Beans, Grains and Madura Foot: Tasty Food, Tasty Medicine

I’m eating quite alot of beans at the moment.

‘Ful’ is the most widely-eaten meal in Sudan. It is made from black beans, cooked until they are soft, and then eaten with cheese, salt, onions and bread. Fasulya is made from white beans, and is cooked in the pot with some meat on the bone for flavour. They, along with some saucy dishes of potatoes, courgettes and peppers form the basis of diet, supplemented by a rather delicious range of fruit juices and the odd half-chicken.

There are many restaurants around Khartoum, serving a range of Sudanese, regional (as in Egyptian, Lebanese etc) and Western food. However due to burgeoning US sanctions, no American companies (like MacDonalds) can set-up shop here.

Being so ‘ful’ of beans (ho ho ho) can be rather useful for long ward rounds. I’ve seen a number of very interesting clinical cases over the past couple of weeks. Briefly, I’ve seen patients with pellagra (vitamin B6 deficiency with the clinical triad of dementia, diarrhoea and dermatitis); with Guillain-Barre Syndrome where polio and mercury- and lead-poisoning from mining were real differentials; with severe, quinine-resistant falciparum malaria and acute renal failure; with a bad drug-reaction to anti-malarial quinine therapy; and with complicated portal hypertension, resulting in different patients from chronic hepatitis, schistosomiasis and alcoholism. At the clinical meetings, I’ve also heard two interesting case presentations, firstly of a patient diagnosed with Churg-Strauss Syndrome (in the textbook this is late onset asthma, eosinophilia, small vessel vasculitis and a range of other potential features), presenting with joint pain, purpuric rash, dyspnoea, peripheral neuropathy, loss of vision and fever. The second case was a patient brought in from Jezira State, south of Khartoum, with DIC (blood clotting inside the blood vessels) resulting from a cobra bite. All these  cases were of  patients on the general medical ward.

I also spent some time at a specialist institute, the Mycetoma Research Centre, at Soba University Hospital. Mycetoma  is also called Madura Foot, named by British physicians in the Indian city of Madurai, Tamil Nadu State. It is found across the world in the ‘Mycetoma Belt’, stretching around Brazil and Mexico, through Africa and Arabia to India and South-East Asia.

It is a progressive, granulomatous inflammatory disease caused by particular species of bacteria (actinomycetes) or fungi (eumycetes). It still most commonly affects patients’ feet and legs since the most common route of inoculation is via a thorn, carrying the bacteria or fungi, piercing the skin.

It presents as a clinical triad of a painless, subcutaneous (under the skin) mass, sinus formation and the discharge of yellow and red (actinomycetoma) or black (eumycetoma) grains. As it is painless, many patients present relatively late (i.e. several months or even years after inoculation). This can lead to devasting consequences, as the mycetoma may spread beneath the skin and destroy deeper structures such as bones. Following evidence-based management guidelines developed at the centre, patients have a set of diagnostic and staging investigations and may then undergo medical (taking medicines) and surgical (cutting bits out or off) therapy. Over months, patients can make a full recovery, although recurrence rates are high.

Both the Mycetoma Centre at Soba, and the Institute of Endemic Diseases at the University of Khartoum conduct  ground-breaking, cutting-edge research in their respective fields – fields which are comparatively neglected in other, richer countries with different burdens of disease. They are staffed by well qualified, highly motivated and internationally published and respected scientists and clinicians.

But a small footnote to this is the effect of the unilateral US sanctions, renewed annually by the US Senate, despite promises to repeal them after the signing of the peace agreement in 2005. These sanctions do not just prevent MacDonalds from doing business here, but also prevent a spectrum of American industries, including scientific, technological and manufacturing companies from engaging in Sudan. As is so often the case, the sanctions are hurting the wrong people. That’s not cool beans.

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Picture Credit: http://pmj.bmj.com/content/75/889/671.full – Akhtar, M., Latief, P. (1999) Actinomycetoma Pedis. Postgraduate Medical Journal (75) 671 

Fahal, A. (2006) Mycetoma: Clinical Monograph. Khartoum University Press. Sudan

Manson, K. (23 July 2012) US Sanctions take toll on Khartoum. Financial Times.

Institute of Endemic Diseases, University of Khartoum – http://www.iend.org/

Mycetoma Research Centre, Soba University Hospital – http://mycetoma.uofk.edu/

‘Khartoum Burns’: What’s the score?

