04-JUL-B-6

ANOTHER DAY AND ANOTHER JOINER FOR THE HAITIAN

CREOLE-SPEAKERS, DR. SERGE GEFFRAUD,

AS WE SET UP FOR A HALF DAY CLINIC IN THE HOSPITAL

IN JIMANI, THEN A HALF DAY IN CLINIC UNDER A TREE,

THEN A WALK TO AND THROUGH THE BORDER WITH HAITI

July 23, 2004

I am sitting in the dark, trying to type a small amount of test with the limited life of a dying laptop battery, and with no water running, there is no point in even a hope for a bucket bath. The brief interlude after a lot of inefficient shuffling today, when we moved the clinic inexplicably out of the hospital to a clinic under a tree in a neighborhood one short block from the hospital in less convenient settings for fewer patients after we had sent a waiting queue of patients away who were left over from the morning clinics. Nonetheless, we have seen lots of interesting patients to use in our patient presentations for the clinical didactics this evening after dinner when we are told electricity and limited water will return around 8:00 tonight. We will see.

Morning clinic started with the usual scramble as the wheel was once again re-invented. This time we had a joiner. Serge Geffroud, the University of Miami pediatric cardiology fellow had come in late and had tried to catch up with us, and had flown into Santo Domingo, arriving around noon yesterday. He had got a taxi to the Santo Domingo center and then had got a bus to go tot her area of Jimani under the assumption that there are not many people there so that it would easy to find wherever we were. He asked for the “Hotel Jimani” and a local pastor made friends with him on the bus, saying he had heard a group of American doctors was working in Jimani and he would help him join up with them. So, he found himself in the small “Hotel Jimani” which, nonetheless, at least does have running water and does not have each of the guests there crammed into beds at least doubled up—as we all are staying in two or more to a bed. The room I have has two beds, but three of us in them, with a small bathroom between us and a room with four of the women in it, but no water running except if someone goes to turn the switch, which cause s the pump to work only if there is electricity. So, it has been bucket bath shampoo at most each day, and even that has to be worked in as early as possible since it is otherwise combat competition to get into the bathroom. I have tried to wash my head as I would in Africa at about 5:00 AM to get ahead of the group, and it usually only takes a minute, since the sound of my being there will start the rush.

As soon as there is the sound of someone up, there are the insistent sounds of “I have to have my coffee!” as though they are expecting to send out for a Starbucks. They try to get the local two girls to get them to produce things they do not have nor do they even understand the addictions or the urgent needs these first worlders have. One thing that was understood rapidly is that as Serge Geffroud came in by bus with the pastor whom he met on the bus and who guided him, is that we were staying in a large house with guest rooms, and that the proprietress of this house was a very wealthy woman who was Haitian and came from the era of the ill-got-gain of the Duvalier era in Haiti. Her husband, a heavy hit man in the regime, skimmed as much money as he and she could carry (in the driveway are several trucks and a Range Rover—not a typical Haitian vehicle!) and in the period in which the General was exiled after the fall of the Duvaliers, he died here along the DR border with Haiti, so this widow of his remains in her imperious position with a few poor Haitian girls who are by any definition modern day slaves. They cannot leave, they are summoned to her imperious will to perform whatever services she insists upon (and one of these is not the servicing of her pre-paid guests nor their conveniences) and she lives out her years in torpid obesity, bemoaning the loss of her privileged position as a pampered Haitian elite. The pastor and Geffroud were surprised how we found ourselves in the house of this relic of all we have come to combat, but it seems we have no there options in a place that is large enough to accommodate a group our size.

Serge is the only other MD now in the group, but he, of course, is a resident, so he is more than eager to have me take charge and only has a small slice of the patient population, and it is a subgroup of the pediatric group at that. We will probably have him come along for a few days into Haiti, but we will lose our Peace Corps Volunteer translator Kathy, who is going to have to leave because the PCV’s are not allowed to return to Haiti because of the instability since the coups and ouster of President Aristede (flown out of Haiti for the second time on a US plane, and after he had been deposed, insisted that he was “kidnapped” by US forces and pushed into exile.

