Haiti Reflections: Day 4 - March 18

The day began placidly. Dawn slowly broke and warm, tranquil sunshine began to fill the room, peacefully bringing each of us out of our slumbers.

Just kidding. Roosters and church bells.

Before we departed for the mountain village of Canon, Sarah lead us on a field trip. Today is Friday and Chantal's market day. The market is less than half a mile from the clinic and an easy walk.

Chantal's main street

We travelled down the dusty gravel road with a lot of the goods that were being taken to be sold. Some of it was carried on trucks, some on people's heads, some was still on the hoof.

The market was a typical third-world market. It's a large area with stalls that are little more than tall tree branches used as supports for corrugated metal roofs.

An assortment of goods could be purchased there. Lots of foodstuffs, including fish and shrimp, but mostly bric-a-brac. There was one stall that sold sticks. Sounds sad but these were bundled in varying lengths from a few inches to 6 or 8 feet and looked for the most part to be pretty straight and sturdy. Another stand sold nothing but rice sacks from relief agencies. No rice, just the sacks. But the relief agencies make sure those sacks are sturdy enough to have a long and useful life after the grain is gone.

Rice sacks for sale - Come to Chantal where relief efforts meet market capitalism

A lot of livestock was also being hawked. Cattle, goats and pigs were plentiful. Sadly, our roosters were nowhere to be found.

After a cursory foray through the bazaar we headed back to the clinic.

16 of us piled into the Hilux. I was one of the 7 who got to sit in the cab (the one with 5 seat belts). 9 more were in the bed with the supplies. It was a very cozy 45 minute drive to Canon.

On the way to Canon we forded two rivers, one just outside Chantal, one closer to Canon. Both had very wide beds, but the one outside Canon had a considerable amount of water flowing through it - and this is the dry season. It was readily apparent that the people who live in and around Canon (and countless other Haitian villages) have a basic healthcare logistics problem. During the rainy season the rivers will be swollen and impassable. The locals can't get to help and help can't get to them. Simple things will become lethal. If your appendix ruptures, you're dead.

Canon is a teeny tiny village. When we arrived, people were lined up waiting. The line went on for quite some distance and we had a lot of work ahead of us. Father Lawrence, the local priest and a Barrack Obama look-alike, greeted us and showed us where we would be working.

Lining up for the doctor

The pharmacy window

Clouds blanket the hills on the other side of the valley

Ginny and I were on triage. We were in a classroom that was hot, lit only by sunlight and had small windows without glass. With people lining up right outside, it was very noisy. We set our initial screening desk at the door (more crowd control tactics) and put the area for vital signs as far from the front as we could. This was only about 10 feet from the doorway so it didn't really help reduce the noise at all.

There was only one urgent situation where a lady collapsed but she was easily buffed up...Father Lawrence took her someplace nearby where her daughter could help her with a shower to cool down.

We had more problems with crowd control here than in Chantal because of the people being right outside our door. They were desperate for care and sometimes things got aggravated in line and they sort of surged. It was a hassle and a distraction but personally I couldn't be angry with them.

One observation I made (which was confirmed by Greg and Rebecca who triaged here yesterday) was that the hypertension wasn't quite as prevalent nor quite as high. Don't get me wrong, it was still really bad, but there was a marked difference between blood pressures in Chantal and Canon. This only adds to the mystery of Haitian hypertension (Haititension? Hypertaitian? Gonna have to work on that...)

Another observation I made was regarding something called "health literacy." There are many definitions but generally, health literacy is the ability to understand health information and to use that information to make good decisions about your health and medical care. There's no standardized scale for determining health literacy but if there was, Canon's would likely be close to zero.

Case in point: I was triaging when a 24 year old woman came in. Through Jean-Pierre, the translator, I learned she was having abdominal pain with her menstrual period. I asked how the pain was different from her normal period. There was a sort of puzzled, spluttering exchange between the patient and Jean-Pierre and I got a very non-specific answer. I don't recall what it was but I knew to try a different approach.  I asked: "How long has this been going on?" The answer: "12 years." 12 years of painful menses in a 24 year old means that nobody ever told her that pain will accompany her periods. She wasn't alone. I had a handful of these, as did Ginny.

Triaging in Canon is also where the full impact of the term "lost in translation" hit me. When Haitians speak of pain in a particular body area, they tend to make sweeping gestures indicating the entire area is affected, whether that be head, chest, abdomen or limbs. It takes some work to narrow it down to what specifically, if anything specific, is hurting.

One elderly lady came in and her gesture was atypical. She didn't sweep across her chest with an open hand. Instead, she used a single finger to draw a fairly tight circle in the middle of her left pectoral.

Jean-Pierre: She says she has chest pain.
Me: Pain in her chest or in her breast?
Jean-Pierre: Uh, what is the difference between them?

Lost in translation. The translators are smart people (hell, I only speak one language) but they aren't medically trained. The difference between breast and chest seems obvious in English. But when translating, your vocabulary can be limited, especially when working in a specialized area like medicine or engineering or finance. If the only word you know for anything between the shoulders and the bottom of the ribs is 'chest' that's the word you have to use. This was something I hadn't been taking into account for the past three days and it still bothers me intensely that I may have been missing things because I wasn't paying closer attention to the patient-translator interaction.

In this case, Jean-Pierre quickly picked up the difference and got clarification that it was her breast. He also added the differential question to his repertoire (he made the difference clear in all subsequent females presenting with pain below the shoulders and above the abdomen). Sadly for this lady, by the time your breast tumor begins to hurt you're probably too far along to be helped by even the most advanced medicine.

Like yesterday in Chantal, the day in Canon was long and mind-numbing. There were a few people that we weren't going to be able to see. They were given white tickets that, if they could make it there, would get them to the front of the line in Chantal tomorrow.

Once everything wound down, we piled back into the Hilux. This time I got to sit in the bed. Oh, lucky me. Father Yves did a very good job of minimizing the bumps but these were rural gravel roads so it wasn't possible to miss them all. Sitting on the edge of the bed, clinging for dear life, was quite literally a pain in the ass. My hands were aching from my death grip. And because of the equipment in the back, my feet were contorted, which wasn't too bad in itself but Sarah kept sliding off the boxes she was sort of sitting on and onto my legs. Trust me folks, you just haven't lived until you've forded a Haitian river in the bed of a pickup with a physician sitting on your ankles.

We arrived back in Chantal as they were finishing their workload for the day. We had the standard dinner, Prestige and debriefing. Then off to bed.