Kenel' first week with urban farmers in Portland, Oregon

Kenel has come to Portland from Hinche to spend the year in Portland, Oregon.  Having, through no fault of his own, lost his agricultural school scholarship in Haiti, Oregon State University offered him a year internship in small farm agriculture and sustainability.  This blog, which we will try to write together hopes to document what he learns and its relevance to life in Haiti.

The United Nations estimates that 6.7 million Hatiens are food insecure.  Three quarters of the people live on less than $2 per day and over half live on less than $1.   Many of the most loved foods and indeed staples are imported and many crops face the challenges of hurricanes, droughts, a lack of irrigation and a loss of top soil due to de-forestation.

In Portland, many people have re-committed themselves to local, seasonal food, small farms, cooperative agriculture, backyard bees and chickens, rain catchment and preserving food.   Can these farmers and alternative technology engineers teach Kenel things that might help the people of Haiti?  Can Kenel come to understand the ancient wisdom of his island; things often lost in the centuries of slavery, colonization and dictatorships.   What can he learn about global economics and politics and how it effected hunger on his home island?

He has been here one week and I am humbled every minute by what we have in comparison to an average rural family in Haiti.  It is making me look at everything.   But for now we are rolling up our sleeves and making pickles, catsup and drying our harvest.  We are digging into the question of food preservation both here and in Haiti.   i look at my yard, full of ornamentals and see all the food that could be grown there; food for my family and food for the food bank.

It has been fun to watch Kenel ride his bike through Portland, work on a small farm, help the school gardner and take his first stab at bee keeping.  He has seen and tasted so much.

Here is Kenel.....

My first week at school in Portland, Oregon it was very good.  I learned a lot about farming, I learned how to plant things to feed people. I think it was pretty easy to me, I hope next week it will be good too.  I learned about bees so I think many of you guys know how important bees is important in the world, the bees help us pollinate plants in the world. I hope when I return to Haiti I will teach people how to do bees more than they know already. I am so happy to be in United States of America for school and then bring what I learned back to Haiti, Haiti needs that and Haiti wants that too in the future.

    

Recovery

I do not recover easily. It is two months and I still am overcome each day with joint pain and exhaustion.   They say it is harder on the elderly.  No one has much heard of it in Oregon and there is not much to do but tough it out.

I organize my day to cope.  The medical community does not offer much but I pick up ideas and try things.  In the living room is a water, foot soaking machine.  I put my feet in when it gets too bad.  My foster son suggests pressure socks which are a miracle for pain relief.  I design one pair for my hands.  I shower, put on ice packs and take a wide range of anti- inflamatory medicines and herbs.   I take naps but then must putter around to relieve the pain and keep my sanity.   I complete small tasks.  I have good days and hard days.

I study viruses for about an hour a day.  I draw diagrams and make illustrations.  I live in a summer sweet place with flowers and soft breezes.  In this place, I retreat and try to give my body space and time to get over the assault to its system.  I try accupuncture and lymphatic massage.  I try positive thinking.  I try despair.

I dream I am on the beach, waiting for a boat to LaGonave and something explodes and is on fire and then I realize it is me.  I am trying to get in the water and put the fire out. The people hold me back and say it is a ship but I struggle because i have to get in the water and put out the fire.

It is hard for me to think about Haiti.  I panic.  But soon Kenel is coming to start his internship and I have begun my study of Kreyol in my quiet afternoons.

I have gotten a small, black baby lamb.  When I thought I was dying I thought I'd like a field of clover with a baby lamb to watch graze.   I know from being a midwife that a big part of overcoming pain is filling your pallet with beauty and so I retreat and let the flowers and good things surround me.   I welcome visitors who sit beside me as I slip off.   Chikun- what?

On the pain chart I am still at focusing on the pain almost always but once in awhile I get it all right for a little while and I am somewhere else.  I had decided to learn global maternal health in the real world.  I prayed for understanding and wisdom.  Will this ever go away?  Will I be wiser or just weaker and beaten by the pain?

I try to focus on how fortunate I am to have the tools I have; to have food that is easy to prepare, water and a soft place to rest.  But when it climbs inside me and I cannot get it to calm down, I struggle with gratitude.  I sink. I do not what anyone to watch this struggle. I an animal who seeks that quiet place.  Sometimes I welcome distraction but it does not work well sometimes.  I try to laugh and keep a smile.  I pull weeds and try to keep my garden alive.

I try to think of others but pain is selfish.  People say I should not have gone there, anyway.  They hope I have learned a lesson.   Is there a lesson to a random mosquito, carrying a virus, landing on you?   I say the virus was around since 1950 making lots of people sick and unable to go to work.   I cannot explain how unfair it is that it is only getting recognition because its coming to the Americas.

There are other problems- a far worst virus breaking out in Africa, wars and children at our borders.   I clean much neglected cupboards.  Too tired to recycle, I build outdoor fires and drink tea while the little black lamb grazes at sunset and the white garden glows in the summer dusk.

Roads, remote clinics and lymphs systems

The plan was to visit each of the four chosen mobile clinic sites in that one week.  We would be able to help with the set up, assess potential obstacles and see what additional supplies and support were
needed.

The sites were remote and far up into the mountains.  We piled into vans and made our way.  The roads were often more of a foot path;  intended only for animals and people walking and not for vehicles.  There were no tap-taps and rarely even a moto.   With each foot spent climbing upwards, I was aware of how it would be nearly impossible to get a woman down in an emergency.   It was far but there were also no vehicles and the going was very slow, even with one.  The idea of the mobile clinics was to prevent complications, treat what could be treated and help women to know if they should wait for their  birth in a place closer to emergency care.  

