#6 - Haiti - STC - Cholera

31 January 2011


It’s been over a week since my flurry of updates. The field trip to Belle Anse and Thiotte was highly productive, good for my psyche and allowed me to gain some perspective on my work with Save the Children. Plus, we didn't roll the car, hit any chickens or blow out a tire. All good.

Before I tell you about the field visits, I want to let you know that I am back in Boulder watching it snow and hoping the temperature might possibly hit freezing today. It’s a bit of a long story, so let me know if you want more detail. Suffice it to say, I did what I could for the medical evaluation and recommendations for Save the Children’s Cholera Treatment Units in the South East Department of Haiti. My time there gave the Jacmel office time to clarify its cholera strategy. That involved creating a Cholera Response Coordinator position (filled with an in-country STC person who will be PERFECT for the position) and hiring Haitian doctors to supervise each CTU. I participated in briefing the doctors, as well as making recommendations to the new Coordinator in regards to the CTU clinical and operational deficits. With the new structure, we all agreed that I would return home. Sad for me, but it’s the best.

Serendipity – the trip from Jacmel to PaP involved stopping in the Leogane STC office. As I arrived, the Jacmel director pulled me into her office and pummeled me with questions about cholera management – they had opened a CTU the week before and were opening a 2nd one in a few days. She had just hired a CTU Coordinator, who didn’t know cholera and, it turned out, didn’t know anything about human physiology, either (“oh, cholera affects the veins, too?). So she and I spent 4 hours visiting their sites, me attempting to download everything I know about cholera management, assessing the CTU, making rec’s for changes, and doing a “physiology 101”. I was so thirsty at the end of those hours, but felt satisfied to have had a chance to help them at such an important point.

I spent the night at the STC director’s home, debriefing with him, feeling so sad about leaving. Yet somewhat resigned to the appropriateness of the decision. I am hearing from the new Jacmel Coordinator that things are moving ahead. My dreams are still full of people, procedures, faces, regrets and gratitude. Time will ease all.

But how about a bit more about Belle Anse and Thiotte?

I finally left for Thiotte and Belle Anse on the morning of Thursday the 20th. Travelling with me were Thomas (my interpreter), Florian [Thiotte’s Water, Sanitation and Hygiene (WASH)] Supervisor and Nelson, the most incredible 4-wheel driver in the world. The first 30 minutes a paved road followed the coast, in and out of small market centers. Turning north, we climbed into increasingly rougher volcanic mountains. Even driving over mounds of old basalt, banging along sometimes as fast as 20 mph! The grade both up and down took all my self-restraint to keep me from begging to walk. At least I got to ride in the front, so I didn’t get car sick!

Belle Anse at 11:30 – we ordered lunch at a sea side “restaurant”. It would take an hour to prepare so we went on to the CTU. They had about 8 patients. The entrance/exit “sprayers”, chlorinators and nurses were in place. One of the clothes washing women was lying on the entrance to the latrines in the shade. The public hygiene promoters (PHPs) were sitting on a bench, complaining to me that they couldn’t do anything without a motorcycle, that the communities were too remote to reach by foot or car. I noticed that the medicines and IV supplies are strewn about the floor of the pharmacy tent, along with empty fuel cans. They need tables or shelves. The patient care area is missing a hand washing station, a sharps container (for used needles) and a trash can. I made a note of these things and we returned to our lunch (fresh fish, fried bananas and fresh grapefruit – my request!). The closest I got to the Caribbean was that lunch, waves beating against a rocky beach 15 feet away.

Leaving for Thiotte, Nelson assured us that the worst of the road was behind us, but I’m not so sure I agree with him. Two hours later we arrived at the Thiotte CTU, probably 30 degrees cooler than BA. We were greeted by the staff and only two patients. After a time of answering questions (Will cholera ever go away? How do I protect myself?), I toured the compound, made some notes and traveled another 15 minutes to the Esperanta Hotel.

Thiotte’s staff, as in the other CTUs, are divided into 3 teams – one on days, one on nights and the third is off. 3 - 4 people shared a room. There are only 2 bathrooms in the hotel, so disgusting that one night I actually deferred showering, not wanting to step into the 2 inches of cloudy standing water oozing out from under the door. At 3,000 feet elevation, it was so cool that I used a blanket at night. I have to confess, I had a little “medicinal” rum every night there – I HAD to sleep!

