Dominican Republic Outreach Project

BATEYES: DOMINICAN REPUBLIC VISIT EXPERIENCE – PRIMARY CARE

By Damir Mazlagic & Oliver Lontok

INTRODUCTION

During our trip to the Dominican Republic (DR) we have visited a number of Haitian bateyes at the northern part of the country, in the region of the cities Puerto Plata and Sosua (red circle on the map). The course syllabus and the reading material assigned prior to the trip will help you get the general picture regarding the conditions and the activities you might expect on your journey.

Before the actual trip all the students who plan to travel are assigned to one of the three working groups, according to the activities they would be performing once they reach the DR. A few of us were in a so-called Primary Care Group that had the goal to collect medication and other medical materials ahead of the trip, and to provide basic primary care services during the visits to the bateyes. The other two groups were: Worming Group (probably more appropriate title would be de-worming, given its mission of distributing the de-worming medication to the residents of bateyes) and Fund Raising Group (the name is self-explanatory).

BEFORE THE TRIP:

A couple of months ahead of the trip, start making contacts with the students from previous trips, with friends, colleagues, businesses, and anyone else you can think off that would be willing to contribute in medications (samples from pharmaceutical representatives, over the counter medications, etc.) or primary care related materials. These might include some dressing material, a few boxes of Band-Aids, and one or two boxes of disposable gloves (medium and/or large size), a scale, a sphygmomanometer, a glucometer, a few penlights, and antibacterial lotion. Of course, if you would come across a free used ophthalmoscope, you should bring it with you. For the additional potential sources of help, consider contacting some of the organizations listed on the Appendix A.

If you are a physician, a medical student, a nurse, or other medical professional planning to take direct medical care of people in bateyes, you should bring with you, if you have them, your own stethoscope, reflex hummer, palm or pocket PC, and anything else that might help you in working with patients. Other useful items would be one or two lined notebooks, several pages of self-adhesive address labels, small plastic containers or Ziploc type plastic bags, several colored sharpies, etc. Be sure that you follow the recommendations given by the course directors regarding other items to bring for yourself, such as insect repellents, rain jacket, etc.

This trip is your ultimate chance to test and sharpen your Spanish, French, or Creole language skills. Most of the Haitians in bateyes speak Creole (a variation of French), while the Dominicans and some Haitians speak a variation of Spanish. Do not panic if you speak only English. The help is always somewhere close and you will do very well just by offering your charming smile and generosity.

Medications and nutritional supply that will most likely be of use:

• Antibiotics (both adult and children/infants dosages if available), such as:
• Amoxicillin
• Amoxicilin with clavulanic acid
• Eritromicin
• Cephalexin
• Ciprofloxacin
• Metronidazol
• Trimethoprim-sulfamethoxazole (Bactrim)
• Analgesics/antipyretics, such as:
• Motrin
• Naproxen
• Tylenol 325mg, 500mg
• Children Tylenol
• Cold medication (e.g. Tylenol Cold, Tylenol Cold Infants)
• Cream for Scabies (e.g. permethrin)
• Nutritional supplements, such as:
• Children’s multivitamins in syrup and in tablet form
• Adult multivitamins
• Vitamin A
• Vitamin C
• Calcium with Vitamin D
• Folic acid
• Ensure in liquid or powder
• Powder milk
• Antacids
• Antihypertensive medications
• Diuretics (e.g. hydrochlorothiazide, furosemide)
• Beta blockers (e.g. metoprolol)
• Calcium channel blockers (e.g. diltiazem)
• ACE inhibitors (e.g. lisinopril)
• Shampoo (Selsun, nizoral, etc.) for superficial fungal infections/seborrheic dermatitis
  

VISITS TO BATEYES

Preparation

At the Crossroads Mission, where we were stationed, the night before the visit to the next day bateyes, we would try to sort out the medical supplies into large plastic containers and/or bags. These would serve as a field pharmacy. One or two students would be acting “pharmacists”, and would hand out the medications or supplements as directed by a physician, a medical student, or other assigned “primary care provider”.

