Malaria Made Me Do It

I almost called this blog, "Two stints in a hospital later, an advocate of health system strengthening is born," but thought the title was too long and vague. But in truth, that is just what occurred. Two experiences in hospitals in Ghana and Zimbabwe have made me a proponent of health system strengthening. This blog recalls when I was hospitalized for malaria as a study abroad student in Ghana during the 1990s.

I've always been an early bird and never missed class without good reason (at least while I was in Ghana, tee hee). After missing my first class, my dorm mate came by to check on me.
Knock, knock, knock. "Tiaji?" I hear a sound at the door, but it sounds far away.
Knock, knock, knock. She tries again. "Hunh?" I finally croak, and am surprised by the feebleness of my voice.
"Tiaji!" She yells more urgently.
"What!" I attempt to yell, but am struck at how quiet my response truly is.
"You missed class today. Are you okay?"
"I'm fine. Just tired."
Knock, knock, knock.
"What!" I respond, this time more strongly than the last.
"Open the door."
"Maybe later. I'm tired."
Knock, knock, knock. She is really starting to annoy me.
"What!" I start to sit up so that I can throw my voice farther, but immediately collapse back on the bed, weighed down by fatigue and a strong headache.
Knock, knock knock. "Open the door!"
"Go away. I'm tired. I just need some rest."
Knock, knock, knock. "It's noon! Open the door!"
My dorm mate is like an annoying mosquito that persists on pestering me no matter how many times I swat at her.

"Uugh!" I express in disgust. "I'm coming." The weight of my limbs overwhelm me and I sink back in the bed.
 Knock, knock, knock.
"Okay, okay. I'm coming."
She clearly will not leave, so I make a second attempt. Sitting up takes an inordinate amount of energy and I sit there a moment while waiting to regain some strength. Her pestering knocks motivate me to stand. "I'm coming, I'm coming." I say in defeat. My feet are too heavy to lift, so I shuffle to the door. After opening it, my dorm mate looks at me and says, "What is wrong with you?"
 "I think I have the flu or something."
"We're going to the hospital." She commands.
"I'm fine. I just need some rest. I'll be better in the morning." I reply while shuffling back to my bed.

I grew up without much money or health insurance. My mother had a three day rule: if you didn't feel any better after three days, we could go to a hospital. Usually though, a hospital visit didn't come unless my uncle (who was a cardiologist) couldn't figure out the problem. I can't tell you how many times I heard my uncle tell my mother, "But I'm a cardiologist." The exacerbation in his voice was not lost on me. I'm sure my mother caught it too, but he was a doctor in her eyes. At least he could tell her if a trip to the hospital was necessary.

In my mind, hospitals became a place to visit only in the most serious of circumstances, and the headache and fatigue I was experiencing did not seem to warrant such action.

"We're going to the hospital." My dorm mate insists with a tone that let me know that the matter is not up for debate. "Let's go!" she urges and attempts to pull me up. She quickly draws her hand back and asks, "Did you take your temperature today?"
"No." I answer while snuggling deeper into my pillow.
"Where's your thermometer?"
"I don't have one."
"I'll be right back."
I'm relieved by her absence and enjoy a few snatches of sleep before being interrupted again.
"Open your mouth." She shoves a thermometer in my mouth.
"103! We're going to the hospital right now!"
"It's just a fever, leave me be. I'm fine." I mumble.
My dorm mate ignores my pleas and begins to gather my clothes and shoes. She sits me up, pulls a shirt over my head, and I meekly raise my arms. She starts to put on my shoes. I'm uncomfortable with being fussed over and push her aside while shoving my feet into my shoes. I attempt to stand and fall back on the bed. She grabs my elbow and pulls me back up. "Let's go!"

My dorm room was on the 7th floor and there were no elevators. As if sensing my apprehension, my dorm mate says, "It's okay. You can do it. Just lean on me." I don't know how her small frame supported me, but it did. On campus, there were a cluster of boys who hung around looking for work. The students aptly called them "Any Work Boys." My dorm mate yelled for an Any Work Boy and told him to go get a taxi. Some time later he returned with a taxi and I collapsed into the back seat. 

We arrived at the hospital and the admitting nurse immediately demanded payment. My dorm mate insisted that this was an emergency and that I needed to be seen immediately. The nurse was not moved and refused to see us without payment. She then launched into a story about Deborah from California who came to the hospital one time and didn't pay. My dorm mate tried to explain that she did not know Deborah from California. The nurse maintained that she tried to make exceptions for Americans, but since Deborah didn't pay, she could no longer extend that courtesy.  My dorm mate would not back down and demanded service.

I laid my head on the desk during their exchange, lacking the energy to advocate for myself but reserving just enough to curse Deborah from California in my head. At some point, the nurse relented and agreed to admit us, all the while mumbling about Americans who don't pay their doctor's bills. We were ushered into a room where a technician pricked my finger and quickly determined I had malaria. "Malaria?!" we parroted simultaneously. I should not have been surprised. I stopped taking the antimalarials after witnessing another dorm mate have a manic episode while using the pills.

