Malaria, unless proven otherwise

At all the wards I’ve been to at the hospital, malaria is by far the most common illness. In the outpatient department (OPD), where I’ve been spending most of my time shadowing Dr. Jonathon, everyone with fever and/or chills is immediately diagnosed with malaria.

In response to my questioning the frequency of malaria diagnosis, Dr. Jonathon responded, “Fever is malaria, until proven otherwise”.

He continued by explaining that during the rainy season, malaria is so common that any complaint of fever or chills is immediately diagnosed and treated as the disease. Often times, patients just have a case of simple malaria, which is characterized by fever, chills, weakness and frequently a lack of appetite and vomiting. Simple malaria is easily treated with a three day course of pills, usually Artemether/Lumafantrine or Artesunate.

I was surprised to discover how straightforward it is to treat malaria. From all the hype about malaria prophylaxis in the US, I was expecting treatment to be a grueling and drawn out process. Instead, malaria is so common, and its treatment so basic, that most people get malaria several times a year and recover by day two of their pill course.

However, if untreated, simple malaria can quickly become severe, and many complications can arise. A common cause of death in children under six, severe malaria is a general term that describes a variety of symptoms. On an assignment from Dr. Jonathon, I researched the different clinical and lab manifestations of severe malaria and discovered that there are about 20. Most common in the municipal hospital, and apparently throughout Ghana, are severe anemia (characterized by hemoglobin <5), cerebral malaria (where the patient’s brain swells and he/she often experiences seizures and loss of consciousness) and prostration (where the patient is too weak to stand or sit up).

In order to avoid an increased incidence of severe malaria, Dr. Jonathon usually prescribes malaria medication to anyone who has any of the illness’ classic symptoms as well as to anyone with a cold (since they are more susceptible to the disease) without a blood film test confirming the presence of the malaria parasite, p. falcipirum.  A very knowledgeable, patient and intelligent man, Dr. Jonathon explained to me that while drug resistance can develop by overprescribing medication, lab technicians often do not conduct an adequate blood film test, consequently incorrectly concluding the absence of the parasite. Therefore, he believes it is better to prescribe the medication, as side effects are minimal.

Dr. Jonathon has been a tremendous wealth of information, both about clinical medicine and about Ghana’s health care system. He not only patiently answers my incessant questions, but also quizzes me on topics he has previously explained or has asked me to research. Standing in for a doctor on leave, Dr. Jonathon had his last day at the hospital yesterday. I’m very sad to see him leave.

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Dr. Jonathon admitting a patient to the Children’s Ward from OPD

Genuinely interested in helping his patients and practicing good medicine, Dr. Jonathon is one of the few medical professionals I have met here who is not yet jaded by the health care system. Despite being restricted by administrative barriers and certain cultural practices, he does his best to advocate for his patients.

Two instances stand out the most in mind. The first occurred a couple of weeks ago with a girl who had hydrocephaly, an enlarged cranium due to an excess of water. Although the girl was at the hospital for a variety of other symptoms that turned out to be malaria, gastroentiritis and an upper respiratory tract infection, Dr. Jonathon was very concerned that nothing had been done about her hydrocephaly when she was younger. He prescribed her a variety of medication for her other complaints, and upon noticing she did not have health insurance and was struggling to make ends meet, gave her money for the prescriptions. He then instructed her to come back in a week, after she had recovered, so he could sign her up for health insurance. It was so touching to see this act of empathy in a hospital environment where many of the staff treats patients brusquely.

The second has been an ongoing battle with hospital administration. While doing rounds in the female ward a few days ago, Dr. Jonathon discovered that a woman with tuberculosis was in the same room as two HIV patients. As they are severely immunocompromised, the HIV patients had a high risk of contracting TB from their highly infectious roommate. However, the TB patient was no longer producing sputum, so although her chest x-ray displayed a very large granuloma, the diagnosis could be confirmed by a sputum test.

Dr. Jonathon has been arguing with the female ward nurses, the head nurse and the administrative staff to have the woman put into an isolated room, to no avail. Despite being told by other doctors that his battle was futile, he is still determined to get the TB patient isolated. The last time he was in the ward, he declared he would wheel her out himself if it came down to it.