Ten years ago, Renee Bach left her home in Virginia to set up a charity to help children in Uganda. One of her first moves was to start a blog chronicling her experiences.
Among the most momentous: On a Sunday morning in October 2011, a couple from a village some distance away showed up at Bach's center carrying a small bundle.
"When I pulled the covering back my eyes widened," Bach wrote in the blog. "For under the blanket lay a small, but very, very swollen, pale baby girl. Her breaths were frighteningly slow. ... The baby's name is Patricia. She is 9 months old."
Bach went on to write that Patricia had fallen sick three weeks earlier. But her parents had been unable to find anyone closer to home who could cure her.
Then, wrote Bach, "One of their relatives told them about a 'hospital' ... with a 'White Doctor.' "
Except Bach was not a doctor. She was a 20-year-old high school graduate with no medical training. And not only was her center not a hospital — at the time it didn't employ a single doctor.
Yet from 2010 through 2015, Bach says, she took in 940 severely malnourished children. And 105 of them died.
Now Bach is being sued in Ugandan civil court.
"Something that I was supposed to do"
How could a young American with no medical training even contemplate caring for critically ill children in a foreign country? To understand, it helps to know that the place where Bach set up her operation — the city of Jinja — had already become a hub of American volunteerism by the time she arrived.
A sprawling city of tens of thousands of people on the shores of Lake Victoria, Jinja is surrounded by rural villages of considerable poverty. U.S. missionaries had set up a host of charities there. And soon American teens raised in mostly evangelical churches were streaming in to volunteer at them.
Bach was one of these teens. On her first trip, in 2007, she worked at a missionary-run orphanage — staying on for nine months.
Once back home in Virginia, Bach — now 19 years old — came to a life-changing conclusion: She should move to Jinja full time and set up her own charity.
In an interview with NPR, Bach says it felt like a calling from God.
"It was a very, very profound feeling and experience. It's kind of hard to even describe in words," she says. "Like there was something that I was supposed to do."
At first Bach wasn't sure what that was, beyond a sense that it should address some need that wasn't already being met by existing charities.
Funded by money raised through church circles back home, Bach rented a large house in one of Jinja's poorer districts, called Masese, and began testing out options, including starting a program to serve a free hot meal to neighborhood children. Twice a week about 1,000 of them would line up by Bach's house to receive a bowl of food. Bach named her charity "Serving His Children."
According to Bach, word of her feeding program spread through Jinja. In the fall of 2009, she says, she got a call from a staffer at the local children's hospital asking if she could help out with several severely malnourished children.
Bach says the staffer told her that from a medical standpoint, these kids had been stabilized. They just needed to be fed back to health. Could Bach take them in?
Bach says seeing a child in this state — impossibly thin arms, ribs poking out, sunken eyes — "was almost an out-of-body experience. And a sense of, 'Oh my goodness, this isn't right. This needs to stop.' "
She says she agreed to help the children. And before long she came to feel that this was God's plan for her: turn the house into a center where malnourished children and their mothers could live while the youngsters recuperated — complete with free rations of the special foods they would need, the medicines doctors had prescribed and lessons for the mothers on nutrition ... and the Bible.
In early 2010 Bach posted a blog entry titled "Here we go!" Her nutrition center was up and running.
A disillusioned volunteer
Jackie Kramlich was one of many American volunteers drawn to the center.
"I went in with a lot of admiration," Kramlich recalls.
It was the summer of 2011.
By this point Bach had hired three Ugandan nurses to help out during the day and stocked a room she dubbed "the clinic" with medical gear such as oxygen tanks, IV catheters and monitoring equipment.
The center was caring for as many as a dozen children at a time.
But Kramlich — who had just been certified as a registered nurse in North Dakota — was taken aback to realize just how sick these children were. They weren't just malnourished. They had complicated illnesses.
"Pneumonia, intestinal parasites, tuberculosis, many were in stage 4 HIV," Kramlich says.
Almost every week a child would die.
Also, it seemed to Kramlich that Bach, now 22 years old, was handling a lot of the medical care herself.
Which brings us back to that baby Bach wrote about in her blog: 9-month-old Patricia.
