HHI’s New Community Health Workers

April 4, 2011

Many people ask how we find our community health workers (CHWs); the answers to that question are as varied and unique as the health workers themselves. Some are former patients, or family members of patients. Some have volunteered during previous HHI field clinics, and some were suggested to us by community leaders. Cumulatively, they are four men and ten women whose ages span from 18 to 54 years. They speak Spanish, English, French and Haitian Creole, and they represent the communities of Negro Melo, Arroyo de Leche, Severet and Pancho Mateo. They are teachers, medical assistants, moto drivers, tailors, mothers, fathers, and now – community health workers.

Larikza, Yeraudiz and Yudi learn how to take blood pressure.


CHWs are nothing new: the barefoot doctor program in China and the accompagnateur program of Zanmi Lasante in Haiti are each at least 20 years old. The idea is simple: community members are trained to act as liaisons between physicians and patients by providing medicines, check-ups and health education to patients. This model can be highly effective in increasing medication adherence, preventing disease, and improving overall community health. Additionally, CHW programs build local capacity by providing basic medical skills and training to people who may otherwise have very few educational and/or job opportunities. For years the developing world has been ahead of the industrialized world on this front, largely out of necessity (e.g. more remote populations, dire poverty, physician shortages). However, the US is beginning to catch up: Dr. Atul Gawande recently published an article in The New Yorker about the success of multidisciplinary teams, including CHWs, in treating patients with chronic diseases (“Medical Report: The Hot Spotters,” 24 Jan 2011). We are seeing, over and over again, in multiple arenas, that CHWs can reach patients where doctors can not.

Genesis teaches other CHWs about the long-term effects of diabetes.


This is certainly true in the Dominican Republic. HHI’s Chronic Disease Management Program has nearly 100 patients, all of whom have hypertension, diabetes type II, epilepsy, and/or asthma. Many of these patients can not afford the moto ride necessary to get to the local clinic, much less the daily medications that their chronic diseases necessitate. Our CHWs fulfill a crucial role by following up on patients diagnosed with chronic diseases during HHI’s medical service trips, bringing them their prescriptions and providing them with monthly check-ups. They also provide health education and basic first aid to their entire communities.

HHI just expanded our corps of CHWs last Friday with the completion of our second training. Each of these new CHWs will add to HHI in different ways: there is Larikza, always ready with an illustrative story or patient example, and Willy, who speaks three languages fluently and dreams of medical school. There is Yeraudiz, whose heretofore-unknown acting skills improved many a class role-play, and Luz, whose prior experience working at an HIV/AIDS organization has already proved incredibly helpful. There is Yudi, who used her new first aid kit to help a neighbor the very first day she got it, and Dania, whose calm and confident manner will be endlessly reassuring to her patients. Carlito and Claudia form a husband-and-wife team whose skills and interests complement each other perfectly, and Genesis is a bright young woman eager to serve her community. This is the varied and unique group of HHI’s new community health workers, who will serve as teachers, caregivers, and community leaders in the coming years. We did not find them; they found us. And, my, are we lucky to have them.

-Meg

New community health workers visit CMC, one of HHI's partner clinics.


For more information about Health Horizons International, please visit our website at: www.hhidr.org

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More than Silver Linings

March 21, 2011

If I’ve learned anything in the DR, it’s how to stay positive – how to carry a mental divining rod that seeks out the silver linings tucked within dark clouds and how to celebrate minor victories in the face of great tragedies. However, this isn’t always easy. The DR’s immense geographical and cultural beauty is thrown into sharp relief by shadows of unemployment, racism, corruption, and illiteracy. If you let your guard down, you start to wonder whether the idea that any one of us can make a real change is egotistical and absurd. It’s a place where good intentions are often tempered by difficult realities. It’s a place that has made me understand the title of President Obama’s book, “The Audacity of Hope” on a visceral level – for holding out hope in the face of such challenges can seem like a proud act of defiance, bordering on hubris. However, for once, the first week of March was not about silver linings or small triumphs, but rather about clear-cut successes and great joys that showed me why we all have the right, and even the responsibility, to keep on hoping.

