From Tetanus to Tuberculosis
In September 2006, I worked in a pediatric clinic at Grace Children's Hospital in the Delmas neighborhood of Port-au-Prince. I posted medical cases that presented each day ranging from tetanus to tuberculosis.
Saturday, September 02, 2006
Neonatal Tetanus
One morning in clinic I was called in to see a baby boy who was just three days old. The little boy’s hands were clenched and his back was arched. His temperature was 105 F and he was unable to take his mother’s breast milk due to lockjaw. The baby had neonatal tetanus.
He was born at home and his umbilical cord cut with a nonsterile razor. His mother’s tetanus vaccinations hadn’t been adequate in number or possibly the vaccine “cold chain” was broken and his mother was given a tetanus vaccine that was not potent to protect mom or the baby.
Tetanus occurs when a very powerful toxin from a bacteria called Clostridium tetani climbs the nerves into the spinal cord. The nerve cells don’t communicate well when this happens and they begin sending too many signals to the muscles and the muscles go into spasm. This is what caused the Haitian baby’s jaw to lock and his hands to clench. His arched back is also due to muscle contraction and is very painful. When contraction of the tracheal and pharyngeal muscles occurs, babies cannot breathe. Seizures and swings in blood pressure are common also.
There was one case of neonatal tetanus reported from the Dominican Republic in 2002 while Haiti reported 60 cases. Babies in the developing world with tetanus do not do well.
This is another tragic story. This baby appeared very well-formed. Once again Haiti’s infrastructure (public health) is at fault and is killing its most vulnerable.
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Saturday, September 02, 2006
Children Raising Children
A Haitian nurse told me the other day that “Children cannot raise children”. This is very true.
There will be more than 15 million children in sub-Saharan Africa that will have lost one or both parents to HIV/AIDS by 2010. Their first line of defense, their parents, are sick or gone. When kids grow up without parents they are subject to many evil things like hunger, lack of touch, and not enough love. They have poor to absent education, and insufficient medical and dental care. They become marginalized and discriminated against. They become a traumatized population.
In Haiti thousands of the kids live on the street and many become restaveks (child slaves).
This is Haiti's future.
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Saturday, September 02, 2006
Haitian Children and AIDS
The child in the photo is an 11-year-old Haitian boy who was admitted to the hospital several days ago with pulmonary tuberculosis. He is receiving antiretroviral medication for HIV and is taking tuberculosis medications also. He receives a plate of hot food for lunch which includes vegetables, rice, and red bean sauce. I told him to eat his bean sauce for the protein and he dived right in. He wants to beat these two illnesses.
Haiti has the highest prevalence of HIV infection in Latin America. Currently, of the children in the Caribbean region who are living with AIDS, 86% live in Haiti. There are 19,000 children living with HIV in Haiti (UNICEF, 2004).
Two million children globally live with AIDS. And a child dies of an AIDS-related disease every minute.
Haiti has the highest prevalence of HIV in the western hemisphere. Three percent of the adult population is HIV positive. One year survival for AIDS patients without treatment in Haiti is 30%. This includes children.
An article published in the New England Journal of Medicine from researchers in Haiti with Haitian patients documented the feasibility of treating HIV in Haiti. Conventional wisdom tells us that HIV combined with malnutrition, tuberculosis, and tropical diseases in Haiti is nearly impossible to treat. The research found the opposite. Both adults and children in Haiti did as well as U.S. patients with HIV treatment. Children had an amazing 98% survival rate after one year with HIV treatment.
I have seen many pediatric patients in Haiti that have watched their playmates die. They know what is coming for them if they do not receive the medication. They usually have lost one or both parents from the disease as well.
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Sunday, September 03, 2006
Tuberculosis in Haiti
Tuberculosis in Haiti
The proud father with his beautiful little girl live in Cite Soleil in Port-au-Prince. The father reports that his daughter has had a fever for months and is not gaining weight. Her physical exam was normal but her chest x ray reveals pneumonia in both lungs that may represent pulmonary tuberculosis. She is being “worked up” for this now. Her father sneaks her out of Soleil to her appointments.
Some one said that tuberculosis is a “social disease with medical consequences”. This just means that poor populations of people get it and suffer the terrible effects of the disease. In the United States, the prevalence of tuberculosis decreased before effective drugs were introduced. This was due to the improved standard of living that North Americans were experiencing as they moved out of the ghettos and obtained good jobs. Their immune systems improved and less people had tuberculosis so less could spread it.
Tuberculosis is the most common infectious disease worldwide and endemic in the developing world. It is spread much easier than is HIV, malaria, or hepatitis. The tuberculosis germs are airborne. Lungs are the primary site for the deposition of tuberculosis but the germ can go anywhere and infect every organ system.
Mortality is 50-80% in untreated smear positive cases, but is less than 5% with active tuberculosis programs. Overall “success” in treatment of tuberculosis in Haiti is 70%.