Photo: Ashraf Shazly/AFP/Getty Images

We had had plans for Friday 14th September. We (me and the four other international medical elective students, from Czech Republic, Norway and Poland) were going to spend the afternoon on Tutti Island, in the Nile, where you can sit in the leafy shade and drink tea.

But then at around 14:00 (Sudan time) we got a text from a Sudanese friend, “Don’t go anywhere alone today. Let me know if you’re going out”.

We had heard about the 14 minute Youtube video that had already sparked events in Libya and Egypt, and so assumed that perhaps today, the first day of the weekend, when everyone attends the mosque for Friday Prayers, there might be some kind of protest in Khartoum.

So we cancelled our plans, spent the afternoon out of sight in the Faculty of Medicine’s open-air cafe, and kept an eye on the news headlines. These did their utmost to out-do each other in the ‘shock-horror’ stakes. “Embassies burn in Khartoum”, “5,000 march on the US Embassy”, “Send for Lord Kitchener”, or whatever they were. Today (Sunday 16th and the first day of the working week here) there still seems to be significant confusion about the chronology of what happened, but from reading reports in the Khartoum and international press, and from speaking to different people here, it seems that this is what happened.

After Friday prayers, around 5,000 people (exactly and approximately) congregated outside the US Embassy. They arrived in buses, organised by ‘no-one-quite-knows-who’. The US embassy has been relocated in the last few years, so that it is no longer in central Khartoum, but about 20-30 mins drive outside it and well past the last houses on the outskirts (on the road to Soba Hospital where I am based). Hence the need for buses. The embassy itself is a long way back from the main road, and looks pretty formidable from a distance.

It was reported that ‘the mob’ gathered in ‘the square’ outside the embassy and started burning things. I drive past ‘the square’ every day at the moment on my way in and out of Khartoum. It would be more accurate to call it ‘a field’, as it has nothing in it except some dirt and some dust. It is lined on the main-road side by half-buried car tyres, presumably to discourage attempts at parking. Driving past this field on the morning after, I saw a boy poking some half-buried wires with a stick. So it would seem that these were the fuel for the fires of Friday afternoon.

It’s hard to say what exactly happened, as reports are rather thin and contradictory, but people here seem to agree that around 250 Sudanese security personnel were stationed there, that tear gas may have been used, and that three Sudanese men were killed in the course of the day.

So after some time at the US Embassy, this crowd got back on their buses, and shuttled into central Khartoum, where a number of other embassies reside. They alighted at the German Embassy – a move that neither the international media, nor our Sudanese friends could explain that afternoon. It seems that the Sudanese security services were also wrong-footed, as here the more reckless, violent elements enjoyed some success. They breached the compound walls, lowering the German flag and raising a black one in its place, smashing windows and starting a fire inside. Moving on to the UK embassy next door, a number of men again apparently scaled the wall, but did not enter the building itself (perhaps the security forces were present in greater numbers by this time?).

What seems clear is that these events were very different to those in Libya. In Khartoum, there was no well-armed, well-organised attempt to kill and destroy, or even apparently to send any kind of strong political message to the government (as some ‘conspiracy analysts’ have suggested was at the root of all of Friday’s protests across the region). It seems to have been more simply an expression of anger at the Youtube film – with the US selected as the focal point for discharging that anger.

It might indeed be argued that there is every right and reason for such emotion – given both the mucky, unhinged nature of the film, and the central, deeply-ingrained part that its subject plays here. The means for expressing such feeling however, is another point entirely.

And the reasons for targeting the German embassy? It was reported in a Khartoum paper that an offensive cartoon was published in a German newspaper in the past 2 weeks. Elsewhere, one international media group suggested it was because the German government had not banned a right-wing protest at which anti-Islamic banners were held. And the UK embassy? No-one really seems to know specifically, perhaps just because it was next door? Perhaps because everyone knows it’s an old devil?!

As I left the faculty cafe that evening, and walked to the bus-stop, past restaurants and street-stalls, parked cars and open lorry-cabs, everywhere the same radio station was blasting out some kind of feverish exhortation. What was it? Reaction to the demonstrations? Demands for more protests?

No, it was football commentary.

Al-Hilal, one of the two big Khartoumi clubs was hosting Interclube Luanda from Angola in the African continental Confederations Cup.  If they won, they would be just one victory away from the semi-finals. We had been hoping to go this match (I was even wearing my Al-Hilal shirt), but decided that perhaps today was not the best day to be part of a large excitable crowd.

