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CAR: Pic Palu is coming

12 Dec 2017

Katie Treble is a critical care doctor who has recently returned from her first assignment with Médecins Sans Frontières Australia, working in a paediatric hospital in Bria, a rural town in the Central African Republic (CAR).

It's the end of April, and the rains are here. I think I understand now why people in Africa refer to 'rains' in the plural rather than just calling it rain: because the singular version of the word doesn’t carry enough weight alone. When it rains here, it doesn’t just drizzle. The fat, plummetting drops smack you with the sting of individual mini belly flops. You’re soaked to the skin in seconds. You fret about the integrity of whatever building you’re be sheltering in. It's completely different rain to anywhere else in the world I've been rained on.

Here, a rainy day starts like any other: hot, sticky, hazy, but as the day passes a vague, moody rumbling builds, and at about 3pm the air begins to crackle with electricity. By late afternoon a fresh breeze picks up, and buxom purple clouds barge in from beyond the horizon. The evening sky glows fierce apricot, and finally, after hours of humid suspense, it utterly pisses down. The thunder is sudden and obnoxious, like someone smashing you over the head with a dustbin lid. Electric pink lightning rakes the sky. Thousands of gallons of water dump onto the dusty land in the space of a couple of hours, and the mysterious trenches dug all around the town reveal their purpose: they're waterways to direct the flash floods away from the not-very-sturdy houses. 

"Here, a rainy day starts like any other: hot, sticky, hazy, but as the day passes a vague, moody rumbling builds, and at about 3pm the air begins to crackle with electricity."

The temperature drop is blissful – I've even worn a jumper a few times – but what follows rain is completely not-blissful. In days, puddles and stagnant ponds of run-off water seethe with mosquitoes. A steep malaria spike sweeps the country, lasting several months until the dry season. The medically-minded folks of Central Africa call this time "Pic Palu" (pic: peak; paludisme: malaria). People talk about Pic Palu all year the same way the Starks of Winterfell talk about winter coming, and with the same dread. And as of a few weeks ago, Pic Palu is here.

Malaria is a disease that affects a third of the people on Earth. It kills half a million people per year, 92% of deaths are in sub-Saharan Africa, and 80% of the dead are children. It is almost impossible to avoid catching malaria if you live in Central Africa – pretty much every mosquito around has just sucked someone else's infected blood and can't wait to plunge its monstrous little snout into your unsuspecting ankles.

A case of uncomplicated malaria in an adult generally feels like a nasty flu. Fever, headaches, muscle aches, stomach cramps, fatigue. Nothing you can't ride out with a few days' rest while the artemisinin-based combination therapy does its job, an easy three-day course of tablets that kills the parasite. Without medication, it’s more severe and takes longer to fight off, but a strong immune system can take care of it eventually. For a baby or a toddler however, malaria is much more likely to be lethal. Malaria is a vicious little parasite that burrows inside your liver and red blood cells, biding its time inside before periodically exploding out of them all at once in a coordinated flourish, causing the swinging high fever.

"It is almost impossible to avoid catching malaria if you live in Central Africa – pretty much every mosquito around has just sucked someone else's infected blood and can't wait to plunge its monstrous little snout into your unsuspecting ankles."

In small children, shredding up the red cells is a big problem, and many children come to hospital critically anaemic, their palms and soles snow-white. Haemoglobin, the protein that carries oxygen in red cells, is released as the cells are destroyed, staining the urine black and earning malaria the nickname Blackwater Fever. There's an uncomfortable paradox in mothers bringing their babies and toddlers to hospital reporting that they are weeing Coca-ColaTM, when so few of them will ever taste something so extravagant in their lives.

A healthy person has a haemogloblin level of around 13g/dL. Any less than 8g/dL and you'll start feeling short of breath, dizzy and weak. Less than 6g/dL and you're in real trouble. Here in Bria, it's an everyday normality to test a toddler's haemoglobin and find it between two and three – numbers I've never seen back home, even among leukaemia patients. We scramble to get blood transfusions into them before their organs shut down, but this isn't without its own risks in Africa, where HIV is so prevalent.

In some severe cases, the parasite gets into the brain and infests the meninges, the filmy layers covering of the brain and spinal cord. The inflamed, throbbing brain, squeezed too tightly in its skull, is deprived of oxygen and begins drowning in its own septic acid. This starts off as a terrible headache and vomiting, then quickly descends into convulsions and coma. In any of my previous jobs, a blue unconscious fitting baby would cause a mild buzz of excitement. Here it happens so often – several times a day in fact – that it inspires as much anxiety as a stubbed toe. We calmly get on with the routine with the slickness of an F1 pitstop team – oxygen on, IV line in, stamp on the pedal-crank to aspirate the airway, and whizz them off to the ICU.

