Life as a woman in Haiti

 

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Patient dripping urine from fistula

Haiti can be a difficult world, both for visitors and for its citizens, especially woman. The unique smell of the country hits you as you deplane; an odor of slightly rotten fruit mixed with burning garbage and body odor. By the next day the odor has faded into the background and you don’t recognize it again until you visit once more. Your feet hurt at the end of a long day on concrete floors in the hospital and your sleep is interrupted by the incessant crowing of roosters, no matter the time of day.

Women in this country live with all this and so much more. As I was told by a Haitian doctor today, “When the choice is between the life of the mother or the baby, we choose the mother because she is needed to keep the rest of the family together”.  Woman are expected to get married and have children but pregnancy comes with unique problems.

Although freely available, birth control has many misperceptions and is not frequently used outside of marriage. Thus, women become pregnant and try to terminate unwanted pregnancies with the use of misoprostol that can be bought from street vendors.  They are often only partially successful due to inadequate dosing or unknown gestational age of the pregnancy. A young woman I met yesterday was one of the unlucky ones – her membranes ruptured and she started bleeding but has not yet miscarried her 4 month fetus that still has a heartbeat. Because abortion is illegal in this country, no intervention can be considered unless she has a life threatening infection or the baby dies.

Severe pre-eclampsia is very common in this part of the world, due to genetics and underlying hypertension that is not well controlled. We rounded on three patients today who are all around 7.5 months pregnant with very high blood pressure. Babies have a good chance of survival here after 33-34 weeks. Delivering these babies now will save the mom but almost certainly result in the infant dying. Each day we have to reconsider the risk of continuing the pregnancy, especially if the woman has other children at home to care for.

Women who live in the mountains many hours walk from any health care center often labor at home with the assistance of their female relatives or a lay midwife (Matrones). When labor doesn’t go as expected, they are carried for hours to the hospital. In November, a slight 18-year-old arrived after 2 days of labor and no progress. Her baby was dead and a cesarean was needed to deliver the infant. A week later she returned with a serious infection that required removal of her uterus to save her life. Now she has a fistula(opening) between her bladder and vagina where she is constantly leaking urine, even with a catheter in place. The surgery to repair this is very difficult and often not successful. She can no longer have children and will probably carry a urine bag for the rest of her life.

As I have written about before, cervical cancer is very prevalent in Haiti due to a lack of screening or knowledge about the disease. We have already had to inform 2 women, ages 31 and 41, that their constant vaginal bleeding is due to large cervical tumors that are too advanced to remove. One woman has a hemoglobin of only 4 (normal is 12-14). Both will leave young children orphaned.

I am only a visitor in this country that I have grown to love for its tenacity.  The physicians, nurses and midwives that are here full time caring for these women are my heros.  I can learn as much from them as they may learn from me.

 

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The Cost of Menstruation

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As I was putting together my thoughts to write this blog post about the monetary cost of menstruation, I realized that there may be a larger cost that I am missing. A patient had cancelled her appointment with me numerous times over the proceeding few weeks. She offered profuse apologies when she finally showed up for her appointment, stating she couldn’t come and see me when she was bleeding because that was “gross”. Her initial reason for making an appointment was for the complaint of heavy bleeding. We are an Obstetrics and GYNECOLOGY office. We see blood daily. But yet this patient and others like her consider  menstrual bleeding to be something that should be hidden and discussed only behind closed doors. Women in other parts of the world are even more limited during their menses, expected to sleep in separate quarters and to avoid touching anyone else in rural parts of Nepal.

Women can also be great minimizers when it comes to describing their menses. When they describe their flow as heavy, I always need to inquire about the number of pads or tampons that are used in a day. Some women describe heavy as using 4 tampons a day and others use a tampon every hour but think that is normal. When women feel social shame regarding the discussion of their menses, they often fail to seek the care they need to improve their quality of life due to heavy menses.

