Yesterday (Monday) was Teresa’s and my first day to go out on the mobile clinic. We went to an area called Ceramon and set up our clinic in a building established on a concrete slab with corrugated metal roofing. It was quite an adventure to get there and back in the Land Rover! Due to several days of recent heavy rainfall, the roads were even less accessible than usual. Getting out of the town of Hinche was also an issue, as police were diverting traffic due to some sort of parade of schoolchildren through the streets. We ended up going down a back road that was barely wide enough for our “machine” (Creole for vehicle) and the crowds of people and their animals and motorcycles that were arriving for market. Driving is an art form in Haiti, and the horn is a well-utilized form of communication. Drivers use it to express anger or frustration at other drivers, as we do in the States, but it is also used whenever going around a corner or over a hill when the people/animals/vehicles that might be ahead would not be able to see you coming. People often drive in the middle of the road, including right down the middle of the “do not cross” line (when it happens to be painted on the road). Our driver quipped that if he didn’t have a horn, he would kill people every day! The horn is also used to claim the right of way (which seems to follow the same rules as I saw in Colombia, where the largest of the vehicles arriving gets the right of way, regardless of who arrived first; a Jeep will always claim the right to go before a motorcycle, for example).
So the roads were sloppy with mud, and the rains had carved deep channels and ruts in parts of the road out to our remote destination. It was a very bumpy drive, and I found myself turning a little green by the end. We had to snuggle up really close to some nearby trees to avoid the most treacherous spots on the road, and our driver would quickly warn us to close our windows so the tree branches wouldn’t reach inside and slap us in the face! (I still ended up with bits of leaves all over my backpack and clothing!) But we made it without getting stuck in a rut or a deep mud puddle.
It took a bit to set up the clinic from the suitcases of supplies we brought along. First was a song and a prayer in Creole, followed by an educational session led by one of the midwives. She asked everyone who had been there before to name the warning signs of pregnancy problems, and they remembered everything except decreased fetal movement. She then used a poster to teach them about nutrition. After that, charts were handed out to the 20 women who had been there before, and the 5 people who were there for their OB intake and physical exam got new charts established.
Teresa and I helped with vital signs at first, all of which took place on the outside porch, with the women sitting on benches. Vitals included temperature, respirations, BP, pulse, weight (which happened on an analog scale which we had a bit of trouble finding a level part of the concrete porch to place it on so we could get accurate readings), and one that is not part of my vitals in the States but is important here: upper arm circumference in centimeters, which is a good approximation of nutritional status. I helped mostly with taking weights, climbing down on the ground in front of the woman on the scale to read the number upside down and translate the reading from the red needle into a French number which I called out to my translator who wrote it in the patient’s chart. Our translators were a lot more involved in the clinic than they would be in the States–I even saw one of them (a young mom herself, with a 6-month-old son at home) helping a mother of a newborn position her baby to breastfeed.
After vitals, it was time for the prenatal exams, which happened inside the building. The exam table for speculum exams was a massage table covered in a sheet and a piece of plastic shower curtain (more for the muddy feet that would be planted on the corners of the table, because there were no stirrups, and less for an impermeable barrier underneath the women, because they all had their skirts underneath them; the sheet was not changed between exams). The midwife performing pelvic exams had a wonderful system of not contaminating the specula: She brought them in a plastic tub, all wrapped in a clean towel. She had a pair of ring forceps that she kept on the lid of the tub, and whenever she needed a speculum, she used the ring forceps to push back the towel and grab a clean speculum and cover up the others still in the bin. She collected the used specs (most of which were the pediatric size today, as we had a lot of teenage primips) on the lid of a bucket to be transferred later into a container to be taken home and sterilized.
The exams happened behind a curtain that separated the exam table from the outside, but there was no other curtain dividing the exam table from the side room where two other Haitian midwives plus Teresa took histories, gave out medications (folic acid, a prenatal vitamin, and iron tablets to every woman; anemia is endemic here), and Teresa did belly checks (Leopold’s for fetal position, fundal height, and fetal heart tones). So, the women getting speculum exams (covered with a lavender sheet as a drape) were having conversations with the women waiting in line to hear their baby’s heartbeat and to get their medications for the next month. Nobody seemed fazed by this, and indeed, for several of the girls this was their first pelvic exam and the others in the room helped to talk them through it, encouraging them to relax their legs, or laughing with them at what a strange feeling it was.
