lack of resources or lack of effort?

Monday, the intern on call presented a case of marasmus (severe malnutrition). He didn't check for low blood sugar, hypothermia, nutrient difficiences, didn't give oral rehydration or feed the child. We talked - for 1.5 hours - about the WHO's 10 steps to recovery from severe malnutrition. I thought they understood (it is not difficult).

Today - Wednesday - the intern on call (a different one) presented a case of marasmus. He didn't check for low blood sugar, hypothermia, nutrient difficiences, didn't give oral rehydration or feed the child.

When I tried to insist on preventing hypothermia, he had the gall to say "we don't do that here"... they don't do it because they don't have any systematic way of treating severe malnutrition. And they have the results to vouch for that with VERY high mortality. Thankfully, Pr. Nacro came to my defense (as he has done on several other occasions) and basically said, "these americans may seem to have crazy ideas but they're right - we are NOT doing this well and the WHO guidelines are correct".

Why tell this story? One of the challenges of the pediatrics department (that I have seen in all parts of health care here) is this inertia, this attidude of "well, we're a very poor country, we don't have any resources - of course we have bad outcomes". I want the interns to make the most of what they DO have. Because it would take 30 seconds to explain to the mother why its important to keep the baby warm & dry. And that doesn't require any fancy machines, expensive drugs or anything but the mom. Because an even easier intervention is to administer a dose of vitamin A. Because we can do better with the resources we have - if we make the effort.

In fact, Pr Nacro has often lamented that those attitudes are one of the downfalls of this country. He's not at all like that - in fact, he hopes that people will learn from out example, from our "can do" attitudes.

Another example is Vitamin A. When I arrived, I was horrified to realize that none of the children with severe malnutrition (much less any one else) received regular vitamin A. Asking around I was told "well, its not provided to hospitals - they only provide it to peripheral clinics". I thought that was a little odd, so over the last few months I've been investigating.

In fact, its not automatically provided to the hospitals.

But it is available if you ask for it. No one asked, so no one gave them the vitamin A. I've asked, and I am hoping we will receive a temporary supply in the next few weeks. In the mean time, I got some high calorie formula to use that is on the verge of expiring. I'm not gonna turn down free formula!!!!!!!

I sure am learning a lot. And if I can learn to inspire effort in this batch of interns, that will be a HUGE success.