Life is a Fatal Illness

By George Douglas

Geoffrey Douglas was born in London in 1945, but lived most of his life in Africa. He studied medicine at Oriel College, Oxford, where he met and married Penny. They had three children. By 1971, Geoff and his young family were back in Africa, where he worked as a doctor.

This book is written as a personal memoir of an extraordinary life, in which the author deals with serious life challenges, including being shot, the death of his youngest son and cancer. Practising medicine in Africa for a UK trained physician proves to be endlessly challenging, but deeply rewarding. Geoff makes the first HIV diagnosis in Swaziland, the country that now has the highest HIV prevalence in the world.

In his retirement, he headed up a UK charity and came face to face with the global nutrition crisis. He applied his scientific mind to the claims and counter claims of the dysfunctional food and supplements industries.

This fascinating book will impart many useful life skills and explain in simple terms what is meant by good nutrition. Geoffrey wrote it while living in Malvern, Worcestershire. He now lives in Haute-Garonne, France.

• Language: English
• Publisher: Lulu.com
• Release date: Feb 3, 2021
• ISBN: 9781716243134

George Douglas

Geoffrey Douglas is a former newspaper publisher, editor, columnist, and reporter whose work as appeared in many magazines. His first book was the critically acclaimed Class: The Wreckage of an American Family. Douglas lives and works in New Hampshire.

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Chapter 1 - The Swazi Way

Never look back

Unless you are planning to go that way

Henry David Thoreau

In Swaziland, in the mid-1980s, something happened that was to change my life forever. It took place in my clinic and, at the time, even after the event, I was not aware of its life changing potential. It was some years later, on looking back, that I understood how, for me, everything had changed from that moment.

But I am sounding mysterious and I am getting ahead of myself. Suffice it to say for the moment that I am a specialist physician. I was born in London in 1945. When I was six, my parents emigrated from a grey, post-war, post-hope England, with me and my two elder sisters. We settled in the copper mining town of Kitwe in Northern Rhodesia (now Zambia). When I was ten, I was sent some five hundred miles away to a Jesuit boarding school in Salisbury (now Harare) in Southern Rhodesia (now Zimbabwe). From there, at the age of eighteen, I travelled some five thousand miles to Oriel College, Oxford, where I began my medical studies. I married Penny at twenty-three and had three children in rapid succession. In 1971, at the age of twenty-five, I was back in Zambia, working as a doctor.

Zambia had gained its independence from Britain in 1964. By the early 1970s, President Kenneth Kaunda and his cronies in the United National Independence Party (UNIP) had succeeded in every way possible to make the land of my childhood a country in which neither Penny nor I wished to live or plan a future. As a white African, I was dismayed by this development and began to look for somewhere I could call home. Rhodesia, to the south, was in the middle of a civil war. South Africa was pursuing its policy of apartheid. Having no wish to experience another independence struggle, Penny and I were looking for a country in Africa that was independent, democratic and functioning. Sadly, the list was short. In 1974 we moved to the Kingdom of Swaziland and we never regretted that decision.

In 1979, I founded the health maintenance organisation (HMO) which was to become known as Healthcare Swaziland. It was a modest start – one nurse, a cleaner, a part-time physiotherapist (Penny) and myself were the only staff.  But, inspired by the early history of Kaiser Permanente in California in the 1940s, I remained undaunted, convinced that the HMO concept was the best way to bring affordable health care of a high standard to the man in the street, who, in Swaziland, had little.

One of the unique features of the HMO is that members are enrolled for a fixed fee, which entitles them to a package of care. The organisation can remunerate its staff only if there is a subscription surplus. So, it becomes important to stress prevention through health education and to treat patients quickly and effectively. This is in direct contrast to fee-for-service medicine, in which the doctor who over-services earns the most.

Starting a new business is always a struggle and, as we grew, I recall many month-ends when, after the creditors had been paid and the staff had been remunerated, there was nothing left in the kitty for me and my family. I remember two bits of advice I was given at medical school, and I ignored them both. The first was that if you wished to become rich, you should specialise in diseases of the rich. I had chosen to work where most people were poor. The other was that if you wished to become rich, you should specialise in dermatology because your patients never died and they never got better. This piece of advice would certainly apply in a fee-for-service environment, but chronic illness was not the best friend of the HMO manager.

