One never knows...

One Never Knows…

Friday is supposed to be a relatively light day at the clinic. That is in contrast to the beginning of the week, when there are generally more than 100 patients to be seen on a given day. For example, this past Monday, we had 114 patients, and on Tuesday, 123. Friday did turn out to be a light day, but only for the two doctors seeing the adult patients; not for me, the doctor seeing the pediatric patients.

I don’t know why there were so many sick children that day. What I do know is that the numbers do not tell the real story. That real story lies not in the quantity of the patients; rather, it lies in the quality, although quality might not be the right word to describe what I saw that day.

The day started with an eighteen month old boy with moderately severe pneumonia. His respiratory rate was in the 60’s (normal would be 20—25/minute). We do have a pulse oximeter at the clinic, so that we can measure a patient’s oxygen level using a transcutaneous probe. This little boy’s oxygen level was 88%. In the United States, the child would immediately be placed on oxygen. Here, our limited oxygen supply requires us to use it only when absolutely necessary. In this case, the child was not in the “absolutely necessary” category. If the oxygen level had dropped in the very low 80’s, or certainly below 80, he would have received supplemental oxygen. However, we don’t have enough of the precious stuff to give it on a continuous basis, even to those who need it.

I will interject a comment here about American modern medicine approach in a similar setting. I believe that too often, we treat numbers, rather than patients. Take, for example, a child hospitalized with asthma or pneumonia. The child is attached to a continuous pulse oximeter to determine his oxygen needs. I have no trouble with that, at least not during the acute phase of the illness. It is more a question of what we do when the child gets better. Clinically, we can see that he is better. He is no longer having trouble breathing. Maybe, in the case of asthma, he is still wheezing, but his energy level is back to normal, as is his activity level. Yet we continue to monitor his oxygen level on a continuous basis. We watch the oxygen level rather than watching the child. We base our medical therapy on that oxygen level. We continue to give him oxygen, even when his needs for that supplemental oxygen are questionable. Let’s say, for example, his oxygen saturation drops to 90-91%. Granted, that is not normal, but does he really need the extra oxygen at that point? I say, no, yet most hospital doctors wouldn’t think twice about insisting that he continue to receive oxygen.

We are lucky, because our supply of supplemental oxygen is both cheap and limitless. Here in Burundi, they are not so lucky. Their supply of most things, including oxygen, is limited. That’s why they reserve those things, including oxygen, for those who really need them.

I digress, but it is my blog, and, therefore, I can digress whenever I feel like digressing. Before I go onto the next case, I will give you follow-up on the little boy with pneumonia. He got better quickly, and went home two days later. I stopped checking his oxygen level once it was clear that he had improved.

Now for the next patient of the day. This one will feature some graphic and possibly disturbing photos. I warn you in advance so that, if desired, you can skip to the next section.

A mother came into my office carrying what appeared to be, from the tiny face, an infant. The baby was wrapped up, so that initially, I did not get a good look at her. All patients are triaged before they come to see me. Triage includes, for the children, weight, temperature, length or height, plus various other demographic information.

I looked at the chart. This was a baby girl of three months. Then I saw the weight: 2.5 kilos (about 5½ pounds). I looked at both numbers. This could not be possible: a three month old baby weighing 5½ pounds. Could the baby have been small at birth because of prematurity? Not here in Burundi: premature babies do not survive in Burundi. The survival rate for babies born at less than 30 weeks gestation is essentially zero. That’s when I made the mother unwrap the baby and place her on the table, so that I could examine her.

I have seen many surprising and shocking things in Burundi. This was above and beyond “shocking.” This was appalling. This was as severe a case of marasmus as I have ever seen, and by now, I have seen many cases. What I saw on that table was a baby who was no more than skin and bones. This was a baby who had been malnourished since birth. I could not conceive how this baby was still alive. Nor could I conceive what kind of organ damage had occurred after such a prolonged period without nutrition. The pictures will give you some idea of what I saw on the table that day.

But how had this happened? How could a three month old baby been deprived of food for so long? Breast-feeding is universal here in Burundi. What had gone wrong? Why had the mother not breast-fed? Or, if she had, why was the baby so tiny? And why had she waited so long to bring the baby to medical attention? Couldn’t she see that something was wrong before it had come to this? Anyone could see that this baby was literally starving to death.

