If there’s one English term that doesn’t translate to Dominican Spanish, it’s “personal space.” The DR is a country where packing three adults and a chicken on a motorcycle becomes a quotidian activity, where your neighbor’s music becomes the soundtrack to your evening, where your skin touches strangers’ skin, your voice mingles with other voices, and even your sweat is subsumed by the collective sweat of the crowd. It is a country of gossip, a nation of open doors, and an island of close quarters. Arriving from the States, it is an assault on the senses, a maddening crowd.

However, over the past few weeks I’ve taken notice of exactly what this seeming cacophony consists of – the shouted salutations, the clattering of Dominos, the inquiries about neighbors, the rhythm of merengue – and I’ve come to realize that the sum of these parts isn’t the chaos I once imagined, but rather a sense of community I’ve never felt before.  Time and time again, I’ve been impressed by how virtually everything here belongs not to individuals or even to families, but to the community as a whole. Just this week, Meg and I trekked up to visit Mercedes, our community health worker in Arroyo de Leche, to find a huge lunch awaiting us. We not only ate with Mercedes’ family, but also with a host of friends and neighbors’ children that were there for the meal.  We saw that while people here do not necessarily have much, what they have is shared.

I’ve also realized that this sense of community is exactly what gives Meg and I hope for HHI.  We’ve seen our community health workers commit their time and effort to help those in need. Currently, they are working to give appointment cards for our September medical service trip to those who are sick, and long after our doctors go home, they will be working to ensure that those same individuals are taking their medicines correctly. Some are doing this work while raising large families, others in addition to working at free clinics, and still others while teaching at local schools. They are of the community and for the community. After these first weeks as IPDs, Meg and I are filled with gratitude for those that are putting the community in community health and making what was once a maddening crowd feel like home.

Saludos,

Nicole

High fever, insufferable headache, pain in the eyes, intense muscle and joint pain, vomiting… the Dominican Republic is on high alert because of the illness these symptoms point to: dengue fever.  Dengue is a viral infection transmitted by the Aedes aegypti mosquito, which lays its eggs in stagnant, clean water, usually in and around homes.  There are several classes of dengue, and in people who have been infected once before, the illness can progress into a life-threatening hemorrhagic form.  Characterized by a distinctive rash, bleeding into the abdominal and chest cavities, and bleeding from the eyes and pores of the skin, this form of dengue is almost always fatal.  There is currently no vaccine and no cure.

More than 8,400 cases of dengue have been reported in the Dominican Republic over the last several months, and 27 individuals have died — an epidemic level not seen in over a decade.  So far, the illness seems to be concentrated in the Santo Domingo and Santiago regions.  The Ministry of Public Health has launched a nationwide campaign to slow the spread of illness and prevent new cases.  The campaign includes educating individuals about dengue prevention, conducting home visits to eliminate receptacles that could hold standing water, and fumigation in certain high-risk areas.

Here in the Puerto Plata region, dengue has not hit epidemic levels — yet.  The regional Ministry of Public Health is proactively working to mobilize volunteers to participate in its prevention campaign.  With the oh-so-catchy slogan “Sin criaderos, no hay mosquitos.  Sin mosquitos, no hay dengue” (“Without breeding places, there are no mosquitos.  Without mosquitos, there is no dengue”), the Ministry hopes to avoid an epidemic.

HHI is collaborating with the Ministry  to do our part in this nationwide public health priority.  Dr. Elisa, an epidemiologist from the MSP, and Laura, a nurse and TB specialist, came to Montellano to do a special training for our  cooperadores de salud on Saturday.  They discussed dengue prevention, symptoms, and treatment, as well as the active steps our cooperadores could take to educate their communities and eliminate breeding places in their neighbors’ homes.  We then made plans for each cooperador to conduct a workshop in their community.  The room was buzzing with creative ideas and energy, so now it’s a matter of carrying them out.  Listos?

