Pictures and stories from Kigutu

Pictures and Stories from Kigutu

I am about to present some of the medical stories of these first two weeks. The stories can only be told with the pictures that accompany them. I give you fair warning that, if graphic medical pictures are not for you, wait for the next blog post, or go back to the previous one.

There is a pregnant woman on the ward, who has been here for a month. She was originally hospitalized and will be hospitalized for the foreseeable future because she needs as strict a regimen of bed rest as is possible in Kigutu. She cannot get that at home, and that’s why she is in the hospital here.

This is her fifth child, and presumably her last. Her previous child was delivered by Caesarian Section. We don’t know the reason for the C-section, but we do know that it was performed at the hospital in Rumonge. I have visited the hospital in Rumonge (more about that in a future blog post). It is not a place you want to have a C-section. It is not a place you want to have any kind of surgery, or any kind of medical care. As Melino said, after we were there last Sunday, “how can anyone get better in a place like this?”

This mother had no choice but to go there (we do not have the facilities to do surgery here). The only possible explanation for her present condition is that the surgeons (and I use the term “surgeons” loosely) omitted one very minor detail after they extricated the baby. They closed the mother’s skin, but did not close her abdomen. They did not suture her abdominal muscles back together, or, if they did, they used dental floss for suture material. The result is that basically, this woman has no abdominal musculature.

What happens if a pregnant woman has no abdominal musculature? Everything on the inside falls out, including the uterus. If you don’t believe me, look at this photographic evidence. That is her uterus, protruding out below her navel.

This is what is known as the ultimate uterine prolapse. If this woman were to stand up, as she has done on occasion, the uterus with the baby inside that uterus, will fall to the level of her knees. I have been told that the uterus and baby swing back and forth like a metronome, as the mother walks. So what will happen to the mother and her baby? Surprisingly, the baby boy in her uterus continues to grow in that prolapsed uterus (Melino has done ultrasounds to document that growth). We will then transfer the mother to another hospital (definitely not the one in Rumonge) when she reaches 35 weeks gestation. It is there that she will have another C-section. Hopefully, this one will be performed more effectively than the last one; that they will close the abdominal musculature this time. Equally hopefully, she will not go into labor before then. If she does, only disaster can ensue. So why not transfer her now? Because no hospital, other than ours, is willing to take her for such a prolonged period of time.

Tuesday, May 24^th: Day 2 at the Clinic:

I saw many children that day. In their own way, they were all remarkable. However, two were particularly remarkable. I present those two.

The first patient was a nine month old little boy who had never previously been to a doctor; at least not to a real doctor. He presumably had been to the mupfumu because he, like over 90% of the children I see here at the clinic, no longer had a uvula.

This child was malnourished, but that was not the reason the mother brought the child to the clinic. Parents here don’t bring their children to the doctor here because they’re worried that their child is malnourished. They bring them in for various symptoms: not eating well; decreased appetite; abdominal pain; diarrhea; constipation; fatigue; and a host of others. The symptoms don’t tell me much. It is only when I see the child that I know that we are dealing with malnutrition. This particular child, however, I knew, even before I saw him. He was nine months old, and weighed nine pounds. It was a given that he was malnourished.

One never gets used to seeing malnourished children. It is always a shock. Sometimes, like the three month old who weighed 2.5 kilos, it is downright appalling. Sometimes, it is merely shocking. This 9 month old was merely shocking. He had thin, little stick arms and legs, contrasted with his large head.

He clearly had to be admitted to the malnutrition ward. But the question was: why and how did he become so malnourished? His mother was still breast-feeding him, but she claimed he was not feeding well. In addition, he had not yet received any other appreciable nutrition other than the breast milk.

It was soon clear why he was not feeding well. He had a major heart murmur that had never been discovered, presumably because the mother had never taken him to the doctor. Mupfumus don’t generally carry stethoscopes. It is hard to imagine that a child in our country would have to wait until nine months of age to be diagnosed with congenital heart disease.

