Not All Things Green Are Good

Saturday, March 17, 2012

For St. Patrick's Day today I had a visit from E. O'coli. This morning while packing up and getting ready to head out of Malawi, I noticed some vague upper abdominal pain. Not much, but noticeable.

Hmmm, that's not good, I thought.

By the time I got in the car for the ride to the airport, things, indeed, were not good. Reminiscent of a wet towel being rung out by Mr. T, I was starting to get hit by waves of abdominal cramps that came every three to four seconds. Probably, my nerd brain distractedly mentioned, in time with the natural peristaltic movements of the intestines. Oh, that's interesting, I thought. I was getting clammy, looking pasty, and starting to wonder if things were about to look like the scene from "Alien". The inevitable self-diagnosis assessment began in order to make order out of this: Hmm, no vomiting, so this epigastric pain probably isn't a small bowel obstruction or a bout of pancreatitis. No high fever or headache (and I've been on prophylaxis), so this shouldn't be malaria. Still a bit of an appetite, so shouldn't be an inflamed appendix. Also probably not a bout of PID (though this, along with a kidney stone, were where Chris placed his vote...as far as I could tell, through his laughter as he drove us to the airport).

Surprised that neither the ticket agent nor the customs official sent me to quarantine (though this might be because it doesn't exist in Malawi), I was able to make it onto the plane. By this time, the preemptive strike of ciprofloxacin, loperamide, and ibuprofen was starting to have a positive effect. And things were best if I didn't move. Or laugh. And this was harder than you might guess, as Chris recounted his best travel diarrhea stories (hang out with anyone who has traveled as much as him, and you'll hear quite a load. Umm, sorry. Couldn't help myself). By the time the one and a half hour flight to Nairobi was finished, I was a new man. What was probably a bacterial infection of the lining of my small intestine that could have put me out of commission for days, was now already being cured with a combination of an antibiotic and an antimotility drug. And without a single trip to the loo.

I'm a lucky man.

Traveler's diarrhea (Montezuma's Revenge, Delhi Belly, Aztec two-step, etc.) is probably the most common ailment faced by travelers. For most, its just annoying, and it can be treated with one to three days of a quinolone antibiotic like ciprofloxacin (though due to high levels of resistant bacteria, especially Shigella, in parts of South East Asia, azithromycin is the recommended agent there). Pop a couple of pills, wait through a little bit (or a whole lot) of pain, and there, you're all better. Right as rain.

But diarrhea for people living in the developing world is a very different story. Most people in countries like Malawi have little access to drugs for this kind of thing. In fact, the World Health Organization recommendations are to not treat diarrhea unless it's invasive (causing fever and bleeding) or has lasted for more than two weeks. Most cases of diarrhea are self limited, even when they are caused by bacteria and not viruses. Treating everybody who has a case of diarrhea haphazardly with antibiotics has lead to a great deal of development of resistance to older antibiotics. So had I been a Malawian farmer working in the maize fields of Kabudula, I would have lived through the pain, had a few days of Malawian March Madness, and gotten on with my life.

But the main problem with diarrhea, and what kills, is dehydration, especially among children. Depending on the year and how the statistics are gathered, diarrhea is the number one or number two killer of kids around the globe, alongside pneumonia. Without water, the body simply can not function. Hypovolemic shock sets in, electrolytes and pH are unbalanced, body systems shut down, and eventually the child dies from cardiac arrest.

A mantra that runs through WAM programs is to provide important, life-changing interventions for relatively little expenditure. Reducing the number of deaths every year from diarrhea shouldn't cost millions. People need education about and access to soap and clean water, a place to dispose of human and animal waste that is away from food and water sources, access to oral rehydration salts to prevent and treat dehydration, and then excellent care at a hospital involving IV rehydration and medications if all else fails. We are starting to help with the last step. Help ensure access to trained personnel and availability of necessary meds and equipment at the hospital level. We also need to look more at systems: why are IV cannulas out of stock again? What needs to be done to prevent this from happening again?

But we hope to also affect change far up-stream from this point. We are finalizing details in a partnership with US Peace Corps to bring in a volunteer who will focus on some of these basic, life-saving interventions. Hopefully with time and a team approach, fewer children in Kabudula will die due to something as preventable and treatable as diarrhea.

Jeff
www.worldalteringmedicine.org