Another lazy Sunday...

Sundays are particularly slow. I basically bide my time between meals and the eventually discontinuation of power, which is usually a good excuse to call it a night.

In my boredom I finally decided to take (a very blurry) picture of Bob, the salamander/reptilian creature who I have shared my shower with the past month or so. At first I was convinced Bob was dead: he was always in the same corner and never really demonstrated any activity. But then, one evening, I saw him in the opposite corner… so, then I thought, “He is either alive or water flow pushed his carcass across the way.” Pretty soon, I stopped thinking about it and just accepted the fact that he was a permanent part of the bathroom (either he was alive, in which case I would leave him alone, or he was dead and I wasn’t touching him). Then a few days ago, I saw him scurry from one end of the stall to the other… so he is in fact, living, which is good, I guess. I was a little dismayed, however, to learn that his entry and exit route is the drain I must stand over to actually take a shower. I reeeeally do not want to know what else uses this drain as a main thoroughfare into and out of the guesthouse.

Is it sad that I am reduced to writing about salamanders? I am now on my seventh book and am almost out of movies/House episodes. As for the work I should be doing… well yeah, that’s still around…

Premye Leson: Fill in the Blank - Don’t ____ where you eat.

So we didn’t exactly phrase it quite like that, though this concept was definitely part of the overall lesson plan…

But let me start at the beginning:

Rachel and her father (who was here visiting these past two weeks) went to service at a local Mennonite church last Sunday; the were later invited (as was I, by proxy) to a delicious lunch that was particularly good, as it was not Haitian fare (I'm sorry, but it has now been nearly a month and a half of some form of rice and beans daily). Currently, there are 5 missionaries living in this Mennonite compound: a married couple who have been living/working there since 1985, as well as three young women (somewhere between the ages of 20-26, from what I could gather) who have each been living in Leogane anywhere from 1-3 years. They run a type of boarding school for approximately 30 girls (6-11 years old), who come from extremely impoverished families living in various villages across the country. The girls reside at this school for two years, receiving an education (as well as clothing, boarding and food) their families are unable to otherwise afford. Although the women running the school admit that these two years are hardly sufficient, the girls do return to their families after this time (as it was explained to me, they try to strike a balance between educating these girls and enriching their lives, without hindering their ability to reintegrate into Haitian society). However, as part of the program each child is visited after their return home at least twice per year (to assess living situations and ensure readjustment); in addition, the program guarantees continued education within their respective villages up until 6^th grade.

While at lunch, Rachel inquired as to whether the girls are ever educated about health issues, particularly hygiene/sanitation, as this is a major concern not only in the cities, but also the rural areas most of these children call home. We were told that the girls do not have any specific sessions regarding potable water, hand washing, etc., but if we were interested in teaching one, that could most certainly be arranged. Thus, we agreed to return on Friday evening to do a quick, informal session on microbes and hygiene. (Initially, we were not entirely sure what would be appropriate, considering the age of our audience and our locale. Nutrition is certainly important, but not a good topic as many Haitians do not have the luxury of even an adequate, let alone balanced, diet. “Do not litter” also crossed our minds with regards to improving sanitation, though with the mounds of trash adorning every street, this did not seem likely to be effective).

In reality, Rachel did most of the talking (yes, I do get nervous even in front of 6 year olds… go figure), though I helped demonstrate proper hand-washing technique as part of our big finale: we had some volunteers lather up for the minimum thirty seconds, while the rest of the class counted (thank you, clinic, for teaching me how to count in Kreyol). We explained that microbes are everywhere, especially on your hands and that post-bathroom washing is key (as is covering your mouth when coughing and sneezing); though these girls knew their stuff (I think we may have been boring them just a little… as exciting as poop and hand-washing really are…), the general population often has difficulty understanding the link between the relatively common outbreaks of diarrhea (and other illness) and poor sanitation/hygiene. We also discussed the necessity of boiling water (if they can’t afford to treat or buy potable water) and the importance of bathing/constructing makeshift latrines faaaaaaaaar away from all water sources. While this information seemed most logical to all the girls, our hope is that they can pass it on to other, less educated family members and individuals in their respective communities.

Needless to say, it was a fun, if interesting way to spend a Friday evening.

Focus

Yesterday I was afforded a much-needed change of pace. Rachel, an OB/Gyn resident currently performing research in Haiti, invited me to listen-in on one of her focus groups. Over an approximate four week period, Rachel has scheduled six such groups (she has since completed five), each comprised of six to ten women. The sessions generally last one to one and a half hours, during which time the women are asked their opinions and thoughts on a number of healthcare issues, as well as issues concerning general well-being. The overall goal is to determine what these women believe their current healthcare needs to be and what they think would be the best/most useful ways to address these needs within their communities.

