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Maddie Barbe & Stephanie Golding It was the morning of June 27, 2017 when we grabbed our bags and started our journey to Port-Au-Prince, Haiti. We landed in Port-au-Prince, and even just in the airport, the cultural difference in Haiti was evident. While waiting for our bags, we noticed that Haitians have less value for personal space and had no problem interacting closely with those who surround them. While Americans would distantly wait their turn to pick up their bags, Haitians were quick to push strangers aside to get to their luggage. Overwhelmed in the small airport, we were then taken to Hopital Bernard Mevs, the hospital where we would be staying for the week and spending the majority of our time working. The next morning, we met Dr. Ryan Fitzgerald, DPM, a podiatrist on FootAid’s Mission Response Team that we would be helping bring much needed foot care to the area.  Haiti, a small country in the Caribbean that shares an island with the Dominican Republic, was hit by a 7.0 magnitude earthquake in January of 2010. Included in the major demolition of the country was the destruction of 50 health centers, part of Haiti’s main teaching hospital, and the country’s Ministry of Health. In the aftermath of the earthquake, United Nations sent aid and established a base in Port-Au-Prince. Despite an attempt to help, the UN peacekeepers played a significant role in the initial outbreak of what became a deadly cholera epidemic in Haiti. The week we were there, the UN troops were withdrawing from Haiti. Today, Haitians continue to struggle, with 59% of the population living on less than two US dollars per day (World Bank 2012). According to the United States Agency for International Development in March 2017, about 40% of Haitians lack access to essential health services. Seven and a half years after the earthquake, Haiti is still recovering. When we got off of the plane and were driving around Haiti, we noticed how hilly and uneven the roads and sidewalks were. There are lots of stairs and the streets are filled with people selling different things, rubble from the surrounding buildings, and piles of trash. For anyone with a foot pathology that affects their ability to walk, it would be necessary to rely on others to help them get around the city. When talking to a volunteer emergency department doctor, he told us that it is not uncommon for patients who require that much help to be abandoned by their families at the hospital. The families drop them off and never come back to pick them up because they can no longer handle the burden of their debilitated family member. Our first day in Port-Au-Prince, we went to a clinic run by FHADIMAC, an organization that, through the work of volunteer Haitian and foreign doctors, helps people with diabetes and hypertension. The clinic was set up with one building used to treat relatively less severe diabetic patients and a second building, which resembled a shipping container, used to treat more severe wounds and infections. We saw several patients, many with ailments similar to those we had seen during our time shadowing in the United States. Things would get much gorier later in the week. A few patients we treated at FHADIMAC needed surgery so we started creating a surgery schedule for later in the week. Our afternoon at FHADIMAC ended early, so we got a chance to visit the Haitian National Pantheon Museum at the urging of some of the FHADIMAC staff. The museum was incredible and had many historical artifacts from the time of colonization (including the anchor from Columbus’ ship the Santa Maria). Our guide gave us a taste of the rich history of Haiti, and we learned about the heroes who successfully rebelled against Napoleon’s army to free themselves and others from slavery. The other days were spent at Hopital Bernard Mevs, a hospital in Port-Au-Prince that is associated with the organization Project Medishare. We mainly worked in the wound care center of the hospital with Dr. Adler Francius, a general surgeon from Haiti specializing in wound care. We assisted Dr. Fitzgerald in wound care, amputation of digits, melanoma removal, treatment of a gas gangrene infection, and correction of a congenitally deformed second toe. Amazingly, these patients underwent surgical procedures in the office, some with local anesthesia and some without receiving any anesthesia. Most of the patients would watch us perform the procedures on them, sitting up with their eyes glued to what we were doing. They watched their toes being removed, their wounds being debrided, and their abscesses being drained. None of the patients ever complained, and only a few made facial expressions that indicated they were pain. We were surprised and amazed by how resilient these patients were. Performing surgery in the clinic was somewhat frustrating at times because we did not always have the preferred tools available, but the wound care nurses made things as seamless as possible. Some of the nurses spoke both English and French and were therefore very helpful for communicating with patients. Even with their help, sometimes they could not understand our English (they said we spoke very fast!), and it seemed that some things got lost in translation. Caption: Large wound seen in wound care center when power was out (Left Image); Before and after treating congenitally deformed