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NP & PA Student Blog

Global Health Rotation: Malnutrition

Published October 9, 2013 1:07 PM by Caroline Pilgrim
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 to know. 

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 empty-handed though. 

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.



So excited about your trip!  I know it will change your perspective tremendously.  I blogged a lot more about the trip at www.handswithholes.wordpress.com if you want to read more about the healthcare system!  May God bless your time in Ethiopia!


Caroline Pilgrim October 24, 2013 10:56 PM
Roanoke VA

Thanks for sharing your story. I am a NP who is getting ready to lead a medical mission team for our first time to Ethiopia. Your story has been helpful in knowing what to expect when we get there.

Karin October 24, 2013 12:43 PM

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