My lists have lists!

Three weeks today I will arrive in Haiti!

Last week I contacted Health Partners International (HPI) Canada to arrange to purchase some medications to take to Haiti. I sent HPI a list of medications in short supply at the Project Medishare Hospital. HPI obtains medications from Canadian pharmaceutical companies and offers the medications at wholesale cost to physicians who volunteer abroad. They have helped me in the past in Nicaragua.  

I rec'd a schedule with a list of volunteer physicians who will be in Haiti during December. Friday, the day I arrive, there will be two pediatricians on the service, but they are scheduled to leave the next day. Presumably we will have time for Changeover Rounds. A key component of good care is the transfer of knowledge, plans, and instructions to the new team. So far, I am the only pediatrician on the list for the first two weeks.  

I made a list of the common medical problems that I will encounter and I've been reading and studying these topics. I might have handled most of the problems before, but I don't manage tropical disease on a regular basis, and a refresher course is always helpful. I condense most of the topics into blogs. Reading, making notes, and then preparing a blog from pertinent material helps me learn a topic. The blog serves as an online resource if I need to remember something. My topics on the study list for the next week include anemia in Haiti, filariasis, worms and parasites, and the status of immunizations in the country. Over the next week I hope to post blogs with some of the information I learn about these topics. 

Lists help me organize my thoughts and lately I have been in list mode. Anyone who knows me understands that I am always in list mode, so what I really mean is that my lists now have lists. 

Community water outlet. Photo from March 2010 trip. 

Haiti ranked 147th out of 147 in a Water Poverty Index study.  

Tuberculosis in Haiti

As a young boy, the only things I recollect about TB were Christmas seals, which supported the care of individuals with the disease, and Sanatoriums, where those infected were isolated from the communities at large.

Acid-fast TB bacteria in a sputum specimen, courtesy CDC

As a young man, I learned that many of my favorite authors (Robert Louis Stevenson, Charlotte Bronte, DH Lawrence, John Keats, Robert Burns, Anton Chekhov, George Orwell, Robert Heinlein, Sir Walter Scott) suffered from Consumption, which is what the disease was called, because the illness eventually consumed the individual.

During medical school and my early hospital years, TB was not a common problem in my clinical world and this continued until the HIV era, which resulted in a resurgence of the infection. With HIV so prevalent in Haiti, TB became a real problem for the population, and the infection is now the leading cause of death in those Haitians infected with HIV.

TB is spread in the air when an infected person coughs or sneezes, and the crowded unsanitary living conditions in Haiti are a perfect setting to transmit the infection. Haiti has the highest prevalence of TB in the Western Hemisphere. About 3 individuals in a thousand in Haiti are known to have TB and experts believe that half as many again have unrecognized TB.

Partners in Health (PIH) and GHESKIO offer TB prevention and treatment programs in Haiti.  Recently, courtesy of support by the Center for Disease Control and other organizations, the ability to diagnose and treat TB has improved in Haiti. New Light Emitting Diode fluorescent microscopes are present in 10 health facilities and allow superior diagnostic accuracy compared to conventional microscopes. A new TB laboratory opened in October 2011 and offers TB culture and drug sensitivity testing.  A cutting edge rapid diagnostic test for diagnosis and identification of Rifampin resistance is available.

Treatment requires a long course of therapy (typically at least 6 months) with multiple antibiotics. Failure to complete the recommended course increases the risk of Multidrug-resistant (MDR) TB and this is a growing problem in Haiti. MDR TB increased from 1.4% in 2004, to 1.8% in 2007, to 2.9% in a recent study in Port-au-Prince. Directly Observed Treatment (DOT) programs minimize the risk of MDR TB. Careful follow up with repeat sputum tests are essential to pick up individuals with MDR TB.

Next month in Haiti I will have my clinical eyes open for children with a wet cough, blood-tinged sputum, fever, chills, and night sweats. I'll also keep a look out for scrofula (TB lymphadenitis) and Pott's Disease (spinal TB). My N95 particulate respirator masks are already packed.

