Monday, July 28, 2014

Roads, remote clinics and lymphs systems

The plan was to visit each of the four chosen mobile clinic sites in that one week.  We would be able to help with the set up, assess potential obstacles and see what additional supplies and support were

The sites were remote and far up into the mountains.  We piled into vans and made our way.  The roads were often more of a foot path;  intended only for animals and people walking and not for vehicles.  There were no tap-taps and rarely even a moto.   With each foot spent climbing upwards, I was aware of how it would be nearly impossible to get a woman down in an emergency.   It was far but there were also no vehicles and the going was very slow, even with one.  The idea of the mobile clinics was to prevent complications, treat what could be treated and help women to know if they should wait for their  birth in a place closer to emergency care.  

The roads in Haiti make transport for emergency medical care in childbirth almost impossible.

Meanwhile the lymph system within me, was also trying to assess the damage being wracked inside it. The tiny viruses ( 1/100 th the size of a bacteria ) were trying to reproduce inside my cells.  They cannot reproduce without invading a host cell and in this case I was the host; bouncing along rocky, dirt  roads.   My body was fighting hard to eliminate them through my own internal paths of immune system.   It was trying to understand who the new virus was and make antibodies to stop it.

We climbed higher and higher,finally coming to a flat, fertile area; isolated but lovely.  The clinic was held in a church and with the help of the community health worker and midwife was quickly set up and seeing the women who had gathered there. They were told the midwife and doctor would come every month.  It was a moment of hope and possibility.

After about an hour, I forced myself to fall  down in the grass rather than faint.   My blood pressure, always low was even lower.  I laid looking up into a tree  with my world spinning about me.  The nurse continued to say I could not possibly have Chikungunya so I lay there wondering what I could possibly have.  

In time, I would see that just as the roads to the village were critical in saving lives, our own internal highways of lymph would be critical in saving my own.  Was it working well?  was it free of rocks and potholes and able to quickly eliminate the dead cells that carried the virus?   Just as I had never thought of roads as a critical component of good midwifery care, I had taken my lymph highway for granted.

When the women were all care for and we packed to go back to town, I began to ached from head to toe.  I limped to the truck, up the steps and fell into a delirium of cold and hot.  Later, much later the CDC in the United States would confirm it was indeed Chikungunya.   By Wednesday night, after our second mobile clinic visit, a nurse had developed some symptoms too and it was decided to go home.

Friday, July 25, 2014

The Plant Doctors

When we arrived, Monday morning, at the clinic, my symptoms were obvious to the women who daily heal friends and neighbors  with plants and water.  I could not stand straight and was already demonstrating the tell tale limp and bent posture for which it was named in Africa.  It means "bent person" and I was bent.

Children learn plant medicine by watching their grandmothers from an early age. Here they laugh as they prepare a bath for me.  

During the presentations and workshop I nearly passed out.   As soon as we were finished, the women, hurried me back to the cooking house and ordered me to take off my clothes.   A large pot of plants were waiting.  The little girls laughed and played.  How many times I had watched, as they prepared plant medicines, just steps from the clinics pharmacy.  These two worlds did not seem to meet.  I would ask the name of plants and press a leaf in my book and try to grasp what it was used for.   It was their main medical system.  They had no money for medicine but there were always the plants and their ancient wisdom. Inside, the doctors complained that there was no medicines anyway and everyone debated why there were no medicines and how to regulate them and if they were being stolen.  Outside they made their own medicines and distributed it to me with love.

Treatment for Chikungunya

Soon, I was being scrubbed, head to toe, with leaves.  The water and the brush of the plants offered some relief.   Their hands moved quickly and with skill.   They knew what had to be done.

The water and the plants and the rubbing all helped support my lymph system which was desperately trying to identify the virus, make cells to destroy it and eliminate it from my body.  With no formal education, they knew what to do.   Had I stayed, there would have been more baths but I left shortly after; bits of leaves clinging to my skin and woven into my dripping hair.

That night my body, taking advantage of my sleep, burned as it tried to further destroy the virus.   I tossed with wild dreams, sweat and chills until morning when I could try to go get a cup of tea and sit in the sun.

Many times, as my body ached, I would recall the bath on the mountainside of LaGonave.

Thursday, July 24, 2014

The invasion of the unsuspecting cell

By the time we arrived at the church compound, Friday night, the virus had begun to make its way into my unsuspecting cells.   They had faced cold and flu viruses many times and had antibodies to fight them but this was a stranger.  The virus tricked the cell into letting them in.  Its kind of like the Trojan Horse.  It pretended it was friendly but soon my cells knew that it's goal was to take over and use my healthy cells as a place to reproduce.

Boats in the harbor of LaGonave

All over the southern hemisphere viruses deposited by this species of mosquito were making similar invasions.  I did not know about the battle starting to be waged inside me.  We walked to the docks and looked at the fishing boats; large beautiful wooden sail boats that now mostly carried cargo and charcoal back and forth from Port Au Prince.  We visited with the sailors and sat in the evening sun. I think it was the last time I would walk  without pain or stiffness and muscle spasms.

