Pictures from Kigutu: Part II

My time here will come to an end shortly. While it is true that soon I will not be physically present here in Kigutu, it is equally true that Kigutu will travel with me wherever I go. It will remain in my heart and my mind forever. The joy that it has brought me, the incomparable experiences, the new friends that I have made will always remain a part of me. But these six weeks in Kigutu are for me only the beginning. I will be back next year to work in the clinic, and the year after that, and... I will be back until I can no longer put that stethoscope around my neck, and do what I love so much to do: be a pediatrician.

I have so much left to say about my time here, and virtually no time to say it before I leave. However, I will say it, and the blog will go on until I say everything that I want to say. But, in the short term, I will be in transit for a few days. Therefore, there may be a gap in blog postings. But don't go away. There is far more to come, and I promise you won't be disappointed by what does come.

I thought that prior to my leaving, I would share a few more pictures with you.

This is a picture of a little boy who had aspirations of becoming a drummer. I think he is well on his way.

This is a group picture of many little boys posing for a picture while the drummers marched off into the distance.

This is the joy that is Kigutu: the drummers drumming and the girls dancing.

This is a a picture of me and my two friends, Elvis and Melino, as I work on my computer. On my left is the little girl with the abdominal pain, whose father had previously sought the help of the mupfumu. She is fine now, and should go home tomorrow.

And, finally, this is "fast hands" Muganga Petero doing what I've always wanted to do: be that little drummer man.

The mupfumu: Part I

The mupfumu are the traditional healers here in Burundi. They refer to themselves as doctors, for they believe that they are doctors. In fact, they believe that they are the true doctors here, the true healers of disease. They are indiscriminate in what they treat, for they treat anything from coughs to cancer; from headaches to back aches to stomach aches to, frankly, any kind of ache. Whatever ails you in Burundi, the mupfumu can fix it.

Is it possible that there are good and conscientious mupfumu? No, it is not possible. It is possible, however, that some of them are more genial and likable than others, but they are all charlatans. They steal money from the people here, money that the people can ill afford to spend. Unfortunately, they have an enormous hold on much of the population of Burundi, and most people here are convinced of the value of what the mupfumu does. Not only does it have no value, but, in many, if not most cases, it is downright dangerous.

It is unknown how many mupfumus there are in Burundi. We know that there are at least ten within an hour's walk of the clinic, but there are presumably hundreds in all of Burundi. It is unclear how one becomes a mupfumu. There is no formal training, nor does there even seem to be informal training. In a number of cases, the job of being a mupfumu is a family business, passed on from one generation to the next. One mupfumu learns at the feet of a relative. That relative could be a father, a cousin, or an uncle. The mupfumu are predominantly male, but there are female mupfumu.

It appears that the mupfumu do have some legitimate knowledge of herbal medicine. However, that knowledge has been corrupted and bastardized into the present state of the practice of the mupfumu business. Do they themselves believe in what they do? Or is their practice simply a cynical attempt to make more money? I cannot answer these questions. Perhaps it is a combination of both. In the end, it does not matter, for what they do is wrong. Now to the details of what exactly a mupfumu does.

The most common procedure that they perform is cutting the uvula. In case you did not know, the uvula is the small piece of soft tissue that hangs down from the soft palate over the back of the tongue. Its shape is similar to a grape. The primary function of the uvula is to prevent food from going in your airway, particularly the nose, when you swallow. The secondary function is for speech articulation and regulation. Obviously, one can function without a uvula. I know that, because most of the pediatric Burundian population that I have seen over these past weeks does function without one. This is a picture of a child I saw in clinic last week. You are looking into the back of her mouth: a mouth that no longer contains a uvula.

Melino told me the story of his own uvula-cutting. He was eight years old at the time, and he was ill with some non-specific illness. Someone came to his house, and told his mother that he would die within 24 hours if she did not take him to the mupfumu. So, off they went to the mupfumu. Who can blame them? If someone tells you that your child will die if he does not go to the mupfumu, you go to the mupfumu.

The uvula cutting was done, as it is always done, with a non-sterilized pair of scissors. The mupfunu inserted a spoon (needless to say, a non-sterilized spoon) into Melino's mouth to catch the uvula as it fell. When the uvula was cut, he caught it in the spoon. The mupfumu proudly held up the uvula in the spoon, and declared, "now, you are cured!" Melino bled profusely from the site where the uvula had been, but fortunately, the bleeding stopped. Melino complained about the pain that resulted from the uvula being cut, as anyone would do.

There is something here called "pili-pili." It is a remarkably hot sauce made from the hottest chili peppers. It is so hot that most people would have trouble tolerating more than a few drops. The mupfunu made a mixture of the "pili-pili" and salt. He insisted that Melino eat an entire teaspoon of the mixture to take away the pain in his mouth. I suppose that it did, for the pain from eating the "pili-pili" and salt mixture caused Melino to faint dead away. He recovered, but did not eat for two weeks, as a result of the pain.

There is much that is both amusing and astonishing in the above story. What is not amusing is the morbidity and mortality from uvula-cutting. Melino has seen five or six children die as a direct result of the procedure, those deaths being secondary to overwhelming infection or extreme blood loss.

Yet uvula-cutting remains standard procedure for most of the patients here. We recently took a poll among the patients on the malnutrition ward. We asked how many of them had gone to the mupfumu to have their children's uvula cut. Of the thirteen patients on the ward, twelve were without uvulas, thanks to their local mupfumu. The thirteenth was going to get it done when she left the unit. In general, the mupfumus cut the uvula when the baby is still an infant, most often between one and two weeks of age. Their justification for doing it then is that it improves the baby's ability to breast-feed. How the absence of a uvula could possibility assist in anything is beyond my comprehension.

Cutting a uvula is one of the most inexpensive procedures that the mupfumus performs. It generally costs between one and two dollars, and, as I have emphasized, that is a considerable sum over here. The monetary impact, however, does not appear to prevent people from doing it. The mupfumus do have a fee structure: the more you can afford, the more that they will do. Let me give you an example of what I mean. This example will also illustrate the pervasive influence of the mupfumu.

There is a well-known patient here on the malnutrition ward named Liesse. She and her mother, Esperance, came to the unit about nine months ago. Liesse was closer to dead than alive when she was brought in by her mother. She was suffering what had to be considered the end stages of malnutrition. She was nine months old at the time, and weighed little more than 7 pounds. The fact that she is now eighteen months old and thriving is a testament to the heroic treatment that she has received here. She was initially stabilized, and then eventually enrolled in the malnutrition treatment protocol.