Even with a normal flow period, the financial cost each month can be difficult. I did an unscientific poll of my college daughters and their friends and the average is 6-8 tampons a day for 5-6 days. A box of 36 tampons costs $7 at my local Target. One year of hygiene is $84 (12 x 7). Imagine the monthly bill if you were a family with 3-4 daughters.  Most women start their menses around age 12 and end at age 52. 40 years at $84 a year totals $3360.  This does not include the cost of medication for cramps, new underwear to replace the “accidents”, possible time missed from work and medications/procedures to treat heavy flow (birth control pills, Mirena IUD, endometrial ablation or hysterectomy). All of this is a burden that is shouldered by women only.  To add insult to injury, many states have a luxury tax on feminine hygiene products. I think most women would argue with the description of a period as a luxury!

Part of the work that I do in Haiti involves supporting a sewing center where we employ women to construct reusable menstrual pad kits that are then sold to Haitian women and mission groups for redistribution. Young women are always thrilled to receive the colorful kits because it often means they have a means of protection so that they don’t need to miss school during their period. When  parents are barely able to afford  school fees and food, paying for disposable hygiene products is unaffordable. Missing school a few days each month can often cause a girl to fall behind in her studies and possibly drop out when her grades suffer and more help is needed at home.

As with most problems, the key to improvement comes with bringing the hidden out into the open and providing education. Part of our program in Haiti has been to provide women’s health education to our seamstresses so that they can pass on this info to other women in their community. In my office, I often encourage women to have frank conversations with their daughters AND sons about a period. Only women have a period – but anyone who has a female in their family should be able to talk about it.

First World Business over Breast

This disturbing article from the New York Times has appeared in my inbox and Facebook page at least 20 times this week. It details the power of large corporations, ie formula manufacturers, to influence not only our government but also international policy in order to increase their bottom line. Simply put, US government officials present at the United Nations-affiliated World Health Assembly this spring tried to pressure developing world countries to place less emphasis on breast-feeding and allow the promotion of alternative feeding methods, namely formula. This is at a time when US hospitals are competing for patients by hiring lactation consultants, providing free breast-feeding classes and training all of the maternity staff in best practices for nursing. We will not allow a formula manufacturer to advertise in American hospitals or clinics, but we are ok with the promotion of formula products in the developing world. Two empiric situations should make clear why this policy will increase childhood mortality.breastfeeding-mother

  1. An American woman is planning to nurse her child but her husband has misgivings about this as he is concerned that he will not be allowed to feed the newborn. Following an uncomplicated delivery, the newborn had difficulty latching to her breast but was finally successful due to the assistance of an experienced lactation nurse and the benefit of a breast pump and breast shields. She was able to exclusively nurse for the first few months of her child’s life and her husband managed diaper changes and the occasional bottle containing breast milk, allowing him to feel more involved in his child’s care. When she returned to work three months after delivery, her insurance provided her with a breast pump and her employer allowed her to take additional 20 minute breaks twice a day to pump breast milk and store the milk bottles in a small refrigerator. The mother introduced solid food when her child was 6 months but continued to supply her child with breast milk until a year of age. 12. A Haitian women delivers one month prematurely due to pre-eclampsia, a common condition in Haiti. Her infant is smaller than average and unable to nurse for more than a few minutes at a time. The woman’s grandmother is helping to care for her in the hospital and believes that the early milk, colostrum, is bad for baby and tries to finger feed the child water. Because the child is not nursing well, the mother does not produce enough milk. After one week, the infant is lethargic and dehydrated. A local mission group shows up distributing medications and has some extra formula that was donated. The grandmother hears about this while she is getting her free blood pressure medications and takes the formula home for the infant. Within days the baby is much more responsive and greedily sucking on the bottle that was donated with the formula. However, the mother’s milk has now completely dried up so the grandmother returns to the site of the medical mission clinic to get more formula. The medical team is gone but has left a message that they will return in 3 months. The grandmother is able to purchase a small amount of formula in town. In order to make it last longer, the mother mixes it half strength with the drinking water they get from the river. Soon the infant develops diarrhea and becomes lethargic again and won’t take even the diluted formula. The family doesn’t seek medical care again as it is too expensive and their extra money was spent on formula. The infant dies a few days later. Since the mother only breast feed for the first few weeks of her infant’s life, ovulation returns within a few months and she becomes pregnant when her child would have been six months of age. Her mind and body have not recovered from her first pregnancy and due to poor nutrition she again delivers a premature infant. The story is likely to repeat.

