Global Health Fellows: Thomassique, Haiti

Long-awaited Hello!!

2011-08-17T11:59:00.007-06:00

Bonjou! We have now been here for nearly two months and what a two months it has been. After a brief one and half weeks of orientation courtesy of Emily and Fidel, we took over as this year's Global Health Fellows on July 1.

Much of our time here has been dominated by the ongoing cholera epidemic. Hearing the wailing of grieving family members of recently deceased patients during the night is something we will not soon forget. Following several appeals for assistance, the Director of the Departmental Ministry of Health asked MSF-Belgium to visit St. Joseph's Clinic to assess the cholera situation in this area. After a brief site survey on July 2, MSF arrived on July 12 (they left on August 6 after Tropical Storm Emily fizzled out) to begin their work in earnest to revamp and revitalize the cholera treatment infrastructure at the clinic.

Building a cholera treatment center (CTC) is no small endeavor as we soon learned. We expected the construction to take no more than a few days and involve the setting up of a few tents similar to the one that was originally being used to handle large patient volumes. How wrong we were.

After 11 days of work, MSF built quite a sight to see: 5 tents (one for triage, one for observation, and three to handle patients based on severity of illness), 4 toilets, 4 showers, 2 footbaths, water treatment setup with 2 bladder reservoirs, stations for disinfecting hands and feet of staff and visitors as well as to wash clothes of patients, a morgue (thankfully we have not had to use this as no patients have died since the construction of the CTC), incinerator to burn accumulated waste, a site to dump patient vomit and diarrhea, and a kitchen to prepare 2 meals daily for patients. Take a look at the slideshow below for a more comprehensive perspective. Words alone do not do the CTC justice.

One of the members of the MSF team included a Health Promoter named Mackenton. Mackenton enlisted two of our community health workers (CHWs) along with a cadre of citizens from Thomassique to help sensitize family members of cholera patients while he helped to provide two of our CHWs with valuable information in countering misconceptions of how cholera is spread.

Part of the difficulty in preventing cholera stems from the aforementioned misconceptions. Back at the end of June during one of our meetings with our health committee in Bouloum, we heard the frustrations of community members over cholera's sudden appearance in fall 2010. Some compared cholera to the arrival of HIV in Haiti in the 1980s and others claimed that cholera was in the air and that drinking chlorinated water would not prevent cholera (subsequently we heard that limes were a better method of treating water). Many of these notions stem from the seeming randomness in who falls ill. That randomness however is apparent primarily because we do not readily realize all of the ways in which we use water each day - to bathe and wash our hands, to drink, to clean clothes and our living space, to wash dishes, to cook (there are certainly other ways). In Haiti, often the same source of water - perhaps a puddle, a stream, a river, or a spigot tapped into a pipe - is used to accomplish all of these tasks. With little water sanitation infrastructure, these water sources can be rapidly contaminated and were in the days and weeks following the introduction of cholera into the Artibonite River. Mackenton accompanied us to our July meeting with the Bouloum committee and was able to dispel many of these misconceptions with simple messages - the only way that one can contract cholera is via the mouth and while there may be rumors over how to prevent cholera, the one guaranteed way to avoid falling sick is by drinking chlorinated water. After hearing Mackenton's simple yet effective presentation, the committee members expressed their appreciation to him and to us. We provided the committee members with additional handouts in the hope that they will help to disseminate correct information about cholera in the committee.

Despite this one success story, the fight against cholera continues here and throughout Haiti as the rainy season is in full swing. We continue to meet with representatives from Partners in Health and World Vision (who are incidentally continuing the invaluable help that MSF began) to learn more about ways in which to sensitize community members against cholera and to coordinate our initiatives (beyond just cholera) with these organizations.

In with the new

2011-07-05T14:05:00.000-06:00

With great bittersweetness, we have come to the end of our year in Thomassique. As those following our blog know, this year has brought its share of challenges: a collapsed bridge, a broken generator, a cholera epidemic, a hurricane, major administrative changes...there never seemed to be a dull moment in Thomassique. Yet despite -- or more likely because of -- these difficulties, we have grown in ways we never could have imagined, and feel an intensified commitment to addressing health injustices in Haiti and across the globe. We are sad to be distanced from the numerous inspirational collaborators, partners and friends we've had the honor of working with this year. At the same time, we are excited to undertake further training in medicine and public health, with the aspiration of returning to contribute to this region in even more meaningful ways in the future.

Our parting is made much easier by the knowledge that the new Global Health Fellows, Anand and Saskia, will continue and undoubtedly improve on the work we have done. We're also happy to announce that the clinic has several newly established Haitian administrators with ambitious goals to make Klinik Sen Jozef the best it can be.

Evens Das, Clinic Manager; Julus Sterling, Lead Physician; Oldine Lucien, Head Nurse

A million thanks to everyone who has supported us throughout this year: the clinic staff, MM board members and supporters, numerous community members in Thomassique, our families and friends, and the previous generations of fellows. Good luck to the new fellows and administration, we can't wait to see everything you accomplish!

Kenbe fem,

Emily and Fidel

Albendazole

2011-07-02T19:57:00.005-06:00

Much of the work conducted by our Community Health Workers (CHWs) can be difficult to visualize in an immediate sense. Health education and encouraging health seeking behaviors are crucial efforts, but only reveal their true impact over long periods of time. However, the CHWs also partake in some activities that have a much more immediate, tangible effects. The bi-annual de-worming campaign is one such example.

Intestinal parasites is a widespread problem in Haiti, with 32% of school aged children infected at any given time. The parasites can consume up to 20% of a child's daily nutritional intake. Consequently, children can suffer from anemia, delays in physical and mental development, a weakened immune system, vitamin deficiencies, and overall lowered energy, in addition to acute symptoms such as diarrhea and stomach aches.

Multiple studies have shown deworming efforts to be highly effective in increasing school attendance, with the positive effects carrying on into adulthood. For example, one study found that regular deworming treatment led to a 25% reduction in school absences and a 20% increase in adult earnings. The intervention is relatively easy to implement; we work with the schools to give each child one pill every six months. It is also extremely inexpensive, costing under 50 cents a year per child, including all training, transportation, distribution, and medication costs. As explained by the WHO, the primary goal of this regular treatment is to reduce the number of worms per child, rather than the number of children with worms. In the long term, the real solution is to improve sanitation conditions, but the current approach "implicitly recognizes that reinfection will occur until effective clean water and sanitation facilities are installed."

Take a look at some pictures from this year's Albendazole campaign!

Catching up

2011-06-21T09:41:00.010-06:00

The last few months here have been quite chaotic, with major changes to the clinic's administration, and an unprecedented rise in cholera cases with the arrival of the rainy season. Regrettably, this led us to neglect out blog. But with the clinic now under a new, strong administration, we will attempt to fill you in on happenings at the clinic, starting with a few pictures from the last month:

Visitors and visiting

2011-02-15T17:52:00.000-06:00

For most of the year, we are the only foreigners living in Thomassique. This is one of the most defining and interesting aspects of our job, giving us the opportunity to fully immerse ourselves in the community and language. But given that Haiti has the highest concentration of NGOs per capita in the world, it's also important for us to collaborate with these other organizations. The last month has offered many such opportunities.

Starting in mid-January, we had a visit from Alix Pahaut, a representative from the IDA Foundation. IDA is a non-profit pharmaceutical supplier which is our main source of medications and lab supplies. Alix's visit allowed us to learn more about the process by which the Amsterdam-based IDA fills and ships orders, and we also gave IDA feedback from the perspective of a relatively small rural customer. Additionally, Alix provided a wealth of information about navigating the customs situation in Port au Prince, which at times can delay the receipt of vital medications by weeks or even months.

A week later, we were joined by Jon Steele, the creator of the Klorfasil water system. Meeting in person rather than over email allowed us to exchange many ideas about improving our program at the clinic as well as increasing the overall impact of Klorfasil in Haiti. We hashed out the details of the supply chain (a common challenge in many of our projects); shared ideas on how to maximize the usefulness of follow up visits to customers' homes; and discussed long-term plans for evaluating the impact of these water systems on health in the community.

The next weekend, it was our turn to visit one of our partner organizations. After an incredibly bumpy 6 hour drive, we arrived at the Meds and Foods for Kids (MFK) factory in Cap Haitien. This factory produces the Ready-to-Use Therapeutic Food (RUTF) Medika Mamba, which we use at our clinic to rehabilitate malnourished children. We were greeted by MFK Fellows Jamie and Eyleen, who gave us a tour of their factory, from the peanut sorting line, to the drying racks, to the lab where the final product undergoes testing. It was also exciting to learn more about MFK's efforts to promote sustainable local agriculture!

Most recently, we received our 3rd shipment of supplies arriving via helicopter from Port au Prince, courtesy of J/P Haitian Relief Organization. We should also not forget to mention our ongoing work with Zanmi Lasante and World Vision in Thomassique, with whom we have collaborated closely on for projects such as cholera prevention and de-worming.

Remembering our role in the larger network of NGOs in Haiti reminds us to reflect carefully on all of the potential impacts of international aid on the community and country - both the positive and the problematic. For example, could a growing dependance on international aid stifle the development of a strong Haitian government? Considering these difficult questions is essential for turning good intentions into meaningful long-term development.

www.medmissionaries.org

Introducing the 2011-2012 Fellows!

2011-01-13T09:15:00.014-06:00

After reviewing a record-breaking 138 applications, we are excited to introduce Anand Habib and Saskia Guerrier, who will be taking our places in Thomassique this June!

Anand is a senior at Stanford, studying biology and writing an honors thesis in International Securities Studies. He is originally from Houston, Texas, and aspires to become an infectious disease doctor working in the developing world. He has extensive international health experience, most recently working with community health workers in the rural Guatemalan highlands to implement a survey regarding conceptions of prenatal care. He also partook in a service-learning trip studying social determinants of health in Oaxaca Mexico, and spent a summer devising and teaching an interactive health curriculum in India through Project Dosti.

He has also pursued his interest in health education domestically, working in schools and at the Boys and Girls Club. At Stanford, he is a Director for the HIV/AIDS fundraiser Stanford Dance Marathon. He has also worked to improve chronic disease management for local underserved populations at Mayview Community Health Clinic through the Stanford Patient Advocacy Program. He was a Truman Scholarship Finalist, serves on the Haas Center for Public Service National Advisory Board, and has been recognized at Stanford for his academic excellence and writing abilities.

Saskia is in her final year at Bryn Mawr, where she is majoring in Anthropology with a minor in Africana Studies. She lived in Gonaives, Haiti until moving to the United States at the age of 10. She plans to ultimately pursue graduate studies in global health.

Junior year, Saskia spent a semester in St. Louis, Senegal, where she studied and also volunteered at a maternity and child health clinic. She also gained many insights into global health issues as an intern at the Office of the Global AIDS Coordinator.

Domestically, she has engaged in health issues affecting underserved communities by working at a health insurance company serving low income residents of Massachusetts. She interns at the Strawberry Mansion HIV/AIDS Clinic, and is working on a senior thesis based on fieldwork at this clinic. Saskia has been a leader in multiple projects regarding social justice and education. She is an Executive Board Member in the Social Justice Partnership Program, and served as a research assistant on several projects researching education and educational access. She is also a coordinator of the Teaching and Learning Initiative, which promotes collaboration and dialogue between professors and students. She is a Posse Foundation Leadership Scholar.

Both Anand and Saskia have strong passions for global health, and we can't wait to see what they accomplish next year!

www.medmissionaries.org

We're Back + A Day in the Life

2011-01-09T08:46:00.000-06:00

After a brief visit home to see our families for the holidays, we have arrived back at the clinic. We were greeted by a visiting team which included Julian Hertz, the original Global Health Fellow! In our absence, the other NGO in Thomassique, World Vision, provided the clinic with several new nurses for the cholera ward. The staff and Julian continued with prevention activities and delivered soap, water treatment tabs and ORS to homes in the most affected areas. After peaking with around 50 patients in the cholera ward in late December, the numbers have decreased substantially, and we now have around 15 patients.

Since arriving, we've jumped right back into all our projects and responsibilities. To give you an idea of what our days are like here, we documented our activities this Saturday (granted, it turned out to be slightly crazier weekend than usual...but not by much!). Enjoy!

Note: If it's too fast, you can click on the slideshow to see all the images and captions.

www.medmissionaries.org

Meet Beana Elma, Klorfasil and Bon Sel Coordinator

2010-12-14T18:41:00.024-06:00

Earlier this month, our original Klorfasil Coordinator, Shelove Belizaire, had to head back to Port au Prince to begin studying economics at university. We are sad to see her go, but are excited to introduce our new Coordinator, Beana Elma!

Name: Beana Elma

Age: 35

Hometown: Beana was born in Bouloum, approximately a 40+ minute drive or 2-4 hour walk from Thomassique, depending on the weather. She has lived there her entire life.

Family: She has 4 sisters and 6 brothers (one of which is Jean Reluse, our Bouloum CHW).

Previous jobs: Most recently, Beana has been working as a seamstress. She also used to be a school teacher.

What motivates her to do this work?: Beana hopes to "improve our health condition in the community." Additionally, the income from the job will help her support her family members, many of whom suffer from serious health problems of their own.

We first got to know Beana through her role as the Vice President of the Bouloum Health Committee. She immediately stood out based on her natural leadership and enthusiasm for improving health conditions in Bouloum. When we needed a new Coordinator, we immediately thought of her. We worked with Shelove to interview Beana and several other candidates, and Beana distinguished herself with her strong math skills, excellent public speaking ability, and dedication to working on health issues in the community. Shelove provided Beana with an in-depth training that included how to prepare and sell the buckets, give education sessions, and work with other Klorfasil employees such as those running the warehouse in Hinche. In addition to selling and promoting the systems, Beana will be making a special effort to educate the community about hygiene and sanitation topics, particularly in light of the cholera epidemic. She will also be managing our Bon Sel project, which we hope to expand to reach more residents in and around Thomassique.

www.medmissionaries.org

Slideshow: Cholera efforts in and around Thomassique

2010-12-09T20:14:00.009-06:00

Cholera Update 11.27.10

2010-11-27T12:36:00.026-06:00

Patient Report: We have now seen approximately 150 cholera patients, and currently have 18 in the ward. We reached a peak of patients early this week, with up to 40 or 45 patients in the ward at one time (note that the graph shows date of admission through Thursday, and does not include patients currently in the ward; click on the image for better resolution). The atmosphere at the clinic is significantly calmer than earlier this week, but it is highly likely that we will see a rise in patient numbers again. The biggest problem continues to be that people in remote areas are not drinking ORS before and during their journey to the clinic. For example, one pastor reported that 14 people died over the last few days in his community, several of them on the way to the hospital. We are working with local pastors and other groups to spread the homemade ORS recipe and educational messages far and wide. Theoretically, there is already a government-run health center in the hardest-hit area (Bokbanik), but the information we are hearing about deaths suggests that it is not functioning. World Vision may have a tent coming that could be used to open a treatment center there, but the problem would be staffing such a center.

Community Activities: The Thomassique Cholera Committee is becoming stronger every day, and we are increasingly impressed and inspired by the level of community involvement. On Thursday, the committee selected Thomassique's Sanitation Commissioner as its President, and a local pastor as its Vice President. The committee has been organized into sub-categories including water, education, and churches, with each sub-category having an appointed leader directing larger numbers of participants. On Friday, the committee went to the local market as a group, spreading messages about cholera prevention and treatment, and inspecting the hygiene conditions of food vendors. Today, we attended a meeting with the Magistrate and 12 pastors that represent a wide geographic area (pictured above). The pastors were equipped with messages to convey to church-goers each weekend, and stacks of ORS recipes to distribute. They also discussed other issues surrounding cholera, such as how to dispel doubts and rumors circulating about the disease.

Supplies: We received 4000 packets of ORS and 1500 liters of Ringer's Lactate IV fluid on Friday, thanks to the help of Fr. O'Hare and Tom Brock, two wonderful contacts we have right across the Dominican border. Thank you to everyone who has donated to the clinic, we appreciate your support and are dedicated to maintaining an adequate stock of supplies at all times. We have designated a room in the clinic as the 'Cholera Depot' and it now contains all of the supplies needed for treatment, employee protection and cleaning. We have also been receiving materials from other local organizations, such as the Red Cross and World Vision; in turn, World Vision has been distributing our soap and hygiene packs during their education sessions.

Election Tomorrow: An added level of anxiety, on top of the cholera epidemic, stems from tomorrow's election. Today, swarms of people crowded around the mayor's office registering to vote; tomorrow they will choose from the 18 candidates vying for President. Historically, Haitian elections have been marked with fraud and violence, so we are all hoping that the selection of a new President can lead to renewed stability rather than unrest.

If you would like to donate or volunteer for Medical Missionaries to help with the cholera crisis, please contact Medical Missionaries Vice President Dr. Kenneth Kornetsky at kkornetsky@msn.com or visit http://www.medmissionaries.org.

Cholera Update 11.24.10

2010-11-24T18:29:00.004-06:00

Cholera has now taken a firm grasp on Thomassique and our clinic. We have seen over a hundred cholera patients, and have had twelve deaths.