It turned out that both Liesse and her mother are HIV positive. They are both being treated with HIV medication. The reason that they are both here is that the mother has nowhere else to go. Until she finds a home, she will stay here. The mother has taken on the role of mayor of the ward, for she tries to boss around the other mothers. Every day, we see Liesse scampering around the malnutrition ward in her inimitable half-crawl, half-walk style.

It was about two weeks ago that Liesse developed a fever. The fever was quite elevated, often going as high as 40 degrees, or even higher (104-105 degrees fahrenheit). We were not sure what the cause of the fever was. We tested her for malaria, but the test came back negative. However, because the test is not definitive, we treated for malaria anyway, but, unfortunately, without success. We empirically put her on oral antibiotics, but, again, without success.

It was on the fourth day of the fever that Esperance reverted to her old beliefs. She snuck Liesse out of the hospital one Sunday, and walked two hours down the hill to a mupfunu. Keep in mind that it is only through our aggressive medical treatment that both mother and daughter are still alive.

The mupfunu, of course, was only too happy to have Esperance's business. He diagnosed the problem immediately. He said that Liesse needed a "nettoyage de la bouche." This is a procedure in which the mupfumu cleans the patient's mouth aggressively using his two fingers. The "nettoyage" is considered a success if the patient bleeds. Apparently, Liesse's "nettoyage" was a success because she bled profusely. Fortunately, the bleeding stopped without intervention.

The "nettoyage" is the simplest and the cheapest procedure that a mufumpu performs. It costs about $1.50. The mupfumu told Esperance that Liesse needed other procedures that day. We are not sure exactly what those procedures were; we do know, however, that Liesse avoided the procedures only because Esperance had no more money.

The "nettoyage"was performed by the mupfumu without gloves. After Liesse, there were five other patients waiting. It is a given that none of the mupfumu's procedures are done under sterile conditions. I mention all of this, because Liesse is HIV positive. Therefore, it is certainly possible that, in view of the bleeding and the lack of the most basic standards of medical safety, any one of these five patients could have been inoculated with HIV that day. Need I say more about the dangers of the mupfumu.

Melino was furious the next day when he discovered what Esperance had done. How could he not be furious? We had provided nine months of free, life-saving medical care to both Liesse and her mother. And, yet, at the first sign of trouble, Esperance had gone back to the mupfumu.

This is what we are up against: the public's blind faith in the mupfumu. We are making every effort to destroy that faith. More about those efforts and more about the mupfumu in the next blog posting.

Before I go, the follow-up on Liesse. As you might expect, the "nettoyage" had no effect. Liesse's fever continued for the next four days. Finally, we started her on daily injections of Ceftriaxone, even though we were not sure what we were treating. However, she did get better two days after starting the antibiotics. Whether she would have gotten better without the antibiotics, I do not know. But the point is that she is fine now, back to scampering around the unit in her half-crawl, half-walk style. Just for fun, here is a picture of Esperance and Liesse, as we do our morning rounds on the malnutrition ward.

More pictures from Kigutu

There is so much about this place that I love and that I will miss: the people, the work itself, the patients, the sense of comraderie. But what I will miss as much as anything is the physical beauty of Kigutu. The clinic sits high above Lake Tanganyika, overlooking a vast expanse below. Hilarie, Melino, and I walked up to the top of the hill above the clinic tonight. I took these pictures with my little camera as the sun set. The only sounds we heard were the birds chirping around us, and the noise of the boys playing soccer that wafted up to us from the field below. I felt a sense of peace and tranquility, and downright joy, as I stood there with my new friends. I think the pictures demonstrate that sense.

You may wonder, however, about the large bandage on my left lower leg. I will explain. We went with Melino to a Burundian wedding in Bujumbura last Saturday. (More about that later). It was completely dark when we exited the wedding. Our car waited for us in the street outside where the wedding took place. I had forgotten about the large ditch that ran alongside the road. This ditch became a step that I should not have taken. I fell feet first into the five foot ditch, causing a rather nasty wound to my leg (Just to set the record straight, I had not been drinking). Melino then took me to a private clinic hospital where the wound was expertly cleaned and dressed. I did have to pay for that expert wound care, and the cost of that care was

four dollars. Yes, of course, that will make you laugh. Unfortunately, four dollars is not so insignificant here.

But now to the beauty that is Kigutu. First, you will see a morning rainbow over Lake Tanganyika, after a heavy night-time rain.

Then you will see pictures of sunset over Lake Tanganyika, a vista that I enjoyed with two of my friends. The two are Hilarie, a superb nurse and a lovely person, and Melino, whom you already know.

My only regret is that I do not have a camera sophisticated enough to capture the beauty of the night-time sky. One speaks about the African night-time sky, but to actually experience it is breathtaking: the thousands of stars shining brightly in the dark night, so close that you feel you can touch them. Here it is especially beautiful, because down below on Lake Tanganyika, one can see hundreds of fishing boats, their lights twinkling to attract the fish.

One never knows...

WARNING: If graphic medical pictures are not your thing, go directly to the next blog post. There are not going to be that many, but definitely enough to merit the warning.

I have seen diseases here that I have never seen in my twenty-nine years as a pediatrician. I have mentioned some of those diseases, as, for instance, malaria and malnutrition. But I have seen other diseases and medical problems that have left me almost open-mouthed in amazement. I give you some of them.

1) A 30 year old man who was carried into the clinic last week because of profuse watery diarrhea and severe leg cramps. The diagnosis that was immediately made by the doctors here: cholera. How did they know it was cholera? Because all of the symptoms were consistent with cholera: the watery diarrhea and the leg cramps as a result of losing so much calcium and chloride. The diagnosis of cholera is generally made on clinical grounds. Laboratory confirmation of cholera is difficult, and our lab does not have the means to do it. The treatment of cholera is primarily supportive, meaning giving large amounts of I.V. fluids to replace the patient's substantial losses. This was done, as well as giving a single dose of Doxycycline to reduce the diarrhea. Fortunately, the patient's disease was not in the severe category. Therefore, he recovered without incident. But the point is that one does not expect to actually see a case of cholera.

