Descent into Haiti

Health care in the face of horror, urgency and ambiguity in an impoverished nation



“Over the years, I have gotten used to the ambiguity. That's hard for American doctors or nurses who go there; we're not used to ambiguity in our own lives.”




“What Haiti needs
is a public health infrastructure, clean water, sewage treatment, latrines. Over time, there wouldn’t be so much sickness, and we could provide ongoing care instead of crisis care.”




NEAR CAP-HAITIEN, Haiti’s second-largest city, Patricia B. Wolff, MD, and the rest of her visiting American medical team have watched the same tragic story unfold again and again. Hungry children, enticed by the luscious-looking fruit of the tropical ackee tree, pick it while it is still under-ripe — a poisonous stage in its growth cycle. Then they take a few desperate bites.

“They are taught not to eat it, but hunger can make any fruit tempting,” says Wolff, associate professor of clinical pediatrics, who has made volunteer trips to Haiti since 1988. “The child becomes unremittingly hypoglycemic, begins convulsing, goes into a coma and dies. Even in the unlikely event that intravenous glucose is available, permanent brain damage has already occurred.”

Starvation and sickness are the twin evils of daily life in Haiti, the poorest country in the Western hemisphere. At their makeshift clinic, equipped with one solar-powered microscope and basic medical supplies, Wolff and her colleagues — including some from Washington University — routinely treat cases they would never see back home: cutaneous anthrax, typhoid fever, elephantiasis, parasites that infest people’s abdomens, lungs or brains.

There are also the mysterious cases that haunt Wolff long after she has returned to the United States and her own private pediatric practice, where asthma and ear infections are the staples of everyday life. Like the young boy who developed a hole in his skull, underneath the scalp. Or the pretty 11-year-old girl with a huge perineal ulcer that did not respond to antibiotics. Wolff and her colleagues took the child to a hospital an hour away and, in the absence of a phone system, never heard what happened to her.

“Over the years, I have gotten used to ambiguity,” says Wolff, who travels to Haiti three or four times a year, usually for an intensive weeklong stay. “That’s hard for American doctors or nurses who go there; we’re not used to ambiguity in our own lives. I also have accustomed myself to so much horror — I just have to deal with it and move on.”

In addition to her work in the clinic, which is sponsored by a Methodist church group in North Carolina, Wolff has initiated a project of her own that is already an unambiguous success. Last August, with a small grant from the Rotary Club, she established a feeding program that gives starving children 175 calories a day for each kilo of their weight. She uses the same formula — peanut butter, sugar, oil, powdered milk, vitamins and minerals — that Mark J. Manary, MD, associate professor of pediatrics, developed to treat malnutrition in Malawi.

“These are children who are barely alive, very lethargic, with orange hair,” she says, recalling some of the 300 patients whom they have fed so far. “Then you see them six weeks later and they are running around with chubby cheeks and new black hair. They look terrific by comparison.”

Patricia B. Wolff, MD, examines a young Haitian patient on one of her many trips to the impoverished country.

On the medical side, too, are some successes, though these often require a creative approach to care. A year ago, one mother brought in her 2-year-old son, worried that he couldn’t walk. Wolff examined him and found little except a mild case of cerebral palsy — so off she went to the Cap-Haitien flea market and found him a used baby walker.

“This January, his mother brought him back and he was walking,” Wolff says, jubilant. “Probably he wasn’t a good walker before and no one had the time to teach him, then the baby walker helped him do it on his own. His legs got strong enough, and now he is doing fine.”

If only all stories ended so happily, she sighs. “It’s horrifying to see how so many Haitians live. Imagine mothers who have babies they know are dying because they have no food for them. No one around them has real food security either — except us, when we come. It’s pretty clear that we Americans are the people with excess.”

As a child, Wolff planned to share her excess with others as a doctor in the developing world. Graduating from the University of Minnesota Medical School, she did a residency and fellowship in pediatric endocrinology at St. Louis Children’s Hospital. But she also married, had two children — and “got off the track,” away from working in other countries.