As we soon realized, after just a couple of initial visits to bateyes, the containers/bags with medical supplies would transform into a fully disordered mass of boxes, plastic bags, bottles, and spilled out medications, within minutes from the beginning of our work.

Hence, we tried to prepack the most commonly used meds or supplements into individual smaller plastic containers or Ziploc bags. Each bag/container would than be marked by sharpie to reflect its content. The prepacked material usually included 3-4 weeks supply of multivitamins for children, adults, women, or prenatal vitamins and a week or two of analgesics and/or anti-inflammatory medications. Other medications would be packed and distributed at the point of care directly to the patient. When handing out the medication or supplement to the patient/person, a self-adhesive address label would be applied to the individual package. The directions for use of the medication would be than hand written (actually, you would rather have to draw the symbols instead of words, given the fact that the most of the bateyes’ residents can not read). The examples of the writing are shown below, but you can use your imagination in any effective way.

• To take one pill twice a day è ☼| ƒ|

• To take one pill a day è ☼|

In addition to the above preparatory work, you would need to be sure to prepare other needed material and instruments. You might also help the other teams prepare their supplies. It feels good to help.

“Real work”

You will fall in love with the sturdy truck that will take you to the bateyes every morning. It will serve as a point of socialization and relaxation for most of the students. Upon arrival to the bateye, you would soon be surrounded by scores of children. The adults would follow, and before you know, you are already examining your first group of patients, literally “in the field”. Even though that was at times very fulfilling, in order to avoid confusion and to work under at least some organized fashion, we would try to find the best stationary location as the spot of providing primary care. That could be the local building that serves as a church, a classroom, or other gathering place. It is preferable that the “room” has two openings, one for entry and the other for exit of the patients.

One of the best approaches to achieve some degree of orderly patient care was to have one student or other person (even local resident), stand at the “door” and call the next patient as one of the primary care providers becomes available. Be ready to treat the patients of all ages and both genders. An improvised divider that would allow some intimacy for the patient, if undressing is needed, would be very useful. It could be a part of the inventory, always at hand on your track.

During our visit we would each see in average between 10 and 20 patients, depending on the size of the bateye. Some of the most common health problems encountered were: musculoskeletal problems (e.g. lower back pain, arthritis), scabies, diarrhea, urinary tract infections, headache, hypertension, and gastroesophageal reflux disease. A few women were treated for pelvic inflammatory disease (PID). Treating their sexual contacts, although recommended, was not feasible. We have seen a few middle ear infections, and a few infected wounds, both more prevalent in children. In one of the villages, a couple of children had hydrocele (fluid accumulation within the scrotum), which, if persist and enlarge, may need a surgical treatment.

For the patients that need follow-up (e.g. hypertension, suspected TB), you should take their picture (date it), write their name, the name of their bateye, and their house number. You can give the collected data to Dr. Grau, so that somebody can revisit the same patient later on.

Improved personal hygiene plays an important part in the prevention and control of scabies and depends on access to adequate water-supply. As you will see, applying these otherwise simple measures can be extremely challenging in bateyes. More likely you will focus on the treatment of patients with acaricide (preferably permethrin) ointments or shampoo. While handing a soap bar to such patients, advise them to take bath before application of the medication. Infested clothing should be washed in hot soapy water. Bedding, mattresses, sheets and clothes may require dusting.

Patients should massage permethrin cream thoroughly into their skin from the head to the soles of the feet. The hairline, neck, temple, and forehead may be infested in infants and geriatric patients. Usually 30 grams is sufficient for an average adult. The cream should be removed by washing (shower or bath) after 8 to 14 hours. Infants should be treated on the scalp, temple and forehead. Cotton mitts or socks on the hands of infants and young children at bedtime will prevent them from rubbing the cream into their eyes. One application will generally suffice. Permethrin 5% cream was shown to be safe and effective when applied to an infant <1 month of age with neonatal scabies; time of application was limited to 6 hours before rinsing with soap and water (UpToDate online 14.1, 2006).

