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Right now, we are nearing the end of the dry season, and the dirt roads we travel on are dusty and hard.  The land around our clinic site is dry and crops are struggling to survive.  We’re hoping some rain will start to fall soon; otherwise, the farmers are in danger of losing many of their crops.  People in this area have a fragile existence, living from day to day at the mercy of the weather and what they can harvest from their small fields.  When food is scarce, health declines and both adults and children suffer from the effects of malnutrition.  Ill people stay at home, because they often don’t have even the small amount of money needed for consultation fees.  When we talk with the patients waiting to be seen in our clinic in Gatineau, we tell them to encourage the ill members of their community to come see us.  We’ll take care of them and give them the medications they need regardless of their ability to pay. We want you to know that we can offer this service to them only because of the generosity of people like you.

You will notice that we write quite often about the goal of providing primary health care to the people in the areasurrounding our clinic site in Gatineau. You may wonder what, exactly, is primary health care? Basically, it refers to the first level of health care in the community and may include some or all of the following:

  • First aid
  • Immunizations
  • Treatment of common (endemic) diseases
  • Nutrition education
  • Preventive activities
  • Family planning
  • Protection of water sources
  • Sanitation
  • Peri-natal care

Many of the services mentioned above can be provided by community health agents –  trained lay persons who are stable members of the community and who carry out community education, first aid, newborn checks, weighing of babies, etc. They act as the first providers of health care in the community and can refer patients to the clinic for more definitive care when needed. Health agents also keep track of all pregnancies, births and deaths in the community and usually conduct periodic censuses of the community for statistical purposes. Of the sixteen communities we visited in our initial needs and resource assessment, only three received theservices of a community health agent. Community leaders everywhere expressed a desire to have health agents in their community in the future; a desire we hope to help them fulfill.

When we think of public health, we think or populations of people, whether in a village, city, country, continent or theworld. In fact, the motto of Johns Hopkins Bloomberg School of Public Health, where I recently received my Master of Public Health degree, is “Saving lives, millions at a time”.  As Christians, however, we are to be concerned about the well-being of every individual. So where does that leave us as Christian public health practitioners? I believe it is our responsibility as Christians to demonstrate the love of Christ to all those in need, especially the most impoverished, through our actions, as well as our words. But, it is also our responsibility to be good stewards of the resources the Lord has entrusted to us, in carrying out our service of love to others. And, this means trying to improve the health and change the lives of as many people as we can, with the resources we have been given. In order to see if we’re doing our job well, we need to have a way of measuring our impact. As in other fields, the measurements we use are called indicators, and in public health, we measure health indicators. In a previous newsletter, we talked about an indicator used to measure maternal deaths called the maternal mortality ratio. Another indicator we commonly use to evaluate the health of a population is the under-5 mortality rate, in other words, the number of children who die before they reach the age of 5 years for every 1000 children born. In Haiti, this rate is very high. 174 out of every 1000 children born today in Haiti will not live to see their 5th birthday. The greatest causes of death in this age group are diarrhea and pneumonia. Deaths from diarrhea can largely be prevented by teaching mothers to use oral rehydration fluid when their infants have diarrhea. If parents are taught some simple signs of pneumonia, they can seek treatment with a local community health agent, and prevent deaths from pneumonia. These are just two ofthe ways that community education and local treatment of early illness can have an impact on under-5 mortality. And, these are things that we plan to teach and do in our clinic and surrounding communities as our program develops.

I wanted to give you a little update about our clinic opening on the 28th of August. There were over 100 people waiting for us when we arrived at the little house where we were to hold the clinic. We took in all our supplies and medications and got all set up, then greeted everyone and had prayer with them. We couldn’t see everyone that day, so we gave out tickets for Thursday, which was our next clinic session. Things went pretty well, and everyone seemed to be happy with their consultations and medications. We haven’t yet hired any staff, so we have to do everything ourselves. Cherlie registers people and collects their consultation fee, then does their vital signs and I see them in consultation. After I’ve seen them, the patient and I discuss what medications they need and what they have money for, and then either Cherlie or I sell them the meds and give them their instructions. It goes a bit slowly because of our extra duties, but gives us more chance to interact with the patients.

