Inreach

On Monday I saw B.R. she is now 10 months old and weighs 3.7 kg (the weight of a very large newborn and well well below what a 10 month old should weigh). She had disappeared from the clinic for the last 2 months and had run out of her medication for the last 6 weeks (very dangerous when you are dealing with HIV which can easily develop resistance). Her mother only came to clinic after one of the nurses had noted that she hadn't been around in awhile and called the mother begging her to come. She said that she had lost the baby's outpatient records (each patient here is responsible for caring around their medical records in a stack of tattered papers) so she thought she would not be seen.  We assured her that we would always see the baby no matter what. I wanted to admit the baby to the hospital for stabilization of her nutrition status, but her mother was worried about what would happen to the 6 other children at home. See here little children must be accompanied by a caregiver in the hospital. The nurses are not responsible for feeding, changing diapers, etc. I understood her point and given that they baby was not in significant distress (as this has been going on for months) I agreed to extremely close follow-up. I involved the clinic social worker, dietitian and several of the nurses. After 1.5 hours we had a plan and B.R.'s mother was in agreement that she would return to the clinic 2 days later so that we could assess the baby again and review the results of blood we took on Monday.

On Wednesday they did not show up. I had a long discussion with the nurse in charge of the clinic about where to go from here. We agreed that we would go to the patient's house on Thursday and see what the issues were. (At the clinic there is an "inreach" team that goes out to visit the homes of patients with complex social issues). We talked about the possibility of placing the child in foster care, as clearly the mother was having significant issues caring for her, but that is really hard to do in Botswana. The places that take care of neglected and abused children are full and have waiting lists. There is one emergency option that cares for babies for 3 months but it is really a last resort and when the child has a mother the mother must be taken to court and charged before the child is accepted. Admitting the child was another option, but she had been admitted for the same issues in October (though that time she was sicker) and nothing had changed about the home situation so the baby was back where she had started. We called the phone numbers she had given us but they did not work. Luckily we had the address though very confusing because there are no street names in addresses here, just an area of the city, a plot number, and "near the Total gas station," not easy to find.

On Thursday afternoon we rounded up a team. A driver from the clinic who knew the area where the patient lived well, one of the nurses and me. B.R. lives pretty close to the clinic. Once off the tarred road we traveled around several dirt roads looking at the house numbers until we finally found the one we were looking for. You really have to know where you are going as there did not seem to be much of a system to me. Our timing turned out to be excellent as B.R.'s mother was just returning home. I took some very discrete pictures of the neighborhood.

 

 From the front the house did not look too bad. But as we followed B.R.'s mother I realized that she did not live there. Rather behind the house were two other structures running parallel to each other, divided by a small alley. There were several doors and the one she opened revealed a very small room. In the room was a 3/4 size bed, a small bureau, and in the corner was the cooking area. With 4 people in the room it was very crowded. There was one window, no fans, and it was 100 degrees!  B.R. lives there with her mother and sometimes the mother's boyfriend.  Her siblings stay there on occasion as well, but they are often in a village outside the city with their aunt.  B.R. was on the bed with a family friend. She actually looked better than she had on Monday. Her mother showed us all of the medications which looked as though they had been taken. We reviewed how to give the medications and mix the special formula the dietitian had given her. She explained that she had not come to the clinic because she had to see the local social worker to arrange for the food basket (Botswana government's version of food stamps).One of the ARV medications was missing, when I asked her where it was she told me that it was in her landlord's refrigerator because it needed to be cold (seeing as she does not have electricity or running water that would have been impossible in her room).  She told us that her cell phone had fallen in water and no longer worked (that explained why we had been unable to reach her).  We talked for about 20 mins, I examined the baby, and we made a plan to see her in clinic. 

Visiting B.R's house made me begin to realize just how many obstacles she is up against.  I am still not sure if her mother will be able to care for her, but now I have a better understanding of why. I hope that she will make it back to clinic next week and maybe she will even have gained some weight!