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.