COMFORT ON A DEADLINE

The Baltimore Sun

PORT-AU-PRINCE, Haiti -- Christelle-Melenchy Fortius' first chance at a reasonably normal life ended badly, with the surgery on her mouth aborted before it began and a Haitian doctor apologizing that the anesthesia didn't work. Her father, Dieumaitre Fortius, said he tried to earn money to pay for another doctor but never got far, and some days he couldn't even afford food.

Last month, Christelle's second chance came unexpectedly, from the United States. The USNS Comfort, a Navy hospital ship, appeared one morning in Port-au-Prince harbor, and three days later 4-year-old Christelle was asleep on an operating table inside, with an oral surgeon and a plastic surgeon taking turns making the tiny cuts and stitches to repair her double cleft lip.

"That ship was like a benediction for me," Fortius said. "There was no hope for my daughter without the Americans. No hope."

But Christelle still needs another miracle.

The Comfort's tightly choreographed 12-nation tour of Latin America didn't allow time to fix Christelle's cleft palate, which prevents her from talking and eating normally. And after surgery on her lip, the ship dropped Christelle off in Port-au-Prince without any provision for follow-up care - neither a check to monitor for infection nor the type of long-term dental work and therapy generally provided by international aid groups such as Interplast or Operation Smile.

Now Fortius is looking to doctors in Cuba to provide the next level of Christelle's care.

Her U.S. Navy doctors said they did the most they could, given the Comfort's limited time in Haiti.

"It's always a concern on humanitarian missions, that you might not get any follow-up," said Cmdr. Craig Salt, the Navy plastic surgeon who fixed Christelle's lip. He weighed the profound effect of surgery against the relatively low risk of complications and decided to do what he could, Salt said. "We had the chance to really change her life, or to do nothing," he said.

But some surgeons in the United States are questioning the depth of the Comfort's commitment to providing humanitarian medical assistance.

"The Americans come in there with all that technology and then they just sail away? Who's taking care of the kid?" asked Dr. John B. Mulliken, a cleft lip and palate specialist at Children's Hospital in Boston.

"I don't want to bash the Navy, but I don't think anyone would say that no follow-up on a 4-year-old surgical patient with a residual cleft palate is responsible care," said Dr. Evan S. Garfein, a New York University plastic surgeon and veteran of several humanitarian missions to Haiti.

'Medical diplomacy'

Christelle's is the story of the United States' "medical diplomacy" in Latin America - the Bush administration initiative to gain public support in the region by deploying American medicine as a tool of good will. From June to October, the Comfort and its crew of 700 military and civilian workers dispensed medical care to 98,000 patients in the region, improving lives even as it left thousands of would-be patients asking for more.

When the Navy's floating hospital anchored off Christelle's hometown, then employed its skills and resources to treat her, it revealed how easily and willingly the United States can brighten the future of the poor communities within a short sail of the nation's coast.

Then, when the ship sailed away the next day and left Christelle to recover in the grubby corners of Port-au-Prince without follow-up care, it exposed the shortcomings of a campaign designed more for symbolism than substance.

And with her parents looking to Cuba for more help, the tiny girl with the colored beads in her hair and the new smile is an unwitting metaphor for the diplomatic grandstanding that some believe the ship's campaign reveals. The Americans proved they have the resources to change lives in Latin America, but Cuban doctors working in Haiti are better positioned to help Haitians get the treatment they need long term.

"Having your cleft lip repaired and not your cleft palate is not a solution to your problems," said Dr. Gilbert M. Burnham, a professor at the Johns Hopkins Bloomberg School of Public Health who specializes in humanitarian medicine.

"You can make a huge impact in a place like Haiti by providing a service that the local health system is incapable of providing," he said. "But you also need a clear goal and good coordination with local doctors, to make the most of your time and resources."

Christelle was born with a double cleft lip, which means she was born with scarcely any upper lip. The skin between her mouth and nose looked as though it had been sucked up into each nostril, leaving a flap of skin and gum the size of a penny protruding just above her front teeth.

It was a most noticeable deformity, but not the only one. She also had a double cleft palate - two cracks along the roof of her mouth. That she survived her first months was an achievement, as her lips and mouth were too deformed to nurse normally. But she managed. Much of what she eats still sloshes into her nose.

Clefts occur in children throughout the world, roughly once in 800 births, but in the United States they are almost always corrected by surgery before a child is a year old. In Haiti, where the state hospital system is scarcely functioning and 85 percent of the state medical school's graduates leave the country, the condition often goes uncorrected.

