Day 1 (continued)

We were still on Day 1 at the clinic when I temporarily interrupted my account to publish my most recent blog post. Now back to that first day. We continued on our rounds uneventfully until we came to the malnutrition ward. I will remind all of you, both new and old to my blog, that we have, here at the clinic, an entire ward devoted to the treatment of severe malnutrition. I am not referring to the type of malnutrition that is a fact of daily life in Burundi; I am referring, rather, to the life-threatening malnutrition that is all too common here in Burundi; malnutrition which dehumanizes the child afflicted with it; malnutrition which is an omnipresent blight on the world in which we live; malnutrition which is always shocking in its appearance; malnutrition which we should be ashamed that it still exists on such a global scale. But it does exist, and the patients that this clinic serves are fortunate that our malnutrition ward is there to serve them. That ward is the only one of its kind in Burundi, and one of the few in all of East Africa. It is a given that there is a need for many more such wards, but it is an equal given that socio-economic conditions prevent their existence.

The VHW malnutrition ward can theoretically accommodate as many as twelve patients. I say “theoretically”, because, if conditions demand, the ward can accommodate more patients. Conditions often do demand exactly that. I have only been here one week, and I have already admitted ten patients to the malnutrition ward. Those ten patients will stay on the ward an average of 7-10 days. It is only after those 7-10 days that they can safely be sent home. It is easy to understand why the ward is almost always full, and sometimes, more than full.

The patients on the malnutrition ward that first morning were in varying stages of treatment. I show you one of them.

This is a nine year old girl who weighs 12 kilos (about 26 pounds). She has acute malnutrition grafted onto chronic malnutrition. That is why she is so small. You can see her face, swollen with the edema typical of the Kwashiokor type of malnutrition. This girl is not your typical malnutrition patient, for she has other, serious medical problems. She has been admitted four times in the past 15 months for severe malnutrition. Her liver is significantly enlarged; she is profoundly anemic with a hemoglobin of 5; she has an elevated white blood cell count; she is moderately jaundiced with an elevated bilirubin; and she has had a prolonged fever. She actually looks better than those laboratory numbers would indicate. We don’t know what’s wrong with her. We have limited diagnostic modalities here. She will ultimately go home without a diagnosis. My thought is that she may have sickle cell disease, but we do not have the means to know that for certain. She will probably be back, if only, once again, to treat her malnutrition. Perhaps then we will make a diagnosis, but I doubt it.

My clinic day began immediately after hospital rounds. I knew even before I started seeing patients that it would be a busy day. Patients were streaming into the clinic en masse as we made our rounds. I could see that many of those patients were children, most of whom were strapped to their mother’s back, African style.

There were a number of routine patients that day, at least routine by Burundian standards: pneumonia, abdominal pain, diarrhea, scabies, secondarily infected scabies, fungal infections, to name a few. Those were patients I sent home. There were also a number of patients that I did not send home nor could not send home. These were patients that I admitted to the hospital. Some of those patients were routine admissions by Burundian standards, some were not. I give you all of those admissions, routine or not.

The first was a two month old boy who was brought into my office on his mother’s back. She removed him from her back and, at my request, unwrapped him. That was when I got my first look at him. It was not a reassuring look. He was clearly in severe respiratory distress. His respiratory rate was 70-80 times per minute, and his little stomach muscles were caving in and out with each rapid breath. He had a fever of 39.3. I listened to his chest, and heard sounds consistent with both pneumonia and bronchiolitis. It did not matter which it was, because he would be treated for both.

I checked his oxygen level with our pulse oximeter, and it varied between the high 70’s and low 80’s. This was a patient who, if he were in the United States, would have been admitted to the ICU. Needless to say, we do not have an ICU. We have a regular ward for sick children. It was, like the rest of the hospital, a ward with limited therapeutic resources. Among those limited resources were nebulizers for the treatment of asthma and bronchiolitis. What was not among those resources were the medications, like Albuterol, that go in the nebulizers. They had run out, and had been unable to get more. This is a sad commentary on the way of the medical world: we at home who have so much, they here who have so little. Fortunately, I had brought a supply of Albuterol nebulized solution.

It is said that the younger the child with bronchiolitis, the less likely that bronchodilators were to make a difference. I can tell you with certainty that the nebulized Albuterol did make a difference for my two month old. I cannot say that the child would have died if I had not arrived in Kigutu with my supply of Albuterol. I know that children here are remarkably resilient. However, I can say that the child is better now, and I believe that the Albuterol is partially responsible for that improvement. Yes, the broad spectrum antibiotic, Ceftriaxone, helped, but I have my doubts as to whether he would have survived without the Albuterol.

There was another element of treatment for this child that we take for granted in the United States. It is an element called oxygen. Every hospital, every clinic in the United States has an unlimited supply of oxygen. The clinic here has an all-too-limited supply of oxygen. My two month old did get some of that all-too-limited supply, but only on an intermittent basis, and only when he desperately needed it.

This two month old is still in the hospital, five days after I admitted him. He continues to breathe fast, and continues to show increased effort to breathe. But he is markedly improved from those first two days he was in the hospital. I am confident that we will be able to send him home relatively soon.

Now to the next two patients, both of whom were admitted for severe malnutrition. I have by now seen hundreds of cases of malnutrition. Yet my familiarity with malnutrition will never inure me nor should it inure me to the sight of another severely malnourished child. To see these children is always a shock, for these are children who are lifeless; children who are devoid of animation; children whose eyes are expressionless. They react little, if at all to their environment. Then there are the physical signs: the pencil thin arms and legs, and the often swollen faces and abdomens. I admitted two such children that morning.

     The first was a nine month old who weighed 4 kilos (a little less than nine pounds). This child's story was different, but no better than the usual one. Her mother had been unable to breast-feed her from birth. Apparently she did not have enough milk. So, instead of breast milk, she gave the baby water with sugar, and, later, regular milk whenever she could get it. The grandmother had seen enough by the time the baby was four months old. That’s when she decided to take matters into her own hands, or more precisely, into her own breasts. She herself decided to breast feed the baby. The only thing working against her was that she was 54 years old by then, and her youngest child was 13 years old. But breast feed she did. I am witness to it. The baby did not seem to care to what breast he attached himself, and he attached himself quite happily to his grandmother’s breast. I cannot imagine he got that much, because I had to admit him for malnutrition. However, he must have received something from the grandmother. If not, he would presumably have not survived even to that point.

     The second patient was a three year old boy who weighed 8 kilos (about 17½ pounds). He had the typical malnourished appearance: the abdomen swollen with fluid; the wasted extremities; and, perhaps most obvious, the vacant look so typical of severe malnutrition. You can see that look in his picture below.

    

     That was half of my first clinic day. The rest remains to be told. However, before I leave you again, I prefer to leave with some uplifting pictures, some feel-good pictures. The first is the positive end result that we generally get when we admit a child to the malnutrition unit. This is a child who presented in the same way as every other child I have admitted to the unit: with that same ennui and lack of life force so typical of malnutrition. You see her at the end of her treatment: a playful, happy, little girl. She seems to have visions of becoming a doctor, because, in the second picture, the papers she carries in her hands are her hospital chart. I suppose she thought she was making rounds with us.

    

These latter pictures I post are scenes from life in Kigutu. You will see these pictures and you will immediately know why I am here, and why I will continue to come here every year. The children are so beautiful, and so happy, yet they have nothing. These pictures speak far more than any ten thousand words I could possibly say.

And, finally, the doctor and the dancing girls: