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Global Health, Haiti, In the News, Stanford News

Stanford doctor discusses experience in Haiti

As previously reported, a team of Stanford physicians and nurses, including Paul Auerbach, MD, recently spent two weeks providing medical care to survivors of the Haiti earthquake. This morning, Auerbach was a guest on KQED’s Forum, where he discussed his experiences and the situation in the country. Audio from the live call-in show can be found here.

Previously: Treating the injured amid the apocalypse of Haiti and Stanford medical team returns from Haiti

Global Health, Haiti

Treating the injured amid the apocalypse of Haiti

Over the last two days, I have spoken to seven caregivers at Stanford who treated earthquake victims in Haiti, all describing what they experienced as life-changing and beyond anything they had witnessed before.

“It was a completely religious experience. It was an unbelievable outpouring of emotion and human bonding,” said Stanford orthopedic surgeon Gaetano Scuderi, MD. He jumped in to volunteer with a Haitian-American nonprofit group after seeing a CNN report of doctors abandoning patients because of security issues. He spent four days in a small village north of Port-au-Prince with 25 other physicians, treating as many as 800 patients with crushed and broken limbs and other traumatic injuries.

“I have to say we operated through tears in our eyes the whole time,” he said. The spirit of cooperation was so remarkable that only days into the relief mission did he discover that the person sweeping the floors in the tiny garage of an operating room was an oncology surgeon and chief of staff at a big Florida hospital.

“Everybody had one goal in mind. We knew people were out there dying. We didn’t want to waste a second.”

A separate team of Stanford emergency physicians and nurses also spent two weeks at the university hospital in Port-au-Prince, arriving to find a scene they described as “hell,” something out of an apocalypse. A sea of patients, some dead or dying, awaited them amid cries of pain and the overpowering smell of infection and death.

“Seeing those mangled extremities, the amputations and the infected wounds, it was overwhelming,” said Anil Menon, MD, a member of the team.

The group, which arrived Jan. 17 and was one of the first medical teams on the site, set up an effective system of care to triage and treat patients, trying to save as many lives as possible, said Robert Norris, MD, chief of emergency services at Stanford. They cared for an estimated 2,000 people in collaboration with other physician volunteers who arrived later on scene.

A podcast on the Stanford team’s experiences is available here.

Previously: Stanford medical team returns from Haiti

Global Health, Haiti, Stanford News

Health care in Haiti before the earthquake: A look back at Haiti’s Albert Schweitzer Hospital

Even before last month’s earthquake, providing medical care in Haiti was a struggle. A 2002 Stanford Medicine magazine article describes the scene back then in one of today’s major sites for care in Haiti, Hôpital Albert Schweitzer. An excerpt:

bedcheck.jpg

Chief operating officer Jackie Gautier, MD, a Haitian who formerly served as the hospital’s pediatric chief, announces that the hospital’s supply of post-anesthesia pain medications is used up with little likelihood it will be replenished in the next month or two.

“Why can’t you hand-carry some in on the next plane?” one physician asks. Gautier smiles thinly. Paperwork, not logistics, is involved, Gautier says diplomatically. Later, other physicians explain that while the hospital is entitled to import its supplies and medications duty free, the bankrupt Haitian government or an official might be waiting for an unofficial payment. In any case, the medication isn’t coming.

Today, the hospital, which is in a rural area outside of devastated Port-au-Prince, is serving as an “overflow valve” for those in need of medical care, says Stanford surgery professor Ralph Greco, MD, who has traveled there many times since the 1970s to work and train surgery residents.

More about what’s happening there day to day on the hospital’s blog.

Illustration by Stan Fellows

Global Health, Haiti

Rescuing Haiti’s HIV/AIDS patients

Among the many aftershocks of the Haitian earthquake is that it left thousands of HIV/AIDS patients in dire need of medical help, including medication. Before the quake, Haiti was doing a credible job of caring for these patients, thanks to the efforts of a number of nonprofits, including Partners in Health and a clinic in Port-au-Prince known as Gheskio. But Gheskio, which cares for more than half of the country’s AIDS patients, was shattered by the temblor, and its operations have been thrown into chaos as a result of the catastrophe, according to a recent story in the Wall Street Journal.

One report in the New York Times described an AIDS patient, 38 years old and pregnant, wandering the street in search of help. She had walked three hours to a downtown clinic from a tent city in the slum of City Soleil. “Having missed an appointment the day after the earthquake, she had run out of pills and found herself racked by diarrhea and vomiting – on the streets, no less,” the Times reported.

