might tell you there are no more gloves.   Such a strange paradox.

Anne K Dougherty MD
Attending Physician, Department of OB/GYN, Fletcher Allen Health Care
Assistant Professor, University of Vermont 

10.19.2013

Numen: The Healing Power of Plants

Let's face it, herbalists are lucky. We get to interact with plants and people in a very special way, one that emphasizes an age-old evolutionary connection between the two. This was recently brought home to me, yet again, sitting in circle with a group of herbalists, on a warm October day, after harvesting a bunch of excellent roots. We spent time giving thanks to the land, to the plants, and to the gatherers' hands. We spent time just participating in a moment of deep animal-vegetable relationship, one which humans must have experienced over and over again in the course of our long journey.
In this timeless moment, we tapped into something more than the botanist, with her rich knowledge of the vegetable kingdom, or the physician, with his clear insight into the human body and pharmacy, can routinely experience. Something born of the fact that the roots we pulled, painstakingly, from the soil can help people feel better - and that people, plants, and ecology can all thrive when they actually interact. It's more than observation, it's more than knowledge. It's something akin to the essence of life itself. The ancients called this essence "numen", or spirit-power, life-force. It isn't something that "is", it's something that "does": the counterbalance to entropy, the destroyer-force. It organizes, creates, loves, heals.



The excellent film by Ann Armbrecht and Terence Youk elegantly brings this life-affirming force into view. Through the words of those whose journey is devoted to plants, healing, and ecological connection, the timeless life-power humans have thrived on becomes clear. For me, it is a celebration! Experiencing the images and words Ann and Terry have woven together reinforces the feelings of connection all herbalists have known. But perhaps the greatest gift that they offer is to those who haven't ever felt this life-power for themselves. It is those who haven't tasted the call of springtime roots and greens, who haven't heard the words of mugwort on a full moon night, who have only a vague idea of how individual and ecological health might be connected, that really need to grok this film.
Which is why I'm really excited and grateful that Numen: The Healing Power of Plants is available for free viewing, for ten days starting on October 20th, to everyone everywhere. It is an opportunity for herbalists to celebrate, and be filled and renewed by, the joy of being plant people. But crucially, it is a chance for us to bring nature-based, herbal life-power into the lives of those who haven't really experienced it yet. It is a chance for our families, and our extended communities, to really "get" why we love this art so much, why we have chosen this path. I hope you share this with those you love. Who knows what will follow.


10.04.2013

In Defense of Gluten

My daughter and I love making pasta. We start from scratch, and enjoy mixing the dough by hand, kneading it while we talk, and finally running it through the Imperia pasta machine to make lasagna sheets, noodles, or squares to stuff with filling. 
The recipe is pretty simple, adapted from my father's teaching and from the work of the late great Marcella Hazan. It can be scaled up for any size meal, or you can just make lots and store the dough balls in your fridge for a week or more, ready to dust with flour and roll out into beautiful sheets of pasta.

Take 1 cup all-purpose flour and make a "volcano".
In the hole of the "volcano", crack and beat 1 egg.
Add 1 TBS of olive oil, and 1 pinch of salt.
Add 2 tsp of water (or tomato juice, or nettle infusion). The water helps the gluten form properly.

To this basic template you can add rubbed sage, or chopped parsley, or calendula petals, or cuttlefish (sepia) ink. The possibilities are endless

Slowly incorporate the flour into the egg/oil/water mix. When it's mostly blended, start squishing the dough with your hands and fingers until it forms into a glossy ball (or multiple balls, if you're using more than 1 cup of flour). Keep kneading until the dough becomes elastic and supple.

Place the ball of dough in a plastic bag in the fridge for an hour or two, then take it out and cut in half. Press the dough into a flat pancake - and you're ready to feed it into the pasta machine!

The quality of the dough relies on a protein present in wheat, called gluten. I've been unable to achieve the stretchy quality of good pasta dough any other way. It's elastic, resilient, and can be rolled incredibly thin without tears or breaks thanks to the gluten polymer keeping everything "linked up". Part of what kneading accomplishes is to link many gluten molecules together to achieve this resilient "sheet" effect. I apologize if gluten offends your sensibilities (or you GI tract) - but it's really a beautiful thing.

The other day my daughter and I were admiring the thin sheets, looking at how the light from our western windows glowed through them, alabaster-like. She came up with some great similes to describe the fruits of our labor. I told her I'd steal her words - which led to a conversation about exactly what I meant by that, how one could "steal" words, what plagiarism is. Good stuff for a four-year-old. Regardless, here's my plagiarism in action. It's an ode to gluten.


Metal rolls thick dough
until, when held up
evening sun shines through it -
thin as a rabbit's ear,
silky and cool. We clear
flour off the pine board
and lay a long sheet out
thin as a petal.