Breast feeding provides maternal advantages as well as being the perfect, age adjusted food for children. Mothers who breast-feed reduce their long-term risk of breast cancer, uterine and ovarian cancer. Exclusive breast-feeding is a means of contraception for the first six to twelve months after childbirth, allowing for better spacing of pregnancies when more effective means of birth control are not available. When women in the developing world don’t have access to a safe drinking water supply, it provides their young children with immunity to diarrhea causing illnesses, the #1 cause of death for these children after childbirth.

Formula has its place in infant care but business interests of large US corporations should not take higher precedence over the lives of children. This article in the Atlantic gives a history, both past and present, as to the lengths these companies have gone to promote their products. Email, tweet or phone these companies ( Nestle and Similac) and let them know how you feel about their policies.

When the Refugees are your Neighbors

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This week, the people of Syria have again made the front pages of the news as President  Bashar al -Assad continues to exert his control via military force and now chemical weapons.  For most Americans, the discussion about these individuals is abstract as we don’t live next door to them. Their needs don’t impact our daily lives or finances. We view their stories in the newspaper but they are invisible in most of our schools or churches.  Americans can debate whether the United States should become militarily involved in the Syrian civil war or whether we should continue to accept immigrants that have become displaced by the conflict.  But what happens when you live in a country where those refugees come from just a few miles away and aren’t allowed to integrate into their new communities?

If you are a citizen of Greece, refugees are your daily reality. The Greek island of Kos is only separated from Turkey by 2.5 miles of the Aegean Sea. Migrants from Syria, Afghanistan and parts of Africa arrive on the shores of this island daily during the summer when the ocean waters are calm.  125,000 refugees have been relocated to camps in Athens and other Greek islands. Greek citizens cannot escape seeing, hearing and discussing refugee issues as the burden of caring for these people affects their daily lives.

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I recently had the pleasure to interview two Minnesotans who have volunteered to work in Greek refugee centers and been witness to some of these difficulties first hand. Dr Dave Dvorak and Rachel Hovland, RN, have spent 2-3 weeks working in medical and construction projects on Samos Island and in Athens. They shared many of the same observations:

  1. Syrian men, often highly educated and previously holding middle-income jobs in Syria, exhibit a senses of hopelessness, depression, uselessness, boredom and anxiety. Women continue with their daily housework and childcare activities and tend to fare better psychologically.
  2. Housing is provided in many different forms. Before coming in contact with aide groups, refugees may only have makeshift tents.  Some previously abandoned buildings that were part of the Olympic venue now house 200-400 people per building and separates the women and children from the men and older boys. This tends to exacerbate the problems listed in #1. Women care for each other and create a community structure within their building. Young men become angry and frustrated and often demonstrate and riot.
  3.  Providing medical care/contraception to women can be challenging as husbands don’t want their wives to use birth control and their culture isolates them from healthcare provided by male health care workers.
  4. Many of the refugees have used up their entire savings to leave Syria as they are charged $750-1000 euros per person for boat passage. They have seen their family members killed and their homes destroyed and realize that they don’t have a country to return to even if the conflict is resolved. They will always be Syrians who live outside of Syria.
  5. Everyone is waiting for travel papers to get somewhere else in Europe while realizing that they will be moving away from other Syrians and their only remaining support system. Most of them will be taking jobs that are much below their educational levels and having to learn a new language.
  6. The children are the element that help to elevate the mood of adults as they play and live in the moment. More organized school classes are being arranged by outside aide groups, but the children are quickly falling behind in their studies and soon must learn a new language with their move beyond Greece.
  7. The surrounding Greek community, initially resistant and fearful of the refugees, has gradually become more accepting as the refugees spend their monthly food dollars in the markets and are seen as customers.

I cannot even imagine the horror experienced by Syrian refugees as they have watched the events unfold over the past week. Their neighbors and remaining relatives may have been involved in the chemical weapons attack or may be in the cross-hairs of retaliatory American military strikes. While worrying about the remaining Syrians in their homeland, they are barraged with headlines as to what the outside world thinks of their country and whether it is necessary to intervene. There are no simple answers but the problem is more than just about ruling a land – it is about the people who have called this land home.

