Haiti Blog August 6-10, 2011

Aug 6, 2011 Post: A Birth at St. Therese

(Days have been so packed that I fell asleep last night while writing this. All good in Haiti, “tout bagay anfom”. I’ll try to send shorter, more frequent updates this coming week.)
Wednesday night was our first overnight at San Therese. For Susan, this would be her first real introduction to birthing in the Hinche hospital. We are told that there is no running water (turns out no standing water either) in the hospital and now, there is no electricity at all. Because of that, there is no available operating room to do Cesarean sections. There would be a remote possibility to transport someone to Zanmi Lasante, Paul Farmer’s hospital in Cange, 45 minutes away if we needed. As the evening progressed, we would find out that the remoteness of that possibility means that only in the most dire of life and death circumstances would there be enough motivation to put all the pieces together for this type of transport. Here’s how the evening went:
When Susan and I arrived at the hospital, around 9pm, the antepartum room seemed full of women laboring. The antepartum room is a wide, open room with 10 beds, 5 on each side. The women labor here, sometimes with family, sometimes alone. The postpartum room looks similar, but there were only a few women there. A few days earlier, we met a woman in postpartum with a 27 week old premature baby. He was “wearing” normal sized newborn clothes that betrayed the size of his small body. Only his tiny head and legs foretold a story that this baby was probably not going to live. He was breathing well for now, and the mother and father were being counseled to take this baby to Cange, to go to Zanmi Lasante, where he would have the smallest chance of surviving. ZL has a “NICU” with 4 incubators, but that doesn’t mean that there is oxygen or the correct resources or personnel to care for an extremely premature child. The family said they would go and they were trying to find the money for the 45-minute ride. The nurse midwife was being summoned to break the news that this woman was also HIV positive.
That family was not there on Wednesday night. Only a few women were sleeping quietly in the dimly lit postpartum room. Some had newborn infants, more did not. In the delivery ward, which has 4 old, torn, and rusted gynecology tables for birthing, all was quiet for the moment. Susan and I took the opportunity to stock the cabinets with the supplies that we had carried on the moto taxi—the two of us on the back of a small motorcycle, loaded down with my jump bag and each hand full of a plastic bag with supplies. Susan is feeling more comfortable on the moto taxis if she sits in the middle. I love every minute of it, riding on the quiet streets in the otherwise pitch dark, a cool breeze relieving some of the heat of the day.
Through most of the night, we end up with only one person in the delivery room. Her labor is slow, finally reaching complete around midnight. She pushes for more than 2 hours with little progress and not very effective contractions. I check her around 2am and her cervix has closed down to 9cm around the baby’s head, a tight ring that is most likely the cause of the slow progress. We decided that it would probably be best to have her stop pushing for a while and wait until she was complete.  We started a pit augmentation, which I hadn’t seen before, Haiti-style. A Pitocin augmentation in Haiti means that they put the Pitocin in a bag of Lactated Ringer’s and manually manipulate the drop rate until it is dripping at 1 drop every 5 seconds. Susan says that this is the way we did inductions and augmentations in the US in the 60’s and 70s.
Around 4am, we were concerned about signs of an obstructed labor. This mother still hadn’t delivered and her cervix had stalled. The Pitocin was turned off because at one point she had a long, continuous contraction.  Her cervix was edematous and not complete. The staff midwife floated the idea that we transport this woman to Cange for pain meds and a possible C-section. When Susan and I started making phone calls to the in-country directors of Midwives for Haiti, no one was answering their phones. We finally called the driver, Ronel, directly, but he said that he would not drive because it was windy and rainy. It actually wasn’t raining, but the weather report was predicting a tropical storm within hours. Ronel wasn’t moving, he wouldn’t take us to Cange. This was certainly our darkest hour, having a mother who needed help, no possibility of Cesarean in Hinche, no one answering our telephone calls, a tropical storm coming, a driver who was unwilling to drive with superstitions around the impending storm.  Susan and I sat back for a while, watching the now busy labor ward swirl around us, matching the energy of the intensifying storm winds gathering outside.  A pregnant midwife was in one of the “rooms”, having her third baby. The woman in room 2 was keening in pain, finally settling into a dark corner on the floor all by herself. She needed doula support so I asked one of the midwifery students to support her by coaxing her out of the corner and rubbing her back. Another woman was suffering from the painful, spasmodic contractions of an incomplete miscarriage. We had gone from a fairly quiet and controlled space, with one woman in labor, to now all the rooms being full. I parsed out 1 student per laboring woman until the delivery area seemed in better control.
Back to our woman with the obstructed labor—to Susan and I, the idea of transport to a higher level facility seemed like the most natural and safest thing to do. Now we were left with the reality that that would not be possible. Would this baby die? Would this mother die after days of an ineffective process? Around 5am, I noticed that her “labor song”, as Susan calls it, had increased and she was really in a lot of pain. I went to her side and found that the student was no longer there. I spoke to her in Creole that we were trying to find a driver to bring her to Cange, that she might have a Cesarean there. Her wailing quieted down and she did not seem upset about this prospect. It seemed that she simply needed some companionship in her travail and some hope that it would be over soon. Truth be told, I didn’t know what was going to happen next. With the coming of daylight, would Ronel be willing to drive to Cange? Would anyone answer their phones? Would a dokte (doctor) magically appear from nowhere with the 8am shift? Were we really going to experience a tropical storm? I decided to give her one last check of her cervix. Lo and behold, she was COMPLETE!! Yay, some kind of change that we could work with. I found Susan and asked for her help, everyone else was sleeping now, but we were going to try to push again.
The midwifery students helped us with the pushing, and by 5:30am we were seeing a significant amount of the baby’s head, enough to give us hope that this baby was finally coming. We encourage and cajoled her in Creole as she pushed and pushed. The mother did a fantastic job and finally, at 5:59am, one minute before our shift was over, we had our first baby of the night—4300 grams! While doing the suturing, we heard the hearty cry of the midwife’s baby: 2 healthy babies, a successful night after all.
Susan and I soon packed up to meet our moto taxi for the ride home. The mom with the incomplete miscarriage had returned to the antepartum room and was now sleeping, having been given the only pain med that they had here. The mom with the doula was sleeping or walking about, her birthing slow but progressing. All was quiet and calm except for the bustle that would always come with daybreak.
Literally, right before we left, the staff midwife drew our attention to a stillborn baby on the counter. WHERE HAD THAT COME FROM?? Was it from one of the mother’s that we had initiated an induction on because their babies were no longer alive? Did someone new just walk in? I did not know. I only know that Haiti was sending us a clear message, “All is not well. “
Here are some photos from the last few days:

Manushka, orphan girl

Rachel, orphan girl, treating her for eye infection

Spaghetti for breakfast, everyday

August 7, 2011 Post: Snippets of Haiti

Haitian Haircut: Monide is the best hairdresser! I have wanted to get my haircut since we arrived. Monide did a great job at her salon called, “Nice Change.” Certainly a nice change for me!
Boat ride on Magdala's man-made lake
Cholera tents
Cholera tents on Magdala’s property: We took a tour of Magdala’s incredible property where she lives. They are already running a school for 600 children. They want to build an orphanage, a guest house and maybe even a birth center with American help. Susan thinks that this is the answer to more humane birth here—Haitian-run, out of hospital birth centers. I am sure you will hear more about this. Magdala and her husband have allowed an acre of their land to be used for cholera tents. They have 7 patients living there.
Children at Gampson's church
Gampson’s church: Gampson is the young man that we met last year with his mother. They were both peddling their goods in front of Maison Fortune. I took a really nice picture of him and his mom, so this year I gave him the photos. They were thrilled and invited us to come down to see the children at their church. The church is a small, one room shack with benches for the small congregation. There were 4 chairs set up in the front. To our surprise, the chairs were for us. We shared with them some baby clothes and thanked them for sharing with us their beautiful country.

A visit from Marie Denise: Marie Denise, one of the midwife students from last year, showed up at Maison Fortune around lunch time. She brought us a liter of fresh cow’s milk, fresh eggs, mangos and corn from her farm. I was surprised and thrilled by her tokens of appreciation. We invited her to stay for lunch, chatting and sharing photos from last year.