It is hard to express the conditions here, which is possibly why we have not been updating the blog (combined with the fact that we are beyond busy handling this crisis). The scene in the cholera ward is unsettling: Cots fill the room, strewn with bodies showing varying levels of alertness. Cholera is not a pretty disease, and the massive quantities of diarrhea and vomit mixed with Clorox give the room a highly distinct and foul scent. On several occasions the ward has been at or above capacity, with two or three children sharing a single bed, and hardly any space for nurses and doctors to move between the approximately thirty-five patients. The sight of coffins and the sound of grieving families have become all too common.

The good news is that cholera is not a particularly complicated disease to treat. As long as the patient is kept hydrated using Oral Rehydration Solution (ORS) and/or IV fluids, they can typically recover. One of the bad pieces of news though (which contributes to the high death rate) is that many of our patients are coming from great distances and are not beginning rehydration at home. For example, the towns along the Artibonite River, such as Bokbanik and Nan Kwa, are a four-hour walk away; patients that manage to get to the clinic without dying on the way are so weak by the time they arrive that recovery is very difficult. Therefore, along with the importance of preventive precautions (treating water, washing hands, cooking food), a main educational message we are promoting is to prepare and begin drinking ORS at home, using a simple recipe of sugar and salt that we distribute on slips of paper.

Producing an effective cholera response is also influenced by the cultural beliefs and practices that provide the backdrop for this epidemic. Voodoo, though not particularly visible on a daily basis, is an important part of many people's belief systems. We do not purport to serve as experts on Voodoo, but we can relay to you some interesting things that community members have told us over the last week: They explained how some Voodoo priests have been spreading the idea that cholera is the result of a 'powder' (powders are a central component of Voodooism) and claiming that they can cure the condition. Therefore, people seek care from Voodoo priests for cholera, rather than accessing the actual care they need (rehydration). Many rumors have been circulating about a public incident in the market last week: In one version we have heard, two men hired by a Voodoo priest 'infected' a woman with cholera using a powder, and the woman was subsequently 'cured' by the Voodoo priest as a publicity stunt. However, several observers caught on to the plot, and the two men were attacked. This is not a simple situation of Western medicine vs. Voodoo; how can the two become more compatible to improve health outcomes?

Another conception we have encountered is the frustrating belief that death from cholera (and other diseases) is simply inevitable. Though it is true that some people cannot be saved, the vast majority of people should be able to survive cholera if they receive proper treatment. We have even seen this attitude among some staff members at the clinic, who seem resigned to the idea that many of their patients will die. Perhaps this conception is the result of experience; premature death is a much more familiar aspect of life in Thomassique than in the United States. But should not all people, Haitians and Americans alike, be able to expect life rather than death in largely-treatable cases like cholera? How can people gain the power and voice to expect and demand quality living conditions and medical care?

In times like these, it is also important to recognize the positive developments. One bright point is the newly formed Thomassique Cholera Committee, which brings together Thomassique's leaders in health, education, religion (including Voodoo), sanitation, water, police and government (though the local government is extremely evasive and goes to great lengths to avoid any involvement in cholera efforts) to address the challenges facing the community. This committee had its second meeting yesterday and will meet again tomorrow. Though we took the initial steps to form the committee, we are encouraged to see that the community itself is now taking more ownership over this committee and working to find solutions to problems such as mass-purification of water and the burial of corpses. One of our hopes for the committee is that collaboration with other organizations can support and expand our community education activities. Education is an absolutely critical component of handling this epidemic and reducing deaths. In the clinic, we provide detailed, one-on-one cholera education for the highly-susceptible families of patients, and our doctors continue to reach large audience through churches and the radio, but the demands of patient care necessitate that we prioritize the essential medical function of the clinic. Therefore, collaboration with other organizations is vital to mount a sufficiently aggressive education campaign in areas such as the previously mentioned towns along the Artibonite.

As we sign off, we want to highlight another bright aspect of the previous week, which was having Dr. Charlie Dyer at the clinic. It was wonderful to have him here, and we want to thank him sincerely for providing his excellent medical skills and advice. We look forward to the arrival of another team of American medical professionals on Monday.

Cholera in Thomassique

2010-11-16T14:38:00.016-06:00

Cholera has arrived in Thomassique, and we are currently treating patients at the clinic. The first suspected cases came on Friday, and there has been a consistent flow ever since. We are anticipating that cases will continue to rise. Although we do not have the laboratory capacity to confirm cholera, the patients' symtoms, including 'rice water stool', clearly mark their illness as cholera. At the moment, we have 17 patients in the cholera ward, and in total we have had 24 suspected cases. Sadly, 2 patients have died at the clinic, and we have heard word of others dying in their homes. Cholera is a highly treatable disease if people take quick action, so one of the key messages we are now promoting is to begin giving Oral Rehydration Solution (ORS) immediately when someone begins having diarrhea or vomiting, and to bring him or her directly to the clinic. It is crucial that rehydration begins immediately, but we cannot distribute ORS to every home, so we are encouraging people to create the solution themselves at home using a simple recipe of water, sugar and salt.

The clinic staff has been working non-stop. If you or someone you know is a medical professional interested in volunteering at the clinic during this crisis, please contact Dr. Kenneth Kornetsy, kkornetsky@msn.com. Our two service year doctors finish their term on the 22nd, leaving Dr. Casseus as the sole doctor; we are already feeling under-staffed, so this additional loss is very concerning.

We have separated off the normal clinic from the new wing extension, designating the area as the cholera ward (pictured at right; in the last couple of hours since we took this picture, the central area has been filled with more cots to accomodate patients arriving tonight). The extension is not quite finished (it has no electricity, running water, or room dividers), but is a good space for cholera treatment. We are working to maintain a tight quarantine on this space to avoid contaminating the rest of the clinic or staff house and have hired additional cleaning staff. Normal consultations are closed, but we continue to take emergencies and maternity consultations.

There is a rotating schedule of nurses and doctors attending to the patients at all hours. Most cases of cholera can be treated solely with ORS, but the more severe cases also require IV fluids, and occasionally antibiotics. We are providing food for the patients. Along with medical care, we are giving preventive education, soap, water-purification packets, and instructions for preparing ORS to patients' families, because they are at a high risk of contracting the disease. The administrative staff are helping with other efforts such as education and record keeping, using a set of recently-developed cholera-specific charts and forms.

At the same time we treat patients at the clinic, it is crucial that we continue our prevention campaign. The cholera forms track each patient's address and water source; we hope that the patterns we see emerging will help us identify contaminated water sources and target our prevention campaigns. On Sunday, Dr. Hippolyte and Fidel made announcements in many local churches, and yesterday Dr. Hippolyte and Emily appeared on the radio. Today we hosted the first meeting of the Thomassique Cholera Committee (pictured at left), which we created to coordinate the efforts of our clinic, World Vision, government officials, religious leaders, school directors, and other organizations working in Thomassique. For example, this collaboration allows for supply exchange: We provided World Vision with ORS, and they gave us several boxes of water-purification packets (we are still waiting on the Klorfasil systems to arrive). The Haitian Ministry of Health is also supporting us, and sent a car full of cots, ORS, bleach and other supplies to the clinic this afternoon. The Community Health Workers continue to provide outreach and education in their communities. Bouloum has seen a couple of cases, but Dahlegran, Barank, and Savann Plat have had no reported cases.

One of the most troublesome problems facing us in this crisis is that we are still without a good source of water. The pipe brining water to Thomassique was reportedly repaired yesterday (after nearly 2 weeks), but we still do not have running water at the clinic or staff house. It is incredibly difficult to adequately clean a cholera ward without sufficient water, so Brian has been traveling half an hour to Dahlegran each morning to collect several large bottles full of water from their local water source. We sincerely hope the water will be back soon.

**To volunteer at the clinic during this crisis, please contact Dr. Kenneth Kornetsy, kkornetsky@msn.com.**

Medical Missionaries

Water, water everywhere!

2010-11-08T19:30:00.019-06:00

Too much water. Too little water. Cholera-bearing water. For the last several weeks, life's most essential liquid has taken a special prominence in our thoughts and activities.

Since our previous post, Haiti's cholera epidemic has expanded, sickening over 8,000 people and killing over 500 in total. Given that cholera only produces severe symptoms in about 10% of infected people, the actual number of infections is substantially higher. We have been carrying out the cholera prevention campaign outlined in our last entry to equip people with the knowledge and supplies to avoid and treat the illness (at right, Fidel helps a student practice proper hand washing at a local high school). Though there have been cholera cases in Hinche and other nearby towns, Thomassique seems to have dodged the cholera bullet as of now. We are continuing prevention efforts with soap distribution and education, and are promoting the use of SODIS and other water treatment techniques as we wait on a new shipment of Klorfasil (we sold our entire stock in 3 days, while it would have normally lasted a couple of months!).

The other prominent water-related news item has been Hurricane Tomas. At the clinic, Tomas manifested as a very large 3-day rain storm. Though Tomas proved less destructive than it could have been, a hurricane could not have come at a worse time. Not only were the tent cities in Port Au Prince terribly exposed to the elements, but the spread of cholera (and any of Haiti's many endemic water-borne illnesses) could be vastly expedited by such a large influx of water. At least 20 Haitians were killed by the storm itself, and 6,000 families were left homeless. Though it is too early to tell exactly how the hurricane impacted the cholera epidemic, the country is bracing itself for a potential swell of cases.

In one way, however, Tomas actually had a silver lining, as it provided a solution to our next water-related issue: a break in the pipe that provides Thomassique with water. For the last 5 days, the clinic, the staff house, and all of Thomassique have been without water. During the hurricane, we were able to collect rainwater (Brian and Fidel brave the elements at left) and treat it with Klorfasil, but since the rain stopped we have had to purchase bottled water downtown. Unfortunately, the vast majority of Thomassique's residents do not have the luxury of being able to afford this. Therefore, many people resort to getting their water from the local river. The same river is used for bathing and washing motorcycles, and often has many animals in and around it. The water pipe should be fixed by tomorrow, but from experience we know that things often take much longer to repair than expected.

This unrelenting series of problems facing Haiti is unbelievable at times, but what seems like 'bad luck' actually has much more complicated roots. Cholera is a disease of poverty, which would never spread in a nation with proper water and sanitation infrastructures. The earthquake and hurricane, though unavoidable, would have had far less destructive impacts if Haiti had maintained more stringent building codes, and had strong medical and emergency response capacities. If you're interested in learning more about the history of Haiti's water problems, we highly recommend that you read this report, which is the result of a collaboration between several groups including Partners in Health. As the report describes, the Inter-American Development Bank (IDB) approved several loans to improve Haitian water infrastructures in 1998. However, over a decade later, no progress has been made on any of the projects, due primarily to the interference of American politicians who blocked the loans to push an unrelated political agenda (a practice which is explicitly prohibited by the IDB).

As the report argues, the human right to water has been severely neglected in Haiti. As we have experienced first hand over the last few weeks, fulfilling this right means having water that is:

Available (the pipe bringing water to Thomassique must be repaired)
Accessible (everyone should be able to access water, not just people like us who are lucky enough to be able to afford the bottled water downtown)
Of high quality (free of cholera and other water-borne diseases)

Though recent events highlight the importance of the right to water, these are problems that Haitians face every day. It is a shame and injustice that it has taken such extreme conditions to draw attention to these issues.

Medical Missionaries

Kontwol Kolera: Our Cholera Control Efforts

2010-10-22T21:42:00.010-06:00

As of this morning, an outbreak of cholera in the Artibonite region of Haiti has killed approximately 200 and hospitalized over 2600. Though we are thankfully not seeing signs of an outbreak in Thomassique as of now, we are implementing several preventive measures to buffer against a potential emergency here.

The key messages we want to convey are the importance of:

Using purified water. For this, we are encouraging people to purchase and use our Klorfasil systems, which we have been selling for the last several months at the highly discounted price of $2.50/system (actual value is $8.50/system). Klorfasil works by using a small quantity of granulated chlorine to treat water within 30 minutes. For people who cannot afford the Klorfasil systems, we are encouraging the use of SODIS, a free purification technique where water is placed in clear water bottles and treated by sunlight. We have a large collection of clear plastic bottles available for distribution. Going along with this message is the importance of properly preparing food.
Practicing proper sanitation. The emphasis here is on hand washing, especially after using the bathroom and before cooking. We have a large supply of hygiene packs which we are distributing widely. Each pack contains soap and a washcloth, and many also contain items such as toothbrushes, toothpaste, and combs.
Responding to illness: People showing signs of cholera should seek immediate medical care to be re-hydrated with Oral Rehydration Solution (ORS) and possibly IV fluids. They should also take measures to avoid spreading it to others.

We are disseminating these key messages through a variety of avenues:

Radio: Clinic Director Dr. Casseus will be appearing on the radio at 5pm to discuss the cholera outbreak. He will also appear on another station tomorrow.
Community Health Workers (CHW): We are having an emergency meeting with our CHWs at 3pm this afternoon. They will be instructed to conduct hygiene information sessions in their communities, as well as look out for and begin treating potential cholera cases using ORS. They will continue to promote the use of Klorfasil systems or other treated water.
Education in the clinic: With the help of our midwife, Mis Ketna, we are creating signs conveying hygiene and sanitation messages to post around the clinic. We will also hold education sessions about prevention each day for patients waiting to be seen.
Schools and Churches: We are collaborating with pastors and school directors to provide educational information about cholera prevention to church goers and school children. Several of the schools were already part of our hygiene program, in which teachers were trained in hygiene techniques to teach their students. The churches and schools are also involved in the hygiene pack distribution.

In addition, we are preparing for the possibility of a cholera outbreak here by preparing our supply of IV fluids and ORS. The department medical director is sending us 16,000 bags of ORS. In the case that pre-made ORS runs out, it can also be made using a simple mixture of purified water, salt and sugar.

This cholera outbreak highlights major ongoing challenges facing Haiti: access to clean drinking water and effective sanitation systems. According to a 2008 report by Partners in Health, approximately 70% of Haitians 'lack direct access to potable water at all times.' Addressing these types of problems in the long term and preventing future outbreaks will require major changes to the water and sanitation infrastructures.

www.medmissionaries.org

World Food Day

2010-10-16T07:31:00.004-06:00

Malnutrition is an enormous problem in Haiti, where 46% of the total population is undernourished, and 17% of children under 5 are underweight. Overall, Haiti has a Global Hunger Index label of Alarming, as assigned by the International Food Policy Research Institute, and an estimated 2.3 million Haitians are food-insecure. In honor of World Food Day, we wanted to share what we've been doing at the clinic to combat the problem of malnutrition in Thomassique.

The first relevant item is our Medika Mamba program, which aims to bring severely undernourished children back to a healthy weight. Medika Mamba is a peanut-based Ready-to-Use Therapeutic Food (RUTF), produced by the Cap Haitian-based organization Meds and Foods for Kids. Along with ground peanuts, the mixture includes powdered milk, sugar, oil and vitamins and minerals; essentially, it's an ultra-fortified peanut butter. Our Medika Mamba program is managed by Mis Solane, a Thomassique native. It was started in 2009 by Global Health Fellow Nick Cuneo.

To enter the program, malnourished children undergo an assessment by Dr. Gibbs, one of our service year doctors who aspires to a specialty in pediatrics. Potential patients are referred to her by other doctors in the clinic; our Ajan Sante; as well as Mis Solane herself, who conducts active patient searching in the community. Currently, there are 14 children enrolled in our program, and treatment usually takes between 6-8 weeks. Once in the program, patients see Mis Solane at the clinic each week to track their progress (measured by weight, brachial perimeter, height, and general demeanor), and receive that week's allotment of Medika Mamba. The great thing about Medika Mamba is that the food requires no refrigeration or preparation, and the treatment can occur in the patient's home. Mis Solane also provides education, hygiene necessities (such as soap, toothbrushes, and toothpaste), and a free Klorfasil system to each patient's family.

Once the child has recovered to a healthy weight, he is released from the program. It's truly incredible to see what Medika Mamba can do, completely transforming a limp and nearly-lifeless child into an energetic and sometimes even chubby one in a matter of weeks! Overall, the recovery rate of children in RUTF programs is 85%, compared to 25-40% otherwise. About a month after a child is released, Mis Solane conducts a surprise visit to his home, to check on his health and conduct a more general assessment of the living conditions (pictured at right). If the child has relapsed to an unhealthy weight, he is re-admitted to the program. Mis Solane also looks to see if siblings of the patient might need to enter the Medika Mamba program; in August and September 3 malnourished siblings were identified in this way and entered into the program. For patients in the outlying areas where our Community Health Centers are located, the Ajan Sante conduct the home visits.

Our second nutrition-related project is the School Lunch Program. In contrast to Medika Mamba's focus on rescuing a select number of extremely malnourished children from severe danger, the School Lunch Program aims to provide general nutritional and educational benefits to a great number of children. In this effort, we partner with the Minnesota-based organization Feed My Starving Children (FMSC), who ship down sea containers full of highly nutritious and easy-to-prepare lunches. Once the lunches arrive in Thomassique, we distribute them to a variety of schools in downtown Thomassique and the outlying towns (below are images from a recent delivery). The schools then take responsibility for preparing and dispersing the hot meals each day to their students. Thanks to an extra shipment of food from FMSC this year, which will be arriving on Monday, we were able to expand the program such that it now will provide lunch to over 3700 kids for the entire school year; that's more than 550,000 meals!

