Dr. Besser's Notebook: African Village Faces Pneumonia

Dr. Richard Besser visits children with pneumonia in Kibera.

March 17, 2011— -- You can learn a lot looking into someone's eyes. Sometimes things that are too painful to be said will be spoken by a look or a look away. When I looked into the eyes of three women in Kibera, the largest slum in Africa, I was the one who had to look away.

I know a lot about pneumonia. I spent seven years working on respiratory infections at the Centers for Disease Control and Prevention. I have been practicing pediatrics for 25 years and have treated a lot of children with pneumonia. I came to Kenya to shoot a story about pneumonia. It accounts for more childhood deaths around the world than any other infection. I couldn't do a series on global health without talking about pneumonia.

In Nairobi I met up with my friend, Danny Feikin, a former colleague from the CDC, now working for the school of public health at Johns Hopkins. He just finished six years in Kenya working on pneumonia control and treatment. It was a great chance for us to catch up and to celebrate the recent launching of a pneumonia vaccine with the potential for greatly reducing pneumonia deaths. We set off for a local hospital to see some of the faces of pneumonia.

Dr. Loice Mutai is a pediatric cardiologist and physician-in-charge on the children's ward at Mbagathi District Hospital on the outskirts of Kibera. She greeted us with a big smile and didn't stop smiling. She trained in pediatrics in Madras, India, and is very proud of the care that she can provide.

She shows us around the hospital. It looks nothing like an American hospital: a one-story building with multiple rooms built around a courtyard. Whitewashed walls, courtyard halls filled with people, mainly women, many waiting in line for a plateful of food being ladled from a giant pot. The smell of Kenyan food masks the other less pleasant smells of the hospital.

She takes us to the triage room where new patients are first examined to determine how sick they are: do they need to go to the room for the sickest patients? Are they well enough that they can be treated and go home?

Together she and I examine a little girl, nearly a year old, breathing with great difficulty. We listen to her chest -- wheezing. It is likely that she has bronchiolitis, a respiratory infection from a virus that inflames the small airways making it difficult to pass air. She'll need to go to the room for the sickest.

We get a quick rundown. They usually have around 150 patients on the wards at any given time, cared for by three senior pediatricians, usually a couple of interns or residents, and a number of less-skilled health care providers. Far too many patients for the number of staff.

Dr. Mutai's eyes are deep brown and exude incredible warmth. She speaks with the calmness and self-possession of one who knows that she is battling against incredible odds to provide the best care she can for children who have nowhere else to go. We have very little here, she explains, but we do the best we can. We could save so many more lives if we had more. She knows that we are there to see patients with pneumonia. No problem. They have many.

Like so many hospitals I have worked in around the world, this hospital is almost a hospital in name only. The room for the sickest children is shocking. A dimly lit space with eight beds, four on each side. The room is packed with people. On one side two beds are pushed together to form one large double bed. I count patients on this one bed: 1, 2, 3, 4? Hard to tell. There are two more: 5, 6! Each little child is lying with her mother. An infection control nightmare, the giant bed reminding me of a massive petri dish, incubating germs for all to share.

There are no monitors to keep track of heart rate, respiratory rate, or blood pressure. No way to measure oxygen in the blood. On the floor along the back wall, edged between two beds is an oxygen generator designed to provide enough oxygen for one patient; here they have rigged it so that it looks like an octopus with little tubes extending off to give a whiff of oxygen to eight critically ill infants and young children. Clearly it does not provide adequate oxygen, it may in fact do more harm than good since each tube is threaded into a child's nostril, blocking normal breathing.

In the back corner on the left there are three patients and three mothers on a bed. She points me to Esther, a 6-month-old who was hospitalized three days previously with pneumonia. Like so many she also has severe malnutrition. Every rib shows through her thin skin, and her face has the worried look so commonly seen in the sickest children. Every breath is an effort and she is breathing so fast. I listen to her lungs and hear the crackling noises that tell me she has pneumonia. In an American hospital she would be in intensive care with machines ready to support her breathing.

I speak with her mother. She appears to be in her forties. Her eyes display a hopelessness that is understandable. Babies born to older mothers (like those born to very young mothers) tend not to do so well. She tells me Esther had pneumonia before, just two months ago and was in hospital for 19 days. Now she has pneumonia again. She never regained her strength after the last illness. Her eyes lack any sign of hope.

This is a typical story. Children who are malnourished are more likely to get pneumonia and to die from it. Each illness is part of a downward spiral: malnutrition setting up for pneumonia leading to more malnutrition and more illness.

As we turn to leave the ward, Danny notices that Esther is now barely breathing. Dr. Mutai snatches her off the bed and races down the hall, back to the triage room. We watch as she and her team try to save her -- CPR and drugs. What Esther really needs: oxygen and a ventilator, are not available. In a chair watching the effort is Esther's mother, tears streaming down her face. I look away. Dr. Mutai speaks with the mother and then rejoins us in the hall.

This is not unusual, she says. Sometimes as many as three deaths in a day. Tell people about this, she says. We could use more oxygen machines.

We leave the hospital shaken by what we have seen; how quickly a life can end that was just beginning. We press on into the giant slum, Kibera. We have one more stop to make. As far as we can see are rows and rows of mud and stick shacks with tin roofs. We are led through the small streets and alleyways to a small shanty.

Inside we meet Margaret, 30, with her two small children. Her 1-year-old daughter, Nicole, is being treated for pneumonia. Fortunately, she looks well. Margaret is determined that her youngest child, Benjamin, will not get pneumonia. She has heard that a new vaccine can help prevent pneumonia and she is allowing us to accompany her and some neighboring children to the clinic to get vaccinated. It is available only for children younger than one year.

In her eyes I see the pain of someone who knows what is at stake, how easy it is for children to die. I also see a flicker of hope that maybe, just maybe, Benjamin will make it.

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