THE DEATH OF A CHILD

«But Jesus said, ‘Let the little children come to me and do not try to stop them, for the kingdom of heaven belongs to such as these. » 
                                                                -- Matthew 19:14.



I faced death this week.

I had met with her a few times since April, but this time, she slapped me in the face…And it ripped my heart apart.

Before I tell you my story, you have to know three facts:

1. The rain has not come yet. We are seeing more and more malnourished children coming to our hospital in serious condition, very serious condition…We are often the last resort for these mothers and fathers, desperate to save their child;
2. During the rare vehicle movements we are conducting – often to transfer patients to another facility – we go from village to village until we reach our destination. Sometimes, in passing, moms come running after our vehicle in order to get some help; and
3. Since the coup, the government has not been able to support his health posts and the latter often contact us to receive some help with supplies, medications or simply for medical care.

Knowing this, here is what happened to me last Wednesday…

We left Boguila early (0600hrs) because we were transferring patients from our hospital to Bossangoa to bring them back home. We thought that we were likely to bring back some patients to Boguila as our facility is more functional in the moment. The MSF project in Bossangoa has just started and it needs to get established. In the meantime, we are trying to support them as best we can.

A few days before our trip, the health post from Nana-Bakasa, normally supported by the national Health Ministry, sent us a note requesting our help with an increase in malnourished children. They also asked for vaccines for the newborns and other medications. We had decided, with the approval of the project coordinator, that we would stop in passing to assess the situation.

When we arrived in Nana-Bakasa, Zéphirin, the person in charge of the health post, tells us that he examined a few children lately. Most are malnourished but not critical, except for one case that he considered urgent.  «It’s a three stars», he said. Since I did not have any experience in malnutrition, I made sure before my departure that I found out what our admission criteria was and I was confident that I would make the right decision.

As anticipated, this child, let’s call him Joseph, suffered from advanced malnutrition. He was very thin and weak. He did not even have the energy to cry. All he could do was whine gently in his mother’s arms. I decided that we would bring him with us to Boguila upon our return from Bossangoa. We told mom to be ready for 1400hrs that afternoon.

We continued our movement to Bossangoa. While en route, we had to stop in a village called Léré, where a mother started running after our vehicle with her child and the rest of the village. After a short discussion to find out what was the matter, I decided to take the child and his mother to Bossangoa where he could be assessed for the fever, diarrhoea and loss of appetite that plagued him in the last few days.

In Bossangoa, the OPD (Outpatient) team took the child and his mother under their wings immediately.

While waiting our departure, we had a look at the facility of this new project. Bossangoa had a beautiful hospital, well managed and well equipped. But during the coup, it was looted and vandalized. The staff and the population fled to the bush. The health services were reduced to nil. Now, the population was returning to the city and the needs were urgent. That is why MSF decided to get involved and started a short-term project (three-six months) in order to reestablish the health services and give time to the government to take charge again. The local staff nurse, André, tells me that there are now conducting around 300 consultations everyday lately.  There is a great demand for health care and follow-ups. André usually works with us in Boguila but we sent him to Bossangoa for a short time so that he would give them a hand to start the project. He is really happy to help the new team out.

Around half past noon, we leave for Boguila. Good news! The child brought from Léré does not require an admission nor a medical follow-up: he can return to his village now. However, we will be bringing back with us two children sick with malaria and dehydration.  In Nana-Bakasa, everyone is ready – we pick-up Joseph and his mom. The baby appears stable and continuously whines weakly. I say a quick prayer so that he makes it alive to Boguila.

During the trip, I communicate regularly with the team of the second vehicle to ensure that all the passengers are well and stable, especially Joseph.  A few kilometres from Boguila, I call ahead to inform the team that we are bringing back three children, one of them in a critical state of malnutrition. I ask that Dr. Flo be ready at our arrival to take care of that child immediately.