In the early 1980s, a new disease was observed in the US among injection drug users and gay men, who showed symptoms of Pneumocystis Carinii pneumonia (PCP), a rare opportunistic infection that occurs in people with seriously compromised immune systems. Soon afterwards, other gay men developed a previously rare skin cancer called Kaposi’s sarcoma. At first, the US Centres for Disease Control and Prevention (CDC) did not have a name for this new disease, but the press quickly adopted the term GRID, which stood for Gay-Related Immune Deficiency. However, once it was realised that the disease was not isolated to the gay community, it was renamed AIDS (Acquired Immune Deficiency Syndrome). In 1983, two research groups led by Robert Gallo and Luc Montagnier independently declared that a novel retrovirus may have been infecting AIDS patients, and published their findings in the same issue of the journal Science. Today this virus is known as HIV.

Initially the disease seemed to single out Haitians, haemophiliacs, homosexuals and heroin users, but it soon became apparent that the disease was common in Central Africa, where it had previously been known as slim disease. It was also discovered that HIV is transmitted primarily via unprotected sexual intercourse, contaminated blood transfusions and hypodermic needles, and from mother to child during pregnancy, delivery and breastfeeding. We now believe that the disease probably originated in non-human primates in West Africa, where it transferred to human beings in the early twentieth century. The disease had never been seen in Swaziland, but we were ready and waiting.

One day in the mid-1980s, a young, well-educated, black man, who was not a Swazi, came to see me as a patient. He complained of fatigue and weight loss. He had a sore tongue, and I noticed that he had swollen lymph glands in his neck. I explained to him that HIV infection was a possibility and that I needed to do a blood test. He was not happy about this, but he gave his consent.

The following day, I received the positive result. It was a shock for me; heaven knows what it was like for him. I spent a considerable amount of time explaining, counselling and answering his many questions to the best of my ability. There was no antiretroviral (ARV) treatment available at that time. When he left the clinic, he seemed to be coping with the news. I was obliged by law to notify the Ministry of Health. I completed the requisite form, which was taken by hand to the responsible officer. Imagine my horror the next day to read my patient’s story, complete with banner headline, on the front page of the Times of Swaziland. They did not mention his name, but they did mention his country of birth, his profession and his place of work. In a small country, this was enough to identify anyone. I was appalled. My patient returned to the clinic that day. He was understandably distraught. He looked at me with disappointment and said, ‘Thank you for nothing.’ There was nothing I could usefully say, other than to explain the notification process and to share his indignation. I do not know how he fared because he left the country shortly afterwards and I never saw him again. It was my first and last notification.

That night, I could not sleep as I was struck by the dreadful realisation that this disease would decimate the country that I loved. Swaziland was and is a polygamous society. The men boasted openly of their sexual exploits with multiple partners. This would be the perfect breeding ground for AIDS – which Swazi men were calling an American Invention to Destroy Sex. My assessment proved prophetic. Shortly after that first diagnosis, a World Health Organisation (WHO) survey estimated the number of people living with HIV in Swaziland to be less than one in a thousand. By 2009 the estimate was fifteen percent of the population. This overall percentage masked the horror that twenty-six percent of young adults and over forty percent of pregnant women attending antenatal clinics were infected. Swaziland now has the highest HIV prevalence rate in the world.

Despite my Catholicism, I decided to be proactive. Swaziland had maternal child health clinics that promoted family planning, but no one was targeting the men. Sexually transmitted infection (STI) was common, and Swazi men did not use condoms. With the financial backing of British aid, channelled through Marie Stopes International, I started a three-year programme called Man Talk. The objects were the social marketing of condoms through a network of peer educators, demystification of condom usage and the education of men about STI and AIDS.

I persuaded my daughter, Emma, who was studying graphic design, to produce a logo, a series of pamphlets in both English and the Swazi language, siSwati, and various stickers, including a bumper sticker that read, ‘I understand Man Talk. Do you?’ The subject was highly contentious and many were offended. We tried to place an advert in the local newspaper showing the logo with the caption, ‘Stay on top with Man Talk’, but the editor vetoed it, arguing that the message was obscene. The idea was to get men talking amongst themselves, and to market condoms in places that men frequented, such as bars, night clubs, service stations and places of work. Wherever the Man Talk logo was displayed, it was possible to find a male peer educator from whom one could get advice and purchase condoms at an affordable price.

For those unfamiliar with the term, social marketing is the application of marketing techniques to achieve behavioural goals for a social good. There are those who hold that the best way to maximise uptake is to give a product away. It is my experience, however, and the experience of those who promote social marketing, that people do not value what they get for nothing.