In her blog, Bach wrote that she immediately ushered Patricia and her parents into "the clinic."
"I hooked the baby up to oxygen and got to work," she wrote. "Took her temperature, started an IV, checked her blood sugar, tested for malaria, and looked at her HB count." (That's a measure of hemoglobin in the blood.)
"I was attempting to diagnose the many problems that could potentially be at hand. Got it: Malaria: positive. H.B. 3.2. ... a big problem ... most likely fatal. ... She needed a blood transfusion. And fast."
Next, Bach wrote, "we" — it's not specified who is meant by "we" — started a blood transfusion for Patricia.
But about 30 minutes later, Patricia seemed to take a turn.
"Her neck and face started swelling. A lot," she wrote. "[Her] breathing went from bad to worse. Her throat was beginning to close."
That's about the moment Bach called Kramlich on the phone to ask if Kramlich could swing by the center.
"So I walk in," Kramlich recalls, "and there's this child, swollen, wheezing." Kramlich could see the blood still being transfused into Patricia's vein. "And [Bach] goes, 'You know, I think she might be having a reaction. But I don't know. Because, you know, Google says that if they're having a reaction, they'll have a rash. And I don't see a rash."
Kramlich says that as was often the case, it was clear to her that Bach was the one making the medical decisions. And in this instance, she says, none of the staff nurses were even at the center.
"It's just horrifying," says Kramlich. In Uganda, just as in the U.S., only a medical professional is permitted to perform invasive procedures like a blood transfusion. She says her thought at that moment was, "This isn't a game. You have no business running blood — at all."
Bach says it's true she would sometimes perform medical procedures such as running the tubing into a child for a blood transfusion or inserting an IV.
And sometimes, Bach says, "without a medical professional standing right next to me, yes. But it was always under the request and direction of a medical professional."
As for her blog posts, Bach tells NPR, "I was just writing to tell a story to my friends and family.
"And a mistake that I made that I wish I wouldn't have is, I very much wrote in first person — which looking back sounded very prideful as if I wanted to allude to the fact that I was, you know, doing all of those things myself. But the reality was that there were medical professionals present doing those things."
In the case of baby Patricia, Bach's memory is that one of the staff nurses at her nutrition center did the blood transfusion. And she says when Patricia seemed to have a reaction, this nurse called up a private doctor, who — over the phone — recommended that Patricia be rushed to a hospital.
Bach and Kramlich do agree that ultimately, Bach drove Patricia to a hospital. And Patricia lived.
But for Kramlich this was too close a call.
"I was just beside myself. I mean furious."
Soon after, Kramlich quit — four months into what she had originally intended to be a yearlong volunteering stint. Kramlich also sent a letter of concern to the charity's board of directors back in the U.S.
Dangers of treatment
Under both international health guidelines and Ugandan law, if a severely malnourished child has the kind of extra complications Bach's center was taking on — serious respiratory infections, dehydration, swelling — this child must be treated in an advanced medical facility.
Ideally this would be a hospital — but at the least a higher-level health center that has been especially approved by Ugandan health authorities, says Dr. Joel Okullo, chairman of the Uganda Medical and Dental Practitioners Council — the enforcement agency for Uganda's health regulations. Treating a child in this condition at even a lower-level health clinic "would be breaking the law," says Okullo.
And at this point, Bach's nutrition center didn't have any kind of health license or any doctors on staff.
Saul Guerrero specializes in childhood severe acute malnutrition at UNICEF, the world authority to which countries turn for help setting their regulations and treatment programs.
Guerrero says malnourished children with extra complications are so fragile that unless a health provider knows exactly what he or she is doing, it's actually safer to do nothing.
"Their metabolism is not working. Their immune system is not working. So once you initiate any kind of treatment that will very often have knock-on effects," he says.
Just hydrating them by putting them on an IV can trigger a heart attack — if the sodium and potassium content isn't continually adjusted to match the child's fluctuating levels.
And if health workers are not treating the child in a facility that is fully equipped to immediately address such emergencies, says Guerrero, "the chances that that child will die are very, very high."