All in all it was a most adventurous day. We took a tap-tap to a “bus station” (not really sure what to call it, as it was a somewhat random conglomeration of stores and market stalls which seemed to be a designated stopping point for tap-taps, moto-taxis and donkeys) halfway up the mountain along the Jacmel road. Here, we secured six moto-taxis (one person on each, to maximize “safety”), which were to take us further along the unpaved, winding mountain roads to the city of Trouin. It was quite a trip! Though the views were undoubtedly breathtaking, I was considerably preoccupied with 1) clinging for dear life to the back of the moto 2) strategically repositioning myself, as I kept sliding forward, right up against the back of the driver and 3) trying to ignore the occasional bouts of nausea (I don’t usually get carsick, and yet…), seemingly induced by the blazing sun, the jolting, swerving ride and the clouds of dust.

Nonetheless, I could not resist digging for my camera to catch the rest of my party as we made our way up the mountain. I managed two pictures before fear of falling off the back of the moto made me hastily throw my camera back in my bag and return my other hand to its death grip on the moto’s rear metal bar.

moto in the mountains

Following our 45 minute ride, we arrived at the clinic. The nurse working there was most friendly and was responsible for inviting local women to participate in the focus group. She had been there for 2 years, and was originally employed by Hopital St. Croix (the former hospital in Leogane); however, once the hospital closed, she stopped receiving a salary… she kept working anyway, and continues to see patients (namely for prenatal care and child-well checks) for free.

Klinic la

As for the focus group, the nearly unanimous (but not very surprising) response: health care access is severely lacking. Previously, patients could at least get care in Leogane (which mind you is well over an hour away, requiring the extra expense of transport); with the closure of Hopital St. Croix, however, there are no good options, except the long trek to Port-au-Prince. In addition, cost remains a major obstacle, with necessary surgeries and even obstetric care exceeding the average Haitian’s means. These themes have been consistent throughout all of the focus groups, as has the women's desire to have a local hospital (which is Family Health Ministries ultimate goal for Leogane). In addition, it is clear that these women recognize the major problems within their communities; they are concerned about the same diseases/conditions (diarrhea and fevers/malaria, filariasis, prenatal care, vaccines and AIDS to name a few) and acknowledge the need for things like improved sanitation, clean water, electricity and nutrition programs. Most are passionate, well spoken and eager to have their voices heard; their responses will hopefully shape the development of the future Leogane Family Health and Research Center (http://www.familyhm.org/Leogane%20Family%20Health%20%20Research%20Center%20Nov%202008.pdf).

On a lighter note, there were a few other interesting things that colored my day:

1. A stroll along the countryside, where we were intermittently followed by gaggles of giggling school children eager to get a look at the blans roaming their mountain town.

let's play follow the blans...

2. A truck from Ridgefield, NJ

3. My trip to the latrine. Hard as I tried to balance the sweating invoked by the sun and my subsequent water intake, I couldn’t avoid needing to use the restroom at least once during the day. I have used latrines before, and as far as latrines go, this was not the worst I have seen. However, the cement block serving as a toilet was not made for the short kids, creating a slight logistical problem. As such, I was forced to maintain the hover position while simultaneously trying to prop myself up against the front of the cement block with my feet. I succeeded (it was quite a balance act, believe me), but the extra time required meant that all the mosquitoes residing in said cement hole had some additional minutes to feast on my un-bugsprayed behind. Needless to say, subsequent water restriction ensued and my next bathroom adventure was in the comfort of the guesthouse.

Random

Not much to report: things have most certainly slowed down! We officially finished screening (grand total: 1,088 women) and began follow-up (6 colposcopies yesterday, not to mention the dozens of women returning for their results).

Three quick things that I thought I would share because they make me smile:

1. I meant to mention this before (and actually had first noticed it when I was here in October). Every now and then, when in the streets of Port-au-Prince, one can catch herself humming along to a familiar tune.

What song, you ask?

My Heart Will Go On, of course

I kid you not (this makes me particularly happy, considering my attachment to the associated movie, the ever-wonderful Titanic... and yes, I also thought of you, Jen). The source? A water truck (oh, the irony).

2. Se Therese ambled over and cornered me last evening while I was using the internet, to ascertain as to whether I am now frightened to stay in the guesthouse on my own. I assured her that I was perfectly fine… still, she remained worried… but reminded me that they (the sisters) are just seconds away in the adjacent building and that the outer gate is locked… not to mention the 4 dogs that roam the property at night and the doctor who actually has the room next to mine three of the seven nights per week. Overall, I feel fairly secure.

