Haitian Child

Haitian Child

Sunday, December 27, 2015

My Mother's Stories

My mother's family was very poor. Her Icelandic mother did not speak English and her Scottish father did not always have work. When I was a little boy, my Mom often told me stories that I could not believe. I could not fathom the poverty she described. My Dad had a very good job and we were certainly not poor and there was no poverty I could see in Calgary. However, my Mom was one of seven children who were born during the years from World War One through the Great Depression. They did not have enough money for anything. There was no money for food, for shoes, for schoolbooks, or for medical care. Mom told me they often survived on bread, fat drippings, and salt. She left school to work after grade seven. One memorable story is that after my Mom cut her thumb seriously with a knife, her mother was obliged to take her to the doctor to have the thumb sewn back together. As my Mom describes the situation, her mother alternately cried and screamed in Icelandic all the way to the doctor because the family could not afford to pay the medical fees. Because of the accident the family did not eat for a few days.

My mother has been in my thoughts a lot during this trip to Haiti. The families in Haiti are likely even poorer than my mother's family, but maybe not. Many children in Haiti cannot afford school and this reminds me that my mother's education was cut short. When I purchased three pairs of shoes for my interpreter I thought of my Mom without shoes as a little girl in Vancouver. Many remark that there is a circle of life. This can mean many things. I think there are many circles, and in a strong sense, this trip helped me to complete a circle started with my mother's stories. 

Saturday, December 26, 2015

The Little Girl and I Both Exhaled

For the last week I have cared for a 2.5 year-old girl with pneumonia. She had only mild respiratory distress on admission. Pneumonia is one of the most common diagnoses on the paediatric ward. Most of these children respond well to an antibiotic, hydration, oxygen, a drug to open up the lungs, time, and the resilience of the human body.

The initial x-ray on the little girl showed pneumonia in her right lung and the pattern implied a bacteria rather than a virus. She was admitted by the Head of Paediatrics and treated with the usual first line antibiotic available at the hospital. On the third day she got worse and notwithstanding a change to the usual second line antibiotic, she continued to get worse. On the fifth day I was very concerned and shared my concern with the person in charge of the ward. She looked very tired and "toxic," the way critically ill children look. My sense at that time was that she might have a collection of infected pus (empyema, lung abscess) in her lung. Until an abscess is drained, even the correct antibiotic will not work. I repeated the x-ray and to my eyes the image suggested that a collection of pus was likely. The x-ray images at this hospital are not as good as in Canada and the technician was not able to accomplish the views I requested to localize the pus. Since I am not a lung x-ray expert, I could not be sure. Still, I thought this was the likely diagnosis. I talked this over with the head physician but she did not agree. She recommended another antibiotic change. The third and even a fourth antibiotic did not make any difference. I repeated the x-ray on the sixth day and this time, the head physician agreed with my diagnosis. I found the surgeon and made sure he saw her early in the morning. He asked for another x-ray (no idea why) and I made sure this happened early in the day. Once the x-ray was done I found the surgeon and took him to see the x-ray. I have learned to be persistent to insure that anything urgent is done. If I had not personally "driven the system," the x-ray might not have been done until later in the day, by then the surgeon would have finished his holiday rounds and gone home, and an entire and perhaps critical day might have passed. My persistence paid off and the surgeon agreed to operate the same day. I attended in the OR. The surgeon placed a chest tube and drained some bloody pus. My relief to witness the pus drain out of her lung was a Christmas present, both for the little girl and for me. Back on the ward, for the first time in a week, I could hear air entering her right lung.

Friday, December 25, 2015

Christmas Day

The Mellon family is an ongoing legend in Deschappelles. Everyone has a Mellon story and they are all positive. The original Dr. and Mrs. Mellon had compassion, a vision, and the financial resources to make things happen. Their descendants continue to encourage the original vision. I do not know anything about the current financial support but I imagine the annual cost to support the hospital is considerable. Kudus to the Mellon family. Well done!

Hôpital Albert Schweitzer shows signs of age as everything does over time but there are ongoing renovations and refurbishing of the various facilities. Today I saw men preparing the hospital entrance for new paint. The climate is harsh. The salt water rusts the metal. The sun and the humidity degrade the wood.

