Pain in Haiti

Several years ago, while working in a good sized mission hospital in the province in Haiti, I realized how poorly patients were treated that were suffering severe pain. We had many post op patients, severely burned patients, cancer patients, and trauma patients that were shot, had machette wounds, and were involved in automobile accidents. 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.

When I would walk through the post op ward or the orthopedic ward in the mornings with my bottle of oxycontin, many hands would flash forward in the supine position, as these patients pleaded for this strong narcotic.

Haitians do not have a "stronger pain tolerance" than do other people. We like to think of it that way, but it is not true. What is true, is that Haitians are "more use to pain" than most cultures. They feel some sort of pain each day. Pain is universal.

The hospital referred to above, had several vials of Demerol in the pharmacy and that was it. This hospital was the only hospital on call 24-7 for over 2 million people. The pain medication we prescribed the most was Talwin. It doesn't work near as well as morphine or Demerol.

Some cultures encourage patients to suffer needlessly in silence, and this allows caregivers like me to turn my head a little easier and ignore their suffering as well.

Achieving balance in natural opiods (morphine) control policy is very important for the local minister of health. We were not getting more narcotics at the hosptial where I worked because he would not allow it. And when doctors and nurses in the developed or developing world have burdensome prescription filling requirements, we are discouraged from writing these very important prescriptions. And we shouldn't worry that our 45 year old Haitian with metastatic cervical carcinoma, that could have been prevented in the first place, is going to become an addict. She needs narcotics to ease her way out of Haiti and into Heaven.

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.

Pediatric Cancer in Haiti

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 she had noticed for the last two months big lymph nodes on his neck and under his armpits. He has an occasional fever.

His exam revealed very firm and very large 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 a small amount of 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 in Haiti. I hope my clinical judgment is wrong and hope that he has tuberculosis that we can treat. Pediatric cancer in Haiti is much more difficult to treat and with this little boy, would be next to impossible.

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 the developing world like Haiti, cancer in kids is diagnosed late when treatment options are limited. National expenditures for childhood cancer take a back seat to 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 here. 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?

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 into the clinic. The baby was very irritable, jaundiced, and had a fever of 104 F. It 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 is amazing and 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 germ 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 IV would infiltrate, 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 never received any. 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. In medical terms this is called malpractice. In the developing world, this is called routine care for people that can't pay cash. The baby has a septic joint and most likely has the bacteria in it’s bloodstream as well and is septic. 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 it 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 started. The State of Haiti has failed this baby and mother. Is Haiti a failed state? You decide for yourself.

Two Angels

Yanick seems like an angel. She just appears. Walking out of clinic today into the sun, I was thinking about giving my Coke bottle back to the street vendor who tries to rip me off each day. Yanick was standing in front of me when I looked up.

She was composed, compared to the last time and I saw her. I didn’t know who she was for just an instant. Then it all came back.

She lost her daughter in the hospital about a month ago. Her daughter’s name was Ferna.

Yanick was dressed nicely and carrying her well worn Haitian bible. She had come down the coast two hours today by public transportation from her home to see me.

We sat on the edge of a wall next to the clinic. She started crying saying that she cannot look at the hospital across the street because her baby daughter died there.

I asked her if she buried Ferna. She said “no” and she does not know where her daughter’s body is. I think it went from our little hospital’s morgue to the general hospital morgue in Port-au-Prince. When poor Haitian families have no money for transportation of the deceased or for their funeral, the bodies from the morgue are laid to rest in a common burial ground.

After talking about thirty minutes, Yanick, who lost her own little angel, got on another crowded bus and headed back up the coast.

Tuberculosis is a Sneaky Disease

Tuberculosis is a Sneaky Disease

One-third of the world’s population (2 billion people) is infected with tuberculosis. 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 is patient compliance. You know the Haitians can be very noncompliant with taking their tuberculosis medications. We all know that. 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, machete- carrying-bandits, kidnappers with 9 mm “Caribbean pistols”, and impending 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 had an illness or medication 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 registering an all time low incidence of tuberculosis.) Tuberculosis, that 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 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 “super infected” 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.

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 south of Port-au-Prince. She and her husband returned to the capital but stayed in a differed location due to the violence in Martissant. He lived with her sister but became ill over the summer and so she went and got him and brought him to the clinic today.

