All the kids in our village had legs and arms covered in milky, irregular scars. You hardly see anyone in the developed world with that many scars.
This is Kampong Speu, Cambodia, two hours by tuktuk outside Phnom Penh. We live in a tiny, fenced-in international school next to a river and a (probably illegal) sand mine. The highlight of a kid's day is buying freeze-dried peas or an ice cream sandwich from a local cart. The ice cream sandich, by the way, is a scoop of ice cream on a baguette.
We in the US are used to kids waking up every day to take their Adderall before going to school. In our Kampong Speu they get antiretrovirals (ARVs) instead of Adderall. In our village, every kid but one has HIV. The money for the ARVs has been coming in for decades from the Gates Foundation. Without a huge amount of international help, none of these kids would be alive.
In the best case ARVs give an HIV-positive kid a functionally normal life. But the ARVs caused some unpredictable changes to the kids' immune systems, which seemed to make them more susceptible to infections and some diseases. I used to bring coconuts from the local market to one girl who liked them. In the past she would have gotten them herself, but somehow the ARVs had destroyed her legs, and the dirt roads don't have acommodations for the wheelchair she now needs.
With stakes this high, the village didn't take chances with any cut or scrape. At the sight of impetigo, the village doctor often took the nuclear option of using maximum-strength antibiotics like vancomycin. So at noon, after having taken their ARVs, a second wave of kids with infected hands and feet would meet the village doctor at the clinic. He'd greet all their little open palms with tiny little gift boxes of antibiotics.
We didn't consider any side effects that such overprescription might have. For one, it's possible those little afternoon gift boxes of vancomycin were creating the ideal breeding ground for MRSA. Instead we only thought about how antibiotics kept us on the safe side, however precarious it may be, lest a wound fail to heal or, worse, spread and kill someone.
I only vaguely took notice of any of this, that is, until one of my infections began to spread.
It didn't take me long to understand why the kids had scars, because as soon as I arrived started getting little, but rather disconcerting, infected cuts. No matter how careful I was, I had little blotches of impetigo everywhere, sometimes just from the friction of my sandals against my toes. At the time I wondered: was it the dirt? The water? The air, where we regularly had "black snow" from burning trash?
One particularly sleepless night I remember feeling like an insect was trying to eat through my ankle. I tossed and turned, sticking out my leg hither and thither to escape the scorching brush of the sheets against my skin. When I checked in the morning I saw a tiny little bump just above my heel with two tiny white dots at the top. Spider bite, I labeled it — reasonably, as there there were spiders and scorpions everywhere — and covered it with a bandage.
Over the next two days the "spider bite" grew and grew. It got puffy, it swelled, spread and deepened until it felt bone-deep. The swelling ate my ankle, then my foot, and then finally my entire right calf.
On one leg, I hopped over to the clinic to see Kathy, who ran this whole operation. I explained to her the situation, brandishing the cartoon leg of a man three times my size. I asked her to cancel my PE classes unless she wanted me to teach the pogo. But Kathy saw exactly no humor in any of this.
"You need antibiotics," Kathy said, "it's cellulitis. I've had it myself. You culd lose your foot, you know." She was a Catholic who talked with the authority of a woman who believes she's the mother of god's every child.
"I'll take them as soon as I need them," I said, "This is what my immune system is for." (My immune system cringed.)
"I'm serious," she said, drawing a purple box from the glass cabinets, "take these."
"Um, shouldn't we start with the weaker ones? Then move on to the vancomycin?"
"Listen," she frowned, "I've had my own kids die in my arms."
Parry and riposte. Can't really say anything to that.
I took the vancomycin from her and headed out the clinic doors. As I limped towards my house, she watched me, imagining me dying in her arms.
When I got home I put the antibiotics, still sealed, on my countertop. Americans like Kathy don't know a lot about medicine, or the drawbacks of constantly taking the strongest antibiotics for everything, like breeding resistant bacteria like MRSA. Still, Cambodians know a lot less. Most of the educated people got killed by Pol Pot in the 1980s leaving a knowledge vacuum that never got filled. Due to a dismal health care system which puts western medicine in the hands of folk doctors, their life expectancy is just barely at the 70-year mark.
I saw Cambodians cruising on motorbikes with IVs sticking out of their right arms, fluid bags and poles in their left. It harks back to a folk treatment — something they apparently did during the Khmer Rouge — where people treated anything and everything with a coconut IV. I prefer to drink my coconut water through my mouth. Call me old-fashioned.
I had read in the newspapers about hundreds of Cambodian doctors who had failed their doctoral exams and never got their medical licenses. They petitioned the Cambodian PM who relented and granted them their licenses anyway. After all, they did pay for the exams.
One newspaper reported that Cambodian doctors who passed their exams still misdiagnosed common diseases four out of five times.
You also have the folk doctors who bike from village to village peddling Western medicines that they knew little about. They have sacks full of pills and injectables that they prescribe to their regular clients. These folk doctors never went to school at all.
