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.
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