The roads in Haiti make transport for emergency medical care in childbirth almost impossible.

Meanwhile the lymph system within me, was also trying to assess the damage being wracked inside it. The tiny viruses ( 1/100 th the size of a bacteria ) were trying to reproduce inside my cells.  They cannot reproduce without invading a host cell and in this case I was the host; bouncing along rocky, dirt  roads.   My body was fighting hard to eliminate them through my own internal paths of immune system.   It was trying to understand who the new virus was and make antibodies to stop it.

We climbed higher and higher,finally coming to a flat, fertile area; isolated but lovely.  The clinic was held in a church and with the help of the community health worker and midwife was quickly set up and seeing the women who had gathered there. They were told the midwife and doctor would come every month.  It was a moment of hope and possibility.

After about an hour, I forced myself to fall  down in the grass rather than faint.   My blood pressure, always low was even lower.  I laid looking up into a tree  with my world spinning about me.  The nurse continued to say I could not possibly have Chikungunya so I lay there wondering what I could possibly have.  

In time, I would see that just as the roads to the village were critical in saving lives, our own internal highways of lymph would be critical in saving my own.  Was it working well?  was it free of rocks and potholes and able to quickly eliminate the dead cells that carried the virus?   Just as I had never thought of roads as a critical component of good midwifery care, I had taken my lymph highway for granted.

When the women were all care for and we packed to go back to town, I began to ached from head to toe.  I limped to the truck, up the steps and fell into a delirium of cold and hot.  Later, much later the CDC in the United States would confirm it was indeed Chikungunya.   By Wednesday night, after our second mobile clinic visit, a nurse had developed some symptoms too and it was decided to go home.

The Plant Doctors

When we arrived, Monday morning, at the clinic, my symptoms were obvious to the women who daily heal friends and neighbors  with plants and water.  I could not stand straight and was already demonstrating the tell tale limp and bent posture for which it was named in Africa.  It means "bent person" and I was bent.

Children learn plant medicine by watching their grandmothers from an early age. Here they laugh as they prepare a bath for me.  

During the presentations and workshop I nearly passed out.   As soon as we were finished, the women, hurried me back to the cooking house and ordered me to take off my clothes.   A large pot of plants were waiting.  The little girls laughed and played.  How many times I had watched, as they prepared plant medicines, just steps from the clinics pharmacy.  These two worlds did not seem to meet.  I would ask the name of plants and press a leaf in my book and try to grasp what it was used for.   It was their main medical system.  They had no money for medicine but there were always the plants and their ancient wisdom. Inside, the doctors complained that there was no medicines anyway and everyone debated why there were no medicines and how to regulate them and if they were being stolen.  Outside they made their own medicines and distributed it to me with love.

Treatment for Chikungunya

Soon, I was being scrubbed, head to toe, with leaves.  The water and the brush of the plants offered some relief.   Their hands moved quickly and with skill.   They knew what had to be done.

The water and the plants and the rubbing all helped support my lymph system which was desperately trying to identify the virus, make cells to destroy it and eliminate it from my body.  With no formal education, they knew what to do.   Had I stayed, there would have been more baths but I left shortly after; bits of leaves clinging to my skin and woven into my dripping hair.

That night my body, taking advantage of my sleep, burned as it tried to further destroy the virus.   I tossed with wild dreams, sweat and chills until morning when I could try to go get a cup of tea and sit in the sun.

Many times, as my body ached, I would recall the bath on the mountainside of LaGonave.

The invasion of the unsuspecting cell

By the time we arrived at the church compound, Friday night, the virus had begun to make its way into my unsuspecting cells.   They had faced cold and flu viruses many times and had antibodies to fight them but this was a stranger.  The virus tricked the cell into letting them in.  Its kind of like the Trojan Horse.  It pretended it was friendly but soon my cells knew that it's goal was to take over and use my healthy cells as a place to reproduce.

Boats in the harbor of LaGonave

All over the southern hemisphere viruses deposited by this species of mosquito were making similar invasions.  I did not know about the battle starting to be waged inside me.  We walked to the docks and looked at the fishing boats; large beautiful wooden sail boats that now mostly carried cargo and charcoal back and forth from Port Au Prince.  We visited with the sailors and sat in the evening sun. I think it was the last time I would walk  without pain or stiffness and muscle spasms.

If the mosquito had carried malaria, it would have found its way to the liver.   The people of most Malaria prone countries, do not take a daily malaria pill and few sleep under treated nets.  They assume they will get the virus and gain immunity over time.  If it was dengue, each time the virus entered the body it would get worst.  It would burst through small blood vessels and cause internal bleeding.  The ChickV would find its way to the joints and cause disability.

Kenel was going back to Port-Au- Prince at dawn to work on his visa application.  He had been accepted in an agricultural internship program through Oregon State University and was anxious to take the next steps.  I would wait for the nursing team that was to meet me there and help get the mobile clinics up and going.  There was an important training on Monday and I was trying to go over and over the plan.  I wanted them to work in village teams with the midwives to plan and implement the clinics.  I wanted to be supportive while allowing them to work together on the details.

By this time, the virus had multiplied and burst out of the host cell and into my blood stream where each new virus would find a new cell.

ChickV Virus

My adaptive immune system was working as hard as it could to make antibodies against the new virus.  A war was being mounted within me.  By Sunday the effects were being felt and I suspected the big mosquito that had made such a splat was the cause.  I did not know much about the virus they were talking about and I had no internet.  I read the CDC hand-out the nurses brought and listened to what other's said.

