Haiti Blog August 11-19, 2011

August 11, 2011 Post: The Candor of Death

Last night we were met at the door of San Therese hospital by the candor of Haiti’s infant mortality rate. We arrived around 7:30pm or so for our 11 hour shift. There was a woman in labor who, within moments, was pushing out her baby. The student midwives were not ready, and I scrambled to find supplies while the others delivered the baby. While gathering instruments we needed, I uncovered a crumpled chux on one of the delivery tables. I opened it up to see if it was usable and found a full term dead baby. In my hurry to deal with the delivery, I was unexpecting and vulnerable. It took me by surprise. But the midwives were working, business as usual. No one seemed very interested in the body. I asked the student midwife what we were going to do with the body. She didn’t have an articulate response. Finally someone, the  night janitor, realized that we needed a box for the body. She ran and reappeared wth one. We placed the baby in the box and of course the question, then what? We needed to keep the baby here until morning until the janitor would dispose of it in the appropriate way.
This is life and death in the maternity ward. I would later learn from the day janitor  that he buries 2, sometimes 3, stillborn babies a day. The math is too horrific to calculate. The midwives deal with this tragedy with calm and flat affect. They are unemotional. They seem disconnected from the possibility that this small body represents more than the products of an ill-conceived conception. This must be the callous of years of death’s relentless mocking. Even with the best of nights, there is the reminder that babies die here on far too regular a basis.
The precipitous birth of the live baby is finally under control and the baby is dressed and weighed. The live baby also is left on the scale for a long time without an attentive eye. I occasionally go over to check the baby and make sure that the quiet is from sleep and not death’s gnarly grip. The mother is dressed and readied to go into the postpartum room.
Another woman has come into the labor room with a referral from an outlying clinic. She is in labor. We have a hard time understanding the French translation of her referral note. Our interpreter insists that it says that the baby is lying up against the mother’s back, a simple posterior presentation. Susan is sure that she sees the French word for twins on the paper. It is all for naught because the student midwife cannot find the baby’s heart tones. Susan tries too and is unsuccessful. We are here to teach the student’s so I ask Marie Carmen, what does she think? What would she do now? What she thinks is best is to wait until the baby is born and to tell the mother then. I disagree, telling her that if her baby is dead, that we must prepare the mother as soon as we know. If the student has difficulty finding the heart tones, they should always ask the senior midwife for help. Marie Carmen and Susan tried one last time to find heartbeat, met again by the mocking silence of death. The staff midwives decided to send this woman on to Cange, to the Zamni Lasante hospital there. She had a ride , otherwise the transfer would not have been an option. We would not bear witness to her grief.
The second baby of the night was born precipitously in the antenatal room. A student ran out saying that the baby had been born. We all ran in to help and to see the baby that had been born so quickly. When we approached the bed, the baby was on the mother’s abdomen but not breathing. The baby remained quiet and limp, eyes wide, even with our immediate tactile stimulation. I asked for an ambu bag and one of the students ran back to the delivery room to get it. The hospital has no oxygen, so the resuscitation effort would simply consist of forcing room air into the baby. The ambu bag arrived and I quickly set to reviving the baby. Even though the baby’s heart rate remained strong, the baby did not perk up as I had expected. It was hard to say why this baby was having such a hard transition since no one had actually seen the birth take place. Had the baby inhaled amniotic fluid on the way out? Was there meconium? Was this baby infected? I continued bagging the baby for what seemed like a long time, repositioning the mask, the baby, asking for a better ambu bag. Long enough to begin contemplating next steps. There was no oxygen, no pediatricians, no NICU to fall back on. This baby would either live or die right here in front of us. I occasionally stopped the resuscitation effort to stimulate the baby again. We were beginning to see the barest of muscle tone and an occasional small cry. A stethoscope appeared and we were able to hear breath passing, though labored, through the baby’s lungs. The baby had classic signs of difficulty breathing: grunting, flaring, retractions.
