Monthly Archives: July 2016

Papalomoyo: The Mark of the Bribrí

While I was in Peru I noticed a bite on my left forearm that wasn’t getting better. That would’ve been the last week of April. I wasn’t really too concerned about it; it wasn’t getting any better but it wasn’t getting any worse either. When I got back to Yorkín, 12 May, it quickly began to grow and look nasty and when I showed it to a friend she said I could rub the leaves of a tree on it and if it turned green it was papalomoyo. I’m not sure if it turned green or not, but the next day more people said it was definitely papalomoyo. In the two weeks that followed I tried various natural remedies suggested by members of the community. One friend suggested red fingernail polish, another put white latex from a succulent plant on it, and yet another also put a white latex substance from a tree on it. Although each of these treatments were derived from different sources, I figured it had something to do with sealing the wound and possibly smothering the microbes (protozoan parasites) which were eating away at the flesh. However, these people offered no insights into why the treatment would work. I also tried two different plants; pajilla and gavilina, which were suggested by two different friends. To round out the list I also tried putting garlic and later, lime, on the wound. It was also suggested by two people that I capture lightning and thunder in my hand and put it on the wound (which I did do, more than once). I never got around to the camphor cure that was suggested. None of these treatments seemed to have any impact on the steady worsening of the ulcer. Papalomoyo (papalotl= butterfly and moyotl= mosquito) is so common in Yorkín that the locals refer to the scar that is left over as the “mark of the Bribrí” or the “mark of Talamanca”. Several people have commented that now I am a Bribrí. The locals perceive papalomoyo as occurring through natural (as opposed to supernatural) causation. It is recognized that the ulcer is caused by parasites transmitted by the bite of a particular type of mosquito. However, at least one of the treatments, thunder and lightning, was seemingly oriented to the supernatural.WP_20160605_003

Although I had already looked up papalomoyo on Wikipedia, I next endeavored to find a scientific article through the UA library databases on papalomoyo and its treatment. The scientific name for papalomoyo, which it is known as locally here, is leishmaniasis. It is basically protozoan parasites eating away at the flesh, entering the bloodstream, and eventually damaging the spleen and liver. Various types of sand fleas and mosquitos act as the vector including female phlebotomine sandflies and in America and Costa Rica a mosquito known as Lutzomyia or “Aliblanco”. The visible symptoms of leishmaniasis are skin sores which erupt weeks to months after the person is bitten. The parasite enters the bloodstream, creating the need for systemic rather than local treatments to avoid long-term infection. In Costa Rica, incidence averages per one hundred thousand inhabitants according to Canton from 2005-2007 were: Turrialba 124.5; Guácimo 126.3; Matina 222.5; Talamanca (where I live) 1179.4; Osa 124.1; Coto Brus 159.7

From Wikipedia:

Cutaneous leishmaniasis is the most common form, which causes an open sore at the bite sites, which heals in a few months to a year and half, leaving an unpleasant-looking scar. Diffuse cutaneous leishmaniasis produces widespread skin lesions which resemble leprosy, and may not heal on its own.

  • Mucocutaneous leishmaniasis causes both skin and mucosal ulcers with damage primarily of the nose and mouth.
  • Visceral leishmaniasis or kala-azar (‘black fever’) is the most serious form, and is potentially fatal if untreated. Other consequences, which can occur a few months to years after infection, include fever, damage to the spleen and liver, and anemia.

Leishmaniasis is considered one of the classic causes of a markedly enlarged (and therefore palpable) spleen; the organ, which is not normally felt during examination of the abdomen, may even become larger than the liver in severe cases.

Leishmaniasis occurs in 88 tropical and subtropical countries. The settings in which leishmaniasis is found range from rainforests in Central and South America to deserts in western Asia and the Middle East. It affects as many as 12 million people worldwide, with 1.5–2.0 million new cases each year. The visceral form of leishmaniasis has an estimated incidence of 500,000 new cases. As of 2010, it caused about 52,000 deaths, down from 87,000 in 1990.

Marguerite Higgins, Pulitzer Prize–winning journalist, died in early 1966 from leishmaniasis contracted while on an assignment the previous year.

Magazine photographer Joel Sartore was diagnosed with the disease after a skin lesion failed to heal following a photo shoot in the Bolivian wilderness. Following intensive IV treatment similar to chemotherapy, his infection resolved.

