Clinic Highlights

Today…

I saw a patient whose name was Serious. I asked him why his parents gave him this name, but he said he had never asked them. Very strange. I would definitely have wanted to know. Fortunately, he had nothing serious wrong with him.

We have had a few cases of mumps recently. I found out the traditional Swazi way to treat this illness was for the sufferer to go to a termite mound and shout out, “Take these mumps away from me!” Then the patient had to walk home without speaking to anyone. In contrast, Zambians with mumps would make a bundle of sticks, put it on their head, walk to a fork in the road, stay there until the sticks fell down, then walk home without speaking to anyone. It is all about unloading your problem, I suppose. Fascinating.

This photograph shows five generations. The little girl is with her grandmother and her great-great grandmother. I thought this was remarkable until they told me that on the other side of the family there are six generations still alive. This is the first Zimmer frame I have seen in Swaziland.

Five generations
Five generations

One of my beloved gogos was complaining about her backache (caused by a mix of osteoporosis and spinal arthritis) and she described it as being “like fireworks going off in my backbone”.

Another old lady in her 80s was having trouble with her arthritic knees. “I bet you were a good dancer, back in the day,” I ventured. She told me that she had danced for the previous King, Sobuza II, at umhlanga (reed dance), along with 10,000 bare-breasted virgins. He didn’t pick her to be his bride.

I can see many patients with trivial illnesses, such as having a headache for a few hours, or an episode of diarrhoea last night, and then someone with fungating breast cancer turns up (I am not attaching any photographs, don’t worry).

Today I saw someone who had nursed his brother in his final illness. Shortly after his brother died of tuberculosis, my patient developed pain in his testicles. He had been treated several times for non-existent sexually transmitted infections at hospitals and health centres. He even had an ultrasound scan which showed no abnormality. He thought he had contracted tuberculosis in his testicles. This is very rare; I have only seen it twice in 38 years working as a doctor. I examined him and his package was completely normal. It took a while to convince him that this was health anxiety, probably related to his brother’s death from TB. It can be difficult “re-framing” the problem in these terms, but he agreed to take notice of what was happening in his life when his testicles began to ache, rather than concentrating on his genitals. He’ll come back if he feels this has helped him.

A few patients later, I saw a man who had had “drop” (urethral discharge from gonorrhoea) for a month before seeking medical attention. He dropped his trousers to reveal a painful pair of gonads the size of a couple of tangerines. The infection had tracked inwards from his urethra, down his vas to his testicles, causing epididymo-orchitis (how many points can you get from that in Scrabble?).

The nurse running the under 5s clinic called me to see a 19 month old child with a lump on her arm after having been vaccinated against measles four weeks previously. Not surprisingly, the little girl developed a rash resembling measles about a week after the vaccination. We normally warn mothers about this. However, this mum had taken her child to another clinic, where the nurse diagnosed chickenpox and gave the child an injection of procaine penicillin, vitamins and paracetamol. The lump was the size of a ping pong ball and fluctuant – it felt squidgy and I thought there was some pus deep inside. I aspirated about 2ml of thick, yellow pus and started her on some antibiotics.

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This is unusual, so I had a word with my supervisor who told me that she had seen tuberculosis present like this. I was so surprised that I went back to the clinic room and hunted through the sharps box to find the pus-filled syringe. Normally, this is against all the rules, but the sharps box was so full that the syringes were sticking out of the entrance and it was safe to find the correct one without getting a needle-stick injury. I took it to the lab and asked if we could do a Z-N stain on a smear of the pus to look for mycobacteria.

Finally, I thought a patient’s symptoms might be related to their employment:

“What work do you do?” I asked.
“Nothing interesting,” he replied.

National Museum of Swaziland

The cultural heart of Swaziland is at Lobamba. This is where 10,000 virgins dance for the King at the Reed Ceremony in August. The National Stadium is there, across the road from the Houses of Parliament and the National Records Office. It is possible to visit Parliament when it is in session, but you must be suitably dressed (I have a wacky animal print tie, but I need a jacket). No such formality is required to visit the National Museum. Ascension Day is a public holiday here, and we were the only visitors in the museum.

