I feel like a Spanish conquistador on a small scale. My past vanquishes from seven trips to Peru include malaria, elephantitis, amoebic dysentery, hepatitis, and last year three fly larva with sprouting wings crawled beneath the skin looking for a way out. Once any disease is identified, the treatment is straightforward and efficacious, as with these. Each ailment, if one is able to study and feel it in progress, is an honor with a merit badge of antibodies or sash of resistance. I was ready for the next exotic disease.
However, I got blindsided yesterday with the diagnosis of chronic anemia from a worm infestation I had pined for since veterinary school out yonder in the Michigan countryside on call at the barnyards (our offices). There the extracurricular dogs, wasted and grown so thin they were shadows of dogs, except with hanging pot bellies, were dosed with worm medicine before we went on to the big jobs of treating the cows and horses. I grew fascinated with intestinal parasites but had no idea that the chronic anemia the suckers caused could nearly kill a person.
Anemia is a decrease in the number of red blood cells or less than the normal quantity of hemoglobin in the blood. Hemoglobin is a main part of red blood cells and binds oxygen. If you have too few red blood cells, or your hemoglobin is low, the cells in your body will not get enough oxygen. Breathing is like drawing air out of a paper bag. The name is derived from Ancient Greek ἀναιμία anaimia, meaning ‘bloodlessness’. Because hemoglobin (found inside RBCs) carries oxygen from the lungs to the capillaries to every cell of the body, anemia leads to hypoxia (lack of oxygen) with varying degrees of anemia fostering a wide range of clinical consequences. Anemia is the most common blood condition in the U.S. affecting about 3.5 million Americans, while the 2014 issue of Blood magazine for medical practitioners reported that the global anemia prevalence in 2010 was 33% or 2.3 billion people.
Chronic is a condition that persists and has been present for at least three months. I’m certain my anemia was contracted nine months ago In Peru when I was unable for one month to escape the delivery boat of a demented captain far up the Rio Tigre and ate and hobnobbed with a string of villagers where hookworms are indigenous and zoonotic among their runt animals that made my earlier Michigan barnyard dogs and cats look like champions of show.
In collecting evidence on a medical subject there are three fronts: observation of the client, his history (more difficult for animal patients), and laboratory reports. My Peruvian doctor said I was as white as a ghost, and then began the history. A physician who takes a good history and a patient who gives one nearly always and quickly solve any mystery that we call illness. I learned the first rule is to take the history chronologically, and the pieces of the puzzle fall together into a diagnosis before the mercury is shaken down into the thermometer. Then he gasped as my lab reports popped up on his computer monitor. ‘You’ll be a very sick man if you’re alive one month from now without treatment.’
My hemoglobin is 6.3 gm/dl while the adult male’s normal range is 14-18 gm/dl. In the laboratory test hemoglobin (Hb) is measured as total hemoglobin and the result is expressed as the amount of hemoglobin in grams (gm) per deciliter (dl) of whole blood, a deciliter being 100 milliliters. My hematocrit by volume is 22% whereas the norm in males is 40-50%. Hematocrit is the ratio of red blood cells expressed as a percentage by volume of the blood. It can be said that I’m existing on less than half the oxygen of what the normal reader is.
The lab report supports my suspicion for the past two months that I am hypoxic; however I thought it due to a heart or lung condition and estimated the reduction of available oxygen at 30%. Unless you have been there, it is hard to explain how a desert dweller develops a skin like a coyote nose that detects water at a distance, and how an athlete who has jogged eight miles a day for twenty years owns a palpable cellular sensation for the presence, or absence, of oxygen. The three symptoms for the past two months have been dizziness, fatigue, and shortness of breath. To climb a flight of stairs has created the same oxygen debt as fifteen minutes of wind sprints with the similar inclination to keel over. Twice I’ve lost consciousness during uphill walks with the faint echo of the inspirational lyrics from The Impossible Dream, ‘To try when your arms are too weary…to reach the unreachable star’.
I could never have imagined that a legion of vampire worms could cause such hypoxia to deprive an adequate oxygen supply and cause a near death experience. There have been a half-dozen instances when I felt I could ‘will’ myself to die as the old folks in homes that I used to do volunteer work at claimed was possible, and in Indian circles. It’s a floating, paradoxical REM sleep. A person may die when, scientifically speaking, he ought to have lived if he is in an almost heaven. Yet, each time as consciousness drained like a liquid from lack oxygen in the brain, a spark ignited alertness perhaps due to old timers urgings such as ‘This ain’t a dress rehearsal, Sonny’, and ‘Get out and milk life dry.’
My nemesis is Uncinaria, a large family of hookworms that infects man and dogs, with frequent zoonotic transmission between them. These hookworms are present throughout the world, and especially in warmer climates. In the United States, hookworms are found everywhere and commonly along the East. Worldwide, zoonotic hookworms are found in tropical and subtropical regions where the parasite is better able to survive in the tropical conditions. Their mecca is the Amazon where they grow three times as large as anywhere else in the world to 1.5 inches.