While filming the latest series of Extreme Dreams in Peru, UK television presenter Ben Fogle caught the disease. He was left bedridden for three weeks on his return home. Fogle was treated at London’s Hospital for Tropical Diseases. 

Treatment usually consists of the administration of some kind of antiparasitic compound, including antimonials, which are considered the first line of treatment for all forms of leishmaniasis. These are usually effective in patients with one or multiple lesions but should be administered with care. Toxicity includes headaches, fainting, muscle and joint pain, EKG changes, and seizures. However, one study investigated the clinical response to treatment of cutaneous leishmaniasis with glucantime and found that fifteen patients (34.9%) were clinically unresponsive to glucantime 6 weeks after initiation of treatment while the remaining 28 patients (65.1%) responded to treatment. This is a pretty significant level of unresponsiveness to the glucantime treatment (lucky me) and suggests the need for research into new treatment regimens, perhaps combining antimonials with topical-plant based medicines (2011). Glucantime Efficacy in The Treatment of Zoonotic Cutaneous Leishmaniasis. Pourmohammadi, Motazedian, Handjani, Hatam, Habibi, and Sarkari (2011). Southeast Asian Journal Tropical Medicine Public Health 42(3):502-8

The next morning, I was helping my friend roof his new addition at his house with zuita palm when he mentioned that a doctor was going to be at the clinic in Yorkín that day and that I should go to have my papalomoyo looked at.WP_20160617_002 I figured maybe it was time to go to visit the doctor even though I was apprehensive about the cost, the ulcer being pretty ugly at this point. I walked down to the clinic and asked the doctor if he would see me. There was some discussion about whether he could or not with the woman who was doing the bookkeeping; the issue being me not having insurance in Costa Rica. After some haggling it was finally decided that they would see me and my name was put on the list. I finally got into the clinic at around two in the afternoon and first saw the nurse who weighed me, measured me, and took my blood pressure. After another half hour I got into see the doctor. He stated that it was actually two bites (this was confirmed by my nurse after looking at photos I had taken- again, lucky me); two infection sites that later converged into one ulcer. WP_20160611_001He prescribed injections of glucantime, 5mL at a time injected into the butt cheek once a day. He suggested not using any more natural remedies and seemed somewhat disdainful of the local treatments. He also diagnosed a fungal infection in the same arm and prescribed a topical ointment for it. He told me I could pick up my medications at the clinic in Bambu and that after my treatment was over they would bill me; at which time I could choose whether or not to pay as he admitted they are not very efficient in collecting money because usually all their services are for free. We’ll see about that.

A couple of days later I was able to get a boat ride down the river to Bambu. The man at the pharmacy window spoke a little English and actually told me to take two injections a day- one in each butt cheek and that it wasn’t really effective to inject any into the site of the wound as people in the community suggest- because the parasite is systemic, entering the bloodstream. He also alluded to the fact that it would be very painful. At first he didn’t want to give me the medication to take with me but said I would have to come to Bambu every day to receive my injections. I told them this was in no way possible, as I do not have a boat and there is no way I could spend five hours a day walking the round-trip from Yorkín to Bambu with the additional time waiting at the clinic. I also told him there is a registered nurse in the community who could administer the injections. After a lengthy discussion he finally agreed to give me my first round of injections to take with me but he would not give me anymore. Next I had to go see the nurse to receive the syringes and needles. I left the clinic with a large box of syringes, needles and medication; ate tamales prepared by local women most Fridays in Bambu, packed two for the road, bought some groceries (including Snickers) at the pulpería, and started the two hour walk home.

