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Changing Planet, Changing Health
How the Climate Crisis Threatens Our Health and What We Can Do about It
By Paul R. Epstein, Dan Ferber
UNIVERSITY OF CALIFORNIA PRESS Copyright © 2011 The Regents of the University of California
All rights reserved.
My first epidemic began quietly, as most epidemics do. It was May 1978, and I was working as a physician at the Central Hospital of Beira, Mozambique, which was the only hospital for hundreds of miles. One morning I was summoned to attend to a dangerously debilitated man in his thirties. The man's family had brought him a great distance from the mato, or countryside. The ailing man was so severely dehydrated that when I gently pinched his skin, it tented, meaning it retained the profile of a small tent where I'd pulled it away from the underlying tissues. His eyes were sunken, his gaze terrified. He was clearly near death.
Three months earlier, I had arrived in Beira with my wife Andy (short for Adrienne), who's a nurse, and we had begun caring for patients in the city's Central Hospital. Beira is a major port city in southeastern Africa and Mozambique's second largest urban center. It lies some seven hundred miles north of Maputo, the capital, in a flood-prone rice-growing region on the Mozambican coast. Although it is not a spectacular city, it does have its share of natural beauty, with long, curving white sand beaches rimmed by the warm waters of the Indian Ocean. The beauty of Beira's beaches, where well-off white Rhodesians once played, could have blinded the casual observer to the existence of ancient diseases rife in the population, diseases scarcely known in Western societies.
Beira was then an impoverished city of about three hundred thousand in a nation that had wrested its independence from Portugal just three years earlier. Andy and I were part of a small troop of professionals, of all stripes and from numerous countries around the world, known as cooperantes, or international aid workers, who converged on Mozambique to help the fledgling nation rebuild its health care system, its economy, and its society (figure 1).
To prepare for my work in Africa, I had audited a course on tropical diseases taught by top experts at the Harvard School of Public Health. Upon our arrival in Mozambique, I had also undertaken six weeks of on-the-job training in the sprawling 1,600-bed complex of the Central Hospital of Maputo, the country's most modern city. In the vast, open wards of the Maputo hospital, a collegial group of local and foreign doctors had given me a hands-on crash course in recognizing and treating the many afflictions common in southern Africa, including well-known diseases like malaria and tuberculosis, along with a multitude of life-sapping diseases caused by worms of all sorts and sizes. These included hookworm, which lives on blood and causes anemia, weight loss, and stunted growth, and schistosomiasis, or snail fever, a debilitating ailment endemic in Mozambique that causes urinary tract and kidney disease.
My suspicions about what was ailing the desiccated, frightened man in Beira did not derive from the training I'd received in Maputo. Instead, the deathly ill man recalled images in tropical disease textbooks I'd studied in Boston. His sunken eyes and dehydration presented the classic picture of cholera, a waterborne disease capable of blossoming into a raging epidemic.
Completing the diagnosis required microscopic examination of the patient's stool for the cholera bacillus. Other strains of bacteria, as well as some viruses and parasites, can cause diarrhea that results in extreme dehydration, and we needed to rule out these infections. I placed a drop of the man's watery stool on a glass slide and peered at it under the microscope. I saw hordes of wriggling, comma-shaped microbes dancing on the slide—telltale signs of Vibrio cholerae. The diagnosis was established when the organisms later grew in petri dishes containing agar made with small amounts of sheep's blood.
Andy and I had become familiar with the host of serious but preventable diseases that afflicted Mozambicans and those in neighboring nations, resulting from poor nutrition, inadequate sanitation, and poverty. But cholera—with the exception of a brief appearance in 1973—had not been among those ills.
* * *
When we applied to work in Mozambique in 1976, the former Portuguese colony had been independent for a year. Mozambique's revolutionaries in the Front for the Liberation of Mozambique (FRELIMO) had fought a successful thirteen-year war for freedom from colonial rule, a war that ended when colonial soldiers returned to Portugal and overthrew their dictator, in turn freeing the nation's African colonies. The revolution held the promise of a better life for Mozambicans, but its immediate aftermath had major repercussions. Upon independence, the Portuguese fled en masse—more than a quarter million Portuguese left the city of Maputo alone.
The fleeing Portuguese packed up their riches as they exited, and, in some instances, they sabotaged development projects on the way out. But the losses to the country weren't solely material. The exodus included virtually the entire professional class of Portuguese settlers, including teachers, foresters, mining specialists, engineers, and doctors. Under Portuguese rule, education for most Mozambicans had ended after fourth grade, with the exception of students sent off to seminaries. When the Portuguese left, most Mozambicans were illiterate.
