Sandra Marzella, MD

Sandra plays "Muscles" with a boy in Pancho Mateo

Once again I am shocked and amazed at what I see here.  The conditions people live in are deplorable.  Babies crawling around in the dirt, trash everywhere, no running water, etc.  Tonight on the phone my son asked about Skylanders.  How do you explained to him that not only do they not have this, but they don’t have a Wii, only few have a TV, and for some, their problem can involve where to get their next meal.  It truly is living in another world.  I can only imagine that they would laugh if I mentioned things such as car seats (here infants travel on laps on the back of motorcycles,) baby gates and safety locks.  I am certain no one in the low income communities owns a crib with matching sheets.  They all co-sleep with their infants as with many of the older children.  Their homes don’t have room for much.  Many have large families.

The unemployment rate is 90% in the towns we have been working in. They have no options for work.  However, they are very happy people. Seems kind of strange but most seem content.  Most people here don’t complain of depression or anxiety.  Much different from home.  Also there is livestock all along the  now muddy, ditch filled roads. No shock absorbers around here!   Our truck has to beep to get the cows to move.  There are sugar cane fields everywhere that are no longer used but people are not allowed to farm them.   When I work with these people I feel very thankful for all I have.  When I get back to my room, I most appreciate the running water, a/c, and electricity which we are not seeing in their communities.  Can you imagine living in place with so little?  This is personally rewarding and yet emotionally difficult at the same time.  They need so much and yet we can only offer a small amount.

Kim take a break from clinic to play with kids in Pancho Mateo

Brad Wilkinson, MD,  Vice Chair, HHI Board of Directors

Brad and Sandra evaluate a sick infant Pancho Mateo

This January’s Operativo was the best of the eight times I have been to the DR. It is enormously rewarding to see the Chronic Care program finding its legs and actually having a positive effect on many many patients. To share in the teamwork of the Cooperadores and the International Program Team members, the enthusiasm and dedication of the QU and Tufts students, the compassion and skill of the physicians is truly a moving experience. And that doesn’t even touch the most wonderful feature of all– the privilege of helping to take care of hundreds of lovely people suffering under the burden of an inadequate, expensive, distant, and episodic health system. I would go back tomorrow if I could.

Written by Dr. Craig Czarsty, President and Chairman of the Board of Directors of HHI

I just got back from my eighth medical service trip to the Dominican Republic and this was the most satisfying of all. HHI has been building a chronic care program and increasing the number of patients in it. We have reached the point that on this trip most of the patients seen were by appointment only. The trip in May will be entirely by appointment. While this may not seem like much of an accomplishment to those who are used to electronic medical records and requesting appointments by email, it is a really big deal for us in the D.R. It means that each patient we see has a chart that contains not only previous clinic visits but interim reports of visits to the patients by the cooperadores and the International Program Team. We know of no other NGO on the north coast doing likewise. Special thanks to Janelle, Rachel and Tracy of the IPT who make everything run so smoothly.

Speaking of the cooperadores, it is particularly gratifying to see how far they have come. For the first time, they worked in intake and triage during the clinics. More importantly, they accompanied the patients they follow to their appointments with the docs. This allowed them to hear firsthand what the docs told the patients so they could help reinforce the message over the next four months until the next medical service trip. The cooperadores are an amazing group of motivated individuals who are anxious to make a difference in their own communities.
We had a veteran group of physicians with us, Brad Wilkinson (Vice President of HHI), Stacy Taylor, Sandra Hughes and Anne Brewer. The QU Physician Assistant students rolled up their sleeves and jumped right in. They are a great asset to HHI. The Tufts undergraduates stayed very busy with their public health project.
On a personal note, I was very proud to have two special people accompany us on the trip. Marc Bouffard is a fourth year medical student at Tufts and he is the one who got me involved in the Dominican Republic in the first place. He called me way back in 2004 and asked if I would like to accompany a medical trip with him. The rest, as they say, is history. Also joining us was my daughter, Mary Frances, who went to high school with Marc so I suppose without her Marc wouldn’t have known me! Mary is HHI’s web master and came on her first trip to observe the operations and take pictures for the website.
It has been an amazing journey for HHI so far and I am really excited about the work we are doing and the direction we are headed.