The week began with a reading of Luisa’s biopsy results. Luisa had been having extremely long, heavy periods and her doctor suspected cancer. While HHI was able to pay for Luisa’s biopsy, we did not have money for further follow-up care. I found myself lying awake at night pondering Luisa’s fate and the role that HHI would play in it. However, when Luisa’s biopsy results came in, a smile crossed the doctor’s face – he explained that her condition was benign and could easily be treated with medicines. Shortly thereafter, I received a phone call from a Canadian family on vacation to the DR who had seen one of our brochures and wanted to support HHI. They bought Luisa the medicines she needed and she is now recovering at home with her family and friends.

Wednesday brought more good news. Paola, a 33 year old mother of three, underwent a successful surgery to correct injuries that occurred when she was left in the hands of an unlicensed medical student during childbirth. For years, Paola struggled with scarring, chronic infections, and bladder prolapse. She was told by doctors that she would never fully recover. However, during HHI’s January medical service trip, Paola received a referral to see a gynecologist. She was taken to Clinica Buen Samaritano where Island Impact, another local NGO, was hosting a team of gynecological surgeons. HHI worked to get Paola pre-surgery labs and Island Impact provided her with surgery, free of charge. At home with her husband and children, Paola now smiles and says that she feels like the woman she used to be.

But perhaps Friday brought the best news of all. Since September, HHI had been working to get Soraida, a bright 20 year old, treatment for painful polypoid masses that had invaded her sinus cavities and the orbit behind her left eye. Many doctors speculated that the masses were cancerous, that Soraida’s condition would be inoperable, and that even with the best medical care, she would still likely face a poor outcome. Indeed Soraida had undergone countless lab tests and seen a surgical oncologist, a radiologist, a hematologist, a maxillofacial surgeon, an ophthalmologist, and two otolaryngologists before finding a surgeon that had both the equipment and skills necessary to remove the masses. Even then, the doctor was concerned that Soraida might lose her left eye. However, on Friday morning we learned that the surgery was successful and that Soraida’s vision was intact. Shortly thereafter, we celebrated the news that the masses were benign and that Soraida would not have to undergo chemotherapy as originally suspected – she had reached the end of her long journey, as healthy and as strong as before.

Soraida smiles with Meg after her successful surgery in Santiago.

Luisa, Paola, and Soraida remind me that even in the face of seemingly insurmountable challenges, it’s possible to rise above and beat the odds. They also remind me that while no one individual can create real change, together we can. The doctors who saw these three women during HHI’s medical service trip, the hospital administrators who gave us discounts on their care, the surgeons that provided them with expert treatment, the donors that bought their medications, and the community health workers who helped coordinate their care have all had the audacity to keep on hoping. They are inspirations and I will forever be grateful to them.

-Nicole

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Windowpane

February 18, 2011

After three too-short weeks in Montellano, following four months of adjusting to life and work in the States, I pressed my face against the airplane window for take-off.  I was surprised to feel the plane arc back, instead of heading straight out over the ocean.  A new flight path, tracing the shore of the north coast from above.

As I watched through a window not much larger than a notebook page, the entirety of my life’s current work was suddenly laid out before me.  I could make out the smokestack of the old sugarcane refinery, and walk my eyes a few blocks to the right, where I knew our office stood in the shade of some coconut trees.  The ocean is much closer than I realized; the tall sugarcane and warnings of danger have prevented me from ever walking that way.  I could trace the main road in Montellano from where it intersects the highway, turning right then left at the old train, memorializing the time when cane was hauled from the fields by rail, and over the rickety bridge to the sugarcane road.  From there, miles of cane and mountains, where I had just said goodbye again to people, communities, hidden from sight in so many ways, the least of which is from up here in the sky.  With the bay of Sosua peeking out from the left, and the unmistakable bend in the highway at Gran Parada on the right, everything and everyone we work so hard to serve and empower were captured in a 10-inch picture frame.

It’s humbling to remember how small we are.  It’s even more humbling to realize how many people — living, dying, suffering, celebrating, healing, hurting, working, fighting people — can exist in a single windowpane.  It’s a dual perspective afforded only by taking a step back — by getting a bird’s-eye view.

