Bush Medicine 101: Lesson 8 - Three Mad(agascar) Bitter Pills To Swallow
Like Life, Swallowing A Bitter Pill, Or Three, Has Got A Lot To Do With Risk vs Benefit
Dear Family, Friends, Mentors, Colleagues and Jane-Your-Younger-Self,
I hope you are well. We are well.
My intention is to do good and no further harm. Always.
Arriving back from South Africa on SA Airlink a 3 hour flight from Johannesburg to Antananarivo, which we locally called Tana because Antananarivo is quite a mouth full…of syllables and Doxycycline as it turns out.
At Tana passport control we received a compulsory 300mg of Doxycycline in the government’s efforts to treat against a Cholera outbreak.
European Centre for Disease Prevention and Control reports that “since 1 January 2024, and as of 24 February 2024, 39 346 new cholera cases, including 698 new deaths, have been reported worldwide. The five countries reporting most cases are Zambia (13 015), Afghanistan (8 402), Zimbabwe (7 219), Mozambique (2 563), and Pakistan (2 405).”
Doxycycline is a drug which in varying doses also treats:
The Plague (which is known to occur regularly in Madagascar)
STDs including gonorrhea, chlamydia and syphilis (also a regular infection to Madagascar)
Acne
Malaria (though Doxycycline is not the modern / most updated treatment)
Cholera
As a proudly South African born, bred and trained medical doctor running my own “dream” Robin Hood community clinic for the past 11 years in Fort Dauphin on the east coast of Madagascar, one of my commitments to my beloved art and science in my practice of medicine has been to try to teach young doctors, old doctors, all doctors, and parents, about the risks of unnecessary antibiotic use.
At med school, like school, I look back and judiciously consider what we were and were not taught.
At med school in total we had a 2 week block dedicated to pharmacy.
We did not have even one lesson on the importance of sleep and why we should be interrogating a patient’s sleep routine as the starting point of trying to do our good and no further harm. Bush Doctor or First World Doctor.
The other vital lesson we missed (not because I didn’t pitch for the lesson, but because it was never taught), perhaps because the science was not yet caught up, or our lecturers were not yet caught up on the science, was the importance of our gut microbiome (the good germs in our gut), how instrumental our gut is to our immune system, how instrumental our gut is for making hormones like dopamine and serotonin which our brain needs to prevent anxiety and depression, and how detrimental injudicious antibiotic use can be to our good gut bacteria and our bodies overall.
Did you know that the gut is the largest endocrine (hormone secreting) organ in the body?
Poor sleep (less than 7 hours), sugar, poor quality carbohydrates (pasta, breads, flour based products), processed foods (foods coming out of packets manufactured in a factory), alcohol, antibiotics (compulsory Docycycline!) all kill our gut microbiome.
Killing our gut microbiome decreases our dopamine, serotonin, and immune system and can be the reason we have a problem being happy and healthy. Or rather, not depressed and healthy.
As an aside, not depressed, by the way, does not equal happy, but that is another subject for another day.
I used to think that the worlds mental health crisis was being caused by gastric worms aka parasites. We all want to find “The Solution” to the world’s problems, me included (when I was younger and more idealistic).
Mostly due to the fact that worms in the tropics are one of our go-to diagnoses when a patient presents with fatigue, lethargy, depression, headaches, abdominal bloating, intermittent pains, and….well actual worms witnessed by those enthusiastic enough to check their stool.
To the naive first world inhabitant, for some reason they tend to have a look of absolute shock and horror at my professional medical suggestion that the reason for the symptoms of mental illness, fatigue and abdominal bloating may in fact be…
Worms.
Somehow first world humans think that their beloved first world pets would never and could never have worms. And on questioning, no, they have not recently, or ever, de-wormed themselves or their pets.
To which I looked shocked and horrored at their thought that worms could never be their diagnosis.
Back in the jungles, deforested plains, dust bowls, villages, towns, and over populated chaotic cities (like Antananarivo), worms are a common ailment, a common diagnosis, for which we commonly treat.
We were taught in medical school (despite not being taught about sleep or the gut microbiome), that common things occur commonly.
Worms.
Occur.
Commonly.
Because we in the third world are not above thinking that we may have worms.
Because lets face it, worms is a better diagnosis than depression or anxiety. In my opinion anyway.
Once the treatment is taken, voila, worms expelled (yes, I write this in plural because where there is one worm, there are many….MANY).
The gold standard diagnosis involves a patient’s stool sample viewed under a microscope.