"Every day I round on all these children, writing medical notes, in French, in 40-degree heat, to the tune of 40 little voices all wailing at once, and I will never, ever again whinge about my working conditions back home"

24 hours of artemether later, and a surprising majority of these resilient children, even the ones with the extra-horrible cerebral/anaemic malaria combo special, wake up fine and go home cured. Right now in peak season, we have several children in each bed, blood transfusions dangling overhead, mothers curled up beside them. Every day I round on all these children, writing medical notes, in French, in 40-degree heat, to the tune of 40 little voices all wailing at once, and I will never, ever again whinge about my working conditions back home. 

Malaria has seasonal peaks and troughs, but there are other dreaded diseases that come steadily all year round. Of all the obscure and exotic diseases here, I have come to hate and fear tetanus most of all. A big part of this fear is that there’s so little I can do – once established, tetanus is very hard to treat. I have a few things to give, then I can only wait for my patient to recover, or die. The younger the victim, the worse their chances, as it seems to be with so many things here.

Late one thundery night, I was called into hospital to see a 1-week-old baby. He’d stopped breastfeeding, and had been crying inconsolably for hours. His 17-year- old mother lived out of town with no access to a doctor or antenatal care, where many women give birth at home and have follow-up care directed by a traditional healer. There are some curious practices on how to care for a newborn’s umbilical cord, but my least favourite is putting cow dung on it. This is a great way for tetanus bacteria to get into the bloodstream, and it’s exactly what had happened to this baby a few days before I met him. 

"His mother sat beside him, still and calm, looking on with a strange mixture of infinite sadness and infinite composure"

Approaching the Emergency Department, I heard two sounds coming from the open door that made me go cold. One was the panicked alarming of the pulse oximeter, a shrill little machine that you attach to a toe to read the pulse and oxygen level. The other was a noise I never want to hear come from a baby again. He was bubbling at the mouth and was the colour and temperature of corned beef fresh from the fridge. Spasms wracked his little body and clenched his tiny jaws shut, which is why he couldn't suckle that afternoon. 

His mother sat beside him, still and calm, looking on with a strange mixture of infinite sadness and infinite composure. I prescribed medicines for the pain, the spasms, the bacterial infection, intravenous fluids, two doses of anti-tetanus immunoglobin, and for good measure, a tetanus vaccine. Better late than never.

The anti-tetanus immunoglobulin was the most important thing he needed on that list, and it's a drug we run out of all the time. It has to be kept in a fridge, and most of our drugs come by warm lorry on a several-day drive from the capital. Our hospital generator sputters out several times a day. Immunoglobulin is expensive. Every baby born at home whose cord was cut with a rusty blade could do with a dose. Every unvaccinated kid with a dirty wound too. But we don't have nearly enough to go round, and how do we decide who gets treated and who has to trust their luck to chance?

"But we don't have nearly enough to go round, and how do we decide who gets treated and who has to trust their luck to chance?"

Pondering that could wait for later - this baby needed the full dose of immunoglobulin, yesterday. I asked the nurses if we had any. Wachaf, a very tall nurse in his fifties with long, elegant hands, a long, elegant lab coat and a booming laugh, loped out to the blood bank to check the fridge. While I waited, I rummaged pointlessly in the cupboards, knowing there wouldn’t be any there. Wachaf returned empty-handed.

I radioed the base to ask my boss about any stocks stashed away. He suggested I go and look myself. Using my phone as a torch, I headed outside into the dark and picked my way through the boulders, holes, tree roots, and patients' sleeping families. The blood bank is a separate hut a couple of hundred metres away from the main building. I unlocked two sets of doors to get in, and inside there was a choice of five locked coolboxes and fridges humming in the dark. I was in the world's worst version of The Crystal Maze.

I tried the thirty-something unmarked keys on the bunch in several hundred combinations, and rummaged through pouches of blood, syphilis and meningitis test kits, antibodies for blood type matching, various other potions and bottles, arranged using an organisational system obviously dreamed up by Alan Turing. Sweating freely by this point and feeling defeat coming for me, at last I found the two precious vials of tetanus immunoglobulin, shining like the crystal balls of Richard O'Brien. I locked everything and ran back to the hospital, lunging over sleeping people in the dark, and slapped the drugs into Wachaf's hands, panting with triumph. He gave me a hearty high-five and administered the goods. We felt a bit better, having done what we can as medics, but later that night I couldn't sleep, knowing that in reality the baby had at least an 80% chance of dying, and the too-little-too-late treatment would probably just prolong his suffering.

The vaccination programmes that spare western children this little boy's fate rely on a robust infrastructure, a lot of money and a climate of long-standing political stability to be completely effective. The Central African Republic, gripped by corruption and civil unrest, has none of these things. Despite our best efforts at the hospital in Bria, the baby died a few days later, and became another of the 10,000* newborn babies to lose their life in Subsaharan Africa each year to this terrible, easily-preventable disease. While it remains impossible to reach every child in this war-torn, chaotic place, Médecins Sans Frontières is making great strides in running successful vaccination programmes in CAR and thankfully, we are beginning to see this fatality rate shrink.

 

*Mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015. Kyu et al, BMC Public Health, 2017

 

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