Sunday, June 18, 2006

"I Can't Breathe"

Suze was a typical patient-- young, attractive, well spoken, and dying. Suze is Haitian and poor and when Maria and I saw her several years ago, she was very thin and barely able to walk due to severe shortness of breath with any exertion. Her heart exam revealed her mitral valve was not working right. She did not have long to live.

She told us how, not long before seeing us, she passed out one day and woke up on a gurney in and emergency department of a small hospital near her home in one of the slums of Port-au-Prince. She was staring out the slats of a window at her friends that were staring in at her. They had carried her limp body to the hospital after she had lost consciousness and taken up a collection of money to get her admitted for medication to treat her heart failure.

Suze survived and came back to the U.S. with us for a mitral valve replacement. Surgical intervention is usually necessary with people like Suze to give them long term relief from their symptoms. After surgery, her personality changed from someone who was waiting for death, to someone who is very happy to be alive.

In Haiti we hear this complaint all of the time: “I can’t walk up the mountain anymore”. Usually it is not from old people but from teenagers that have come to the clinic and have rheumatic heart disease. It breaks your heart to see these kids suffering so much. They want to go to school and be like normal kids--but they can’t due to their sick hearts.

Rheumatic heart disease has been around as long as strep throat has afflicted humanity. For some reason when one gets strep throat, the immune system can attack the heart, joints, brain, and skin. “Antigenic mimicry” and nasty strains of streptococcus are argued as possible causes for rheumatic fever, but no one knows for sure why some people get strep throat and do fine, and others are crippled with its sequelae. Any part of the heart can be attacked and damaged. We examine kids that had acute acute rheumatic fever when they were much younger and show up when they are 18 years old with valves that are destroyed.

The mitral valve is the valve most likely injured in rheumatic fever and may not close well or may not open well or a combination of both. These kids are in a world of hurt because as they years pass, they become unable to do much requiring physical activity because their lungs fill with fluid.

Rheumatic fever is a major public health problem in many developing countries like Haiti. Two-thirds of the world’s population is considered poor and this is where rheumatic fever is found. The magnitude of rheumatic fever in the developing world is the same as in the United States 60 years ago---before widespread use of penicillin. Rheumatic fever is not gone in the United States, but it is not the first thing I think of in an American kid who presents with joint complaints and fever.

There is a real danger that research regarding atherosclerosis in the developing world will divert resources and attention from rheumatic heart disease, cardiomyopathies, and tuberculous pericarditis. These are the three major causes of heart disease in Haiti and Africa. Of the nearly 2.4 million children with rheumatic heart disease living in developing countries, nearly half live in sub-Saharan Africa. According to Lancet, June 10, 2006, “They cause great morbidity and mortality in young, economically active people, but with isolated exceptions, they are largely neglected targets of epidemiological, etiological, and therapeutic research.”

The Lancet continues, “Eradication of rheumatic fever depends on social changes, including improved primary health-care services, elimination of poverty, better housing, and application of existing knowledge on primary and secondary prevention of the disease”.

There are many patients in Haiti that we are treating for rheumatic heart disease. Few will make it out for definitive surgical repair.

Saturday, June 17, 2006

Health Disparities Between Races

June 17, 2006

In the USA, race and ethnicity are major factors predicting who will live a long life and who will not.

Lancet, June 10, 2006, reports that, "The life expectancy of an African-American man is 69 years, whereas that of a white man is 75.3. Infant mortality is 5.75 per 1000 livebirths for white infants, 14 for African-American infants.

Buried in Cement

June 17, 2006

The Miami Herald reported a story on May 27, 2006 titled “Embassy Denies Visa for Funeral”.

Menes Daniel, who left Haiti in 1981, died entombed in quick-drying liquid cement in a construction accident in early May. He and two other workers were working in the Bal Harbour high-rise building when the roof collapsed, sending a torrent of wet concrete over them. They died almost immediately.

Mr. Daniel’s funeral was scheduled for June 3 and his common-law wife and two children in Haiti applied for a temporary visa to attend his funeral.

The non-immigrant visa section of the American Consulate in Port-au-Prince denied their request for visas. His Haitian family were unable to provide any evidence of “ties to Haiti that would compel their return from the U. S.” They could not prove they had assets in Haiti to come back to from the U.S. Mr. Daniel had been wiring his family money for years so they could survive in Haiti while he worked in south Florida.

