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.

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

Our medical service team left September 12, and in the intervening weeks Nicole and I have been feverishly trying to round up all the patients who require further follow-up. Some patients with hypertension were immediately entered into our Chronic Care Management Program, to be followed by our community health workers. Other patients with diabetes will have their blood sugars checked and medicines refilled monthly. Still other patients will be taken to area hospitals and clinics for any lab studies, specialist appointments and/or imaging that our medical service team was not able to provide during the field clinics.

Thus… our field trip to the big city!! On Tuesday Nicole and I took four patients to Centro Medico Bournigal, a private hospital in Puerto Plata. Arranging transportation alone was a fairly involved process, at various points employing motos, private taxis, public carritos and guaguas to get patients and their assorted family members down from the mountain and into the city by 9:00. But thanks to many reliable and kind moto and taxi drivers, it all worked out well.

Ride to Puerto Plata

One of our patients was Blaya, a four-year-old from Pancho Mateo. He was found to have a heart murmur during clinic, and so was referred to a pediatric cardiologist. We know Blaya as one of the half-naked little tykes running around Pancho with his friends, always eager to show us some new dance move. But Tuesday morning, when we picked up Blaya and his mother for our big trek, we almost didn’t recognize him: wearing tight new cornrows and even tighter new shoes, Blaya was quiet and patient and ready to go.

That day, as he waited in interminable lines to see the doctor, get a chest x-ray and receive a blood test, Blaya exhibited incredible maturity and patience. The only time we were reminded of his young age was when the lab tech approached him with a syringe for his blood test. His eyes grew huge, and as fat tears careened down his cheeks, he grabbed at Nicole, screaming, “Griiiiinga!!! Llévame de aquí!!! Nos vaya, gringa!!!” (“White lady!!! Get me out of here!!! Let’s go, white lady!!!”) After his traumatic experience, we plied him with chinola juice and video games on our business phone, but our attempts at entertainment were quickly superceded by his first elevator ride: he was soon full of raspy giggles as he pushed button after button and felt the sudden rush of ascent.

Cell phone games must have been invented by someone needing to pacify a small child.

The good news is that Blaya’s tests all suggested that his heart murmur is benign. His new pediatrician will see him again in January for a check-up. Unfortunately, some of our other patients’ tests did not come back so well that day, and we have had a week of extreme highs and lows as we vacillate between celebrating small triumphs and mourning profound tragedies. Our work continues, both with these four patients and with others who require physical therapy, CT scans, vascular surgery and more. But for now, whenever I feel a bit overwhelmed, I will close my eyes and think of Blaya, with his strong heart and raspy giggles, waiting in Pancho Mateo to show us gringas his latest dance move.

Blaya and friends in Pancho Mateo

–Megan

From the porch of Estela’s house in Negro Melo, I can see the horizon where the sky meets the ocean. My mind’s eye swims to shore, where miles of sugarcane begin to rise and fall with the hills. A grove of coconut trees, a few conucos of yucca and plantains, framed by a rolling ridge dotted with trees like tufts of fur on a caterpillar’s back. The dirt road emerges from the green, where the motoconchos sputter up the final hill from Caraballo. There is a row of barracks to one side, painted bright blue with colorful flowers along the foundation – a missionary group’s contribution to alleviating the darkness of living in a one-room cement block. A bright yellow church stands alongside, across the road from a jumble of wooden houses with tin roofs. Children, horses, pigs, church hymns, roosters, dogs, motorcycles, bachata, mothers, fathers, babies… a symphony of community.

A few doors down, a woman lies under her mosquito net in bed, in almost constant pain from some unknown illness. The doctor who saw her during our recent medical service trip thinks it is cancer, and our plan is to refer her to a specialist for testing and diagnosis. And then, we reassess. Case management capacity, funding commitments, negotiations with the referral source… it is neither fair nor just that we are forced to translate the suffering of a woman into an equation of logistical factors that tell us whether or not we can help her. It is neither fair nor just that she is forced to accept this uncertainty simply because she is poor.