Deworming procedure is prepared and performed by students in the Worming Group, while other students help when needed. Since this activity usually attracts a lot of attention at bateyes, we suggest that it be used for co-administration of Vitamin A to the same children, as recommended by the World Health Organization (WHO). This has not been the practice on our January 2006 trip. Vitamin A-replete children have an enhanced chance of survival and less severe childhood illnesses. The most commonly known effect of vitamin A deficiency is blindness. It is also essential for the functioning of the immune system. Even before blindness occurs, vitamin A deficient children are at increased risk of dying from infectious diseases such as measles and diarrhea. As a result, vitamin A supplementation of vitamin A-deficient populations can reduce child mortality by as much as 23–34%. If you would like to work on this project, please refer to the 2004 World Health Organization/UNICEF brochure How to add deworming to vitamin A distribution at http://whqlibdoc.who.int/hq/2004/WHO_CDS_CPE_PVC_2004.11.pdf.

Because medical attention is not abundant, your patients will have multiple complaints hoping that you can satisfy all their needs in one short visit.  Unfortunately, you must be firm and treat only one ailment.  Question your patient and ask “What one thing bothers you most?” This is done for a few reasons:

1. Multiple complaints may require multiple medications.  Compliance with several concurrent medications is not certain.
2. There will be many patients waiting to see you.  Treating the most severe condition will afford you time to see more people.
3. Unfortunately, there may not be enough medication to go around.

Following is a list of conditions we encountered during our visits to the bateyes.  This list is NOT exclusive and should NOT be used as a sole medical reference.  Its purpose is to offer the healthcare professionals on the trip a short field guide based on previous experience.  It is our hope that future participants will be better prepared to address the needs of the people of the bateyes.

CANDIDIASIS

Candida albicans is the most common Candida species, causing symptomatic candidiasis.  It is found in approximately 90% of cases and frequently inhabits the mouth, throat, large intestine, and vagina normally. Clinical infection may be associated with a systemic disorder (diabetes mellitus, human immunodeficiency virus (HIV), obesity), pregnancy, medication (antibiotics, corticosteroids, oral contraceptives), and chronic debilitation.  Diagnosis is based on the clinical features of the disease as well as the demonstration of candidal mycelia and a normal vaginal

Clinical Findings

• Intense vulvar pruritus
• a white curdlike, cheesy vaginal discharge
• burning sensation may follow urination
• vulvar erythema
• erythematous labia minora
• Clinical manifestations may worsen just prior to menses

Nonabsorbent undergarments should be avoided as well as douching. Multiple topical medications are available in different forms and lengths of treatment. Inclusion of a topical steroid (Mycolog, Lotrisone) may also be beneficial if the patient remains symptomatic to help decrease inflammation and relieve itching externally. Lotrisone contains a potent corticosteroid, so it should not be used extensively in pregnant women in large amounts or for a prolonged period. A single 150-mg oral dose of fluconazole has also been shown to be effective in treating symptomatic candidiasis in nonpregnant patients.

During pregnancy

• treatment should be avoided until the second trimester
• Nystatin 100,000 units, 1 tablet vaginally at night for 2 weeks, may be given during the first trimester.

TRICHOMONAS

Trichomonas vaginalis is a unicellular flagellate protozoan that infects the lower urinary tract in both women and men. It is a sexually transmitted disease; other forms of transmission are infrequent because large numbers of organisms are required to produce symptoms.

