Do I Make a Difference?

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During my many trips to Haiti since 2006, I always return with the same nagging questions. This time was no different, but at least I had one small answer. The question is this: “Do short-term medical mission trips really make a difference?” I always think I could help more by donating the costs of my trips to a local Haitian hospital that employs Haitian physicians. That is why this trip had a different purpose. For 2 weeks, I was teaching Haitian ob/gyn physicians how to improve their surgical skills, rather than leading an American surgical team. But even 2 weeks is not long enough for a teaching mission and the same question came to my mind. Until I encountered three patients.

During my second day at Hospital Albert Schweitzer a young woman returned to the hospital hoping the American doctor (me) could cure her problem. She had arrived at the hospital in October after an obstructed and prolonged 2 day labor at home. Her baby had died sometime during those 2 days and she required a cesarean to deliver the baby. This was followed by a severe pelvic infection and the need for a hysterectomy a few weeks later. During the healing process after her second surgery, she developed a fistula between her bladder and vagina, causing her to leak urine uncontrollably.  Fistulas from childbirth are rare in the US and most ob/gyns have no experience in this repair, including myself. Urologists have experience in fistula repairs related to other causes, but there is no urologist at this hospital. Fortunately, I knew of a Minnesota urologist who would be working at the site of my previous short-term missions, 4 hours away. Phone calls were made and the patient was transported by private vehicle to Hospital Bon Samaritan where she had her fistula repair surgery and then returned home in less than 48 hours. She is only 18 years old and will never be able to have children, but she won’t be saddled with the need to carry a urine bag for the remainder of her life.

Severe pre-eclampsia is a tremendous problem in Haiti, necessitating the premature delivery of infants for the health of the mother. During my first week we delivered 4 infants weighing around 3 lbs. Each day that I visited the special care nursery checking on these babies, I noted other Haitian mothers caring for their growing premature infants. often feeding them formula via dropper or syringe. Formula is very expensive in Haiti, but because these women didn’t have access to a breast pump soon after delivery, their breast milk supply dried up before their infants were mature enough to swallow. Unfortunately, 2 out of the 4 premature infants had died within a few days of birth, but there will soon be 3 breast pumps at the hospital that I was able to order upon my return. Better nutrition and at a less expensive price.

During my second week of clinic, a mother brought in her quite shy 6-year-old daughter who had suffered thru numerous medical appointments in the past, both at this hospital and in Port-au-Prince. She was born healthy but with ambiguous genitalia, neither fully female or male. While being raised as a girl, she is likely genetically male with a enzymatic blockage of full testosterone production. It is important to know her genetics (XX or XY) as she is at great risk of testicular cancer if she is XY. After contacting a pediatric endocrinologist in Minnesota as well as friends who work in Haiti, we were able to determine that there was no possibility of chromosome testing in country but that we will have the chance to get a tube of her blood to a lab in Boston in March that is willing to perform the testing, which is very expensive, for a much reduced rate. We can’t change the girls chromosomes, but we can offer risk reducing surgery in the future and also give her mother some answers to the questions she has been asking.

These patients are a reminder to me that sometimes even short-term medical missions can provide aid. Passing on surgical skills as well as making connections that I have cultivated over the years has a benefit and can make a difference.

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Where are all the Haitian doctors?

 

I had the opportunity to work closely with four Haitian physicians over the past two weeks at Hospital Albert Schweitzer, 90 miles north of Port-au-Prince. The hospital was founded in 1956 by an American doctor, Dr Larry Mellon (a member of the wealthy Pittsburgh Mellon family) who saw a great need in the rural, impoverished area. Initially the hospital was staffed by long-term American medical volunteers who learned the local language and provided care with the resources that they had available. This has gradually changed so that now all of the staff is Haitian and American/European volunteers only stay for short terms and work alongside staff to increase knowledge and skills.

Most of the Haitian doctors and nurses that I worked with are not from the local area and have family in other parts of Haiti. While they are working, they live in housing next to the hospital and visit their families on the weekends they have off. Each physician is “on call” for a week at a time, meaning that they are the provider called in the middle of the night for surgery or a complicated delivery. The average salary for a Haitian physician is $20,000 which certainly elevates them out of poverty, but does not make them wealthy. They often use their week off to work in an outpatient clinic near their family, where they can charge higher fees to urban patients.

Just as in the US, rural areas in Haiti have the most need and are less favorable locations for doctors to practice. The acuity of patient care is much higher as Haitians with few resources do not seek care until their condition is well advanced. Physical resources to provide care are often in short supply as they need to be transported from the larger urban areas. Due to the locals medical illiteracy, as well as illiteracy in general, it can take much longer to have a discussion with a patient about their illness. The volume of patients to care for is tremendous, with the hospital courtyard packed each morning with patients waiting all day to be seen in clinic.  Combine all of this with living away from your family and friends for weeks at a time and you can appreciate why these rural jobs are often seen as a stepping stone to a job closer to family in an urban area.

Brain drain is a common problem in many developing world countries, but particularly a problem in Haiti where 80% of Haitian trained physicians often travel to surrounding islands in the Caribbean or Mexico to practice. The reality is that they are better able to support their families back in Haiti with their increased salary than if they worked a Haitian job.

Rwanda has recently addressed this issue with their new medical school (partially sponsored by Partners in Health which has it origins in Haiti) and are seeking out students from the local rural area where the hospital is located. 70% of the first class are women as it is felt that they will more likely stay in a job near their families. The school will also focus on the use of basic technology (x-ray, a limited panel of blood tests) and careful physical exam to make a diagnosis as well as public health measures that can prevent disease or treat in earlier stages.