In 2005, in the United States, there was the lowest incidence of tuberculosis ever recorded—4.8/100,000 people. The incidence in Haiti for 2002 was 319/100,000 people. This disparity is incredible. Remember, the United States has about 290 million people and Haiti has 8.6 million. Regarding tuberculosis, Haiti is ranked at 151/194 countries for prevalence of tuberculosis. Not real good.
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UN Peacekeepers in Haiti
The Lancet 2006; 368:816
6 months after democratic elections, Port-au-Prince has seen another upsurge in violence. Staff at Médicins Sans Frontières report treating more than 200 gunshot wounds in July, double the previous month's number of injuries. The fighting raises questions about the effectiveness of the UN peacekeeping mission, whose intermittent 15-year presence was extended for a further 6 months on Aug 15.
In today's Lancet, Athena Kolbe and Royce Hutson report human rights violations in Port-au-Prince. Central to their findings is the fact that civilian welfare fails to attract the attention it deserves from authorities in times of conflict, with neither the Haitian government, nor the UN peacekeepers being able to estimate the effect of the conflict on civilians. Yet in just 22 months—from the departure of President Jean-Bertrand Aristide to the end of 2005—an estimated 8000 people were murdered and 35000 women sexually assaulted, half of whom were under the age of 18 years.
Most perpetrators were identified as criminals, but police, armed forces, paramilitaries, and foreign soldiers were also implicated. Although UN peacekeepers have been investigated for accusations of sexual misconduct in Haiti and elsewhere, Kolbe and Hutson's survey did not find evidence for their involvement in murder or sexual assault. However 14% of the interviewees did accuse foreign soldiers, including those in UN uniform, of threatening them with sexual or physical violence, including death.
UN Secretary-General Kofi Annan has spoken out firmly against exploitative behaviour by UN peacekeepers. In 2005, at Annan's request, Prince Zeid of Jordan, whose soldiers serve in Haiti, proposed a number of measures to reduce sexual exploitation by UN personnel. One result has been the active investigation of allegations. Yet since 2004, only 17 peacekeepers have been dismissed and 161 repatriated out of 313 allegations worldwide. Annan's stand needs to be followed by stronger action to restore both international and local confidence, without which local security cannot be assured. Severely traumatised populations remain vulnerable, and as Kolbe and Hutson show, suffering does not stop when peacekeepers arrive. UN peacekeepers must no longer add to that suffering.
6 months after democratic elections, Port-au-Prince has seen another upsurge in violence. Staff at Médicins Sans Frontières report treating more than 200 gunshot wounds in July, double the previous month's number of injuries. The fighting raises questions about the effectiveness of the UN peacekeeping mission, whose intermittent 15-year presence was extended for a further 6 months on Aug 15.
In today's Lancet, Athena Kolbe and Royce Hutson report human rights violations in Port-au-Prince. Central to their findings is the fact that civilian welfare fails to attract the attention it deserves from authorities in times of conflict, with neither the Haitian government, nor the UN peacekeepers being able to estimate the effect of the conflict on civilians. Yet in just 22 months—from the departure of President Jean-Bertrand Aristide to the end of 2005—an estimated 8000 people were murdered and 35000 women sexually assaulted, half of whom were under the age of 18 years.
Most perpetrators were identified as criminals, but police, armed forces, paramilitaries, and foreign soldiers were also implicated. Although UN peacekeepers have been investigated for accusations of sexual misconduct in Haiti and elsewhere, Kolbe and Hutson's survey did not find evidence for their involvement in murder or sexual assault. However 14% of the interviewees did accuse foreign soldiers, including those in UN uniform, of threatening them with sexual or physical violence, including death.
UN Secretary-General Kofi Annan has spoken out firmly against exploitative behaviour by UN peacekeepers. In 2005, at Annan's request, Prince Zeid of Jordan, whose soldiers serve in Haiti, proposed a number of measures to reduce sexual exploitation by UN personnel. One result has been the active investigation of allegations. Yet since 2004, only 17 peacekeepers have been dismissed and 161 repatriated out of 313 allegations worldwide. Annan's stand needs to be followed by stronger action to restore both international and local confidence, without which local security cannot be assured. Severely traumatised populations remain vulnerable, and as Kolbe and Hutson show, suffering does not stop when peacekeepers arrive. UN peacekeepers must no longer add to that suffering.
Comments from 2021--
- Keep in mind that this article was written four years BEFORE the UN forces in Haiti introduced cholera to the Haitian people. And over the next decade cholera would infect close to a million people and cause the death of at least 10,000.
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Monday, September 04, 2006
"It's Not Your Fault"
This mother and baby pictured came into the clinic this morning. Mom appeared very sad, poor, and pregnant. Her baby’s name is Peterson.
Mom reported that Peterson, who is 14 months old and weighs six kilograms, has been coughing, running a fever, and having diarrhea for “some time”. I noticed their address on the dossier is Cite Soleil.