The benefits of this type of program are multiple, and extend beyond the overall nutritional benefits. As the Haitian saying goes, sak vid pa kanpe; an empty bag doesn't stand up. In other words, it's impossible to think or do anything when your stomach is growling! Having a nutrient-rich lunch helps students focus and learn more in school. The School Lunch Program is extremely popular in Thomassique, and we frequently have local school directors approach us asking us to be added to the program. Last Sunday, there was an especially nice moment as we delivered food to the school in Dahlegran: Virtually the entire neighborhood came to help unload the food, including women in their Sunday-best on their way back from church, and small children who marched to the depot with their future lunches balanced precariously on their heads.

Introducing Brian!

2010-10-13T08:42:00.011-06:00

What do a generator, 64 batteries, 2 water purifiers, a water booster pump, a water tower, a wall, an inverter, 2 washing machines, a fridge, a copier, a car, and numerous toilets have in common? The answer, regrettably, is that they all broke or had problems during our first couple months in Thomassique.

Unfortunately, diplomas in French and Biology did little to help us confront these pressing challenges, which heavily affected the daily functioning of the clinic and staff house. Getting things fixed in Haiti is no easy task. Repair supplies are rarely available in Thomassique. More frequently we'll have to go to Hinche (an hour away); Port au Prince (5 hours away); or sometimes even Santo Domingo (requiring a full weekend trip) to get what we need. There is also a shortage of skilled technicians in the region. We did our best to find solutions, such as using Klorfasil to provide the staff house with purified water, hiring local repair men, and hosting teams of American technicians to work on large issues. It became clear, however, that the clinic needed someone who could address these types of problems on a full-time basis. But who could handle this job? We needed someone who could fix a wide variety of things, from cars to doors to microscopes. The prospect of finding an individual who not only had the appropriate skills but also desired to spend a year in rural Haiti seemed slim. Thankfully, we found Brian Dierks!

Brian joins us from Fort Collins, Colorado, where he most recently owned his own bike shop. After volunteering with one of Medical Missionaries' earthquake relief teams earlier this year, he saw a posting about our need for someone to help keep the clinic facilities running. Upon reading the job description he quickly decided it was a perfect match for him, and accepted the position. Among other things Brian is an EMT, a commercial pilot, and a former lab technician. He is exceedingly well-traveled, having spent considerable time abroad, across 5 continents. Most importantly, Brian is an easy going but hard working individual who seems to capable of fixing virtually anything. He is already popular at the clinic thanks to his reputation as the guy who brought back electricity, and his culinary talents as a bread baker. Brian will be here for approximately a year, and is responsible for overseeing the clinic and staff house facilities. He will also be collaborating with us on the many projects and initiatives we run from the clinic. We couldn't be more excited to have him here!

For more information about Medical Missionaries, please visit www.medmissionaries.org.

Bouloum CHC Opens!

2010-09-12T14:00:00.001-06:00

Top: Ajan Sante Jean Reluse (far left in green) and the rest of the Bouloum Health Committee at their new Community Health Center; Bottom Left: Bouloum residents celebrate at the opening; Bottom Right: Dr. Cassesus addresses the crowd before the mobile clinic begins.

After months of discussion, planning, and training, our fourth Community Health Center (CHC) is finally open in the outlying village of Bouloum! The opening day started with a presentation by our Clinic Director, Dr. Casseus, in which he explained the CHC's main function: to serve as a location where Bouloum residents can find basic first aid, health education, and disease prevention resources (such as Bon Sel and Klorfasil). In honor of the opening, a Klinik Mobil was held, where approximately 65 patients were seen, and a feast of delicious Haitian food then followed.

The opening at Bouloum was a particularly joyous occasion for several reasons. The first cause for celebration is that Jean Reluse, who will serve as Bouloum's Community Health Worker, or 'Ajan Sante', is incredibly devoted to his role. Before training to become an Ajan Sante, Jean Reluse had been Bouloum's school principal, and had no background in the health professions. Motivated to learn everything he could for his new work, Jean Reluse showed admirable dedication throughout his 3 months of training at the clinic and with Zanmi Lasante (Partners in Health). Even after the final patient left the clinic each day, he could be found sitting outside the clinic guest house where he resided, diligently studying his Ajan Sante handbook in the dwindling daylight (as shown at right).

Another reason we are excited about CHC Bouloum is that the Bouloum Health Committee is extremely enthusiastic about their involvement. Already, the committee has been very actively selling Klorfasil systems, and sold 90 systems in a month, before the health center had even opened. At left, members of the Bouloum Health Committee attentively practice using the Klorfasil system.

Finally, we and the rest of the community celebrate the opening of CHC Bouloum because Bouloum is an especially remote area that will greatly benefit from the presence of a CHC. The route to Bouloum is extremely long and rugged, even when compared with Haiti's notoriously rough roads. This remoteness can be illustrated well by our personal experiences venturing to Bouloum. During one visit in July our car became stuck in the mud for over 3 hours and ultimately had to be pulled out by a pair of bulls (pictured above). Even in good weather, the drive takes at least 45 minutes. Needless to say, accessing healthcare is a significant challenge for the residents of Bouloum. The demand for healthcare in this community was clear when we held a Klinik Mobil there in June and saw over 110 patients in one day, far more than are seen at a typical Klinik Mobil. Although the journey to Bouloum can be difficult, engaging with this highly motivated and deserving community is certainly worth the trip.

For more information about Medical Missionaries, please visit www.medmissionaries.org.

2011-12 Fellowship Application

2010-09-10T22:40:00.005-06:00

We hate to think of leaving Thomassique...but the application is now available for next year's fellowship! Click here to learn more and access the primary application (now due by October 1o, 2010, 11:59 pm EDT).

Feel free to share this incredible opportunity with any recent college grads interested in global health.

Maternal Health at Klinik Sen Jozef

2010-08-30T16:03:00.021-06:00

San fanm pa gen lavi

This Haitain proverb, which means 'without women there is no life', has a particularly literal meaning in the context of maternal health. Protecting this source of life requires well developed health services for pregnant women, something which Haiti has sorely lacked. Though no local data are available for maternal health indicators in Thomassique, the national statistics paint a concerning picture:

Haiti has by far the highest maternal mortality ratio in the Western Hemisphere: 670 women die from pregnancy-related causes per 100,000 live births. To put this in perspective, the ratio is 11 deaths per 100,000 live births in the United States.
Overall, the lifetime risk of maternal death for a Haitian woman is 1 in 44. In the U.S. the risk is 1 in 4800.
85% of pregnant Haitian women receive antenatal care at least once, but only 54% have 4 or more visits. The actual statistics for St. Joseph's patients are probably much lower because we serve a rural and largely uneducated population, which are characteristics associated with poor antenatal coverage.
Only 26% of births in Haiti are attended by skilled health personnel (doctors, midwives or nurses). Compare this with the U.S., where skilled health personnel are present at 99% of births.

So, what's being done at Klinik Sen Jozef to promote maternal health, and what plans do we have for the department? These were questions addressed by Maggie Emmott (now a medical student at the University of Colorado) who spent 7 weeks this summer working alongside our midwife, Mis Ketna (pictured below with Maggie); midwife's assistant, Mis Merlinda; and maternity administrator, Madame Saphira, as they provided prenatal, postnatal and birthing services. By observing patient visits in the maternity ward, speaking with clinic staff, and meeting with other maternal health providers in the area, Maggie collected important information about our services and developed many constructive recommendations.

Her suggestions centered on three main themes:

(1) improving supply management; (2)

enhancing cooperation with other clinics and hospitals; and (3) increasing community outreach for maternal health services.

If you've read our earlier posts, you know that keeping the clinic stocked with necessary medicines and supplies is a huge challenge. We were dismayed last month when we exhausted our supply of iron supplements, which is prescribed to virtually every maternity patient to prevent anemia. Though we had placed an order months ago, a received word in June that a large shipment of medications (including iron) had arrived for us in Port-au-Prince, tracking this shipment through Customs and after has been a nightmare; we still do not have the medications. In the meantime, Mis Ketna and our Clinic Director Doctor Casseus have been pulling strings and going the extra mile to obtain crucial prenatal medications from other sources. To avoid future shortages we are implementing a new system for tracking maternity supply use, and looking into sources for purchasing medications on a short time frame in the Dominican Republic. This problem may also be alleviated by working on Maggie's second recommendation of networking with other clinics, through medication exchanges or sales.

The area where we are making the most progress is in Maggie's third recommendation, community outreach. Several of Maggie's suggestions centered on accessing the extensive local networks of matwòn (traditional birth attendants). Many women opt to deliver at their homes under the care of matwòn rather than coming to the clinic. This means women give birth in poorly sanitized conditions, without access to medical technology, and without medical professionals that are properly trained to handle complications. Ironically, women pay for the services of matwòn, while delivery services at Klinik Sen Jozef are free. We are planning a study to examine why many women choose the services of matwòn over coming to the clinic, but previous research and discussions with Mis Ketna suggest that motivators could include cultural norms, habit, lack of knowledge about the risks of delivering without a skilled attendant, lack of transport to the clinic, distance from the clinic and mistrust of medical care. Thanks to a recent grant through the Soins Obstetricaux Gratuits program ('Free Obstetric Care' – a collaboration between the World Health Organization, Pan American Health Organization and the Haitian Ministry of Public Health and Population), we are implementing a new initiative in which matwòn are given financial incentives for referring and accompanying patients to our clinic. Mis Ketna also has plans to implement a Klib Matwòn, where matwòn will come together to share about their work, and receive education from clinic staff.

Our ajan sante, who staff the 4 newly established Community Health Centers in outlying areas of Thomassique, are another important source of maternal health outreach efforts. Their role is to encourage pregnant women in their communities to access the clinic's many maternal health services, and provide relevant education and support. The ajan sante refer any pregnant women that come to their Community Health Center to the clinic, and also conduct home visits to actively seek out women in need of pre or post-natal care (above, our ajan sante Jude, Mary Madeleine, Jean Reluse and Anya review the home visit guidelines and forms). Additionally, Mis Kenta will be speaking on the radio to widely disseminate educational messages and promote the use of our services.

Many thanks to Maggie for all of her excellent work. All of St. Joseph's wishes her the best in medical school and beyond!

Medical Missionaries

Klinik Mobil

2010-08-08T08:46:00.033-06:00

As we mentioned in our last post, access to medical care in the Thomassique region is severely impeded by the issue of transportation. Most people in the region travel by foot or mule, and it takes many of them 2 to 4 hours to reach St. Joseph's Clinic when sick. One of our solutions is the Community Health Center (CHC) project, where people can get first aid and help with simple illnesses, but there are many patients who need to see a fully trained doctor. For this reason, the physicians of St. Joseph's conduct regular Klinik Mobil at various sites in the region. The establishment of the CHCs has been very helpful in facilitating these because the Community Health Worker (CHW) can help locate and organize patients, and the health center is a perfect facility for the consultations. Here's what happens at a Klinik Mobil, demonstrated by a recent day at our CHC in Dahlegran.

1. The CHW and members of the local Health Committee inform the community in advance that a Klinik Mobil will be coming. There is usually great interest in these clinics, so patients gather outside the health center to wait for our arrival. If at all possible, we try not to turn any patients away.

2. Our CHW (in Dahlegran, Mary Madeleine) intakes the patients, recording each patient's name, age, temperature and blood pressure. On this day in Dahlegran we saw 47 patients. At other such Klinik Mobil, we have seen over 110 patients in a single day!

3. The patient is seen by a doctor (here is our Clinic Director, Dr. Casseus) in a separate room. The doctor prescribes medications and provides medical advice. Sometimes patients have conditions that need further tests and attention, such as a woman seen at Barank yesterday with advanced goiter. In those cases, the doctor refers the patient to seek additional care, either at St. Joseph's or Zanmi Lasante's hospital in Hinche.

4. Before leaving for a Klinik Mobil, the doctor collects a box of commonly prescribed medications. An auxiliary staff member from the clinic (at Dahlegran it was our wonderful lab tech, Elizabeth) and ourselves staff the 'pharmacy'. We distribute and explain the doctor's prescriptions, and track the medications distributed.

Once all the patients have been seen, we pack everything up and get back in the clinic's Range Rover with our trusty driver Philip. Half an hour to an hour later, depending on the site and the weather, we return to St. Joseph's and finalize our record keeping.

For more information about our Community Health Centers, please visit the Medical Missionaries website (www.medmissionaries.org).

Our first month!

2010-07-23T10:22:00.017-06:00

Bonjou tout moun and welcome to our blog!

It's hard to believe, but we have now been in Thomassique for a full month. After a whirlwind orientation from Katie and Kavita, we have quickly assumed our many roles as fellows and already survived a few ti pwoblem along the way, including mechanical difficulties, illnesses, and embarrassing Kreyol misunderstandings. For the next year, we'll use this blog to give updates about our work in the clinic and community, for anyone that is interested! This post is admittedly overdue, but we promise to post more frequently in the future.

Clinic Updates

Our central goals this year focus on improving St. Joseph's Clinic itself, so we'll begin with an update about the happenings in our klinik. For those who don't know, St. Joseph's is a rural clinic that provides primary care, maternity services, lab tests, basic radiology and emergency care to approximately 100,000 people in Thomassique and the surrounding areas.

We have quickly learned that supply management is a significant challenge at St. Joseph's. This is a common problem for clinics in the region, and has been further complicated by the increased medical needs in post-earthquake Port au Prince. So, in an effort to improve our oversight of medications, lab tests, and other supplies, much of our time has been spent organizing and inventorying items in the clinic. After countless hours of moving, sorting and labeling, we finally have three sparkling rooms full of neatly organized boxes: The medications depot (pictured at left, alphabetized and labeled with expiration dates), the orthopedics depot and the storage room which once held the Tuberculosis program. The ER depot will also be completed soon, and after that loom the surgical and pediatrics depots. Though it may not be glamorous work, knowing and tracking what we have in each of these spaces is incredibly important for keeping the clinic consistently stocked. We've already found supplies that clinic staff thought they lacked and have a better concept of what and how much to order in the future.

Another development at the clinic (which is probably more exciting to you than hearing about rooms full of boxes) is the impending reinstatement of a Tuberculosis program! The government will be sending us a nurse specifically to run a TB program starting next month, which we welcome enthusiastically.

Community Health Centers

There are also many promising advances being made outside the clinic. Most notably, three of our new Community Health Centers (CHC- previously known as Satellite Health Centers) are now open in Savann Plat, Dahlegran and Barank. After trainings with Zanmi Lasante and at St. Joseph's, our Community Health Workers (or Ajan Sante) Anya, Mary Madeline and Jude are each busy providing first aid, essential medications, referrals and health education to 35-40 patients daily. Many of these patients (such as those pictured above, waiting to see Jude at Barank) would otherwise be unable to access care due to their remote locations. Additionally, we are incorporating our Bon Sel and Klorfasil projects into the health centers. Each Ajan Sante promotes these items to patients and community members, and is responsible for conducting home-visits to ensure that the Klorfasil systems are being used properly.

We are continually inspired and impressed by the dedication of our Ajan Santes and Health Committees (groups of community members that support and guide each CHC) to improving health in their communities. In fact, it was the Barank Health Committee that first suggested the concept of a CHC and it is a testament to the hard work of many community members this idea has become a reality. In the image to the left, our Klorfasil expert, Shelove, demonstrates how to use Klorfasil systems to the Bouloum Health Committee (which will open a CHC in early August).

Looking Forward

In all, one of the strongest impressions we have gained in our first month is that there is no shortage of incredibly caring and passionate individuals in Thomassique working towards the same goals as us; the Health Committees are only one example of this. We are thankful to the past fellows for cultivating relationships with some truly inspiring organizations and leaders, and are excited to work with these extraordinary people in the coming year.

Thanks for reading; we'll be in touch again soon!

Our Farewell Post

2010-07-15T22:25:00.025-06:00

After spending over a year living in Haiti, we have mixed and complicated feelings about leaving. On one hand, we are sad to leave all of the friends, community partners, and co-workers who have been so crucial in making this year a success. At the same time, we are excited to share our experiences beyond the community of Thomassique as we embark upon our careers in medicine. Over the past year, we have learned so much about community, global health, development work, and ourselves. We are both extremely grateful to have had this opportunity.

Kavita will soon be heading off to Ann Arbor, Michigan as a member of the Class of 2014 at the University of Michigan Medical School. Katie will similarly be studying medicine at the University of Pennsylvania. Emily and Fidel have been living at St. Joseph's Clinic for a few weeks now, and will be taking over our roles, as well as this blog. We will be sure to check it often because we cannot wait to see what they will accomplish over in the next year!

We would like to thank our family, friends and other followers of this blog. It has been, just as we predicted in our inaugural post, a "challenging and incredible" year. Thank you for sharing it with us!

