The pediatrics ward this past week at Rwinkwavu Hospital in rural Rwanda was as busy as I'd seen it in several years. Children were packed two or three to a bed, with parents and healthy siblings squatting or playing in the narrow intervals between the closely spaced beds. Still, as I rounded that morning with a young Rwandan physician, fresh out of his medical school training, it was easy to pick out the small three-year-old girl, lying on the fifth bed on the left as we made our way through the crowded ward. She had arrived late the night before, and she was certainly one of the sickest children there. Her small size, swollen legs, and frizzy, light colored hair identified her as one of the several children on the ward suffering from undernutrition. She was lethargic, not moving or opening her eyes and only making a high-pitched whine when you tried to arouse her. Small beads of sweat were scattered across her face, and her chest rose and fell with shallow, rapid breaths. The most noticeable thing about her, however, was that she was all alone; unlike all the other children on the ward, there were no parents or family members at her side.
Speaking with the nurses who'd been on overnight as well as the mothers of other children on the ward, we soon pieced together a bit of the child's history. She had been brought to the hospital the night before by neighbors from her village, along with her mother and two siblings. According to the neighbors, the family was quite poor and all three children had recently been suffering from bouts of diarrhea and vomiting. Then, on the day prior to arrival, the mother and all three children had abruptly developed high fevers. They had been brought to the hospital within a few hours of being found by their neighbors, but by the time they arrived the mother and both of the other siblings had died, leaving this child all alone.
Not surprisingly, the child's blood smear came back positive that morning for malaria. The majority of the children currently on the pediatric ward have severe malaria, due in part to a large outbreak that had been ongoing for the past several weeks in that part of Rwanda. Malaria cases have actually dropped significantly at this small rural hospital over the past several years that I have been coming here, since the Rwandan Ministry of Health had begun distributing bed-nets to all households, though recent heavy rains, perhaps coupled with a growing sense of complacency about malaria in local villages as well as bed-nets that were beginning to wear out, had recently led to a sharp spike in malaria cases. To complicate matters, this child also suffered from undernutrition, and was clearly dehydrated as well from her recent diarrhea. Per our hospital protocols, we started her on antimalarial and antibiotic medications, and began treating her with oral rehydration and protein-energy supplementation through a tube we placed through her nose into her stomach. A few days later, the child was sitting up in bed, completely alert, and able to eat and drink on her own, but unnervingly quiet and withdrawn. Nobody had yet said anything to her about her mother and siblings, but it was clear the child could sense they were gone.
In many ways, child health is one of the great success stories of global health in recent decades. The number of children under five years of age dying worldwide has fallen by almost half, from 12 million per year in 1990 to 6.9 million per year in 2011.(1) In Rwanda, where I have been serving as a volunteer clinical advisor at several rural, government hospitals, progress has been even more impressive, with the child mortality ratio falling from 183/1000 live births in 2000 to 53/1000 live births in 2011, a reduction of over two thirds. Still though, over 19,000 children continue to die every day worldwide, and the rates of death are becoming more uneven with time; nearly 1 in 9 children in sub-Saharan Africa will die before their fifth birthday, compared to 1 in 152 children in wealthy countries. And the major causes of death in children have remained largely unchanged over the last several decades: pneumonia, diarrhea, malaria, preterm birth complications, and undernutrition.
The recent outbreak of malaria here demonstrates that even in Rwanda, which has made substantial improvements in child health through preventative interventions such as near-universal vaccination as well as increased access to basic healthcare at both the community and hospital level, constant vigilance is needed to ensure that hard fought gains are not lost. Even simple interventions, like distribution of bed-nets to prevent malaria, are not so simple in practice. They require massive campaigns, significant amounts of human resources, bulk purchasing of supplies, and the difficult task of convincing an entire population, one family at a time, of their importance. And then, in a few years time, the campaign needs to be done all over again, or else the impact wanes. The little girl on the crowded pediatric ward at this small hospital in rural Africa provides a stark reminder, however, that we can neither throw up our hands in a fit of nihilism or become overly complacent with gains made to date, but instead must continue the long, hard slog of slow progress until child deaths in sub-Saharan Africa and other resource-limited settings are as rare as they are in wealthy countries today.