Got Milk?
The turnoff to JND Hospital is a confluence of three dusty highway ribbons. Their crossing points are a predictable chaos of wobbly wheeled yellow rusty cabs, vroomng red motorcycles, and clunky mini-vans loaded inside with a tangle of arms and heads and outside with mattresses, plastic basins and the occasionally traumatized goat. Bordering the cloudy streams are wooden thatch roofed stalls selling anything from individual red or green oval slightly shriveled hot peppers arranged in groups of ten, to green bananas to batteries to phone cards. People stagger through the bustle-- women in bright colorful large patterned fabrics and men typically in khaki slacks and short sleeve dress shirt--becoming all at once its animation and scene. Those that want a cab flip their right wrists as if dealing a deck of imaginary cards as they walk. Forty Liberian dollars or sixty cents to most places one would ever want to go, but guaranteed the ride will be accompanied and it’s going to be hot.
I have seen intersections of this sort in every developing country I have traveled. In Guatemala it’s Los Encuentros. In Rwanda it’s Kibuke. In Yunnan it’s an entire nameless town where half the residents ruminate and squat. These are the places that on their faces are dirty hell holes; places where famished foreigners after an 8 hour trip on a chicken bus look for food like fried chicken, plantains and French fries as a way to avoid dysentery only to get sick; places where all wayward buses must stop, passengers disembark, people stare and driver's piss. Beneath the grit is likely something much more hopeful and fruitful. It is the promise of exchange, a way for resupply, an insistence that all things must pass through a common human funnel. In and out. In and out. These places are pumps, 24 hour sex, greasy engines, population-based CPR. They are the common experience that binds a daughter visiting her family after five years of school upcountry, crinkled diploma in hand, with the man who is trying to sell enough flip-flops to put food on the table, with the sweating bureaucrat in a blue-striped three-piece suit who would soon nuke it all but thankfully cannot. It is through this fertile sooty mass I drive. My truck is big, there are not road rules, but I signal and simultaneously wave to boost race relations. I have a Liberian driver’s license now.
JDJ Hospital is in a way the opposite of Redemption. I only halfway joke that it resembles a 1970’s Khmer Rouge torture house—a innocent appearing off white school with three stories and blue trim—until you go in. JDJ hospital was during the years of Charles Taylor by Doctors without Borders (MSF) -- Spain. Last June, we took over because MSF no longer regards Liberia as a disaster, and as such, left the country. MSF did a great job training JDJ hospital staff. But whereas MSF had fourteen doctors, we have five, one of whom has a hard timing getting to work. Basically, JDJ is a medical train wreck and damn if I’ll let my organization run a crappy hospital twenty minutes away from the main office. I have decided JDJ will be our showcase hospital, that it will undergo a transformation and that we will meet al; our promises to our funders.
Just to make sure this is the case, I have decided to personalize the pain by working the pediatric ward each Saturday morning. I’ve made it a kind of ritual. I get up at 6:30 to do basketball drills at the American school up the road from TGH apartment; regret my existence by running suicides towards the end of the workout; startle the neighborhood with my appearance during the walk home; and praise life drinking bottled water beneath a cold shower. I eat a banana, dress in scrubs, black sweat wicking T-shirt and white striped Adidas. With stethoscope around my neck, Purell and surgical scissors clipped with hemostats to my waist, pen and iphone in my back pocket and ID, house key, and money hanging from a black MIT (Made In Taiwan, baby!) lanyard off my neck, I head out the door.
I love the kids at JDJ. It’s that simple. Seeing them with their quiet stoic mothers, in all sizes, all states of dress some shaking empty cups, some staring straight, some waving, some sleeping, some breathing too fast, some breast feeding and some sweating, my purpose is clear. When I first visited JND four weeks ago, a third of the children hadn’t been seen by a doctor in three days. Of the 2/3 that had been seen, 1/3 were diagnosed incorrectly with usually a detailed note written by a physician assistant with variable experience justifying a pithy comment by the physician much along the lines of “continue current care.” One three week old with whom I took a liking to not having die, hadn’t been fed for eight days. His compliant but shriveled mom wasn’t producing sufficient milk for the baby. She had brought the baby to the hospital because it wouldn’t eat. The baby had perhaps had a fever. The doctor in the emergency room diagnosed, “rule out sepsis” and ordered intramuscular antimalarials and IV antibiotics. When I saw the baby at hospital day three, the child was weak, but when I looked at the vital signs, he had never had a fever. In addition, the rapid malaria test had turned out negative. The baby on exam had clear lungs, a strong suck, a soft abdomen, but was his arms and legs were like skin covering bird bones, all his ribs were showing and there was little fat along his temples, a sign of chronic weight loss called temporal wasting. When I talked to mom she felt that simply the baby now four weeks old was hungry. I agreed. I stopped the anti-malarials and antibiotics and wrote an order for feeding, for the child to be weighed daily, got consensus from the team that we would have this child gain 15-30 grams a day, had the team give each other high fives for caring about child nutrition and then moved on.