By Sunday night my immune system raised my temperature and I was on fire all night long.   Hot, shaking, burning body with a extreme head ache.  By morning,  the fever passed and the head ache subsided. My legs no longer worked as they had. I could not bend my knees.  I was in constant pain.

I couldn't eat and did not eat for days.  I suggested that I thought it was the chickungunya virus that people talked about.  The priest and the Phd nurses were absolutely sure I did not have it. They shook their heads in the courtyard and said "no, its something else."  I was pretty sure if it was something else I was going to die shortly.  It was not anything I had experience before but had no energy to or information to confirm my suspicions.

I only hoped I could pull off he training and would not fall over in pain and weakness.

Getting to know the mosquito

I try to get to know the mosquito who. long dead and decomposing, has caused  me and so many others  lives to be turned upside down.

She ( the female is the one who sucks your blood ) so I know she was a mother; a mother who needed to fill her abdomen with fresh blood in order to feed her young.

Here she is.  The mosquito that causes yellow fever, malaria, dengue and the virus I got; chikungunya. 

Her relatives, all 3500 species, cause 700,00 to a million deaths each year in mostly young children.
She is known as the anophiles mosquito.; aedes aegypti.  Mosquito means small fly in Spanish.

I think of her being born in the small cave across from the clinic; a hole with large rocks where garbage is thrown.  It is a perfect place to be laid and turn into a grown mosquito.  Her along with some 500 brothers and sisters floated there in an egg based raft.  There they could survive in dry times, waiting for the rains that would come and set them free.  There she hatched into a larvae and wiggled and wiggled changing her skin four times, swimming and diving before merging into a pupa stage for a quiet day of rest and fasting before emerging as a grown mosquito.  Did she rest there letting her body harden before making her way to a rock where she let her wings dry in the sun.  She would not live long but longer than the boys who hatched with her.  She had a few weeks but they only had a few days to mate and carry on the cycle.

There beside the limestone rocks she found her mate and began to grow her own young.  I could not have been her first tasty meal of blood.  She had to have sucked blood from someone else with chickungunya.  Others would suck blood from a person infected with malaria or dengue.   It was all being exchanged from person to mosquito all around us.  Her small wings flapped 500 times in a second.  This might have warned me but we were all talking and laughing.  It was afternoon but never mind.  She did not wait for evening as some mosquitoes.   Afternoon was fine.  She needed blood to complete the life cycle; her life purpose.

When she landed on me, she acted quickly, inserting her flexible mouth tube into my skin. It bent searching for a vein to get blood from and releasing the infected salavia into my system.  She neither filled her abdomen or lived to lay her eggs.  Swat.  A young child's hand reached out and smacked her, blood smeared on my leg and their hand.

Had she been sucessful, she could hve flown back to he edge of the same pool and laid her own eggs or waited a few more days for another blood meal.

Though she dies, the virus was busy finding cells to enter inside my body and beginning its task of reproduction.  For the next week if another mosquito bit me, I passed on the virus to the new mosquito who in turn gave it to another person. All over Haiti and the Caribbean this cycle was being duplicated in a rising epedemic.

My immune system, unaccustomed to the virus, had to create a way of attacking the problem.  As I continued to do trainings and prepare for the mobile clinics, a war was taking place in my body.  I had  come to do a very specific task and had created a schedule that I had hoped would result in the greatest benefit.  I had hoped it would set the stage to prevent death and disability in the mountains.

But I, like hundreds of thouands of people around the world would be stopped in my tracks by the same species of mosquito that caused yellow fever, malaria, dengue and now chickungunya.   Twenty four hours after the blood feast, I headed to town. The driver was sick; crazy sick.   We were all spreading it, from ignorance and poor diagnostic skill, passing the virus from one to another through the mosquito.

My personal mosquito was dead but the effect of her blood meal was gaining speed and power within me.

Chikungunya - The Bite

I am sitting on the steps outside the Bill Rice Clinic in LaGonave.   We had just had a great training with the matrones and community health workers.   Spirits were high and the children I had known so well, were gathered around me.  Kenel, from Henche was translating for me and was there too.  It felt perfect.   The children scream "Sarah" and swat a large mosquito who was biting my leg.  It is huge and stripped.  Blood goes everywhere.  It is not like any other mosquito I had ever seen before but I did not think about it.  We returned to our laughter and chatter.

Minutes before "the blood meal" they take pictures of the matrons and agent santes who attended the training. 

The good, good woman who helps me there comes over to us. She is walking with a stick and is all bent over.

"What happened?" I ask her, with concern.  She looks in so much pain.

"A mosquito."

I beg her not to help me.  I'll be fine I tell her but she shakes her head and smiles through the pain.  I remember that smile.  The smile that comes through the pain.  The need to be distracted and to keep moving so the body does not freeze.

Later we sit out back while everyone prepares for night.  Fires our built. Water is gathered.  Girls fix each others hair.   They try to fix mine.  Kenel is on the roof with the midwives; laughing and looking down at us.

I did not, could not know that the virus was beginning to take hold in my body.  The mosquito that bit me was dead but four days earlier she had bit someone else with chikungunya.  Its how it is passed from person to person.   It was first described in 1952 in Tanzania.  It made its way to the small mountain village of Haiti where I rested in days end.

As I laid down, under a veil of mosquito nets, the virus was invading healthy cells and reproducing.  Outside people were talking in the dark; telling stories and letting their laughter drift over my body.

