04-JUL-B-4
THE SECOND DAY OF OUR OPERATIONS IN
JIMANI,
OUR WORK IN THE HOSPITAL AND IN A
RE-SETTLEMENT
RECONSTRUCTION FOR DOMINICAN VICTIMS OF
FLOOD DISASTERS
We have a carefully laid out itinerary and schedule forwarded to us from Ulrick Gaillard, a lawyer who is CEO of the Batey Relief Alliance, who is not here but is represented by Maria Virtudes, who is accompanying us and for whom I have been serving as translator. However, we seem to be at the mercy of the rather passive aggressive employees of the BRA who are to accommodate us with meals and rooms and the facilities—none of which seems to be happening. In fact, our dinner was brought over from the hospital Cucina last night, since there was no move to do anything at all on the part of the group here, and they have not been alarmed when it seems we have no water to bathe or flush and our predicted breakfast, carefully explained last night as to time and content, with a pointed reminder of our prepayment for these services, has been met with a yawn and a no-show this morning. So, we are stymied at the getgo with a lot of standing around and waiting for nothing to happen, until one of us goes out and makes it happen. This means our efficiency is decreased and that we will always be late and short. A lot of stuff is abused this way---like sterile gloves are being torn open to be used as the container for a few pills to send home with patients. It is easy to see how most of the good will that sends out first aid packages will be wasted on the far side when no one can quite understand what should be done or how, and just plucks over a few of the items and sees what they can expropriate for some other use.
Later I learned what I already suspected: the woman who runs this boarding house—hardly a hotel, but a big house on a hill as evidence of richness, and the several trucks and vehicles in the drive with Haiti “Prive’ license plates. She is the widow of a strong man during the Duvalier era of heavy hitters who cannot return to Haiti since he was exiled in one of the cleanups, and then died here and she cannot go back to Haiti but doesn’t have to since eh has carried a good deal of the wealth of the country along with her. So, she is not a very conscientious hotel keeper, and has several bored young girls who are sullen stalking around to avoid us. They are all “sobrinas” –nieces,-- but more like indentured servants treated more like slaves, who can never leave the premises. They are somewhat less motivated for this reason toward joyous service of humanitarian projects, but quite happy to collect fees, and minimize services.
We went down to the hospital for our first half day clinic there, and it was a predictable scrum there. Only one successful thing was improved, and that is I had staked out Anthony and Neely as the ones in charge of the pharmacy, while a door guard kept people from crowding in on it and seeing the cornucopia spread out before them, convinced that they would clean it down to zero on the basis of their wish list. I found that the chief people in violation of reasonable prescribing rules are the local doctors, who may shoot the moon in prescribing any and everything for the patients since it id no risk to them, and only enhances them to say they are going to see that these folk provide lots of free meds to them, and let the onus of the disappointment fall upon us if we cannot deliver five or six exotic and expensive items they “ordered” given to the patients. But the local doctors have been doing end runs on the pharmacy and going to pick up whole boxes of protein bars or soap or anything else that is there and whether requested or not, it is then given to whomever they favor—like a liberal Democrat freely and generously disposing of someone else’s’ resources to take full credit for their liberal generosity. But, we have two weeks of clinics to function out of these three MAP boxes and they have consumed two of them with small half day clinics thus far in the less destitute Dominican stating point of our medical mission which is going to leave us nothing to dispense in Haiti, which is poorer, with more patients expected and a lot of need to be addressed with a stripped down cupboard. I tired to explain this to the team, who pointed out that they have been judicious and careful in the prescription practices, but there persistent problem was the local doctors who were free to dispense everything we had carried and even more if directed at people they had befriended or were related to.