Kenbe fem,

K&K

Community-led Initiatives in Thomassique

2010-06-10T15:26:00.010-06:00

Festive music emanated loudly from large speakers. Crowds of people mingled, greeting one another and chatting. The atmosphere was vibrant and full of energy; this could easily have been a scene out of a wedding reception or town fair. Actually, this was last Saturday’s mobile clinic for the physically disabled people of Thomassique, organized by a community-led organization called ACAHT (Association pour la Canalisation d’aide aux Handicapés de Thomassique). Upon arriving at the event, we realized that this was not merely a mobile clinic, but an opportunity for the community to come together and celebrate the fact that much-needed services are now being provided for handicapped people in this area. The event was an embodiment of all that ACAHT and other local community-led initiatives seek to do – bring people together to effect positive change in Thomassique.

ACAHT is just one of many successful locally led initiatives in Thomassique. Here, we will highlight the work of several other organizations with which we’ve worked this year. This is just a small sample of countless community initiatives that exist here.

ACOSAT
Within our first week in Haiti, we were approached by Jocelia, a woman who runs an organization and school for orphans in Thomassique. The organization, called Association Communautaire Orphelinat secours d'Enfant de Thomassique (ACOSAT), aims to provide services for guardian families taking care of orphaned and abandoned children. While this is a perennial problem in the community, it has been a particularly pressing need in the months following the earthquake. ACOSAT was one of the local organizations (along with ACAHT and the World Vision Earthquake Relief Committee) that we partnered with to distribute the earthquake relief items that were sent to Thomassique from the US in the months following the disaster.

An innovative thinker, Jocelia has also begun a program to fund ACOSAT’s school by starting a business as a seamstress. She plans to teach young women in the school how to use manually-powered sewing machines. They will make and sell uniforms, clothing, and decorative cloths. All profits will benefit the organization and school. In an environment in which external funding is nearly impossible to come by, it is this kind of entrepreneurial spirit that can sustain community initiatives such as ACOSAT.

Lekòl Tèt Ansanm
The lack of an adequate education system is a persisting problem in Thomassique. The government-run school has the capacity to serve only a small fraction of children in the area. For the majority of children who cannot find seats in the government-run school, private school is the only chance at an education. The cost of a private education – tuition fees, books, uniforms, shoes - can be unmanageable, especially for families with multiple school-aged children. In response to this problem, there are several locally run free or low-cost schools that have been introduced in Thomassique. We collaborate with several of them for our School Lunch Program. One of them, Tèt Ansanm, was started by Down Belizaire (our x-ray technician at St. Joseph’s Clinic) and his friend Betony. This free school is open to Thomassique’s poorest children, and the teachers work on a volunteer basis. Other free and low-cost schools in this area include Lekòl Fermi and Lekòl Pòv.

Kay Pòv
Kay Pòv (the Poor House) is a home for the aging and infirm of Thomassique. Managed by Pierre Louis, a local leader who also directs Lekòl Pòv (the Poor School), Kay Pòv exemplifies the social services that are made available to those most in need – not by any governmental or international aid program, but by a neighborhood coming together to support its residents.

Association Femmes de Thomassique (AFDT)
It seems that we are constantly learning of more community initiatives in Thomassique. Just last week, we attended a meeting with the Association Femmes de Thomassique (AFDT), an organization dedicated to the empowerment and mobilization of women as key players in development work. We met with the committee of over 50 women from Thomassique and discussed their needs and ambitions. One of their goals is to begin a loan program for women, using pooled funds to support entrepreneurial ventures. They also expressed interest in collaborating with the clinic to address issues of women’s health in Thomassique. We plan to collaborate with AFDT as we look to expand the outreach services of our maternity department. Furthermore, the board members of AFDT expressed interest in selling Bon Sel as a way of promoting good health practices and fundraising for their organization. AFDT’s salt sales began last week.

The presence of multitudinous community-led initiatives in Thomassique was a surprise to us when we first arrived here. Not knowing much about the area, we had originally anticipated that community-led initiatives would require a certain base level of material resources that were lacking in Thomassique. We were impressed to find that, even with extremely limited resources, several programs have been implemented. This is not to say that resources are not needed. Indeed, money is the limiting factor in every one of these programs. But we were surprised and impressed by the fact that community collaborations such as these exist even in the absence of material resources; such initiatives are fueled by the resourcefulness, determination, and civic-mindedness of the people of Thomassique.

This week marks our one-year anniversary at St. Joseph’s Clinic. One year ago, our friend Rigot Thomas asked us a question that has resonated with us ever since: kijan w wè Ayiti? How do you see Haiti? The answer is complicated, to say the least. Every day in Thomassique, we witness the effects of global injustice: hunger, preventable diseases, lack of access to clean drinking water, and abject poverty. But it is unfair and inaccurate to reduce this country to a poverty-stricken, victimized nation. The people of Haiti are not passive recipients of misfortune or aid; they are active and invaluable players in development work. In the face of a harsh reality, it is they who best understand the needs of this country. Our work in Thomassique this year would not have been possible or effective without our local partnerships. We continue to be inspired and moved by the competency, compassion, and undying commitment that these organizations have to this community.

Improving Access to Healthcare in Thomassique

2010-05-20T12:14:00.012-06:00

Imagine finding yourself ill and knowing that the closest health center is two to three hours away by foot. This is a reality that the majority of our patients at St. Joseph's Clinic face whenever they seek care. We are centrally located in Thomassique, but for our patients that live nan deyo (in outlying zones), the clinic is far from accessible. If they get a cut or have a cough, they must walk several hours to access medical care. Unfortunately, this means that many people do not seek care until the last minute- when small cuts have become seriously infected, or minor coughs have progressed to pneumonia.

The severity of this issue was brought to our attention by our Salt Committee in Baranque (see previous posts for more details on this project). As partners in improving health in their area, we asked the simple question: what does your community need? They replied that one of their biggest concerns is not having medical personnel in their area- someone to provide first aid, over the counter medicines, etc. So, we went back and spoke with some board members at Medical Missionaries about how we can address this need.

Now that funding for this initiative has been secured, we are ready to launch one of our most exciting projects: Satellite Health Centers (SHC). About a month ago, we held our first Community Health Committee meeting in Savane Plate, an area about 45 minutes by car from our clinic, or at least a 2.5 hour walk. Convened in the local school, the commitee was comprised of men and women, representing a range of ages and religious denominations. They discussed the multitude of health-related problems in their community; they told us of neighbors who are paralyzed with no access to wheelchairs, food insecurity leaving children hungry when they come to school, and of course, the lack of primary care in their area. We assured them that we would offer our support in addressing the health problems they identified, but also asked for their help in expanding some of our exisitng health programs- namely the salt and water projects- to Savane Plate.

Since that first meeting, we have formed three other Community Health Committees in Dahlegran (pictured above), Baranque and Bouloume- all areas with no other source of healthcare. In addition, we asked the committees to nominate individuals from their communities to act as ajen sante (Health Workers). After an interview process, one individual from each of the four communities was selected to be the Community Health Worker for their hometown. Their duties will include providing primary care, referrals to our clinic and assisting us in introducing health projects into these areas (see the newly set up SHC in Savane Plate to the right). We hope that the SHCs will also be a vehicle for introducing future community health projects to populations nan deyo. We have already started Bon Sel Dayiti sales and introduced Klorfasil into the local school in Savane Plate.

By the end of this month, our Community Health Workers will have completed their training at the Zanmi Lasante (Partners in Health) Center in Hinche, and the SHCs will be prepared to open their doors to patients in their communities. We will keep you updated on this exciting project as it develops!

Tet Ansanm

2010-04-18T22:05:00.005-06:00

Tet Ansanm is a Haitian Creole phrase meaning "heads together." This phrase describes how people in Haiti approach the momentous task of improving their lives. Change happens when groups of people work together, when we put our heads together. We made this movie to be about St. Joseph's Clinic, but it is also about how the community views the work done by the clinic, how they work with us and how we hope to continue making change in Thomassique.

To view this video full screen, you can find it here.

Introducing: Klorfasil!

2010-03-17T07:29:00.009-06:00

For years now, our doctors have dealt with diseases caused by our patients using poor quality water in their homes. These diseases disproportionately affect the most vulnerable population- particularly children under five years old (see previous post on the Water Crisis). This fact has led us to look for useful interventions that can improve access to treated water in Thomassique- and hopefully reduce the incidence of disease and number of preventable deaths that we see at the clinic every day.

Klorfasil is a simple, point-of-use intervention that uses granulated chlorine to treat water at home. Itwas initially introduced in Thomassique last year, as part of the water study conducted by Rita Baumgartner, '08-'09 Global Health Fellow (see previous posts on the Water Study and Boutey Soley). While Rita found that the price of Klorfasil would be prohibitive for many families, the households that were provided with the system used it effectively and the incidence of diarrhea among young children decreased during the study. A benefit of this system is that it is very easy to use. Simply fill the provided bucket with water, put in a small dose of granulated chlorine, and in thirty minutes the water is fully treated. The dose of granulated chlorine used in the Klorfasil system is controlled by a custom-designed dispenser head, which ejects a precise quantity of chlorine each time the head is turned. One additional benefit of the system is that the presence of chlorine in the water prevents recontamination after treatment.

The Klorfasil promotion model is also very innovative. It has incorporated social marketing techniques to advertise- providing a Klorfasil plaque for all participants to display outside their homes. This simple strategy builds social pressure for everyone to start treating their water within a community- Don't be the last one to get Klorfasil! In addition, the founder, Jon Steele, hopes for Klorfasil to eventually be the first home water treatment system that is self-sustaining- run like a profitable business so that it doesn't constantly need subsidies from grants and donations. On the other hand, purchasing Klorfasil is not simply a commercial transaction; it is an opportunity to encourage good sanitation practices and raise awareness about the connection between untreated water and disease. Each family not only receives a water treatment system, but also enrolls in the Klorfasil program that includes a full education session and regular follow-up home visits to ensure proper use of the system.

For the last two years, Klorfasil has been sold in Hinche (a larger town about two hours away)with great success. Not only has the Hinche program reached several thousand households, but the follow-up data have demonstrated that families are using the systems properly and consistently. Since then, Klorfasil executives have been looking to expand to a wider region. Impressed by the proven effectiveness of Klorfasil, Medical Missionaries board member Peter Dirr, procured funding to launch this program in Thomassique. The funding is necessary to offset the cost of the Klorfasil system from US $8.50 to the more affordable US $2.50. In the next nine months, we hope to sell over 3500 Klorfasil systems in Thomassique- targeting vulnerable patients at our clinic and parents of young children.

A few weeks ago, we hired our Klorfasil Coordinator, Shelove Belizaire (pictured on the left at our clinic), to begin implementing this program in Thomassique. She finished her training in Hinche last week and is ready to start launching the project! This week, we will be meeting with directors of several schools in Thomassique to give them the opportunity to participate in the program by providing their schools with Klorfasil systems, free of charge. From there, we will begin selling the systems to our patients and parents at the participating schools. This will ensure that those most vulnerable to water-borne illnesses have access to treated water, and that the children of Thomassique will be able to find safe, clean drinking water both at home and at school.

Surgical Visit 2010

2010-02-10T11:20:00.019-06:00

Last week, a team of seventeen surgeons and nurses arrived at St. Joseph’s Clinic for the annual surgical visit. After months of planning, the team came prepared with the supplies and know-how to work through an intense week of operations. Before their arrival, we rearranged the clinic, organized supplies, cleaned the floors and walls, and prepared the operating rooms and inpatient rooms. Over the past year, the doctors at St. Joseph’s had been collecting the names of patients in need of surgeries, and those patients were tracked down and told to come into the clinic upon the surgeons’ arrival.

The team – consisting of two orthopedic surgeons, an OB/GYN, two general surgeons, a urologist, an anesthesiologist, six nurses, three scrub nurses, and a nurse anesthetist – got straight to work…and didn’t stop until the end of the week. In just four and a half days, the team completed 85 surgeries and over 100 surgical consultations! The surgeries performed included prostatectomies, hernia and hydrocele repairs, exploratory laparotomies, circumcisions, clubfoot repairs, a leg amputation, and numerous minor operations (see chart below for a breakdown of the surgeries performed). While some patients were victims of last month's earthquake, many were residents of Thomassique with persisting health problems.

The surgical visit was an incredible experience for both of us, in part because we played a very active role in the goings on of the week. For example, we devised a patient identification and record keeping system for the surgical cases, by which patients were tracked following their operations. Post-surgery, they can now receive appropriate follow-up care here at the clinic because we can easily find their records.

Each day during the week of the surgical visit, one of us worked in triage (where we translated for surgical consultations and managed the record keeping system), and the other scrubbed into surgeries. Scrubbing in was unimaginably exciting – not only did we observe the surgeries, but we were able to participate by holding retractors, using the Bovie to cut and cauterize tissue, putting in sutures, and assisting the surgeons in any other way possible (see photo). We also learned about spinal anesthesia, how to put in an IV, and how to insert a foley catheter. The week left us with a renewed enthusiasm for clinical medicine. The clinical skill set, dedication, and compassion that the team brought to their work was inspirational, and we hope to emulate their approach in our own careers.

Since the team’s departure on Friday, we have been reflecting on the impact that this year’s surgical visit has had. In just a few days, 85 lives were dramatically improved. It was refreshing to experience the immediate and tangible changes that result from a medical trip such as this. In many of our other projects, we find ourselves working on larger systemic problems at a community level. While these endeavors are essential for addressing chronic problems, it is often difficult to gauge what kind of an impact we are having, or how much time it will take to make a difference. This week gave us a chance to experience another approach to global health, where impact is as immediate and palpable as the lengthening of a tendon or the excision of an infected scar. In all, though, both of these efforts are two sides of the same coin. It is by integrating these individualized and community-based approaches – by addressing both the immediate needs and the systemic roots of disease – that we can begin to make real and lasting improvements to health in Thomassique.

The 2010-2011 Global Health Fellows

2010-01-24T18:06:00.007-06:00

After carefully reviewing over 130 applications, we are pleased to introduce the 2010-2011 Global Health Fellows!

Emily Dansereau is originally from Seattle, WA and is currently a senior at Stanford. While there, Emily has excelled academically and was elected to Phi Beta Kappa as a junior. She studied Human Biology and has been involved in a number of extra-curricular activities that have exposed her to the underlying issues that affect health. She did significant hands-on work with under-served communities in East Palo Alto through East Palo Alto Tennis and Tutoring as well as Stanford's Patient Advocacy Program at a local clinic.

In the summer of 2008, Emily was awarded a competitive grant from Stanford to travel to Cochabamba, Bolivia. While there, she worked in a rural health clinic doing a variety of activities. During that time she also implemented a program designed to teach children about dental hygiene and secured funding to provide tooth brushing kits to children in local schools as well as those that come to the clinic.

Fidel Desir was born in the Dominican Republic, but was raised in Puerto Rico. He is a senior at Washington University in St. Louis. As an Annika Rodriguez Scholar, Fidel has demonstrated academic excellence, dedication to medicine, and a commitment to working with under-served populations. During the summer of 2008, Fidel and another scholar received the highly-selective Davis Projects for Peace grant to conduct an eight-week HIV prevention project at a maternity center in the Dominican Republic. For this project, Fidel led seminars about HIV/AIDS, targeted towards women.

In addition to international work, Fidel has made it a priority to work with under-served populations in the US. He is the co-Director of College Connections, a service program that prepares low-income students from St. Louis high schools to get into and succeed in college.

Beginning in June, Emily and Fidel will be taking our places here in Thomassique. Both of these individuals have great enthusiasm for the program, for global health and for addressing health disparities worldwide. We look forward to seeing how they grow and what they accomplish in the next year!

Post Earthquake Update

2010-01-21T12:56:00.005-06:00

Everyone here in Thomassique has been working furiously over the last week in response to the devastating earthquake of Jan. 12th. The brunt of the 7.0 earthquake was felt in Port-au-Prince, where many of our staff have family and friends. Luckily, though we felt the earthquake in Thomassique, no one was hurt and nothing was damaged at the clinic. We have been very fortunate all around as our staff members' families were also largely spared from death or injury.

Many of our community health projects are now on hold as we make plans to mount an effective response and offer relief to those who need it most in the wake of this catastrophe. While we expect that the effects of this earthquake will reverberate within our community for years to come, the immediate need is monumental. Tomorrow, a team of 16 people (including 6 doctors and 2 orthopedic surgeons) from the US will be coming into Thomassique to perform operations and emergency procedures for victims of the quake both here at the clinic and at facilities in nearby Hinche. After they leave, another team of surgeons and nurses will be arriving on their heels to continue in the relief effort.

We will keep you all updated as things develop in the coming weeks and months. In the meantime, we ask that our readers consider donating to one of the charities below to help Haiti in this time of great need:

Our parent organization: Medical Missionaries

Partners in Health

The Red Cross

Doctors Without Borders

Water Update

2009-12-24T07:40:00.016-06:00

Last Tuesday morning, we awoke as usual, ready for a busy day of work. We were surprised to find, however, that this particular morning was far from typical: there would be no face washing, no showering, and (much to our dismay) no breakfast. As it turned out, a pipe near the water source (at the river about fifteen miles away) had broken, and thus all of Thomassique was without water. As the day wore on, we realized how dependent we are on having water – there was no way to do our laundry, no flushing toilets, and (much to our dismay again!) no lunch. Luckily, we had a container of drinking water to get by on, so we avoided dehydration. Eventually our amazing cook, Mme. Gilbert, thought of innovative ways to prepare food without water so that we wouldn’t go hungry. Still, we were struck by how drastically our lives were changed in the absence of water.