Tomorrow we would work on the mobile clinic bags, create a pharmacy list and do Helping Babies Breathe with the whole staff.

Inside my body, my immune system was beginning to mount its defense against the invader.   I had several things working against me. I was older and had only nine months earlier had radiation for breast cancer.  My immune system had already taken a beating.

Chikungunya - This is the health department

Chikunguya


The voice is from the health department.  She has to talk to me because I am host to a battle between the virus, Chikungunya, and my own compromised immune system.  She is asking me when I went to Haiti, when I thought I was bit by the troubling mosquito, when I left.

Chikungunya was first identified in Africa and spread to Asia.  The CDC watches its spread to the Americas.

Did I leave the hotel in Florida?  Was I bit there?   They are afraid someone will bring it back and then a US mosquito will bite them and it will begin to spread as fast as it spread throughout the world.

"I only walked to the Denny's across the parking lot. I don't think I was bitten again but I can not be sure." I am no longer sure of anything.

I tell her I need to look at a calendar.  I can not think about time.   I learn to live in the present; dealing with the constant pain I have felt since chikungunya entered my body.   Has it been weeks? Months? Days?   I only can think of what I can try to stop the pain.  I use ice bags, buy supplements, rest, drink fresh juices, take pain medicines but it is always, always there.  I try anything and everything but a disease which has crippled millions of people is mostly unheard of here.  I am the only case in Oregon.  My doctor looked it up on the internet before seeing me.  The main concern was reporting it to the CDC.   "There is no cure."  she tells me but I knew that.

I try to answer her questions.  I cannot focus but then she tells me she worked in Haiti for a year and we turn our conversation to Haiti.   If I am in pain, what are the people there doing?  Will few volunteers arrive with the much needed pain  killers?   I take warm showers, ice my feet, wrap body parts in pain strips and drink clean water.  I have tylenol and mobic.  I can watch the whole 9th season of Greys Anatomy.

But I am trying to answer her questions. "Why did I go to Haiti?  Where was I ?   What was I doing?  When did I first notice I was sick?  What did I do?  Were other people sick?'  

I try to think and then the nightmares of memory return.   Everyday I look it up on the internet.  I search for the experiences of other people.  I look for reassurance and understanding.  

Since I was a child, I used writing to my life in order; to relieve the pain and confusion and to look for hope.   This is my story of global maternal health.  It has many chapters and this is one of them.

I can see the look in people's eyes or they come right out and say it.  "You shouldn't have been there in the first place.  We told you Haiti is not safe and now look at you."

I walk with a limp. I feel crippled.  I hope it will pass but I do not know.  I look at people on bicycles with wonder.  I once rode a bike. I once hiked in the forest.  I had walked up the mountainsides of Haiti.  Did I understand my risks?   Would I have gone anyway?

Here is my story in installments.

Pack it out.

Coming back from the mobile clinic, I look out the window at the dry river beds.  I am not sure why it is no longer filled with water but I can see it is filling up fast with plastic water bottles and garbage. The people of LaGonave do not drink water in water bottles so it is volunteers, like me.  We are filling the river with clear water and soda bottles.

Every other volunteer house I ever worked with bought large, recyclable bottles and people filled water bottles but we have a large, never ending source of water bottles.

My suggestion; bring you own refillable bottles and pack out any snack paper you bring.   I remember walking on a beach in Haiti and there was all this garbage and the man was complaining.  I asked why they just din't pick it up and he said, "But it isn't our garbage."  I looked around and knew he was right.  

I just got back from Haiti where I left many non biodegradable bottles in their waterways and countryside.  My joints may hurt form the mosquito bite but this hurts more.  Ouch.  A painful realization.

A few hours of plastic bottles and snack wrappers

No medicine

The children bring me to where a sick schoolchild refuses to eat lunch and waits with her head down to see the doctor.

Sweet, smart, dedicated, funny.   This doctor sits at the mobile clinic.  He has no medicine to give any patients.

Why are there no medicines?

Volunteers bring medicines, the partners send money but there is no medicine for day to day illnesses.   Who pays for medicines?  Who picks it up?  Who inventories it?   Is medicine that is donated allowed to be sold or should it be free?

I have thought this over.   The clinic charges for medicine; even donated medicines.   So, in a way this should be like a  micro loan.  The money made back should go into new medicines.  The inventory should, after the original investment, be self supporting.   It should go into buying new medicines but it does not.   It is not clear where it goes but it does not buy new stock and so there is no medicine.  It is never replenished by the clinic in Haiti.  They wait for a new amount of money to buy more.  This would make sense if the medicine was free but it is not.   Where is the profit from the pharmacy and the sale of medicines going?

As for me, I give  the medicine I brought to stop bleeding, directly to the midwives and tell them to keep it with them and never put it in the pharmacy.   It can also induce an abortion so it is a valuable commodity.  Are things taken, sold ?   I have no idea but you can not run a clinic without medicines.   It is an emergency but I can see it is not an emergency- anyway not the stop whatever you are doing and lets change this now, nothing is more important emergency.   The Dr tells me this is a serious problem.  He says people walk hours to come to the clinic and there is no medicine.  He says that is why no one comes anymore.  I say I will try but I am way,way down the line of anything close to having influence.  He begs me. He has tears in his eyes.  I look away.   

I ask whose responsibility this is.  It is, of course,the job of the priest who is also running all the churches, schools, lunch programs and lives on the mainland.  I suspect they think it is paying him great honor to ask him to micromanage things he knows nothing about.  

