- © 2007 Canadian Medical Association
Susanna peers out at us disdainfully from behind the edematous folds of her face. She is 2 years old and suffering from severe Kwashiorkor malnutrition.
“The signs of Kwashiorkor,” explains the clinical officer who has become my mentor during my elective in Tanzania, “are edema, dermatitis, and misery.” Susanna has all 3 in abundance.
I examine her as she sits ever so still, wrapped in her mother's emerald green kanga with its elfin little hood hiding her thin, brittle hair. She is clearly not improving despite weeks in the hospital.
After rounds, I venture out of the pediatric bungalow into the lush vegetation of the hospital grounds in search of the nutritionist. We exchange the necessary multitude of greetings in Swahili, and then I ask him abruptly why Susanna is still receiving maize porridge as her sole treatment. He tells me that after recent financial cutbacks at the hospital, malnourished children are no longer eligible for free food. Susanna's mother can only afford maize porridge.
Unsatisfied with this standstill, I persist. That afternoon I am informed that there is a policy that children with Kwashiorkor should be referred to the regional hospital for re-feeding with UNICEF formula.
I feel outraged that Susanna has been wasting away while this formula was available.
Why hasn't Susanna been referred?
The next morning I arrive at pediatric rounds feeling uncomfortable that as a visiting “mzungu” (white person) medical student I am about to deliver a lecture on health policy to my mentor. When we reach Susanna, my mentor picks up the chart — “the nutritionist says Susanna is to be discharged today.”
I blink in disbelief and explain, perhaps too emotionally, about the regional hospital, the UNICEF formula, and the policy.
My usually patient mentor looks annoyed. After all, how many standstill cases has he been forced to accept each day in his hard-working career?
He turns to Susanna's mother and speaks rapidly in Swahili. “She says, she knows about the regional hospital, but she cannot afford the 30-cent bus fare to get there,” he translates.
Finally understanding and feeling helpless I, the mzungu, pass Susanna's mother a few bills and wish that we were not all in this position.
My mentor replaces the blue discharge form with a pink referral form. And I begin to wish that I had spent my 6-week elective in Tanzania petitioning UNICEF for re-feeding formula for this district hospital, rather than shadowing doctors.
It is too late now. I am leaving in 3 days for Canada.
Footnotes
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CMAJ invites contributions to Dispatches from the medical front, in which physicians and other health care providers can provide eyewitness glimpses of medical frontiers, whether defined by location or intervention. The frequency of the section will be conditional on submissions, which must run a maximum 350 words or be subject to our ruthless editorial pencils. Forward submissions to: Wayne.Kondro{at}cma.ca