HIV in Haiti

Almost a third of a century has passed since AIDS secured a top spot as one of the medical scourges of the twentieth century. In Canada, a diagnosis of HIV is no longer a death sentence and some, I suspect, presume the disease is something like polio, an historical infection that we no longer need to be concerned about. In Haiti this is certainly not the case. Even in Canada the infection continues to be a health care challenge.

T4 cell (green) infected with HIV (red) courtesy of Medscape

In the early 1980's the Center for Disease Control in Atlanta, Georgia, in a moment of glibness, determined that AIDs was a problem in homosexuals, hemophiliacs, heroin users, and Haitians. This played well for the press but did not tell the real story. Sadly, Haiti was labeled as a member of the "4 H club," and this stigma has stayed.

Haiti, however, has done better than most under-developed countries to prevent infection with HIV. Pro-active preventative efforts reduced the prevalence rate from 9.4% in 1993, to 3.7% in 2003, and to 1.9% by 2009, the year before the earthquake. About 120,000 people in Haiti are infected with HIV and of these, 61% of the adults are women. There are about 12,000 children with HIV.

Courtesy of Partners in Health (PIH) and other groups, antiretroviral treatment (ART) is available free and in 2011, this group alone provided ART to about 6,300 individuals in Haiti. However, PIH understands that while lifesaving, the medications are not the real answer, and that without housing, water, food, and psychosocial support, the problem will not be solved. To paraphrase a Haitian proverb, to provide medicine alone is like asking someone to wash their hands and then dry the hands in the dirt.

The cost of the medications has been an obstacle but after worldwide pressure from a variety of important groups, the phamaceutical industry has reduced the cost of ART from several thousands of dollars a year to less than $150.

A recent New England Journal of Medicine article about HIV in Haiti (Severe et al, 2010;363:357-65) reported that earlier treatment with ART, when the CD4+ counts are 200 to 350 per cc (higher than current criteria to start treatment) resulted in a 75% reduction in death and a 50% reduction in the incidence of tuberculosis. Wow! The authors estimated that the cost for 2 years of ART in this group of individuals is about $400 per person.

Next month in Haiti, I expect to see children with the infectious complications of HIV and AIDS. I will have my clinical eyes open and my gloves on.

Cholera In Haiti

Cholera is as old as recorded time but amazingly, this infection is new to Haiti! 

Hippocrates (2,500 years ago) wrote about an illness that was likely cholera. In the last two centuries the world has suffered 7 cholera pandemics. The seventh started in Indonesia in 1961 and the bacteria reached Haiti in the aftermath of the quake in 2010. Prior to that, cholera was one of the few plagues that had not affected Haitians in the last century. 

Vibrio cholerae, the bacteria that causes cholera, can kill in hours, and in the first two years since the quake, cholera has killed more than 7,000 Haitians and infected at least another half million (5% of the population). Cholera continues to kill in Haiti and in the aftermath of the recent Hurricane Sandy, a rise in deaths due to cholera occurred. 

                      Vibrio cholerae, courtesy Harvard Gazette.

Doctors who work in Canada do not see cholera. Cholera is a disease of poor countries and of people who do not have access to clean water and modern sanitation. Since my experience with cholera is limited, and since the disease is now common in Haiti, some research on the topic seemed appropriate. 

The bacteria infects a person who ingests contaminated water or food. Person-to-person transmission or contagion from an animal or insect is not a concern. The infection rate in household contacts is about 20 to 50%, because families eat and drink the same meals. The amount of the bacteria necessary to cause disease is lower when acquired in food compared to water. The bacteria affects the cells in the first two parts of the small intestine and causes horrendous losses of salt and water in the gut, and death is usually due to shock. 

There are over 200 serogroups of cholera and of these, the O1 and O139 types are the ones responsible for most of the disease. The Haiti serogroup is O1 and identical to the bacteria from Asia that is responsible for the 7th pandemic. The Haitian bacteria is thought to have arrived with Nepalese soldiers with the United Nations Peacekeeping Force. Ouch!

After a 24 to 48 hour incubation period, an infected individual develops profuse watery diarrhea that looks like "rice water." Vomiting is common. Abdominal cramps might occur. Fever is not common in adults but might be present in children.  

