Timely malaria treatment a matter of life and death

Posted on May 8, 2012 by

As the sun went down and the ridges of the Mitumba mountains turned a smoke blue, a line of mothers sat quietly on a wooden bench in front of the nurses’ station in the paediatric tent. The children lying in their laps were new admissions, too weak to protest against the nurses, who wore miners’ headlamps to help search for a vein to place a drip.

These children in the east of the Democratic Republic of the Congo (DRC) have “severe malaria”: a combination of signs and symptoms, lab results (if you have them) and infection with one type of malaria parasite, Plasmodium falciparum. After the parasite has invaded via the drill-like proboscis of a blood-hungry female anopheles mosquito, the falciparum parasite replicates fast. Like a microscopic wrecking ball, it smashes red blood cells – leaving its victim breathless with severe anaemia – and sticks to blood vessels in the brain, causing seizures, coma and death.

Time is everything. Delay treatment and the parasites multiply unchecked, the patient reaching the point of no return. The duty nurse Lejuif and I started with the sickest-looking child, 18-month-old Bahati. His feet were cold, signalling he was in shock. He didn’t respond when we rubbed him vigorously on his chest – he was in a coma – and his chest heaved up and down. He had severe respiratory distress. His haemoglobin, the measure of how much oxygen his red blood cells could carry, was very low. He needed an immediate blood transfusion.

We rushed between the tent and the single-storey building containing our intensive care unit (ICU). The unit has an oxygen concentrator, which we used to help him breathe while we placed a drip, gave anti-malarials and arranged for a transfusion.

Families have to donate blood if a child needs a transfusion. Bahati’s mother had walked from the gold mining town of Misisi, 15km down a dirt road, unaccompanied by her partner. As she was pregnant, she could not donate. There was no suitable blood in the hospital freezer.

A nurse, Wilondja, went back to the paediatric tent and persuaded another of the parents to give blood. We started antibiotics, as we had no means of ruling out meningitis or another blood infection, especially since Bahati had undergone a traditional treatment the previous day involving the removal of his uvula (the projection of the soft palate between the tonsils).

Political will and funding to buy bed nets, insecticide spray and medications that both cure malaria and stop the onward transmission of the disease have saved many children’s lives in sub-Saharan Africa. There is now hope for a vaccine.

Experience in the Kimbi-Lulenge health district would seem to bear out evidence from the World Health Organisation’s (WHO) latest world malaria report (2011) that the DRC is defying the trend, with cases actually rising. Médecins Sans Frontières (MSF) treated 15% more malaria cases in South Kivu in the first two months of 2012, compared with 2011. However, the new project in Kimbi would also fit WHO findings that suggest better access to treatment has led to a rise in the recorded numbers in a remote population made even more inaccessible by a smouldering war.

In MSF’s more established operation in the town of Baraka, on the shore of Lake Tanganyika, the proportion of under-fives presenting with severe malaria in January and February this year was 9.3%. In Kimbi, this proportion was 25%. The difference is most likely timely access to healthcare. Much of the population around Baraka can now get to primary healthcare centres, which have reliable stocks of anti-malarials. In remote Kimbi, where MSF started operating only last October, there have been complex supply issues to overcome. But it has now started supporting health centres such as the one in Misisi so that children like Bahati can find treatment closer to home before they get so ill.

Bahati had a stormy course and remained in a coma, with periodic seizures, for two days. His name in Swahili means “luck”; with the care of the nursing staff in the makeshift ICU, he pulled through. But this year thousands of children in the DRC will die from malaria, a disease that is both preventable and curable.

• Names have been changed to protect patient confidentiality

This post was first published by the Guardian online

Posted in Democratic Republic of Congo, Doctor, malaria | Tagged , , , | Leave a comment

The flying creatures I sleep with

Posted on March 6, 2012 by

We’ve taken over a compound from another aid agency as a temporary MSF base. ‘Compound’, however, is probably too grand a term for the small, single story building of mud, riddled with termite holes, its bare wooden beams roofed with corrugated iron and surrounded by a flimsy stockade of bamboo.

The strong smell of ammoniac pervades the building as it hosts a thriving colony of bats. They’re quiet during the day but as I turn in, they start to scratch, screech and shuffle about after returning from sorties to feast on the copious and diverse clouds of insects that race like electrons around the bare bulbs run by a noisy diesel generator at night.