The receptionist saw that I was driving an MSF car and charged us local admission rates. I think she was so grateful to see us that she left her cubicle and showed us into the main exhibition hall, pointing out the most interesting displays. I liked the montages of everyday household items, such as three-legged milking stools, porridge stirrers, pots, drums and woven baskets. Even the backdrop was excellent – beautiful line drawings of people using the implements.

I also enjoyed the mannequins dressed in traditional clothing. There were no undergarments on display. I saw a chap wearing a traditional cloak, wrap and furry animal skin in the clinic today. Like a true Scot wearing a kilt, this man had no difficulty showing me what was wrong just by hitching up his loincloth. All was revealed.

There were a few pieces of art created by modern Swazi artists, which were excellent. I was taken by the embroidery: “Women wearing pointy shoes, never do any work, just sit and wait for payday.”

No museum in Africa would be complete without a few dusty dioramas, a stuffed buffalo being chased by a moth-eaten lioness. But there were some witty touches regarding the origins of man and the development of tools.

P1020284The strangest exhibit was a stone statue of Krishna which had been found in Swaziland fifty years ago. No one seems to know how it got there from India. One theory has it that the gilded image was brought across the Indian Ocean from Portuguese colonies (Goa, Daman & Diu) to Lourenco Marques (now Maputo, capital of Mozambique) as a totem to be traded for goods in the hinterland.

My favourite area was a marvellous display of sepia photographs of Swaziland dating from the late 19th century. A collection of ladies posing for the camera wearing ill-fitting brassieres, recently distributed by missionaries, no doubt. King Sobuza II, as a little boy, standing in front of a beehive hut with his mum. In his tribal and British regalia. The post and telegraph office set up by the British in a tent at Mbabane. A poor Boer family of sheep farmers. A Catholic priest’s altar set up on a Norton motorbike. A group of priests resembling the Rasputin Brothers.

Swaziland is a small country, so people tend to know one another. But it was by sheer chance that last weekend, I went game counting with Bob Forrester, the only archaeologist in the country. I found out that he designed the museum, virtually from scratch. He was pleased I noted all the humorous touches. Bob was born in Swaziland and has put together an amazing collection of photographs of the history of the nation. All these pictures can be seen in the digital archive. I think you’ll agree, he has done a wonderful job.

http://www.sntc.org.sz/sdphotos/

Matchstick

Despite her expression, this is NOT the lady concerned.
Despite her expression, this is NOT the lady concerned.

A large elderly lady eased herself gently into the patient’s chair in my consulting room recently. I listened patiently while she went through the inventory of her complaints.

Headache. √

Sides pain. √

Total body pain. √

“Is there something else?” I asked.

She then had a long conversation with my translator, using a quieter voice. Perhaps this was the real reason for her consultation, the “hidden agenda”.

“The suspense is killing me,” I said. “What’s she saying?”

“She is talking about her anus and a matchstick, doctor,” said the translator.

I had this sudden vision of this elderly lady adopting an undignified posture, lighting her farts with a match. My jaw must have visibly dropped in astonishment.

“Her bottom is itchy and she uses a matchstick to scratch it,” explained the translator.

I had to restrain myself from asking two unprofessional supplementary questions to satisfy my natural curiosity.

Which end of the matchstick was she using to ease the itch?

Was she able to use the same matchstick to light a fire afterwards?

I settled on prescribing a soothing ointment for her to use instead.

Feet – not for the squeamish

Last week, I took over from a nurse who had been working for two hours in a consulting room in outpatients. I washed my hands, dried them on tissue paper and stepped on the pedal to open the normal waste bin. It was empty. I flipped open the clinical waste bin and found it was empty, too. I could think of three reasons – the bins had recently been emptied, the nurse hadn’t washed her hands or the nurse hadn’t needed to wash her hands because she hadn’t touched any patients.

I like touching patients. It’s a humane thing to do, reaching out and making contact. It demonstrates concern and compassion. But some health workers are concerned about contamination, especially in a clinic where there are many patients suffering from tuberculosis. I know one hospital doctor who wears an N95 surgical respirator all the time at work, no matter whom he is treating. In an MSF clinic, some nurses wanted to wear gloves when handling patients’ paperwork and medical records, out of fear of contamination.

