Global Health Rotation: Malnutrition
I just returned from Uganda 5 days
ago -- a harrowing 43 hour journey with a more than a few moments of thinking
we might not ever get home, but I did. And I wanted to recount a day with a
problem we as NP/PA students don't face much in the U.S.: malnutrition.
Bugabero is in the Manafwa
District, a sort of rural suburb of the city we are staying in, Mbale. It is
about one hour on rough roads from where we stay and not far from most of the
villages we visited. Kissito, the organization sponsoring our time in
Uganda in concert with the government, has developed a malnutrition clinic
which runs every two weeks.
Parents of malnourished children
come to get their child assessed, get them medications, vitamins/minerals and
food supplements. A lot of times, the malnutrition in kids is not necessarily
due to poverty, but it is due to lack of education. Mothers feed their
children posha (cornmeal) too early, do not provide milk or eggs, and when
their child loses their appetite or gets sick with malaria, Kwashiorkor or
Marasmus quickly follows.
It is a heart-breaking
problem. Many of the times, fathers abandon their malnourished kids as they
become sicker and weaker. Moms give up on feeding. Children die.
We arrived at the clinic at 9:30
and it was already very hot. Bugabero is always very crowded because it has the
reputation of having the supplies it needs. There are families camped out
on the grass around the compound, laundry drying on the grass, kids playing,
cows and goats and chickens make their home anywhere they please in Uganda.
A Ugandan health educator came up
to us as we were milling around the mothers sitting on the grass waiting for
things to get started. She asked us in Ugandan English if there was anything we
PA students wanted to educate the mothers about. I jumped in, "We will listen
to what you say first and then we can add information after? So we don't repeat
what you say?" I don't think she understood. Fortunately, Matt jumped in and
said he would educate on breast feeding. Uthman translated.
Then the "health educator" spoke
to the 50 or more families squished together on the grass. Her lecture was
tragically unhelpful. Most of these children have protein malnourishment. She
did not speak about protein. What I do remember her saying was, "When your
child gets sick and is unhealthy from malnourishment, fathers leave child
because he is sick. Feed your children so the father doesn't leave."
After the "health education," the
chaos ensued. Dana, my classmate, and I were paired off with the clinical officer
(like a PA) named Ephraim. We went into the hospital building and there was a
table and a bench for the patients.
A mother came in with her child
who had a fever, diarrhea, and was malnourished. Ephraim was going to
send the child for a "BS" (blood smear) for malaria but apparently the lab was
locked that day so we wouldn't be doing any blood tests. He seemed to take too
long with all the patients without finding out much about them or even doing
much of a physical exam. If you only have 3 ways to treat a patient, there
can only be 3 problems. Is it malaria, HIV, or pneumonia? If it isn't one of
those, then there's no point in finding problems you can't fix. It's reasonable
in this setting, but not the way I was trained to think.
In this small room, there were
three mothers with babies on their laps. All the children we saw Monday were
sad. So weak, so skinny. They looked like stick figures with their big
round heads, poky arms and legs and large bellies -- a picture of a person a
kindergartener would draw with unrealistic proportions.
The saddest case was a child who
initially I thought was convulsing from cerebral malaria -- malaria gone so far
it causes swelling in the brain and neurologic deficits. The child's jaw was
open and its head would nod back and forth, and it was having decorticate
convulsions with its arms curling up into its chest. The child was very hot to
the touch, clearly febrile.
Lindsey, a Kissito worker, kept
asking Ephraim why he wasn't attending to this child. Ephraim then explained
the child had cerebral palsy since the age of 3 months and was now 2 and a
half. He would refer her to Mbale (the hospital from my last post). It's
scary seeing a kid that skinny and convulsing and no one seems to mind. I
wonder who gave the diagnosis of CP. Perhaps the 3-month-old little girls
did have malaria then and had deficits that never remised. There's no way
I wrote the history of present
illness in her "chart" (a flimsy notebook the mother carries around) and the
physical exam. Ephraim commented, "Wow, wow, this is nice." I would've
gotten an F on that note in the U.S. I left out so much. All I could think
was, "Any pediatrician would've spent 1 hour assessing this child and it
would've had 10 referrals."
Later in the morning, I saw the
mother pouring orange coke into her open mouth. She apparently can't
swallow well. I suppose any of us would look completely wasted if our
primary nutrition was liquid sugar.
Dana and I next rotated and helped
weigh the kids. Imagine two trees close together with a strong stick nailed between
them creating a bar. Then there's a grocery-store like scale and a harness. You
put the child in the harness and hang it on the scale to get their weight in
kilograms. We helped weigh and document the weight on the patient's log
for 30 minutes. Ugandans are nothing if not resourceful.
We briefly tried to help assess
the arm circumference. It was very confusing to understand which patient was
next in line. Basically, we would just wait for the health worker to tell us
and then tried our hand at checking for edema and arm circumference.
If a child has edema, you tell
them to go straight to weighing because the swelling from protein imbalance
will ruin your arm circumference measurement. There were many kids with edema.
Also, if the child's arm was "too fat" they didn't qualify for the program. I'm
ninety-nine percent sure they were all malnourished. Resources are slim however
and you have to turn some people away.
By this point, about three hours
into the morning, most of the patients had been weighed; they were just waiting
to get their medicines and nutrition. The scariest part of the day was
when I was assessing patients with Uthman translating. I saw three
babies. The mothers would hand me their books and I'd try to see if the
patient was gaining weight, was their symptoms were. As Dana clearly put
it, "These mothers all say the same thing: my child has been coughing for 1
month, has diarrhea, and has been vomiting."
It might be true but it
becomes difficult when literally all the stories are identical. I would
listen and poke the kids. All of them seemed like they had malaria and
anemia secondary to that. To play it safe I wrote "anti-malarials" on
most of the plans. It's horrifying to "prescribe" when you have no true
clinical picture of your patient. I didn't want them to leave
Uganda is nothing if
not confusing. There is so much lost in translation and lost in not
understanding how people work here. But after a day like this you do know
one thing: kids need food. And maybe
that will change something.