Daniel 2/10/11

We have a very active inpatient malnutrition program here in Ethiopia. In the last month we admitted 22 patients with either severe wasting or a kind of malnutrition called kwashiorkor (swelling malnutrition). Every day we check weights and their intake of special UNICEF formula. Most kids stay at least a week or two and then we follow them for the next three months. Since the kids are around for a while and developmental education (play time) is an important part of the program, we tend to get to know the kids pretty well. There have definitely been a number of children that I have really connected with . . . but now there is Daniel.

                We estimate that Daniel is 2. His mom died 9 months ago and his dad has been trying to take care of him alone. When dad came to Lalmba he was not there because the baby was sick; he was there because he wanted us to take the baby. It was too much for him and he hadn’t worked in 4 months. All he wanted was for someone else to take care of this child. When Daniel’s dad was in the management office Kari walked in and immediately recognized that Daniel was severely malnourished. He had both severe marasmus (wasting) and kwashiorkor. When he was admitted he weighed 5 kilograms (12lbs) and was so weak that he could not lift his head and didn’t even make eye contact. We weren’t sure he would make it through the night.

                We admitted him to the program and convinced dad to stay until the baby was healthy, then we said we would help him find an organization to take Daniel if he still wanted that (our children’s home only takes older kids). The first few days it was clear that Daniel had been left alone most of his life. His legs were contracted and he didn’t respond to affection. Dad would leave the compound for hours at a time leaving him lying alone on the bed. Whenever I went over to the hospital and saw Daniel alone I would pick him up, talk to him, and carry him around with me. After a few days we got his dysentery under control and he started gaining weight. Then, an amazing thing happened: he looked at me. He looked right at me, reached out his arms, and snuggled into me as soon as I picked him up. There was a real child in there! But, he was clearly in pain. His little expression went from completely blank to an agonizing grimace. It was heartbreaking.

                Over the next week he grew stronger, lifting his head, sitting up when propped on his arms, then sitting alone. With encouragement dad started to figure out what he need to do as well. He started sitting outside with Daniel, massaging and stretching his legs, and holding him when he cried. Daniel started to thrive. When dad would take the cup of formula away he would reach out and hold the cup himself. But, he still had his little frown on all the time.

                Saturday I walked in to the malnutrition ward in the afternoon to check on him. He still reached out for me when I walked in the room, and wanted to have his cuddle. So, I walked over and went to pick him up, and then . . . he smiled. It was the most amazing smile I have ever seen. I picked him up and tickled his belly just so I could see him do it again. Finally, an expression of happiness: a sign that there is still a sweet joyful little kid in that body that has already been through so much.

 It’s now been two and a half weeks and my Daniel is giggling and playing. Yesterday he kept sticking his foot in my hand so I could tickle his toes. He has made one of the most amazing transformations I have ever seen. I still don’t know if his father will take him home or if Lalmba will help him find a new home, but I do know one thing. There was a child who came into our hospital near death and now there is a giggling two year old boy who is finally learning to walk. I would be lying if I said that I didn’t consider adopting him myself, but it really wasn’t possible. It was very hard to leave him. I know that he will not remember me or his time in Chiri, but he will also not remember the pain he went through. He came to us a dying child and will leave a happy little boy. If I did nothing else during my time in Africa, I help bring Daniel back.

Outbreak 7/19/11

              On Tuesday morning I was walking over to my office after rounds.  Andrew (the Project Director) called me over to his office.  There had been a man here the previous day telling us about an outbreak of some kind in a village about an hour and a half away. He seemed very worked up about it and apparently the village chief was making quite a fuss.  Now the government health desk wanted us to go with them to see what was going on. We have the only vehicles in the area, so the health desk “invites” us to go places with them quite often.

                The description that we got from our government source was 10-15 people with large wounds that wouldn’t stop bleeding. The man didn’t seem to know any more information, though he claimed to have been there and seen it himself. These symptoms could be a lot of things around here: anthrax, relapsing fever, yellow fever. There was no way to know without more information. So, one of our lab technicians and I got lab supplies to collect samples: we also got as many gloves and surgical masks as we could find (strange diseases are interesting only when they happen to other people). We could test urine, blood, and even skin scrapings. We were all sorts of set and I was really excited to be going out to the front line of an epidemic. Andrew and I decided that we were going to call the disease McSparron Fever.

