Sad News

Festus, the clinical officer who is facilitating the Integrated Management of Childhood Illness course, manages to link all twelve nurses up with suitable clients for their practicals within a few minutes. Most of them are sitting outside the OPD under the shade of a tree. A couple of them are in the nearby pediatric ward. I move around taking pictures as they take temperatures, gather histories and follow their flow charts to arrive at a diagnosis.

Several of the children have significant findings so Festus has us gather round to observe. A young boy suffers from acute painful mastoiditis. One of a set of twins has the high temperature, rapid breathing and indrawing of pneumonia. Then we come to Immaculata, one of the nurses, who is examining the most severely malnourished infant I have seen in Uganda. Gently Festus reviews the history and demonstrates the signs. The child is 5 months old and weighs only 2 kg. The skin on his buttocks hangs down to produce what is called the “baggy pants” sign. He has been breast feed and mother says he is sucking eagerly but when asked to demonstrate, her breasts are dry. His palms are almost white. Festus quietly points out that the mother too is malnourished with the silky thin hair of chronic malnutrition. Signs of severe dehydration are confirmed in addition to severe anemia, so the child is taken immediately to the clinical officer.

We return to the classroom. During the break, I go with Immaculata to visit the child on the ward next door to the classroom. Immaculata has obtained a detailed history so we know that the family has no land and are unable to produce their own food. In this place, at this time, HIV is also a real possibility. We realize treatment of this child and family is not going to be easy.

But when we get to the ward, the child and his mother are not there. I look around the compound outside while Immaculata tries to find out where they have gone. Nobody on the ward seems to know. Immaculata goes back to the clinic, locates a hemoglobin result and finds out that the child has been referred to the nearest hospital for a blood transfusion.

As the mother was unable to afford the transport, she has taken him home. It is that simple. She didn’t really have any other option.

“Oh, no,” I think, “We didn’t even start him on ORS. We could have done that much.”

I am consumed with remorse. Immaculata is as distressed as I am. We had determined the mother had no money. How could I have trusted the system to look after them? Others suggest, kindly, that it was clearly such a desperate situation, maybe the mother took him home to die.

As we are sorting out what has happened, the high keening sound made by a mother when a child dies, rises from the health center. It is still a hard sound for me to hear, but one that Africans seem better able to take in their stride. It is heard much too frequently but one never gets used to it.

It is a terrible sound, this immediate, bottomless grief of a mother. It clutches at soft places inside you, holding you in its thrall. Later, the mother will be consoled, but at this time, it seems, she needs to physically exorcize the grief with howls of pain. Today, I am so distressed by our inability to assist the severely malnourished child, that only later do I realize that I don’t even know what else was happening in the health center.

Immaculata offers to send a message to the mother in the village to come back. I think at the time she is just placating me, but I thank her.

The next morning, Immaculata comes to tell me that the mother and the father have returned. I am amazed she has managed to get the message to them so quickly. I can see them standing over by the OPD with the baby wrapped in a clean white shawl. This time the mother has brought a plastic basin and a other few things wrapped in a cloth that she will need to care for the child on the ward.

“They just arrived and as I was examining him, he passed away in my arms,” she sighs.

Together we talk to the mother, finding out she has three others under five at home. The three year old, she tells us, is also malnourished. Immaculata and I think that, given her own state, probably all of them are in a bad way. I notice there is no keening for this child, more like a quiet resignation but maybe we are seeing the impact of depression or the hopelessness of chronic starvation.

Festus announces the death to the class. He is a good teacher and avoids judging the situation or people but wants the students to understand the importance of their work.

Later that evening, I am watching CNN, beer in hand, in a darkened shack all by myself. The TV is powered by a generator which is operated by an energetic business woman who also provides my breakfast of milk tea and chapatti each morning. The CNN news clip has to do with a Druze wedding on the Syria-Israel border. When a Druze woman marries someone on the other side of the border, she can no longer visit her family. CNN seem to have lifted their story in its entirety from an evocative documentary I have recently seen. It is sad alright, but when the tears start to tunnel silently down my cheeks, I know it is not just for the Druzes I am grieving.

Photos: Interviews under the tree; Interview in OPD; SevereMarasmus; SeverMarasmus2; Coffins