Malaria Update

**Another post I wrote in early November**

So, since I’ve learned from Will that my ridiculous bad luck now has his family worried that he’ll get malaria, I’ll give a quick update on my road to recovery. It’s funny because I felt like such a hero saying “I have malaria (gasp!!)” to people, since it’s so far out of the realm of normal for us. When I told Americans, the response was always “omigod are you ok? I can’t believe this is happening! Will you still be able to travel or will you be laid up for days/weeks/months?” When I told Kenyans, it was always, “uh-huh, and what else is new?” Further reinforced that the scary and out of the ordinary for us can be not such a big deal.

Anyhow, malaria makes you feel really really really bad (as I wrote in a feverish text message to Pras all the way off in Uganda). But miraculously, I started my coartem, got a bit worse, then within 3 days was feeling almost back to normal. I even packed up all my stuff, got on my plane to Nairobi to meet up with my Mom and was on a 6 hour bus to Tanzania on Saturday when I’d only been diagnosed on Thursday. Wasn’t feeling the best I’d ever felt, but really by Sunday I was almost all better. It was just too bad that I got sick for my last couple days at FACES, since I didn’t get a chance to say good-bye to everyone as I would’ve liked.

I was thinking though, if I hadn’t gotten my smear and my coartem in Kenya, but instead went back to the US and got sick then it would have been a nightmare. I mean, there’s no coartem in the US, it probably would have taken days to get diagnosed, involved an absurd hospital admission, lots of unnecessary testing, definitely an ID consult and IV meds. So glad to have avoided that! I guess the moral of the story is, run of the mill, uncomplicated malaria really isn’t all that bad as long as it doesn’t happen in San Francisco.

Reflections on Medicine and FACES

** I wrote this in early November, but wasn't able to post anything while I was travelling**

Since I came to Africa to work in HIV medicine (among many other less altruistic sounding motives), I was a bit surprised looking back at what I’ve written about to see how little I’ve actually posted about my medical experiences here other than those where I was the patient. In many ways I’ve hesitated to write about medicine as I’ve seen it in Kisumu. As a doctor practicing in a new place with very different resources and very different problems, it can be very easy to talk about what seems to be lacking, or things that aren’t done the way we’d do it back home (often with the implication that different = bad, or worse than we would do it).

I have seen things that have shocked and surprised and saddened me, but I’m really not sure how useful it is for me to write about them here, either for myself or anyone left who might be reading this. I mean, it’s no big secret that Kenya is a developing country and that there is a lot less money and a lot less capacity to pay for medical treatment than we see in the US. Then again, how often do I rant and rave against an injustice that has been done to one of my primary care patients at SFGH, or am I horrified by the fact that I have had to do things that are below the “standard of care” because we lack the political will to make that standard of care available to everyone in the US?

In reflecting back on FACES, the feeling I am left with most strongly is amazement at how much this small organization is able to accomplish for their patients. Yes, there is NGO money behind it, but I feel as though so much of what is being done has come to be through the sheer force of will of every single person working there. It’s not like there’s one, Paul Farmer-like individual who through the cult of personality has been able to accomplish great things. Instead there are many, many Kenyan people at every level of the organization who say, “this is what is right, this is what our clients deserve,” and then find a way to make it happen. It’s a wonderful sight to see.

The pace of medicine moves differently at FACES; things we would admit someone to the hospital for, run a million tests to work up, give some expensive treatment for, with the goal of finding an answer within a week don’t really occur. But problems - HIV-related or not - present, minds come together and a work up is undertaken that may take months and be lacking all the latest technological bells and whistles but is really often enough. Sometimes an answer is not found and one of the empiric treatments that was tried works and we assume we know the diagnosis. And sometimes the things we tried don’t work and the patient doesn’t do well. But don’t we see that all the time?

When I first got here, the second patient I saw walked into clinic incredibly sick: febrile to 40, tachy to 130, CD4 around 80, with a headache for a few days, cough for a few weeks, and abdominal pain. Oh and by the way she was 34 weeks pregnant, too. I looked at her and felt completely useless – take me away from the tertiary care center, strip away the 8 billion lab tests and scans and consults that she would get from our ED and I felt like I couldn’t do a single thing despite having the end of my residency looming not far away. We even entertained a brief discussion of whether or not she really needed to be admitted, since she didn’t have any money. But so quickly it became normal when we saw a sick person to figure out what we could and couldn’t do diagnostically, make a plan to treat the one or two things that seemed most likely, and send them off with the hope that those tests would happen and that when we saw them again in a couple days we would have more info from tests and treatment response to go on.

As a medical resident here for a month, one can’t really hope to do or accomplish much. It would be an incredible arrogance to assume that my brief presence could make a significant impact. I was really here for my own learning, to see a new system, to learn new ways of thinking and to become inspired by the amazing individuals I met at FACES. Hopefully some of that will have a positive impact on what I do and how I treat patients in the future. I really hope that one or two things I may have done while I was here were at least slightly useful, so that I will have contributed just a little bit with my presence instead of only gaining myself.

Malaria

(Not my smear, it got thrown away before I could see it - I wanted the souvenir!)

Well, my exciting news of the day is that I have malaria. So much for doxycycline prophylaxis & using a bed net! Although I was looking at my doxy bottle this morning thinking there were maybe too many pills left, so maybe I wasn’t the best prophylactee.

I was feeling lousy 2 weeks ago – really tired and feverish – but figured I was just getting too much sun and it was really hot out. I was going to check for malaria then, but I got better so I never did. Last night after getting home from dinner I started to feel horrible – really feverish, terrible headache, nauseated. I barely slept because I was having crazy dreams and was so hot. This morning I still felt really wiped out, so I went and got a malaria smear. Much to my shock and amazement, it was positive.








So I started my Coartem (not available in the US, so that’s kind of exciting), and am expecting to feel better momentarily. The whole thing is kind of funny, actually – I mean, how many Americans can say they’ve had malaria? Definitely rounds out the whole African experience. Now all I need is TB…




It’s really interesting, malaria is so common here that it’s often treated for empirically without even checking a smear, or we’ll treat anyway even if the smear is negative. If someone presents with headache, fatigue and “hotness of the body,” we’ll frequently just treat them. It makes me think about my clinic patients at home, who when they present with those vague symptoms I often tell them to rest a bit, try Tylenol and figure it will likely just go away. Malaria doesn’t usually cross my mind.

When I was an intern I took care of a really sick patient who had been airlifted from Africa after having really bad malaria that was treated in the hospital there, but he was now intubated and close to death. We ordered malaria smears, and had to call in the heme path resident and attending in the middle of the night to read them. They couldn’t really tell if they were positive, so we decided to treat anyway because the patient was so sick. But in the US it’s hard to get IV quinine, so we tried to get quinidine but the hospital didn’t have any in stock so we had to try to get it from SFGH across town. It was a crazy, comical production. And in the end the quinidine never came and he didn’t even have malaria anymore after all.

But here it’s just an everyday thing – when I asked someone a couple weeks ago what it feels like to have malaria, she laughed and couldn’t believe I’d never had it. Everyone here has had malaria at least a couple times. Today, I just got a fingerstick, rubbed some blood on a slide and 45 minutes later had my diagnosis. No attending called in from home involved. The good part, as several people have told me, is that next time I come I’ll at least have partial resistance. And not a bad story to tell.