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 


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.


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.


Three simple medicines for winter health

Consider these quick, easy preparations to add to your pantry as the season gets colder. They are based on three general ideas in herbal therapeutics: tonify immunity using botanicals that interface with our innate immune systems via gut-associated lymphatic tissue; improve circulation and load the bloodstream with pungent, volatile, antiseptic substances that escape through the respiratory tract; and reduce inflammation while encouraging perspiration to relieve symptoms of congestion and fever.

Bliss balls:
1 1/2 cup nut butter or tahini
1 cup molasses
2-4 Tbs maple syrup
2 cups cacao
8 Tbs powdered herbs - Astragalus and Reishi (Ganoderma lucidum, G. tsugae), in equal parts.

Mix nut butter, molasses and syrup. Add cacao and mix. Slowly add herb powders and mix well - roll into 24  2" balls, dust in cacao, take two daily.

These are nourishing, rich in immune-active glucans and saponins, and have a high compliance rate.

Fire cider (a classic recipe, via Rosemary Gladstar):
2 onions
2 heads of garlic
1/4 cup grated Ginger
4Tbs turmeric
1/2 cup grated Horseradish (fresh)
1/4 tsp cayenne
3 qts. Apple cider vinegar
Mix all ingredients together. Shake occasionally, and allow to steep for at least two weeks; strain and bottle. Take 1/2 to 1 teaspoon three (or more) times a day at the first signs of cold or flu.
Definitely fiery, you may want to use caution in more sensitive constitutions. A great remedy for the fiery type who gets stopped in mid-stride by the flu. Soothes the belly, provides warmth, encourages perspiration, and protects the lungs from infection.
Herbal decongestant tincture:
(all herbal ingredients are dry)
2 ounces Elderflower
2 ounces Catnip
2 ounces Goldenrod
1 quart (liter) of 100-proof spirits (vodka, e.g.)
Mix all ingredients and seal in a closed 1/2 gallon mason jar. Shake occasionally, and allow to steep for at least two weeks; strain and bottle. Take 1 teaspoon in a little water three times a day for congestion and/or fever.

The high bioflavonoid concentration (quercetin and related compounds, e.g.) in goldenrod reduce airway inflammation and swelling, while elderflower and catnip thin mucous secretions and gently encourage perspiration to help manage fever.