second toe (Center & Right Images) Every afternoon, the power would go off, leaving us in the dark with patients, so we tried to get an early start in the mornings. This wasn’t difficult since we stayed across the street in the dorms of Hopital Bernard Mevs. We also had a friendly rooster outside our window, who made a few 5 am wake up calls. There were a few other volunteers, including doctors, nurses and other healthcare professionals staying for a few weeks at a time. We went to dinner at the now closed UN Base every night. It was a very unique experience with tasty food, which we washed down every night with a Prestige (the Haitian beer of choice). Our final day in Haiti, we brought three patients we had seen earlier in the week to the operating room in Hopital Saint Louis, another hospital in Port-Au-Prince. The surgeries were a melanoma removal, a transmetatarsal amputation, and a diabetic ulcer procedure. The OR here was similar to an OR in the US, except it lacked some of the proper surgical instruments needed for the procedures Dr. Fitzgerald would be performing. The afternoon prior to our day in the OR, Dr. Fitzgerald and Dr. Francius went through a large pile of surgical instruments, where Dr. Fitzgerald picked out what he thought we would need in the OR. Dr. Francius made sure to bring those instruments with him the next day for the surgeries. We were able to scrub in with Dr. Fitzgerald on these procedures. This time, the patients received epidurals (no one received general anesthesia) and were draped off. With no power tools available, the removal of bone in the OR was a major challenge. Dr. Fitzgerald used a Gigli saw with two hemostats clipped to the end as handles on the patient that received a transmetatarsal amputation, for example. While the operating room still functioned like an American OR, it felt outdated and lacked many of the surgical instruments that American surgeons expect will be available during their procedures. Luckily, Dr. Fitzgerald was excellent at adapting and improvising to accomplish his goals with each surgery. Our day in the OR ended in true American fashion (delivery from Domino’s Pizza, the only American chain on the island). Before and After Photos of the ulcer  Melanoma (before surgery) Dr. Fitzgerald plans on returning to Port-Au-Prince in the fall to see some of these patients again, as well as find new patients to treat. We expect the culture shock will be less, but the rich experience we had there will carry through on his many future trips. We felt very fortunate that we were able to learn so much from Dr. Fitzgerald, Dr. Francius and the wound care nurses, and we also hope to return to Haiti one day in the future! 
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Julie M. Chatigny, DPM, AACFAS I arrived in Honolulu on 3/13/2017 and met up with Dr. Michael Goran and one of his former students, Skylar Steinberg, to discuss our plans and goals of our week in Kiritimati. I, being a foot and ankle physician and surgeon with a clinical emphasis on diabetes, and Dr. Goran, being a well-published, highly respected researcher in the field of pediatric obesity and diabetes found that we had very similar interests and goals, as well as, many questions. First and foremost, what is contributing to the high incidence and prevalence of type 2 diabetes mellitus? We left Honolulu on 3/14/2017 just after noon, had a three-hour flight, and arrived in Kiritimati on 3/15/2017 as we had crossed the international dateline. Our travel companions included about twelve fly fishermen from the United States seeking a week-long catch-and-release adventure fishing for bone fish, giant trevally, and trigger fish. Upon arriving at the Cassidy International Airport, we were greeted in the airport’s VIP lounge by Dr. Teraira Bangao, several members of the Ministry of Health, and staff with a beautiful flower headpiece and cold coconut milk. We were provided a rental car and followed Dr. Teraira to our accommodations at The Villages. As it was evening when we arrived to The Villages, we were not going to start work until the following day. We took a walk along the main road from The Villages toward London. We stopped to watch kids and young adults playing soccer, saw many people walking along the road carrying bags of rice and coconuts, people riding bicycles and motor scooters, and people at their homes getting ready for the evening. What struck me the most was that nearly every person we encountered was not wearing shoes. Even walking along the asphalt road and riding bicycles, people were barefoot. Over the next several days, I spent time at the London Hospital where I worked with Dr. Teraira Bangao, Dr. John Tekanene, and their incredible staff of nurses, pharmacists, and a midwife. Together, this group of people treat everything from congestive heart failure to pneumonia to diabetic foot infections as well as have a maternity ward. At the hospital, I helped Dr. John debride a diabetic foot and leg ulceration and infection, drained a heel abscess that had extended proximally along the tarsal tunnel jeopardizing a woman’s leg, and diagnosed a tendinitis due to a flatfoot deformity. Dr. John and I attempted to perform a below-the-knee amputation on a non-diabetic man with Buerger’s disease (thromboangiitis obliterans) which had resulted in infection and gangrene from smoking, but he and his