I guess we have moved on from the food concerns. She continues to overfeed me: I have now had a brownie sundae (with homemade ice cream) twice this week. What a sin.

3. If you ever wondered where school buses go to die, look no further. They are used for public transportation in Haiti, donated from the United States. Occasionally, I can discern where they were originally used (Miami-Dade County being the only place I actually recognized), though usually the town/school is blacked out. Regardless of their former use, they are driven as recklessly/frighteningly fast as all other automobiles here, which is why it is particularly amusing when the flashing lights and stop sign still function when they pull over to let people off. Believe me, no one is stopping.

Felisitasyon

We managed to see patient nonm mil this afternoon. Today, alone, we saw a record number of women: one hundred and eight. If I do say so myself, we functioned like a well-oiled machine (not surprising, considering the amount of practice we have had by this point). We will continue seeing people tomorrow, until the last of our vials/test reagents run out (which should be after some 50-60 additional women are seen). I continue to be amazed by the turnout. Women have come from well beyond Leogane; five of our patients last week came from some remote village/town with a name I did not recognize: it took them over 24 hours to get to our clinic. It is simply amazing to think that mere word of mouth was sufficient for us to reach such distances and secure 1000 patients in a short period of time. Now, the difficulty will be the necessity of turning people away (particularly those who have traveled a long way, necessitating the expenditure of both time and money) once we run out of tests. These women are well informed and willing to address their healthcare needs, they just lack the means to do so.

Our next task: follow-up of women who have been seen at the clinic over the past one and a half years. Many of these women never came back for their results or never returned for appropriate treatments. Previous research at the clinic has demonstrated that approximately 20% of the population will test HPV positive, with nearly 5% having cervical cancer. Thus, follow-up is key, and is obviously severely lacking! My main concern over the next three weeks: getting this follow-up underway and getting it done now that Jackie has returned to the States! Instead of using her as my constant translator, I am now on my own… a scary thought indeed.

(And, of course, a more self-centered concern: the likely onset of intense boredom…)

A taste of the weekend (and some other senses, too)

I suppose the weekend officially started with our daily walk back from the clinic on Friday afternoon (after seeing ninety nine(!!!) women... I was encouraged to volunteer as patient #100, but politely declined). As we slowly ambled back, a young gentleman on his bike yelled, "Hey blan you want to come with me?” I casually replied, “No, mesi.” I have actually become quite accustomed to “hey you” and “blan… blan… BLAN!!” which are frequently voiced during our routine treks. They generally make me smile (their persistence is most admirable, as is their apparent conviction that if you continue yelling, eventually someone will respond). This particular entreaty, in English no less, was particularly winsome.

Friday night was more or less uneventful. We saw some 300 women this week alone, and needless to say, we were tired. One cold shower and one laptop viewing of Four Weddings and a Funeral (I forgot how funny it was) and Jackie and I were more than ready for bed.

On Saturday, I got to accompany the Duke group on their brief foray to the clairin “factory.” Clairin, an alcohol made from distilled sugarcane, could definitely be smelled from outside the door. And by smelled, I mean that it singed your nostrils from some 20 feet away. I had the tiniest of tastes and was immediately greeted with a flush of warmth from head to toe (not so pleasant, considering the already pervasive heat). Needless to say, it is fairly strong … and I had to smile, because unbeknown to me, I had most certainly tasted it before: in the form of a “rum” punch a few weeks back. I had thought it was a little robust.

(Bubbling clairin)

Saturday night, the group was entertained by a local music group; my favorite member: the perpetually drunk (so I have been told) banjo player (seen in the background), who is also a wonderful local artist. Afterwards, we headed out for some salsa dancing. And by we, I mean members of the group… I went, but remained perfectly content watching.

The highlight of the evening, though, was undoubtedly the rara bands. Jackie and I decided to stay the night at the guesthouse with the group, and were thus able to see one of the rara bands up close and personal from the second floor-balcony. It was a most interesting and entertaining sight. Overall, it was nice to finally have an image associated with my frequent weekend late night/early morning awakenings. Last night was no exception. While I enjoyed watching two groups go by the guesthouse, I was less enthusiastic when two more groups passed by and looped back around (mere feet from my oh-so-quiet porch bed) between 2 and 4 AM.