“That is my dream,” Cedric concludes, leaving us to ponder his words in a powerful silence.  For the past 20 minutes, we’ve been sitting in a small, sweltering church, listening to Cedric, one of HHI’s community health workers, talk about his hopes for his community and for himself.  “I want to help the people here in Pancho Mateo and also serve as an example for my community in Haiti.  I want to show them that while we cannot achieve much as individuals, as a group we can.  Si se puede, si se puede.” Cedric’s words, softly spoken in lilting Haitian accent, come as a font of inspiration for us.

Cedric, our community health worker from Pancho Mateo

We have been here just over two weeks, and yet it feels like years since we have come to live on this little Caribbean island. It is an island of extremes: cool and refreshing mountain villages just minutes away from hot and dusty city streets, lavish five-star resorts dotting a landscape of extreme poverty, and the coexistence of distinctly unique Dominican and Haitian cultures.

Similarly, the past two weeks of our training has been filled with extremes. There have been lows, to be sure: walking through the barracks constructed by sugar companies for their Haitian migrant workers to see stagnant water, garbage aplenty, and chimney-less homes filled with smoke from cooking fires.  At times, the problems here have seemed overwhelming in their magnitude and scope: one of our first nights, we happened upon a serious motorcycle accident on the highway.  With no helmet laws, no streetlights, and no ambulances, the situation was dire and we felt completely helpless.  It was an immediate and horrifying introduction to one of the many public health issues that abound in this country.

Meg and Nicole with Estela, our community health worker from Negro Melo.

However, there has also been hope.  We spoke with Peralta, a community leader from Saman, about the many initiatives his neighborhood committee has spearheaded, from a public park to a basketball court for children.  We met with Donna, an inspirational and dedicated Canadian who built a clinic up in the mountains in remembrance of a young girl that died of a urinary tract infection — a death entirely preventable by adequate primary care.  We have also partnered with SESPAS, the national Public Health Department, to arrange a class for our community health workers regarding dengue fever prevention.  And, of course, we are continuously grateful for and amazed by Angi and Laura, the outgoing International Program Directors, who have done an incredible job of laying the groundwork for Health Horizons International.

In the end, we’ve realized that Cedric isn’t alone in his dream of promoting community health and neither are we.  Thinking back on the people who have bridged this country’s extremes – rich and poor, Haitians and Dominicans, international NGOs and local leaders – we come to the conclusion of our training with a resounding sense of gratitude and hope.  And with a renewed sense of confidence that “si, se puede.”

Saludos,

Nicole and Meg

Packing my handful of t-shirts and Caribbean souvenirs into two suitcases – 15 minutes.

Changing over names and information for Internet and lease accounts, saying goodbye to friends, neighbors, cooperadores, community partners, and Laura, Jon, Dana, Meg, and Nicole – 1 week.

Fulfilling my term as co-founder and one of the first International Programs Directors for Health Horizons International – Eternity.  And by eternity, I mean 10 months.  But it feels endless.  The work is never-ending, and my dedication enduring, after all.

I write as I sit on the plane flying me back to New Jersey, and my mind simultaneously resists the urge to parachute myself out of here back to Montellano (where neighbors and friends said goodbye by sharing fried cheese and offering gifts of plastic angel figurines) and the urge to propel myself faster than this plane is capable of taking me into the United States (where seatbelts and efficiency, comfort and family will be at my fingertips).

With Mercedes - from whom I drew incredible strength

I don’t have the words that sum up what this past year has been like for me or for Horizontes de Salud.  Something akin to parachuting out of an airplane and propelling forward toward a destination, I think.  What I do have is an extreme amount of gratitude for everybody and everything that allowed for it to happen.  What began as a year-long adventure on a tropical island, a single feeling of compulsion to commit to action, and a glimmer of hope in the musings of a handful of dreamers, has developed into a fully functioning international not-for-profit organization fighting to effect sustained positive change – the first of its kind in the region of Puerto Plata.

