Anthrax in Haiti

Anthrax is the deadly spore that resulted in five deaths during the bio terrorism attack in the US in the weeks following 911.

Cutaneous anthrax is endemic (always present) in Haiti. 

Anthrax is caused by Bacillus anthracis, a bacteria that forms spores. The spores can survive for extended periods in the soil and are eaten by domestic animals who graze on contaminated vegetation or drink contaminated water. The infection develops when the skin is in contact with an infected animal (cutaneous anthrax), when a person eats meat from an infected animal (gastrointestinal anthrax) or when an individual inhales spores from the hide of an infected animal (pulmonary anthrax).  

Cutaneous anthrax usually involves the skin of the head, neck, forearms, or hands. The spores enter the skin through minor cuts or abrasions. The incubation period is usually 5 to 7 days, during which time the spores germinate, multiply, and release toxins, which are responsible for the symptoms. About 20 percent of cutaneous infections spread into the blood stream and result in sepsis, meningitis and death. As such, all cases of cutaneous anthrax should be treated with antibiotics. With prompt antibiotic therapy, mortality from cutaneous anthrax is virtually zero. During the anthrax scare in September 2001, many government officials were treated with a preventative antibiotic.  

The infection starts as a painless, itchy papule. The lesion enlarges and develops a central vesicle which progresses to an ulcer with a central depressed black area. The surrounding tissue is swollen and the regional lymph nodes are increased. Fever and headache might develop.  

Cutaneous anthrax lesion with central depressed black area.
Photo courtesy Wikipedia.

The diagnosis requires a gram stain of the lesion and the demonstration of the typical gram positive rod.  

Oral ciprofloxin (15 mg/kg) divided bid is the recommended treatment.

Anthrax in humans is not considered contagious. 

Goat-hide souvenirs exported from Haiti are a reported source of the infection.

While in Haiti I will keep my eyes open for skin lesions with a black center.  

Bedside Assessment in Haiti

There is a lab at the hospital where I will work in Haiti but the availability of even routine tests will likely be limited.

Lab tests are usually an expensive component of health care costs. The equipment is expensive and often needs servicing. Two of my six post-grad years were spent in a University of Toronto laboratory where I did bench research. For my research, I used equipment that measured sodium, potassium, chloride, TCO2, pH, and pCO2 in blood and urine specimens. The equipment was always breaking down. Some days I spent literally hours cleaning, standardizing, and repairing the equipment. Technology has definitely improved, but my point is that high technology often requires constant servicing, and this has a cost. Supplies for the equipment is now a huge cost for the new technology. Salaries for personnel to run the equipment are another cost.  

In Canada the costs for laboratory tests ordered by a physician are paid for by the government at no cost to the patient. The hospital protocol in Haiti is that some patients are expected to pay for lab tests. Does the hospital expect that the patient can afford to pay? Is there just not enough money to pay for even limited tests? Or, is this policy a method to make the physician think twice before ordering a test? Perhaps all three? I don't know, but I do know that making a decision about a lab test in Haiti will be more complicated than a similar decision in Canada.

Health care is a right but cost is a concern that must always be considered. Many years ago I read an excellent article in the New England Journal of Medicine by one of the foremost health care economists of the time. This individual suggested that there were three factors to consider in health care - quality, access, and cost. Simply put, only one or two of these three factors could ever be excellent in any health care system. Canada has excellent quality, very good access, and a high cost per capita. The United States has excellent quality, poor access for the lower third of the population, and less cost per capita compared to Canada. Haiti has terrible access, modest quality, and a very low (excellent) cost per capita.

One of the challenges of health care anywhere in the world therefore, is to offer good care and access at an affordable cost.

After thinking about the lab tests in Haiti, I decided to take along some technology to perform routine bedside tests in Haiti. I will bring urine dipsticks, a blood glucometer, and a device to measure oxygen saturation (see photos above). Urine dipsticks cost about 50 cents each, and a glucometer test strip costs about a dollar. I will take sufficient supplies to do 200 urine tests and 200 blood sugar tests. The oxygen saturation device has no cost apart from a battery. This intervention will save the hospital and the patient the costs for these routine tests.   