With the end of the year upon us, HHI is proud to present our first Annual Progress Report. We are so grateful to everyone who has made this year possible, and invite you to share your thoughts and questions after reading this reflection on 2011. Thank you so much for reading our blog and following our journey this year. It is an honor to know that people near and far have become invested in our work to improve community health in the Dominican Republic.

I hope you will keep our patients and partner communities in your thoughts this holiday season – the challenges they face each day remind us that our work has only just begun.

When Angi and I moved to the Dominican Republic in October 2009, we arrived with a vision for establishing the foundation of HHI, and little else to recommend us. In those first few months, I learned that HHI would succeed only if we could build trust — and the only way to do so would be to demonstrate results. As we listened to community members, based our goals on their insights, and proved our commitment to following through on our word, people began to believe in us. We have been truly fortunate to welcome amazing staff, community health workers, and volunteers whose actions continue to build and fulfill the trust of the people whom we serve — and of people like you whose support make it possible.

This year, you watched us grow from five community health workers to fifteen. You read about our first attempts to respond to patients with uncontrolled blood pressure and diabetes, and offered your support as we developed a comprehensive Chronic Care Program. You heard about our efforts to help patients in need of surgery and specialty care. You responded, and watched us build a network of local referral partnerships while also providing one-on-one, community-based follow-up to our patients. You asked what our plans were for addressing public health issues, and encouraged us as we undertook research studies and illness prevention initiatives that enable us to make a long-term impact. None of this has been easy, nor will the path forward be perfect — but, together with the people we serve and partner with, we are fulfilling the trust we earn.

There is such a need to make a difference in this world, and I hope that you are all able to give to a cause that you are truly passionate about this holiday season. If you have followed our work this year, and believe in our dedication to improving community health alongside people affected by poverty, please consider making a tax-deductible donation to HHI. Your solidarity has made our impact possible. Thank you for continuing to walk with us on our journey in the Dominican Republic.

With gratitude and sincere wishes for a wonderful holiday season,

Laura

Your donation helps to build a new vision of health in the Dominican Republic ~ this holiday season and beyond.

Checks may be mailed to:
Health Horizons International
c/o Community Health Program, Tufts University
112 Packard Ave.
Medford, MA 02155

Donations may also be made online by clicking the button below. Please note that PayPal retains a 3% transaction fee.

Thank you for believing in our cause.

To learn more about the impact your gift makes, please click here to download our 2011 Annual Progress Report, or click here to view it online.

HHI is a 501(c)(3) non-profit organization. All donations are tax-deductible to the extent permitted by law.

Water is accessed in many ways in the Dominican Republic, usually through a combination of waiting for the local city water to be turned on (most likely not potable), buying water from large trucks that come house to house (not potable), buying large 5-gallon bottles (supposed to be potable), or gathering water from a natural source like a spring, well, or river. I came to the Dominican Republic to work with Health Horizons International (HHI) to investigate local attitudes and practices surrounding water use and access in several small communities around Montellano. The plan was to use the information I gathered to both aid HHI in their public health planning around water in the local communities and to form the basis of my MPH thesis.