He tells us his daughter is sick and has to go to a clinic in Port-Au_Prince.  I trust the clinic will have the medicine she needs, he will have the means to get there and was paid so that he can buy the medicine.  

How can it change?    They can stop charging for medicines until the clinic demonstrates  a system of inventory, ordering and record keeping.  After time, let it be a  micro finance pharmacy business and let the pharmacist / clinic make a small profit after re-stocking the shelves.

There is a flurry of solutions proposed but when we leave the midwives have no mobile clinic pharmacy.  Volunteers get sick and we leave.   It is a sort of epidemic so perhaps no one will return for sometime.  No one really expected we could do anything anyway.  We hug and wave goodbye.  I lie face down on the ferry floor, trying to keep myself from throwing up.  I am grateful when the waves pour over me and I am cooled down.  With each sway of the boat, my head is smashed into the bench.  I am going home.  All the medicines I need for the virus will be easy to get.  

Oh the little girl.  She most likely has what many people have; a virus caused by a large, striped mosquito.  It hurts, I know, but I am home now and have pain medications and can get in a warm shower if it really bothers me.   We had nothing to offer her for her pain.  We drove back down the side of the mountain and she walked up a small trail to her home somewhere further up the hillside.  

Clinic Day

School children watch as the midwife listens to a baby's heartbeat.  

I love the drive  along the sea and up into the mountains of LaGonave. I study the soil and how many domesticated animals people have.  I notice if children are in school or walking along the roads.  I notice the location of the central market and how far it is form the village we are visiting.  Was World Vision once serving the community and is there now a hole in past services?   I notice these things as we pull into a lovely cluster of school and well and church.  It flat and the soil is a rich, dark color with well tended crops.  The churches large and all the buildings are well cared for.  This village has a strong partnership back in the United States and so perhaps this is the result of  long term care and support.

The ajan sante greets us.  There is no sign of the matrons and I wonder why.  We set up the church, pulling a series of shower curtains on a rope across the church.  They are sue to mobile clinics and know what to do. This is not true in our next site.  But it is always the same process sod setting up and turning any available site into a clinic while women sit on steps or under trees.

The midwife provides prenatal care on a school room floor.





The mobile clinics see about 25women on their first day. The plan is for the midwives to return once a month.
For the entire island to gain access to care it would require about 20 mobile clinics visiting villages once a month.  If each village had 50 women who needed care ( prenatal, postpartum and family planning ) it would cost about $2500 per village or $50 a woman.  With the ability to choose pregnancies and to gain reasonable assurance that they and their children would survive pregnancy and birth, families can begin to build strong futures. That women can choose when to have a baby and can have a chance not to die in birth is a human right.   What we need is 20 groups to adopt one village and to have that process run by the women of LaGonave; by the midwives and agent santes and mothers.   This seems pretty basic, right?   Its about like saying, there will be no rocks on the roads.  It seems impossible.

Getting ready for the mobile clinics

 I returned in June of 2014 to LaGonave, Haiti and tried my hardest to begin a process of establishing mobile prenatal clinics in remote villages.  Four villages were chosen by The LaGonave Partnership; a group of US churches who support and maintain a relationship with a village on LaGonave.  All the villages are connected by the Episcopal Church that appears to act as the governing body.  Each village has a small church with a lay leader, a school, a school lunch program and an adult literacy program.  All have a community health worker who lives in the village and, in theory, provides day to day health care.  The villages are 1-3 hours from a hospital, over very poor roads. in the event of a matronal emergency, it is unlikely the mother can reach care.  It is uncertain that there is a means to get her to care or that mergence services will be able to care for her should she arrive in time.

Meeting with the midwives, akan santes and matrons to play the new mobile clinics

The goal of the mobile clinics are the following;

1. To prevent, through education, screening and treatment, maternal and newborn problems leading to death and disability.
2. To allow families to build local economies without the additional burden of health care costs, orphaned children and the death of a mother.
3. To identify women who should have their babies in town, closer to emergency services.
4. To provide prenatal vitamin, safe birth kits and other medications as needed.
5. To support the collaboration of the the midwives, ajan santes, lay leaders and matrons.
6. To provide transport in the event of an emergency.
7. To provide safe waiting homes for women presenting with high risk pregnancies.
8. To provide life saving measures and medications to women in remote villages.

Everyone has fun practicing skin to skin birth techniques at a training on preventing postpartum problems for matrons, midwives and ajan santes.

My schedule for the "launch" of matronal/ newborn mobile clinics was intended to be democratic, inclusive and involve the people it would impact most,  in the decision making.  Within hours, if not days, I was made aware that there were no medications, no complete charts, no educational materials, and that the midwives and not been paid in months.  The "ambulance" is the car for the church.   All decisions go through the Father and must wait his approval.  The doctor, who is the medical director, also must ask him for everything; copies, medicines, water.  There is no system of independent, creative problem solving.  While I have worked for over a year to empower these two midwives to be critical thinkers, independent, responsible and caring practitioners, they are part of a large, complicated system that stretches across seas and countries and moves very, very slowly.  Despite this, bags are packed and we go to the villages ties and hold the clinics.   

"The women just die. We cannot get them anywhere."

After a crazy, wet speed boat ride to LaGonave from the mainland, I tumbled into the Episcopal Church where the lay leaders sat in scattered chairs waiting to meet.  I tasted like salt and was still dizzy from the ride.  I had not actually known they were really coming.  I had asked for the meeting but there they were.  The lay leaders are the ministers of small, distant villages who take care of the small churches and schools that are sponsored by the parish.   They are the leaders and had wanted to get  their support and advice in the starting of the mobile clinics.

