First Blog Post! A Silent Epidemic: Malnutrition

Since this my blog first post ever, I feel it would be best to start with an anecdote. 

This past summer, I spent a few weeks in August in an AIDS clinic not to far outside San Jose, Costa Rica. As a student of public health, my goal was to explore a world of medicine unfamiliar to me where I would be completely out of my element. I have always been interested in global issues regarding health, particularly those of the third world. Last year I worked in a cardio-physiology center in Jerusalem, Israel, which is far from being a developing country. So I schlepped off to Costa Rica really not knowing what to expect or how I would react to such a situation. That was kind of the point though. 

Upon my arrival, I was greeted by a broad-smiling taxi driver who didn’t speak a word of English and then, as I walked outside, by the moist warm air. I was expecting the tropical climate but not so much the lack of English spoken throughout the country. A couple days after settling into my host family, my Spanish skills grew from absolutely nothing to passable after a few intense lessons. I was ready to be placed in the clinic. 

My first view of the clinic was a concrete yellow-cream building surrounded by high barbed-wire fences. I had to buzz a large garage-like door in order to even get in. Once I entered I was perplexed by the set-up. The entire clinic was a long hallway of rooms enclosed by sky blue concrete walls with a large rectangular hole in the shallow roof which was created purposely to feed sun to the garden placed beneath it. I had been there less than a minute and already I could tell that rectangle of sunlight must be the majority of the patients’ exposure into the outside world. How depressing. 

I was introduced to each patient, 14 of them to be exact, and then to the nurse. She was the only nurse for all 14 patients and she was a seriously tiny person. Each of the patients varied in terms of their abilities due to their individual disease progress and to the degree they were affected by ancillary illnesses. The best patient, Rita, looked as though nothing could stand in her way. She was bright and bubbly and dressed in the most garish yet cheerful garb. She spoke a fair amount of English so we were able to communicate rather well. The worst off patient, Randall, was bed ridden. He could not speak nor eat properly and was so arthritic that he was almost permanently in the fetal position. Also he had decubitus ulcers or bed sores right down to the muscle from his lack of movement. I knew Randall, along with some other similar patients, would be a real challenge for me. 

While I am no physician and not necessarily an expert on the AIDS epidemic I am rather knowledgeable about the topic of malnutrition. I would go as far as to say half of the patients at this clinic were severely malnourished. According to Gary Cohan MD there is usually a combination of reasons why people with AIDS become malnourished. 

First of all, HIV itself changes the body’s metabolism, which can cause it to burn calories much more quickly. If a patient is not in-taking enough nourishment to make up for the high caloric burn rate, then naturally weight will be lost and eventually muscle will deteriorate. Another metabolic deregulation that is sometimes found with HIV is cachexia. Normally, when someone is malnourished, their body burns fat and preserves the lean tissue mass. With cachexia, there is accelerated tissue loss, with an almost immediate depletion of lean tissue mass. This speeds up the wasting and brings on immediate threats. Furthermore, diarrhea is a common symptom of HIV which prevents the body from absorbing the calories it requires after consumption also leading those who suffer from it to eat increasingly less due to sheer discomfort. If you’ve ever had food poisoning you know what I am talking about. Other symptoms that prevent those with AIDS from eating are nausea, lesions/ulcers in the mouth of esophagus and last but not least - depression. 

All in all it is apparent that when left alone, AIDS patients can often be at risk for malnutrition and from what I can guess (and only guess because I was only at the clinic for a month) this is how many of the patients at this clinic lose their lives. Not infection, not cancer, but a simple lack of sufficient nutrients. 

After meeting all the patients I was extremely curious to decipher why they appeared so underfed. It came time for lunch and I got my answer: saltines and coffee. I was astounded. From everything I have read on malnourished children in African countries it is evident that proper food can be hard to come by. But not here, not in Costa Rica where food is extremely cheap, fruit grows a plenty and beans are served for breakfast. 