2) Recently, I saw in clinic a fifteen month old with a mass behind the right eye. The mass had been present since birth, but was getting bigger. It had now grown to the point that it was pushing the right eye forward, as you'll see in the photo below. We did not know what the mass was. I thought, based on the history and appearance, that it might be an hemangioma, but I really did not know. I sent the photographs of the patient to an excellent pediatric ophthalmologist in Los Angeles. She was kind enough to respond quickly, and you will see her response just below the photo.

I looked at the images with some fellow ophthalmologists here and we
agree that he definitely needs to see an ophthalmologist. The mass is
most likely lymphangioma or capillary hemangioma but can't rule out a
solid mass (rhabdomyosarcoma would be less likely but still needs to
be ruled out). Would need imaging (orbital MRI w/ contrast to r/o
vascular v solid tumor would be ideal) to see if solid mass or
lymphangioma/hemangioma. Hope this helps!

What she wrote was, as I said, very helpful. Her suggestion that we do an MRI is completely appropriate. Unfortunately, there are no MRI's, or CT scans in Burundi. That makes it unlikely that we will be able to get the orbital MRI that she requested. The other problem we have is that there are only three ophthalmologists in Burundi, and they are all in the capital city of Bujumbura. Moreover, those three are private doctors, and it is unlikely that, if somehow, our patient can get to Bujumbura, she can pay for the services of any of these ophthalmologists. So what happens next to this patient? I really do not know, nor do I have any means of knowing.

3) A seven year old girl named Olive was carried into clinic by her mother two weeks ago. The history is as follows: she was completely healthy until eight months previously. At that time, she developed neck pain, which lasted for a month. The neck pain disappeared, only to be replaced by severe back pain. The location of the back pain was unclear, varying between lumbar and thoracic. She had lost a significant amount of weight in the ensuing six months, and her back was so bowed now it looked like a semi-circle. When she came into the clinic, she was severely malnourished, her arms and legs pencil-thin. She was unable to stand because, one, she did not have the strength, and two, because the back pain became intolerable when she tried to do so. The pain was radiating down both legs. She brought X-rays with her (we do not have an X-ray machine here). The X-rays had been obtained elsewhere, and were of poor quality. However, we did not see any significant changes in the area that was visualized: the lumbar and sacral spine. Of note also is the fact that Olive did not have a history of fever or cough or any other systemic symptoms (other than the weight loss). She did not have vomiting or diarrhea, nor did she have any other bone or joint involvement. Here is her picture.

So what was wrong with Olive? What disease process could possibly cause this degree of malnutrition and spinal deformity? I can tell you it was not a malignancy. I can also tell you it took several weeks before we had the answer. She was sent to Bujumbura to be evaluated by a neurologist. He put her in the hospital, where he did some blood work, and repeated the X-rays of her back. That was about all he could do, because, as I just mentioned, there is no such thing as a CT or MRI here. The repeat spinal X-rays were initially read as normal. However, they were then sent to a radiologist, which accounted for much of the delay in her treatment. There is only one radiologist in the entire country of Burundi. It was only because we had influence that those X-rays were even read at all. But eventually, that one radiologist read Olive's spinal X-rays. He saw an abnormality in the lower thoracic spine: an area of lysis (bone destruction) in the tenth thoracic vertebra. The diagnosis could be made on the basis of the X-ray and the clinical symptoms and history. Olive has extra-pulmonary tuberculosis, which is also known as Pott's Disease. This type of TB is different than the one we are most used to: the one that affects the lungs. The spine, especially the thoracic spine, is affected. Olive did not have any pulmonary involvement.

I should add that my friend, Melino, made the diagnosis almost immediately after seeing her. However, we could not start treatment until we had radiological confirmation that Olive did indeed have Pott's Disease. The good news is that Olive should do well. She will be on several anti-tubercolous medications for a long time, and she will get appropriate nutritional support. But the end result should be a favorable one.

4) The following picture says it all. This is obviously a woman with untreated goiter. .

One thing that I have noticed here is that the presence of physical deformities does not cause people to shy away from the camera. As you can see, she looks directly into the camera as the picture is taken. One other thing, people here love having their picture taken, especially if you show it to them afterward. I have never had a patient refuse to allow me to take his picture.

There was a possibility for this woman to have surgery last year, but it never happened for unknown reasons.

5) The following story occurred today:

A woman in labor came into the clinic last week to deliver her baby. It was her first baby. She was progressing well, until, for unknown reasons, her contractions stopped. We ultimately had to transfer her via our ambulance to an obstetrical center an hour away, where she could have a C-section, if necessary. She did end up having a C-section, and was discharged from the hospital three days ago.

Today she came into the clinic to have her stitches removed. The baby, now one week old, was, of course, with her. We asked how the baby was doing, she replied, fine, that there were no problems. I happened, simply by chance, to look down at the baby's right forearm. It was then that I knew, despite the mother's claims to the contrary that something was seriously wrong.

We sort of pieced the story together. The mother said that the baby was "quiet" at birth. Perhaps the doctor at the hospital thought that the baby had low blood sugar. In any case, an I.V. was placed in the baby's right forearm, and we think that the baby got a strong solution of Dextrose (probably something called D10) to correct the presumed hypoglycemia. We don't know if they even checked the baby's blood sugar. The I.V. was kept in the baby's arm for two days. We don't know why. Perhaps they gave the baby antibiotics. What we do know, however, is that the I.V. infiltrated into the surrounding skin, causing extensive tissue damage. The damage could have been the result of the D10 not going directly into a vein, but, instead, going directly into the skin itself. The cause does not matter. What does matter is that no one checked on that baby's I.V. No one monitored whether the I.V. had infiltrated. You see the result below. What you are seeing is essentially a burn almost down to the layer of bone.

The mother was told, presumably by the nurse taking care of the baby, that there was nothing to worry about when she took the baby home; that the skin would heal itself over time; that she did not have to do anything with the arm. How was she to know differently? She took the nurse's word at face value. Remember, this is not a sophisticated population. A doctor or nurse tells you something here, you believe it.

I can and do accept many things in Kigutu: the paucity of medical resources, the lack of supplies and medication, the logistical difficulties of providing medical care to the population we serve. But what I will never accept, whether it be here in Burundi or at home in Los Angeles, is bad medical care.This was not just bad; this was a complete, callous disregard for another human being's health and welfare; even worse, this was a newborn baby's health and welfare. This was medical negligence of the worst kind. I am convinced that the baby would have died at home, if not for the fact that, serendipitously, he had not come in today. That wound would have unquestionably gotten seriously infected.

