Dom Rowland emerged from the Indonesian jungle in mid-September this year. The expedition he was with, BRINCC, charted the course of the Barito river on the island of Borneo. They spent six months removed from civilization, recording the flora and fauna of the forests – they even discovered a new species of butterfly. But at the end of the expedition, about three days after leaving the jungle, one of the team, Andrea, fell ill.Although not a doctor, Rowland has an MSc in tropical medicine and was the expedition’s medic. Andrea had been under the weather for a few weeks, and but after a few days in Paruk Cahu, a town in Borneo, she developed fever and bone-ache. Rowland took her to the local hospital, where she was diagnosed with typhoid. But Rowland suspected that her sore bones were not typhoid; typhoid causes a fever, but not such severe joint pain. The doctors in Paruk Cahu refused to even test Andrea for dengue or malaria so Rowland sent her to Jakarta, Indonesia’s capital city. It is a 13 hour trip from Paruk Cahu to Jakarta, but Rowland thought she did not have typhoid, and wanted a second opinion. She had classic dengue fever symptoms, and in Jakarta, she tested positive for the virus.
Dengue fever is caused by a virus. The virus originated in East Africa, and arrived in Indonesia in 1968. Since then, the Aedes aegypti mosquito has carried the disease to every province in Indonesia, and dengue is now considered endemic in most of the country. Dengue is not generally fatal, but can develop to dengue haemorragic fever. DHF has a death rate of around 25 percent.
A few days after Andrea fell ill, Rowland and another expedition member became feverish and developed sore joints. Both went to hospital. Having misdiagnosed Andrea, the hospital in Paruk Cahu “reluctantly agreed” to test Rowland for dengue fever. The test came back negative. It can take several days for the body to develop dengue antibodies, which is what the tests were looking for, but the doctors in Paruk Cahu didn’t take this into account. They diagnosed Rowland with typhoid, and sent him away with antibiotics. Rowland says that giving antibiotics to treat viral infections is “pretty much standard procedure across the whole of Kalimantan [the island of Borneo].”
Over-prescription of antibiotics is a common and serious problem throughout the developing world. When antibiotics are used, resistance develops among bacteria, and the antibiotics become less effective. In the West, we are familiar with screaming tabloid headlines about MRSA. In the developing world, tuberculosis is rife, and strains exist which are now untreatable with antibiotics. Prescribing antibiotics for the viral dengue fever is not only useless, but on a large scale makes other diseases more deadly. Rowland didn’t take his antibiotics, and organised for both him and Mike to travel to Jakarta. There, both tested positive for dengue.
Dengue comes in four strains, or serotypes. It’s generally thought that once you’ve caught one strain, you can’t catch it again. But even in Indonesia’s capital city the hospital didn’t have the DNA sequencing technology needed to distinguish the serotypes. The first step to stopping any disease is knowing where it exists in the first place. Dengue infections sometimes show no symptoms, and as Rowland’s experience demonstrates, are frequently misdiagnosed. Typhoid and flu are similarly widespread and can have similar symptoms, and so confusion often occurs. Despite this under-reporting, dengue and DHF are one of the top ten causes of child death in Asia.
By the time Rowland arrived in Jakarta, he had a temperature of over 40°C (104°F). In hospital, he was put on a saline drip and given twice-daily blood tests.
The doctors in Jakarta fell over themselves to treat Rowland and his friends. They said he was on the verge of developing DHF, and kept them in hospital for four days. On the fourth day, they offered him an X-ray. Rowland smelt a rat. He had a viral fever, not a broken leg, and as far as he could tell the Indonesian doctors were simply trying to find ways to claim money from his Western insurance company. He promptly left, and booked himself into a four star hotel.
Most of Indonesia’s 90 million people do not have Rowland’s medical knowledge or money. Indonesia has a GDP of £2,946 per person, according to the World Bank, less than a twelfth of the UK’s equivalent figure. “We have no health system,” says an Indonesian doctor quoted in TIME magazine. “There is no quality control.” WHO reckons dengue fever costs up to $1.8 billion worldwide in lost work hours, treatment and prevention costs.
Dengue is one of the neglected tropical diseases WHO hopes to eradicate. But if doctors can’t even identify one of the most common diseases in Asia, then WHO’s aim of tracking and stopping the disease seems impossible.