Robert Levin, MD, in Uganda

The Smallest Victims: Fighting Malnutrition Amidst Civil War

Robert Levin, MD, a family physician from Minneapolis, Minnesota, returned recently from Lira, a town in northern Uganda, where he treated malnourished children admitted to a therapeutic feeding center operated by Doctors Without Borders/Médecins Sans Frontières (MSF). The following is an account of his six-month mission (December 2003 through May 2004)—his third with MSF—as told to MSF. His other missions were in southern Sudan and Sri Lanka.

We only had a short period of time each day to work though because the roads are extremely insecure after dusk. Numerous attacks on civilians have been attributed to the Lord's Resistance Army (LRA), the rebel group that has been fighting the Ugandan government.


Robert Levin, MD

When I first saw Evaline sitting under a tree on the grounds of Lira District hospital I swore she was at least 30 years old. Malnutrition had stolen the youth from her cheeks. Her ribs were protruding and her arms were not much more than skin on bones. She appeared to be suffering from tuberculosis (TB). Parentless and abused by her older brother's wife, Evaline had been left to fend for herself with devastating consequences for her health.

Evaline exemplified so many aspects of my experience in Uganda. There she was, so close to death, surrounded by other children in a similarly vulnerable and uncertain situation. But with the appropriate medical care and nutrition she battled back. When she was only gaining small amounts of weight we started to treat her for TB. She began to eat like a "horse." In less than three months she gained a tremendous amount of weight-her smile was contagious.

Evaline as she arrived in the feeding center, and 3 months later.

I was introduced to Evaline several months into my mission, which was to work in a newly opened MSF therapeutic feeding center (TFC) for severely malnourished children living in and around the town of Lira in northern Uganda. Tens of thousands of people have been forced to abandon their homes and livelihoods because of violence in the region.

Originally, the TFC was operating in 11 tents on the grounds of Lira District hospital but with terrible results. It was nearly impossible to keep track of the more than 100 children in the TFC because parents would often take their children out of the sweltering hot tents, leading to woeful adherence to the feeding program. A quarter of the children in the TFC were diagnosed with malaria. There were weeks that 20 percent of the children admitted to the TFC were dying.

MSF-constructed feeding center.

Finally in mid-March, the team was able to move the TFC out of the hospital to an MSF-constructed center about a mile away, and leave behind the oppressively hot tents for the relative cool inside the concrete building. In the new center we were able to track the children much better and as result the adherence to treatment increased dramatically and death rates among the children continued to fall. The children that gained enough weight were transferred to the supplementary feeding centers (SFCs).

During my mission, I spent about four weeks away from the TFC working in the mobile clinics we were sending to camps for internally displaced people (IDP). Lira district had only felt the effects of Uganda's 18-year-old civil war over the last year. The other northern regions have been constantly ravaged by war, and in those areas the IDP camps have become permanent. New generations of Ugandan children have been born there. It is a way of life.

In Lira the large number of IDP camps had emerged only last year. Massive numbers of people have been displaced and more people are being displaced on a daily basis due to the war and insecurity. These people have all been torn from their homes and their way of life. It was difficult to see and to hear about. It was so immediate. Yet, somehow, they had the strength to adapt to their incredibly difficult situation.

We visited the camps to provide medical consultations and often enrolled children into our supplementary feeding program. We had approximately 1,500 children receiving supplementary feeding from MSF. We weighed and measured the children, and checked their nutritional status using the mid-upper arm circumference, or MUAC, test. The severely malnourished children were transferred to the TFC.

We only had a short period of time each day to work though because the roads are extremely insecure after dusk. Numerous attacks on civilians have been attributed to the Lord's Resistance Army (LRA), the rebel group that has been fighting the Ugandan government. But most often civilians are the victims of extreme violence. Thousands of children have been abducted to serve as soldiers, porters, or sex slaves.

In Lira district the violence was daily and devastating. It was like nothing I had ever seen before—even in southern Sudan. In Bahr el Ghazal, Sudan, the violence—at the time—was sporadic. Occasionally I would see a gunshot wound. I was in the Lira District hospital when the wounded from two separate attacks in February were brought in. It was horrific.

Most of the men had gunshot and hand grenade wounds while a majority of the women and children had severe burns received when the huts they were hiding in were burnt down. Other people, including children, had machete wounds to their heads and bodies. There it was right in front of me and still it was hard to imagine the actual act of violence that resulted in these wounds. We treated 51 wounded people. Nearly 200 people died in the attacks.

Beyond the brutality I witnessed in February, the hardest part of my mission was seeing children die. Coming in to the TFC early in the morning to find out that the little one, at whom I had given everything I had to save, had passed away, was so demoralizing. Some days I would wonder if I really wasn't much of a doctor, and I would question my skills and my knowledge.

Robert Levin, MD at work in the theraputic feeding center.

Just when I thought I couldn't handle it anymore, I would visit the phase-two children within the TFC. In phase two, the children are eating well and the various infections that had affected them earlier have healed. These children, like Evaline, who had nearly died, are now smiling and laughing and growing wonderfully. Visiting them helped me realize my work was making a profound difference in many of the children's lives. Then I would go back to the phase-one children reinvigorated and as ready as I could possibly be to confront their reality.

When I left Uganda, the death rate in the TFC had fallen to 4 percent.