Martissant is the name for mountain top slums that ring 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 the belongings they could carry on their head. 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 web log, 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 medial care. Louis-Jacques could be one of them.

Another Lancet article from June, 2006 says the following: “Children under 5 years of age have the highest mortality rates I 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 appeared so similar to the hundreds of other babies that flood the clinic each week. He didn’t smile. He looks terrible. His hair is orange and he coughs a thick nonproductive cough. His mother seemed to care for him as much as she could. Life is very hard here.

I sent him for a chest x ray but the machine is not working. It will be fixed tomorrow. I asked the mother to return with Louis-Jacques tomorrow for the film to see if he has tuberculosis. I gave them a prescription for oral rehydration and antibiotics for pneumonia. Hopefully they will return. They live quite a ways from the clinic and the streets are still “hot’ in more ways than one.

Haiti is in the middle of a civil war after suffering many years of “low intensity warfare”. 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.

"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 today. 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.

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 non responsive 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 mouth and looked 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!)

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.

"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 he had 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” 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 reported that she has four kids at home. None can go to school now because of the civil war in the slum and she has no money since the children's father is gone. They have no money.

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.

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.

UN Peacekeepers in Haiti

The Lancet 2006; 368:816

UN peacekeepers in Haiti

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.

The Lancet

Haitian Children and AIDS

AIDS and Children

The child pictured 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).

A child dies of an AIDS related disease every minute around the world. 2.3 million children live with AIDS globally.

Haiti has the highest prevalence of HIV in the western hemisphere. 3% 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.

Many HIV positive children are now being treated in Haiti and around the world. Their chances for prolonged survival with a higher quality of life have been improved.

Children Raising Children

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. Many become restaveks (child slaves). The children are abused.

Haiti has one of the highest infant mortality rates in the world. Forty percent of Haiti’s children less than five years old suffer from moderate to serious growth problems. Over 90% of Haiti’s kids have worms at some point in their lives.

Neonatal Tetanaus

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 arched. His temperature was 105 F and he was unable to take his mother’s breast milk due to lock jaw. The baby had clinical signs of 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 they were not kept cold enough to retain their potency to allow the mom to mount an immune response to protect 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. 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 due to muscle contraction and is very painful. When contraction of the tracheal and pharyngeal muscles occurs, periods of apnea can occur, and the baby 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.

This is another tragic story. The baby appeared very well formed. Haiti’s infrastructure is pathetic. Low intensity warfare that exists in the developing world is killing its most vulnerable.

Twenty-Eight and Counting

Twenty-Eight and Counting

I counted the number of kids and young adults on the Haitian Hearts list today that need heart surgery. There are 28. The cases are evenly divided between congenital heart disease and rheumatic heart disease. They all need heart surgery.

Some of the 28 patients are OSF-SFMC patients that have been operated in Peoria. OSF refuses to care for these children now. They will die without surgery and other medical centers don’t really jump at the chance to operate international children that have been operated somewhere else. So these Haitian Hearts patients are really in trouble. I examine them here and Haitian Hearts pays for their medication from Peoria, but they need the surgical cure.

Pictured above are four patients that are representative of the 28 on the list that need heart surgery.

The girl at the top is Mirlande. She has the beret with USA printed on it. She is 14 years old and has been short of breath for two years. She can’t walk up a hill very well at all and Port-au-Prince is built on the side of a mountain. Mirlande has a leaky mitral valve that was caused by rheumatic fever that has put her in chronic congestive heart failure. She needs a new mitral valve.

The baby boy below Mirlande, being held by his father, is Ocean. He is 14 months old. If you look closely, you can see that his left chest is larger than his right chest. The reason for this is that his heart is large and pushing the left side of his chest outward. He has a very ominous sounding murmur due to a hole between the lower chambers of his heart called a ventricular septal defect. Each time his heart beats, it sends too much blood to his lungs and too much blood back to his heart. He needs the hole patched in surgery. A good pediatric heart surgeon and team can do this very easily. Before the heart lung bypass machine was available, cardiologists around the world knew their patients had ventricular septal defects, but could do nothing about it except treat them medically. At autopsy, the hole could be seen quite easily. If Ocean does not have surgery, it will not be due to lack of heart lung bypass machines. The technology is in the developed world to help the pediatric heart surgeon perform successful surgery. The problem is the will is not there to help kids like Ocean.