We saw some interesting patients in the random scatter that eventually came down to a more manageable series once we had established the drill and made a more orderly sequence out of seeing the patients. I heard a very loud heart murmur in a small girl and rather than just letting her go, I brought her around to several students to listen to and then just as a courtesy, brought her to our pediatrician, who listened and immediately wrote out a referral to a cardiologist. You must understand what this means, like the student who wrote out a referral to a gynecologist yesterday in the refugee camp to have the patient turn up on his doorstep in the hospital today—he had pretended that he was providing a big service here by sending the patient to someone who knows what is going on, giving himself and the patient a hopeful note of progress, and then found out that the referral was to himself, and he certainly had not learned any gynecology overnight no matter how instructive the tutorials were at night, to make him the freshman expert who would not handle the problem he had “turfed” over yesterday in the illusion of a helpful professional referral.
I had to tell the students what should have been obvious: to see that a child has malnutrition and anemia and advise the mother that they should be feeding the child lots more meat, fish and fresh vegetables, is not just specious, it is a gratuitous insult, and even more so, since it is not recognized as such by the fatuous advice. Telling a patient not to work so hard in the fields and not to carry heavy loads is another favorite of mine—perhaps they should convert to computer programming instead? I believe that I understand more about the cultural sensitivity than most of those who insist that they do, since they cannot think outside the box of the spoiled first worlders, and cannot understand that everyone has fewer options than they do. So it is not ignorance or willful misdeeds that make their child poor and sick. What mother would want to give her child less than the best available to her? And what mother would feel less helped by someone telling her that she is doing all the wrong things to keep her child from a healthy life by her ignorance and deprivation?
We finally got out of the pharmacy after a long wait, and had lunch after which I told them about the uncontrolled pharmacy sacking that was going on which had left us after two half day clinics with no pediatric suspensions and with fewer of everything than we would need even to finish here in the DR, let alone to carry anything forward from here to the needier citizenry on the other side of these mountains where we will be moving on Sunday. And we have a half day in the refugee camps this afternoon and two full days more in the hospital setting here in Jimani in the next two days. I pointed to the hospital’s newly washed out walls and floors and asked if they thought there was any medicine being practiced here without our presence? So, sending a patient “to the hospital” is exactly the same as sending the patient to oneself, and there is no improvement expected for sending them to an empty shell and then getting there to intercept your own referral. And what good is it to suggest that a patient go to get an X-Ray ( in the classic game of buying time to hope somebody else can solve whatever the problem is while temporizing outside one’s own powerlessness) if the information so obtained is first impossible, and not at all helpful in changing or even starting any treatment?
I heard several stories of the events around the flood, which almost always started whatever the people had to say about heir illness, such as, :when I was in the water struggling…” The cook who would be making us a special Haitian meal as a gesture of gratitude from his hospital experience here was hired on May 4 the day before the flood. His father was Dominican and since everyone knew that, he was allowed to remain, even though his father was one of those who disappeared in the flood. A young woman who was all dressed up in her bright orange synthetic polypro dress was sitting in front of us with several small complaints, one of which was a chipped tooth. When she “was in the water” she had been pounded around by a lot of debris and when she was somehow found later, she was missing all five of her immediate family members—mother, father and three sibs “who have not been found yet.” She is 11 and her aunt who was here with her had brought her over, in a dress borrowed from someone else and a bit big for her, but it is all she has right now. One of the young men came by with a foreign body in his hand with a reaction to it that was already draining. How did he get it? He did not know, but while he was up to his neck in the debris and water and mud, he had been hit any number of times by a lot of stuff that had swept away everything and everyone else that he knew.
Almost everyone here has lost not just one, but most all of their families and friends. It seems I am talking to the rare survivors who by some fluke were caught on a snag above the debris or got tossed aside in the swirling currents of junk that came down with the mountain. It was as puzzling to them then as to what was happening as it is now, and no one can quite explain how it is that the mountain, a seemingly permanent piece of the surroundings had come down to wipe them out. Many were even unaware that there was an old streambed nearby since it had never had water in it in recorded history according to their recollection, and only the elders could remember a trickle of some sort once having been there. In a culture as superstitious as this one, it is all quite mystical.