Another nurse entered the room and ushered me into a hospital bed. I immediately collapsed into the bed and passed out. I awoke sometime later in a darkened room. An IV was in my arm, and as my eyes adjusted, I noticed my blood was going up the tube towards an empty bag. I called for a nurse, but my hoarse voice got no response. After a few more attempts, it became obvious that no one was coming. I got out of bed and went to push my IV stand. It did not budge. I looked down and noticed, it did not have wheels. I barely had strength to walk and was dismayed by the prospects of carrying my IV stand.

I gathered my strength, picked up the IV stand and exited the room in search of a nurse. This time, she heard me and came over with haste. I smiled with relief as she approached. "What are you doing out of bed?" the nurse yelled at me while roughly pushing me in the chest. My face fell as I fell into a stunned silence. I'd never been assaulted by a health professional. "My bag." I recovered, while pointing to my blood now readying to fill it. She roughly yanked the IV out of my hand with her own ungloved hand and my blood gushed out. "Now look what you made me do!" she chided. My eyes shifted to the floor and I stood, frozen in place, watching my blood collect on the floor while she swept out of the room in search of additional supplies.

I couldn't make sense of the whole exchange. Why was she so angry with me? What had I done wrong? Perhaps she'd heard about Deborah. While replaying the scenario in my head, the nurse returned. She seemed annoyed that I was still out of bed and went to push me towards my room again. This time I was ready, and deflected some of her force by yielding my body. She jostled me back into bed and replaced my IV needle. "Don't get out of bed!" She commanded before leaving the room.

I awoke the next morning feeling much better and anxious to leave. With my strength restored, I quickly dressed and prepared myself to take on the mean nurse. There must have been shift duty in the middle of the night, however, because the next nurse who came in bore none of the same hostility. She checked my vitals and let me know that I was ready for discharge. My dorm mate had already settled my bill and was waiting for me in the lobby with the Program Director.

I'm not sure if he said "I told you so" in his head, but I imagined he had. Our Program Director faithfully drank a cup of neem tea each morning to prevent malaria infection. He'd been living in Ghana for 15 years and had never contracted the disease. The first time I tasted the tea, I gagged and and told him I'd take my chances. Now that I'd actually contracted malaria and underwent rough treatment while in the hospital, I'd changed my opinion on the matter.

I got malaria two years later while living in Senegal. Now familiar with the symptoms, I did not hesitate to act. With memories of Ghana still fresh in my mind, I went to the neem tree that grew right in front of my house and made tea. Within a few hours, my energy was restored and I felt completely refreshed by the end of the day. I was relieved that the tea had worked and that I would not have to go to the hospital.

In the early phase of the Ebola outbreak, I was frustrated by some of the press reports that featured stories about people fleeing or avoiding health clinics, because most of them failed to mention the unsafe conditions people faced in many of the health settings. The implicit tone in some of the articles seemed to imply that backwardness or mistrust of Western medicine prompted these actions rather than a rational evaluation of the risks associated with presenting at a clinic. Some six months into the epidemic, stories about the conditions people faced in health clinics began to emerge in the press, offering greater balance to the "fear and flee" messaging.

As the international community gained greater control over the outbreak, foreign health workers began to share "lessons learned" stories. Several donors discussed the importance of working with local leaders before launching into public health campaigns. Many donors noted that partnering with local groups could have accelerated the delivery and acceptance of culturally appropriate Ebola prevention messaging. Engagement with local leaders should be seen, however, not only as a strategy for building trust around a public health message, but also to learn strategies for developing a public health intervention that is appropriate for the local setting. 

Conventional Western wisdom says to go to a doctor when you are seriously ill and especially if you contract an infectious disease like Ebola. In a functional health system, it makes sense to advise people to go to a health facility. In a dysfunctional health system, however, such advice may exacerbate the problem, as occurred during the early phase of the Ebola outbreak. In many low-resource settings, hospitals and health clinics are ill-equipped to treat basic ailments (at best) and because of equipment shortages, including basic protective equipment, can be the source of disease transmission.

The Ebola outbreak has generated conversations about health system strengthening, but the international community has not yet developed a sound strategy for achieving this goal. Developing a standardized approach to health system strengthening is difficult, as each country faces a unique set of challenges that causes health system deficiencies. The system constraints usually extend beyond inadequate access to brick and mortar health facilities. Deficiencies are also typically evident in the distribution networks that deliver the goods and services, the application of regulatory frameworks that oversee service delivery and ensure compliance with quality and safety guidelines, the funding mechanisms through which health services are paid, the retention and distribution of health workers, the leadership and policies that guide service delivery, and information systems upon which health policies are based.

This story is intended to provide a real world example of what some of these terms mean. Particular health system deficiencies I experienced during my hospital stint involved inadequate access to ambulance services, poor adherence to infection prevention protocol, inefficient financing mechanisms, and human resource constraints.

I can identify with the mistrust some people in Ebola-affected countries have for health facilities, as I developed my own aversion to hospitals in sub-Saharan Africa following my experiences in Ghana....and I was at the "good" hospital that is recommended for Americans. When I moved to Zimbabwe, those sentiments deepened after an experience in a public hospital, but that's a story for another time.