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Thursday, December 12, 2013

Third trip to Haiti: inspiring projects on La Gonave

I just got back from the Haitian island of La Gonave (lagonav in Creole) after 8 days there visiting people who work on projects we help to fund. I’m glad to be home, because this is where I live and I missed toast with jam, my dog, and not being sticky sweaty all the time. Still, it was a wonderful trip and full of things to get excited about.

I first visited Haiti in 2010, about 3 months after the big earthquake hit the main island and killed more than 250,000 people, primarily in Port Au Prince. I went to La Gonave, 35 miles off the coast of Haiti, on a trip that was planned before the earthquake and which had nothing to do with the acute worsening of misery associated with the widespread destruction of the main island’s marginal infrastructure. La Gonave was definitely affected by the earthquake, but nobody was killed, mainly due to the fact that there were very few large buildings and very few people inside in the late afternoon in the few places that did collapse. Poorly constructed houses did fall down or become uninhabitable, so some people were homeless or had to live in rickety structures of wood or palm leaves or in cramped quarters of their extended families or in chicken coops.

Many were anxious or grieving because of the loss of friends or family members in Port Au Prince. People came to the island from Port Au Prince to get away from the destruction, with injuries, needing food and water and medical care, but by the time we got there most had gone home and life was returning to its baseline.

Baseline for La Gonave is very rural. It is about 8 by 25 miles and is home to about 200,000 people, most of whom live in the main town of Anse a Galet. There is very little tourism, and almost all of the non-Haitian faces belong to aid workers of some sort or another, and there are very few of those.

We visited a community in the mountains above Anse a Galet, 6 miles away, though it takes 1.5 hours by truck due to terrible roads. In the mountains there is no running water, no electricity and very little cash economy. The island was once a tropical paradise, I hear, but the French and then the Haitians deforested it and when it was brown and ugly, sent undesirable people there to suffer. There is very little in the way of government programs. Apparently it is possible to get a policeman to come eventually if something happens, but I have never seen a policeman. There is a hospital in the main town which is charitably funded by Episcopals, I think, and is slimly staffed. It is beyond the financial means of most of the people who live there, and so they get very little medical care. Foreign aid groups such as World Vision provide for some services like vaccination, but a minority of people are able to access care.

Human beings are amazing, though. Put them on a brown hot deforested island and they make communities, build schools, grow gardens, organize for the rights of women and children, and make music. The people who live on La Gonave descended almost entirely from African slaves. Their common language became Haitian Creole, which combines a kind of phonetic French with words from English and other languages.

After France recognized Haiti’s independence, the country was saddled by crippling debt to both the U.S. and France, hindering its ability to become economically viable. Haiti has also had terrible and cruel leadership for decades, and political unrest and official corruption has resulted in very poor infrastructure, despite huge amounts of aid which pours in on the heels of the various disasters (hurricanes, droughts, earthquakes) which befall them. La Gonave gets only a very tiny amount of that aid, though in the 2 years since I was last there, a UK based charity, Concern Worldwide, has built over 100 deep water pumps which have drastically improved everyday life for people who spent hours a day fetching a few gallons of water from the few springs scattered around the island.

Church organizations give some money to support churches and schools that have a religious mission. The most energetic of young people make their way to Port Au Prince for education and then to the U.S., wiring money home to families, which bolsters the tiny, cash-based economy of the island. There are essentially no exports, except sometimes fruit or fish, which go to Port Au Prince. It is a subsistence culture, but it is also green and beautiful, and safe and welcoming to someone like me.

My thoughts in visiting La Gonave have evolved significantly since I first visited. I initially supposed that I should just bring as much medicine and medical testing equipment as was practical because I was sure to see lots of people dying because of lack of medical care. It turns out that there was some ill health, but more just discomforts of being human and working really hard, and there was very little I could treat. The sickly die in childhood, those who are left are pretty tough.

Older folks couldn’t really get to where I was, and many people who might have been helped by my services, like those with hypertension and diabetes, would have needed those services long term for me to have done any good. I did save a goat who was sick and maybe a baby who had pneumonia survived due to an antibiotic I gave her, but I was unable to do anything for the woman with advanced breast cancer or the one with the non-healing wound, or the grandmas whose blood pressures were upwards of 200/140.