The few months after I returned to the States in September were, in retrospect, more challenging than I even realized at the time.  Progress was made and plans were implemented, but every day brought a greater list of things we should do than things we were doing.  We were connecting dozens of patients to needed referral sources, but desperately needed to reassess our capacity and priorities for patient care versus public health and education.  We more than doubled our bank account, but we still needed more strategic and on-going development initiatives.  We were engaging students in project development and fundraising, but were continuing to question how to fit medical service trips into a long-term organizational vision.  It was daunting to manage these conversations and decisions while also establishing HHI’s stateside presence from scratch.

Being back in the DR afforded me the perspective to recognize and articulate these very real challenges, and fostered significant conversations about HHI’s future.  After a year and a half of trial and error, successes and failures, and most importantly, taking the time to learn about and form relationships with people and communities, we are in a position to make tangible moves toward a long-term vision.  Thanks to the more than doubling of our (wo)manpower in the weeks post-medical service trip, we are now focusing on growing our community health workers program, developing public health initiatives, and creating new partnerships to strengthen the existing local health system.  I returned to my office on the Tufts campus in Medford almost three weeks ago, inspired and energized to go.

I still picture that windowpane when I think about the details, the action items, the goals.  I’ll always remember that perspective…

~Laura

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HHI Does Teamwork

February 7, 2011

We are pleased to welcome Dr. Wes Williams back as a guest blogger.  Thank you for sharing your reflections on your second HHI trip, Wes!

Dr. Wes Williams with a young patient on one of HHI's clinic days.

Leading up to the January 2011 HHI medical service trip, I had some concerns. I was excited, to be sure, and very much looking forward to getting back to the Dominican Republic where the weather is as warm as the smiles on the people’s faces. I was also looking forward to seeing my friends and patients from the September medical service trip. But I faced a fair amount of uncertainty over the size of the group. With only eight people, the September trip was so small and personal – the eight of us worked together so well. But how would it go, how could it go, with 28 people milling about? The little churches in Negro Melo, Severet and Pancho Mateo barely seemed large enough to accommodate three physicians with interpreters, triage, pharmacy and patient education with Dr. Herman. How in the world could we effectively utilize six providers PLUS translators PLUS students with triage, pharmacy and patient education? Not that I questioned the abilities of the HHI board members, Meg, Nicole or the community health workers, but I really didn’t see it going smoothly. It was just… too… much.

But now, as I reflect back on a highly successful trip, I realize the glue that held together a group of such radical diversity was a common desire to serve the people of the Domincan Republic, and to learn. For some of us it was a desire to learn how best to apply the limited assets we have to the unlimited needs of the communities we serve. For some, it was a desire to learn how to sift through the vast assortment of data with which patients bombard us, and glean the relevant facts to form an assessment and prioritized treatment plan. For most of us, there was a desire to learn and understand more about the culture of this island that is so close to our home. And for me, at least, there was a desire to learn more about myself as a human being, about why I’m here and what I intend to do with these four score years I have to inhabit this globe.

Dr. Wes Williams with QU Physicians Assistant students and HHI Community Health Workers in Severet.

We each possessed a desire to serve and to learn, and despite my initial misgivings, this common thread allowed us to overcome the obstacles we encountered and function as a highly effective team. It was this teamwork that made us successful, allowing us to serve and to learn even when the numbers seemed overwhelming. Puerto Plata province is a better place, and we are better people since HHI brought us together.

- Dr. Wes Williams

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2011 Updates

January 27, 2011

It’s been some time since we last posted, but we’ve certainly been keeping busy since the start of the New Year. Admittedly, by the end of 2010, I was feeling a bit burned out. After a wonderful but exhausting trip home for Christmas and an even more exhausting dash through Newark airport, I arrived back in the DR thinking of the copies we needed to pick up, the medicines we needed to pack up, and the litany of other tasks we needed to complete for our January medical service trip. From there my mind skipped to all the arrangements we would need to make for our referral patients after the trip had left. In my head, 2011 was quickly evolving into a monstrously long “To-Do” list and I wondered when I’d have time to finally check everything off, sit down, and breathe.

