DRC: Part 3 – “Knowing the basics did not prepare me for the extreme cases that I see here”

In Bili, a significant portion of our work is with children under the age of five, with over 75 per cent of those being treated for malaria. I thought I knew a bit about malaria, but knowing the basics did not prepare me for the extreme cases that I see here every day.

Malaria is a disease caused by the ‘Plasmodium’ parasite, of which there are five subtypes. ‘Plasmodium falciparum’ is the most severe, and that’s the one that we have here. Transmitted by the bite of the Anopheles mosquito, the parasite invades the red blood cells and gets into the liver cells.

Uncomplicated malaria is characterised by fever and flu-like symptoms including body aches, nausea/vomiting, chills and sweats. Severe malaria is when it gets scary, and that’s where there seems to be the biggest discrepancy between the books and reality. Severe malaria is essentially when there is organ failure as a result of the malaria.

The most common cases I’m dealing with here are severe malarial anaemia, when the red blood cells have exploded because of the malaria parasite, which means the body can’t get enough oxygen and there’s a state of shock; or cerebral anaemia, where there’s coma, or repeated convulsions that can go on for days. 

The textbook treatment for severe malaria is simple: give an intravenous antimalarial drug derived from sweet wormwood for 3-7 days and once the patient is conscious or can eat and drink, switch to a tablet form of artemesinin combination therapy.

The treatment suddenly isn’t so easy.

However, most of the people living in the villages here believe malaria comes from the rain and that convulsions are due to sorcery. Their preference is to go to the ‘tradipraticien’ (traditional healer or herbalist) if there’s a fever, who then gives the child a concoction of herbs which at best doesn’t cure the malaria and at worst makes them so intoxicated they’re in a coma. Some perform ritual cutting which in unvaccinated kids can give them tetanus. With the complication of tetanus, then the treatment suddenly isn’t so easy. The children are often brought in far too late, when there’s nothing to be done.

A few weeks ago, I had a rare moment of anger borne of complete frustration. I met a young patient who not only had severe malaria but was also severely malnourished and needed a blood transfusion. Sadly, the blood bank was out of his blood type. We asked his father if he would consider donating, given he had been by his side every day. But he refused. We explained that his son was going to die if he didn’t receive the blood transfusion. He refused again and said that he had 25 children so he couldn’t just donate his blood to this one.

He didn’t donate, the child didn’t get the transfusion, and the inevitable came to be.

It made me so angry and so sad. The discordance was incomprehensible to me in that moment – how can you stay by your child’s side every day in hospital if you won’t do the one thing that save their life? 

“After walking those few steps, I nearly cried – I was so happy.”

Another patient, five-year-old Marianne* came to the hospital with impaired consciousness and a fever. We initially thought she had cerebral malaria, which is endemic here. However, she soon developed the classic signs of tetanus: rigid spasms with hyperextended joints, lockjaw and an arched back.

Tetanus is caused by a bacterial toxin that easily leads to death if left untreated. In Bili, very few children are completely vaccinated (if at all), and the traditional practice of ritual cutting increases their risk of exposure to tetanus. Newborns can be exposed through the cutting of the umbilical cord with an unclean tool. Newborns are more at risk if their mothers haven’t been vaccinated because the mothers don’t have protective antibodies to pass onto their babies.

For the first few days of her treatment, Marianne could only move her eyes because all the muscles in her face were in spasm. Her father, who had brought her the 50 kilometres from home to the hospital on his bicycle, stayed by her side for weeks. Every day, he’d report her small improvements – moving her mouth, then her fingers, then her arm.

Nearly three weeks after she was first admitted to hospital, I’d been away for a few days doing staff teachings in the peripheral centres. When I got back, I desperately needed a ‘win’ – too many sick kiddies and I was just tired. I went searching for Marianne in the intensive care ward, but she wasn’t there. Instead, I found her walking in the paediatric ward, holding her dad's hands. They both recognised me, and her dad had her take a few independent steps towards me.

As she grabbed hold of my hands after walking those few steps, I nearly cried - I was so happy. She went home a few days later, a completely different child to the paralysed patient I’d met a few weeks earlier. I got my win, but more importantly she got to go home. 

*Name has been changed
Dr Marina Guertin was placed in Bili for six months during 2018.