The child was admitted to the malnutrition ward, and started on the malnutrition protocol. The picture you see below is Melino using one of the few diagnostic tools we have here: an ultrasound machine. We do not have the ability to do X-rays at the clinic. As for more sophisticated imaging equipment, there are no CT or MRI machines in the entire country. However, Melino is a wizard with his portable ultrasound machine.

The child’s heart defect consisted of a large communication between the two atria, as well as a malfunctioning tricuspid valve. Despite his heart disease, he did relatively well on the malnutrition protocol. He was discharged from the clinic today. He had gained weight, and looked better. He was sent home with a month’s supply of Plumpy-Nut, the nutritional supplement made from peanuts.

It was more than the child’s heart disease that caused his malnutrition. He was not getting enough calories from the breast milk alone. It is possible that his caloric deprivation can be corrected. It is not possible, however, that the heart disease can be corrected. This child needs heart surgery, and will need it more as he gets older. There is a zero chance that he will have that heart surgery. Such a thing does not exist in Burundi. Therefore, he will ultimately die as a result of his congenital heart disease. I cannot predict when, but I can predict that it will happen. Such is the nature of life in Burundi.

The second patient was a one year old girl who was brought in by her aunt. She was brought in because of facial swelling and decreased appetite. Her weight was about 12 pounds (5.5 kilos): not much for a one year old. Even that weight was deceptive, though, because a significant part of those 12 pounds was due to fluid overload. She was markedly edematous, as you can see by the picture.

I will, in a later blog post, discuss in detail the story of malnutrition in Burundi, as well as the treatment of malnutrition at the clinic. However, some basic information is in order now. There are two types of malnutrition: Kwashiokor, which is due to protein deficiency. The children who have Kwashiokor are edematous, with swollen faces and abdomens, as well as pitting edema of the lower extremities. The other type is marasmus. The children with marasmus have emaciated, pencil-thin arms and legs. The three month old who weighed 2.5 kilos is a dramatic example of marasmus. The children with marasmus suffer from severe caloric deprivation. The two types of malnutrition are not mutually exclusive. Those with Kwashiokor also suffer from marasmus, because they have caloric deprivation as well as protein deficiency. Last year, at the clinic, I saw more Kwashiokor patients. This year, for some reason, I have seen primarily marasmus patients. I cannot explain the reason for this.

This child was classic Kwashiokor. We quickly discovered the reason for her malnutrition. The mother was at term, about to deliver her next child. (She did deliver two days after the child was admitted). That was why she had delegated to the aunt the responsibility of bringing the child to the clinic. The child had been breast-fed until about five months. It was then that the mother had stopped breast-feeding her because of the universal belief here in “la maladie du sein.” The pregnant mother believes that, if she is pregnant, she must stop breast-feeding. If she does not, she will become ill with vomiting and diarrhea. Therefore, this child received no breast milk after five months. She was fed a diet consisting almost exclusively of “bouille,” a kind of porridge made from corn, wheat, and possibly sorghum. However, it is expensive to make, and deficient in protein. It is also a very thick mixture, and an infant of six months or even twelve months can only consume a small amount at a time. It was inconceivable that this one year old was receiving enough calories and certainly enough protein from the “bouille” itself. Proof of that lies in her appearance when she arrived at the clinic.

The little girl was immediately admitted to the malnutrition protocol. Her evolution over the course of the ten days has been interesting. I will show you pictures of her as she has improved. This first picture shows that her facial swelling has diminished.

This last picture is graphic. What you see are the multiple folds of skin, hanging off her legs and back. Those extra folds of skin are the result of the loss of the edematous fluids that she was carrying on her body.

She actually lost 900 grams (two pounds), as a consequence of the successful treatment of her malnutrition. Thus, her real weight on admission was more like ten pounds: again, not much for a one year old. She will be discharged tomorrow, with her one month supply of Plumpy-Nut. After that, we can only hope, as we do on so many occasions here in Burundi.