I ask for their names and villages and what problems women faced in childbirth.  One by one they told me the same thing. Their village is hours from the hospital and mostly they do not try to get women to the hospital.  She simply dies.  It is too far.  Sometime, they said, they carry her on a bed down the mountain but even if they get to the hospital they might not see them.

There is no prenatal care.  Never.  World Vision use to supply some in some places but they left.

I explain that the clinic is sending a team out to work with their matrones and agent santes and that they will come once a month to provide some care.  In time, we hope to send a nurse or doctor who will also provide primary care.  I explain these things.  I tell them it will be free.  I explain that they can come to Bill Rice for free too.

Although the Bill Rice Clinic had been offering free prenatal care since I left, I could tell that no one had told them about that or about the birth center.  It is often too far, it is true, but they were not told.

As they talked about the many mothers who die each year in their villages, I felt  waves of such sorrow and injustice.  

I look at each village on the map and wee how far away they are and how difficult it is to get there.  I listen to what they tell me.  "The matornes have never been trained."    "We have no vehicles at all if something goes wrong."   "They bleed to death."   "They have eclampsia and never wake up."

The Hatien doctor, says each woman needs 3 sonograms in pregnancy.  I look at him in disbelief.  Is he listening?  They have no prenatal care and sometimes no matrone even and no transport in an emergency.  He is a sweet, charming man and he is the director of the program.  He had doubted this was possible but I hope by listening to the stories he feels a deeper commitment.

We have 10 days to set this in motion.   It is not too difficult but it is at the same time almost impossible.  They have to get to me or I have to get to them.  It is hours on bad roads.  The training takes time and yet their is not enough time to train people in skills often reserved for specialists.   We must prepare supplies and try to get a system of reporting and charting organized.

Kenel, who I met at Midwives for Haiti, is translating for me.  I am trying to help him with a farming internship in Oregon. He is starting a Fruit Trees for Haiti Project.  He does a good job and later we walk down to the small port and visit with the people who work there.  It is a warm, lazy evening in Haiti.  Tomorrow is a training with the matrons and agent santes.  I am hoping to build this sense of a health care team in the villages.  We review films and pictures and then I sleep until the church bells wake me at dawn.

Returning to LaGonave - June 2014

Lagonave

June 2014

The waiting area at the Fort Lauderdale Airport is filled with Haitians who happily greet one another. They form small, happy groups who visit until it is time to board the plane.  I let the sounds of Kreyol spill over me and drift back into my heart.   I speak in my awkward version of a language that is meant to be rhythmic and full of life.   My attempts are slow and labored as my brain switches gears and looks for the right words.

The people, who wait with me, have the means to travel back and forth and are a long, long way from the mountains of LaGonave.  They have money and a visa.   I wonder if they know what it is like for so many Haitians. But then someone could say that in my country too.   Do they look at me and think- ah a white missionary coming to save the souls of Haiti?  I say I am not a missionary but a midwife and they smile with a shrug.

I am never sure that the Haitien people would put maternal and newborn health at the top of their wish list.   They are ranked the highest for infant and maternal mortality in the western hemisphere but I suspect that data means far more to those of us committed to global maternal health than to the individual person in Haiti.   I remember the Haitien social year doctor telling me the statistics were all part of a plot against Haiti and were not true.   But then US medical people also gave me articles saying that the placement of the US alongside Cuba was also not true and a plot.   The rankings are suppose to make a country want to try to improve; not dig in their heels and defend what they are already doing.

I doubt myself.   I get sick and throw up in a planter in the airport.   Am I sick or is my body rejecting another plane ride and the wear and tear on body and soul I am about to put it through once again.

I had hesitated to come.   I had said I would return if they ever wanted to get mobile prenatal clinics up and going.  It was an offer in the midst of hopelessness.   Your island and your health care system are so broken there is not much of anything I can do to help but if you ever want to have mobile clinics I think it would help.  I also say that it should have village leadership. I picture small, rural maternal/child health councils where women demand that they not be left to die in childbirth.  My mind drifts and I see the women standing up to the powers to be; marching to Port-Au-Prince and demanding healthcare and transport.   I say it must be a grassroots form of care with the matrons, agent santes and lay leaders. 

My last experiences in the hospital in Henche had left me believing that the village system has to be given the tools of education, diagnosis and transport.  We use to debate, which comes first prenatal care or emergency obstetrical care.  Of course we wanted both.  But, we would say, what if we had to choose. I am a midwife and an educator so I chose the village and mobile clinics.  But it is jus tone part of the puzzle that includes prenatal care, a means of transport, a skilled birth attendant and then good care should you need a hospital.   In LaGonave I have offered to help with the prenatal care and transport plans.

In the days, leading up to me leaving I am not sure that the villages have even heard of the new prenatal mobile clinic system, let alone be involved in the planning and implementation.   They cannot even tell me what villages we will visit.  They say the ones on the list are too remote and we will all get tired visiting them.  I try to explain that this is the exact reason why they were chosen. Emails fly and I feel caught.   The premise for my returning was establishing community based maternal health care and no one seems prepared for this.    I think of my gardens and grandchildren and projects I am working on in Portland.   I think how I might cancel my ticket to Haiti.   I do not want to go down and be a white person arguing with the powers to be for the basic medical rights of women in Haiti. 