I reminds me of reading Mary Douglas text on pollution and taboo while studying Social Psychology at Cambridge. In 1991 it was listed by the TLS as one of the 100 most influential non-fiction books published since the Second World War: http://en.wikipedia.org/wiki/Purity_and_Danger

Medical students learn that making a diagnosis involves three basic steps. Taking a history, examining the patient and carrying out special investigations. The history provides most of the information, with examination and investigation helping to support or refute your diagnostic hypotheses.

Given my non-existent communication skills in siSwati, my history taking is rudimentary. I don’t have access to a wide range of fancy laboratory investigations. So, the physical examination of the patient assumes greater importance for me. I use all my own high quality instruments, brought from UK – I need all the help I can get!

I’m trying to improve the care of our 200 diabetic patients. This means examining their eyes and feet. When I am checking feet, I sometimes sneak a peek at my translator who can’t hide her distaste. Occasionally, I have trouble, too.

This man could not feel this deep ulcer in the sole of his foot because he had lost all sensation of pain.

The patients in wheelchairs usually have the worst feet, mainly because they can’t walk on them. Last month I saw a man with one foot blackened rigid from gangrene. Last week I saw another patient who had been bed bound for four years at home following a stroke and vascular dementia, with pressure sores eroding his heel bones.

I called the local hospital about this lady’s gangrenous big toe. The SMO said it wasn’t an emergency and she should come to surgical outpatients next week.

Complete desquamation of the sole of the foot is rare. This happened two years ago in an Zambian cross country runner who did not use shoes at the Mfuwe Sports Day. The hard sole just sheared off from excessive friction.

The photograph below shows a man who has had bacterial cellulitis for two weeks before seeking medical care. The skin of his leg has already peeled off, with just the sole to go.

Sometimes I am amazed by the fragile condition of patients’ socks. They can look so worn out that there are more holes than material. It is a mystery how they manage to put their socks on without them falling to pieces…or perhaps it isn’t.

Gifts from a patient

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It’s unusual for doctors to receive gifts from patients in Swaziland. I was delighted to get this branch of bananas, sack of sweet potatoes and sugar canes from a grateful patient.

I have posted this image here because I cannot add it to my comment in ABetterNHS blog “Giving and Receiving” on http://wp.me/pBQAA-1h9

Link

What’s in the news today?

The news this week has been dominated by marijuana. Among pot smokers in Europe, “Swazi Gold” has a good reputation as a quality product. Here it’s called “dagga”. The best dagga is grown in the high veld. The growers are often quite elderly. It is not uncommon to read reports of gogos being arrested for being in possession of hundreds of kilos of marijuana. Perhaps they are just sitting on the product at home, rather than being involved with production.

I find it amusing when the newspaper expresses the value of a confiscated batch of dagga down to the last cent. For example, recent in Hhohho region, police seized “2,447,313 kg with a street value of 1,468,387.80 Emalangeni” or £79,158.70 at today’s rate.

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The Royal Swaziland Police Force called in the Press to witness the destruction of more than 4 metric tonnes of dagga in a furnace.

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A worrying development is the appearance of a drug called “nyaope” which is a mixture of drugs used to treat HIV, rat poison and marijuana. Some people must be desperate.

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Other stories included coverage of a fundraiser for Leonard Cheshire Homes, which do a great job with disabled children, rehabilitating people who have had strokes. Look at the expression on Princess Phumelele’s face when she was told about a disabled person who became an engineer.

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The King recently proclaimed an end to AIDS in Swaziland by the year 2022. This clipping has an obvious misprint, “an AIDS free generation by 20222”, a long way in the future.

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Finally in the National News section, a Headteacher has been accused of being pompous. It’s all gripping stuff.

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What, more animals?

I drove Dr Srinu and Kei, the MSF technical/laboratory adviser, to the Royal Hlane Game Reserve last Saturday. We did a guided tour to see the main attractions – lions, rhinos and elephants – and after lunch, we did our own game drive, looking for giraffes and zebras. We didn’t have much success, but I have posted a few photographs to share with you.

Battle of the Choirs

I only found out about the competition by accident. A local newspaper reported that two of the main participants in the 23rd Standard Bank Choral Music Championships had pulled out. They needed to prepare for a bigger show in a few weeks, apparently. To my mind, taking part in the championships would have been good practice.