Since the baby, a girl, was breathing on her own, we decided to stop the resuscitation. She was out of the danger zone but the next moments would reveal whether she could make it on her own. She remained stable by Haiti standards. In the US, this baby would have been immediately whisked away for resuscitation and continuous observation. The student midwives did a good job of helping out, but observed with an air of bearing witness as opposed to the heroic obligations that drove Susan and me to act. The baby settled quietly onto the mother’s chest and I told one of the students to check the baby closely for the next hour. She should check the heartbeat and respirations every 15 minutes, then check in with me after an hour. If anything changed, she should also let me know.
A quiet calm settled onto the Maternit√® around midnight. I laid down on the cement floor outside of the ward on a yoga mat that Susan and I brought from the orphanage. I told Susan that I was too wired to sleep. She told me later that I was snoring within 15 minutes. I awoke sometime later to find a laboring woman sprawled on the floor across from me. She was on her back, heavy in labor, complaining that she was dying with each contraction. She was accompanied by a shadow sitting next to her, her mother I had assumed. When I heard the American accent of Susan’s creole, I realized that she had moved over to support this woman in her labor. As she sounded pushy, we moved her over to the labor ward. A fifth timer, with 2 living children, I was surprised that it was taking her so long to push. Susan suspected a posterior presentation because of the amount and location of the woman’s pain. She continued to often say that she was dying, which is disturbing in a country where that is a distinct possibility. Her baby was born, without event, bringing us to three live babies for the evening.
At 4am, the praying began. From the depths of the darkened antepartum room, we could here gospel singing and the sounds of a female pastor calling upon God and Jesus to remember them in their suffering. The singing was beautiful and eerie, wafting up from the depths of Haitian spirituality. All 10 women in the antepartum seemed to singing in unison, in harmony, interrupted by the intermittent wail of a contraction. I got up from the yoga mat and watched through the half open, Dutch door for a while. The pastor was walking up and down the aisle between the rows of beds, calling on Jesus in her supplication for redemption. The women were calm and peaceful, obviously knowing the lyrics from years of Haitian church-going.
As the light of day brightened the courtyard of the hospital, a small, old man shuffled in to begin his day’s work. He is the janitor. He emptied the trash barrels into his wheel barrel and picked up the bloodied, medical trash strewn about by the nocturnal scavenging dogs. I knew that this was the man who would dispose of our baby in the box on the labor room floor. I was determined to see this process.
Eddy, for that is his name, loaded the box up on top of the rest of the trash in his wheel barrel. I followed him out of the hospital, explaining that I just wanted to see what he did with the dead baby. He was patient and kind with me, perhaps I was the only “Blan” he had ever spoken to. He loaded up his pick ax and shovel onto the wheel barrel and I followed him out to the back of the hospital. We followed a small dirt trail to the area where he burned the trash every day. The piles of plastics and IV detritus was encircled by a lush grove of greenery and vines. Eddy parked his load and walked into the grove. He selected a spot and began to dig. I asked him if he did this everyday. Yes, there are 2, sometimes 3, every day. The pick ax was almost as big as him and he swung and swung until a small, rectangular grave had been dug. I helped him by bringing over the box with the dead baby. I asked him if he had children. He said only one— the other he had already buried. The current box that the baby was in was too large, so he found a smaller one amongst the rubble and placed the baby inside. I offered him my gloves since his had ripped. I was called away at this point, but felt content with my understanding of the process. The fertile soil of the lush grove entombed hundreds of dead babies each year.

I said goodbye to the woman in postpartum whose baby we had resuscitated. The baby was breathing perfectly now and the mother was all smiles. The ride home on the moto taxi was cool and breezy. I held on to Susan, saying that we had survived the night. Tonight we will be at the hospital again.


August 16, 2011 Post: Cholera: Up Close and Personal

Our last night at San Therese was peacefully uneventful. We had two live births within a half hour of each other around 2am. The rest of the night Susan and I napped on a yoga mat or chatted, disturbed only once by the keening of a woman across the courtyard. I immediately recognized it as the signal that a loved one had died.