About three days after I arrived rumors of cholera began spreading through Pancho Mateo and the other small communities along the river near Montellano. A baby died of suspected cholera in Pancho Mateo and more suspected cases were arriving in both the small, local hospital and the larger community hospital in Puerto Plata. The local Ministry of Public Health took action and decided to host a community forum comprised of a panel of local water and public health officials as well as members of the military. Through the networking of the HHI team here, we were introduced to the director of Public Health for the Puerto Plata region (Dr. de Pena) who then came to give a charla (group information session) to the HHI community health workers and invited us all to attend the larger community forum.  The first announcement from the Ministry of Public Health was that they were planning to “militarize” the river and block the communities from continuing to bathe, drink, defecate, and throw garbage in the river. They explained the etiology of cholera and how it was a feces borne illness that proliferated in conditions where people came in ready contact with contaminated human waste. They urged everyone to wash their hands after going to the bathroom, before preparing food, and after changing a baby’s diapers, and they urged everyone to buy chlorine and chlorinate all drinking water in order to avoid the spread of the disease.

Many leaders of the local community groups and neighborhood associations arrived at the forum well prepared with statistics and data regarding the chronic lack of access to potable water and proper human waste disposal. They voiced their frustration that the concerns they had been raising for the past few years to the government about the lack of water access and a sanitary means of disposing waste had now created living conditions where cholera could thrive. Times are tough here and many people in these communities are unemployed or underemployed. The community leaders were beyond frustrated that the ministry and the government was insisting their community institute a plan that requires them to have access to something (clean, regular water and latrines) that many don’t have and can’t afford to have. I was very impressed at how organized and knowledgeable the community leaders were and how prepared they were to fight for improved conditions in their communities. After a lengthy debate that lasted well after dark, the ministry of public health announced they would be sending trucks filled with clean water which would be distributed for free in order to provide the community with a consistent alternative to the river.

With this as a backdrop, I began my research here and decided to focus primarily on two communities; the small but densely populated community of Pancho Mateo where the suspected cholera outbreak was and where both Haitians and Dominicans live side-by-side, and the rural and remote community of Arroyo de Leche which is comprised primarily of Dominican agricultural workers. My first order of business was to check out the river in Pancho Mateo and the various water access points in both Pancho Mateo and Arroyo de Leche. I immediately saw that despite the seemingly absolute declaration that the river would be “militarized” I saw no military presence and many people continuing to use the river for water access. I also discovered that no free water was being delivered as planned and even now, nearly four weeks later, only one free water truck per week arrives and this is apparently via an evangelical church in Arizona. I spoke with several water truck drivers and they all assured me that they charge for the water in their tank. Many people in Pancho Mateo continue to complain of diarrhea related illness and many expressed the thought that whether it’s cholera or not, being sick is just a normal part of life here.

Last week Tracy (Public Health director at HHI) and I had a productive meeting with the Ministry of Public Health. When I expressed interest in seeing the local water filtration plant they said that we could come with them on a visit there this week. One of the scientists working on water analysis (Dr. Marmolejos) was surprised and upset to learn that no free water had been arriving in Pancho Mateo as promised.  He was equally surprised and upset when I showed him pictures of the rudimentary water access points in Pancho Mateo. I hope we can address some of these concerns when we meet with the water filtration officials.

What I’ve found, to my surprise, is that the remote community of Arroyo de Leche has fairly regular water access. They tap into the local acueducto and for a fee, they pay to have piping installed in or near their homes. There are also many natural springs that flow regularly and provide seemingly clean drinking water. So far, no one in Arroyo de Leche has expressed that they are without water or that they suffer regularly from diarrheal illnesses.

In the meantime I plan to continue interviewing households in both communities to see what the common water themes are. I have two fantastic local research partners, one of whom is able to help translate Haitian Kreyole during the interviews with the Haitian community and can also explain the intricacies of Dominican slang. Already it’s clear that the Haitian section of Pancho Mateo has the least consistent access to water and latrines, which also adds to their sense of feeling stigmatized since cholera arrived on the island in Haiti first. As I’m quickly learning, water access is a complex political issue. One woman I spoke to in Pancho Mateo insisted that the water pipe being fixed in front of her home was the work of the PLD, which is the major political party here. In an ironic twist, it may just be the cholera outbreak on the eve of a presidential election here in the DR that helps bring water to Pancho Mateo.

