Saturday, February 25, 2012

Cite Soleil

Photo by John Carroll--February 25, 2012

These men in Soleil were working like this to make a few cents today while the Haitian Prime Minister was resigning a few miles away.

Que lastima!!

Tuesday, February 21, 2012

Deconstruction of a Haitian Heart


Teledjol is a Haitian word which means gossip or rumor mill. It is the way news is spread in Haiti. Facebook is here too but teledjol is still king.

When Haitian Hearts comes to Haiti it doesn’t take long before we are seeing patients with heart problems.

The other day a polite 16 year old girl showed up with a “heart problem”. I will call her Beth.

Beth came with her mother who does laundry at a hotel in Port-au-Prince. Mother makes 5 dollars per day and she commutes a long ways via public transportation.

Beth lives in downtown Port-au-Prince with her mother and siblings in a place called Carrefour Feuilles.

Beth told me that in October, 2011 she became short of breath and started coughing up blood. She was hospitalized in LaPlaine for ten days and got better. Her doctor told her she had a heart problem and started her on a strong diuretic (furosemide).

However, Beth told me that she is still short of breath with exertion. She takes her furosemide daily, but she does not know the dose and only had a couple of pills left in a crumpled tiny baggy.

At the appointment with me Beth did bring her chest x-ray and an echocardiogram. Both had been done last fall when she was sick.

I like to talk with patients and examine them before I look at their test results. I want to make my diagnosis with just the history and physical and quantitate a pre-test probability of disease BEFORE I look at test results. Test results can lead physicians astray because tests frequently "lie" and test results need to be combined with the patients exam to arrive at a proper diagnosis.

Beth appeared calm and not short of breath. Her oxygen level (pulse oximeter) was 98%. Her skin was warm and dry.

However, Beth’s blood pressure was bothersome. It was 132/50 in her right arm. That sounds good, but there is too much of a gap between the top (systolic) and bottom (diastolic) number. And in Haiti that frequently means that her aortic valve is not competent. In other words, her aortic valve may be leaking which allows blood to flow in the reverse fashion when the heart is resting between beats. This allows too much blood to flood her main pumping chamber (left ventricle) with blood which can hurt the chamber over time because of volume overload.

Her neck did not reveal any distended neck veins. This was good because it means that the venous return of blood was entering the heart unobstructed-- not blocked from a totally failing heart.

Beth’s heart exam revealed a heart that was slightly enlarged. And sure enough, listening along the left border of her sternum revealed a high-pitched decrescendo murmur during diastole..which meant that her aortic valve is leaking.

Inching the stethoscope out to the apex of her heart below her left breast revealed another murmur. It was loud, medium pitched, and radiated to her left armpit. This told me that her mitral valve was also leaking.

In Haiti these findings mean that Beth most likely had at least two bad heart valves from rheumatic fever that she unknowingly acquired as a child.  (Rheumatic fever is caused by strep throat that is never treated with penicillin. The body’s immune system attacks the strep bacteria and can attack the heart valves at the same time.)

So I peeked at her chest x-ray. It showed a slightly enlarged heart (not too bad) and a big left atrium (not too good). This meant that her mitral valve was indeed leaky and maybe tight (stenotic) too. The good news about her chest x-ray was that her lung fields are fluid in the lungs.

Her echocardiogram, which cost her mother $80 US here in Port-au-Prince,  showed both her aortic valve and mitral valves to be diseased and leaky, but the function of her heart muscle is good. The left ventricle is beating well because the heart muscle has not been damaged to the point where it is stretched so much that it can't contract efficiently.

So what now?

Beth needs heart surgery. And she needs it sooner rather than later. She does not have the cardiac cachexia brought about by a severely weak heart...yet. She can still withstand the organized assault of heart surgery.

Haiti is in shambles. Her heart surgery cannot be safely done here.

So I told Beth and her mother to start working on obtaining her Haitian passport and Haitian Hearts would start looking for a medical center to accept her.

I also started her on other medications to help her heart beat stronger, diurese more fluid, penicillin to prevent further rheumatic fever, and an aspirin to keep her blood thin so she does not form a blood clot in her distended left atrium and have a stroke.

And all of this was caused because she lacked basic health care. No treatment for a sore throat when she was a kid.

John A. Carroll, MD

Saturday, February 18, 2012

Karnival in Soleil

Photo by John Carroll--February 18, 2012

Why We Bring Haitians to the States for Heart Surgery

Photo by John Carroll--February 18, 2012
This is the Internal Medicine Department at St. Catherine Laboure Hospital in Cite Soleil. Doctors Without Borders quit staffing the hospital in December, 2011. MSPP (Ministry of Public Health) in Haiti is now in charge.

Including this dying lady, there are four adult patients in the tiny internal medicine unit. St. Catherine's is the only hospital for hundreds of thousands of people in Soleil.