Time there was intensely focused on establishing an inventory control system for the pharmacy and other supplies. Supplying Thiotte is no small challenge. The Administrative manager didn’t have a clue that he needed to request supplies well ahead of running out of something. Or requesting petty cash reimbursement. With a 6 ½ hour drive each way, planning ahead for resupply was a concept that I felt imperative to help them all understand. One of the nurses on each shift is the “pharmacy nurse”. The one I worked with was so unresponsive to my questions and suggestions that I wondered if she was getting anything that I showed her. I am quite concerned about integrity of the Administration manager. (I later learned that gangs regularly infiltrate non-profits and if anyone tries to report, they do so at risk of being killed for “ratting”.)

I held two staff meetings that included letting them know that eventually STC would no longer provide their food. You can imagine that was a big hit. I also had to negotiate a new contract with the hotel for our staff’s lodging (and I added meals, just to see what I could get!) We had been paying about $20,000/month. I got them to agree to $15,000 for 60 days, including food and to only put 2-3 people in each room. I actually couldn’t believe it when they agreed. I will be really interested to hear what the written contract sorts out to be. I was pleased to at least move the negotiations in the right direction. It was so difficult to leave, as I had little time to actually sit with the nurses – of course their charting is in French, so reviewing it was a bit of a challenge for me.

I had an interaction that was a little humorous. Outside the exit (where you step onto a footbath that has a chlorine-soaked rug and the “Sprayer” sprays the bottoms of your shoes with chlorinated solution) there was just rough dirt. Bad enough when dry, but not a pretty picture at all when the rains start. Just about 10 feet away was a big pile of gravel. I asked the engineer if any of her workers (who weren’t busy) could spread a small amount outside the exit. She said no, it’s not their job. So, I walked over, picked up a shovel and started spreading rocks. Two of the younger guys jumped up, brought over another shovel and a wheel barrow and took my shovel from me, laughing heartily. So, the little mud-hole is covered!

Leaving Thiotte Tuesday morning, we arrived back in BA to a bit of a panic. Eleven patients, no fuel for the vehicles, they had received calls from 4 patients to be picked up out in the remote communities – and we had heard that one had already died, waiting for help. The family was in a panic about how to handle the body. Oh, and this CTU’s Administration manager told me there was no petty cash to buy fuel locally (they are supposed to request fuel from the Jacmel office – it’s $5.50/gallon in the field!!) So, you can guess who started shelling out money.

And still the PHPs whined to me about not having motorcycles, all the while sitting on their comfy bench. I was not pleased. The medical director is at least aware of community issues – he organized the mayor and a policeman to accompany him, a chlorinator and one of the PHPs to drive out to the family of the deceased patient. Hours later they returned and Thomas and I were eager to find our hotel and some dinner. Another oops. We only got the hotel owner to give us rooms with the doctor vouching for us as STC employees (yup, we did have badges). After driving around town, finding no food available, we BEGGED the hotel to make us a meal (as well as the 2 guys who had been out on the trip with the doctor). And how did we pay? I had exactly the equivalent of $25 and that’s what she charged. Dinner was ordered around 7 pm. We ate around 9:30. I was so tired I could hardly sit upright to eat! It was exquisitely beautiful, though. Orion was directly overhead, and I even saw Scorpio rising. I could hear the waves crashing on the beach. Eventually I fell asleep, planning to leave at 5:30 am and knowing the ride back to Jacmel would be tough, physically and emotionally.

Back in Jacmel, I met with the new Cholera Response Coordinator as he briefed the 3 new CTU Supervisors – all MDs. I yearned to spend a day with each one, but had to leave it at about 30 minutes with the group. I prepared several reports for the new manager and said good bye to the few people in the office with whom I had connected. My ride to Port au Prince was scheduled for the next morning. Leaving that place was so bitter sweet, it was almost unbearable.

The lists of what yet needs to be done still cycle through my brain and I hope that I did enough, that somehow my recommendations will be integrated in ways that made sense for those left to care for the patients. In PaP, my angst was somewhat relieved by meeting with STC’s Country Director, debriefing both the process of my hire, as well as the status of cholera care in the South East Department. Even in my disappointment about leaving Haiti, I know that my time was well spent and trust that, somehow, I was able to help ease the cholera burden.

Thank you all for hearing me out…for your support, for your willingness to hold the people of Haiti in your hearts and prayers.

Much love,
Beverly

PS I know my email lists are not so perfect (thank goodness I’m a better nurse than computer geek), so I’ll put my emails on my blog: LyneGlobalHealth.blogspot.com.