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Namibian Didge Lessons

As a kid growing up in rural Australia I was fascinated by the prehistory of our continent.  The ancient Aboriginal stories and creation myths permeated our Western culture.  The opportunity to play the “didge” came up whenever we discovered a discarded length of PVC tube or Mum’s vacuum cleaner pipe laying around.  For those of you who are not familiar with this instrument – picture a hollow tree branch about six feet long with a mouthpiece fashioned out of bee’s wax.

The didgeridoo or “didge” is played like a trumpet – the lips are pursed against the mouthpiece and air vibrates them together to produce a long, deep and haunting drone.  Skilful players can control the pitch and overlay shrieks and other sounds.  To play it continuously one needs to employ “circular breathing” to maintain a constant flutter of the lips.

I suggest you listen to this awesome sample of didge from Yanni via Youtube as you read the rest of this post.

I have been passionate about working in Aboriginal Australia for many years. When I was a fourth year Med student ( in the 90s) I entered an essay competition on Aboriginal Health and was lucky enough to win a scholarship elective in rural Namibia.  That summer I spent three months in a tiny town called Keetmanshoop, on the edge of the Kalahari.  I had the fortune to work with some amazingly skilled and battle-hardened doctors in a remote, beautiful and strange world.  If you ever saw the movie “The Gods Must Be Crazy” – then you have an idea.

Namibia, Keetmanshoop in Namaland

Now, my University faculty were keen to thank the Namibian doctors for their generosity in hosting a clueless student.  As such they decided to send a gift, a ceremonial didgeridoo, to the team as a cultural token of thanks.  Of course this meant that I had to carry an eight-foot long, polished tree branch through three borders in order to deliver this gift.

Imagine this scene.  At the tender age of twenty one, I am standing in the Windhoek airport terminal.  The building itself is literally a massive, domed hangar, a single metal room filled with a thousand local travellers.  In my jet-lagged haze I was aware of the fact that mine was one of a few white faces in the crowd queuing at the passport control.   This was the first time in my life that I felt like an “other”, an outsider distinctively different to the crowd.

My passport was stamped and I was asked to present my luggage to the customs officer.  The broad smile of the Namibian official disappeared as I produced a suitcase and what looked like a cannon wrapped in brown paper.  The airport bustle continued around me as he asked me to unveil the contents of my peculiar parcel.  The didgeridoo was completely foreign to this man, he could not conceive of it’s purpose.

“What is this?”

“It is a didgeridoo.”

” Okay…..” he paused, confused. Looking down the lumen for a clue, surely expecting it to be packed with drugs, diamonds or devils.

“It is a musical instrument – you play it.” I explained as he rolled it over like it were a dead snake.

After contemplating my claim for a tense moment, he smiled.

“Okay, man. Play it then.”

I thought he was joking. However, the intense look on his face suggested he was very serious. “Play it!” he insisted.

The desert heat, the crowded queue and the situation had me sweating intensely.  I had raspberried on the domestic vacuum-hose as a kid but this did not fill me with confidence  I knew I could get a note out of it… but would that sound convince this chap of my claims?

I pursed my lips against the now-melting beeswax and took a deep breath.

The long, deep note reverberated all around the huge hall.  A thousand Namibian voices stopped.  The suddenly-silent hangar filled only by my lonely didge drone.  A thousand pairs of eyes now watched as I did my best to convince the officer that this was what a didgeridoo does do.  For what seemed like a long time, but was probably 20 seconds, the room was transfixed by my performance.  The crowd’s response was not applause but laughter.  Hundreds of locals laughed and pointed as my breath expired and the droning didge died. The customs officer could not control his own smile and gave a giggle as he waved me through the gates.  My first hour in Namibia taught me a lot about being an outsider, an “other” and being different.  That moment left a deep imprint in my memory!

That feeling dwells deep in my limbic system.  I use it.  When I see the ancient Aboriginal man in my modern, white ED – my mind goes back to that moment.  I imagine how it must feel to be in a foreign place, where the language is strange, the customs alien and try to be a better human.  Empathy can be deliberate – having walked in the shoes of an outsider for just a few months can give one the skills to practice more inclusively.

That summer in Keetmanshoop was inspirational.  I developed a love of rural and remote medicine.  Living and working in a small community was clearly the best job in the world of medicine.  But that is for another day.  This post is about the didgeridoo – an ancient instrument that just might provide a cure for a very modern disease.

