SUGGESTIONS ON HUMANITARIAN FOLLOW-UP
ON ASSA GOITER PROJECT FROM PERSPECTIVE OF CAUSE AND EFFECT
AND MY RESPONSE WITH THE ESSAY OF
"THE LION, THE PASTOR, AND THE CRETIN"

From: Glenn Geelhoed
To: Peter Hotez
Date: 11/8/01 6:57PM
Subject: Re: an idea

Thanks!

I had considered that, and had written on the subject as well. When I had brought original data from such research to the prior committees, they were distinctly uninterested, but had wanted my "research" to be done in a library setting, mining Michel Foucault or other post?modernists, to show how my being there was a residual of post?colonialism and cultural dominance that needed to be deconstructed. I append an insight, contained in a story supported by a good deal of photojournalism (see below.)

Further, I cannot??yet??go "back": the Hutu/Tutsi holocaust of Central Africa has eradicated many of my places and most of my friends, and as the anthropologic "participant/observer" method calls them, my "informants." This is carefully described in Out of Assa: Heart of the Congo.

I am going back to Africa next year, but probably to Malawi in the South and Ethiopia in the North??but once again, my prior committees have been cool to the idea of my doing any real?world work and describing to them the results (which are viewed as interplanetary to "Human Sciences") but do something they are more comfortable with in terminology and framework??theoretic post?modernism.

I would be very happy to discuss what can be done in what should surely be the easiest part of the whole Human Sciences Program for me??the thesis??since, like you, I must be generating several of these monthly. But, just this part is the vulnerability, since the committee had said that a thesis would "come too easily for me??he should wrestle with the imponderables, not models of problems with surgical?type solutions." Peter Caws has described this as a recommendation that he did not want to see a "runner, but a wrestler??arguing the body of literature in the field of Human Sciences." I had thought that the Human Sciences was exactly the program to bridge the two cultures of CP Snow and to bring "Consilience" (EO Wilson) from multiple disciplines. This reference brought out the greatest derision from Bernard (that??by the way is his name, which you had written as "Byron") Wood who asked if I had sent the pre?publication manuscript of Wilson's thesis to them to "edify" them. If so, it apparently did not work!

I will be delighted to work on the themes we have discussed and you have described in the humanitarian application of medical science for the "treating" of others with multicultural sensitivity and evaluation that is "scientific"??both medically and culturally. I have not yet found across campus any scholar who has not got his bona fides in one category without abjuring the other??and I am classified as archtypically "other."

Thanks for the encouragement and the original "epiphany" that may ??as Ray had said, produce the "win?win" synergy and help support the Medical Humanities Scholars program with a department member with this thesis straight down the middle of his strike zone.

GWG

Here is an essay that is all factual, and goes to the heart of your suggestion:

THE LION, THE PASTOR, AND THE CRETIN:

A STUDY IN CAUSATION OF DISEASE

FROM OUT OF AFRICA

Glenn W. Geelhoed

AB, BS, MD, MA, DTMH, MPH, MA, FACS

Senior Fulbright Scholar

African Regional Research Program

Address Correspondence to Dr. Glenn W. Geelhoed

Office of the Dean, George Washington University Medical Center

Ross Hall 103, 901 23rd Street NW Washington D.C. 20037

Phone 202/994?4428, FAX 202/994?0926

Email: gwg@gwu.edu WWW URL:
http://home.gwu.edu/~gwg

AOL: GlennGWUMC@AOL.com

A lion, you say? A man?eater inside the village?

The story sounded bizarre. Only in this part of Africa would I listen even
this far into the story as it was blurted out in breathless fragments, broken
up in imperfect translation. Surely, something must have been added, or
deleted, in the retelling through the third language layer! But, wait, this is
Africa, and hoofbeats??at least in this part of the Dark Continent??more
often foretell zebras than horses. This story reported facts that seemed too
bizarre to be invented, so, let's listen further and try to confirm or refute the
details that are coming together from various sources.

From earliest Greek historians to the present, story tellers and listeners
expect something different in Africa than that to which our Western
standards??criticizing the incredulous??would apply, since was it not
Herodotus who said, "Ex Africa siempre veni aliquod novi?" So, hear
me out!

But, a lion? Right in the middle of Ndamana village? Dragging him right out
of his hut at night? Well, this story would reward looking into, and would
turn out to be even more African than the black?maned male man?eating
lion that captured the pastor, quite physically, and my vivid attention, quite
literally, from the opening. Then, the story impressed itself much more
morbidly on the center of life in Ndamana than the lion had, in a village
important to my interests in being here in Central Africa.