wife continued to refuse the amputation. Although Dr. Elizabeth Beale was unfortunately unable to accompany us to the island, she was paramount in organizing medical items to donate to the hospital and clinics. She developed a foot exam form and her daughters put together medical illustrations and folders to provide to the hospital and clinic staff. When I brought in the items and folders, the medical staff was greatly appreciative, but a bit overwhelmed. I met with the nurses and Dr. John individually to explain the folders and how to go about a diabetic foot exam. Again, it seemed a bit overwhelming and the nursing staff did not seem to understand the importance. I decided to take a different approach and learn as much as I could about what people ate and drank, did for entertainment, why they presented to the hospital and clinics, and better understand the culture so I could figure out a better plan to educate the health providers and staff. Also, as Dr. Goran and Skylar collected their data, they identified several children under the age of 18 years old who had a HgbA1c > 6. As I was located at the hospital while they were out at the schools, one of the nurses drove the identified children to the hospital where I interviewed them and collected information on their diets and knowledge about their parents and diabetes. The following is a summary of what I learned over the week I was visiting the island: Food:
It’s rude to offer a guest of your home a drink of water. You need to offer a sugary beverage. People often seek the medical aid of a “healer” before they will seek medical help from a doctor. Average life expectancy is 55 years old. High infant mortality rate. People often have > 4 children. People do not recognize the correlation of consuming sugar and having diabetes. For example, a husband and wife came to me to learn how to read their glucometer. They kept stating that the Metformin was causing their sugar to be high. It took several attempts and several different descriptions for them to finally understand that the sugar they ate and drank was causing the high blood sugar and that the medication was helping them, not hurting them. I now have a much better understanding of what needs to be accomplished as far as education and assisting with intervention. It will definitely take time and a multidisciplinary team of dedicated individuals to set realistic short-term goals with the long-term goal of helping the people of Kiritimati live a longer, healthier life. The people of Kiritimati were warm and welcoming. I appreciate their patience with me asking all of my questions. I am especially thankful to Dr. John as we were able to spend many hours together learning from each other. Thank you to Carlton Smith for this incredible opportunity; Dr. Elizabeth Beale for seeking me out, your help and organization; Dr. Beale’s daughters Alexis who has an incredible talent for medical illustrations and Stefi (and her boyfriend Eric) who put supplies together and met me half way to deliver them; Dr. Teraira for helping make our journey so comfortable and successful; Dr. Lydia Lam for your insight and recommendations; and thank you to everyone that helped make this organization a success.  Author Dr. Chatigny received her Bachelor of Science degree in Biological Sciences from CSU, Sacramento. She spent the next 12 years working in the fields of Molecular & Cellular Biology as well as Genomics & Genetics in multiple research laboratories in Utah and Arizona studying brain, breast, and ovarian cancer as well as Valley Fever and tuberculosis. Dr. Chatigny was a private contractor / consultant for the Southern Arizona VA Healthcare System’s VA Biorepository Trust in Tucson, AZ, the Warm Autopsy Program at Sun Health Research Institute in Phoenix, AZ, and the Molecular Profiling Research Institute – now Caris Life Sciences, in Phoenix, AZ.  |
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Medical Malpractice Concerns
For those providers who are forced to face malpractice concerns in their practice in the United states a few things should be understood:
1. W. “Ted” Kuhn: Medical Malpractice in the Developing World. Global Medical Missions, Winepress Publishing, 2007
For those providers who are forced to face malpractice concerns in their practice in the United states a few things should be understood:
- “No malpractice claim has ever been filed against any American health care worker providing humanitarian services without charge in the developing world.”(1) The malpractice risk is almost nonexistent as long as the practice is limited to the indigenous population and that care is provided free or at minimal charge.
- The only documented malpractice against american physicians in the developing world is the care of “western” patients in “for profit” health centers and hospitals.
- There is a small civil liability noted in the developing world. This only involves traffic accidents and accidental injury and death when American health care workers are involved in an incident in a non-medical capacity.
- In 2003 a study was done that found that not one volunteer or missionary agency provides malpractice insurance, as coverage of this type in simply not available.
1. W. “Ted” Kuhn: Medical Malpractice in the Developing World. Global Medical Missions, Winepress Publishing, 2007
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