Wordless Wednesday: Carry the Weight


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Sixteen and scrawny, Jonathan sticks out on the bench of mothers and aunties and grandmothers waiting with their children to see the pediatrician in the HIV clinic. An older boy among the line of women.

I often see adolescents who come to the clinic by themselves, often walking for over an hour to the clinic to collect their medicines and see the doctor each month. Jonathan is not here at the clinic for himself though. He is here because he has become a mother of sorts for his young cousin.

George’s mother and father died from HIV in the course of the past two years, leaving six-year-old George in the care of his aunt, Jonathan’s mother. Then, the virus took her life too, leaving both Jonathan and George orphaned, leaving Jonathan to take over the responsibilities of the household. Jonathan also watches over his younger brother, an 8-year-old.

Jonathan tries to take good care of George. He gives him his HIV medicines every day, although it becomes clear in our discussion that he has a hard time getting George some of his doses on time. He tries to get enough food for George every day, but “food is a problem” the 16-year-old tells me. I see the worry in his eyes.

I am worried too. George is not growing. He is losing weight, and the cells that mark how well his immune system is holding out against HIV are getting lower and lower and lower. I am worried that this sweetly smiling six-year-old needs more food and new HIV medicines. I am also worried that both George and Jonathan could really still use a mother.

One million children in this country have been orphaned by HIV. George and Jonathan are just two of one million.

I tried my best with my usual set of doctor tools – a physical exam and blood tests and prescriptions and lots of counseling about how to take these medicines so that they work. I was at a far-away clinic that did not have a nutritionist or a social worker today, but we attempted some arrangements for Jonathan’s little family to get some extra help and extra food.

I am thankful for Jonathan, who has stepped forward to take care of his brother and his cousin amidst the devastation of his childhood and his family. I am thankful for a clinic with teachable, kind clinicians and my faithful study team who will follow families of any kind very closely. I am thankful for our Orphans and Vulnerable Children program, who will use what few resources they have to help children like these. How I depend on them… I want these teams at every clinic.

We’ll do our best to offer Jonathan a few less days of worry, even though I find myself worrying about those two still.

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On the Streets

I have a hard time thinking of a group that is more marginalized than children who live on the street. Forgotten. Neglected. Feared.

When you see a dirty boy clutching a bottle of glue and lying in the gutter in a city in the world’s poorest places, it is hard to know what to do. Often, you just want to walk quickly past. Knowing that 100 million children are living on the streets right now is impossible and sad beyond belief.

100 million boys and girls like Philip and his friends.



Sometimes, the best thing that can happen in the face of great, big problems is to shine as bright a light as you can on them. The world’s orphaned and neglected children, the forgotten, the poorest of the poor – they really need that light.

One of the teams of researchers in our Kenya partnership studies issues involving street children, especially the risks they face from things like substance abuse. Our team just published an analysis in the journal Addictions looking at substance use among street children around the world. The review makes it clear that substance use is incredibly common among these children, and they face all the risks that go along with using drugs while their bodies and brains are still developing. If you look at that photo that Philip took, the boy has one hand on the precious soccer ball they found in the trash and a bottle of glue in the other hand.

I’m thrilled this publication on street children has been featured in some other places like the Toronto Star and the Voice of America, with interviews with my colleague Paula Braitstein. It also highlights the work my friends have done at the Tumaini Children’s Drop-In Centre to empower and serve street children here in western Kenya. If you want to do something for children on the streets, support the Tumaini Centre.

In poor places, children often turn to things like glue to numb their hunger, cold, and the pain in their hearts. Substance use among street children is a complicated problem to try to solve, but shining a bright light on their needs is a good start.

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Friday Gratitude


I am very grateful for my big, blue beast of a car that carries me and my study team across terrible roads to the clinics in Kenya’s remote corners where mamas and babies wait.



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Protein for Paul


Paul’s dad has a great smile. His warmth captures me as I observe his obvious care for his young son and his attempts to get the shy toddler to smile for me.

But when I look at Paul, a smile is not the first thing I notice. Instead, I notice all the signs that his little body is not getting the protein that he needs to grow.

In poor places, young children often suffer from a particular kind of malnutrition when they are weaned from their mother’s breast milk. Very often, they move from breast milk to very basic starches. They may get little protein, even if they are taking in enough calories for survival. Meat or eggs are too costly, and their parents may not realize the difference that other proteins would make.

Paul’s father loves him very much, but he can usually only afford to feed Paul ugali (the corn meal mush that is the staple starch here) and a thin form of porridge. Ugali fills Paul’s belly, but it does not give him what he really needs. Without the protein that he needs, Paul’s belly is big, his face and hands are swollen, and he is no longer growing. Paul is very malnourished.

Paul’s little body needs protein right now. This is the critical time when his bones and brain are growing. We know that being deprived of what he needs right now will likely affect how big he gets, how he learns and does in school, and how his body metabolizes food for the rest of his life. Paul cannot wait.

Malnutrition is far too common here in Kenya – and far too common all around the world. 150 million children in developing countries around the world are malnourished. A number that defies understanding. A quarter of Kenya’s children are malnourished. In our HIV clinics, almost every child coming in qualifies as being malnourished. In the area where Paul lives, there has not been enough rain, and the families are poor, poor, poor. The children’s bodies are the first to show this deprivation.

Child malnutrition: a huge and overwhelming problem.

But Paul is the child in front of me today, and his father is smiling at me, convinced that we can solve his son’s problems. And maybe we can. It takes more hours than it should for phone calls and tracking down the right pharmacist and begging social work for assistance, but I manage to get Paul a supply of a special paste made from nuts that will give his body back some of the protein he needs.

Another one of the research studies we presented last week at the International AIDS Society in Malaysia was about the difference that food supplements like this make for children with HIV. “Ready-to-use foods” like this nut paste significantly cut back the chance that a child like Paul will die or will get other infections. They save lives.

When I finally get them, I carry the packets of this nut paste into the clinic like they are pure, squishy gold. And, truly, they could not be more precious for this child’s body.

We’re going to find Paul’s smile.

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