Professor Kennel
Charles and Barry: Charles is a young man who teaches French, Spanish, English and Creole in the local high school. His uncle is building a high school called the Mahatma Gandhi School. We are meeting people everywhere we go. I now have two “Haitian sons” and many Haitian friends. Our Creole is getting better everyday, especially with the help of Kennel, a young man at the orphanage who gives us Creole classes almost everyday.

Tobacco lady
Tobacco lady and the Salt lady: My favorite ladies from the market last year were two women selling tobacco and salt. Of course we wanted to see them again, but the market has changed around some with the majority of the vendors now under a large pavilion. We walked around for a while and stopped to buy pineapples. While we were there, a woman said she could take us to where the tobacco sellers were. Before long, we found the tobacco lady who was thrilled to see us once we explained that we were here last year and gave her her photos. The salt lady was right behind her and we agreed to meet up next market day to chat with her.

August 7, 2011 Post: It is 10pm In Hinche

It is 10pm in Hinche and I am miserably hot. So hot that I can’t sleep. It’s probably not even 100 but the humidity is heavy and the air is still. The earlier thunder and lightning did not pan out to the rainstorm I had hoped would cool us down. The heat has chased us out of our rooms and onto the veranda to sleep. We, there’s four of us again, pulled out our mattresses and lined them up to be a little cooler. Dina and I use a mosquito tent but the other brave souls go without.
Courtney left a few days ago and is now safely home with her children, visions of the Azeal orphanage still swirling in her head. We have a nurse practitioner that joined our group yesterday, Jane Smith, from Virginia beach. Today, Sunday, was our day of rest. We hung around Maison Fortune, venturing out only to cross the way to see the girls or to cross the soccer field to our Kreyol lesson.

This morning I was enthralled with a young girl named Sofia. She had been assigned the job of making the chicken legs. The children here get meat once a week. Last year it was goat— they would bring in 2 goats every Saturday and that would feed 200 children. This year they have switched to chicken legs. 3 large boxes of frozen chicken legs from the Dominican Republic arrive every Saturday on the back of a motorcycle. On Sunday morning, they boil the chicken, then fry it. This is their Sunday midday meal. Sofia was frying the chicken, sweat beading up on her face. She wasn’t complaining, the heat from the charcoal fire obviously something she was well accustomed to. 


This evening I made my grandmother’s tomato sauce on the Haitian coals. I went over and called Sofia, asking her if she wanted to watch me cook since I had watched her cook this morning. Kennel, our fantastic 19 –year-old Kreyol teacher, helped me get the coals going. We used cans of tomato paste from the one air-conditioned market in town. The 14 oz. cans that we usually see at home with peeled or crushed tomatoes were filled to the brim with tomato paste. I made a large vat of sauce while the curious children looked on, laughing at how much tomato paste I was using. We also made hard boiled eggs and pasta. All of this was a welcomed change from the endless rice, peppered with beans, that has been our daily diet. Often we also have bean sauce, a soup-like liquid made from pinto beans but really much more water than beans. It is usually accompanied by another sauce with bits of beef or goat, onions, potatoes, sometimes a green.
Grandma’s tomato sauce Haiti-style was a complete success. I gave Sofia a small pot with the extra pasta and smothered it in tomato sauce. The children at the orphanage eat plain spaghetti here every morning, so tomorrow I am going to give the girls our extra sauce (of which there is plenty). They eat with their hands so I am not sure how it will go over, but I am sure that any change would be welcomed. I will be happy to see them get some Vitamin A and C, for once. We have wondering about how they are looking and seeming so healthy on a diet of spaghetti and rice and beans. Every day.
Tomorrow we go out on the Mobile Clinic again. We’ll meet the pink jeep in the morning along with the other midwives and students. A structured week lies ahead as we also follow the ebb and flow of visits from our new Haitian friends.