However, then something unexpected happened. On January 2nd a group of 28 doctors, students, and volunteers arrived at the Puerto Plata airport and instead of feeling overwhelmed, I actually felt reenergized. From the start, seeing such a disparate group of people, from seasoned physicians to undergraduate community health students, all share in HHI’s goal of improving community health reminded me why I came to the DR to begin with. As the week progressed, I was truly inspired by how well the group worked together in clinics and how much they accomplished in just one week. From administering tetanus shots to a child who had cut his foot on barbed wire to providing palliative care to an elderly patient with lung cancer, the group worked tirelessly to provide over 400 patients with the treatments they needed. In addition to working in the clinics, I was able to accompany a group of Tufts students as they implemented a community mapping project in Pancho Mateo. Going door to door with the students, who wielded GPS devices, survey questions, and unflagging smiles, I was blown away by the rapport they developed with community members as well as the diligence with which they carried out their work. As the week came to an end, I realized that despite the long hours and hot days, the trip and all its members had motivated and inspired me more than I could have possibly imagined.

The group poses for a photo after the last clinic day in Pancho Mateo.

Just two days after the medical service trip team departed, we were given an even greater boost as our fearless leader Laura, and our even more fearless patient care management volunteer, Ellie arrived to help us sort through an impressive stack of over 60 patient referrals. From the start, Ellie threw her energy into everything from the mundane task of picking up patient lab reports to the more personal assignment of accompanying groups of patients to specialist appointments. A week later, Ellie was joined by Michelle, a psychiatry resident at Boston University, who helped conduct bereavement counseling sessions for parents who had lost children and provided other community members with mental health support. And of course, throughout these weeks, our efforts were joined by our invaluable community health workers, who tirelessly worked to locate referral patients, answer their questions, and deliver their medicines. By the end of two weeks, our team of volunteers, community health workers, and local doctors had provided follow up care to nearly 50 patients and I felt more energized than I had in months.

Volunteer Ellie Colson follows up with patients, and takes a quick break to play.

 

Dr. Michelle Durham checks in on one-year-old twins with upper respiratory infections.

As we near the end of January, our “To Do” list is still long. There are still patients who need follow-up, new community health workers to train, and public health projects to implement. However, I no longer view the road ahead as an overwhelming series of tasks to be quantified by photocopies and spreadsheets, but rather as an ongoing journey of stories to be heard, friendships to be formed, and challenges to be met. Thanks to Ellie, Michelle, Laura, Meg our community health workers, local partners, and MST volunteers, 2011 has already been marked by a spirit of determination and collaboration. I thank all of them for putting a new spring in my step as I see where the year takes us.

Saludos,

Nicole

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Holiday Spirit

December 20, 2010

It is a bit difficult to get into the holiday spirit in the Caribbean.  This time of year, I am used to snowy climes, cloying Christmas music, and massive amounts of sugar cookies.  However, in the Dominican Republic, December temperatures hover in the mid-70s, the only background music is ever-present merengue, and typical Christmas fare consists of apples and grapes (neither of which is ever frosted to look like a snowman, much to my dismay).  But perhaps the most difficult thing about being in the Caribbean at this time of year is being far away from family – surely the most essential ingredient for a happy holiday.

A nativity scene set up in the central park of Montellano.

On a recent warm and sunny morning, I swallowed all that Christmas sulk and climbed onto a moto to go check up on some patients.  Estela, our community health worker from Negro Melo, had told me of an infant with a white scaly rash, and one of our hypertension patients was running low on her medications.  After a 45-minute moto ride filled with mud and mosquitoes, I arrived at Estela’s door to see a warm bowl of beans and rice waiting for me on her table.  I laughingly admonished her; she always has a warm bowl of beans and rice waiting for me, and feeding me is definitely not part of her job description.  She batted away my protestations, telling me I was far too flaca (skinny) when I first arrived in this country, but now I’m looking a bit more fuerte (strong) and she feels personally responsible for that change.

Meg, Estela and Estela's youngest daughter

After my second lunch of the day, Estela and I headed over to Blanca’s house to check on her baby.  As I spoke to Blanca, neighbors and community members slowly started filtering in, as is the norm.  First came Maria, who has called Estela her doctora and me her cardióloga ever since the blood pressure meds we give her started working; after myriad attempts to inform Maria of our correct titles, I’ve finally given up and now just accept her nicknames.  She plopped down at the kitchen table and brought out her medication bottles for a refill.