When built, the hospital must have looked like a palace to the citizens. You can feel the grandeur of this place. For the time, the facilities were likely "state of the art." Notwithstanding the daily press of illness through the doors, the facility still functions very well.

The grounds are well landscaped. I read that Haiti had no trees because the people cut them down for fuel. Not so here. The trees and shrubs have been well tended and nurtured. The poor and the sick at least look out over the verdant lushness of their native land. The flowers and the music are the happy things about Haiti.

One of the overwhelming aspects of this trip has been my isolation as literally the only white face in a sea of poor and sick black faces. My previous trips to Haiti were with teams of white physicians, nurses, and other medical personnel who worked alongside the Haitian personnel. I expected to see white faces here. This was intimidating at the start but feels much less so now as I end my stay.

The eleven consecutive days I have worked on in the hospital has been just enough for me to figure out how this works, or doesn't work. The nurses and physicians have been very patient with me. Thank goodness for the interpreters.

Thursday, December 24, 2015

Christmas Eve

The hospital feels deserted. The hallways are empty of stretchers. There are empty beds in the wards.

Disease does not take time off for any holiday but the inpatient census goes down over Christmas all over the Christian world. The walking wounded return home to their families.

I did my share and discharged three children this morning. The three infants were all improved and ready to go even if this were not Christmas Eve. Some of the children live a long distance away and there is no efficient transportation. Sending a sick child home prematurely might be a disaster.

The mother of the sickest child that I follow, a 2.5 year-old girl with very serious pneumonia, told me her husband is coming and they want to take the child home. This is her right, but I suggested she should keep her in the hospital. Today, for the first time, her fever is down and a blood test showed modest improvement. She is still very weak. Apart from treating children with cystic fibrosis, I do not recollect a sicker child with pneumonia. I am happy her temperature is down but the x-ray shows that her right lung is not contributing much at all to her breathing. She needs oxygen. She cannot tolerate oral feedings. She is on three intravenous antibiotics. If the parents stop the oxygen and antibiotics, I do not think she will survive long. The Mom is very discouraged. She has been in the hospital a week. The little girl is modestly malnourished. She was sick but looked better during the first two days in hospital and then she got much worse. The antibiotics were changed twice and the last change seems to have made a difference. Over the last 36 or so hours she has started to slowly improve. I hope they don't take her home.

Since the clinic is closed today I went with Renold, my interpreter, to the market. I asked if I could purchase something for his three children. He picked out three pairs of shoes, which don't look like much, but Renold was very happy about this gift. His wife died from hypertension seven years ago and his mother has also passed on. His 80 year-old father was formerly a cook for the hospital and he still lives with them.

Wednesday, December 23, 2015

So Many Absurd Situations

The patients who arrive in the outpatient clinic often wait for hours to be seen but without any good reason. The child is there. The physicians are there. But the clinic nurse does not give the chart to a physician. I keep asking the interpreter to ask for a chart but I cannot seem to make this process speed up. There is an inherent slowness to the system. No one seems to be concerned. The patients wait in silence. I do not understand this.

Today I saw a three month-old baby brought in by a mother whose breast milk stopped 8 days ago. She has been giving the baby soda pop for food. I wrote a prescription for formula and she will be able to get this for free.

I did not see a child who was brought to the clinic by a friend of the mother. The child was in hospital a few weeks ago and asked to return for follow up. The requested follow up was for yesterday but the family could not come. Instead they sent the child today. The hospital number on the follow-up note was wrong by one digit so they could not find the chart. I sent the interpreter to help but he said nothing could be done. I took the note to the paediatric ward and asked the clerk to look up the child and we found the correct number. The child went back to administration for the chart but they refused to allow the child to be seen because the child was not with the mother. I do not understand this.

A man who spoke good English asked me to sign a note so his child could be assessed in the clinic today. I signed the note. Later I saw the child with the mother. The mother looked very well turned out. This is not your usual poor Haitian family. The story was fever every night since November 30th. The mother was very specific. The fever started exactly 23 days ago and has continued every night. The child is otherwise well. The boy is happy and he eats, plays, and sleeps fine. He has no other symptoms except fever. The six year-old boy had a completely normal physical exam. I could find nothing wrong. I think the parents wanted a check up by the Canadian doctor.

