Puebla Day + 2 of plumbing and neutrophils

The Puebla plumbing has been holding up well for the past two weeks. Although a noxious almost volcanic smell still greets me first thing every morning when I open the bathroom door, rather as it did in the BBC house in Kabul and indeed in Baghdad.

Thomas Crapper, Alexander Cummings and Sir Joseph Bazalgette, that secular trinity of the water closet and the public sewer, really should have travelled more widely to spread the word of bog.

Through all my travels, it has struck me forcibly and olefactorily that the real difference between the haves and the have-nots of this world is in the possession of working indoor plumbing.

Never mind the Big Mac index, what of the having to Crap in a Field, Lake or a River index? For us, slumming it on the occasional camping tour or music festival, the occasional outdoor relief is a bit of a treat, one that might even bring you closer to nature, as well as helping you avoid the overflowing toxic chemical loos.

And once you are lucky enough to be the proud possessor of indoor plumbing, the quality thereof is another key yet often unspoken marker of progress (in which Japan is currently world-beating on the bottom-cherishing front, or perhaps back.)

The BBC house in Albania, near the border with Kosovo, during the war in 1999 sported a very jaunty white porcelain lavatory bowl. I was delighted to note its existence on our arrival, as the loo at the hotel I had stayed in on the way in from Tirana kept me up all night with a strange boggy gurgling that never ceased.

It may have been an alien life form’s attempt to communicate its arrival in Albania, but it had chosen the wrong hotel guest to tell, and doubtless went back to its spaceship to report no intelligent life on planet earth, and that the plumbing was pretty patchy in parts.

The only problem at the new BBC house in Kukës that spring of 1999 was that when this particular BBC loo was flushed, the force drove everything upwards and towards the sitter, rather than away.

Likewise, an eccentric local plumber (or perhaps a very well-trained but sadistic local plumber) had somehow cross-connected the water supply for the shower with the electricity, so that every morning, the shower woke you up with an electric shock when you turned on the tap.

As most days were spent filming at the nearby refugee camp, where thousands of the Kosovo Albanian families driven out of their home were housed in bleak rows of tents amid the red faecal dust of Kukës, none of us living at the BBC house nearby felt we had much to complain about. We were warm, housed, clothed and fed. What were a few electric shocks upon waking? It made the inevitable Today programme early two way that much livelier.

I’d already forgiven the US Air Force on that same trip for almost killing us as we filmed on an Albanian hillside at exactly the time that NATO decided to put B-52 Stratofortress bombers into action to strike areas on the border with Kosovo. Unfortunately, the little stick figures that the pilot in the glorious blue skies above appeared to be aiming at were a bunch of journalists from the UK and US rather than Serbian troops.

Luckily, the pilot’s payload – perhaps of Mk 82 bombs weighing some 225 kilos each – ended up hitting the ground well below us, successfully and very expensively obliterating a good few of the late Stalinist dictator Enver Hoxha’s bizarre defensive bunkers.

The country Hoxha managed to all but bankrupt with his policies could boast more than 750,000 of these small concrete toadstools (for a population of around three million people, though nothing much in the way of shops or an actual economy).

The pilot’s direct hit on the toadstools looked like the military equivalent of nuking Noddyland. And it was, it turned out, an accident. Albania and Kosovo clearly looked very close on his map. Or maybe the pilot’s aerial satnav had been telling him to turn around when possible, and he just wouldn’t listen.

Nonetheless, as the plane circled in the skies to take anther look at what was below (and clearly the hastily-scrawled BBC sign in marker pen on my helmet might not have been legible from that distance), I spent a good half hour cowering underneath the then ITN correspondent Bill Neely, always a good man in a tight spot.

Here at Inspiralita, there are no electric shocks from the shower, nor any B52s, and even Donald Trump has not yet built his fabled wall with Mexico. Perhaps he could instead put US labour to work spearheading a global plumbing revolution instead. Now that would be an international legacy to be proud of. It could even have its own slogan: Dump With Trump.