Whilst walking past people on the street, and waiting at the bus stop, I must admit to feeling a little bit nervous after the furore earlier. But the only bared teeth were set in smiles, and the several shouts aimed at me were all directed in praise of my Al-Hilal shirt.

So what should I conclude after all of that?

Were the demonstrations in Khartoum trivial? No.

Were they exaggerated in the desire to create a story of arching Middle-Eastern chaos? Yes, I think so.

Photo: CAF Online

Khartoumi society (still less Sudanese or Islamic culture) is not some monolithic conformity; 5,000 people from a city of 10 million is not such a large proportion (1 in every 2000 actually), whilst I need to take my shoes and socks off to count the number of people from my small circle of acquaintance here who have quietly apologised to me for the offense of the violent excesses. Overall, passions may be strong here, but are they really so different to those you might find in London or Barcelona, Madrid, Munich or Milan? There are people who like to burn things everywhere, but the majority have rather healthier interests, like the beautiful game. My decision that morning to wear an Al-Hilal shirt may have been inadvertently fortunate, but I don’t for a second believe that it saved my life.

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P.S. – From afternoon reports on Sunday 16th September

I’ve also seen reports in the international media that the Sudanese Foreign Ministry has refused to allow the US to deploy extra marines to protect its embassy – instead committing to use its own security forces. To my eyes, this story was put across with a negative, almost sinister spin, as if the buried question was “does the Sudanese government not want the US to be able to protect itself? Do they in fact want the US embassy to be imperiled?”

But isn’t it natural that a sovereign government should wish to trust its own security arrangements, and resent or refuse attempts to usurp its authority within its own capital city? Aren’t Sudanese forces likely to be more experienced and adept at handling Sudanese protesters than American marines? And couldn’t you argue that the government’s trust in its own forces was vindicated (at least as far as the US embassy goes)?

Leishmaniasis galore!

My placement at Soba Hospital hasn’t really settled into any kind of rhythm as yet. Its all a little bit haphazard. I’ve spent quite a number of hours just waiting around, wondering if I’m in the right place. In some ways thats reassuringly familiar – its a major educational dimension of just about every placement I’ve had in London too ! But its also rather familiarly frustrating.

So I’ve started taking a little more initiative, and have been creeping (walking) around the hospital, lurking (waiting) in the places where I know my team of doctors might be – the outpatients referral clinic, the male medical wards, procedure rooms and so on – and then jumping out (standing up) and asking if I can join them.

Through this subtle method, I’ve found out the times and specialties of the clinics each morning, and I’ve seen some very interesting patients.

For example I caught the last three patients in the chest clinic today. The first man had pulmonary TB (in the lungs), with bilateral pleural effusions (water in the lungs). The second was a young man with congestive cardiac failure (a bad heart), with a very clear textbook pansystolic murmur (his heartbeat sounded wrong).The final patient was a young lady in her 70s, who had disseminated TB, including pulmonary, lymphadenitis (Scrofula or TB in the lymph nodes of the neck), Pott’s Disease (TB in the spine) and a TB psoas abscess (an abscess in one of the muscles of the leg). All of this can (and would) be treated, although I’m not sure of the prognosis. (Photo of TB Lymphadenitis below taken with permission of patient)

On Mondays and Thursdays I go the Omdurman Hospital for Tropical Diseases, a 20 minute bus journey across the Nile from Khartoum.

Again, each morning starts gently with some stretching and yawning in the consultation room for an hour or so. But when the consultant arrives, its a fantastic learning experience. I think I probably saw more tropical medicine in my first clinic there, than most UK physicians get to see in their whole careers, and after each patient we discuss the case with the doctor.

From a 17 year old boy, with portal hypertension (high blood pressure in the liver’s blood vessels) from chronic schistosomiasis, through patients with TB, malaria, leprosy, suspected HIV, tertiary syphilis, others with schistosomiasis, to three patients with Cutaneous Leishmaniasis. This disease is endemic in parts of Sudan (as is Visceral Leishmaniasis). One of these patients has a typical history. He is a soldier in his 40s, in the Sudanese army, and has been stationed in the south of Sudan (in South Kordofan State). He has three circular, raised, painless lesions on his arm, the largest is around 5×6 cm, with a dry, ulcerated centre. These are caused by the body’s reaction to infection with a species of Leishmania parasite, which is transmitted via the bites of sandflies. If left untreated, they may resolve themselves, but (depending on the species) may also spread further, or cause Mucocutaneous Leishmaniasis (involving the linings of the nose and mouth) (which is worth avoiding). I think there is a multinationally-sponsored programme for Leishmaniasis in Sudan, and so he will be put into this and recieve for free the treatment of Sodium Stibogluconate (Pentostam). Whilst it may be good in the long run, it has to be administered via painful injections (the drug has local toxic effects) – so this man has some tough days ahead.

