I saw my first patient in the Congo today. Her name is Yohanita Nyiahabimana. She is a 41-year old woman who lives in the village of Malehe, about an hour from Goma. She was carried out of her house by her neighbors when they heard that we were coming. There she lay on some tattered blankets, all 50 pounds of her under the unforgiving African sun.“Skin and bones” would not even adequately describe her. She was completely emaciated, with no body fat and no muscle. Her shriveled limbs were contracted, and her eyes sunken and scared. Her heart rate was in the 130s, and she was taking deep, raspy breaths. She felt warm to the touch, yet she was shivering and her teeth were chattering. Moving her from side to side elicited excruciating screams. On her groin and buttocks were multiple bedsores up to three inches in diameter. All of the sores were to the bone, and were oozing and teeming with flies.
Who is Yohanita? How did she get like this? We were visiting the village of Malehe, whose 12,000 inhabitants had been driven out during recent conflicts and just returned in February. While they were gone, the rebel soldiers burned down houses, destroyed crops, and stole cows and goats. There had not been time to replant seeds before the harvest, and the returnees have been literally dying of starvation.Villagers said that there was a woman not far away who was very sick. They did not know why she was sick, but we followed them up the hillside, past the rotting crops and burned buildings, to see her. Outside her house, there was a very thin older woman sitting under a tree. She was taking shallow breaths, had signs of leg ulcers, and appeared malnourished. “Before the war came to the village, we had enough to eat. We had many crops and cows and goats,” she told us. Now all of their crops and livestock are gone. She said that since May, she and her family have eaten nothing but bananas. The last time she had even bananas to eat was the day before yesterday.
This is the mother of Yohanita. While she was talking, some men brought out a bundle from the house and deposited it near our feet. As soon as I saw Yohanita being carried out on the tattered sheet, her body all but a skeleton wrapped in rags, I knew that she was at death’s door. If I learned anything in medical school, it’s to recognize when to get help. I knew what needed to be done—she needed immediate medical help—but I was not sure how to do it. There was no way anyone could treat her in her village without any supplies. I certainly could not just leave her there, on the fast track to death.
I began to explain the situation to her elderly parents. Yohanita is very sick, I said. She has fever and signs of infection, and her heart rate and breathing are very fast. She really needs to go to the hospital, or she will die. We can take her in our vehicle. Her parents seemed to understand the gravity of the situation, but were reluctant to have her go to a hospital. Their main concerns were that they could not afford it, and that nobody would be able to take care of her there (hospitals in the Congo require someone to accompany the patient to cook and clean for them). We offered to pay for the cost of her care (the total would probably be around $100), and found a local neighbor girl to accompany Yohanita.Enough people consented that we finally began to move Yohanita down the steep hillside. I thought that the discussions had ended when we lay her down in the vehicle. It had already been at least an hour since we first saw her. I waited with her in the car thinking expecting for the driver and other passengers to jump in, but a large crowd was gathering outside. More issues had come up. The girl who was to accompany Yohanita disappeared. The head of the village disagreed with the choice of hospital.
I could not believe that such discussions were taking place while Yohanita was lying in the car, dehydrated, severely malnourished, and literally at death’s door! She felt hotter, and I could barely detect a pulse. The delay was unacceptable. Yet somehow I could not get this point across. As the decision was put off further, my frustration was mounting, my anxiety increasing, and my hope plummeting. Even if we removed some of the barriers to her care, more barriers seemed to come up. I felt I could help, and knew how to help, yet somehow was powerless and helpless.
Finally, after what seemed like hours of discussion, our vehicle took off. Yohanita ended up going to a hospital in Goma, and is now in the capable hands of HEAL Africa. The doctor who accepted her into their intensive care unit agreed that her degree of extreme emaciation could be due to multiple causes, with AIDS and famine being the two most likely. Yohanita could very well have both. She had been raped during a previous conflict and has a 6-year old child from the rape. We found out that she had been well until April, when she became progressively weaker until she was bedridden. It was unclear as to whether she stopped eating because of her weakness, or just couldn’t eat because there was no food. The doctors are looking into her underlying diagnosis, and in the meantime are giving her fluids and antibiotics and starting a gradual refeeding program. I will be following up with her in the remaining days that we have in the Congo.
As we left HEAL, I felt relieved that Yohanita is in the care of physicians. I also had a horrible realization that cases like hers occur everywhere. We just happened to pick one village of returnees, and found someone as emaciated and ill and without medical care as her. There are hundreds of villages like this one in the Congo, and dozens of resettlement camps where displaced people live in abject poverty with absolutely nothing but disease to rule their lives. We could have been in any village in the Congo and discovered a case like her.Yohanita is a tragedy of war. When we think of the effect of war on people, we often picture civilians killed in crossfire. Next time I want you to picture Yohanita. She is the human cost of war. So are the families whose livelihoods are ruined when conflict destroys their farms and businesses, the elderly who die in epidemics caused by lack of basic sanitation, and the children who lose years of education. Are these consequences of war that we are willing to accept, in the Congo, in Iraq, or in the United States?
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Leana S. Wen was born in Shanghai, China. She came to the U.S. on political asylum in 1991, and grew up in Utah, California and Missouri. Her experiences as an immigrant in diverse communities are driving forces behind her interests in public health and international health policy, and her commitment to fighting for social justice around the world. A recent graduate of Washington University School of Medicine, Leana has served as a Global Health Fellow at the World Health Organization in Geneva; as a National Security Education Program Boren Fellow in Kigali, Rwanda; and as National President of the American Medical Student Association, the nation's largest independent organization of physicians-in-training. Leana is a Rhodes Scholar-elect, and in the fall, she will begin two years of study at the University of Oxford to examine health systems in developing countries. After her return, Leana plans to enter residency training in emergency medicine.