There are drug dispensaries on the island, with various medications which might be useful, but people can rarely afford even the very reasonable prices for these. What really improves the lives of people in developing countries (the U.S., around the industrial revolution, was a good example) is clean water. Diarrhea, mostly transmitted by contaminated drinking water, kills more babies than any other disease. In Haiti, AIDS also kills people, and starvation is a significant part of the disease syndromes that shorten peoples’ lives. Anything I might do for my Haitian friends would tend to be temporary, but anything they can do for themselves sustainably might make a long term difference. This time I focused on projects that could be made to be sustainable, without unacceptable long term financial support from aid agencies or our Haitian focused nonprofit, Paloma Institute.

We provide some financial support and ongoing intellectual collaboration with a group of master gardeners and community leaders called JLLP (jaden legim selavi paysen, vegetable gardens are the life of the people.) They, in turn, support gardeners, a school, education and sanitation projects and do some micro-lending for various other community projects. During this visit we walked through several gardens which were much larger and more lush and productive than they were the last time we visited, and brought some gardening equipment which is not available there. Transporting seeds to Haiti is theoretically strictly regulated, but vegetable seeds are what they need most, so I may or may not have brought various organic and non-genetically-modified-organism seeds of the type that grow well in a hot humid environment.

One of the master gardeners, Eligene Deravil, is particularly knowledgeable and devoted to garden experimentation and educating other people who want to have successful gardens. He has a huge garden with beautiful compost piles, grows 3 crops per year and has 3 people who work for him. He was a very poor child, a restavek (domestic slave) when he was small, but is self-motivated, unselfish and tireless in all the projects I’ve seen him take on. It is inspiring to watch him work.

We also try to mentor people in art and craft projects, because most people have very little ability to make money, are very motivated to create things, and La Gonave could sure use an export. We worked with women who were making beaded jewelry and purses out of recycled waste to find items that would potentially sell to U.S. consumers.

There is clay, and we worked to find a good source and have, in past trips, explored sustainable pit firing, but have been hindered by lack of good quality material in the area we visit. One man, though, took the clay idea and created a form out of the rather crumbly clay that is easy to find and began to make vessels out of concrete. He was excited about creating large sturdy buckets to be used as composting toilets. He was able to make a very solid and culturally acceptable container during this visit which can be used by families who can’t afford a pit toilet, and which can be covered while composting begins, then used as humanure compost for gardens. This will require ongoing experimentation, but in any case is an improvement on what those families do now, which is to poop on the ground, without regard to groundwater contamination or hygiene. He could make one of these for $5 U.S. dollars, which is affordable to people there, and we gave him some startup money to make some to give away to families with no money. He will eventually paint them, and perhaps have deluxe models that will sell for more money to families that are more financially comfortable.

My traveling companion does wild animal rehabilitation at home and we both keenly feel the tragedy of the domestic creatures who get even less TLC than their poorly fed owners. It is fine to be a chicken in La Gonave, since there are plenty of bugs and nobody cares where you wander. Eventually you become food, but it is in everybody’s best interested that you be treated well and kept comfortable before that happens. It is not so good to be a dog. Dogs are dependent on humans for food, and there are very few scraps, and nobody has ever heard of dog food. Puppies routinely starve after they are weaned and this is part of the ecology of the place since there is no doggy birth control. Goats do pretty well, much like the chickens, though they are tied up to keep them from raiding peoples’ gardens. Donkeys have the worst lives. They exist only to carry heavy loads so it is not necessary that they be treated with any kind of consideration beyond that which keeps them on their overburdened feet.

There are people trained in animal medicine, not real vets, but people with training. One of our friends had attended a 2 year animal medicine course given by the aid organization World Vision, but had had little opportunity to use his skills. We came upon a donkey with a saddle sore that was so severe that it was liable to have ended in the animal’s painful death before too long. We were able to give him $20 to buy some standard veterinary pharmaceuticals and then give the donkey a little love and debridement, some penicillin and worm medicine and a chance to live a few more years. The owner got a chance to have a functional donkey again and some education in animal care, the under-employed animal medicine technician got practice and publicity, and stories like this travel. We had another such patient in a couple of days, with more people wanting to see how to care for it, and maybe some good will come of all of this.

Birth control and safe sex are vitally important in the developing world and are very tricky due to cultural norms and deeply believed misinformation. I had a terrific translator, a man who had worked in the U.S. for 9 years before being deported due to a visa violation. His understanding of the language and culture made it possible for him to translate not only what I said, but what I meant, and his winning personality made people hear a message that they might have tended to reject. I gave a talk to about 30 people, many of them community leaders, about how wonderful condoms are, and gave out about 1,000 very attractive but quite inexpensive (for me, I bought them in bulk online) condoms for distribution. We talked about AIDS, unwanted pregnancy, the way they work and that they don’t break and go to your heart and kill you. I talked about personal experiences and people laughed and had a good time. Condoms are not hard to get, and many organizations are set up to provide these free of charge if there is demand. In my tiny way, I hope to create demand, which will mean that use of condoms will be potentially sustainable without me. At the very least, we talked about sex in a way that was open and honest and the 1,000 condoms represent 1,000 opportunities to not get pregnant or contract a sexually transmitted disease.

