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Week of March 19:   When we first met Kwame he was sitting quietly on a bench, with his paralyzed legs dangling, while watching other children play. Kwame Yeboah is a 7 year old boy who never received any protection from polio and reportedly had an acute onset of flaccid paralysis, first with one leg and then the other. No polio virus, however, was isolated in his stool and so we needed to investigate to find out what might have happened. We first reviewed his hospital records and then after an hour's drive over dirt, washboard roads we arrived at the village where Kwame lived.  Our first contact was the Community Based Surveillance Volunteer (I'll tell you more about community volunteers later), who led us past mud homes and hovels, many with their walls broken down, until we came to this unsmiling boy sitting on a bench watching other children play.

We questioned the mother for a detailed history and learned that the reason he was brought to the hospital was that he couldn't urinate. Then he complained of pain in his lower left leg and had difficulty walking on it. the day after this both legs became paralyzed. He had only one recorded fever spike. Now he is able to urinate but does not have full bowel control and the paralysis is complete in both legs, including the toes. Now before he had problems with urinary retention he had a boil on his left buttocks, which was painful and evenetuall finally burst, right before his urinary retention symptoms began. On examination he has feeling and deep tendon reflexes, but is unable to control the movement of his lower extremities. 

We don't have access to MRI, Scanners, EMG, etc., and no lumbar puncture was done, not even a CBC and so our diagnosis is merely and educated guess, but perhaps I suspect he developed a subdural abscess from his boil, and the focus of abscess was around the area of his sacral nerves. Then the common Guillain-Barré Syndrome must be included in the rule out, but Poliomyelitis is not high on the list of probabilities.

This the final work of surveillance; Investigating every AFP reported, and there were 265 of them last year.

Holding Kwame for the picture is a CBSV, a Community Based Surveillance Volunteer. One of the programs of the Ministry of Health is to develop and train a volunteer in each community, who will be able to recognize an unusual health problem that needs to be reported and perhaps investigated. This would include polio, AFP, measles, maternal and neonatal deaths, neonatal tetanus, meningitis, yellow fever, yaws, Guinea Worm, etc. The training usually involves two days of interactive participation and providing information. It also means feeding, lodging and transporting the volunteers and presenters, which brings the cost to about $25 a person trained. This is beyond the current financial capacity of the Ministry of Health and therefore the various districts are trying to provide training to a limited number of volunteers and finance it with their anaemic budget, which doesn't even cover the routine operational costs. Many of the AFP reports have originated from the community. Many health problems are first presented to the traditional healers of the village, the herbalists and ritualists and if they are brought to a govenrment health center usually a few weeks later, when the traditional healer is not successful. That is why these volunteers are so essential -- to act as eyes and ears and later on to provide basic First Aid and medication for the most common problems, like malaria, etc.

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