Sunday, February 17, 2013

The black hole

Friday morning, after driving 3 hours from Hinche to PAP and enduring the stop and start traffic of the city, I was told for the second time at the immigration office that I did not have everything for my Haitian ID. I need a Haitian ID so we can buy a car because our Jeep breaks down too often and we are spending too much money renting other cars and drivers to take our midwives out to their mobile clinics.

I was so angry. I was told that the translation of my birth certificate had to be certified that it was an accurate translation by an "official" translator, that Terrie's letter affirming I was an employee of Midwives For Haiti had to be translated, including the names of the positions of the board members on the letterhead. And written by hand on the list of 10 required documents was an addition for employees of NGO's (non-governmental organizations)- permission to work in the country from a government entity. We have a signed contract with MSPP in the Central Plateau so I can get that but the insanity of the translation stuff made me furious. I asked how a translation of the letter from my employer could possibly be deemed official because it would not be written or signed by Terrie. The immigration official just shrugged.

Rita told me this morning that the two Haitian men who live at her house in Illinois had to pay someone to stand in line for them when they wanted to get their ID. Without the payment you would never progress in the line no matter how long you stood there. Then they had to pay someone to write their blood type on the document. This involved a ritual of putting some water on a piece of paper and having it "read" by the nurse and she wrote down any old blood type she felt like at the time. Later, when the men both became CNA's in the U.S. they realized what an absolute ridiculous farce this whole process had become because of greed.

With so much anger inside of me, we stepped over the trash and debris in the road, dodged the motor bikes and cars who never stay in their lane and climbed in the dusty van with our driver. We were to meet Rick Martensen, the President of World Wide Village. While waiting on him at Servotel Hotel, Emmanuel, Steve, the driver, and I had a fairly decent cheeseburger and some fries. We are a bit beef-starved now and then. Servotel is a hotel near the airport built from shipping containers but you would not know it unless you looked very closely.

When Rick arrived we told him a little about Midwives For Haiti and that we were on our way to Leogane to throw up the white flag of surrender to that project. He proceeded to tell us some amazing post-earthquake Leogane stories. About a donor that was going to build an $8 million dollar hospital at a damaged hospital site. A powerful Haitian priest wanted to skim 10% off the top for himself, as he had been doing for many years with other donations.  So they looked elsewhere for land to start a new hospital. But that same priest stymied efforts to get permission from the government to build it  because he was angry about their move away from the hospital where he was connected.

 The only maternity care available in Leogane is at the Medicins Sans Frontieres (Doctors Without Borders) hospital. They arrived after the earthquake and they currently deliver between 500 and 700 babies per month and have the only trauma care for miles and miles. They plan to leave the structure and pull out of Leogane in 2014. They have an excellent facility with staff and medicine in good supply. They charge nothing for their services so the businesses of local obstetricians who were charging for their services have been gravely harmed. Everyone knows that when MSF leaves, women without means will go back to delivering at home with unskilled matrones.

Rick told us about the donation to WWV of a pre-fab hospital to Leogane after the quake that saved thousands of lives, delivered hundreds of babies, performed hundreds of surgeries. A year later it was to be turned over to a reputable Christian organization to  run.  But the community heard rumors that it would become a cholera center and vandalized and burned it to the ground. So Rick has a sour taste left from Leogane experiences and thought we were doing the right thing in ceasing our 2 year effort to start a school there. We learned about other World Wide Village work in Haiti with food and nutrition and talked about community health workers and skilled birth attendants and what each could contribute to rural communities.

After several attempts at assisting another hospital to get their maternity services open last year, we realized it would never happen under the current administration. MSF became the only option for a clinical site for midwifery students so we met with the administrator of the MSF hospital. She agreed that training skilled midwives could be part of MSF's exit plan for the community. but she was reluctant to give permission without the consent of the District Director. For weeks we had tried to get an appointment with her.  He advised that we let him and his friends in high places petition on our behalf. He wrote letters, submitted our documentation, our curriculum, talked to officials and we waited.

So one main reason we were throwing in the towel in Leogane is that we had no agreement with a clinical site to train our students. We had hit a brick wall one too many times. That with the bad politics (to put it mildly) between persons in the U.S and persons who owned the land our classroom was on, we had decided to call it quits.

I knew that going to Leogane to break the news to the students and teachers that the school was on hold indefinitely and that we could not ask them to put their lives on hold any longer would be difficult. I had no idea.

After sharing pancake recipes with host and ex-Army medic Rick Hutchinson at Family Health Ministries Guesthouse after breakfast we drove to the campus to meet the students. Twelve beautiful students arrived (ten women and two men) with teachers, Mirline and Alcidas and sat under the pavilion near Dr. C's small clinic. Next to us was the locked building that held over $2800 worth of tables, chairs, fans, beds, and cabinets we had bought for our classroom. Inside in a locked depot was two large bags of supplies donated by Diane Rousseau. There were Childbirth Graphic posters, the student's Creole textbooks, BP cuff, book bags, and other teaching aid equipment waiting for classes to start.