These nematodes are slender beasts with bent heads like a hook for leverage of a hammer claw and a mouth with cutting plates and an inner single pair of teeth to bury deep in the intestinal mucosa to gnaw through the walls to the capillaries. All hookworms suck blood, and the Amazon variety are capable of removing 0.2mls of blood per worm, per 24 hour period. They are in competition with themselves for space and blood along the walls like bickering tenants in a skid row hotel, or old revolvers in newly opened mining districts so that when they do want RBCs, they want them badly. Dogs have been known to carry thousands of worms in their intestines, and I suppose given the chronic anemia that I may harbor as many.
The Uncinaria were positively identified yesterday in a microscope slide report at an Iquitos clinic that was tardy relative to the other results which had provided a clean bill of health. The lab report didn’t quantify the infestation beyond ‘heavy’, and was supported by a greatly elevated eosinophil count of 27% (eosinophils usual account for less than 7% of circulating leukocytes) which makes it a textbook case of parasitosis, according to my Peruvian doctor who has seen several as severe.
The patient has two sleeves, one containing a diagnosis and the other a therapy. The diagnostic lab is my favorite area to place the first sleeve, and in vet school I worked six illuminating months as a budding medical Sherlock Holmes, as we all were, diagnosing diseases by a battery of tests – blood, fecal and a few others. The laboratory spun with tubes and slid with slides like a rock concert. The medical lab is the bastion of the fight against disease where the etiology of each is identified by the tests. Sometimes the lab reports weigh as much as the emaciated patients, so much the better. Reading them is exactly like perusing an Ellery Queen mystery such as The French Powder or The Dutch Shoe mystery and solving for the crime before the last page is turned. (By the way, Ellery Queen is both a fictional character and pseudonym used by two cousins from New York.) The laboratory is a palace of probability that few pathogens can sneak by undetected, and once fingered they stand little chance of survival.
‘This is Good Medicine!’ I cheered the doctor, on the way out the door, and he understood that modern medicine had diagnosed and would conquer another microscopic army that had tried too hard to infest a human body. If more smartly evolved, the worms would have allowed me to remain asymptomatic while sucking me dry instead of my plan to load for bear to kill them and then taking the advice of the oldsters to suck life dry.
Hippocrates advised, ‘The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.’ That is exactly what this seasoned tropical doctor did, and I walked out his office on lighter feet. He was a general physician, and It must be understood that no one can be a good physician who does not perform surgical operations. There is as great a difference between a physician and surgeon as between a mechanic who has learned from texts and one who has lifted hoods and had his hands in the muck. Never settle for a doctor or specialist who is not also a surgeon. Even in middle age he seems astonished at being paid for doing something as enjoyable as solving daily medical mysteries and curing. Wherever the art of medicine is loved, there is a love of humanity.
The doctor proposes that my severe condition, which he’s seen in villagers that have a 20% incidence of hookworms, requires no blood transfusion. In the USA, in contrast, a severe anemia is defined as hemoglobin of 8.0 or less with symptoms present and is considered life threatening and prompt treatment is required. In U.S. my case would probably be met with a blood transfusion, which currently is controversial with a circulating slogan ‘Anemic patients should know they have the right to speak up for a transfusion.’ However, I’ve seen thousands of potbellied people and pups around the world looking more bedraggled than I, and don’t worry a bit about the diagnosis. The anemia is a blessing, but a change, and requires a moment in the thick of the crisis to check the flow and redirect the focus.
After the diagnosis comes the treatment, as he penned two prescriptions in striking calligraphy: Albendazole and Confer. The former is a broad-spectrum anti-helminthic for roundworms, hookworms, threadworm, whipworm, pinworm, flukes, and other parasites that works by killing the worms straight out from the blood. It doesn’t taste badly to me and I suspect something is added to intoxicate the toothy heisters. This really is war, with my life at stake, and theirs. Despite their sophisticated mouthparts, and a nervous system that may also deliver an almost heavenly state of consciousness, these bloodsuckers have no excretory organs and no circulatory system, that is neither a heart nor blood vessels.
I’m not a pill Frankenstein tampering with nature, but there are many bull’s-eye synthetic and natural medicines that are literal miracles that I will take, and otherwise would be dead a few times over if having lived in the time of Tarzan a century ago. Albendazole is an efficacious one. It is commonly prescribed worldwide, and particularly in USA for zoonotic infections. It’s on the World Health Organization’s List of Essential Medicines, a tally of the most important medications needed in a basic health system. In 2013, GlaxoSmithKline, the principal international marketer of the drug, donated 763 million Albendazole tablets for the treatment and prevention of parasitic infections in developing countries such as Peru, bringing the total to over 4 billion tablets donated since 1998. Closer to home, since 2010, and for understandable reason, the U.S. price of Albendazole has increased by 4000% to over US$100 per 200-mg tablet. Disease is the biggest money maker in our economy. I paid 20 cents a tablet yesterday for my two-tab a day supply for one week totaling about $3.
