Notes From Leogane No. 20: Achte Pen

Bourik swe pou chwal dekone ak dentel.

(Haitian proverb : The donkey sweats so the horse can be decorated with lace.)

Si travay te be bagay, moun richla pran li lontan

(Haitian proverb : If work were a good thing the rich would have grabbed it a long time ago.)

Dear Family and Friends:

I’ve heard more one than one doctor down here say that lymphatic filariasis (“LF”) is a disease of poverty. My first note of this year mentioned a number of things that have not changed since my first stay at Hopital Sainte Croix (“HSC”):

“Some of the same street vendors walk past my window each morning. I have yet to hear last year’s bread lady, who I remember calling out “achte pen” (buy bread) about every 15 seconds. The parade of school children in ironed uniforms remains pretty much the same. Patients still arrive outside the locked entrance to the HSC outpatient clinic 1-1 ½ hours before it opens.”

I worry now that there is more going on with the bread vendor  than her finding more customers on a street other than Rue Pere Thevenot on the western edge of the hospital. I miss watching this 5‘10” regal woman walk by my office each day. She’s someone for whom carrying a metal basket on her head, selling a loaf of bread for 10-15 gourdes (25-30 cents) to feed her family, was easily matched with a showing of gracefully movement, almost.

This time last year she walked with a slight limp in the right leg. A year ago, you could tell she was afflicted with the early manifestations of LF. I fear this dreadful disease now has progressed to the point where it is extremely difficult for her to walk. The cause of lymphatic filariasis is not pleasant to contemplate. Lymphatic filariasis can result in an altered lymphatic system and the abnormal enlargement of body parts causing pain and severe disability.

*      *     *

Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease.  Infection occurs when filarial parasites are transmitted to humans through mosquitoes. When a mosquito with infective stage larvae bites a person, the parasites are deposited on the person’s skin from where they enter the body. The larvae then migrate to the lymphatic vessels where they develop into adult worms in the human lymphatic system. Infection is usually acquired in childhood, but the painful and profoundly disfiguring visible manifestations of the disease occur later in life. Whereas acute episodes of the disease cause temporary disability, lymphatic filariasis leads to permanent disability.

  

The attached photograph of a woman in Leogane, with bilateral lower extremity LF, provides but one example of the grotesque ballooning of the limbs and genitals associated with this dreadful disease. For males, the disease often manifests itself with enlarged testicles/scrotum. Soon after I arrived in Leogane last year, I was walking to Belval with an American who had been living in Leogane for more than a year. When the subject of filariasis somehow came up, I was asked if I had seen “the wheelbarrow man.” I had not. I’m now told that he received hydroceles surgery, to drain fluid and dramatically reduce the size of his genitals.

It is not my purpose here to overwhelm your thoughts with images of the victims of LF. But, you cannot fully appreciate the challenges of life in Haiti, and other impoverished tropical environments, without a candid discussion of the ravages of lymphatic filariasis. The images you may be contemplating right now may be tempered somewhat by a brief report on the progress being made in the fight against LF, particularly in Leogane.

     

In Leogane, “the percentage of residents testing positive for the young [LF] parasites plunged from 30% in 1995 to 5% in 2005.” (ND Newswire, The priest and the parasite, University of Notre Dame, June 06, 2005). The ND Newswire article acquaints the reader with Father Tom Streit, a Catholic Holy Cross priest who now has been living in Haiti for more than fifteen years. (Photo of Fr. Streit attached)

The Filariasis Clinic he founded is supported by various organizations, primarily the University of Notre Dame, the Centers for Disease Control (“CDC”), Hopital Sainte Croix and the Haitian Health Ministry with grant funds from the Bill and Belinda Gates Foundation. The clinic is next door.

The importance of this clinic was first brought home to me last year, the day before I left Leogane to return to Arizona. I went next door to say goodbye to an American volunteer at the clinic. During my visit, I was told that the 20-25 men in the waiting room were there for follow-up visits after they all had undergone successful hydroceles surgery.

