Yaws in Haiti

In the Dubois book I reviewed in a prior blog, Haiti - the Aftershocks of History, I learned that Duvalier, the infamous Papa Doc, graduated and worked as a medical doctor before he became a much-reviled tyrant and dictator. As a medical doctor, he worked on a Yaws eradication program in Haiti. Go figure.

"Yaws," I thought when I read the book. "What do I know about Yaws?" "Not much" was the answer, and since this disease is still present in Haiti, some reading was in order. 

According to a May 2012 World Health Organization (WHO) report, Yaws is "widely prevalent" in Haiti. Almost 75% of people affected with yaws are children under 15 years, and the peak incidence occurs in children aged 6–10.

  

Yaws is a chronic bacterial infection due to Treponema pallidumpertenue, a slender spirochete that is serologically indistinguishable from the bacteria that causes syphillis. The germ is transmitted primarily through skin contact with an infected person.

After an incubation period of about three weeks  (9-90 days), the primary lesion, or the mother yaw, develops where the germ enters the skin in a scratch, bite, or abrasion, most commonly on the legs, feet, or buttocks. The initial lesion is a red, non-tender, papule or nodule.

The mother yaw ulcer develops a honey-brown crust and enlarges up to 1 to 5 cm in diameter, sometimes coalescing with satellite lesions. The crust frequently sloughs and reveals a raspberry-like base. The exudate of the raspberry-like ulcer is teeming with treponemes and these lesions are highly infectious. After the mother yaw heals, an atrophic scar with central hypopigmentation remains.

Following about 6 to 16 weeks of latency, disseminated skin lesions, bone lesions, and constitutional symptoms develop. The cutaneous lesions, or the daughter yaws, resemble the mother yaw but are smaller and only up to 2 cm and are frequently located adjacent to body orifices, particularly the mouth and the nose. The daughter yaws expand, ulcerate, and exude a fibrinous fluid teeming with treponemes, which dries into a crust. The exudate attracts flies, which are bothersome to the person who is affected.

Secondary "daughter yaws." Photo courtesy WHO.

Lesions on the sole of the foot can form thick, hyper-keratotic plaques that become fissured or eroded. These lesions are painful and cause a deliberate crab-like gait (crab yaws).

Relapses develop over a lifetime, and can occur at intervals of up to 5 years.

The diagnosis of yaws is made by identification of the typical spirochete lesions in serum obtained by squeezing the base of a lesion and examination of the liquid by dark-field microscopy.

Treatment of yaws got much easier after a January 2012 study was published in The Lancet. A study in Papua New Guinea revealed that a single dose of oral azithromycin is as effective as a single injection of benzathine penicillin. At 6 months of follow-up, 96% of patients in the azithromycin group were cured, compared with 93% in the benzathine benzylpenicillin group.

A thorough physical exam is always part of my assessment. Now that I know what to look for, perhaps I will see and help cure this chronic infection in a few children.  

Book Review - Haiti The Aftershocks of History by Laurent Dubois

Professor Dubois is a Duke University Professor of History and his 2012 book is likely to be the standard academic reference on the history of Haiti for some time. I've read a lot about Haiti over the last decade, and this easy-to-read book brings it all together. This blog includes a small selection of the informative points that I culled from his book. Direct quotes from Dubois are in bold blue italics. My highlighted thoughts are in regular bold font.

A strong ocean current from Europe flows directly to Haiti, which explains how Columbus arrived in 1492. There is another strong set of currents from Africa straight to Haiti. Mother nature therefore placed Haiti at the intersection (in the cross hairs) of the European commercial interests and the African slavers.  

There were about 500,000 to 750,000 indigenous people on the island when the Spanish arrived, but within a century these aboriginals were almost completely eliminated by war, forced labor, and disease. These people called their land Ayiti - land of mountains.

At the time of the Haitian revolution, the French colony of Saint-Dominique was perhaps the most profitable bit of land in the world. Slave labor and sugar canes intersected in a commercial success story for the French.