Mothers are obliged to take their child to the lab or x-ray to have these procedures. They are also obliged to go to the pharmacy to pick up oral medications. My job is to fill out a requisition or prescription and give this to the nurse who explains the process to the mother. The mother is supposed stop by at hospital administration for the requisition or prescription to be officially stamped. About a quarter of the time the mother returns to say they were not allowed to have the test or to be dispensed the medication because there was no official stamp. This is a daily frustration. I cannot fathom how the communication breaks down so often. I do not understand why these forms are not stamped on the ward.

There are no bathrooms on the ward for the children or parents. The older children sit on pails to poop or pee. There is a very public bathroom by the entrance. Mothers take naked sponge baths in this open bathroom. Modesty is a luxury that these poor people cannot afford.

Tuesday, December 22, 2015

Misery Begets Misery

The parents of the children are tired, sad, and worried. The mothers keep a mostly silent vigil by the bedside. I see resignation in their faces. When I ask them if they have any questions, they hardly ever do. I asked Renaldo, my new interpreter, about a song I heard the mothers signing. The song is common he replied. The main lyric, repeated many times is, I don't need to worry because God is with me.

Today, to make a sad day of suffering so much worse, a mother dropped dead in the hospital. She was 15 years old. This was quickly a hospital-wide event. People congregated in the hallway to see what had happened. You could not walk in the hallways. Movement stopped much like highway traffic does when there is an accident to witness. Humans seem unique in our curiosity about injury and death. I presume this is because that while we understand our mortality, we do not know how this will present. Death is a compelling personal mystery.

People started to shout. Rumours circulated about the death. My interpreter wanted to share the gossip with me but I told him I did not need to know. Likely no one will really know what happened. Later, in the middle of the afternoon I passed her shrouded body. She was alone. At end-of-day rounds there was no one by the crib of the baby who lost her mother. I passed the shrouded mother again on my way out of the hospital, but this time she had a modest retinue of people with her.

Monday, December 21, 2015

Time Warp

I entered a time warp, two time warps in fact. Must be a Star Trek thing. Perhaps I fell though a worm hole and I am now in a parallel world. 

The first time warp is very familiar and takes me back to 1973 to 1979, when I was a young resident at Sick Kids in Toronto. At that time my job was to see my patients in the hospital, talk to the parents and children, write orders, review the orders with the nursing staff, follow up on lab and x-ray results, and then reassess the patients at the end of every day. This feels a lot like my time as a resident.

The second time warp is totally unfamiliar. This time warp goes back before my time as a doctor. Ostensibly, this time warp has transported me to well before my training, before immunizations, and to the dark ages of health care in Canada when medicine was not socialized and when health care was not accessible to every citizen as a right.

Today I admitted two very sick children from the outpatient service. I had just returned from a quick lunch. The next two children presented with acute infections that I have never seen before. Since I am older and have seen a lot, for me to see two brand new infectious diseases back-to-back is nothing short of amazing.

The first patient is a 6 year-old boy with tetanus. Tetanus disappeared from Canada before my time. Routine immunizations made this happen. I had presumed that I would never see a case of tetanus. Go figure. The boy cut his leg on a metal gate 8 days ago and today he presented with spasms of his muscles in the typical fashion of tetanus. He has "lock jaw!"  Fortuitously I had reviewed tetanus a few weeks ago. "Why not," I thought. Glad I did. There is good and bad news for this boy. He came in early with the symptoms and the neural toxin has not spread very far. The bad news is that there is no Tetanus Immune Globulin (TIG) in the hospital. This makes a bid difference to neutralize the toxin. All I could offer today was an antibiotic to kill the remaining germs. The toxin already present will continue to cause neurological symptoms. I went to the pharmacist and asked about TIG. He confirmed there is none. I asked if we could obtain some in Port-au-Prince. He replied that he did not know but that the Medical Director, Dr. Sannon, would know. I tracked down Dr. Sannon and he agreed to find out. Cost is likely an issue.

The second patient is a 3 year-old boy with mastoiditis. I have looked for mastoiditis all my life because early in my career this was still a possible diagnosis in Canada. Since immunizations were introduced for H. influenzae and S. pneumonia, the most common causes of mastoiditis, the problem has become even less common. The boy today had classic mastoiditis. I treated him with IV antibiotics and asked for the surgeon to see him. He might need the infection drained. 