I asked Mom if the baby has a father. She replied that his father died eight months ago. When I asked if he was sick she said that he was shot and killed by “blan”. Blan means foreigner in Haitian Creole. She said he was caught in a crossfire between the United Nations forces and the “chimere” in Soleil. Chimere means "dragon" and the dragons are gang members in Soleil. When he left the house that day, he did not know it was so “hot” (dangerous0 on the street according to mom. She touched my wrist for a second and told me that it was not my fault that the father of her children was killed by blan.
Mom told me that she has four kids at home. None can go to school now because of the "war" in the slum and she has no money since the children's father is gone.
Peterson’s lungs sounded very noisy and a chest x-ray revealed pneumonia. With his malnutrition and the fact that Peterson looked so bad, I admitted him to the hospital. There is a very good chance that his pneumonia is tuberculosis.
Tuesday, September 05, 2006
Haiti Still Has Slaves
New York Times
Published: September 5, 2006
Haiti, founded two centuries ago by ex-slaves who fought to regain their freedom, has again become a hub of human trafficking.
Today, tens of thousands of Haitian children live lives of modern-day bondage. Under the system known as “restavek,” a Creole word meaning “stay with,” these children work for wealthier families in exchange for education and shelter. They frequently end up cruelly overworked, physically or sexually abused, and without access to education.
The most effective way to root out this deeply oppressive but deeply ingrained system would be to attack the conditions that sustain it — chiefly, impoverished, environmentally unsustainable agriculture and a severe shortage of rural schools.
This is an area in which America can and should help. Washington has been quick to respond to political turmoil in Haiti, with its accompanying fears of uncontrollable refugee flows. But the frenzied flurries of international crisis management that follow typically leave no lasting results.
A wiser, more promising alternative would be to help create long-term economic options by improving access to schools and creating sustainable agriculture. Meanwhile, the United States should work with nongovernmental organizations to battle the resigned acceptance by many Haitians of the restavek system. They could, for example, help local radio stations broadcast programs of open dialogue about how damaging the system is, and include restavek survivors or human-rights experts.
The primary responsibility for eliminating the restavek system lies with the Haitian people and their government. After years of political crisis, there is a new democratically elected government. Eradicating the restavek system should be one of its top priorities, combining law enforcement efforts with attacks on the root social and economic causes.
The former slaves who won Haiti’s freedom 200 years ago dreamed of something better for their children than restavek bondage. The time is overdue for helping those dreams become reality.
Comments from 2021--
- One of the Haitian doctors I worked with in Haiti over the years had a restavek. The child used to accompany the doctor to clinic and she looked perfectly cared for and acted "normally" to me. There is a wide range of treatment of restaveks in Haiti.
- One of the children I brought back for heart surgery was a restavek in Haiti and her treatment was not all that good. More to come.
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Tuesday, September 05, 2006
"All He Had Was A Fever"
“All he had was a fever. He didn’t have diarrhea or vomiting. It started on Friday night at midnight. I took him to the hospital which was run by nuns. They gave me medicine which I gave him and brought him to this hospital today.”
These were the words this afternoon of another Haitian mom who lost her child. She was shrieking these words out as she rocked back and forth on a wooden bench alone. She took the medication out of her purse which was a multivitamin, vitamin C, and acetaminophen and slammed them down on the bench. They hadn’t worked. She was missing the point as most poor Haitians do. In other words, they often blame something more distal than more proximal to the cause. They have been mislead their entire lives.
Early this morning, this mother had brought in her four-year-old boy in a coma. One pupil was bigger than the other. He was breathing quickly and was nonresponsive even to the insertion of the needle for the IV in the back of his left hand. He never woke up.
As his respirations slowed near 1 PM, I had her hold his jaw open to help “maintain” his airway. His respirations stopped and I turned him on his side. His heart continued at a furious pace but to no avail since his oxygen levels were dropping. I didn’t do CPR. His mother screamed and left the room. Three other sets of families, all nursing their babies with IV’s, barely seemed to notice the death of this innocent four-year-old boy in the tiny “rehydration room”.
His mother's sobbing could be heard in the hallway. Other moms in the clinic stared at her and peered at her around corners. Children stood with their fingers in their mouths and stared at this pathetic lady. The student nurses, in their freshly pressed uniforms, walked by barely looking at her. The veteran nurses said nothing to her. When the mother knelt on the floor crying, the janitor gently swept dust, debris, and plastic cups around her.
Her deceased son was wrapped in a white sheet and it was tied at both ends. The body was left in bed in the rehydration room surrounded by the three other babies in their cribs fighting for their own lives.
Mother continued to wail as she waited to receive the body of her son who "only had a fever". “Maman-mwe! O Bon Dieu. Pa bliye nou!” (Mother. Oh, good God. Don’t forget us!)
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Thursday, September 07, 2006
Civil War Hard On Kids
This is Louis-Jacques.
