Haiti

Haiti clinic makes real gains

Long days at Boucan Carré mean better health for neighbors

On a typical day, patients start lining up two hours early for outpatient services at the Boucan Carré clinic. At 8, they head into the large central waiting room. There, they get weighed, get their blood pressure taken, and wait for their name to be called. Staff photo Rose Lincoln/Harvard News Office

"13 October 2003."

Saintyl Louistess remembered the exact date she found out she had AIDS. She had been suffering headaches and losing weight while living in the Haitian capital, Port-au-Prince, and returned to her parents' home in the remote country around Boucan Carré, a small community alongside a river of the same name that runs through Haiti's impoverished Central Plateau.

Her parents had brought her to the nearby clinic - a tiny, three-room building that until recently had been staffed by a single nurse auxiliary and which was chronically short of medicines and medical supplies.

But Louistess was in luck. Months earlier, in March 2003, doctors from Harvard Medical School and Brigham and Women's Hospital, working through the nonprofit Partners In Health, had arrived.

In collaboration with the Haitian Ministry of Health, they brought with them supplies for the pharmacy and a commitment to always have a doctor available and never turn anyone away. They also brought Partners In Health's community-based health care delivery model.

With a focus on primary health care, women's health, and childhood nutrition, and targeted attention paid to AIDS and tuberculosis, the organization has made strides in care of the world's rural poor that public health officials thought impossible a decade ago.

From its roots in Haiti in 1983, the organization, founded by a handful of people that included Maude and Lillian Presley Professor of Social Medicine Paul Farmer, Francois-Xavier Bagnoud Professor of Health and Human Rights and Professor of Social Medicine Jim Yong Kim, and Partners In Health President Ophelia Dahl, has now expanded to nine countries around the world.

In the five years since Partners In Health arrived at Boucan Carré, there has been a virtual revolution at the clinic. It quickly became apparent that the original building was woefully inadequate for the community's needs. Though the nurse auxiliary was only seeing 10 to 15 patients a day, as the news spread that doctors with medicines were treating people free of charge and that sick people were getting well, patient numbers quickly swelled to between 150 and 200 a day.

Soon after PIH's arrival construction of a new clinic began. The new building has a large central waiting room with a row of consultation rooms nearby. It has dedicated space for a laboratory, where testing for HIV, tuberculosis, anemia, and other maladies can be conducted; a pharmacy stocked with stores of medicines; a small, 18-bed inpatient ward; a maternity room; and another room for administering a nutritional program for children. It has a small operating room, a room for medical records, and upstairs, offices and sleeping quarters for staff members far from home. More recently, a separate building to house the TB ward and isolation rooms was constructed. The original clinic is now the campus kitchen.

"Compared to what it was, it's unbelievable," said Louise Ivers, an assistant professor at Harvard Medical School, infectious disease specialist at Brigham and Women's Hospital, and director of the HIV Equity Initiative for Partners In Health in Haiti.

On a typical day, patients start lining up two hours before the 8 a.m. opening for outpatient services. At 8, patients file in, gather their medical records, and head into the large central waiting room. There, amid a cacophony of conversations, coughs, crying babies, and a television playing health education messages, they get weighed, get their blood pressure taken, and wait for their name to be called.

Doctors, nurses, and technicians work all day until the last patient - sometimes their 300th - is cared for.

Medical personnel there see it all, the whole suite of ailments, from colds and diarrhea - a frequently deadly affliction that each year kills 1.6 million children in poor communities worldwide - to more complex illnesses such as meningitis, cancer, AIDS, and tuberculosis. Mixed in are the accidents and injuries - cuts, contusions, and broken bones - that are inevitable wherever people work and live together.

Octav Pierre, a nurse at Boucan Carré since 2001 and one of eight working there in January 2008, has seen the changes. Before Partners In Health arrived, she said, several patients died because there were no doctors available and no vehicle to take them to a medical center where they could get better care. Today, she said, she feels good coming to work every morning because she has a job to do and a place where she can be effective.

Francine Ponte de Jour, a midwife at the clinic who lives hours away in Port-au-Prince, said she enjoys being able to help people who can get care in Boucan Carré whether or not they can afford it.

The clinic operation is just the most visible part of the program there. With a commitment to community health care, the clinic employs a small army of 90 community health workers who every morning and evening fan out in the surrounding hillsides, touching base with those living with HIV and making sure they take their medicines as prescribed. While they're there, the workers assess the patients' living situation, making notes of the condition of their shelter, the health of family members and neighbors, and other information that could guide future interventions.

On a recent trip to visit one HIV-infected woman, Marie Jean, community health worker Lagenie du Morney heard that the woman was being evicted from her brother's house because he was getting married. Du Morney passed the word along and workmen came to repair an old two-room house nearby, with mud walls and a metal roof. On a subsequent visit, Ivers expressed displeasure that the house had a dirt floor, substandard for Partners In Health's home-building program.

