Hi all, its Michelle again. During my recent stint as blogmaster (during which I posted one blog entry), some of my family asked me to report on what's been happening at work lately. So here goes....
Work has been extremely busy. Most months of the year, I'm working in the clinic, seeing kids with HIV as outpatients, monitoring their treatment and prescribing ARV's. For 3 of the 12 months, however, I serve as ward attending on the pediatric medical ward at the government hospital, which is directly adjacent to the clinic. Two of my months have fallen consecutively, and I'm in the wards in February and March. So I've just finished a very busy month and am now starting on the second month. It looks like (fingers crossed) things are calming down.
The reason February was so busy was that there was an outbreak of diarrhea in Botswana, which led to an increase in hospital admissions for vomiting, diarrhea and dehydration, as well as malnutrition. The cause for the malnutrition admits may not be as obvious. Basically, one of these kids might get diarrhea, lose a LOT of weight, then have to try and recover on their usual diet, which for a lot of people in Botswana, is "soft porridge," a sorghum based porridge that for many is eaten 2 or 3 times/day as the diet staple. There's not enough there to get the kid back in shape, and the result is malnutrition that requires medical intervention. Also, kids with this type of severe malnutrition makes kids more susceptible to infections, so they were coming in very critically ill for the first part of February. The ward was packed. The peak census was 65-70 patients in a 5 cubicle ward. We were lucky to at least have enough mattress pads to put on the floor for the patients and their moms, but it seemed like everywhere you stepped, there was another patient. Also, the crowded nature of the ward made it difficult for every kid to get the level of observation they required (some might say this is a problem no matter how many kids are in the ward, but that's another blog post).
Treating severe malnutrition in the hospital is not too technically complicated, but it is extremely labor intensive. There are certain milk-based formulas that are used to "refeed" and they have to be given in specific amounts every 2 hrs around the clock to start with, with the volume and the interval between feeds being very gradually spaced out. If the kid can't or won't drink the milk, then a tube has to be placed through the nose into stomach so the milk can be pushed with a syringe into the tube. The logistical problems with all of this just didn't stop. If the kid is having diarrhea as well, then a special type of pedialyte-type drink has to be given as well, or in place of the milk. Andy alluded to this in an earlier post - the mom's were having to make up the solution themelves, but to do that required an empty bottle. If they didn't bring an empty liter bottle to the hospital (not sure in what situation that would be intuitive), then they had to wait for someone to bring it from home. Most of the people aren't cruising around in their own cars, so you can imagine the difficulty of getting a bottle from your village on public transport to your child in the hospital who's just been admitted. There was finally enough pressure on the staff to start making the solutions up in common pitchers, which eliminated the problem of patients having their own empty bottles, but created new problems.
"Did your baby take the milk last night?"
"No."
"Why not?"
"That lady (points across the cubicle) is taking the spoon she feeds her baby with and using it to mix and pour the milk out of the common container. My baby is going to get sick again."
So then we've lost 12 hrs of feeding.
Other problems: ran out of NG tubes. Ran out of syringes that fit the NG tubes. The shipment of one of the therapeutic milks got stuck at the border with South Africa because the hospital hadn't paid their import taxes and was there for 3 weeks. On a Friday, ran out of 3 of the 4 main IV antibiotics we use to treat severely malnourished paitents. The CDC arranged for 500 doses of a medication to treat diarrhea but it took 3 weeks for it to get from the main storehouse to the hospital pharmacy (a distance of 1 mile). You get the idea.
Throughout all this, there was a good amount of death. The second week of February we were losing 2 patients/day. To put this in context, malnutrition - famine type malnutrition that you associate with really horrible humanitarian crises - is not usually a problem in Botswana, by most accounts. However, this year there has been more rain than usual, and with that comes sanitation problems - pit latrines overflowing, contamination of common taps in villages, kids playing in stagnant water. This same thing happened 2 yrs ago, also following a particularly rainy season. So maybe we're less prepared than other African countries when this type of crisis hits. But following it up does highlight the fact that even though Botswana is considered a "middle income" country, there is still a lot of poverty here. We have the moms come back to the ward to follow up and make sure that the child is not losing weight all over again once they go home. This week I took one of those moms over to the nutrition clinic and listened to her interview with the dietician. It was really painful to watch. The dietician asked her to detail what the child eats in a day. The answer was, 4 meals, each of soft porridge with sugar, and water, and the mother was tearing up telling the dietician this. No milk, nothing else actually. When they talked about what could be done to improve the situation, it was clear there wasn't much. The mother's grandfather supported the family (the great-grandfather to the child) at a job making 180 pula/month, which is about 30 US dollars. The mother had 3 other children and no job. We're lucky here in Botswana that the government has committed to providing food baskets monthly to the orphans, but its much more difficult to get for someone who has a living parent. I left the dietician working on a letter for the local social worker, to try to prevent the child from landing back in the hospital. This child was 18 months old, and that's probably the average age of most of the patients we see with malnutrition. Breastfeeding has stopped so they lose a good source of nutrition and can't keep up.
So the good part about all this is that...the rain stopped in the beginning of the month. Things finally seem to be settling down. The census is normal and the new news is that 25 volunteers from the US are coming to repaint the peds ward, I think next week. I'll be interested to see where they are from.
So I hope that wasn't too depressing....the good news is that it seems to be over. I'll stop for now and next time talk about the prop plane ride a month ago to do an outreach visit. In summary, we landed on a dirt airstrip and when we went to a lodge for lunch and asked what the choices were, they said "goat." It was really good.
Til next time and more cornhole details...