As I go on to medical school, “going home to be able to come back,” in the words of new IPD Meg, I leave behind an organization continuing to build a new vision for improving community health in the barrios and bateyes of the northern Dominican coast.  I trust HHI’s leaders will improve the current system that links the passion and experience of international personnel and resources with the realness and necessity of local capacity building and health improvements, while learning from challenges and successes along the way, openly and constructively, never too proud to change for the better.  I enthusiastically remain on HHI’s Board of Directors, playing whatever advisory and supportive role I can this upcoming year.

Laura, Nicole, and Meg - the leadership of HHI.

I know Laura, Nicole, and Megan will continue to effectively expand upon this idea of serving the underserved and marginalized based on a model of solidarity, even though the geographic, cultural, historical, and social distances between the reality of the situation on the ground and that which those of us that work there have the capacity to understand, seem impossibly large.

Still, before moving to the island last October, I had been back and forth several times throughout the past five years, learning, acting, and becoming better, proving to the universe that distances are not so stagnant, or so impossibly long.  I believe the space between here and there is dynamic and relational depending on where you are coming from, where you are, and where you want to go.  For me, it has never been so clear yet so hazy.  I have never felt so full of strength but also ridden with anxiety.  I continue to parachute and propel myself onward, respecting the journey, designing the path, and remaining optimistic of what remains beyond the horizon, regardless of the length of the distance or number of hurdles along the way.

With hope and gratitude posting from New Jersey,

Angi

After months of recruitment, preparation, and anticipation, we finally welcomed HHI’s new International Programs Directors, Megan Schultz and Nicole Pfeiffer, to the Dominican Republic last week.  Over the course of the year ahead, Meg and Nicole will be taking to new heights what Angi and I began here in the DR.  Our first few days of training have been filled with ideas, questions, community introductions, and meetings, and they will soon be taking the reins as Angi and I transition out.  Loyal blog audience, meet the newest additions to HHI:

Nicole comes to HHI from Chile, where she spent the last two years working for the English Opens Doors Program, a joint initiative of the Chilean Ministry of Education and United Nations Development Programme.  She taught English in the desert mining town of Copiapo, and was later hired to manage international promotion for the EOD program in Santiago.  Originally from New Jersey, she graduated from The College of New Jersey in 2008 with a Bachelors Degree in International Studies and English, and also completed study abroad programs in Argentina and Thailand.  She brings experience working on behalf of marginalized communities around the world, including elderly and disabled residents of inner-city Trenton, low-income high school students in Union NJ, women and children affected by AIDS in Thailand, refugee children from Myanmar, and abandoned and runaway teenage girls in Chile.  She also interned for the International Organization for Adolescents, where she assisted in researching strategies to prevent child trafficking, and was awarded the International Studies Research Award from TCNJ for outstanding independent research.  Nicole is passionate about improving global health and promoting cross-cultural exchange.

Meg comes to the Dominican Republic after completing her third year at the University of Wisconsin School of Medicine & Public Health, and will be dedicating the next year to HHI before returning to earn her MD.  While an undergraduate, she studied abroad in the Dominican Republic with a focus on community and public health.  After graduating from college with majors in English Literature and Spanish, she joined Teach for America and worked as a high school Spanish teacher in Baltimore.  She obtained a Masters in Education from Johns Hopkins University in 2005 before moving to Boston to complete the post-baccalaureate pre-medicine program at Harvard University.  She also worked at Partners In Health, assisting with multi-drug resistant tuberculosis research in Peru and later developing a curriculum for community health workers in Rwanda, Lesotho, Malawi and Haiti.  As a medical student, Meg was named a Future Leader in Preventive Medicine by the American College of Preventive Medicine and a Global Health Scholar by the American Medical Student Association.  She served as President of the MEDiC Council, a network of student-run free clinics in Madison, and Student Leader of the UW Chapter of Physicians for Human Rights.  Meg is passionate about the roles of education and healthcare as agents of social change and justice.

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With one week until Angi’s departure and the beginning of her first year of medical school, and two weeks until I move into my new role as HHI’s Executive Director, we are on the brink of a major transition.  It’s encouraging and motivating to know that our international presence will be in strong hands with Meg and Nicole.  The blog will not be the Angi-and-Laura Show anymore, but will be expanding to include articles by the new IPDs, trip members, Board members, and other guest bloggers — anyone who is involved with HHI.  Many welcomes and much growth ahead!