My academic interest is piqued but mostly my heart is saddened to see these serious but very preventable diseases. 

Sunday, December 20, 2015

Sounds of Haiti

Every day at least one church group visits selected children in the paediatric ward. The minister shouts and screams. He sounds angry. I think he is exorcising the illness that "devils" the child. Then the minister and his followers sing. I enjoy the songs.

Inside the hospital there are large signs in every area with a picture of a Haitian nurse with her finger over her lips. The word "Silence" is written in very large font at the bottom of the sign. The sign makes good sense but the people are not silent. How could they be with so many people crowded into so small a place? In the paediatric ward there five rooms that each hold 15 to 20 children and their families, packed cheek-to-jowl around the outside. The rooms are the size of an ordinary living room in a Canadian home. There is not enough room to walk between the children. The parents sleep on the floor or sit and rock their child. Mostly I examine a child while the mother breastfeeds. She has the child in her lap and I kneel on the ground to do the exam. Kneeling is a gesture of supplication, as with genuflecting to acknowledge the power of a God. In my case, my posture acknowledges the power of poverty and misery. I am certainly humbled.


While I am in the building where I sleep, a baby goat bleats about every hour or so and periodically the animal bleats continuously ten or so minutes. Until now I never realized how similar the bleat of a baby goat is to the cry of a human baby. Likely the bleat and the cry are for the same thing; to be fed, to be cuddled, to be loved.

Dogs race around the compound. Overnight and occasionally when I am around by day, I hear dogfights. I presume the fights are territorial. There are clearly coveted spots to rest; usually soft earth without stones and in the shade of a tree. Since the dogs are not vaccinated, I give them all a wide berth.

The other common sound is the roosters who crow mostly at dawn but over the entire day.

In the evenings there is singing in many of the homes that are close the building I sleep in. The songs have a religious cadence. One person sings a line and then there is a chorus of people who respond. Often the same line is repeated over and over again, as many a dozen times. Still, the music is pleasant.

Elections are ongoing in Haiti. There are trucks with loudspeakers that extol the virtues of one of the candidates.

One sound that is uncommon is the sound of spoken English. I have only seen five other white faces since I arrived. 


Saturday, December 19, 2015

Day five

Saturday, so no outpatient clinic, but not as many physicians for the hospital service. Dr. Touissant, the head of Paediatrics phoned me today from Port-au-Prince to advise he is on official leave to marry and a well deserved vacation from his regular onerous duties. I congratulated him. 

Dr. Isadore and I managed to cover the inpatients in about five hours. She did about 75% of the children. I don't seem to be able to take less than 15 minutes for any one patient. I saw about 20 and she saw many more.  

The boy with meningitis is better this morning. He is apparently a good student and his only question for me was whether the meningitis would make it hard for him to do well in school. My sense is that if he is smart enough to ask this question, then everything will be ok. His hearing however might not come back. 

I "created" a social problem.  Gerard, my interpreter is poor. I have had him back to the place where I sleep and shared my lunch with the him on two days last week. This is apparently against the rules. My sense was that the ladies who cook always make three times as much as I can eat and that Gerard should be able to eat too. Apparently not. This became a big problem that involved the Head of Paeds, the Medical Director of the Hospital, and Junior, the Visitor Coordinator. I offered to pay for Gerard to eat with me and this seemed to be possible ($10 per lunch, which does not make sense), but in the end Gerard refused. He thinks he will get in trouble with the Medical Director and might not get more work as an interpreter. I understand. Too bad.

The photo below shows how much the ladies make me every day for lunch. I always leave most of the food. Too bad.  The table that day was set for two so Gerard could eat, but he never came.  




Friday, December 18, 2015

Day Four

Now that I understand the routines, the work seems more straightforward. The day flies by with lots of patients. 

I took on four new patients today and discharged two. I see problems that are no longer seen in Canada because we have such a good immunization system. For instance, today one of the new patients is a 10 year-old boy with bacterial meningitis. This problem is now rare in Canada. Worse, the boy already has hearing loss in his left ear. Ouch! This usually means the hearing will not come back in that ear. He was very sick this morning and less sick late this afternoon.


The photo above shows my sleeping arrangements. The mosquito net above the bed fell onto me the first night and I replaced this with the mosquito net that I brought. The room is clean. The bed is flat and firm, which works for me.




