3000

I think I overestimated my strength.  I basically challenged a two ton beast to a game of tug of war this evening #MoreThanICouldChew.

Mission Matana has a cow (bèf) named Bella and she is preggers.  Throughout the day, Bella just hangs out in the yard and eats grass.  She has a twenty-five foot rope tied around her head that is “secured” to around the stems of about six weeds.  I would wager a guess that she can go about anywhere she wants and no one could really stop her.  In the evenings, it is Guirlene’s job to guide Bella down to the canal so she can get water.  I honestly don’t know how often this happens, but it just so happens that this evening Guirlene asked me to help her.  I’ve never really guided a cow before, but she only has one functional arm #BeenThere so she could use a hand #BadPun.

I’m not a cowboy.  My jeans are breathable.  My back pockets do not contain skoal can rings.  I own only one flannel shirt and no ten gallon hats.  I’ve ridden a horse, but never on a cattle drive #ButThatWouldBeAwesome.  And I’ve let a “Yall” slip every now and again, but that’s probably the extent of my behavior that could be considered remotely close to that of a cowboy.  Basically, what I’m trying to say was that I was making this up as I went.  I had my rope.  We had a cow.  And she needed to fetch some water to drink.  I started pulling.

I yank and she starts ambling through the yard, slowly.  She tops every now and then to nibble on some of the vegetation and I get out in front showing her where we’re going.  It’s a little intimidating to stand a few feet in front of a cow with a set of horns trained at your lower back.  So much so that I instantly change my mind and step to the side to let her go out front.  And then something clicked.

I’m not sure what it was.  Whether it was a landmark in the yard.  Maybe she realized that she had just crossed the threshold of her previous confinement.  But Bella knew that she was no longer tied down.  And Bella started running.  I gave a firm tug on the rope to try and keep her under control.  She slowed, but immediately picked up her gait.  Guirlene starts yelling, “Lashe!  Lashe!”  And, suffice it to say, my Creole lessons never involved cattle driving vocabulary.  Hmmm, ‘lashe’?  Wonder what that means.  I definitely don’t want to lose the cow because I’m sure that would be a big ordeal.  Maybe I’m supposed to use the rope in some sort of whip fashion?  Like ‘lash’ with the rope?  I’m being pulled by the taught rope connected to the 3000 pound beast, but try to send a wave through anyway.  It has no effect.  I’m now in a cross between a controlled fall and a run behind Bella.  I wrap my hands in the rope.  I take a quick hop, set my feet and give a sharp pull of the rope.  Her head careens left and she stumbles, but regains her pace almost immediately.  “Lashe!  Lashe!”  I hear behind me.  I try again to whip Bella, failing miserably to do anything but lose my balance.  I hop.  Plant my feet.  And pull.  She doesn’t even notice.

I resolve that I need to just run with her at this point.  I clearly can’t slow her down right now, but maybe there will be an opportunity for me to regain control.  We tear off through the field with Bella leading the way.  If I was a running back in the NFL and she was my lead blocker, we would destroy all of the records #BeastMode.  We cross over the back alley to the nearby house and then find ourselves in weeds again.  Would’ve been nice to apply some bug spray before this little adventure.  And then I see it.  The canal is up ahead about thirty feet.  It’s make or break time.  She’s full speed and heading straight for it.  And just when my visions of her falling into the canal and breaking her legs get painfully graphic, she stops.  Takes a couple slow steps.  And drops her head into the canal.  That wasn’t so hard. 

I anxiously stand beside her waiting for Guirlene to make her way down the path.  My heart rate is still up from being drug through the field.  Guirlene steps through the weeds and has a big grin on her face.  “Lashe” she says.   “M pa konnen, lashe.”  I hand her the rope insinuating that I want her to show me what I was supposed to do.  How was I supposed to send a ‘lash’ through the rope and into Bella in order to control her?  What direction did I need to direct the yanks on the rope to get her to slow down?  She’s laughing.  “Lashe” she says once again.  And throws the rope on the ground.

