Monday, June 16, 2014

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.   

Thursday, June 5, 2014

"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.

Wednesday, June 4, 2014

Returning to LaGonave - June 2014

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.