Anemia in Haiti

Anemia is very common in Haiti. About half of the rural children under the age of 2 years have a hemoglobin less than 100 g/L.

Red blood cells carry oxygen, which is necessary for the optimal function of every cell in the body. Anemia can affect the function of every organ in the body. In children, anemia is reported to affect the ability to learn.  

The reasons for anemia in Haiti are similar to the reasons for anemia everywhere else in the world. A low hemoglobin is caused by decreased red blood cell production, increased red blood cell destruction, or blood loss. 

The most common cause of anemia worldwide, and Haiti is no exception, is iron deficiency anemia. If there is not enough iron, the body cannot produce enough red blood cells.

Blood smear in iron deficiency anemia. Note the RBCs have pale centers.

Iron deficiency in Haiti is much more common than in Canada. Poverty does that. The children are often not supplemented with iron after they are weaned from the breast, and thereafter, the diet of the average Haitian child is not rich in most nutrients, including iron. In Haiti the iron is also low because of intestinal blood loss due to worms and parasites.  

Iron deficiency anemia due to poor nutritional intake can be prevented by starting supplemental iron when an infant is weaned off breast milk. About 1 to 2 mg/kg/day of elemental iron is necessary to prevent iron deficiency anemia.

Another common cause of anemia in Haiti is the presence of hemoglobin S (sickle cell) or hemoglobin C. In these conditions, the red blood cells break down faster than normal red blood cells. These conditions originated in Africa, the ancestral home of the Haitian people. Hemoglobin S is usually seen in populations of central African origin and hemoglobin C in populations of western African origin, and the conditions can co-exist. A study carried out between 2002 and 2009 revealed hemoglobin S in about 15% of the population tested.

Blood smear in Sickle Cell anemia. Note the classic "sickle" cells.

The blood test to diagnose anemia is the Complete Blood Count (CBC). There are likely few individuals in Canada who have not had this basic test on numerous occasions. This is not the case in Haiti where access to modern health care is a chronic social problem. However, there is a laboratory in the Project Medishare Hospital where I will work, and this test will be available.

Treatment of iron deficiency anemia requires supplementation with 6 mg/kg/day of elemental iron for 3 months.  

I expect that most of the children who leave the hospital will have iron supplementation as part of their discharge planning.  

Minimum Wage in Haiti

After writing my last blog, Health Care is a Basic Right, I decided to learn about minimum wage in Haiti and to compare the data to other countries.

Wikipedia has a page with "official" information on recent minimum wage data. Likely the data is OK, but the numbers do not take into consideration local cost of living, so the numbers are "relative" and meant only to stimulate thought and discussion. The numbers in the graph below are the yearly income in US dollars based on the minimum wage.

I included Nicaragua, where I worked four times in the last few years. My experience is that the cost of living in Nicaragua is about the same as Haiti and that a lot more Nicaraguans have jobs. There is therefore a lot more money in Nicaragua. As poor as Nicaraguans are, the people are definitely rich by Haiti standards.


As low as the minimum wage is in Haiti, when the amount is adjusted to the rate of inflation, the minimum wage has likely fallen over the lasts 30 years!

In 1980 the minimum wage was 13.2 gourdes a day. This increased to 15 gourdes in 1984, 36 gourdes in 1995, and to 70 gourdes in 2003. President Preval passed legislation in 2009 to increase the minimum wage in steps such that the amount would be 200 gourdes in October 2012. Textile owners complained about this increase and apparently Preval negotiated a two-tiered minimum wage with 125 gourdes ($3 US) for the textile workers (mostly women) and 200 gourdes ($4.75 US) for other labor sectors.

Any increase is great but whether the increase can be enforced is another matter. Would the government shut down the textile industry (or any industry) when only 20% of the population has a job at all and there are no other jobs available? Would the workers go on strike and lose the minimal subsistence income they have?