Ndamana is hardly more than a wide spot in the trail leading through
northeast Zaïre to the river border with the Central African Republic
(Figure 1.). It is in a region of this impoverished corner of the savannah
abutting the Ituri Forest that some of the world's highest rates of endemic
goiter and cretinism might be found. Ndamana was a centerpiece of a study
of this metabolic disorder, and the eleven percent cretinism rate and nearly
one hundred percent goiter rate among the adults who survived childhood
and developed even minimally beyond the cretinoid failure of mental and
physical growth retardation. The biological data collected in our survey
showed extremely well the low values for thyroid hormone and
astonishingly high levels of thyroid stimulating hormone??a combination
reflecting the world's epicenter of endemic hypothyroidism.

This study of endemic hypothyroidism is not only the reason for my
presence in this village but also linked indirectly to the pervasive animism of
the Azande culture, the anthropologic grouping of this tribal unit victimized
by this disease. Causation of illness may be somewhat mechanistic and
simplistic for western investigators??in this case clearly iodine deficiency
plays a major role, with goiterogenesis also contributed to by a diet high in
the staple cassava that is the staple starch of dietary intake, and some
further implicated co?factor in selenium deficiency??the hypothesis still to be
completely explored. These unfortunate people live with chronic
micronutrient deficiency and marginal macronutrient adequacy, a setting in
which hypothyroidism is both cause and effect, even possibly adaptive to
this resource?poor environment. Ndamana, therefore, is a ripe field for
study of the biologic and cultural effects of the disease hypothyroidism and
vice versa. But, there may be more to be learned here at even more
abstract levels in the adaptation of these people and their subsistence in this
environment.

The Pastor and His Wife

The facts ascertained about this startling story in Ndamana relate to the
pastor and his wife. They lived in a dominant hut in the center of Ndamana
village and were prominent citizens in this small community with the added
cachet of his clerical role. There was some unsettling in this role when an
assistant pastor was assigned from outside the village to Ndamana, largely
to assist in setting up the clinic for the evaluation of the hypothyroidism
project and an intervention program to enable prevention in this endemic
process. The week before our arrival, there had been some direct
confrontation over roles and limits of authority, and we later heard of an
open challenge during the course of one of the Sunday worship
services??details of which I was unaware when I first heard the lion story.

There is not much "evening" in this equatorial location, and after the single
meal of the day at dusk, the fires sputter out and it is time to retire into the
shelter of the thatched hut. This the pastor and his wife did, and soon were
fast asleep lying quite close together on a woven cane wicket?work bed
under the thatched roof and distant from the waning cooking fire.

Enter, the Lion

It was some time at night when the wife woke up abruptly. She screamed
with pain. Something had seized her foot, and she would not have
awakened for the inconvenience of insect stings, nor even rat or snake bite.
There it was again! This time her screams woke up her husband who sat
bolt upright and seemed to understand in an instant what was happening
before he uttered one exclamation and was no more. "Praise God!!", he
murmured and his skull was crushed in the darkness quite audibly next to
the ears of his terrified wife. An enormous powerful form was standing on
her leg and reeking of rotten flesh now with the added smells of hot sticky
blood mingling from husband and wife.

The big male lion had crushed the life out of the pastor by closing powerful
jaws over his head and snapping shut. The big cat jerked up with hind
claws imbedded in the pastor's wife's leg as he shook the pastor's lifeless
body and began to drag it from the hut.

The villagers aroused by the wife's screams and the commotion peered out
of their huts to see in the moonlight a dark shadow dragging a body by the
head, carelessly stepping on the dangling limbs and jerking forward until it
left the clearing and disappeared into the bush. There was a noisy sound of
thrashing and dragging as the lion retreated further from Ndamana and then
the deep hollow bass roar and even more frightening sounds of
dismemberment and bone crunching by the feeding lion. The wife continued
to scream and ululate and her neighbors kept up the high pitched keening
wail of mourning without any impact on the satisfied sounds of the primary
performance in the bush.