The third photo down is Joseph. He is 16 years old and has rheumatic heart disease that has destroyed his mitral valve. He needs surgery very soon or he will die. He is an excellent student, has a passport, and is ready to travel.

The last child on the list is Jhiny. She is 14 years old. I examined her for the first time and she has a hole between the upper chambers of her heart. This is called an atrial septal defect. She is chronically short of breath. You can see that the left side of her chest is larger than the right side because her heart is sick and enlarged. She needs surgery too. Interestingly, a medical center in the United States evaluated her echocardiogram four years ago and sent her mother a letter stating that Jhiny was "invited" to their medical center for repair for a mere $27,500 dollars but if she stayed longer than seven days, she would be charged $1,500 dollars per day. This seems kind like a cruel letter to send. Her Haitian mother could not afford this since her income is less than $100 dollars per year. So Jhiny is four years sicker.

If anyone out there in cyberspace has any ability to help these kids, please do so soon. If you have a good contact with an administrator or someone who sits on the board of a medical center, please contact them. As a rule, physicians love to take care of international patients, especially kids with heart problems, and will waive their fees.

Thank you.

John Carroll, MD
drjohn@mtco.com
309-648-1087

Guns in Sun City

Guns in Sun City

At night in Port-au-Prince, my wife and I watch the sunset over the ocean. It is beautiful from where we are sitting, but we know all is not well below us in the slum. Cite Soleil (Sun City) is a slum built on a garbage dump on the Bay of Port-au-Prince. We often hear gunshots from automatic weapons coming from that direction. The sounds are very scary to hear and we are two miles away.

Who is shooting? We never know, but we do know the guns are powerful. It could be coming from the gangs in Cite Soleil or from MINUSTAH, the acronym for the United Nations forces in Haiti. The UN forces are at about 8,000. Haiti’s national police do not have the weapons or the training to take on the gangs in the slum and won’t go near them. Almost, no one, except people that live in Soleil can come and go, and they do so only with trepidation.

Two weeks ago President Preval asked the gang leaders to turn in their weapons in an attempt to restore order in this country of constant chaos plagued with armed robbery, car jackings, and kidnappings in the middle of the day. President Preval made it clear that blood would be shed if the guns were not turned over. The gang leaders responded that they would turn in their guns yesterday, but then changed their minds. The gangs blame MINUSTAH for continuing their violent assaults in the streets of Cite Soleil and their leaders state that MINUSTAH doesn’t really want “peace and disarmament because they want a justification for their presence here (Haiti).”

Several months ago, my wife and I “toured” Cite Soleil with the protection of two gang leaders. Soleil looks and smells horrible as usual, but the pock marked bullet ridden buildings are very scary and sad to look at. This dump is the home for hundreds of thousands of people. The gang leaders insisted that all they want are jobs which can provide them with enough money to feed their families.

Each morning in clinic, I see babies carried by their mom or dad who have walked out of Cite Soleil that morning, sometimes dodging bullets, to get rudimentary medical care for their child. They are risking their sick baby’s life and their lives to venture out of the slum. The parents act like parents in the states. They want the best for their children and will do anything they can to provide it including going through gunfire to get it. I often ask myself what that parent would be doing in the United States. Would they be using a computer, would they be working in a bank, or would they be a mechanical engineer? These parents have no real jobs even though they work all the time to put a little food on their children’s plates at night. But their hopes for their children are the same as ours.

When people with big guns fight, the little people are always caught in the middle. The kids that cannot go to school, get a good meal, or obtain basic medical care, suffer the consequences. A simple medical problem can and does become life threatening as the guns keep firing in Sun City.

Two Haitian Babies on Hunger Strike

Two Haitian Babies on Hunger Strike
Port-au-Prince, Haiti
August 9, 2006


Two Haitian babies from Port-au-Prince are on a hunger strike. Blackson, aged seven months, and Saintvil, aged four months, are the two babies identified. Authorities believe that hundreds of thousands of other Haitian babies are in hiding and doing the same.