When her children were teenagers, the whole family traveled to Haiti with a St. Louis group to spend time as volunteers. They saw abject poverty, bodies left by political killings. Each day, they tended to dying patients at a clinic in Port-au-Prince; many had giant cancers, advanced tuberculosis or HIV/AIDS. “My kids were shocked,” she says. “I think it changed their world view.” One son, Andrew, MD 02, later returned to Haiti as a college student.

In 1991, Wolff herself wanted to go back and heard of a program initiated by a North Carolina couple who visited Haiti and were shocked by the conditions. Today, their work has grown into two full-time clinics run year-round by nurses, with the periodic help of the American teams. Pediatricians, internists, urologists, dieticians, physical therapists and some non-medical staff participate, squeezing in as many patients as they can during the hot, back-breaking days.

On past visits, Wolff has been joined twice by Washington University pediatrician Matthew I. Goldsmith, MD, instructor in pediatrics, and nurse practitioner Nancy Quigley, then of the University-affiliated Medical Care Group. This January, fourth-year medical student Lindsay Peakman, who began her pediatric residency at St. Louis Children’s Hospital in July, also traveled with the group.
“I didn’t know much about Haiti before I went,” says Peakman, whose French minor in college had prepared her for work in a Francophone country. “But I knew that it doesn’t get much worse than Haiti; I knew that what I would be seeing would be some of the worst cases of my career.”

From their Cap-Haitien hotel, they rode 15 miles — a one-and-a-half-hour trip because of the deeply rutted roads — out to the clinic where hundreds of people were waiting each day. Peakman quickly learned that the poorest of all were those who wore rags, since even impoverished Haitians tried to dress up for clinic. Under Wolff’s mentorship, she found herself treating diseases she had only seen in textbooks: dysentery, Giardia, scabies, fungal diseases of all kinds.

Since the group’s departure, the violence and chaos surrounding the overthrow of President Jean-Bertrand Aristide has caused the food and medical situation to deteriorate. Wolff does not know what she will find on her next visit. In 2000–01, she took a sabbatical year off and traveled around the world to work in Malawi, Uganda, Cambodia and other needy places. Still, Haiti ranks as the worst she has ever seen.

“What Haiti needs is a public health infrastructure, clean water, sewage treatment, latrines,” she says. “Over time, there wouldn’t be so much sickness, and we could provide ongoing care instead of crisis care. I hope someday to work myself out of the business of malnutrition treatment.”

For right now, there is still an urgent need for aid. Wolff’s food project is in critical need of funding. Children at a nearby orphanage, founded by an American physician, need sponsors to help them go to school. And individual children under Wolff’s care, who could benefit from a specific treatment, are in dire need of “adoption” by American families — often for a modest amount.

Meanwhile, the horror and ambiguity remain. “We saw a child who was poisoned last January; six people in his family had died in the previous week and now he had the symptoms. We took him to the hospital, gave them money to take care of him, came back two days later and he wasn’t there. Nobody knew where he was,” she says. “We just don’t know.”

To contact Patricia Wolff, MD:

From the personal diary of fourth-year medical student Lindsay Peakman, January 2004

Okay, I surrender. I do not know enough. I should have been studying before this trip — I should have been doing more physical exams. But God has been good in not giving me any really sick children.

My patients this morning had a variety of problems, but for some reason they all seemed to have the same story. I got a sense of dread around 11 a.m. that I was missing the big diagnosis and the big picture. Then lunch came, a welcome break, and then we went to see the orphanage. I lost it. Fifty-one beautiful children came out and sang to us as we arrived, and were so glad to see us. I just couldn’t help it any more — tears welled up in my eyes.

They had so little: no parents, no toys, and yet they were so happy. How am I so lucky, Lord?…
I am glad that there are only two days left. I am ready to go home; I have learned what I came here to learn. I want to come back! Only next time with more training and confidence. But I am also glad I have two more days to help — I am getting the hang of things. I know what I can easily treat and what I need to think about. Maybe I can do more labs in the next few days, get more information. Oh, the lab; with the microscope using only daylight. It astounds me that you can practice medicine even with very few medicines and little technology.

Lord, give me strength for two more days — wisdom and discernment and confidence are what I desire. Keep us safe on our trips back and forth, and safe from any illness. Be with us as we try to help these people in whatever way we can.