To deal with the smell, I keep my bathroom window open all night, just in case that helps, but somehow the miasma of gas simply rises all day and through the night from the four floors below before it ends up with me on the fifth. And perhaps in its spare time (I almost find myself hoping so), it wanders up to plague the 6th and 7th and 8th floors as well.

I’ve got accustomed to the smell now, and it doesn’t bother me too much, apart from on the chemo nausea days, which I think are now behind me. And there have been no further floods or plumbing disasters for which I’m grateful, as my white blood cell count falls precipitously every day, as expected.

Thanks to all the stem cell stimulating done by the drug filgrastim, a week or so ago I apparently boasted a white blood cell count of something approaching 49,000 white blood cells. Rather more than the usual average of 4,500-10,000 white blood cells per microlitre. Now my white blood cells (the lymphocytes) have been depleted to just 2,000.

Likewise, my platelet count is down from 191,000 to 128,000. And my haemoglobin – the molecule in red blood cells that carries oxygen from the lungs to the tissues and returns carbon dioxide back again to the lungs – has gone down from 14.3 to 12.6.

As the kindly biochemist took my blood this morning, I wondered what the tiny red blood cells inside the ruby drops filling his vial must look like, imagining them like miniscule red doughnuts without the hole, or wine gums with a little dip in the middle of each where the manufacturers have had to economise post-Brexit to keep the prices down.

When my white blood cells start to go below 1,000 there’ll be a higher than normal risk of infection for me, as my immune system will be very low indeed.

And the new haematopoietic stem cells released from my bone marrow via my blood and transplanted back to me, which must now (I assume) be buzzing their way around my system, perhaps just don’t know quite yet the different jobs each of them will have to learn to be properly qualified as new white blood cells.

These stem cells are the crème de la crème of cells, though, I’m told. Chosen as the brightest and the best. They can become anything they want in the white blood cell world.

I imagine them a little like earnest medical students, dressed in white coats, following their godlike Professor around the wards of my veins to look more closely at the trail of physical devastation left by their predecessors in my immune system, as they try to find out what it is they should be doing to make me well again.

First do no harm, the Consultant teaches them with a smile, as he takes them further down the crowded, rather narrow corridor.

“And here,” the Consultant – now a Professor White Blood Cell – will tell the eager young stem cells, their notepads at the ready, as he stops at a particularly messy junction, “you can see where the last lot made a real hash of it, attacking her immune system. You, on the other hand, will know not to do that. Won’t you,” and he gives a stern glare over his spectacles.

Silent nods, as the young cells shuffle along to the next ward, trying to decide whether they’d like to become a neutrophil, the immediate response cell that forms 55 – 70% of our white blood cells, and helps to fight bacterial infections. That’s quite a glamorous job, and you probably get to pick up a lot of chicks as you rush to the scene to clear up the latest bacterial strike dressed in your snazzy white uniform.

Mind you, it’s not much of a long-term prospect, and no time to enjoy your date, as each neutrophil lives for less than a day. So you’d have to think up some pretty fast chat-up lines before the bone marrow churns out your replacement. A bit like being a supermodel in the internet age, or leader of UKIP.

And perhaps not quite as glamorous. The neutrophils are the ones that go to attack the bacteria at the site of a wound, their corpses left behind on an infected wound as pus.

Perhaps, then, the Consultant professor says, the very best of our stem cell students might like to specialise as the 20 – 30 per cent of white blood cells that are lymphocytes (our B and T cells, and our NK natural killer cells) to make antibodies to fight infections. It probably attracts better pay, and maybe the hours are more predictable, though the consequences if you muck up the job can be quite severe.

Some of those may want to travel to the thymus and mature into T cells, while others (most likely the introverts) will decide to stay quietly in the bone marrow and develop into B cells.

The Consultant professor carries on further in the same vein, pushing past a gaggle of blood cell management consultants, paid a lot more than he is, doing time and motion surveys as they try to figure out how best they can shave another 10 per cent from this year’s vein budget without the medical staff or patients bleeding too much.

He looks at them with irritation, says nothing, and continues. “The bigger and more extrovert stem cells amongst you might want to think about becoming a monocyte,” the Consultant Professor might suggest.