What the Haitian people need are jobs. A good approach for those who want to help would be to sponsor a business in Haiti.  

Health Care is a Basic Right

I received some policy documents from the hospital in Haiti where I will work. There were aspects of hospital policy that concern me.

When I worked for this hospital in 2010, the medical care provided, including medications, was free. According to the documents I received today, the hospital is "no longer able to provide care completely free of charge." Patients are "expected to pay" for initial assessments, lab tests, and medications.

The document also notes that the Chief Medical Officer and the executive directors "have a system in place" that allows them to determine "patient payment and exonerations." Sounds like a "means test," something that I do not agree with. Means tests are demeaning and are obstructions to access in health care.

This is disappointing news. Money should not be a factor in access to health care. When access to care has a price, then access is restricted, and care is not available for the poor. This is wrong.

How can anyone expect that a parent in Haiti can afford to pay anything? Haiti continues as the poorest country in our hemisphere and only about 20% of the population have a job. For workers in the garment factories, the pay is only 31 cents an hour ($2.50 a day!). In 2009, the Preval government voted a minimum pay law that would be implemented in steps and in October 2012 the minimum wage was scheduled to increase to 62 cents an hour ($5.00 per day).  Even if the industries pay this, the amount is still below a subsistence level estimate of $12.50 a day for a mother and two children! 

The hospital is surrounded by tent cities like this.
How could anyone who lives here afford to pay for hospital care?

Reading the document brought back a flurry of memories. 

As a young intern at Sick Kids in Toronto I was asked to go on strike for higher wages. I refused and together with some (a minority) of the other young physicians in Toronto, we refused to leave our work for more money.

When I interviewed for my job as the Associate Professor and Head of Paediatric Nephrology in South Carolina, the most important question that I asked my future boss was if I would ever be obliged to deny care to someone if they could not pay. My boss reassured me that I would never be required to restrict care. I accepted the job. He was true to his word and I never had to deny access if a person could not pay. However, once working in South Carolina, I realized that my perspective was not the norm and that many of my colleagues routinely denied service if a family could not pay. I found this repulsive but held my tongue. I was the foreigner. However I made it a point of honor to purposefully seek out Medicaid families and to treat them in an identical fashion to the patients with money or private insurance. I was resented by some of my colleagues because I did not conform to their double standard. I have many stories to tell about how the double standard was practiced in South Carolina and about the depth of the hypocrisy I found there. I stayed in the state long enough to build up the largest Medicaid service in the State and was honoured with the 1998 Maternal and Child Heath Care Award by the Governor of the State of South Carolina for my service with poor mothers and children. This award remains high on my list of achievements.

When I worked in the United Arab Emirates as the Chief of Pediatrics at the Royal Hospital, I witnessed another system where money determined access. Again I was reassured that I would never need to deny care, and I was never required to, but once working there I learned that there were two hospitals in the city. One hospital was for the poor foreign work force (from Pakistan, Sri Lanka, Bangladesh, Indonesia) who provided cheap labor to the country and one hospital was exclusively for the Emirate citizens. I only had authority at the hospital for the Emirates. My hospital offered care similar to that offered in Canada (sort of), and the other hospital offered decidedly second class care. There was another top level of care available to the Royal Family. I have many stories to tell about the triple standard in the UAE. There was at least no hypocrisy in the Emirates. Citizens of the Emirates actually believe they deserve better than the rest of us.

After my first visit to Nicaragua to work in a rural clinic I learned that the clinic charged a modest fee for the patients to see me and another modest fee for medications that I prescribed. I insisted that there would be no charge for my personal care or for the medications that I brought with me and dispensed. The clinic agreed and with this understanding and I visited four times to help out.

I will need to find out the true meaning of the hospital policy such that families are "expected to pay." My principles are idealistic for some, but they are my principles, and they are important to me. I want my time, my experience, and the medications that I bring to be free for families in Haiti.