Blackson is from Cite Soleil. His main dislike is the continuing violence in his slum that has not allowed his mother to sell crackers and soda on the corner to earn enough to buy him any powdered milk during the last month. Her milk is gone with her own medical problems. Gang violence is the main problem with nearby shootings occurring almost everyday. But Soleil has never been good since it was built on a garbage dump on the edge of the ocean, and most residents have no clean water, enough food, electricity, work, schooling, medical care, or hope. Blackson’s mother is 19 years old and reports that he has a fever, his hair has turned orange and is falling out, and his skin is swollen. He is also refusing the baked mud pies that she makes for him each morning

Saintvil is from downtown Port-au-Prince close to St. Joseph’s Church. Saintvil’s mother is 16 years old and takes him to a free medical clinic run by the Missionaries of Charity sisters on Saturday mornings. He is one of 500 babies that show up. Like Blackson, Saintvil has orange hair and a high fever. He also has sores that have crusted and become bloody scabs over much of his body. Saintvil’s mother reports that he has bloody diarrhea and has a nasty cough. His blood count appears very low with his skin appearing almost white. He refuses to eat for similar reasons as Blackson.

Both babies declined treatment at the General Hospital in Port-au-Prince and insisted on being taken to the Missionaries of Charity home for their care. Their mothers report that they are very upset with the shooting of a sister in a city two hours north of Port-au-Prince over the weekend.

Blackson and Saintfil refused to be interviewed for this story.

"Secretary Annan, Ferna is Dead..."

Attention: Secretary-General Kofi Annan, United Nations


Dear Secretary Annan,


Pediatric Clinic in Port au Prince this morning began as usual. The first baby was seven months old, had a fever, and was breathing 84 times per minute. Both lung fields had wheezing and crackling sounds. The baby was fussy but not especially toxic appearing. I took him to the rehydration room and started bronchodilator aerosol therapy which he seemed to like. The baby was also given a shot of a strong antibiotic and sent home to return tomorrow.

The second baby was a four day old that I saw yesterday with a fever of 103. The baby had been born at home with a midwife (matron) helping with the delivery. The only source of fever that I found was an umbilical cord that was tied off with a dirty piece of string. The matron had cut the cord with a Gillette. I gave this baby a big dose of antibiotics and advised the mother that fever in a baby this age could be very dangerous and even deadly. As she promised, she returned to the clinic today. The baby was afebrile today and looked ok. We changed the umbilical dressing again and gave the baby another shot of antibiotics.

Secretary Annan, as I was beginning to call the third patient into the room, my office door burst open. Falling into the room was the sobbing mother of Ferna who we admitted to the hospital in April. Her face was contorted in pain, sweaty, and tears were flowing as she was screaming, “Ferna died!” I tried to deny this was happening, but after so many years in Haiti, I knew almost immediately this was indeed happening and this is how death takes Haitian children and destroys their mothers. Ferna’s mother is named Yanick.

I literally drug Yanick into my office as she knelt on one knee and sobbed uncontrollably. I closed the door as all the mothers and babies in the waiting area were witnessing the grief of this young mother. I stood over her and rubbed her back not knowing what else to do. Her shoulders were shaking in grief. She told me that she had just come to the hospital across the street to visit Ferna and was told by the nursing staff that Ferna had a seizure and died last night. Ferna’s bed was empty. She had lost her ten month old precious child.

After several minutes of talking, I was able to lift her into the chair where children and their mother’s sit and tried to calm her down some more. Nurses came in the room and put dossiers on my desk barely recognizing the sobbing 29 year old mother in front of them. It wasn’t a sign of rudeness on their part. It was just another routine day in a Haitian pediatric clinic.

Secretary Annan, my heart and insides were repulsed with everything. I didn’t want to see any of the patients or their dossiers that were quickly piling up on my desk. I just wanted to leave. But I knew that would be wrong for many reasons.

After a few more minutes I helped Yanick to the exam table in the office where she laid down and with coaxing was able to slow her breathing. Profuse sweat and tears still flowed freely as she wailed again and again, “Oh Jesus! Ferna is dead”. Her eyes searched my eyes as if she was asking if what she was saying was really true. The pain on her face was so deep.