Information sheets about cholera in both Kreyole and Spanish

Dr. de Pena presenting at the community forum

One of many community leaders explaining (yet again) why they need access to clean water and latrines

This woman said she was a chemistry teacher and had performed her own test of the local water. She challenged the local water district director on his assertion that the water that did occasionally arrive from the city was free of bacteria

A community leader in Pancho Mateo (and HHI Community Health Worker) being interviewed by the local news the day after the cholera community forum.

Water collected from the river in Pancho Mateo

Some members of the community continue to use the river in Pancho Mateo

Willy (research partner and HHI Community Health Worker) investigating a water access point in Pancho Mateo. Residents said they aren’t really sure when the water will arrive, but since the cholera outbreak some parts of Pancho Mateo are now receiving city water every three days.

Elena in her house in the Haitian section of Pancho Mateo with the buckets she uses to collect rainwater from her roof. She said she also shares this water with her neighbors.

One of several water access points in the Haitian section of Pancho Mateo that was being used for corn preparation. I was told jokingly that the water arrives here every year on January 1st.

Investigating one of many cisterns, found primarily in the Dominican section of Pancho Mateo. When the city does send water, people can fill their cisterns but otherwise they have to pay to fill them.

Consistent running water access in Arroyo de Leche

Washing dishes in Arroyo de Leche

Corina (HHI Community Health Worker) and Nuorcia standing across the stream from one of several natural springs in Arroyo de Leche

Water being delivered, for a fee, to a nice neighborhood in Montellano

Bottle of “purified” drinking water in the HHI staff house which we purchase for about 1 USD each. There isn’t any regulation on the water purification companies that sell these bottles so everyone relies on local word of mouth regarding which is the best. A public health official just told us that “Agua Honey” is the best.

Dr. Marmolejos preparing to show us how they test the mineral balance of the water.

“Oh, thanks, but you don’t have to…” I say, trying to show that I can lift it.
“No, no, Janelle,” the mother says with a smile. “It’s no problem. A tu orden.”
I thank her, secretly relieved that I don’t have to carry the giant jug of water up the stairs, and grateful once again for the sacrificial helpfulness of the Dominican people.

“A tu orden” – a phrase which in effect means, “at your service,” has come to symbolize Dominican hospitality to me over the past 2 months since I moved to Montellano to become the Clinical Programs Director following Megan and Nicole’s return to the states. I don’t know how many times people have said this phrase to me, and to others Dominicans front of me, since I arrived here, but it has certainly been an almost every day occurrence. The help I have received from so many neighbors, Community Health Workers, and even strangers via this phrase is one of the things that has made transitioning to life here in Montellano relatively easy.

It strikes me that in the U.S. the only time that someone would say “at your service” to you is if they’re a butler at a fancy hotel, or perhaps someone who is trying to keep your business – someone who finds themselves working for you and thus is at least pretending to want to help you as a part of their job. But here in the D.R, people say this to their neighbors, their friends, even Gringa strangers who clearly seem confused, and they follow it up by putting their lives on hold to help you with whatever small thing you might need at that moment.

I have had moto-taxi-drivers, who need money desperately, offer me free rides to the office because they’ve noticed me walking with a heavy bag. “No, no, it’s no problem.,” They say. “You need help.” I’ve had people who work in the morning so they can feed their families in the evening give me the last avocado off their tree just because I happened to stop by to say hello. They of course refuse to take it back even if I try not to accept the gift. They shove it into my hand saying “no, no, a tu orden! You can have avocadoes off my tree, anytime.”

I’ve had little children reach for my hand to guide me up steep hills. I’ve had strangers pull me onto their porches when the rains come and I have no umbrella. They’ve served me coffee and we’ve talked about their families, and I’ve left, not as a stranger, but as a friend. I’ve even had a middle class woman with a full time professional job come by to clean my house for free just because she said “you’re here helping people, right? So I want to help you. Let me clean your house, ok?” And when she left she said “Hey, if you want me to come clean your house again next Saturday, just call me. I can come any time. A tu orden.”