Finally, we see the hospital – we park the vehicles. The next few minutes resemble a scene from a Hollywood movie: the whole team is there and ready for action! I direct Dr. Flo to Joseph and she takes him in her arms to bring him to the emergency while the other two nurses take the other children. I accompany Dr. Flo to give her a hand – we need a venous access quickly so that we can give some glucose to Joseph: he needs energy. When we enter the emergency, all the equipment is layed out and ready for use. We attempt many times to get an intravenous into Joseph but he is so dehydrated that we are unsuccessful. As a last resort, we attempt an access of the femoral vein, trickier to get. Dr. Flo gives it a try – we think we have it. We quickly give the glucose dose and start the fluids. Unfortunately, the site becomes interstitial, which means that the solution we are giving is not only going in the vein but also in the surrounding tissues – our access is not good.  With all this commotion, Joseph hangs on – he continues to whine and I am holding his little hand.  I whisper in his ear: «Don’t give up little guy…You are strong…We can help you! I know it hurts but you will feel so much better after! Hang on little man. » I also pray to God to give him the strength to fight. His mom is also there, a little behind so that the team can do its work. After five or ten minutes, that’s it! We have an access – a vein on his head has decided to cooperate! We continue our treatments, get the oxygen tubing on, take his vital signs, and give him the prescribed medications. We breathe a little easier now!

It’s the end of the afternoon. I am reassured on Joseph’s status. I think all is well now that he is in good hands.

I leave to have my shower. I take my supper and go to bed.

The following morning, as I am walking to the hospital for report, the guard at the entrance stops me and says: «Please, would you mind helping me with this mom. Her child died last night and she wants to bring him back to her village for the burying. » I turned around and saw Joseph’s mother, sitting on the bench, pain written on her face. My heart just stopped for a few seconds. Tears welled up my eyes. I did not understand what had happened. I was in shock. Regaining my mind, I asked the guard to tell the mother that I was very sorry for her loss, to give her my sympathies, and that I would take care of it. During report, I found out that Joseph had had a respiratory arrest in the middle of the night and that efforts to resuscitate were not successful. The staff immediately saw that I did not take this news very well – they offered support and good words. I kindly thank them for this. But when I got to the house for my breakfast, I could not keep the tears from rolling down my cheeks and I cried just as if Joseph had been my own child.

Another malnourished child...

Death had taken another victim.

«Your children are not your children. They are the sons and daughters of «Life’s longing for itself. They come through you but not from you. And though they are with you yet they belong not to you.»
      -- Kahlil Gibran, The Prophet

Janique

PS: The names in the text have been changed to respect the privacy of the patients and personnel. 
 

THE DIRECTIVE

"The Prime Directive is not just a set of rules. It is a philosophy, and a very correct one. History has proven again and again that whenever mankind interferes with a less developed civilization, no matter how well intentioned that interference may be, the results are invariably disastrous." —Jean-Luc Picard, Symbiosis

This week, I am asking myself a lot of philosophical questions…I guess that had 

Village house in Nana-Bakasa

to happen at some point during my stay here. Isn’t our life a series of lifelong questions anyway?

I was thinking about the history of humankind and the fact that nowadays we want to help so much and change the world, give some of our time and share our money, offer education to the less fortunate and show them how life can be fulfilling. All these good gestures of course, go according to our own perception of the world. But who are we, in reality, to decide that our model is the one that must prevail? How can we answer such a timeless question…?

Since the « civilized » world started to travel and conquer, it has always wanted to impose its own lifestyle and norms to the populations under its control. Examples include Greeks, Romans, England, France, Portugal, Muslims, Catholics, Jews, and more, including the United-States and Canada.

Is it a fundamental human need to want to impose ourselves? A need so important that we have to see our way of life and thinking dominate? What kind of impact does such a decision have on a conquered community? I am not talking here of the immediate impact but of the long term effects of it…

Boguila hospital was founded in the 50s by American Christian missionaries. Initially, this « œuvre médicale » included a hospital, a nursing school, a dental office, a church and many well equipped health care posts. The missionaries left Boguila at the beginning of the 90s and left the management of the hospital to a group called « comité local », which consisted of senior employees as well as religious and community leaders. For a while, without any external support, the managers successfully administered the hospital without deficits and provided care to the neighbouring communities.

