Just as I was about to leave for the day, Steve, one of the nurses, asked me if I could see this one case before going. Beatrice (not her real name) was two years and seven months old when she arrived in our paediatric hospital tent, in Kimbi Lulenge, South Kivu, in the Democratic Republic of the Congo (DRC). A quick glance at the prostrate child in the dim circle of light cast by the tent’s single bulb and I guessed she was another malaria case. Steve shook his head. “Non, docteur. C’est un nouveau cas de malnutrition” (“No, doctor. This is a new malnutrition case”).
Dr Chris Bird (L) and a nurse show a mother a record of her child's weight gain in the Inpatient Therapeutic Feeding Centre. Photograph: Emily Lynch/MSF
I quickly felt the child’s feet – icy cold. A careful look at Beatrice showed that all the curves and dimples of a healthy child’s face had shrunk, leaving the forbidding lines of a woodblock print. Beatrice was alert, but silent, which formed an ominous void amid the children crying in the rest of the tent. There was a glint of anxiety in her rheumy eyes that grew dimmer as she seemed to fall into it.
I gently pulled back the cotton wrap. The malnutrition had ravaged her skin, causing it to flake off, leaving behind weeping sores across her arms, legs and chest. There was no healthy protest when a drip was placed in her arm.
The nursing staff went into action. They gave her glucose to prevent low blood sugar, antibiotics through the drip to fight off infection; they advised her mother to keep her warm, as hypothermia takes the lives of many of these children at night. Careful fluid management and gentle refeeding was started: give too little and the child will succumb to dehydration and shock; too much and the child will die of heart failure.
Treating a malnourished child is complex. It is not simply a matter of doling out cups of milk and packets of peanut paste when a child like Beatrice finds her way into our tent, tied to her mother’s back after she has walked a day to get to our hospital or, if she’s lucky, on the back of a relative’s motorbike along the treacherous dirt roads.
She needed intensive care; the kind of care where one nurse sits at the foot of her bed, monitoring her temperature and vital signs hourly, helps to prepare the mother for the full timetable that refeeding these children requires, and attends to the skin wounds that look as though they belong to a burns victim.
This situation of need in the midst of such want brings to mind the work of the British doctor Julian Tudor Hart. In the 1960s, he pioneered pro-poor healthcare in the Welsh town of Glyncorrwg. His experience prompted him to come up with the “inverse care law” – that the “availability of good medical care varies inversely with the need for it in the population”.
The grand-sounding Inpatient Therapeutic Feeding Centre (ITFC) is my favourite part of the hospital. In a tent set apart from other patients you get to see these little children, with so much stacked against them, gradually put on weight, start to smile and play with their parents. With the extra staff we have hired, our care is as focused and intensive as it can be, given our limited means.
But Beatrice arrived before our ITFC had been established. That night there were only two frazzled nurses in our paediatric tent. It was rainy season so it meant malaria cases were high and our hospital was busy.
Beatrice arrived when the light was fading behind the tent’s white canvas walls; she was already very ill. After gently warming her by placing her close to her mother and monitoring the dosing of the initial fluids, Steve began her feeds. He tended to her skin and then, when she began to have difficulty breathing, he put her on the hospital’s only oxygen concentrator, the maximum level of care for our most severely ill children.
But when I was called to see her later the next morning, her heart had already stopped. The anxiety in her eyes had gone.
Beatrice’s mother sobbed as we wrapped her daughter in the green cotton cloth in which she was brought. Her father lifted her easily in his arms and left the hospital, his face immobile. Her mother walked, crying, behind him, stopping on the dirt road from time to time as she doubled up in grief. An elderly man going the other way, a Red Cross armband on his left arm, dismounted his bicycle and gave a formal salute to the family as they walked past.
You won’t read much about malnutrition in DRC because it doesn’t fit the dustbowl paradigms that govern the concept of starvation or malnourishment. Where I am in the east it is green and lush, but after years of war, insecurity and economic collapse, all the children in our tent are malnourished to some degree. It is this underlying weakness that determines how children respond to the infectious diseases that claim their lives with unrelenting regularity.
An estimated 9.7 million children under the age of five will die this year of largely preventable illnesses. Malnutrition is estimated to contribute to half of these deaths. What do numbers like these really mean?
It means a small, fragile girl like Beatrice, whose parents loved her, who left us as quietly as she arrived.
This post was first published by the Guardian Online
Thank you, Dr Bird. You remind us that malnutrition is not just hungry children or thin children, but also desperately sick children with a variety of dire symptoms I myself was not aware of. This must be nearly as hard for you as for the heartbroken parents. I sponsor a woman in Congo through Women for Women and knew they had suffered many years of war, literally a lifetime of turmoil for some, like “my” young woman. But I did not really comprehend how severe the situation there is on a personal, in-the-flesh level. You really give it feet. Bless you & your work.
Thank you for all you do. Please continue your good works and may God bless you and all the people you serve.
