04-JUL-B-3

OUR OPENING DAY IN JIMANI NEAR THE HAITIAN BORDER

IN THE MONTAINS OF THE WESTERN DOMINICAN REPUBLIC:

OUR TOUR OF THE GENERAL MELENCIANO “HOLLOW” HOSPITAL AND THE DEVASTATED AREAS OF THE WASHOUT

OF THE MAY 5 FLOOD VICTIMS AT JIMANI

July 20, 2004

We are in the hospital at Jimani, a town that is on a steep hillside within sight of the border with Haiti in the mountains of Western Dominican Republic. The town has no river, except for a long fried out stream bed which had a road across it with a bridge, But sine there had been no water in that river since about 1992, there was little inhibition about cobbling together ramshackle huts as houses along the dried up course of this inactive stream. The dried creek bed was on a hill side below a very steep mountain side, which is now scarred by a large avalanche chute. The people here describe what was in many senses a supernatural eerie phenomenon that occurred on May 4, on Sunday night. After a two day all-day rain on Saturday and Sunday, people all went to bed on Sunday night in much the rhythms of life here—using daylight as a signal when to get up and when to retire, since there was no t much in the way of electric light.

In the middle of the night, most people were still asleep when the wall of water and rock hit them. They often did not wake up, if at all, until they were far away from where they had gone to bed. Boulders larger than trucks and full trees came sweeping down the course of the old dried stream bed, and the force of the blows wiped out all before it like a scythe mowing down everything, The road on the bridge pilings disappeared, and the houses along the way were pushed through a cemetery, and it was resurrection day for those who had been buried in vaults in well plotted out lines of tombs. The long dead bodies and the parts of them that had been recovered later were not a high priority compared with the new ones, but eventually all such parts were put into a common mass grave at the edge of the old washed out cemetery.

The living were not as lucky. Almost everyone has a story of what happened “when the waters hit them.” It was not so much drowning as trauma, as the force of the blow perforated eardrums. We discovered young men who had foreign bodies like nails or twigs driven into there hands or skin and subcutaneous tissue. We had at least two children who had lost both parents. The cook here at the hospital was hired and began work on May 4, the day before the disaster. He was Haitian and brought here by his Dominican Republic father who died the next day in the washout. Because his father was DR, he is allowed to remain her as a Dominican. Those who were Haitian squatters, and had come here as refugees for a better life—in the bleak surroundings giving some idea of what it is that they had left behind on the other side of these porous borders in which one can simply trudge over the roadless mountains to get to the other country, if avoiding the roads or check points at which Dominican Republic border guards would fire upon the invading Haitians, so that they were accepted here regardless of what nationality they had started out with, each of them impoverished. The languages on the street seemed to be more Creole than Spanish. The people who were unearthed, it is said, had no nationality, they were just as dead whether they had come from one side or the other of the mountain nearby that marks an arbitrary border.

The wall of water and debris slid down the side of the hill where we are staying in a large house with a few guest rooms into which we have been packed by none too hospitable caretakers who view our appearance here as an intrusion that is nettlesome. The hospital is downhill to our right, but still on terrain that I would have called level rather then valley or lowland. That did not save it. The front of water mud and car-sized rocks came through the locked double doors of the hospital and wiped it out, with a slurry of mud and debris that was up to the ceilings in the hospital on water lines seen after it subsided to just a meter or more of gook in the rooms. All the patients’ archives were lost, and the business administration of this hospital had 24 computers—no more The OR’s and all the special areas were destroyed, including the laboratory. They have been diligently cleaning and repainting the rooms and trying to rehabilitate the empty shell of the hospital that is left with a World Bank emergency loan of two million dollars. The majority of this seems to have gone for an earthen levy along the course of the scoured stream bed to prevent this from happening again, but the pitiful barrier that remains is studded with items of colorful cloth that was clothing at some time recently with body parts inside.

