This static-filled telephone call from a park ranger started an incredible chain of events. The mzungu,(roughly translated as European), turned out to be a 27-year-old Peace Corps volunteer who was working in a national park in Malawi. We immediately started planning how to transport him to the medical unit in Lilongwe. The first leg of the trip was in a park ranger truck that met the Peace Corps Land Rover on the highway. When he finally got to the medical unit, his blood pressure was 80/40, his pulse, rapid, and his temperature, 40.1 C. Following re-hydration, he perked up a bit and we awaited lab studies, suspecting malaria. When the results came in we were stunned. Trypanoso-miasis, probably Trypanosoma brucei rhodesiense, was the diagnosis. Following a rapid review of Trypanosomiasis in my tropical medicine book, we quickly decided that we could not handle this in Malawi. We arranged for an air ambulance flight to South Africa where he was admitted to the ICU and started on suramin. His lumbar puncture was negative for CNS involvement that would have indicated adding arsenic, as suramin does not cross the blood brain barrier in adequate amounts. I have never treated anyone with arsenic, but it does not sound like something fun to do. As I write this, the volunteer is out of the hospital and doing well.
Avoiding an Epidemic
The next step in this saga was a phone call to the ministry of health who informed us that Malawi does not have Trypanosomiasis any more because they had undertaken an eradication program two years ago. Well the bugs won again; five more cases were diagnosed in the same park area, all in Malawians. There are known tsetse flies in a number of areas in Malawi and neighboring Tanzania. There is no immunization against the protozoan parasites they carry. So we were faced with what to do with the other volunteers in the area. Thanks to modern communication, we were able to call for advice from the Peace Corps Headquarters and set up a plan for selected removal of some volunteers in known tsetse fly areas. So far, no additional cases in volunteers have occurred. However, we receive daily calls from volunteers who have been bitten by something and are worried they have African Sleeping Sickness.
Reflecting on the Incident
As I look back on this case, several things stand out. First is the issue of emergency transportation. There is no 911 system. It is rare to even find an ambulance outside the major cities. We recently went to see a reported new ambulance in Madagascar that turned out to be a mini-bus with a litter. There was a driver and an attendant with no training. "But daktari, he is real strong." Earlier, I sat with a volunteer with acute appendicitis driving over rutted dirt roads in a vehicle with shocks that had long ago given up. I felt each jolt and knew he was suffering. I had no idea if this jostling was more likely to produce a perforation but sure hoped not. With the financial resources we have as a US agency, we can access air ambulances that are quite good. These are a godsend, as the in-country medical care resources in a place like Malawi are fairly primitive. There are some great doctors, but they just do not have the medicines, facilities or support necessary to care for really sick patients. I do feel a little guilty that we can fly the volunteer to an ICU in Pretoria when this is far beyond the finances of most Africans. However, I also realize that if the finances were available, they would be better spent on basic health supplies and initiatives, not air ambulances and ICUs.
Remembering the Basics
The second reflection was on tropical diseases. I flashed back to my parasitology course at the Indiana University School of Medicine. I remember saying to myself that I just had to memorize this stuff for the exam, since I would never see these bugs in patients. Like so many other things I knew as a medical student, I was wrong. However, I have found that it is not as hard as it sounds to take care of cases like this. The basic principles are the same. You need to deal with things like shock and dehydration. Once the patient is stabilized, you have time to look up these different diseases and read how to treat them. With access to the Internet and telephones, knowledge about tropical illnesses is readily accessible.Whose Lifestyle Is Unhealthy?
The third reflection concerns my admiration for the Peace Corps volunteers. Most volunteers complete their service with nothing more than an occasional bout of diarrhea. However, they live in remote villages often without electricity. They use pit latrines and rig up outdoor sun heated showers. They boil and filter the water they carry in buckets to their houses. They buy their produce at the village market and soak it in a chlorine bleach solution before cooking, as night soil [human feces] is the standard method of fertilization. They are constantly exposed to all kinds of parasites and viruses. They self-treat as much as possible with a medical kit supplied to them and a copy of "Where There is No Doctor." Yes, they do get diarrhea, URIs, various skin infections, both bacterial and fungal, and lots of anxiety symptoms. However, overall they do remarkably well and almost always return home healthier than when they came. Maybe the real message is the unhealthy life styles too many of us fall into in the United States.
Well, enough for this month. Daktari Bob signing off.