So now Mr. Daniel is dead, his family is stuck in Haiti, and his children will be seeing no more money from him. And his family cannot come and say good by to the man that allowed them to stay alive.

Wednesday, June 14, 2006

Poaching Nurses

June 14, 2006

Poaching Nurses

The Lancet medical journal June 3, 2006 contains an article “Poaching Nurses from the Developing World”.

The article gives grim statistics. The American Hospital Association reports that here are 118,000 current vacancies of qualified nurses in the U.S. Nursing schools in the U.S. do not have sufficient staff and 32,000 students were refused entry into Baccalaureate level nursing programs in 2005.

Developed countries have long looked upon the developing world as a nearly limitless source of willing labor to fill the nursing shortage. 50,000 nurses have immigrated to the US in the last decade. Most of the countries from which these nurses come are facing extremely serious public-health problems, including epidemics of HIV/AIDS, malaria, and tuberculosis. These are the same problems we see in Haiti everyday. Haiti and the rest of the developing world cannot afford to lose these nurses who frequently manage an entire ward of a hospital when there is no doctor available.

The Lancet reports, “Only 10% of the global burden of disease is concentrated in the Americas, but 37% of all health professionals work there”. A UN report reinforces that this brain drain of health workers is effectively subsiding care in the rich world. Clearly, further migration of workers will be disastrous for developing countries.

OSF-SFMC in Peoria and other large medical centers in the U.S. that attempt to lure nurses from their dirt-poor home countries should realize what they are doing. Diana Mason, editor of the American Journal of Nursing, said the main problem here is the “primary moral issue of draining these countries of their much-needed nursing resources and further undermine their healthcare infrastructure and the health of their people (and thus of their economies).” Mason states that a recent report by the Institute for Women’s Policy Research suggests that the nursing shortage continues as a result of collusion among hospital administrators to keep wages down and of longstanding gender-based wage discrimination. Can you believe it?

According to Lancet, the U.S. Congress should be creating ways to fund and strengthen the nursing infrastructure in the US, thereby developing a local workforce. Nursing salaries could rise and the poaching of nurses from the developing world would no longer be necessary. And most importantly, patients in the Philippines, Africa, and Haiti wouldn’t lie in their hospital beds without care.

Saturday, June 03, 2006


Almost every child we examine in the clinic in Haiti has worms at one time or another. Their mothers mention that the baby defecates worms or coughs them up on a routine basis. I think the Haitian mothers report this with the same amount of emotion that a mother from the United States reports that her baby has the sniffles.
Haitian moms frequently state that the baby grinds its teeth at night or cries out in its sleep or complains of abdominal pain. Also, a depigmentation of skin where the nostrils join the face is another "telltale" sign of being infested with worms.

In Lancet May 6, 2006, the Seminar is "Soil-transmitted Helminth Infections". The article reports:

More than a billion people world wide are infected with at least one species of worm. Of particular interest are the roundworms, whipworms, and hookworms. They are considered together because it is common for a single individual, like the kids we examine in Haiti, to be chronically infected with all of these worms. Such children have malnutrition, growth stunting, intellectual retardation, and cognitive and educational defects.

These soil transmitted worms are one of the world's most important causes of physical and intellectual growth retardation. Yet, despite their educational, economic, and public-health importance, they remain largely neglected by the medical and international community. This neglect stems from three features: first, the people most affected are the world's most impoverished, particularly those who live on less than US $2 per day; second, the infections cause chronic ill health and have insidious clinical presentation; and third, quantification of the effect of these infections on economic development and education is difficult.

So as soon as the Haitian babies quit taking their mother's milk and are placed on the ground, they are subjected to these unrelenting parasites. Haiti's infrastructure breeds all types of parasites which diminish the quality and quantity of life for Haiti's most innocent. Haiti's future adults are compromised from the beginning and Haiti's future as a viable country is jeopardized as well.

Medicine should be politics. They can never be separated. Public health care experts and doctors need to continually repeat how the two are related. Taking care of the infrastructure will take care of people and make the country viable in the competitive world in which we live.