Then Rosario stopped by.  A lifelong epileptic, Rosario used to suffer two seizures daily, and she wears the resulting scars externally: one of her eyes is permanently diverted to the right, and the last time I saw her, one side of her body was completely covered in bruises and scrapes from a recent seizure.  Anticonvulsants are hard to come by in this country, as well as expensive, so Rosario’s seizure control had been sporadic at best.  But last month, HHI started supplying Rosario with daily antiseizure meds, and Rosario was here today to declare their efficacy.  She hugged me immediately upon entering Blanca’s kitchen.

“¡Esos medicamentos me dio son buenos!  Ahora puedo fregar los platos, y tomar café con mi esposo – ¡soy fuerte!“  Those medicines you gave me are good!  Now I can wash the dishes, and drink coffee with my husband — I’m strong!”  I smiled, but the room immediately erupted in laughter.  I sat, thoroughly confused by everyone’s delight in Rosario’s increase in coffee consumption, until Estela bashfully explained that “drinking coffee” has two meanings in the Dominican Republic.  A light bulb went off above my head, and once I finally got the joke, everyone burst into hysterics all over again.

Eventually I took my leave from Blanca’s warm and joyful kitchen, and on the way home I thought about my afternoon.  I thought of Estela, always trying to feed me yet another bowl of beans and rice; I thought of Maria and all her nicknames; I thought of Rosario and her indomitable spirit; and I thought of  the multitude of laughing children, always eager to hug my waist and braid my strange straight hair.  Somehow along the way, despite my skin color and my continuous mangling of the Spanish language, I managed to form a little family here.  They may have never seen snow, and they may prefer apples and grapes to sugar cookies, but we can still share stories, and meals, and jokes.  We can still learn from each other and laugh with each other.  And right there on the moto, amid all the mud and mosquitoes, a wave of holiday spirit washed over me.

Giggles all around in Pancho Mateo

-Meg

For more information about Health Horizons International, please visit www.hhidr.org

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Reasons to Be Thankful… A Belated Thanksgiving Post

November 29, 2010

The Sunday before Thanksgiving, I received a phone call from the mother of one of HHI’s patients, Amadito. A four year old boy, Amadito had been diagnosed with leukemia a few weeks earlier and HHI was helping to provide for his treatment. While earlier in the week, Amadito’s mother told me he was doing better and reveling in the novelty of having a TV set in his hospital room, on Sunday, her voice was strained and desperate over the phone. I arrived at the hospital in Santiago only to discover that there was nothing left for HHI, or anyone else, to do. A few minutes later, Amadito passed away.

I returned from the hospital in a daze only to wake up the next morning and learn that the DR had diagnosed its first cases of cholera. I spent the next few days fighting off a terrible headache and an even more terrible sense of hopelessness. I started out the week leading up to Thanksgiving thinking of the world’s overwhelming injustices, rather than concentrating on what I had to be thankful for.

However, as Meg’s last posts reveal, even during the rainy season, the sun always manages to make an appearance when you need it most. And so, on Wednesday, the day before Thanksgiving, I began to remember all that I had to be grateful for. I started out the morning by taking another patient to Centro Medico Cabarete. After the appointment, she beamed about how beautiful the hospital was and how well-respected she felt by the doctors and staff. On the way out, I stopped to pay our month’s bill, which included a litany of highly-discounted consults and labs as well as a successful surgical procedure for one of our patients. I smiled for the first time in days thinking about how one of the wealthiest private hospitals on the North Coast had been so willing to help some of the area’s poorest people, treating them with the dignity and respect they deserve but so rarely receive.

Centro Medico Cabarete has offered HHI highly discounted rates on procedures and services, greatly benefitting our patients.

