The day had finally come. Pierre was ready. With his oversized pants hoisted up by a weathered black belt and a checkered blue and orange shirt tucked underneath, the little boy exuded the air of a wizened old man ready for a long journey, not a four-year-old child getting discharged home from the hospital.
His mother had taken pains to plaster down his wisps of blondish-brown hair, a sign of his vitamin-deficient state, that had started to grow back. She’d made sure he would go home in style, with pride.
I caught mirth in Pierre’s eyes and a grin that revealed carried teeth as he waved good-bye. This young boy was a far cry from the tired, fragile little one who had been admitted to the inpatient malnutrition ward a mere three weeks prior.
During my time as a clinical fellow working in the pediatric ward at Hospital Saint Nicolas in Saint Marc, Haiti, I’ve had the opportunity to take care of infants and children who have etched indelible stories of both heartbreak and triumph in my heart and mind. However, the faces and stories from the malnutrition ward, where those children who are too sick to manage in the outpatient malnutrition program are admitted, stand out most vividly.
Malnutrition: Sobering statistics
Worldwide, malnutrition plays a role in one-third of childhood deaths. According to the most recent Haitian national survey published in 2012, 5 percent of Haitian children under the age of 5 are unsafely underweight for their height, which is referred to as wasting and indicates an acute state of malnutrition. Moreover, 22 percent of Haitian children are too short for their age, 8 percent severely so. This is referred to as stunting and is an indication of chronic malnutrition.
Zanmi Lasante, the sister organization of Partners in Health (a Boston-based, international non-governmental organization), supports malnutrition programs in several regions within Haiti. Saint Marc has the largest of these programs supported by Zanmi Lasante. Hospital Saint Nicolas is unique in that it has the only inpatient malnutrition program within the Artibonite Department.
Experiencing the problem firsthand
I remember meeting the child with gaunt eyes, sunken into their sockets; with cheeks, ribs, arms, hips, legs, all melted away into bony prominences. His state of malnutrition had progressed so much so that his body had begun to shut down. And he was not the only one. The tragedy with malnutrition is not only a disease that senselessly kills, but it also denies countless little ones the opportunity to reach their full potential. Every child admitted for malnutrition is a symbolic neon sign that says we’ve collectively failed not only him or her, but also his or her family.
Every day, children in various stages of malnutrition are managed in the outpatient malnutrition clinic in Saint Marc by a team of nurses who work to avoid the need for admission. Not infrequently, however, these children come with already weak immune systems and develop complications such as pneumonia or gastroenteritis that necessitates inpatient care.
New patients are also referred to the program and, often, a child’s first interaction with the malnutrition program occurs when they arrive to the hospital severely ill. Frequently, new patients arrive with swollen faces and feet — proof of their protein-deficient state — or sometimes in a state of lethargy and shock from severe infections, dehydration and hypoglycemia. These children not only require enriched therapeutic milk, but also antibiotics, vitamins and often other interventions before they can be stabilized.
It is pretty remarkable to witness the emergence of a child’s face when the excess fluid from their bloated faces and bodies diurese away and their nutritional state improves. Children who were listless at admission often emerge with personalities and sass by the time they go home.
It is a great day when I can leave the ward remembering a smiling mother with her child safely in tow, like that day Pierre waved us goodbye. While the challenges are not insignificant, my experience in the malnutrition program at Hospital Saint Marc has undoubtedly been a privilege. I know that my friends and colleagues here will continue to take care of children with malnutrition as they work toward lowering mortality and morbidity related to malnutrition in the years to come. It would be a remarkable day indeed if, within our lifetimes, a malnutrition clinic such as ours in Saint Marc becomes an obsolete relic of the past.
Learn more about how doctors from Boston Children’s are making a difference around the world through the Global Pediatrics Program.
Saji Perera, MD, is a clinical fellow in the Global Health Program at Boston Children’s Hospital. She spends six months each year in Saint Marc, Haiti, working with Partners in Health/Zanmi Lasante. While in Saint Marc, she works alongside local pediatricians, family medicine residents and nurses in the department of pediatrics at the district hospital providing care in the inpatient ward, outpatient clinics and teaching residents. Her particular interest is in improving care delivery for the pediatric malnutrition ward. Before joining Boston Children’s Hospital, Dr. Perera completed her training in pediatrics in the global health track at Children’s Hospital of the King’s Daughters/Eastern Virginia Medical with a certificate in public health. She has worked in Belize, India, Thailand and the Philippines prior to her time in Haiti.