He is 20 months old and weighs 15 pounds. His mother brought him to clinic yesterday morning for fever, chronic cough, diarrhea, and malnutrition. Mother stated that when things became very dangerous in Martissant in June, she and the baby's father moved him outside of Martissant to Leoganne which is a city a few kilometers south of Port-au-Prince. She and her husband returned to the capital but stayed in a different location due to the violence in Martissant. Martissant is the name for a mountain top slum that rings the southern quarter of Port-au-Prince. Gangs were on a rampage in May and June, executing people and burning down their shacks. Refugees from Martissant fled the area with only the belongings they could carry on their heads. Many took refuge in a nearby Baptist mission while others fled to a seminary. Conditions were bad in both locations due to the massive number of people and lack of food and drinking water.
A recent Lancet article documented earlier on this weblog, stated that 8,000 people have been killed in Haiti since the coup of President Jean Bertrand Aristide in 2004. Not included in the 8,000 are the countless people that have died due to their inability to receive adequate medical care.
Another Lancet article from June 2006 says the following--
"Children under 5 years of age have the highest mortality rates in conflict-affected settings. In some situations when childhood interventions have been disrupted for periods, older children are similarly affected. Diarrheal diseases, acute respiratory infections, measles, malaria, and severe malnutrition are the most common causes of death in the early phases of conflict-related emergencies. In addition, outbreaks of other infectious diseases such as pertussis, typhoid, and meningococcal meningitis, can contribute substantially to childhood morbidity and mortality."
Louis-Jacques stayed with his maternal aunt in Leoganne but he became ill over the summer. So his mother went and got him and brought him to clinic to be checked.
Louis-Jacques appeared so similar to the hundreds of other babies that flood the clinic each week. He didn't smile. His hair is orange and he has a thick nonproductive cough. And his mother seemed to care very much for him.
I sent him for a chest x-ray but the machine was not working. So I asked mother if she would return with Louis-Jacques to obtain the x-ray when the machine is working to see if he has tuberculosis. She agreed.
I gave him a prescription for oral rehydration powder and antibiotics to treat the pneumonia and sent them on their way.
Haiti is in the middle of a long "civil war". The Louis-Jacques and their parents, like the 8,000 people overtly murdered, are caught in the middle and don't do well during times like this.
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Sunday, September 10, 2006
Tuberculosis is a Sneaky Disease
Tuberculosis is a Sneaky Disease
One-third of the world’s population, about two billion people, is infected with the tuberculosis bacteria. That is not to say that one-third of the world’s population has active disease; but it means that one-third of the world has been exposed to the tuberculosis microbe and many have the disease and many will get it in their lifetimes.
Tuberculosis is the number one infectious disease in the world that causes death. It killed more people in the decade of the ‘90’s than any other decade in history.
Tuberculosis can be acquired just by talking to another adult with active tuberculosis on the bus. Children, as a rule, do not transmit tuberculosis to other children or adults. Tuberculosis in a child means only one thing: There is an undiagnosed case of active tuberculosis in an adult who has given the disease to the child.
There is a tuberculosis vaccine that was developed about 80 years ago and has not improved since. Its efficacy is questioned by many experts around the world. The tuberculosis skin test is antiquated as well and will be “positive” in many patients that do NOT have tuberculosis and will be “negative” in many patients that DO have active tuberculosis.
The treatment of tuberculosis hasn’t changed much with first-line drugs in decades. However, if one does not have multi-drug resistant tuberculosis (MDR-TB), chances for cure, even with these “old” drugs are excellent.
The problem in Haiti and everywhere else is patient compliance. You know that conventional wisdom tells us that Haitians can be very noncompliant with taking their tuberculosis medications. For some reason, Haitian mothers have a hard time walking and riding 5 hours to the clinic with their children over dirt roads with huge water-filled holes, with machete-carrying-bandits, with kidnappers with 9 mm “Caribbean pistols”, and through hurricanes. It sure is not MY fault when the Haitians don’t show up for their 8 months of tuberculosis medications which makes them sick and can give them hepatitis.
Tuberculosis is a very sneaky disease that frequently infects its victims, goes away, and reappears years later when the person has aged or has an illness that causes the immune system to dysfunction. Their doctor may not even look for tuberculosis because he/she doesn’t think of this disease in the United States. (The United States is currently registering an all-time low incidence of tuberculosis.) Tuberculosis, which the patients were able to fend off successfully years before, comes back and kills them.
We frequently think that tuberculosis infects the lung. It does, but it can infect every organ system from the skin, central nervous system, the heart, gastrointestinal, and genitourinary systems. Tuberculosis can even infect your eyes and ears.
I see kids every day that look quite healthy, but their Haitian parents tell me something is not right. The kids may have a cough, fever, and some weight loss. These symptoms may have occurred slowly over the course of months. They may be playing in the office like usual kids.
When I listen to them with the stethoscope, their lungs may sound normal. The brother and sister pictured at the top of this post had these symptoms and were chasing each other around the clinic. However, their mother was being treated for active pulmonary tuberculosis during the last 3 weeks.
Both of the children had chest x rays which showed extensive pneumonia in both lungs and both had “highly positive” skin tests. Both have just started their 6-month course (pediatric courses in Haiti are 6 months, not 8 months), and if they are “nice and compliant” patients and finish their treatment, they will stand a good chance of surviving.