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International Women’s Day – The Lessons I have learned from Haiti

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As I watched the powerful feminist speeches at the Academy Awards this week, I reflected on my experiences in Haiti that have made me an advocate and messenger for women not only in the developing world but also here in the US.  Unlike women in Hollywood, Haitian women often don’t have a voice – either in their homes or their communities –  but what happens outside their sphere of influence can make an immense difference in their daily lives.

Haitian women, similar to women in most developing world countries, perform all of the household and child-rearing chores with no help from their male spouses. These tasks are often accomplished without the benefit of running water or a steady supply of electricity. No refrigerator, washing machine, microwave, toilet.  Monetary funds are controlled by their spouse and may be wasted on drink and games of chances, while the pantry is empty of food and the kids need new shoes. Physical and emotional abuse is overlooked by a society that places a lower value on females.

These same women have taught me what perseverance and a source of income can accomplish. Each year when I return to Haiti, I am able to meet with the newest microloan group and connect with some of our previous Helping Haiti Work loan recipients. I impress on the women who have been successful in loan repayment that they owe it to the new loan groups to give them advice and support. Numerous of these women have related their personal experiences of the benefits of the loans. Not only do the profits help with clothing and food, but the women are given a higher status in both their immediate family and in the community. Their husbands treat them better because they are bringing money into the family. The women have control over how the income is to be used. Their children see them as a more capable adult and that hard work has more than one dividend. Other women in the larger community ask their advice and apply for the microloan program.

We are also seeing some of these same changes in the women employed by our sewing program. They have brought us ideas as to what products they think will sell well in the market rather than only sewing the reusable menstrual pad kits and diapers.  One of our seamstresses was proud to use some of her funds to pay for a needed surgery for herself. Each time we visit with them they are becoming more outspoken and empowered.

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My journey to make all of this happen also requires perseverance and the commitment to empowering Haitians so that they are better able to help themselves and each other.   I am often asked why I don’t focus my fundraising efforts on causes that would benefit women in the US rather than Haiti (that is another blog post in itself). Just as the Hollywood elite are using the #TimesUp movement to bring recognition to those women who may not have a voice, I hope that the monetary loans provided by Helping Haiti Work and the examples of female leadership by our participants will touch many more women than just the ones that we serve.

Come join us this weekend as we listen to great music from the 60’s and 70’s by the band Morpheus and help to raise money so that more women in Haiti can be empowered to make a difference in their lives. Visit Helping Haiti Work to purchase tickets and for details of the event.

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Female Body Parts 101: The cervix – Soon to be #1 Cancer Threat to Women Worldwide

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I have previously written about the uterus and menstruation, but have been lax in finishing the reproductive system. Two patient stories reminded me of how neglected the cervix can be.  As I was interviewing a new patient, age 24, I noted that she had not received a Gardasil vaccination in her teen years. I informed her of the benefits of the vaccine, preventing Human Papilloma Virus (HPV) infection of the cervix, thus markedly reducing her long term risk of cervical cancer. The vast majority of cervical cancer is caused by HPV, with strains 16 and 18 accounting for 70% of cervical cancer. The vaccine can be administered from ages 12-26 in both boys and girls and is covered by insurance. Following our discussion, she declined the vaccine stating “My family doesn’t believe in vaccines”.

Later in the week, I was called to the ER to see a 65 year old woman who presented with vaginal bleeding after menopause. She had not seen a physician since her last child was born in her late 30’s. A large tumor had completely replaced her cervix and was extending into her uterus. Her survival chances are around 60% – after radiation, chemo and extensive surgery. Due to age this woman did not have the option of a Gardasil vaccine, but the cancer could have been detected in a pre-cancerous state by a pap smear and easily removed via an office procedure.

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Obtaining cells for a pap smear

The cervix is a muscular structure that is located at the top of the vagina and encompasses the lower third of the uterus. It is the gateway that allows blood to leave the uterus during a period and remains closed to keep the developing fetus inside the uterus until labor ensues. It responds to uterine contractions by slowly dilating to allow for passage of the infant.

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Pap smears were developed to screen for pre-cancerous changes on the cervix that could be treated before they developed into cervical cancer. We have only recently discovered that HPV is the virus that causes cervical cancer and now screen for HPV when we do pap smears. HPV is a virus that is passed back and forth between men and women during intercourse. It is a silent infection in men – no symptoms, no testing available, no treatment and no long term health consequences. Completely sexist but so are many health problems – ie breast cancer, pregnancy, uterine and ovarian cancer.  So it only follows that vaccinating young men to prevent them from transmitting the virus will help to reduce the burden on women.