The General Health Law of 2001, reflecting the Constitution of the Dominican Republic, states that “health is an inalienable human right that must be promoted and satisfied by government and state” (my translation). The law further proposes that the institutions charged with protecting the health of the people and ensuring access to health care must modernize and coordinate their infrastructure, policies, programs and services, in order to achieve universal health care based on the principles of equity, solidarity, and efficiency. It declares (again my translation):“Health is simultaneously a means to the achievement of communal well-being, and an end in itself, as a fundamental element of human development. The social production of health is intimately linked to the overall development of society […], so that, individually and collectively, people may realize their potential for well-being.”

The discussion of theory versus practice in policy-making and program implementation is not a new one, but it is situations like this that bring the challenge to life. A beautiful landscape belies suffering as easily as beautiful words can hide a difficult reality. It is easy to be angry at injustice, at the wrongs that marginalized people around the world are subjected to. But, I realize I cannot be motivated by anger. In coming to know the people and communities I have lived, worked, sweat (a lot), laughed, cried, dreamed, thought, and acted with this year, I am filled only with hope in them and for them. One day, the sum of all these steps, all these parts of the process, will result in change. If I can critically reflect on our journey over this last year and still come to this conclusion, then at worst, I can be accused of pragmatic, not naïve, idealism.

In the meantime, I can sit on the edge of a sick woman’s bed and share with her the knowledge that she is not alone. I can talk with my community health worker, whose dedication to her role has blossomed in the last few months, about her symptoms, and know that her community will be healthier because of her commitment to health education and chronic disease prevention. I can listen, see, and act in solidarity, because I believe in individual and community health as a pathway to social justice. I believe we are on that path.

In three days, I move back to Boston. I will miss this place and the people here more than I can put into words. Goodbyes have been both sad and reaffirming of the relationships I have been blessed to form here.  I hope that as Executive Director, I’ll continue to stay closely connected to the communities and the on-the-ground work that Meg and Nicole have so capably taken into their hands. With continual reflection and thought, I have faith that our visions and theories will indeed, one day, be realized.  Thank you for continuing to take this journey with us.

With much hope, gratitude, and excitement for all that lies ahead,

Laura

Saturday night after arriving in Pensacola, I went to a little get-together. One of the guys there asked me if I was glad to be back or if I wished I was still in the DR. How directly to the point; I didn’t even hesitate in my response. I would rather be bouncing over a goat trail clinging desperately to the back of a moto doing home visits in Severet than driving my truck (even though I love my truck) along mirror-smooth paved roads on my way to work in an air-conditioned ER. I would rather be playing ring toss at Tubagua with Ayaz and Rob drinking lukewarm Presidente than flipping through 67 channels of cable TV with an ice-cold American beer making rings on my coffee table.

Dr. Wes and Meg go on a housecall. Photo by Rachel Geylin.

I can’t overstate how much I enjoyed this trip, nor can I list all the reasons why. But for starters I have to thank all the dedicated members of Health Horizons International, from my original contact with Craig Czarsty, the Chairman of the Board, whose initial response to my interest in the trip was “In short, yes, we really need you” to the interpreters who patiently suffered my pathetic attempts to habla espanol on my own (and who unconfused my patients when I mucked it up). But three groups deserve special attention. First, the other members of the team – Lissa, Rachel, Rob and Ayaz – were fantastic companions and colleagues. I couldn’t have asked for better company and co-workers. Second, the community health workers, or cooperadores de salud, who labored long and hard to prepare their communities for us to waltz in and play the heroes, and who are now following up on all the patients we saw, and in general, advancing the health and wellbeing of the people they serve. And last, but certainly not least, the International Program Directors. I may have met a more impressive group of young people in my life, but I really can’t remember when. As if their intellect, compassion and cheerful dispositions weren’t enough, I was, and am, in awe of Meg, Nicole and Laura’s absolute selflessness in doing a job that must, at times, seem pretty thankless. My only regret is thatI didn’t get to meet Angi, but I feel as if I did, as her impact continues to reverberate through HHI. Somehow I think our paths will cross one day.

The group poses for a photo after its final clinic day in Pancho Mateo. A job well done!

All in all, I think I’m pretty lucky. Despite its frustrations, I still love being an ER doc, and it affords me the opportunity to do what I’ve discovered I really love- medical mission work. I miss my kids, but I’ll get to see them soon and when I do, I hope I can convey to them the importance of finding what you love, then finding a way to do it. It’s taken me 47 years, but at least now I know what I want to be when I grow up.

By Dr. Wes Williams

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