Malaria

"Pole sana, mama. Mtoto amekufa." My kiswahili was never very good, and has deteriorated, but this phrase is burned into my mind. "I am very sorry, mama. The child has died."

I was called to the children's ward at 6 a.m., with the message that a child had "changed condition." I know from experience what that is likely to mean, and indeed by the time I arrive, the child is pulseless and obviously dead. There is no reaction from his mother until I pronounce these words, but as soon as I speak, it lets lose a torrent of tears and quiet wailing.

Emanuel was a chubby and apparently healthy three year old, admitted by me the afternoon before, yet another child with high fever, convulsions, and malaria parasites in his blood smear. He was put on the usual treatment (IV quinine, the standard treatment for severe malaria since the Jesuits discovered the bark of the "fever tree" in South America in the 17th century). There was no reason to believe that he was one who would not survive.

This week I have been responsible for (among other things) the pediatric ward, and each day for the first three days, a child died. It is sobering to look around at the end of morning rounds at the ten or fifteen children, and wonder which one might die today.

Sometimes, the death is unexpected, like Emanuel's. Other times, it is more predictable. Brian was 5 and appeared malnourished. He continued to have seizures for several hours after admission and never woke up, before dying the next day. And sometimes, malaria is just one contributing factor, as with Gideon, age 8, admitted moribund from the HIV clinic. We were able to resuscitate him, only to lose him several hours later.

Children with complications of malaria make up the bulk of our admissions to the pediatric ward. Often they are either having seizures, or comatose. Still, most do in fact recover remarkably fast. Often after a few doses of quinine, followed by the more modern and effective oral medications, and they are ready to go home after just 3 or 4 days.

And sometimes we have memorable success. Faith is 12, newly diagnosed with HIV (her father died of AIDS several years ago, and her mother is ill). She was admitted from an outlying dispensary, in a coma for 3 days. Because of her already advance AIDS, we worried about all the unusual infections (cryptococcal meningitis, tuberculosis meningitis) but in the end she seemed to have cerebral malaria, woke up after three days of quinine, and walked out of here after a week. She has been enrolled in the HIV clinic and will start her medicines in a couple of weeks, and she should do well, for at least a few years and possibly for decades.

We used to say that malaria kills more than a million people a year, 90% of them African children under age 5. However, over the last 2 to 3 years, remarkable progress has been made, and deaths in Africa are down. The reason for this is probably two-fold: the ready availability of a new drug (derived from a Chinese shrub), and the widespread use of insecticide-impregnated bed nets, to keep the mosquitoes from biting while children sleep. The progress has provoked enough optimism that experts are once again talking about "eradicating malaria" (as they did in the 1950's).

Still, this week's experience reminds us that that goal is still far off. The reality here in rural western Kenya is that all children will have several bouts of malaria during their first few years of life -- and any episode can be fatal.