04-JUL-C-5
ANOTHER FULL
DAY OF CLINIC ACTIVITY IN YET ANOTHER SITE AT SAVANNE PLATE IN MARMONTE,
WITH A
DEBRIEFING FOLLOWED BY
A SPECIAL
VOODOO CEREMONY FOR US IN THUMONDE,
AS I SORT OUT
SURGICAL SUPPIES FROM THE OVERSTOCKED BAGS FOR TOMORROW MORNING’S VISIT
TO PAUL FARMER
AT
After a quick tour of the Project MediShare headquarters (which I had had two days before gong over the regional maps with Marie Cherie, particularly of Cass) we had a brief public health session under the tree in her yard with those who want to consider some kind of project that would entail their non-clinical information base in public health. We then piled into the SUV’s to take on the next to last clinic, in a distant setting known as Savanne Plate
Savanne Plate = 19* 02.57 N, and 71* 57.27 W
As we arrived the colorful “parking lot” of burros was crowded, and the church yard was overflowing with people who had been waiting, and some had set up little cooking fires. As busy as I was in setting up and spinning around the four stations to see all the patients, there was one persistent fellow who had a little English and insisted he see and talk privately with the head man—and he then tried to explain that he was the teacher who was trying to set up a school and he needed my help and financing. I explained that there were several hundred people who needed my help right now and I could not speak with him about his plans right now since I was otherwise occupied as the only licensed practitioner in all of Marmonte District at this active moment, so he would have to step aside. He did, and he simply waited for the next several hours, not too much in the way, but certainly not contributing as the church overflowed with people coming and gong. His English was not good enough to be a translator as I had suggested to someone he be impressed into service and she rejected him immediately. He was still there hours later, hoping to get the last moment of my time, until the rains began.
I had an amazing series of twins! I saw a woman with a huge belly and I pulled her aside and listened carefully, finally despite the noise, hearing two heartbeats. I made this portentous announcement that she had a couple of small fellows in there! She shrugged. No big deal. She had six kids already. OK, but what is so special about that? She had only been pregnant four times! She had three prior sets of twins and was about to deliver her fourth! She had a set of fraternal boys, fraternal girls and a set of each. I had explained in a previous didactic that the once group on earth among whom twinning is the highest is the Yoruba tribe of Nigeria , the largest tribe in the world of over 22 million members, quite a number of whom could not avoid becoming American slaves, so it is well represented in the new world, (as an example our own Anthony has Yoruba roots) and she certainly was Yoruba! The incidence of twins is close to one in seventy pregnancies for them, and ALL the excess twinning is made up of fraternal twinning, with no higher rate of identical twinning.
We saw hundreds of patients, with details like—polydactyly—an extra finger on each hand with one of them squeezed off at the base an autoamputated like a case of Ainhum in the toes. We saw a large orbital lipoma, of no consequence except cosmetic. We saw LOTS and LOTS of malaria
AN OMEN OF
STRANGE PORTENT:
THE GOOD LUCK
CHICKEN
LAYS TWO EGGS
A woman was carried in, clearing a large swath as she came, obviously weak and sweating profusely. Alongside, her family carried a tiny bundle, in which was wrapped a newborn tiny baby, looking like a premature hairless rabbit, stirring weakly. The baby was delivered five days ago, and she had a fever ever since. Today she had broken down in a profuse sweating and shaking chills that one of the people had called a seizure. But she was “Exhibit A” of my prior discussion of hypnozoites coming out to flood the blood stream from the reticuloendothelial system where the plasmodium falciparum had been hiding until she lost a unit of blood with her post-partum hemorrhage, and she had contracted her liver and splenic capacitance reservoirs to shower her bloodstream with a recrudescent attack of malaria. We treated her with cholorquine and propped her up and gave her one of our precious cold cokes.
In the course of her lying down on what would have been the pulpit area of this lapstrake daub and wattle church with its primitive slatted wall A/C, someone brought in a chicken, and threw it across her. I would consider this “hedging bets” against the Western Man’s medicine, adding a little Voodoo charm to the potion. The chicken made a lot of squawking sound as it hid behind her at the front wall of the church. When it got to within pecking range of the baby, all of about the same weight as the hen, I shooed it away, to discover that the clucking sound had been produced at the same time as two round eggs laid in the front of the church. The big Mama has nothing on the birds around here for twinning!