The little one pictured at the bottom of the post presented with a very high fever and a large pneumonia in her right lung which can be seen on the chest x-ray. After one week in the hospital receiving intravenous antibiotics, her fever has dropped some, and her chest x-ray has cleared to a large degree, as can be seen in the bottom chest x-ray.
However, since tuberculosis is so sneaky, if one looks at the improved x-ray, one can see radiographic findings consistent with tuberculosis. What happened with this child is that she developed pulmonary tuberculosis that became “superinfected” with another type of bacterial pneumonia that caused her severe symptoms. This bacterial pneumonia was successfully treated which “uncovered” her underlying tuberculosis in her lung. She should do well now with treatment focused on her tuberculosis.
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Thursday, September 14, 2006
Failed State Equals Failed Babies
Haiti is not supposed to be called a “failed state”. So I won’t call Haiti a failed state. I don’t like the description either. But Haiti failed the baby pictured above.
Yesterday, the baby’s mom brought this 16-day-old baby boy to the clinic. The baby was very irritable, jaundiced, and had a fever of 104 F. He was critically ill.
As you may see in the picture, the left knee was very swollen, hot to touch, and very tender. The x-ray shows the knee joint full of gas with swelling of the soft tissues around the knee. This would be the "case of the week" at an academic center in the States. But you NEVER want to be the case of the week if you are the patient. In Haiti, this baby is not even a blip on the medical radar.
The baby has a severe infection of the knee joint and adjacent tissues with a bacteria that produces gas. Mother stated that at 3 days of age the baby’s left knee began to swell. She took the baby to a hospital and the baby was admitted for one week. The hospital employees haven’t been paid in 5 weeks. When the baby's IV infiltrated, it would not be changed and the baby received only one dose of antibiotics during the entire week according to mom. The baby needed surgery very quickly to open the joint, but had no surgery. She took the baby home 3 days ago because of the lack of care for the baby in the hospital and the baby’s continued deterioration.
This medical negligence by the hospital is not uncommon in Haiti. No money usually means no treatment.
The baby has a septic joint and very well may have bacteria in his bloodstream as well. The severe jaundice points to a serious infection. If the baby survives, which is unlikely, it will have a destroyed knee joint because the cartilage and bone were damaged within the first few hours after the joint became infected two weeks ago. At best, the baby will be crippled for life with a knee that will not work.
Mother tried to get the baby admitted to another hospital after she left the first hospital, but the second hospital had no open beds, and she has no money for a private hospital.
After some “finagling”, we were able to get the baby admitted yesterday to another hospital where the knee was drained immediately and antibiotics were started.
Haiti's systems, like health care in this case, are very weak. The State of Haiti has failed this baby and mother.
Is Haiti a failed state? You decide.
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Friday, September 15, 2006
Pediatric Cancer in Haiti
Yesterday I rechecked the 5-year-old boy whose picture is on this post. His name is Joseph. I saw Joseph for the first time last week and sent him for a chest x-ray, TB skin test, and blood work.
His mother stated that for the last two months she has noticed big lymph nodes on his neck and under his armpits. And he has an occasional fever.
His exam revealed very large and firm lymph nodes on both sides of his neck and in his armpits. I could not feel an enlarged liver or spleen, so that is good. His lungs were clear and he had a smile that would not quit.
His chest x-ray revealed pneumonia in both lungs and his TB skin test was positive at 15 mm. Mother did not have enough money to get his blood work done.
In Haiti, big lymph nodes with pneumonia and a positive TB skin test usually means active tuberculosis. However, I have my worries about this boy because his lymph nodes don’t feel like other tuberculosis lymph nodes that I have examined in the past. Also, they are not draining, like TB nodes frequently do. However, I do not want to think or believe that he has cancer. I hope my clinical judgment is wrong and hope that he has tuberculosis that we can treat. Pediatric cancer in Haiti is a very difficult situation.
Eighty percent of all children in the world with cancer live in the developing world. The developing world is the world without money and resources to adequately diagnose and treat cancer. Forty years ago childhood cancer in the United States was almost uniformly fatal. Today, most children in the United States with cancer live. In Haiti, cancer in kids is diagnosed late when treatment options are limited. National expenditures for childhood cancer take a back seat to common infectious diseases such as tuberculosis, malaria, and AIDS. Amazingly, cancer kills more people around the world than all three of these diseases combined.
In Haiti, I have seen retinoblastomas, osteosarcomas, kidney tumors, and leukemias in children. All of these kids die. In the Dominican Republic, the country that shares this island with Haiti, poor children can receive care for these treatable cancers. I have seen it happen. Honduras, in Central America, has cancer internet clinics for kids that live outside of the capital.
More than 900 million dollars in aid was provided to Haiti’s last “government” that took the place of Haiti’s exiled President Aristide in 2004. How much of that money will help children in Haiti with treatable and curable cancer?