"This obviously is not ideal," Ivers said, inspecting the house, which was empty except for a duck and a few chickens. Ivers said they would pour a concrete floor and get the woman a bed, telling her. "Keep your courage up. We're in the battle with you and will do the best we can."

The interventions needed in the region are many. Haiti is the poorest country in the Western Hemisphere and one of the poorest in the world. Many of its roughly 8 million people are subsistence farmers, trying to scratch a living from the nation's deforested hills and depleted soil.

Outside of the major cities, health care is scarce. The nation, which shares the island of Hispaniola with the Dominican Republic, has the Western Hemisphere's highest death rates for infants, children under five, and women in childbirth, according to UNICEF. It also experiences outbreaks of preventable and treatable diseases, such as measles, polio, and diphtheria. Malaria is widespread, as is chronic malnutrition. In Haiti's Central Department, where Boucan Carré is located, an estimated 44 percent of children under age 5 suffered the effects of chronic malnutrition in 2006, according to the World Health Organization. Hunger and malnutrition cause nearly 10 percent of deaths among children under 5 in Haiti and contribute to another 30 percent or more by weakening children and making them far more likely to die of common neonatal disorders and diseases like pneumonia, diarrhea, and measles.

Partners In Health's nutrition program is built around the identification of children suffering from malnutrition and intervening with a fortified peanut butter product that mothers can take home and give to severely malnourished children. The organization also distributes a grain and bean-based supplement given to those children in danger of becoming severely malnourished.

"We give it as a prescription - food as medicine," Ivers said. "We have so much malnutrition. If a kid comes in starving to death, you can be pretty sure the whole family is in rough shape."

Ivers said malnutrition is so widespread that just getting everyone fed properly could have broader societal gains.

"I have a feeling that if you get people nourished, not anemic, able to concentrate, and not tired when they get to school, we could have a revolution here," Ivers said.

The clinic also runs a small agriculture program to teach farming techniques and to raise saplings - some fruit trees for food and some fast-growing trees to fight deforestation. They're also starting a pilot program to provide families with goats, saplings, and tools, a mix of things that can lift them from starvation's edge.

"The idea is to go beyond the health center . so a family has a backup plan," Ivers said.

Haiti has the highest rates of HIV/AIDS in the Western Hemisphere, with about 3.8 percent of the adult population infected, according to the World Health Organization. AIDS is the leading cause of death among Haitian teenagers and adults, causing 21.6 percent of deaths from known causes among those aged 15-49.

Five years have passed since Saintyl Louistess found out she was HIV-positive. She recalled the intervening time as she sat on a folding chair outside her two-room house, perched on a rural hillside just a few feet away from her parents' house on their tiny family compound. Chickens squawked nearby while a skeletal dog did its best to stay out of the way of du Morney, Ivers, and other visitors.

Sitting on Louistess' lap was her year-old daughter, Saintlouis Midora, a chunky, healthy-looking baby with shining eyes and tiny hoop earrings.

Louistess praised the care she's received at Boucan Carré, saying her health worker makes sure she takes the antiretrovirals that control her body's HIV every day. She has followed Partners In Health's advice and bottle-fed Saintlouis, going against the prevailing wisdom in international health circles that HIV positive mothers in poor countries breastfeed their babies for six months. Despite the danger of transmission of HIV to the baby in the breast milk, the recommendation is based on data that indicates the danger of dying from diarrheal disease from formula mixed with dirty water is greater than that of contracting HIV. But instead of promoting a policy that is potentially harmful to the baby and which would never be implemented in developed countries, Partners In Health gives mothers the knowledge and tools to ensure the water they use to mix formula is safe. Their mother-to-child HIV transmission rate is less than 2 percent, Ivers said. So far so good for Louistess and her daughter. As of early 2008, Saintlouis Midora was HIV negative.

Though much has been accomplished at the clinic at Boucan Carré, much more needs to be done. Communication recently received a major boost with the installation of cell phone towers nearby. Doctors at the clinic can now call the main Partners In Health hospital at Cange when they have severe cases, summoning an ambulance and ordering the operating room be prepped.

But getting in and out of the clinic remains a challenge, particularly in the rainy season. The road is little more than a jumbled bed of rocks, requiring even a four-wheel drive vehicle to move along at just a few miles an hour. On a recent visit, a hired driver refused to travel the route until the vehicle's spare tire was fixed and aboard.

The main river crossing near the clinic is another problem, and Partners In Health is petitioning the Haitian government to build a bridge there. Fordable during the dry season, during the rainy season the Fond Enfer, or "Deep Hell," often becomes uncrossable. There are numerous stories of difficult river crossings, and Ivers said that she witnessed two women die of complications from their pregnancies while waiting to be transported across. In 2006, an ambulance that stalled midriver was swept away and destroyed when a flash flood sent a wall of water coursing down the riverbed, highlighting yet another challenge facing those who would bring health care to the poor of Boucan Carré.

"I've seen two women die because we couldn't get out," Ivers said. "Both needed C-sections. We got them here and just couldn't cross."

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