Tribal Tradition

Every day in the Emergency Admissions Unit (EMU) is different and on a daily basis we would see something unique. But in the same way that muddy pot-holed roads soon become a normal part of life in the city, so to the extraordinary in the hospital becomes the norm and what would once have made us turn away in horror is dealt with in calm acceptance. There are still some occurrences that sear the mind like a branding iron on a cattle’s behind. I came one day to find a man semi-conscious on the bed in the haze of the early morning in the EMU. The flies were buzzing and the air was thick with dust, moved only by the one working ceiling fan in the corner of the ward. His family were with him, a not unusual event here given the tight knit family units. I looked closer and saw that his legs were chained and pad-locked together and deep abrasions decorated his legs. Immediately I assumed he had been brought from the prison. I was wrong. The man had become gradually more confused over the preceding weeks and had caused so much mischief and destruction in his village that his family had purchased the lock and chains and immobilised him. After multiple attempts by the traditional doctor to heal him with herbs he had been dragged, carried and hoisted to the hospital and deposited, chains still in situ, onto the bed. The man had TB (Tuberculosis) meningitis.

This brings us to the traditional healers that I do not think we have mentioned except in passing. There is still a huge commitment to traditional medicine here, and nearly all my patients have sought the help of a local healer before visiting the hospital (and that was without knowing that they would be seeing me). Traditional healing takes many forms, but the most common here takes the form of cutting. Traditional blades are heated and the skin sliced in specific patterns and positions to treat the ailment. A headache may be treated by shaving a square of hair from the head and three deep cuts made in the scalp. A painfully enlarged liver will be decorated with many parallel incisions, and a swollen spleen will be similarly adorned. In fact, you can detect organomegaly (enlarged organs) without touching a patient simply by looking for the sites of the steel assault. If the pain is generalised cuts may be made in distinct patterns around the abdomen or chest to cure the ailment. And remarkably when you ask the patient, many say the healing works- and who am I to argue. To be fair, the healing is rarely cuts alone but the wounds are rubbed with special herbs and barks collected from the bush which doubtless have some medicinal content.

Cutting, or scarification, is not restricted to traditional healing. I have mentioned the facial scarring of some of the tribes here before. The Dinka have three diagonal stripes cut in to their forehead when they are young. The Nuer have parallel lines cut from ear to ear around the forehead in rings. On examining the abdomen of one woman I found the most intricate designs of raised spots and scars covering her entire chest and stomach. Felling her skin was like reading brail (which I am not particularly familiar with) and the beautiful array of whirls and loops decorating her skin looked like a Van Gogh painting sculpted into her. The stories behind the history of these scars are many, with a number of people looking accusingly at me as they explain that their grandparents told them that it was the British that introduced this barbaric practice as a way of distinguishing the tribes. This is not true since the early explorers found tribes here with scarring as they stumbled through the untouched jungle. Moreover there are over 60 tribes here and very few practice scarification. A more plausible story was that the practice was started due to child abduction during tribal wars in the distant past. If a child was scarred as a baby and then taken by a rival tribe during a raid they would always be identifiable as from the original tribal group. Others have just said that traditionally it has represented a sign of beauty and has been done simply to improve the features of the individual. Either way, the practice is dying out as communities move to the towns and Western influences are brought in. No doubt it is a different case in the bush.

We have taken very few photographs of these practices and I have always felt uncomfortable taking pictures of my patients. Though I doubt they would mind, their suffering can seem so all consuming that a photo simply seems inappropriate and still, when you are caring for them other priorities come to mind such as getting the correct drugs given at the right time, and selecting the few relevant tests that can be afforded. I should add as matter of interest that the traditional healers are often 10 times MORE expensive than the government hospital, though payment is usually in livestock rather than cash. A goat can cost 100 Sudanese pounds (20 pounds sterling) and a cow 10 times as much. A traditional healer will frequently ask for 2 goats in payment when a consultation at JTH costs 1 sudanese pound, a chest X ray 10 sudanese pounds, a malaria film 5 sudanese pounds and many of the drugs are initially free.

Given the lack of photos to support this essay (yes, I am sorry it appears to have emerged as something deserving that description) I will finish with a description of a recent meal we attended with some South Sudanese friends of ours.

Ronald Woro, Eluzai Hakim and Wani Mena took us to a local restaurant specialising in traditional food. What arrived at the table had been pre-ordered by Ronald and was nothing short of amazing. A whole goat’s head, boiled, sat in a bowl. Next to it in 5 smaller bowls was a gleaming end of thick bone surrounded by a glutenous soup: this was boiled cows hoof known as ‘Gbakasa’. Two bowels of fried termites, ‘konga,’ and the essential ‘Ilong’ (maize meal) and the millet equivalent also adorned the table. As I plucked out the eyes Heidi tucked into the tongue and it wasn’t long before I turned to see Heidi holding the entire cranium up to her lips as she sheared off the muscles at the back of the neck with her incisors. The skull was then cracked and the brain released from its bony cage to find a new home in our stomachs. The latter tasted like over-cooked liver, but the eye-balls were delicious. The termites were crunchy and delicious with the dried fish soup that was added to wash them down. We all sat back sated after an hour of solid demolition, Ronald left sucking the marrow out of the bone that had once carried a hoof. All washed down with a White Bull, the locally brewed lager. An awesome day all round.

