Monday, December 18, 2017

An Internal Medicine Rotation in Mirebalais, Haiti: Some Reflections from Two Weeks in Haiti

Anastasia Vishnevetsky
Resident in the Partners Neurology Program, preliminary year in internal medicine at Brigham and Women’s

An Internal Medicine Rotation in Mirebalais, Haiti: Some Reflections from Two Weeks in Haiti

It’s been now almost two weeks that I have been in Mirebalais, so here are a few reflections from my time:

1. On daily life as a resident: 
A first year resident in internal medicine at Mirebalais, starts their day around 6:30, with prerounding and seeing approximately 8-10 patients. At 8:00AM, most residents go to the resident’s lounge for a quick breakfast. At 8:30, they have ‘morning report,’ which is a formal presentation of all the new admissions from the previous nights with the internal medicine attending physicians and all of the residents. There’s usually some informal teaching and discussion at morning report as well, which is completed around 10AM. After morning report, residents will break off to the different wards (women’s ward, men’s ward, or isolation ward for patients who are being ruled out for TB) for ‘small rounds,’ which are bedside rounds with the senior resident and sometimes the attending as well. This continues until noon, with the residency gathering again at 12PM on Tuesdays, Wednesdays, and Thursdays for an interesting case presentation on one of the wards. Everyday, except Friday, there is a teaching conference around 1pm, and around 2pm the residents go for lunch. The interns are on a Q5 day call schedule, staying for long call until around 2AM every 5th day.
The intern day here is quite different from Boston. There’s significantly less paperwork and fewer labs to follow up, consults to call, or orders to put in - a natural consequence of fewer medications available, limited lab test availability, and few specialty services. The days are just as long however, with group case presentations taking up almost half the day.  The interns have shared housing on the campus of the hospital and work 6 days out of the week.

Writing notes at the hospital

The Arbonite river flowing through Mirebalais, about a 10 minute walk from the hospital. This is the river that was affected by the cholera epidemic brought by the UN in the aftermath of the 2010 earthquake. Signs demanding reparations from the UN can be seen throughout the city, and anti-cholera vaccination efforts are ongoing.

2. On practicing medicine in Haiti:
Life as a doctor in Haiti is hard even after training, and many of the residents have their eyes set on foreign medical exams after residency. The government provides little public funding for physician salaries, and most needy patients have neither insurance nor the capacity to pay out of pocket for health care. Equipment and lab testing is difficult to come by, and costs can be very high. Healthcare is often provided by foreign NGOs like Partners in Health, which provide free care, but there are a limited number of attending positions at these institutions.  One co-intern who has thought about trying to move to Spain after residency, laughed when I said Haiti needs doctors to stay in Haiti: “Easy for you to say.” Indeed, easy for me to say. He added that of course he would want to stay in Haiti and make a living here, but at some point ‘you have to think about where you want your kids to grow up and what kind of life you would want for them, and so if you have to leave, you leave.” It’s a sad thought, especially looking at some of the talented residents I’ve worked with here in Mirebalais. On admitting nights, I’ve worked with one of the best residents I’ve worked with all intern year, whether in Boston or Mirebalais. I joked that I came down to Haiti just to learn from this brilliant resident, but in all seriousness, I think it would have been worth it for him alone. I heard later that he is studying to take the USMLE.

3. On the importance of language:
The vast majority of patients and people in general in Haiti speak Haitian Creole amongst themselves. French is only used in official and administrative settings (including between doctors in the hospital or during presentations in the hospital). English is rarely used at all, though some doctors can speak it, and most residents can understand it to some degree. The language barrier creates an immediate division between expats and locals that is troublesome and makes it difficult to form deeper and more significant local relationships. For me, speaking French has allowed me to get closer with many of the residents and function as a resident in the hospital, but I still wish I could speak in something other than the former colonialist language. The requirement to speak French, which is spoken almost exclusively by the Haitian elite, in official settings and also to study in French in schools perpetuates the inequalities in Haitian society. Creole is incredibly similar to French in terms of vocabulary, but learning to understand spoken Creole from a base of French is much more difficult.  It was very worthwhile to learn some Creole before coming to Haiti, and I wish I had learned more.

