Marion* was quietly waiting for the MSF team. We found her in Sihep, one of our outreach sites here in southeastern Chad. In this village, MSF performs ambulatory therapeutic feeding for malnourished children, alongside care of pregnant women. We drove there with our team and equipment in the early morning sun. We were hot and sweating before 9 a.m. Our driver quietly played some traditional music on the radio and the team joked and talked inside the Land Cruiser in a mix of French and Arabic. Trains of camels, beautiful tropical birds, cattle, goats and dogs slowed our progress time to time. A baboon hustled into its tree when it saw us. Villagers exchanged waves of hello with our driver and I. One village had a large gathering of men dressed all in white, all seated on mats on the ground. They all returned my wave. Sand and dust were everywhere.
Marion was sitting under a massive tree. This spot is where MSF has been serving the surrounding community for three years. A minimally-equipped health post squatted next to the tree. It had seen better days. Part of our mandate is to improve the function of this health post. We make structural improvements, build latrines, dig holes for medical waste and provide midwives and nurses to help the Chadian Ministry of Health employees carry out their work.
Marion, age 3, is from a Nomad family that migrates with its cattle. She was joined by her mother and older sister. Marion came to medical attention when an MSF outreach community health worker performed a "MUAC" test on her arm, as part of his regular surveillance work in their community. MUAC stands for "middle upper arm circumference." The community health worker hired by MSF placed a special measuring tape around Marion's arm and found the size fell into the severe malnutrition category. Our health worker then invited Marion's family to bring her to our weekly visit to this tree location. Marion, her sister and her mother came by donkey. Her mother walked and led the donkey with both girls riding atop. Once they arrived, Marion's mother removed large sacks from the donkey, tied its front legs loosely together to prevent it from wandering, and it grazed on the slim pickings.
Our team set up all its equipment. A quick snack was had during our team meeting where we discussed any local security problems or worrisome epidemic diseases. I was offered a handful of tiny fried birds and because I felt comfortable with our team, I politely refused. My colleagues chuckled as if I was refusing cold ice cream.
Marion was first registered in our malnutrition program. She was measured and found to be 90 centimeters tall and was only 9.9 kilograms. For her to be moderately malnourished she had to be at least 11 kilograms. Next, she was tested for malaria, which is systematic for all malnourished children. She was found to be infected by the severe form of malaria by a rapid test that was performed under the tree by an MSF nutritional assistant.
Next was Marion's appetite test. She was first made to wash her hands with soap and water and then given a small package filled with ready-to-use therapeutic food (RUTF). RUTF is a tasty peanut butter-like substance that quickly treats malnutrition among children who will eat it. Marion liked it and her mother and sister understood the nutritional "medicine" was just for her. Sisters being sisters, I later spied Marion sharing a tiny bit of it with her sister. Meanwhile, children and mothers flooded the mats laid on the ground under the tree, all performing the same circuit of tests and treatments. Everyone seemed happy except the babies being put in a large bucket hanging from a tree branch in order to weigh them. Infants stood up in the bucket and cried and community health workers tried to comfort them and keep them still enough to get a reliable weight.
After she passed the taste test, Marion had a medical consultation with a nurse. Her mother explained the child had been having fever, occasional diarrhea and had not been eating. Her physical exam and hydration status was relatively normal, except her malnutrition. The nurse prescribed routine medications including antibiotics, vitamin A, folic acid, antimalarials and paracetamol (Tylenol). Another nurse sharing the same plastic fold-away table, and consulting on other children, commented that if Marion had malaria, then probably the rest of her family also did. Consequently, the MSF nurses tested Marion's sister and mother, and they were found also to have malaria. The three of them were counseled and treated for malaria. They received a bednet, as all malnourished children do, to prevent future malaria infections. As with all MSF interventions, medical and preventative care is provided free of charge. The poor and vulnerable cannot pay for essential medical services here.
Marion and her sister waited while her mother queued in line and picked up the medications from the MSF pharmacist. Lastly, Marion's mother obtained enough RUTF for one week. The sun was very hot by this time and so Marion's mother pulled out a metal bowl and filled it with clean water MSF had set aside for drinking and hand-washing, and gave it to her daughters to quench their thirst. Marion's mother then got the donkey ready, and the three of them took off into the dust and heat of the dry season. Marion and her family will return next week to be re-examined and hopefully she will have gained weight. Hopefully she will join the hundreds of children whose malnutrition was diagnosed and treated under this mighty tree.
Farewell for now from the house call... to Chad.
* the patient's name has been changed for reasons of privacy.