I noticed that on the floor next to my desk was a piece of cloth that the mother with the febrile infant had accidentally dropped on the floor when she left my office. I poured cool water on this cloth and placed it on Yanick’s forehead and temples and covered her eyes.

I told her that Ferna was in Heaven and would watch over her now in Haiti and that God wanted her and she couldn’t question that. I told Yanick that Ferna would now help her when she fell under Haiti’s heavy load. She nodded her head. Tears rolled down the side of her face under the wet cloth, but she said nothing. This was all very horrible.

I made the decision then that I needed to get it together, as Yanick had done, and see patients that were waiting. I let Yanick lay there while I examined children all morning and gave their mothers advice. I wondered what Yanick was thinking about all of my “advice” at that point.

The mothers would stare at Yanick as she laid about 8 feet from them as I examined their children. Word had spread in the waiting area that she had lost her baby. No one offered any sort of support for her whatsoever. They all had their own problems with their sick little ones. Severe poverty everywhere is paralyzing.

During the day, I changed her wet compress frequently. Yanick continued to lay supine and remained silent. She may have gone to sleep. Towards the end of the clinic, I offered her Coke which she sat up and drank and then laid back down.

Yanick and her husband come from a city an hour north of Port-au-Prince and had rented a tiny room in a nearby slum named Jeremy City. She needed to get back to the slum to call her husband, who she thought had gone home, and tell him of Ferna’s death. Ferna’s little body will be held in the morgue at our hospital and then transferred to the general hospital morgue downtown where her mother and father will have to retrieve it if they want to bury her near their home. Another problem is they need to hire an ambulance to transport their daughter because no tap-tap driver will knowingly take a corpse. That, of course, is an expensive ordeal and is the reason some Haitians take their loved ones home from the hospital right before they die so they don’t incur the cost of transporting the body. The last few days, Yanick seemed quite concerned when she came to the clinic to visit, but Ferna’s death was not anticipated.

As Yanick and I prepared to leave the clinic, the head nurse told Yanick to protect me because of the frequent kidnappings in the capital as I walked her to her slum. Yanick promised she would as her body was still shaking in distress from her daughter’s death. At that point, I did not know who was helping whom.

Secretary Annan, Yanick and I left the clinic and headed out onto the street that runs in front of the hospital. The sun was out in full and helicopters were circling above us with your arrival and first visit to Haiti. How did Port-au-Prince look from the air?

As we walked up the crowded street Yanick started to weave and began crying again. I lightly held her right elbow. Many people watched us as we proceeded. A number of women tried to help her and talk to her as she kept repeating, “Ferna is dead”. After we walked one half mile one of her leather sandals fell apart and she walked barefoot on the hot cement until another lady retrieved her shoe, fixed it with a piece of wire, and Yanick slipped back into her pathetic sandals.

We soon turned down a paved road as Yanick pointed to the left and after walking another quarter mile arrived in her horrible slum. I asked Yanick if we were close to where she and her husband were staying and she said yes. Dust, squalor, dogs, and debris were everywhere. A few feet later, she began pounding on a door and screamed wildly. The door was opened slightly by a woman and we slipped inside.

There were about 5 adults and 3 kids in a small central area with the whole compound about 40 square feet. The heat inside was unbearable. Their seemed to be no air circulation. Two babies were perched on a green army cot and a smiling eight year old boy was squatting next to them on the dirt floor. The roof was corrugated steel, and three of the four walls were slapped together with steel and pieces of plywood. The fourth wall was made out of 10 foot high compressed garbage.

Yanick immediately began jumping up and down in the dirt, barefoot and screaming that her baby had died. The adults looked at her but only the lady that let us in did anything. She gave Yanick two tablespoons of real strong appearing cold coffee loaded with salt, as Yanick fell into a broken metal chair. Amazingly, a 20 year old looking man was sitting in another beat up chair a few feet away receiving a pedicure from a teenage girl who barely looked up from her job.

Someone told Yanick that her husband was in their room. This startled both of us and she walked about 15 feet around the side of the compound. I followed her and looked into a small dark room and saw her husband lying on a thin cloth mat on his stomach. He looked up just briefly at us as Yanick screamed about Ferna’s fate. He then put his head back down and said nothing.