Most individuals who are infected do not have any symptoms and most of those who do usually have a stomach flu illness that does not look much different from ordinary gastroenteritis. However, for the 5% of individuals who develop Cholera Gravis, the outcome might be fatal. In developed countries, the fatality rate is about 1%. In Haiti the fatality rate was as high as 9% at the outset in 2010 and is still as high as 4.5% in the regions outside of Port au Prince, but is now only 0.7% in the capital. 

Prevention is always the best method to control any problem. However this requires clean water and modern sanitation, which sadly is not an option for the immediate future in Haiti. Only 63% of the population has access to clean water and fewer than 20% have improved sanitation (Lancet 2012). The goal is to keep contaminated poop away from water and food.  

Still, good hand washing and food preparation techniques. and good water supply management can make a big difference. During an epidemic in London, England in 1854, Dr. John Snow identified water from a pump on Broad Street as the source, and removal of the pump handle contained the epidemic!

Boiling water, water purification tablets, chlorine, and ultra-violet sterilization of water are all effective. If you are boiling a crab, 8 minutes is not enough, but 10 minutes is sufficient. 

Breastfeeding is protective because this limits exposure to contaminated food and water, and there might be protective antibodies present in the mother's milk. 

The literally lifesaving treatment is to replace the salt and water lost from the body and to keep up with the ongoing losses until the infection runs the natural course. The body can lose 250 ml (one cup, 1/4 liter) per kg of body weight over a single 24 hours!!!

Antibiotics reduce the diarrhea and the length of time the bacteria is excreted. Low blood sugar is common and even more common in malnourished children, which is a sad fact of life in Haiti. 

In about a month, I expect my limited experience with cholera will change.   

Going Back to Haiti

After the devastating earthquake in January 2010, help from all around the world poured into Haiti.

The spontaneous and enormous outpouring of international aid at that time raised a hope that notwithstanding the abject misery and the rubble, that perhaps a new and better Haiti would emerge.

Sadly, in the almost three years since the earthquake, Haitians continue to suffer and despair reigns in place of hope.  

Haiti is still the poorest country in the Western Hemisphere. Only 10% of the population have a job. Over 300,000 people continue to live in squalor under tarps as the only housing available.

During the two weeks I volunteered in March 2010 I worked for several days in the Project Medishare "Mash" hospital tent. Project Medishare continues to run the  only acute care hospital in a country of 10 million!

This Christmas I decided to return to Haiti to work in the Project Medishare Hospital. Health care professionals and supplies continue in very short supply. I will do my best to help those I can in the three weeks I have available. Surely if we all continue to help, Haiti can be re-built as a better place.

My report on my experience working in Haiti in the aftermath of the earthquake was published in Consultant Pediatrician. You may read the report together with photos in the link below, but you are requested to sign in to their free website. 
http://www.pediatricsconsultantlive.com/display/article/1803329/1633367
You may read the report without photos in the link below that is on my clinic website. 
http://www.childrensclinic.ca/html/haiti_relief.html

Health Care Data

I came across some data on the changes in a variety of conventional indices of health care in Nicaragua since 1995. The data was complied by MINSA, the Ministry of Health for Nicaragua, for the Pan American Health Organization/World Health Organization PAHO/WHO

	1995	1998	2000	2001	2005
Percent of infants with low birth rate	8.7	9.0	8.2		8.4
Percent of children less than 5 years with moderate to severe malnutrition		24.9		20.2
Percent of mothers who exclusively  breast feed for the first 120 days of life		29.5		39.3
Percent of births assisted by skilled health personnel	68	69.2	73.3	73.4	79.8
Annual vaccine preventable illnesses	458	2604	402	242	48
Annual number of dengue cases		2618	1009	2661	1915
Annual number of malaria cases	71380	34146	23878	10498	6642
Annual number of TB cases	69	54	47	48	35

The data suggests progress, which is great, but also shows the need for continued efforts.

One out of four adolescent women 15 to 19 years is already pregnant. Adolescent mothers, low birth weight, and chronic malnutrition are linked. The one adolescent mother who attended the clinic during my last visit ("Very Young Mothers," January 5, 2012) had a low birth weight infant and the infant was not gaining weight. Without intervention this infant is destined to be one of the 20% of children less than 5 years who will be malnourished.