Water seems to have been a theme in our lives as of late: our waterless day was the culmination of a month when we had a broken UV water filter and two broken water pumps. While water crises have just recently descended upon our personal lives, Thomassique’s serious water crisis – a lack of access to potable water - has been a major focus of our community health projects for quite some time (check out previous posts on Boutey Soley, the Water Study, and the Water Crisis).

Recently, we have been discussing how best to direct the future of the Water Project. One of our main goals – both with the Water Project, as well as with our salt and malnutrition projects – is to integrate the education program into the daily clinic routine. While outreach and community education remain crucial components of this project, it is important that all of our patients, too, are well acquainted with methods of water treatment. Therefore, we are encouraging the health care professionals at the clinic to give brief education sessions that focus on point-of-use water treatment methods (namely solar disinfection), especially targeting expectant mothers and patients with diarrheal diseases.

A major appeal of the Boutey Soley system is its suitability for a resource-poor setting; it only requires clear plastic bottles and sunlight. There is no shortage of sunlight in Thomassique, but we’ve found that procuring the plastic bottles presents a barrier to many families in the community. To address this, we have partnered with Jasmine Carver, a Peace Corps volunteer who is working on environmental issues in Pedro Santana, a border town in the Dominican Republic. Jasmine has been working to start a recycling program in Pedro Santana, and she’s agreed to help us collect clear plastic bottles. We got our first batch of bottles a few weeks ago, and we’re hoping that as Jasmine’s recycling program continues to expand, we’ll get enough bottles to meet the need in Thomassique.

While point-of-use interventions are effective immediate strategies for decontamination of water, they do not guarantee access to water in the first place. Currently, almost all water sources in this region are contaminated. Mack Leazer, a Virginia-based well driller and friend of Medical Missionaries, is exploring the possibility of increasing access to drinking water by drilling wells in this area to provide people with improved access to safe drinking water. During a visit to Thomassique in November, Mack learned of wells that have been drilled in the area by World Vision, with limited success. Those wells have been drilled in conjunction with a US-based NGO, Haiti Outreach. Mack has been in contact with Haiti Outreach in order to explore ways in which Medical Missionaries can collaborate with their organization to improve access to potable water for the people of Thomassique and its outlying villages.

If there is anything that we’ve learned about water in the past week, it’s that its effects are pervasive. We have long known that inadequate infrastructure in Thomassique results in an increased incidence of dehydration and diarrheal diseases. We have witnessed the effects of this serious problem in hindering access to food and drinking water for the people in this region. Though normally, St. Joseph’s Clinic is equipped to maintain a steady supply of water, we too are affected by this reality from time to time. Our experiences over the last month have brought home for us the significance of this particular community health project as well as our own dependency on having a supply of clean water—and just how harsh it can be when all of a sudden the fragile system in Thomassique breaks down.

Back in Thomassique!

2009-11-17T12:46:00.014-06:00

After a three-week trip back to the States to spend time with our families and attend medical school interviews, we arrived back in Thomassique just a few weeks ago, and things have been pretty hectic right from the start. A steady stream of Americans made the trip down to the clinic for our first week back. First to come were Ron Burrell and John Rossi. Ron is our main engineer—he designed and maintains our electric and water systems here at St. Joseph’s. He and John, an electrician, installed some beautiful solar panels on our guest house—allowing us to have more power during the day. They also took care of a few other technical problems we have been having around the clinic.

Right on their heels came Dr. Ken Kornetsky, a nephrologist and vice president of Medical Missionaries. He addressed several staff issues and observed the day-to-day functioning of each department at the clinic. We took turns translating for Dr. Ken as he shadowed in the lab, the maternity ward, the pharmacy and with one of the doctors. Over the course of the week, we developed some new systems for reporting broken equipment, supply shortages and other issues that may arise in the clinic. Hopefully this work will make the clinic run more smoothly in the long run.

In addition, we were lucky to see our first surgeries performed here at the clinic! Dr. Snyder, an orthopedic surgeon, came down along with Sherry Pace, a surgical nurse. During the course of the week, Dr. Snyder tested the capacity of our burgeoning radiology department (which recently gained the ability to develop x-rays!) as we looked at fractured forearms, clubbed feet, broken bones that had healed incorrectly, crushed feet, and more. In the course of translating for these patients, we were also given the opportunity to scrub in on a few surgeries—including one jaw surgery that released an ossified tendon which had blocked our patient’s jaw from opening fully. Dr. Snyder gave us a crash course in performing sutures (as demonstrated by Katie in the picture above) along with endless information about the varied cases that came to us.

Basically, we have been running around like crazy ever since we got back. Once the team left last Sunday, we immediately set ourselves to work organizing a newly-arrived shipment of medications in the depot, putting away the supplies that arrived on the sea container, meeting with our new community health worker Nicole about the water project, and following up with our surgical patients.

It was very exciting to see the capabilities of our small clinic in performing surgical procedures! Despite limited resources, we were able to make real strides in assisting patients who otherwise would not have any access to medical care for their orthopedic problems--or would have been forced to turn to sub-par medical care, as we saw from a few of our patients who had been put in poorly-constructed casts, etc. We are looking forward to the surgical trip scheduled for early February, and we now feel that we have a good idea of what to expect and how best to prepare for that week.

Salt Sales Begin in Baranque!

2009-10-04T20:51:00.020-06:00

Sunday, September 13th marked a milestone for our Salt Project: it was the first day that Bon Sel Dayiti was sold in Baranque, a rural community located about ten miles outside of Thomassique. Within the first half-hour of sales, 78 one-pound sachets of co-fortified salt had been sold. What excited us most, however, was not the high quantity of salt sold, but the enthusiasm shown by the citizens of Baranque. As people poured into the small house adjacent to the local church to purchase their first bags of iodized, DEC-treated salt, they were visibly excited to take an important step in ameliorating iodine deficiency and preventing the transmission of lymphatic filariasis. (To read more about the University of Notre Dame’s Bon Sel Dayiti program and the health benefits of co-fortified salt, read our earlier blog post).

In early July, we began making presentations about iodized/DEC-treated salt at the Catholic church in Baranque. The church has an important presence in Baranque, and thus connected us to a large social network. After introducing ourselves to the community and explaining Bon Sel Dayiti, we returned each week and spoke with community members about their salt consumption, ideas for distribution of Bon Sel, as well as their general ideas for improving health in Baranque. During one such discussion with the congregation, someone proposed forming a Salt Committee in Baranque, to manage sales and lead an education campaign about the benefits and proper use of the co-fortified salt. The formation of this committee, an idea generated by community members themselves, demonstrates the extent to which the citizens of Baranque feel a sense of ownership over the Bon Sel initiative.

It was agreed that Ilrick Dubuisson, a respected community leader and sacristan of the Catholic church in Baranque, would nominate individuals to be delegates of the Baranque Salt Committee. The committee consists of eleven community leaders, five women and six men. Included on the committee is Mimos, a salt vendor from Baranque. During the first committee meeting in August, a secretary and treasurer were appointed to manage the bookkeeping for salt sales. All of the delegates are responsible for actively publicizing the availability of Bon Sel in Baranque, and educating their fellow community members about iodine deficiency and lymphatic filariasis. Furthermore, the committee educates about the proper use of the salt: Unlike the other salt available in the market, it should not be washed because the DEC will be lost. They also spread the word that the salt should be used just like normal salt, instructing people not to use higher quantities than normal.

Currently, Medical Missionaries acts as a middleman between Notre Dame’s Bon Sel Dayiti factory and the Baranque Salt Committee. Our ultimate goal is to establish a self-sufficient program in Baranque that does not rely on our organization to order and transport the co-fortified salt. Given the enthusiasm and efficiency of the Baranque Salt Committee, this may well be a feasible goal.

What marked Sunday, September 13th as one of our most exciting days in Haiti was not just the successful launch of the salt project, but the efficacy of the health committee model. As the members of the Baranque Salt Committee proudly wore their nametags and organized the salt sales that morning, they were empowered to improve the general health of their community. We hope to use this health committee model when implementing and expanding our other community health projects, as well. This model allows for people to have a vested interest in health programming, and to realize that they are uniquely situated to effect lasting positive change in their own communities.

School Lunch Program

2009-09-16T12:48:00.042-06:00

One night during our first few weeks in Thomassique, two young brothers named Bensi and Benson came to the clinic staff house in tears. The usually upbeat, energetic boys looked weak and somber. They explained to us that they had not eaten for two days. Their family of fourteen could not sleep because they were so hungry. Could we help them?

Surely we had enough extra food in the staff house to feed Bensi and Benson that night. But what about their parents and ten siblings? What about the many more hungry nights that inevitably lay in their future? And what about the thousands of other hungry children in Thomassique? We were overwhelmed by the gravity of the situation at hand.

That night, we made sandwiches for Bensi and Benson. We explained that this was a one-time occurrence – we are a clinic and not a food program; we simply to do not have the capacity to feed children every day. It was a Band-Aid solution – immediate but unsustainable – to the widespread, persisting problem of food insecurity in Haiti. That night was the first of several instances in which we have been asked to hand out food. Such situations present us with a recurring dilemma: Our instinct is to feed hungry children, but we must realize that haphazardly handing out food creates unsustainable dependencies that could ultimately threaten the efficacy of our programs in Thomassique.

A more effective way for us to begin to establish food security in Thomassique is to collaborate with organizations that have the resources and expertise to implement sustainable, broad-reaching programs. That is just what Rita and Nick, the ’08-’09 Global Health Fellows, did last fall when they contacted Feed My Starving Children (FMSC), a Minnesota-based nonprofit organization dedicated to providing nutritious food through feeding programs worldwide. Rita and Nick applied to receive enough lunches for two local schools – EMSH and Tèt Ansanm, where lunches were served four times a week for the remainder of the school year. Given the success of the program last year, they sought to expand to more schools in Thomassique. After fundraising to purchase two large food storage containers and reaching out to the directors of several other schools, two new schools were added to the program: Lekòl Fermy and Lekòl Me, the Catholic school.

A few weeks ago, the new FMSC shipment (40,655 lbs of food!) arrived in Banica. A sufficient portion of the food was delivered to the clinic, and we’ll continue to receive truckloads from Banica throughout the year. We calculated the appropriate quantity of food to distribute to each school every month, and met with the school directors to discuss the logistics of food delivery, storage, and preparation. The directors expressed a great level of enthusiasm and gratitude for the School Lunch Program.

The nutritious meals, which are packaged in sachets containing enough food for six meals, consist of rice, soy nuggets, vitamins, minerals, and dehydrated vegetables. The meals are easily prepared by boiling water and cooking the packaged food for 20 minutes. Each meal costs just US$0.17 to produce, and the food is completely paid for by FMSC. Rita’s fundraising covered the costs of shipment and storage. This year, we’ll be working to think of new ways to fundraise to cover these expenses in the future (if you are interested in donating to this program, please email us at mmfellowship201 0 @gmail.com).

This past Tuesday marked the beginning of the school year, and was indeed a very exciting day for us. We visited Tèt Ansanm (a free school co-founded by a clinic employee, Down Webelson) as the children received hot meals. Our feelings were indescribable – it was incredible to witness tangible improvements to the lives of so many children. Through our School Lunch Program, 1690 children will receive 270,864 meals this year.

This year, Bensi and Benson will attend EMSH, one of the schools in our lunch program. We are happy to know that they will regularly receive nutritious meals. Remembering that difficult night three months ago, we realize that the School Lunch Program is only a first step in addressing a problem that is chronic and expansive. However, we truly believe that our partnership with FMSC exemplifies the kind of programmatic collaboration necessary to effect real and lasting change.

For an update on food security in Haiti, check out this article.

Medika Mamba Update!

2009-09-04T12:57:00.022-06:00

In March 2009, the pilot Community-Based Therapeutic Care (CTC) program for child malnutrition was launched by Nick Cuneo, ’08-’09 Global Health Fellow (for more background info, see his blog post from February 10, 2009). Through a partnership with Meds & Foods for Kids (MFK) St. Joseph’s Clinic has been prescribing a locally produced Ready-to-Use Therapeutic Food (RUTF) called Medika Mamba to children that present at the clinic with severe malnutrition.

Last Friday, Dr. Casseus was seeing patients as usual when a mother brought her one-year-old daughter in to see him because she had the flu. He immediately saw that the little girl was severely malnourished, noting that both of her little feet were swollen to almost twice the normal size (edema caused by protein deficiency). Immediately, she was referred to Ms. Solane, the nurse in charge of the Medika Mamba program. Ms. Solane confirmed that she was eligible for the program because she had a weight-for-height score three standard deviations below the median WHO child growth standards.

Ms. Solane ran through the normal intake procedures. She sat down with the mother and explained to her the requirements of the program, including weekly visits to the clinic to check up on her daughter’s progress. After the mother agreed to participate in the program, Ms. Solane counseled her one-on-one and explained how best to administer the Medika Mamba to the little girl each day. She also explained the Boutey Soley (Solar Disinfection) system to the mother, explaining to her the importance of point-of-use water treatment and proper hygiene for keeping her daughter healthy. Ms. Solane concluded the counseling session by explaining to the mother how to store the Medika Mamba and reiterating how important it is to come back each week for her appointments. The mother walked out of the session not only with two bags of nutritious food, but also with the knowledge and tools necessary to rescue her child from severe malnourishment and keep her healthy in the years to come.

This is how the course of Medika Mamba treatment is started for most of the children enrolled in our program. To date, we have fully cured 35 children and we are currently treating 8 more. In the beginning, there were a few hiccups in the implementation of this program, as might be expected for any pilot project. As a result, we have treated fewer children than we expected. However, we have corrected the errors that led to these problems and at the moment we are very confident that the program will prove to be very successful in treating our patients that come to us with severe malnutrition. We meet every week with Dr. Mondesir, the director of the program, to review all new cases and those that have been discharged. Through this additional oversight, we have been able to track the progress of all our patients to ensure that discharge procedures are properly followed and examine why some might drop out of care.

Dr. Mondesir relates that the therapy is incredibly effective in bringing children up to an appropriate weight. He sees that the children not only gain a significant amount of weight during the program but also their overall health improves as a result of better nutrition. When implemented properly, there were no non-responders to the therapy. In addition, the families expressed interest and appreciation for the program. Many people commented on the importance of addressing malnutrition in Thomassique and are extremely grateful that we have taken the initiative to begin a program for such a pressing need in the community.

Look for more updates as we work to turn this exciting pilot project into a permanent program at St. Joseph's Clinic!

Bon Sel Dayiti

2009-08-15T17:58:00.014-06:00

Most people do not even notice that their salt is iodized. However, this simple public health intervention provides millions of people worldwide with the essential nutrient iodine—without which people would suffer from goiters, mental retardation and growth deficiencies.[1] The worldwide effort to iodize salt has significantly reduced iodine deficiency, but some small, impoverished countries such as Haiti have yet to make this change. In fact, Haiti is one of only 19 countries left in the world that continues to have iodine deficiency problems. [2] Using iodized salt to address iodine deficiency is considered one of the world’s most cost-effective interventions. It is estimated that a $1 investment yields a $28 return in the national economy due to improved health and increased productivity of the population. [3] As such, the Haitian Ministry of Health has made the production of iodized salt a major priority in the country. However, due to a lethal combination of lack of funding as well as severe hurricanes that washed away the nascent salt industry, this program has yet to get off the ground. Currently, only about 14% of the salt in Haiti is iodized (mostly imported salt) and only 11% of households use an adequate amount iodized salt.[4] In a 2001 study of Haitian schoolchildren in Leogane, over 75% were determined to have severe iodine deficiency, according to WHO guidelines.[5]

At St. Joseph’s Clinic in Thomassique, we see every day how this public health issue is written on to the bodies of our patients. Our clinic director, Dr. Casseus reports that goiters are a common complaint seen at the clinic. He further suggests that iodine deficiency likely contributes to poor mental and physical development of the children in the area. When we arrived in Thomassique, an iodized salt program was underway to slowly change the community’s salt supply in order to address this serious need in the community. We were excited to discover that our planned intervention addresses not only the issue of iodine deficiency, but also combats lymphatic filariasis, a nationally endemic disease.

Lymphatic filariasis (LF), the infection that causes elephantiasis, is a debilitating and disfiguring disease caused by a parasitic worm that lives in the lymphatic system of its host. It is transmitted through mosquitoes and while acquired during childhood, it does not usually become symptomatic until later in life. It is estimated that over 26% of the population in Haiti is infected with the parasite.[6] The manifestation of the disease is particularly devastating because it physically incapacitates its victims. Men are more commonly affected than women where the rates of genital damage, especially hydrocoele (fluid-filled enlargement of the sacs around the testes), can reach 10-50% in endemic communities. In these populations, up to 10% of men and women can be affected by elephantiasis (swelling of up to several times the normal size) of the leg, arm, breast, vulva, penis or scrotum.[7] These deformities prevent symptomatic individuals from being productive members of society, and are also socially isolating, causing incalculable psychological distress.

