Gradual recovery and slow change in season

After one month in Zinder, Niger, the heat is finally beginning to abate somewhat and sand storms are coming in. The locusts came by and created their own storms, covering the windshields of our vehicles, walls of the houses and our entire patio, especially attracted by light sources at night time. Having come through the city also means that they ravaged crops in the countryside, and are now on their way further south into Nigeria. Smaller locusts or “crickets” as they are called here, are a popular snack after they are dried and mixed with spices and onions. People collect them in little plastic bags or cups, including mothers of patients at the hospital, in order to be able to prepare them at home and often sell them. I have to admit that crickets are actually quite a tasty snack which I have come to appreciate and which has improved my evolving phobia of locust storms.

A little girl enjoying her Plump'y Nut The hospital is just as busy as always, especially on market day which is Thursday, when people come in from the surrounding countryside to sell their wares and take the occasion to make a trip to the hospital for themselves, relatives, or to bring in their sick child. On the way to the hospital in the morning, I pass the “marche de betail”, or the livestock market, where camels, goats, cattle and other animals are sold in a large open area. The streets are full of oxen pulling small wooden carts filled with various items on their way to the market. There is much excitement in the air on market day, which tends to be transmitted even through the gates of the hospital as people carry various food items to relatives on the ward.

The therapeutic feeding centre is full to capacity this week and the phase 2 or recovery phase has been moved to the tented area near the end of town, which used to house the entire feeding program. My weekly visits to this area are among some of my favourite moments so far, as this is where I see children who came through the ICU, who are now seated on woven mats with their mothers on the sand some already smiling and playing with sticks or utensils, eagerly awaiting their supplementary food package. This is where I played with little Charifa this week, a 13 month old little girl with Down’s Syndrome whom I have become attached to, as she for some reason had been smiling already in the ICU, while we tried to manage her heart failure. She is always smiling and very little seems threatening to her. Her mother has a very strong bond with her and is entirely oblivious to her special needs, yet fully aware of what a special child she is in every other way. This seems more important at this time in this context and has pushed Charifa to progress quickly through the phases. She achieved her goal in weight at the end of the week and was discharged home.

The focus in phase 2 is especially on the mother child relationship as it relates to patience and nurturing while feeding. Many mothers struggle with wanting to force feed their children, hoping that they will put on weight more quickly so that they can go home. The nurses and nutritional assistants in this phase ensure that mothers remain patient with feeding, as many children at this stage relapse quickly into refusing milk and need much encouragement in order to avoid regressing back to feeding tubes and phase one.

After the peak of hunger season has passed, a part of the project here in conjunction with acute medical care, will be to set up a play area in the centre, in order to help stimulate those children in phase 2 to help their recovery. Psychological recovery in malnutrition is included as a section in the MSF protocol for treatment of acute malnutrition with a focus on physical and emotional stimulation. I think that we often forget what an important part of healing, play is for children, especially for malnourished children whose entire energy for weeks has been focused just on basic functions, such as keeping body temperature stable and whose experience of touch has been distorted by the state of their body and the pain associated with touch.

A memorable moment for me earlier this week, was the discharge of a 4 year old girl in whom we placed a chest tube to drain an infection in her lungs. She came into hospital weighing 6 kilos and after 3 weeks of treatment for TB, she has made a rapid recovery. We were unable to approach her during rounds and she would scream incessantly when we examined her. She made absolutely no eye contact with anyone for weeks. The day of her discharge, she stood giggling, holding her package of therapeutic food and when I finally picked her up, she hugged me and clung to me for several minutes laughing and laughing. After many difficult moments over the last month, Amira’s laughter, Charifa’s smiles and the privilege of witnessing my patients’ first smiles after weeks of illness as they show signs of recovery, has been significant in helping me remain positive in such an urgent environment.

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Step by step, one day at a time

My first glimpse of Zinder Niger was from the air while locating the runway from the WFP (World Food Program) plane, among mazes of paths around red clay huts, towers of mosques and sand with little shrubbery, having turned green with the recent rainy season. The flight had left Niamey several hours prior, making a few stops across the country, flying over a panorama of red earth and sand scattered with specks of clay huts neatly encircled by clay walls. I was picked up by an MSF vehicle at the tiny quiet aeroport, while the WFP plane refuelled, filling up with a new set of passengers before turning back towards the capital Niamey. The scenery along the road into town filled me with energy after a long trip and continues to do so on days when I feel drained during the jeep ride to or back from the hospital.