Clinical Findings

• generally worse just after menstruation or during pregnancy
• persistent vaginal discharge
  • profuse, extremely frothy, greenish, and at times foul-smelling
• vulvar pruritus
• vaginal erythema
• multiple small petechiae
• strawberry spots
• labia minora may become edematous and tender

Therefore, partners should be treated simultaneously, with intercourse avoided or a condom used until treatment is completed. In resistant cases, which most likely are related to reinfection, oral metronidazole may be repeated after 4 to 6 weeks if the presence of trichomonads has been confirmed and the white blood cell count and differential are normal.

Trichomoniasis is associated with many perinatal complications and an increased incidence in the transmission of HIV. Women with trichomoniasis should be evaluated for other sexually transmitted diseases, including N gonorrhoeae, C trachomatis, syphilis, and HIV.

OSTEOARTHRITIS

Essentials of Diagnosis

• Commonly secondary to other articular disease.
• A degenerative disorder without systemic manifestations.
• Pain relieved by rest; morning stiffness brief; articular inflammation minimal.
• X-ray findings: narrowed joint space, osteophytes, increased density of subchondral bone, bony cysts.

General Considerations

Osteoarthritis is the most common form of joint disease, sparing no age, race, or geographic area. Ninety percent of all people will have radiographic features of osteoarthritis in weight-bearing joints by age 40. Symptomatic disease also increases with age.

Clinical Findings

• onset is insidious
• articular stiffness
• pain on motion of the affected joint
  • worse by activity or weight bearing and relieved by rest
• Deformity may be absent or minimal
• bony enlargement of the interphalangeal joints is occasionally prominent
• Crepitus
• Joint effusion and other articular signs of inflammation are mild
• limitation of motion of the affected joint or joints is common

Differential Diagnosis

Because articular inflammation is minimal and systemic manifestations are absent, degenerative joint disease should seldom be confused with other arthritides. The distribution of joint involvement in the hands also helps distinguish osteoarthritis from rheumatoid arthritis. Osteoarthritis chiefly affects the DIP and PIP joints and spares the wrist and MCP joints (except at the thumb); rheumatoid arthritis involves the wrists and MCP joints and spares the DIP joints. Furthermore, the joint enlargement is bony-hard and cool in osteoarthritis but spongy and warm in rheumatoid arthritis. Skeletal symptoms due to degenerative changes in joints—especially in the spine—may cause coexistent metastatic neoplasia, osteoporosis, multiple myeloma, or other bone disease to be overlooked.

Prevention

Weight reduction reduces the risk of developing symptomatic knee osteoarthritis. Maintaining normal vitamin D levels may reduce the occurrence and progression of osteoarthritis, in addition to being important for bone health.

RHEUMATOID ARTHRITIS

Essentials of Diagnosis

• Prodromal systemic symptoms of malaise, fever, weight loss, and morning stiffness.
• Onset usually insidious and in small joints; progression is centripetal and symmetric; deformities common.
• Radiographic findings: juxta-articular osteoporosis, joint erosions, and narrowing of the joint spaces.
• Rheumatoid factor usually present.
• Extra-articular manifestations: subcutaneous nodules, pleural effusion, pericarditis, lymphadenopathy, splenomegaly with leukopenia, and vasculitis.

General Considerations

Rheumatoid arthritis is a chronic systemic inflammatory disease of unknown cause, chiefly affecting synovial membranes of multiple joints. The disease has a wide clinical spectrum with considerable variability in joint and extra-articular manifestations. The prevalence in the general population is 1–2%; female patients outnumber males almost 3:1. The usual age at onset is 20–40 years, although rheumatoid arthritis may begin at any age.   Early, aggressive treatment is now the standard of care.

