Letter to the Editor


Dear Editor,

The above article by David Attwood and Stephen Raimon is excellent and very relevant to the said environment. There are lots of questions I would have liked to ask but to keep the spirit of research alive I would like to settle for a few.

My questions are:


  1. Were the authors involved in the patient care from April to July 2011 inclusive? If not do they think daily basic clinical teaching on the ward round would have made a difference even without the protocol and the intervention part of which was bed side teaching? If yes what had gone wrong before the audit?
  2. According to the authors’ introduction malaria was “the leading cause of mortality in the Medical Department of Juba Teaching Hospital (JTH)”. There has however been a report in 2006 suggesting malaria may not be the leading cause of death in the very same setting but worse resources in time (2). Would they kindly give a reference?
  3. The pillars of Malaria Control Program are reduction of transmission, reduction of morbidity and reduction of mortality (3). The authors reviewed 50 (fifty) case notes in July 2011 and 40 (forty) in December, 2011 but did not report on fatality the very primary outcome of managing severe and complicated malaria (4). They recommended as number 1 “A mortality study to assess the impact of the restructure on malaria related death”. Was there any study limitation for their omission? Now that they have missed a “golden” opportunity, against what would they assess the impact of the said restructuring?




1. Attwood, D; Raimon, S. Management of Malaria at Juba Teaching Hospital: a Clinical Audit. SSMJ; 5(3): 56-61.

2. Tombe, M; A report and sequelae of a specialist volunteer physician: SSMJ; 5(4): 92-95.

3. Ministry of Health. The Goal of Malaria Control in Uganda: Uganda Malaria Control Strategy

2005/06 – 2009/10: 26.

4. Government of Southern Sudan. Severe and Complicated Malaria. Prevention and Treatment Guidelines for Primary Health Care Centres and Hospitals; 2006: 95-101.


 Yours faithfully,


Dr. Martin Tombe M Med (Medicine)


Specialist and Consultant Physician

Letsholathebe II Memorial Hospital Maun, Botswana

Email address: [email protected]


Dear Dr  Martin Tombe,

In your letter you asked a number of questions. My responses correspond to the three points:

1. The authors were not involved in patient care from April to July 2011. In our opinion, basic clinical teaching would not have made a difference because patients with malaria were dying because of complex multifactorial system failings, of which training was one aspect. There were no drugs, patients were not being clerked on admission so the diagnosis was often missed, nurses were not giving the medications, and there was no HDU for patients needing oxygen and monitoring. Most significantly, there was poor motivation and morale amongst the staff, who needed empowering. Training alone would not have bridged this gap. In fact, without addressing the other issues no one would have attended training.

2. The Malaria Consortium has demonstrated through research that malaria is “a leading cause of mortality in South Sudan and in the under five age group is the biggest cause of mortality” (ref: http://www.malariaconsortium.org/pages/sudan_sudan.htm). In 2008 myself and James Ayrton analysed the mortality data for Juba Teaching Hospital (A retrospective analysis of mortality distribution at Juba Teaching Hospital, SSMJ Feb 2009) and although it is not in the study It was evident that malaria was the leading cause of mortality. I also ran a mortality study alongside the malaria study and I would be happy to supply the draft figures which show that malaria was the leading cause of mortality in the Medical Department. I never published the data because I left a month after our audit and although I could demonstrate an improvement in malaria care, the study was too underpowered to demonstrate an improvement in mortality, especially when allowing for confounding variables such as the dry season.

3. Our work was an audit not a mortality study. I completely agree that it would have been extremely desirable to combine this audit with research that demonstrates a reduction in malaria mortality. However, there were serious issues with data collection due to poor note-keeping (an assessment and diagnosis of the patient were seldom mentioned) and archiving. This was not rectified until we had completed a comprehensive overhaul of the medical department, which included better note-keeping. In my opinion an adequately powered study would have taken one year to complete and as I was there for four months it couldn’t be done.

I hope this helps with your enquiries.

Dr David Attwood (BM BSc MRCP PGCertMedEd)

Specialist Registrar in Stroke Medicine and Care of the Elderly, Torbay Hospital, Devon UK

Email: [email protected]