Eamonn blogs from Kenya about a very young patient he met in the midst of a national strike...
There has been a near complete and indefinite shutdown of public healthcare in Kenya over the past few weeks. A nurses' strike was announced on the 5th June resulting in patients being discharged en masse from wards and no new admissions to public hospitals. Currently, if you can’t afford private healthcare, and you or your child happens to fall sick, then you have to either sell all your possessions to attain some private services or else pay a visit your local herbalist.
Although Homa Bay District Hospital is a public hospital, MSF employ a handful of the nurses here, so we have managed to keep two wards open. The main difference to our work is now about half of our patients are kids as the paediatric ward is closed. We also a have a smattering of surgical patients whom I’m really hoping will get away without needing operations as there are no functioning operating theatres.
A young child receives a medical consultation. Photo: Bruno De Cock / MSF
Amid this general chaos, a two year-old girl called Beatrice was abandoned in the outpatient department on Friday afternoon last and, with no other options available, was admitted to our ward. She seemed OK, a little bit malnourished but quite happy and playful. A good Samaritan who was in the out patients’ department herself that afternoon had volunteered to mind her, and with our nursing staff already overstretched, we were more than happy to accept her help.
I saw Beatrice again on Saturday and she was doing well. The woman from outpatients was still happily minding her and hit me with a startling request - she asked me would it be possible for her to adopt Beatrice. I was completely taken aback. I explained to her that it’s not my decision and we would need to talk to social services, but I figured it was a possibility.
Over the next few days Beatrice began to get a bit non-specifically unwell. She didn’t have any temperature but she was more irritable and sleeping a lot of the time. On Monday afternoon her caregiver mentioned that she seemed constantly thirsty. We decided to check her blood sugar and, to our surprise, it was high enough to confirm that she had type 1 diabetes. The mystery of her abandonment was solved. This diagnosis was probably felt by her parents to be more than they could handle.
This seemingly insurmountable challenge isn’t actually insurmountable
It seems extreme to abandon a child on the strength of this. But then again diabetes is unbelievably challenging to manage in a young child anywhere in the world.
At the very best of times you walk a tightrope trying to keep blood sugar low enough to ensure good health in the long-term, but terrifyingly, a blood sugar too low can kill in minutes. This is made all the more lethal in a young child by the fact that a two year old can’t recognise the symptoms of low blood sugar and so by the time a parent notices it may be too late.
Then if you’re a poor person in a poorly resourced health service you have several more issues besides: blood glucose monitoring equipment is too expensive to buy; you don’t have a fridge for insulin; malaria can quickly and catastrophically drop blood sugar without warning; medical help is difficult to access and there’s a good chance you haven't had a lot of educational opportunities and struggle to understand the condition
But stories like Beatrice’s are all too common
Taking this perfect storm of a tricky medical condition and awful social circumstances into account, Beatrice’s parents’ decision seems like less of a heartless one.
In any case, I know for a fact that this seemingly insurmountable challenge isn’t actually insurmountable. There are plenty of healthy type 1 diabetics in Africa, I’ve met some of them. And besides, Beatrice’s caregiver was as enthusiastic as ever about minding her. So we initiated appropriate treatment to hydrate and to try to bring the blood sugar level down slowly with a view to getting her eventually started on a sustainable and safe treatment regimen.
I sat stunned for about five minutes
I got a call later that evening to say Beatrice had deteriorated suddenly and died. We don’t have post-mortems but most likely what happened was a complication of acute diabetes whereby there’s a shift of fluid into the brain tissue when hydration improves and blood sugar starts to fall. Malnutrition and the insidious rise of her blood sugar over the previous days probably made this happening more likely.
This was actually the first time I’ve encountered a child dying as a doctor and it hit me like a train. I sat stunned for about five minutes. Then I spent a weird minute trying to think up of scenarios in which the people informing me of this might be mistaken. When I finally gathered my thoughts, I did the doctor thing of furiously Googling how this could have happened and landed on the above explanation.
But stories like Beatrice’s are all too common.
Conservative estimates suggest 52 out every 1,000 Kenyan children die before the age of 5. This compares with an average about 3 per 1,000 in a high-income setting. That means that 49 (52-3) per 1,000 children born in Kenya die avoidable deaths before they reach their 5th birthday. If you do the maths, that makes 76,000 children per year. And Kenya’s actually far from the worst off in that regard. Although removing public healthcare for a few weeks/months won’t help those numbers.
At least the MSF project in Homa Bay is of sufficient scale that we can provide something of a stopgap while the strike continues. Besides poor Beatrice we have had plenty of very sick children make excellent recoveries that they probably wouldn’t have made at the local herbalist.
The nurses’ demands are entirely reasonable so hopefully the hospital will be back to full capacity soon.