The question of Malaria

I am pleased to report that Barney survived his experience at the Vets and returned home to us as good as new. The total bill was 250,000 Tanzania Shillings which is about $210 USD. This was for blood work, three electrical stimulation treatments (still not sure what those were for) and 2.5 weeks lodging with food. A good deal, all in all, especially when compared with the $250 my brother-in-law just spent on one visit to the Vets in the states for a check-up and a few shots for his new puppy. This also happens to be the full cost to surgically repair a patient with vesicovaginal fistula in many sub-saharan African countries (see www.endfistula.org and more on this topic later).

We were in Bukoba two weeks ago helping to teach the first ALSO (Advanced Life Support in Obstetrics) Course in Tanzania. The flight across lake Victoria from Mwanza was truly spectacular and surprisingly uneventful given that we were flying in a plane that was older than I am with pilots who were half my age. The course was a success. We trained over 40 people in caring for obstetric emergencies and hopefully generated some interest in the widespread dissemination of this teaching throughout Tanzania. The maternal mortality ratio (number of maternal deaths/100,000 live births) in Tanzania remains high at 500 - 900 depending on who's counting. This compares to about 12 in the US.

Towards the end of our week there, I began to feel sick. Chills, Sweats, a pounding headache, muscle aches and fatigue. I nearly passed out giving a lecture on post-partum hemorrhage. Our kind hosts insisted that I go to the hospital in Bukoba to get evaluated. There was no question in anyone's mind, except for mine, that I had malaria. I had been living in Moshi (where the rate of malaria is felt to be quite low) and had been taking Mefloquine for prophylaxis. That said, there is a widespread propensity to make the diagnosis of malaria for anyone with concerning symptoms. I have seen the same in Niger and suspect that this practice is widespread wherever malaria has been common in the past. I had some blood tests done at the hospital. They showed moderate anemia and possibly an atypical infection, viral or......MALARIA! The smear for malaria was negative. I took the pills for malaria, of course, and over the next few days, slowly began to feel better: A scene that has played itself out countless times in Africa and elsewhere: Treatment for malaria when the diagnosis was almost certainly something else. I returned home to Moshi and, feeling a bit weak still, I had the lab tests repeated at the Duke lab and they were normal. Significantly abnormal labs at the Bukoba hospital were likely wrong, leading to assumptions that were also likely wrong. Laboratory issues that people here deal with all the time. No anemia, no abnormal white blood cell counts.... Probably a viral illness. Something my immune system had never encountered outside of East Africa.

The reasons for overdiagnosis and treatment of malaria are many and complex. People are dedicating their careers to figuring this out. Most providers here have seen dozens if not hundreds of people die from malaria. To be wrong about the diagnosis and withhold treatment leads to disaster. To diagnose and treat malaria when it is actually something else that will resolve on it own is somewhat of a self fulfilling prophecy. Treat for malaria...patient gets better...must have been malaria. It reinforces the practice of treating liberally in the absence of data or with data that is suspect. Fortunately the treatment is fairly benign and most people get better. I have spoken to a number of people here who say that they get malaria many times a year and keep the medications on hand and self treat at the first signs of fever or malaise. Have to wonder what this all is doing to the efficacy of the drugs.