Tag Archives: mosquitoes

The Malay Experience

In 2008, after a short 4th year of medical school, I caught a flight to Kuala Lumpur. My first trip to Asia. Solo. I cannot remember how I came to choose Malaysia. I think I wanted to go to Asia, wanted an English speaking setting and importantly somewhere warm. Sri Lanka was another option but I didn’t know anyone there so Malaysia was the choice I made.

My mama as a human rights activist worked with an organisation with close links to Malaysia so she had been to visit many times and had made some good friends there. When I asked her for help, she was on it. She contacted her friends and asked whether any of them had medical connections in Malaysia. Fortuitously, one of her friend knew the health minister in Kelantan State. The only question was did I want to go to Kelantan, being the most conservative of states, quite ‘Muslim’ in its ways? Well, being a very modern Muslim I could see why some would question my willingness to be in a community that was rather more conservative than I chose to live my life. But I wanted an experience so I had no hesitation in saying yes.  Then I had to find somewhere to live for the month. Another one of my mama’s friends had a GP husband who was resident in Kota Bharu, the capital city of Kelantan state where the hospital was located. His home was too far to walk to and from the hospital so he organised for me to stay with his sister.

A few days before I was to fly out, he emailed to say that unfortunately his sister had a family emergency so she wouldn’t be in Kota Bharu (KB) for my arrival and he didn’t know when she would be back. Before I could panic, he went on to say I was welcome to stay at his and I would have to catch rides with his grandchildren to and from the hospital. So back to the beginning, I arrived in Kuala Lumpur on a warm afternoon. As I got off the plane after my 12-hour trip, I felt a queer tingle in my feet. I looked down and lo and behold my feet was swollen and my toes resembled little chipolatas. Remember I was only 22 years old so this was rather foreign. I wriggled my little sausage toes and poked both feet. Clearly, I should have mobilised more on the long flight. Noted. I made my way through baggage retrieval, immigration and customs and got to my hotel without incident. One of my sister’s uni friends generously came to find me later and took me out for dinner. The next day, after he kindly took me to get a phone and camera, we went to the Twin towers. What a sight! My jetlag was cured and I was suddenly filled with excitement. My first adult adventure in foreign country! The next day, my mama’s friend who had been instrumental in organising the whole trip took me to the famous Batu caves where we took in the impressive sights and also had one of the best Indian meals I have ever had.

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I think the sister in KB being away was a huge blessing in disguise. My new digs were rather luxurious compared to what I had been expecting. Dr R and his children were excellent hosts and made me feel at home. Bibi, their Indonesian housekeeper, was a godsend. She couldn’t speak a word of English and I couldn’t speak a word of Malay or Indonesian (a variant of Malay). It didn’t matter! She was a lovely lovely woman. She was short (average for the population) and portly for want of a better word. A little like Mrs Potts in Beauty and the Beast – very motherly figure. She always had a smile on her face and fed us beautifully. When I came home, there was always a jug of iced tea waiting to cool me down. It was very hot in the afternoons and the icy drink was like manna from heaven. I would change into my cotton Malay dress and throw myself down on the sofa in the upstairs living room which I made my own and down the cold fluid. That was all the activity I could manage until the sun went down and brought with it some refreshing breeze.42

The only cloud on the sunny Malay sky, apart from the relentless over 30-degree heat, were the mosquitoes. I was told soon after landing in KB that we were in the middle of a Dengue outbreak, spread by pesky mozzies. Now I am one of those who will get bitten wherever I go, regardless of covering or insect repellent. I like to say I have juicy blood. So what were my chances of contracting Dengue. Well, reassuringly (not!) I was informed the virus was only carried by the mosquito with the striped-back. I laughed about this – pray how was I supposed to tell whether a mosquito had stripes on its back? And if I had such keen senses, surely, I could just squash the little terrors before they bit me (whether they were the evil striped ones or not). Also I was helpfully informed that I was more at risk of catching Dengue Haemorrhagic fever in my first episode of the illness (I have since learnt that you are more likely to catch the severe strain on a second episode). Fabulous, I was at risk of catching a deadly disease (risk of death from the haemorrhagic disease was significant, 2-3 per 100). I got a few bites despite precautions but avoided Dengue fever thankfully.

The medical experience was quite opening. Based on the old British system, it was still quite paternalistic and the doctors knew best in most cases. A big population of KB was poorly-educated farmers and fishermen so many of the patients had no interest in being given hard choices. They wanted the doctors to diagnose them and tell them what was to be done. The nurses and healthcare assistants were also very much directed by the doctors and there was a noticeable hierarchy. The respect for doctors was palpable and that extended to us the medical students. To be fair, the doctors I came into contact with were respectful in return.

