Greetings from Kampala, Uganda! My name is Laura Anne Salm and I am a Master of Public Health candidate in the global health leadership track at the Keck School of Medicine USC. Over the next month, I will be doing a clerkship at Mulago Hospital, which is affiliated with Makerere University in Kampala, Uganda.
I have been assigned to the Child Malnutrition Unit within Mulago Hospital for this week. It has been an eye-opening experience unlike anything I have ever seen, given child malnutrition is not something that is encountered very often in the United States.
Patients are referred from all over the country by various clinics and humanitarian organizations, along with police jurisdictions who are responsible for placing abandoned children in orphanages or transferring them to medical treatment if they are unwell. The clinic is staffed by many nurses, intern and attending physicians, registered dietitians, along with ancillary staff. There are between 45 and 100 patients at the clinic at any given time, with new patients being admitted on a daily basis. All patients are evaluated upon arrival and assigned to the Critical Care Unit, for those who are gravely ill, or to P1 where they require less intensive treatment. The children are subsequently transferred to P2 and finally P3 once they have maintained their weight and other medical issues have resolved.
The average stay for a patient with an “uncomplicated” case is approximately three weeks. For more complex cases, which involve underlying medical conditions or infectious diseases (tuberculosis, meningitis, malaria, yellow fever, dengue), the patients may be there for one to two months. One of the most interesting aspects of the clinic is that the staff members rely heavily on the mothers to assist with the child’s treatment plan, whereby the mothers feed the children high-nutrient formula every two hours 24 hours a day and the mothers stay at the clinic. For abandoned children, they are often sent with an advocate.
Today I met a lovely young woman who was the custodian for a Severe Acute Malnutrition (SAM) little girl who had been abandoned by her family as she was a product of incest. She will remain at the clinic until the child is ready to be discharged to a receiving orphanage.
SAM and its cousin Moderate Acute Malnutrition (MAM) are pervasive issues throughout Africa and are primarily due to poverty, social exclusion, loss of entitlement, food insecurity, inappropriate infant feeding practices (partial or non-breastfeeding), inadequate control of infections via vaccinations, insecticide-treated bed nets, early and effective case management, along with HIV infection and avoidance of HIV vertical transmission by not breastfeeding (Gill, Mabey, Parry, Weber & Whitty, 2013).
In SAM, there is severe wasting and pitting edema (also known as kwashiorkor) of both feet, whereas in MAM, moderate wasting is noted and edema is absent. The exact cause of kwashiorkor is unknown, but may be linked to protein, zinc and fatty acid deficiencies. If kwashiorkor is present it causes severe dermatosis and profuse sloughing of the skin, which provides a point of entry for infections to set up shop and prey upon the already taxed immune system of the child.
Treatment of SAM includes identifying and treating all life-threatening complications, re-establish physiology and metabolism, treat infections, and promote growth and repair (Gill et al., 2013). Patients are susceptible not only to infections, but also dehydration, hypothermia, hypoglycemia and electrolyte imbalances.
I am so impressed with how engaged the nurses, physicians and other staff members are when it comes to patient care in an under-resourced clinic. They deal with drug and basic medical supply shortages on a daily basis and are able to provide the best care possible. The nurses make everything run smoothly even when there is chaos and if you need to know anything, they are the ones to ask. Everyone has been very gracious to me and I look forward to learning more over the next three weeks!