August 10, 2011 Post: Poorest of the Poor

Hinche is considered the sticks to all who reside in Port Au Prince. This is where the poor people live, out in the countryside. It is the 5th largest city in Haiti, with 50,000 people, a hospital, bustling commerce, a central plaza, a large market on Wednesdays and Saturdays. The people here are poor. The hospital does not have running water nor 24/7 electricity. The Red Cross blood bank was temporarily shut down when their solar panels were stolen.
Hinche Market
At the orphanage, boys play soccer with torn, knee high soccer sox, no shoes. Some play without even that, kicking barefoot a soccer ball on the dry, dusty, rocky earth. The children here are orphans or have been left because their families were too poor to feed them.
The midwives are paid $1.50 an hour for work that saves peoples lives. A teacher can possibly get paid $3.25 an hour at the better schools. The midwives say that their pay is not enough. I ask them what they can do about that and there is not really an answer. I think they just live without enough. The unmarried midwives still live with their families. Midwives that are now working in Port Au Prince live communally to afford their living quarters. They say that everything in Port Au Prince is expensive.
We were invited by Gampson, a local boy, to visit his church. He told us that we were going to where the poor people live. A turn off of the main road, heading toward the river, told me that we were heading into the rougher part of town. There were less smiling faces calling out friendly greetings as we walked by. A young boy ran up to me and asked me to take his photo. I snapped the photo and was immediately reprimanded by an adult in the community. “Why are you taking his picture?” I told him that the boy had asked for the photo and his angry interchange came to an end. This is the ghetto, poorer than the Hinche poor, relegated to the river’s edge.
Women and children bathe themselves, their clothes, and pots and pans in the river. The river represents one of the town’s borders. Last year we were told that this was the only place that we should avoid. As we walked deeper into the ghetto, my hyper-awareness increased as the narrow dirt road wound its way closer and closer to the river. We stopped in front of a small tropical shack. This is their church—dirt floor, no electricity, a pastor that was outside to meet us. It seems that everyone’s father is a pastor here, so they don’t look very differently from the other men in town. Within the church, 8 benches, 4 per side, were lined up and filled with children. Dina asked what activity brought them all there this afternoon. The answer was us. It was hard for me to not think about the soccer games, jump rope, cards, chess, music and swing sets that the orphans had at their disposal at the Maison. The orphans weren’t so bad off after all.
Four plastic yard chairs were lined up against the front wall of the church. These were for us. We sat down and they clapped. Gampson’s mother appeared and soon Gampson was handing out the baby clothes that we had brought for them. He handed them out one by one and forced the women to pose with their babies and the new piece of clothing that they chose for their child. I felt badly that we only had baby clothes and nothing for the older children. I asked Gampson to he walk back with us to the orphanage later so I can give him a bag of piwilis (lollipops) for the kids. 
Kids outside church
We are the curiosity and the hope and the problem. Gampson’s mother has been praying for someone like us to come along and take interest in their community. She wants us to come back and set up a health clinic for the people. We tell her that next year we will be coming back with the chiropractors and we can set up a clinic at their church. She feels that her prayers have been answered and she will pray for us all year until our return.  A year is a long time to wait and a three-day fix is only a band-aid.
Gampson's church
With the mobile clinics, we travel to villages outside of Hinche where even poorer people live. They have minimal resources, sparse crops that can be brought to market in Hinche twice a week. Each Saturday, on the outskirts of Hinche,  animal markets sell goats, cows, straw, saddles and rope.  Crowds walk the sides of the roads and for a moment, I feel that this is what India must be like. This is the developing world, what Brother Harry calls the “fifth world,” where oxen pull wooden carts with bent axels, humans pull oversized wooden wheel barrels with unfathomable loads. More people than can be counted go without shoes, a change of clothes, enough food, clean water. At the mobile clinics, we see dehydrated children with fevers and skin rashes, old folks blinded by cataracts.
 At the mobile clinic, the midwives charge 25 cents per visit. Some women don’t even have that. The midwives see close to 40 pregnant women at the busy clinics. At one impoverished village, a rare fight broke out perhaps a result of the heat and frustration of having to wait. One woman arrived topless to the clinic. As she was lying on the sheet-covered platform to have her prenatal exam, I thought her lack of clothing was just temporary. I later saw her speaking with the midwives, bare-breasted—the poorest of the poor. I wanted to give her the labor skirt that was donated by a mother from the US. On this particular day, however, tensions were high and the unfairness of giving to one and not all may have caused a riot.
The spectrum of poverty is multi-dimensional, flowing freely like the river. We observe from the river banks, sidelined, casting nets. If we can catch a few souls, even for an hour or a moment, we feel that we have done what we came to do. The river is endless and deep, such that the retrieval of a few makes an invisible difference.