My piles of pictorial teachings lie in folders. I make graphic plans of how it all could work.  I look at my countless workshop plans.  I have downloaded films.  My approach was to include the lay leaders, the matrons, the agent santes and the midwives.   I was going to try and build teams that solve problems and work together.     I know that I appear casual in my dress and in my manner but I am a person who cannot live a moment without a notebook to write plans in.  I am a planner and they are not.  I have sent my training plan and they send me back shrugs – we can talk about it when you get here.   I sent the plans months ago and I do not want to go without a plan.  I have ten days for this and want every minute to count.   I have not recovered from the eclampsia and

Cardboard box of dead babies from the last trip.   I need a plan.   Was it too many years as an administrator?  Trainings have schedules, start and stop times and plans.   I cannot, it seems, go in without a plan.  I have tried it before in Haiti but not again. 

 But I consider the woman with eclampsia in the hospital bed; in a coma after a five-hour motorcycle ride down the mountainside. They tied her between two men. She had four other children and after the birth had a seizure.  With good prenatal care and a transport plan this did not need to happen.   It is difficult, yes, but can be reduced.  She is a real mother, being held in her husband’s arms for days while she is in a coma.   I felt powerless and I do not want to return to the world of male decision makers who seem oblivious to these deaths and disabilities.  They say to me, “they will never change.”    Did this woman even have a choice?   They say “women in Haiti like having their babies at home.”   I say but they can do that and still have prenatal care and be screened for risk.  We can do so much. 

My sister takes me to the airport at 6:00 am and I throw up in the planter.  The suitcase is four pounds too heavy and I have to repack on the airport floor.  The small gifts for children pour out and I scoop them into different piles.   There are toothbrushes and crayons and handheld lenses a school was disposing of.   I bring very few pieces of clothing.   My sister puts one suitcase in the other so I have one to leave for a family who needs it for storage.   This is a very good idea but there are small things all over the floor; seeds and baby blankets and old window shades to write on.  I smooth the dirt over my vomit and consider it is something I ate and not my hesitation about the trip.

My body says – maybe this is not such a good idea but I stand and smile; take my boarding pass and walk to the gate where I wait for the plane to Haiti. 

It is a short flight.  It is only an hour and a half.   As we fly over Haiti, I see the ring of turquois water and white sands.  It is a greyish brown but as we get closer, I see a patchwork of fields and houses and rivers.  At a certain altitude it does not look so different.   We glide through white clouds and then Haiti comes into focus; the now empty rice fields and houses only half built, muddy rivers and broken roads.  I begin to see what for one moment, flying at a certain altitude I could almost pretend wasn’t there.  There is music as you enter the terminal; always music. Even after the earthquake there was music.   And with this music I accept that despite my resistance I have come home.

Breastfeeding inequities in their village and in mine

In my village but never theirs....

I had come home from Haiti, wanting to do a few things.  One of them was to look at the many ways that all people share common problems and concerns.  I had wanted to look at the birth practices of my own community. I had wanted to find that common thread and to understand the meaning of "best practices' world wide.  I had wanted to simplify my thinking and in that find some universal truth.

I also undertook the work of taking the 90 hours of lactation education related to Baby Friendly Certification which I have found to be a unifying way of caring for babies endorsed by WHO and UNICEF.  As I watched still another mother and baby struggle to live, I considered that this could be a unifying good for Haiti' mothers and babies as well as the mothers and babies in my own community.

I was only home a few days when the classes began.  They were 9 to 6 and required large amounts of time on the computer.  I jumped from a world with very little electricity to a classroom totally dependent on electricity and the internet.  I went from a world where people sat at sunset and talked to a world where we were suppose to chat on line.   I was still having nightmares about a box of dead babies spilling onto the floor while I was delivering a baby.  I was shaken by that and then by the death of a dear friend.   I was experiencing cultural shock that was exasperated by on-line learning, yes, but something more.

I had helped thousands of mothers bring their baby to breast with no difficulty.  I had considered it part of the birth. I would have no sooner left a birth without the abby nursing than I would have left a placenta in. It was part of the birth.  It was my job as the birth attendant.  Here I was in a world where helping the mother to breastfeed was a whole other vocation.  I was trying to get LaGonave caught up on prenatal care and they are fast moving into a world of breastfeeding so foreign to me; even in my own community.

Through the course, I could see that many babies in my villages do not latch easily or early because of drugs and procedures used in childbirth.  Women in my villages, thousands of them, have surgeries to improve the look of their breasts.  In my country, women ahve the time and money to worry about how their breasts look.

As I move through the course, I can see that there is not much I can bring back to Haiti or any low resource setting.  A great deal was based on electricity, plumbing and computers.   Mother is Haiti rarely have access to lab work, NICU's, and high tech birth.

In some ways, the mothers of Haiti are far more successful.  I am sure their breastfeeding rates are far higher.  Not breastfeeding means almost certain death to a baby there.  In my village they have milk banks where milk is psateurized, tested and cooled.  I think they cannot even do that for cow milk for older children, let alone babies.

We review the metabolic diseases, jaundice, prematurity, low milk supply and I think well, I guess in Haiti all of those babies simply die.  Sometimes I consider still the box of dead babies. I see them all with their arms around each other and the tiny hands.  I find myself trying to determine their gestational age as we are shown slides of premature babies in my villages NICU.  The babies were not that young - perhaps as they say they were late prematures or they were term but no one knew how to care for them at birth.

Some will die of infections passed from mother to baby that are never tested let alone treated.  Some will surely have blood types that cause them to die in the first hours of life.  The inequities of care go on and on and on.  I sit through a 90 hour journey of extreme inequity of global resources.  In my village women have breast surgery, have fertility treatments and keep their babies alive for months in the NICU.