Having learned of a possible association between bats and the dreaded viral haemorrhagic fever, Ebola, I was not happy to find two of them, wings folded, clinging upside down to the mosquito net over my bed. The net is often covered with tiny black pellets each morning – bat poo.

One night there was a scrabbling sound close to my head. I turned on my head torch, expecting to find a bat or one of the many rats that also plague the compound – I saw two of them swimming in our latrine – but instead found a grasshopper half the size of my hand trying to climb into bed with me.

We also cohabit with: even larger moths, as fabulously coloured as the cotton scarves worn by the women; flying ants or their military relations that march in neat columns from one end of the compound to the other; the malaria-bearing mosquito; large, agile cockroaches that like to charge you as you squat in the latrine; centipedes with impossible numbers of legs; frogs that make the noise of an old fridge; and the odd praying mantis – one landed on my shoulder as I read a book in the compound’s courtyard.

There are a couple of tabby cats who we’ve allowed to stay on in a rather lame attempt at pest control but they look frankly exhausted and not enthused by the task we’ve given them. A wild monkey was spotted near the compound but years of war and the resulting hungry population means there is not a lot else in the way of wildlife.

The best part of the day is a shower. Water is heated up on charcoal braziers in large, dented aluminium pans and I’m rationed a third of a bucket of hot water, topped up with rainwater collected from the roof (all our water is either collected on from the roof or from a pump near a river close to the hospital and filtered). I take my bucket to a rectangle of space the size of a telephone box partitioned with plastic sheeting and soap up next to a papaya tree under an open sky.

Food has so far been a valiant attempt to vary the staple of rice, pasta, beans and ‘foufou’, dough made of cassava flour and a food that has poor nutritional value, but a staple of the people’s diet. The fridge for the cold chain medicines, including anti-venom for snakebite, arrived last week and we’ve commandeered a small corner to keep a few bottles of soft drinks cold. My other luxury is a cup of coffee made each morning with an Italian espresso maker I brought out with me, heated over the charcoal brazier.

Congo’s rickety communications contribute most to the feeling of remoteness. When I worked as a reporter, I started without satellite technology and remember a group of telephone operators were the guests of honour at a journalist’s party in Tbilisi, capital of the former Soviet republic of Georgia. Things have moved on and handheld satellite phones have replaced the 25kg trunk with antenna that I first used in the 1990s. However, satellite technology is expensive so instead, I’ve bought a local SIM card for an old mobile phone to try and keep in touch back home.

Mobiles have revolutionised communications in Africa, leapfrogging the need for expensive communications infrastructure, and are now used to transfer money and to remind patients living with HIV to take their antiretroviral medication as well as for texts and calls. So when I receive a text in Lulimba from my family in the UK, asking ”Can you stand under the mango tree?” I head for a slightly elevated corner of the MSF compound and wait in the dark shade of the tree hoping that my family doesn’t have to dial more than 10 times to get through and that the quality of the line will be slightly better than the roar of ocean you get when you put a shell to your ear.

Posted in Democratic Republic of Congo, Doctor, Healthcare provision | Tagged , , , | 4 Comments

The silent cost of child malnutrition

Posted on February 16, 2012 by

Just as I was about to leave for the day, Steve, one of the nurses, asked me if I could see this one case before going. Beatrice (not her real name) was two years and seven months old when she arrived in our paediatric hospital tent, in Kimbi Lulenge, South Kivu, in the Democratic Republic of the Congo (DRC). A quick glance at the prostrate child in the dim circle of light cast by the tent’s single bulb and I guessed she was another malaria case. Steve shook his head. “Non, docteur. C’est un nouveau cas de malnutrition” (“No, doctor. This is a new malnutrition case”).

Dr Chris Bird (L) and a nurse show a mother a record of her child's weight gain in the Inpatient Therapeutic Feeding Centre. Photograph: Emily Lynch/MSF

Dr Chris Bird (L) and a nurse show a mother a record of her child's weight gain in the Inpatient Therapeutic Feeding Centre. Photograph: Emily Lynch/MSF

I quickly felt the child’s feet – icy cold. A careful look at Beatrice showed that all the curves and dimples of a healthy child’s face had shrunk, leaving the forbidding lines of a woodblock print. Beatrice was alert, but silent, which formed an ominous void amid the children crying in the rest of the tent. There was a glint of anxiety in her rheumy eyes that grew dimmer as she seemed to fall into it.

