Lost in Translation

In Kinyrwanda, the word for health and the word for life are the same. I always find these facets of translation fascintating. A light into culture - found through translating. And for the children I see and help manage in the hospital and in the community, having a life is about having your health. It is something that many parents and children don’t even have to be aware of in the U.S. The issue of not enough food. Without it, they also have no ability to go to school or to develop physically and mentally as is expected for a child of that age. Take away adequate food from your child, give them an inadequate amount of only bananas and rice from 1-7yo and not only are you small in stature, but behavioral, emotional, intellectual development are not the same either for a toddler or small child. The drawings of 11 year olds here who are stunted and malnourished, are more like a 5 yo on a Denver Developmental scale. And the ones who have parents who have had the opportunity to be educated and have jobs and are able to provide for their children not just materially, but educationally and culturally, well, these children are just like kids from the U.S. So in both countries, kids who have not had access to healthy food, ideas, teaching, demonstration, papers, pens, colors can be their decline. Five children have died on the wards since I’ve been here. One was already lifeless when we arrived at the bed. Wrapped up underneath a blanket, the doctors pulled it down, couldn’t feel a pulse, and started CPR. Although no one admitted this, I think she was dead before they begun. A young thing, about 2 years old, but physically, a two year old here is commonly 8kg and they look 9 months old. The diagnosis was malaria. But in truth over 50% of the deaths here, that are attributed to 4 main illnesses: respiratory infections, malaria, diarrhea…have an underlying malnutrition which means the immune system is not as able to fight infection as a healthy well-nourished child would fight. Malnourished, you are more susceptible to every disease. And I have recently been discussing with the staff the issue of incorporating some form of age criteria into our malnutrition program, right now we only use a height-weight percentile of the median of a WHO established standard deviation. So, if you are 45cm and 4kg you are fine on our admission chart. You do not fall into hospitalization zone. But add to that equation that the child is 9 months old and it does not take a blink of an eye for a person from a developed country to say at the site of the scrawny premature looking child, admit the kid. But last Thursday, when we were weighing and measuring many children from the area to see if they meet criteria to be in the food program, or need to be hospitalized, the nutritionist and nurse assistant protested. They say that can’t start including age because all the children are stunted. All of them they reinforced. I tried to throw around Joia’s name, the medical director of PIH, and say that it is her wish, look at this child’s medical record, Joia wrote right here that the child needs to be in our ambulatory food program, and the staff said, well then if we accept her, than we have to accept her and her and him and him…and they start pointing to many other children waiting in line to be measured and weighed on our food distribution day. And they were right, if we are to accept one like that, than we need to be accepting everyone like that. And then exasperated they said, we don’t have enough food to have all those children, we’d be accepting all of the Rwandan children. I said, “No. Not all. Not ALL children fall that extremely off the growth curve.” Couldn’t they see this case was extreme. Why wasn’t it hitting them as extreme. This one case amongst the others? But getting them to understand that the degree of this child was severe, was dramatic, more dramatic than most other cases was difficult. I tried to explain that they didn’t have to admit a 4 foot 10 year old, but that a 8 pound nine month is not acceptable. I have an internal calibration. I don’t know where my danger zone ends or begins, but when I see it, the assessment is automatic. IT doesn’t seem like you need training to understand “On deaths door.” But then again, maybe I underestimate the degree of different people’s assessment skills. And to these nurses, it didn’t seem like this teeny little child was grossly, out of proportion to what it should be. The 9 month old didn’t strike them as any more dramatic than the 10 year old. Severity didn’t seem to register. So I told them I’d show them. That yes, most of these children in our line waiting for us to measure them will be off the curve, but not dramatically. Not -3standard deviations according to the WHO field tables I had printed out for us that day (although I didn’t discuss minus three SD, I described it in different lingo). And I asked Josee to call a couple children from the list out at random. And so did I. But low and behold, our anecdotal experiment of picking out four or five children from the list and recalculating their numbers so we weren’t just looking at height-weight, but also height-age, and weight-age, well every child we chose at random either met criteria for our ambulatory food program, or in-patient hospitalization. This means that every child we picked at random, I called some from the list, Josee the nursing assistant picked some randomly from the list, fell either -2 or -3 standard deviations off of the WHO growth curve. To the staff, they said they would not do height age. They were adamant.They just would not do it. They said if they were to do anything they would consider weight-age, and so we did weight-age on these same randomly chosen children from the list, and children who were passing and not meeting criteria to be in the food program because they were healthy enough gheight-weight wise, were now coming out very low on the weight-age growth curve again -2 to -3 standard deviations off the WHO growth curves. And it would have meant we accept almost everyone into the nutrition program that day. And although the staff would have protested because they already work 7 days a week and feel overwhelmed, with 2 kids to a bed and not enough room to work, I also was wondering what resources we have available to us. Can the ambulatory program be amped up 5 times as much? I didn’t know. Almost everyone seemed to meet criteria using one curve or another. And at this discussion the nutritionist and nurse got very frustrated, and I insisted that we still accept this child that Joia had written a note to admit “because Joia said to do so.” I thought wielding her name would have some impact, some deference of “Well OK, since she said so we will.” But instead they said they didn’t care who wrote the note. They said, then tell Joia to come here and sit with us and do this job with us, day in and day out, and understand what we see, then she’ll understand the extent of the problem. And that is exactly it. I think it has to be decided, to what extent are we trying to solve the problem of malnourished children in Rwanda. Are we trying to annihilate malnutrition? Are we prepared to feed ALL of our cachement area? 300,000 families? Do we want to provide life-long food subsidies? Can we get some agricultural programs, educational programs, other kinds of programs in tow so that these families aren’t relying on food subsidies for two-four months from us, and then they are getting nothing. Neither food nor training. The problem of malnutrition is a systemic one. Yes, we can get the acute kids on their feet again, literally, with our inpatient feeding centers. But then what. Two months of subsidy to a small group that fits into WHO and PIH-made criteria of who is eligible and who is not also seems grossly insufficient to me as well. And then I notice on the piece of paper that I’m writing on, that it has our PIH symbol, four hands joining together from four directions. We are supposed to be joining hands here. In Kinyrwanda the translation of Partners in Health is Friends in Health. And friends can have a meaning of a deep intimate friend or a more casual friend. And Health can also mean life. So the whole reason we’re here is not just to be friends in health, but friends in life. And if I am to be all of these children’s friend in life…well. Then I think I would have to say…until we have a better solution that is life-long and sustainable, until people can have resources and funding and eduation to start lifting their own circumstances up more, well than you have got to support the children in life. It is, I think, going to mean more food subsidies for the time being. Patching up the gaps, until there is a better solution, that makes food subsidy unnecessary or less important, that I think…we need to feed any kid who meets -3SD on any curve.