Adios for now,

Laura

Jon screening for cardiovascular risk factors in Severet

As many of you avid HHIBlog readers know, Angi and Laura have done an excellent job conveying both the fascinating and important work they do here as well as providing for us, the loyal readers, a snapshot into the day-to-day lives of these awesome individuals. But now, as Dana and I (or Jon and I, as we are writing this together) transition from HHI fans to HHI staff, I think there is one necessary aspect that we need to convey-

Everything here is so small! One thing I will say about Laura and Angi, despite the fantastically huge achievements of theirs, physically they are not quite as imposing. So we were in for a little bit of a surprise when we stuffed ourselves onto gua-guas with legroom for our 14 year old selves, or packed onto motoconchos with butts hanging off the back and knees jutting out into the sugarcane. Not a lot of comfortable travel options for the giant gringos that we are! In fact, after over 250 heights collected in various communities around Monte Llano (as well as blood pressures, blood sugars, weights and circumferences!) not a SINGLE man has been taller than Jon nor a SINGLE female taller than Dana!

Dana - HHI's Summer Investigadora

That’s ok though – because there is a serious benefit to being the giant gringos wandering door to door in these communities. We are very recognizable! Being both extremely recognizable and working in the communities day after day has really ingratiated us to the people that we are collecting data from. We have been offered coffee, limoncillos, and coconuts freshly retrieved from the 30 foot tall tree (we have accepted). We have been hunted down and asked to go screen a person’s aunt or friend across town. We have had throngs of children excited to wander with the giant gringos, or perhaps more morbidly, excited to watch us poke people with (a very tiny) needle and create 1 drop of blood for a glucose reading.

Jon screening community members in Pancho Mateo

The most gratifying thing for us, though, has been watching people in the community get on board with our project. As we first approach a group of houses people are generally wary of us. What do these tall people who appear to be siblings want from us? To test my blood pressure? A BLOOD TEST?! Why would I do such a thing!? But after we conduct all 6 minutes of the survey and measurements and they realize how quickly they can learn substantial things about their health, they are quickly gathering their grown children, their neighbors, their parents, everyone nearby so that these people too can learn about their health and contribute to the picture of cardiovascular health in their community. Nobody helps us more to convince those unwilling to submit to a blood test than the person that we have just tested immediately prior. It’s amazing to watch again and again. After awhile, even the ever-present children are running to us begging to have us take their blood sugars so that they can contribute too (we don’t oblige them, although sometimes a joking reach for the needle will make them think twice).

Dana taking blood

Last weekend, we celebrated a great milestone in our work to establish HHI’s international programs: the end of our community health workers training course.  The last eight months since we started the course have been an incredible learning process, and while this is really only the end of the first step, it was worth the celebration.  About sixty friends, family members, and community partners were there to honor our sixteen first-ever cooperadores de salud, and the beginning of their roles as promoters, providers, and leaders in health in their communities.

After a delicious lunch of rice, beans, chicken, and salad – cooked by the two wonderful women of the Rancho Típico Montellano, a local restaurant/bar/club/carwash (a common combo in the DR) that we rented out for the afternoon – Angi, Jon, Dana and I welcomed the guests. I was glad that so many community members were there to hear more about HHI and the cooperadores program.  The more individuals that understand and are engaged in our work, the better and more effectively our programs will be able to serve their communities.  Angi then said a few words to remind everyone of the value of service and the power to create change – themes that we continually highlighted throughout training.

The cooperadores then stood an recited the Community Health Workers Oath:

“With my family and my community as witnesses, I promise to be an honorable, fair, and kind community health worker.  I will use my knowledge and resources for the benefit of my entire community.  I will treat others with compassion and patience.  I will work together with my community and with HHI. I will fulfill the responsibilities of a community health worker and dedicate myself to improving community health. I will do this work out of my own will, from my heart, for the love of God and the world.”