I gently pulled back the cotton wrap. The malnutrition had ravaged her skin, causing it to flake off, leaving behind weeping sores across her arms, legs and chest. There was no healthy protest when a drip was placed in her arm.

The nursing staff went into action. They gave her glucose to prevent low blood sugar, antibiotics through the drip to fight off infection; they advised her mother to keep her warm, as hypothermia takes the lives of many of these children at night. Careful fluid management and gentle refeeding was started: give too little and the child will succumb to dehydration and shock; too much and the child will die of heart failure.

Treating a malnourished child is complex. It is not simply a matter of doling out cups of milk and packets of peanut paste when a child like Beatrice finds her way into our tent, tied to her mother’s back after she has walked a day to get to our hospital or, if she’s lucky, on the back of a relative’s motorbike along the treacherous dirt roads.

She needed intensive care; the kind of care where one nurse sits at the foot of her bed, monitoring her temperature and vital signs hourly, helps to prepare the mother for the full timetable that refeeding these children requires, and attends to the skin wounds that look as though they belong to a burns victim.

This situation of need in the midst of such want brings to mind the work of the British doctor Julian Tudor Hart. In the 1960s, he pioneered pro-poor healthcare in the Welsh town of Glyncorrwg. His experience prompted him to come up with the “inverse care law” – that the “availability of good medical care varies inversely with the need for it in the population”.

The grand-sounding Inpatient Therapeutic Feeding Centre (ITFC) is my favourite part of the hospital. In a tent set apart from other patients you get to see these little children, with so much stacked against them, gradually put on weight, start to smile and play with their parents. With the extra staff we have hired, our care is as focused and intensive as it can be, given our limited means.

But Beatrice arrived before our ITFC had been established. That night there were only two frazzled nurses in our paediatric tent. It was rainy season so it meant malaria cases were high and our hospital was busy.

Beatrice arrived when the light was fading behind the tent’s white canvas walls; she was already very ill. After gently warming her by placing her close to her mother and monitoring the dosing of the initial fluids, Steve began her feeds. He tended to her skin and then, when she began to have difficulty breathing, he put her on the hospital’s only oxygen concentrator, the maximum level of care for our most severely ill children.

But when I was called to see her later the next morning, her heart had already stopped. The anxiety in her eyes had gone.

Beatrice’s mother sobbed as we wrapped her daughter in the green cotton cloth in which she was brought. Her father lifted her easily in his arms and left the hospital, his face immobile. Her mother walked, crying, behind him, stopping on the dirt road from time to time as she doubled up in grief. An elderly man going the other way, a Red Cross armband on his left arm, dismounted his bicycle and gave a formal salute to the family as they walked past.

You won’t read much about malnutrition in DRC because it doesn’t fit the dustbowl paradigms that govern the concept of starvation or malnourishment. Where I am in the east it is green and lush, but after years of war, insecurity and economic collapse, all the children in our tent are malnourished to some degree. It is this underlying weakness that determines how children respond to the infectious diseases that claim their lives with unrelenting regularity.

An estimated 9.7 million children under the age of five will die this year of largely preventable illnesses. Malnutrition is estimated to contribute to half of these deaths. What do numbers like these really mean?

It means a small, fragile girl like Beatrice, whose parents loved her, who left us as quietly as she arrived.

This post was first published by the Guardian Online

Posted in Democratic Republic of Congo, Doctor, malnutrition | Tagged , , , , | 14 Comments

Il faut se debrouiller! (You’ll just have to muddle through!)

Posted on January 27, 2012 by

Kimbi Lulenge, South Kivu, DRC

Our team arrived to start working at the Lulimba Hospital at the height of the malaria season. We barely had time to unpack our boxes because we were greeted with a crowd of sick children that have been arriving in ever greater numbers since. We found out very quickly then that Lulimba Hospital had only one thermometer.