Because Mozambique needed so many kinds of experts to build its new infrastructure, Mozambique's first president, Samora Moisés Machel, and his government reached out around the world for assistance. My wife and I were part of the wave of international cooperantes who responded to that call. Indeed, during our time in Beira, Andy and I worked alongside cooperantes from, among other places, England, Holland, Sweden, Russia, Bulgaria, Cuba, Zambia, Brazil, and Chile.
The new government had many concerns to address. Perhaps the most immediate had to do with medical care for their newly liberated citizens, who were overwhelmingly rural farmers. Many nurses had departed, and almost all of Mozambique's Portuguese doctors had abandoned the country, leaving just a handful of physicians to care for a population of twelve million.
Fortuitously, President Samora Machel, whom Mozambicans knew simply as Samora, was a trained and experienced nurse, and he assigned health care a high priority in those early heady days. Samora's aim was to develop a well-distributed health care system that integrated public health services. Achieving these worthy goals was difficult with so few resources and health practitioners at hand. At Samora's insistence, neighborhood health clinics were opened throughout the country and stocked with a carefully selected list of imported generic medications. These efforts led the World Health Organization to recognize the Mozambique health care system as exemplary. But that was only a beginning. One of the important tasks for medical cooperantes was the training of Mozambican nurses, nurse practitioners, and new doctors in the nation's one medical school in Maputo.
From 1976 to 1978, we waited while our applications to work in Mozambique wound their way through the fledgling, byzantine Mozambican bureaucracy. At last we were informed that we would be welcome for a two-year posting. Although we were officially employees of the Mozambican Ministry of Health, our sojourn had been arranged by the American Friends Service Committee, the Philadelphia-based Quaker organization that supports humanitarian aid and peacemaking efforts around the world.
Upon our arrival in the country in February 1978, we were relieved to discover that we could speak our rudimentary Portuguese haltingly with Mozambicans. (It would be six months before we could hold our own in a dinner conversation.) Assured that we were capable of taking a medical history, we got to work immediately. Our children adapted in a different fashion. They played silently for the first six weeks with the children of our Mozambican, Chilean, Swedish, and Portuguese neighbors and coworkers. Then, suddenly, they began to speak the lingua franca fluently, interjecting the word coisa (thing) for whatever object they could not yet name. It was an exciting time.
With FRELIMO's explicitly race-blind policy, we felt welcomed and accepted in this beautiful port city of a million people, with its vistas of the radiant Indian Ocean. With our children we walked downtown and through shantytowns, exploring the spicy and delicious victuals. Fish and shrimp and chicken were abundant—and cold, cold beer (bem gelado) as well. In our hotel, there was only the occasional mosquito, but crickets, birds, and roosters could be heard everywhere.
During our six weeks of training at Maputo's Central Hospital, a delightful, well-trained Cuban hematologist befriended me, easing my transition from Western to tropical medicine. When Andy arrived in the surgical ward, her first patient was a man who'd been bitten almost in half across his abdomen by an alligator while crossing a nearby river. With surgery and good medical care, the man survived intact.
Most of the diseases afflicting Mozambicans presented with signs almost as obvious as an alligator bite; thus diagnosis was generally easy. Prevention, on the other hand, was difficult to implement, given the country's low level of development, which made even simple preventive measures for many common maladies hard to come by. Few women or children wore shoes (figure 2), which would have spared them the anemia caused by hookworms that enter the body through the skin of the foot and then line the sides of the intestines. (Men, who benefited more from the country's limited prosperity, were more apt to be shod.) From our vantage point on the ground, the shape the nation's development would take was not obvious. Even today, the questions of how to develop and to power that development remain central issues for Mozambique, as they are for many underdeveloped nations.
Shortly after arriving, we were posted to Beira, the second largest city in Mozambique. After completing our training at the seven-hundred-bed Central Hospital in Maputo, Andy and I launched our family's four-day trip on the northerly road to Beira in a spirit of adventure seeking and with a sense of purpose. We traveled a hardscrabble highway, which was intermittently paved, and ascended onto the vast African savannah dotted with wide-crowned acacia, mango, and cashew trees. If Maputo had seemed exotic, the landscapes and civilization we encountered on our journey to Beira were even more so. We stayed overnight at a hotel in the beach town of Vilancoulos, where we were the only guests. We were served by a Mozambican staff that otherwise stood quietly behind nearby palm trees, shoeless but clad in white colonial-era uniforms, as if the revolution had never happened. We swam for the first time in the surprisingly warm sea. That evening, the four of us stood surprised and transfixed, watching a lunar eclipse from the hotel balcony. The moon seemed just a few feet away as it dropped into the sea.
