Gang Violence, Cholera and Poverty: A Turbulent Age in Neurology

Article summary

Haitian neurologists share their stories and examine the tremendous challenges the country continues to face in medicine and beyond.

From an early age, Louis Lemoine Lafleur, M.D., knew how difficult it was for residents of his hometown to get to medical centers.That “true obstacle course” always haunted him, he said Neurology Today.

“The distance traveled, the bad weather and the bad road conditions they had to brave were unfortunately always at odds with the health emergency they faced,” he said.

When Dr. Lafleur became an adult and began studying medicine, he felt this injustice even more. “We understood that there would be few or no neurologists in the country, so people with neuropathologies would not be diagnosed and treated in Haiti. [or she] I could afford to leave the country,” he said. “Given the high prevalence of clinical neurological symptoms in the community, this shortage of neurologists was a death sentence for many.”

Similarly, Roosevelt François, MD recalled hearing about the doctor shortage in Haiti from childhood. There, his desire to help the community drove Dr. François to school and eventually to his career as a doctor. He wanted to specialize in neurology, an area he felt was in great need. It was difficult to travel to places.

“Faced with this obstacle, I entered internal medicine, which I practiced for about 18 years,” he said.

For Martineau Louine, MD, access to healthcare was personal. As a child, he had to drop out of elementary school so that his mother could accompany him to a university hospital where surgeons might treat inguinal hernias.

Coming from a poor area of ​​Port-au-Prince, he said, it was especially hard. However, Dr. Ruinu did not undergo surgery and treatment until several years later, when painful complications took him to the emergency department. This experience, and the knowledge that such complications can be avoided, motivated Dr. Louine to pursue his medical career.

Dr. Louine then worked with Partners in Health (PIH), an international health and social justice organization, in underserved rural areas of Haiti, initially through an HIV/TB program.

“One day I was asked to see a colleague at the health center. Within three days, he died without diagnosis.Unfortunately, we have seen patients die tragically from HIV due to lack of adequate medical resources. “I was used to doing it, but this case was particularly troubling because no one knew how to diagnose or treat this patient,” he recalled. “The management of such patients was complicated by little knowledge of neurology and lack of appropriate equipment.”

Neurology training comes to Haiti

Neurologists in the United States and other countries have collaborated with Haitian doctors to create neurology training programs. In 2012, Aaron Berkowitz, MD, PhD, FAAN, Professor of Neurology at the University of California, San Francisco (UCSF), worked with PIH and its local sister organization, his Zanmi Lasante (ZL), to develop neurology started offering education and counseling to patients. Haitian primary care physicians and primary care physician trainees. He was the only neurologist in the entire country of nearly 11 million people at the time, and he died just a few years later, Berkowitz said. These doctors had essentially no training in neurology. ”

When the PIH opened its Academic Center (Hôpital Universitaire de Mirebalais, or HUM) in Mirebalais, it offered residents in internal medicine, pediatrics, surgery, obstetrics and gynecology, and emergency medicine. Dr. Berkowitz provided a neurology rotation for internal medicine residents. He then helped develop a complete neurology training program with PIH. Each year, Dr. Berkowitz and a team of US-based physicians spend several weeks mentoring neurology fellows in Haiti.

“Dr. François became the first neurologist to be trained in HUM’s PIH program, which he has directed for several years. For some time he was the only neurologist in Haiti. I was a doctor,” Dr. Berkowitz said.

Dr. Lafleur has just returned to Haiti from a fellowship in France, becoming the fourth neurologist to be trained in the HUM Neurology Program.

Dr. Louine worked with PIH to develop a neurology training program at HUM, recently completed a neurology residency in the United States, and is currently a Fellow in Neuroinfectious Diseases and Neuroimmunology at UCSF. He was mentored and advised by PIH co-founder Paul Farmer, MD, PhD (who passed away in February 2022) and his Dr. Berkowitz. Dr. Luin wants to return to Haiti.

Thanks to these opportunities, “neurology is becoming more or less popular in Haiti. Physicians and patients know which conditions must be treated by neurologists,” says Dr. François. He pointed out that in the past, all Haitian neurologists had practiced abroad, so neurosurgeons had to play the role of neurologists.