Americans like to develop a long-term relationship with a physician they trust. There are 280 physicians for every 100,000 Americans, compared to Haiti with 25 physicians for every 100,000 people (almost a ten fold difference). Haitians just hope that there is a physician in the house when they are in need and are not concerned if they have ever met that provider in the past.

I am grateful that these physicians have allowed me into their lives for the past two weeks and to tell their stories. Taking the extra time on rounds each morning to explain what they are discussing (I still don’t understand Creole, the local language) as well as trying to learn new skills can make life stressful for both of us. They handled it with the usual Haitian humor and perseverance. We both benefitted from this experience as I have a new appreciation for work-life balance and they have improved surgical skills and some new clinical knowledge.

Privacy, Privilege and Practicality

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The hospital where I have been working for the past few weeks, Hospital Albert Schweitzer, has a policy requesting volunteers to refrain from taking pictures while they work in the hospital. This is to protect the privacy of the patients as well as their families. For fundraising purposes, the hospital has taken professional pictures of patients, but only after a written consent is obtained (these are the pics that I have posted).  Contrast this to other Haiti mission trips that you have seen. Pictures are posted on social media of volunteers surrounded by cute, smiling kids or of a patient undergoing an interview/exam. I was guilty of this in my first few trips to this country as well until someone much smarter than I reminded me of what an American would experience if a stranger took a picture of them in the hospital as they were nursing their newborn, only to show that picture to all of their friends back home.

Contrast this with the practical side of privacy in the hospital.  The hallways are lined with patient gurneys, an extension of the hospital wards that each house 6-7 patients. When we make hospital rounds, there is very little privacy as you remove a dressing and examine a patient that had surgery the previous day.  Charts are distributed in the maternity ward by the nurse asking a patient their name over the din of another patient screaming in labor. As you discuss a patient’s medical condition, the surrounding patients are listening as well as their families. In clinic, there is one ultrasound machine for 3 exam rooms. I can be interviewing a patient as another patient is having an ultrasound only 6 feet away. It is quite difficult to ask questions about sexual health and maintain a semblance of privacy as well as get an honest answer from a patient. I have heard of 2 immaculate conceptions this week alone.

A presentation earlier this week by one of the physicians concerned respecting patients and providing “bad” news in a private setting. A heated discussion followed the lecture that was translated to me as “Great idea but impossible to implement in our circumstances. Even if we are able to give the patient the info without others hearing, the patients often ask their families, friends and others in the hospital what they think.”  This must be the Haitian version of Google!

In the developed world, we have the privilege of privacy. We can get our test results via secure email, be confident that a conversation with a provider in a room with a closed door will not be heard by others in the waiting room and expect a private room with a shower in the hospital. Providing patients here with a small vestige of privacy by skipping the medical voyeurism is a worthy request.

Dear Anti-Abortion/Pro-life Protester, Come to Haiti

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You would love it here. Abortion in Haiti has always been illegal and always will be. 90%+ of Haitians are Christian with the 2 predominant religions, Baptist and Catholic, conservative and anti-abortion. Most of you probably identify as conservative Christian also. You certainly don’t need to worry about equal rights for women or the #Metoo movement , as male dominance is very prevalent in both church and home. Abstinence outside of marriage is the preferred method of birth control for young people and for married people “children are a woman’s duty and gift from God”.

But if you decide to visit, please don’t dig any deeper than the surface, as the reality is much different from what you will hear. In speaking with one health care worker who has been here for many years, they estimate that 70% of Haitian women have attempted to end an unwanted pregnancy at some time in their life. This may only be an estimate but was based on a 6 month survey of women. Read that again … 3 out of 4 women have tried to end a pregnancy, most without success. A “didn’t want” pregnancy can be ended thru misoprostal (this is one of the drugs that is used in the US for medical abortions) bought from a street vendor, Pitocin from a bootleg pharmacy, a surgical abortion from a doctor who has a clinic to make extra income, drinking some type of poison and on and on. The doctors here think that things have improved for women since they have been able to obtain misoprostal as there are less women trying to end a pregnancy with sharp objects stuck in their vagina, perforating tissue and the uterus.

If you come, please bring health education and particularly sex education materials. Although contraception is provided free by the government in family planning clinics, many women have misperceptions about the benefits of contraception and don’t use it. This is also likely due to the perceived sin of using artificial means of contraception within the Catholic church. In only 1 week here, I have heard from patients that they will lose weight, not be able to have future children, develop mysterious aches and pain and build up too much blood in their system. The best excuse – Their partners don’t like them to use anything.

Don’t bring your thoughts and prayers. They don’t feed your 2 young children when you are too sick from pregnancy to go to work. They don’t protect you from a husband that beats you. They don’t make your married boyfriend answer his phone after you have told him that you are pregnant. They don’t prevent your parents from making you stay home from school when they find out you are pregnant age 16. They don’t stop the boy next door from raping you one night on your way home. These are the circumstances that many Haitian women find themselves in and why they choose to end a pregnancy. They take the risk of bleeding, poisoning or bodily damage because the alternative of continuing the pregnancy is much worse.

If the United States overturns Roe v Wade, some states will make abortion illegal. They will also limit access to contraception and education for women.  Women will still get pregnant with a “didn’t want” pregnancy and become desperate to change their situation. Parts of the US will look like Haiti. Be careful what you protest for.

 

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.

 

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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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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