Even at 4 years old, Christelle had grown self-conscious about her looks, her father said, particularly when the other children laughed. But her deformities were not purely cosmetic. Because her cleft palate prevented her tongue from properly forming sounds, she spoke in a garbled Creole that only her family could understand.

A Cuban doctor in Port-au-Prince, one of several hundred sent by the Castro government to live and practice medicine in Haiti, promised to arrange a surgeon for Christelle if she could travel to Cuba, but her family couldn't raise the money. Fortius, who has worked as a security guard, is unemployed, and Christelle's mother, an artist, earns little. They used to take Christelle to a free doctor at a Catholic school for handicapped children, but the doctor left Haiti more than two years ago, and the family has not had medical care since.

When the radio announced the arrival of the American doctors in early September, the Cuban physician urged Fortius to meet them. The next morning, Fortius arrived at the dusty hospital in the suburban neighborhood of Delmas, the site of one of two clinics the Americans had established in Port-au-Prince. Hundreds of Haitians had the same idea, however, and at 8:30 a.m., Fortius and Christelle joined the long line of people peering through the hospital's outer fence.

They had anticipated the crowd, and had two strategies for defeating it. The first was a blue cap, purchased from one of Port-au-Prince's ubiquitous used-clothing vendors and emblazoned with the name USS Barry, a Navy ship. He hoped it would catch someone's eye. The other was Kelly Jacques, a 37-year-old friend trying to form a children's assistance group through his church, who had taught himself to speak passable English.

For 3 1/2 hours they waited, sheltering Christelle from the sun and the shoving of the crowd. Whenever someone asked, Jacques claimed to be a family member, worried that the Americans would disregard him otherwise and make him leave. The plan was a success. When a Navy petty officer inside the compound spotted the three of them and saw the girl's obvious deformities, he invited them into the hospital's open-air waiting room to meet with the doctors. Once inside, Jacques put on the blue cap and went back to apologize to anyone deceived about his identity.

"Please know, I'm trying only to help the little girl," he said.

Even if Christelle's encounter with the U.S. Navy had ended there, as she sat on a plastic chair drinking cold water and eating cheese ravioli from a sailor's MRE, it would have been a day of improved fortunes for her and her father.

Difficult passage

But she would encounter many more strange people and foreign possibilities over the ensuing two days, along with an incalculable amount of money and good will expended to help her, and they would change her life - or at least begin to.

After a screening for tuberculosis - itself an unattainable luxury for most Haitians - Fortius and Christelle climbed into an SUV and headed for the waterfront, where the Navy crew searched the two and helped them squeeze into orange life jackets. The civilians who operate the Comfort's boats helped them board a launch for the 20-minute ride to the ship. The chop had picked up in Port-au-Prince harbor by midafternoon, and Christelle's seat on the starboard side took the brunt of the spray. She arrived alongside the Comfort soaked in salt water and deliriously happy.

With her surgery still a day away, Christelle and her father waited on the white-sheeted beds in the ship's recovery ward. Someone gave Christelle a Barbie, and she bounced from bed to bed for hours, entertaining the nurses.

When Salt, a San Diego plastic surgeon, walked in about 8:30 p.m. wearing a white coat and scrubs, Fortius shot upright. Having just finished a marathon day of surgeries two decks up, Salt was preparing for the next morning by making the rounds among his patients. He examined Christelle's mouth and explained the procedure to Fortius through an interpreter.

Christelle's lip surgery required a complex sequence of Z-shaped incisions and skin flaps that would be fashioned into a presentable shape, Salt explained again later. He would have liked to have fixed the girl's palate, too - a more complicated procedure - but the ship's schedule didn't give them time. And because a 4-year- old with a cleft palate is unlikely to ever speak properly, even after it is repaired, he decided that repairing the lip made the most sense.

Follow-up care was an issue, but by using absorbable sutures and painting her incisions with a protective glue-like substance he could minimize the risks, even if she never saw another doctor, he said.

"How are you going to make the most impact on the child's life?" Salt asked. "Are you going to prevent stuff from coming through her nose or are you going to make her look right?

"We'll make her look better, which will be a big improvement for her," Salt said. "We can't give her everything she needs, though. Back in the United States, she'd probably need $100,000 worth of medical care."

While too complicated for an undeveloped health care system such as Haiti's, the surgery and related follow-up care to correct cleft lips and palates are fairly routine in the United States. An American child typically has a cleft lip repaired before he is 6 months old and a cleft palate fixed before he is a year old, and then might receive years of related dental care and speech therapy.