When certain germs enter the body, they quickly rush to the site for attack – again, a good and decent job if only you can make sure you’re attacking the right thing. Usually they’re the fatter cells that make up some 2 – 8% of the circulating white blood cells, and can work to engulf large particles and pathogens.

It’s almost the end of the ward round in the vein. The stem cell students who haven’t yet heard a job that interests them prick up their ears as the Professor continues.

“So…If you’re a stem cell with an interest in allergies, then becoming a basophil is for you. It’s a specialised job for less than 1% of circulating WBCs. They accumulate in damaged tissue and release histamine, which dilates blood vessels, and heparin, which prevents blood clotting, so a vital and sometimes overlooked role,” he finishes with satisfaction, as it’s almost time for lunch followed by an afternoon at his private Harley Street clinic.

It’s the only way he can afford to pay off his second ex-wife, the young stem cell he should never have married, but her curvaceous lymphocyte looks and sense of humoral immunity were irresistible from their very first date.

And then he remembers. “Last but not least, if you don’t pass the exams tonight for all the above, and you are perhaps feeling a little more juvenile, you – young stem cell at the back, are you listening?” he growls, “You could always think about being an eosinophil, making up just 2 to 4 per cent of the WBC, because then you can have all the fun of excreting toxic compounds against parasites that are too large to engulf. So probably more one for the boys.”

And the stem cells peel off to their next class. As you can see, blood has begun to obsess me a little, just as global plumbing or the lack of it did throughout my years of travelling for work, although I can’t guarantee that any (let alone all) of the above is medically correct, rather than the produce of an over-active imagination kept in quarantine for the second day.

I am, after all a patient with access to Dr Google, and not a medical student, though I am pretty sure about that bit about the Harley Street Clinic and the second wife.

Blood has always mattered. We used to talk of ‘bad blood’ that ran in a family. My cousin, too, has MS. Do we have bad blood? Or simply blood and an immune system that can’t cope with a specific type of attack, thanks to a combination of genes, exposure and environment? My T or B cells were certainly not lazier than most – the opposite. They have been very busy indeed attacking me. And how about noble blood? At night, I watch The Crown on Netflix – or at least did before the internet went down tonight – and wonder at the magic of monarchy, sustained and passed on by blood, but in some earlier generations cursed and killed too young by that same substance.

But what about this miraculous stem cell treatment – blood that can cure? How can a stem cell transplant potentially do so much to help so many auto-immune diseases, when we still apparently think of MS chiefly as a disorder of the immune system involving the central nervous system, rather less as one of the blood – though more and more auto-immune disease is being treated successfully with aHSCT, with fewer side effects or risk of death than in the earlier years.

I don’t know if it’s working for me yet, as I slide gently into neutropenia, that low number of neutrophils in the blood that can make you more prone to infection. My main concern since my first and now my last bout of chemo, is not the Mexican plumbing but my own. Those of gentle stomach eating their breakfast, please look away now.

The problem after chemo here seems much more likely to be constipation than anything else. And it’s a problem that many with MS are inclined towards anyway, as the digestion slows with the disease.

With enormous relish on the very first day of chemo, my nurse Joy produces an evil-tasting liquid called Metamusil, made of psyllium husks. At first it looks like a simple orange powder in the bottom of glass, into which Joy pours cold water. So on that first day, I was caught out. I dallied and ate my porridge slowly. And by the time I got around to drinking the Metamusil, it had morphed and swelled into a glass full of large, unruly and  exceptionally evil orange jellyfish. It was undrinkable.

On the second day, I knew to swallow the concoction straight away. But even Metamusil was not enough to combat the constipating power of chemotherapy and the neutropenic diet of ‘safe food’ delivered today.

And now, I am stuck in the flat – unlike last week, when Joy and I were able to wander the supermarket for hours looking for prunes, figs, walnuts, dates, almonds, kiwi fruit, more porridge, pineapple, brown rice, even popcorn – anything with a husk or roughage that might encourage some action downstairs.

Days passed. More chemo, and more nausea – my digestive tract was working overtime at the top, getting rid of almost everything I ate on chemo days. But downstairs, despite eating pretty normally on all the other days, came nothing.