The event was staged at the Mavuso Trade Centre, just like a miniature version of the NEC in Birmingham. The competition was sponsored by a bank whose logo is a flag in blue and white. The massive room looked like a tent, with diaphanous blue and white material gathered at a peak on the ceiling. This arrangement disguised the fluorescent tubes providing the lighting, but it made the stage quite dim and it was difficult to take good photographs. You can see the white balance is off in the photos not shot in RAW.

I persuaded Dr Srinu to come with me but I don’t think he understood what he was letting himself in for. “My goodness, it is like opera,” he said. Apart from the Korean pianist and her page turner, we were the only expats in the hall. We were ushered into VIP seats in the “stalls”, but I thought I could get better photographs by sneaking into the cheap seats closer to the stage. I didn’t realise that the VIPs were served lunch of chicken and rice.

Along the front edge of the stage there was a display of the trophies to be won. As well as prizes for the best standard andP1020146 large choir, there was an award for best conductor. These were ostentatious gilt cups, supported by columns and topped with a lyre.

The team of adjudicators sat in high-backed, white armchairs, directly in front of the stage, like the judges in the X Factor. The qualifications of the two judges took up the entire back page of the programme. It was clear that this was serious stuff.

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Standard category choirs (under 30 choristers) sang in the morning session, with large category choirs (over 30 choristers) performing after lunch. They each sang three pieces: one from Africa, one from George Handel and a piece of their own choosing.

The standard choirs could chose from either  “Love and Hymen, hand in hand” concluding Act 2 of Hercules or “United nations shall combine” from Ode to the Birthday of Queen Anne (which earned Handel a royal pension of £200 a year). It celebrated the Treaty of Utrecht 1712, which brought to an end the War of Spanish Succession. This was followed by an African song, “Ludvumo” by Sidumo Lukhele, and another piece of their choice.

 United nations shall combine
To distant climes their sound convey
That Anna’s actions are divine
And this the most important day!
The day that gave great Anna birth
Who fix’d a lasting peace on earth.

The large category choirs could choose from “Tyrants now shall no more dread,” from Act 3 of Hercules and “Wretched P1020192Lovers” from Acis and Galatea. They all did an African rendition of “Usuyizwe eMazweni” by Mbeki Mbali as well as a free choice.

All the choirs performed an African piece for their free choice. Usually, the singing was accompanied by synchronised dancing. One choir had two men out in front looking like Jake and Elwood in the Blues Brothers, doing a strange stamping routine and waving one leg around. The crowd loved it.

P1020190The choristers were all dressed immaculately. The Manzini choir members wore matching outfits made from the Swaziland flag. Men in the other choirs wore tuxedos with bowties and white shirts. The women wore matching ball gowns, blue for the Royal Swaziland Police Choir, white and green for His Majesties (sic) Correctional Services Choir.

I thought the choice of Handel’s works was interesting. The “Love and Hymen” piece is about Hercules’ jealous wife accusing him of having an affair and the “Wretched Lovers” describes a love triangle between Acis, Galatea and the cyclops Poliphemus, who bashes Acis’ head in with a boulder out of jealousy, but instead of dying, Acis is turned into a river. It is all about sex and violence. I wonder what the choristers made of it.

The Master of Ceremonies, Mzwakhe Khumalo, was a larger-than-life character who soon had the audience eating out of the palm of his hand. He reminded me of lovechild of an American fundamentalist television preacher and the compère Jerry St Clair (played by Dave Spikey) in Phoenix Nights. Between choirs, he kept reminding us about the wide variety of bank accounts provided by the sponsor and their relative merits. All in siSwati. Just as we were getting bored, he would burst into song. This electrified the audience, most of whom joined in, singing along in close harmony. Some stood up, waved their hands and started dancing. Mzwakhe would only have to sing the first line of a song and the rest of the audience would immediately take it up. He would do a little dance and exclaim that “the fire was in him”. All his routines would be punctuated by cries of “Hallelujah” from the rank and file. When the next choir was ready to sing, he would have to calm the audience and remind them of the virtues of silence.