Unfortunately, during the civil war in 2002, the population left Boguila and the hospital was looted and vandalized. Many months later, the senior staff returned and attempted to reopen the hospital without any external help. This proved more difficult and thankfully, at that time, they received some donations from a few different NGOs. Then, in 2006, MSF arrived and took over the management of the hospital in order to continue to offer health care to the population.

Despite the fact that the hospital managed to operate for many years, the arrival of the civil war and the governmental uncertainty created a need high enough for MSF to get involved. With the events that have transpired since December 2012 and the successful coup of March 2013, the ministry of Health (ineffective since the coup) remains today almost non-existent, unable to provide for medications, medical supplies, and support for its health posts outside of the capital. In fact, we have already received numerous requests in the last few weeks for donations of vaccines and medications to treat illnesses such as malaria and malnutrition.

Child being transported back to his village

What will happen then, when MSF leaves the area to offer its help to other projects that are more urgent? Who will respond to the population’s needs? Will the ministry of Health be functioning at that time, ready to fulfill its role?

Our presence here, at this moment, brings many benefits and has an immediate impact. But let’s ask ourselves the following: even if we feel and think that we are doing the right thing, will the ramifications of our assistance have a negative long term effect…? Because we will leave one day, thinking that all is great and beautiful, without realizing the extent of our choices and impositions and their influence for the future. I suspect we will likely leave them with minimal resources and they will have to carry on without our help. Was it wise then to come here in the first place?

Star Trek fans might see here a quick allusion to the « Prime Directive » - decree that dictates the non-involvement with less advanced civilizations. The philosophy behind this order refers to the fact that invariably, in all of human history, when a civilization gets involved with a less developed population, results are more often than not tragic We just have to think of the arrival of the early settlers of North America and their impact on Native Americans and the Inuits, or even closer to me right now, the Africans. These cultures have been forever changed; some even lost their history and language in the process. Have we always really been constructive benefactors in these cases?

Now I hear someone say: « On the other hand, wasn’t it our duty to intervene in order to prevent human suffering and the death of a population? » I agree to a certain degree, but say: « At what price? »

Think about it…

But who am I to impose my point of view to the rest of the world…

Janique

RAIN, RAIN, WHERE ARE YOU?

When I arrived in Boguila, I expected the rainy season…However, we have only had four or five days of rain since April. This is not enough, unquestionably not enough…

The population is hungry. The lack of rain is delaying the crop. Seeds cannot be planted because nothing grows without water. There are no (or very little) fresh vegetables. The national situation and the lack of security on the roads prevent the distribution of fresh produce from the capital to the regions. The markets have very little to offer – we can sometimes see a few tomatoes, cucumbers, onions. Otherwise, nothing. And the population grows hungry…

In our « fortunate » subconscious, we are assuming that everyone in Africa is hungry. What a stereotype! Also, don’t we tell our kids in Canada: « Think about the little children in Africa…They would eat what you have in your plate! » It’s true; the situation is quite problematic in many countries of this continent. However, here again, we are somewhat immunised to their suffering as we are not living in their conditions. Wouldn’t you be hungry if you did not have any food available or if you had to walk kilometers to find a little bit of beans? What would you do if the village market did not have any food items to sell? Would you be able to live with only one meal per day? To whom, in your family, would you choose to give the little food you have found – The kids because they have to survive? The dad because he has to find work in order to bring back a little food? The mom so that she can take care of the household and the kids? Difficult choices indeed…

According to UNICEF, four basic causes impact malnutrition and mortality – resources (human, structural, financial), political ideology, infrastructures and local priorities (MSF Nutrition Guidelines [edited version], 2006). As you know, the political and military situation in Central African Republic has been pointing toward chaos for a while. The Boguila population reports instances of looting, theft, and violence. In fact, some people do not go to work in the fields because they are afraid of the presence of this violence. This little country has been living with this uncertainty for a long time and this ambiguity can be felt all the way to small towns and villages just like Boguila. There is no financial support, no security, and the human resources and infrastructures are almost non-existent.