Many obstacles ahead

Despite these improvements, however, Dr. Lafleur’s neurology training was nerfed by two major challenges. Lack of technical, material, and biological diagnostic tools has made it difficult to confirm the condition, leading to a shortage of drugs available on the market. very limited treatment.

“I wanted a better healthcare infrastructure with access to medicines and adequate imaging centers,” said Dr. Lafleur. Often we know what to do, but are very limited by lack of means.

Dr. Louine said he had a vivid memory of one patient he saw during training. She was a woman in her 70s who came to the clinic with acute ascending paresthesia and weakness in her lower extremities and her respiratory muscles became involved.She had to be intubated and was unlikely to survive. I could not do it.

“The suspected diagnosis was Guillain-Barré syndrome, but I don’t think she had that test (CSF analysis, electromyography, nerve conduction studies, or any type of imaging to look for caudal equina augmentation or imitation exclusion). “And even if we had decided to treat her empirically based on her clinical symptoms, we would not have had intravenous immunoglobulin or plasmapheresis to do so.” There was no.”

At a time when Haiti still struggles to treat cholera, malaria, and tuberculosis, Dr. Louine believes financial decision makers should focus on more cost-effective health care, rather than focusing on these rare conditions. said he knows he is choosing to invest in equipment. Still, as a doctor who wants to be able to treat all patients, he struggles with this.

“Dr. Farmer always referred to the 5S of staff, space, staff (equipment), systems and social support if he wanted to provide healthcare,” said Dr. Louine. “We have tremendous limits in every category.”

During the current cholera epidemic, which relapsed in October 2022, Dr. Lafleur identified not only one patient who likely developed central pontine myelination after acute resolution of hyponatremia. , was asked to attend to patients with seizures. Dr. François said he has not seen many cholera-related neurological complications at this time, but during the last outbreak in 2010, he heard of many cases of ischemic stroke and severe dehydration.

In recent decades, the daily situation in Haiti has become increasingly difficult. Political turmoil and gang violence have brought much of the country to a standstill, along with recent earthquakes and new cholera outbreaks. Dr. Francois said things appeared to be getting worse.

“Medical practice is almost impossible,” he said. “We are threatened with kidnapping every day and at any time. It is very difficult to move from one point to another. We are just waiting for political change.”

Dr. Lafleur said the situation has become “very bad” for both doctors and patients.

“Anxiety is reaching unprecedented levels,” added Dr. Louine. “Armed gangs are expanding their territory, and roadblocks and gang violence are making it more difficult for patients to reach medical centers.”

He cited the death of talented Haitian dentist Dr. Mackendy Guerrier, who was shot in the neck while leaving the clinic. Other doctors were kidnapped and had to pay a ransom to get their freedom.

“Medical staff continue to flee the country to come to the United States and Canada,” said Dr. Louine. “People living near the border between Haiti and the Dominican Republic, especially pregnant women, have to seek treatment in the Dominican Republic, putting pressure on the Dominican health care system.”

After losing his wife’s sister to COVID-19 and his nephew to gang violence over the past year, Dr. Louine said: But at the same time it is clear that he lives there. [that] It is very likely that you will die for some reason. A doctor who chooses to remain in Haiti to care for a patient should be treated as a hero. ”

In the meantime, Dr. Berkowitz and his colleagues have provided support via phone and Zoom for lectures and case discussions with Haitian neurology trainees. “With the president’s assassination and increased violence and unrest, my colleagues at PIH/ZL do not feel safe with me or others traveling to Haiti to work on the ground,” he said. Neurology Today.

Asked about ways in which he can help his Haitian colleagues, Dr. Berkowitz said that PIH “helps in many ways, such as donations to help run hospitals, community programs, educational programs, or by donating time through lectures and discussions.” can be obtained,” he said. Case through zoom.

“One of our recent graduates is interested in doing an electrophysiology fellowship in France and starting an EEG and EMG program in Haiti, looking for the possibility of donated equipment. ‘ he added.

Further resources for remote and in-person education are also needed to strengthen Haiti’s neurology fellowship program, said Dr. Louine.

“We need more equipment in this area (MRI, electromyography and nerve conduction studies, intravenous immunoglobulin, plasmapheresis),” he said. “We are currently in talks with hospitals in Boston to support a neurology fellowship program in Haiti. , or a safe environment where one can teach and learn without fear of being killed.”