A quick glimpse into the life of Zinder as seen from the car due to current security restrictions: endless stands selling numerous items, a variety of livestock along the road including herds of goats, camels, cows, carts drawn by donkeys accompanied by shepherds bringing wares to the market.; Men resting on thatched mats in groups drinking tea and immersed in discussion or simply watching the passing activity, motorbikes carrying men and women, their scarves flying behind them. And of course everywhere children playing, begging, some searching through garbage, but many smiling and laughing as they do everywhere else in the world. I like the sunset most, coming down within minutes and accentuating the red sand and cragged trees, creating a glow as my vehicle bumps along the paths home. This is the time of evening prayer and the sound of call to prayer echoes across town from numerous mosques, either simultaneously or one after the other.

Here in Zinder my work is based at the therapeutic feeding centre (TFC), where I spend every day in the intensive care area of the malnutrition program. The MSF run TFC has recently been integrated over the last 3 months into the town’s National Hospital from a tent based structure run by MSF since 2005 and located on the other side of town. The inpatient malnutrition program consists of the ICU, “phase one” and “phase two” buildings with those patients who are mostly free of medical complications and working on nutritional rehabilitation, as well as the infant malnutrition ward targeting those patients under 6 months of age. The program has 120 beds and as it is currently peak season, is near capacity with recent expansion back into the tented area.

The ICU where I spend my days, has 40 beds for now, all full, divided into those children who are critical or “cote rouge”, those who are “cote vert”, or on their way either towards recovery or back to the red and those who are “cote ouest”, or on their way out to phase one, unfortunately at risk of regression to cote rouge sometimes in a matter of minutes.

The first two weeks are hard, several deaths this past week, mostly from malnutrition complicated by severe malaria or sepsis. Intensive care here means availability of oxygen, IV fluids with some necessary urgent medications and closer monitoring by 4 nurses assigned to the area and the physician on call. The hardest part has been examining children who are terrified of being touched due to the pain of starvation and whom I touch and lift ever so carefully so as not to add to their discomfort. The average 2 year old and even a few 4 year olds arriving in ICU weigh 5-6 kg, the average weight of a 6 month old. The care is tailored to extreme fragility, a careful balance in every aspect of management so as not to push these children over the edge which they cling to at all times, either in fluids, temperature, blood sugar, severe anemia and blood transfusion. Every decision needs to be thought out so carefully, yet there are so many children who are critical, that it seems hard to keep up. It seems that when you spend too much time with one, another deteriorates nearby while you turn your back for a few minutes. After rounds I spend most of the day going from bed to bed and feeling pulses, checking perfusion and temperature of extremities, uncovering those children who have been covered by their mothers to keep the flies and locusts away.

I think that the first message for me after reflecting on my first two weeks, my interactions with patients and their mothers, as well as with my Hausa language teacher and colleagues, is: little by little, step by step, day by day… children suffering from malnutrition progress slowly, one tiny step at a time often followed by a couple of steps backwards before moving towards a hint of recovery; a couple of weeks minimum before infections are fully treated, before they can hold a cup, before they can sit, more than that before skin begins to heal, and much longer than that before they begin to smile and exhibit the first signs of play.

I think as I am beginning to learn here, is that a fundamental value may be patience, which is echoed again and again in Hausa greetings and daily life: “ may god give patience, and may god carry us until tomorrow”, as a mother first told me in response to my explaining her child’s critical condition. I was given many goals as part of my mission here and I will tackle them one day at a time. I try to keep smiling and also laugh along with mothers who are amused at my attempts at Hausa; I pace myself regardless of the urgency of a situation, as I think that it helps me and perhaps those around me who rarely show signs of panic and work calmly in this urgent setting. There is always so much to learn from people around me, especially from my patients and two weeks have already been a wealth of knowledge.

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About Elisabeth

ElisabethElisabeth Canisius is a Pediatrician currently working for MSF in Zinder, in Southeastern Niger.

She completed her medical studies and residency in Pediatrics at McMaster University in Hamilton, Canada, after having finished a Masters in Social Work at McGill University in Montreal.

She has worked as a Pediatrician in the area of General Pediatrics as well as in Child Maltreatment at McMaster Children’s Hospital.

She has experience working overseas in Haiti, Uganda and Rwanda. This is her first mission with MSF.

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