Sunday, August 8, 2010

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).

Thursday, June 10, 2010

Community-led Initiatives in Thomassique

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.

Thursday, May 20, 2010

Improving Access to Healthcare in Thomassique

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!

Sunday, April 18, 2010

Tet Ansanm

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.

Surgical Visit 2010

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

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

Water Update

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.

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.

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 Clinic.  St. Joseph Clinic 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, 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 project 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 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!