The students were stunned. If we thought they would just give up and walk away we were badly mistaken. They asked questions and ultimately said, "What if we all came to Hinche and you taught us there?" "I have a tent I could live in," said one of the guys. "Since we would be coming back to Leogane to live and work in the community, would the Leogane Rotary release the funds to us anyway?" "I have had my uniform ready for months and I want to go to midwifery school so badly." It was heartbreaking.

Frankly the idea of bringing them all to Hinche had not occurred to us. And we doubted the Leogane Rotary would agree to give us funds to teach in Hinche even if it was Leogane midwives we were training. And how would we afford the teachers if we had no grant money?
We took their phone numbers and email addresses with promises to let them know if we could change the situation in any way. 

When we finally stood up to leave, I was heavy-hearted. I had already fallen in love with their faces and the potential for good that the each represented. As we walked to the van, I suddenly became very light-headed and felt like I would pass out. The day before I had not had enough water to drink. Then during the night I was sick from something I ate, took migraine medicine for a migraine and had eaten very little breakfast. So now I was probably  just too dehydrated. I remembered that Hilary Clinton fell because of dehydration and got a concussion so I allowed Steve to half-carry me to the van. Laying down seemed to help.

Even though I drank a bunch of water, when we arrived at a local engineer's house to talk to him about the morning, I still could not get up without feeling I would pass out. I waited with Mido, our driver, in the shade while Steve and Emmanuel talked to the him. He was kind enough to come out to greet me and wish me well before we left.

On the way back to PAP and all the way to Hinche I hit a severe low in my spirit. Not being able to sit up without being light-headed or lay down without being nauseated did not help. I watched out the window as the endless dust and traffic moved with us. Most of the morning we spent standing still in the traffic and swirling dust. It took three hours to go a distance that should take 30 minutes in the U.S. Along the way the poverty and bleak lives of the Haitians is so evident. What must it be like to be so poor you cannot buy a new tarp to replace the holey, ripped one that serves as the roof to your family's dirt floored home?

When I thought about all the greed and evil that has stopped good from coming to Haiti, I felt for the first time in all these years that maybe it was really too big and too powerful for us to continue our work. How much time and money we had spent getting signatures, having meetings, trying to placate the right people, and once we thought we were getting somewhere the officials changed jobs and we had to start all over. Our efforts to get officially registered as an NGO were getting nowhere and everyone who had tried it, grimly wished us luck. I felt I was in a black hole that would suck us dry financially and psychologically.

Meanwhile, in the back seat, Steve was having  completely the opposite  thoughts. He came up to talk to me over the back of my seat and to make sure I was still drinking water. He had been thinking about the idea of bringing the Leogane students to Hinche and really liked the idea of never going to Leogane again and having several classes running in one place to save us administrative time and money. He was playing with the budget in his head. He pointed out that students are in class 2 days a week and in clinical for the other 3 days and that we could stagger use of the classroom and use of the clinical sites for two groups. Why had we not thought of this before as a way to teach more students than 15 per year in Hinche?

Hope rose again in my usually optimistic self. When we finally arrived home to our house in Hinche where Carrie and her warmth and organization, sweet and energetic volunteers were waiting ready to be put to work, and nourishment and showers revived me, I was happy once again with the possibilities of our work.

This morning at church I stood beside Rita Ledbetter as we sang along with the Haitians singing "I surrender all". The women's choir and the congregational singing held beautiful harmony and was healing and inspirational.

Still a little wobbly on my feet, I knew I needed to push fluids today. We stopped at the hospital because although Rita had volunteered with us after the earthquake she had been in Carrefour and not in Hinche. I wanted to give her a tour.

Entering the maternity wing we found graduate and preceptor Magalie Gadet caring for the antepartum unit. In postpartum, graduate Edith Rose Gilles had a postpartum women on MgSO4, oxygen, and was giving Lasix to a newly delivered mother who was so severely ill with preeclampsia that she had pulmonary edema. In the labor and delivery unit, graduate Ysemonique had two laboring women on Pitocin and Mg SO4 for severe eclampsia. Another woman was getting IV antibiotics and being induced for prolonged rupture of membranes. Two more were walking the sidewalks in obvious labor.

Ysemonique greeted us with her hands held stiffly away from her body and explained she was "dirty". She had no gloves! Again the hospital supply was inadequate and this happens often on weekends when "our" supply closet was locked up!  So Rita and I climbed back on our motorcycle taxies, went back to our house, got sterile and unsterile gloves, returned with them and the key to the closet. Ysemonique wanted Apresoline, alcohol wipes, in addition to the gloves. We had them all. She assured us she had Misoprostel because we all know the MgSo4 makes these mothers at high risk for postpartum hemorrhage. She put on sterile gloves and checked the woman with ruptured membranes. She was 7 centimeters dilated. Ysemonique was pleased. The woman was in a lot of pain and she spoke to her softly, reassuring her.