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I was with a group of female medical students, most of whom were indigenous Kelantanese girls coming home from KL for their elective. They were lovely girls. Very welcoming. They were my unofficial translators with the patients and did the job without minding how much of a drag it was.  They were all quite petite. I think the tallest was 2-3 inches shorter than I was. At 5 foot 6, I never thought of myself as tall but there I was being referred to as the tall foreigner. It felt rather nice. The girls all wore the hijab (hair covering with their traditional Malay dress) and were all shocked to learn that I was  Muslim as I wore the lightest formal clothes I could find and no head covering. However, they didn’t judge me. If anything, they seemed to be impressed by my independence. One of them, Nurul became quite close to me and I got to visit a more traditional Malay family and eat with them. Again, her family was so welcoming and humble that I wanted to adopt them all. Nurul had a small car which she generously used to take me and the girls to the markets, museums, cultural centre and even the seaside. Their culture was beautiful as was their food, music and natural environment.

Back in Dr R’s home, I made friends with the loveliest little girl called Ayin. His granddaughter, the youngest of his 3 grandchildren who I shared the school runs with. She was a tiny little thing. I think she was 4 or 5 years old and either she didn’t understand that I understood not a word of Malay or she didn’t care. She would come to my room after work and tell me all about her day (in Malay). She would share jokes and laugh. She would admire my little knick-knacks and tell me how much she loved my things. I would laugh with her, reply in English and invite her to look closer at my things and show her what new things did. She particularly loved my Malay silver butterfly earrings which I got there in KB and I would let her borrow them. One afternoon, me and my little friend were hanging out and chatting when Dr R came home early from his GP practice. As he walked past my room, he heard us conversing and was amazed. At dinner, he asked what it was we were talking about. It amused him to hear that I had no idea what Ayin was talking about but that we had these conversations. I was her ‘aunty’ and she was my little niece. Didn’t matter one bit that we spoke completely different languages but we were great friends which was all that mattered.

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The month in Malaysia flew by and although I was off on holiday to Thailand for 10 days, I was quite sad to leave my new family. I had an absolutely amazing elective in KB, met the most wonderful people and experienced healthcare with different levels of expectations and resources. I haven’t been back since then but I definitely want to take my husband and baby there so they can experience the great country that is Malaysia.

Mythical Malaria

My mama came back to London from a visit home to Nigeria in 2002 and felt feverish. Like most people where we come from, she thought it might perhaps be malaria but wasn’t unduely worried so decided to wait and see. On the Monday, she had the typical malaria vomit so she thought ‘I best get some antimalarials before it flattens me’. That evening, I came home from college, cooked dinner and waited for my mum to be home around 7pm as usual. 7pm came and went. Then 8pm which is when I realised something was up. I called her phone which went straight to voicemail. She did come home late sometimes especially on Mondays so I wasn’t all that worried but I did feel she shouldn’t work so hard.

She came in at 9pm irritation written all over her face. ‘What did she do this time?’ I asked, assuming it was the lady who had recently been promoted to the top position in their human rights NGO office who seemed to have gone power-mad and was intent on taking all the joy out of my mama’s life. My mum shook her head and over dinner told me about her ordeal in Whittington Hospital. Basically, she had tried to call her GP for an appointment and had no luck (what else would you expect in a London GP?). After work, she went straight to the closest A&E (Whittington Hospital) rightly thinking that she should not wait until her GP had an appointment for her to get treatment for malaria. Rookie that she was, she got straight to the point when asked what the matter was. I think I have malaria, she said. Pandemonium broke out. She was ushered in ahead of everyone else into a side room to isolate her. She had blood drawn before she could say ‘what’s up?’ and they were admitting her to a ward. When she finally got someone to stop and talk to her, she was informed that she would be going to the ward shortly and they would need at least 2 more blood samples off her as per the malaria protocol and she was being isolated. I wasn’t there but I know the look of amazement that my mama would have had.

Long story short, she refused to be admitted. She told them under no circumstances was her daughter going to be left alone all night, never mind I was 16 and had stayed the night alone before, in fact more than 1 night in a flat alone in Lagos at the age of 15 which was a damn sight more dangerous than Muswell Hill in London. Anyway, the doctors were beside themselves and there was a lot of hand wringing because malaria in UK is kind of a big deal and there are strict protocols and the Health Protection Agency red tape to jump through. My mama was not to be persuaded. She said she would be off within the hour and either they give her oral medication to go home with or she would walk out without. Either way, she was going to her baby. After a lot of negotiation, they gave the oral medications and she came home to tell me the story. The deal was that she had to go back in for her second blood test before work and for them to make sure she hadn’t developed cerebral malaria and died on them. Mama and I rolled around laughing at all this hoo-hah over something as simple as malaria.