Twins Issan and Neya before their departure from the nutrition centre



We now have all the basic causes in place …and they bring without doubt the underlying causes of malnutrition with them. The lack of infrastructures and resources translate locally into (1) household food insecurity in regards to access to food and its availability; (2) changes in social care and the environment – direct caring of children and elderly, social and familial organisation; and (3) disruption in access to health care and water.



So at this instant, with all these causes present, the wheel of malnutrition starts to roll: the lack of food and the diminution in its quality increases the sensitivity to infections of individuals at risk (kids, elderly) because they are suffering from an impaired immune system. Illnesses start to appear and the lack of nutrients, their mal-absorption by the body and the decrease in food intake continues to decrease the immunity required to get better so their risk of infections increases and their length of stay in hospital augments, which reduces the immunity, which gets worse because there is no food, which…And so the child or the elderly finds themselves in a state of malnutrition, which can eventually lead to death.



In order to return to a healthier, a patient suffering from malnutrition must be admitted to the hospital and his treatment followed very closely. Most of our malnutrition cases are children. They arrive at our outpatient clinic in a precarious health, sometimes even too late. If you think about the images often shown on television of hungry African children, the following must inevitably come to mind: a thin child with a large abdomen or another with edematous eyes and legs. The first example suffers from « Marasmus » and the second, « Kwashiorkor ». These are the two clinical presentations of severe malnutrition with children; we can see them separately or combined together. In the three situations, metabolic function is seriously disturbed – the immune system is impaired, blood sugar is low, temperature decreases, electrolytes are in a state of imbalance, severe infections develop, apathy and lethargy are seen. These changes in the body can be translated by severe loss of muscle and fat mass in both presentations. In addition, with the Kwashiorkor, we see bilateral pitting edema in lower legs, feet, and face to which we can add skin lesions. All these can mistakenly hide the loss of muscle and fat mass.



Baby Moussa before he left Boguila



Hospitalization in the nutrition centre takes place over two phases, separated by a transition phase. The height and weight of the child are taken and a ratio (Z score) is calculated to determine the extent of the malnutrition. Phase 1 lasts usually seven (7) days. The goal of this stage is to restore and stabilise the body’s metabolic function. The child normally receives eight (8) meals per day; each meal is calculated according to the age, the weight and the height of the child, and consists of a measured portion of therapeutic milk F75. This special milk is meticulously formulated for the severe malnutrition cases and contains a limited amount of proteins, fat and sodium as well as a great caloric value (75kcal/100mls). This makes it much easier to digest and thus, favours the return of a normal metabolic function.



When the child shows a gain in energy and appetite, he/she is ready for the transition phase, which lasts between 1 and 3 days. At that time, the child continues to receive eight (8) meals per day but a progression from therapeutic milk F75 to F100 (similarly formulated but with more calories - 100kcal/100mls – and proteins) or Ready-to-use Therapeutic Food (RUTF) – nutritive bars or Plumpy’Nut® (peanut paste with milk). The bars are made with a mix of skim milk powder, cereal flour, fat, sugar, and vitamins and minerals. Each bar contains between 150-300kcal. Plumpy’Nut® essentially contains the same elements but its consistency makes it easier to take for younger children – it looks like peanut butter. In both cases, there is no cooking involved – they are ready for consumption!

At the end of the transition phase, the child moves to phase 2. The number of meals changes from eight (8) to six (6) per day. At this time, we are looking for a substantial weight gain so that treatment can come to an end. This phase also prepares the child to

start eating traditional food as well – when discharge approaches, we encourage moms and dads to offer home meals and complement with Plumpy’Nut® or the bars. As soon as the targeted weight is reached, the child and his/her family can go home. It is at that time that we can see the success of our nutrition program. The smile of these children is priceless! Following discharge, the child continues to be followed by the outpatient nutrition clinic once a week to ensure continued weight gain and health stability.



Once again, thank you for reading me. And please, send us a little rain…

Janique