Volume 197 - Issue 10
Kala-azar: the world’s guilty secret
Author: Benjamin H M Hunn
Med J Aust 2012; 197 (10): 584-585. || doi: 10.5694/mja12.10767
Published online: 19 November 2012
Published online: 19 November 2012
The clinic of the Sudan Medical Relief Project (www.sudanmedicalrelief.org) is in Old Fangak, in what is now the Republic of South Sudan. In 2010, I spent 7 weeks working there with an American medical team, before being evacuated owing to increasing violence in the area.
We flew with one backpack each from Lokichoggio, on Kenya’s border, into South Sudan. Our plane was a twin-engined Cessna with an ...
The clinic of the Sudan Medical Relief Project (www.sudanmedicalrelief.org) is in Old Fangak, in what is now the Republic of South Sudan. In 2010, I spent 7 weeks working there with an American medical team, before being evacuated owing to increasing violence in the area.
We flew with one backpack each from Lokichoggio, on Kenya’s border, into South Sudan. Our plane was a twin-engined Cessna with an upside-down no-smoking sign that did nothing to strengthen our confidence in our transport. We thrummed across the parchment landscape, terrified of falling out of the sky. Gently losing altitude, our plane buzzed the dusty dirt landing strip — bovine occupants begrudgingly moved aside so the plane could land — and turned around to make a final approach. We quietly uncrossed our fingers as the plane bumped to a halt. A congregation of eager small faces formed our greeting party. They accompanied us while we carried drug cartons to a waiting boat, intermittently fascinated and scared of their new visitors. We travelled down the fast-flowing river, which was a tributary of the Nile known as the Giraffe’s Neck, and reached our destination, Old Fangak, 2 hours and 20 minutes after we took off.
Our boss was Jill Seaman, an American doctor who had worked in Sudan for two decades. She showed us around. A collapsing British colonial building was the essence of the hospital. There were bats in the rafters, and we were told they carried rabies. The inpatient ward had an unlucky thirteen beds, and every bed was occupied. The common eating area was a mud-walled house a few hundred metres from the hospital. We assembled the mosquito-net tents that we would sleep in for the next 7 weeks. It was a Sunday afternoon and we were to start work in the morning.
In the morning the clinics opened, with hundreds upon hundreds of patients lining up for treatment. The headline disease in South Sudan is visceral leishmaniasis, better known as kala-azar (Hindi for black fever). Kala-azar is the second most common parasitic disease in the world — but it is a secret to most of the planet. The parasite is transmitted by the sandfly, and infects the organs, especially the spleen and liver. Sudan and India bear the major burden of kala-azar, and diseases suffered by poor nations receive neither publicity nor research funding. This Monday morning there were three clinic groups receiving the treatment for kala-azar, with around 100 in each group. The patients were all children, and the toddlers screamed when they were weighed, and then screamed again when they received treatment. The weighing was important; if the children fell below the fifth percentile they would receive extra food. The basic treatment for kala-azar has remained the same for decades, and is based on derivatives of antimony. Sodium stibogluconate (SSG) is the form of this medieval element given at these clinics, being relatively cheap in its generic form.1
The evening brought night clinic, and my first admission. This was a severe kala-azar case that I would come to understand was typical: a young child, with high fevers for weeks, who had been carried for days by his mother to the clinic. He was perhaps 4 years old, with his skin pulling taut against the outline of his ribs as he drew quick breaths. His lungs were clear. His spleen was extending across his umbilicus, and I drew its contour with a felt-tipped pen. His temperature was 39°C. The inpatient nurse, a former child soldier, was called Mut. He did a finger-prick test for malaria, which was negative. We would test the boy for kala-azar in the morning, as the tests were done in daily batches. I drew some blood to measure his haemoglobin level. We used a handheld colorimetric device that you looked through like a kaleidoscope. I read the result as 45. Sure that I had stuffed up the measurement, I handed it over to Mut. He said it was closer to 40, and started to cannulate the child. I went to talk to Jill.
Jill said we should organise a transfusion, so Mut taught me to type the patient’s blood, an experience entirely similar to a medical school haematology practical I half-remembered. We put drops of blood and drops of antibody on a glass slide, and held the slide up to the one light in the ward. B positive. Mut, a veteran of the war and the ward, knew that he was this type also. I put a cannula in Mut and drew a little blood into a syringe to crossmatch with the patient’s blood. I swirled their blood around together with a toothpick on a glass slide and watched for the telltale clumps of cross-reaction. Satisfying Mut and myself that the blood was compatible, I drew 250 mL into a transfusion bag. Mut connected the bag up to our patient’s cannula, and we watched the blood drip rhythmically through the infusion set. Because of his severe presentation, our patient qualified for the more expensive kala-azar treatment, liposomal amphotericin B, which is a better treatment than SSG, but is tens of times more expensive.2
Day after day, similar patients would be admitted, with spleens in the boots they didn’t have, and temperatures rivalling the nearby Sahara. The inpatient ward was half-full of patients with kala-azar, mostly children, but also adults who were immunosuppressed because of HIV infection. The rest of the ward was filled with the casualties of African unrest: tension pneumothoraces from gunshot wounds, severe malaria, and undifferentiated presentations that you couldn’t hope to solve without access to basics such as x-rays or renal function tests.
After 7 weeks of learning the workings of the clinic, and all too soon, the African unrest caught up with us. The foreign nationals who had been working at the clinic, including us, were evacuated by boat back across the river. We waited overnight in a fruit farm while men strolled past with AK-47s in hand. In the morning the plane came to our dusty landing strip, and we flew back to Kenya. Leaving South Sudan brought mixed emotions. Relief, certainly, came from exiting a dangerous situation. But there was also the guilt familiar to anyone who has worked in a developing country: the guilt of leaving. Here we had been confronted with a disease that was one of the most important in the world, a disease that kills seven-tenths of a population if left untreated.3 Despite its known lethality and relative ease of treatment early in its course, kala-azar remains one of the world’s secret humanitarian problems. And we found ourselves flying away in a plane, leaving the south Sudanese to deal with this problem all on their own.
References
- Veeken H, Ritmeijer K, Seaman J, Davidson R. A randomized comparison of branded sodium stibogluconate and generic sodium stibogluconate for the treatment of visceral leishmaniasis under field conditions in Sudan. Trop Med Int Health 2000; 5: 312-317. 0_i1115596
- Sundar S, Mehta H, Suresh AV, et al. Amphotericin B treatment for Indian visceral leishmaniasis: conventional versus lipid formulations. Clin Infect Dis 2004; 38: 377-383. 0_i1115598
- Seaman J, Mercer AJ, Sondorp HE, Herwaldt BL. Epidemic visceral leishmaniasis in southern Sudan: treatment of severely debilitated patients under wartime conditions and with limited resources. Ann Intern Med 1996; 124: 664-672. 0_i1115602