So obviously we are not entirely looney and we know malaria is potentially serious and in a few cases even fatal despite medication. Since you, my readers, are not all medics like me I will explain the things that the media and doctors in the UK it seems don’t appreciate at first glance. There are 4 strains of malaria and 1 of these strains is the bad boy of malaria. It is called Plasmodium falciparum or P. falciparum. The millions of deaths from malaria are mostly due to this strain of malaria but actually most malaria is of the other 3 strains and in Nigeria, most people will get at least one bout of malaria in their lives. As children, we all got malaria several times. I think I was one of the lucky ones who only got 3 bouts of malaria in my life and the last time I had malaria was when I was in primary school (coming up to 20 years ago). Actually a lot of the malaria burden is probably not even malaria because we are so used to malaria that anyone who has a fever longer than a day and that is high enough to make them want to lie down, self-diagnoses malaria and trundles off to the chemist to get antimalarials (we don’t need prescriptions per se).

Now back to P. falciparum. This bad boy is the strain that causes cerebral malaria i.e. it likes to infect the brain and so makes you delirious and causes seizures and can rapidly kill you because the fever is so high causing all your body enzymes not to work (so your bodily processes a.k.a. your metabolism stops) and the seizures can be very hard to control so starve your brain of oxygen, turning it into mush and in most cases, killing you unless you get IV (intravenous) antimalarials and fluids very early on.

I do not make light of this malaria at all. I worked in FMC Yola for 4 months and I saw more children die from it than I would like to recall. It is terrible. But let’s put it into perspective. The Centres for Disease Control and Prevention (commonly known as CDC) has the following stats. Nigeria is one of the countries where malaria is endemic and transmission is rife, everywhere in the country. In 2012, there were 207 million individual cases of malaria reported worldwide and of them 627,000 died. That makes it a death rate of 0.3% – which is not as high as pneumonia or diarrhoeal illnesses. And that includes P. falciparum and the other 3 strains of malaria.

Now here are my own stats. Of all the cases I know that have died of malaria, they are mostly children or very old or people with other illnesses making them too weak to fight off malaria like those with sickle cell disease. Usually, these patients would have had the fever for longer than a week and their bodies would have tried to fight for so long and then got to the stage they have nothing left to fight it with so that by the time they are admitted, they are wasted, dehydrated and their body salts are so abnormal that this is what gives them seizures and kills them. Even those with the bad boy strain are usually completely fine if they get treatment in a timely fashion. And this treatment is highly effective for majority of cases and is just as effective given orally as long as the person is not vomiting copiously (which sadly does happen with malaria).

So I am writing this not only to debunk the knee-jerk panicked reaction of UK-trained and UK-based doctors with no first-hand experience of malaria but also to educate. Some strains of malaria can be as bad as the common cold. Some can be as bad as avian flu which although it is a ‘cold’ virus is more dangerous and needs treating. All malaria infection should ideally be treated even if it is a mild infection. People like me who lived a long time in a malaria endemic area develop resistance so malaria for us is much less of a big deal generally than for a malaria-naïve person. Also those of us with the sickle cell trait have extra protection against malaria. But for you who are not so lucky, you should absolutely take antimalarials when you travel to endemic areas. You should absolutely have mosquito repellents and in addition, wear long sleeves (or as Nigerian girls do have a light scarf wrapped over your neck, shoulders and arms) to prevent the persistent mozzies from nibbling on your ‘fresh’ blood. If you are white or even just a fair brown person, be extra careful as mozzies are attracted to fairer softer skin too. I would also sleep under a mosquito net.

Take it from me because although I am fairly immune to malaria I think, I am one of those ‘special’ people that give off the pheromones that drive the mozzies wild. It doesn’t matter if there is only 1 mozzy that gets into the room of 20 people and they are all in bikinis or even bare-chested, I will be the one bitten through my scarf and long skirt. I will be the one walking around scratching the large lumps left behind by each mozzy that found me. I will be the one waiting impatiently for my near-abscesses to heal weeks after I have come back to Birmingham. Le sigh!

Unfortunately despite your best efforts, you may still catch malaria. So if you have recently been to sub-Saharan Africa (or the other endemic regions, see CDC for more information) and you develop a fever high enough to give you the shakes (rigours), run to the doctor. If your bones and joints all begin to ache and all you want to do is sleep in addition to a fever even if mild, I would get tested. And definitely pack an overnight bag if you develop a fever then start to puke up your guts and the vomit is green has such a bitter taste it makes you want to puke again despite having nothing left. That is the malaria vomit (bilious vomiting in medical speak) and you will be admitted and isolated and the whole she-bang if you do seek medical advice which you should. In fact, pack a bag that will last at least 3 days and make sure you have books/a laptop/cards/smartphone/sketchpad or whatever else you need to keep your sanity because being in isolation is no fun. Also be prepared to be pricked several times for blood cultures. But it is for your sake that all this is being done so don’t hate on my fellow doctors ok? Stay safe!