Haiti has one of the highest rates of HIV outside sub-Saharan Africa, with an estimated 120,000 people living with the infection, according to UNAIDS. The prevalence rate among adults is 2.2 percent. Many of these patients are on antiretroviral treatment, but the rule of thumb is that these drugs have to be taken with clockwork regularity to remain effective. Patients who don’t follow a strict regimen not only leave themselves vulnerable to illness but are also at risk of developing drug-resistant forms of the virus. So making these drugs available to patients on a regular basis is critically important.

In response to the crisis, the Ford Foundation announced it will provide $250,000 to the Clinton Health Access Initiative to help maintain Haiti’s HIV/AIDS Services. The two organizations had been working in Haiti before the quake to strengthen the country’s HIV/AIDS programs. “HIV was a crisis in Haiti before the earthquake,” the foundation’s president, Luis Ubinas, said in a press release. “It is essential that HIV treatment is integrated into the crisis response. Emerging from this tragedy we have an opportunity, and a responsibility, to help build a strong and effective system of prevention and treatment that endures for the future.”

Global Health, Haiti, Stanford News

Reports from Stanford medical team in Haiti

UPDATE JAN. 28, 2010: Paul Auerbach, MD, and Robert Norris, MD, have e-mailed a brief description of the medical and cultural experiences the Stanford team encountered while treating earthquake survivors in Haiti. The physicians’ letter is available here.

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An eight-person team of Stanford physicians and nurses has been providing medical care to survivors of the Haiti earthquake as part of the larger International Medical Corps group. Three of those members have been blogging their experiences working in a Port-au-Prince clinic over the past 10 days.

The two physicians and nurse describe the widespread destruction, constant flow of patients and their frustration at not being able to do more. The reports are both horrific and hopeful.

Paul Auerbach, MD, who is pictured above watching Ian Brown, MD, perform a curbside sonogram, provides nearly daily progress reports of team operations on his Healthline blog.

Over the weekend he reported:

We saw a lot of progress today at the hospital. The surgeons are seeing a decrease in the number of patients that need emergency surgery for crush injuries and fractures, but that doesn’t mean that we are anywhere near a point where less-than-massive resources are needed. There are countless broken bones, deformities, facial injuries, burns and so forth, and we are encountering the sequelae of the initial surgeries that were performed in difficult settings. These mostly include infections that requires wash-outs of wounds and revisions of the prior surgeries. This is to be expected in our situation. The U.S. military has given the hospital tremendous report in facilitating the transfers necessary to the USS Comfort, which is thankfully still involved in this relief effort.

The hospital campus is evolving with some decent structure. We now have a central pharmacy, three operating rooms for adults, one operating theatre (within a tent, as are most facilities) for children, and arrangements for childbirth, children, postoperative patients, triage and emergency assessment, and so forth. These are crowded and extremely busy areas, staffed by dedicated physician, nurse and technician volunteers. We are moving toward 24 hour coverage. We have decent drinking water and food distributions. Phone lines will hopefully begin to come in tomorrow. We may soon have some reliable laboratory testing and do have a small blood bank.

There was great sadness and an unsettling moment as a body was recovered within our compound from under the wreckage of the nursing school. I have a fairly strong stomach, but had to walk away. There are perhaps many more bodies in that location. We lose an occasional patient now, and we are particularly saddened by the deaths of those we have come to know, and have tried unsuccessfully to save.

Anil Menon, MD, describes patient cases and daily life accounts through text messages, which are transcribed on a Healthline blog and on a friend’s blog. In a recent post he said:

Apparently, not everyone got hurt in the earthquake. I wouldn’t have known it from what I saw. A young kid was playing with his ball amidst the rubble and I realized that life moves on, no matter the magnitude of the problem. I’m worried that we will move on and forget the external fixtures that protrude from so many legs, or a nation full of amputees and without infrastructure.

Nurse Gaby McAdoo chronicles the treatment and recovery of a 5-year-old boy who was been trapped beneath a collapsed building for nearly eight days on her blog Out Of The Rubble Comes Hope.

Previously: Stanford sends medical team to Haiti
Photo by Chuck Liddy/The News & Observer (Raleigh, NC)

Global Health, Haiti, Mental Health

Next hurdle for Haitians: coping with PTSD

When I came across this ABC News article today on the emotional trauma being experienced by Haitian earthquake survivors, I immediately contacted David Spiegel, MD. The Stanford psychiatrist has done extensive research on post-traumatic stress disorder (PTSD), and I was eager to get his expert opinion on the situation in Haiti. Here’s our brief Q&A.