I saw several more previously undiagnosed TB cases. I saw a woman who had a fever and a burning on urination, I asked if she had incontinence when she sneezed or coughed and how many pregnancies she had had, suggesting to Siayavash that she had a cystocoele from a relaxed pelvic floor. The answer came back through translation, “Why, yes,, now that you ask, and she had seven prior full term births.” I believe Siayavash was more impressed with the power of history taking in asking the right questions efficiently than the patient was in being treated for her UTI. She needs a Marshall Marchetti, elevation and lengthening of the urethra.
If I tell you any more of the scores and hundreds of patients that I ran through, I may run interference on the case presentations by the students so I will let them tell their stories. We piled back in the car after taking a group photo of the gang outside the Savanne Plate church just as the rains began and my teacher/mendicant disappeared. We went back through the muddy roads with a lot of lateral sliding and gyration, and came at last to the Delva’s Celine Guest house with the rains hitting and the thunder clapping. I said we would assemble soon to get the didactic underway, since we all had a heavy entertainment schedule tonight and promised the lead off in the discussion of the evening’s activities would be a brief cultural presentation on Voodoo.
INTRODUCTION
TO VOODOO
The evening
performance would be from a local voodoo priestess named Mumbo Fune, and
CASE
PRESENTATIONS,
AND CLINICAL
DISCUSSION POINTS FROM THE WEALTH
OF PATIENTS
FORM AMONG THE POOR
OF SAVANNE
PLATE
A-1 Anthony: a fifty-year old woman with no menstrual period since December and a large abdominal mass. Because this woman thinks she is fifty, it may not be too unusual to have her menstrual cessation at this alleged age. But, uncertain of her age and with her undeniable abdominal mass, it becomes significant. The mass was solid (recall the hydraulics lesson we had previously on this subject,) but this one was not a mobile intra-abdominal mass that felt cystic with a fluid wave. This one is solid. That means one of two things, the more likely being a common condition—a large uterine fibroid tumor. The second is less likely but more worrisome, since a sold tumor could also be ovarian but stuck to the pelvic sidewalls. She would need an ultrasound, and in any event she is going to be symptomatic soon from the weight of this mass on her bladder. I would recommend she get to Cange for a hysterectomy, and we made such arrangements with her family.
B-1
Vesta: A woman reported to clinic with
the chief complaint of sore breasts. Her
past medical history includes the fact that she had a shot to prevent
pregnancy—Depo-Provera. While we are on
this case, I should also add another 22-year old who had menstrual bleeding
continuously since she had a Norplant installed. These are the two symptomatic cases of an
otherwise successful birth control series of methods that I rather like since
it is empowering to the one person who should have to bear the pregnancy she
might not want, and it means that having a pregnancy is turned from a “default
position” to an active choice—one goes to the clinic to get “turned on” rather
than “turned off” and it does not entail cooperation or lack thereof on the
part of a spouse or other less concerned males.
We went through the reasons that these two methods do not seem to be
common or popular in the
C-1 Lindsay: Tachycardia in a young woman; this introduced the team to the differential diagnosis of tachycardia—a fast heart rate inappropriate to the circumstances of exertion or high output for run-off such as an A-V fistula (the placenta is one such) a metabolic problem (hyperthyroidism is one such) and opened the discussion of conduction abnormalities.. PAT (“Paroxysmal Atrial Tachycardia”) is a runaway heart rate that comes from a conduction defect in the atrium so that the SA node is not controlling the heart rate which then accelerates to the AV-ventricular heart rte which is faster. There are two ways to slow it down by increasing vagal nerve tone—pressing on the eyeballs or massaging the carotid sinus, or Valsalva Maneuver. For longer term slowing of the rate, a quinine derivative can be used, a discovery of lots of people taking quinine for malaria prophylaxis, so that this is the indication for which Quinidine or Quiniglute are now used. Acutely one can use lidocaine for the same purpose, or over a longer term Pronestyl. She slowed with carotid sinus massage, and then we started her on chloroquine.