That day I insisted that I stay for their snack and dinner as well. I should make it known that there was a slight difference between patients in terms of their consumption. Those who were up and about ate some basic soups, rice and beans with lettuce, and an assortment of cookies. Not what I would call balanced but one could get by on that for sure. What I didn’t understand was that it was those who couldn’t feed themselves, those in the most need of nourishment, that were given just coffee and crackers (or a variant carbohydrate) throughout the day. Not to mention giving these patients coffee was an obviously vicious cycle. I would know since one of my many responsibilities was to wash them after they had wet their beds. 

This issue in general also really hit close to home. Growing up as a ballerina I was surrounded my young woman desperate to be thin all the time and who took drastic measures to make that happen. Now I was watching these young men and women desperate to be anything but thin and there was nothing anyone was doing about it. Awful. Unfortunately, having been there for only a few weeks and not knowing Spanish limited my clout in making a change at the clinic. At the very least I made sure I left my ideas with someone. I spoke with a group of men from Texas who came every week to take a few of the patients for an outing (yes, they only went out once a week if that). I advised them on what I thought should and needed to be done. They were the only ones I could communicate with who might of had the potential to make something happen. Plus they spoke Spanish. 

One recommendation was to bring in a fortified food for them to eat. Last year I researched Plumpy’nut, a recently developed “Ready-to-Use-Food,” (RUF) that has revolutionized the way severe acute malnutrition is treated in several African counties. For instance, when recently used in Niger, children given Plumpy'nut had between an 81% to 95% recovery rate (MSF, 2008). It costs 5 cents per package, each with 500 calories, and, best of all, it’s just like sweet peanut butter paste. Now, unless you are allergic to peanut butter it is a simple and brilliant solution to acute malnutrition. If brought to the clinic, the patients could easily eat and even enjoy it perhaps with a nice glass of milk (well, I saw some in their fridge at least). Plumpy’nut alone would save those patients from a death of starvation and in the case of AIDS would most likely prolong their lives substantially. But like I said, I couldn’t make anything happen myself, and who knows if those Texans actually took my advice. Lesson for the future: learn the language of the country you’re visiting and prepare to make change!

Malnutrition is like a silent epidemic because too many people with AIDS are dying from it and too few health care providers are doing something about it. What I witnessed at the clinic, (also known as the best clinic in San Jose by the way) is a situation that must now change. Patients cannot be left to starve to death. Nutritional analysis and nutritional intervention, if called for, should be a part of the treatment program for anyone with HIV disease. Even for those of low economic standards. There is simply no excuse for such treatment. 

My mother brought up some possibilities for why the patients were being fed so poorly. She hypothesized that, for the same reason they were being given sleeping pills instead of AZT drugs (yes, I am serious) they were being given crackers and coffee; to lessen the burden of care. While this may be the reason behind it, it doesn’t make it remotely ok. Truth be told, there were dozens more issues with the clinic other than malnutrition but unless you care to know more I think I will stop here for now. 
__________________
Global health is a substantial aspect of medicine and health science that is on the rise. Considering the world is incrementally shrinking, it is important that we as part of the population of this world are made aware of what is going on and what is being done or what can be done. 

My purpose here in this blog is to inform and discuss with you issues through global news, anecdotes, research and opinions covering topics on disease, health care policy and systems, narrative medicine, food, water, drugs, etc. While much of what my interest stems from the issues in the developing world, I will also be concentrating on the Western world and how our cultures can be improved in terms of our life styles. Furthermore, I am particularly interested in nutrition and its influence on countless aspects of our lives (as you can see) so I will be most likely alluding to the topic on a regular basis. 

Just to end on a personal note: I am currently a senior at Sarah Lawrence College studying psychology and pre-health (graduating in May with a BA) and within the coming year I hope to begin my Master’s in Public Health hopefully, leading to a MD and/or PhD focusing on nutrition. But we shall see. 

I would very much like to have a post up each week, perhaps more HW permitting. The exact day of the posts will be confirmed at a later time. For now that is all. 

Care and be aware. Stay healthy and happy. 
-Eva

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