In 2011, of the 129 children Bach took in, 20% died — nearly a third of them in the first 48 hours. In 2012, the death rate among these in-patient cases was 18%.
By 2013, Bach had hired two doctors and the death rate was 10%.
But Guerrero says even that rate is high by the standards set by international aid groups. He adds that a designated government facility in Africa may have a death rate of 20% or even higher at its in-patient ward if it is serving a very vulnerable population. But facilities with those rates "make it all the way up to New York, to us at HQ, because they are seen as a problem," he says.
An American attitude
Bach says she took in these complicated cases "not because we felt like it was fine." But because there didn't seem to be a better place for them.
"I mean I can tell you time and time again," she says to NPR, "taking kids to hospital after hospital, and them being like, 'meh — we don't really deal with malnutrition. Your best bet is to take them back to your nutrition center.'
"It wasn't ideal. But what do you do in a non-ideal situation?"
Hanifa Bachou, a Ugandan pediatrician who specializes in malnutrition, finds Bach's explanation preposterous.
"No, no, no. I don't accept that," says Bachou. During the period at issue, Bachou, then based at the NGO University Research Co., was working with Uganda's government on a U.S. government-funded project to set up in-patient care for severely malnourished children across the country. And by 2010, Bachou says, Jinja's regional referral hospital had a well-established malnutrition unit to care for complicated cases of severe acute malnutrition.
But even if there was a need for more in-patient care facilities for malnourished children, specialists in medical ethics say it was not appropriate for Bach to try to provide it.
"Just think of the arrogance," says Lawrence Gostin, who heads the Center on National and Global Health Law at Georgetown University. "Who are you to assume that you can do better than they can? It's not your judgment call to make."
Gostin adds that while the circumstances of Bach's case may seem exceptional, he sees her actions as stemming from an attitude many Americans bring to developing countries.
"The American cultural narrative is that these countries are basket cases."
And so, says Gostin, Americans assume that whatever their qualifications, they're sure to be of help.
The result, Gostin says, is that everyone from college kids to credentialed doctors routinely parachute into poor countries for medical missions that completely disregard local laws and conditions.
"People think that they're doing good. And they have no idea how much harm they can cause."
And people back home in the U.S. are often complicit, says Gostin. Because when these volunteers write blogs or post videos to share their exploits, "They're celebrated."
Kramlich, the volunteer at Bach's center, says this mindset is a big reason that even after quitting, she didn't go straight to the police. That is what she would have done had she encountered a center like Bach's in the United States.
But in this instance, she says, "people are praising [the center]. And [Bach] is receiving funding. And she looks like Mother Teresa. You think, 'It's so out in the open that, well, surely there must be something to this that's OK.' "
But in February 2015, after hearing from an employee at Bach's center that problems there persisted, Kramlich filed a report with Ugandan police.
A month later a district health officer shut the center down.
In his report, the inspector noted that in 2014, Bach had obtained a health license for the center. But it had expired. And in any case, the license had only authorized the center to operate as an outpatient clinic. Instead, on his visit to the charity, he had found "very sick children who need referral to higher centers."
"It is what shocked most of us," says Primah Kwagala, a Ugandan civil rights attorney. "We couldn't imagine a human being without skill taking into her care people that were almost on their deathbeds."
Bach notes that a few years later, the government authorized her to reopen her center, this time in direct partnership with a government health center in a different district and with Bach no longer involved in the medical care.
But Kwagala, who runs a legal aid group specializing in public health, says Bach should have been held accountable for the deaths of children in her care. So early this year, she filed a civil lawsuit against her. It's on behalf of the mothers of two of the children who died.
Her court filings include excerpts from Bach's blog as well as a blog posted by a supporter of the charity who visited and took photographs — including one of Bach inserting an IV catheter into the vein of a severely malnourished child.
The next hearing date is scheduled for January 2020.
Bach says the publicity in Uganda over the suit has already made it untenable for her to remain there. "I get death threats all the time." She has moved back to Virginia and has no plans to live in Uganda again.