Thursday, December 17, 2015

Day Three

Today I asked Dr. Toussaint if I could take over the care of children in one of the five major rooms on the paediatric ward. He was OK with that. During the first two days I accepted care for about half and tomorrow I will start early at 7 AM so that I can review and take over care for the other half. The children in this room are infants and toddlers, most with infectious disease problems. I believe I can handle the ten children in this room. The severity ranges from getting ready to go home to one who almost died last night.

The child who almost died is 4 months old, was admitted with pneumonia and anemia 10 days ago and deteriorated after a blood transfusion the night before. The child is working very hard to breath, doesn't move much, and is still in a precarious situation. I checked up on this child multiple times over the day and revised the IV orders and thankfully the child was a bit better by the end of the day, which is encouraging. 

The photo above shows my desk in the paediatric outpatient clinic. This clinic is outside and much cooler than the inpatient sweatshop. There are flowering hibiscus and bougainvillea surrounding the clinic, which makes this a very pleasant place to work. The better chairs are chained to the table to avoid theft. The metal chairs can be moved around and make a terrible screeching sound when dragged over the concrete floor.

The Mellon family founded Hopital Albert Schweitzer and the family still plays an active role in the hospital. Today was the annual Christmas luncheon for the hospital staff. I dropped by for about 10 minutes and met Mrs. Mellon who hosted the event. I enjoyed a coke and then returned to check on the sick child. 

  


Wednesday, December 16, 2015

Day Two

Very different day. 

The inpatient service is much the same. Busy and noisy. The acoustics in the hospital are terrible. The walls and floors are concrete and the fixtures are metal. There is nothing to absorb the sound except the families, who are social and talk a lot. Sometimes the families are not so social. Last night a fight broke out on the ward and security had to intervene. 

The halls are crowded with patients on stretchers because the rooms are full. 

During end-of-day rounds a church group visited every room on the ward. They danced and sang religious songs. Many parents have a bible by the bedside. Religion is a very important part of this culture.  

Gerard, my interpreter, continues as a great help. I learned today he has five children and no regular job. His work as an interpreter is sporadic. He really appreciates this work. Like every man he wants to provide for his family. I am advised that the wage for an interpreter is $10 per day. During my first visit to Haiti in March 2010, the NGO I worked with paid the interpreters the same amount. The poor wages have not changed in six years!  Gerard looks chronically tired and often puts his head down to rest between patients. Yesterday after lunch I noticed that he ate two hard candies. Curious, I inquired if that was his lunch and he confirmed it was. Ouch! Today he came back to the house and ate with me. He ate at least three or four times as much as I did. He was very hungry. This worries me. 

Gerard tells me that life was better under the Baby Doc regime! At that time, notwithstanding the dictatorship and the political oppression and corruption, there were at least jobs available and men could provide for their families. There was money for food. Now, he explains, there is only "misery." I certainly see the despair in the families in the hospital.

The outpatient service today was quiet and I was able to see my share of children. No one was seriously ill.  

A very young looking Mom brought in her one week-old baby. The Mom looked 14 but told Gerard she is 16 years old. She presented as overwhelmed by motherhood and breastfeeding. The baby looked fine but unless Mom can sort out the rhythm of breastfeeding, the baby will not thrive. She will come back in two days to be weighed. I reviewed breastfeeding basics with the Mom and watched her feed to insure she has the basics of position and latch. She and the baby live with the maternal grandmother, which is positive. There are no breastfeeding nurses in the hospital. Mother nature, my advice, and grandma will have to do.

Half of the inpatient service are infants less than one or two months of age. Prematurity is common, likely due to less optimal prenatal care. Malnutrition is common. Most of the babies are admitted with sepsis. 











Tuesday, December 15, 2015

First Day

Without two prior trips to Haiti, this first day might have been overwhelming. Nothing like experience!

Hôpital Albert Schweitzer has a very dedicated and small medical staff for the number of patients. Back in the "dark ages" during my fellowship at Sick Kids in Toronto, there were substantially more physicians per inpatient. That was 40 years ago!  

Hard work, organization, a dedicated support staff, and spirit compensate for the lack in medical staff. I'm impressed.

The day starts with teaching rounds at 7 AM. Today the topic was Benign Prostatic Hyperplasia - a urology topic. Go figure!

