The little ones

Profession	Medical / Health
Date	January 1, 2010

This evening ritual is not limited to the herding of turkeys, however. To go out at this time of the evening is to risk being caughtin ‘peak hour traffic’, country style, as cows, goats, sheep and donkeys return from their day of grazing on the hills. Most herds are a mixture of all of these animals, and most come from a number of different homes. Yet, somehow, as several children run along behind, ensuring no stray is left behind, each animal seems to find its way into the correct yard as the herd goes by.

Though this may sound like a story about animals, it’s actually about the children. As a paediatric nurse I hold children’s issues close to my heart. For the past few years I have been working in a project that provides health care in an isolated, geographically challenging area of Central Asia. In that time I have been struck by the high number of children who are brought to us with serious health complaints, often too late for us to make any difference, or with diseases and conditions that would be easily treated or prevented back in New Zealand. I have often become angry about what I considered to be cases of blatant neglect. However, it almost never turned out to be quite that straightforward: what I perceived as neglect was a complicated mix of desperation, ignorance and accepted cultural practices.

Sitara was a beautiful nine-month old girl, just old enough to crawl… and just old enough to fall into the family ‘tandoor’. The tandoor is an in-ground oven, hot enough to cook bread quickly, and when Sitara landed on her elbow, she suffered full thickness burns which exposed the joint. The burn was over a week old and infected when I saw her. Her father had taken her to the local clinic nearest their home, but when informed that the clinic was not equipped to deal with such a severe burn, he had refused to take her to our hospital.

I re-dressed the burn, but explained to the family that, at the very least, Sitara would need skin grafts. Indeed, she probably would require even more radical surgery, which we were not able to do. I referred them to a children’s hospital in the capital city, about 450 kilometres away, but Sitara’s father was reluctant to make the two-day journey, claiming hardship and poverty. I continued to impress on them the severity of Sitara’s situation and the necessity for further help, and they finally agreed to go. When they said they did not have the money, I eventually agreed to help with transport costs.

Although my heart grieved at the inevitable disability little Sitara would have to live with, I was confident that she would receive good care at the children’s hospital in the city. However, as days turned into weeks and we received no word of the family’s arrival in the city, I realised that the family must have decided not to go, and had instead taken their little girl home, most likely to die.

My feelings of helplessness and anger were overwhelming, as I struggled to make sense of the situation. One thing that helped was putting myself in the father’s shoes: what factors influenced his choice to take his seriously ill daughter home instead of to the hospital? I believe there were several: they were an extremely poor family and, even with assistance, it would have been an expensive trip which he had no real way of financing; he had never been to the city before, and the thought of travelling all that way for a treatment that, in his mind at least, would be unlikely to save her life, probably seemed pointless; he understood that losing children was inevitable – he had already seen several of his children die in infancy; he had other
children to provide for, and in his absence there would be no-one to take care of his family and his small piece of land.

For many families the decision about whether or not to seek treatment is complex. It involves the gender of the person – sadly it is still true that often women and girls will have to wait longer before they receive any form of health care; the time of year – spring and early autumn are difficult times of the year due to planting and harvesting crops, winter is difficult due to snow and higher river levels; distance from the health facility; the financial status of the family; the perceived value of the person who is sick; and religious and cultural beliefs.

I have also learnt that the clinic or the hospital is rarely the first stop for a child who is ill. The family will usually take them first to a local ‘healer’ in their own village, then to the nearest mullah (religious leader), who will provide prayers and talismans, depending on how much the family can afford. Finally, if none of that works, they may then take the child to ‘the doctor’. All of these steps are important, culturally and spiritually. There is a habit and a pattern to what is accepted and expected, and if the pattern is not followed and the child remains sick or dies, then the one who made the decision to not first consult the local healer and mullah will be blamed.

Working through it in this manner helped me to better understand the complex situations I was dealing with, but of course did not change the sad reality for little Sitara or the reality for many other children like her. In a country where one in four children will die by the age of five years, it’s easy to get the impression that a child’s life is viewed as of very little worth. But I have seen the agony as a father pleads for some action
to be taken to save his precious son or daughter, and the pain behind the fatalism of parents accepting the loss of yet another precious life. And all I can hold on to in those situations is the hope of a Father who sees when even one sparrow falls, and who will not forget these little ones, or those who mourn them.

Kelly is a Kiwi Partner and a nurse, who has been serving in Central Asia for six years.