It reminded me all too much of another trip almost exactly a decade ago, when feeling a little jaded in the stomach area after three years of living in Paris, and in need of something to pick me up and perhaps cleanse me from the inside out, I was persuaded by my best friend James to go to the Maharishi Ayurveda spa at Bad Ems in Germany.

Cleverly, he showed me a glossy brochure with a photo of a luxurious hotel, with fluffy towels and robes, and with all the right words for a woman of 39, teetering on the tired edge of 40: revitalising, rejuvenating, reinvigorating. It also mentioned a detox. Hmm. I was not so sure about a detox.

I liked to tox, and I think that for much of my younger life, my liver and kidneys did an absolutely admirable job, considering the challenges. But James’s soft, siren Scottish tones tempted me on. Apparently, the Maharishi Ayurveda spa offered daily full-body massages, with hot oil dribbled over the entire body, rubbed in by two people simultaneously. OK, I was now persuaded.

We both booked straightaway, though I realised as I paid in euros, a currency I still hadn’t quite got my head around by 2006, that I could also have bought a new bicycle for my daily Paris commute with the same money and got fitter that way instead. And had a bicycle to show for it. But we live and learn.

The name Maharishi rang a vague bell, but I could not think why. I looked again at the brochure, and noticed that it had a picture of the man himself – the Maharishi Mahesh Yogi – an Indian with a serene, other-worldly expression and a long white beard.

I began to suspect that all might not be quite what I expected when the health check questionnaire arrived from the spa a few days later. It seemed utterly and solely fixated on matters of a deeply personal nature – namely my digestion, and more specifically, the exit. How often did I go? What did it look like? Colour? Consistency?

I had already discovered several years before that many (most often elderly) Germans were obsessed with all things produced from the posterior when I worked as an auxiliary geriatric nurse in Munich in my early 20s, so it didn’t entirely come as a surprise.

That was back in the mists of 1986 or 1987 or even 1988, I think, as my memory is terrible on dates without my old diaries to which to refer. On the ward round on day one, at 5am, I discovered to my horror why German toilets had ledges: so that each individual production could be examined in detail.

“Nurse, nurse!” would come the cry from Frau Lindner or Herr Ackermann in the morning, as I tried to distribute the bread rolls. Clutching me with a bony hand, they’d drag me into their bathroom, usually still warm with that special morning miasma.

“Come and look at what I’ve produced! Do you think it looks normal?” and an anxious look. Most of the time, I could reassure them that, 75 patients later on the ward round, it was indeed and absolutely entirely normal.

By the end of my several-month stint at the Bavarian Red Cross Home Kieferngarten, I did think that there should be a book or a chart to help the aspiring junior nurse on the faecal matter front, and even contemplated writing and illustrating one myself. But then I got side-tracked into journalism, and writing of a very slightly different nature.

The job at Kieferngarten was the very last one in my life (I think) that I allowed my darling Dad to broker for me. He was working at the International Red Cross in London by then, and has always had a wicked sense of humour. When he promised he’d help me get another job to improve my German (he’s also an optimist), I little suspected it would be geriatric nurse.

Flash forward to 2006 and the spa at Bad Ems. It was a rainy, bleak January crawling into February, that grim time of the year when everyone really does need something to cheer them up. Like a detox, or a new immune system. So despite some qualms, James and I arrived at the solid 18th Century spa building in Bad Ems, on the banks of the River Lahn, that constituted the Mahareshi’s ayurvedic emporium.

In her spotlessly white consulting room, the German doctor gripped me firmly by the arm and fixed me with a steely eye. The decaying nuclear sarcophagus at the Chernobyl reactor, it seemed, had nothing on the toxins I was harbouring.

This was no ordinary diagnosis but an ayurvedic diagnosis, taken from the pulse and consisting of a vocabulary entirely new to me.

“Your doshas are out of alignment,” she said. “Your kapha is excessive, and as you’re a mixture of pitta and vata, we’re going to need to do a lot of work on rebalancing your doshas.”

She wrote down my treatments, and I could tell that rebalancing my doshas was going to cost me. A lot of dosha.