From 8 AM, the children admitted to hospital are reviewed. Today there were five physicians - the head of paediatrics, a family physician who works full time at the hospital, two interns who spend one month in paediatrics, and me. 

I have the most experience or the least, depending on the patient and the perspective. I have only modest experience with the culture, the language, and the various tropical infectious diseases. However, if you add up my years of paediatric experience, I have more than all the other four combined! They are all very young!

Fortune smiled on me for my first patient. The prior night a 6 year-old boy was admitted with generalized swelling and heart failure. The swelling and heart failure is due to glomerulonephritis, a kidney problem. Nice to start out with a problem in my specialty!

I am slower with the inpatient assessments because I needed to learn how the system works. As well, the medical chart notes are written in a mixture of French or English. My ability to read medical French is OK and physician handwriting being what it is; the language difference is not a big deal. My interpreter could not read the French notes any better than I could read the English! 

My interpreter, Gerard, has good experience at the hospital and he is very helpful. Thank you Gerard.

And so it went for three hours in the hospital.

From 11 AM, four of the docs, including me, saw patients in the outpatient clinic. Only about 45 children were assessed and again I was the slow poke. I only saw 7 of the children, which implies the other three docs each saw about 12 patients. My assessments got faster as the afternoon progressed.

The medical problems at the outpatient clinic were similar to what a paediatrician might see in the office in Canada. Bronchitis, pneumonia, ear infection, anemia, and so forth. Nothing complicated today.

Later in the afternoon the head of paediatrics was called to attend an emergency Cesarean section for fetal distress. The baby did not cooperate and breathe for the first 1 to 2 minutes, which was tense. Everything worked out pretty well with some suction and bagging with oxygen.

At 4 PM the docs make rounds on every patient in the hospital. This was not a very thorough round, but the head of Paediatrics is on call and he knows them all very well. He is very capable and confident. He is the major reason why the unit functions so well notwithstanding the limited number of physicians. He knows his paediatrics and would do well in any North American hospital.

Once the night orders were written, I left in the dusk for the house where I eat and sleep.

Each day will be much the same but I will get better and faster and hopefully by the end of my stay I will be able to keep up with the rest.

Monday, December 14, 2015

Finding Common Cause

To reach Haiti I need to fly in three countries and navigate four airports. My flight itinerary takes me from Calgary via Los Angeles and Miami to Port-au-Prince. 

Airports offer a microcosm of the world that flies in and out of each city. The world seems very small.

Modern airport security procedures are a great equalizer. We are all the same when security is concerned. Everyone is obliged to follow the same rules. Airport security ignores gender, age, disability, colour, culture, faith, and everything else to insure the collective safety of the travellers and the airport personnel. Seems to me that this is good practice for the 21st century. 

Canada will welcome 25,000 Syrian refugees over the next few months. I am very proud to be a Canadian. I believe Justin Trudeau. Canada is back. Good on us!! 

I am wearing the same pants that I wore when I first travelled to Haiti in March 2010. I arranged for a Canadian flag to be sewn onto my pant leg for that trip. I wanted the world to know that Canadians cared and wanted to help. I didn't care if anyone new my name. I was not looking for personal fame or fortune, but I was happy to advertise Canada. 

While negotiating security at the LAX airport one of the security workers called me Mr. Canada, and this pleased me. Earlier in that same line I watched while a person ahead of me waited very patiently for a disabled man to get his gear in the trays. The disabled man had a movement disorder and his coordination was poor. He managed the task, but he struggled, and you could sense that he felt bad about holding up the line. He indicated to the person behind to go ahead. The next man, however, waited and I applaud that fellow for his patience. 

The world is small. The problems in the world will get better if the citizens of the world unite in patience and tolerance. I believe this will happen, notwithstanding the recent climate of terrorism and the ugly racist responses of the political right in America and Europe. I believe that someday soon the world will unite in a common cause. We will be obliged to unite because as the world becomes progressively smaller, we will not be able to escape the recognition of our similarities. Differences will no longer drive the equation. Common cause will bind us together.  

I think this is why helping out in Haiti is so important. 