He pointed out VIPs in the audience, such as an old lady, who had been involved with choirs for the past fifty years, a man who was his choirmaster when he was a boy, and two priests, “The men of God are in the house!”P1020187

To keep our interest in the sponsor’s banking products, he invited members from the floor to answer quiz questions about various accounts. The prizes were rather cheesy: cups or shopping bags emblazoned with the bank’s logo. A chap behind me said, “That man got the question wrong and he still got a prize!” Evidently it is not good PR to send a punter back to his seat empty handed.

Most British audiences keep deathly quiet. Sneezes and coughs are suppressed. Programmes barely rustle. Here, there is usually some whispered conversation going on while the choirs are singing. If the performance is uplifting or the tune is catchy, some members of the audience will start to sing along. It is a mark of respect if people stand up and boogie to the music, almost like jogging on the spot.

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After the morning session, we went out for lunch and Srinu decided not to return. I was entranced by the whole spectacle and had to go back for the afternoon. On the way in, I met the Master of Ceremonies. He introduced me to his family and I complimented him on his performance. “How do you do it?” I asked. He said the Holy Spirit was working through him.

The afternoon session began with the Five Tenors, one of whom was cringingly flat, belting out a couple of arias. Interestingly, they didn’t get much applause when they finished.

Competition between the large category choirs was very keen. They are like Premiership football clubs, recruiting players to improve the squad. One of our drivers told me that he was approached with a job offer in HM Correctional Services (as a prison officer) if he joined the choir. He sang in their choir for three years without getting the promised job, so he quit and became a driver for MSF. He did get a share of the prize money, though.

His Majesties Correctional Services Choir was technically the best and won the trophy, but the RS Police were close runners up with their free choice performance which got the crowd on its feet. Manzini choir wore the flag, but the prison officers finished off the competition with the national anthem. The Royal Swazi Sun Choir won the standard category, with my choice, Florence Catholic Church Choir, coming in second place.

I apologise for failing to publish video footage on YouTube because of copyright issues. Why should the devil have all the best tunes?

Lifestyle and Health

Last month, WHO published a report based on a survey of the health of 3,281 adults in Swaziland. Compared with other countries, few people smoke – just 6% on average, mainly middle aged men. Alcohol consumption is lower too, with just a quarter of Swazis drinking, though men tend to be more excessive.

As you may have read in a previous posting, the Swazi diet is heavy in starch. Only 8% of Swazis eat five-a-day fruit and vegetables. Constipation and haemorrhoids are very common problems.

Princess
Half the population is overweight. A third of women and a tenth of men are obese. These figures are similar to UK, where 26% of both sexes was obese in 2010.

There does not seem to be the pressure on young women here to be a “size zero”. Plus size women can even get to the final stages of beauty pageants. Temphilo Princess Nxumalo, “a confident big lady”, almost won the title of Miss UNISWA (University of Swaziland).

One of my patients who suffers from both hypertension and diabetes has been dieting after we had warned her she was seriously overweight. When I saw her, she had lost 20kg, coming down from 132kg to 112kg. I congratulated her and said that she only had another 30kg to lose and she would move from “morbidly obese” to “overweight”. She looked at me in horror. “All my friends think I have HIV because I have lost this weight. They think I am ill. No one believes me when I say I am losing weight for the good of my health,” she said. “I have lost enough weight now. I am happy with this size.”

Another middle-aged lady, who looked pleasantly plump, told me she was worried about her weight. I measured her and said that her Body Mass Index was 27, meaning overweight, but not excessively so. I advised her that she was close to a healthy weight and would not have to lose much. “Lose weight, dokotela?” she exclaimed. “I need to put weight on. All my friends think I am too skinny.”

P1010101Swaziland has one of the highest rates of type 2 diabetes in Africa. About 5% of the population are affected. Swazi women tend to be pear shaped and carry a lot of additional weight in their backsides. I remember reading about this racial characteristic in an anatomy book at medical school. It was termed “Bantu buttocks”.

One obese lady consulted me about lower back pain. Via my translator, I asked her if the pain went into her buttocks. My translator looked at me over the top of her glasses and said, “Doctor Ian, you should not use that word. It is not polite.”

