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By Dr. Tisha Titus*

We arrived in Haiti six months to the day after the 2010 earthquake, not quite knowing what to expect the conditions in Port-au-Prince to be. Would we be safe in transit? Would the roads taking us out of the city be blocked or damaged? Were the conditions really what had been shown on the news?

Flights into the country were difficult for us, in part due to a massive influx of relief workers and other organizations, but also in part from damage to part of the airport that was in the process of being repaired.
As we walked the several blocks to the temporary parking, the lines for outbound flights were out the door and down the street. As we winded through the city, there were some small areas of damage, but massive piles of rubble were notably absent. As we continued, most of what I saw seemed striking similar to what I had seen before the earthquake – in progress construction, demolition, renovation and the occasional unfinished project. Then came the tent cities.

As we neared the outskirts of the city, the sea of white tents came into view. Definitely suboptimal living conditions, but tolerable given the circumstances and lack of other options. As we passed through, there were UN guards at the entrance to one area with a line of port-a-potties seen in the background. A few scattered faces walked through the maze of tents, mostly women and children tending to daily chores that provide some semblance of normalcy as they work to rebuild their lives. In the few seconds it took to pass the tent city, we could all see the aftermath of the quake – not so much rubble, but shattered lives of the many who had lost nearly everything.

As we talked about what we saw and made comparisons from past trips, we all settled into our seats, gearing up for the ride to the Central Plateau. Those of us, who had come previously, already knew the road “experience.” We had told the new folks in great detail about the bumpy roller coaster ride up and over the mountain. Fast moving trucks close the edge of the cliff, abrupt darting to miss potholes the size of small cars, and intermittent games of highway chicken – all part and parcel for the ride once the pavement ends.

We continued to brief the new folks on what to expect during the daily clinics and then I noticed something. I recalled that last year a short section of the road had been paved, complete with drainage and cliff barriers, but I did not recall any intersections on that stretch of road, and we had just driven through one. I started to pay better attention to the construction and also noticed what appeared to be concrete power poles lining the road. There were also diversion culverts being put in to prevent the usual road wash-out during the rainy season.

I was amazed. The drive that took us over four hours last year was only about two and a half hours this year, with an overwhelming majority of the road paved, tarred or graded and a least two or more lanes wide. There were trucks, backhoes, packers and graders for the actual road construction, but the intricate details of the roadside drains and much of the culvert work appeared to be done without the benefit of machinery. The newly transformed road and soon-to-be power poles took us right into Thomonde, where there were piles of pavers waiting to be put down for the roads there. We started each clinic trip on solid pavement, which significantly reduced our travel time…except for the day our lead truck settled into foot-deep mud. It was also our safety when the rains shut down our clinic early and we scurried like mad to get in the trucks and get out – the pavement let us know that we were on solid ground and would make it back to Thomonde without the risk of getting stuck.
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By Jennifer Browning

After turning off of National Road #3, the SUVs tossed,  tumbled and slid across the mud caked roads saturated after the downpour the previous night.

Traveling to the mobile clinic location this morning, the lead SUV with all the medications was deterred by the mud. After about 30 minutes, the truck found its way out and Project Medishare staff determined an alternative location for today's clinic. Photo by Jennifer Browning.

The caravan halted just a few miles down. The lead truck with all of the medications was stuck.

“My primary concern was is there another route or how are we going to get to the clinic,” William Moore, a second year MPH student from Morehouse School of Medicine said. “We prepared so much this morning to leave earlier than before to assure that we could provide as much as we could for today’s clinic, when we saw this obstacle, I thought we weren’t going to be able to service as many people as we originally planned.”

With the road impassable, once the lead truck made its way out of the mud, Project Medishare staff worked out an alternative location which ended up being the property and house of a resident in the community. A messenger was sent down to the original clinic location to tell those waiting to be see,  that the location had changed. Patients walked 45 minutes to get to the alternative location.