Combating this disease should also be seen as part of the fight against poverty. Lymphatic filariasis overwhelmingly affects the poorest and most vulnerable members of society, further immiserating those least able to cope with such a debilitating disease. In Thomassique, the prevalence of infectious filariasis appears to be low by national standards. However, clinically we see that manifestations of the disease, such as hydrocoeles, are among the most common afflictions necessitating surgery during the annual surgical trip.

Researchers at the University of Notre Dame have been studying the transmission, prevention and treatment of lymphatic filariasis in Haiti for over twenty years. Centered in Leogane, the Notre Dame Haiti Program, led by Fr. Tom Streit, is at the forefront of the global fight against lymphatic filariasis . The program has focused mainly on mass drug administration of diethylcarbamazine (DEC ) and Albendazole to eventually eliminate the disease. However, this intervention has faced significant obstacles as it is difficult to ensure that a largely asymptomatic population will adhere to treatment. The elimination of LF transmission would require effective mass drug administration over several more years. In 2001, the Notre Dame group studied a new intervention in Miton, Haiti. By providing a special kind of salt fortified with iodine and DEC, they were able to effectively eliminate iodine deficiency while simultaneously reducing the prevalence of the LF-causing parasite by 95%.[8]

Given the proven effectiveness of this intervention, the Notre Dame Haiti Program partnered with the Haitian Ministry of Health along with others to begin the mass production of Bon Sel Dayiti, a high-quality salt that is fortified with both DEC and iodine. This is the salt that we will be using in our salt program based at St. Joseph’s Clinic. We are one of only a very few communities in Haiti that currently have access to this salt. Hopefully, Bon Sel Dayiti will eventually be widespread throughout Haiti to eliminate lymphatic filariasis as well as iodine deficiency nationwide. Unfortunately, the Bon Sel Dayiti factory in Port au Prince does not currently have the capacity to supply this salt to everyone in Haiti. In addition, until a sufficient economy of scale is reached, the salt will need to be produced at a fiscal loss that is inevitably passed on to those organizations implementing the program. The production of the salt is subsidized by Notre Dame bringing the sale price down from 29 cents per pound to the market price of about 12 cents per pound. However, in order to ensure that poorest of the poor have access to this salt, costs for transportation, marketing and education campaigns will need to be supplied by organizations like ours for the time being.

This week, we had the privilege of attending a conference about the Bon Sel Dayiti in the Residence Filariose in Leogane. While there, we had the opportunity to meet with researchers, students, administrators, public health officials and professors who work tirelessly every day to combat lymphatic filariasis in Haiti. We were inspired by the dynamic and innovative ways that academic research is able to inform effective public health solutions through programs such as the Notre Dame Haiti Program. We learned about the history of Bon Sel Dayiti, as well as our role in the national implementation of the program. By effectively introducing the salt in Thomassique, we will not only address a local public health concern but also contribute to the national campaign to spread brand recognition of the product and raise awareness about lymphatic filariasis and iodine deficiency.

In the upcoming weeks, we will begin to introduce Bon Sel Dayiti into the market of a small outlying community called Baranque. For the last two months we have spent much time studying the salt market, meeting local vendors, coordinating with local parishes and conducting salt consumer surveys. As of now, we have a good grasp on how best to introduce the fortified salt to our community without negatively affecting local businesses. In addition to supplying the salt, we will begin a massive education campaign so that all those who buy the salt know not to wash it. Much of the salt currently on the market in Haiti is contaminated with grime that is not removed by processing. However, during the fortification process, Bon Sel Dayiti is thoroughly washed and comes out clean. If people wash this salt at home, the medications will be washed out. Therefore, our marketing and education campaign will concentrate on both changing the salt preparation practices of our community as well as emphasizing the positive health effects of switching to Bon Sel Dayiti. Look for updates as we begin this exciting project!!!

[1] Institute of Medicine Report 1998. Prevention of Micronutrient Deficiencies: Tools for Policymakers and Public Health Workers. Washington, DC: National Academy Press.
[2] MJ Beach et al. "Short Report: Documentation of Iodine Deficiency in Haitian School Children: Implication for Lymphatic Filariasis Elimination in Haiti." Am. J. Trop. Med. Hyg., 64(1,2), 2001 pp.56-57
[3] Aid for Haiti. http://aidforhaiti.org/?p=492
[4] Network for Sustained Elimination of Iodine Deficiency. Country Profiles: Haiti. http://www.iodinenetwork.net/countries/Haiti.
[5] MJ Beach et al. "Short Report: Documentation of Iodine Deficiency in Haitian School Children: Implication for Lymphatic Filariasis Elimination in Haiti." Am. J. Trop. Med. Hyg., 64(1,2), 2001 pp.56-57
[6] University of Notre Dame Haiti Program. http://haiti.nd.edu/index.html
[7] Lymphatic Filariasis WHO Fact Sheet no.102. September 2000. http://www.who.int/mediacentre/factsheets/fs102/en/
[8] A Freeman et al. "A Community Based Trial for the Control of Lymphatic Filariasis and Iodine Deficiency using Salt Fortified with Diethylcarbamazine and Iodine." Am. J. Trop. Med. Hyg., 65(6), 2001, pp. 865-871

A Day in Thomassique

2009-08-15T00:16:00.006-06:00

There is no such thing as a typical day as a global health fellow in Thomassique. Still, we wanted to give our friends, families, and fellowship applicants a sense of what we do on a daily basis. Thus, we compiled a photojournal of our activities on a random day - Monday, July 27, 2009.

We hope that you enjoy it!

Pwoje Dlo a and Boutey Soley

2009-07-27T15:49:00.010-06:00

A note written by our awesome guests from Duke University, Meryl Colton and Chrissy Booth:

Few needs are more fundamental than good food and clean water. Although diarrhea is one of the leading causes of death for children under five in low income countries like Haiti, the WHO estimates that 94% of diarrheal diseases are preventable with interventions to increase access to safe drinking water. The goal of increasing access to safe drinking water for each family in Thomassique in a cost effective and sustainable way became the heart of "Pwoje Dlo a", the water project being run out of the St. Jozef Clinic. This summer, the two of us had the wonderful opportunity to visit Thomassique and work on this project while living at the clinic for two months. As Duke undergraduates, both of us are studying Global Health and were excited to to apply what we had learned in class to address an actual health concern in Haiti. We are so grateful for the chance to have worked in Thomassique, met amazing people, learned more about Medical Missionaries and how NGOs can function in developing nations, and worked together with community members to improve the water and sanitation situation in order to keep families in better health.

The water project began with Rita Baumgartner, one of the 2008-2009 MM Fellows in Global Health, who ran a study comparing two different Point of Use (POU) interventions and a control population. Simple Coliform water tests made clear that the water coming out of the public water standpoints (tiyos) shows high levels of microbiological contamination. A natural response may be a desire to treat that water, so it is clean at the point of collection. However, many people gather water at rivers or natural springs, and many buckets of water become re-contaminated with dirty hands, feces, or dirty cups between the time the water is collected and ingested. For these reasons, POU interventions provide an opportunity for people to ensure the water they are about to drink is free of contamination and will not make them sick. The two interventions Rita explained to families living in Thomassique were called Klorfasil and Solar Disinfection (SODIS), both relatively inexpensive and simple ways to treat the contaminated water people collect from the public tiyos, springs, and rivers. The Klorfasil system is a small bottle of Clorox powder which can dispense one dose of this chemical into a five gallon water bucket with a spout. Although most families are receptive to Klorfasil when a system is given to them, the cost of a Klorfasil bucket as well as the cost of refilling the Clorox supply is too large an economic burden for many of the rural households. SODIS takes advantage of the ever-present heat from the sun in Thomassique and uses that heat along with UV rays to disinfect water. The system involves placing clear plastic bottles in the sun for six hours, preferably on a tin roof or another hot surface. After six hours, the water is treated and is contained in a bottle with a narrow neck, which is a great step for preventing recontamination.

Of all the POU treatments that Rita tested, Solar Disinfection (SODIS) showed the most promise for having a substantial influence on the population of families we were working with. It was clear from the pre-intervention surveys that no one was willing, or more importantly able, to pay for a water treatment, so the fact that SODIS was essentially FREE made this treatment a huge hit. We decided to commit our summer to studying the most important variables in promoting adoption of SODIS, especially seeing how giving bottles affects finding more bottles and seeing if group education sessions were detrimental in capturing all the details. We conducted four different trials: going house to house giving families one bottle, doing group education sessions without giving bottles, giving group education sessions giving out 1 bottle, and giving group education sessions giving out 5 bottles. Katie and Kavita will finish the last trial for us, but the rest really helped us get an idea of the biggest problems people encountered. It was clear that in the group education sessions, people had a higher chance of getting confused and taking the idea of solar disinfection but using buckets or green tinted bottles to treat the water, which doesn’t work. The good news was that not giving people bottles, didn’t seem to hinder people’s ability to find new bottles.

For this project, we were supported by the Duke Global Health Institute (DGHI) as well as the Robertson Scholars. Throughout the spring 2009 semester, we met each week with our DGHI advisor, Sumi Ariely, to formulate plans, discuss options, and find resources in the area so we could learn more. With Sumi's help, we wrote and edited the IRB proposal to be certain our research study would be conducted with beneficence, justice, and respect for persons. Additionally, we were able to keep in touch with Rita via email and Skype to hear about her project updates and ask her advice on how things work in Thomassique. Throughout our time in Haiti, we kept in touch with DGHI and were able to consult with Sumi about curve balls and bumps in the road, such as our initial realization that the difficulty of transportation in Haiti would complicate our project design.

The second project that we pursued was working with eight schools to promote the WHO’s Water, Sanitation and Hygiene (WASH) standards for schools in low cost settings. This project was such a gratifying experience. We first held a focus group with the directors and many of the teachers to talk about the biggest problems with sanitation in schools and what ideas THEY all had to make the situation better. It was great to see the teachers come up with a lot of the standards the WHO thinks are important even before we introduced the document. We then finished by going over the WHO document and brainstorming ways that we could implement all of their standards, including having a place to wash hands, having a latrine for kids to use the bathroom, and having treated water for kids to drink. At the end, we agreed to help the schools get a treated water bucket in each classroom from a nonprofit that provides a cheap “Klorfasil” (translated “easy chlorine”) system to the area. We also helped the schools get two basins, pitchers, and soap to set up hand washing stations. Finally, we agreed to build 4 latrines for the schools that did not have a latrine. The schools’ directors were the most compassionate and genuine people that we’ve ever worked with, and we were constantly impressed by the community initiative that produced these schools. The most frustrating thing about this project was that all of the schools complained that hunger was the biggest barrier facing kids ability to learn in school. Although half of the schools were enrolled in Rita and Nick’s school lunch program, the others were not and complained how kids come to school hungry and can’t learn. We both hope that this wonderful program can expand in the future.

Of course the sustainability of both our projects is the most important aspect of our stay in Thomassique. To ensure that the expansion of SODIS continues we trained our hard working translator, Bellevue, to continue giving house to house education sessions and giving four group education sessions a month. We also brainstormed various social marketing tools to encourage the use of SODIS, including a promotional video to be shown at the clinic, calendar distribution, and teaching vendors of plastic bottles about how to teach people about SODIS. In six months we will evaluate the program to see if it is running smoothly. To make sure that the WASH program in schools continues, we sat down and talked with teachers about various ways to prevent loss and damage to the hand washing stations, treatment buckets, and latrines. In the fall we will have Bellevue, or our new community health worker, check in on the schools to make sure that everything is going well and to give the schools more soap if they run out. It is great that the clinic will be available to monitor both of these programs into the future.

This experience impacted so much of our perspective on global health and international aid. At times, it was easy to grow discouraged; watching young mothers struggle to sustain families of up to twelve children, witnessing the difficulty of economic growth or commerce in Thomassique, hearing the laments of schools directors that students come to school starving every day. To be sure, there are seemingly insurmountable obstacles to be faced daily by people living in poverty. However, barriers to equality with regards to health care, education, agriculture, and economic possibility can be addressed. We were so impressed by the innovation and compassion of community-run initiatives in Thomassique. In our short time there, we encountered school directors who taught students for free and didn't even require uniforms or shoes (cost-prohibitive rules for many children). We visited a "poor-house" where elderly men and women and one disabled child lived and were supported by the surrounding community. We heard of plans for a technical school, to teach agriculture and masonry, and we experienced first-hand the generosity and hospitality ubiquitous in the people we met.

Working in Haiti was one of the best experiences we have ever had. You can read about a place and the challenges it faces, but you can’t form your own opinions or apply everything you’ve heard until you go there. Working in Haiti really helped us integrate all of the global health information that we have collected at school and make us question why we want to work in global health. Something we often talked about was how guilt drives so many people to work in foreign aid or how feeling privileged to live in the US fuels the need to “help poor people.” But this trip helped confirm how detrimental this perspective is. The people in Thomassique are no different than struggling people in the US or anywhere else. Sympathy and guilt don’t change the structures that continue the poverty trap, and those feelings only hinder your ability to get to know the people you meet abroad. Although we can’t say we will miss the slow Haitian dancing, we will definitely miss the compassionate and genuine people that we met at the schools we worked with, at the clinic, and through all of our work. Haiti is a country that gen anpil espri (has a lot of spirit), but there is so much unnecessary suffering. We know that Katie and Kavita will be able to help empower this community and bring knowledge that could change the history that has brought Haiti to the state it is today. We hope to find a time to go back soon and witness the growth of the people we met.

Our Inaugural Post!

2009-06-30T11:08:00.013-06:00

Welcome to the official blog of the ’09-’10 MM Fellows! We hope to use this page as a forum to share our triumphs, obstacles, goals, and insights as we embark on what promises to be a challenging and incredible year.

The torch has been passed, and we are now in our fourth week at St. Joseph’s Clinic. St. Joseph’s is a dynamic place, and we’ve been inspired by the dedication and strong work ethic of the clinic staff. The doctors, nurses, midwives, and other staff members have helped us learn about how the clinic operates. Our first weeks have been filled with many small victories and challenges: we organized the pharmaceutical depot, took an inventory of the surgical depot (see photo!), dealt with several technical problems (including a lightning strike and subsequent loss of power in the clinic!), and have begun preliminary research for our future projects (more updates to come).

We are immensely grateful to Rita and Nick for facilitating a smooth transition. They have been incredibly supportive, and have laid a strong foundation for future generations of MM Fellows. We are committed to solidifying the projects that they began: we recently submitted a report encouraging the continuation of the childhood malnutrition program, and will perform a full-scale program evaluation in the next six months. The water project has been hugely successful, and two awesome Duke undergraduates (Chrissy Booth and Meryl Colton) are here for the next several weeks, expanding upon Rita's preliminary findings. We will be continuing the last leg of the study and will later perform a Boutey Soley program evaluation.

Over the past several weeks, we've come to understand the important balance between completing tangible concrete tasks (e.g. organizing the med depot) and working towards our more visionary long-term goals. Both are essential for our success as MM Fellows. As we continue to adjust to life in Thomassique - learning Kreyol, making new friends, and setting goals for the upcoming year - we are beginning to understand the endless possibilities that lie ahead of us. We are thrilled to be here, and excited to share our experiences with all of you!

Passing along the Torch...

2009-06-29T08:43:00.005-06:00

Dear friends, family, and other readers,

Thank you so much for keeping up with our blog this past year. Your support has been crucial to our happiness and success in Thomassique. Our year was demanding, enriching, and enlightening, but it has now come to an end, as we proceed to new places and new challenges. In August, Rita will head to Los Angeles, California to begin studying at the David Geffen School of Medicine at UCLA, while Nick is already well established in Johannesburg, South Africa, where he is doing research on a U.S. Fulbright Scholarship. Katie and Kavita are now settling down in our place and are well on their way what is sure to be a very rewarding and successful year in Thomassique. We wish them the very best as they begin work at St. Joseph's and look forward to reading about their anecdotes, activities, and accomplishments on this blog.

Love,

Nick and Rita

Pre-intervention Questionnaire Results

2009-04-07T13:49:00.006-06:00

Just a quick update from the first step of the water pilot project, the pre-intervention questionnaire! We had really great reception from the community for this project; everyone who we talked to agreed to participate and people were generally very excited to share their opinions and feelings about their water and sanitation situations and to answer our questions.

Part of the pre-intervention questionnaire was based on a document published by the WHO called “Core questions on drinking water and sanitation,” which is a list of standard questions meant to be incorporated into larger surveys so there can be some consistent, comparable data between different surveys. From responses to questions from that questionnaire, we gained some very important and interesting information:

Percentage of study population using improved water sources: 48/60= 80%
Percentage of study population currently using adequate water treatment methods: 7/60=11.7%
Percentage of study population that takes more than 30 minutes round-trip to haul water to home: 18/60=30%
Percentage of population using improved means of excreta disposal: 6/60=10%
Percentage of population using sanitary means of disposal of children's feces (for households with children under 5yo): 3/45=6.7%

An important thing to note from this data is that the indicator used to measure adequate drinking water is percentage of the population using “improved” water sources. Millennium Development Goal 7 strives to halve the percentage of people without access to clean drinking water by 2015 but because household water testing is costly, access to improved water sources was chosen to indicate success in working towards this goal. Examples of improved water sources are piped water into dwelling, piped water into yard, public tap (this is what most people in Thomassique can access), tubewell, protected dug well, protected spring, bottled water, or rain water. Unprotected springs, unprotected wells, tanker trucks and surface water are considered unimproved sources.