D-1: Adam: a 27-year-old came in with a Haitian cultural peculiar pregnancy problem. She had been bleeding for 17 days and this was described as “Paducia”. This is not a miscarriage, but is based in the belief that during the nine months of pregnancy, the menstrual blood is backed up and is then released at a later time around the post-partum period. This is folk medicine, and should not be so interpreted as to say that if it continues she might not benefit from a D & C to relieve her of all that past pent-up menstrual blood.
A-2 Sonbol: She presented an 8 month pregnant woman who was a high risk pregnancy (several had elevated blood pressure and we do not know if some might also have had albuminuria.) She was told to go to Cange, and she responded quite simply: “However do you expect me to get there?” Since she could not get there ordinarily, how is she expected to make her way in the is dangerous pregnant state? A reasonable question and the kind of full-stop that paralyzes medical programs that realize they cannot take on the whole infrastructure and economics of the society in which they are trying to accomplish something. So, this bit of advise had stymied Sonbol, who had also heard of “Mothers Clubs” and other programs that did not extend out this far into the remote hinterland, and there is a whole region in Cass, and still worse beyond us here in which the paths are inaccessible to a bike, so must at best be negotiated on a donkey—an outreach problem of some considerable dimensions.
B-2 The excessive twinning rate was discussed—using the example of my four times running maternal twin pregnancy previously described, and a repetition of the story of the malaria attack following parturition. Huda and Loren were sitting outside in the shade when Marie Cheri got them and the family into one of our vehicles since she did not look like she could walk home. They got several miles toward their hose, but were still several miles away when the rains had started, and the SUV mired down in the impassable road. IN the rain they offloaded the malaria Mom who had been shaking and sweating only a few hours before, and she set out with her family the several miles more in the rain, very disappointed that the vehicle could not go any further—Why? Since they wanted to gather some eggs and other gifts to give those who had helped! They explained that they had to hurry back with the vehicle to fetch us before we would be marooned by the rains and mud, and I had added, that we already go two eggs out of the ceremonial chicken!
C-2 Siayavash: Presented a man with what seemed like lactose intolerance. He was already seen and known to the health care team since he is the only person that came in that I am aware of with a pre-existing diagnosis of AIDS and is on the anti-retroviral drug program and DOTS therapy for MDR TB. He is the one patient who had already benefited from both diagnosis and treatment in the clinical programs already intact, and was showing us that it can reach into the further outposts of Marmonte District.
D-2 Anisha: a 16-year-old boy presented with chronic illness and weight loss. After a quick glance, I had asked only if the rest of his family was also being checked for TB. He is going to go for the full DOTS program and his intimate family for TB testing. It is ironic that the one disease that requires the most labor intensive follow-up and protracted treatment among the infectious diseases (with the exception of the viral disease associated with HIV) should be so rampant in the most skilled-labor and materials deprived areas of the world, with remoteness nearly a pre-condition for the majority of the world’s HIV and TB victims, with only the exceptions being inner city special groups out of the mainstream (IV-drug users and “commercial sex workers.”)
The medical education program has been one of the few unqualified success stories in this medical mission, with a consistent pattern of excellence, whatever the clinical care standard can be elevated to its same exemplary status. More and more of the students are realizing the value of the experience, and the most appreciative are those who have already seen the most medical school curriculum adding that the freshmen do not yet appreciate how much they are learning until they get the “anamnestic response” over the next two years, in which every hour of every class, they will recognize something as quite familiar this next time around.
THE VOODOO
CEREMONY WITH MUMBO FUNE,
AND MY SPECIAL “BLESSING” FROM HER MINISTRATIONS.