                The three of us (Andrew, Mechullo, and I) got into the Land Cruiser and drove into town. There we waited for the other members of the expedition team (as well as a bunch of other people who wanted a ride in that direction). We started on the road not knowing how far we would be able to get. It was the beginning of the rainy season and the road was notoriously muddy. Fortunately, after picking up and dropping off about 8 people, we were able to get all the way to Angela, the first village afflicted. Downtown Angela consists of 8 mud huts with grass roofs. We stopped at the local watering hole (ten women sitting on the ground outside the mill drinking honey wine out of gourds). We asked them where the sick people were and they directed us down a path. Everyone seemed to know about the outbreak. We walked down the hill and approached a number of huts until we found the right person. When we asked her to show us the lesion she stuck out her hand a pointed to a small sore near her wrist. She went on to explain that it had been a bump, then someone cut it open and pus came out, and now it looked like this. What it looked like was a healing abscess. We told her to go to the local health post for an antibiotic and decided to move on.

                As we drove down the road people came rushing out to see the car, and the white people inside. Bezu from the health desk would stick his head out the window and ask people about the illness. They would run off or call out to their family to bring everyone over. Soon people crowded along the side of the road to see what the verdict would be. We were shown four people with the mysterious disease. Two had ring worm and two had impetigo (a minor bacterial skin infection). Not a drop of blood among them. Again, we suggested that they visit the nearest health post.

Finally, we arrived at the area hit hardest. We stopped in front of a mud building with a tin roof which apparently was the regional seat. There we were told about many people who had been very sick and some who had even died after contracting this illness. When we asked to see the sick people everyone kind of looked lost. It seems that everyone had heard about the condition, but no one could think of anyone specifically who had it.  Finally they brought out a health looking middle aged man who explained that he had ear pain and drainage. Sure enough, he had an ear infection. So much for McSparron fever. We did take a sample of his blood and a scraping from a small rash on his face. Mechullo turned out to be even more interesting than the white people when he pulled out his gloves and syringes.

                After a lot of gawking, we all piled back into the car. No anthrax, no relapsing fever; just a couple of villages full of people with poor sanitation and little access to health care. While I may have been a bit disappointed, it did make a good point about my experiences here. Everyone thinks of medicine in Africa as strange and exotic, which it can be. But, for every person with anthrax or leprosy, there are hundreds with minor illnesses that can be prevented with good sanitation or treated with very basic medications. That is what medicine in the developing world is about; treating and preventing the most basic illnesses so that people have a chance to live a healthy life.

Asayech 5/3/11

I was walking down toward the hospital when I noticed some commotion near the OB room. As I drew closer I saw a bamboo and thatch stretcher lying outside. I walked into the delivery room as Solomon (one of our midwives) was turning on the vacuum machine. “I’m delivering a still born.  I know that you are not supposed to use vacuum for these cases, but the head is crowning and mom is exhausted”. The other nurses explained that the mom had been in labor for 3 days and had not felt the baby move in nearly a week. Finally today her family decided to bring her to us. It was clear that she was seriously ill and that the amniotic fluid was severely infected. There had not been a heartbeat on the nurse’s exam.  As Solomon finally got the head out I saw a perfectly formed little face and was so sad that the mother had to go through all of this; laboring for days to deliver a baby she knew was dead.

                Solomon delivered the baby and held it upside down to cut the cord. Suddenly, one of the eyelids twitched. Then the eye opened. “The baby’s not dead!” Kari cried. We rushed the baby to the table and began rubbing and suctioning her, but she still wasn’t breathing. The nurses grabbed the resuscitation mask and began to use the hand pump to help her breath. As we were checking her we noticed large purple and red marks on both side of her ribs. The skin around was stretched and buckled. The marks looked like scars, but from what? And the fact that there were scars meant that whatever it was happened some time ago. Clearly this little one had had a rough few months.

                After a few minutes the baby started breathing on her own, but it was very rapid. She and the mother were admitted to the hospital; the baby on oxygen and both on strong antibiotics. We left for the night not knowing if she would still be there in the morning.

