White blood – Authors' reply

With surprise we read the Case Report “White blood: the tip of the iceberg?” by Marlies van Wolfswinkel and colleagues (Nov 28, p 1866). It concerns a woman who was treated in our district hospital, and in the central teaching hospital in Blantyre, Malawi. The report contains a number of fallacies. The initial referral by the “rural district hospital” had in fact been a self-referral. The diagnosis of diabetes mellitus was not established at central level and “recommendations for treatment” were not given. That the woman “did not attend follow-up at her local hospital” is incorrect: she came soon afterwards. We agree that Malawi faces “diagnostic and logistic challenges” to decentralisation. However, contrary to what van Wolfswinkel and colleagues suggest, white blood and deregulated diabetes had already been noticed in our hospital. After starting treatment, we consulted the specialist at central level, who postulated hyper lipidaemia. The reason for subsequent referral was the inability to monitor potassium levels. We provided transport, and applied our “limited means of communication” to ensure adequate transfer of information. Later, our logistics traced the woman at the request of the central hospital. The real challenge at stake is that district health staff had to read much of the outcome in The Lancet, rather than receiving direct communication. If we had seen the report before publication, it would have been more accurate. Academic institutions should recognise district hospitals as essential partners. They must ensure that teaching hospitals take responsibility in providing complete feedback to district staff and include them in the continuum of care.