Each year, between 5 and 10% of the slave population died due to overwork and disease and this necessitated a continuous influx of new slaves from Africa. This staggering statistic implies that the plantation owners did not expect slaves to live. Slaves were purchased with the full knowledge that the majority would die within a few years. The turnover in slaves was such that in 1791, the year of the slave revolt, only one third of the half million slaves in Haiti had been born in the country. The rest were born in Africa. About 10% of the slaves had arrived in the preceding year, and this group arrived with a unique skill set. Many were former soldiers from central Africa, and their experience played a role in the success of the revolution. 

Toussaint Louverture was one of principle leaders of the revolution. He was a slave who was given freedom as a young man and who briefly owned his own slave. At the beginning of the revolution he helped his former white masters to safety before joining the rebels. Throughout Haiti's history, the majority of the leaders have had a soft spot for the white or mulatto merchant elite in the country. 

Over the next two centuries, various leaders, including Toussaint, tried to maintain the plantation system with measures that kept the black population working on the land without ownership. The freed slaves were paid with a quarter of what was produced. Another quarter went to the state, and half to the owner. The state authorities and the owners were mostly light-skinned Haitians.

The black Haitians desired ownership of the land and pursued a quiet, non-violent revolt. Rather than work on the plantations, they chose to live and work on small communal plots in rural areas outside the easy scrutiny of the state. Regional markets developed to support these communities. This communal system, referred to as the lakou, continues to this day, although the shift in the population from rural to urban over the last century has diminished the role. One lakou tradition illustrates the powerful bond of the Haitians to their land. In the lakou, the umbilical cord of each newborn was buried in the yard and a fruit tree was planted over the cord. The fruit from the tree was used to purchase clothes for the child.

The rural communities did not become a source of taxation for early governments and instead, the state relied upon export and import taxation for revenue. Over time this created a very influential, and often non-Haitian and white mercantile class, who were uninterested in the fate of the nation.

Although Haitian independence was achieved with an armed revolution between 1791 and 1804, the new country was obliged under French military duress to "purchase" international recognition of their sovereignty. In an agreement in 1825, with French warships poised offshore, the Haitian government "agreed" to pay "damages" to the French government. By 1898, fully half of Haiti's government budget went to paying France and the French banks. By 1914, that proportion had climbed to 80%. As such, there was never any money for the state to spend on education, health, roads, or any of the other essentials for progress.  

United States did not recognize Haiti as a country until 1862. Americans, especially those with slaves, did not want to recognize a country of emancipated black slaves.
Recognition came as the international abolitionist movement gained momentum and during the American Civil War. The United States gained access to Haitian ports, which were important bases in the battle against the Confederacy. United States commercial and political influence grew, and by 1905, 71% of the imports to Haiti were from America. American influence culminated in the two decade US occupation of Haiti from 1914 to 1934. The Americans re-instituted slavery, in all but name, so that they could to complete a variety of public works projects. The American government forced changes in the constitution to allow foreign ownership. Prime land was sold to American corporations and existing Haitian owners were displaced.  

Duvalier was elected president in 1957 and ushered in three decades of violent repression of any opposition. After securing power Duvalier declared, I have conquered the country. I have conquered power. I am the new Haiti. To wish to destroy me is to wish to destroy Haiti itself. It is thanks to me that it breathes, thanks to me that it even exists. After changing the constitution so that he could be President for life, Duvalier declared, There will never again be an election to elect a chief of state on the soil of Haiti. I shall be lord and master. 

Over the last 25 years, the two major socio-political changes have been the influx of Non-governmental Organizations (NGOs) to provide a method to stream humanitarian aid to Haiti but bypass the various corrupt governments, and the emigration of Haitians who fled the country to seek a better life elsewhere. 

Vodou, which has legitimate and traditional cultural values for Haitians, has been vilified over the years by the "civilized world" and continues to be used as an excuse to explain poor progress in Haiti. The day after the earthquake, televangelist Pat Robertson remarked to the world that Haitians were suffering because they had sold themselves to the devil.

Reading the Dubois book was a wrenching experience. The suffering experienced by the people of Haiti should never have happened in a civilized world at any time, much less in the last, more "enlightened" century. The racism and intolerance inflicted on these people is a ongoing tragedy.