Sadly, it is unlikely that anyone will be held accountable for the actions that caused that baby's wound: neither the nurses who did this, nor the doctors who are ultimately responsible for the baby's care. We will try to find out who did what, but it is unlikely that we will get any answers. Even if we do, what difference will that make? Burundi is not what you'd call a litigious society.

So what will happen to the baby? Surprisingly, he looked well. But what we did today was to immediately start two antibiotics, Gentamicin and Ceftriaxone, via injection. We will also do daily dressing changes to the right arm. I expect, from an infection point of view, the baby will do well. I also expect that he will lose some permanent function in that right arm.

6) This next one is more in the human interest category, rather that medical. I saw a nine month old baby girl in clinic yesterday by the name of Irene Igirineza. She had been brought in by the grandmother because of concern that she was losing weight. The reason that the grandmother had brought the baby in, rather than the mother, was because Irene's mother had died when Irene was only seven months old. We think that perhaps the mother had died of breast cancer, but we can't be sure. In any case, the grandmother had assumed care of the baby. When I say she had assumed care, I mean that she had really assumed care. She was now breast-feeding the baby. The grandmother was now 45 years old, and her youngest child was now twelve years old. That meant that she had not breast-fed for at least ten years. However, there was no doubt that she was breast-feeding; no doubt from the baby's point of view anyway, as this picture shows.

The baby was avidly breast-feeding every chance that she could get. Unfortunately, whatever milk she was getting, (and she must have been getting some, because she was not dehydrated), was not enough. She had lost weight in the two months since the mother had died. Irene was now malnourished to the point that we had to admit her to the malnutrition ward. However, she should do well at this point, and I fully expect a satisfactory outcome. She will need nutritional supplementation when she goes home. The grandmother's milk is clearly not sufficient to sustain her.

A corollary of that story is one that Melino told me. He had taken care of a baby in a similar situation. The mother had died and the grandmother had nursed the baby. That baby had also been admitted for malnutrition. I say that the grandmother was nursing the baby, but it actually may have been the great grandmother. I say that because the woman who was nursing the baby was 80 years old. Of course, you presume that I am making this story up, that it must be apochryphal in nature. It is not, for I saw the picture. However, I think it is a fair assumption that a baby being nursed by an 80 year old woman is not getting a whole lot of milk.

The dancing girls

The following are pictures of the girls' dance troupe. In the first one, they are doing a group photo, posing for the camera. In the second, as you will see, they are actually dancing. The girls are so adorable, and the dancing so touching that it would bring tears to your eyes (it did to mine anyway).

Note: that is Melino in the background, clapping as the girls dance.

The girls have never had uniforms. They had seen pictures of girls from Bujumbura in dance uniforms. For a relatively small price, a certain muganga, who shall remain nameless, purchased them himself. This particular muganga did not do the choosing or the actual buying of the uniforms. Let us just say that he made the appropriate donation. The cliche says that "it is better to give than receive." That cliche could not have been more true for the unknown muganga than it was when the girls put on their new uniforms. You cannot imagine the girls' joy and excitement.

Epitaph for Kevin

I have given you heartwarming and uplifting stories of our successes here at the clinic; dramatic successes like Richard and Fiacre. These were children whose lives we saved. I am proud of those successes, but, in the same vein, I must also tell you of our failures. Today was a failure of the worst kind: a child died today. Was it a failure on our part as physicians? By and large, I think not. The failure today was an institutional failure; a failure of the beliefs that are so much a part of the culture here; a failure that only education and time can prevent in the future. That is not to say that I don't have my regrets on what we could have done differently in this case, and I will come to those regrets. But first the story of Kevin.

Kevin Kezimana, a 14 month old boy, was brought into the clinic six days ago by his mother. She had carried him from her home in Kagoma. The trip, like almost the trips here, was arduous, for she had traveled two hours up and down mountain paths to get to the clinic. She had brought Kevin in for the usual complaints that parents have when their children are malnourished: he wasn't eating; his abdomen was swollen; he had diarrhea; and he had a fever and a cough. I can tell by now, after two weeks of working here, when a child has malnutrition. The malnourished children all have that same vacant look, that same total lack of emotion and animation in their face. Their abdomen is always distended with fluid, and one sees that same fluid accumulation in their faces and their hands and feet.

I have been here two weeks, and I feel that I can diagnose malnutrition in a child. But any physician on his first day here would have known that Kevin had severe malnutrition. Kevin had that lifeless look, that complete lack of energy. He cried occasionally, but it was an irritable cry, as opposed to the strong, lusty cry of a normal 14 month old baby. This was the worst case of malnutrition that I had seen, and also the youngest. The reasons for Kevin's severe malnutrition became instantly clear when I took a brief history from the mother.

The mother was now almost at term with another child (I don't know how many children she has already, but it is a safe bet that Kevin was not an only child. The mother's age would indicate otherwise). She had become pregnant when Kevin was five months old. She had stopped breast-feeding him at that point. Why? Because of the universal belief here in what is called the "maladie du sein," or, in English, the sickness of the breast. What this means is that, if a woman is pregnant and continues to breast-feed her child, that child will become ill; specifically, he will very quickly develop vomiting and diarrhea.

I am not a pediatrician who, when I am home, proselytizes about the virtues and necessity of breast-feeding. I support breast-feeding and I believe in it. However, I do not cajole mothers into breast-feeding. If the mother does not want to or simply cannot breast-feed, I support that decision too. But that is only because there are viable and healthy alternatives to breast-feeding in the United States or any other developed country. A mother can go to the store and pick up a myriad of formulas; any one of those formulas will provide more than adequate nutrition for her baby.

Here in Burundi and in most of Africa, there are no alternatives to breast-feeding. That is why 100% of the mothers breast-feed, often until ages far more advanced than we are used to in the United States. It is common for a child to be breast-fed until the age of two or even older. This does not mean the child is exclusively breast-fed until that age; his diet will be supplemented with food starting at around six months.

This is also why one does not generally see malnutrition in children younger than a year. The breast milk, just by itself, ensures that the child gets adequate nutrition for at least six months. Even after that, it continues to be an important and vital source of protein and other nutrients.

To the best of our knowledge, Kevin's mother breast-fed him successfully until he was five months. We have no reason to believe otherwise. It was at that point, under the specter of the "maladie du sein" that she stopped, for it was then that she became pregnant again.