Relaxing reading the papers before the feast

The konga (termites)

Gbakasa (the hooves)

Boiled goat head

James retrieving the eye

James about to enjoy the eye

The skull after it was opened and the brain before we had a taste

Ronald enjoying the food

The next event involved the consumption of the local home brew. Eluzai had arranged his relative Martin to locate some of the local beer and ‘wine’. The latter we were assured tasted like Chardonnay. The local beer, kwete, has a long and complicated brewing process using fermented sprouting maize. It is filtered through old cloth to rid it of most of the solid material and emerges resembling a thin alcoholic porridge in look and texture. Anyone who has visited Zambia may be familiar with ‘Shake-shake’ or ‘Chipolopolo- hits like a bullet’ which are a similar beverage. The wine is called Douma and is made from fermenting millet with honey and yeast. It is stronger than the Kwete and much sweeter resembling a strong cider rather than wine. The beer was delivered in an old sunflower oil can, the Douma in a bucket (and it needed sieving to get rid of the lumps). We enjoyed them with Robin, a British guy teaching English here with the British Council, and shared a bottle or two with the Ethiopian bar manager and the Ugandan site manager. The beer had to be drunk that night and we couldn’t manage the 3 litres so the rest was enjoyed by the Sudanese kitchen staff!

All is all and amazing few weeks.

Sampling the kwete (in the yellow bottle)

The douma before filtering

Filtering

Us wih Robin having filtered the Douma and bottled it up in water bottles

Ball Boys

In a brand spanking new country there are always going to be a lot of ‘firsts’- the first time the flag is raised, the first time the National Anthem is sung, and in the days after the Independence celebrations the first international sports matches. The two big confrontations were to be the newly created South Sudan football team against Kenya and the basketball team against Uganda. However, there were two problems to overcome. Only two I hear you cry! But these two were BIG. Read on...

The basketball team were staying in our Camp and were suitably tall so as to confirm that they were ball players of international quality even without the Air Jordan shoes and the ubiquitous basketballs that were carried around. They were all South Sudanese but many were schooling abroad in the States, Australia, England or East Africa. I am told their eyes sparkled with a quiet confidence as they strolled the Riverside, but I was unable to see this since clouds generally formed around the region of their mid-chest and their heads were obscured in the mist at that height. The game was delayed for days and rumours were awash in Juba. It turned out that the stadium had not been finished and with no court there would be no match. All was rescued when the local school offered their court to the teams and the match was scheduled for the following day.

The school was buzzing in the cool of the evening; chairs standing in rows and crowds pouring in. Heidi arrived early to get a good seat, walking down with our medical students (we finished teaching early to ensure the entire game would be caught). I was delayed after being called to see a collapsed bishop in church. That is another story but I will indulge it here briefly, only because of the prior treatment he had received. This gentleman had in the past had interventional treatment to his heart in Kenya after being sent there by the church with a heart attack. Despite this advanced Western treatment in the past, his initial response to feeling unwell was to visit a ‘local doctor’ or ‘traditional healer’. After an afternoon of soaking in chicken’s blood and a number of other herbal remedies he felt no better and then the incident I was called to review occurred. It is just a reminder of how deeply entrenched the traditional life here is. And who’s to say that some of these treatments don’t work (though I am fairly sure the chicken’s blood did not help his angina)?

Anyway, back at the school basketball court the atmosphere was hotting up as the air temperature cooled with the falling sun. Amidst the cheering and ululating and chants of ‘Uganda is dead’ in Juba Arabic the players fought it out on the concrete. A great game and even though the South Sudanese physically dwarfed the Ugandan players the final result saw Uganda finish a hairs breadth ahead. The Score keeper was probably the most tired of all the people on the day having to constantly write the latest score up in chalk and quickly rub it off and re-write it every few seconds, usually having to rescue his chalk from the children who were drawing pictures on the back of the board.

A few of the medical students before the game

The Republic of South Sudan team get ready to represent their country

The challengers Uganda

Uganda made a very strong start

South Sudan fighting back

A lot of patriotism amongst the crowd

A battle of the flags

The children finding something to do with the chalk and blackboard scoreboard

The crowd getting behind the local team as they bring the score to a draw

Atmosphere and tension mounting

Tension showing in the final few minutes for the ROSS team

The football was a more organised affair- from the South Sudanese end. The Kenyan national team had been double-booked and was unable to come, only discovered by a roving South Sudanese journalist who spotted it on their website. Instead one of their top premiership teams was sent last minute to face the white shirted team from the South. The newly refurbished stadium (pimped up in record time by a Chinese team that seemed to never leave the site) was crammed full. Heidi and I had to slip in with borrowed ‘PRESS’ passes to sit in the journalist’s area. The game was great fun, though less atmospheric than the basketball, particularly being separated from the real local supporters, many of whom had climbed onto the walls to see the action. South Sudan scored three of the four goals on the day but lost 3-1. South Sudan, however, was the first team to score in the opposition net and led 1-0 for most of the first half. It is early days for the National teams since many of the players had never played together before and these matches only represent the beginning of a new sporting era here.

Apart from all the events around Independence work has continued in the hospital with regular teaching sessions and visits to see patients at the UNMISS hospital to review the sick while their physician was away. And so it continues.

Onto the football James and his 'press' pass to help get us into the stadium

The walls filling up

The wall full

The national anthem, a small error of the sprinklers starting briefly

The teams hitting the pitch

A last minute team talk in front of a packed crowd

If there was anything to climb up it was

The brand new floodlights were also put to good use.