For me, tomorrow holds a gastroenterology clinc, so lets see what that throws up (sorry for the pun!).

Pete

Mix-ups and Marriages

Greetings from Khartoum!

Its Friday, the first day of the weekend here. And no,  I didn’t get married through some slight misunderstanding, but I have now completed my first working week (Sunday to Thursday) at Soba University Hospital, just outside Khartoum.

Its been great fun, but really all about finding my feet and getting my bearings. I’ve felt a little like a fish probably feels out of water – hooked by something I don’t quite understand, but realising that some pretty speedy evolution is going to be rather handy!

For example on my first proper day (after some introduction and orientation on the Sunday), I got to the front of my accommodation (I am staying in the doctors’ mess) to catch the shuttle bus to the hospital, which supposedly went at 08:00am. After waiting peacefully alone for a few minutes,  I went up to a man sitting in the shade of a tree nearby (the mess sits in a large scrub field a little way from Soba Hospital) to ask about the bus.

Me: Hi, is there a shuttle bus now?

Man: No bus.

Me: When is the next bus?

Man: Uh?

Me: (In faltering arabic) At what hour is the next bus that goes to the hospital of Soba?

Man: (In English) The next bus?

Me: Yes

Man: Not now.

Me: Oh (pause). At what time?

Man: Uh?

Me: (Arabic) At what time is the next bus?

Man: (English) This evening.

Me: Ah (pause). Okay, so I can walk?

Man: No.

Me: Oh (pause). But I think maybe I walked yesterday with one of the doctors?

Man: Not now, too hot.

Me: Ah (pause).

(We watch for a few seconds as some of the doctors from the mess stroll past on their walk in to the hospital)

Me: But I think really I should go in to the hospital, so maybe I should try to walk.

Man: Okay, I will walk with you.

From one perspective, I think this gives an idea of my first few days. Its taken just a little time to adjust to h0w things are – from routes into Soba Hospital and bus routes into Khartoum, to meal times, ways to stay hydrated, and how to shift my sleeping patterns to make the most of the cooler parts of the day (day time average is about 40 degrees C at the moment).

What that 2 minute ‘conversation’ barely touches though is just how friendly, welcoming and helpful so many people have been to me in these first few days – particularly at Soba Hospital and in the doctors’ mess. I spend my day shifts with the house officers, who mostly speak excellent English. They have helped me to see patients, taking some histories and doing examinations, correcting my clinical technique and encouraging me to try and pick up the odd medical word in arabic (and if I ever remember any they could be useful as many patients don’t really speak English).

I have also been to a pre-wedding ‘henna’ party – at the kind invitation of the chief administator at Soba Hospital – which I think is essentially about the groom (or the bride) celebrating the end of their single days and forthcoming marriage. From 21:00 onwards, around 200 people were up dancing to the live music and songs. One of the female singers in particular had a fantastic voice, kind of the female equivalent of Tom Waits, only I think with an even bigger set of lungs.

I have to come into Khartoum to use the internet (which takes around 40 mins via 2 microbuses) – so it may be less easy to blog as often as I had hoped.

I will post again soon – particularly about the medicine I’ve seen, including my first day at Omdurman Hospital of Tropical Medicine – where I will be spending 2 days a week from now on.

Pete

Khartoum in English – Hello from me!

Summer reading

I’m currently a final year medical student at University College London Medical School.

In September I’m off to Khartoum, Sudan, to spend two months based in one of Khartoum’s main teaching hospitals. This is my medical elective (of which more later).

Whilst I’m there, I hope to keep feeding this blog at least once a week with any little snippets and morsels of what I’m doing, seeing and thinking (assuming anything vaguely noteworthy happens!).

I’m new to any form of blogging, but I’m pretty sure anybody can reply to my posts – so it’d be great to hear from anyone and everyone. Tell me about places you’ve been to, similar experiences you’ve had, things I should (or shouldn’t) eat, see or wear, ask me any questions, or chip in with your own thoughts. In short, stay in touch in whatever way you want!

Before I arrive in Sudan, I’m going try and get in a couple of posts – about medical electives in general, and about Khartoum in particular.

Will write again soon!

Pete.