Clinical Findings

• articular signs of inflammation is usually insidious
• prodromal symptoms of malaise, weight loss, and vague periarticular pain or stiffness
• Symmetric joint swelling with stiffness, warmth, tenderness, and pain
• Stiffness persisting for more than 30 minutes (and usually many hours) is prominent in the morning, subsiding later in the day
  • duration of morning stiffness is a useful indicator of disease activity
• any joint may be affected, the PIP and MCP joints of the fingers as well as the wrists, knees, ankles, and toes are most often involved
• Synovial cysts and rupture of tendons may occur
• Entrapment syndromes
  • particularly of the median nerve at the carpal tunnel of the wrist
• Palmar erythema is noted occasionally, as are tiny hemorrhagic infarcts in the nail folds or finger pulps
• Twenty percent of patients have subcutaneous nodules, most commonly situated over bony prominences but also observed in the bursas and tendon sheaths
• Dryness of the eyes, mouth, and other mucous membranes is found especially in advanced disease
• episcleritis and scleromalacia, the latter due to scleral nodules (Refer to photo below)

                   

After months or years, deformities may occur; the most common are ulnar deviation of the fingers, boutonnière deformity (hyperextension of the DIP joint with flexion of the PIP joint), “swan-neck” deformity (flexion of the DIP joint with extension of the PIP joint), and valgus deformity of the knee. Atrophy of skin or muscle is common, caused by the combined effects of disease and treatment (particularly prednisone

Osteoarthritis, for example, spares the wrist and the MCP joints, in contrast to rheumatoid arthritis. Degenerative joint disease (osteoarthritis) is not associated with constitutional manifestations and the joint pain is characteristically relieved by rest, unlike the morning stiffness of rheumatoid arthritis. Signs of articular inflammation, prominent in rheumatoid arthritis, are usually minimal in degenerative joint disease. Although gouty arthritis is almost always intermittent and monarticular in the early years, it may evolve with time into a chronic polyarticular process that mimics rheumatoid arthritis. Gouty tophi resemble rheumatoid nodules both in typical location and appearance. The early history of intermittent monarthritis and the presence of synovial urate crystals are distinctive features of gout. Septic arthritis can be distinguished by chills and fever, demonstration of the causative organism in joint fluid, and the frequent presence of a primary focus elsewhere, e.g., gonococcal arthritis. Septic arthritis can complicate rheumatoid arthritis and should be considered whenever a patient with rheumatoid arthritis has one joint inflamed out of proportion to the rest.

Treatment

Basic Program (Nonpharmacologic Management)

The primary objectives in treating rheumatoid arthritis are reduction of inflammation and pain, preservation of function, and prevention of deformity. Patient satisfaction and the success of therapy depend on how effectively the clinician utilizes the nonpharmacologic measures outlined in the following paragraphs.

Rest

The amount of systemic rest required depends on the presence and severity of inflammation. With mild inflammation, 2 hours of rest each day may suffice. In general, rest should be continued until significant improvement is sustained for at least 2 weeks; thereafter, the program may be liberalized. However, the increase of physical activity must proceed gradually and with appropriate support for any involved weight-bearing joints.

Exercise

Exercises are designed to preserve joint motion, muscular strength, and endurance. Initially, for inflammatory disease, passive range of motion and isometric exercises (such as straight leg raising) are best tolerated. As tolerance for exercise increases and the activity of the disease subsides, progressive resistance exercises may be introduced. Patients should follow the general rule of eliminating any exercise that produces increased pain 1 hour after the exercise has ended.

Heat and cold

These are used primarily for their muscle-relaxing and analgesic effects. Radiant or moist heat is generally most satisfactory. Exercise may be better performed after exposure to heat. Some patients derive more relief of joint pain from local application of cold.

Nonsteroidal Anti-inflammatory Drugs

The first drug used to treat rheumatoid arthritis is an NSAID. These agents have analgesic and anti-inflammatory effects but do not prevent erosions or alter disease progression. A number of NSAIDs are available, including aspirin, ibuprofen, naproxen, sulindac, diclofenac, nabumetone, etodolac, ketoprofen, celecoxib, and others.

Additional Drugs

Disease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis of rheumatoid disease is certain.