Somehow, squatting on my haunches in this small, dark cement building for over an hour, lit only by a headlamp and whatever sun streamed in through the windows, helping a midwife perform gonorrhea and chlamydia tests (with only a massage table and a rickety chair as exam furniture) was a better leg workout than I’ve had in recent memory. (My quads are speaking their mind this morning.) Far more rewarding, too! I learned how to perform the rapid GC/CT tests, which required separate swabs, tubes, test media, number of drops, number of times of swirling the swab in the test media, number of minutes to wait (if any) prior to adding the media to the cassette (which looked like the pregnancy tests we use at my office), and number of minutes to wait to read the results. I counted out the drops of test media and swirls of the swab in Creole (thank goodness I paid attention in French class over a decade ago–I still remember how to count!). It was interesting that the packets said “not for use in the United States”–I’m not sure why that is, except that we have a system of labs that can perform the tests for us, and that infrastructure does not exist in Haiti.
After all of the pregnant women and the three postpartum clients and their babies had been evaluated, we packed up our supplies back into their suitcases, tied them back onto the top of the Land Cruiser along with the benches the clients sat on while waiting, and started the bumpy journey back to our home base.
Today, bright and early, we got up to prepare for our separate morning and early afternoon projects. I was in the classroom with the 30 new midwifery students, and Teresa went to the hospital with a translator where she worked with a few people in labor, including people who were being induced preterm with pre-eclampsia.
My role in the class was to teach GTPAL, which is a system of categorizing pregnancy numbers and outcomes. The acronym in Creole is a little different, GPTPAV, standing for gravida (total number of pregnancies), para (number of births after 20 weeks), term (births at or after 37 weeks), preterm (births from 20-37 weeks), abortions/miscarriages (prior to 20 weeks), and number of living children (enfants vivants in French). The students, for the most part, listened carefully and one asked 95% of the questions in class. She tried to stump me with a great hypothetical question: if a woman was pregnant with twins, and she delivered the first twin at 11:59 p.m. on week 36+6, and then had the second twin 10 minutes later, at 37 weeks exactly, and a twin birth only counts as one in the “para” category (because it is one single pregnancy that is ending, and we are not counting the number of babies until the last category), then which slot do you put it into? Term or preterm? I heard this question explained to me through my fabulous interpreter, and I loved the question and its asker dearly. (The long answer I gave her is, it depends, and you get to use your clinical judgment, and thankfully situations like this don’t happen super often, and when you are interviewing a woman about her pregnancy and birth history, she might not know the exact number of weeks she was when she gave birth, and logically we know that ten minutes’ difference doesn’t make much of a difference in terms of whether a baby is term or preterm, so use your clinical judgment in whether the babies seem term or preterm if you have to decide.)
I also taught how to determine due date based on factors other than last menstrual period. I told them the story of my own birth, where my mom was breastfeeding my 6-month-old sister when she got pregnant with me, and had not had a period yet so had no LMP to go off of. Ultrasound dating was similarly not available, especially in rural Colombia. She had a scheduled repeat c-section (I told the students how I was born via surgery during a power outage in Bogota, and the surgeon continued by flashlight–blackouts are quite common here, and they all looked at each other in surprise that this white midwife would have a birth story that they could relate to!), and when the doctor pulled me out, he noted in my birth record that I looked to be about 36 weeks’ gestation. I weighed just a little over 2.5 kilos at birth (I was a tiny little peanut!). They loved this story and I think it helped to underscore how you need to use all of the available data to make the best estimate of due date possible, because otherwise you might cause problems further down the line.
Teresa has her own stories from her time in the hospital today (her close Doppler monitoring of a mom who was being induced for pre-eclampsia at 35+ weeks, and noticing that the baby was having late decels down to the 60s-80s after every contraction, and her insistence that the baby was not doing well, likely encouraged the staff to move towards a cesarean birth sooner than they otherwise would have, and may well have saved this baby’s life, if indeed the baby survived its birth–I will check on them tomorrow), and I will let her tell those in as much details as she desires to share.
After returning from the hospital, and after my class was over, we ate a quick lunch of rice and beans and vegetables, and then hopped onto a moto-taxi to spend a few hours at Azil, a feeding center for starving children and a hospice center run by the Sisters of Charity (Mother Teresa’s order). The nuns there wear the traditional white robe and head cover with blue stripes. Teresa and I found our way upstairs to a series of connected rooms on the second floor of the compound. About thirty or forty toddlers and young children sat in small plastic chairs against the walls in the hallway, having just eaten their 3:00 meal (likely protein porridge). There was a mixture of emaciated-appearing children and those who were extremely bloated with huge, round, firm bellies (indications of kwashiorkor, or protein calorie malnutrition). Some were so edematous that their eyes were almost swollen shut. The children were all sitting quietly and patiently in their chairs in the hallway, which is atypical behavior for children this age but common in institutionalized children. Most of these kids had families who had brought them here for care and feeding for a temporary period of time, and once they were well again, they would return home. The families are allowed to visit once per week on Mondays, and the children who are well enough return home on those days. This being Tuesday, new children were being brought in, and they were all lined up in chairs waiting for an examination by the doctor. Some of them had wild looks of confusion in their huge eyes.
