The extraordinary becomes the ordinary

There is never a day without a medical surprise here: some medical entity that I have never seen; some disease that I only read about in one of my textbooks in medical school. For instance, before I came to Burundi, I had never seen in my twenty-five years of practice nor in my three years of pediatric residency a single case of malaria or true malnutrition. Yet, in the one, short week that I have been here, I have already seen countless cases of both malaria and malnutrition. Not only have I seen them, but I have treated them. But there have been other medical entities and diseases which are completely new to me. I give you two such cases, both of which occurred on Thursday, April 29th.

The first was the thirteen year old boy with an amebic abscess of the liver, who is now on I.V. Metranidazole (Flagyl). This is a boy who had previously been seen by Dr. Basile here and referred to a medical center in Bujumbura for evaluation of an enlarged liver. An ultrasound was performed in Bujumbara which showed a cyst or abscess in the middle of the liver. The child returned to the clinic for further evaluation and treatment. In the United States, many more tests would have been done to identify the nature of this cyst or abscess. In Burundi, no further tests were needed (or, even if they had been, they would not have been available; not here in Kigutu anyway). The diagnosis here was evident. Any cyst or abscess in the liver, by definition, had to be an amoebic abscess (an abscess caused by the amoeba parasite, which localizes in the liver). The child was immediately started on I.V. Metronidazole (Flagyl), and is doing well.

The second was not unusual in terms of the diagnosis itself: an inguinal hernia, of which I have seen hundreds. What I have never seen, however, is an inguinal hernia of this size. This was the King Kong of inguinal hernias, the "can you top this" inguinal hernia. The patient in question was an approximately 40 year old man who must have had this hernia for years, but never got it repaired. What made him seek medical attention now is not clear. I have to imagine it was because of increasing discomfort. The hernia was the size of cantaloupe, maybe even a honeydew. It was reducible, meaning that he could, with a great deal of effort, put it, or most of it anyway back into his abdomen. He was referred to a surgeon, but, unfortunately, like many people here, he was destitute. Therefore, he could not afford the surgery. What will happen to him is not clear. He is, at least for the moment, the victim of the Burundian medical system (and far more about that in later blog posts).

However, neither of these patients won the "patient of the day" contest that day. That honor goes to an 17 month old little boy named Evrine Nihagaritse. His diagnosis here, as I have quickly learned, was not unusual. He was diagnosed with severe malnutrition, and admitted to the malnutrition ward of the hospital. What was unusual, though, was what I would call the family situation.

This little boy was brought in, Burundian style, meaning wrapped in a sash on the back, by his aunt, age 13. Accompanying the aunt was the boy's father. Try to follow now, because it gets complicated. The father was also the boy's great grandfather, and the grandfather to the aunt. If you're thinking incest, don't. The explanation was that the baby's father and simultaneously great grandfather had four separate women (we won't call them wives), one of whom was deceased. Those four women had borne him a total of thirty-five children, and I have no information on how many of those children were still alive. The mother of the baby in question was unable to bring her son in herself, because she was both sick and pregnant with the father's (aka the great grandfather's) 36th child. The father, when asked, could not remember the name of his son who was being admitted for malnutrition. I suppose, if one has 35 and soon to be 36 children, one has a logical explanation for not remembering the name of a given child. We asked the father how old he was, and he said he didn't know exactly, but he thought he was somewhere between ninety and one hundred years old. I now show you a picture below of father and child. You be the judge of the accuracy of his report.

You may question the veracity of the entire story, but I, for one, do not. I have been here long enough to know that it is possible for one Burundian man to have four women that bore him thirty-five, and soon to be thirty-six children. Could that same man be 90-100 years old, and continue to be capable of impregnating a woman? I find that hard to believe, but who knows? This is, after all, Burundi.

The story is for all of us both shocking and amusing. However, it illustrates one of the most salient points of life here in Burundi: the virtual absence of effective family planning. But far more about that issue in future blog postings.