What do you expect we’ll see in terms of PTSD and depression among earthquake survivors?

There should be plenty of it. Virtually everyone was exposed to a life-threatening stressor (the earthquake and many aftershocks); many were injured or witnessed death or serious injury and now face threats to survival based on lack of food and water, disease, and violence. I would expect at least 1/4 of the population to have PTSD on that basis alone.

Then there are the many losses – home, possessions with memories attached, loved ones, work, neighborhoods, routines, lack of identification of bodies and proper burials – total disruption of personal and social networks, as well as injury and medical illness. Rates of depression increase with concomitant stressors, including medical illness, especially for people with a past history of depression or genetic vulnerability to it. And as the outlook for much relief gets grimmer, depression will increase. I would expect at least another 1/4 of the population to be depressed.

The ABC article notes that “months may pass before symptoms of PTSD or clinical depression emerge.” Does it typically take that long for symptoms to appear after a major event like this?

Yes, PTSD can emerge months later, and by our definition it cannot begin before a month after the initial traumatic stressor. Acute Stress Disorder can begin within two days of the stressor. Some hide symptoms as well, but even if careful diagnosis is done now (and it won’t be), more people will be affected over time.

Right now the focus in Haiti is on people’s basic needs. At what point should the focus turn to mental health?

Even now, behavioral problems are hampering the rescue efforts: violence breaking out around food distribution points, doctors withdrawing because security was not provided. Obviously, keeping people alive is paramount, but planning for emotional support and social organization will help survival. People with PTSD and depression are less likely to get needed food, water, and medical attention.

In terms of treating survivors with PTSD, what sorts of lessons have we learned from Hurricane Katrina and other major disasters?

High rates of PTSD in New York after 9/11 (12% throughout the city, 20% below Canal Street near the World Trade Center) resolved pretty quickly – about 6 months – largely because there was much emotional and social support, treatment was available, and people could resume their lives quickly. In New Orleans, the biggest long-term problem was depression, as people realized their city was pretty much lost, and it wasn’t coming back any time soon. The poor government response contributed, I think, to pervasive hopelessness and depression. I expect plenty of that in Haiti, since the goverment has all but evaporated.

Global Health, Haiti, Women's Health

Addressing Haitian women’s health needs

Haitian woman.jpg

Speaking of Haiti, the Feminist Peace Network recently discussed the unique, post-earthquake health needs of women there:

In Haiti, as is always true in the aftermath of a major disaster, in addition to the urgent need for what we traditionally consider the pillars of immediate aid – food, water, shelter, medical care – there are needs that are specific to women, particularly for pregnant women and mothers with new babies and the need to address the added vulnerability to violence that women face when government infrastructures are dysfunctional. According to the International Research and Training Institute for the Advancement of Women (UN-INSTRAW) and the United Nations Population Fund (UNFPA):

“(W)omen of reproductive age face limitations in accessing pre-natal and post-natal care, as well as greater risk of vaginal infections, pregnancy complications including spontaneous abortion, unplanned pregnancy, and post-traumatic stress. An increase in violence against women was also recorded”

The blog Our Bodies, Our Blog compiled a list yesterday of organizations specifically focused on Haitian women and girls. One such group is Partners in Health, which my colleague blogged about earlier today.

Photo by United Nations Development Programme

Global Health, Haiti

Some perspectives on Haiti

The current relief and rescue efforts are being hampered by the chronic, dismal state of the Haitian physical infrastructure (communication, transportation, health-care network, sanitation, urban planning, education, etc.) and the limited response capabilities of the nation’s population. These two factors are compounding the impact of the earthquake.

I worked in Haiti in 1981, conducting an epidemiological study of an acute outbreak of gastroenteritis. Also, I became familiar with the nation’s history for personal reasons when I followed closely Professor Leslie Manigat’s victorious presidential campaign in 1988.

As the international community works to help Haiti recover from last week’s earthquake, many of my friends and colleagues have asked: How did Haiti’s situation become so dire, and what is the solution? In my opinion, the situation stems from the following interacting scourges:

(1) Colonization/occupation: Spaniards (1492-1697), French (1697-1804) and Americans (1915-1934) have ruled the island primarily in their own interests.

(2) Politics:

(a) Early independence (first in Latin America), for various reasons, greatly isolated the island from the rest of the world.

(b) Dictatorships from emperors, military rulers and the Duvaliers alienated the majority of the population

(c) Instability from coups-32 of them in 206 years prevented progress by lack of leadership continuity.

(3) Natural disasters: Recurrent tropical storms (four in 2008 alone) and earthquakes (the most severe in 1770 and 2010), which can be largely predicted and whose aftermaths can be mitigated (like in Japan), have resulted in periodic setbacks.