In our afternoon clinic we visited a re-development, like the refugee camp, but it is surrounded by a barbed wire fence and is staked out in tents with all Haitians inside guarded by a Dominican Army group. This Camp Number 1 is a series of cement block houses laid out on concrete slabs, and is in an open area with a big sign of President Hippolito Mejira in front of it, as much as Hizzoner in Chicago would have done it. These are Dominicans and have rights, in addition to the human rights which NGO's and the UNHCR is a guardian for the refugees, but they still remain invaders; not so the Dominicans, who are getting a new subdivision of houses probably “better than before” with the kind of aid money that came in almost immediately to start rebuilding this area. A very big and well made series of cement troughs or gutters are being placed with a cement mixer grinding along to make the paving, so that the water, should it come again, would be sluiced around and away from the new houses. There was a young girl happily playing in the water, having dammed it in the new trough and her cool private bathing pool was a source of great interest to our photographers in the group. Also there was a ceremony being held under the trees as we were holding clinic. It turned out to be a baptism, with several Catholic priests in robes and a few nuns, one with a guitar playing music for an infant baptism under the adjacent tree, one of few left standing. From a discreet distance, I made a couple of photos of this private group.
We already
have a precedent set of group dynamics that is patterned almost exactly on the
experience in
We will have to improve crowd control using local and Creole speakers, since we will get the increasing push as we have two full days here and they have every intentions of getting what ever stock of supplies they can see laid out before us in the pharmacy, heedless of our need for these same packs to last us through busy clinics in Haiti. So, we are instituting a rationing system, and will try to keep the Dominican “doctors” out of range of dipping in to toss out into the crowd whatever strikes their fancy as their own largesse to dispense. We are moving along, rather as usual in the stagger starts of the clinics.
At night,
there was an impromptu birthday celebration for at least two of our group,
Neely and Huda who will have birthdays while on the tour. After that celebration could be throttled
back we had a rather good session in the didactic of case presentations and the
discussions of the pathophysiology of 1) gangrene, 2) PID to distinguish it
from acute abdominal pain, 3) an adolescent nipple discharge, and 4) sisters
with impetigo. We had just completed the
first round, when someone insisted we had to break since there would be a
chance to take showers and the water might be turned off later. So, instead of getting each of the teams to
present two of the patients meaning that each one of the participants would
have been evaluated on their case presentations, every one went eagerly off in
search of the promised shower—to discover quickly that there was no running
water, hot or otherwise. So, the goal of
getting a shower was futile, but the immediate goal of disrupting the didactic
part of the medical education was nicely accomplished, again reminiscent of the
HHE in
DIDACTIC INTENSIVE MEDICAL DE-BRIEFINGS
WITH CASE PRESENTATIONS:
A Zeb: open wound care—the difference between an eschar (devitalized, insensitive dead tissue, often from a burn) and granulation and an attempt to foment the latter; a good discussion about wound healing and the different kinds of gangrene, since the wound presented us was dry gangrene from devitalization at the time of the floods when the patient got a blow in the water from an unknown object.
B Huda: a 22-year old woman with pelvic pain: she had PID with cervical tenderness, and was so treated: the important differential diagnosis of inflammatory disease versus an acute abdomen as with appendicitis or a ruptured ectopic pregnancy.
C Martha: a 12 year-old girl with an oozing nipple discharge: we went through the worrisome nipple discharge characteristics in an older woman, and pointed out that this was pubertal change in a menarche girl.
D Vesta : two sisters each with a honey crusted rash diagnostic of staph infection called impetigo
We went
through a complete early pathology course to describe the differences in
ailments whether of inflammatory, (sub-set infectious or traumatic),
neoplastic, congenital and the kinds of questions to ask to distinguish the
histories of each. I then went through
the life cycles of the most common parasites here, the intestinal round worms,
the hook worm and the passage through the lungs, and most importantly malaria
of the falciparum type, sensitive to chloroquine, with Tb and HIV being tandem
problems here as well.