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Friday, September 15, 2006
Pain in Haiti
Several years ago, while working in a hospital in southern Haiti, I realized how poorly patients were treated that were suffering severe pain. We had many post op patients, cancer patients, and trauma patients who were shot, had machette wounds, and were involved in automobile accidents. And we treated them all very inadequately for their pain. Even children that were having their skin debrided and dressings changed each morning for their burn wounds, were not pretreated with pain medication or with medication to sedate them. Their screams could be heard all over the hospital.
We were not getting more narcotics at that hospital because he would not allow it. There were only a few vials of Demerol in the main pharmacy. There was no morphine at all.
Haitians do not have a "stronger pain tolerance" than do other people. However, Haitians are more use to pain than most cultures. To be alive in Haiti is to have some sort of pain almost every day.
Haitians do not have a "stronger pain tolerance" than do other people. However, Haitians are more use to pain than most cultures. To be alive in Haiti is to have some sort of pain almost every day.
WHO predicts that over the next 20 years, the number of cases of people diagnosed with cancer will double to 20 million cases/year worldwide. Pain care will be very important, especially in the developing world. When we don't prevent or diagnose in a timely fashion someone's cancer, the least we could do is prevent some of their pain at the end of their lives.
Friday, September 22, 2006
Eugene
Several mornings ago in clinic, a little girl about four and one half feet tall appeared in front of my desk holding a baby on her hip. I glanced down at one of the dossiers in front of me and asked the girl if the baby’s name was Eugene. She said yes. I asked her where the baby’s mother was and she replied that she is the baby’s mom. Believing that she had not understood my heavily accented Haitian Creole, I asked her again where the mother was. She assured me that she is the mother. I could hardly believe my eyes.
The mother, whose name is Mikerlange, had a beautiful smile, was very polite and not demanding. She is 16 years old. She just wanted her baby to get better. She answered questions regarding two year old Eugene as a seasoned mother would do.
Eugene has had a fever, cough, diarrhea, and lack of appetite. She stated that she and the baby live with her grandmother. Her father is dead and her mother is a domestic and lives in the house that she cleans. Mikerlange rarely sees her mom.
Mikerlange said that she does eat when her grandmother can find them some food. Like most poor Haitians, they have no food in the house. When she offers Eugene food---rice and beans--- he refuses and takes only sips of water. Mikerlange will actually chew up food and give it to Eugene to swallow because he is too weak to chew. She cannot remember the last time he ate anything on his own.
Eugene’s exam revealed that he weighed 12 pounds and had a fever of 102.5F. He was very irritable and did not want to be examined. He swung at me with his tiny hand.
A chest x-ray revealed pneumonia in her right lung near the heart margin on the right side.
Eugene and his mom are really not unique in the clinic or in Haiti, except that his mother is quite young. She has no social systems supporting her and her baby. She has nothing except her grandmother. Eugene is dying from lack of food and pneumonia. He did not meet the criteria for admission in many Haitian hospitals, so I had one choice…and so did Eugene---I called Chris Nungester.
Chris and Hal Nungester are use to bailing babies out of trouble as well as helping troubled doctors when they have no where to send sick and dying children.
Chris drove to the clinic, picked up Eugene and Mickerlange, and drove them to the orphanage. We worked out a medical plan for Eugene.
Eugene is making slow steady progress over the last several days at the orphanage. He is receiving antibiotics and rehydration fluid. Will he survive? Only God knows. But H.I.S. Home for Children and his little mom are giving Eugene the chance that he deserves.
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Monday, September 25, 2006
Medical Search Engines
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| Luke, 2006 |
I feel real guilty when I sit at the computer and use my favorite medical search engine. Working in Haiti plays with my mind all of the time.
For example, if I search “pediatric pneumonias” I find all of the latest information that exists. The search engine tells me how to diagnose pediatric pneumonia, which microbe is most likely the cause, what the chest x-ray looks like with this type of pneumonia, and which babies with pneumonia should be hospitalized. Everything is nice and neat and the protocols have been developed by specialists that rate their recommendations for clinicians in the trenches like me.
For my little Haitian patients, it would be nice to have a search engine available that would give recommendations regarding issues such as these:
- What does the physician do when the mother can neither read nor write?
- Who should pay for the chest x-ray for the baby when the mother has no money?
- Who will pay for medication when it is needed to treat the pneumonia?
- When should I ask the mother and baby to return to the clinic because travel is dangerous and the mother usually has no money?
- Who will take care of the mother’s children at home while she is taking her sick baby to the doctor?
- Who will make sure the mother understands the proper dosing of the baby’s medication including acetaminophen which comes in all different strengths?
- Where will the mother find clean water to add to the antibiotic powder and where will she refrigerate the medication if needed?
- Who will sit down and spend some time with the mother explaining the issues regarding the baby that would warn the mother that the baby is failing outpatient therapy?
- If I "elect" to admit the baby, who will pay for the admission to the hospital? Also, how will mom tell her family that she will be staying with the baby and not returning home for a few days?
