Anniversary

We celebrated Princess’ birthday party at the hospital yesterday.  Princess was really happy.  She had never had a birthday party before.

“When is your birth day,” I asked Princess in December during one of her visits to JDJ Hospital.  I was making a chart for her.  My health assistant Augustine had pointed out the obvious.  If we were going to hold what had become essentially a makeshift Saturday diabetes clinic between our rounds in the intensive care unit, we had best record the content of the encounters:  insulin regiments, vital signs, physical exam, plan and the like.  Our patient numbers were growing and it was getting harder to keep track.  I hate it when Augustine is right.

“I don’t have a birthday,” Princess said. 

“She doesn’t have a birthday, O,” confirmed Princess’ mother

“Well I must say, Princess, that your ghost is a very beautiful,” I said, “What is it like to fly and to not be real?”

​Seongeun setting up  decorations in JDJ play-room for Princess' surprise birthday party

Everyone looked at me as if were strange man, who talked and acted likea thing not quite like any other.  Augustine as usual intervened.  “Princess’ birthday was never recorded, so she doesn’t know when is her birthday,” he said, “sometimes this happened during the war. There was a lot going on and there may not have been tools to write events down.  And Princess cannot be the only child.”

 “Cannot?”  I asked.  Liberians say "can" when things happen, but rarely had I heard "cannot".  I "can" eat means I will eat. The response to the question, “Can you pick me up?” is, “yes, I can.” If you dare ask, “Does that mean you will?” you get, “I can pick you up,” and the thing goes back and forth until one wonders why bring up things without resolution in the first place.    

“There are other children in the family,” Augustine patiently explained, “It might be hard for the mother to remember everyone’s birthday.”  I am convinced that Augustine is a disguised Shao-Lin monk.

 “Well, Princess,” I said, “You are going to have to have a birthday.  Every good honest Liberian must have one.  I mean what date will you put on your driver’s license?  How will you collect the gifts at the birthday party we throw for you?”

Princess looked embarrassed and happy.  She mumbled after prodding, “January 13.  My birthday is January 13th.”

“January 13th it is then,” I said, “we will celebrate January 13th.”

*          *          *          *

How to hold a party for a girl with diabetes?  Do you make a cake with artificial sweetener?  How about the flour?  It contains a carbohydrate load that would send one’s blood sugar through the roof.  Doctors have a tidy dirty secret.  We never took nutrition classes before.   There’s no room in the medical school curriculum between courses on medical ethics (can you teach that?) and on biochemical pathways designed to dissolve as soon as they enter the brain.  Of course this does not mean that doctors do not pretend.

Usually, I do not sweat the small stuff.  Here we have a girl who has never had a birthday party before.  Why not give Princess a full-on birthday cake?  Do we really think that she, who lives in a small hut, whose father died before she could know him, whose mother is too matter-of-fact, would not eat any food presented to her say, plantain chips with a warm orange Fanta, any other day?  When I first began managing children with diabetes in Liberia, I tried to do it like we do in the States.  I started by sending patients home on an insulin regiment charted out on stiff graph paper only to find out they couldn’t afford insulin (they came back dying).  I then sent them home with insulin but didn’t realize that most Liberians don’t have refrigerators (let alone electricity).  I then sent them back home with insulin to be placed on ice with different types of insulin depending on their sugar readings only to find that the testing strips cost more than the insulin and resultant sugar readings resembled numbers on a bingo sheet—random and without hint of a pattern that could win.

So now we just get the children close.  Normal blood sugar is 80-120 g/dL.  We accept anything below 250.  I tell families to let the children eat whatever they want during meals.  But after receiving their insulin, they must eat a full meal or else the children risk literally dropping down with their blood sugar.  We no longer give two types of insulin but a mixture of long and short acting types to avoid dosing errors.  We don’t regularly give out blood glucose machines to cut down on costs and we ask that families reuse syringes and bury them deep in the ground when they are done.  We can only hope that we are buying enough time until one day the technology of insulin-pumps or pancreatic transplantation hits west Africa with the same vagary that diabetes strikes children here today.  At least for eight months and thanks to good follow-up, none of the children have been readmitted to the hospital and all are back in school.

​Princess in Princess hat holding presents

We settle on a party without food but with bright streamers, colorful balloons, a crown for Princess and of course, presents!  We hold the event in the room adjacent to the ICU where Seongeun has begun conducting art classes for patients.  While we are checking out Princess in the ICU, Seongeun has the other children help her decorate.  From my gift box, which consists of items gathered from travels around the world kept for special occasions, Seongeun and I selected a silk purple scarf, a fine lined journal and a handheld compact mirror decorate on the outside with inset stones in swirls.  We wrapped the gifts in tissue paper cut from larger temporary and festive tablecloths and tied them with bows spun from random strands of rope which we somehow found.

Princess communicates mostly with her eyes. Her mouth is as usual pursed shut but her dimples show.  Her eye brows raise as she is brought into the crowd filled room and she presses her finger tips together in alternating twists upon seeing the decorations, the other children, and the shoulder to shoulder mothers gathered at the opposite doorway wondering what the hell.  We hand Princess her presents, which she carefully opens so as to not rip the paper.

​(left to right)  George, mother and Augustine watching festivities

Since we are in sub-Saharan Africa and this is an anniversary, there are speeches.  First, Augustine says that Princess because she is special and has never had a birthday party, we wanted to have this party at JDJ where she is cared for and loved.  Then I continue how Princess was our first diabetic patient and how much we admire her strong spirit, her charm and how it makes us happy to see her each Saturday even at a hospital.  Then Princess temporarily stands.  She is now wearing her new scarf though it is close to ninety-five degrees. She looks pretty and unlike me she is not sweating.  “Thank you all and God," she says.  I am happy on my new birthday.  I can be very happy on this day.”

​Princess one-year later at "diabetes clinic" with Augustine and George