“But what should I call this area? I can’t think of any nicer term,” I said.

“It is our natural African beauty,” she replied. I misheard her and said, “Her booty? That’s what Beyoncé has. I believe they call it junk in the trunk.”

“Eh doctor, you can be very naughty at times,” she replied.

A friend, Emeritus Professor of Nutrition at King’s College London, Tom Sanders, told me that the cause of obesity is likely to be consumption of large portion sizes of starchy food, rather than drinking excessive amounts of sugar-laden fizzy drinks or eating Western-style food.

I see very few malnourished children in our urban clinic at Matsapha. Those that are invariably suffer from tuberculosis and/or HIV infection. But I do see some grim dental caries in well-fed children.

Kung fu class at the Manzini gym
Kung fu class at the Manzini gym

For many older obese patients, going to the gym to exercise is not an option. They would need a car to get there. Few people want to walk, most use Kombis, but many aspire to owning a motor. There are more than a dozen second hand car lots in Manzini. Some specialise in importing pre-owned vehicles from Japan. The cars at the front of the lots tend to be more desirable German saloons from Mercedes and BMW.

Lots of people want to drive their own car, but before they do so, they have to pass their driving test. There are several driving schools in town, but one caught my eye recently. The sign on the roof of the small car said “Leaner Driver”. It could have been a typographical error, or perhaps fatter people really do need to learn to drive in bigger cars. Sadly, I could not get my camera out in time to capture the moment.,

Googling this, I found Lombhindza Driving School, “Instruct leaner for defensive driving skills… also help foreign people to change into Swazi driving laws. They have branches in Manzini.”

P1010611Every week the local newspaper names and shames those drivers who have been caught and punished for driving while under the influence of alcohol. I was amused by the story of one driver who was almost three times over the limit when stopped by the police. His excuse was that he was normally a cider drinker, but his friends had given him whisky instead. The magistrate told him to thank his ancestors “because they worked under crisis” (trying to keep him out of trouble).

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Another driver had failed to stop when instructed to do so by the police. He had compounded his crime by speeding away, failing to stop at a red traffic light and a stop sign. He pleaded guilty but in mitigation, he said was that he was rushing home to his children as it was his turn to babysit and cook for them. His wife had gone out to a church service on Good Friday.

The magistrate said, “If your wife makes you cook, take her to SWAGAA (Swaziland Action Group Against Abuse) for abusing you. It is her responsibility to cook at home.” He still found him guilty and sentenced him to pay either $200 or spend two years five months in jail.

Healing Jesus Campaign

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When one of my irreverent colleagues first saw this sign, she said, “Healing Jesus? I didn’t know he was sick!” And this was just after Good Friday.

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Recently Swaziland has been visited by the evangelical Ghanaian preacher, Dag Heward-Mills. Almost a month ago, coloured posters appeared overnight, fastened to fences along the main road. Banners were attached to lamp posts and bridges crossing the dual carriageway between Manzini and Mbabane. The two main national newspapers covered the story, whipping up interest (not really a frenzy) among the Christian community. One of our drivers took to playing religious music in the Toyota LandCruiser. I would not have minded if it was funky gospel, but this was like a dirge.

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Last Wednesday night, the Mavuso athletics field was floodlit for the crusade. Thousands of people attended to hear him speak. There was a strong police presence to maintain (holy) order.

Like the king, Dag kicked off with a song, “All things are possible.” Then he started at the beginning, Genesis 3, the story of the Garden of Eden. The serpent and sin came into our lives. Dag warned the congregation not to let the devil into their lives. Even the United Nations could not defeat evil, only the Prince of Peace could do that.

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Taking the snake metaphor a bit further, he went on to tell a tale about his friend who felt he had to sell his car because he had found a snake inside, which then disappeared. “The presence of the snake can cause everything to lose value,” he said. But I feel sorry for the person who ended up buying the car, not knowing a serpent had taken up residence.

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Dag asked the crowd, “If anyone wants to accept Christ into their lives, then they should stand up!” Not surprisingly, almost everyone stood up, even those on crutches. Dag did a little dance with a pair of crutches. People came to the podium to testify how they were blind and now could see.

The sick had been healed. They left their redundant wheelchairs at the venue.