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Saturday, September 30, 2006
Sickle Cell Anemia in Haiti
Sickle cell anemia is a big problem anywhere there are people of black descent. In the United States 1/400 African Americans have sickle cell anemia. Haiti is a country with greater than 8,000,000 people who are densely packed together along with their Dominican neighbors on the island of Hispanola.
The mean survival of men in the United States with sickle cell disease is 42 years. The mean survival of women in the United States with sickle cell disease is 48 years. The mean survival of men and women in Haiti with sickle cell disease is about 25 years. If you are born with sickle cell disease in the developing world, you are in trouble.
The main problem with sickle cell anemia is that hemoglobin within the red blood cells is formed improperly which causes the blood to be sticky, not flow like it should, and this abnormal blood blood blocks small blood vessels in organs which causes the organs to fail.
So what does this mean for the little girl pictured in this post who was in the middle of a sickle cell crisis when this picture was taken? Pain is a big part of a crisis when blood flow becomes stagnant. Her feet hurt (dactylitis) as did other regions of her body, but she complained mainly of her feet. She did not want to walk.
Sickle cell disease allows infections to become more severe and the leading cause of death with sicklers is infection. However, involvement of renal, pulmonary, bone and joint, and the central nervous system (stokes), occurs frequently with this disease.
In the last several decades, in countries with resources, multiple advances in the treatment of sickle cell disease has occurred which has improved the quality and quantity of people’s lives. However, these improvements have not occurred in Haiti on a large scale.
What could be done in Haiti to help kids with sickle cell disease?
- Infection control and prophylaxis: Educate parents what they should watch for with their child with sickle cell. Fevers have to be respected. Immunizations to prevent bacterial and viral infections. This is not done in Haiti because the poor cannot pay for these “second generation” vaccines. Receive ongoing penicillin prophylaxis to prevent infection. Folic acid needs to be taken each day to build more red blood cells that are chronically being destroyed in the circulation of someone with sickle cell disease.
- Pain management: Sickle cell disease is one of the most painful diseases on earth. The painful crises come and go. Narcotics are frequently necessary. This is not done in Haiti either.
- Management of infection: Hospitalization is frequently necessary with appropriate blood tests, IV fluids, and powerful antibiotics. Where do poor people in Haiti go when their child needs to be hospitalized? Very few options exist at present.
- Transfusion therapy: Blood transfusions and exchange transfusions need to be done. This can be safely done in the hospital setting, but in Haiti? Also, the transfused blood needs to be properly typed and screened and be free of infectious agents.
- Hydroxyurea is a drug used all over the world to increase the amount of fetal hemoglobin which helps the patient with sickle cell disease. Hydroxyurea even decreases the incidence of strokes. A child with a stroke is always bad news. However, hydroxyurea is not available in Haiti for the majority of the poor.
Once again, Haiti’s medical system and the international community are failing Haiti with yet another disease. Haitians are scourged with sickle cell disease and it should be a priority.
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Saturday, September 30, 2006
Does This Girl Look Sick?
As stated in a previous post, tuberculosis can be a very sneaky disease.This young Haitian girl appear sick? But when I listened to the left side of her chest with a stethoscope revealed no breath sounds due to the fact that she had a large pleural effusion. A pleural effusion is fluid that collects in the pleural space surrounding the lung. This fluid has also pushed this girl's heart to the right because fluid is not compressible and so the heart has to give.
Most likely, this fluid is caused by tuberculosis. Physicians have to know what is prevalent and endemic where they practice. If this girl were from Peoria, and had not travelled recently, and had no contacts with adults with tuberculosis, I would not think she has tuberculosis. Unfortunately for her, she lives in Haiti, where getting tuberculosis is almost expected.
I referred her for 8 months of tuberculosis treatment. Her chances for cure are greater than 90%.
A Haitian proverb says, "One sees from where one stands."
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Saturday, September 30, 2006
Moses
On Friday, several days ago, this sweet-grandma-appearing-woman brought this 5 year old boy to the clinic. His name is Moses (Moise). She told me she named him after the biblical character. I don't remember why she brought him to the medical clinic.
I asked her if Moses has a mother or father. She waved her hand "no" behind him so he would not see her response. Moses stared straight ahead.
The lady told me that one night she heard a baby crying and went out side and found him lying in the street in the rain. She brought him in and she is raising him. She knows nothing more regarding Mose's beginnings.
I told her she was doing a good thing. She smiled and said that God picked her to raise Moses. She said she is only doing her job.
I asked her if Moses has a mother or father. She waved her hand "no" behind him so he would not see her response. Moses stared straight ahead.
The lady told me that one night she heard a baby crying and went out side and found him lying in the street in the rain. She brought him in and she is raising him. She knows nothing more regarding Mose's beginnings.
I told her she was doing a good thing. She smiled and said that God picked her to raise Moses. She said she is only doing her job.
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Saturday, September 30, 2006
No Good Choices
This baby boy was from a small Haitian village near the Dominican Republic. His parents couldn't take care of him because they had no money and so
they put him in an orphanage. He was a healthy baby.
