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June 7, 2020 | Rome, Italy

Don’t mess with tetanus

By | 2020-02-15T12:42:11+01:00 February 15th, 2020|"Bedside Manners"|
Getting a tetanus booster in Africa of the 1970s was a nearly impossible task.
L

ong before I went bottoms-up in the Nile, the medical perils of southern Sudan had landed on my head — literally. After our plane from Khartoum touched down in Juba, my ex and I took a taxi to our hotel. When we got there, the cabbie opened the trunk and I leaned in to pull out a bag. Lids stay up, right? Wrong. This one came down on my head. Blood poured out, normal for a scalp wound. It’s a welcome form of self-cleansing. Andrea (the ex) immediately got to work trying to staunch and disinfect the ragged cut.

But there was another more ominous problem. Every roadway – even in Italy and the United States – comes with vast quantities of tetanus (aka lockjaw) spores. In Italy, their general headquarters is the feces of Carabinieri horses. In Manhattan, think Central Park carriages.

In sub-Saharan Africa, Juba included, animals are ubiquitous, which makes outdoor contamination the norm. Every object is a tetanus hive.

Like most physicians, I’m sloppy about my own health. I hadn’t gotten a tetanus shot before the trip.

In sub-Saharan Africa, Juba included, animals are ubiquitous, which makes outdoor contamination the norm.

To count back to my last one, I needed all my fingers and all my toes. And after a decade you’ve likely lost your immunity.

So there we were, only just landed, condemned to start our Sudanese sojourn with a crisis. I needed a booster shot of tetanus toxoid (the vaccine we all get as kids, followed by boosters every 10 years). I also needed immune globulin (serum), the shot of antibody soup we’re all supposed to get if we suffer a contaminated wound.

The hunt was on. First, we tried the public hospital, a crumbling structure whose “furniture” consisted only of bed frames and their springs, no mattresses. These were jammed into every available space, each one holding two patients arranged head to foot. The sick were surrounded by encamped relatives.

I explained my predicament to the head doctor but he didn’t seem to know what I was talking about.

The year before, visiting a mission clinic while traveling in Kenya, I had noticed that the only tetanus medication they had was serum harvested the old-fashioned way, from horses. In 1911, the product was a miracle of modern medicine. But it had the unpleasant tendency of producing severe and even fatal reactions. The medical world heaved a collective sigh of relief when a more benign and effective version of immune globulin, derived from human blood, arrived in the late 1960s. But in Juba of 1979 I was a beggar, not a chooser. The toxic horse serum sounded better by the moment.

After the hospital fiasco, Andrea and I made the rounds of all the half-dozen private clinics in town. No joy, no booster, no horse serum, no human serum, no nothing. As a traveler and a scientist, this trip had become an anthropological odyssey. I was getting an inside view of medical facilities in one of the major cities of a country one-fifth the size of the United States (Sudan had yet to be officially partitioned). But as a patient I saw no upside to this exposure.

Finally, at the last clinic we visited, this one run by missionaries, I hit the jackpot. Or at least I found someone who knew exactly what I was talking about. An earnest Dutch doctor kindly explained that tetanus toxoid, the booster I needed, was completely unheard of in southern Sudan. But he could get me some immune globulin. And this immune globulin wasn’t the toxic kind once made from horses – it was of human origin, like the products used in Europe and the U.S. Except, my savior added, for one slight difference: the serum wasn’t a sterilized commercial product but a concoction hand-produced in Juba from the blood of locals.

No joy, no booster, no horse serum, no human serum, no nothing.

It took me a minute to realize what this meant. Unprocessed serum from south Sudanese blood could be – would be – loaded not just with antibodies but with germs. Nowadays the most-feared constituent part would be HIV, but this was years before the appearance of AIDS — or hepatitis E, West Nile virus, or Zika fever.

Nonetheless even in 1979, the list of blood-borne diseases was already long, led by malaria, syphilis, and hepatitis types B and C (then known as “non-A, non-B”). A somewhat less serious category included brucellosis, toxoplasmosis, Chikungunya, and Dengue fever. Finally, an obscure but deadly blacklist featured trypanosomiasis, babesiosis, leishmaniasis, and Ebola. Maybe you’ve heard of the latter.

For a south Sudanese patient who’d never had a tetanus shot and had already been exposed to most of these infections, the risk posed by the homemade serum might have been worth it. For me? Not on your tintype.

The outside incubation period for tetanus is six weeks. My Nile swan-dive came a few days later, initiating a countdown to diseases that thankfully never struck. Still, my lockjaw scare hit me hardest. Even with modern medical care, the disease can kill you.

However, my jaw never locked, which isn’t to say I didn’t learn some precious lessons about medicine, and myself.

— This the second in a three-part series about the author’s travels in Africa in the late 1970s.

About the Author:

Susan Levenstein
New York native Susan Levenstein, MD, moved to Italy in 1978 and has maintained a successful Rome primary care practice since 1980. She has a professional website and writes a blog. In May 2019, Paul Dry Books published her memoirs, entitled "Dottoressa".

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