Cleft surgeries have become popular among humanitarian groups and health care missions in developing countries, partly because they offer quick improvement of a patient's quality of life, but also because they are generally free of complications, even in austere settings, said Dr. Richard J. Redett, director of the Johns Hopkins Cleft & Craniofacial Center.

Still, many humanitarian surgical missions have learned from experience that the most effective way to perform such operations is to send an advance team or link up with local doctors who can screen patients and schedule procedures weeks in advance, Redett said. And most won't perform such procedures unless they can be assured that patients will receive a follow-up consultation a week or so later.

The Comfort coordinated follow-up care with local hospitals in some countries it visited this summer, particularly in more developed nations such as Trinidad and Tobago and Panama, but less so in nations with little health infrastructure. In Haiti, where recovery is complicated by questionable sanitation, the scarcity of clean water and a dysfunctional hospital system, patients were left largely to care for themselves.

"A better model is to go overseas and work with local physicians who can help screen patients before you arrive, and who, most importantly, can provide the additional care the patients might need," Redett said. "And if that's not available, you need to establish it. Anytime you operate on someone, you're responsible for their follow-up care."

Mulliken, of Children's Hospital in Boston, treats patients from around the country and said he typically won't let them leave Boston for 10 days so he can keep track of their recovery.

"If you're going to see an infection, it's going to be in three or four days," Mulliken said. "If the wound is going to break down, it will be in four to five days.

"There are a lot of models for doing this type of thing, but this is the worst of the worst," he said of the Comfort's in-and-out mission.

The awakening

The Americans were the first doctors Christelle had seen in roughly two years.

When the reality of what was to happen finally made sense through Christelle's 4-year-old eyes, her disposition turned sour, and by the time the doctors started the anesthetic, she had cried herself to sleep.

From 1:30 p.m., when Salt began sketching marks on her face to map out his incisions, until 4:20 p.m., when the final stitch went into her lip, there were never fewer than six medical professionals in the operating room with Christelle, and sometimes as many as 11. Wounded soldiers in Iraq rarely command as much attention.

She awoke, whiny and tired, in the Comfort's recovery room soon after surgery. A nurse retrieved Fortius from the waiting area, and he walked cautiously around the corner to where his daughter was dozing, smiling slightly as he inched closer to her.

He stroked Christelle's hair as she nodded in and out of sleep, and an interpreter was called to answer any questions.

"Is the surgery only on the outside?" Fortius asked. "Or is it also on the inside?"

"It's only on the outside - the lip," the nurse replied. "We didn't fix the palate. Not the roof of her mouth, just her lip."

Salt had been through it all with Fortius the night before, explaining the difference between a cleft lip and a cleft palate and why he could fix only the former. Christelle's father seemed to understand at the time, and he had signed a consent form, but it was in English, and no one but Fortius could be certain what the interpreter had explained.

Fortius cradled Christelle in his lap and stared at her stitches.

"Is that the way her lip is going to look?" he asked.

"It's swollen now," the nurse replied. "Don't worry, she looks great."

He sat back and told about the party he was going to throw - the party she would want to have, because now the kids wouldn't make fun of her.

Fortius and Christelle left the Comfort the next day, with a three-week supply of antibiotics and pain medication.

Hopes and cares

Reached at his home in Port-au-Prince a month after the Sept. 6 surgery, Fortius said that Christelle's incision was healing well, with no sign of infection, and that it looked more normal as time passed. Christelle, he said, is happy with her appearance. She had not been seen by a doctor since the surgery, he said.

The Cuban doctor has promised to arrange the repair of Christelle's cleft palate if the family can get her to Cuba, and Jacques said he is hoping to use his new assistance group to raise the money. Fortius said he had lost hope for Christelle until the American ship sailed into Port-au-Prince, but now he thinks anything is possible.

Still, doctors interviewed in the United States said they hope the Comfort's mission doesn't become America's model for humanitarian medicine.

"I'm sure she did fine, and I'm sure the net benefit is positive, but just because they got away with it doesn't mean it's right," said Garfein, the NYU plastic surgeon. "It's the U.S. Navy. It could have just said, 'We're going to set up a temporary follow-up clinic in all of these ports.'

"As a profession, as a country, as a Navy, I hope we can all agree that the standard for a 4-year-old girl should not be 'fix and forget.'"

robert.little@baltsun.com

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