Friday was our last full day in Hinche. My day was crowded with last minute filming of Genette, the bright, young clinical professor at Midwives for Haiti; packing; stopping for one last time at the Ebenezer (the air-conditioned super market); making Grandma’s tomato sauce one more time on the open charcoal fire; going to Magdala’s for dinner at 4pm and figuring out how to carry the still warm sauce with Dina and I on the back of a moto bike; getting back from Magdala’s in time to meet Genette and my other Haitian midwife friend, Esther, at the Crystal Bar for one final farewell.
Within the folds of my busy final day, I was introduced to cholera. When we went up to the hospital to film Genette, we asked if we could observe the UNICEF cholera tents set up in front of the hospital. Twelve large, white tents were set up, each with a UNICEF stamp on the front. They were much more like circus tents than camping tents, having the neatness and formality of a well-heeled NGO. There was a triage tent as well as men’s, women’s and pediatrics. Most of the tents were empty or only partially occupied, which was a relief to the senses. Each tent had 8-10 stretchers lined up in two rows. Each stretcher had a hole in the center with a bucket underneath, carefully containing the vector of a deadly disease.
Most people did not seem in intense suffering. Many had IVs, but most were hovering about, biding their time for the disease to run its course. There was a fascinating container that was the encampment’s water supply, a 12 ft. by 12 ft. giant water balloon, used for bathing and drinking. A naked man on a stretcher was being carried away, perhaps after a needed rinsing off.
To leave the cholera area (the whole encampment is walled off with security at entrance and exit), you need to have your hands rinsed with water treated with bleach and step on a pad soaked with disinfectant to clean off the bottoms of your shoes. We had made our observation. No photos allowed. My obligation to witness the suffering of the Haitian people is fueled by my desire to comprehend the magnitude of the disparity that I wish to amend. I am constantly trying to evaluate whether we are making a difference.
Nilove

In the afternoon, I had an even closer look at the cholera epidemic. When we arrived at Magdala’s house for dinner, a very special invitation I might add, she said that she had to place an IV in a child up in the tents on her land. Of course, I offered to help and we all trekked over to the small plot of land that she had let the government use as a cholera encampment. There were only 4 tents, each labeled: triage, observation, transition, morgue. A small, dehydrated 3 year-old girl, dressed only in her underwear, was on her mom’s lap. She was sitting up and animated, but the two nurses who monitor the encampment had decided that her condition had gotten worse and that she now needed an IV. We set about to work, looking for the most accessible vein to place an IV. On a healthy three year old, this is always a challenge, tiny veins, a scared patient, few options. Working with Nilove proved to be no easier, her dehydration making it even harder to find a strong, plump vein to work with. We tried multiple times to insert the IV catheter, each time to the wailing and tears of our little patient. Her cries were eerily reminiscent of the laboring women, a uniquely Haitian song of pain and suffering. It was heartbreaking to understand what she was saying in Creole, “Mama, let’s go home, let’s go home.” We tried on her hand; we tried in the antecubital space. None were successful. I found a small toy in my pocket that I had figured could be given away at some point. Here was that point. The toy calmed Nilove for a few moments. We finally got a good stick in her hand but the sigh of relief was only momentary as the little girl jerked her hand away and the catheter pulled out. Both Magdala and I looked at each other in disbelief. Our only good stick was now worthless. We tried in her foot, the other antecubital, and the other hand. After 6 tries and running out of the smallest angiocaths that we needed, we gave in to our own failure.
Nilove would have to continue her oral hydration therapy and hope for the best. She would not die; she simply needed hydration support until the cholera passed, and isolation to help prevent the spread of the disease. The only other patient at Magdala’s encampment at this time was an older woman, in her 70s. She too was ambulating and would not die, simply biding her time. We rinsed our hands and stepped on the disenfectant pad. As I saw the iodine-colored water run up over my flip flops and onto my bare toes, I wondered how effective this ritual was.
