Global Doc: A historic snapshot of public health

Author: Dr. Vincent DeGennaro Jr. ’02

“Can I ask you some questions about your health?” With that opener, a community health worker walks into a humble house to explain more fully the reason for the visit. What happens after that is nothing short of miraculous.

Three young men knock on the door of every third randomly selected house in this village, entering to stay for anywhere from ten minutes to two hours. If the participant isn’t home, the visit is brief and ends with an appointment to come back. If an interview takes place, the questions, measurements and finger-sticks may require a full two hours. Some balk at the time commitment and ask to not participate. Others refuse to let their blood be drawn out of fear of the pain or out of Voodoo beliefs.

This is the largest study of its kind in a low-income country — ever. While there are only seven of us healthcare workers conducting the study, we’ll visit a half dozen towns over three months to survey over 2000 people. We will measure subjects’ height and weight and stick their fingers to obtain a sample of their blood. We will also walk them through a 22-page questionnaire. Through it, we will learn about Haitians’ diets and exercise habits, the stressors in their lives, their education and even what they think of the person asking them all these questions.

Once finished, we’ll be able to estimate the rates in Haiti of high blood pressure, diabetes, high cholesterol, chronic kidney disease, obesity, smoking, depression, anxiety, post-traumatic stress disorder, substance abuse and other illnesses. Only a handful of studies on any single chronic disease in extremely poor countries like Haiti have been published and none report the rates of all of these diseases at the same time.

The results of the study, funded by the University of Florida and executed by Project Medishare, will help us to understand the gravity of the present epidemic of chronic diseases in Haiti. The Haitian government will be able to plan better for treatment and the international community may better recognize the resources that are needed, potentially increasing aid for the necessary care. Increased funding has already benefited the fights against HIV/AIDS, tuberculosis and malaria, and similar programs may be needed for chronic diseases. Only after measuring their impact will we understand how much funding is required.

Today, in the middle of a small town high in the mountains of Haiti, we walk the streets carrying our supplies in the kind of backpacks typically used for camping. Inside each pack is a scale, a tape measure, a cooler with an ice pack, three small testing machines and test strips, a biohazard bag, a plastic container to hold used needles, and the papers needed to record the data. Each bag probably weighs about 20 pounds.

The equipment enables us to test blood for hemoglobin A1C (an indicator for diabetes), cholesterol and creatinine (which can tell us about kidney function). Having worked in some of the top hospitals in the United States, I’m blown away by the fact that we can obtain these test results in such a remote location. Seeing them for the first time means that anything is possible here.

In Haiti, home visits are essential for the painting of an authentic picture of national public health. We could have collected data from the charts or blood samples of thousands of hospital patients, but those results would be biased, since hospital patients are more likely to have some kind of illness already. In this study, we’re speaking with randomly-chosen subject inside randomly-chosen house in randomly-chosen towns.

A similar study in the U.S. would follow a different protocol. Health workers would draw whole tubes of blood to support a dozen different tests. They’d use centrifuges to separate out the different components of blood and store the remainder in a liquid nitrogen-cooled freezer. In Haiti, we simply prick fingers, express a drop of blood into a test strip and place it in the machine. Within seconds, the results flash on the digital screen, and everything but the machine is discarded, leaving behind no trace. Without the machine’s portability, rural Haitians wouldn’t even be counted. They’d be forgotten once again because of their remoteness. Even those who live in the poorer zones of Haiti’s cities would likely not be reachable, since the samples we’re gathering require attention before the end of the day.

So we walk, door to door. Drunk men might harass the study team, usually with a good nature. No matter what street we walk down, one schizophrenic man always finds us, hurling paranoid accusations. Children gather to watch the foreigners walk down their street. The people who invite us inside their homes might offer us one of the two chairs in the house, chairs framed in local wood and upholstered with woven palm fronds. The questionnaire asks if there are rats or cockroaches in the house and whether that causes them stress. (Universally it’s a ‘yes’ to both.) It asks about the things in their life that might have led to a diagnosis of PTSD.

We’ve just begun the study. The rural portion launched last week and the urban portion starts in August. We expect to knock on nearly 4,000 doors to interview the required 2,000 people. While we’re planning for a three-month study, we really don’t know how long it will take or what obstacles will confront us. For now, after receiving the research grant and 14 months of intense planning, we’re just happy to have gotten started.

Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.