“A tu orden.” Wow. It’s the sign of self-less Dominican hospitality. It’s the idea that people will stop what they’re doing to help other people, every day, all the time, even if there’s no benefit in it for them. What a wonderful practice. It’s something I can certainly learn from.

So as we at HHI prepare for the September Medical Service Trip, 2011, this is a great opportunity for us to serve the people of the D.R. with the same attitude with which they serve and show love to us. Many Dominican’s have selflessly welcomed and assisted HHI as an organization. They also welcome the volunteers, interns, and staff with open arms. So, HHI helps – not because there’s something in it for us; not because we have nothing else we could be doing. (I do have a game of Dominoes and some laundry to finish, after-all). No, we help because in front of us is a person in need of medical care. And therefore, as their global neighbors, helping them is the hospitable thing to do. So we reach our hands out to assist the people of Poncho Mateo, Negro Melo, Arroyo de Leche, and Severet. We pause to help the strangers, our neighbors, and friends – just as they often pause to help us.

I gingerly cut off the top and bottom and hack off the sides, careful to not remove too much of the fruit. I select a piece that looks especially juicy and slightly darker yellow. The pineapple instantly satisfies my sweet tooth; then it turns slightly tart, trying to prove it has an attitude and is not all sugar.

From the market in Montellano

From the moment I entered the country, I was embraced by the welcoming arms of the Dominican communities. I stayed with Laura in the staff house for the first few days so I was not by myself; she greeted me with a stir-fry of gandulesand vegetables that introduced me to the bold flavors of eggplant and onions here. Later, as Charlene and I were doing our patient interviews, we followed our noses into the homes of the Community Health Workers, who greeted us like old friends. I remember a particularly hot day in Pancho Mateo when Claudia and Carlito gave us grape soda—perhaps the best soda my dehydrated body had ever gulped.

Mercedes and Charlene, Sarah's co-researcher, making arroz con dulce

The Dominican passion for sharing food extends to more than just hospitality; even the poorest Dominicans are able to sacrifice what little they have in order to feed a stranger. One family with whom I have grown close lives in a small tin hut in a crowded community. When I asked the mother if I could buy some of the peanuts she sells, she immediately stated rummaging around her large basket to find the perfect ones for me. She handed me two bags of peanuts, two pieces of peanut brittle, and one coconut treat I have decided to name “I died and went to coconut heaven” (I didn’t tell her that; my attempts to make jokes in Spanish have been largely unsuccessful). When I tried to pay her, I was met by a stern look and a shaking head. I persisted but in the end she would not allow me to pay. She might be 80 pounds and 4’8’’, but that woman was strong. In hopes I too would gain superhuman strength, I devoured her gifts. The tastes of roasted peanuts, caramelized coconut, and pure sugar, as well as the taste of the pure desire to do something sweet for a fellow human, still linger on my tongue and in my heart.

Fresh avocado and tomato with black beans and rice - qué rico!

As we have learned through our hypertension research, Dominican food can also affect the heart in other ways (and I don’t just mean due to the effects of fried food and red meat). From their gardens and conocos (small farms), Dominicans can produce foods that they use to help manage their hypertension. We have been told of the healing powers of anise, passion fruit, guanabana, and noni, among others. I honestly have no idea if these remedies work. But I mention them because to me, these methods represent a sense of control for these patients. On an island where a significant proportion of the population suffers great discrimination, in a country that doesn’t think they deserve paved roads, in an area where the closing of a factory a decade ago is still felt by the economy – these are people who have had little control in their lives. And now they have hypertension, a disease they cannot feel or see. So food is their power: they do not need someone to give it to them because they can grow it themselves, from their land. Of course, the medicines provided by HHI help a great deal. However, providing medicines is not the only way in which HHI has improved health care here; they empower individuals through education and responsibility.  And in the same way, food gives individuals power: to welcome a stranger, to bridge the gaps of social class, and to heal. For some patients, all it takes is agua con azucar y un chin de sal (sugar water with a touch of salt) to help with their hypertension. I wish that we could all gain peace of mind from such a simple recipe.

