Today I went with Vicente and Dominga to Xejuyu to follow up on patients with asthma, hypertension, diabetes, malnutrition and acute complaints. I feel a little out of my element with hypertens
ion and type 2 diabetes but I have to say that trying to treat the malnutrition is my greatest challenge by far. It may be the complaint I most dread of all the complaints here.
Two months ago, when I was questioned first by a mom in clinic about her child’s weight and what she could do to make her eat more and gain more, I winged it. I hadn’t had time, and still haven’t had time, to look up all the conditions that are new to me here and figure out how to tailor my approach to the setting, so I often struggle the first several times I see something. I start explaining things as I would in the States and usually realize that I’m being anything but helpful. I laugh disappointedly at myself now as I remember what I actually said when faced with this first case of
an underweight child: normal kids won’t starve themselves as long as you provide them with plenty of nutritious food. Well, of course, there isn’t plenty of food in 99% of the homes here. If you actually ask, many will admit that there truly isn’t enough money. What do say? There’s no way to explain that away. Even trying to tell parents to limit sweets and save the money for nutritious foods seems like I’m just trying to make myself feel better and deny that the solution comes from providing resources not counseling.
Then they usually explain that they do try to give as much food as they can but the child doesn’t like to eat. They will only eat a half a tortilla and say they are full. When they are 23 pounds at 6 years of age, it’s hard to say, well, you can’t force a kid to eat, you just have to make good choices about what you provide. They want ideas. Once again, I’m at a loss for words, literally. You can’t say try things coated in high fat, tasty foods like peanut butter or cheese or full-fat milk, because they don’t have PB here and don’t have refrigeration for milk or cheese.
Most would like a vitamin to make the child hungry. I haven’t been taught that vitamins make a child hungry but that is the conventional medical wisdom here (confirmed by Rafael)
and I don’t want to start a unilateral debunking campaign. So I try to explain that vitamins are best absorbed directly from food. I try to promote the concept of ensuring the child eat a fistful of food from each food group daily. I realize, though, that I’m not even sure what I’m teaching is right for the context. Maybe sheer quantity is more important than eating from each food group. If there isn’t enough money, that money might best be spent on more beans and tortillas; forgetting fruit and eggs that are more expensive.
After finding myself feeling helpless in the face of malnutrition over these past 2 months, I decided to read as much as I could about it this weekend, so I could do a better job of counseling. I read a great guide for nutritional counseling of children under 2 years in the developing world that provided a lot of data about quantities and types of food that are needed and timing for introducing the foods. I was really excited about the idea of having some true knowledge behind my counseling.
ion and type 2 diabetes but I have to say that trying to treat the malnutrition is my greatest challenge by far. It may be the complaint I most dread of all the complaints here.Two months ago, when I was questioned first by a mom in clinic about her child’s weight and what she could do to make her eat more and gain more, I winged it. I hadn’t had time, and still haven’t had time, to look up all the conditions that are new to me here and figure out how to tailor my approach to the setting, so I often struggle the first several times I see something. I start explaining things as I would in the States and usually realize that I’m being anything but helpful. I laugh disappointedly at myself now as I remember what I actually said when faced with this first case of
an underweight child: normal kids won’t starve themselves as long as you provide them with plenty of nutritious food. Well, of course, there isn’t plenty of food in 99% of the homes here. If you actually ask, many will admit that there truly isn’t enough money. What do say? There’s no way to explain that away. Even trying to tell parents to limit sweets and save the money for nutritious foods seems like I’m just trying to make myself feel better and deny that the solution comes from providing resources not counseling.Then they usually explain that they do try to give as much food as they can but the child doesn’t like to eat. They will only eat a half a tortilla and say they are full. When they are 23 pounds at 6 years of age, it’s hard to say, well, you can’t force a kid to eat, you just have to make good choices about what you provide. They want ideas. Once again, I’m at a loss for words, literally. You can’t say try things coated in high fat, tasty foods like peanut butter or cheese or full-fat milk, because they don’t have PB here and don’t have refrigeration for milk or cheese.
Most would like a vitamin to make the child hungry. I haven’t been taught that vitamins make a child hungry but that is the conventional medical wisdom here (confirmed by Rafael)
and I don’t want to start a unilateral debunking campaign. So I try to explain that vitamins are best absorbed directly from food. I try to promote the concept of ensuring the child eat a fistful of food from each food group daily. I realize, though, that I’m not even sure what I’m teaching is right for the context. Maybe sheer quantity is more important than eating from each food group. If there isn’t enough money, that money might best be spent on more beans and tortillas; forgetting fruit and eggs that are more expensive.After finding myself feeling helpless in the face of malnutrition over these past 2 months, I decided to read as much as I could about it this weekend, so I could do a better job of counseling. I read a great guide for nutritional counseling of children under 2 years in the developing world that provided a lot of data about quantities and types of food that are needed and timing for introducing the foods. I was really excited about the idea of having some true knowledge behind my counseling.
But today I felt as helpless as ever. The elephant in the room is that there just isn’t enough money for food for all the kids in the family and that numerous other social factors are playing into the malnutrition that can’t be solved by a doctor in a clinic visit. I know I will continue to be faced by this challenge all year and will continue to search for a more satisfactory app
roach. For now, I think it’s the things that don’t require my medical expertise that are probably making the biggest impact; things like deparasiting and the nutrition program of the health promoters, though the potential for such programs to make a positive impact has been debated. The health promoters are out of money for nutrition programs for the rest of the year anyway. They need $20/month to keep it going. I said I could fund the rest of the year (seeing as will cost about half the price of a haircut back home) but what do they do when they are on their own for funds. It’s a never ending problem.
roach. For now, I think it’s the things that don’t require my medical expertise that are probably making the biggest impact; things like deparasiting and the nutrition program of the health promoters, though the potential for such programs to make a positive impact has been debated. The health promoters are out of money for nutrition programs for the rest of the year anyway. They need $20/month to keep it going. I said I could fund the rest of the year (seeing as will cost about half the price of a haircut back home) but what do they do when they are on their own for funds. It’s a never ending problem.
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