The Director of the hospital took me around and showed me several areas, but then took me outside in a small area of a parking lot alongside the malaria standards laboratory. There is a space for maybe a dozen cars. He said that all this area was stacked in cadavers that had been recovered from the immediate are, stacked up to a level he marked on the building walls, a total of more than 450 cadavers from those killed in the disaster—a large percentage of the immediate regions population. But, he added, that this would not include any of those bodies recovered from the higher mountain areas or along the washout of the stream bed, and that certainly the majority that were never recovered, since they would have been buried under unmovable rocks the size of a couple he pointed to in a now vacant lot, with trees wrapped around them.

After our hospital tour and the idea that we would be setting up shortly in a set of rooms that had been cleaned up for us, with one of them still being covered in mud and debris, which was later all cleaned when we came by for stacking our medicines in it. We have been very inefficiently received, with our long periods of standing around while nothing happened, and then a series of conflicting orders (”empty the bus of all medicines, then re-pack the bus and carry it all over to the hospital where it is unpacked again so the bus can leave,") but this would mean that the medicines are assumed to all remain here, and none would be available to go on with us to Haiti. We also were deployed in the hospital then told we would go out to the refugee camps, then reversed again, and finally when all set up with our med stock in the hospital and the teams assigned, we were scooped up in an old bus and with two incomplete boxes of MAP medicines hurriedly put aboard the bus, we went to Refugee Camp Number Two—a tented enclave surrounded by barbed wire fence and containing about thirty white tents and another dozen olive drab tents on a gravel base baking in the hot sun. There was a Dominican Republic guard on the camp and the people were getting aid and fed by some NGO and we were part of that relief operation. We aligned the Haitians as best we could, and they crowded into our Red Cross tent, where we tried to set up four teams, as the Haitians pushed their way into the tent to get out of the hot sun. The most disruptive part of the operation was having the youngest of the whole team, a “volunteer” with BRA named Greg, who knew nothing about either medicines or the medical mission at the pharmacy. He is fifteen years old and seems to have Asberger's Syndrome, in repeatedly tagging along on me when I am busiest and asking repeatedly the same question, which is usually "off the wall." He is one of two people on the trip that I did not choose, and the other one turned out to be even less a gift, in absorbing far more time and attention in a demanding self-centered way than any contribution from translation services would warrant. As I attempted to supervise each of the four medical teams and the overall mission, he took me as his personal instructor and not one single prescription would come to the pharmacy which he would not immediately grab me and say “What is this, and what is it for?" and then he would tear through the carefully packed MAP boxes which have to last us two weeks and dig into the bottles and pass out stuff as though each patient were our last. He would get in the way of every operation and took more of my time than if I had simply run the pharmacy myself, and several time is tried to eject him from the pharmacy to put him elsewhere, such as on door control, but he kept coming back, and as a “translator” he was less knowledgeable about Spanish than I—and even that was not useful in a Haitian refugee camp in which everyone spoke Creole.

We will repeat this operation tomorrow, getting up earlier, allegedly, and starting with a breakfast at seven, begin at the hospital for our first clinic and the Refugee Camp Number One for the afternoon. A lot of improvement will have to happen in our operations before then, but the supporting infrastructure is absent in several areas. For example, the support facilities where we are staying are not very helpful. Somehow, these arrangements were a last minute change from a Jimani Hotel reservation which was closer, cleaner, had running water, was more capacious and had longer periods of electricity than this "Guest House," but for reasons unknown, this very much more expensive non-facility was the one switched to for all but Serge Geffraud who arrived later and had found out how much better the facilities were in the Jimani Hotel, particularly when he recognized the unsavory past history of the proprietress who runs the one we were staying in. We were each assigned a roommate and a bed I a room, and then we find that the same room would have been assigned three or more times. There is a shower in the room, as well as a commode, between tow rooms, one of which houses four women, and my room in which Mike Williams and I are roommates, but at least one other ‘drop-in” from other rooms is usually falling in as well. The door to the single bathroom does not even close, let alone lock, so there is no way to protect between the two rooms using the same bathroom. And, then, there is no water. There is a pump run by a generator which needs to be turned on to function and the secret of how this works was well guarded. We tried to get a bucket of water to be used as a bucket bath, but even that was a struggle. And our “breakfast at seven” is not very likely, since the caretaker and her two workers do not even get up until an hour or more later, regardless of our schedule. It seems that the BRA had had four relief groups here and has an ophthalmology group coming in September, so they are all eager that this goes well. But the CEO named Ulrick is out fund-raising for which reason he would be eager to have good digital pictures of our operation, and Maria is his liaison with me. It at least exercises my latent Spanish, learned here forty years ago in the same DR, as I act as translator from her to the group, but the others seem to be only half heartedly involved, and would get paid whether or not any services from us were forthcoming. So, our accommodation and facilities are much less than they can or should be, given the resources available, and the passive noncompliance of the third order staff. WE are getting to the point that the team may be working as well as it might be able to given the good will and motivation of the group, but we have a mixed group that is not medically sophisticated, and that means we have a lot of explaining to do at each turn.

