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).
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