Mercedes taking her oath.

Thanks to generous donations of first-aid supplies, stethoscopes, and blood pressure cuffs from Covidien, McKesson, Deb & Cris Freitas, and this year’s medical service trip participants, we were able to provide each cooperador with a certificate and first-aid kit.  As a side note, Angi bought out the entire supply of lunchboxes at La Sirena to turn into first-aid kits, and it was probably quite a sight to see Jon, Dana, Angi, her friend Kristin, and me walking down the highway carrying sixteen brightly colored lunchboxes on our arms.

Blanco receives his certificate and first-aid kit.

Isabel steps up to a round of applause.

With their new knowledge, support, and resources, the cooperadores will be responsible for following up with patients, including those being treated for chronic illnesses like hypertension.  They will design and present health education workshops three times per year, as well as hold weekly “office hours” for people in their communities to come talk or consult their course materials, which cover topics like first-aid and emergencies, community education and public health, preventing and treating chronic and infectious disease, and caring for vulnerable populations.

The cooperadores from communities where we hold medical service trips will also play a crucial role in ensuring our clinics provide the best quality care possible.  As the program gets going, they will be able to identify community health problems, design interventions, and implement solutions with HHI’s support – creating lasting change in the health of underserved communities.

As we wrapped up, our cooperadora from Severet, Dorka, asked if she could say a few words.  It’s always an experience to hear Dorka speak – as a pastor, her passionate eloquence and ability to deliver a message is rivaled by few.  Her words, full of appreciation and hope, inspired her fellow cooperadores to take what they have learned and put it into practice.  She also generously offered a beautiful prayer for HHI and the people who work to fulfill its vision.

After that, photo-ops!

Antonia & Chichi

Estela and her proud family.

Now the work of management, evaluation, adaptation, and growth begins in full force.  The new IPDs (stay tuned for an introduction!) will be spearheading these efforts over the course of the next year.  We have such an opportunity to create change in the way health is understood, promoted, valued, and defended.  I know it will continue to be a long and challenging road, but at the end of it, I cannot be anything but optimistic.

Felicitaciones a todos!

With a sigh of relief at the amazing fact that an event in the DR went off without a hitch, and a high-five for all the day represented, we set off back down the highway.  Saturday afternoon was spent at the beach, for sure.

Always,

Laura

PS: Thank you Kristin for all her beautiful photography during the celebration!

… Jon and Dana, our first-ever investigadores, or summer research interns.  Beginning on Monday, they will spend seven weeks living in the rural community of Caraballo, conducting epidemiological surveys, and pioneering HHI’s plans for engaging in research and evaluation.  With Angi’s support, they have already done fantastic work designing a project and securing funding from the Arnold P. Gold Foundation, and I can’t wait for them to arrive on the ground.  Specifically, they will be collecting data on the prevalence of risk factors for hypertension and diabetes in several of the communities we serve.  We will use this information  to base future chronic case management and prevention programs, and to better develop a baseline for treating hypertension and eventually diabetes.  We’ve also arranged some days for them to shadow doctors in the area, visit other health organizations, and get a feel for the history and culture of the region.

Of course, this will leave plenty of time for weekends at the beach.  No se preocupen.

Jon Silver is a rising 2nd year medical student at State University of New York – Downstate College of Medicine.  Jon grew up in Queens, New York, graduated in 2007 from Tufts University with a degree in Biopsychology and Biomedical Engineering, and studied improv comedy in Chicago before starting medical school.  At Downstate, he has taken an active role advocating for healthcare reform as a member of Physicians for National Health Program and is passionate about equitable access to healthcare services.  Thanks to the Arnold P. Gold Foundation and its Student Summer Service Fellowship funding his research, Jon is very excited to spend his first summer with HHI!

