Sex, Drugs, and Public Health

He was assigned by an out-of-town agency to work with us just one day a week, but the big, balding Teddy Bear who came to the office every Tuesday had quickly charmed the ladies. He didn’t try to disguise his half bald head with a comb-over. He took time to chat and laugh with the secretaries, nurses, and managers of other Public Health programs.

And on the summer day they replaced the carpeting in our office, I returned from a meeting to find all the staff, evicted temporarily from their desks, sitting outside on folding chairs. Naomi and Cindy worked on papers they held in their laps; Francine and Mickie helped callers with their usual efficient cheerfulness. Their phone lines cascaded from an open window and coiled on the sidewalk beneath their chairs. Electric fans, connected to extension cords, swept the group.

“It’s so hot out here,” Cindy said to me, “that my papers are sticking to my forearm.”

“Sorry,” I offered, feeling a little guilty about the weather, “I’ll check on them and see if we can get back in within the hour.”

“Oh, we’re O K,” chirped Naomi. “He’s brought us a pan of brownies he baked all by himself.”

They turned to smile at the Teddy Bear, some of them still munching. He sat with the rest of them, on a folding chair too, his knees almost up to his chest, scribbling on a notepad. He looked like a parent squeezed onto a  kid’s chair at the pre-school.

“I had to do something to help us get thru this day,” he shrugged at me.

It was only a couple of weeks later that I stumbled upon a small article in the nearby big city’s newspaper:

“Paramedic accused of trying to poison wife with heart drug.”

Why did I take time to read that page thirteen filler? Was I temporarily bored? Or was it the ironic headline juxtaposing “wife” and “heart drug?”

A nurse had accused her paramedic husband of slipping doses of digoxin into her food or coffee or something. This Agatha Christie-esque plot line would have been a mere curiosity except that the husband – whose marital relationship was clearly in the I C U – had a name identical to our Teddy Bear’s. Our Paramedic Teddy Bear’s.

I called the agency for which the Teddy Bear worked. They promised to talk with the local Sheriff and get back to me.

“Marital problems,” they reported back. “Messy divorce. Apparently no evidence to confirm her complaint.”

So the next Tuesday that he came to work, I spoke with him.

“Aw, it’s embarrassing,” he hung his head a little. “We’re going thru an ugly divorce. She’s jealous of my girlfriend. She’d say anything.”

Then, a couple of weeks later, the newspaper disclosed that her family had reported her missing.

I asked the agency to remove him from my office, temporarily, until issues were resolved.

“We’re in touch with the Sheriff’s office,” they told me. “He’s under surveillance. Innocent until proven guilty.”

“But I have an office full of people to protect,” I lobbied.

“Can’t. Unfair labor practice,” they retorted. “We’d be sued. Have your lawyer discuss it with our lawyer.”

So, while the lawyers talked and the Wheels of Justice (whatever those are) ground away at their usual pace, I planned to be at the office an hour early on Tuesdays, stay there all day, and remain until everyone was gone.

Then, one Tuesday, he didn’t show up for work.

“They took him in for questioning,” the agency head replied to my call. “He told me, when I asked him, that she was hiding out in Mexico with a friend, trying to frame him.”

So I gathered my staff together and went thru the information I had. None of it condemning, all of it circumstantial.

I think I saw Naomi shiver for a second.

“But, he’s SUCH a NICE guy,” Cindy wondered aloud.

“Must be a mistake, “ Francine shook her head.

Naomi remained uncharacteristically quiet. Until, as if mumbling to herself:  “I ate the brownies.”

She shivered again.

I anticipated that everyone’s mood would change for a while after I spoke to them. People gathered in clumps in each other’s offices several times each day. The usual office bustle was replaced with slowly shuffling feet and murmured voices. But I hadn’t thought that they’d remain spooked for as long as they did. For over two months, no one would go into his office space. People continued to bring baked goodies to the office to share, but it was over six months before I saw brownies again.