We trundled off after the heavy rains that had fallen during our didactic session, and I went with Laurie who was feeling ill with diarrhea, promising to go out with her whenever she had had enough. We soon saw the flickering candles on the ground over the chalked in outline of this “landing site” for the spirits adjacent to the strategically placed red painted pole—the “axis mundi”. As we filed in under the dripping thatch from the recent rains, I carried the small headlamp which I had not turned on, and the camera with which we were invited to take pictures if wanted. An unusual thing happened as all we as guests sat in the bleachers along the front of the ceremony, and Mumbo Fune asked that no Haitians sit at our backs, behind us, since apparently that was an ill omen and also that a few of the “blan” had been spooked out, and trampled by the crush.
Out came Mumbo Fune in a huge
muumuu looking larger than life and billowing in a way that might smother the
unsuspecting. Along side me on the left,
were a number of young girls and boys
who were in rapt attention, and were trying to look straight ahead a the while
their hands were mischievously groping around me. I thought first they were eager to get into
my pocket, but my wallet pocket was zipped shut and the camera was the only
valuable thing and that was already in my hand with the tape recorder in the
other. I then realized, I had about ten
hands resting on me, a number of which were just eager to make contact with a
“blan” and the leader of the group at that—since I was so designated by Bryan
in the introductions. He translated what
Mumbo Fume said, which was how happy she was to have us here to witness the
ceremony, and that we did not have to be afraid. There was nothing to worry about since she
was going to become the incarnate goddess of love and we all had live for each
other. When you leave
An offering of rum was scattered on the four corners of the white patterned insignia on the ground. Mama began teetering back and forth with her eyes rolled back in time to ht rhythmic banging of drums and bongos. She was swaying around dangerously for her, since there were flickering candles at the hem of her flowing gown around her bare feet. As she would go to one side, a little trail of flame from here gown would follow, then extinguish. I finally got up and moved around h ere in her early trance, and moved the candles back out of the way. It did not matter a lot, since later a number of the women got to dancing and they trampled the candles heedless of them, which also accomplished the effect of extinguishing them.
Mumbo Fune, then pushed her
forehead against the central pole and with eyes rolled back vibrated as the
spirits channeled their way down to her.
She came over to touch hands with each of the “blan” but then got to me
and pulled me to my feet. She and I
embraced then she put her forehead against mine and stood there swaying. After I returned to my seat, she had danced
around a few times and retreated to the candle lit back room where there was a
big washtub of rose water with floating blossoms and some kind of scented
oil. She selected me out of the crowd
for the first blessing, and I went back with her to get the anointing of the
oil and then she rubbed the scented stuff in my hair, and poured it on my open
hands showing me I was to rub it all over my face. I then got a liberal dousing of the rose
water. I went back to the group after
she proclaimed that I have special powers and she wished she could join in
those powers [I asked
Instead of a beatific vision upon my return, I imagined I must be a sight with talcum powder sprinkled over the rose water splashes and my hair messed with scented oil. I was reeling with the perfume, and volunteered to Huda to serve as her deodorant. I was then given to understand that I was the one to pick the next person eligible for the blessing, and I picked Zeb, both because of his recent illness from which he was recovered, and also because he had come along on this trip to escape a broken heart. He was hauled away by Mumbo Fune and received the same treatment.
One by one, each of the “blan” received this treatment until we were all redolent of lilacs, and then we were each doused again with the talcum powder or flour whiteness. The kids were wide eyed as they continued to fondle and touch me. Then at some signal, they began to dance. We were all pulled in a s a mass of staggering black and white, with a few staggering more than others thanks to the gift bottles of rum that had been circulated. The little kids were ecstatic when they were pulled into the fray.
An especially powerful bottle of klaren had been Bryan’s gift to Mumbo Fune, and she came out holding it high, coming right over to me, and tipping my head back she delivered a bolus of 200 proof klaren into my gullet, at least a bit of which was rapidly absorbed through my bronchus. All of us then were whirled around, but especially me, since I was Mama’s dance partner—a bit like trying to lead a hippo in a tutu.
The event was suitably recorded on
film and tape. At this point, Laurie
said she had about enough, and I offered to go back with her on foot to the
Delva’s Guest house, and we walked through the heavy mud that follows the late
afternoon rainy season downpour. I was
reminded as I had left the thatched hut in
“Déjà vu all over again!”