Tuesday, June 26, 2012


Malaria season. 

It started today.

11 new patients – all with malaria.

24 patients.  23 bed pediatric ward. 


I think 7 transfusions – Hemoglobin of 2, 3, 4

The one with the Hemoglobin of 2 died waiting for blood

If they are that anemic – you can be sure its malaria – the malaria parasite, in this area plasmodium falciparum, attacks and breaks down red blood cells –  these injured RBCs adhere to and block the microvasculature in a process called sequestration, and they also stick to other RBCs.  RBC synthesis is also inhibited often leaving the patient very anemic.

This anemia is most pronounced and deadly in children. 

Children with whitish tongues, gums, nail beds, conjunctiva

Soles of the feet, palms of the hands




We transfuse whole blood here – not as effective as Packed Red Blood Cells but life saving

Normal hemoglobin is 12-16.

She died of anemia.  Because of malaria. Because she was born in Tchad.  Because she probably didn’t sleep under a mosquito net.  Because decades of bad politics and environmental lobbying have kept indoor residual spraying of DDT from becoming a reality in the areas that need it most. 

By the way – there isn’t a vaccine for malaria.  It is being studied, but not yet available.  Not one that is marketable, getable, giveable.

If there was – life as we know it in Tchad would be radically changed

My friend, belonging to the “Africa Club” at her school – was told there was a vaccine – kind of like a shrug of the shoulders, not my problem kind of response – just use prevention and vaccine and voila!

Well, think again Africa club.  In fact.  Come to tchad. 

See for yourself.  Auscultate the lungs drowning from pulmonary edema – sponge kids with tepid water that have a temperature of 105.  Watch a baby die from probably cerebral malaria after 7 days of IV quinine and ceftriaxone – talk to his mother, hope with her that just one more day will make a difference.  Watch him convulsing still on the 6th day – feel helpless not knowing what else to do for him – after he dies wonder what you could have done differently – come here, do this, and then tell me there is a malaria vaccine.  Tell me a simple answer.  I dare you.

Malaria is not just a health problem, it is much more far-reaching and sinister than that. 

Malaria changes the face of Sub Saharan Africa. 

Malaria governs customs, behaviors, beliefs.

Malaria means that you are going to have 10 kids instead of 2 or 3.  Malaria means you have a good shot at losing half of them before they are grown – Malaria means you know this cold fact and so you deliberately have more children. 

Malaria means malnutrition.  Malnutrition means malaria.

Malaria causes what we would term “poor family planning”  Malaria makes this make sense.  In Africa, in Tchad – children are everything.  A woman that cannot have children is ostracized, divorced, subjected to plural marriages, is insulted – is told “why are you eating?  You are eating for nothing.”  A woman without children has absolutely no value in Tchadian society.

A man without children also loses value, respect, standing in the community, even friendships. 

Children are everything here. 

They are your retirement.  They are your lineage.  They are what bring you meaning.

Family is strong here.  Building your family, expanding your family, creating the next generation, securing your lineage.

A man without children will not be remembered, they say. 

Replacement.  It is by far the most common explanation as to why children are so important here.  So we have someone to replace us. 




It is what gives a man and a woman personal meaning in life here. 

1 in 4 children living in the village of Béré will probably not grow up. 

I have talked to women that have lost 8 children, 9 children, 10 children.  I have talked to women who after they lost their last baby were driven from their homes by their husbands.  This surprises no one. 

I can think of only a few instances in my entire time in Tchad when I talked with someone who has not lost a child. 

And so you have more.  Given the essence of value in this culture, it makes perfect sense. 

Have 12 children.  Six or more might make it.  3 or more might be boys – the ones that take your name, make you proud, work your land – stay in your family. 

Girls are valued less because among many reasons they marry into a different family.  Not the one you are building.  Not the one that will replace you.

Family planning will never work here until people can be confident that their children will live past childhood. 

Malaria means poor education, fewer children in school, less attentiveness for the ones that go, the wrenching decisions of who to send and who stays home.

Malaria causes poverty.

It perpetuates poverty, it impoverishes the rich, makes destitute the poor. 

A death in this culture devastates you.  The funeral can cost half a year’s earnings.  It can put you into hopeless dept.  It can drain every penny you saved for a better life.

So, you have 10 children.  You can’t afford to feed them properly.  They get sick even quicker, get malaria more often when they are malnourished.   You are poor.  You don’t have hardly any food.  It is rainy season.  Several months before the rice harvest.  The hardest months. 

You aren’t really sure that its Malaria – no one ever really told you what do look for.  You just know that your child is burning to the touch, that he won’t eat or drink, that he’s vomiting, that now, suddenly, he is having seizures.  His eyes have that exhausted, rolled back half closed look.

You begin to panic while already accepting that he will probably die

You go to the traditional healer.  They palpate the abdomen, make rows  of small cuts over the liver, the spleen, other parts of the abdomen.  They suck out the poison.

Now your baby is in a coma.  You can’t stop thinking about how this is what his sister looked like before she died.

You sell your last bag of rice – you run to the hospital.  You spend all day waiting – finally you get a bed.  Except it has no mattress on it.  You put down a cloth and curl up around your baby.

The white nurse is emphatically telling you something in French that you don’t understand because you never went to school.

You watch the 4 year old beside you start gasping for breath.  You start to pray.  You already want to leave.  Your heart is chilled with dread.  You want your baby to die at home.  Not here.  Not like this.  You wish you hadn’t come.  But you still have a stubborn desperate strand of hope. 

And all that hope is hanging on a bottle of D10 mixed with IV quinine. 

You put your hand on the heart of your baby and will it to keep beating.

Your other neighbor dies


Who will it strike next.

Stop and imagine for a second.  Imagine there was a season, lets say summer, where you knew that there was a very good chance you would lose one of your children.  All the pollen in the air.  They could get sick, very sick, and die at any time.  This would be your certainty.  Your reality.

Imagine you had very little money – only enough to buy the barest amount of food.

Imagine you have no health insurance.

Imagine that if you take one child to the hospital, the other might starve. 

Imagine watching your child die, and not having the knowledge, the connections, or the resources to prevent it

Imagine that you took your last one to the hospital, and it died there. 

Imagine that you keep looking at your babies, trying to memorize their faces, knowing that you will probably lose one of them this year. 

Imagine that you had to go through this hell year, after year, after year


The mothers watch the rains come in, sweep the caked mud out of the dirt floors, gather their children tighter around them, and wait

And hope

And tie amulets of leather and wood around little feet, wrists, necks.  String red and black beads around the waist.

Pound the millet.

Sift the rice

And life goes on – but the old gnawing fear is in the bottom of your soul. 

As you watch the layers of grey roll in across the thatch roofs of the houses, as you feel the stinging wet wind on your face, as you see your baby splash in the puddles chasing ducks, you hope – and sometimes you don’t even dare to hope consciously – but you hope that not this child, not this time, not this season, not this year. 

Pound the millet

Sift the rice





Not this child

Not this time

Not this season

Not this year

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