Meg and Tsubaru, a moto driver and father of six, prepping for a photo op.

Meg with Catherine, a community health worker from Severet, and a young patient.

Meg with Willy and his mother in front of their home.

Dorka, Meg and Pastor Pedro in Severet.

– Meg

For more information about Health Horizons International, please visit http://hhidr.org

Patient Care Management Volunteers, Rachel and Kate, along with HHI's International Programs Directors, after interpreting for patients during pre-surgical consults.

The commitment demonstrated by HHI’s cooperadores is a reflection of the commitment demonstrated by the organization to empower local people as a means of building local capacity. I believe that there will come a day when Montellano’s public hospital will have means to provide the services it is currently unable to offer, and the magnitude of patients it is currently unable to manage will receive a quality of care that is just. The list of barriers is infinite and the problems profound, but witnessing the impact HHI’s encouragement has on natural-born leaders like Larikza, enabling them to make the changes they want to see in the health of their communities, I have reason to believe in HHI’s vision. I look forward to seeing how the organization will continue to grow under the new IPDs, and I thank my teachers, Nicole and Megan, both for their perseverance and for all the teaching moments that made this experience so inspirational.

Rachel works with cooperador, Yeraudiz, to triage patients.

The outstanding group of community health workers (cooperadores) is a collection of extremely dedicated individuals who strive to educate themselves on essential health issues in order to educate their communities and improve the quality of life of those around them. In the weeks and months before I arrived in the DR, a new group of cooperadores began their training and started reaching out to members of their communities to provide basic health services and support. These nine newcomers joined the six veteran cooperadores to form a small army of community health workers. I was absolutely blown away by their commitment and enthusiasm. Many of the cooperadores spent the clinic days greeting the patients to whom they had given appointment cards, taking blood pressures, and sometimes accompanying their respective patients to consults with the HHI medical service trip physicians. After the conclusion of the service trip, this team of dedicated community health workers performed home visits to follow-up on patients’ progress. With the newly-expanded team of cooperadores, I know that the communities will continue to receive the support and education that they need.

Kate works at patient intake along with cooperadora, Catherine, during a field clinic in Severet.

Lastly, with the staff house now freed from filing cabinets of patient records and suitcases full of medications, our apartment seemed a bit more like ‘home.’ Employees and volunteers now have a great place to congregate, discuss the day’s activities, plan for the future, and then relax at the end of the day. Even more exciting was the purchase and installation of an inverter that will keep power running at the staff house 24 hours a day! This addition also means that the internet modem and router will keep the world-wide web flowing through staff house all day, every day—connecting HHI’s staff with those who care about the organization’s progress. I cannot express how important this advancement was and how it will continue to impact HHI’s ability to outreach to the Board, stakeholders, former volunteers, potential volunteers, family, friends, and more.

I feel so privileged to have spent nearly a month working with HHI—an organization that truly lives its mission and strives to perfect its model. I look forward to following HHI’s progress and seeing how it continues to grow and develop in the future with the help of amazing staff members, volunteers, and cooperadores. Que les vaya muy bien!

Kate with cooperadores Claudia and Willy along with Willy's mother in Pancho Mateo.

Dr. Good and Ricky, a medical interpreter, speak with one of HHI's chronic disease patients.

HHI volunteers Mary Lockwood and Rebecca Good working hard in the clinic pharmacy.

Drs. Brad Wilkinson and Michael Good pose with the community health workers from Pancho Mateo.

– Dr. Good
For more information about Health Horizons International, please visit: www.hhidr.org