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.


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.


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.