The mango season is coming to an end, but the heat persists.  It's 35 degrees Celsius, inside the office! Sweat is dripping down my face, down my arms, down my back.  There is nowhere to escape the heat. So I alternate between typing, drinking water, thinking and wiping the sweat from my face. The promise of rains and cooler weather has not yet come. Again I am working on endless reports, hospital scheduling and preparing teaching sessions.  The work is interesting, but I feel completely exhausted every day.  Multitasking and interruptions have been taken to a new level. "Can you help me book my holidays?"  "My pen ran out of ink, can I exchange it for a new one?" "I need to talk to you about my work schedule" The radio crackles with my name. "We are really busy and short staffed today in the outpatient clinic, can you find us another nurse?'' "my grandmother died, I need to go to her village 200km away, how many days off can I get?'' "We ran out of hospitalization forms in the inpatient department. The depot has not delivered the order, can you call them and get the forms for us, there are already 5 patients waiting to be admitted." "Can you find the surgery team; we need to do an emergency c-section now!" "the computer won't turn on, can you help me?"  "just to inform you we have run out of mosquito nets in the pharmacy. oh ya, and we've also run out of Paracetamol" "can you help me finish the teaching session that I have started preparing?'' "Can you come to the maternity department; the oxygen machine won't turn on." Can you come sign a nutrition prescription?" Again the radio crackles, in the background I can hear babies crying.. "I have a 4 year old child in the outpatient department for you, severely malnourished; can you come do an assessment and write the necessary prescriptions?''  All these requests require time, energy, power, creativity, multitasking, problem solving and patience.  The days are not easy.  Busy does not even begin to describe my work, but it is definitely never boring! I grab my radio and head to the outpatient department to see the malnourished child.  There are two kids sitting on the mothers lap.  A chubby healthy looking baby that is smiling and babbling away; and an older child, skinny, serious, scabs all over his body and his hair is thining and turning a reddish brown.  I greet everyone in the room.  I lift the child onto the examination table.  He is staring at me with big eyes.  He can't seem to decide if he should be terrified or curious.  I shake his hand again and smile at him.  Slowly his eyes soften and melt into a smile; he relaxes,deciding that I was not too scary after all, despite my white skin, my big nose and my straight light brown hair! I start with a physical assessment, check over his skinny little body; listen to his lungs, heart and tummy with my stethoscope.  He is cooperative for a 4 year old boy; he goes by the name of Mathias.  It always intrigues me how children of the same family can have completely different nutritional states.  His baby sister is clearly still getting maternal milk, to give her chubby cheeks, energy and immunity.  The older child is left to fend for himself.  Is he getting neglected?  Is he sick with another pathology; TB or HIV? Or is there just not enough food for the whole family? Getting a proper history from patients and families is extremely challenging.  Using a nurse to help with translation, I embark on the quest for information and hints as why Mathias is so skinny. "Since when has the child been loosing weight?"  - Three months. "Do you have enough food at home?" -  Blank stare. "Is the child interested in food?"  - No. "What are you feeding him?" -  Blank stare. "Does the child have diarrhea?" - No "Is he vomiting?" -  No. "Does he have fevers at home?" – No. "Is he playing or interacting with other children?"-  Blank stare. I repeat the question.  - Blank stare. "Is the child coughing?"  -  Blank stare. "Is anyone else in the family sick?" -  No. "Is anyone in the family coughing?" Yes. "For how long?" -   Blank stare. "Where do you live?" -  Blank stare. I repeat again -  A village about 25km away. "If I ask you to come back in 1 week, will you come with your child? "Yes. "Promise?" Yes "I will give your child some energy food and medication to help him gain some weight and feel better.  The food and medication is ONLY for Mathias, not for the whole family to share.  In a week I want you to come back to see me and we will weigh your child again and see how he his doing.  Do you understand?" - Blank stare.  We repeat everything three times. Then ask the mother to repeat back to us.  She seems to finally understand what we are asking her to do. I fill out the prescription for medication, plumpy nut (a high calorie therapeutic food, made from peanut paste) and a bar of soap to promote good hygiene.  I register the child in the ambulatory therapeutic feeding program and hope that he will return for his follow up.  Mathias smiles at me on the way out and shakes my hand again. Mathias came back a week later.  His mother told me the child ate all the food.   I noted no weight gain.  My thoughts, did she feed the food to her sick child? Or did she sell it? Or did the family share it?  I asked her to explain how many times a day she fed Mathias? Did he like the food? Did he ask for more? She was unable to answer any of the questions - blank stare. Mathias had deteriorated during the week.  We admitted him into the inpatient nutrition program to properly monitor feeding times.  Over the week, he slowly started to eat, but barely gained any weight.  He lay in bed all day, looked tired and unhappy.  He would sit up when I came into the room and slowly shake my hand, but I could tell it took a lot of effort. Mathias' weight gain was unusually slow for a child that was eating.  He started spiking fevers at night and started to cough.  We started to suspect tuberculosis.  After several weeks of hospitalization, with little improvement and minimal weight gain, we filled out the clinical survey to assess whether Mathias could have TB.  The key indicator being,  that he is not responding to nutritional support and his cough is not improving with antibiotics. We sent the mother to adherence counseling to see if she was able to support her child through the complete TB treatment, which would take 6 months. The first two months are spent in the hospital.   She agreed to stay.  And we started the treatment the next day.  Within a couple of weeks, we could see the improvement.  Mathias started gaining weight, he started having a bigger appetite. He started to smile more, he started to interact with people around him.  Mathias started looking and acting more like a 4 year old boy, instead of a sad, depressed, sick boy. The prevalence of TB is high in this area.  Children are especially vulnerable, as their immune systems are not  yet fully developed.  And one of the biggest challenges is convincing patients to stay in hospital for the first two months of treatment.  Mothers often get messages from their husbands; demanding them to return home.  The mothers feel pressure to go home and support the other children, to go prepare the fields for planting, to cook, take care of the house and please their husbands.  The counseling team in Boguila spends a lot of time with these mothers explaining the importance of finishing the treatment in hospital for their children, encouraging them to stay and supporting  them through this challenging time. After two months of intensive treatment, Mathias was finally ready to go home.  He had become a happy boy, he loved to eat, loved to play and loved the attention he was getting at the hospital.  The day of his discharge, Mathias found me and told me he was allowed to walk home today. I sent them off with a package of food, medication and a follow up appointment in a month's time.  He walked off with a smile on his face and a small bundle of belongings balanced on his head.  His mother had a bigger smile and a bigger bundle of food and medication on her head and her other baby slung on her back.  They both waved as they walked down the red dirt path toward their village.

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