GASTRITIS

Essentials of Diagnosis

• Most commonly seen in alcoholics, critically ill patients, or patients taking NSAIDs.
• Often asymptomatic; may cause epigastric pain, nausea, and vomiting.
• May cause hematemesis; usually not significant bleeding.

General Considerations

The most common causes of erosive gastropathy are drugs (especially NSAIDs), alcohol, stress due to severe medical or surgical illness, and portal hypertension (“portal gastropathy”). Uncommon causes include caustic ingestion and radiation. Erosive and hemorrhagic gastropathy typically are diagnosed at endoscopy, often being performed because of dyspepsia or upper gastrointestinal bleeding. Endoscopic findings include subepithelial hemorrhages, petechiae, and erosions. These lesions are superficial, vary in size and number, and may be focal or diffuse. There usually is no significant inflammation on histologic examination.

Clinical Findings

• Erosive gastropathy may be asymptomatic
• Anorexia
• Epigastric pain
• Nausea
• Vomiting
• Upper gastrointestinal bleeding

Differential Diagnosis

• Peptic ulcer
• Gastoresophageal reflux
• Gastric cancer
• Biliary tract disease
• Food poisoning
• Viral gastroenteritis
• Fuctional dyspepsia
• Pancreatic disease
• Esophageal rupture
• Ruptured aortic aneurysm
• Gastic volvulus
• Myocardial colic

Prophylaxis & Treatment

• H₂-receptor antagonists
• Sucralfate suspensioin (1g orally every 4-6 hours)
• Cimetidine (900-1200mg)
• Ranitidine (150mg)
• Famotidine (20mg)

HEARTBURN

Essentials of Diagnosis

• Heartburn; may be exacerbated by meals, bending, or recumbency.
• Typical uncomplicated cases do not require diagnostic studies.
• Endoscopy demonstrates abnormalities in < 50% of patients.
• Barium esophagography seldom helpful.

General Considerations

Gastroesophageal reflux disease affects 20% of adults, who report at least weekly episodes of heartburn, and up to 10% complain of daily symptoms. Although most patients have mild disease, esophageal mucosal damage (reflux esophagitis) develops in up to 50% and more serious complications develop in a few others. Several factors may contribute to gastroesophageal reflux disease.

Clinical Findings

• Heartburn 30–60 minutes after meals and upon reclining
• Dysphagia
• “Atypical” manifestations
  • asthma
  • chronic cough
  • chronic laryngitis
  • sore throat
  • noncardiac chest pain

Treatment

• lifestyle modifications
• Antacids
• avoid lying down within 3 hours after meals
• Elevating the head of the bed on 6-inch blocks or a foam wedge to reduce reflux and enhance esophageal clearance is recommended, especially for patients with nocturnal and atypical symptoms
• avoid acidic foods
  • tomato products
  • citrus fruits
  • spicy foods
  • coffee
• avoid agents that relax the lower esophageal sphincter or delay gastric emptying
  • fatty foods,
  • peppermint,
  • chocolate,
  • alcohol
  • smoking
• Weight loss
• reduction of meal size
• H₂-receptor antagonists
  • cimetidine 200 mg
  • ranitidine 75 mg
  • nizatidine 75 mg
  • famotidine 10 mg
• proton pump inhibitor (for persistent symptoms)
  • omeprazole 20 mg
  • rabeprazole 20 mg
  • lansoprazole 30 mg,
  • esomeprazole 40 mg
  • pantoprazole 40 mg

The maintenance doses of proton pump inhibitors may escalate over time, with over 20% of patients eventually requiring double or triple doses of proton pump inhibitors to control symptoms.

EAR INFECTIONS

General Considerations

Acute otitis media is a bacterial infection of the mucosally lined air-containing spaces of the temporal bone. Purulent material forms not only within the middle ear cleft but also within the mastoid air cells and petrous apex when they are pneumatized. Acute otitis media is usually precipitated by a viral upper respiratory tract infection that causes auditory tube edema. This results in accumulation of fluid and mucus, which becomes secondarily infected by bacteria.