Some men had emerged from their huts and were stirring up the dying fire
from the embers to make fire brands and torches, not to follow the lion's
trail, but to attempt to ward off his return. No one slept in Ndamana for the
rest of the evening, each cowering in his or her own thoughts as some of the
women attempted to attend to the pastor's wife, binding up her stump that
was squirting from where the lion had bitten off her foot. The pastor's wife
seemed less aware of the pain at that time than her bigger loss that was still
ongoing and sickeningly audible not far from the hut. She was taken out of
the hut and brought to a neighboring hut where she became much weaker
and was whimpering when dawn arrived and she was carried over to the
minimal clinic.

The Pastor's Remains

At dawn the men of the village gathered in a group outside the hut, some
looking in, but none entering. By now they had the torches burning in
earnest, and very gingerly they advanced down the spoor of the very wide
and bloody drag line into the bush with four wide?eyed men in the lead. In
the second echelon, yet equally fearful, was the pastor's assistant. They had
only gone three hundred meters when they found the pastor's half?eaten
corpse without evidence of the lion's presence at that moment. They quickly
pulled on the remains to retrieve them from the bush and hurried back to
the village where renewed outcries and keening wailing was heard from all
but the widow who was spared the sight of what was left of her husband
having been taken off to clinic for an emergency operation by the
Assa?trained nurse. She was then transferred over to CAR where the
expatriate nurse cared for her, debriding the wound and suturing bleeders.

With as much formality as could be mustered by the assistant pastor, a
grave was dug right by the roadside, one hundred meters opposite the hut
in which he had lain down to sleep for the last time. As seen in Figure 2, the
pastor's grave was fresh when I came upon it, with the half of his body that
was recovered interred with as much haste as the formalities of the event
could afford.

The lion returned. The assistant pastor had sent a runner to the district
officer and the men of the village had gathered in a defensive committee,
soon reinforced by the delegation from the district officer. That night, the
lion returned, as they lay prepared for him at the sight where the pastor's
remains had been abandoned. The big male lion was riddled with spears.
Snarling and roaring he retreated back into the brush where soon he was
heard gurgling and gasping as the final brave villager approached to touch
his eye with a spear until it no longer blinked.

With as much triumphant relief as the still numbing shock of the pastor's loss
would allow, they dragged the lion with all of their efforts a short way back
to the village whereby the women could file out to see the dead beast and
curse and spit upon it. Some of the young men who were not present at the
kill still contributed by perforating the dead body until there was little of the
hide to be saved. He was a very large black?maned male lion, with very
worn down incisors, but no other evidence of crippling that may have
occurred before he turned man?eater. There had been previous reports of
missing sengi dogs in the area, but no other instance of attacks on people,
and none has occurred since.

The Widow

The name of a widow in Pazande is "poor person". The properties of her
husband (NB: and her??as women are not considered worthwhile enough
to own anything; typist's note) are divided among his male siblings, and she
is not included in his estate. The typical outcome for a widow the age of the
pastor's wife is a very short and unhappy life span, but even more so that
she is crippled, as she had been in the same incident that took the life of her
husband. In Figure 3 the widow is seen as she is learning to hobble with the
aid of a stick on the remaining heel stump of what had been her foot. Her
further status is unknown, and only a few of the women of the village knew
about her for any but a few weeks after the event. She had received
medical care, and the post?injury infection had been drained secondarily,
but suffering depression from both the loss of her husband and her social
status, she had very little will to live by last reports.

The Fatal Hut

Probably the principle asset in the pastor's estate was the hut that he had
built with the help of his kinship and which was a well?constructed,
ventilated, centrally located thatched dwelling in the center of Ndamana.
Until the time of our visit, no one had entered it. It was clearly a hut that had
brought misfortune upon those who lived within it, and this ill luck lingered
around it to make it in current real estate parlance "unsalable". There had
been talk of burning it. Still other suggestions were to perform some
ritualistic purification rite, which was under consideration by the assistant
pastor, who was otherwise quite busy with higher priority issues. It was
suggested that the curse could be lifted if some stronger magic would carry
the evil from it that had been visited upon its inhabitants. The author (Figure
4.) without much hesitation, and probably mainly based in ignorance of the
intense circumstances that were yet to be told in the village dynamics
revolving around this fatal hut, went in to explore it and even lay down in
the wicker? work bed and imagine the horror of that night for at least the
surviving victim. The lion would have to be a very brazen beast and
extraordinarily hungry to pass the smoldering fires and enter the center of
the village and its dominant hut; but even if extraordinary, these
circumstances appear to be substantiated in fact with unfortunate
circumstances that resulted for all, grave injury to one, and death to the
principle person in the village.

