Wednesday, November 18, 2015

Telemedicine in Rural Haiti

Advances in information technology have revolutionized health care in developed countries, and we have use low-cost, user friendly technology in a rural hospital in Haiti with considerable success. Despite deficiencies in electricity, clean water and sanitation, much of Haiti has been wired to the internet by Digicel, an Irish Communications Company. We are now able to receive pathology and radiology reports in a timely fashion, contact patients (someone in a neighborhood or village will have an inexpensive cell phone), and communicate readily with colleagues both in Haiti and in the United States. Two technologies have been particularly useful: the development of patient tracking and data collection systems, and telemedicine.

A unique patient tracking system. Patients’ compliance in return visits to clinic is a major problem encountered in practicing medicine in rural, underserved areas.  Carson Crane, MFP’s information technology specialist, developed a unique computer program that assists us in tracking and finding patients as well as alerting us to delays in laboratory reporting or patient follow-up. Consequently, we now have a nearly 100% patient follow-up. This is remarkable since many of our patients come many miles over difficult terrain to attend or hospital clinics and rural dispensaries. Further, MFP health professionals in the U.S. can monitor patient data in real time during clinic visits of difficult patients of particular concern to us.

Telemedicine. Simple, low-cost communication technologies hold promise to bring expert medical consultation to remote medical facilities in the developing world who do not have access to specialists.  Carson has developed a unique, secure MFP website for Medicine for Peace that primary care physicians in Haiti can easily access to receive consultations by MFP dermatology experts in the United States.

Teledermatology consultations consist of a primary care physician in Haiti sending a clinical history of a patient and images of the patient’s skin lesion on the secure website. Within twenty-four hours an expert MFP dermatologist in the United States interprets the history and the images, and provides a diagnosis and recommendations for treatment. The system put in place is in accordance with guidelines put forward by the American Academy of Dermatology Task Force on Teledermatology. This service not only provides expert consultation to Haitian patients living in a remote area of the country, but provides a teaching opportunity between care givers in the United States and Haiti.

Our Women’s Health Initiative will benefit from this technology as we are now instituting similar  technology for physicians in the U.S. to offer consultation on problematic cervical examinations in our cervical cancer prevention program.

Monday, July 20, 2015

Why Srebreica Matters.

 MFP physician Dr. Lewis Marshall at the refugee camp at Tuzla.

In July 1995, Medicine For Peace sent a medical team to Tuzla, Bosnia to assist displaced women and children who had survived the massacre at Srebrenica. We stayed in Bosnia for six more years, operating a school-based mental health program in Kozarac, one of the first Muslim towns subjected to the Serb campaign of ethnic cleansing.

On July 8, 2015, the U.N. Security Council debated a resolution condemning the Srebrenica massacre that occurred during the Bosnian war as a crime of genocide.

Forty thousand Bosnian Muslims sought refuge in the U.N. designated  “safe area” of Srebrenica in July 1995, under the protection of a small contingent of Dutch U.N. peacekeeping forces. The Bosnian Serb Army and Serbian paramilitaries held the often play the “atrocities occurred on all sides” card were often children and the elderly were terrorized and sexually assaulted before being forcibly expelled from the area. Over the next ten days, approximately 8,000 Muslim males, age 12-77, were systematically executed at nearby killing fields, thrown into mass graves, and covered over using bulldozers. Both the International Criminal Tribunal for the Former Yugoslavia (ICTY) and the International Court of Justice have ruled that these events constitute the crime of genocide because it was a deliberate, preconceived plan of mass executions and forced displacements with the intent of ridding Eastern Bosnia of its Muslim population. In their ruling, the International Courts relied on sworn testimonies from more than one thousand survivors, as well as forensic data from twenty years of unearthing mass graves.

Russia vetoed the Security Council resolution, with China, Venezuela, Angola and Nigeria abstaining. Russia, a fellow Christian Orthodox country, is a traditional ally of Serbia. Also, Russia and the countries abstaining have economic and military agreements with Serbia. Their statements after the vote all read from the same script: the Security Council resolution would doom the region to more tension, and that atrocities occurred on all sides of the conflict. Individuals and Governments who are apologists for the massive and disproportionate slaughter of civilians by the Bosnian Serbs and Serbian paramilitaries often play the “atrocities occurred on all sides” card.