It is hard to imagine what Kevin's source of protein and other nutrients was over the next nine months. Whatever it was, it could not have been close to adequate. We know that, simply based on Kevin's appearance in clinic six days ago. I will demonstrate graphic evidence of that appearance by showing you a picture of Kevin and his mother in the clinic that day. No commentary is necessary, and, therefore, I will make none.

We immediately admitted Kevin to the malnutrition ward, and he was started on the usual malnutrition protocol. I will discuss in future blog posts that protocol as well as the workings of the malnutrition ward. But what I will tell you now that, in the two weeks I have been here, I have admitted fourteen children for severe malnutrition, ranging in age from one year to nine years. The other thirteen have done well. By three or four days on the unit, they have visibly improved. They became more animated, more interactive, more energetic. Kevin never showed the slightest improvement from day to day.

I made it a point of taking daily pictures of Kevin in order to follow his progression. I show you now the picture from day 3 on the unit. Again, no commentary is necessary.

I don't know why Kevin did not improve. I do know that we could never get an accurate answer from the mother how much he was taking of the F-75 formula (this is the formula that all children receive for the first several days that they are on the ward). If a child is too weak to drink it, then the mother is supposed to give it to the child via spoon or syringe. Was Kevin's mother not giving it? Was he too weak to take it? We don't have an answer to that.

We discussed alternatives every day during rounds to improve Kevin's status. The thought today was that, if he were too weak to eat, we would put a tube down his nose into his stomach, and feed him that way. However, his mother reported later this morning that he was actually taking the F-75 by mouth. That was confirmed by Melino, who discussed the situation with the mother.

It was early this afternoon that I got word that Kevin had suddenly died. There had been no warning. I rushed to the ward to see if anything could be done at that point. What I found, instead, was a lifeless baby laying on the bed, the mother standing by the bedside weeping. I listened to Kevin's chest, desperately hoping to hear even the faintest of heartbeats. I heard none.

I show you now the last picture that I have of Kevin. The picture was taken this morning during rounds. I took this series of pictures because, despite the severity of Kevin's malnutrition, I assumed he would get better just like all the others had. I wanted to have a photographic document of a severely malnourished child getting better.

This picture requires commentary. What you see here is a child with increased facial swelling, especially noticeable around his eyes. This means that his protein deficiency was worsening, rather than improving, causing his edema to increase, rather than decrease, as we normally see.

I sat in that malnutrition ward for several minutes after Kevin had died. I was overcome by a melange of emotions: overwhelming sorrow that a 14 month old child had died; frustration that such an event could happen in today's world; but, also regret that more had not been done to prevent this from happening. I asked myself, as any physician would, should we have done things differently? Should we have put the tube down into his stomach earlier, and fed him that way? I don't know, and I suppose that, in the end, it does not matter.

I do know that we here at the clinic are not responsible for Kevin's death. Malnutrition, and the mythical beliefs that led to that malnutrition (chiefly, "maladie du sein") caused his death. The truth is, that, no matter what we had done for Kevin, a 14 month old human being cannot survive after nine months of completely inadequate nutrition. Too much damage had been done to too many organs. Our short term intervention, as effective as it normally is, could not reverse that damage. The story of the treatment of malnutrition here in Kigutu is a story of triumph against great odds. Yet, one should never forget, and I never will, how precarious life is for the malnourished child. Life is but a slender thread, and that thread is so much more slender for the child who suffers from malnutrition.

Some come from far, others come from farther

Clinic days are from Monday to Friday. The patients all gather at the entrance to the clinic before 8 A.M. They then come streaming in en masse as soon as the rope is lifted. In general, there are between 100-125 patients each day. Below is a picture of about one third of the patients (my camera could not get the rest) waiting yesterday morning at the entrance to the clinic.

I see all the sick children that come into the clinic that day, and they range in age from newborn to 18 years. Each patient that I see comes from triage with the following information: weight, length (height), and temperature. The patient and the parent (usually the mother) sit in one chair, and I sit behind a desk. Elvis, whom you will see in the following picture, acts as my interpreter. The way it works is that I ask a simple question, something along the lines of, "how long has she had a fever?" Elvis then has a lengthy conversation with the mother, lasting anywhere between five and ten minutes. The answer finally comes back in the form of a couple of words, something like, "two days." I often wonder what Elvis and the mother are talking about during those five to ten minutes. However, my role is not to question Elvis, for he is far more than an interpreter here. I am not sure what his defined role in the clinic is, but I am sure that he is essential to the effective functioning of the clinic. I do know that he speaks about ten languages fluently, including Kirundi (the language of Burundi), Swahili, English, and French. Elvis has worked here long enough to have almost as much medical expertise as the doctors, especially when it comes to diagnosing malnutrition. To say that Elvis is indispensable to my effective functioning in the clinic is to not give him enough credit. You see below a picture of Elvis in action, translating for me while simultaneously making friends with the family.

Normally, I see between fifteen and thirty patients per day, with the average being in the low twenties. Yesterday was a typical clinic day: typical both for the number of patients seen as well as for the types of diseases those patients had. Here is the list of those patients:

1) Two year old girl with malaria and pneumonia: treated with oral Quinine and Amoxicillin

2) Four year old boy with malaria: treated with oral quinine

3) Eight year old boy with intermittent jaundice: probably secondary to what is called "hemolysis," which is rapid breakdown of red blood cells: treated with supplemental iron

4) Eight year old girl with fever and cough: diagnosed with pneumonia and treated with oral Amoxicillin

5) Five year old boy with presumptive malaria (not proven): treated with three day course of Artesunate-Amodiaquine

6) 16 month old girl with diarrhea, possibly due to parasitic infestation: treated with Albendazole, an anti-parasite medication (used very frequently here)

7) 11 year old girl with abdominal pain, possibly secondary to parasitic infestation: treated with Albendazole

8) 15 year old girl with abdominal pain for one year: possible gastritis or heartburn: treated with a medication called Omeprazole (used for gastric reflux)

9) 3 year old boy with cough and fever: diagnosed with pneumonia: treated with Amoxicillin

10) 18 month old boy with diarrhea, decreased appetite, and abdominal swelling: diagnosed with severe malnutrition and admitted to malnutrition ward at the clinic

11) 5 year old boy with scabies: treated with Benzyl Benzoate

12) 1 year old girl with otitis media (ear infection): treated with oral Amoxicillin

13) 1 year old boy with severe eczema: treated with Hydrocortisone Cream

14) 4 year old girl with infected scabies: treated with Benzyl Benzoate and Amoxicillin

15) 9 year old boy (sibling of above patient): also had infected scabies: same treatment

16) 7 year old boy with weight loss: diagnosed with severe malnutrition (weight on admission for this 7 year old was 24 pounds) and admitted to malnutrition ward

17) 12 year old girl with malaria and vomiting: admitted for I.V. Quinine, because she could not tolerate the oral medication

18) 15 month old boy with mass behind right eye: diagnosis unclear: sent to ophthalmologist in Bujumbura (more about this one in a later post)

19) 18 year old girl abdominal pain for two years: possible infection with a bacteria called Helicobacter (which is common here): treated with antibiotics and Omeprazole.