When you lack most tests, being able to take a temperature in an area endemic for malaria and other tropical diseases is critical. So the staff spent the first days running between the outpatient clinic, maternity, paediatrics and internal medicine, chasing the small tube of glass and mercury to place under the arm of a hot, lethargic child. When the bottleneck was discovered, we found a further two thermometers when we raided MSF’s own medical kits, kept in our vehicles.

While we waited to fully unpack, set up our supplies and for a rush order of additional resources to deal with the unexpected numbers of sick people, I was carefully guarding the paediatric department’s one thermometer after it found its way out again to outpatient consultations, bringing the ward round to a grinding halt.

The lack of thermometers is only one of many shortages that beset the hospital, which is now trying to cope with a surge in patient numbers since health care was declared free with the arrival of the MSF team.

There are plans to build a new hospital.

But what do we do now? We are roaring through our first tonne of medications, especially antimalarials and paracetamol. The numbers of children are growing, with two or three children to a mattress, along with their mothers and often their siblings. And the hospital staff is overworked, handling the white water ride of this start-up with patience and humour.

When I asked one mother after seeing her child if there was anything else I could do to help, her reply in Swahili prompted musical laughter from the other mothers. The nurse on duty, Silele, grinned and translated for me: “She was asking if you could sort out the problems between her and her husband but I think we have enough to do already.’’

The shortages, particularly in terms of nursing staff, impede our work at every turn. At the start, we lacked a rapid test for malaria (there’s apparently a shortage of these tests across the globe) and the large numbers of children presenting with fever overwhelmed the tiny lab, a dusty little room where the one microscope is placed carefully in front of a pokey window to capture enough light in the search for the parasites that plague our hospital population. The lab technicians use a torch at night to bounce off the microscope’s mirror.

In the operating theatre, the patient is anaesthetised with ketamine and a small wisp of cotton wool is placed over one nostril. If it moves up and down, the operating team knows the patient is breathing.

The wisp of cotton wool in place of winking, bleeping machines found at the anaesthetic end of operating tables at home is the perfect example of a phrase in French that is on everybody’s lips – Il faut se debrouiller!

Building a hospital takes time but with the flood of patients, we’ve had to improvise quickly. We’ve moved the internal medicine and paediatric services out of their overcrowded, dark rooms into four large tents while we wait for the new hospital. This has also created space for other services.

We now have bed nets against mosquitoes for each patient in a bid to prevent the mosquito vector from spreading malaria from one patient to another. Each service now has buckets with chlorinated water for drinking water and hand washing to help prevent cross infection.

The operating theatre now has a light and the instruments are sterilised in a proper autoclave in place of the pressure cookers placed on charcoal braziers when we arrived. We now have a generator which we can use to provide oxygen to patients with breathing problems. We simply treated all feverish kids for malaria until the rapid tests arrived (when we subsequently started collecting data from these tests, 85% of them were positive for the potentially deadly P. falciparum form of malaria).

I was woken this morning by a crack of thunder and the pummelling of heavy rain on the tin roof. The rains threaten more malaria, more patients and the already parlous dirt roads and airstrip that we rely on for the delivery of drugs and equipment that this isolated hospital so desperately needs.

This post was first published by the Guardian Online

Posted in Democratic Republic of Congo, Doctor, Healthcare provision | Tagged , , | 5 Comments

Journey to Lulimba

Posted on January 5, 2012 by

Long journeys in the Democratic Republic of Congo (DRC) are a part of the dizzying extremes in this country dripping with precious minerals but where one in five children die before their fifth birthday. Of the 153,497 km of mapped roads that cross the territory two-thirds the size of Europe, only 2,749 km are paved. As soon as we leave the outskirts of Bukavu, the main city in South Kivu Province, the tarmac ends.

I’m heading for Lulimba, a small, remote town in eastern DRC. It’s 300km away from Bukavu but the journey takes two days in a four-wheel drive vehicle. You can’t fly in as the dirt airstrip, originally cleared by a long abandoned church mission, is reported as uneven and potholed. The jolts along the red dirt tracks, river crossings full of children splashing about (I wonder how many of them carry the worms of schistosomiasis) and short exchanges with armed men en route make it impossible to study the French grammar book open on my lap.

