Specialty Care is Fundamental

When I first saw her in the emergency department, she didn’t look like a child with recent onset blindness who we were told would arrive that day.  Her uncontrolled, bobbing head, wildly darting eye movements, and wobbly gait implied there was a broader explanation for her problems, and her constant tears made it clear that she was miserable. For almost a month, she had difficulty seeing and walking, and she arrived the Partners in Health’s (PIH) tertiary referral hospital in Mirebalais, Haiti after winding through a stream of doctors visits, email referrals, car rides, and brain scans.  Upon seeing her uncoordinated attempts at standing, my mind replayed a recent conversation with a pediatric neurologist: “If you see any kids there with chorea, it’s probably Sydenham’s.”

Dr. Joanna EEG on patient

Dr. Joanna Hellmuth performing an EEG on a patient

     When I first started working in Haiti after the 2010 earthquake, I worried that my neurologic skill would be superfluous in the face of malnutrition, cholera and tuberculosis.  That concern quickly resolved (but was replaced by others) when a busload of US missionaries tipped over on a rugged mountain road, filling the tent hospital with case after case of traumatic brain injury.  While topics like infectious disease and maternal-fetal health have dominated the broader conversations of global health, non-communicable diseases such as stroke and traumatic brain injury actually cause of a significant proportion of the morbidity and mortality in developing countries.  And in a country with just one permanent neurologist plus me, a 4th year neurology resident, our work is cut out for us.  During my six months in Haiti, I bring the ratio down to 1 neurologist for every 5 million people, which is far from the 3 to 4 neurologists for every 100,000 people we benefit from in the States.  Currently, there are no neurology training programs in the country to change that statistic.

Not long after starting a neurology consultation service at PIH’s University hospital, I began to expect the constant stream of patients with stroke.  They usually present weeks after the stroke occurred, are about a decade younger than I see in the States, and invariably have uncontrolled stroke risk factors, particularly hypertension.  The patient histories are all too similar: many carried a diagnosis of hypertension and briefly took medications, only to think they were cured or didn’t need them anymore when their prescriptions ran out.  This, in contrast to our well-developed global response to the HIV/AIDS epidemic, where daily home visits from community health workers has been PIH’s successful measure to help ensure HIV medication compliance in Haiti.

In emerging medical systems, cardiologists, neurologists and other physicians of non-communicable disease are essential components for providing broad-based, sustainable healthcare. However the role of a neurologist is much broader than just treating stroke, as neurologic need is woven into all departments of the hospital.  Neurology helps the woman on the OB/GYN service with eclampsia who is still comatose post-partum; the young HIV patient on Internal Medicine with new paraplegia; the neonate on the NICU with hypoxic-ischemic encephalopathy; the many men on the Surgery service with traumatic brain injuries; and the child in the Emergency Department with refractory status epilepticus.

A week after initiating treatment for post-streptococcal Sydenham’s chorea, the crying, wobbly girl started improving, and soon she confidently walked out of the Pediatric ward with clear vision and a shy smile.  While I take pride in her recovery, this was not due to a lucky fate of being accurately diagnosed.  She improved because of the thoughtful, deliberate vision that keeps Partners in Health on the vanguard of global health efforts: the notion that specialized services, such as neurology, aren’t superfluous in low-income countries, but instead are a fundamental part of providing comprehensive healthcare to all people.  My short time in the country will only touch upon the vast clinical training needs and systemic capacity building needed in neurology; it will take advocacy work and the dedication of many to build a sustainable system allowing every person in Haiti to get the neurologic care they deserve.

Joanna Hellmuth, MD, MHS ~ Global Health Chief Resident in Neurology, UCSF

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Partners in Health’s University hospital in Milrebalais, Haiti, as seen from the surrounding hillsides.

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A closer look at the PIH University hospital in Milrebalais, Haiti.

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