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"Asama." Once again, the first thing I have learnt to say in the local
language is "open your mouth". "Asama." Looking along the ward, where
the sickest children in the feeding centre are admitted, I can make out
enough tiny figures among the overflow of beds and mosquito nets, and
mothers with their pots and pans and other children, to know that we
will be demanding a lot more open mouths before the morning is over.
MSF's therapeutic feeding centre opened a few days before my arrival.
Local mud bricks, wood and plastic sheeting, combined with MSF water
bladders, piping and generators, have made a 600-bed centre out of
this block, next to a regroupment camp from the mid-1990s, when the
population was being systematically displaced to "flush out"
rebels. It will end up housing over 1000 people when the mothers and
siblings, and occasionally fathers, of the malnourished children
are included.
We start the day's work with the night's admissions. Despite
struggling to read the French scribble of the MSF doctor who took the
call, it seems that the condition of many of the children has improved
from just a few doses of artemether (an antimalarial) and some
rehydration. Some, of course, have not responded and it is difficult
to reassure their mothers, looking desperately at their children
unconscious with cerebral malaria and then hopefully at the
Burundian nurse and me, that these children will recover. I explain
the basics of our malaria treatment in bad French, which is translated
into Kirundi, and the mother smiles. With absolutely no idea of what
she ended up hearing, we move on. "Asama."
There are about 60 children in this so-called "special care" ward. We
need to discharge about 20 to the normal wards each day just to keep the
numbers manageable. Every day, admissions seem to increase. Mothers
are walking for hours with their marasmic, febrile children to reach
the feeding centre here, and every afternoon our minibuses arrive
filled with children who present to the MSF supplementary feeding
centres throughout the province, but who are too malnourished to be
managed with supplementary feeding alone. We know that some children
die on the way and, of course, despite all the efforts of the Burundian
nurses and MSF workers, some also die after admission.
It is hard to consider the beauty of this place alongside the death and
illness brought by malaria and war. Taking a break from the ward round,
I stand outside with the Swedish nurse whose job it is to manage all
this. We stare beyond the adjacent construction site — to be another
feeding centre by the end of the week — and remark on the beauty of the
clouds as they drift up the mountains to unveil the miniature figures
marching through the rice fields below. Then she points out that the
stagnant water of these rice fields is probably the source of all this
malaria and the mountains here blur with the mountains we see from the
United Nations plane on the way from the capital, Bujumbura — the
mountains that are almost impossible to cross because of rebel
attacks, and where, a week before my arrival in Burundi, rebels
stopped a bus from Rwanda and killed everyone on board. This made the
international news because an English volunteer teacher was on the
bus. I have no idea how many other buses are stopped and their occupants
massacred without the incident being reported in the international
media.
Back on the round, we have a glimpse of what medicine must have been like
150 years ago back in Sydney. Happily, the patient is getting better.
So is her mother, who gave birth overnight in her sick child's bed. The
other mothers helped her through the early labour, and then the night
nurse apparently just parked the medication trolley and popped the
gloves on for the delivery. We do our review of malaria treatment and
nutrition status for the older child, a baby check on her new brother, a
quick obstetrics review of the mother's postdelivery condition, and
move on. At lunch we hear that another woman gave birth that morning in
one of the transfer minibuses. The visiting epidemiologist from MSF
headquarters in Europe is left with the problem of incorporating
births into the weekly activity report of MSF's nutritional service.
Besides the addition of chips to the usual menu of fried potatoes and
boiled potatoes, there is good news at lunch. A 12-year-old girl, who
was brought to the local hospital two weeks ago and urgently
transferred to the closest MSF surgical service, was back and making a
good recovery. She was severely beaten by bandits who stole the goats
she and two other children were herding. The other two children, both
younger than her, were stabbed to death in the attack. We choose to
focus on her recovery. The two other Australians and I can only follow
the conversation for so long before the French starts to sound like
Kirundi and we sneak off for a quiet anglophone coffee before heading
back to work.
The afternoon brings seemingly endless queues of children, all
apparently identified as having fever since the end of the morning
rounds. And so begins the almost impossible challenge of
distinguishing malaria from typhus from typhoid from the remaining
diseases in the tropical medicine textbook, with only a stethoscope.
Then the minibuses begin to arrive. We operate a simple triage system:
any child who is unconscious or fitting is seen first. Fearing that we
may soon have to resuscitate the Burundian nurse, who has been on
admissions all day, all the expatriate medical staff and as many
Burundian nurses as can be spared from the wards finish the admissions
by torchlight while our logistician gets the generator working for
overnight.
Many of the children are febrile at admission but almost all the
mothers report treatment already with chloroquine. It has been
fairly clear since the beginning of the epidemic that resistance to
chloroquine is high. No doubt the treatment failure rate contributes
to the extraordinary patient overflow in the province's health
centres, where triage has become an exercise in crowd control and
diagnosing malaria has become guesswork in preference to ordering
thousands of thick films made with out-of-date reagents. As we finish
the admissions for the day, we hope that the results of MSF's malaria
resistance study will soon be available to promote a new national
policy with a first-line treatment that actually works.
After a dinner of potatoes, most of us head off to the local bar for warm
beer and some social time with the Burundian staff. The publican by
night is a nutritional assistant by day, and so supplies almost all of
the town with nutrients of one form or another. A Burundian version of
Tom Waits is singing for beer, but the more beers he drinks the more he
seems to sing. I order a soft drink and turn up the two-way radio — the
MSF equivalent of the on-call page. Remembering my last call, when the
first note reporting a pregnant woman of 38 weeks' gestation with
eclampsia and a transverse lie was a joke from one of the other doctors
but the 3:00 am postpartum haemorrhage following a cervical tear was
not, I lean towards our expat midwife and quietly ask if she objects to
being woken up overnight.
Reassured by her response, I pass by the hospital before bed. Despite
the flicker of the kerosene lamps, the conjunctivae of the woman who
had a caesarean that morning seem pink enough and her urine output is
good. No-one is in labour. The Burundian night nurse and I decide to
treat a newly admitted child for cerebral malaria, despite the
mother's insistence that her son was bewitched. At least we can treat
malaria.
The greatest challenge to sleeping is not so much the bursts of static
from the on-call handset, but the MSF pig rooting around outside the
bungalow. Plastic sheeting and bamboo muffles only so much sound. I
know the pig is roaming the garden at night because the Europeans want
him fat for eating as soon as the Australians, apparently the only
conscientious objectors to eating one's pets, leave. I don't think
about it. You can only focus on one day at a time here.
I know that tomorrow we will see the same wizened, marasmic and puffy
kwashiorkor faces, as well as a few new children of both expressions,
febrile from malaria, but hopefully no children will die overnight.
And I hope we can discharge more than we admit. All of us working in these
hills at the moment are simply aiming to pass the peak of this epidemic.
We'll know we're winning when we start demanding "asama" less often
each morning.
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