In Swaziland, where family planning pills and injections were provided free by the government, and could be obtained at no cost, even through private clinics, we witnessed such social behaviour. The injectable contraceptive, Depo-Provera, was free. The only other injectable contraceptive, Nur-Isterate, was expensive. Over and over again, women demanded Nur-Isterate, whilst any attempt to explain that the products were equivalent fell on deaf ears. Eventually the Ministry of Health decided to switch from Depo-Provera to Nur-Isterate. Unbelievably, women who had previously insisted on Nur-Isterate now insisted on Depo-Provera.

In setting the price of a contraceptive, there are clearly many issues to consider. If the product is priced too low, or provided free of charge, the consumer may perceive it as being of low quality. On the other hand, if the price is too high, some will not be able to afford it. In balancing these considerations, social marketers usually end up charging a nominal fee to increase the perception of quality and to confer a sense of dignity on the transaction.

In Swazi culture, it is not proper for younger men to disagree with their elders or to publically voice a different opinion. Nor are men of different age groups happy to consult each other. This was one of the many hurdles we faced, but a breakthrough came in the form of my seventeen-year-old son, Giles, who had chosen to stay at home for his gap year. Despite his youth, or perhaps because of it, he threw himself into the condom business with enormous enthusiasm. He drove all over the country, talking to anyone who would listen and distributing condoms en route. Swazi men warmed to this father/son endeavour and came forward in significant numbers to be trained as peer educators.

It soon became clear that health messages do not sell product. Giles felt we needed to get across the message that, if you were a hip and groovy man-about-town, you would always carry and use a condom, whereas, if you were a hick from the sticks, you would not. As part of this strategy, I contacted the London Rubber Company (LRC), enquiring about their Black Shadow condoms. The condoms we were using came from America and were multi-coloured. The condoms I sought were black, and I intended to market them as a premium product. Some people argued that black men would not accept black condoms, because they would feel that the condoms were made especially for them and were, therefore, likely to be inferior. I did not agree with this argument and when LRC got back to me saying that they were discontinuing Black Shadow, but that Man Talk could have as many as we wanted at no cost, I was ecstatic. When they arrived, I was convinced that the upmarket packaging, showing a man in a top hat, would do the trick. They were sold at a slightly higher price and proved to be an instant success. Many years later, young men would stop me in the street to ask where they could buy Black Shadow.

And what did we teach? It is a very British view, which dates from the Victorian era, but is still prevalent today, that no matter what the problem is, it can be solved with education. So, what was the message we wanted our peer educators to impart? There were two parts to this – creating awareness and promoting behaviour change.

The awareness bit was intentionally scary and was based on the UK slogan, ‘Don’t die of ignorance.’ The key points were that AIDS is untreatable and usually fatal, and it is caused by HIV, which is spread by unprotected sex and contaminated needles. We also wanted to reassure people that you could not contract HIV from door handles, shaking hands, toilet seats, swimming pools, cups, glasses or a chalice. Then, as if to reassure, we told everyone that HIV was actually quite difficult to catch!

Promoting behaviour change was as simple as ABC – Abstain, Be faithful, use a Condom. Unfortunately, in the African context, the ABC approach was far from simple. The first problem was that people felt the three messages were contradictory. It was necessary to explain that abstinence was certain to work, that being faithful to one faithful partner was also pretty effective, and that condom use was essential where one was unable to comply with abstinence or faithfulness.

In the beginning, most men expressed the view that abstinence was impossible, faithfulness nigh impossible and condom use unSwazi. This stance was confirmed when we did a survey in three secondary schools to determine the sexual attitudes and practices of final-year male pupils, all of whom were teenagers. One of the questions asked was how many different sexual partners had the pupil been with in the past year. The possible answers where none, one, two, three or more than three. All the boys in one school said that they did not understand the question. When it was explained to their satisfaction, they then argued that it was a silly question because they had all had more than three different sexual partners in the past week.

The second problem concerned the issue of faithfulness. How could one ever know whether one’s partner was faithful? But the biggest problem was that the ABC approach is based on a Western, Judeo-Christian view of the world. It assumes that the recipients of this wisdom believe in cause and effect, self-actualisation and individual responsibility. The African tradition is often at odds with this. On one occasion I was asked to give the closing address at an AIDS workshop for headmasters of secondary schools. I distinctly remember the chief organiser saying, ‘Please say something nice.’ My reply was, ‘Don’t I always?’ Her response was, ‘No, sometimes you are quite confrontational.’ In the early morning of the day in question, I had been walking around my small farm with my indvuna (farm manager). We had reached the fence at the bottom of the farm which bordered on Swazi Nation land. Our conversation went something like this:

‘Themba, why is it that, on this side of the fence, there is lush green grass, whereas on that side, the soil is parched and barren?’