When I got back to Yorkín I asked a friend if he would be willing to give me my first round of injections that evening. He admitted that he had been drinking chicha and suggested I call either of two people who were both certified to give injections, one being a registered nurse. I of course chose the female of the two who was also the registered nurse (I was later told that Bribrí normally choose the oldest person, so I once again broke cultural norms). A couple phone calls later and she was asked if she could deliver the injections. I texted her and asked when I should come to her house. She replied “No, Greg, at your house.” Ok. The reason for this would become clear later. She showed up that evening around 4:30 and expertly prepared the two syringes; set them aside, and cleaned out the wound. I asked her if I should stand up and lean over the desk so she could have access to my two butt cheeks. “No Greg, on your bed. You will not want to move for a while.” “Really?” “Yes, it is very painful.” Great. Now, I already have a tremendous fear of needles and this statement put my stress factor over the top. So I grabbed my laptop and started playing the Dark Star medley from the Grateful Dead show at the Capitol Theater in 1970 hoping it would relax me. WP_20160620_003I pulled down my pants a little bit, my nurse asked me if I was ready, and told me to take a deep breath. The needle went in smoothly and she began injecting the 5mL into my upper left butt cheek. Surprisingly, it really wasn’t very painful. She had a gentle and deft touch. After a minute or two of relaxing she asked if I was ready for the second injection. She then told me to take another deep breath and injected the needle- this time when she began pushing the serum into my butt there was tremendous throbbing pain, it was all I could do to not flinch. It seemed forever before the needle was empty and she removed it gently from my butt cheek. She pulled my pants up and made a quick exit, saying that she would return at the same time tomorrow. It was probably two hours before I had the wherewithal to get up and walk to the kitchen for dinner which I ate standing up.

The next day everybody was interested in my injections and offered various opinions on treatments. It seems as if everybody has a different idea on treatment but there is limited consensus on dietary taboos which include beans, pork, beef, fat, sugar, and eggs. I consulted the literature on this and there is no information regarding these types of foods as contra-indicators for papalomoyo or its treatment; the literature did state however that a high-protein diet was important. I also asked the doctor about this and he said the diet had no bearing whatsoever on treatment efficacy (however, both my nurse and a different doctor would later suggest limiting fats and dairy). In reflection, it seems that the dietary taboos are all things which they already do not eat much of, except sugar, suggesting to me that their ideas on dietary restrictions stem from already existing food taboos. In the literature I also read that papalomoyo often heals on its own; to me this explains the various treatment ideas and the lack of consensus. People would put on the wound some kind of substance or adhere to a certain diet and the papalomoyo would eventually heal, the treatment could have had much, little, or no effect- as the papalomoyo can simply heal on its own. I also heard stories from people who said they received injections while using another type of treatment, either diet or plant-based. Invariably these people suggested that it was the natural remedy and not the injections that caused the wound to heal.

The next day my nurse returned to my house and suggested that she only administer one injection of 5mL for the day; I was more than happy to go along with her idea. I once again found the injection quite painful and was quite sore afterwards. The soreness last throughout the night and through the next day; my butt cheeks were still sore when I received the next injection.

On 6/14/2016 she made a paste of the glucantime and sulphur to put topically on the ulcer. I put the paste on after receiving my 7th injection (again, very painful). I have also been experiencing severe headache, muscle and joint pain; all side effects of the glucantime.

6/18/16

Yesterday’s treatment was brutal. I had been feeling feverish for about three days and the day before yesterday a really bad infection sprung up at the wound site. That night my nurse cleaned out the wound really well before I got my injection. She used a cotton swab with the cotton removed from one end and sterile gauze wrapped around it, meticulously picking at the dead and rotting flesh. WP_20160619_007Yesterday the infection was just as bad if not worse, and she spent a long time digging out the infection and rotting flesh. She then cut the tip off of a plantain and squeezed the juice from the peel into the wound; it burned like hell. She said the juice contains an antibiotic compound. She is proving to be much more than solely a nurse; she is really a curandera; attending to my illness experience holistically. After her work on the wound site I received my 10th injection in the butt, which is now very sensitive and sore- so each injection just gets more and more painful. It is Sunday, and I plan on seeing the doctor when he comes to Yorkín on Tuesday. If the infection is still bad, I assume I’ll have to go to Bambu to get antibiotics.

6/20/16

Well, last night I received my 12th injection. My curandera again cleaned out the wound and dribbled some of the antimonial medicine into it. WP_20160619_009She said it is looking better. Still looks horrible to me. Yesterday I pretty much spent the entire day sleeping or just laying around; I have had a nauseated stomach and do not feel like eating; still have somewhat of a fever. This morning, even though my stomach still wasn’t feeling well, I forced myself to walk down to Ida’s and have some breakfast.

