Worldwide, rates of malaria are falling. Here in Kakumbi, they are rising. In May 2014, 870 patients had a positive blood film or rapid test for malaria, twice the figure for May 2013. We did not treat anyone for malaria “on clinical grounds”. These are proven cases. The health centre serves a population of just over ten thousand people, although some people from further afield might come to the clinic because there is a doctor based here.
There is a quick’n’easy test, known as RDT (rapid diagnostic test) which costs a few pounds. It uses a fingerprick sample of blood and gives a result in about five minutes. It can detect parasite rates of 100,000 per millilitre. We were only issued with 600 tests, however. Over 1,400 patients needed testing.
The traditional way to confirm malaria is to make a “thick film” of blood on a glass slide, dry it to fix it, stain it with Giemsa for 12 minutes, dry it again and look at it down the microscope with an oil emersion lens. It is more complex and time consuming than an RDT, and requires a skilled microscopist, but it can detect lower levels of parasitaemia, down to 50,000 per millilitre.
We referred three children with malaria to the district hospital as they were extremely ill. One with severe anaemia died in heart failure on arrival. The other two were HIV positive and had cerebral malaria, with convulsions which were impossible to control. I am still waiting for feedback on these two. The friendly doctor at Kamoto Hospital sends me a text whenever any of my patients die.
There is a saying in medicine, “common things are common”. It may sound trite, but it is important to realise that rare presentations of common diseases are more likely to occur than rare diseases. In the past week, we have had a patient with hemiparesis (one side of the body is weak), another so stuporose that they were unable to speak, and a lady with panic/hyperventilation syndrome, who all got better when their malaria was treated.
With malaria being so rife, I have to be constantly aware of the possibility that the patient might have another disease as well. My “pattern recognition” skills allow me to make quick diagnoses. I have a typical GP’s sixth sense that “something isn’t right” which rescues me from missing other diseases. When lab facilities are primitive, you need to cover all the angles when devising management plans. This isn’t treating something “just in case”; it is a skilled risk assessment mixed with damage limitation.
So I find myself taking hundreds of decisions a day, based on my tolerance for uncertainty. When I come home to the lodge, I sometimes sit and stare out over the dried out lagoon. I am not consciously thinking of anything. I am just being quiet and tranquil. Then the waiter requests what I would like in my lunchtime sandwich and I can’t decide. “What would you have?” I ask him.