Immunizations in Haiti

Routine immunizations for tuberculosis, diphtheria, tetanus, pertussis, polio, and measles have been "available" in Haiti since 1977, rubella since 2009, and Hib and Hepatitis since June of 2012. In January 2013, pneumococcus and rotavirus are scheduled to be added to the schedule.

Woman taking Cholera Vaccine. Photo courtesy MSF.

The table below shows the differences in the routine immunizations that are offered in Canada compared to Haiti.

Infection	Haiti	Canada
Tuberculosis	Yes	No
Diphtheria, Tetanus, Pertussis	Yes	Yes
H influenzae HIB	Yes	Yes
Hepatitis	Yes	Yes
Polio	Yes	Yes
Pneumococcus	Yes	Yes
Rotavirus	Yes	No
Meningococcus C	No	Yes
Influenza	No	Yes
Measles, Mumps, Rubella	Yes	Yes
Varicella	No	Yes
HPV	No	Yes
Tetanus	Yes	Yes

By next year, on paper at least, modern immunization protection will be available for Haitian children. 

A recent paper (Rainey et al, Vaccine 2012;30:1746-51) reported on the results of a survey done in 2009, a year before the earthquake. Only 40% of the children surveyed had received full coverage of the recommended immunizations (similar results in Canada would be at least 80%). The coverage was highest for TB (87%), the first dose of diphtheria-tetanus-pertussis (92%), and the first dose of polio (93%), and was lowest for measles (47%).  

Just because a vaccine is recommended and available is not the same as received.

World Health Organization (WHO) data from 2008 in Haiti reveals that pertussis was reported in 696 individuals, diphtheria in 10, and neonatal tetanus in 16. To report a communicable disease requires that the infection be recognized (patient needs to have access to a physician and physician needs to make a correct diagnosis, which often requires precise lab testing) and that the physician takes the time to document the illness and to send this documentation to the proper authorities. This likely does not happen very often in Haiti, so the reports of any infection are likely a gross underestimate.  

My clinical eyes will be open for children with diphtheria, polio, tetanus, measles, German measles, H flu, and other infections that have been uncommon in Canada for over two decades. 

Review Notes - Haiti after the earthquake by Paul Farmer

Paul Farmer, MD is a co-founder of Partners in Health (PIH), an organization devoted to help improve the welfare of the poor in the world. PIH (Zanmi Lasante in Kreyol) has had a major impact on health care in Haiti for 25 years and is now the largest provider in the country. PIH has helped build or refurbish about 60 hospitals and clinics and employs about 5,500 Haitians.

This blog is not a critical review of the content of the book or his writing. Rather, this blog is a selection of informative ideas that I culled from from the book - Thinking Points. 

Farmer opens the book with an invocation to the indefatigable spirit of the Haitian people and he chose Neg Mawon as the symbol of this spirit. Neg Mawon is a free man, a former slave, who has cast off the shackles of oppression. The statue of Neg Mawon survived the earthquake and stands in the center of Port au Prince.

Neg Mawon. Photo courtesy of Women in Charge

Farmer writes that as a physician there is a continuing tension between serving those right in front of you and seeking to reduce the longer-term risk of others ending up in the same situation. He refers to this as the tension between Praxis and Policy. Health care workers make good decisions one patient at a time (good Praxis), but the social situation never changes and the patients never stop coming (public Policy problem). As an example, Farmer quotes a physician with Medicines Sans Frontiers (MSF) who wrote that after the start of the cholera epidemic, Haitians were deluged with text messages to wash before eating but they were still obliged to bathe their children in largely untreated sewer water.  

Farmer reports that in other parts of the world where large populations suffered natural or war-related disaster, that the average displaced person spends over a decade in a "temporary" settlement.  

Haiti is a Republic of NGOs. Even before the quake there were more Non-Governmental Organizations (NGOs) per capita in Haiti than in any other country except India. Farmer suggests that aid from NGOs has had much less impact than desired because the NGOs do not report to the government, there is no communication and collaboration between NGOs, and that for some of the NGOs, the mission of the organization, albeit intended as well meaning, has served other non-Haitian, non-productive goals, and has actually created problems. Farmer references "Alms Dealers," an essay by Philip Gourevitch, in the New Yorker. Gourevitch wrote, NGOs are "Sowing horror to reap aid, and reaping aid to sow horror."  