Today (Tuesday, 6/21/16), I spent much of the morning waiting at the clinic with mostly women to see the doctor on his bi-weekly visit to Yorkín. It was a pleasant surprise that the doctor was able to speak English and he gave me a thorough checkup. I had lost 8 pounds since I first started receiving the injections two weeks ago, and this was concerning to him. In addition to more antimonial injections (20), he prescribed Tylenol for the pain, electrolytes for dehydration, and something for my stomach. He, echoing my nurse’s advice, suggested to keep the consumption of fats and dairy products to a minimum.

On Friday I caught a ride in a canoe down to Bambu and walked to the clinic where I received my medications (even though I was told last time that I couldn’t take them home). After consuming two tamales and purchasing two to take with me from the ladies who prepare them most Fridays in Bambu, I walked the two hours home. As the week went on, the injections got more painful as my behind was becoming more and more sensitive. On Sunday, my nurse had a bit of trouble getting the needle into my flesh, possibly the result of a bad needle – this was the 20th.

7/1/16

The last three injections have proved to be incredibly painful. I spent yesterday pretty much just laying around and not doing anything. I cannot even sit for very long to write, and it is even painful to lay in the hammock for very long reading, and the nausea continues. Last night my nurse said it looked as if the parasites at the wound site were dead. We talked a little bit about ending the injections. Earlier that day, one of the men in the community told me about how after his 20th injection he chose to quit getting any more, only to have the papalomoyo return and him having to receive 40 more injections before it was finally healed. I did not want to experience this type of scenario – when the injections are done, I want them to be done. We decided, because I need to leave the community to go to Panama for three days to renew my visa, that we would continue the injections through Sunday night (we actually decided to stop after Friday), and while I was away Monday through Friday I would apply the medication topically onto the ulcer twice a day. “This is the law Greg.” Okay, I would do anything she asked of me at this point, and seeing an end to, or even a brief respite from, the injections filled me with relief. Not only has she been cleaning my wound and expertly administering the injections every evening, she has also attended to my emotional health and other physical needs. Every night she brings me some sort of food – fresh-baked bread, cacao jelly, fried fish, coconuts. She also gave me a book used by the Adventists in the community, and often we discuss religious concepts. She came back to Yorkín after earning her nursing degree and working in San Jose to take care of her mother and revitalize the family finca. She takes care of three young boys on her own and performs all the farming duties; harvesting and hauling bananas and cacao, chopping brush, taking care of chickens, hauling wood for cooking, etc., etc. She came to my house every day to clean the wound, talk, lift my spirits, and give me my injections- she asked for nothing in return. As for my treatment, I do not know what I would have done without her.

It is now several days later; I am in Panama for three days. I came with stuff to clean my ulcer every day and antimonial medicine with syringes and needles to apply topically- and strict instructions to take care of it twice a day, “la ley Greg.” OK. It is now Thursday, the 7th– my last injection was Friday- finally, I am not nauseous and my butt is not sore. It was a fitting last injection. I had gone to a friend’s house for lunch and afterwards visited some other friends who were taking the day off and playing Dominoes. I sat down to play- soon the chicha (bLok in Bribrí, pronounced brlo) came out. After some drinks we began playing guitar, accompanied by more chicha. After what seemed like a short interval to me (chicha has a way of making the time fly) another friend showed up and said “Greg, are you getting your injection?” “Si” “Well you are late.” Oh fuck, I gathered my belongings and made a hasty retreat to my casita. I have no idea how I navigated the path with my bags and a guitar slung over my shoulder (chicha has a way of clouding the memory) and when I got to my place the nurse was waiting on the path for me. These next couple points I can neither deny nor confirm- due to the chicha; however, my curandera asked me upon my arrival “Don Gregorio, are you drunk?” “No” “Don Gregorio, la verdad.” “Si, estoy boracho.” I was not supposed to be drinking alcohol on my medication, oh well. I vaguely remember the injection hurting like crazy (this was number 26) and I was told that after the needle was removed I yelled loud enough to alert the entire community. The next day I was thrilled when she said there would be no more injections for now and we would re-evaluate after I got back from Panama.WP_20160707_001 Now, the ulcer looks better and I am somewhat hopeful that the injections are behind me. Tomorrow I make the long trip back to Yorkín and will see what she says- hopefully all that will be left is to see what kind of cool scar it will leave me with- “The mark of the Bribrí”.

End note: My curandera says it is looking healed; I only need to apply the antimonial topically for 3 days- then use cacao butter (which she made) to help prevent scarring. WP_20160711_003