The trip back was much smoother #QuickLearner.

Coliforms

I’ve put my translator, John, through a lot of shit during our time together.  Anyone who has read my previous posts probably detects that I’ve lost my patience with him and definitely said things that I shouldn’t have.  I’ve been bossy, in a bad way.  I’ve been motivational in a good way.  I’ve been rude.  And I’ve tried to always end our days on a good note.  That would prove to be more difficult on this occasion.

For those of you who haven’t been keeping up with other CHI contributors, @ShaunHarty wrote about his time in Arcahaie working on the clean water project.  First he went around testing all the different water sources for coliforms #PoopBugs.  The tests were positive everywhere they shouldn’t be, including the water I was drinking at the compound for ten weeks #UnstoppableGITract.  It became clear that the people were going to be collecting contaminated water.  We can’t stop that without partnering with the government to create a water system seen in the US #NotUpOurAlley.  So we did what we could.  We partnered with the Gadyen Dlo project to borrow their design and infrastructure to help out the local community.  Long story short, they distributed a crazy amount of buckets and helped set up this entire chlorine distribution market.  Community Health Initiative added four new Haitian employees and we are fairly confident that nearly 500 houses have clean water security that they did not have before #Ballin. 

I was in Arcahaie during the dry season earlier this year, so people didn’t really complain of diarrheal illnesses – although 20% of the houses surveyed reported recent diarrheal illness.  But, in speaking with them they offered insight into their struggles with clean water security during the rainy season.  They recognized that cholera, other diarrhea etiologies, and even malaria were much more common during the rainy season.  I could never get any person to specifically say it was because there was more fecal contamination of the drinking water, just that the water was “dirty.”  Looking at the river I would agree.  It almost looks like a dirt road. 

Although the water project is pretty much awesome the impact is limited if other issues are not addressed.  One of these is appropriate waste disposal.  Another CHIer, Mike Barthmann, has been working with Top Digue on some latrine.  He’s contacted a number of other NGOs that specialize in latrine design and implementation #PoopSpecialists.  Community meetings were called and small groups were encouraged to voice their opinion. 

And then my job was given to me.  My primary goal was to survey the local area about their water useage, latrine situation and a potential engineering project to connect them to other roads leading to markets.  Beyond this, Mike was pumped to check out one of the old latrines to see if they actually worked and broke down poop into compost.  And then Sandy struck.

Plans change in Haiti.  I already discussed this point in the Yellow Spotted Plague post.  So Mike was forced to cut his workweek short due to the weather and leave some work for me to complete.  So I donned my #FrogToggs rain jacket and headed over to Top Digue with Steve.  The hurricane rains were dying down, so this seemed like a perfect time to dig out a 3 year old latrine #PetrifiedPoop.  My dad always talks about being an archaeologist.  Perhaps I should tell him this is the training ground.

I don latex gloves, a surgical gown and a disposable mask and begin pulling rocks off of the latrine.  Steve helps and we carefully avoid the broken glass.  “Just one to two feet” of rocks cover the former hold of the latrine.  The process is slow going and my terrible back picked now as the perfect time to remind me of how badly it hates me.  Minutes pass and a young lady shows up with a borrowed shovel.  It is one of the same young ladies that cooked diri avek sauce pwa for me last time I was here.  We begin shoveling.  Every now and then one of us bends down to take a sniff to determine if we’ve struck brown gold yet or not.  A few Haitians take a turn with the shovel, but needless to say our effort and willingness to get face first into a shitter earned the blan some respect. 

The deeper we go the more we expect to see positive signs for life: worms, bugs, root systems, etc.  We don’t like to see non-degradable material like plastic, foil, clothes, tins, etc.  Compost latrines function by combining carbon-based material such as yard waste with fecal matter and allowing it to digest into combined sludgy dirt than can then be used as compost.  The compost is rich in most vitamins and minerals and studies have shown that unlike American fertilizer this product will actually leave the soil better than before.