There was a twentieth patient that day, but this patient requires special comment. This was a two and a half year old girl with mumps. I have posted the picture below. It shows one side of her face, but the other side is exactly the same. I have never seen a case of mumps, although there is now an outbreak in the United States. So, then, you may ask, how do I know that is mumps? Because there is virtually no other disease that causes bilateral, symmetrical swelling of the parotid glands. I also know that they do not vaccinate against mumps here. They vaccinate for measles, but they cannot afford the MMR vaccine that we use at home. Thus, they logically chose to vaccinate for the most dangerous of the three, measles.

The girl with the mumps will be fine, but we warned the mother that other children in the family may also get mumps.

The list of diseases that I saw yesterday is extraordinary. But what is even more extraordinary is how far the patients traveled to get to the clinic. I made a point of asking Elvis how far they did travel, and here are the answers. Remember, the times quoted are one-way, and refer to travel on foot.

1) One and a half hours

2) Three hours

3) Two hours

4) Four and a half hours

5) One hour

6) Two and a half hours

7) Two hours

8) Two hours

9) Four to five hours

10) Two hours

11) Two hours

12) Two and a half hours

13) Two hours

14) Three hours

15) Two hours

16) Three hours

17) One and a half hours

18) Two days: five hour walk, followed by a bus ride of two hours. Stayed overnight somewhere, and then three hour walk in the morning (the patient is the girl with two years of abdominal pain)

19) Six-seven hours

20) Two hours

But is not just the distance that these patients travel that is so impressive. It is the difficulty of the walk itself. I now know from experience how difficult that walk is. Last Saturday, I, along with Melino, Brad, and Peter made an approximately hour and a half walk up the mountain adjacent to the clinic.

Granted, I am much older than most of the patients who make that walk. Granted, I am not a native here, and therefore, not accustomed to hiking up and down mountains. However, I exercise virtually every day, and I consider myself to be in relatively good shape. Even more importantly, on my walk, I was not carrying an ill, or even a well child on my back when I made the trek.

The climb itself is arduous. The path that one takes is no more than 12-18 inches wide. It is a dirt path, filled with large and small rocks. At many points, it is simply rocks, no dirt. The footing is treacherous, and the climb uphill is very steep. At many points on that path, one is ascending at a 45 degree angle, maybe even more.

I made it to the top of that mountain, but not without a struggle. I was overjoyed that I did, one, because of the sense of accomplishment, and two, because the view it afforded was spectacular. Case in point: three of us enjoying that view.

Yet the trip up the mountain was easy, compared to the trip down. Each step down was a step that carried the risk of disaster. The walking stick that I carry in the photo is not for show. Without that stick, I would have tumbled head over heels countless times. Even with the stick, it was only the presence of Melino behind me that saved me from falling several times. He was the one who caught me as I was going down. The following picture shows us going down the mountain. It may give you some idea of what I am talking about.

I did that three hour walk in the middle of May. The rainy season had almost come to an end, and it was dry that day. The rainy season here is nine months: from September to May. I cannot imagine how difficult that walk must be in the rainy season. It must be like one gigantic slip and slide, and I am sure the descent would be even more treacherous than the ascent. How does a mother carry one, and often two children, and still traverse that terrain under those conditions? I honestly don't know.

But, of course, they do, and I saw it first hand. There were many mothers that day going up and down those mountains with children on their backs. Perhaps the most dramatic of these was a mother carrying her one week old baby on her back, as she made the three hour journey to her home.

I made it up and down one mountain that day, and I have made it clear how difficult that journey was. Yet, my trip was easy compared to the trip that many patients face. They must traverse two, or even three mountains to get to the clinic.

So why then do our patients travel such long distances to come to the clinic? Is it because there are no other doctors in Burundi? No, there are other doctors, and some are in much closer proximity to these patients than we are. So why not go to them? Is it because we are basically a free clinic? We do not charge for doctor visits, nor do we charge a patient for being in the hospital. The only thing that we do charge for is certain medications, but only if the patient can afford to pay for that medication. They pay what they can, based on what would be considered an honor system.

I believe that the financial aspect is only a small part of why patients travel such long distances to see us. I have asked several patients this very question, and the answers they gave are very interesting. Take the mother of the 18 year old girl with abdominal pain for two years. Why did she make a two day journey to see us? Her answer: because the word is that "people come here and get healed." Another mother who traveled a similar distance said that she does not like to go to other doctors. Those other doctors don't listen; they write prescriptions for medication even before you finish telling your story. But here at the clinic in Kigutu, the doctors listen, they ask questions, and they examine the patients. And, finally, today I had a patient who came from an area near Tanzania. She carried her 18 month old on her back, and her five year old daughter walked beside her. Her journey consisted of the following: two hour walk, followed by two hour bus ride, followed by two hour walk to a town named Mugara, overnight in Mugara for the three of them, and then two hour walk this morning to the clinic. When I asked her why she had traveled so far, her response was that she had been to our clinic before, and she could trust the doctors here. She could not trust other doctors that she had seen.

I suppose then that, in the end, no journey is too long, no trek too arduous to get quality medical care. And that is what we do here: provide quality medical care under humane and compassionate conditions. That is very much the exception here in Burundi, as you will graphically see in future blog postings. What I will tell you then you will find hard to believe.

One more point before I go. How do I satisfy the needs of a mother who travels two days to see me so that I can "heal" her 18 year old of her abdominal pain of two years duration? I probably cannot, but, at least, I can listen. I can ask the appropriate questions, and I can examine the patient. I did all of those, and found nothing seriously wrong with the patient. So what did I do then? I am not in the habit of prescribing medication simply to prescribe medication. Yet I felt that I had to do something to justify this mother's faith in me, as well as to justify the distance that she had traveled. Therefore, I gave her medications to treat gastritis and acid reflux. Will those medications help? Did they help? I will never have the answers to those questions, but I am confident that I did no harm. Thus I followed the dictum that we, as physicians, must live by, the dictum that says "primum non nocere" (do no harm).