Two days later, following a stop in Xai-Xai to visit a Mozambican friend who had studied in Boston and taught us Portuguese and Mozambican history, we reached Beira. The city had been a major trading center for goods from Salisbury, Rhodesia (now known as Harare, Zimbabwe), in the heyday of colonialism. By the time we arrived in 1978, however, it was a diminished outpost populated by a few Indian shop owners and many unemployed Mozambican men. Women were barely in evidence in the modern part of Beira, which the locals called the "cement city." The town's center seemed almost abandoned. The real life of Beira, we discovered, could be found on its outskirts. Dirt roads and narrow paths weaved among houses made from sticks and stones, cement, or sugarcane stalks. Outside, children played and women sewed and sold goods from stalls, keeping one another company. Women tended the cooking fires, and the air was infused with the sweet scent of burning acacia. We lived nearby, and from our cement house we could hear batuki (drumming) well into the wee hours on the weekends.
I was soon appointed chief of medicine at the Central Hospital of Beira, and I set about working with the thirty other international doctors and one dentist. Each medical cooperante put in one twelve-hour work shift a week in the hospital's emergency ward. Andy worked there each day as well, performing a form of triage, determining when patients required hospital admission, simple packets of pills, or treatment in a neighborhood health center (figure 3).
In the evenings, our home was a magnet for this multicultural crowd of international coworkers, Portuguese friends and coworkers, and Mozambican locals and their families. The children, lacking television to mesmerize them, kept us entertained with their improvised theatrical and musical productions.
Conditions varied on the hospital's wards. A common problem on the women's ward was severe anemia from hookworm, acute malaria, or both. The problem was exacerbated when women were pregnant, as the body's blood volume rises from five to seven quarts and already scarce iron is stretched even thinner. Other patients had one or more of a range of debilitating diseases, including mosquito-borne elephantiasis, amoebic dysentery, and schistosomiasis. Mosquitoes infected and reinfected our patients with malaria, and they infected Andy and the children with malaria as well, despite the chloroquine pills they took to prevent it. Then there were the diseases imposed on Mozambicans solely as a result of inadequate sanitation, poor nutrition, or both, among them rickets and gastroenteritis from many sources. "It's a wonder there are so many people walking about," I wrote in one of my earliest letters to our sponsors in Philadelphia. On the other hand, the pervasive diseases of industrialized societies—diabetes, hypertension, and heart disease—seemed nonexistent.
Our work was demanding but rewarding. After working all morning in the hospital, we'd head out to the shantytowns—the bairros. Andy worked in the health clinic of a bairro called Inhamudima near our home, while I worked in another clinic out in Munhava, the largest of the bairros ringing the cement city. The locals introduced us to locally available foods, and we taught them about nutrition and other healthy practices. We saw patients—usually about twenty-five each day—throughout the afternoon. The medical and social needs were enormous.
* * *
An epidemic is defined as an unusual occurrence of disease—an unexpected number of cases occurring in a particular time and place. Understandably, epidemics are often not immediately recognized. But in the case of the cholera epidemic that erupted in Beira in 1978, the breadth of the outbreak was evident in a matter of days.
That the disease was cholera made the episode all the more remarkable. Cholera had spanned the globe in seven pandemic waves since the 1800s, including the London cholera epidemic in the 1850s that crusading epidemiologist John Snow had helped stop. Epidemiologists knew that cholera was circulating in Asia in the late 1970s and was, in fact, considered a permanent blight in the many countries bordering the Bay of Bengal, reaching from India all the way to Thailand. But the disease had been absent from Africa for most of the twentieth century, so its appearance in Mozambique was surprising. The deathly ill man from the mato was the first, or "sentinel," case of the epidemic, and his illness indicated that the seventh pandemic wave had now spread to East Africa. In the weeks that followed his arrival, hundreds of people in all stages of the disease found their way to us, to Beira's neighborhood clinics, and to clinics in surrounding towns and villages. In addition to those presenting as ill, we knew there were thousands more in the Mozambican countryside who were carrying the bacteria but showing no symptoms. It was truly a major epidemic.
When the cholera epidemic first hit, we were fortunate to have the staunch support of the province's health officer, the capable Dr. Pascoal Mocumbi, a practicing obstetrician and gynecologist who would later become the nation's minister of health and then its foreign minister. Working together, in short order we organized a thirty-bed ward staffed by four doctors and eight nurses.
Excerpted from Changing Planet, Changing Health by Paul R. Epstein, Dan Ferber. Copyright © 2011 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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