Pitfalls and Peculiarities

Traditional medicine is alive and well in this part of Niger. Here are three anecdotes about some of our early encounters with traditional healers and hexers.

Anti-scorpion medication
Some days ago a small, excited crowd gathered outside the gate to the guest house where we’re all staying. We went out to investigate. Usually the sick or injured are taken to the hospital and not brought here but we were asked to look at a young man in the center of the small crowd. As we approached we could see that there was something on his face. A closer look showed a large scorpion. One pincer covered the man’s left eye and the other rested on his right cheek. The stinger - tipped tail waved menacingly. I’ve never seen this problem described in any medical text and we were at a loss as to how we were going to proceed. I’m sure our quandary was apparent to the crowd as well. Suddenly laughter broke out. Our victim opened a small bag a pulled out another scorpion which he effortlessly, and without being stung, passed from hand to hand. It turns out that he is well known in these parts as a “scorpion handler”. His business is selling scorpion protection. For 200 Francs he’ll sell you a small amount of a specially formulated (by him) powder which will protect you from scorpion stings, and I guess let you walk around with a scorpion on your face as well.

Something missing
One of the local gendarmes brought a highly agitated and frightened young man of about 20 to the clinic shortly after we arrived here. The officer’s French, like mine, wasn’t particularly good and the young man spoke only Hausa so we struggled for a while, but finally the story was pieced together. The evening before the young man had encountered an old and apparently rather frightening man on one the dark streets here. Without warning the old man grasped the young man’s hands, uttered something and then disappeared into the gloom. The young fellow was uninjured but frightened. Later, to his horror, he learned that he had been “attacked” by an old man widely reputed to have the power to remove a young man’s testicles with a single touch of the hand. For a price however the testicles would be returned in the same way. My young patient had spent a sleepless night agonizing over his dismal future as a eunuch since he couldn’t afford the price of the ransom. The morning of his visit to the clinic he had “experimented” a bit and found that in fact “things” just wouldn’t work. He became so agitated that his friends summoned the police who brought him for a visit.

Well, I thought, this should be easy. A brief exam disclosed completely normal anatomy – everything was there and nothing had been taken. I put on the mantle of authority, the visiting consultant if you will, and explained to him that I had some experience with these things and that I could assure him that everything was alright. The old man, I continued, was just trying to trick him and steal his money. He shouldn’t give it another thought.

The next morning he was back. “Things” still weren’t working and he appeared morose. Authoritative reassurances were clearly not going to work. Bigger magic was needed. I told him to return in the afternoon and I would have something which would restore the testicles. I walked over to the pharmacy across the street and bought a 50 mg. sildenafil (Viagra) tablet and put it in a small box. When he returned I gave it to him and told him this would make everything right. He never came back for another clinic visit but I saw the gendarme a few days later. He told me that after taking the medication the young fellow had had a rather remarkable experience and now considered himself cured.

A Near Tragedy

This past weekend a 7 day old child was brought to the hospital. His parents reported that he had suddenly begun to vomit blood. He was terribly weak and anemic and required a blood transfusion. Fortunately no further bleeding occurred and he became stable. We began trying to figure out what had caused the bleeding. We have very little if any diagnostic equipment or laboratory here and we doubted that we could make a diagnosis. Fortunately one of our nursing students who speaks the local dialect well came up with the answer. There is a tradition among some of the Fulani tribes of clipping the uvula – the “flipflop” that hangs down from the soft palate in the back of the mouth. It is thought to promote growth and to prevent vomiting. We got a good look into the back of the throat, and sure enough, the uvula had been clipped. The child’s mother and older sister had had the same treatment as well. Fortunately all turned out well, but a tragedy was narrowly averted.

Steve Humphrey
Maine-Soroa, Niger
July 30, 2007

A Death

Aissa, the younger sister of my good friend Mahamadou died yesterday. We first became acquainted with her a few weeks ago, shortly after we arrived here. Her problem was growing weakness, lack of appetite, weight loss, some fever and diarrhea from time to time and recently a persistent dry cough. One of us saw her in the clinic. She was thin, weak and had very abnormal breathing sounds. A screening test for the presence of HIV (the Human Immuno-deficiency Virus) was positive.