Later in the day, I met up with Meg and we headed to a Haitian community center where Tsipa, one of our community health workers, was giving a lecture about health care. The classroom was outdoors, the side of a shack served as the blackboard, and the students struggled to hear over the sound of traffic and jackhammers. As night began to fall, the class moved their chairs forward to better see in the dark.  Despite the obstacles, the class’s concentration was unbroken and afterward, the students sincerely discussed their desire to improve health in their communities. I left deeply inspired by the students’ willingness to not only better themselves in the face of challenges, but to better their communities as well. Although the class was conducted in Creole, I was deeply grateful for all that I had learned.

Tsipa gives a lecture on health at a Haitian community center using HHI's curriculum.

However, I was most moved that day by visiting Amadito’s parents, Manuel and Rosa. I arrived at the house on the back of a motorcycle carrying a limp bouquet of white flowers. After the heartbreak of Sunday, I hesitated before entering, not knowing what to say. However, before I had time to say a word, Rosa’s arms embraced me in a strong hug that eliminated the need for speech. Rosa then introduced me to her entire family, and despite the fact that almost all her resources were depleted by the costs of Amadito’s care, insisted on buying me a Coca Cola. Manuel showed up shortly thereafter. The atmosphere in the house wasn’t the one of sorrow that I expected, but one of love and even joy as each person took turns sharing happy memories about Amadito. As the conversation turned towards small talk, Rosa told her family that she sincerely hoped to be one of HHI’s new community health workers so that she could help other children in her community. Manuel, who makes whatever money he can as a moto-taxi driver, said that he wanted to deliver medicines to HHI’s patients for free. When I left the house, the tears in my eyes weren’t of sadness, but rather of gratitude for Rosa and Manuel, who in a time of unspeakable loss, gave enough of themselves to strengthen me.

Ironically, in the Dominican Republic, I felt more gratitude on Thanksgiving than I ever had before. And so to Meg, my parents, my boyfriend, Laura, Angi, Rosa, Manuel, our community health workers and all those that have shown me that love, be it love for a son, love for a community, or love of the idea of a better future, can overcome even the greatest challenges, THANK YOU.

-Nicole

T

Thanksgiving dinner... Dominican style.

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Lessons Learned

November 18, 2010

Everyday, this country, this job, and these people teach me something.  This week, I thought I’d share a few lessons I learned along the way.

Heavy rains have left the road to Arroyo de Leche thick with mud. Barely visible is the red hat of Franklin, the moto driver, as he pushes the moto uphill.

1) When Your Moto Gets Stuck in the Mud, Sometimes You Have to Get Off and Walk. As perhaps evident from the tenor of the past few blog posts… it has been a rough month.  Between the heartbreaking patient cases, the unrelenting rainstorms, and the frustrations surrounding treatment adherence, it has been all too easy to feel discouraged.  However, this past Friday, a funny thing happened: the sun came out.  And then, like so many dominoes, things started to fall into place.  One of our patients with a back mass was diagnosed with a benign cyst, and promptly received compassionate, quality care.  The secretary for the mayor of Montellano agreed to set up a meeting with HHI to discuss trash collection in one of the Haitian bateyes where we work.  And, with the reprieve from the rain, I was finally — finally! — able to get up the mountain to visit some of our community health workers and patients.  It wasn’t the easiest route: halfway up, our moto lurched to a sudden stop, the wheels grinding fruitlessly in the mud.  Concerned that my trip would be delayed yet again, I asked the driver, “What do we do?”  He looked at me like the true idiot gringa that I am and said, “Nos bajamos y caminamos. We get off and walk.”  Oh.  Right.  So we got off and walked.  And sure, it took a bit longer to get there… but we made it.

2) It is Possible to Save a Dying Pig Using Only a Sewing Kit and a Bottle of Hand Sanitizer. Apparently adult female pigs are wont to attack other pigs’ offspring in some sort of territorial, Darwinian attempt to ensure the dominance of their own bloodline (yet another “lesson learned” this week).  This recently occurred within the pigsty of Cedric, one of our community health workers: a female pig bit into the stomach of another pig’s newborn, effectively eviscerating the piglet.  Cedric, ever the resourceful and ingenious community health worker that he is,  promptly fetched his first aid box and a sewing kit.  Over the next two hours, he proceeded to clean out the intestines of the piglet with HHI-supplied hand sanitizer and then sew up the wound with tailor’s thread.  After a recent visit to Cedric’s pigsty, I am happy to report that the piglet’s stitches have since been removed and it is recuperating well.