Anyway, things went well the first day and we saw about 35 patients. As we were packing up to go home, someone brought us a letter written by the local government committee. It said they wanted to meet with us as soon as possible. When we asked why, we were told that they thought our consultation fee was too high and they wanted us to change it (we charge full price for adults and half price for children and pregnant women). Needless to say, it was not what we wanted to hear on our first day! But, we’ve had a chance to interact with people about it since then, and feel that, for now, we should stick with our price and re-evaluate further down the road. It would be very harmful politically to let the local leaders dictate what we do per se, although they will certainly have a voice, along with other communities’ leaders in what we do in the future. We have had anywhere from 10-20 patients a day since then, and no one has had a problem paying the consultation fee and buying medications. We’ve let it be known that we will not turn anyone away because of lack of money, but, obviously want to avoid having people say they’re poor when they’re not. Payment is a difficult situation for any medical facility.

We have had some positive feedback regarding our quality of care. One of our Haitian friends here in Jeremie overheard a man talking about his son, who I had seen in consultation last week. He apparently hadn’t been able to eat well, and now, after taking the medication I prescribed, is eating everything in the house! So, the father was thrilled. I also saw the mother of the government official who had signed the letter to us that first day. She told him what a “beautiful” consultation she had with us, where we explained everything about her illness and prescribed medication that gave her relief of her long-standing abdominal pain. So, he told others that he was ashamed to have signed the letter that day, since it was such a gift for the community to have a clinic like this in their midst.

We feel, as always here, that it’s two steps forward and one step back, as we continue on this journey the Lord has placed before us. It has become increasingly more difficult to work in Haiti, because of distrust towards foreigners that has developed in the past few years as well as the worsened economic condition of the people. So, we need lots of stamina and a firm belief that we’re doing this for the Lord, and not for men. But, the Lord gives us just a little bit of encouragement once in awhile, and helps us to see that our progress, though measured in inches rather than miles, is significant.

One of the things that is very important to us in terms of the sustainability of our work here in Haiti has to do with community participation. When the local community participates in the development of a project, both in terms of planning and implementation, the project is more likely to succeed over the long term, because they are motivated to see results from their own efforts continue far into the future. They take ownership of the project and treat it as if it’s theirs. This is known as community sustainability, and is based on community participation, which has to be cultivated from the start of a project. This is opposed to the “hand-out” mentality, where those responsible for a project come into a community and announce that they are there to do a project. In this situation, the community plays no active role in the process, and dependency is created, rather than empowerment.

The community needs and resource assessment we are presently conducting helps us to have a better understanding of the issues related to health care availability, barriers to access of care, and overall health needs in the communities. Once this information is summarized, it will help us as we develop our programs and decide our priorities of service. But, it also helps to begin the process of community participation and, hopefully, long-term community sustainability.

One of the things that is very important to the success and long-term sustainability of this project is community involvement.  Those of you who have spent time in Haiti know how difficult it is to get Haitian communities to organize themselves to accomplish a task.  They don’t trust one another and don’t often like to share what they’ve learned with others.  And, in many areas, they have become dependent on outside assistance to do things for them. So, one of the first things we will be doing is to meet with the communities and their leaders and begin a dialogue with them, learning what they feel their greatest health needs are, what they do now when they have health problems or emergencies, what they would like to see in terms of medical care in their area and how they think we can help them to improve the health and well-being of the community. This dialogue will also give us a chance to emphasize the fact that our work in the Gatineau area is dependent on their input and contributions as well. We’re not there to put a hospital in their midst. We are there to cooperatively design, build and operate a health care system which has the potential to improve the health of thousands of people in that area of Haiti, and to change the hearts of people as we minister to them in the name of our Lord. We want the local communities to take ownership of that idea and that vision and work with us in achieving it.
I mentioned in my last newsletter that we will be work-ing closely with Haitian Health Foundation (HHF), an organization that is based in Jeremie and has a very extensive community health program in the Grand Anse area. They have trained community health agents in most of the small villages in the mountains outside Jeremie, and these agents do health teaching in the communities, organize immunization programs, run Mother’s Clubs and Father’s Clubs, give antibiotics for childhood pneumonia, and act as the first line of referral to more advanced care for people who are ill. HHF recently received a 5-year grant from USAID to conduct a birth preparedness program in the communities, teaching them how to recognize problems in labor and delivery, and to have a plan in place for transportation of women who are having complications of pregnancy. Mater-nal and neonatal mortality rates are very high in Haiti, largely due to the fact that, when a woman has a problem at the time of delivery, she is unable to get to a hospital for emergency obstetric care in time to save her and/or her infant. In the whole Grand Anse area, there is only one hospital that provides these types of services, and that is a government hospital located in Jeremie itself. So, one of the areas of service that we want to emphasize from the outset is maternity care, both prenatal consultation and the provision of emergency obstetric care in the form of C-sections and assisted deliveries in our outpatient clinic. We will, in essence, be a clinic with maternity services, so that we can rapidly begin to make an impact on the significant problems of maternal and neonatal mortality.