A 2006 to 2007 survey reported that the fertility rate rate fell from 4.9 children per woman in 1995 to 2.9 a decade later. However there is a huge difference between the urban centers and the rural areas. In 2005 the fertility rate in the cities was 2.5 children per woman compared to 5.5 in the rural areas. My experience in the rural clinic where I help out supports this. Maternal mortality account for nearly 4% of all deaths.

A 2006 to 2007 survey reported child malnutrition in 20.4% of children under 5 and 5.1% with severe malnutrition. Malnutrition is twice as common in the rural regions.

Acute pesticide poisonings are vastly under reported.

Immunization coverage of children under 1 year with polio and pentavalent vaccines has declined by almost 6% since 2001.

The leading causes of infant mortality continue to be acute diarrheal diseases and acute respiratory infections.

Only 31.1% of Nicaraguan households have household water connections to potable water.

Book Review - The Naturalist in Nicaragua.

Belt, Thomas. 
The Naturalist in Nicaragua, 
University of Chicago Press, 1874.
Book Review and Selected Notes.

Thomas Belt was a 19th century mining engineer whose professional career included work in Australia, North Wales, Nova Scotia, and finally Chontales, Nicaragua. He was born in Newcastle, England in 1832. Belt was a naturalist by nature and wherever he worked he made precise and often ground breaking discoveries of the local flora and fauna. Charles Darwin hailed his book as “the best of all natural history journals which have ever been published.” High praise indeed. My reading supports Darwin’s opinion. Belt had a historically precocious scientific sense of animal behaviour.

Belt’s Nicaragua journey started with his arrival by boat at San Juan del Norte, the Atlantic outlet of the river that drains Lake Nicaragua. He travelled inland by river and at one point, “calculated that the highest elevation between the two oceans is only about 133 feet.” “There can be no doubt that at this point occurs the lowest pass between the Atlantic and Pacific in Central America.” This route was the main alternative to the Panama Canal.

Coffee, indigo, hides, cacao, sugar, logwood and india-rubber were the principle exports of the time. Today coffee, cacao, sugar, and hardwood continue as export commodities. Maize was sown in May and December, which is still the situation. Belt planted orange, lime, and citron trees, and lived in Nicaragua long enough to see the trees bear fruit. He described mango, avocado, pineapples, fig, grenadillas, bananas, pumpkins, plantains, papaws, and chioties. Notwithstanding the abundance of fruit he noted that the local diets were “beef, or a fowl, brown beans, rice, and tortillas,” and he commented about local markets, “Not a green vegetable, not a fruit, can you buy.” Balanced nutrition continues to elude poor Nicaraguan families.

Insects were a special interest to Belt, and how birds or other animals related to the insects was a common topic. For instance he describes the Toucan bill as
“beautifully adapted for picking up the ants before they reach the nest,” and for “picking insects out of crevices and corners.”

Ancient artifacts captured his attention. Nicaragua was part of the Aztec and Mayan empires. He noted the cross in some artifacts and commented that the
“cross in Central America greatly astonished the Spanish discoverers. In Yucatan and throughout the Aztec Empire it was the emblem of the “god of rain.”

About family, children, and marriage, he wrote,
“Nicaragua men and women often change their mates. In such cases the children remain with the mother, and take their surname from her. Baptism is considered an indispensable rite, but the marriage ceremony is often dispensed with; and I did not notice that those who lived together without it suffered in the estimation of their neighbours.” My blog "Poverty, Child Labor and Child Prostitution" (January 6, 2012) reports that this cultural practice continues.

Politics does not seem to have changed much. “The states of Central America are republics in name only; in reality, they are tyrannical oligarchies. They have excellent constitutions and laws on paper, but both their statesmen and their judges are corrupt; with some honorable exceptions, I must admit, but not enough to stem the current of abuse. Of real liberty there is none. The party in power is able to control the elections, and to put their partisans into all the municipal and other offices.” Many current observers would agree that this 138 year-old statement is an accurate description of the November 2011 election in Nicaragua. 

Greater Yellowlegs.
As the shore water receded after late afternoon waves, small minnows flopped and sparkled in the surf. A Snowy egret, Spotted sandpiper, and this Greater Yellowlegs competed for the tiny fish.