Photo of dripping tap in my kitchen in South Africa
Drip…drip…drip...
A succession of soft wet thuds from my kitchen sink punctuates my thoughts as I write these words. I am in South Africa and the beat of water drops has been the soundtrack of my life for the past five weeks. Those monotonous notes stoke violent passions within me. My irritation at the unstopping din is only outweighed by my exasperation at the paradox of wasted water in a drought-stricken land. Of course, I did get extended reprieves from the incessant dripping whenever we lost running water for days at a stretch. As inconvenient as it is to collect muddy water from a rusted tap outside my trailer, as onerous as it is to wash clothes by hand, as impossible as it is to get soap off my dishes without running water, at least the dry periods were free of that horrid dripping. Death by a thousand thuds.
Three weeks ago, after a particularly peevish attempt to choke the leak with brute force, I stalked off to the TB ward, hissing a few choice invectives under my breath. The ward had six rooms, and each room had six patients. Large windows let in fresh air, sunlight, and—in the afternoons—torrid heat. We tried to see each patient at least once every week. Some patients had been there for more than a year; others had arrived overnight. But the handiwork of TB was evident in them all.
Not for nothing did TB earn the moniker of “consumption” in Victorian times, for its victims seem to be ravaged by an invisible demon. As the disease progresses, patients become impossibly skeletal. Sinews rise to surface. You see the muscles and bones glide smoothly underneath the skin as they walk, talk, or cough. Their sunken eyes testify the depth of their suffering. Ironically, patients with “consumption,” consume very little as the disease robs them of hunger. Malnutrition begets TB— a fifth of the world’s TB burden is attributed to the immunodeficiency of malnutrition—and is exacerbated by it. The return of appetite after starting TB therapy augurs well for the success of the treatment.
One of my patients that morning was a little boy. I had noticed him while rounding on the previous days and had reckoned him to be about eight years old. I approached him with hesitation. After almost three years of dedicated training in adult medicine, I felt squirmy managing children. On closer inspection, he had short hair on his head and a few scars on his face. He was about four and a half feet tall and weighed about fifty pounds. His wrists were twig-like and he must have borrowed his shoulder blades from a sparrow. Despite his lack of brawn, he sat comically upright like a soldier awaiting orders. Every now and then, a smile crept hesitatingly across his face. Though he usually looked away sheepishly when this happened, I glimpsed a flash of teeth, white as polished ivory, every time.
I opted for a banal conversation starter: “So what do you want to be when you grow up?”
“A lawyer,” he intoned shyly.
“Goodness me! Like Nelson Mandela?”
He tried suppressing his grin: “Yes.”
“And what will you do as a lawyer?”
“Busy work,” he explained.
“Sounds like a plan, my man.”
He had the air of someone who had finished speaking his mind so I opened his file and gasped audibly: he was 16. I looked incredulously from the file to the boy and back again. Surely this was a clerical error. At sixteen, I had been more than a foot taller than him and three times his weight. Thinking that he was genetically stunted, I asked him how tall his father had been. He told me that he was taller than me.
I dug through his file for answers and found them pretty soon: he had been given HIV as a grim birthday present from his mother, but it had gone undetected until he was five. The boy had spent a life of abject poverty with his parents until they both succumbed to the virus. His impoverished upbringing had left him malnourished and stunted--perfect substrate for TB. He had spent the last seven months receiving treatment for TB in the hospital since his grandmother was not able to stick to the prescribed regimen at home. He was still to regain the weight he had lost from TB disease. This tragic story he shared with countless children across Africa.
After finishing with his chart, I began examining him. His heart beat like the wings of swallow fleeing a hawk. The boy gave me a curious look after I had spent about a minute listening. In response, I placed my stethoscope’s earpieces onto his ears while keeping the diaphragm on his heart. Little hands reached up and held the binaurals and, after initially widening with astonishment, his eyes glittered with undisguised glee. After a minute or so, he took off the stethoscope and said something to the translator. She smiled, looked at me, and told me that he wanted to compare my heart to his own. I knelt down and put the diaphragm over my chest. After a minute, he announced that mine was much slower than his. I concurred, patted him on the back, and stood up.
After adjusting his medicines and ordering his labs, I turned to go. The boy called after me in Isizulu as I did so. The nurse started to laugh. I looked at her bemusedly. Still chuckling, she told me that our little escapade with the stethoscope had changed his mind. He now wanted to be a doctor. I erupted with laughter and the little man joined in.
Even as we were united in mirth, I knew how high the deck was stacked against him ever becoming a doctor or a lawyer. Malnutrition in the first two years of life has a disproportionate impact on growth. Nine episodes of diarrhea before the age of two can cause a loss of 3.6cm in height by the age of 7. Cognitive growth goes hand in hand with physical development. For instance, an Indian study showed that taller children more likely to be able to write. Stunting has also been correlated with decreased academic performance. An incredible study tracked the fates of Guatemalan children over forty years and found that those who had been rescued from early childhood malnutrition went on to make more than 40% higher wages than those who hadn’t. This difference was attributed to the cognitive impact of malnutrition.
Delayed treatment for HIV, malnutrition, and TB had colluded to swindle this lovely, ambitious boy of the stature and cognitive prowess that should be his. Of course, were he to somehow transcend the physical and cognitive morbidity of disease, he would still be held back by the poverty that disease had wracked upon his family. I hope he defies his disadvantage in the years to come and realizes his dreams.
I sit at the kitchen table, staring blankly at the droplets. One after another, they peek out tentatively, swell up like harvest grapes, then fall onto the metal surface of the basin with a familiar thud. In that moment, my dysfunctional tap seemed the perfect symbol for the global health crisis. Drop by drop, we neglect the preventable and the treatable; and drop by drop, we leak human potential.
Drip…drip…drip...