A woman was sitting on the steps of the clinic, gazing at the ground. I was told that she had mental health problems and wouldn’t speak. She was pregnant and had indicated that she had belly ache. A nurse had prescribed paracetamol and the woman had tried to take all the tablets. I sat down next to her. She stank to high heaven. Her clothes were filthy, she had no shoes and her hair was clogged with dirt. She wouldn’t speak to me so I asked Daillies for some background info.
No one knew her name, but she was from Malawi. And she was crazy. She never washed and she slept rough on the streets in Cropping. “Do we know her HIV status?” I asked. No one knew. “A man offered to give her n’shima (maize porridge, like polenta) if she would have sex with him. They went off into the bush and when they came back, he told her he had a wife and said goodbye,” said Chandra, the health centre volunteer. “Now she’s pregnant.” “You have to do something, doc,” said Daillies, “Or she will deliver at the side of the road.”
There is a social worker in the district, 70km away, but when I contacted her in the past about a psychotic patient with social problems, she was unable to offer much help other than to admit the patient to a hospital ward. I will have to discuss what possible courses of action there are with some more experienced people in the village, but it doesn’t look good at all.
Most of the staff had drifted off to lunch by 12.30pm but there was still someone in the waiting area. A mother sat quietly with her four year old daughter draped over her knees. I felt the child’s forehead and she was “burning up” as they would say in Leicester. An aural thermometer read 39.9C. Mum couldn’t speak English, so I just went ahead and did a malaria rapid test myself. The line showing a positive test came up within 30 seconds, even before the control line.
I needed to calculate the dose of treatment according to the child’s weight. I led them to the weighing beam balance, but the child was too weak to stand. So I got mother to hold the child and get on the scale together (65.5kg). Then I asked mother to give the child to me. I cuddled the child while I fiddled with the balance (49kg), the difference being the weight of the child.
As I was doing the math, I became aware that the limp child felt really hot against my body. I thought to myself, the poor wee mite. Then I felt the heat spread down my trouser leg, and my shoe filling up with the child’s hot urine. She was so ill that she couldn’t control her bladder. Her mother was mortified and clutched her back from me. I told her not to be upset, it was only a bit of water. Unfortunately, my dreadful, mind-of-its-own Huawei “smart” phone survived the deluge.
I would have preferred to start an intravenous infusion to administer quinine and some glucose, but we don’t have any iv fluids in the clinic. I insisted that we keep her in the ward for a few hours until her temperature goes down and we are sure that she has ingested Coartem, and not vomited it. It is the children under five who bear the brunt of malaria. They have the least resistance. Once you have had malaria regularly for ten years, you will have built enough immunity to defeat the infection yourself (unless you also have HIV). Most of the fatalities are in young children. We haven’t lost one yet this season. This child was our 1,216th case of malaria in May. Last year in May, we had less than half this number. So the public health authorities didn’t spray the mosquito breeding areas this year.
As I drove home to change my clothes, I thought that I really didn’t mind being peed on; at least she hadn’t gone into renal failure.