Clinical Findings

• Occur at any age, but most common in infants and children
• Otalgia
• Aural pressure
• Decreased hearing
• Fever
• Erythema
• Decreased mobility of tympanic membrane

IMPETIGO

Essentials of Diagnosis

• Superficial blisters filled with purulent material that rupture easily.
• Crusted superficial erosions.
• Positive Gram stain and bacterial culture.

General Considerations

Impetigo is a contagious and autoinoculable infection of the skin caused by staphylococci or streptococci (or both).

                   

Clinical Findings

Itching is the only symptom

• lesions consist of macules, vesicles, bullae, pustules, and honey-colored gummy crusts that when removed leave denuded red areas
• face and other exposed parts are most often involved

SCABIES

Essentials of Diagnosis

• Generalized very severe itching.
• Pruritic vesicles and pustules in “runs” or “galleries,” especially on finger webs and the heels of the palms and in wrist creases.
• Mites, ova, and brown dots of feces visible microscopically.
• Red papules or nodules on the scrotum and on the penile glans and shaft are pathognomonic.

General Considerations

Scabies is caused by infestation with Sarcoptes scabiei. The infestation usually spares the head and neck (though even these areas may be involved in infants, in the elderly, and in patients with AIDS).  Scabies is usually acquired by sleeping with or in the bedding of an infested individual or by other close contact. The entire household may be affected.

Clinical Findings

Symptoms and Signs

• Itching
• less generalized excoriations with small pruritic vesicles, pustules, and “runs” or “burrows” in the web spaces and on the heels of the palms, wrists, elbows, and around the axillae
  • burrow appears as a short irregular mark, 2–3 mm long and the width of a hair
• Pruritic papules may be seen over the buttocks.
• Characteristic lesions may occur on the nipples in females and as pruritic papules on the scrotum or penis in males

 

Treatment & Prognosis

Treatment is aimed at killing scabies mites and controlling the dermatitis, which can persist for months after effective eradication of the mites. Bedding and clothing should be laundered or cleaned or set aside for 14 days in plastic bags. Unless treatment is aimed at all infected persons in a family or institutionalized group, reinfestations will probably occur.

TINEA CAPITIS

Tinea capitis, predominantly a disease of preadolescent children, is a dermatophytic trichomycosis of the scalp. Clinical presentations vary widely, ranging from mild scaling and broken-off hairs to severe, painful  inflammation with painful, boggy nodules that drain pus and result in scarring alopecia-

             

Appendix A

 

Links:

• Barnard College’s Haitian/Dominican Students Association
• Catholic Medical Mission Board
• Church World Service
• Club Rotario Arroyo Hondo Santo Domingo
• Country Club Christian Church
• Direct Relief International
• Dominican’s Ministry of Health (SESPAS)
• Dr. Paul Farmer’s Partners in Health
• Food for the Poor, Disciples of Christ’s Week of Compassion
• HIV testing project (USAID’s Proyecto CONECTA through Family Health International)
• Interchurch Medical Assistance
• Lions Clubs International Foundation
• Margarette Sanger International
• New Jersey Lions Eyeglass Recycling Center
• Plan International
• Planned Parenthood International’s
• SMART Work-Haiti
• The Association of Haitian Physician Abroad (AMHE)
• The Batey Relief Alliance
• The Clinton Foundation HIV/AIDS Initiative
• The Dominican Republic’s National Tuberculosis Control Program
• The Dominican’s State Sugar Council (CEA)
• The Washington-based Group of Dominican Professionals
• Union Hill Presbyterian Church
• VOSH
• Wallkill Valley Rotary Club

ONLINE RFERENCES

1. Habif: Clinical Dermatology, 4th ed., 2004

1. Kasper: Harrison’s Principles of Internal Medicine, 16th ed.

1. Merck Manual of Diagnosis and Therapy, 17th ed., 1999