“It just impresses upon me how people here make such personal sacrifice traveling in the heat, traveling in the mud, being able to walk carrying their kids long distances to get to the mobile clinic location,” Bande Mangaliso Virgil, a pediatric resident from Morehouse Medical School said. “It says how much faith they have in us as physicians and that is humbling. They walk one, two hours or maybe even a half a day to receive healthcare.”

Erica Shantha, second year medical student at Morehouse School of Medicine, agreed.

“I thought it was great. A local allowed us to improvise and basically take over their home and land to do today’s clinic,” Erica said. “I thought it was amazing how the people could

Erica Shantha, a second year medical student at Morehouse School of Medicine takes a patient's blood pressure at the triage unit at the mobile clinic. "Everyone worked to gether today as a team. We saw the most patients, and it was all set up and organized. It was the most productive day we've had all week in spite of the change in clinic location." Photo by Jennifer Browning.

come there so fast. It seemed to take them 15 minutes to get word that the clinic had moved.”

Normally for the mobile clinics, Project Medishare operates out of a local school house or a church. This provides separate rooms for the various specialties. Today, the whole clinic operated under a sprawling Mango tree and the Obstetrics and Gynecology clinic operated in the back of an SUV to offer some sort of privacy.

“You do what you have to do to get the job done, and that was the only private secure place we had to see our women, so we made it work,” Dr. Tish Titus, assistant professor at Emory University School of Medicine. “The women were so happy to come lay in the truck and listen to the sound of their babies on the portable doppler.”

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Bande Mangaliso Virgil, a pediatric resident from Morehouse School of Medicine, examines a patient in a pediatric clinic in a small school in Marmont. This week as part of Project Medishare's University Partnership Program, doctors, medical and MPH students are volunteering with the community health program. Photo by Jennifer Browning.

By Jennifer Browning

As part of Project Medishare’s University Partnership Program, Morehouse School of Medicine is working with Project Medishare’s community health staff in Haiti’s Central Plateau this week.

This year there are two returning doctors, and three returning students. Many from the team are surprised with what they have found while working

A Project Medishare community health agent works with the people waiting to be seen at the mobile clinic. The local staff operates the mobile clinics in the more rural areas outside Thomonde two to three times a week. Morehouse School of Medicine doctors and students are working with Project Medishare's local staff this week. Photo by Jennifer Browning.

the mobile clinics.

“It’s really been amazing to see how the Haitian community is dedicated to seeing to the well-being of their children and families,” Bande Mangaliso Virgil, a pediatric resident from Morehouse Medical School said. “You see how dressed up they are to come to clinic and how long they wait to be seen.”

Bande said that with all the negative imagery the media reports about Haiti, that there is actually hope even here, in rural Haiti.

“You see how far this country has come with the limited resources, because we hear in the media in the U.S. just about the turmoil and negative coverage when there is actually a lot of hope and progress here,” she said. “I mean they have along way to go, but I think programs like Project Medishare and just the commit of physicians globally that a lot of great things can happen here and Haiti. Here there is already a community that is receptive to having outsiders come in to help build infrastructure, help with healthcare and education.”

Bande said that while she is a resident, that working in Haiti this week has taught her to rely more on her instincts when she is diagnosing and treating patients.

“In the U.S. we rely heavily on technology like ultra sounds, X-rays and CT Scans. Being here I have to rely on clinical judgment based off a good history from a patient and a physical exam to make sound decisions for patient care,” she said. “That is sort of like a dying art in medicine right now and the way were are trained, and so I find this experience invaluable right now.”

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During a prenatal exam in Savanne Perdu, Dr. Tisha Titus and a Morehouse Medical student uses a portable doppler to allow their patient to hear her baby's heartbeat. Photo by Jennifer Browning.

During a prenatal exam in Savanne Perdu, Dr. Tisha Titus and a Morehouse Medical student uses a portable fetal doppler to allow their patient to hear her baby's heartbeat. Photo by Jennifer Browning.

