"Are you adopted?"

Easter is here and I am enjoying travelling around east Africa during the break. However, before I proceed with the rest of the post, I just want to reassure some of my worried readers - the noisy rooster is still alive and will not be the main course for Easter. In fact I now get concerned for the poor thing if I don't hear it in the morning. The noises from the rooster, the frogs, the random birds, crickets and the boda bodas (the forbidden motorbike taxis)have become part and parcel of everyday life in Jinja for me.  What I will miss this Easter though, are Easter eggs and daffodils; I do like spring at home.

On one of our escapes from the hospital a couple of weeks ago something very funny happened and I thought I would share it with those I haven't already told. We were out at a meal for one of our housemates’ leaving do before he went back to England. At the table, there were several people from around the world, a few Danish girls (young student nurses and student teachers), myself and Sarah, the boys and our Ugandan host family. One of the Danish girls was new to the group and had to be introduced to everyone. At the end of the meal, this 19 year old lady curiously asked me where I was from, she said she was confused by my accent. I did the usual explanation of my dual nationality, Nigerian by birth but have lived in England for a long time. She looked at me with utter confusion and said: "How come? Are you adopted?", at which point I nearly spat out the drink in my mouth as I could not stop laughing. Everyone at the table that heard this looked somewhat shocked. I politely explained migration to her and we all laughed about it.  My biggest regret was not replying with a line that Sarah later suggested... "Yes I was adopted, I am one of Madonna’s kids".

Interestingly, I was not offended by this young lady - this was her first time in this part of Africa, she works in a village teaching young children and to her all she sees of Africa is lack of education and poverty. She only knew one side of the story.  I do not blame her at all as I also often worry about the lack of education amongst some of the parents and children I see in the hospital. Uganda is an ex-British colony, this means that English is an official language in Uganda, in fact lessons in school from as young as nursery classes are taught in English. Despite this, more than 60% of the mums and children I see do not appear to speak or understand English - maybe the problem is mine and Sarah's accents. However, on top of the language difficulties, the majority of mums here are less than 18 years old, some as young as 14 years. This suggests they are not in school or at least not in Secondary school/higher education. This is a huge problem and it contributes greatly to the high child mortality rate we see in these hospitals.

Lack of education plays a major role in child mortality and of course has an enormous impact on the level of poverty these mothers and their children will face. An educated woman is more able to advocate for her family, more likely to seek appropriate health care promptly, less likely to be forced into unwanted relationships, less likely to believe health misconceptions, and be more likely to find a job and help provide for her family. This is why female education and empowerment is one of the millennium goals I wrote about a few weeks ago. The UN identifies how important it is to educate children and not exclude girls from school; in fact, we know that maternal education is the single most effective health intervention we can implement. My recent experiences have shown me the truth behind this statement. As President Kim said: "Education is not only a basic human right, it is a fundamental to ending extreme poverty". More work needs to be done in the community to encourage these young girls to go to school, though sadly, girls are often passed over for education and their brothers preferentially encouraged to attend school.

Whilst this educated young Danish lady can be easily forgiven for her blunder, what is ironic is her need for further enlightenment.  It is one thing to learn languages, sciences and art, it is another to learn about the world around you to avoid the problem of seeing only one side of the story (Click here to hear C. Adichie's TED talk). I am sure this lady will learn a lot on her travels.

Wishing you all a wonderful Easter.

Rant!

I will apologize in advance because this post is more of a rant than an informative post.  Both Sarah and I had a tough week last week; we both had moments of extreme frustration and upset. We had 8 deaths, 4 of whom were children less than 28 days old (neonates). I saw 5 children with severe malaria, 4 needing blood transfusion, and 1 child with cerebral malaria (malaria affecting the brain) and convulsions.  7 patients ran away because they were unable to afford the treatment and some because of the misconceptions I will discuss in this post.  Of these upsetting cases some were particularly heart breaking and it is those that stick in my mind. Sarah beautifully wrote about 2 cases on her blog (click here to read), and here I will write about some of the others.  The running theme amongst these cases is that the deaths may have been avoidable with some parental education.

In Uganda, parents associate 2 medical interventions with death. They believe these interventions kill the children as opposed to whatever illness had made their child unwell enough to require the intervention. They are:
Nasogastric tubes (a tube inserted through one of the nostrils into the stomach that can be used to monitor the stomach contents but also to feed children that are unable to feed. This tube passes through a natural orifice and although the initial insertion is uncomfortable for the child, it does not cause any pain or distress once it is in place)
A child being commenced on oxygen

For the last 4 weeks I have spent a significant amount of time explaining to each parents why these things are not the cause of death but lifesavers and essential for care. There seems to be an ingrained misconception about these 2 things. Death because of lack of resources, late presentation or overwhelming illness is one thing, but preventable deaths due to misunderstandings are incredibly upsetting.

One of the neonates that died this week had a gut infection called necrotizing enterocolitis (NEC). The mainstay of treatment is to stop feeds, rest the gut, insert a nasogastric tube and treat the baby with intravenous antibiotics until the gut heals.  We stopped feeds, inserted a cannula (which thankfully we had) and gave the baby intravenous antibiotics and fluids containing sugar and some of the salt the baby needed. We also the inserted a nasogastric tube (NG tube) to monitor the stomach content and help judge progress and aid reintroduction of feeds once the gut had healed.  Initially the baby improved, each day I stressed to mum why it is important not to feed, rest the gut and keep the tube in the stomach to monitor if the gut is getting better. I knew she was unhappy about the plan but there was no other way of treating this unwell preterm but to use the strategies mentioned above. After 2 days I was told by the nurses that each day they had to re-insert a new NG tube and a new cannula as the mum was pulling it out. She did not believe her child could survive with the tube in and no breast-feeding. Pulling the tubes out was her way of hoping she could avoid them going back in. What I did not realize was that she was feeding the baby when there were no medical staff around; 3 days into treatment this baby died of overwhelming infection.


The other case is a 2-year-old boy who weighed 5 kg and was on the malnutrition unit for stabilization and rehabilitation. At 5kg he weighs less than an average 6-month-old back home in the UK. After 2 weeks of intensive therapy following the WHO malnutrition guideline this boy was not gaining weight. On discussion with his mum it transpired that the little boy flatly refused the reconstituted milk containing the calories, micronutrients and fat he needed to gain weight. Whilst he would eat some dry food, he refused the milk as well as the plumpy nut (sweet-tasting calorific paste).  From his history, examination, a chest x-ray and some blood investigations, it was apparent that he had no other medical reasons to not gain weight or drink the milk, so it was decided that an NG tube was crucial as he was in fact losing weight on the nutrition unit. After an hour-long discussion with mum she agreed to have the NG tube inserted much to my delight. Unfortunately the following morning, this mum was nowhere to be found as she had ran away from the hospital with her little boy leaving me with a lot of dilemmas - should I have just left him without the feeds he needed? Would he have been better on the unit with some nutrition rather than running away? What will happen to him now?

In both these cases the mothers felt they were doing the right thing for their children and stopping the doctors from harming them.  This is a reoccurring theme; every day we fight a losing battle with parents about NG or Oxygen.  At the root of this problem is poor education and misconception, how do we go about educating such a large amount of people about these untruths in the short while I am here?   Shall I walk round my entire ward round with an NG tube in and see if that helps.  Maybe a radio jingle or a TV advert might help, either way something needs to change……