Despite the high access to improved water sources in the study population, this population does not necessarily have access to clean drinking water. The source of water in Thomassique is a spring which bubbles out of a rock and then flows into a reservoir and is piped to Thomassique. The reservoir is unprotected which leads to high chances of contamination, especially in the rainy season. Furthermore, the reservoir is not well protected. On both occasions I have visited the spring, people have been bathing in the reservoir and there were animal feces littering the path. This example highlights the importance of household-level treatment options to ensure that people are drinking potable water.

Some other interesting things from the pre-intervention questionnaire:

Mean household size: 7.2 people
Average number of births/woman: 5.8
Number of children under 5 reported to have diarrhea/total number of children under 5: 34/98=34.5%

Last week, I began visiting houses and conducting the education sessions. These sessions, which last about 15-20 minutes, were very successful. I hope to have visited all 60 households in the upcoming week and to get them started with chlorination or solar disinfection.

More updates to follow!

Lunchtime at EMSH

2009-02-12T11:54:00.008-06:00

Sorry so much time has elapsed since we last posted on our blog! We both returned home for wonderful winter holidays with our families and satisfied our longing for cold weather and a break from the stifling heat of Haiti. Upon our return, we first hosted a group of volunteers who helped finish the new guest house and paint Thomassique’s “kay pov” or poor house. A week after that group left, we had the surgical team come down for a week of amazing and life-changing surgeries. More details on that trip to come.

In the time between those two groups, a significant event occurred: the first lunch served at EMSH! This was a really exciting event for the two of us because it was the realization of our first attempt at effecting change in Thomassique outside the clinic walls. We were walking through town one day, commenting to one another about the huge number of malnourished children in Thomassique and wondering how we could improve nourishment in town without turning the clinic into a soup kitchen. Nick had recently done some reading regarding the double edged benefits of school lunch programs—improved learning outcomes and better nourishment—and I had heard from my awesome Aunt Linda about Feed My Starving Children (fmsc.org), an organization based in MN, so the idea of a school lunch program at EMSH was born. We wrote the original grant in September, and the food was shipped in October and arrived in Thomassique right before winter break.

On January 19, 2009, we went to EMSH and witnessed the preparation and serving of lunch at EMSH. Everything went relatively smoothly: 180 meals were prepared in two large pots cooking over open fires, benches were brought from one of the classrooms (we are having benches built specifically for lunch), the five classes came out one by one for lunch, and each child received a heaping portion of nutritious rice fortified with soy protein.

It is hard to explain precisely how we felt watching the kids at EMSH eat their lunch: relief that the preparation was not complicated and that the kids seemed to like the food (which is good because that is the same meal they will be getting every day for the rest of the semester and hopefully beyond!), fulfilled in that we were finally seeing the results of months of grant writing and emailing about logistics, definite happiness knowing that that meal was the best some of the children would get that day, but not total satisfaction. As we walked home, we were already discussing the possibility of extending the program to 5 or 6 additional schools in Thomassique and raising money to send an entire container of food to Thomassique over the summer, ready for next school year. To document the event, we put together the video below:

We have realized that this is one of the most challenging and most inspiring aspects of the fellowship year: nothing is ever really finished, no problem is ever completely solved. Small successes are definitely possible but each one leads to another possibility for change and improvement.

We have started scouting additional schools who serve poor children that would greatly benefit from a school lunch program and are getting ready to reapply to FMSC asking for more food for next year. If you are interested in donating to help get the container to Thomassique, please contact us at mmfellowship2009@gmail.com. Thank you!

Introducing the 2009-2010 Fellows!

2009-02-10T20:03:00.006-06:00

Meet Katie O'Neill and Kavita Vinekar, next year's fellows. Selected from nearly a hundred impressive applicants from top schools across the U.S., Katie and Kavita have already achieved remarkable things in the realm of global health and are looking forward to following their passions to reduce health disparities down here in Thomassique. We are thrilled they decided to commit to the fellowship and cannot wait to see what they accomplish next year!

Kathleen (Katie) O'Neill majored in biology with a concentration in anthropology at Columbia University, from which she graduated Phi Beta Kappa and summa cum laude in 2008. At Columbia, Katie volunteered with the Peer Health Exchange--where she led a group of five other students teaching a comprehensive health curriculum to NYC public high school students--and volunteered at St. Luke's hospital in the cardiology department, among other activities. In the spring of 2007, Katie studied abroad in Bolivia, where she conducted a project analyzing the barriers to health services for women in a rural community. This past year, Katie has worked as a treatment adherence counselor for the AIDS Services Center in NYC.

Kavita Vinekar is a senior at the University of Pennsylvania, where she is majoring in biology and minoring in English. She has spent the past two years as co-director of Penn's Alternative Spring Break program and is an editor of the Penn Bioethics Journal. At Penn, Kavita also co-founded a program to foster leadership, debate skills, and a commitment to service in exceptional inner-city Philadelphia high school students, called Philly LEADS. Last summer, she traveled to Botswana to establish a peripheral blood cell isolation technique at Princess Marina Hospital; while in Botswana, she also collected epidemiological data on cryptococcal meningitis/HIV coinfection.

Why Water Matters (and what we are trying to do about it)

2009-02-10T12:52:00.005-06:00

Increasing sustainable access to clean drinking water is an essential step in promoting health in developing countries. Worldwide, over 1.1 billion people lack reliable access to potable water and each year, over 1.8 million people die from diarrheal diseases which are overwhelmingly caused by the defiency of clean water. This burden of disease falls very highly on young children: over 90% of deaths from diarrhea are among children under five years old. Drinking water can be contaminated with pathogenic bacteria, parasites, and viruses at the source, within the delivery system, or during transport to homes for use.

However, this situation is far from hopeless. The WHO estimates that up to 94% of diarrheal illness are preventable with interventions to increase availability of clean water and through improved sanitation and hygiene. Recent research has suggested that point-of-use (POU) water quality interventions are highly effective in improving microbial water quality and reducing incidence of illness and death from diarrhea. POU water quality interventions are interventions that affect the quality of water from where it is accessed in the community as opposed to treatment at the source or changes to the infrastructure. Examples of POU interventions include large slow-sand filters at community water pumps, household filters, boiling water in the home, chlorine and other chemical disinfectants used in the home, and UV or sunlight treatment. POU interventions are ideal for improving water quality in developing countries because they are highly cost-effective, can be rapidly deployed and taken up by vulnerable populations, and are considered some of the most effective of water, sanitation and health interventions.

Access to clean drinking water is an important issue in Thomassique. Thomassique’s major source of water is a spring located approximately 15 miles away in the town of Cerca-la-Source. The water delivery infrastructure was constructed in the 1980s and has had little repair since this time. Very few Thomassique residents have water piped to their households and there is no quality control. All other residents get water from concrete public standpoints (tiyo in Kreyol, pictured above).

Beginning next week, we will be beginning a pilot study to increase understanding of Thomassique residents’ current drinking-water and sanitation practices and to learn what POU intervention is most effective in Thomassique. The proposed study will increase knowledge in 5 areas:

Residents’ current drinking-water and sanitations practices
Residents’ opinions regarding the quality and accessibility of water in their community
Rates of diarrheal diseases among children under 5 years old and adults over 50 years old
Residents’ willingness to invest in public and private POU interventions
Relative effectiveness of two different POU interventions—chlorination and solar water disinfection (SODIS)—to reduce reported rated of diarrhea among residents of Thomassique

The study has three steps: a pre-intervention questionnaire, based on WHO’s “Core questions on drinking-water and sanitation for household surveys,” a 15 minute general education session regarding water, sanitation and hygiene followed by a 5 minute focus session discussing the specific intervention, and a post-intervention questionnaire to assess if people have changed their drinking water or sanitation practices following the education session. With the information we gain from the study, a large-scale clean water project will be designed in order to extend positive outcomes to a greater portion of the Thomassique community.

Medika Mamba

2009-02-10T12:49:00.006-06:00

Another recent exciting development has been the final stages of planning for another major health project we are commencing here at the clinic: an Outpatient Therapeutic Program (OTP) for acute childhood malnutrition using the Ready-to-Use Therapeutic Food (RUTF) MedikaMamba (pictured below). This program, which we are working on with Peter Dirr, a board member of Medical Missionaries, will provide outpatient treatment and care for children with moderate and severe malnutrition in Thomassique. We will be hiring a trained local nurse to oversee the program and will be starting with a group of 100 children. After collecting data on their progress throughout the treatment, we will then sit down and evaluate the potential of a long-term program at the clinic.

People are considered to be malnourished (more specifically, undernourished) when they do not consume adequate calories, protein, and nutrients to satisfy their bodies’ growth and maintenance requirements. Long dismissed as an indirect—even negligible—factor in child mortality, acute malnutrition is now indicted for its insidious and indeed major role in eight of the eleven million child deaths that occur worldwide on an annual basis. Malnutrition is a major concern in Haiti, where 22% of children under the age of five are reported to be definitionally underweight in contrast to just 5% in the neighboring Dominican Republic.

Severe malnutrition is directly implicated in over a million child deaths each year and is defined as severe wasting (weight-for-height that is more than three standard deviations below the median World Health Organization (WHO) growth standards) and/or the presence of nutritional edema (swelling of the legs due to protein deficiency). There are about 20 million severely malnourished children worldwide, who make up an estimated 2% of the child population in underdeveloped countries. The prevalence of severe malnutrition in Haiti has most recently been reported as 2.2%.

Moderate malnutrition has a much higher prevalence than severe malnutrition and is responsible for a far greater number of child deaths annually; indeed, children with moderate malnutrition are up to 12 times more likely to succumb to preventable disease (e.g., measles, malaria, diarrhea, pneumonia) than well nourished children. Defined by a weight-for-age score between two and three standard deviations below the median WHO child growth standards, moderate malnutrition can evolve into severe nutrition if not treated effectively. The prevalence of moderate malnutrition in Haiti has most recently been reported as 6.9%.

The United Nation’s Millennium Development Goals were set out to galvanize nations and organizations across the globe to come together to meet the needs of the world’s poorest and most vulnerable inhabitants. Addressing childhood malnutrition falls under two of these eight goals: eradicating extreme poverty and hunger (goal 1) and reducing child mortality (goal 4).

While international agencies have long engaged in preventative efforts to curb malnutrition in countries such as Haiti through the support of large-scale food provisioning programs (e.g., World Vision), therapeutic treatment programs for malnourished children are not nearly as widespread. While preventative programs are an essential part of combating malnutrition, they have not been proven effective in treating acute malnutrition (i.e., providing adequate energy for catch-up growth). As a result, millions of children are continuing to die preventable deaths each year due to a lack of mobilization around this major public health issue.

Community-based programs for treating child malnutrition were proposed as early as 50 years ago but have been revolutionized in the last decade with the advent of Ready-to-Use Therapeutic Foods (RUTF)—high-energy, high-protein, nutrient-rich products that do not require any preparation or equipment on the part of the caregiver. In contrast to in-patient treatment (i.e., hospitalization) of acutely malnourished children—which requires access to a suitable facility (limited in underdeveloped rural areas) and the constant presence of the child’s caregiver (at great cost for the family), while also leaving the child susceptible to hospital-acquired infections—community-based management can treat children who present with non-complicated cases of acute malnutrition at their homes. This method of treatment (domiciliary rehabilitation) has already been shown to be very effective and achieve high levels of coverage in both emergency and non-emergency situations.

With the advent of BP100 and Plumpy’nut, the two commercially available RUTFs, as well as their many locally produced equivalents (e.g., MedikaMamba), a majority of acutely malnourished children can now be treated on an out-patient basis, with the RUTF being “prescribed” as a medicine, to be taken on a routine basis at the child’s home under the supervision of his/her caregiver. This situation drastically reduces the costs of treatment for both the supervising organization and the acutely malnourished child’s family, since the caregiver and child are only required to travel to the CTC center for RUTF resupply and check-up on a weekly or fortnightly basis. CTC (especially its outpatient component, or Outpatient Therapeutic Program (OTP)) has been the greatest “area of growth” in the management of childhood malnutrition, with many programs reporting significant success.

As “the hemisphere’s hungriest country,” Haiti faces a situation of chronic food insecurity that continues to devastate its most vulnerable citizens, especially children. At 460 kcal/day, Haiti’s average daily caloric deficit per inhabitant places it among the bottom three-ranked nations worldwide, along with Afghanistan and Somalia.

Around 31,000 Haitian children under the age of five die each year, leading to an under-five mortality rate of 120 per 1000 children, the 37th worst worldwide. Moderate and severe malnutrition are identified as the primary cause of death in a full 28% of these deaths and are a contributing factor in many more. Forty percent of Haitian homes face daily food insecurity, with food supply programs covering only 55% of the total population. In every respect, the nutritional situation facing Haitian children is exigent, requiring immediate action on the part of development and relief agencies worldwide.

As shown below, Thomassique (indicated by the black arrow) is located in an area of highest vulnerability to food insecurity on Haiti’s Central Plateau (USAID, 2008). Malnutrition is certainly observed among children who come to the St. Joseph Clinic, with clinic health professionals estimating there to be about 6-7 severe and 30-40 moderate cases presented each month.We are very excited to start this program in the next month or so and look forward to providing a much-needed service to one of Thomassique’s most vulnerable patient populations—acutely malnourished children. We, of course, are always looking for funding for these projects so if you are interested in contributing specifically to this initiative please contact Peter Dirr at peterdirr (at) gmail.com. We will keep you posted as the first children start to receive their doses of MedikaMamba in the coming weeks.

Mission Accomplished

2008-12-11T14:25:00.005-06:00

Our first major project at Saint Joseph Clinic was to do a total reorganization. We sat down with a blue print of the clinic and went through dozens of different scenarios, trying to figure out how to best serve the expanding patient population at St. Joseph. It took over three months, but on October 22^nd, we had gone through EVERY room and opened EVERY box. Above you can find an updated virtual tour of the new and improved St. Joseph Clinic! Below you can find a numbered floor plan with explanation of each room.

Front Desk
Emergency Room
Laboratory
Emergency Room Storage, a.k.a. the “Little Pharmacy”
Sick Patient Waiting Room
Dentist Room/Storage
Patient Records Room
Dr. Casseus’s Office
Dr. Mondesir’s Office
Dr. Sterling’s Office
Male Inpatient Room/Operating Room
Front Hallway/IV Supplies
Female Inpatient Room
Pediatric Inpatient Room
Maternity Waiting Room
Maternity Consultation Room
Maternity Inpatient Room/Delivery Room

In the other clinic building, which we renamed the "Clinic Services Pavillion," there are five more rooms. Although we do not have a blueprint available, below is a list of the rooms in the order in which they appear in the virtual tour above.

Pharmacy
Medicines Depot
General Depot
Tuberculosis Room
Orthopedic Supplies Depot

World AIDS Day 2008

2008-12-03T15:11:00.004-06:00

On December 1st, in honor of Worlds AIDS Day, the clinic hosted its first annual HIV/AIDS awareness celebration (sansibilizasyon, in Creole). The theme of the event was “ansanm, annou proteje tout timoun kont SIDA” (“together, let’s protect all children from AIDS”). Hospital staff visited a number of different local schools, gave short presentations on HIV/AIDS, and invited the children and their family members to the main event on the clinic grounds.

The celebration was an overwhelming success. Over 500 children, young adults, and parents attended. The event included a variety of fun and games, such as musical chairs and a quiz competition, vocal and dance performances by local children and young adults, and a main presentation on HIV/AIDS by Dr. Casseus.

The event was conceptualized, planned, and executed almost entirely by the health professionals at the clinic. Our main contributions were to make HIV/AIDS ribbons, signs, and informational cards in Haitian Creole and to act as support staff. It was truly impressive to see the clinic staff mobilize to educate the community on this important and relevant issue. We offer our highest congratulations to everyone at the clinic on this amazing effort and look forward to reading about an even bigger celebration next year!

Medical Missionaries Newsletter Update--11/08

2008-11-14T12:01:00.000-06:00

It is an exciting time to be at St. Joseph’s Clinic. Since we arrived just about four months ago to start our fellowship year here in Thomassique, the clinic has undergone a dramatic expansion in its layout, staff, and services, increasing the standard of care being provided and attracting greater numbers of patients each week. Working with Dr. Casseus—the clinic’s outstanding acting administrator—and the rest of the staff to implement these changes has been an incredible learning experience for the two of us.

We are very fortunate to have received several amazing additions to our staff here at the clinic. Merlineda, an auxiliary nurse with specialized training in midwifery, arrived in September to assist Ginette, our extraordinarily tireless and capable midwife. With help from Saphira—who maintains records for prenatal patients—the two are providing exceptional care to pregnant women at the clinic. In the emergency room, a stream of auxiliary nurses has been coming to the clinic for training under the first-rate supervision of Caty, our emergency nurse. Down, our promising x-ray technician in-training, has been receiving instruction at a nearby Partners-In-Health/Zanmi Lasante facility in Cerca La Source and is now ready to start doing radiography at the clinic. While he awaits installation of the x-ray machine, Down has been selflessly volunteering dozens of hours in the clinic lab, where he assists Rigot, our resourceful lab technician, in conducting a growing battery of laboratory tests.