Monday, February 13, 2012

Patient "154" Arrives in USA Today for Heart Surgery

Haitian Hearts patient number 154 arrives today for heart surgery.

Many thanks to his family in Port-au-Prince for never giving up on him and to Miss Ginny and Miss Amy for supporting him through some tough times.

More later.

Thursday, February 09, 2012

Impunity in Port-au-Prince

February 8, 2012
(Photo by John Carroll)

Impunity in Port-au-Prince

Port-au-Prince, Haiti

IT has been painful to watch as Jean-Claude Duvalier, who inherited the brutal dictatorship that once ruled Haiti, swanks around the hot spots of Port-au-Prince, flanked by the dregs of his regime — including former members of the dreaded secret police, the Tontons Macoute — as if he were just another member of the capital’s thoughtless, partying elite.

Since his return in 2011 from a 25-year exile, Mr. Duvalier — Baby Doc — has managed to insert himself into semi-polite society, even finagling a seat near the new president, Michel Martelly, at the memorial ceremony for the victims of the 2010 earthquake. The president has filled many positions in his government with former Duvalier officials and their relatives. In short, he is rehabilitating Mr. Duvalier — and along with him, the extrajudicial code he and his father, Fran├žois Duvalier, governed by. Last month, Mr. Martelly proposed a blanket pardon of Baby Doc — who has been accused of corruption and human rights abuses — telling The Associated Press, “I do believe that we need that reconciliation in Haiti.”

A day later, after a cry of indignation from Haitian and international groups, he claimed he had been misunderstood. But it turned out his pardon wasn’t even necessary. On Jan. 30, the investigating judge on the case recommended that all human rights charges against Mr. Duvalier be dropped and that he be tried instead in a lesser court on charges of financial malfeasance. Amnesty International called the investigation “a sham.”

It is the continuation of Haiti’s tradition of impunity (the veiled meaning of “reconciliation”) that has led directly to the convulsed, inconclusive and violent gyrations the country has made in its attempt to move toward democracy since the overthrow of Baby Doc. Haiti will not achieve real democracy if its justice system remains unwilling to condemn the crimes of the past, punish the perpetrators and make it clear that such abuses will not be tolerated in the future.

In nearly 30 years of power, the Duvalier regimes offered impunity for their operatives. The army and the Tontons Macoute committed gross violations of human rights, including arbitrary arrest, prolonged incarceration without trial, starvation and torture of political prisoners and the persecution and killings of their associates and families.

The violence persisted after Baby Doc fell. While he and his family fled to France aboard a United States cargo plane, crowds wielding rocks and machetes destroyed the homes of known Duvalierists and hunted down and killed dozens of Tontons Macoute.

They did this, a Haitian friend once explained to me, because they knew the courts could not or would not bring the Tontons Macoute to justice. These killings were mostly revenge murders — score settling — and no one in the crowds was jailed or prosecuted for them.

While the country was ostensibly laying the groundwork for democracy, known perpetrators of human rights abuses were only occasionally arrested. Most were promptly released; many escaped. Few have been brought to trial, and even fewer convicted.

In 1987, elections were aborted when a mob of former Tontons Macoute descended on a polling place and slaughtered 34 voters. More were killed in other polling places. It took nine years for Claude Raymond, the former head of Baby Doc’s army and the suspected mastermind of those attacks — if one can use such a term — to be arrested. (In that time, he even presented himself as a candidate for president, though he was excluded from participating in the elections.) He was never tried and died in prison in 2000.

In 1991, Haiti’s first fairly elected president, Jean-Bertrand Aristide, was ousted from office, and in 1994, at least 23 of his supporters were killed by paramilitary forces in Raboteau, a shantytown on the western coast. In 2000, after Mr. Aristide returned to power, 16 of the perpetrators were arrested and found guilty. But after he was overthrown and exiled for a second time, Haiti’s supreme court overturned 15 of those convictions. Only one person connected to the attacks has been incarcerated; he was tried and convicted — of mortgage fraud — in New York. Another person tried in absentia had his Florida lottery winnings garnished and distributed to victims of the massacre.

Today, besides a few bright points — like the conviction last month of eight police officers for killing prisoners after the earthquake — impunity remains the country’s fallback position. It has made a functioning justice system, and therefore democracy, impossible.

That’s why Mr. Duvalier must be prosecuted for his crimes against humanity. If they are dismissed, it will send a cheering message to past and future perpetrators of similar abuses. If he is tried and convicted, those who have relied upon impunity will know that they, too, risk a turn in the dock.

The Haitian people want justice, and the international community must support them. Two days ago, on the 26th anniversary of the overthrow of Baby Doc, a small but vocal crowd of his regime’s victims protested in front of the Palais de Justice. They painted the words “Aba impinite” — down with impunity — in blue spray paint on the court’s white wall.

Amy Wilentz is the author of “The Rainy Season: Haiti Since Duvalier.”