The dramatic drop in the rates of LF infection among the citizens of Leogane Communale (“Leogane Region”) is attributable to an aggressive mass drug administration (“MDA”) program initiated by Notre Dame/CDC/Ste. Croix  under the auspices of the Filariasis Clinic. Studies here and at the World Health Organization (“WHO”) have determined that “MDA should be continued for 4-6 years to fully interrupt transmission of the infection.”

By 2010, worldwide “thirty-seven endemic countries had already completed five or more rounds of MDA in at least some of the endemic areas. From 2000-2010, more than 3.4 billion treatments were delivered to a targeted population of about 900 million individuals in 53 countries, considerably reducing transmission in many places.” (Lymphatic filariasis , WHO Media Centre Fact Sheet No. 102, January 2012.)

While it is much harder to reverse the damage from advance stage LF, it is preventable. “[I]n 1997, . . . the World Health Organization named filariasis among several diseases able to be eradicated. WHO’s target date to complete eradication is 2022.” (ND Newswire)  Until its worldwide defeat, LF will remain a disease of the poor; unquestionably so in Haiti.

“The majority of the worst cases are among poor Haitians, who are unlikely to visit a doctor. Others are too ashamed to appear in public.” Father Steit is blunt in his assessment:

“I challenge people to come up with another disease so tied to poverty. You look at the world where it exists and there is always horrible poverty.”  (ND Newswire)

I have a more basic take on the tie between poverty and lymphatic filariasis. When Watson and I, and the moto driver, hopped on one moto this past Tuesday, we took a short cut, rather than the paved highway back toward Santo, which would then have required another two miles on a dirt road.

The short cut took us by many temporary shelters and tents in Santo. Many of these tents were vacated by the new homeowners who moved into the Habitat and Haven built houses in January 2012. There had been an absolute downpour for about two hours Monday night. Tuesday morning there was standing water everywhere. I could see where people had shoved water out the door of their shelters and tents. I was reminded of another trip to a tent city, last April 2011. Then, I walked up to the largest open air market in Leogane City Center looking for a used tie to wear at the Easter service next door. The half circle road, along which tarps and blankets were placed on the ground for the display of items for sale, served as a border for the largest tent city I have yet to see in Leogane City Center. The tents were located in a depression below the grade of the road. The berm of the road would keep water from flowing away from the tents during and after a downpour.

I returned by moto to the guesthouse with my used tie in hand. A few hours later, the skies open up. As I enjoyed the sights and sounds of this cleansing rain, I stopped to think about the families in the tent city next to the market, and other tents in Leogane, because I already had been told that during major downpours many parents have to pick up and hold infants to keep them out of the standing water.

My simple lesson learned is that the more resources one has  the higher one’s home, both in terms of locating a house above low lying areas and being able to afford an elevated foundation that sits above expected flood levels such as the new houses in Santo. Pockets of standing water provide breeding grounds and living quarters for moustik.

I fear that today you may feel I’m painting too gloomy of a picture. That is not my intent. The efforts of Father Streit, Notre Dame, CDC and Hopital Sainte Croix are good works of hope and promise.

Another story of improvement is being played out today at the hospital clinic downstairs while I type this note. The clinic usually is closed on Saturdays. But today 1-5 year-olds from all over the Leogane Communale are here to receive their vaccinations from the Haitian Ministry of Health.

  

“The wealth of the rich is their fortress; the poverty of the poor is their ruin.”  Proverbs 10:15

I hope this note finds you and your family in good health and spirits.

Peace,

David

21 April 2012

May 12 Second Postscript

 About fifteen minutes ago, I heard a familiar voice say "achte pen" outside my window for this first time since I arrived in Leogane on March 30, 2012.

You can't see the right leg of my favorite bread vendor in the attached photograph (0801). 

 I'm happy to report that while madame still has a slight limb, I didn't see any increase in the size of her right leg since I last saw this woman in late June 2011.

I may have been mistaken last year when I assumed this woman was in the early manifestation stages of lower extremity lymphatic filariasis.  I hope so.

Peace,

David 

12 May 2012