By Tisha Titus, MD, MPH

After several hours of rapid fire pregnant women in search of their first, and potentially only, prenatal visit, there is one patient for this day that stands out in my mind. I will wonder what has happened to her for months and maybe even years after returning home. I would like to say that this remembrance is due to the stellar care that I was able to provide to her and her baby or my great clinical skills that caught the often missed rare diagnosis, but this is not the case. She stands out in my mind for what I was not able to do for her.

She was in her early twenties and had come in the first trimester of her first pregnancy with the usual complaints of fatigue and lower abdominal pain. As it is not uncommon for dates to be off by several months, I began to feel her belly and watched as she winced when I pressed near her pelvis. Through the interpreter I asked her to tell me about the pain – where was it, how bad was it, did it hurt all of the time? She pointed to her left side and I apologized as I began to feel that area to sort out what I was dealing with. A mass that caused considerable discomfort. With her positive pregnancy test, my options quickly all converged to an ectopic pregnancy.

I know what to for an ectopic, but I had no idea how to get it accomplished in the environment of a bush clinic with nearly no resources an absolutely no capability for urgent surgery. After some quick discussion we found the referral form to send her to the nearest hospital and a second local interpreter to discuss this with her. She had come to the clinic with other family and her children were at home being tended to, but before she was willing to go to the hospital, she needed to find her sister and the children that had come with them and then head home to make arrangements to have all of the children watched. Transportation was another issue – she was going to walk home and then to get back to a main road to try to find a ride to the hospital.

The urgency of the situation was explained several times by the interpreter, but she held firm that her family needed to be tended to first and her looming medical crisis would have to wait. I had no other option but to hand her the hospital referral slip and beg to her to go as soon as possible knowing very well that she may not go at all, or may rupture and die on the way.

This was the only ectopic pregnancy, but definitely not the only concerning encounter regarding prenatal care. Many of the women were having their first prenatal visit well into their third trimester and a fair number of them also had a sexually transmitted infection or urinary tract infection requiring treatment. Many of them were planning on have a midwife assisted home birth, but in a number of instances this was not appropriate because of the high risk for complications due to fetal presentation or previous c-section.
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By Jennifer Browning

Morehouse Medical School students and doctors worked this past week in Haiti with Project Medishare’s medical staff. The group helped Project Medishare conduct mobile clinics in Baille Touribe, Savant Plate, Marmont, and Savanne Perdu where each day they saw between 180-250 patients.

Click here to check out photos from their trip!

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By Leo Moore

SAVANNE PERDU, Haiti—As a third year medical student at the Morehouse School of Medicine (MSM), my interests lie primarily in combining clinical practice and public health research in the fight against HIV/AIDS. HIV is currently a major killer in the African-American population in America as well as among the Haitian people. Although I was aware of this before arriving in Haiti, never did I imagine that I would actually have to diagnose a patient here.

Today, a 27-year-old woman arrived in the clinic complaining of loss of appetite, diarrhea, and weight loss over the past year. During her history, she admitted to having unprotected sex with multiple partners. On physical examination, I also noticed muscle wasting. These were classic signs of a patient with HIV. Project Medishare Program Coordinator Gabriele Denis and I decided to test the patient for HIV. Upon testing her for HIV, her test revealed a positive HIV status.
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By William Moore

MARMONT, Haiti—As a Masters in Public Health (MPH) student at Morehouse School of Medicine with a focus on health education and health promotion, it was important to me to gain experience with educational preventive behavior in a developing world.

Today I only had one opportunity for sex education. One of the very first patients, a young man, received a goodie bag filled with a toothbrush, soap, toothpaste, and two condoms. As part of my role here, I explained in detail regarding all the items in the little brown bag. My one-man audience paled in comparison to my first day of clinic.

That day an audience of 30 men laughed at me as I attempted to communicate to them about condoms in their native tongue. I didn’t have a penis model present with me so my instincts as a professional community health educator kicked in.

I had to improvise.
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