I left full of hope. Without our graduates at Ste. Therese these women would be left to the mercy of fate. Before we arrived, women just did not come to the hospital, especially on weekends, because there was no one to care for them. Now there are MFH graduates, many paid by a grant to the government and some paid by us, to care for women and save the lives of them and their babies.

I am not in the black hole anymore. I am baking bread today which makes everyone happy. Rita is emptying the large bags of supplies she brought to us. Including Hershey's chocolate bars. She and Micah will go help the nuns at Azil feed the starving children at 3 pm. Life is good here. Can you tell?

Saturday, February 9, 2013

February 9, 2013

Several people have said, “Blog, Nadene. You should write about your life here in Haiti.”

Perhaps today I can start. It's Saturday and a little more relaxed although the “to do now” list remains impossible.

Yoga with Carrie, iced coffee and a last breakfast with Marion Alex, CNM from Nova Scotia, washing my clothes by hand and hanging them in the sun. Checking to make sure Renald's abscess on his face is getting better with antibiotics. This is my morning.

This past week we went to Leogane again to meet with Dr. Charles and Rotary president and past president- our second visit in a month. They are all so eager to see us start our classes there at the CAMEJO campus but we are not certain how to proceed without causing increased difficulty with a partner in the U.S. who is very much against us using the CAMEJO building. It is on Dr. Charles' property. Dr. Charles says it is for midwifery training and rent-free for the first year. It needs some plumbing and electrical wiring completed before the teachers can move in and we are willing to pay the $1000 it would take for Fanfan, the technician, to complete the work.  This person in the U.S. wants us to pay $1100 for the use of the classroom and $50/night for use of the 2 bedrooms for the teachers- a total of $2600/month for use of “his” building. This is not in our budget for training midwives at Leogane. 

Part of his antagonism stems from a misunderstanding about what kind of midwives we train. He thought we had agreed to train midwives who would “go back to their communities to work, not stay in hospitals to work”. It is true that our long term goal is to get skilled midwives out into the rural communities. What he did not understand is what a “skilled birth attendant” is and what it takes for her/him to practice as a skilled birth attendant when she/he has completed our program. Without IV's, medications, clean birth tools, ambu bags, the ability to sterilize, one cannot practice as a skilled birth attendant no matter how good your education has been. Without a salary and an ongoing supply chain it is not possible to put skilled midwives in rural communities. They will not have the means to establish themselves and keep a sustainable practice in a mountain community without some outside support.

The Rotary Club in Leogane understands what we do and why very well. In the Central Plateau we have accomplished this by connections with NGO's who want to hire skilled birth attendants and place them in rural communities. An example is the birth center at Thomassique supported by Medical Missionaries. One hour from the nearest hospital three of our graduates provide skilled care to hundreds of rural women each month. They deliver 35-40 babies each month, give prenatal care, educational classes and have an outreach program to local matrones so that more women at risk are referred to them appropriately. There are more of those examples across the country.

It is true that we have fourteen of our graduates working at the hospital here in Hinche. But with more and more communities sending very sick women and women at risk to Ste. Therese they are absolutely necessary. The third leg of saving lives – a well-staffed and equipped tertiary center- did not exist five years ago. When we began our program in Hinche in the fall of 2006 no skilled care givers could be found in the maternity unit most hours of any day. Only occasionally was a Cuban doctor there. Women avoided coming unless they were desperate and sometimes the housekeeper was the only one there to catch their babies. Maternal and fetal death happened there EVERY WEEK!!! No wonder no one wanted to come.

The picture has changed at Ste. Therese because women will come if they know they will get compassionate and skilled care. In Leogane they flood to the Doctors Without Borders hospital there to receive skilled care. But what will happen when they leave in one year? Women will go back to delivering at home unless there are skilled caregivers readily available at small birth centers and clinics in the surrounding communities. That is what we want to do- start training now for immense need for skilled birth attendants in Leogane.

Meanwhile in Hinche, seventeen new students have completed 4 weeks of training. We are continually improving exams, training teachers, and adding French and Creole resources. The day-to-day problem-solving on the logistics of precepting 17 students in labor and delivery, prenatal clinic, matrone outreach, mobile clinic, antepartum and postpartum and post-op units is a daily challenge. But this is what gives me the greatest joy- to see the learning happen, the lights go on, the self-confidence grow. 

I do not know what the next week brings for our plans in Leogane. We live by faith from one day to the next. The obstacles seem sometimes insurmountable. Next week we will not have the same problems- just new ones. Too many lives are at stake to give up.

The mobile clinic had an eventful week- unbelievable stories. But that is another blog for another day.