Sunday, January 29, 2012

Implementation of basic oral health care delivery systems in Haiti (Trois)

Cap Haitien, Haiti

Since the rocky start at the Justinian, I'm pleased to report that the rest of the clinic days were largely a success. As part of the mobile dental clinic program, we visited a variety of clinical sites including Limonade, a girls' orphanage, and Shada. The Tauzin Clinic in Limonade, a municipality about an hour from Cap Haitien, was accessible by tap-tap, the communal "taxis" in which passengers are transported in the bed of a sometimes decorated pick-up truck. We set up the clinic in a large barn used for a judo club, with four stations for patient care. A sterilization table was designated, and instruments were sterilized with a betadine soak and heated in a kitchen pressure cooker. Universal precautions were a bit of a reach, as we had no barriers and supplies were very limited. Patients were lined out the door, as they had arrived very early in the morning to take a number for treatment. It became quickly obvious that access to care was a major issue for the patient pool in this community, as many of them had extremely poor oral health care and presented with acute issues. We mostly performed extractions with this population, and a number of the children presented with abscesses and cellulitis. Pediatric care was quite a challenge in this clinic setting, as I could not employ the usual psychology and distraction techniques used in the States due to a gap in communication with my French and the locals' Creole. At one point, several of the Haitian dentists had to bolster down a screaming, kicking 7 year old as I extracted her grossly decayed teeth and drained her abscess to prevent it from manifesting into an airway-compromising submandibular space infection. Another point of contingency was the inability to check blood lab values before performing extractions, especially with patients that exhibited extensive post-op bleeding. With most of the adult population, who likely also suffered from multiple undiagnosed and uncontrolled systemic issues, I was uneasy to proceed with extraction without relying on my usual boundaries of INR and absolute PMN values. I have to admit that while we used Surgicel and sutured to obtain primary closure, I would have preferred to have some sort of follow-up with the patients. I wondered how they would get care if complications did occur, seeing that the hospital was over an hour away and transportation was oftentimes too expensive to afford.

Food For the Poor orphanage was another clinical site where we treated orphaned girls ages 3-13. Most of the children lost their families due to the 2010 earthquake or TB/HIV. We were informed that a number of the girls were affected with pre- or perinatal HIV. There were approximately 50 girls in the orphanage, divided into 4 buildings with one house mother per building. We set up in a similar manner with stations. For this demographic, I was surprised to find that most of the children were nourished, well cared for, and exhibited decent oral hygiene. Most of the treatment was through atraumatic restorative treatment and preventative sealants using a novel effective material- Fuji IX glass ionomer. This is a durable self-cure fluoride-releasing resin that I have only recently had experience with in using with our stem cell transplant and chemo patients who require elimination of all infection prior to admission. This method of restoration only required one instrument and a simple base-catalyst set up and resulted in efficient and effective outcomes. Hand instrumentation of decay was a elegant answer to a clinical setting with no access to water or electricity, much less a high speed turbine drill. Though this method does not remove 100% of the bacteria, the literature has shown that by sealing off the lesion with Fuji, the hope is that the oxygen required for the intraoral aerobic bacteria (namely S. mutans) would be eliminated and therefore demineralization arrested.

Perhaps the most poignant clinic site visited was the neighborhood of Shada, the most impoverished community in Cap Haitien and, in my experience, the worst living conditions that I have ever encountered in my travels. Children made up the large majority of the population, with a number of them exhibiting dental abscess and facial trauma. We treated over 70 patients, while having to turn down another 30 due to running out of essential supplies and materials by the end of the day. Walking through the village, one waded through excrement and trash, and were followed by a mob of children barely clothed. At one point I was looking into the river filled with the neighborhood waste, and noticed that all of our biohazard materials- contaminated gloves, gauze, sharps- were all dumped by the locals into the only source of drinking water in town. It was an appalling and moving sight, as I knew that there was no infrastructure for garbage removal nor way of dealing with sewage and sanitation. I remembered how I had been cautioned that the experience of Haiti would be a rollercoaster of highs and lows, wins and losses, and the recognition of how difficult life is in Haiti with the Creole saying: "beyond the mountain there is another mountain." It is with these observations that each of us must carefully construct our own framework and understanding of this country to share with the international community.

Haïti est une terre de grande beauté et grande souffrance. Piti, piti, wazo fe nich li.
[Haiti is a land of great beauty and great suffering. Little by little the bird builds its nest.]

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