                The next morning during rounds the baby was lying on the bed next to the mother. She was clearly hungry. We told mom to breast feed her more, but mom just looked away. We asked her what was wrong and she replied that she did not want to put the baby to her breast because she was afraid it would die. She kept staring at the baby’s scars. She didn’t want to get attached. We tried to explain to her that while there was a chance that the baby would die, if she didn’t feed her it would be a certainty. The mother wouldn’t listen. Fortunately, we had a secret weapon . . . grandma. The baby’s grandmother spent the next week by the bedside ensuring that the baby got what it needed. She would physically hold the baby to the mother to make sure she was feeding. After a few days the mother seemed to soften a little and started to feed the child without coercion. Then she began to hold the baby and play with her.

                After a week, both mom and baby were done with IV antibiotics and the baby was able to breathe without oxygen. We didn’t really know what would happen with the baby, but we had done all that we could and they were ready to get home. On the morning they were preparing to leave we asked what they were going to name the baby. The mother smiled and replied “Asayech”, which means “mirror image” because the mom though the baby looked just like her.

Welcome to Chiri 4/25/11

As you all probably know, I’m no longer in Matoso. Through a series of visa issues and other unforeseen circumstances, I was transferred to Lalmba’s other facility in Chiri, Ethiopia. This is a very different facility in that it has a 14 bed inpatient hospital in addition to the outpatient clinic and children’s home.  Chiri is at a very high elevation and a very different climate than Matoso, so we see very different illnesses. Life is always an adventure and always gives us opportunities to learn.  So, by way of introduction to Lalmba Chiri, here is a tour of the inpatient ward and the patients we are caring for there today.

                In the first bed is an 8 month old with tuberculosis. He has been coughing for 4 months and now has pneumonia on top of it. He also has a giant lymph node on his neck that may or may not be TB. Oh, and he has a vitamin D deficiency, too.  But, he is doing well on antibiotics and we have talked to the mom about making sure he gets enough sun exposure.  Unfortunately, Ethiopia has a shortage of Vit. D supplements so we can’t provide it to the family.

                The second bed is a four month old girl with pneumonia. She has scars all over her abdomen from visits to a traditional healer. The method of drawing out anything bad is to burn the skin over the affected area.  The burns are healing without any complication, but the cough continues. The good news is that she has been weaned off oxygen and is breathing fairly well on her own. We are just waiting for the fever to subside.

                The third bed is a one month old boy with apnea. When he came into the clinic he would stop breathing every 3 or 4 minutes. His heart rate would slow from 140 beats per minute to 40 beats per minute. Finally his brain stem would kick in and wake him up, but he was getting so tired. He’s been on IV medication for over a week and has not had an episode. Now we are weaning him off and seeing how he does. Hopefully he’ll go home soon.

                Bed four is a baby who is going home tomorrow. He was admitted with dehydration and pneumonia, but is now eating and drinking well and his lungs sound great. His parents, who can’t be more than 16, are getting prepared for the 6 hour walk home.

                Bed five is empty. There was a two year old girl with a lung infection. She had been improving and then took a turn for the worse. The referral hospital didn’t have the equipment to treat her and the family didn’t have any money to pay them anyway. We told the grandmother that we could try one other antibiotic and keep her on oxygen, but the grandmother declined. She wanted to take the child back home to see her mother before she died. We had to respect that decision. Unfortunately, they live a 2 hour walk from Chiri. Without oxygen the child likely died in her grandfather’s arms on the way.

                Bed six has a little boy who came in severely dehydrated. He got IV fluid and hasn’t vomited since. Right now, he’s screaming his lungs out and trying to pull out the IV. Around here, that’s a really good sign. He should be going home soon.

                The three beds in our isolation room are filled with adult TB patients. One is a man with very severe anemia. He has been on TB treatment for 2 months, but is still coughing up blood. Fortunately, his anemia has improved with Iron and he has not required a blood transfusion.  Another is a man who came in with pneumonia and then revealed that he had been coughing for a few months and had lost a lot of weight. So, we started him on TB treatment, too. The last is a woman who came in so weak that she could barely stand. She said that she had only been coughing for five day. We did a test anyway, and, sure enough, it was positive. So, she went to join the isolation club and started on antibiotics and IV fluids.

