Bon Sel Dayiti

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 fort ified 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

 

Pwoje Dlo a and Boutey Soley

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 o ur 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.