It had taken us an hour to finally acquiesce to our lack of success. Magdala is an amazing midwife, giving of herself in areas where she should not be taken to task. She says they have seen over 50 people in her tents. We walked back to her house for an amazing Haitian feast of fried tilapia, beet salad, a green salad with fried goat, avocado, cornmeal cakes, a “lasagna” of sorts (layers of lasagna noodles separated by a ground meat) that went perfectly with Grandma’s tomato sauce, Haitian spicy coleslaw, spicy goat sauce with onions, fried plantains, a few fried potatoes, and black rice with dried mushrooms. It was a feast of appreciation and hope for our future working together. Magdala’s husband is a pastor and deeply religious, he asked me to say the prayer before the meal.
When a pastor asks you to say something, you speak: I prayed for the little girl up in the cholera tent, I prayed for the continued strength of Magdala and her family to offer safe haven for the poor and the sick. I prayed for Magdala’s continued work as a midwife, to reach the pregnant women in the villages and bring them a better birth experience. I prayed for strength for us all and for hope, for our continued working together, each year, to create a better world.


August 19, 2011 Post: Leaving Haiti

Even our exit from Haiti proved to be a metaphor and a challenge. When we had arrived 2 weeks prior, I knew that one of our most challenging moments of the whole trip would be getting out of the airport with all of our baggage and wits intact. Last year, gratefully, Sister Mary from Matthew 25 House, met us at the immediate exit from baggage claim. Calm and seasoned, she greeted us and led us through the maze of porters to our van. Even with our “chosen” porters, there was still jostling and arguing as others tried to get a piece of the action. This year, Sister Mary was not there to greet us at the gate. Courtney, Susan, Dina and I were in our most unwieldy moments — Courtney had 3 large duffels plus her personal items, the rest of us had 2 plus carry ones. At least we had 2 carts to carry the mother load.
Since Sister Mary wasn’t there, I implored the group to stay together and to stay put. I went further down the exit way and looked for our ride there. No one with the Matthew House sign was about. I went back to where everyone was waiting and we decided to make our way down to a waiting area that was underneath an awning. Of course, the porters followed suit and wanted to help us every step of the way. I didn’t want to engage them just yet because our ride wasn’t even there yet. Of course, now everyone said they knew Sister Mary and Ricardo, the driver. Most of this was just a rouse to get us to pick them as our porters. Annoyed by the constant pestering, I finally gave in to one of the porters who insisted that he knew where Ricardo might be and that we could wait there. Again, I told my group to wait while I investigated. I was highly suspicious about this “VIP” parking lot that this man was talking about.
As suspected, the porter led me over to a secluded parking lot that did not contain the Matthew 25 house van. Instead, I recognized it as the place where, last year, a group of men surrounded one of our volunteers and stole her iPhone. There was no security here, so it is a perfect place for a heist to an unsuspecting visitor. I told the porter thanks, but no thanks and made my way back to the shaded waiting area. I would know our guy when he arrived.  Thirty minutes later, we were safely on our way to Matthew House.
Leaving Haiti proved to be an even greater challenge. Last year we went on American, simply waiting on line with the rest of the travelers to check in and go through customs. This year we were at the other gate.
Haiti’s airport is small by any standards. It does not have terminals. It simply has two entrance ways: one for American Airlines, and the other for all other international flights. An even smaller airport down the road services in-country flights on 6-seaters and small prop planes. The international airport, named after an ex-slave, army commander who led the country’s fight for independence, is frenetic at best during midday when most planes take off. We arrived with 4 and half hours to spare (little did we know that we would need every minute of that!). Porters again were vying for the few dollars they would earn by carrying our bags. This time, the tease was that they would take us to a special line, “just for us”, ahead of all the chaos. Somehow I felt that this was unjust and metaphoric. Don’t the rich always do that? With the power of money, we literally step over those at the bottom, those without means, and give ourselves the best ride. I was happy to patiently wait with the Haitians on line; we had 4 hours, after all.