                The last patient is in our malnutrition room. His mom is one of the patients in the isolation room. She has been so ill that she has not been able to feed him well for almost a month. He is 5 months old and looks like a newborn. But, he is hungry, which is a good sign. His goal is 1 ½ cups of special formula a day; he is averaging 3 cups. We will treat him with the formula until he gains weight and mom is able to feed him at home.

                So, those are our patients. What I have learned during my time in Africa is that if you focus on the patients you can’t help, you will lose hope. The only thing you can do is focus on the victories and know that you did the best you could for the others.

Fishin' in the dark 4/1/11

Lake Victoria has a very diverse aquatic life.  From the abundance of tiny snails that carry Shistosomiasis to Nile perch over 100lb. But one of the most interesting is the omena.  Omena are a tiny fish, usually about an inch and a half when full grown.  In other parts of the world omena would probably be ignored or used as bait, like the minnows in US lakes.  But, not in Africa. Omena are caught, dried, and eaten all around the lake.  You can see huge nests of the tiny fish spread out on the beach every morning, waiting for the sun to bake them.

                We were sitting at our favorite hang-out (the only place to buy a beer in Matoso), talking with some friends about omena.  We stared asking about the boats that we saw out on the lake every night and how they are caught.  It turns out that our friend Sammy worked on an omena boat as a young man. “Would you like to go out and see it for yourselves?” he offered. Of course!!!

                So, a few days later Matt and I were walking to the beach at 8:30 pm ready for a few hours out on the high seas.  We met with the boat owner.  He had a motor that we could use, so he had made a deal with another boat of fishermen.  He would tow them out to the fishing grounds if they would let us watch them fish.  They seemed to think that was a pretty good deal, and went about starting the pressure lamps.  These are kerosene lanterns that you pump to increase the pressure of the gas so it burns brighter.  They are a vital part of the omena business.   

We had managed to procure three life vests making us the only people going out on Lake Victoria that night wearing bright orange, reflector clad outer wear.  We definitely got a few looks, but once I saw the state of the boat, I was okay with looking silly.  The four of us (Matt, Sammy, the driver, and I) hopped into the long wooden vessel and put our feet into the three inches of water in the bottom.  It had been raining, so we didn’t think much about it.  Sammy started to bail the water out with a small pail.

We tied the other boat to ours and began slowly moving out into the lake. As the shore receded into the darkness I became thankful that I was not navigating.  You see, there is no electricity in our area, which means no lights.  And this particular night, there was no moon (which makes it perfect for fishing).  So, the only guide posts to navigate by were the stars and the cell phone towers 20km in either direction.  Everything else just melted together in the darkness.  Ahead was a sea of yellow lanterns bobbing gently.  We got to a spot that seemed promising and unhooked the other boat. They began paddling around dropping their lantern floats into the water.  Then we waited.

The way you catch omena is by attracting bugs.  So, the fishermen put bright lanterns on the water and wait 30 minutes.  The omena are attracted to the swarming insects and begin jumping out of the water around the lights.  Then the boat circles the lantern with a net and slowly pulls the net in collecting all of the fish underneath.  This takes a team of four men and typical net-full wouldn’t fill a grocery bag.  The fishermen fish all night just to make a small profit if they are lucky.   

After the second catch we noticed that Sammy was bailing water again. Now there were 6 inches of water in the boat. It seemed like a good time to turn back. So we thanked our new friends and started motoring back to shore. As we pulled away from the lanterns it became clear how amazing the night was; a sky full of stars and the Milky Way stretching right through the middle and behind us thousands of lanterns all across Lake Victoria. It looked like a city stretching out on the water. I have never seen anything like it. As we walked home Matt and I marveled at the amazing adventure and felt privileged to be some of the few “mazungus” to ever experience it.

Attack of the lake flies 2/15/11

Yesterday afternoon I was sitting at my desk working on a lecture. Suddenly I heard yelling and saw people running into buildings. Julian ran into the building I was in and slammed all of the doors. Now, most people living in a developing country would be concerned about this. Are the Tanzanians attacking? Is it a pack of hungry hyenas? But I knew better. I had seen this before. It was an assault, a full on invasion . . . of lake flies.