That, it turns out, is the most successful part so far: we had two briefings so far and the medical education component has been the most valuable. The case presentations last night had occurred with two patients each presented from the four teams worked fairly well in exploring the pathophysiology of the conditions seen and also the little notes about the sociocultural phenomena of a captive group of refugees in a tent camp. So, we are underway, with the first day’s mixed results already discussed with a session involved in how we can make this better, and each of these successive days should be better run than the last one.

JIMANI = 18* 29.26 N, 71* 51.04 W

WHAT IS THE DIFFERENCE BETWEEN A “BATEY” AND A “BARRIO”

A Batey is a plantation unit of indentured servants grouped to cut and process cane. They are not much removed from slaves, with most of their pay coming from the plantation store in credits that make them indebted for virtually ever. There are Bateys in the DR, in Haiti, stemming from the days of the Raphael Molina Trujillo in the former and the Duvaliers in the latter. There are also Bateys in Cuba. The “barrio” is the slum ghetto in a town, where at least the people are loose from commitments to whatever poverty they might experience but not virtually owned in the Batey. The Batey is an agricultural migrant enclave with an oppressive structure.

THE NIGHTLY DIDACTIC INTENSIVE MEDICAL COURSE

IS A DEBRIEFING WITH PATIENT PRESENTATIONS:

I WILL SUMMARIZE THOSE OF EACH SESSION—

THIS ONE MAKNG TWO ROUDNS OF OUR FOUR TEAMS

A: Lindsay: presented a woman with a tympanic membrane perforation, a result of the explosive underwater sounds during the flood in which she was submerged. We talked of the open middle ear and the possibility of otitis and suppurative osteomyelitis of the ears conduction bones and the eventual outcome of a “cholesteatoma” or mastoiditis.

B. Sombol: presented a woman with reflux esophagitis (common) but this one also had weight loss and a problem passing urine; we discussed gastric carcinoma and the Krukenberg tumor, or rectal shelf, that might link the two symptoms together.

C Duc: a man with abdominal pain, which on an exaggerated sit-up showed the diastasis rectus, and epigastric ventral hernia.

D Adam: presented a 11/2 year old girl who looks to have Downs’ Syndrome in the refugee camp; she has the stigmata of Trisomy 21, but without evidence of heart murmur—the exception to the rule of an endocardial cushion defect.

A Zeb: a man with a hand laceration during the turmoil of events when he as caught up in the flood: I had shown a serous packet with an extruding foreign body being expelled along with drainage; encouraged to soak until the process had completely expelled the FB

B Bryan: a woman with reflux, but when asked her last menstrual period, she could not respond, so will check her with our urine pregnancy test (most all the early tests we did were positive.)

C Anisha a two-year-old with emesis and distension—the first of multiple later discussions of parasitic versus nutritional abdominal distension from hypoproteinemia; this one was wormed

D Siayvash: a small boy with swollen scrotum: the differential between hernia and communicating hydrocele—this was a hydrocele that did not communicate nor reduce.

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