Medicine: Malaria Bites

I was working late in the office one evening, when my phone rang. “On a besoin de toi, tout de suite au Rea,” (“we need you, stat, in reanimation”) said a voice on the other end. “J’arrive,” I replied, rising, hanging up, and throwing my stethoscope over my neck. I jogged down to the Rea to see what was going on. I could hear the kid breathing before I entered the room. A four-year old boy lay on the bed, chocking on his own spit and vomit, after having just seized. I grabbed a suction machine and tried to clear his airway. After four or five passes, the rasping and bubbling in his throat cleared. I positioned his head and neck to allow him to breathe more clearly. Even with these interventions, his breathing was labored and you could feel the rattle through his chest from the stuff he had aspirated into his lungs.

While another nurse attached monitoring equipment, another helped me ask questions of the parents. The child had been sick for four days and this was his third seizure. Malaria. Not good, I thought myself, you don’t want to fool around with malaria. (It’s not that my diagnostic skills are that good, it is just that 99% of kids coming in right now are malaria cases.) But encouraged by our recent string of victories, I was still very calm. The monitoring equipment seemed to be malfunctioning, so I asked the nurse to go get a new machine. She left, and I pulled the lower lid of the kid’s eye down to look at the conjunctiva. (The third-world version of a quick blood-count.) Where normally you find a rosy red inner eye lid, I saw a pale white. “Oxygene!” I yelled. I sent one nurse running for oxygen and the other for IV start supplies.

In an instant, I went from calm to significantly panicked. Before either of the other nurses came back, I saw the boy’s chest start to move irregularly. Then a pause, and a gasp. I jammed my fingers into his neck to feel his pulse. Bump, Bump…Bump…….Bump……Bump………. The word I screamed in my head at that moment was very unsanctified, very not-missionary; but I hardly know a word that is more sufficient to express my feelings on this disease.

I pulled the sheet over the little kid’s face, and turned to look at the stone-like faces of his mother and father. Sorry, I half-said, half-whispered. Without making a sound, the mother got up and left. The father lingered a moment. I had one of the nurses translate my condolences, and then explained that the malaria had progressed too fast and there was nothing we could do. He nodded solemnly and then walked out.

I made final arrangements with the nurses and then walked out. At first I wanted to play the “what-if” game. What if I had started the IV sooner? What if I had gotten oxygen sooner? I should have looked at his eyes sooner. What if… But my background in critical care medicine has taught me that this is never productive, nor does it represent any form of reality. So I tried hard to stop. I called Brett (the pediatrician), played the what-if game a bit more, and stopped when he spoke the same words that I knew to be true. “The kid just got to us too late.”

And then I got mad.

And I’m still angry. At first, I couldn’t find one direction to point my anger. I wanted to yell at the parents for waiting so long, for not even getting some kind of treatment. I wanted to tell the government that they had done a crappy job at educating their people. I wanted to write the UN and tell them to ship an army here, because we are getting flogged by this disease. But the parents looked poor to me, so I knew that they had waited part because of financial pressure, part from lack of education, and more than likely, they lived in an outlying village and it had taken some time to get to the hospital. The government is already providing free medicine for malaria, and though it is far from perfect, it’s doing a decent job as far as governments go. And the UN…well, whatever…it just doesn’t feel very productive to get mad at the UN.

But I’m still angry. The next day, we lost two more. A little later, I watched two parents throw themselves on the floor in tears as their seven-year-old, their only child, passed away moments after they laid him on our hospital bed. (First W.African man I’ve ever seen cry.) This past week, we’ve had at least two or three new cases a day that we admit. (That’s a lot, considering that pediatrics isn’t even technically open. And that’s not counting the ones seen in outpatient clinic who are sick but well enough to go home on meds.) Some of them get better, some we lose. And all of a sudden this mysterious, tropical disease has an ugly face to go with its name for me.

Isaac, who before the opening of the hospital worked in a rural clinic, told me that during this season every year it is not that strange to have at least one death a day in the village from malaria. Brett has asked, more than once, out loud, “How do any children survive here?” I wonder the same thing. It’s no wonder that some parents stay a bit aloof of their young children. (They often don’t cry at deaths, first because they are so over-exposed to death and second because Islamic teaching says that if a child dies it is Allah’s will; to cry is to tell Allah that you disagree with his will. This is not true of every family.)

The problems are multifaceted. The first is a lack of education. Some seem to be unaware that their malaria problems have a season. During the dry season, we don’t see malaria, but with the rains come the mosquitoes. So in May, when your kid vomits, you relax and figure it is just a stomach bug. If they vomit in September, you should load them on the moto and get to the nearest hospital. That doesn’t seem clear to them. The seasonal-ness of malaria here may also be part of the problem. If kids were exposed to small numbers of parasites during the whole year, they might form antibodies better. Instead they go through a period of little or no exposure, and then are hit with a wave of parasites.

Medicines are also problematic. The government gives out a very good malaria treatment. However, it comes in pill form. The pills work well, if they are started in time, and the kids keep them down. A frequent symptom of malaria is nausea and vomiting. Some parents don’t even have access to these pills. Others try traditional treatments first. Still others try single-drug syrups or injectable quinine, which can work, but malaria often develops resistance to single-drug therapies. The very best treatment (in country) is expensive and is only sold in a box set for adults (making it much more expensive). We offer this treatment much cheaper because we share the vials among our multiple pediatric patients. (i.e. making it possible for the kids to get just the doses they need instead of having to buy a box set that they won’t use all of.) So when a child comes down with severe malaria, parents often waste precious time getting them the very best treatment because they try other options first.

And then, frankly, the reality is that malaria doesn’t exist in first-world countries. We wiped it out with the use of DDT and other extreme measures. We have, however, placed bans on DDT as it no longer affects us. (And I’m not necessarily advocating the use of DDT here.) And this is where my frustration and anger have found roost. How is it that we know so little about this disease in the West?! (And truthfully, care less.) Between 100-300 million people (mostly children) die every year from malaria. 36 million people die from starvation every year. Contrast that with the 25 million HIV-related deaths BETWEEN 1981 and 2006! We hear a ton about HIV (and rightfully so…) but hear little about malaria, even though malaria kills 100 times the number of people! Or, do I dare say it? Yup, the number of world-wide abortions every year is estimated at 46 million. Not saying that HIV and abortion aren’t worthwhile concerns, but it seems like if we wanted the most bang for our buck, we’d go after malaria. I wonder why we have so separated ourselves from this disease. (Grain of salt…statistics taken from Wikipedia.)

I feel a certain moral-outrage about this disease. It is a smear on the face of our world. It is a symptom of our world, corrupted by our sin. It is made worse by our complacency. I’m ashamed that I didn’t know more about it before now. Do what you want…but I’ve asked the Lord to never allow me to become complacent about this disease. As long as He allows me the privilege, I’ll be here kicking back.