Here is the story: the woman with the baby was not the mother. She was a neighbor who had brought the baby to the clinic. This baby was one of twins. I then asked if the other twin was doing better. The other twin was exactly the same. It was unimaginable: three month old twins, both weighing 2.5 kilos. So why had the neighbor not brought the other baby with her? Because she had come from so far away, and she could not carry both twins. (The trip had taken over four hours, partially on foot, partially in the bus). The mother was at home, taking care of the second twin and another child.

But how had the baby gotten to be like that? That was the obvious question. The mother had been unable to breast-feed from the beginning. I have no idea if that was a result of the babies having difficulty latching on, or simply the mother’s inability to produce adequate milk. It matters not, for the point is that the mother did not breast feed either twin.

There is no such thing as formula here in Burundi, except perhaps for the few members of the elite that live in Bujumbura. The cost of any formula would be prohibitive. Therefore, what did the babies eat? They did not have breast milk or formula, so what then are we left with? The answer is regular cow’s milk, and not much of that either. The mother would go to the store and buy what was presumably non-pasteurized cow’s milk for the babies. I have no idea how much the babies took of the cow’s milk, but clearly not enough to make a difference. I also have no idea how she gave the milk because there are no such things as baby bottles here. Did she give it in a cup? With a spoon? I cannot answer that question.

So there we had a baby closer to dead than alive; a baby in urgent need of admission for nutritional resuscitation. We rarely had babies that young on the malnutrition ward, so we would have to make adjustments in the usual protocol. We had no idea at that point what we would do if we did ultimately succeed in reversing the starvation process. What would happen if we did send the baby home? What would she feed then? That wasn’t our problem at that point. All we knew was that we had to get that baby into the hospital as soon as possible.

I am afraid that’s when my story takes an even darker turn. Any baby admitted to the malnutrition ward has to have an adult (usually the mother) stay with him to give the baby the feeding solution provided by UNICEF. We do not have nearly enough nurses to provide that kind of 1:1 care.

The neighbor could not stay, and, in any case, it appeared that the other twin was equally in need of our malnutrition services. There was only one solution: the neighbor would take the baby back to the mother. Then, the next day, the mother would return with both twins. We repetitively made the neighbor promise that she would convince the mother to do so.

The mother has not returned with the twins. It is now five days later, and there is no sign of her. I have lost hope that she will come. If she has not returned by now, she will not return. Is it possible that she took them to another and closer hospital? Yes, but there is no other facility in all of Burundi that does what we do; none that treat malnutrition in a systematized and appropriate way. What will happen? The twins will die. I wish I had another answer, but there is no other answer. I don’t even know if, under the best of circumstances, we would have turned this around. The baby I saw that day was on the abyss of death by starvation. I cannot imagine her twin was any better.

So who is the villain in this tragic story? Who is to blame? There are no villains, only victims. Yes, I believe the mother should have not let have things to deteriorate to this point. Yes, I believe that she should have sought help far sooner than she did. Yes, I believe that she should have brought the twins back the next day in what might have been a vain effort to save them. However, she is as much a victim in this story as the twins. She will lose her babies. No, what is to blame here is abject poverty, and lacking the means to correct what, in a humane world, should be correctible.

Thankfully, we now go to the lighter side of “a day in Kigutu.” I present you now with a photo of a patient and his mother: this is a 15 month old who had to be admitted to the hospital for treatment of a very large abscess in the right upper chest.

I now present you with a photo of the next patient that I saw that day. This too is with his mother. The patient is a four year boy who also had to be admitted to the hospital for treatment of a large neck abscess.

Try to follow this. I warn you that it gets complicated. The two boys that you see here have the same father. The second mother (the mother of the four year old) was the father’s first wife. She divorced him. The first mother (the one with the 15 month old) is the father’s second wife, but both boys live with the second wife. The first wife is HIV positive, and is being treated at the clinic for her disease. She was at the clinic that day coincidentally. She had no idea that her son would be at the clinic that day. However, she subsequently saw the second wife with the two boys. She grabbed her son away from the second wife, and the two of them had to be separated. Neither the father, nor the second wife have been tested for HIV, nor have either of the children. It is a safe bet that the father is HIV positive, but, so far, he has refused to be tested. The mother of the four year old insisted that her son be tested; we await word on whether the second wife feels the same about herself or her son. The two mothers and their respective children will be placed on the same ward, presumably no more than a few feet apart. We anticipate the possibility of fireworks between the two of them, especially if the father shows up to see his children. Drama here in Kigutu. A final word on the situation: I have no explanation why two children in the same family would simultaneously present with large abscesses, other than the fact that living conditions were presumably less than sanitary.