Lying on my floor I thought to myself. "You're a problem solver. The information is out there. Put two and two together. If you go to one of these witch doctors they'll just make a bad situation worse."
A voice popped into my conscious mind.
Arrogant of you to assume you know better, it said. Also, Alec, how predictable.
"Well, maybe knowing absolutely nothing is better than knowing whatever this guy knows," I said.
Maybe, it said, just before it disappeared.
I did the math. I had the antibiotics, and I had at least a few days of cellulitis before I'd lose my leg. Plenty of time — well, maybe enough time — for an emergency helicopter flight to Bangkok.
With the deftness of a blind ape I cracked open my MacBook Air and started punching the keys: P-U-B-M-E-D. I-N-F-E-C-T-E-D-W-O-U-N-D. H-O-W-T-O-T-R-E-A-T-S-T-A-P-H. Et cetera. I was squinting, concentrated, my fingers a blur. Firefox clenched its sphincter in preparation for my surge of open tabs.
PubMed taught me that I ought to clean the wound more often since a clean wound heals faster. I gathered my supplies: some gauze, a water bottle, tweezers, a flame, disinfectant. I sterilized my own water, created a pressurized squirt bottle, tweezed out the dead skin and regularly soaked the wound in iodine. This helped somewhat. More importantly, it gave me a tremendous sense of agency. "I'm a doctor now!" I thought to myself, "I'm practicing medicine! On me!"
Then I read something, and I sincerely don't remember how I discovered it and I wish I did. It was about doctors using table sugar to treat all kinds of infections. Chronic infections. MRSA. Diabetic ulcers. Shotgun blasts to the chest.
I thought to myself, "this is just the kind of thing Alec would do."
And if it's not true? emerged the voice from my subconscious, about the sugar?
It couldn't hurt to double check. I opened the laptop again.
PubMed told me that Zimbabweans used sugar as a wound dressing for centuries. The dissolved sugar causes the bacteria to pump water out of their insides, basically making them shrink and dry out, like undoing the knot on a water balloon. According to some news articles (including one from the BBC) sugar worked about as well as anything else, including triple antibiotic ointment, when it came to surface wounds like mine.
I had gotten all the information I needed. I took the bag of plain table sugar in my cabinet — leftover from when we tried to make tiramisu from oreos — and from that day forward I packed it into the hole in my ankle whenever I got the chance. Sometimes three times a day, sometimes four, and sometimes even more, changing the bandage constantly. The sugaring made the wound weep ceaselessly.
Meanwhile, I walked around the village with my leg taped up. Kathy would ask me if I was taking the antibiotics. "As needed," I would say, without lying, and thinking of the shrink-wrapped box still on my countertop.
At least I wasn't losing my leg. But the sugar didn't miraculously cure me, although that would have made for a neater story.
As things started to plateau, I decided to give the old "witch doctor" a second chance. I went to his office and asked him to take a second look. In his good judgment (and perhaps with a bit of exasperation) he tweezed out a huge chunk of necrotized skin that I had failed to notice. Maybe I had underestimated the experience of the man who deals with infections all day, every day.
What was left in my leg after my little operation was about cubic centimeter of empty space.
"I'm gonna need more sugar," I thought.
Over the next few weeks, with my foot elevated and marinating in that sweet nectar, I had time to think about why sugar wasn't more commonly used to treat cuts and wounds. How could we not know about a solution that's so cheap, effective, and widely available? The answer: probably because there's no money in a solution that's so cheap, effective, and widely available.
Out of sheer curiosity I called a clinic in Greenville, Mississippi: I had read that they'd been treating wound patients with sugar for forty years. I wondered how they saw the issue. Were they as excited about sugar as me?
A nurse picked up the phone. I said I'd like to know more about the sugar program. She asked if I was from a newspaper. "Oh, I'm just a student," I said, "just interested in hearing about what you guys are doing. Writing a little article."
"Um, no comment," she said, and hung up.
To this I wish I could tell her that she had nothing to hide, nothing to be shameful of. I'll never know what she thought however because that clinic never returned my follow-up.
As my wound healed I tried to explain the sugar methods to the village: the simplicity, the cost. No one cared. People liked to do things their own way. Instead they told me about their choice ointments: Tiger Balm, iodine, Neosporin.
I nevertheless dreamed about children entering that little village clinic with their palms open, and instead of pills, little sugar cubes would fall into their hands. No more resistant bacteria, no more disrupted gut-brain axes, and no more pharma-industrial complex. But a dream it shall forever remain.
Still, I'll always remember my infected wounds in Cambodia, and how much they taught me about thinking for myself.
Kampong Speu being what it is, it couldn't resist sending me away with a little parting gift. I took to Greece an abscess in my pinky toe which I eventually had to get drained at a walk-in hospital.
That was the last infection I had. And now I have my scars, too.