Stories from South Sudan: Cerebral malaria in children

Working as a paediatric doctor for MSF has been a long-held dream for me, so when I was offered the position of paediatric doctor in Aweil, South Sudan, I eagerly accepted. Aweil is the capital of the Northern Bahr El Ghazal state in South Sudan and, although it is a large city, the facilities are limited. The MSF project here in Aweil falls within a big referral hospital, which has adult and outpatient services run by the Ministry of Health.  

MSF took on the paediatrics and obstetrics departments 12 years ago. The vast majority of the 400 or so staff in the MSF hospital are South Sudanese, including a small group of highly skilled general doctors. The role of the paediatric doctor here is to support the general doctors, clinical officers and nurses, particularly with more unwell patients in the paediatric intensive care unit (PICU) and neonatal unit.  

I’ve arrived at the start of rainy season and with it, malaria season. My first patient in Aweil is a three-year-old girl with cerebral malaria. Cerebral malaria is a terrible condition, and affected children often present to MSF in various stages of coma. We treat them as best we can but have to just wait and hope the treatment works. We hope that they don’t stop breathing or go into the prolonged or recurrent seizures of status epilepticus. We hope that they wake up.  

This little girl has been brought in by her mother, who describes a short history of fever and lethargy, with a declining conscious state. We start the girl on antimalarials, antibiotics and fluids, and then we start the wait. 
  
By the next morning, she is completely unconscious, and her breathing is more laboured. Her mother pleads with us to save her child, but we can only continue her treatment—and wait.  

A two-year-old has been admitted overnight to the bed across from her. He also has cerebral malaria and is now on the resuscitation bed being manually ventilated with a bag and mask. He went into status epilepticus for several hours during the night, and was given multiple medications which seem to have finally stopped his seizures. But his level of consciousness is now very low and he repeatedly stops breathing. It does not look good.  
  
Each morning I hold my breath as I enter the PICU, hoping the beds are still occupied by the same patients as the day before. In my short time here thus far, I can already see that the national staff are incredible, and they do the best they can with the resources they have. But they know the challenges better than I: children come in very sick, some survive against the odds, and some don’t.  

As I arrive on my third day, the three-year-old girl is not in her bed. She did not survive the night. Instead I see another child, equally as unwell.

Dejected, I turn, and am amazed to see the two-year-old boy sitting up, breastfeeding. He cries when he sees my gleeful face, and it is a beautiful sound. He will survive. For this we are all grateful.