When finally we overcame the inertia of the “we have never done it this way before” of the local staff in the hospital, and the patients who wanted to see that we were really here an open for business, the usual two hour delay for our early start had passed ineffectively, and we then had a rush of patients we had to make up for the lost time. Among this group of patients were a number with each of the kinds of extremity vascular problems, venostasis, varicose veins, traumatic necrosis, and a classic diabetic foot ulcer; each of these would furnish good discussion material for the last didactic session tonight the longest and best of the week in a wrap-up session.

When we got to the noon lunch break, we were sending patients away with the confused message that they would be seen this afternoon, or tomorrow, or not at all, and then after a long wait, we heard that there would be a clinic out in the village, with a clinic to be held where allegedly the homes were destroyed, and the people were worried about coming to the hospital, and that it was a long way to come to the hospital. It turned out that it was not so far away that we did not all walk there, and carry a box of medicines also—always a clumsy operation to pack up the pharmacy boxes and carry them along, at which they are open to plunder along the way. Why we did this is unknown, since the community is a block away from the hospital, the people here could easily have come, none of them were worried, and there were no destroyed homes. We spread out along the street trying to escape from the high overhead sun, and got into the shade of two neighboring houses, on the porch and also simply on the streets between the houses. It was unnecessarily clumsy to set it up with exactly the same delay no matter where we started, and we saw the couple dozen people who came to have us check them, presumably since it inflated the local prestige that the whole mountain had to be moved to Muhammad, and they were not inconvenienced by walking the block to the hospital we had just covered in return...

At least this gave the students exposure to one other English speaking US in training doctor, the pediatric cardiology doctor Serge Geffraud. He had left Haiti and gone from Alabama to University of Florida where he had met my confreres down there including Dr. Small in Pathology, Rosemblum in Pediatrics, and Dr. AF Burns in Anthropology. I had been the inaugural Global Health speaker last spring for the University of Florida from which he came before he left to go to University of Miami. He is eager to see some parts of the Haitian refugees, but is also out of hi sown time and on his own schedule, so he had at first said he would not be going on to Haiti with us, but only joining us for the last days in the DR. Now it seems he will be going on to Haiti but only for a day. Maria was going to go back with our exiled Peace Corps Volunteer Kathy and the gawky fifteen year old Gregory, who was born in Iran and is going to be met and carried from the border by his parents to return to Santo Domingo. But, Maria is now working on trying to join us in the Haiti extension, and that may be one of the reasons we are going a round about way to cross the border a five hour ride away from where we are now to another border crossing on the northern side of the lake we can see from here.

We returned from the odd street-side afternoon clinic and had a chance to make a brisk walk along a well-paved road to the border of the DR and a 100 meter “no man’s land” before crossing for ten minutes into the Haiti border. WE then walked back—the only exercise we have had this week, which constituted a four mile walk. We came back for a quick dinner, then thorough and good case presentations and didactic for the whole group. One of the seniors remarked that the entering sophomore medical students would never know just how much medicine, tropical medicine, surgery and pathophysiology they had learned until they encounter it for the second time next year in classes where over half of what they study will be very familiar to them from this intensive course in medicine based in the presentation of the best of 750 patients.. I will include the case studies of tonight’s group under the DR list in Jul-B-5 “Case Reports.”