                Lake flies are the size of a gnat. Singly they would probably never catch your attention, but they never come singly. It starts as what looks like a pillar of smoke hanging far out over the lake. The male lake flies have hatched and mated. Now they are ready to come on shore to land and die. You see them hovering in a cloud, but which direction will they go? Is the wind out there the same direction as it is on shore? Can we hope they will end up in the next bay over? Come on, go toward Muhuru Bay.

                As the plume gets closer to shore, people start preparing. They cover dishes, shut windows, and get inside. Not that being inside will help much. They are so small that they can fit through screens, and even through our trusty bed nets. There is no stopping them. Like a cloud of smoke they roll in engulfing everything in their path.  Some land on any surface they find; trees, walls, and doors, covering them with layers of flies. Others hover in clouds just at head level, daring you to walk through and breathe them in. All seem to be searching for the most inconvenient place possible to spend their last hours.

                Woe to the person who has a light on at night; much less a computer screen. Matt and I put out candles to distract them, but the tops of the candles get so many dead flies on them that the flies catch on fire and the candles become raging torches and burn out in a few minutes. I have taken to leaving a decoy light on in my house when I am reading. It doesn’t help that the security light outside my house is the only outside light for miles attracting flies like a beacon.

                I am told that in previous generations, lake flies were made into patties and eaten. It seems that people had nets with very small holes that they would wave through the air a few times to collect a bag-full. Then they would dry them, mix them with oil and fry them up.  If your diet is low on protein it makes sense. I guess I should stop complaining and learn a lesson from my Kenyan friends. If the world gives you lake flies, make lake fly burgers.

The day after 2/8/11

I decided to write an entry for the “A day in the Life” section of the PA professional journal. While writing it, I was disappointed that it could not be as colorful as I wanted it to be. So, here is the day after “A Day in the Life”.

5:00 awoken by the only car in the village blaring its horn

6:00 awoken by pigeons playing “king of the hill” on my tin roof. (scuffle, scuffle, scuffle, slide). Go outside and throw rock at said pigeons

7:15 awoken by alarm clock

7:30 down largest cup of coffee I can find. God bless our French press!

8:00 Staff assembly. The entire staff forms a circle. Every person must shake the hand of every other person. Then we sing a song in Dholuo and stand around awkwardly waiting for any potential announcements. People slowly begin wandering off to work.

8:30 Agree to catch a ride to our remote clinic in Ochuna at 9. Begin collecting necessary materials.

9:00 all ready for Ochuna

9:45 actually leave for Ochuna

10:15 Arrive at Ochuna dispensary (two concrete buildings and a grass hut, none of which has electricity). Greet staff and meet my translator for the day (a young friend of one of the staff). Said translator promptly asks me how he can get a visa to the U.S.  . . . sigh

10:30 Set up our public health student to administer surveys for the mothers in our malnutrition group.

10:35 Establish rapor with families in program (ie. play with babies)

11:00 Prenatal exams with only a stethoscope and a measuring tape. Have to inform a woman that she is having twins. “Are you sure?” “Well, either that or the baby has two heads.” She doesn’t seem impressed with either option.

12:30 Measure and weigh babies in malnutrition program . . . play with babies

1:15 Enter Ochuna dispensary data into quarterly report. Spend 15 minutes convincing translator that the calculator on my computer will give the same answer as the one on his phone. More questions about US visas.

1:30 catch ride back to Matoso in the ambulance. Almost hit cow, donkey, and child on the way.

2:00 tuna salad sandwich – I love you, Joyce (our cook)!!!

2:30 Staff meeting complete with extensive condom discussion and near fisticuffs over who is more to blame for AIDS, men or women. Then we pray.

4:30 Back to the house to try to figure out what the heck just happened.

5:15 Hard core workout in my house involving a jump rope and some hand weights. Hi, Jackie, the 1980s want their exercise back.

6:00 Voice of America on the shortwave radio and a beer on the porch with Matt and the cows. Perfect ending to a perfectly typical day.