In Haiti. we are happy if they get prenatal care and can get to help if there is an emergency.  Some of us dedicate hard won fund raising dollars to getting care to women through mobile clinics or birth centers. it is not , I tell myself, the women's fault.  My country has created this culture of disparity.

I sit and watch. I do my assignments and try to take part but I am a world away.   I wonder if some children are worth more than others.

I will go back in a few days and help the matrones and agent santes and midwives with breastfeeding complications. I plan a workshop on this topic but I know I will not bring any of the gadgets, pumps, feeders, banked human milk, lab equipment and vast technology of the NICU in the village where I live.  I will bring some pictures.  i'll work with a translator and do the best I can.  There are no lactation consultants.

Many of the reasons women struggle with breastfeeding, in my village, are reasons related to birth, the media and the need for mothers of young babies to return to work.  I try to find the simple truths beneath all I have learned.   I try to think about what it mans to care for the young in any culture, in any place on earth.

It is a beautiful morning. I consider what it means to be born fully awake and alive with no drugs pulsing through our bodies to a mother who reaches down and brings us to her breast.   This is almost always true in haiti and almost never true in my villages.   Our babies are often induced, born through surgery, effected by maternal drugs.  The women in Haiti have much to offer the women in my villages about birth and breastfeeding.  I am angry and confused about all the things they don't have that US women have but then I can see that in many ways they have the most important things to help a baby latch and establish a good milk supply;  a culture that supports and appreciates a breast feeding mama.

"My Mom has died. " Melove in Haiti

In loving memory of Melove's grandmother who loved her family and cared for them though many joys and hard times.  In this photo she is making castor oil from the beans Melove picked.  She sold them in front of the house she shared with Melove and her children.  She had polio as a child and could not walk. I did not know  she had diabetes which led to the amputation of her feet at Justinian.  Despite this drastic measure, she died this week, leaving an empty place on the road to Bois-Camain.  She always welcomed me and any other guests, pulling up a small.market chair for us to sit on.  She was a Seventh Day Adventist and loved her church.  Despite the rocky road, someone would push her to church each Saturday for services.   A warm and welcoming person, I will miss her when I again walk that way and I am so sorry for Me love and her children who depended on her kindness and love for their very survival.  Brave, courageous and gracious, we celebrate the courage and faith in which she lived her life.   She lived through many political changes, natural disasters and personal tragedies.   May the beauty of Haiti wrap he rin their arms and offer peace and comfort.  

Landslides and deforestation; in your village and in mine

Landslides and deforestation;

In your village and in mine

Land slide in Haiti caused by de-forestation

Landslide in the United States caused by de-forestation

One of the things people say to me about Haiti is how they saw a photo taken by NASA that shows the border of the Dominican Republic and Haiti.   The photo shows Haiti with 100% brown dirt and no vegetation and a green Dominican Republic.  

When I traveled between the two countries I did not see any difference in the landscape but I understand that Haiti, like my country, lost most of its original forests.   I live on a mountainside and all of the original trees were cut down a few hundred years ago; the same time Haiti’s were.   The difference is that the trees on my hillside are growing back and the climate in Haiti makes this very difficult. 

When the forests were cut, in their villages and in mine, the small streams and springs were filled in with dirt and animals fled.   Water, which was once absorbed by large trees became floods of water heading down the hill to the river.   Smaller trees and bushes were knocked down along the way.   Thousands of years of deeply rooted and naturally nurtured topsoil was washed to the sea.   Food and medicines and habitat for wildlife was destroyed.   The food chain which fed and clothed people were destroyed.

Although much of this wood was used to build the small towns and farms of Oregon, it goes without saying that the first people of Haiti and Oregon managed to live happily without destroying all the old forests.  It is also true that most of the timber was sold and not used for the basic needs of the local communities.

Later, the forests in Haiti and the forests in Oregon were taken over seas and sold.   Wealthy and powerful people took the trees and the earth beneath them wept with the loss of springs and topsoil.  

Without the complex root system that was part of the mountainside, the land slid down hills taking people, houses and wildlife with them.   Recently in my country many people died and a town was destroyed by a landslide.   It is estimated that 5 million cubic meters of dirt on heavily logged land slide down the hillside after heavy spring rains. When it was suggested that it was caused by decades of clear cutting, the critics were silenced and called disrespectful.   It has taken the dedication of many, many people to protect the forests and streams of my villages.   De-forestation, in my village and in Haiti’s village, cause climate change, a loss of forest food and medicine and yes, landslides. 

When people ask me about the picture of Haiti I answer, “Yes, it was de-forested by colonial powers who sold it to become very rich.  Our forest were logged too and we have very few ancient forests, as well.  This is a problem in all the world’s villages.” 

When we value healthy, sustainable lifestyles for all living things we can help prevent landslides; in my village and theirs.   Beneath rests the question of how rich, is rich enough?   Do some people’s need for wealth justify the poverty of others? 

The line between Haiti and the Dominican Republic is the line we walk each and every day.  It is the divide between rich and poor,  between walled communities and borders between nations.   Somewhere,  someone left the ground bare and scorched; in my village and in theirs.   The impact of deforestation and land slides on families is significant.  In my villages and theirs, families morn the loss of friends and family. Homes are destroyed and lives are forever changed.  Mothers need solid ground, clean water and top soil to help their families grow.  These are the things we all need; in my village and in theirs.