After about 15 more painful minutes, I felt my contributions were extremely minimal at this point, and told Yanick I would see her back at the hospital in the morning. We would talk about what to do with Ferna.

I felt no fear from anyone walking out of the slum that has been the home for this mom and dad as they visited their hospitalized daughter almost everyday since April. What I witnessed today will forever be etched in my brain. The pain of the poor is horrifying. I have seen many babies die in Haiti, but Yanick’s total desperation, grief, and loneliness in a city of three million people were too much.

Ferna had congenital heart disease and tuberculosis. She put up a great fight but the cards were stacked against her from the beginning. We couldn’t find a hospital for her in the United States to repair her heart. Ferna gave us time, but we who have everything didn’t come through.

Secretary Annan, as I walked home, the helicopters continued their security checks as you were arriving to meet with Haiti’s leaders. The misery on the ground is intense. We all hope your meetings with Haiti’s new leaders will be productive.

Sincerely,

John A. Carroll, MD

Ferna

In April we examined a seven month old Haitian girl in the clinic in Port-au-Prince. She only weighed nine pounds and had been having fevers and labored breathing. She was brought to the city by her mother from her home about an hour north of here. Her name is Ferna.

Ferna’s exam revealed a loud murmur over her chest. A murmur is “audible turbulence” from flow of blood through the heart. Some murmurs are considered innocent and others signify real disease. Ferna’s murmur definitely reflected real disease. She also had a fever and crackles in her upper portions of her right lung which most likely meant she had some type pneumonia.

I told Ferna’s mom that she needed to be admitted to the hospital across the street from the clinic. Her mother was very happy to receive the news that her daughter would receive care. However, there was no room in the pediatric section of the hospital, so she and Ferna slept in the hospital courtyard that night and Ferna was admitted the next day.

Her chest x-ray revealed a large heart due to congenital heart disease and her lung fields were filled with an infiltrate that appeared to be tuberculosis.

Several months have passed since Ferna was admitted and she remains in the hospital which is the best place for her in Haiti because she is fed nutritious food prepared in the hospital, gets her medication each day, and her mother gets to visit her. She has been placed on the national Haitian tuberculosis regimen for which is three drugs for two months followed by two drugs for the following six months. Her fevers have abated and she looks some better.

However, her congenital heart disease persists and her echocardiogram performed here in the capital shows a hole in the wall between the lower chambers of her heart which allows too much blood to circulate through her lungs with each heart beat. Therefore, she is taking diuretics to keep her lungs dry.

So now what? Do we successfully treat her tuberculosis and discharge her to her city north of here so she can die from her congenital heart disease that can only be repaired with surgery? If that is the case, why are we treating her tuberculosis so aggressively so she can die from another treatable disease?

Paul Farmer and his colleagues have proven that treatment of multidrug resistant tuberculosis and even HIV is possible to successfully do in resource poor settings, such as Haiti. Treating these hard-to-treat diseases actually improves the general level of care given to poor populations. Who would have predicted this? Would performing heart surgery in Haiti some day increase the overall level of medical care? Extrapolating from Farmer’s research would say that it would.

So if developing world patients receive treatment for HIV and very hard-to-treat tuberculosis, why does Ferna not deserve surgical treatment for the tiny hole in her heart that is wreaking havoc on her circulation and will cause her death? What exactly is the down side to saving Ferna’s life?

I propose that Ferna be operated quickly in the United States. I also propose that no baby in the world should die from a hole in their heart in 2006 due to negligence from the world that has everything. The technology is available and a good repair of a mechanically deficient heart can lead to many good years for the child. With the obscene amount of money spent in the developed world for cosmetics, dog food, cigarettes, and military expenditures, developed countries have no excuse not to operate these children from around the world and set up programs to teach developing world physicians the science of delicate pediatric heart surgery.

I also believe that skilled physicians in the United States that want to perform pro bono surgeries in their medical centers on babies like Ferna should be allowed to do so. Doctors need to do what is right and patching holes in babies that are slowly suffocating is the right thing to do. If Catholic hospital administrators disagree because of medical center costs, they need to figure a way to lower costs.

