Friday, September 5, 2014

Something is very wrong

This is a clinical sign of vey low calcium levels: leave the Blood Pressure cuff  on for a few minutes and the hand involuntarily adopts this posture
Imagine you were a homicide Detective and you were sent to work in a precinct you had never been to before, far from your usual workplace. On your first day at work an innocent young pregnant woman dies in a grisly fashion just up the road, the sort of fatality you’ve heard about or maybe seen once or twice  over the years before, but now youre confronted with it again, a tragic and disturbing death, that fortunately is of a kind you know to be rare, but something you have been trained to cope with. Imagine your reaction the next morning when a similar thing happens again – another young woman dies tragically and unnecessarily in similar circumstances – and then, in the afternoon, theres a third, though this one survives, and the next day, another. What on earth is going on? you ask yourself and then you realize you are confronting something ghastly, sinister  and inexplicable, a serial killer in the community. A sense of dread and dismay starts to fill your mind as day after day the toll of innocent victims mounts, young women, some surviving but all devastated and shattered by a relentless serial killer, dead babies and dead or damaged mothers. And the killer is Eclampsia, the unique pregnancy related disorder which manifests as convulsions, unconsciousness and a host of other highly dangerous complications : brain injury, kidney failure, liver failure, bleeding disorders, placental bleeding, feral death, even horrible burns from falling into the fire. Its supposed to be rare but its happening all round you.
Now this little metaphor of mine may sound like hyperbole, but let me tell you, it is not. Every western Obstetrician who has ever come to Jahun has been as shocked and perplexed and completely dumbfounded by what they have witnessed here as I have been.  Even the doctors from other parts of Nigeria are baffled. It is unlike anything we have ever had to confront before, the great deluge of this appalling and devastating disease that damages and often kills unborn babies and their mothers, and is happening in ways and to women that all our text books say it shouldn’t be. Something is very wrong out here.
This woman started convulsing at home and fell into the fire. Hers is the second such case in a week, of burns sustained during eclamptic fits 
The books say that in developed countries Eclampsia affects about 1 of every 2000 to 3000 pregnancies, but they also say that in developing countries like Nigeria the incidence is much higher –  Ive seen estimates of its incidence in Nigeria at 1:235 to perhaps as high as 1:70. That would mean for Jahun, in a month, about 12 cases  – but yesterday morning between breakfast and lunch time we admitted three cases, and there were already four in the ward from the previous 48 hours - a staggeringly high occurrence rate of such a devastating disease that is truly rare in the west.

These syringes are full of Magnesium Sulfate to be given to our many eclamptic patients

The question that occurs to all of us is why? What is so different about this place that this disease has become rampant?  The truth is we know so very little about the health of this population that we can only guess but we do know that poverty and anaemia are rife, high blood pressure and kidney diseases seem to be common – and these are all risk factors – and genetics are always part of the picture. But most interesting is a theory proposed by  Ray, one of the MSF Obstetricians who was here earlier in the year : he believes that its to do with calcium. We already know from studies in the west that giving calcium supplements to high risk pregnant women reduces their risk of developing the antecedent to eclampsia, a common condition called PRE–eclampsia.  Ray showed in some preliminary studies that the severest Eclamptics – the ones who died  when he was here – had extremely low calcium levels.
They say it mostly happens to women having their first baby, and to younger women, and that is what we observe in Jahun where many of the women are thought to be much younger than their given age of 17 or 18 – being illiterate they don’t actually know their age but many look very much younger than that, perhaps 14 or 15, and the local midwives will say so. But many of the eclamptic women have had one or more babies before and are closer to 30 and according to the texts they aren’t supposed to be fitting. 

One of the reasons for the low calcium, apart from the poor diet is that Islamic women are all covered up. Their skin doesn’t get exposed to sunlight, something which is necessary for the production of Vitamin D, and its Vitamin D that controls calcium metabolism. But it must be more than that – there are covered women all over the world, and most of them are not suffering like these women are. No doubt there would be research scientists interested in pregnancy diseases who would be eager to come here and investigate this extraordinary phenomenon if they knew about it.

Even without the research it would seem that giving calcium supplements to pregnant women out here might help to stem the flow of tragedy. Alternatively, my suggestion would be to ditch the Hijab, get a new religion, get educated and do a bit of sunbathing! Incredible to think that sunlight on skin could be all that’s needed.

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