In addition, I filled a prescription for an oral iron supplement called Confer. Unlike salt licks, you may not find the nearest igneous outcrop and expect to lick usable iron. Because iron is the principal component of hemoglobin, consuming a supplement and iron-rich foods will raise your hemoglobin levels. Dietary iron must be attached to either animal meat or plant tissue to be absorbed by our intestines, and the supplement probably contains both. I’ve also started eating iron rich seafood, red meat, and leafy green vegetables. The doctor assures that my 6.3 hematocrit will increase two units per month so that in four months I’ll reach the low norm, a triumph as complete as Operation Detachment in the Battle of Iwo Jima.
But I also have my own ideas about disease recovery to cure. Walking is first rate medicine and is my first thought to accelerate the doctor’s prescriptions. Healing is a biological process and there are few ailments that do not respond immediately and expansively to the increased circulation of a vigorous walk. Walk in increasing increments with escalating weight to let the clean air blow the cobwebs from your body.
In the aftermath, there’s money in the bank to cover the cost of the trip to Peru and lots of salads and seafood. The medical expenses totaled $US200. In the USA it would have cost twenty times that, with additional superfluous tests and requisite specialists, and taken weeks instead of two days. One well-trained physician of the highest type will do more for a patient than ten specialists because everything medical within the body is interrelated and cannot be separated.
A Darwinian view of medicine makes disease more meaningful. Diseases arise ultimately from past natural selection. It’s a continual war within one’s lifetime, and over the centuries, of the forces of pathogens vs. the soldiers of the immune system. They evolve after each skirmish, and then counter-evolve like in Mad magazine’s wordless black comic strip ‘Spy vs. Spy’. Paradoxically, the same capacities that make us vulnerable to disease often confer benefits. The capacity for suffering in itself is a useful defense After all, nothing in medicine makes sense except in the light of evolution.
Nature didn’t find the perfect place to hide the little assassins in my gut; but rather the Uncinaria developed through epochs of struggle and earned their position. Now they have revealed themselves and will die. Perhaps a few during the Albendazole fusillade – one in 10,000 – will adapt, survive, and reproduce resistant pathogens. Such is life.
Through hard traveling and having contracted and beaten a string of diseases that remain like untied knots the emotions have been, ‘I love you. I hate you. I like you. I think you’re a loser. I think you’re wonderful. I don’t want to be with you. I want to be with you. You should have believed me.’ Health and disease, unlike what you may have been taught in middle school Health Science 101, are the same thing – vital actions intended to preserve, maintain and protect the body. There is no more reason for celebrating health than disease. After vet school my body became like an aquarium to me and I always carry a fishing pole to catch and squeeze every ounce of information I can out of each condition. I´ve had and recovered from nearly 33% of the ailments listed in the physician´s bible called the Merck Manual only to conclude that life is so short to learn so long a craft as disease cure.
In a subsequent medical text of alternative cures that I wrote, a certain pleasure is revealed that came from nudging the ill layman in the direction of terror, and bringing him back safely and happily and licking his wound. It´s too bad, but given the conventional medical wisdom that’s the sort of paradigm shift required to accept like a Third Worlder that disease is a normal course of life. We don´t have to get as sick nor as often in the First World, but our attitude can become saner by accepting rather than fleeing in dread from the knock of unfavorable conditions at the door.
If you ‘listen’ to your body and intuition, they’ll guide you well through sickness and into better conquering forthcoming illnesses and old age. You´ll gain wisdom about anatomy, physiology, biology and the mind. There are countless ways to develop the listening skills such as sports, dancing or drumming, but most of all by awareness through disease, while keeping a journal. Read about it in texts. It’s more interesting to examine an ailment in onset, flow, and remission than it is gazing at virus Facebook.
The public bladder about medicine is that one must see a specialist and get a battery of tests when actually as much and almost instantly for free can be gleaned from recovered peers at an online chat forum for specific ailments. Such a well-chosen anthology of case histories is a complete dispensary, as well as studying the progress of one´s own conditions. Always pick a physician who is older, seasoned, a surgeon, preferable a sports medicine practitioner, and lord help you if he is busy. The profits will follow a good physician to the grave, but he is more difficult to find nowadays in USA, and all the more reason to seek professional treatment at a fraction the cost in other countries. Perhaps this is the only solution to whip the ill American health care system back to health.
As for Global Anemia, already the dead worms are evacuating, and I say, ‘I tried to tell you. You said you didn’t care, remember?’ Today we fight. Tomorrow we fight. The day after, we fight. And this disease plans on whipping us, but if we have paid close enough attention they had better bring a sack lunch for the extra innings.