I give my adult patients the choice, you can take 400mg of Albendazole per day for three days, and repeat this dose in 2 to 3 weeks.
Or.
You can go to the toilet, fish out a stool sample (where you may see your worm/s up close and personal), bring my lab your stool sample in a yogurt container (let me be clear here, do NOT BRING IT TO ME BUT MY LAB).
After which you will never eat yogurt with the same enthusiasm again, and then I’ll prescribe the Albendazole as mentioned above.
“It’s really your choice”, I kindly, sweetly and reassuringly tell my patients, because what the client wants the client gets. And as in all-world consumerism, the client is always right.
I have never once had a patient say, “yes please, I would like to fish around my toilet bowl and bring you my spoils for a microscope test”.
Oh wait. Yes. Once I did. It was a German patient.
Germans, in my experience, are the only nationality that insist on diagnosing what type of worm.
Guess what, the treatment is the same for all types of worms.
It’s funny the number of times I’ve had parents proudly bring me soiled nappies, empty jam jars, yogurt containers and other non specified containers with the actual worm within.
For your information, if you are ever my patient one day, you really do not need to bring me, in any way or form, a sample of the said parasite, because at the end of the day and at the end of your bowel movement, I am always going to prescribe the same medication at the same dose for the same duration.
A worm is a worm is a worm.
I am not German.
I am proudly South African and now proudly living in Madagascar using my South African training and my 14 years of Madagascan experience to the best of my abilities.
I have no desire to diagnosis whether it’s a pin worm or a long worm or a fat worm or a thin worm or a round worm or a tape worm.
I will prescribe treatment for worms. Blanket diagnosis. Blanket treatment.
I repeat, please don’t bring me your worms.
Coming back to being forced to take Doxycycline military style on entering Antananarivo from Johannesburg this last week at passport control.
Cholera sadly kills patients and my intention here is not to underestimate the tragedy or belittle the efforts to prevent cholera from crossing international borders.
We all saw how Covid spread throughout the world. We also saw how militant protocols became during Covid.
Being forced to take 3 tablets of bitter tasting Doxycycline did leave me wondering how effective the Doxycycline was going to be in reality, and how many cases of cholera we were actually going to prevent by this militant move to treat everyone at the boarder.
I also considered whether it would not be better to treat all people exiting Madagascar for worms and STDs (sexually transmitted diseases), because these Neglected Diseases are something we commonly treat in my clinic amongst locals and tourists alike.
While I was wondering how we would be able to scientifically tell if we were actually going to stop cholera at the Madagascan passport control and the benefits of treating people leaving the country, I wondered how much drug resistance to Doxycycline we were causing, and how much disruption to our precious gut microbiome, and dopamine and serotonin production, and our invaluable immune system.
What I’ve learned in becoming an adult and a Bush Doctor, is to question the risk vs the benefit (and the cost vs the benefit) when doing good and no further harm, including any treatment I am going to prescribe to a patient. Particularly antibiotics.
Worms are maybe not the cause of the global mental health care crisis. Or maybe they are together with the over use of antibiotics?
Doxycycline was the first antibiotics I’ve taken in over 11 years, since I got a breast infection with my 2nd and last born in 2012 (my husband said if she had been our first she would have also be our last born because she was very full of “character”, I think is how he put it).
This week it was 3 bitter pills of Doxycycline to swallow which left me wondering if my beloved medical profession is doing more harm than good in efforts to prevent a cholera outbreak, and whether the militant decision has been influenced by our previous experience during Covid.
It also puts into question the saying, “what doesn’t kill us makes us stronger”. Three tablets of Doxycycline certainly didn’t kill me, however I’m not sure it’s made my gut microbiome or immune system stronger either.
As I write this, as far as I know there has not yet been a cholera outbreak in Madagascar.
Who knows, maybe it’s been stopped at Tana passport control and I’m wrong in my skepticism. It’s always a valid question to ask to justify swallowing a few bitter pills in life.
Kind and mad regards, with the intention to do good and no further harm.
Mad Madagascan Mum & Medic,
Jane
ABOVE: Family trip to South Africa February 2024…before having to take Doxycycline.
Great to hear from you Debbie!
I know those "worms on the toes" well. They come in seasons. And I tell tourists if they don't get those kind of worms they have not really traveled well in Madagascar (same applies to gastric worms ;) )
I love your "gap year after 60".
Does your husband still practice?
Thanks for taking the time to read my post, I appreciate it.
I totally agree, they did not even ask a medical history.
I did but threw at least some of them up after they made me so nauseas.