We found two unmatched sandals, food wrappers, old clothes, and a mandible.  When I stumbled upon the teeth with the shovel the crowd of people got awful excited.  I had no idea what was being said, but I can only imagine it was some form of conjecture about the species of beast the bone and teeth came from.  My bet was on goat, which is a shame because usually they cook the entire head in their stew #Wasteful #NotSoTasty.

We shovel even deeper.  I’m about waste deep in the pooper at this point.  The rain has stopped and the sun is turning my scrub gown into a bright blue oven.  Sweat pours down my face as I take my turn with the shovel.  Just trying to earn the street cred I so desperately need for my own personal gratification.  I keep waiting to see something that will tell me definitively that the composting latrine was a success or a failure, but then I realized that the only “sign” we could possibly “see” is a layer of preserved human feces.  My stomach lurches.  Four years of medical school and I’m digging for poop #WhatADeal. 

I’m about waste deep.  Another local brings a long, metal rod filed on one end to produce a point.  John starts to break up some of the dirt so I can shovel it out of the hole and with one quick toss the pole drives two foot into the earth.  That seems like we just reached our make or break point.  I look at Steve to see if he registered the same thought.  Obviously he was light-years ahead of me.  “If there’s just soil on the pole I think it’s safe to say that the cold compost system worked.”  I pretended like I knew the difference between cold compost and hot compost and did what had to be done.  I pulled the pole out of the dirt, bent down, and took a big whiff of the brown material on the end of it.  No smell #ThankGod.  The peanut gallery was sent into giggling fits seeing me smell what they assumed would be a bunch of poop.  But we did not have poop.  We had soil.  This soil would probably create a welcoming environment for any plant that they decided to plant in it, as is our plan.  Hopefully our latrines won’t be twenty feet down and covered with three feet of rock.  We’ve got a long way to go yet before we start building, but we’re moving down the #CHIt road.

Fracture

The river was rushing mightily from the mountains.  Four straight days of heavy rain have taken a normally shallow stream and turned it into a weapon of destruction.  Banks being beaten mercilessly.  Plants and trees slowly remitting to their harsh undoing.  The brown river did not discriminate with its wrath. 

During my time here in the spring I was told of a yearly flood that ripped through the town of Repo and the lower levels of Delice.  This could very well be the 2012 version as the river seemed like it would continue to rise until I was crying out for Noah.  Little did I know that the river had bigger targets on its mind than the meager “kay” that inhabited the low-lying flood plains.

We arrived to Haiti on a typical Sunday morning.  A relatively uncomplicated trip that gave us about 3 hours’ use of a La Quinta hotel room #ThreeHourTour and then sweating through customs with four bags of medical equipment.  We were picked up and taken to Arcahaie with ease.  Others were not so lucky.  Dr. Angie and her husband arrived to Port-au-Prince two days later in the afternoon.  The hours passed with no notice from them or Peter, the driver that was to pick them up.  Rachel and I waited and finally they rolled in at nearly midnight.  “The bridge was out” and they had to take a detour.  The entire traffic system was thrown out of whack.  Buses and tap taps without clear routes.  The poorly designed back road now carried the traffic of the main highway.  Needless to say, traffic was not moving.  The story I received from Angie and Steve was that in their second hour of sitting in the detour traffic jam that a set of motos came cruising along the side of the road.  They had to ditch their luggage, but were able to finally get back to the compound.

I visited the bridge, just a short walk from our compound, and saw for myself why it was closed.  An entire section of the support was lying in the river.  However, you could still walk across it and they were letting motos drive across it.  Tap taps waited on either side of the bridge ready to take passengers to their destination.   But you can’t leave a lame gazelle in the path of a lion and expect it to still be there in the morning.