The Duvalier dictatorship ended in 1986. Notwithstanding billions of dollars in AID, there has been little if any progress in Haiti. Farmer asks the question, What has gone wrong in four decades? One of his answers is that only a tiny percent of the aid money has been under the control of the government. Without money, the government has been powerless to help. Farmer points out that in 2002, the government budget for Haiti, a country of almost 10 million, was a quarter of the budget for the Harvard University hospital where he works!

Haiti was once the world's leading exporter of sugar, but now is a net importer. A local refinery produces only 2% of the sugar that is consumed in the country. Farmer asks what happened to this thriving industry? One of his answers is that less expensive and foreign subsidized sugar has undercut the local market. The same phenomena happened after the quake with rice, another important local crop. 

The victims should be allowed to speak for themselves. For their entire history, others have routinely spoken for the common Haitian. First as slaves, then as free men but under the oppression of a series of dictators, then as citizens but without an effective government and at the mercy of bureaucratic and often ineffective NGOs. 

Farmer makes some suggestions to turn the corner and to make progress. He recommends that NGOs be integrated into the public sector. The plans and operations of the NGOs should be approved by the government. He also recommends that a freely elected democratic government should be allowed to control the humanitarian aid money and to pursue reconstruction policies made by the elected members. 

Farmer writes very favourably about former President Bill Clinton's support for Haiti. Two of Clinton's phrases resonated with Farmer. Build Back Better and Get Stuff Done (GSD). Farmer took the GSD message to heart. PIH will soon open a new modern state-of-the-art teaching hospital in Mirebalais, the largest town in Haiti's Central Plateau.   

Elephantiasis in Haiti

Lymphatic filariasis is a mosquito-spread worm infection that is present in 80% of the regions of the country, which really means in every region of the country.

Microfilaria of Wuchereria bancrofti. Photo courtesy CDC.

There are five stages in the life cycle of the worm. Mosquitoes ingest the first stage or microfilariae and the second and third stages develop in the mosquito. Third stage larvae are inoculated into humans for the final two stages. The larvae take about a year to mature to the fifth stage worm. The worms invade the lymphatic system and the symptoms of elephantiasis are due to blockade of lymph flow, which leads to permanent swelling of an arm or leg, or of the scrotum in men. Female worms are about 3 to 4 inches long and the males are half that size. Elephantiasis is the common name for the affliction, and describes the gross deformity of the affected region of the body. Filariasis is rarely fatal, but the gross deformities that result are such that the World Health Organization (WHO) identified the disease as the second leading cause of permanent and long-term disability in the world, after leprosy.
  

Haitian mother with elephantiasis. Photo courtesy New York Times. 

The most common symptoms of an acute infestation are fever, increase in the size of the lymph nodes (groin, axilla, elbow), scrotal pain, limb or genital swelling, and skin exfoliation. The urine can turn "milky" if fatty lymph fluid is present. The swollen skin is susceptible to secondary infection with a fungus or bacteria.  

Albendazole and diethylcarbamazine (DEC) kill the larval form, which if not treated, will mature in about a year to a worm that cannot be killed. 

Studies have shown that if an entire population takes the drug once a year, and every year, for a sufficient number of years, the amount of parasite circulating in humans and mosquitoes will fall low enough to eradicate the infection. One estimate is that 70% of the population needs to take a medication once each year for eight consecutive years.

A Center for Disease Control (CDC) survey recently reported that 8.7 million Haitians (over 80% of the population) received one dose of medication by two years after the earthquake. If that successful effort can be sustained for seven more years, there is hope to eradicate filariasis in Haiti!

However, "every mouth counts." Providers must not presume an individual takes the medication. For success (compliance), providers have learned that they must be present when an individual swallows the medication.

Salt fortified with DEC has been used to widen coverage. This strategy was invented by Frank Hawking, the father of Stephen Hawking, and was used in a filariasis-eradication campaign in China in the 1980's.