Dana Sanderson will be a 2nd year Medical Student at the State University of New York- Downstate College of Medicine in Brooklyn, NY. She grew up in Buffalo, NY and received her Bachelors Degree in Biology from Boston College where she also focused on Spanish Language and Literature and Sociology. At BC, she also participated in a school-sponsored service/immersion trip to Nicaragua that piqued her interest in global medicine. Dana studied Medical Anthropology and spent time working in mobile health clinics in Cape Town, South Africa. She looks forward to continuing her participation in global health care and aspires to become a Primary Care Physician.

Between getting ready for our summer staff, managing our cooperadores’ internship and planning for their graduation next week, working on logistics for the upcoming year’s medical trips, and preparing for the big transition to the new IPDs (more to come on that!), I feel like we are winding up in order to wind down Angi’s and my time as IPDs.  It’s exciting to think about how much growth we have ahead of us — we’re on the brink of a turning point.

Looking forward to a great summer,

Laura

Mercedes, our cooperadora de salud from Arroyo de Leche treats my site visits to her community like they are day-long play dates.  It’s great.  I take the 40-minute motorcycle ride up a mountain, past the patches where the road is so bad that I have to get off and walk on foot, over 4 bridges, and arrive on schedule ready to meet with HHI’s hypertension patients.  Mercedes is super relaxed, washing her hair, preparing lunch, or stacking the wood planks for the new room in the house.  She tells me we will have the meeting with the patients “ahorita,” in “a little while,” which means anything from 2 minutes to 4 hours, depending.

The last time I was in Arroyo de Leche, “ahorita” was in such a long while, that I was not actually able to meet with our patients (the sole purpose of my visit) before having to speed away on a motorcycle to escape the afternoon downpour that would have left me stranded, the roads too muddy to return home.  I left the task for Mercedes to do independently.

Luckily, I did not escape an enormous and scrumptious home-cooked Dominican lunch and after-meal coffee so super-saturated with sugar that there was a sweet sludge slicked onto the side of my tin mug.  “Just take a taste and let me know if you need a little more,” Mercedes tells me.  I take a sip and immediately develop a cavity.

Mercedes making fried plantains

When I tell her it is never necessary for her to go so far out of her way for me, she puts her knife down, looks at me with sincerity, and says “!Oye!  Angi, esto no es nada.”  “Come on!  Angi, this is nothing.”  Even though I know it is something.  I know that it costs at least 70 pesos in gas just to get down into town to buy groceries, that her husband no longer has a job, that she put the beans on the stove at 6:30 in the morning, and that she is using a better cut of meat.  I know.

Mercedes, Franklyn, Marielly during a site visit

Since Laura has been in the United States, blazing HHI trails stateside and taking a short “vacation,” I have somehow managed to become the pity of my landlord, my neighbors, and in this case, our cooperadores.  “You’ll waste away living alone like that!  Come over tomorrow at noon for lunch.”

It’s hard to say no to fried plantains, rice and beans, salad, and chicken criolla, but it’s also sometimes hard to correctly interpret a person’s situation and intention, the multiple layers of my inter-personal relationships, my responsibilities to my organization as a young professional working in the field, and my desires and curiosities as a young American woman living in a new culture.

When Laura and I would share meals with families in Villa Ascensión, we always bought all of the groceries plus more, ate little, and refused seconds.  There, the situation was such that feeding two extra mouths for even one meal was almost impossible.  The last time we ate at Arroyo de Leche, however, I bought a sack full of groceries for Mercedes, and she was so embarrassed and surprised, that I realized right away that I had offended her.

I could go on about all of the miscommunications, misinterpretations, and sometimes unfortunate and always hilarious (in retrospect) mishaps that I have endured during these past nine months.  I live in a bit of a paradox: working in partnership with underserved communities while acting as the supervisor of our cooperadores; befriending and relating to other young foreigners volunteering in the field while spending my working hours relating to local male doctors, public health officials and administrators, cooperadores, patients; and working to do what I consider the right thing while learning everyday that all things “right” are extremely complicated.  I’m determined to figure it out (ahorita, okay?)  For now, fried plantains, miscommunications, misinterpretations, and mishaps galore call my name.

-Angi