(4) Diseases:

(a) Epidemics like those caused by anthrax (1770), yellow fever (1790s and early 1800s), smallpox (1518, 1920), syphilis (1927), malaria (1963), measles (1990s), meningitis (1994, 1995), pandemics (plague, cholera, influenza) and water-related diseases (cholera, typhoid fever, hepatitis A, leptospirosis, acute gastroenteritis) primarily after floods have been devastating. Currently, HIV/AIDS is disproportionately affecting the young adult population, main source of manpower.

(b) Endemic diseases such as tuberculosis, tetanus, parasitic diseases (particularly, intestinal worms and schistosomiasis), acute respiratory infections, goiter, Type III diabetes;.

(c) Genetic diseases, mainly sickle cell disease. People who survive these illnesses, which have high prevalence in Haiti, are often weakened against infections.

(5) Malnutrition: The Pan-American Health Organization states that more than one-third of all Haitian children who survive their first birthday show signs of severe growth retardation. These children will have serious immunological and intellectual-development challenges.
(6) Diaspora/brain drain. Two million Haitians, or 20 percent of the nation’s population, live mainly in the United States, Canada, France, Cuba, the Dominican Republic and the Bahamas. This deprives the local workforce of its valuable elite.

However, the country has natural resources such as bauxite, copper, gold, marble, calcium carbonate, coffee, sugar cane and fish. Moreover, geothermal, solar, wind and hydropower energy (80 percent of all Haitian energy is renewable) and scenic settings ideal for tourism could be tapped for the first time or on a much bigger scale.

The economic solutions proposed and implemented by international institutions to lift Haiti out of misery have shown sketchy and disappointing results, mostly because of the paucity of multidimensional approaches. The GDP grew negatively in 2001, 2002 and 2004, and the nation received assistance equivalent to $1 billion in U.S. dollars from 2004 to 2006 (for an annual economy equivalent to $9 billion in U.S. dollars), according to the International Monetary Fund. The same organization announced in 2007 that Haiti had turned the corner while at the same acknowledging the country’s horrendous poverty, with 76 percent of its population surviving on less than $2 per day.

It is high time that developed nations met their full historic and moral responsibilities toward Haiti through a Marshall-like plan to ensure that massive financial and technical aid is sustained after the crisis intervention. Linked to assistance of this magnitude would be a mandate for the emergence of stronger and more reliable democratic and educational institutions, like in post-WWII Europe. This will lay the foundation for the development of a large middle class, which will increase the chances of democratic stability. Success will be declared when Haitians begin to return en masse to their native land.

Hopefully, the 2010 earthquake will serve as a wake-up call.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia.

Global Health, Haiti

FACE AIDS responds to the emergency in Haiti

One of the organizations on the Stanford campus that has always impressed me is FACE AIDS, a group of very energetic students who have taken it upon themselves to fight AIDS in Africa. Since 2005, this student group has raised almost $2 million to support Partners in Health (PIH), a nonprofit working in Africa but with deep roots in Haiti as well. PIH was among the first groups to provide emergency services on the ground in Haiti to respond to the recent calamity, and FACE AIDS is doing everything it can now to support that effort. The student group has partnered with Sterling Stamos, a Menlo Park, Ca.-based private investment firm, to raise $100,000 for PIH’s Haiti earthquake relief and reconstruction efforts. Sterling Stamos is providing a $50,000 challenge grant that it will match dollar-for-dollar with funds raised by FACE AIDS.

“We find that years of investment in building a strong local partner organization mean that we are again in the position of responding effectively to a natural disaster,” said Paul Farmer, MD, the Harvard physician who founded PIH and now the deputy to former Pres. Bill Clinton, the UN Special Envoy for Haiti. “We are very proud of our team.” He said the organization has been working very closely with the United Nations, the Haitian and U.S. governments, and other nonprofits to meet the immediate needs of Haitians, as well as to work toward the long-term rebuilding of the country.

I can’t think of a worthier effort to support. You can contribute online here.

Global Health, Haiti, Stanford News

Haitian med student worries, makes plans to aid country

Yesterday, my colleague Ruthann Richter met with Johan Guillaume, a first-year Stanford medical student who was born in Haiti. He shared with Ruthann his concerns for his grandmother and other family members there – he had been unable to reach them – and his plans to mobilize students to collect needed medical supplies for shipment to the earthquake-stricken country. Ruthann’s story can be found here.

Previously: Stanford sends medical team to Haiti

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