My own journey to DR Congo as a doctor has taken a little longer. Before medical school, I worked as a reporter on frontlines from Bosnia to Afghanistan. Refugees, civil wars, political unrest – these were the stories I wrote about from the field.

Reporters gravitate towards hospitals and clinics because they provide the starkest index of suffering among populations trapped by conflict. I spoke with doctors and nurses behind many frontlines and the more I talked with them, the more difficult it became to simply take notes while they risked their lives to treat the sick and wounded, often with minimal medications and equipment. I put down my notebook and started right back at the beginning, entering a London medical school.

A decade on, as I’m bumped about in the back of a Landcruiser on my journey to Lulimba, driving past a bar painted a marine blue and called Clinique a la Soif (Thirst Clinic), I worry about the sudden increase in my clinical remit. As a doctor in the UK, I manage patients in a busy emergency department but I don’t have to worry about getting hold of antibiotics or a chest X-ray. In DRC, which sits at the bottom of the United Nations’ Human Development Index, resources are scarce. I’ve been warned that as well as seeing patients, I’ll need to keep track of hospital supplies, possibly face widespread cholera or measles outbreaks and help set up treatment for patients with tuberculosis and HIV, both diseases which come with complex pathologies and social issues that are challenging to treat in the UK, let alone isolated Lulimba. I’ve also been given a bright yellow book with simple black and white line drawings: Minor Surgical Procedures in Remote Areas.

When we arrive in Lulimba, our truck carrying about a tonne of precious medications is lurched over at a 45-degree angle, stuck in the mud on the main street. There is no electricity for the squat homes made of mud brick and reed thatch. When the MSF team arrives at the town’s hospital – two single-storey buildings of mud brick roofed in iron – we tell the hospital staff about our plans for free health care. That evening, the staff enthusiastically removes the handwritten posters listing the prices for treatment.

Overnight, word gets around of our arrival. The next day a large crowd of women wearing brightly printed cotton wraps clutching coughing, feverish children, assemble outside the dilapidated outpatient building for a free consultation. Georges, one of the hospital nursing staff, looked a little forlorn in his white coat. “Treatment is free, so now everyone will come!”

Before MSF’s arrival, the hospital saw 231 patients in the month of September. We’ve seen over 300 in our first week.

The hospital is situated on a low rise in lush grassland at the foot of Kivu’s spare Mitumba mountain range. The beauty of the place belies the population’s desperate healthcare needs. On my first day, I found a 14 month-old toddler in the paediatric ward who weighed 5 kilos. He is suffering from marasmus, a severe form of malnutrition with the typical pinched ‘old man’s’ face. He has to share a tattered bed with another sick child as there aren’t enough cots. Sharing a bed is dangerous as the malnourished child’s immune system is unable to fight infections. Pierre, the MSF nurse I’m working with, and I are currently treating the tuberculosis which likely underlies his malnutrition (we can’t test for it so we use a special scoring system to diagnose TB clinically) while starting a careful therapeutic feeding regime. Pierre, who has much experience with these cases, is optimistic.

The hospital’s doctors, Serge and Albert, ask me to attend a caesarian section in the operating theatre. This is a bare room with no electricity or lamp. They depend on a plastic skylight in the roof to see what they’re doing during the day, and use head torches during the night. They don’t expect the baby to survive as the mother’s uterus was ruptured. They were performing the operation to save the mother’s life. But with a few puffs of room air delivered by a bag and mask to inflate the baby’s lungs, the little girl let out a hearty cry and both mother and baby are doing well.

Underlying Lulimba’s health problems is DRC’s chronic conflict. In 2009, the hospital was attacked by an armed group that destroyed or pillaged many of the building’s meagre resources. But if the needs are great around Lulimba, one can only imagine those in Congo’s even remoter areas. To get to Lulimba, we had to drive through an area called Foret 17, notorious for banditry and the constant to-ing and fro-ing of the many armed groups that roam South Kivu. At an isolated health post nearby, the nurse in charge said recent fighting had driven hundreds of villagers into the forest. They will have no help to fight the malaria, pneumonia, diarrhoea and other treatable illnesses that continue to cause so many deaths in Congo.

This post was first published online by the Guardian

Posted in Democratic Republic of Congo, Doctor, Healthcare provision | 18 Comments