Kwagala says the suit is deeply necessary. These families deserve justice, she says. And there's a larger principle at stake: Imagine, says Kwagala, if a 20-something Ugandan woman had gone to the U.S. and set up an equivalent arrangement to treat impoverished American children.
"She would have been prosecuted. She would have been behind bars," says Kwagala.
In the U.S., says Kwagala, "I don't think she would have lasted two hours."
AUDIE CORNISH, HOST:
One-hundred-and-five children died at an unlicensed treatment center for malnourished kids in Uganda. It happened between 2010 and 2015. Now the American missionary who founded and ran the center is being sued over those deaths. NPR's Nurith Aizenman has the story of Renee Bach.
NURITH AIZENMAN, BYLINE: When Renee Bach was 18, she left her home in Virginia for the Ugandan city of Jinja to volunteer at a missionary-run orphanage. A year later, Bach made a life-changing decision. She would move to Jinja full-time, start her own charity. She says it felt like a calling from God.
RENEE BACH: It's kind of hard to even describe in words. Like, there was something that I was supposed to do, and I wasn't sure what that was.
AIZENMAN: But a few months in, she thought she'd hit on it after coming across several children with severe acute malnutrition - impossibly thin arms, ribs poking out, sunken eyes. They were in a hospital, but Bach says the nutrition coordinator there told her that medically, these kids have been stabilized. They just needed to be fed back to health.
Soon, Bach was raising funds to set up a center that would offer malnourished children and their moms a free place to stay while they recuperated, complete with the special foods and medicines they'd need and lessons for the moms on nutrition and the Bible.
(SOUNDBITE OF MUSIC)
AIZENMAN: That's a promo video. Bach set up shop in a large house...
(SOUNDBITE OF ARCHIVED RECORDING)
UNIDENTIFIED PERSON #1: And you can help a child.
AIZENMAN: ...Came up with a name.
(SOUNDBITE OF ARCHIVED RECORDING)
UNIDENTIFIED PERSON #1: Help now at servinghischildren.org.
AIZENMAN: Jackie Kramlich was one of many young Americans drawn to volunteer at Serving His Children.
JACKIE KRAMLICH: I went in with a lot of admiration.
AIZENMAN: It was the summer of 2011. Bach had hired three Ugandan nurses. She'd stocked up on oxygen tanks, IV catheters, monitoring equipment. More than a dozen kids at a time were being cared for. But Kramlich, who'd just become a registered nurse, was taken aback to find that a lot of these kids weren't just severely malnourished. They had complicated illnesses.
KRAMLICH: Pneumonia, intestinal parasites, tuberculosis - many were in stage 4 HIV.
AIZENMAN: Almost every week, a child would die. Also, it seemed to Jackie Kramlich that Bach, now 22 years old, was handling a lot of their medical care herself. It all came to a head over a baby girl named Patricia. Bach kept a blog about her experiences, including the day Patricia's parents brought her to the center wrapped up in a blanket. This blog has come to haunt Bach. She's since taken it down, which is why NPR is having someone else read what Bach wrote.
UNIDENTIFIED PERSON #2: Under the blanket lay a small but very, very swollen, pale baby girl. Her breaths were frighteningly slow. I hooked the baby up to oxygen and got to work - took her temperature, started an IV, checked her blood sugar, tested for malaria and looked at her HB count. I was attempting to diagnose the many problems that could potentially be at hand. Got it - Malaria, positive. HB, 3.2 - a big problem, most likely fatal. She needed a blood transfusion and fast.
AIZENMAN: But after a blood transfusion was started, Bach wrote, Patricia seemed to take a turn.
UNIDENTIFIED PERSON #2: Her neck and face started swelling a lot. Her breathing went from bad to worse. Her throat was beginning to close.
AIZENMAN: That's about the moment Bach called Kramlich on the phone to ask if Kramlich could swing by the center.
KRAMLICH: So I walk in, and there's this child - swollen, wheezing, blood's running. And she goes, you know, I think she might be having a reaction. But I don't know because Google says that if they're having a reaction that they'll have a rash, and I don't see a rash.
AIZENMAN: Bach says she would sometimes run the tubing into a child for a blood transfusion, insert IV's, and sometimes...