If the mosquito had carried malaria, it would have found its way to the liver.   The people of most Malaria prone countries, do not take a daily malaria pill and few sleep under treated nets.  They assume they will get the virus and gain immunity over time.  If it was dengue, each time the virus entered the body it would get worst.  It would burst through small blood vessels and cause internal bleeding.  The ChickV would find its way to the joints and cause disability.

Kenel was going back to Port-Au- Prince at dawn to work on his visa application.  He had been accepted in an agricultural internship program through Oregon State University and was anxious to take the next steps.  I would wait for the nursing team that was to meet me there and help get the mobile clinics up and going.  There was an important training on Monday and I was trying to go over and over the plan.  I wanted them to work in village teams with the midwives to plan and implement the clinics.  I wanted to be supportive while allowing them to work together on the details.

By this time, the virus had multiplied and burst out of the host cell and into my blood stream where each new virus would find a new cell.

ChickV Virus

My adaptive immune system was working as hard as it could to make antibodies against the new virus.  A war was being mounted within me.  By Sunday the effects were being felt and I suspected the big mosquito that had made such a splat was the cause.  I did not know much about the virus they were talking about and I had no internet.  I read the CDC hand-out the nurses brought and listened to what other's said.

By Sunday night my immune system raised my temperature and I was on fire all night long.   Hot, shaking, burning body with a extreme head ache.  By morning,  the fever passed and the head ache subsided. My legs no longer worked as they had. I could not bend my knees.  I was in constant pain.

I couldn't eat and did not eat for days.  I suggested that I thought it was the chickungunya virus that people talked about.  The priest and the Phd nurses were absolutely sure I did not have it. They shook their heads in the courtyard and said "no, its something else."  I was pretty sure if it was something else I was going to die shortly.  It was not anything I had experience before but had no energy to or information to confirm my suspicions.

I only hoped I could pull off he training and would not fall over in pain and weakness.

Wednesday, July 23, 2014

Getting to know the mosquito

I try to get to know the mosquito who. long dead and decomposing, has caused  me and so many others  lives to be turned upside down.

She ( the female is the one who sucks your blood ) so I know she was a mother; a mother who needed to fill her abdomen with fresh blood in order to feed her young.

Here she is.  The mosquito that causes yellow fever, malaria, dengue and the virus I got; chikungunya. 

Her relatives, all 3500 species, cause 700,00 to a million deaths each year in mostly young children.
She is known as the anophiles mosquito.; aedes aegypti.  Mosquito means small fly in Spanish.

I think of her being born in the small cave across from the clinic; a hole with large rocks where garbage is thrown.  It is a perfect place to be laid and turn into a grown mosquito.  Her along with some 500 brothers and sisters floated there in an egg based raft.  There they could survive in dry times, waiting for the rains that would come and set them free.  There she hatched into a larvae and wiggled and wiggled changing her skin four times, swimming and diving before merging into a pupa stage for a quiet day of rest and fasting before emerging as a grown mosquito.  Did she rest there letting her body harden before making her way to a rock where she let her wings dry in the sun.  She would not live long but longer than the boys who hatched with her.  She had a few weeks but they only had a few days to mate and carry on the cycle.

There beside the limestone rocks she found her mate and began to grow her own young.  I could not have been her first tasty meal of blood.  She had to have sucked blood from someone else with chickungunya.  Others would suck blood from a person infected with malaria or dengue.   It was all being exchanged from person to mosquito all around us.  Her small wings flapped 500 times in a second.  This might have warned me but we were all talking and laughing.  It was afternoon but never mind.  She did not wait for evening as some mosquitoes.   Afternoon was fine.  She needed blood to complete the life cycle; her life purpose.

When she landed on me, she acted quickly, inserting her flexible mouth tube into my skin. It bent searching for a vein to get blood from and releasing the infected salavia into my system.  She neither filled her abdomen or lived to lay her eggs.  Swat.  A young child's hand reached out and smacked her, blood smeared on my leg and their hand.

Had she been sucessful, she could hve flown back to he edge of the same pool and laid her own eggs or waited a few more days for another blood meal.

Though she dies, the virus was busy finding cells to enter inside my body and beginning its task of reproduction.  For the next week if another mosquito bit me, I passed on the virus to the new mosquito who in turn gave it to another person. All over Haiti and the Caribbean this cycle was being duplicated in a rising epedemic.

My immune system, unaccustomed to the virus, had to create a way of attacking the problem.  As I continued to do trainings and prepare for the mobile clinics, a war was taking place in my body.  I had  come to do a very specific task and had created a schedule that I had hoped would result in the greatest benefit.  I had hoped it would set the stage to prevent death and disability in the mountains.