The days were as dark as the nights and the rain continued its assault.   Guirlene, Rachel and I had just returned from visiting a patient and were trying to settle in to ride out the storm.  There isn’t much else you can do in the midst of a hurricane aside from seek shelter and read under your headlamp, but Guirlene was determined to finish her daily duties for the missio.  And then it happened.  She was hustling quickly from building to building wearing her loose flip flops and hopping over puddles collecting on the rain-soaked tile.  Her footing was bound to fail.  Dr. Angie and Guirlene shuffle into the downstairs bedroom supporting Guirlene’s right arm.  She had a FOOSH.  We doped her up with the few narcotic pain medications that we had saved and braced her arm. 

The rain did not slow down to celebrate its new victim.  It had loftier goals in mind and Guirlene’s wrist was a small piece of collateral damage.  The river gushed over the dam towards the sea.  Nobody was on the road when the bridge started to shake.  The rushing water beneath obscured the sound of the bridge’s impending death, but the supports were failing.  It was a rapid demise.  A large chunk of the center of the bridge suddenly wasn’t there as it was gobbled up by the rapids below.  The northwest was now completely separated from Port-au-Prince.  

Yellow-Spotted Plague

There were no systemic symptoms, but the patient complained of a rapid-onset, non-pruritic rash for the past two days.  Rashes are common in Haiti.  Generally speaking, hygiene is not a priority although cleanliness is valued.  Houses are small while families are large.  Contagious rashes spread through families quicker than rumors through a junior high school cheer-leading squad #FastLikeUsain.  So, in just hearing this complaint of a rash, regardless of how it was described, infectious etiologies were at the top of my differential. 

On exam the lesions ranged from 1 mm to 1 cm plaques, or slightly elevated above the skin.  They were not erythematous, but the lesions clearly had a yellow color to them.  They were well demarcated and the patient reported that they were not tender to palpation.  The lesions involved the upper extremities, abdomen, chest, shoulders, back and face.  Mucous membranes were not involved.  The patient denied fever/chills, weight loss, nausea/vomiting, diarrhea/constipation, headache, upper-respiratory infection symptoms, and urinary tract infection symptoms.

The patient was me and I knew very clearly the etiology of my skin “lesions”.  They were drops of yellow paint from helping out with the finishing touches on the new guest rooms.  Yes, I came all the way down to Haiti to help paint.  Yes, I’ve gone through four years of medical school so I can come to Haiti and help paint.  #Overqualified?  To be fair though, my painting skills were pretty bad #Underqualified. But that doesn’t matter in Haiti.  The workers around the Matana compound are pumped to see a ‘blan’ working after hours to help them out with painting. 

Dr. Chris mentioned to me before my last trip that you can arrive down in Haiti with all these big plans, bright ideas, and will to “help” only to find out that instead of needing a clinic doctor they could really use a motivated and dedicated worker.  The example that you can set by working hard and not complaining can do wonders by providing a role model for the other workers.  During our lessons with the new health agents today they were discussing “pwoblèms” the community faced.  Number four on their list, “Having to work too hard.”  Talk about cultural differences.  

My list of projects when I came down here included: looking into water and waste disposal for a nearby community, using the microscope to study disease etiology, and investigating a possible bridge site.  What I’ve found so far is that the community is already committed to getting a pump installed, we have no microscope, and an engineer is coming in a couple weeks to investigate the bridge location.  So now I’m a painter and I found a half-constructed church that needs completed. I see patients every morning and then go about finding ways to stay busy all day long.  Today that was entirely clinic based.  Tomorrow it’ll likely be setting up for a larger clinic and buying some supplies.  But even that might change.  Frustrating?  Perhaps, but that’s also one of the joys in coming down here.  If you keep an open mind you can open your heart to more people and truly connect with them.  It may not always be a glamorous operation, but are we working in Haiti to tell stories or to help out?  