BACH: Without a medical professional standing right next to me, yes.
AIZENMAN: But, she says, always...
BACH: Under the request and the direction of a medical professional.
AIZENMAN: As for her blog posts...
BACH: I was just writing to tell a story to my friends and family. And the mistake that I made was I very much wrote in first-person, which, looking back, sounded very prideful as if I was, you know, doing all of those things myself. But the reality was is that there was medical professionals present doing those things.
AIZENMAN: In the case of Patricia, Bach remembers a staff nurse doing the blood transfusion. And when Patricia seemed to have a reaction, she says, this nurse phoned a private doctor who recommended rushing the girl to a hospital. Bach then did just that, and Patricia lived. But for Kramlich, this was too close a call.
KRAMLICH: I was just beside myself, furious.
AIZENMAN: Soon after, she quit and sent a letter of concern to the charity's board of directors back in the U.S. because under international guidelines and Ugandan law, if a severely malnourished child has the kind of extra complications Bach's center was taking on, this child must be treated in, ideally, a hospital but, at the very least, a high-level health facility that's been specially approved by Ugandan authorities. At this point, Bach's nutrition center didn't have any kind of health license or even a doctor on staff.
Saul Guerrero specializes in childhood severe acute malnutrition at UNICEF. He says malnourished kids with these extra complications are so fragile, if you don't know what you're doing, it's actually safer to do nothing.
SAUL GUERRERO: Their metabolism is not working. Their immune system is not working. So once you initiate any kind of treatment, that will have, very often, knock-on effect.
AIZENMAN: Just putting them on an IV can trigger a heart attack.
GUERRERO: The chances that child will die are very, very high.
AIZENMAN: In 2011, 20% of the children Bach says she took in died. The next year, the death rate was 18%. By 2013, Bach had hired two doctors, and the death rate was down to 10% But Guerrero from UNICEF says even that's high by international standards.
Bach says she took in these complicated cases...
BACH: Not because we felt like it was fine...
AIZENMAN: ...But because there didn't seem to be a better place for them.
BACH: I can tell you time and time again taking kids to hospital after hospital and them being, like, sorry, we don't really deal with malnutrition. Like, the best bet is to take them back to your nutrition center.
AIZENMAN: Dr. Hanifa Bachou is a Ugandan expert on malnutrition. When I reach her on her cell phone, she says she doesn't accept Bach's explanation.
HANIFA BACHOU: I don't accept that.
AIZENMAN: Bachou is working with the government to set up inpatient care for severely malnourished children across the country. And she says by that point, Jinja's regional referral hospital had a fully-fledged malnutrition unit to care for complicated cases. But even if there was a need for more inpatient facilities, Bach's critics say it was not appropriate for her to try to provide it.
LAWRENCE GOSTIN: Just think of the arrogance.
AIZENMAN: Lawrence Gostin heads a center for global health law at Georgetown University. He sees Bach's actions as a particularly extreme result of an attitude a lot of Americans bring to poor nations, from college kids to credentialed doctors.
GOSTIN: The American cultural narrative is that these countries are basket cases.
AIZENMAN: So, he says, Americans assume whatever their own qualifications, they're sure to be of help.
Ultimately, in February of 2015, Jackie Kramlich filed a report with Ugandan police. A month later, Jinja's district health officer shut Bach's center down. By then, Bach had gotten the place licensed as a health clinic. But in his report, the officer noted that the license had expired, and he'd found at the center, quote, "very sick children who need referral to higher centers."
PRIMAH KWAGALA: It is what shocked most of us.
AIZENMAN: Primah Kwagala is a Ugandan civil rights attorney.
KWAGALA: We couldn't imagine a human being without skill taking in people that were almost on their death beds.
AIZENMAN: A few years later, Bach opened a new center in partnership with a government health center and with Bach no longer involved in medical care. But early this year, Kwagala, the Ugandan attorney, filed a civil lawsuit on behalf of the mothers of two of the children who died. She says she wants Bach held to account. These families, Kwagala says, deserve justice.
Nurith Aizenman, NPR News. Transcript provided by NPR, Copyright NPR.