News and notes

It is time to bid adieu to someone who has become an old friend of yours over the last ten days. His name is Richard, and he went home yesterday. He is cured of whatever he had, and he is fine. Before he goes, I thought you might want to see two pictures of him before he left the clinic. You can readily see that he is a happy, healthy, not to mention beautiful baby.

Now, on to other events.

Last Sunday morning, the baby girl that you see in the following pictures was born in the road leading up to the clinic. The pictures were taken approximately 30 minutes after the birth. The baby still had several leaves on her body when the mother and baby arrived in the clinic. The mother was brought in on a wicker stretcher after she delivered. The cord was then cut, and the baby was cleaned off. The Burundian method of tying off the cord is as follows: two strings tightly around the cord, and then the abdomen is wrapped in gauze. If the mother is still present in the clinic the next day, the gauze is changed. If not, which is more likely the case, the gauze is ultimately removed by the mother at home.

This baby is small: a little bit less than 4 pounds. The mother is 20 and this is her third child. She did not know her due date, but we thought that the baby was delivered at term. I was called immediately to examine the baby, which, as you can see by the pictures, I am doing. The baby appears to be doing fine, and the physical exam, despite the baby's small size, is normal. The mother, as you can see by the picture, breast-fed the baby immediately. There may be something to be said for the Burundian way of delivering babies. Not a lot of fuss, and fancy technology. I don't think they go to a lot of Lamaze classes. I also don't think they need to go to a lot of Lamaze classes.

The mother and baby went home the next morning, both in good condition. The grandmother of the baby came to the hospital to help the mother take the baby home. The grandmother, age 42, was herself pregnant with her tenth child. Her daughter, the mother of the baby, seems to be on the same path: three children by the age of 20. (Much more about the family situation in Burundi in future blog posts).

Obstetrics is, as you might expect, much different here than at home. Melino is our Kigutu obstetrician. It is he who is responsible for seeing the pregnant women for their prenatal visits. Those prenatal visits usually start late in the pregnancy. The vast majority of the women who do prenatal care here at the clinic do not deliver at the clinic; they deliver at home. Melino sees about 100-125 pregnant women per month. However, the average number of deliveries at the clinic is only 4-5/month. As you know by the size of the families here, that number is infinitesimal compared to the number of deliveries that occur on a monthly basis in the community.

So what then is the point of seeing doing so many prenatal visits if so few of those women deliver at the clinic? For the simple reason that Melino can identify the women at risk during pregnancy. He will then do an ultrasound on those women to determine if there is indeed a problem and the nature of that problem.

As an aside, Melino is a magician with his portable ultrasound, and loves doing them. At a moment's notice, he will ultrasound any organ that needs an ultrasound, the heart being his favorite. I have seen him take more than an hour doing a cardiac ultrasound, gathering all the data that he needs to gather: visualizing all the heart valves and assessing cardiac function. During the entire procedure, the patients lay there completely immobile, not saying a word, never protesting the length of time that the procedure takes, never questioning Melino as he does his work.

Returning to my story: if Melino determines that there is a problem with the pregnancy, he can then refer to an obstetrical center at Rumonge, a town an hour away (remember, all distances quoted here are distances on foot). There is no such thing as a Caesarian section at the clinic, but a C-section is possible at the center in Rumonge. However, if a woman in labor comes into the clinic, and it is determined that the baby is in breech presentation, there is no other option but to deliver that baby vaginally here at the clinic. It would be impossible to transport her to another hospital, even one relatively close, like Rumonge. That is why Melino has delivered countless numbers of breech babies, even footling breeches (the worst kind), vaginally. Moreover, he has done so without complication.

I give you now an example of prenatal care in Kigutu. This is an example that occurred yesterday. A woman in the ninth month of pregnancy was admitted to the clinic approximately ten days ago for pre-eclampsia. She is 35 years old, and having her eighth child. The reason she was admitted was because she had significant edema of the lower extremities, as well as protein in her urine. Her blood pressure over the ten days in the hospital remained stable, and the edema gradually improved with bed rest. She wanted to go home at that point, and it was decided that we could safely discharge her.

Melino performed an ultrasound prior to her discharge to determine if there was a problem with the baby. What he found was that the baby was in the breech position, with the head in the upper left part of the abdomen, and the baby's body curling around so that the feet ended up in the lower left part of the abdomen. The estimated size of the baby, according to the ultrasound, was somewhere between 8 1/2 and 9 pounds. In view of the baby's size, there was no chance that he would turn so that he was in the normal vertex position.

Melino strongly recommended that the mother go to Rumonge in order to be admitted to the obstetrical unit there. He was concerned on two fronts: one, that vaginal delivery would be difficult with a large baby in that position; two, that, this being her eighth delivery, her uterus had been so weakened by previous births that she risked uterine rupture during a vaginal delivery. A uterine rupture would be an almost certain fatal complication.

The mother refused Melino's advice. She insisted on having the baby at home. And the reason for her refusal? She had seven children at home who had already been without their mother for ten days. But what about her husband, you ask. Couldn't he take care of the children during her absence? Apparently not. That's because he, the father of her present child, had another woman with whom he had three children, plus another on the way. He was living with the other woman at the time.

So what had happened during those ten days that the woman was in our clinic? Who had taken care of the children? She had older children, including ones who were fifteen and eighteen; presumably, they had taken care of the little ones when they were home. However, during the day, the older ones were in school, leaving a seven year old, a four year old, and a two year old to take care of themselves during that time that the older ones were in school. The father had stopped by occasionally to make sure that no harm had come to the little ones. However, he had not done so on anything like a regular basis.

Now one understands the mother's motivation to remain at home for the remainder of her pregnancy. Fortunately, after much cajoling and insistence, Melino was able to convince the mother to go to the hospital at Rumonge. She was taken there in a car, and she will be there until she delivers.

So what will happen to her small children when she is away? Nothing has happened so far, so, hopefully, nothing will happen in the future. I am sure that you find it hard, if not impossible to believe that one could leave two, four, and seven year old children to take care of themselves for an extended period of time. I do not, not here in Burundi anyway. I have seen many small girls, no more than six or seven year old themselves, carrying around smaller children on their backs or hips. I can only assume, based on this, that a six or seven year old Burundian child can take care of a two year old. I hope so anyway.