Cedric's happy hog

3) Share, Care and Cooperate. Technically, I learned this lesson in Mrs. Gueller’s kindergarten class, but its themes reverberated this week as HHI collaborated with two different NGOs in the area.  On Thursday afternoon, HHI partnered up with The DREAM Project of Cabarete, supplying hand sanitizer and educational handouts in an effort to inform the community about the recent cholera outbreak in Haiti.  (http://www.dominicandream.org/)  Then on Saturday morning, HHI showed up at The Mariposa Foundation to participate in a discussion about domestic violence (http://www.mariposadrfoundation.org).  It was an honor to “share, care and cooperate” with both organizations, and hopefully we will continue to do so in the future.

Girls involved with the Mariposa Foundation's leadership classes

4) You Can Always Talk about Food. Sometimes it can be a bit daunting, when sharing a meal with our patients and their families, to think of a conversational topic that will be able to span vast differences in culture, language, age and socioeconomic status.  For example, the classically American habit of asking about one’s job is simply not done here.  However, over time and through a considerable amount of trial and error, I’ve discovered a few talking points that will spark conversation without fail:

  • the weather
  • friends and family
  • the health of one’s friends and family
  • good food

Looking at that list, and also thinking of all the topics it excludes, I’m beginning to think that Dominicans have it all figured out.

Mercedes, our community health worker from Arroyo de Leche, cooking up a feast

5) Girls Rule. A study recently published in the medical journal Lancet found that increased educational attainment among women has directly contributed to decreased child mortality worldwide since 1970 (Lancet 376(9745):959-74).  Specifically, the study contends that 4.2 million fewer children died in the last 40 years solely because they had educated mothers.  Reading that study made me think…  80% of our salaried community health workers are women…  and two of our female community health workers  have brought their children to class with them before… and twice in the past month, I’ve gone on patient home visits with female community health workers who brought their young daughters along.  Up in Arroyo de Leche recently, Marielis, the 4-year-old daughter of our community health worker, watched as her mom measured a patient’s blood pressure and counseled him on  various lifestyle changes.  Afterward, the patient pinched  Marielis’ cheeks and teased, “¿Vas a ser médica un día, mi corazón? Are you going to be a doctor someday, sweetie?”  Marielis shyly nodded, and I thought, “She just might.”

Sisters from Arroyo de Leche

- Meg

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

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Rainy Season

November 5, 2010

I sit under the shade of Estela’s palm-roofed patio, waiting for her to change her clothes and brush her hair before we go on a patient home visit.  Rainy season has come early this year, and my trek up to Negro Melo had already been delayed three days due to the swollen rivers. Today has brought the relief of a sunny afternoon, however, and Estela’s neighbors have collected themselves on her patio as if to dry themselves out: a Haitian woman is washing her clothes, a cigarette dangling from her mouth.  A young man tinkers with his motorbike nearby, shirtless and covered in grease.

Lunchtime in Negro Melo

Clemente is also here, talking about the eye surgery he desperately needs. Clemente is missing his right eye (it “fell out” after a “blow”: so go patient medical histories in this country) and in a cruel twist of fate, the vision in his left eye is quickly deteriorating due to retinal detachment.  I know his story; we took Clemente to an ophthalmologist two weeks ago, where we learned that the only hospital that performs the eye surgery he needs is in Santo Domingo and costs $750.  And that is where we reached an impasse with Clemente: because Negro Melo, surrounded by acres of sugarcane and the greenest hills I have ever seen, is six hours away from the hospital and ten years away from any of its inhabitants having $750.

My phone rings; it’s my colleague, Nicole, in Santiago with a patient’s family.  Their 4-year-old son was just diagnosed with leukemia.  Her voice comes over the line fraught and rushed, anomalous in these quiet rural environs. “I tried to donate my blood to Amadito because his dad was rejected as a donor, and the hospital’s blood bank is empty, but now they’re telling me my platelets are too low.  Why are my platelets too low?  How can I raise my platelets?  And what kind of hospital has an empty blood bank?!?”