However, if only one doctor approaches hospital administration regarding operating a child from abroad, he or she can easily be rejected and marginalized. Physicians need to show a united front with the entire pediatric department demanding to treat international cases each year. If administrators disagree, they should be removed from their positions as the Ethical and Religious Directives for Catholic Health Care Services imply (Directive 5). Catholic bishops around the United States need to support these physicians and children like Ferna and not try and just appease the big Catholic Medical Industry in their diocese. The Catholic medical centers need to be challenged to do the right thing and act for the reasons for which they were founded---taking care of the poor who need their care.

The Haitian physicians and medical system are doing their best with Ferna. Her mother now hopes and prays for heart surgery for her baby daughter in the United States. In Haiti, the technology eventually needs to come here for complicated heart surgery that requires bypass. Haitian physicians need to be trained, and Haitian babies need to be operated here in Haiti by Haitian physicians. But in the mean time Ferna is not going to wait for all of us to make this happen.

The clock is ticking. Any advice on what I should tell Ferna’s mother?

When Grandma is Gone....

July 21, 2006

We are working at a clinic in Port-au-Prince right across the street from the hospital where we admit the sickest kids. We walk to this clinic in the morning and pass three Haitian police. The officers, one with an automatic rifle, stop the oncoming traffic to check the registration of the vehicles and verify the driver’s license. Several weeks ago a Haitian lady was attempting to stop a carjacking just outside our clinic in the middle of the day and was shot to death in the street by the thieves.

In the recent couple of weeks, the kidnappings have increased in the capital and all the Haitians tell us the “streets are bad”. Many memos on the internet talk of the renewed chaos and violence in Port-au-Prince. Dozens of kidnappings apparently occurred this month. Deposed President Aristide’s birthday was the other day, so he was blamed again for the violence, even though he now lives in South Africa. We were warned by an American friend, who was a kidnapped last fall, not to walk the streets in this part of PAP, and he offered us a vehicle he sent down for our use. But we feel safer on foot and taking public transportation.

Today was a potpourri of pathology in the Haitian pediatric clinic. All pathology is bad especially if you are the one that has it, live in Haiti, and almost no one cares.

One of our first patients today was a baby girl named Tamaika who weighed about ten pounds and was nine months old. She had been having vomiting and diarrhea for one week and had a temperature of 105 F. Her mother stressed the fact that she has no job or money and could not take the baby to the doctor before today.

The baby was obviously very dehydrated and severely malnourished. Her eyes were sunk and her skin tented when pinched. Her arms and legs were sticks—almost completely devoid of muscle. But, as a true Haitian would, she would swing her arms at me and fought when I attempted to examine her.

A baby like this can be septic along with the dehydration. We brought down Rocephin and gave the baby a big dose immediately and admitted the baby to the hospital for IV antibiotics, fluids, and work up.

A five year old girl, Cynthia, came with chief complaints of two weeks of shortness of breath, fever, lack of appetite, and crying with abdominal pain at night. Her attentive father and mother offered the history at the same time. The girl looked well developed but would scream out in an irritable fashion and then almost fall asleep the next second. Of note were the bounding carotid pulsations on the left side of her neck and the hyperdynamic pulse at her right elbow. This meant that her blood was so thin it was causing her vessels to expand and collapse quicker than normal thicker blood would do. Her conjunctiva where white and her tongue and mucous membranes were very pale. Her liver and spleen were very big and intimately involved in her anemia. Her heart rate was only about 100, so she had compensated for her anemia. In my opinion Cynthia had been this way for awhile. Sickle cell is most likely with some iron deficiency contributing to her severe anemia.

We admitted her also. Her blood was very thin and looked like pink Kool-Aid.
Her hemoglobin returned very low at 2.5 and her white count was very elevated at 59,000. Her father will need to go to the Haitian Red Cross and donate blood and obtain blood for her transfusion.

A beautiful five year old angel was one of our last patients and was brought in by her grandma who appeared to be about 60. According to grandma, the child’s mother had died one and one-half years ago when “she had abdominal pain and became thin” in a city 12 hours from Port-au-Prince. Grandma is now doing another family’s laundry in Port-au-Prince to support the little girl. The girl’s check up was pretty good except for anemia and pneumonia.

At the end of her exam the little girl kissed my wife Maria when she got a piece of gum. As grandma and the little girl left the room Maria wondered what would become of the little girl when Grandma is gone.