Beyond the point of making your meal taste a little better, though, hunger becomes dangerous. Extreme hunger is even lethal. This problem occurs mainly among rural, impoverished, and sick or isolated individuals. Most rural Ugandans are vulnerable to hunger because they participate in subsistence farming, cultivating small plots of land that supply just enough produce to put food on the table each night. (Or each morning, as 1 meal a day is standard for the very poor.) When someone becomes sick and can't manage the garden, or is socially isolated and can't benefit from community harvest, hunger sets in. From here, things usually get worse: the hunger causes weakness, and weakness leads to more hunger, which leads to greater weakness, which leads to more hunger, and so on.
Lack of food is the beginning of an especially steep downward spiral for our HIV-positive patients. They all have to take daily medications to keep their HIV infections under control and prevent other opportunistic infections. Since antiretroviral therapy (ART) needs to be taken with food, many become "ART non-adherent" or "defaulters" when food is scarce. HIV then rises up, out of control. Other infections like TB, PCP, and cryptococcal meningitis can pounce. The body becomes weak, wasted, immune-compromised ... and people perish. While every patient in our clinic is technically living in poverty, the ones who struggle to eat are the poorest and sickest.
One woman, NA, used to complain of "dizziness" whenever she spoke with clinic staff; this was her way of letting us know that she was lightheaded from not eating enough. Then, last month, she stopped coming to clinic. When our community health worker went to her village (a full day's journey - 120 km round-trip on narrow dirt paths) to find out why she was missing appointments, he found NA on the floor of the family's mud hut. What he saw, when he looked inside, is not captured by the simple words "weak" and "wasted". There lay a young woman, previously plump and smiling, reduced to a 2-dimensional shadow of a body on the floor. She was nothing but skin and bones, literally, with her breast tissue so completely consumed that only 2 wrinkly sacks of skin were left hanging from her chest. The tuberculosis infection had taken root in lymph nodes throughout her body, causing swollen nodes and large abscesses in her left armpit and under her chin. Both were draining blood and pus. NA's left arm, held for so long in a crooked position while she was ill, had developed a contracture - the skin grown taught across the inside angle (like the kink in a chicken wing) so that she couldn't extend her arm past 90 degrees. Too weak to stand, NA was carried out of her village in a stretcher. We wasted no time in admitting her to the hospital and starting treatment for TB. But, of equal importance I think, recently we added to her treatment plan an allowance of 5,000 Ugx (about 2 USD) per week to afford some food. Now she is eating better, undergoing observed TB and HIV treatment by the nursing staff, and doing self-physiotherapy for her arm. Her weight has increased to 27 kg. She can almost stand alone. Her left arm extends to 120 degrees. A finished plate of food rests on the bed beside her head. Things are looking up! NA's goal for discharge is to walk back into the village on her own 2 feet, and we couldn't agree more.
Another severely wasted patient came to us 2 weeks ago with signs and symptoms of a brain injury. Like the young lady above, NG had run out of money and strength for food and stopped taking his ART. While his body degenerated from hunger, weakness, HIV, and possibly other infections, he suffered one additional blow: struck by a motorcycle while crossing the street, there was report of a serious hit to the head. When one's reserves are so low, all it takes is a single unlucky event to put the body over the edge; infections are not the only threats to the immune-suppressed! By the time his family carried him into clinic, NG was disoriented, losing motor control of his limbs, and had a coarse tremor in his arms and lips (signs of cerebellar, brain coordination center, dysfunction). Needless to say, he was also just skin and bones:
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| Instead of buying new clothes, people here tie cloth bands to keep loose pants from falling off the waist. You can tell how much weight one has lost by counting the number of bands he uses. This man needed 3 strips of cloth, tied to his belt loops and wrapped around his waist, to hold up his previously well-fitting pants. |
We ran through the possible causes of brain injury in such a patient: certainly trauma to the brain from the motor vehicle accident could have caused a bleed into his brain, but brain infections are also common in people who have stopped taking ART. Through an incredible (and I really mean in---credible) triumph of the public health system, we managed to transport NG to Mulago in Kampala and get him seen by the neurosurgeons. They determined that he had a brain abscess and performed emergency brain surgery the following day. Last Tuesday we visited with NG at home. The 40-year-old man who greeted us - sitting up, smiling, eating plantain stew, with a well-healing scar on his lower scalp - was barely recognizable from the 70-year-old-appearing limp skeleton that we had carried into Mulago last week. With antibiotics, and of course another 5,000 Ugx per week to keep food on the table and ART in his body, we hope that NG will continue to recover.
Now that NG can speak again, he has told us another amazing story.
It all started with our question, How did you come to clinic that day 2 weeks ago? Dropped off by the ambulance that was carrying my mother to Kampala. Your mother, oh...what happened to her? She was burned. Hmm, I see...well how did she get burned? Now the story unfolds!!! NG explained to us that about 4 weeks ago, just after his accident, no one was home but himself (bedridden), his mother, and a young girl attendant. While fetching water outside, the old lady reportedly fell down and started shaking - what sounds like a seizure. Reason's unclear. Anyway, the girl heard the noises, went outside, found the woman convulsing, and called the local witch doctor to come give treatment. When the witch doctor arrived, he said that her seizure was caused by evil spirits. These spirits, he announced, resided within the woman's chest and needed to be burned out. The woman was lying prone (face-down) on the ground, so he stuffed dry grass under her body to fill the space between her breasts and the earth. Then, with a crowd of villagers gathered all around, he set fire to the bundle. When the last of the grass had burned out, the onlookers came and turned the woman over. There they discovered a gruesome mistake: her chest was raw, weeping, and - once endowed with a generous bosom - now completely flat. The witch doctor apologized for her injuries and promised to help with the wound care. The old woman was carried inside and laid down to rest. For the next 2 days, the witch doctor hired a local nurse to apply antibiotic ointment and change the bandages. But on the 3rd day, instead of fetching the nurse, the witch doctor ran away into the hills. Without proper wound care, the old lady's chest became infected: first superfically, then deep into the tissue, and finally spreading into her bloodstream. Within a week, her whole body was septic. All the while, NG was deteriorating on the mat at her feet. It is hard to imagine a more hopeless situation: mud hut, empty food shelves, not a shilling to spare, abandoned by the witch doctor and forgotten by the local nurse, a son with a brain infection and his mother with an infection everywhere else. Then, out of nowhere, the ambulance appeared! We still don't know who procured that ride.
These stories are hard to believe and may seem totally unique, but - if you have time to listen - every person you ask has similarly unbelievable stories. I am reminded of the mottos from San Francisco General Hospital,
As real as it gets (official motto)
You can't make this shit up (unofficial)
which, taken together, mean that real life is the strangest. From San Francisco to Kiboga, I have found this to be a universal truth.So, allow me to organize my thoughts from this very long blog post:
Real life is unreal.
Enjoying hunger as a delicious sauce is a privilege and a luxury.
Recognizing hunger as a lethal global scourge is much more important; in fact it is a necessity.
As we head toward the American day of thanks and feasting, it seems appropriate to remember that there are basic material needs that we, all humans, share: food, water, access to information, and access to quality health care. Our patients' lives have shown me that providing support for these needs is not only simple and cheap, but also at least as important as any other global health intervention.