But it wasn’t really a line. It was a cramming of people up against a door, that wasn’t open yet. No one was moving, just waiting. Even those on the “VIP line” were just waiting like the rest of us. It was hot. Dina and I had a lesser load than on arrival, but we still had our wheeled luggage, plus my jump bag, back pack, Dina’s Timbuktu bag and her heavy camera backpack that held thousands of dollars worth of video equipment. We had to keep an eye on it all, carefully holding onto our spot in the throng. It took an hour before they even opened the door and started to let people in. It was the worst of bottlenecks. 6 or 7 porters at a time, trying to make good on their promises to get people in first, the “secondary” line trying to cram it’s way in through at the same time. Literally around 300 people trying to make their way through one small doorway, and don’t forget their luggage. As you can imagine, we moved by inches. When we finally got to the ramp that led up to the door, we were boxed in by people. Tensions were high and shouting matches erupted more than once. I didn’t feel anxious, just curious to witness this glaring example of disorganization, a metaphor for life in Haiti. No one wanted to be last. Everyone was in a me-first, dog-eat-dog frenzy to get what was rightfully theirs. The line was moving, even at a snail’s pace. We still had 3 hours.
Once we were at the top of the ramp, I thought the pressure would ease as we entered the airport lobby. For a moment, we had breathing room as we all made our way down a ramp to the first x-ray security check. All of our bags had to go through and I am quite sure that they did not do a thorough job. I was only concerned about getting to the other side and collecting our bags before the masses enveloped us again. On the other side of the security check, the wall of people was immense and still. It seemed that no one was moving. It was unclear exactly what to do, but I figured that if we followed the crowd, we would get to where we needed to be. We were travelling to St. Maarten on an airline called Insel Air and we had met a few people on the line that were doing the same. I figured that if I kept one eye on these few markers, I would know where to go.
At one point we found ourselves waiting in the middle of the sea of people that now completely filled the airport lobby. Again we inched our way forward, trying to keep our spot in the “line.” Dried mango slices and one water bottle sustained us for the hours of waiting and inching. We were passed by a number of American Christian groups with slogans like, “Puttin’ Feet to Faith” and Rock Solid Church. They wore the tell-tale dusty sandals of mission work in Haiti. A college group from the University of Pittsburg had done the same. All were headed back home on the Delta flight. All had paid their way to the head of the line.
At this point, an airline agent said to everyone on the right, “Insel Air,” and pointed to the left. So now everyone on the right had to cram their way through to the other side.
It was almost 2 hours later before we reached the check-in counter. But an even more curious thing had happened. By the time, we reached the counter, Dina and I were almost exactly at the end of the line. How had all those people passed us? I had always seen us in the middle of the pack, jammed fore and aft with someone else’s suitcase. It was fascinating. I also realized that it had really been no big deal. We were going to get through with time to spare. Dina noticed that the man at the very end of the line was trying to cut in front of us. Would it really make a difference if he made it in front of us now? With great effort, he snuck his luggage up to the counter in front of us, causing an argument with the meager security guard. It was that important for him not to be last. I told the guard in Kreyol, “N’ap prale.” We are all leaving. “Pa gen pwoblem.” Leave it, it is not a problem.
After passing through Customs, there were roped queues and plenty of space. The fight was over. The same group of people who moments ago were clawing for position melted into a calm group of civilized travelers.
We had half an hour to spare.
The fight for the bottom is something that is demonstrated wherever human stratification exists. Who is first? Who is last? Who is the richest? Who is the poorest? No one wants to be the bottom. It is demonstrated with midwifery politics: CNMs versus CPMs versus “lay midwives;” gang fighting: Asian vs. Black vs. Latino; abusive households where the man beats the woman, the woman abuses the child, the child kicks the dog. In Haiti, there is a desperation to not be at the bottom of every heap, already having claimed that spot in the Western hemisphere for such inglorious attributes as maternal mortality, infant mortality, literacy rates and poverty.
We all got on the plane. We all made it out of there. Most Haitians fly to St. Maarten for employment. We were perhaps 2 of only 5 white people on the plane, headed to an inconceivable resort island, too close to justify the disparity, too far to share the wealth. When Dina and I arrived at our timeshare on the island of St. Maarten, we were astounded by the beauty and opulence. We had dinner and went back to our room, cold, by the way, from air-conditioning and a ceiling fan. After two weeks of sleeping on the porch in a mosquito tent, Dina’s only comment was, “This pillow is ridiculous.” We settled underneath the down comforter, and didn’t wake up until 12 hours later.