Breaking the Cycle

In the last half-hour, as the doctors have been talking, another child has died. Her name was Anne Achieng. She was 4 months old and had lived about five miles away, in a village called Obambo. She arrived at the hospital last night with severe anemia brought on by malaria, according to the medical report. There was also evidence that, before arriving at the hospital, someone had tried treating her illness with useless herbs, a common folk medicine of sorts that is often used in lieu of a real anti-malarial for one reason: People can afford nothing else. Anne Achieng had enough herbs in her that she was also suffering from herbal intoxication.

The next day, Heppner is back in Kisumu. With so many young malaria victims in the hospital wards of western Kenya, there is little time for doctors to dwell on names. The medical staff of Kisumu District Hospital tends to refer to each of the young patients as "this one" -- as in, "This one here is in some trouble." This one, the 14-month-old girl lying on the pillow in bed 18, the one with a couple of flies dancing on her face, arrived at the hospital the other day in a coma, suffering from critical malaria. Her name is Bibianca Anyango. A Kenyan doctor named Bernhards Ogutu hovers over her bed. Ogutu leans down, stares at the closed-eyed and motionless Bibianca and presses the center of the girl's tiny chest with his index and middle fingers. Hard. Then harder still. He wants her to feel a spasm of pain, hopeful of eliciting a reaction that might signal that her coma is ebbing.

No reaction.

What has happened to Bibianca is what always happens in severe malaria cases. Days ago, after she was bitten by a mosquito, the falciparum parasites swiftly made their way into her liver, with each parasite ensconcing itself in an individual liver cell, where it was protected against her body's immunological defenses. The parasites developed and multiplied, bursting in about six days from Bibianca's liver into her bloodstream, where each parasite invaded a red blood cell. Unchecked, the parasites multiplied yet again, bursting from those cells into new red blood cells in about two days. That triggered the release of toxins that brought on the early symptoms of her malaria, including fever and chills. In this oft-repeated 48-hour cycle of breakout and invasion, the disease soon had produced hundreds of billions of parasites in Bibianca. The parasites destroyed her blood cells and fed off her hemoglobin, which, in a healthy person, carries oxygen to the body's tissues and organs. By the time Bibianca arrived at the hospital, death was a possibility.

Parasites had clogged her oxygen-starved blood cells and blocked blood vessels, leading to her coma and likely beginning the stages of organ damage.

Bibianca's mother, a stately woman named Benta Okoth who sits on the edge of the bed in a long dirt-stained white skirt and a blue sweater over a ragged brown T-shirt that says VERSACE on it, has been stolid. But something in the renewed urgency with which Ogutu is pressing on the child's chest dissolves her. She jerks her head away. She stares out a window screen, shielding her bloodshot eyes with a long hand. Ogutu keeps poking Bibianca's chest. Finally, in a noise that sounds like something from an inanimate doll, a moan escapes from the little girl's shut lips. Her eyes stay closed. Ogutu looks at Heppner and smiles wanly.

"No movement, still comatose with severe malaria, but the moan means a little improvement," Ogutu says, shrugging.

"A little."

"A little" is mixed news. A little means, on the one hand, that Bibianca will probably come out of her coma and survive -- which in itself will be no small feat. But escaping death might mean trading horrors. "She still has a significant chance of brain damage in a case like this," Ogutu says, touching Bibianca's forehead, feeling her fever. "It will be harder for her to learn if that happens. She might have problems with mobility or with one or more limbs. She could have behavioral problems that will be mistaken for [disobedience]."

He looks over at Heppner and, talking in medical shorthand, describes the symptoms and prognosis, his shrug reflecting the limits of what either man can do here. "Her coma could have been avoided," says Ogutu, the principal clinical investigator for the U.S. Army's malaria field trials in Kenya. "But that's the way it is with a lot of malaria cases. This is a case where, if they had had the right things in other [health facilities], this girl would never have arrived here in a coma. You ask yourself, What happened?"

It is a question he also poses to Okoth, to whom he speaks softly in Luo, their tribal language. Okoth's explanation for what happened to her daughter over the past week has a familiar ring to Ogutu, a story illustrative of the maladies of a typically poor and inefficient African health system. Five days earlier, while at home in the western Kenya sugar plantation village of Chemilil, Okoth had become alarmed when a touch of her listless daughter's skin seemed to indicate a fever.

In Kenya, the most reliable antimalarial drugs cost about $6, or about four days' earnings for the average Kenyan. The drugs are generally unavailable in shops. Accessible antimalarials in Kenya generally mean cheap antimalarials -- usually ranging from 10 to 30 Kenyan shillings, or roughly 15 to 40 cents -- but they are also the least effective treatments, as the disease has become wholly resistant to many of these drugs once famously effective.