I do not believe in miracles, but...

My daughter asked me yesterday if there was a triage system in place in the clinic, meaning do the more urgent cases go to the front of the line? Yes, absolutely. Case in point: a nineteen month old little boy by the name of Fiacre Magishsa.

Fiacre was carried into the clinic yesterday morning by his mother. The triage nurses took one look at him, did vital signs, and immediately brought him to see me in my office, which also serves as my examining room. The history, which we obtained very quickly, was that the baby had a two day history of fever and diarrhea.

The reason we took that history so quickly was that this little Fiacre may have been the most acutely ill baby I have ever seen. The only frame of comparison I can give you is Richard, whom you all know so well by now. I do not exaggerate when I tell you that Fiacre was far sicker than Richard.

Fiacre had a continuous high-pitched irritable cry, like when you step on a dog's tail. He was virtually unresponsive, reacting only occasionally to painful stimuli. His pupils reacted to light, but were completely unfocused. He had what is called nystagmus, meaning that his eyes darted back and forth, both in a horizontal and a vertical direction. Every few seconds, his legs and arms would stiffen spasmodically. This is what is known as posturing. We could not be sure, but Fiacre might also have been having seizure activity. All of these signs: the unresponsiveness, the acute onset of nystagmus, the posturing, the possible seizure activity all indicated to me that Fiacre had suffered some gross neurological insult. Or, perhaps, he was in the process of suffering some gross and irreversible neurological insult.

The other doctors, Melino and Bazile, and several nurses immediately joined me in the resuscitation process. My first thought was that Fiacre had overwhelming bacterial meningitis. Fiacre was placed on the examining table, at which point he proceeded to have profuse watery diarrhea several times. A spinal tap was attempted in order to determine if he had meningitis, but, unfortunately, the spinal tap was unsuccessful. Fiacre did not react, or perhaps reacted minimally to the painful stimulus of a needle being inserted in his back; that needle being inserted not just once, but several times in a vain attempt to get spinal fluid.

We knew that Fiacre had to have some infectious process that was affecting his brain. The two most common causes here would be meningitis and cerebral malaria. In cerebral malaria, there is acute swelling and inflammation of the brain, but the exact pathophysiology causing that swelling and inflammation is unknown. The possibility that Fiacre had meningitis dictated that, even without the benefit of having spinal fluid to analyze, he be given an intramuscular dose of Ceftriaxone, the same broad spectrum antibiotic that had been given to Richard during his resuscitation.

What we did next is not recommended, according to several tropical medicine books, because it has no proven benefit. What was more pertinent to us, though, was that it had no proven risk. At that point, we felt that we had nothing to lose. Therefore, we gave Fiacre an injection of corticosteroids to hopefully reduce the swelling and inflammation in his brain.

The nurses, who are extremely expert here in getting I.V.'s into the smallest of veins, made several unsuccessful attempts to get an I.V. into Fiacre. Fortunately, as with Richard, we did not have to go the intra-osseous route. One of the nurses shaved off what little remaining hair that he had on his head (as an aside, you probably will notice that the vast majority of the Burundian children, both boys and girls, have shaved heads. This is done for practical, not cultural reasons: to avoid lice and fungal infections of the scalp).

A tourniquet was placed around the top of Fiacre's head to access a scalp vein. One of the nurses was able to get an I.V. into one of the scalp veins. Cerebral malaria, one of the two diagnoses we were considering along with meningitis, often causes hypoglycemia. Therefore, Fiacre was immediately given fluid containing glucose through the I.V. He was then given a large dose of I.V. Quinine, the medication that is used here to treat malaria.

There was absolutely no change in Fiacre's neurological status over the almost three hours that we worked on him. If anything, he seemed to worsen. That ominous neurological activity, the posturing, the non-responsiveness, persisted. Moreover, his breathing became somewhat irregular. His heart rate remained steady, but I was, at that point, extremely pessimistic about his chances of survival. In fact, I thought the end would come very shortly. There was no way that he could recover from whatever gross neurological insult that he had suffered.

It was felt that Fiacre, despite his extremely tenuous condition, could be moved into the hospital ward, an open room with ten beds. There is virtually no separation between the beds on the ward. In the United States, Fiacre would almost certainly have been admitted directly to the ICU, where he would have been under constant surveillance with 1:1 nursing care (meaning one nurse to a patient). In Burundi, such a thing, of course, does not exist. Instead, Fiacre was on a ward with one nurse taking care of ten patients, and that nurse was generally not present on the ward. So, basically, Fiacre was for the most part unobserved by any medical professional the majority of the time.

I felt that even the most skilled and vigilant of nursing care would have made no difference for Fiacre; simply put, the child was going to die. Over the next two hours, I checked on him every five to ten minutes. There was no change in his condition, his neurological status showing no improvement.

There was nothing I could do at that point. All that could have been done had been done. Fiacre had been given all the medication that we had at our disposal. Therefore, I went back to seeing patients in the clinic. It was about an hour later that I was informed that Fiacre was sitting up in bed, wanting to eat. I rushed into see him, and it was indeed true: Fiacre had pulled the I.V. out of his head, and he was indeed sitting up, wanting to eat.

Two days after that resuscitation effort, Fiacre remains fine. He will be here for a while, because he was suffering from malnutrition, in addition to being acutely ill. Therefore, we have to treat both the malnutrition and the illness, whatever that illness may have been and is now.

Just so you know that I was not alone in my assessment of the situation, I asked Melino later that day if he thought the baby was going to die. He said, absolutely, yes, that his neurological status was so ominous that he thought there was no chance of recovery. So how and why did Fiacre get better. Was it the Ceftriaxone? Was it the steroid injection? The I.V. Quinine? The I.V. glucose? Was it a combination of all of these? Who knows? Perhaps there was some unknown factor that came into play. All I know that his cure was not a miracle. Rather, I believe that whatever we did in that resuscitation room made Fiacre better. What exactly it was we will never know, and that's fine. The salient point is that Fiacre is better, not how he got there.

I show you below a picture of Fiacre taken yesterday. I will warn you in advance that he is a much more timid child than Richard, and not as playful. Therefore, you may not be as charmed by him as you were by Richard. Also, you should remember that Fiacre is still suffering from malnutrition. But the point is that Fiacre is cured from whatever he had, and I think you can see that in the picture.