The Serbian President, Tomaslav Nikolić, an ultranationalist in the mold of Slobodan Milošević, called the vote “a great day” for his country. His Bosnian Serb counterpart, Milorad Dodik, described Srebrenica as “the greatest sham of the twentieth century”.  Clearly, the past twenty years have not been a period of self-reflection for the majority of Bosnian Serbs or the Serbian Government. In the face of overwhelming evidence, the Serbs deny participating in what the International Courts have described as crimes of war, crimes against humanity, and genocide. The Bosnian Serbs fear that accepting a modicum of culpability might lead them to a dreaded place-- a dialogue between Muslim and Serb, and the possibility of a new vocabulary in a country where discourse is dead.

The Obama Administration appears to be on the right side of this issue. Samantha Power, the U.S. Ambassador to the U.N. supported the Srebrenica resolution. A few days later, she and former President Bill Clinton attended the twenty-year remembrance of the massacre at the Srebrenica Memorial at Portočari in Bosnia. Lest we forget the history of the Balkan Wars, the U.S. has some self-reflection to do, as well. For most of the long, four year war, the U.S. Administration maintained that it had no vested interest in the conflict, even as it watched, unmoved, while large scale atrocities against Bosnian Muslim civilians were uncovered. It was not until the eve of the 1996 U.S. Presidential elections that the Clinton Administration brokered the Dayton/Paris Peace Accords. The Accords stopped the fighting, but in separating Bosnia into Serb and Muslim/Croat entities, it legitimized the Serb ethnic cleansing campaign. The division of Bosnia has been an impediment to effective governance, and to any movement toward political reconciliation.

Finally, the Security Council’s rejection of the Srebrenica resolution reminds us of the inherent weakness of the U.N. to prevent massive human rights abuses, as witnessed in Srebrenica, Rwanda and Sri Lanka.  The U.N. has accepted responsibility for its failure to protect Muslims trapped in the Srebrenica enclave, and has implemented an action plan for early detection of human rights abuses, and effective response measures to prevent or end genocide in the committed to develop indicators of potential genocide, and effective actions to prevent or end genocide in the future. The future is now, as minorities are threatened in Myanmar, Sudan, Burundi, Central African Republic, and in Iraq. The critical question is, as it always has been, whether the U.N. member states are willing to act on the ground to protect threatened civilians.

Michael V. Viola, M.D.


Tuesday, June 16, 2015

Women's Health Month in Gros Morne

"Ankourage Sante Fanm"-Promote Women's Health- March is Women's Health month
and marks the fifth year anniversary of the MFP women's health initiative

The banner that hangs in front of the Alma Mater Hospital read , "March is Women's Health Month. Free Examinations and Treatment." Medicine and treatment have always been at no cost for our patients, but in March we waved the minimal fee that the hospital charges for clinic visits, as well. During the past months, Orna, our head nurse, spoke at all the Sunday Church services, and on the three radio stations in town.

"Protect your health. Come to the women's clinic, Do this for your children, do it for yourself."

MFP nurses walked through the market passing out flyers that explain that Haiti has the highest rate of cervical cancer in the world, and that it is a preventable disease if it is diagnosed early. Some women commented that they had friends who died of breast or cervical cancer.

On March first, women began gathering in front of the hospital at 6 a.m., waiting for the 8:30 a.m. clinic to open. Each women received a breast and gynecological examination, and was screened for cervical cancer, AIDS, syphilis, and other sexually transmitted infections. Each women who attended clinic received a bright red Medicine For Peace bracelet that said, "Promote Women's Health". Scores of women now walk through the market proudly sporting their colorful bracelets.

By the end of the month, two patients with cervical cancer were discovered and received potentially curable surgery, ten patients with pre-cancerous cervical lesions were treated with cryosurgery, eight new AIDS patients were diagnosed and placed on first line anti-retroviral drugs, and more than a hundred patients with sexually transmitted infections and other gynecological problems were diagnosed and treated. Most important, five hundred and fifty women were brought into the health care system.

There are many lessons to be learned from MFP's  women's health month. For a cancer prevention program to be successful, community education has to be ongoing, aggressive and unfaltering. In countries with entrenched poverty, even a minimal fee is an impediment to promoting comprehensive women's health. If a woman has the option of a doctors visit or a few bowls of rice, she will opt for feeding her children. Free medical care does not promote dependency, as some assert, it just prolongs women's lives.

There is a Creole saying that explains, "Analphabet pa bet". (We may be uneducated but we are not ignorant). Haitian women understand the importance of good health, and will seek out medical care if it is offered to them.