After he was convicted, Naomi’s eyes peeked into my office.

“You have a minute?”

“Sure. Come in.”

“But he was so nice. Not like what we expect a murderer to be like.”

“What did you expect a murderer to be like?”

“Oh, we don’t know, but – – -”

“ ‘But” what?” I encouraged her.

“I mean, how could he have done it? He’s, basically, just like us.”

Jim, a healthy, muscular thirty year old, took antibiotics for – – – well, something. Something relatively minor, as I recall: bronchitis or an ear ache.

Unfortunately for him, the antibiotics wiped out, among other bacteria in his body, the normal bacteria that lived in his gut, where they helped him digest his food. I saw him in the Emergency Room with cramping, miserable diarrhea, including blood. That almost always gets the patient’s attention.

Jim had Pseudomembranous Colitis – an inflammation of his gut caused by a new bacteria moving in where his “normal flora” used to reside. It’s actually, a relatively common complication of antibiotic use. And a fairly serious complication.

So, how do we fix this problem? It may not surprise you to hear that, in this society of ours, the treatment for this problem caused by antibiotics is – – – to give more antibiotics. Different antibiotics. Expensive antibiotics. And cross your fingers.

Now, some people, thinking in the right direction, try to replace the “good bacteria” by eating yogurt, kefir, and other potential sources of bacteria. This approach has not been an overwhelming success for several reasons.

But now, taking the same thinking a little further, we have a new therapy that I learned about at a medical conference in San Francisco. It’s called “Fecal Transplant,” or, for those either squeamish about the words or into New Age cures, “Human Probiotic Infusion.”

The vision you’re imagining right now is probably exactly correct.

“You need two things,” the professor of Medicine elaborated: “a donor, – – – and a blender.”

How creative. How logical. How frustrating to the pharmaceutical companies.

For those of us who specialize in Prevention, the problem of Pseudomembranous Colitis from antibiotics is just another warning (along with increasing bacterial resistance) that we’re WAY overusing antibiotics.

And that form of drug abuse is coming back to bite us.

Question your doctor whenever (s)he prescribes antibiotics, to be sure it makes sense to you, before you put that drug into your body. Jim will be doing that, probably for the rest of his life.

The set-up was there.  In April, when I was in Haiti with a medical team, this is what I saw: people living in tents pitched on the rubble, in city parks throughout the capital, even on sidewalks; Streams of foul smelling waste water flowing through the streets, right past people, tents and food stands; Kids in clean uniforms walking to school, crossing these polluted flows.

There are dozens of tent camps, with hundreds of tents all crammed next to each other, both in the capital and along the road leading north, to St. Marc.  I saw very few portable toilets among the tents.

In Saint Marc, the city north of the capital where we conducted clinics, the major river was a thick brown color.  The irrigation canal, which serves that area, roiled with brown foam and floating garbage.  I watched children swim naked in the canal, and women scoop water from it.

The bacterium that causes cholera is very unique.  It can live in both sea water and fresh water.  The disease is endemic in the waters of India, but had not been seen in the Americas for decades until it exploded as an outbreak in Lima, Peru in the early 1990’s.  My family and I were in Bolivia at that time, and Public Health officials were working feverishly to prevent its spread to the tropics.  The fear was that people migrating from the mountains near Peru, down to the tropics, would bring the disease with them (they did).

In addition to building protected water systems and closing lakes to bathing, the local hospitals built special beds in a separate “cholera ward”.  These beds were merely cots, with plastic covered mattresses that had a hole in the center.  A patient with cholera is placed, naked, on the mattresses with his buttocks over the hole.  A bucket is slid under the cot to catch the diarrhea.  A cholera patient may lose up to ten quarts of water a day.

The hospital’s storeroom was stocked with bags of IV fluid.  Cholera patients die of dehydration, not infection. So the goal was to replace the volume of lost diarrhea fluid with an equal amount of IV fluid, and prevent dehydration.