Sunday, December 13, 2015

Cholera in Haiti

In October 2010, in the aftermath of the earthquake, cholera arrived in Haiti. The strain was likely brought into the country by well-meaning workers from Asia. Sadly, the setting was ripe for the rapid spread of this scourge. Within a year of the outbreak there were over a third of a million cases of cholera and 5,500 deaths! Within several years there were more than two thirds of a million cases and 8000 deaths. Cholera persists and the government has an ambitious program to eradicate the disease within a decade.

Cholera can kill within hours. Vibrio cholerae, the infecting bacteria, produces a toxin that interferes with salt and water transport in the duodenum and the upper jejunum, the first portions of the small intestine. The toxin activates adenylate cyclase, which increases cyclic adenosine monophosphate, which blocks sodium and chloride absorption, and promotes chloride and water secretion in the bowel. This results in profuse watery diarrhea that can rapidly lead to severe dehydration, shock, and death.

V cholerae is a saltwater organism that lives in association with plankton.
Cholera has 2 main reservoirs, humans and water. The bacteria is ingested in contaminated water or food. The bacteria is inactivated by acid in the stomach and infection depends on a large enough dose to circumvent the acid. Anything that reduces stomach acidity (antacids, histamine receptor blockers, proton pump inhibitors, H pylori infection) increases the risk for cholera.

Infection rates in household contacts range from 20 to 50%. Past infection results in antibodies to cholera and immunity to repeat infection.

Rapid rehydration with intravenous fluids is life saving.

Antibiotics are administered for moderate or severe infections. A single dose of tetracycline, doxycycline, or ciprofloxacin is effective to reduce the duration and volume of diarrhea. Single dose doxycycline is the preferred antibiotic. This antibiotic can cause permanent discoloration of the teeth if administered to children under the age of 8 years but the risk is small with a single dose. 

Tetanus in Haiti

Haiti is the only country in the Western Hemisphere where neonatal tetanus has not been eliminated. 

Clostridium tetani is a bacteria that forms spores that are resistant to heat, desiccation, and disinfectants. The bacteria is found in soil, house dust, animal intestines, and human feces.

To germinate, the spores require specific anaerobic conditions such as wounds with dead or devitalized tissue or a foreign body. The source of infection is often a minor wound such as a wood or metal splinter, or a thorn. Stepping on a nail is a common antecedent injury. Once the spores germinate, the typical symptoms are caused by a toxin that is released from the spores.

Tetanospasmin is the toxin responsible for the symptoms. By weight this toxin is one of the most potent known. The estimated lethal dose is only 2.5 nanograms per kg body weight!

Tetanus usually presents with the acute onset of hypertonia, painful muscular contractions of the muscles of the jaw and neck, and generalized muscle spasms without any other apparent medical cause.

Generalized tetanus usually presents with trismus (lockjaw), which is the inability to open the mouth secondary to masseter muscle spasm. Risus sardonicus, the scornful smile of tetanus, results from facial muscle involvement. Localized tetanus presents with persistent rigidity in a muscle group close to the injury site. 

The "spatula test" is a simple diagnostic bedside test that involves touching the back of the throat with a tongue depressor. In a normal individual this should elicit a gag reflex and the patient should try to expel the tongue depressor. In a person with tetanus, the patient develops reflex spasm of the jaw muscles and bites the tongue depressor.

In countries without a comprehensive immunization program, tetanus mostly develops in neonates and young children. 

Neonatal tetanus results from umbilical cord contamination during delivery. The risk factors for neonatal tetanus include an unvaccinated mother, home delivery, unhygienic cutting of the umbilical cord, a history of neonatal tetanus in a previous child, and application of a potentially infected substance to the umbilical stump (mud, clarified butter).

At the end of the first week of life, infected infants become irritable, suck and feed poorly, and develop facial grimacing and severe spasms and rigidity precipitated by touch. Mortality with neonatal tetanus exceeds 70%.

Antimicrobials are used to reduce the number of bacteria and production of the toxin. Metronidazole has superseded penicillin as the drug of choice. 

Passive immunization with human tetanus immune globulin (3,000-6,000 units as 1 dose) shortens the course of tetanus and might lessen its severity.

Once the tetanospasmin becomes fixed to nerve cells, the toxin cannot be neutralized by tetanus immune globulin. Recovery of nerve function requires the formation of new nerve terminals and the formation of new synapses. Recovery is slow and usually occurs over 2 to 4 months.