We all adjourned down to the corner store, where we could hoist a beer in honor of the fifteenth time we have sung happy birthday to Huda, whose birthday is on July 30 as we leave Haiti. We talked and listened as the free flowing fears and interests of the group mixed with the popular culture and the buffetings of medical school were apparent, and some soulful blues songs sung by Zeb along with his own harmonica accompaniment. So, this is the wrap on the medical mission on the DR side despite the brief stop for some political, but certainly not medical, reasons, tomorrow morning returning to the same Refugee Camp #2 where we had started on our first afternoon here in Jimani. Altogether we saw 750 patients, which might have been twice that number with no more effort and half as much flailing, but it is better to have a leisurely start here before the immersion in the “deep end of the pool” on the Haitian side. Medical Week One was highly instructive for each of the students engaged intensively in it, and probably quite therapeutic to over half of the people we encountered. That is probably far better odds than any clinical rotation they might have had in the settings of US medical care however better the facilities may have been. AS Paul Farmer is quoted in “Mountains Beyond Mountains” as saying, his priorities were three, in order: 1) Patients, 2) Prisoners, and 3) Students: whatever happiness or annoyance may have been generated by others in the course of trying to make something happen here, it seems that the priorities were well served.

CASE PRESENTATIONS AND THE LECTURES ASSOCIATED WITH EACH “TEACHING CASE”

A Sarah: the whole group puzzled over a man with an unusual lesion in the roof of his mouth, and they thought it was significant: in a glance, I confirmed the “torus palatinus” and we differentiated that with any of the more significant problems, such as salivary or epidermoid cancer; otherwise, a torus palatinus is of no consequence to anyone but a prosthetist.

B Zeb: a man with diabetes and a neurotrophic foot ulcer. The seriousness of this lesion is something that will almost inevitably lead to amputation if not aggressively cared for, and we debrided it and showed him how to do wet-to-dry gauze treatment. We had a good teaching session with the ability to differentiate in all one day the venous stasis ulcers, arteriosclerotic vasculopathy ulcers, and the neurotrophic ulcer of diabetes (the only similar one I would suggest for the tropics is leprosy.) The major complications of diabetes are neuropathy, nephropathy, retinopathy and vasculopathy.

C Anthony: another foot ulcer, but this one traumatic from a laceration sustained in the floodwaters and now necrotic and needing debridement also, but would be able to heal or take a graft.

D Martha: a fungal foot infection and dyshydrosis of both feet with dry cracked skin in a rather remarkable lesion that was disabling; we treated her for the one that should resolve, but the other is a difficult problem.

A Mike: an 83-year-old woman who had depression since the flood—an understandable and supportable problem, along with the survivors’ guilt--and varicose veins. We went through eh differential of deep venous thrombosis as a lethal complication of pulmonary thromboembolus and the superficial thrombophlebitis, with varicosities from incompetent perforators. We prescribed support stockings which we just happened to have.

B Siayavash: hemoptysis in a 14 year-old, a question of whether this was emesis or coughed up blood, resolved when the child did produce a fit of coughing and showed the red tinged blood which he had swallowed then vomited: an almost perfect case example of the next parasitic worm infestation. We distinguished infestation from infection (the former is the number of worms entering the body and not reproducing into more worms in the host, but passing those eggs out, the latter being replication in the host. The hookworm which wiggles through the bare feet from the soil in which the larvae wait in climates that do not have freezing winters, give the Necator americanus or the Strongyloides stercoralis—the dog hookworm which also hits the human host. So we could actually see (bloody sputum) and hear the asthmatic wheezing) and would have seen the eosinophilia on the CBC of this pulmonary passage of this large cause of the syndanemias—the others being Malaria and HIV.

C Duc: 20-year-old with right inguinal hernia and back and flank pain: the differential of direct and indirect inguinal hernia—each of which Was seen in clinic

D Lindsay: a child with scabies; we run through the differential of arthropod borne infestations and scabies is from an eight –legged MITE which is an ectoparasite, and can give rise to secondary skin bacterial infections.

To date our total in 7 clinics in three and a half days is 710 patients seen in Jimani, with another 40—5- expected in our half day tomorrow. There is a mixed report on whether we are going to be here tomorrow and get up extra early to make the very long end-run around the lake to get up to Belladere, or whether we depart sooner to get to better facilities along the way. It seems odd since we can, and did, just walk to and through the Haitian border which is within sight of us here in Jimani.

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