In Haiti, the people know their water resources are polluted.  So, when they can afford it, they purchase water.  It comes in small, sealed plastic bags the size of your palm.  But on the plane bound for Haiti, an elderly Haitian woman in a flamboyant dress told me:   “doze bags of water, don’t you drink dem.  Bad.”

When people carrying the cholera bacterium within their intestines, come from St. Marc to Port-a-Prince to visit relatives in refugee tents, it’s gonna be a catastrophe.

As before, for any of you who want to help, I’d advise you contribute to Partners in Health.  They are a competent medical organization that has been in Haiti for over twenty years.  They will help the ill.

That will have to suffice until Haiti’s Public Health Ministry can, someday, separate the water from the sewage.

– – – is how a colleague mis-pronounced what I’d said.

“Haiti,” I corrected. “I’m going to Haiti.”

They sent us to St. Marc, a city north of Port-au-Prince and beyond the zone of impact from The Earthquake.  But tent cities of blue plastic metastasized from the maimed capital, to line the road north, leaking streams of sewage like pus from sores. These clots of densely packed refugees from Mother Nature’s attack remained camped out, waiting. For something. For someone. The parched and stripped Haitian landscape around them gave no hint of where they’d find water.

Our van stopped at a roadside market halfway to St. Marc. The primary items for sale were food and water. The food was the same from every vendor – deep fried something. It looked identical on every platter carried by the competing hawkers. Water was sold in sealed plastic bags the size of your palm. This was the water I’d been warned about on the airplane by a flamboyantly dressed Haitian woman:

“Da water dey sell in bags – don’t you drink it. Bad.”

St. Marc is a densely packed town surrounded by thousands of farmers’ small plots. Our clinics were set up in churches scattered among the farm homes, barefoot kids, free range pigs, and roads as rutted and pitted as horse trails. To get there, we bumped alongside an irrigation canal churning with brown foam, in which naked children played and from which women scooped water.

Throngs of people appeared at the clinic doors from amid this landscape, and grew quickly to a chaos of jabbering Creole voices. We admitted them in a controlled manner, to sit and wait their turn, only to discover that the chaos was now inside, at our elbows.

From this outside squalor and the chaos of waiting people inside, we brought patients, one by one, to our tables:

A thin grandmother wearing a clean and colorful dress stood, in shoes, with two granddaughters flanking her. I was surprised to note that the old farm woman didn’t smell of sweat and mud. Both girls had ribbons braided into their hair and tied in bows. They wore clean Sunday-go-to-church dresses, and they both wore sandals.

“Dis one, she won’t eat, and da other is always tired.”

Intestinal parasites in both; medicine for the two of them.

A six year old boy, on his mother’s lap, wore a suit – dark slacks and matching jacket over a crisp white shirt. His shoes shined like black mirrors. He had a congenital problem that meant he couldn’t control his bowels. “Dey tease him at school,” his mother worried. “He maybe will drop out of school. Den how he get a good job?”

A teenaged girl stood mute by her mother’s side. She wore a clean dress of multi-colored flowers, and smelled of perfumed soap. Her face had no expression.

“She was in Port-au-Prince,” her mother nodded toward her, “when the earthquake hit. I brought her back here because she was so terrified to stay there. She lost her words.”

Lost her words?

“She hasn’t spoken since the earthquake.”

Luckily, we had a French-speaking counselor on our team.

After we’d listened, examined, then prescribed, they each smiled and thanked us effusively for the little we’d done.

“Merci, Doctor, merci.”

One middle-aged woman told me, “You are the first doctor I’ve ever seen.”

On our way back to the airport, weaving thru crowds of people who were barefoot again, incompletely covered by tattered clothes again, it was obvious to me that, while our medicines may have helped a few people for a few days, what the appreciative and classy people of Haiti really need is water which is separated from the sewage.

Real simple concept. Apparently, monumentally difficult in Haiti.

So maybe my colleague was right. The people are powerless to drink anything other than the contaminated water of Hades.

Ticking time bomb.