A week later I am back. The same baby, a vigorous but weakening son of a gun, has not been weighed since the last visit. I make the nurse put the baby on the scale and it has lost forty grams. The doctor that had seen the particular child the day previous scribbled in the chart, “Starvation. Encourage breast feeding.” Not an entirely wrong diagnosis but still idiotic. I look from the chart to the mom with saggy empty breasts attempting to feed her voracious infant by forcibly squeezing the front of her breast into its mouth as if to be able to milk remnant milk, to the chart and back to the now resolved baby again. I imagine the uproar in the anti-septic hospitals where I worked back in the States about there not being a breast feeding room in the facility. I think, “I will give a million dollars to anyone who shows me a breast feeding room in Africa. I will give a million dollars to anyone who then builds a breast feeding room, then burn it down.”
I round with a physician assistant named Marley and nurse Grace who used to work with MSF so they are pretty good. Marley and the nurse are perfectly gracious and like going over patients with me though I slow down the work. I give them the option not to. “We welcome you,” they say.
“I guess you don’t like this child,” I declare pointing to the baby trying to breast feed off of a empty teet.
“Excuse me?” Marley asks
I point to a different baby-- a smug strangely plethoric baby in the corner bin, “That child must be your nephew because you are feeding it. This child on the other hand must be a stranger which you regard as ugly, because it has not been fed since the last week I was here. So it will die and make things simpler for all of us. I am not even sure I like this child.”
Marley and the nurse Grace look nervous. They smile unnaturally but proceed with vociferous protestations, “Doctor, we love all children,” Marley says, “We don’t have milk. We have told the mother that she must buy milk but she refuses. What is there to do?”
“Well I think the mother must be a bad person,” I say, “Because I just saw her get dropped off by her husband in a Mercedes. Last night I saw her at the sushi restaurant where I was eating and beneath her traditional beautiful Liberian blouse I bet she wears gold chains”
There is silence and confusion as the team wonders what kind of diabolical medical stranger has come to their work place. “No,” Marley says, “She is poor. What is sushi?”
I continue my casual dialogue, “Well what can we do? How come we can put a needle in a patient, inject it with hundreds of dollars of antibiotics but can’t feed a baby with milk? I thought this place was called the ICU. We are funny. We have an intensive care unit where you can get the latest and greatest in Liberian interventions but can’t get a bite to eat. If fact, you might starve to death as you get better.”
The discussion is long and drawn out. I am trying to weave a ridiculous situation that someone internal to the hospital that is not me, must untangle. Is it not in anybody’s resources to procure milk for a starving child? Whose job is it to take charge of this baby? Is there no medical director? Don’t we have $500 dollars in petty cash for these purposes? What are we trying to do here? Would you bring your own child here? What would you have a stranger do?
It is time to conclude. We have spent 30 minutes on this patient and there are 15 more to see. It is my day off. “Here,” I say, pulling 10 dollars out of sock, “I will never convince you that I am not rich but in heart, but I can’t wait for someone to find this dastardly child milk. You can reimburse me later.”
We send the nurse aid to the market to buy F100 milk powder. (You can buy F100 in the market?) We calculate a 120 cc per kilogram a day feeding schedule divided every three hours. Child will start with breast feeding to continue stimulating the mom’s breasts to produce milk, but then get 40 cc of F100 by mouth or nasogastric tube every three hours no matter what. We create a chart that has in one column a place for 8 feeds in a day that is to be marked and another column where daily weights are to be calculated. We put in bold capital letters the type of formula and volume the child is to take in. I tape it to the wall.
“But Dr. Wang, the blue paint,” Marley says.
I sigh and place the feeding and weight sheet next to the baby’s head.
The morning is getting hotter. There is little crying in the ward. My experience is that poor babies cry less than rich babies. My body has acclimated to Liberian heat, it is rare for sweat to pour down my face now and I would not say I am not not uncomfortable. I swig some water. I look outside through the window slats and it is bright, the landscape still dusty, the ocean flat and light blue in the distance. I make the team give some high fives for good caring care.
We move to the next patient.