My co-intern at Saut d’Eau, a famous Haitian waterfall with great importance in the Vodou tradition. We took the trip about 25 minutes outside of Mirebalais on our Sunday off.

4. A reading recommendation:
‘The Big Truck that Went By: How the World Came to Save Haiti and Left Behind a Disaster.” This book, which was recommended to me by another doctor who has repeatedly come to Haiti, was one of the best books that I’ve read in a long time. It is written by the AP journalist who was in Haiti at the time of the earthquake in 2010, and who later broke the cholera epidemic story. I’d particularly recommend it to anyone interested in global health or development, or to anyone interested in coming to Haiti and understanding the complex and often fraught relationship that Haiti has with foreign aid.

5. On Haiti:
Haiti is incredibly beautiful. I had heard that Haiti was mountainous and beautiful, but the landscapes here truly blow me away. The mountains, beautiful sunsets, which then roll into a perfect turquoise Caribbean Sea have to be seen to be believed. The fact that Haiti is not overflowing with tourists speaks to the infrastructure problems, as well as to the negative mythology that surrounds Haiti. I’m still a few weeks away from leaving, but I can tell I’m going to miss it!

The view from Saut D’Eau,

Mobile Clinics and Chronic Disease Care in Haiti

Anastasia Vishnevetsky
Resident in the Partners Neurology Program, preliminary year in internal medicine at Brigham and Women’s

Mobile Clinics and Chronic Disease Care in Haiti

As part of my elective time during my intern year at Brigham and Women’s Hospital, I’ve chosen to rotate on the internal medicine wards in Mirebalais, Haiti for 1 month. My hope is to return in the future as a neurologist, but with a better foundation in Creole, medical French, and some understanding of the way the local medical system functions.

Upon arrival to the airport in Haiti, I found my Partners In Health driver. He spoke just enough French to tell me we would be waiting for another passenger for about an hour and a half in his car. He asked me if I knew any Creole and I replied that I had been trying to learn some basic Creole, and would be happy to try it out. After about 20 minutes of pleasantries (driven entirely by the questions I had learned to ask), I was out of words and told him I could just say more medical words. He laughed and answered, “Well doctor, I can be your first patient.” We were about an hour in and had established that he had a fever, weight loss, cough, diarrhea, abdominal pain, a headache, leg pain, night sweats, reduced appetite, and depression. He taught me how to say ‘I’m sorry about that’ after I kept nodding and making exaggerated fake sad faces in response to his litany of complaints. I could then tell him to open his mouth, turn his head, raise one arm and put it back down, open and close his eyes, and breathe deeply. He hilariously obliged. After that, I had exhausted my Creole vocabulary and we turned on some French music on the radio.

On my first evening in Haiti, I arrived in Kay Construction (Kay means ‘house’ in Creole, and apparently construction workers for the hospital had previously lived here)  in the small city of Mirebalais. Kay Construction houses approximately 10 expats who are in Mirebalais for short-term stays. It is run by a Haitian lady named Madame Bo, and serves 3 meals a day. The house is a sort of meeting place for many of the foreigners working in Mirebalais and is located directly behind a very active and sonorous church about a 7-minute walk from the hospital.  It’s a wonderful place to meet other expats, particularly those from Boston, though I often find myself wishing that we were more spread out and integrated amongst the local community.

A sunrise hike from Kay Construction to a local hilltop with some other doctors living at Kay Construction

Late at the end of my next day in Mirebalais, I received an email from one of my global health mentors at Brigham, introducing me in Creole to a Haitian community health worker at the Mirebalais hospital, and asking if he would bring me along to one of the mobile health clinics. On my second day in Haiti, I woke up to around 6:30AM and saw the reply that said, ‘Yes, absolutely, we’ll be leaving today at 7AM.’ As I jumped out of bed, I prayed this meant 7AM Haitian time, and grabbed my stethoscope, pen, bug spray, sunscreen, some granola bars, and my fanny pack (of course) and headed out to the hospital. At 7:20, I still had not figured out where in the hospital I was supposed to be going, but luckily, when I did find it, the driver had not yet arrived. The mobile clinic location was about an hour and a half from Mirebalais, high up in the beautiful Haitian mountains. A few times along the way, we all got out of the van and walked after the van when the ascent was too steep for the van to do with us inside. At another point, the whole van erupted in giggles as we bounced up the mountain road, all roller-coaster like. When the van came to a stop, it felt to me like a random bend in the road, and I thought we had popped a tire. Everyone started to get out of the car and unload the supplies, and then Fidje, a Haitian pediatrics intern, showed me a small walking trail by the road that would lead to the village school and mobile clinic center after a 20 minute walk. 