I take a deep breath. I came to the Dominican Republic expecting to help provide primary care to underserved populations, to help train a corps of community health workers, and to initiate public health projects in rural and batey communities.  What I didn’t expect, however naively, were the myriad obstacles that would present themselves along the way.  I knew there would be poverty, yes, but I was not ready for the complicated patient cases; the impassible roads; the institutional racism; the desperate needs for patient advocacy and education; and the dearth of basic healthcare necessities from toothbrushes to x-ray machines.  It’s not just the logistical nightmares that prove frustrating: it’s also the ethical ones.  Is our time better spent teaching 20 children how to brush their teeth, or sitting at the bedside of one very sick little boy?  Is our money better spent buying trash cans for an entire community or buying eye surgery for one blind man? Prevention and education may be more cost-effective in the long run, but this is a zero-sum game, and the losses in the short run are heartbreaking.

Estela appears at last, in a clean shirt, with her hair smoothed back into a ponytail. She has a pencil stuck behind her ear and a bag of medicines to deliver in her hand.  “Lista?” she asks, “Ready?”  I take another deep breath and nod.  Sometimes, things work out: Nicole was eventually able to find a friend in Santiago, a kindhearted man from Connecticut, who miraculously had the same blood type as Amadito and rushed to the hospital that night to donate his platelets.  However, Clemente is still waiting up in Negro Melo for his surgery, and tomorrow, the rains may come again.  But for now, right this moment, it is sunny and warm, and together, Estela and I step out into the light.

-Meg

Estela and Meg on a home visit in Negro Melo

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La Bomba

October 11, 2010

It’s nearly 2 am on Saturday night and I’m sitting with friends in a gas-station-turned-Merengue-club. The atmosphere is gritty, the sound system blaring, the beer ice cold, and the music red hot. I am transfixed by those who dance around me; the surroundings may be coarse, but the dancers are smooth, swaying hips and hands in a perfectly fluid expression of intimacy and joy. My friend’s boyfriend, Niko, takes my hand and leads me out onto the floor. I hesitate and remember my dismayed Polish grandmother telling me during an attempted polka lesson that I danced like a horse. Since then, I’ve always likened myself to the Tin Man- my hips don’t move without the help of an oil can. I immediately step on Niko’s feet.

Fumbling on the dance floor, I also flashback to the missteps of the past week. Faced with the daunting task of checking in on patients who were entered into our hypertension management program, I feel much like I do on the dance floor- awkward and discouraged. As Cedric and I go door to door to check on patients, it becomes painfully obvious that many are not taking their medicines correctly. In hopes of avoiding this problem, we had instituted a seated pharmacy in our clinic, designed handouts and created pictorial instruction labels for patients who cannot read. But in spite of these seemingly good ideas, I feel like we’ve somehow stumbled.

 

Dr. Hermann shows a patient how to properly take her medicines using a pictorial instruction label. Unfortunately, patient compliance is still a challenge.

Dr. Hermann shows a patient how to properly take her medicines using a pictorial instruction label. Unfortunately, patient compliance is still a challenge.

 

However, as the Merengue plays on, I also think of the week’s steps forward. I see myself as I check in on a patient at the local hospital. HHI has paid for half of his much needed hernia surgery and while he is still coming out of anesthesia, his family is greatly relieved that everything went well. I relive the excitement of hearing back from another NGO, which tells me that they can sign our patients up for free cataract surgeries. I remember my feelings of gratitude when a supermarket agreed to donate several boxes of toothbrushes, toothpaste, and floss to HHI so that we can teach dental hygiene on our next service trip. I think of the patients who ARE taking their medicines correctly and remember that there are ways to further educate those who aren’t.

And so at a Dominican gas station/dance hall, I come to realize that working in community health is not unlike learning how to dance. Just like I’m new on the dance floor, HHI is still new in the field, and both of us are bound to stumble sometimes. But I also remember that every dance requires changes in direction, and even an occasional few steps back. While our motions may not yet be fluid, the important thing is that we’re here and that paso a paso (step by step) we can move forward. Niko laughs and takes my hand again- this time I don’t hesitate. The music plays, and under the gas-station light, my hips begin to sway…

- Nicole

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