‘It is because you are lucky.’

‘Don’t you think it has something to do with the fact that we plant special grass, that we irrigate it and that we camp the cattle with electric fencing so that they cannot overgraze?’

‘No, sir, it is because you are lucky.’

‘But you do all these things. Why do you do them?’

‘Because you tell me to.’

‘So, if I was not here, you would not do them?’

‘I would not. It is not the Swazi way.’

‘No, that is the Swazi way,’ I said, pointing to the wasteland in front of me.

I was reminded of this exchange, half way through my address at the workshop, and it made me mischievous. ‘I am sure you have had an interesting few days and have learned a great deal, but I suspect it has been a waste of time.’ There were gasps of surprise in the room. I paused and then I shared with them my morning exchange with Themba on the farm. I followed it with: ‘I am sure that you have been taught that if you practice abstinence or are faithful or, if you use a condom, you can avoid AIDS.’ There was surprise in the audience that I was aware of the workshop material, even though I had not attended. I continued, ‘But Themba does not believe that the decisions we make today can change our tomorrow. Do you believe it?’ There was consternation in the room and they requested a pause so that they could deliberate amongst themselves. Eventually they were ready and they settled down. They had appointed a speaker, who rose to say:

‘No, we do not believe it.’

I responded, ‘So, in whose hands is tomorrow?’

The reply came with conviction from the entire room: ‘God, fate, luck or the ancestors.’

My gaze found the chief organiser, who was standing at the back of the room. She was looking distraught. ‘Thank you, gentlemen.’

And there were even bigger problems. Swazi men define their masculinity and potency, not by their virility, but by their fertility. Furthermore, in Africa, one’s offspring are one’s security in old age. Our message was a threat to both. Many people, particularly women, do not feel empowered. In Swazi culture, the female of the species is transparent and her status is entirely derivative. Traditionally, her name is never used. When young, she is someone’s daughter; later, someone’s girlfriend; finally, someone’s wife. If she proves her usefulness by the birth of a son, she is known as someone’s mother. That someone is always male. It would be impossible for a woman to insist that a male partner be faithful or use a condom.

Our message was not always understood. I recall hearing of a health worker who used to demonstrate the correct application of a condom by unrolling one on a broom handle. Apparently, the message that some people got from this demonstration was that to avoid AIDS you should unroll a condom on a broom handle before having sex. This reminded me of a health education trip into the Zambezi valley in Zambia to educate villagers about the perils of sleeping sickness, a disease transmitted by the tsetse fly. At the end of the workshop, the local chief rose to thank the visitors.

‘I am grateful that you have come to our village to tell us about the tsetse fly, and I am pleased that it is not a problem here.’

The lecturer interjected, ‘But sir, it is a serious problem and that is why we are here.’

The chief chuckled and went over to the display chart. He pointed at the image of the tsetse fly and said, ‘The flies we have here are very small. I have never seen a huge fly like this one.’

Our other task was to introduce the subject of safe sex. This was fraught with problems in a society with sensibilities, where sex was never discussed, and where virility was intrinsically linked to procreation. At this point, as a Catholic, I feel it is important to dispel the view of some that it is the Pope who is responsible for the disinclination of people in Africa to use condoms. I have never met a Swazi who was remotely interested in the views of the Church on this subject.

So, despite our best efforts, the epidemic continued to escalate. Looking back now, I realise that this was a major factor contributing to my eventual departure from Swaziland, but at the time, I was fully occupied dealing with the sick and the dying, when most of these poor souls should have been enjoying the prime of their lives. It was a bitter pill, especially for someone who had been trained in, and still did not doubt the merits of, the biomedical model of health. This is the descartian basis of the modern medical science that I had been taught but, in Swaziland in the mid-1980s, it had little to offer those living with, and dying from, HIV/AIDS.

In this sea of tears, and abandoned by the pharmaceutical industry, I learned two truths. The first was that if a patient believed that being HIV-positive was likely to be a death sentence, he tended to sicken and die quickly. We call this the nocebo effect. The second was the power of touch. One of our colleagues in the clinic became ill with AIDS. I saw him every week and treated the various symptoms that arose, but I felt increasingly helpless. One day, when it was clear to us both that he was in decline, he looked at me with tears in his eyes and pleaded, ‘Doctor Geoff, you must help me. I am relying on you.’