But I, like hundreds of thouands of people around the world would be stopped in my tracks by the same species of mosquito that caused yellow fever, malaria, dengue and now chickungunya.   Twenty four hours after the blood feast, I headed to town. The driver was sick; crazy sick.   We were all spreading it, from ignorance and poor diagnostic skill, passing the virus from one to another through the mosquito.

My personal mosquito was dead but the effect of her blood meal was gaining speed and power within me.

Tuesday, July 22, 2014

Chikungunya - The Bite

I am sitting on the steps outside the Bill Rice Clinic in LaGonave.   We had just had a great training with the matrones and community health workers.   Spirits were high and the children I had known so well, were gathered around me.  Kenel, from Henche was translating for me and was there too.  It felt perfect.   The children scream "Sarah" and swat a large mosquito who was biting my leg.  It is huge and stripped.  Blood goes everywhere.  It is not like any other mosquito I had ever seen before but I did not think about it.  We returned to our laughter and chatter.

Minutes before "the blood meal" they take pictures of the matrons and agent santes who attended the training. 

The good, good woman who helps me there comes over to us. She is walking with a stick and is all bent over.

"What happened?" I ask her, with concern.  She looks in so much pain.

"A mosquito."

I beg her not to help me.  I'll be fine I tell her but she shakes her head and smiles through the pain.  I remember that smile.  The smile that comes through the pain.  The need to be distracted and to keep moving so the body does not freeze.

Later we sit out back while everyone prepares for night.  Fires our built. Water is gathered.  Girls fix each others hair.   They try to fix mine.  Kenel is on the roof with the midwives; laughing and looking down at us.

I did not, could not know that the virus was beginning to take hold in my body.  The mosquito that bit me was dead but four days earlier she had bit someone else with chikungunya.  Its how it is passed from person to person.   It was first described in 1952 in Tanzania.  It made its way to the small mountain village of Haiti where I rested in days end.

As I laid down, under a veil of mosquito nets, the virus was invading healthy cells and reproducing.  Outside people were talking in the dark; telling stories and letting their laughter drift over my body.

Tomorrow we would work on the mobile clinic bags, create a pharmacy list and do Helping Babies Breathe with the whole staff.

Inside my body, my immune system was beginning to mount its defense against the invader.   I had several things working against me. I was older and had only nine months earlier had radiation for breast cancer.  My immune system had already taken a beating.

Chikungunya - This is the health department


The voice is from the health department.  She has to talk to me because I am host to a battle between the virus, Chikungunya, and my own compromised immune system.  She is asking me when I went to Haiti, when I thought I was bit by the troubling mosquito, when I left.

Chikungunya was first identified in Africa and spread to Asia.  The CDC watches its spread to the Americas.

Did I leave the hotel in Florida?  Was I bit there?   They are afraid someone will bring it back and then a US mosquito will bite them and it will begin to spread as fast as it spread throughout the world.

"I only walked to the Denny's across the parking lot. I don't think I was bitten again but I can not be sure." I am no longer sure of anything.

I tell her I need to look at a calendar.  I can not think about time.   I learn to live in the present; dealing with the constant pain I have felt since chikungunya entered my body.   Has it been weeks? Months? Days?   I only can think of what I can try to stop the pain.  I use ice bags, buy supplements, rest, drink fresh juices, take pain medicines but it is always, always there.  I try anything and everything but a disease which has crippled millions of people is mostly unheard of here.  I am the only case in Oregon.  My doctor looked it up on the internet before seeing me.  The main concern was reporting it to the CDC.   "There is no cure."  she tells me but I knew that.

I try to answer her questions.  I cannot focus but then she tells me she worked in Haiti for a year and we turn our conversation to Haiti.   If I am in pain, what are the people there doing?  Will few volunteers arrive with the much needed pain  killers?   I take warm showers, ice my feet, wrap body parts in pain strips and drink clean water.  I have tylenol and mobic.  I can watch the whole 9th season of Greys Anatomy.

But I am trying to answer her questions. "Why did I go to Haiti?  Where was I ?   What was I doing?  When did I first notice I was sick?  What did I do?  Were other people sick?'  

I try to think and then the nightmares of memory return.   Everyday I look it up on the internet.  I search for the experiences of other people.  I look for reassurance and understanding.  

Since I was a child, I used writing to my life in order; to relieve the pain and confusion and to look for hope.   This is my story of global maternal health.  It has many chapters and this is one of them.

I can see the look in people's eyes or they come right out and say it.  "You shouldn't have been there in the first place.  We told you Haiti is not safe and now look at you."

I walk with a limp. I feel crippled.  I hope it will pass but I do not know.  I look at people on bicycles with wonder.  I once rode a bike. I once hiked in the forest.  I had walked up the mountainsides of Haiti.  Did I understand my risks?   Would I have gone anyway?

Here is my story in installments.