The Duke group was up and out the door by 6AM (they were headed back to the States), meaning I was up, too. A little bit of strong Haitian coffee (which looked like mud), together with some mamba (peanut butter), flat bread and a banana and we were off to the clinic to straighten up and organize some of the supplies. Each bag we went through released CLOUDS of mosquitoes. However, they paled in comparison to what I discovered in a box I was carelessly going through and moving about:

So I hate bugs, particularly spiders. Even very small ones. Therefore, tarantulas are only kind of okay when seen through a glass tank. Deeeeeefinitely not in the wild. Hiding in boxes that I happen to be holding.

Made it back to Cardinal Leger in time for a delicious and much needed lunch complete with a sweet potato dessert (whose name I have yet to learn, but which I absolutely love). Se Therese was grinning from ear to ear (literally), as my plate was piled high. Her comment: “I’m so happy to see you go for more [I think this was about the time I went up for the third or fourth time… not kidding… there was protein in the form of roast, not fried, chicken and I couldn’t get enough]. I worry [seriously?].”

Jackie, Kara and I then took a brief foray to the local market, which I picked up some interesting shoes for 75 gourdes (less than $2) as well as some Haitian coffee (which I manage to make in non-mud form).

Another week awaits. Contary to our previous concerns, I think we might finish screening our 1000 women this week!

Pase Bon Jounen

A typical day:

During the week I wake up at 6:30 (I’ll sleep in until 8 or so on the weekends, but it is really hard to sleep any later secondary to lots of sun and lots of noise in the form of goats, roosters, tap-taps and music). We eat breakfast with the sisters at 7 and then walk the 15 minutes down the road to the clinic. Here we pass the afternoon, after which we walk back to Hopital Cardinal Leger for dine (lunch, which they have at noon but keep warm for us until we get back from work, usually around 2 or so). Naps, the work I should be doing more regularly, and reading occupy my time until dinner with the nuns at 6 PM. Following dinner everyone helps in the clean-up process (washing/drying dishes and putting everything away); I’ll then use the internet or head out on a moto taxi to Hopital St. Croix to spend some time with Jackie’s friends there… if we don’t make it back before 10, I am forced to take my cold shower in the oh-so-luminous beam of my headlamp (balanced on the towel rack)... not an easy task, I assure you.

My current room (oh-so-neat, as per usual):

Our little kitchen area:

Outside:

The walk to the clinic…

Start:

(Including my favorite cow)
Fine:

(Figurative) Mountains Beyond Mountains

Over the past three plus weeks, my general participation in the screening program and my slow improvement with regards to my ability to make small talk in Kreyol has made me feel increasingly connected (or attached) to this patient population. The results for the first group of women we screened have actually returned, and in a recent meeting, we were formalizing the exact course of action to be taken for those women who tested HPV positive. While new evidence available in the States indicates that immediate visualization of the cervix via colposcopy is the logical next step, things are not so clear-cut here… a fact that was, at first, somewhat difficult for me to understand.

Since my arrival, I had a certain idea about the clinic and cervical cancer screening, a view on how things should be done, what was necessary, etc. I was convinced that my potential way of doing things (or the way things are done at home) would be more beneficial or effective or whatever. But things are very obviously not the same here as they are in the States, and the people who live and work in Haiti are more likely than I to know what will and will not work, knowledge that I have only begun to appreciate. Not to say that the overall process is not (very frequently) frustrating. With regards to our discussion concerning appropriate follow-up for HPV positive women, Dr. Merisier continued to insist that we perform Pap smears on every woman prior to colposcopy, even though this would be a complete waste of time, money (that many of these women do not have) and resources (Pap smears miss a lot of the lesions colposcopy can readily detect, not to mention this additional test requires women to return to the clinic an extra time, thereby increasing the possibility that they may not return again and subsequently be lost to follow-up). This decision annoyed and surprised me; I just could not see the logic, that is, until things were explained more fully. Not surprisingly, the test’s true necessity is culturally related. As Pap smears are still considered the standard of care in Haiti (despite evidence to the contrary elsewhere), not performing the test could open Dr. Merisier and the clinic to scrutiny and difficulty with the health ministry (whose jurisdiction is irregular and fair from objective).

So, basically I am slowly learning that although things often seem straightforward. they are most certainly not… and unfortunately it often occurs that there are no easy solutions. Yet another example: Leogane, though not nearly as large (or overwhelming) as Port-au-Prince, is still a fairly large city with a large population desperately in need of health care. As of now there is no functional hospital (the only affordable hospital, Hopital St. Croix, recently closed… at Hopital Cardinal Leger patients will not be admitted unless they pay upfront, regardless of the circumstance). When Dr. Merisier needs to perform a surgery, or even an emergency C-section, he has to wait for the arrival of an anesthesiologist from Port-au-Prince (at least an hour away… but taking into account “Haitian time,” it could actually be several hours… back in Novermber, Dr. Merisier was forced to perform a C-section with mere local anesthesia). There are no anesthesiologists here in Leogane, no one on overnight call, no one available for surgical emergencies.