Pap smears should be performed every 3-5 years, depending on age, and don’t need to be performed after age 65 if you have not had an abnormal pap in the past 10 years. A common misconception is that pap smears are performed whenever a speculum is placed in the vagina – NOT!  Pap smears are never done in the ER or urgent care, even if a speculum is placed or pelvic exam done. You just need to believe me on this fact.

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By 2020, cervical cancer is expected to exceed deaths during childbirth as the number one killer of women during their reproductive years. Currently, 70% of cervical cancer is diagnosed in the developing world due to lack of screening for pre-cancerous abnormalities. In 2011 Rwanda initiated a school based vaccination program for both boys and girls and thus far has a 93% coverage of eligible youth. The current rate in the US is 60%, with many states less than 50%. Rwanda, still recovering from a horrific genocide and 70% of it’s population rural, beats the US in vaccination rates by a great distance. We are the richest country in the world with the most expensive health care system. Treatment for the 65 year old patient described above will cost hundreds of thousands of dollars. Where are we willing to spend our dollars?

Cervical cancer is one of the few cancers that is well understood and has a single cause; HPV.  We have the ability to eradicate this cancer in the near future via robust vaccination programs and regular screening. Former president Jimmy Carter had a vision to rid the world of Guinea Worm, a parasitic infection in tropical countries. It will soon be the second disease eradicated in the world, after smallpox. Cervical cancer can be #3 and the first cancer.

 

My Love Affair with a Sh*thole Country

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I first visited Haiti in 2006. It was not love at first sight, or even a like. I spent a week on a medical mission trip, missing my family and sweating in the operating room while I performed some of the most difficult surgical cases of my career, without adequate lighting and unfamiliar instruments. Climbing the steps of the airplane to return home was a welcome relief from the searing heat of the tarmac and the aroma that is Haiti (think rotting fruit mixed with exhaust fumes and burning charcoal). I’m not sure when the amnesia set in over the next few months, but I was soon planning my return visit the following year. 15 or so trips later, I look forward each visit to spending time in a country that I have visited more frequently than any other.

My  trip last week coincided with the recent comments about Haiti from President Trump. While he was ranting about the immigration of Haitians to America, I was participating in distributing microloans to a new group of 10 Haitian businesswomen. The women received $200 to help fund their small businesses and will be responsible for paying back the loan over 10 months with a low rate of interest. Each of these women has worked hard selling clothes, food, shoes and motor oil to support their families. This is in addition to the daily tasks that a Haitian woman must perform without the benefit of running water or electricity. Entitled or lazy would be the least descriptive terms that I would use.

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The following day I worked with one of the Haitian seamstresses that we employ to construct reusable menstrual pads for distribution to Haitian girls. She uses a manual sewing machine and is able to make $4 a day working  5-6 hours. She also participates in menstrual hygiene instruction at area schools so that young girls will have the benefit of knowledge about their bodies and not the fear that her generation of women experienced. She has no desire to immigrate to America away from her family, but wants the opportunity to make her life in Haiti more comfortable.

I am not quite sure why this country has occupied so much of my time, energy and pulled at my heart. The opportunity to leave a frigid Minnesota in January makes the idea of sweating in the operating room more palatable. But is much more than that. Haiti is a land of contradictions – corruption and family strength, sadness and laughter, illiteracy and value of education.  There is very little black and white, rather many shades of grey. But it makes my brain think and try new ideas, something that is more difficult to do in my American job. I have been the recipient of many opportunities in the US, and although I have worked hard and been the first to graduate college in my immediate family, there were many along the way that provided encouragement and a helping hand. I would like to think that I can be that helping hand for Haitians – providing business loans for women, saving a baby’s life when her mother is suffering from seizures/eclampsia, removing an enlarged uterus so that a woman can better perform her household chores and providing education and hygiene products so that young girls are able to stay in school during their period. Yes, Haiti is a destitute country that has suffered from both outside forces and its own corruption. But its people are willing to change that – if we would only give them a fighting chance. And remarks such as those from our President don’t help to provide that chance.

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