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I present to you patient Janel, a 23-year-old male student with no prior medical history, born and currently living in Savanette, presenting for evaluation of headaches evolving over several months, a sense of vertigo when he stands, and difficulty walking.
So began an email that would intertwine the lives of Dr. Martineau Louine, the patient he described, and me. Most patients in need of neurologic care in Haiti go to primary care doctors like Martineau. Primary care doctors in Haiti can’t simply refer patients to a neurologist the way they would in the US or other wealthy countries, since the only neurologist in Haiti—one for a country of more than ten million citizens—practices in the capital city of Port-au-Prince.
Port-au-Prince is only about ninety miles from Savanette, but the trip takes close to four hours. Much of the journey is on dirt roads that become impassable mud in the rainy season. The rest of the way is on paved but treacherous winding mountain roads, all the more treacherous when riding packed into the back of a pickup-truck taxi called a taptap, or balanced in groups of two or three on the back of a motorcycle behind the driver. The cost of transportation to make this trip—let alone the cost of an appointment with a specialist—is beyond the means of most people in Haiti. More than half the population lives on less than two dollars a day, and about a quarter on less than one dollar a day. So patients go to the closest doctor they can find. In poor, remote rural communities like Savanette, that may be a young doctor who has just finished medical school, practicing alone and without supervision—a doctor who has gone to medical school in a country with no neurologists to teach them about the diagnosis and treatment of neurologic conditions like stroke, seizure, or Parkinson’s disease, let alone how to approach a more complex patient like Janel.
When I received Martineau’s email about Janel in September 2014, I was just a few months out of my neurology residency training and had recently begun my first job as a neurologist at Brigham and Women’s Hospital—Brigham for short—in Boston. At Brigham, I’m one of more than 100 neurologists on staff, and Brigham is one of several hospitals with large neurology departments in Boston, a city with a population of less than 700,000. One of my Brigham colleagues who worked in Haiti had asked me if I could help provide neurology training for Haitian doctors through the Boston-based non-governmental organization Partners In Health (known in the field as PIH). Founded by global health luminaries Paul Farmer, Ophelia Dahl, and Jim Yong Kim, PIH had begun its pioneering work providing healthcare to the world’s poorest patients in Haiti, later expanding to work in Peru, Rwanda, Malawi, Mexico, Lesotho, Russia, Navajo Nation, Liberia, and Sierra Leone.
So I started going to Haiti to teach neurology for two weeks at a time, first yearly, then a few times each year. Martineau had identified himself as an eager and skilled collaborator. He began asking that all patients with neurologic conditions who came to PIH’s recently opened Hôpital Universitaire de Mirebalais—the largest hospital in central Haiti—be referred to him. When I was in Haiti working with PIH, Martineau and I saw patients together. In between visits, he emailed me about patients he found challenging to diagnose or treat, like Janel.
Martineau’s email continued:
On physical examination, the patient had increased reflexes most notable in the lower extremities. There were trembling movements of his right arm and right leg that affected his walking. The tremor in his right hand affected his coordination when he moved his finger from his nose to my hand.
Martineau had attached a shaky one-and-a-half-minute cell phone video to his email. In the video, Janel is sitting on an examination table, his hands resting on his lap. Only his torso and legs are visible. He’s dressed in a white button-down shirt with thin vertical purple stripes, dark blue pants, and shiny black dress shoes that dangle motionless over a white tile floor. An electronic monitor beeps continuously in the background from another clinic room. Martineau’s slender arms enter the frame in a starched white dress shirt, holding his reflex hammer. His stethoscope dangles from around his neck, swinging back and forth between his arms like a pendulum as he tests Janel’s reflexes. “Lage men an, lage men an,” Martineau says (“Relax your hands, relax your hands”) as he hits each elbow crease in turn with his reflex hammer, sending Janel’s hands leaping off his lap. Then Martineau hits just below Janel’s kneecaps, causing his legs to kick out briskly. In the last moments of the video, Martineau asks Janel to reach his hands forward. A subtle, rapid tremor emerges in Janel’s right hand, making it quiver briefly like a hummingbird’s wing. Then it stops. “Okay,” Martineau says, and the video ends.
For neurologists, the physical examination holds important clues to the cause of a patient’s symptoms. While the stethoscope allows doctors to listen to the activities of the heart and lungs, it’s the patterns of weakness, abnormal movements, reflexes, and other elements of the physical examination that neurologists observe to determine the precise site of disease within the nervous system: is the problem in the brain, the spinal cord, the nerves, the muscles? The jumpy reflexes Martineau demonstrated in the video were a clue that his patient’s problem was in the central nervous system—the brain or spinal cord. The tremor that appeared with movement and disappeared with rest suggested dysfunction of the back of the brain in a part called the cerebellum.
During my first visits to Haiti, the bedside examination was all we had in neurology. Lab testing was limited, and the single CT scanner in the capital city was too expensive and too far away for most patients to access. My colleagues and I struggled to try to help many patients for whom we felt that if only we had a CT scan or an MRI, we might be able to figure out what was wrong and how to treat them. Examining a patient might lead us to conclude that there was a problem in the brain, but what was it? A stroke? An infection? A tumor? Without a scan, it was often impossible to determine.
This is the reality for many doctors and their patients in low-income countries, where there are an average of 32 CT scanners per 100 million population, more than 100 times fewer than in high-income countries. Many of these CT scanners are broken. And even where there are CT scanners that work, they are often inaccessible to most patients due to the cost or distance necessary to travel to them.
Haiti’s 2010 earthquake led, albeit indirectly, to the country’s first publicly available CT scanner in 2013. The earthquake devastated Haiti’s overpopulated capital of Port-au-Prince, killing hundreds of thousands of people under the rubble of poorly constructed buildings and displacing more than a million people who lost their homes. Haiti’s largest public hospital and nursing school were among the estimated 25,000 non-residential buildings that were damaged or destroyed. The nursing school was in session when it collapsed, ending the lives of a generation of future nurses and the teachers training them. As part of a “building back better” campaign drawing on the extraordinary outpouring of generosity toward Haiti after the earthquake—over half of US families donated—PIH built Hôpital Universitaire de Mirebalais. Called HUM for short, it’s a three-hundred-bed, solar-powered public hospital with modern operating rooms, an intensive care unit, and, most important to a neurologist, a CT scanner.
The arrival of the CT scanner in Haiti allowed me to imagine what it must have been like when this technology first became widely available in the 1970s. Before CT scans, learning to perform brain autopsies was an essential component of a neurologist’s training—aspiring neurologists learned by diagnosing patients after death whom they couldn’t diagnose in life. How exciting it must have felt the first time neurologists used CT scans to peer behind the curtain at the brain itself while the patient was still alive. This is something we now take for granted in most of the world. Not in Haiti. With so many patients whose neurologic illnesses previously remained undiagnosed medical mysteries, the CT scanner at HUM was similarly revolutionary for us. It was a great leap forward in our ability to provide neurologic care in Haiti, despite still being many decades behind most other countries.