Some nurses and community health workers look out over the valley after our van stopped to unload supplies for the mobile clinic. In the background, some local community members help us carry boxes down the trail leading to the mobile clinic location.

Fidje, who had just started her residency a month prior, was my saving grace that day. After setting up in the school, and introducing the whole mobile clinic team to the roughly 100-150 villagers who had gathered, we had about an hour of time to kill while the nurses took vitals and did the initial intakes. Fidje took that time to teach me about the different presentations of malnutrition, including Kwashorkior and marasmus, as well as the Haitian government’s malnutrition guidelines and the most common presentations of malaria. She had a tablet with an impressive collection of references and textbooks that she used throughout the mobile clinic if she had any doubts or questions. We also took an inventory of the medications in the USAID box that we had available to give out (amoxicillin, erythromycin, prenatal vitamins, iron supplements, paracetamol, ibuprofen, HCTZ, enalapril, nifedipine, omeprazole, cimetidine, TMS, metronidazole, ciprofloxacin, among a few others) and the labs that we could order (just RPR, TB screening, and finger stick blood glucose).

I had originally thought I would just shadow, but there were over a hundred patients and just 3 doctors, including myself, so I was soon putting my medical Creole to good use. Fidje sat directly next to me, seeing her own patients, but also providing back up in case I couldn’t understand something in Creole and needed a French translation, or patients needed more thorough counseling.  Our agenda that day was mostly TB screening, diabetes screening, and blood pressure treatment, as well as identification of any serious conditions that needed referral to the hospital.

Some of our medications at the mobile clinic are laid out on the pharmacy table. Through the curtain, you can see a small fraction of the patients waiting to be seen that day.

The most common chief complaint from the patients was some version of ‘everything hurts and everything is wrong.’ My first patient answered ‘Yes, a lot’ to every question I asked (‘Do you have a fever? –Wi, anpil!”, Do you have a cough? – Wi anpil!, Do you have abdominal pain? – Wi, anpil!, Any trouble sleeping? –Wi anpil!, Do you have pain? – Wi, anpil, everywhere.)  I thought something was lost in translation and asked Fidje to re-ask the questions, but the result was the same.

Medically, the most striking thing I observed was the hypertension – blood pressures of 190 or higher were a regular occurrence, and more blood pressures were over 150 than not. I actually wondered if the cuffs were broken, but then I would see a few young and healthy patients with normal blood pressures. At that point, I had worked in the hospital in Mirebalais for just one day, but now after two weeks in the inpatient women’s ward, those blood pressures made more sense. More than half of the patients admitted at any given time were there for complications of hypertension: peripartum cardiomyopathy in young mothers was devastatingly common, hytertensive cardiomyopathy and stroke as well. Back at the mobile clinic, I handed out HCTZ like candy, but felt little faith that a 2 week supply of HCTZ, and a 5 minute visit, finished off with a ‘you must follow up with a doctor and take your medication every day’ would make the difference for patients living hours walking from the nearest physicians.  The mobile clinic does cycle back frequently to the same location, so perhaps those patients would get a new supply within a month or two. But how would one provide good chronic disease care, with reliable access to medications, consistent counseling, routine laboratory checks, and follow up in this setting? I left the clinic with more questions than answers on that point.
We did see a few more acutely ill patients at the mobile clinic as well, including a woman with a tennis ball-sized painless thyroid mass, where we were able to spend some more time counseling about the importance of coming down to the hospital to be evaluated.
By the end of the day, I had seen around 30 patients, Fidje had seen over 50, and a Haitian third year family medicine resident had seen even more. Between the stifling heat and the long day, I fell asleep just moments after sitting down in the van for the ride home. A few hours later and my second day in Haiti was drawing to a close.

(From left to right) Fidje, myself, and the family medicine resident before starting the mobile clinic.