Yet as the ten days or so rolled by, there was something almost blissful at Bad Ems about surrendering oneself entirely to people in white coats who claimed to know better.

I’d been feeling truly appalling for some time, but the only western diagnosis I could get was clinically isolated syndrome (which I knew could lead to MS, so I didn’t Dr Google it just in case that made it more likely) or chronic fatigue syndrome. The latter seemed about right, as I was permanently exhausted. No amount of sleep seemed to help. So perhaps the Mahareshi’s expensive treatment might just work?

This, after all, was holistic. Their cure for the ills of my flesh was to eat only vegetarian food. No smoking, of course, which I was just about managing. And no meat, no tea, no coffee, no milk, no sugar and above all, no alcohol. Oh, and no sex.

After a few days of all that detoxing I could not even imagine having the energy or desire, even as my dosh depleted and my doshas were (apparently) restored, though I still had no idea how they could tell.

The ayurvedic treatment plan at Bad Ems was a gradual one. It appeared to consist of several days of deprivation, followed by two days of rice soup, then – several massages later – an explosive grand finale of enemas.

Cocooned indoors, in rooms that smelt of sumptuous oils and scented candles, where soothing Indian music wafted down the corridors, I allowed myself to be slowly seduced by the ayurvedic. Every day, in a warm white dressing gown, I was led down solid marble steps to a gleaming white treatment area.

There, behind doors that creaked heavily shut, two young, long-haired women in white cotton dresses awaited me each afternoon. Silently, they would lead me to a white room, to a wooden bench, where, for hours at a time, soundlessly and wordlessly, they would pour hot oil onto me and gently massage it from head to toe.

The ritual was always the same as the honeyed, spicy sesame smell of the oil mingled with the candles. And whole hours passed in seconds. It was like a dream sequence from the best of any Haruki Murakami novel. It seemed unreal and yet it happened. And barely a word was said.

Only occasionally would the women speak, but when they did, they had the faraway look and the gentle voices of the saved. As my mind drifted, it dawned on me where I had heard of the Maharishi before – in a newspaper piece about the Beatles and their Indian guru… that same serene, white-bearded man.

And then I remembered a general election campaign in Britain a few years back. Maharishi posters featuring a public promise that his devotees would save the world with an act of what the world had been waiting for… yogic flying. So on the appointed day, the sceptical British media turned out to witness this mass levitation.

And after much fanfare, the devotees of the Maharishi turned out for something that resembled not flying but a yogic bounce. In the lotus position. It looked eye-wateringly painful, but it definitely was not flying.

But their pain was nothing to mine when I got the final bill at the end of the week or so of massage and starvation. It turned out to be perhaps the ideal holiday for a hedonistic sadomasochist. The bill was even more eye-watering than the enemas, although they were the one thing that did prove slightly less traumatic than expected.

But as I left the spa with James, via Frankfurt airport, where he would carry on back to Luxembourg while I returned to Paris, I had to admit that I did feel a little better. I was more relaxed. So zen as I checked in that I may even have had the beginnings of that enigmatic Maharishi smile.

I mused on it all as I absent-mindedly sat down at the airport cafe to order a cappuccino with plenty of sugar to go with my frankfurter and coke. And they were so good that I ordered another. And another. And by the time I got on my flight home I was feeling quite normal again.

Tonight, as I ponder neutropenia and my next quiet day in Mexico, wearing my blue face-mask if leaving the flat for the clinic here, I sit with less dosha than ever.

And patchy internet. For some unfathomable reason, the tiny fibre-optic lifeline that connects me to the outside world has gone tonight, with no explanation, leaving me unable to upload photos. Or perhaps this blog, unless I connect to some expensive data roaming.

Just before the internet clicked off with a tiny death rattle tonight, Clinica Ruiz kindly sent me my official receipt for treatment here. This time, compared with Bad Ems, I do think every single solitary peso will be worth it (or $54,500 in US dollars) if their stem cell transplant halts my MS.

And even more so if Joy’s Metamusil can help me tonight as I go to commune once again in hope with the Puebla plumbing.