In the kitchen, Mdme. Jilber, the clinic’s talented cook, is now joined by Delimène, whose assistance in preparing quality food for our live-in staff is certainly appreciated. Finally, two Haitian social service physicians, Drs. Mondesir and Julus, will be arriving in December to work alongside Drs. Casseus and Baudelaire, doubling the number of doctors at St. Joseph’s. Their presence will greatly reduce the burden on the two current physicians, whose patient loads (as many as 70 patients each on some days) are nothing short of formidable.

After months of unpacking, sorting, moving, and scrubbing, we have doubled the amount of usable space in the clinic, allowing for substantial improvements to the clinic’s layout and functioning. Pregnant women now enjoy their own recovery/in-patient, consultation, and waiting areas physically separated from those dedicated to the clinic’s sick patients. Sick patients now see the triage nurse, Lineda, and wait for their consultations in a well-ventilated waiting room and, if necessary, are housed for overnight observation in one of three separate in-patient rooms based on their gender and age. The clinic’s pharmacists, Mdme. Jezula and Manoutha, fill prescriptions in a significantly larger pharmacy and Jean and Patrick, who run the front desk, now have a whole other room to house the clinic’s growing collection of patient records. Finally, François, Faustin, and Ygnace, the clinic’s maintenance and cleaning staff members, have been working with Ron Burrell to construct a new dormitory building for use by visiting American teams.

In addition to x-ray radiography and sonography, which should be available in the near future, the clinic has started to offer nutritional consultations twice a month for pregnant women in collaboration with World Vision, a Christian relief, development, and advocacy organization that does work throughout Haiti. Representatives of World Vision come twice a month to the clinic to do the consultations, thereby encouraging pregnant women in the community to utilize the prenatal services available at the clinic. With the help of Peter Dirr, we are also exploring the possibility of starting our own nutrition program for undernourished children using Medika Mamba, a fortified peanut-based RUTF (Ready to Use Therapeutic Food) manufactured in Haiti.

Outside of the hospital walls, we are at various stages in several projects within Thomassique. While enrolling children in school (as part of a school funding project for which we are in the process of seeking US sponsors) we came across Pastor Resulmy Metellus, the director of Ecole Mixte Secours d'en Haut (EMSH), a local school that provides low-cost education to students of all ages. After a series of pleasant and profession interactions with Pastor Metellus we decided to pursue funding for a school lunch program at the site from the Minnesota-based Feed My Starving Children non-profit organization. To our excitement, the grant was accepted, and 35,640 meals are now on their way to Thomassique! In addition to helping oversee the implementation of the program when the food arrives in January, we are teaching weekly English and health courses at the school. Finally, we are in the nascent stages of a water filtration project, with which we hope to involve a team of Duke students this coming summer through the DukeEngage program.

So far our time in Thomassique has been productive and stimulating. Getting to live, work, and interact with the Haitian staff at the hospital is truly rewarding. There still is certainly much work to be done here at the clinic and throughout Thomassique but we are excited to move forward. We have been given an incredible opportunity by Medical Missionaries and are anxious to make the most of it.

PWOBLÈM!

2008-11-14T11:56:00.000-06:00

We sincerely apologize for not keeping the blog up to date. We were shocked when we went to the page and realized it has been over 2 months since we last posted! Our lack of posting does speak to the busy and hectic schedule we have had—our major projects of late have included completely reorganizing the hospital in order to accommodate two new Haitian doctors who will be joining the staff at Saint Joseph (and we will soon be posting an updated virtual tour), working on the logistical details of the school lunch program, and further researching and designing the clean water project and a project to address childhood malnutrition in Thomassique.

In addition to our intense work schedule, we have some technical difficulties which actually physically prevented us from posting. About seven weeks ago, the clinic’s temporary wind measurement device was struck by lightening which caused a small electrical fire in one of our inverters and (as a result of its subsequent fall) broke four of the 24 solar panels on top of the staff house. We then hired a local electrician to come look at the problem and he rewired the panels incorrectly, blowing out the diodes in an additional 12 panels. “PWOBLÈM!” as we say in Kreyòl.

After the electrical problems, we were left running mostly off our generator which uses diesel at a very fast rate. In order to cut down use, we were down to only a few hours of electricity each evening. To make even more complicated, we woke up one morning with no internet access—our satellite dish was no longer picking up a signal. We called the company only to find they had replaced the satellite we were using (without notifying us we were about to lose service) and now our dish was no longer pointed in the right direction. After weeks of heated discussion with the company, and several broken promises on their part, a technician from Port-au-Prince finally made it out to Thomassique last week to re-position the dish.

About half-way through this ordeal, both of our computers’ power cords had mysteriously stopped working. After obtaining new power cords special delivery from visitors to the clinic, we had even greater computer issues—Nick’s monitor no longer works and my hard-drive is completely fried.

Eventually the Medical Missionaries engineer/our personal savior for all things that go wrong at the clinic, Ron, made it down to Thomassique and repaired the diodes so we are again running with power almost all the time.

Despite all these trials, we are still greatly enjoying our time in Thomassique and have been able to make good progress at the clinic. We just have not been keeping up the blog. Please accept our apologies and we will do our best to keep it more up to date!

Good News . . .

2008-09-10T18:00:00.002-06:00

SCHOOL LUNCH PROGRAM APPROVED!!! Updates to come!

Kreyòl

2008-09-10T17:43:00.001-06:00

One of the most challenging and rewarding components of the fellowship experience so far has been learning how to communicate in Haitian Creole (kreyòl), which is spoken by over 12 million people across the globe (8.5 million in Haiti and 3.5 million diasporic Haitians abroad). Kreyòl is the only language that is truly shared by all Haitians (less than 10% of whom are proficient in French) and is the major medium of communication at the hospital. With vocabulary from 18th Century French--along with some Portuguese, Spanish and (more recently) English--plugged into syntax of West Africa origin, kreyòl is a mesh of influences that is both extremely fun and at times a bit frustrating to tackle.

Extremely fun, for one, because of its simplified grammar. After eight years of Spanish, it has been a true pleasure dealing with kreyòl grammar, which is much more similar to Asian languages like Chinese (in that verbs do not change and there is no gender) than to the romance languages from which it draws most of its vocabulary. Rather than indicating tense by changing the verb, kreyòl has a limited number of small tense markers that are placed in front of the stationary verb. For example: I walk = M mache, I am walking = M ap mache, I walked = M te mache, and I would walk = M ta mache. Since memorizing verb inflections was basically the bane of my Spanish-learning experience, I have found this difference to be rather exhilarating.

Probably the most frustrating part of learning Haitian Creole is its glaring lack of standardization--both with regard to the major lexical differences in the spoken "rek" (dialect) across regions as well as the lack of consensus on its written form. Regional differences in dialect are certainly not unique to Haiti or kreyòl, but have nonetheless led me to pull out proverbs and slang phrases I learned from the various texts I studied before coming here only to be met by blank stares or giggles. What is even more embarrassing, perhaps, is when people play along and it is only until much later that I find out (usually from one of the kids who hang around the clinic) that the phrase I was using so fondly actually comes across as complete gibberish here in Thomassique. It turns out that most of the authors of my kreyòl textbooks are not from the eastern part of the Central Plateau--go figure!

The non-standardization of written kreyòl, on the other hand, is intimately tied to Haiti's history and is the direct result of decades--indeed centuries--of refusal on the part of the national government (historically controlled by the Haitian elites) to acknowledge kreyòl as a wholly developed language deserving of its full support. As a result of this neglect, colonial French (which still carries a certain amount of prestige among those who speak it) has been, and still is, the preferred means of written communication in many formal settings (e.g., schools, hospitals). Indeed, despite the strong efforts of Haitian Creolists in the past couple decades to bring about written standardization of the language and produce a number of kreyòl texts, many schools still strongly emphasize French at the expense of kreyòl, so even many educated Haitians are not fully literate in their native language.

This particular point was brought home the other day when the clinic's chief physician, Dr. Casseus, joked that I (who have never taken a French course in my life) was probably more literate in kreyòl than he was after I made fun of him for texting his wife (with whom he speaks exclusively in kreyòl) in French. Indeed, even though I thought it would be a major burden at first, my lack of previous exposure to French has turned out to be somewhat of a blessing in that it is freeing me to learn a more pure version of kreyòl than might otherwise be possible if I were free to fall back on a reservoir of French vocabulary, which is often understood here though not used preferably.

All in all, learning kreyòl has definitely been one of my favorite parts of being here and is something I very much hope to continue after I leave. There is a relatively large diasporic population of Haitians in South Africa (where I will be living after my time here) and a huge population of Haitian Americans in Boston (where I am originally from) so I am pretty hopeful, but it will certainly take a conscious effort.

Community Health Projects: Part I

2008-09-02T12:03:00.002-06:00

Upon arriving in Thomassique, the poverty and need in city are immediately obvious. For the first few weeks however, the poverty seemed to be just a vague presence and we did not have any concrete ideas on how to go about effecting change for the inhabitants. One of the coolest aspects of the fellowship is that, once ideas do inevitably arise about how to improve life in the city, the fellows are free to formulate ideas, design a plan, and implement any project they want. For Nick and me, it only took these few weeks before our combined experiences and contacts in the States coalesced into two initial projects we are incredibly excited about.

The first project we are working on is a school lunch project for Ecole Mixte Secours d'en Haut (EMSH), an elementary school with about 175 students located in downtown Thomassique. Through our contact with the director, Pastor Resulmy Metellus, while enrolling children funded by Medical Missionaries personnel, we learned how EMSH seeks to provide affordable, quality education to children in the community who are unable to pay for the other local schools. Given the school’s humanitarian focus and reasonable size, we decided that this school would be an ideal site for reaching children in great need of additional nourishment.

Although many children in Thomassique are under- or mal- nourished, the city currently has no food program for children. A school food program is an ideal means to address this deficit; such a program would improve both the health status and mental development of the children involved. Numerous studies (e.g., Food for Education: Reviewing the Evidence; UN World Food Programme 2006) have established a concrete link between providing meals to hungry children in school and improved health and learning outcomes.

We submitted our proposal for food to an international organization, Feed My Starving Children, which takes care of the costs of food and packing and, if our request is approved, we will be raising money through Medical Missionaries for the shipping. With a bit of luck we hope to be able to implement the plan by December and organize its continuation and expansion for next year.

Our second project is still in its conception stages but we have the next 10 months to perfect it. Thomassique currently does not have any location where inhabitants can find potable water and diarrhea is one of the most frequent problems we encounter at the clinic. To address this we want to start a clean water project, beginning by installing large sand filters at 5 schools and then providing an education session at each school about why it is essential that people drink only treated water. We are also working on how to install filters at the community pumps where most people obtain their water. This is proving to be a more difficult endeavor based on the huge volume of water consumed at each pump everyday. We will be meeting with the Thomassique Water Committee in the next few weeks to discuss with them their ideas for the project and to identify how we could best incorporate the community in the installation and upkeep of the filters.

Although both projects are really just beginning, imagining ways to make the community better and then designing precisely how we can effect these changes has been a very exciting process for the two of us. Updates to follow!

Mission Impossible--Organizing the Hospital

2008-08-12T17:37:00.005-06:00

One month! We can hardly believe four weeks have gone by, but as we think back and consider what we have accomplished in the clinic so far we realize that we’ve been using our time pretty well. We showed up in Thomassique just one day before the arrival of a sea container (a sea container is the back compartment of a semi-truck packed by Medical Missionaries volunteers in Virginia with everything the hospital needs, plus a few extra treats like brownie mix and a new x-ray machine), which meant refills of all hospital essentials but also a huge organizational challenge for the two of us. The clinic is fairly small and does not have much space for storage, so efficient and organized distribution of supplies is of the utmost importance.

We began in the “ti fanmasi” or “little pharmacy” (room #4 in the blueprint above) where all the supplies for bandage/dressing changes and emergency care are stored. After hours of sorting different sizes of sterile gloves, packing lockers full of band-aids and antibiotic ointment, and figuring out which sutures are useful at the hospital, the ti fanmasi was again in functioning condition. From there, we moved to the “sal gwo fenet” or “big window room” (room #5). This room was originally conceptualized as a break room for staff members but slowly evolved into an overflow storage room. At this point, we sat down and had a serious brainstorm about re-imagining the arrangement of the entire hospital to improve patient flow and overall feng shui. The big window room appeared to us as the perfect space for an official waiting room. Previously, patients waited in chairs lining the hallway that leads to the doctors’ consultation rooms (rooms #8 and #9) and the mid-wife’s office (room #10). We decided that this arrangement both impeded flow and grouped patients with many different illnesses closely together in a poorly ventilated space. Furthermore, the pregnant women waited in the same area as the sick patients—far from an ideal arrangement. And so the big window room became the sick patient waiting room. We are beginning the new arrangement this week and in a few weeks we will update you on how it has been working.

The next challenge we faced was reclaiming the pediatric room (room #7) from the brooms, cleaning supplies, dust, and random boxes which made it unusable for housing inpatients. After relocating the cleaning supplies and boxes, scrubbing the crib and bed already in the room, and digging out some “Little Mermaid” and “Tazmanian Devil” sheets, the pediatric room has finally become a place where pediatric patients and their families can stay while in the hospital. After we have finished all other organizing, our plan is to repaint and decorate the pediatric room so that it really resembles a haven for children in a place that can sometimes be scary.

Finally, we headed downstairs to reorganize the depot where medicines are stored (room #16) and to clear out the big room where patients receive vaccines and wait to have prescriptions filled (room #15). The depot took some work, but after Nick repacked about 100 boxes and Rita applied her favorite blue labels (which can be found on literally every box in the entire hospital) we now find it a place of relaxation and peace--sometimes we go there to meditate. Not really, but it’s so clean and organized we probably could.

If you look at the slide show above, we hope you can get an idea of the layout of the clinic and what the conditions are really like. Our next projects involve sorting clothes and shoes which have been donated to the clinic but have not yet been organized or distributed to the community. Distributing these items will allow us to both give these much-needed items to the community as well as gain two large rooms being currently used to store the items. One room will be used for our x-ray imaging lab which we hope will be functioning by the end of October and we are imagining the other one as an overnight space for mothers and their newborns. Updates on the rooms will come up in a few weeks!

Our first "patients"

2008-07-30T18:03:00.000-06:00

Practice makes perfect, so they say. These past few weeks, under the guidance of Julian and Dr. Casseus, we have been diligently practicing our suturing and local anesthesia administration technique on some very stoic patients...a half dozen mangos! It turns out that mangos work especially well for practicing suturing due to their fleshy tissue and tough skin. Despite the ridiculousness of performing a medical procedure on a piece of fruit, we have been trying to take the practice runs very seriously—tightly maintaining our sterile fields and making sure to provide ample Lidocaine to prevent the 'patient' from feeling anything. We've included some photos of the end results of two recent trials above.

Welcome to our blog!

2008-07-30T16:42:00.004-06:00

In an effort to stay in touch with our friends and family back home and to give next year's applicants a sense of what it is that we do here, we have decided to keep a blog of our progress as the 2008-2009 Medical Missionaries Post-Baccalaureate Fellows working at St. Joseph Clinic here in Thomassique, Haiti. We hope to update the blog on a bi-monthly basis and will be posting stories, pictures, songs, and anything else you might want to experience from life in Thomassique. Julian Hertz and Ashley Pavlic, last year's fellows, will also be posting retroactively about their experiences here as they begin their medical school careers at Duke and Northwestern, respectively.

St. Joseph Clinic opened in June 2007 and is funded by Medical Missionaries, Inc., a Virginia-based non-profit organization dedicated to providing health care, medical support, medical education, and training to under-served communities around the world regardless of race, religion, or political affiliation. We are here at the clinic acting as liaisons between the US organization and the fully Haitian staff at the hospital, helping run and organize things at the clinic, coordinating logistics and translation for visiting teams of US doctors, and assisting staff members throughout the day in providing care to its many daily patients.

St. Joseph Clinic is located on the northeastern corner of Thomassique (check out maps.google.com: Thomassique, Haiti, then click satellite view), about a 15 minute walk from downtown. Thomassique proper has approximately 45,000 inhabitants but, including the surrounding countryside, the clinic serves about 100,000 people. The next nearest hospital is a 1.5 hour drive away. The services provided by the clinic include consultations for sick patients, deliveries, prescription and non-prescription drugs, a number of laboratory tests, and basic emergency care. The clinic most notably does not have a resident surgeon (and thus does not provide regular surgeries, including caesarian sections) and does not currently have an AIDS program. The clinic is run by an all Haitian staff (excluding the Medical Missionaries fellows) comprising two doctors, one mid-wife, one nurse, two front desk attendants, a laboratory technician, two pharmacists, and two triage/auxiliary nurses. The clinic hopes to add x-ray imaging to its available services and is therefore in the process of hiring an x-ray technician. Periodically, teams of American physicians and surgeons come down for one to two week trips to see patients, do surgeries, and offer any assistance they can to the clinic.

Thank you so much for visiting! We hope you enjoy our postings and we'll try to provide interesting and frequent updates. Below you can find a slideshow of photos from our first couple weeks here in Thomassique!

Love,
Rita Baumgartner and Nick Cuneo