Learning to play the didgeridoo might fix your patient’s (or your own) obstructive sleep apnoea.  Way back in 2006 the BMJ published this paper:

Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial 

This was a Swiss study conducted in Zurich.  Which is pretty much as far from Aboriginal Australia as one can get both geographically and culturally!  Of course the mountain folk do have their own version of the didge, the Swiss horn…swiss horn

Image from the BMJ paper above – Swiss man playing the plastic trial didgeridoo

So what did this trial actually do and what did they find?

This was a randomised controlled trial of just 25 Swiss sleep apnoea patients – so not a massive cohort!  They had OSA but were not yet receiving CPAP or taking any sedatives / excessive alcohol.  They also excluded patients with a BMI > 30 which would exclude a lot of OSA patients I imagine!

The patients were stratified by OSA severity using a few measures (Epworth scale, Pittsburg score, “partner sleep disturbance” and the apnoea-hypopnea index).

They were randomised to either remain on the waitlist for didgeridoo lessons for the 4 months that the trial ran.

The intervention group received didge lessons and instructions to practice for 20 minutes 5 days a week.  Specifically they did learn the circular breathing techniques that involve a lot of upper airway muscle training.  IN the final analysis they actually played on average 6 days a week for 25 minutes… hardcore protocol adherence!

And guess what – it worked!  Well, sort of, it depends on how you measure the success of the intervention.  3 of the 4 measures showed a statistically significant improvement (yes, the all mighty p< 0.05….) Only the Pittsburg score was not significantly altered.

The numbers on the Epworth scale are here:


Now before you all start writing angry comments about the relative weakness of this data… lets remember – this is basically a group of Swiss-German middle-aged men getting together and playing a didgeridoo. I cannot see the downside to this intervention as long as we ignore the auditory insult of their families / neighbours / friends.

I love this trial.  Applying ancient skills to fix a modern problem.  It makes sense to me on a physiological level – stronger pharyngeal and glottic muscles should reduce the airway’s tendency to obstruct.

The cost is basically the cost of a plastic didgeridoo ($94 in this trail).  Of course, they could have just used the family vacuum tube as a cheap, available alternative.

OK, so there you have it.  That is what has been occupying my mind this week.  I actually think I will recommend didge lessons / practice to my patients with OSA symptoms.  Given that I work in the north of Australia -this may be the most culturally-appropriate intervention ever devised for a common problem in Aboriginal health.

Let me hear your thoughts.

Casey

Comments

  1. Tim Senior says:

    Thanks Casey,
    Those rare moments for those of us in a dominant culture to experience being the “other” are really important moments, as that is how our patients must feel much of the time, especially Aboriginal and Torres Strait Islander patients *in their own country!*
    That BMJ paper on COPD and didgeridoo playing is one of my favourites. It’s been tried in asthma too: http://www.citeulike.org/user/timsenior/article/12551477
    One of my Aboriginal colleagues pointed out that culturally only men are allowed to play the didgeridoo, and that alternatives need to be found for the women. So, in a similar vein, singing may be useful: http://www.citeulike.org/user/timsenior/article/6644480
    I wouldn’t be surprised if part of the effect on health was not just about airflow in obstructive bronchi, but about connection to community and culture!

  2. tom fiero says:

    thank you for introducing a Brooklyn boy to whole other worlds.
    tom

  3. Etwell Mari says:

    Hello Casey
    It’s 4am when I open the favourite blog. Reading about PE the navigation through Wells and PERC then I hit the Broome Docs. As a RRM African doc who has worked in Derby& Broome (locus) I got interested and diverted a bit to see what the link has in store. I loved it.
    My story is the reverse side of yours. As an IMG coming to Australia and going through competence assessment at KEMH and Freo ED to get the accreditation to work rural. I remember being asked so how man C/s have you done. I asked you want life time total or last year, my consultant said last year then I gave the figure he paused and said the local reg can not achieve that in two years. I smiled and said send them for exchange attachment in Africa and please remember to send them with suture material. The answer is obvious- resource utilisation cultures are different.
    Drs need to see the other side outside the four walls in the nice ED and experience patient life and then they will appreciate why patients sometimes get intimidated by being sent to big smoke. I am glad Broome hospital has grow to what it is now. I remember the 4 bed ED when I passed through to get my final signature to go to Derby and be a GPO.

    Nice story to refresh after a heavy shift in ED

  4. Thanks alot for sharing this interesting artcile .
    As a Non VR GP who has been just dx with OSA and due to see my RGP today to find out what I can do about it ,I think I will try this method and see if its work as its very practical and feasible way I think ,and I will ket you know in few months .
    Regards

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