A couple of weeks ago I witnessed the most terrible infection I have ever seen. It also reminded me, in a hardcore fashion, of the difference between living in a Western country or being raised in a low resource environment. What was it about? Dogs, bites, rabies. The bottom-line of this blog? Sometimes life is unfair.
A young boy was brought to the clinic on the Thai/Myanmar border one month after he had been bitten by a street dog. The father had killed the dog immediately, but they hadn’t come to the clinic for care.
I’ve worked for seven years in Dutch hospitals dealing with patients. Some severely ill, some having a hard time accepting they weren’t (frustratingly big group). All these patients have one thing in common; they never worried about costs of diagnostics and treatment. They live in a country where all necessary (and sometimes unnecessary) tests can be done and almost all therapies are paid for.
On the Thai/Myanmar border things are different. Not all the tests and treatments are available, and those that are cost money. Might not be a lot of money in the eyes of the Westerners, but here many families don’t have money. People don’t come to the hospitals because they are afraid of what it will cost, or they wait too long to come.
When the family did come, it was too late. The boy suffered from rabies. A disease that you can’t diagnose until you have symptoms and once you have symptoms, death is inevitable.
Rabies is transmitted from mammals. Usually dogs or cats but also bats and monkeys. They bite you or lick you and the virus goes into your nerve-system, starting its travels towards the brain. When it reaches the brain, it’s over. The whole travel is asymptomatic for the patient and no blood test is helpful. When it reaches the brain, most of the time the patients become highly agitated, raging and the jaw muscles stop functioning causing patients to drool. But the most interesting feature is that they become afraid of water. Yes, really.
When I offered a bottle of water to the small boy after he didn’t drink for two days he turned his head away. The boy was captivated by fear. It was a terrible sight.
There are two ways of preventing rabies; Pre-exposure and Post-exposure. With Pre-exposure you get three vaccines now and if you ever get bitten, go to a clinic/hospital within 48 hours and get Post-exposure vaccinations, no special immunoglobulins injection needed. Post-exposure means you go to a clinic within 24 hours after a bite to get a special immunoglobulins injection, followed by a series of vaccinations. Then you’re ok.
I used to think that the only advantage of the Pre-exposure was that you gain some time. And you can always reach a hospital within 24 hours nowadays, right? So, go Post-exposure… Well, my opinion changed.
Working first in Africa and now here, I see that the immunoglobulines that you absolutely need is very expensive and not available in most clinics. Time is scarce. This means that you have to travel to one of the bigger cities to get your treatment or even fly to a different country. Most of the tourists will be able to do that, albeit with effort and money (and probably nagging about the healthcare system). For locals this is not an option. Immunoglobulins already cost about a month salary here, just like the needed other vaccines. Add the travel costs and the hospitalization costs and families are bankrupted. Families with maybe five or more children. So not only time, also money is scarce. On the Thai/Myanmar border that is a dark and unfair combination.
The boy died the same night that he came to our clinic. A different and conflicting emotion rose, it was a sad feeling of being glad. Glad that the small young boy didn’t have to suffer much longer. That the family didn’t have to suffer much longer. The family didn’t complain, they were calm in the whole situation and they appreciated everything we tried to do, knowing what the outcome was going to be.
What a privilege to get vaccines easily, to get tests done if needed, to be able to get a diagnosis and a treatment within 24 hours if needed. Appreciate what you have, because some don’t have the same privileges. They are one dog bite away from death. And yes, that’s life and it is unfair.