To its credit, Niger has a national program for the treatment of AIDS (Acquired Immuno-Deficiency Syndrome) which is caused by HIV. The program is vertically integrated which means it includes periodic clinic visits, appropriate lab tests and also free medication not only to treat the virus itself but also to treat some of the common infectious complications of AIDS such as tuberculosis, chronic pneumonias, and fungal and yeast infections. To enter the program a patient must travel to one of four centers in the country. The closest to us is in Zinder – about a six hour drive to the west.

As soon as the screening test results were available, Aissa was seen by the social worker here and referred to Zinder to enter the program. She and Mahamadou traveled there about three weeks ago. A more accurate test for HIV was performed and confirmed the results of the screening test. She then had some other blood tests and a chest x-ray. One of the most important blood tests, the CD4 count was not performed because the laboratory had insufficient money to purchase the reagents needed for the test. The CD4 test is basically a blood count which gives the number of a certain type of white blood cell. These cells are critical to the function of the immune system and are attacked by the HIV. As the infection worsens, the number of CD4 cells drops. When the count reaches a certain level, the immune system stops working well and all the chronic infections associated with AIDS begin. When the CD4 count reaches this threshold level, antiviral drugs are started in hopes of reducing the amount of HIV in the blood and improving the function of the immune system.

It’s at this point that Aissa’s problems worsen. AIDS treatment and many other health programs in countries such as Niger depend on foreign aid for funding. Assistance may be in the form of government grants or a myriad of other programs operated by non-governmental organizations (NGO’s). These programs usually operate under rather stringent protocols and protocol violations can result in the withdrawal of funds. For example, antiviral drugs for HIV cannot be given unless the CD4 count is at such and such level. Giving antiviral drugs to everyone who just has a positive HIV test is very expensive, and for people who still have a good CD4 count, it really doesn’t help. It may even help resistant forms of the virus emerge, so there’s a good reason for the rule. As a result, since no CD4 count could be done, no antiviral drugs were given to Aissa. Instead, she was instructed to return at a later date for the test and possibly medications. She never made the return trip to Zinder. Her condition worsened abruptly and she died suddenly, probably of an overwhelming pneumonia. In retrospect of course her CD4 count must have been very low. Would the antiviral drugs have made a difference? No one can say.

Her death points out many of the difficulties in administering health care in developing countries. Physicians and administrators have to juggle many different protocols and programs and even though a program is in place on paper, patients may still not benefit.

Many ironies exist in these schizophrenic systems. For example, last year a US based NGO came to this area with a very successful program aimed at eradicating trachoma, an infectious conjunctivitis which is highly contagious but which is also very readily treated by a single dose of an antibiotic called azithromycin. Over a period of thirty days, this well organized program gave the entire population of the region a dose of azithromycin and has essentially eradicated trachoma from the area. Azithromycin is also very effective for the treatment of a number of other infectious diseases including ear infections, venereal diseases, pneumonias and so on. There have been numerous occasions in which the antibiotic could have been used here; however, neither the hospital pharmacy nor any of the private pharmacies here have any. Here’s the irony. The warehouse of our hospital pharmacy contains several thousand doses of azithromycin, due to expire at the end of this calendar year; however it cannot be used because it belongs to the NGO. No one here knows if the NGO is planning to return or to use the medication for further trachoma eradication. The hospital administrator however is very clear that the medication cannot be used by the hospital. For physicians taking care of patients this is very frustrating. NGO’s take a macro view and physicians a micro or individual view. Of course the large programs do much good for many people. It’s just that I’d like a few doses of azithromycin.

Today I went to see Mahamadou. It was the day for visitation. In keeping with Muslim tradition Aissa was buried yesterday – before sunset on the day of her death. Outside the mud-brick wall of his house cloth awnings had been erected and rugs and mats placed on the sand. All the men sat together under the awnings. Inside the wall of the compound the women sat together in the same fashion. Small charcoal fires heated tea. Little was said. It was very peaceful and comforting just to sit together, quietly. Open displays of emotion are not the custom here. If there were recriminations, or anger, or frustration with “a system” I could not detect them. The air was one of acceptance.

Two houses away a wedding was underway with laughter and the sound of the griot’s horn. I made some mention of it.

“We are happy that life continues,” was Mahamadou's reply.

Steve Humphrey
Maine-Soroa, Niger
8 July 2007