Relapse

It has been approximately 204 days since I left Haiti earlier this year.  I wrote of Haiti-itis previously, but I didn’t anticipate myself going through any withdrawal in the near future.  I was burnt out.  The physical and emotional toll of the last three weeks got to me and I wasn’t sure when I would muster up the energy to return.  Bedica, CHI’s little angel, made it to the U.S.  What more did I need for closure at this point?  I had pages of pages and data to analyze and, like I mentioned, I was burnt out.  Dr. Chris asked me to help lead a team to the area where I had spent my weeks in, to the mountain clinic that I found and contacted, to reconnect with the people whom I had come to know.  I declined.  I wasn’t ready.  And there hasn’t been a day since that I don’t regret not going with that team.  Bedica passed away three days after the left and I have been dealing with guilt and emptiness since.  At this point I never wanted to go back.

I certainly went through some dark moments after I received the news.  I penned a blog post that forced an immediate phone call from my parents who urged me to take it down.  I distracted myself with studying for my Step exam.  Interests were no longer interesting.  Fun was no longer fun.  But then I got back into medicine and my world slowly started coming back together.  Tough decisions were about to be made regarding my future so I had to have a clear head.  As I applied to residency I leaned on my interest in international health and my Haiti experience for my applications, but I still had no desire to go back.  However, that’s exactly what I started planning with Rachel Bender as she looked for an international experience to sneak in after SICU and before interviews.

Before I could second-guess myself flights were booked and projects were designed, and redesigned, and redesigned…  As the date got closer though I couldn’t help but think about running away - canceling my flight and staying true to my resolve not to return.  It sucks.  I’m not ready for it.  For someone like me who absolutely loathes emotions, especially crappy ones, why would I voluntarily subject myself to returning to Arcahaie?  I don’t know.  But I’m here.

The ride from Port au Prince was just as familiar as it was during my last days in the spring.  However, this time I had managed to arrange a comfortable ride in the backseat of an SUV instead of a cramped truck.  It certainly cost a lot more.  St. Medard hasn’t changed much, if at all.  The windy, gravel road up to Mission Matana appeared slightly more developed.  Maybe some houses that were mere shanties with tin-roofs were more substantial.  The landscape was definitely greener.  But familiar faces were everywhere.  Even kids that seem to number in the thousands around here had faces that I honestly thought I could place from my previous trip.  They were probably wearing the same clothes, so that helps.

After Rachel and I settled in at the mission I offered to show her around the communities a little.  It had been a while since I had been identified for being a ‘blan’.  We cut through the houses and followed the canal to the back road.  A path that was painfully familiar.  I directed us north to avoid the past and address the future.  The dam was finished, I think.  The water was flowing well and some kids were enjoying the well-fed canal system.  Standing on the top of the dam I pictured a bridge connecting the river banks.  “Doable” I say to myself.  We continue up the hill towards Top Digue, CHI’s newest community.  I take us straight to Nola’s house, one of our health agents and a certified nurse midwife.  In a word #Badass.  I knew Rachel was pumped to meet her and I honestly think that she is going to do some great things if we provide her with the assistance she needs.  She’s very bright, has natural leadership skills, and community support #TripleThreat.  Our conversation is as extensive as my creole allows.  So it lasted two minutes of which half of the time was spent in awkward silence #StoryOfMyLife.  Doesn’t matter.  She got the message to come to clinic tomorrow so we’ll call it a win.

I was ready to turn around and head back when a young girl started talking to us.  It was just the usual pleasantries at first, but then she started gesturing around her head and saying words I didn’t know (there are many words that I don’t know).  And then she motioned for us to follow her.  Okie dokie.  We continued down the path and then slipped through a gate into a small, dirt yard.  I about fell over.  Sitting on the ground, naked as the day she was born, was our little girl with hydrocephalus.  Her mother screamed, ran over to me, and gave me a great big hug.  I don’t really know why.  I bent down and picked up little Charles Norline.  She was a giggly as ever.  We stayed there for probably twenty minutes, taking family photos and, most importantly, smiling.  And while it was a reminder of the baby smile I wouldn’t be seeing this trip, the sound of her voice brought back that feeling that me being here is a positive thing.

I’m not ready to walk down the back road, but I may finally be ready to be here.