The Longest House Call

It took 1.5 hours to make the 700-mile trip from Miami, Florida, to Port-au-Prince, Haiti. The trip from Port-au-Prince to Les Cayes, approximately 110 miles on a paved road, took 4 hours. After spending the night in Les Cayes, we embarked in our four-wheel-drive vehicles on the 50-mile, 5-hour journey across the mountainous spine of Haiti's southern peninsula to the coastal village of Pestel. The next morning, a Haitian captain took us in a wooden sailboat to Anse St. Marceau, Au Basse, and Z'Etoit. These villages, just to the east of Pestel, are accessible only by boat. It took 50 hours to travel the almost 900 miles to Z'Etoit, our furthest destination.

We were visiting Haiti as part of Project Medishare. Miami, Florida, has strong ties to Haiti because of its well-established Haitian-American community. The University of Miami has several Haitian-American faculty members and students and a strong commitment to volunteerism and community service. After the embargo on Haiti was lifted, concerned physicians and nurses formed Project Medishare to provide medical equipment and supplies and to establish educational exchange programs to revive the health care system of the poorest country in the western hemisphere.

In the mountains of Haiti, there are few distinct villages. The people live in homes constructed of thatched and woven palm fronds, spread throughout the countryside and connected by footpaths. Almost all of the children we passed on the road showed signs of malnutrition: red hair and swollen bellies. The Haitian health care workers who accompanied us assumed that all of the children were infected with worms. They had brought gallons of piperazine, which they distributed, followed by a handful of bread and a piece of candy, whenever we stopped.

Mere Maxime's house in Pestel started as a small home on the harbor. She expanded it through the years until it was the largest home in that coastal village. She insisted that we stay with her; staying at the village hotel, she said, would be unthinkable. The open-air porch on the second story served as both our dining room and dormitory. When we arrived, Mere Maxime, her daughters, and her sister prepared a meal of rice, peas, fresh fish, and plantains. They heated water in large kettles over charcoal fires so that we could bathe. Pestel has no running water, no sanitation, and electricity only 3 hours per night. Looking from the porch into the darkness down the coast, it was clear that 3 hours of electricity was a very local luxury.

The village of Anse St. Marceau (St. Mark's Cove) on Grande Cayemite Island stands on a dead coral reef no more than 5 feet above sea level. The houses, built of wood and plaster with palm-thatched roofs, formed straight rows: 3 to 5 houses deep, 20 to 25 houses long. Fishing is the principle means of subsistence—without refrigeration or transportation, nothing caught or grown can be shipped for profit. The people are industrious. Four large wooden sailboats were in various stages of construction when we visited.

We were visiting Anse St. Marceau and other locations on Haiti's southern peninsula to assess the suitability of these sites for rotations for our students and residents in family medicine. We did not arrive planning to make house calls; they just happened.

The first patient in the village who invited us into her home had daily fevers and drenching sweats. Her diaphoresis was so severe that a puddle actually formed beneath her on the dirt floor as we spoke. Miriam Frederick, the missionary-nurse who had involved us in this part of Haiti, made the correct diagnosis after asking only three questions in Creole. As we rounded the corner of the patient's house, we noticed a pit of stagnant water, dug for the animals. Mosquitoes leapt from it. In addition to giving the patient chloroquine, we recommended a layer of oil for the malaria pit. This was not good for the environment, but the pit was dug into solid rock, and there was neither a way to drain it nor dirt with which to fill it.

Once we started making house calls, we could not stop. It seemed as if every household invited us in to see someone seriously ill—a family with tuberculosis, an old man with arthritis, a child with cerebral palsy and seizures, a middle-aged man with a hernia. All conditions were diagnosed on the basis of directed history and physical examination. The pattern continued on Au Basse and Z'Etoit. On Z'Etoit, we saw an older woman who thought she had broken her arm after a fall. Her hand was swollen, but she had full range of motion of all her joints. We reassured her without the benefit of a radiograph.

Most of the patients we saw could be treated with medicines we had brought with us, with reassurance, or with the promise of future surgery. Our last patient, however, was different. She was on Z'Etoit, the most remote site we visited. Her family asked me in because they thought she was gravely ill. I found her sitting on the dirt floor of a two-room home that had no windows. Her family referred to her as a child, but her habitus indicated that she was a young woman. She was severely retarded, with microcephaly and withered lower extremities that suggested spina bifida.

Why had the family asked me to see her? It was clear that her problem had been present from birth. A brief discussion revealed the answer—the family hoped that I had magic powers with which to restore the patient to health. I could only praise them for the care they had given her for so many years and tell them “nou pa ka fe pi bon … courage.”

There is no world record awarded for the longest house call. Even if there were, I doubt that ours would qualify; thousands of physicians have traveled further and served those in need for longer than we did. But this was a personal “longest house call.” The journey home gave me ample time for reflection. Actually, the whole trip to Haiti was a “journey home” for me, in the sense that it returned me to the goal of “just being a doctor” that had originally motivated me to choose medicine as a profession. Haiti made me realize how much our career choices are dictated by our own needs—how much money do I want to earn, how many years of residency are needed, can I master the subject matter, will it stimulate me intellectually?—rather than by our patients' needs. The joy of helping people in such places as Haiti is unbounded by the constraints we face in the United States. No need to bill or collect; no “defensive medicine”; no technology overload; no demanding, hostile, over-utilizing patients; no petty rivalries between specialists and generalists. None of the statistics about Haiti that I had read in advance—lowest income in the western hemisphere, highest infant mortality rate, life expectancy of 57 years, epidemic rates of tuberculosis and malaria—impressed on me the suffering of the Haitian people as much as that puddle of sweat on the dirt floor. My “house calls” in Haiti cost $400, for airfare, food, transportation, and lodging. Don't talk to me about cost-effectiveness. I'm going back to Haiti as often as I can.

“Ayiti te met yon hounga sou mwen.”

• Copyright ©2004 by the American College of Physicians