The visit also offered an opportunity to learn about schools in rural Haiti. There are many. They are usually not free. The cost per year is $25-$30 USD, and most parents pay this. There are no standards for teaching, and beating and yelling at students is common. Sexual contact between male teachers and female students is frowned upon but not unusual. There is a standardized test at the sixth grade level, which has some influence on the content of what is taught. Haitian Creole is the language used in most schools up until third grade, French thereafter. Some schools are religious and are supported by churches outside of the country. Schools sometimes pay teachers a little bit, but teachers often work for nothing but the promise of someday being paid and the opportunity to have a job in their community. Schools really want money from outside because it is very difficult to make a school self-sustaining.

Students learn better if they are fed, and making beans and rice for everybody in a small school costs a lot of money. School supplies are less expensive in Haiti than in the U.S., but in La Gonave they are in short supply, as are books. It is hard to know, as an outsider, which schools deserve supporting. We talked to the leaders of several schools in our area about forming a school district to share resources and ideas, and our translator expressed his desire to start a program to teach adults skills such as teaching and translating so that the quality of education could improve. In our area many of the schools incorporate teaching gardening and crafts so that students might develop practical skills. Education is key to allowing these rural poor children to have real choices in their lives and so we will try to support their efforts.

I saw very few actual patients, since I didn’t advertise my visit that way, but did see some. An old woman with a stroke provided an opportunity to talk about high blood pressure prevention and treatment. Hypertension is common in older Haitians and results in the usual complications that we see in the U.S. Regular treatment with medications is usually not affordable, but high salt diet and late life obesity are modifiable risk factors.

Painful knees and backs from hard work on steep terrain with heavy loads were common, and people were grateful for a few aspirins, since over the counter medications are hard to find and expensive. I saw a couple of people who truly needed acute medical care, a baby with probable malaria and a young woman with a severe leg infection, and recommended immediate transfer to the hospital in Anse a Galet, but I have no idea what happened. Both patients would have been hospitalized immediately in the U.S. I was able to do a few ultrasounds with my handheld machine, and everyone loved looking at babies, who were appropriately positioned and appeared to be healthy. These procedures were primarily to open up conversation about healthy pregnancy, and ultrasound always seems to have the ability to make people appreciate their bodies. I would love to do a more widespread screening for hypertension and cardiac disease, but would prefer to do this as part of a larger effort that might potentially include treatment. I would also need easy access to an electrical outlet, which I did not have.

I’m home now, glad to eat toast with jam and wear thick wool socks and sweaters. E-mail will allow me to see some of the projects that happen in La Gonave, and the miracle of wire transfers will make possible contributions from me and other people who find this stuff inspiring.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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3 Comments:

Blogger David Fritz said...

Thanks for what you're doing for La Gonave. Very interesting place. I'd be interested in where in the mountains you're working. Always good to compare contacts.

I have been there five times in four years and always find it an amazing place.

Oh, and the hospital in Anse-a-Galets is Wesleyan (Methodist).

December 13, 2013 at 7:19 AM  
Blogger Janice Boughton said...

Hi David--It would be great to see another doctor when I am there, if our visits overlap. We visit Bwa Nwa and the communities around it. I knew that about the Wesleyan Hospital, but somehow I have it wrong in my head. Thanks for reminding me.

December 17, 2013 at 1:12 AM  
Blogger David Fritz said...

Actually not a physician. A journalist by profession, but in Haiti as part of a long-standing twin parish relationship. Mostly do technology and bridge-building (in the figurative sense) between the two communities, here and there. We try to help underwrite large portions of a 1,000-child school in Anse-a-Galets.

Not familiar with Bwa Nwa, but there are so many little villages and the maps are lacking. Just tried to google for it and only found your national anthem video and a couple of references related to it being an hour's walk from Manetwa. Covers lots of territory.

I'm not sure if I'll be making it in February this year, but if not then likely in June and November. Ping me here when you're going back or drop a note to david.c.fritz (at) gmail.com.

Cheers.

December 17, 2013 at 8:47 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

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Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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