The director of the orphanage went to the United States and returned to Haiti and found him in this condition. One of the nannies said he fell and broke his leg. There was no more history.
This baby had to suffer so much as he developed gangrene of his left thigh due to an infection in his deep thigh muscles. His suffering had to be great as he remained neglected at the orphanage. The infection eventually spread to his blood and gave him multiple organ failure.
In the hospital he appeared to be awake but his eyes were looking nowhere as he lay in a beneficent coma. A unit of blood was being wasted on this dying boy. No medical personnel really thought he would recover.
Fortunately, death came for him a couple of days later. His parents should never have had to place him in a terribly run orphanage in the first place. But when you can't feed your children in Haiti, you don't have good choices.
This baby had to suffer so much as he developed gangrene of his left thigh due to an infection in his deep thigh muscles. His suffering had to be great as he remained neglected at the orphanage. The infection eventually spread to his blood and gave him multiple organ failure.
In the hospital he appeared to be awake but his eyes were looking nowhere as he lay in a beneficent coma. A unit of blood was being wasted on this dying boy. No medical personnel really thought he would recover.
Fortunately, death came for him a couple of days later. His parents should never have had to place him in a terribly run orphanage in the first place. But when you can't feed your children in Haiti, you don't have good choices.
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Saturday, September 30, 2006
Haiti's Parasites
Haitian women request worm medicine all of the time because their children frequently have worms. Jean, the baby in this picture, had vomited over 70 long white worms out of his mouth and nose over the course of 3 days before his mom brought him into clinic. He also had been febrile for one week, and at 28 months of age he only weighs 14 pounds.
Most likely, this baby has Ascaris, which is type of roundworm. It migrates through the lungs and into the digestive tract. Ascaris worms can be as long as 15 inches. Can you imagine the alarm of a mother from the States if her child coughed up a long white worm or dozens of long white worms?
There are approximately 3,200 types of parasites. They can invade the body through food and water intake or through an insect that transmits the parasite like a mosquito or a fly. Parasites live in or on other organisms from which it obtains nutrients to live and frequently harms the organism in the process.
Because most people in Haiti do not have potable water and their living conditions are dismal, they unwillingly ingest the parasites. Parasites can steal vital nutrients from their bodies and they usually attack and hurt the undernourished and weak---like children that sit in the dirt.
Haitian kids have stomach bloating, abdominal pain, diarrhea, malabsorbtion, anemia, pneumonia, and even perforated intestines due to parasites. Their mothers report that their children grind their teeth at night. Studies have shown decreased intelligence in children infected with parasites.
What is the answer? Justice for the poor, which means jobs, education, clean water, nutritious food, all of which will result in a higher standard of living in Haiti. Until that happens, parasites will continue to infest Haiti’s weakest and most susceptible.
There are approximately 3,200 types of parasites. They can invade the body through food and water intake or through an insect that transmits the parasite like a mosquito or a fly. Parasites live in or on other organisms from which it obtains nutrients to live and frequently harms the organism in the process.
Because most people in Haiti do not have potable water and their living conditions are dismal, they unwillingly ingest the parasites. Parasites can steal vital nutrients from their bodies and they usually attack and hurt the undernourished and weak---like children that sit in the dirt.
Haitian kids have stomach bloating, abdominal pain, diarrhea, malabsorbtion, anemia, pneumonia, and even perforated intestines due to parasites. Their mothers report that their children grind their teeth at night. Studies have shown decreased intelligence in children infected with parasites.
What is the answer? Justice for the poor, which means jobs, education, clean water, nutritious food, all of which will result in a higher standard of living in Haiti. Until that happens, parasites will continue to infest Haiti’s weakest and most susceptible.
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Saturday, September 30, 2006
Rheumatic Fever in Haiti
Acute rheumatic fever is a febrile illness which can cause arthritis, heart problems, skin rash, and a movement disorder called chorea. Rheumatic fever occurs several weeks after a pharyngeal infection with Group A beta hemolytic Streptoccus. Rheumatic fever continues unabated in developing countries. There are approximately 5-10 million cases each year in poor countries where two-thirds of the world's population lives. Children are the most likely victims between the ages of 5-9 years of age.
It is believed that the body recognizes the streptococcal germ and attacks it and also attacks the heart valves. Something in the valves reminds the immune system of the streptoccus and the valves are attacked also. Therefore, rheumatic fever can lead to damage of heart valves which causes decompensated congestive heart failure and death. We have seen many young teenagers and young adults in Haiti with severe valve problems which are due to rheumatic fever when they were younger. Without heart surgery, most of our patients die very miserable deaths.
With the introduction of antibiotics in the 1950's, there was a decline in rheumatic fever in the United States. Also, with appropriate antibiotics to prevent the recurrence of the disease, rheumatic fever is much more preventable in the developed world.
Haitians, like the 5 year old boy pictured above, lack penicillin for their strep throat, and develop rheumatic fever. His knees were very painful, swollen, and warm. I could not hear a heart murmur, so maybe he will be fortunate and escape the cardiac manifestations. Time will tell.
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