Deeply sad and profoundly grievous for parents to watch their child die because they didn’t have the resources to adequately feed her! THEY were the ones left in utter pain/loss; the child, on the other hand, was freed from a life of severe poverty and struggle.
This is not always a bad thing – I know personally that death is sometimes a strange “gift” to the most fragile, or those who have accomplished their earthly mission: My extremely psychologically wounded mother died when she was 30 in an auto accident. I was only 10 yrs old at the time and immediately KNEW that her instant death was a strange “gift” to her as well as to her 4 children, as she was unable to properly care for herself or her babies. Then, only 18 months later, my 32-yr-old father died from injuries sustained while serving as a law enforcement officer. He was a very good and strong man, and he died at home right after speaking to me, yet I spiritually sensed that he had handed me a powerful “baton” of life that I wouldn’t have taken as seriously (at age 11) as I would have had he continued living and being my hero and protector. Life was very difficult and stressful for the next 15-20 yrs., yet I gripped this “baton” and God/Christ in such a way, that nothing or no one could quench the force of life handed to me right before my second parent faded from me right before my eyes.
So I weep with “Beatrice’s” parents, yet cheer for Beatrice in her new existence of strength and peace and love and bounty! I see this as humanly tragic, yet a strange “gift” at the same time.
Debbie Hillyard (daughter of Dan Leo Hillyard)
As an LPN working in a Canadian Emergency Department, I am humbled. We currently are facing “the winter rush”, which means that our department often holds 125 patients in a department designed to house and treat 1/3 of that number. As stressful as that is, I can easily imagine the distress that this situation brings.
One day, I would like to be part of the solution by physically being there. For now, I will spread the word. I hope it helps.
This is my first time reading your site. I know nothing about malnutrition except it kills. Why, if the parents were strong enough to walk to the doctors which to me says they were eating, did they not share their food with the child? I’m sure I’m missing a lot of pieces of info here and probably assuming things too. Please explain. I want to learn.
When I first started doing my social work practicum with the homeless in East St Louis, I was manning the phones – so to speak. An elderly lady called and wanted to know what kind of help do we do for people. I explained that we provided emergency shelter for women and children. She replied, “Maybe you can help this woman and her kids that I keep sleeping in my car.” I asked her to give me more information. She said that this woman and her three children frequently get in her car and neighbor’s cars to sleep at night. She guessed that the children were maybe 14, 6 and 1. She only caught glimpses of them. Now the woman seemed to trust her a little bit and she keeps her car unlocked so they have somewhere to sleep. She and the neighbors leave sandwiches out for them to find. She didn’t want to get involved but maybe we could round them up and bring them in to the shelter. I asked her what she meant by round them up. She replied that the family was a bit skittish and could disappear quickly when people came around. I gathered that they had gone feral. I asked my advisor if we should get the authorities and try to bring them in for help. Clearly they were in dire need. She said to leave them alone. I was not happy with that answer. She explained. The police won’t help and the woman may have a pimp. If you help her, her pimp will come after you. No, you have to let them come here for help. So we left her and her children in the street to fend for themselves and hope that the kind neighbors will be able to coax them inside for a real meal and maybe the mother and her children will learn to trust again. God only knows what situation they were in that made living in the street outside the human community better than being inside.
I think we all have to be thankful for the wonderful work you do everyday, and realise these things can no longer happen. I hope I get to help people like you do when I grow up. I am most admired by your strength.
Best wishes for you and your patients from Uruguay.
Thank you so much for your work and your words.
definately keep writing dr bird. our prayers and good wishes are with you and your colleagues. As the highest degree of a medical professional certainly is to have served the planet as DOCTORSWITHOUTBORDERS and yourself do . thank you . stay in the light. paix,jpg
I think it was the last line that was so desperately sad.I think it is our responsibility to give a voice to the young.
Dr.Bird we are so thankful that you are a part of MSF. I wish more people would read articles such as yours.
We donate monthly to MSF and will continue to do so.I hope others will do the same so perhaps on another day a little girl can return home to her family with a smile on her face.
Kindest Regards from Canada,
Andrea
What a terrible situation in Congo! Here in Mexico malnutrition is also a health problem in people who live on mountains chains. For example, Tarahumara people (an etnic population in Chihuahua) is envolved in serious malnutrition problems because it’s difficult to send them help, food and medications. There are also many ethnics that goverment has forgotten in help supply. I would like to know more about your labor in Congo, i’m a medical student yet but I really want to help for changing the world’s condition in this topic. Malnutrition doesn’t have to kill any other person around if human beings work together for preventing it.
Thank you very much for your post, I will be reading more about your work in Congo or wherever you go and post about it.
Franky Santillan
Keep writing, Dr. Bird. May God bless your work with the children.
So important that you keep articles like these coming. Thank yu so much!
Thank you for this post. It makes me feel connected to something that is after all not so very distant.