Why not train a local nurse to at least be available afterhours for such emergencies? Great idea! Except he/she would need an anesthesiologist to train under and all the physicians have refused to participate in such training, seeing certified nurse anesthetists as competition. They (somewhat understandably) do not want to jeopardize their job security. Ok, fine. We can bring anesthesiologists from the States to train one or two nurses… but where exactly will this training take place? Hopital Cardinal Leger is where the surgeries are performed and they cannot just tell the current anesthesiologists to stop showing up for surgeries. So, though there is this dire need and although there are potential means to fill it, a countless number of obstacles make something seemingly simple near impossible. Oftentimes it seems that for every good solution, there are five or more reasons why said solution would not actually work. Sigh.

Pap test la

Clinic has definitely picked up since the middle of last week, such that we are now averaging some 50-60 women per day. Not surprisingly, mornings pass by in a blur of activity: people coming and going, translators rushing around, nurses scurrying for more supplies (namely speculums (specula?) as there never seem to be enough), previous patients returning for results, while current patients make small talk and ask questions. Factor in the top floor of the clinic, which is still under construction, and you get a background noise laden with hammering, sawing, pounding and yelling. And then, of course, there are the continual sounds of Leogane, itself… the persistent honking of tap-taps and motos, Haitian music blaring nonstop from the La Perfection hotel/nightclub just across the road, mixed with Sri Lankan tunes originating from the UN basecamp opposite the main thoroughfare (one day I even caught strains of “I Will Survive.” I got very excited). Through the windows, one can smell any number of charcoal fires burning; the exact fare fluctuates with changes in the wind. Overall, it is not the setting I normally associate with clinic, though in the past few weeks it has become the norm.

Where do I fit in the chaotic scheme of things? I was helping the physician/nurses obtain specimens (there are two HPV tests for each patient) and prepare/label them accordingly. Yes, it is as glamorous as it sounds, but in all honesty, is not as boring as one would expect, as the continuous flurry of activity does not leave all that much time to think. However, over the past two days, I have actually been performing the exams, perhaps to the dismay of the ladies—I am sure—secondary to my inexperience. But I am getting better:having done a dozen or so sample collections yesterday and over 50 (yes, I was proud) today, I am significantly more proficient (if not efficient with regards to time).

My only gripe at this point remains my complete inability to learn Kreyol. While I have some key phrases down (for example, the Pap test = Pap test la (which interestingly is not the test we are doing, but most women call any vaginal “test” a “Pap”)… I can also count to 50… useful in clinic but not really anywhere else), I cannot effectively interact with the patients or staff, which is extremely frustrating. It is somewhat annoying to never have any clue as to what is going on or being said, and it becomes all too easy just to tune it all out. Dr. Merisier says it is time I start speaking Kreyol to every patient… so, I’m working on it. Particularly in the past two days, I have increased my repertoire (to a grand total of 25 or so words) and am feeling slightly more confident, which I hope will help.

A quick note, sorry for the delay in posting as of late (to the 4-5 people who actually care =) ); it was mainly due to a combination of busy-ness (we took a trip to Port-au-Prince this past weekend and there is currently a group from Duke visiting for the week) and general laziness (the slooooooooowness of the internet is nothing short of painful).

Dollars and Sense

One of our patients last week presented with a cervical lesion that was somewhat concerning on gross appearance; we told her to return the next afternoon for colposcopy (a colposocope being an instrument that permits a magnified visualization of the cervix).

Dr. Merisier was not overly worried following this subsequent exam, and at the time, I was somewhat surprised that he chose not to actually biopsy, as the woman had already returned and it was possible to do it right then and there. After all, with a biopsy, we could more or less definitely determine if the woman had a precancerous or cancerous lesion. Dr. Merisier explained, however, that although this is often done in the States, he would prefer to wait until the woman’s HPV status was known (for if she was negative, it was unlikely her given lesion was pathological/cancerous). His main reasoning: the patient would have to pay a considerable sum for this biopsy and there was no need to place such a financial burden on this patient unless it was clear the given procedure was truly necessary. Of course, cost effectiveness is important in the US too, but here, where the majority of individuals cannot afford routine healthcare, financial conservatism is of the essence.