After the author's perhaps foolish foray into the hut, others followed, and
the assistant pastor announced that it would not need to be burned, but
further disposition would be brought up for later consideration after much
higher priority issues had been resolved. I took this as a positive
development, and knew nothing of the reference he was making.

The Plot Thickens

We went about our medical business and lined up all the children of what
would have been called school?age, and a similar queue of men and women
to assess goiter size, reflexes, weight, blood pressure, pulse, and blood
sampling for thyroid functions to measure the effects of intervention of
depot?iodine supplementation. Ndamana remains a remarkable village for
the data obtained in the thyroid study. Perhaps more remarkable still is the
discovery through rumor of some of the goiter study participants of a much
more involved dynamic in the evidently self?fulfilled prophesies they had
witnessed firsthand.

It was gradually confirmed and details filled in that the row that had broken
out before our visit in the eventful weekend preceding the clinic
establishment was occasioned by one person's diagnosis as to the cause of
his child's disease. The disease itself was not a diagnostic dilemma??it was
cretinism, plain and simple. But the "how?" was not as powerful as the
"why?" had been to one credible judge of the event.

During the course of a worship service in the week preceding the fateful
night, the pastor had let fly at the assistant pastor a threat to keep him in his
place and to delineate his prior authority and the limits of infringement.
Rather than responding directly to this challenge, the assistant pastor began
an impassioned litany bewailing his own misfortune. After a prolonged
period of infertility and stillbirths, his wife had conceived and carried a child
to live birth which was a source of great joy upon his arrival in Ndamana.
However, it was becoming increasingly apparent, that the child was a
full?blown cretin, developmentally retarded in mental, social and physical
milestones and would not be a contributing member of the family that his
Father had so desperately longed for. He had loudly opined that he knew
who had visited this curse upon him and that a sure sign from God would
befall the perpetrator of this evil who had robbed him of his right to a child
in a true sense.

No one needed any more proof than the bizarre thunderbolt that hit the
dominant hut in the center of Ndamana village when a shaggy black?maned
lion entered with a frightening roar. All the Azande animus and confidence
in cause, effect and retribution were underscored beyond contradiction, and
whatever the goiter team was doing to try to illuminate some minimal
scientific inquiry into this major problem was minimally interesting and
massively irrelevant. They already knew "what?" too well; but, more
dramatic proof of "why?" could not be gainsaid.

We came, we saw, we went away with numbers. We believed, within
specified confidence limits, in one independent variable's effect within the
limits of our observation that was data?based . They were overwhelmingly
convinced by a signal event so obvious and self?evident that no explanation
was needed and no refutation was expected. We have some preliminary
evidence and suggestions as to "how?" hypothyroidism has become
endemic in the Ndamana region; the Ndamana community is fervidly
convinced as to "why?" it severely affected one of its members. For what
more proof could you ask?

Both sides learned from our study in Ndamana; Africa, one??molecular
biology??nothing.

LEGENDS

Figure 1. The areas of Africa (A) in Northeast Zaire, Central Africa (B) is
the location of Ndamana (C) site of both culture's inquest into the causation
of hypothyroidism.

Figure 2. The pastor's fresh grave as I had come upon it within the week of
the fatal event, to which half of his remains were retrieved and interred.

Figure 3. The pastor's widow (translated in Pazande, "Poor Person") now
bereft of her husband, social status and one foot, crippled by the lion's
attack.

Figure 4. The author enters the fatal hut, the first person to do so since the
fatal encounter with the lion took place within it, lifting the curse of
misfortune from it to be carried away on foreign shoulders.

>>> Peter Hotez 11/08/01 06:27PM >>>
Glenn; since you know more about endemic goitre and hypothyroidism in developing countries than just about anyone...what if you focused on this for your thesis...but from a different perspective...you use your data collected out in the field and published in 1999 as your baseline info...but now go back to this area and collect information either about what the disfigurement caused by goitre meant to these individuals, or their perceptions of what happened after they recovered...OR what it means to them to have a cretin for a child, etc. Bring into this discussion, perceptions of illness in this particular part of the world. Idea here, is to build on your strengths. Regards, Peter

Peter J Hotez MD PhD
Professor and Chairman
Dept. Microbiology and Tropical Medicine
The George Washington University
Ross Hall, Room 736
2300 Eye St. NW
Washington DC 20037
Tel. 202?994?3532
Fax. 202?994?2913
Cellphone 202?841?4148
email mtmpjh@gwumc.edu

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