Reena* is a four-and-a-half year old girl, who in her younger days was partial to eating a bit of soil. Her parents have brought her to us out of simple desperation. She has been very sick for about three weeks prior to arriving at the MSF Stabilisation Centre.
To say she is "not in a good way" would be an understatement which even the English would be uncomfortable with. She is barely conscious, almost completely unable to move her body, more skeleton than flesh. Vomiting, fever and diarrhoea are her main symptoms. Her father, a carpenter, has spent large amounts of money on local doctors (well, about £40, but it works out as many weeks salary for him). They have prescribed for her the usual mix of placebos and domestos-strength antibiotics, all to no avail. They think she might have typhoid fever. Now the doctors refuse to see Reena, saying there is nothing more to do, and that she will die. They advised the parents to take her to the district hospital, about 1½ hours from Biraul.
Just a bit of background for this hospital. It is very overcrowded - it acts as a referral centre for as far away as Nepal, 60 paediatric beds for too many millions of people - so the level of care there varies. And it is far away. In the end, Reena's father says there is no way he would even consider taking his daughter there.
The first week is rough for Reena. Despite her pitiful moans whenever we have to examine her, the defiance in her eyes says she is a fighter. We rehydrate her intravenously, which is a start. Anything we try to put into her stomach via the nasogastric tube just comes straight back out of her mouth – this makes her nutritional treatment tricky. We load her with antibiotics, but if anything the fevers get worse. We examine and re-examine her stool, which is reported as normal. On the third or fourth day, now too weak to move, she develops bed sores, something familiar to me only in patients at least 60 years older than this poor creature.
Over the weekend, blood and mucous start to appear in her diarrhoea - dysentery. We have no lab technician on a Sunday, so I decide to have a look under the microscope myself. I've not picked one up for about three years since my tropical medicine training and I feel quite pleased with myself when I find the 'on' switch. I prepare a very poor slide of her stool, and immediately notice large numbers of something that to me looks like a worm egg.
The next 48 hours are spent discussing this finding and pouring through text books trying to identify it. The lab technician initially tells me it is a food particle, but after showing him enough of them, I convince him otherwise. Besides, the poor girl hasn't even managed to keep any milk down since she got here, let alone food. Eventually we decide it is a trematode worm egg, which would fit with many of her symptoms. We give her a dose of the standard deworming treatment, and low and behold, she passes a number of fat, half-centimetre little worms in the next few stools. These particular worms do not always respond well to the standard treatments though, and our very kind logistician spends a morning in Darbhanga doing a pharmacy-crawl, trying to source a slightly more targeted treatment. His hard work is rewarded with Reena passing hundreds if not thousands of the little parasites over the next couple of days. We never got a precise diagnosis for this worm, although we narrowed it down to the genus at least - Echinostoma. I suspect the number of them had something to do with the soil-rich diet.
For the next few days things go well. Her fevers start to subside, the vomiting stops, and after almost a week of watching her waste away, we finally start to get some milk into her. Even the diarrhoea improves. The lethargy turns into irritability, which we all have to try hard to remind ourselves is a good sign.
More than anything, I wish I could say there was a happy ending to this story. But the improvement is only short-lived, and after more than two weeks with us, Reena starts to deteriorate again. The fevers return, and the domestos-strength antibiotics are wheeled out once more, but to no avail. I see the fight go out of her eyes, and at this point I have an incredibly bad feeling as to how this is going to turn out. At the limit of what we can do for her, we take her to the district hospital for some outpatient tests and to see a specialist. He advises her to be admitted to the hospital, but again the parents refuse. Unhelpfully, the tests come back pretty much normal.
Late the next evening, I get the phone call I was both expecting and dreading. Reena, the little fighter who ate soil, has passed away. I ask after the parents – there are no tears shed. I think they had resigned themselves to this outcome weeks ago. I ask after the staff (we have all grown very attached to Reena during her time with us). Everyone is very sad, but again, for the last few days we have all had a sense of the probable outcome.
Sepsis got the better of poor Reena. Whether things would have turned out differently had she not been malnourished… no one can say for sure, but at least she would have stood a better chance. So it is for many diseases. If a young child gets severe malaria, pneumonia or diarrhoea, they might be in trouble even at the peak of physical health. To start from a point of malnourishment is to start on a very disadvantageous playing field indeed.
Young or old, no one should have to face this uphill struggle, due to a simple lack of nutrition. As for the team, there is no consolation in words. We are all professionals, and we do our best to separate the human tragedy we have just witnessed from the actions we must now take - picking up the pieces, learning whatever lessons that can be learnt, and continuing to treat the malnourished with renewed determination.
*Name changed to protect anonymity
This post was first published in Spanish in 20minutos.es