I did not know what to say or do. Then I stood up, beckoned him to come to me, put my arms around him and held him tight. As I held him, knowing that I was breaking every rule of the doctor/patient relationship, he convulsed with sobs. I kept hold until he calmed himself. The following week, he seemed to be a little better. I told him I was pleased and that I would see him again in a week. He got up to leave, but then he paused and said, ‘Where’s my hug?’

Chapter 2 - Creating Reality

They can because they think they can

Virgil

In the previous chapter, I referred to the biomedical model of health and how a belief in one’s demise can become self-fulfilling. It is important to say more about both.

The biomedical model, also known as allopathy, conventional medicine or Western scientific medicine, has been around for about one hundred and fifty years, which makes it relatively new in the history of medicine. This model, which is considered the epitome of scientific, objective and reproducible medicine, is based on the following main principles.

Health is viewed predominantly as the absence of disease, and sickness is explained within a biological framework that emphasises its physical nature. This follows from Louis Pasteur’s and Robert Koch’s views on pathogenicity – disease is caused by physical agents external to the body. Health services are geared towards treating sick and disabled people. Their main function is remedial or curative – to get patients back to productive work. Doctors diagnose illness and sanction the withdrawal of patients from work. A high value is placed on the provision of specialist medical services, mainly in institutional settings, such as hospitals or clinics. A high value is also placed on scientific knowledge and on using scientific methods of research. In this research, quantitative (measured) evidence has a higher status than qualitative (observed) evidence.

The biomedical model considers professional knowledge to be expert, rational and scientific, whereas lay beliefs are devalued, being perceived as ill informed, non-rational, unscientific and superstitious. Lay people have beliefs; doctors have knowledge. So, doctors are knowledgeable experts who always know best. Indeed, it is acceptable to ridicule a patient who fails to conform to the assumptions, expectations or requirements of doctors. In this scenario, patients cease to have their own identity; rather they become stereotyped or labelled. The doctor's job is to diagnose relevant symptoms, which are prioritised to the extent that they conform to diagnostic models. The focus is on objective, measurable phenomena, increasingly aided by technology.

Biomedical purists hold that psychosocial factors have no part to play; the mind and body are separate, with neither influencing the other. Health care interventions should centre on the physical aspects alone. The emotional side of life is secondary and best left to psychiatrists. They also hold that patients can and should have no control over or involvement with what happens to them regarding their health and wellbeing. It is the doctor who treats disease, which means that it is the doctor who dispenses health. Effective doctor-patient communication is important only because patients need to know what is expected of them, so that they can comply with instructions regarding taking medication or adherence to a regimen.

The biomedical model has enjoyed proven success in the diagnosis and treatment of numerous diseases. Examples include the once-lethal infectious diseases that antibiotics can cure, or the once-devastating viral illnesses, such as smallpox, polio or measles, that vaccines have all but eradicated. But the model is intrinsically flawed. Its failure stems from its core belief that an illness has a single cause, and that removal or attenuation of the cause will result in a return to health. Unfortunately, this does not apply to today’s chronic health problems. A single drug, or even a single micronutrient, cannot be the ‘cure’ for tuberculosis (TB), cancer, asthma, arthritis, diabetes, high blood pressure, obesity, heart disease, stroke, mental illness or dementia.

The first scientific challenge to the biomedical model came with the disease beriberi, which had been described in 1630 by the Dutch physician, Jacob Bonitus, who encountered the disease while working in Java. The disease attacks the nervous system and the heart. Wasting and paralysis result from damage to the peripheral nerves. The patient experiences difficulty in walking, with increasing paralysis of the legs, numbness and pins and needles in the hands and feet, pain and mental confusion. The effects on the heart include swelling of the legs, breathlessness, increased heart rate, worsening heart failure and death.

By the 1880s, beriberi had reached endemic proportions in the Dutch colonies. In 1888, another Dutch physician and professor of physiology, Christiaan Eijkman (1858–1930), who had studied the latest ground-breaking medical research with Robert Koch in Berlin, was appointed Director of the Medical Laboratory at the Military Hospital in Batavia and Director of the Javanese Medical School. He had been sent to Indonesia to study beriberi and, in accordance with popular thinking, to find the pathogen that caused it.

For his experiments, Eijkman bought chickens, which he housed in large cages in the shade under the laboratory’s extended roof. After less than a month, all the chickens sickened with the symptoms of beriberi. He bought more chickens and kept them isolated in smaller cages. But