Last week we managed to get a weather window permitting us to visit Isla Guanaja, about 30 miles east of Roatan. This island, which was heavily damaged by Hurricane Mitch, has only one small Centro de Salud public clinic, and only one doctor for the 10,000+ people living on the island. We plan to visit again on our way south towards Panama and drop off a shipment of medical supplies, so this was our chance to visit and see what the particular needs of the community are and what the clinic could really use.
We left from Oakridge at dawn, around the corner from our little clinic there. We were fortunate to hitch a ride with Captain Larry from East End Divers; when we come back here in our ship we will have already been over the ground once with Captain Larry. Now we know where the safe approaches are, where the anchorages are, and how the winds and currents normally run. As it happens, Captain Ed talked to the mayor of Bonacca Cay (the largest settlement on Guanaja) while we were there and managed to get us secure dockage when we return, so it was a very helpful trip!
There is no better way to understand the needs and capabilities of a clinic than to roll up your sleeves and get to work in it, and since we had contacted the
Centro de Salud in Guanaja to let them know we were coming, we had a long list of patients waiting when we got there. On islands, sometimes particular genetic conditions become very prevalent in the population, and we saw a lot of diabetes and high blood pressure–perhaps not surprisingly, we also saw way more obesity on Guanaja than on Roatan.
Whenever I have patients with high blood pressure, I treat with advice on how to lower blood pressure combined with medication to control their blood pressure. Sometimes I see patients on expensive brands of blood pressure pills that they can only get on the mainland (if at all) or can’t afford, so they end up with their blood pressure intermittently controlled and rebounding. The Centros de Salud nearly always have some basic blood pressure medication, so I always try and change people onto medication that they have access to or can afford rather than some of the things private doctors put people on when they can afford to go to one.
Our volunteer acupuncturist Megan did 24 acupuncture treatments, mostly for chronic pain, insomnia, neck pain, and anxiety. The patients really took to it; several came for a second treatment on our second day on Guanaja. Noah saw a lot of adults and kids with poorly healed fractures and soft tissue injuries, and spent time with them teaching exercises to improve their flexibility, support weakened joints and regain strength and flexibility. With our ultrasound, we drew a lot of pregnant women and we ended up distributing over 6,000 vitamins.
As well as diseases, bumps and scrapes that are common to both the developing world and developing nations, we did a house call on a 24 year-old man who weighed 450 lbs and had a huge, painless swelling of his lower right leg developing over the last couple of years. After examining it and talking to him, I am pretty sure he has filarial elephantiasis, sometimes mistakenly called ‘Elephantitis.’
Elephantiasis refers to huge amounts of lymphatic fluid (the clear stuff that makes your organs all wet and shiny looking and that seeps out of your skin
when you get a bad graze) getting trapped in some part of the body, very often the legs or genitalia. If the lymph glands in your body (little balls of immune tissue that your lymphatic fluid seeps through to be filtered) get clogged, the drainage of lymphatic fluid from that part of the body can be blocked and enormous swellings can occur.
Over 120 million people in 80 countries suffer from elephantiasis, primarily in the tropics and with a very high incidence in parts of Africa. There appear to be two kinds of elephantiasis;
one caused by persistent barefoot contact with irritant volcanic soils (particularly in east Africa), and another caused by the parasitic filarial worms like Wucheria bancrofti. Transmitted as larvae in the saliva of mosquitoes, Wucheria nestles in lymphatic glands and blockage of lymphatic flow occurs.
The swelling is painless (though physically and socially debilitating), but crusting and thickening of the skin (probably in part to the victim’s own immune response to the parasite) can result in secondary infections, and the stretching of the skin can cause itching. Rigorous moisturizing, cleaning, washing and drying of affected area is helpful for avoiding secondary infections and other complications, and the worms can be treated with Diethylcarbamazine, Ivermectin, Metrifonate, Suramin, Mebendazole and Levamisole, but most of these are most effective against larval worms and do not get all the adult worms.
Doxycycline over 8 weeks has shown great success at eliminating both larval and adult forms of the worm (possibly by killing the symbiotic bacteria in the worms), but that creates its own special problems. When the worms have been killed, their dead bodies nestled in the lymphatic glands can cause a massive anaphylactic reaction–you could break out in a rash, your blood pressure could collapse, and your throat and airways could swell shut. These symptoms can be treated with antihistamines and steroids, but if the reaction is severe, a patient might have to be intubated.
With the patient we saw on Guanaja, this could be a real problem. Because of his weight, his neck already has a lot of compression on it (and a tracheotomy would sure be hard, as would
IV access) so intubating if his throat started to swell to that level of danger could be a real nightmare. I am going to inquire about whether the initial dose can be done in the hospital on the mainland with an anesthesiologist present–maybe not necessary (prophylactic steroids, antihistamines, and IV access and nebulizer beforehand might be enough) but I don’t think the risk is worth it. I’d rather he was inconvenienced by a long trip to the mainland to have his first doses in hospital only to have nothing bad happen, than to have him risk it at home and be inconvenienced by his own funeral.
If any doctors reading this have more experience treating elephantiasis with doxycycline, please contact me if you have any advice or suggestions. I plan on seeking many expert opinions in my search to find a solution for this young man. Even if the worms are safely eliminated, the swelling may be difficult to get rid of (though massage and compression bandaging can help), but I really want to find a way to get this guy treated.
This is the problem with remote paradises, especially very, very poor ones. The sunrises are beautiful, like this one on our way to Guanaja…but sometimes care for a problem that can be taken care of with some basic treatment is an impossibly long way off. By the time we come back to Guanaja on our way south I want to have a solution for this guy.
Please click on one of the thumbnails below to view a slideshow of pics from our trip to Guanaja
All pictures of patients used with patients’ consent