We moved on into the room with the youngest babies and sickest children. About twenty old wire cribs filled the room in rows. Each crib was lined with a plastic square covered in a cloth the size of a pillowcase, for easy changing throughout the day when the babies wet through the cloth diapers most of them wore without plastic covers (though a few tiny babies were in huge disposable diapers many sizes too big), or when they had diarrhea and got their clothes and sheets dirty. Several of the babies had thick, chesty coughs. The nuns invited us to sit down in short chairs they pulled aside for us, and pointed towards the cribs encouraging us to pick up a baby to cuddle. We each scooped up a little one and sat down. The first baby Teresa held was somewhere between nine and 18 months old (difficult to guess because of the malnutrition), and she kept trying to nurse at Teresa’s breasts. She appeared blind with some cognitive and motor delays, and she was covered in burn scars. It was heartbreaking. I held several babies, and when one fell asleep, I would put her down and pick up another. I held a four-year-old girl named Marielil the longest. She was the size of a young toddler, and she reached up her rail-thin arms to me from her chair and begged to be held. When I cuddled her, she kept calling me “Mama, Papa,” and when it came time to put her down, she would not stop crying. Walking away from her in her crib, reaching out for me with tears running down her cheeks, nearly ripped my heart out of my chest. Teresa and I also both held a young infant who seemed to be less than a month old.
There was minimal stimulation in the room, and some serious attachment issues. A lot of the babies didn’t want to be touched or picked up when I offered, though one enjoyed playing games with me (copying facial expressions, and giggling hysterically when I told her my name in Creole–I guess she didn’t expect the blan to speak her language!) but refused to let me pick her up, and I didn’t push it.
There were no toys in the cribs, but there were a random assortment of toys and religious artifacts on the walls, including a shelf with a statue of the Virgin Mary beside one of those giant plastic baby bottles used to give baby shower favors in. Curious.
I am not sure how I will go to sleep tonight thinking of that little girl in her crib begging me to come back for her. I have so many feelings about the experience. Those babies are there because of poverty, malnutrition, disease, because of political corruption and historical occupation of their country, because of war and greed, because of everything that is at the root of all of the problems in the country. I know there are such babies in Seattle, as well. This is not an isolated problem. But to see about 80 babies and young children separated from their families for weeks to months at a time during critical periods in their development is just heartbreaking. And the problem is so much bigger than anything I could possibly to do fix it. So I go, and I bear witness, and I get dirty, and I snuggle the hell out of those babies, and I leave when I must, but I leave changed at a molecular level. I cannot unsee what I saw there. Some of those babies will die, and some will survive and return home to families who cannot feed them food that helps their minds and bodies grow, and the cycle may repeat itself.
I had such a strong sense of being in a place when Teresa and I were on the motorcycle on our way to Azil. I saw the beautiful landscape in front of me, felt the breeze on my face, held tightly to the waist of the moto driver and felt Teresa holding tightly to me, saw the people and the goats and pigs and chickens wandering the streets, felt every bump as we drove over it, and noticed the warmth of the sun causing hot beads of sweat to trickle down my back. I was so very present, so very HERE. It is a moment captured in my memory that I plan to return to again and again.
So much of what is here is not up to me to change. I had another profound moment in the classroom this morning, sweating bullets in front of the class. I realized in a deep way that I was here for them, for the students who will become midwives and will scatter throughout their country and do more good here than I could ever hope to do. I am here to support this program, whose mission is to make more midwives for Haiti. I will go back home in 12 days, and I will continue this mission long after I return to my own practice with my own patients in my own hospital where I do not have to bring whatever equipment I need for that day.
Tomorrow, though, I will spend my first day at the hospital. Anything I plan to want to use, I need to bring. I packed a backpack and a fanny pack full of supplies. I am impressed with how much I could fit into a medium-sized fanny pack! From memory, I know I had the following in there:
- A doppler
- Doppler gel
- Several pairs of sterile gloves
- Sterile lube in packets
- A blood pressure cuff
- A stethoscope
- A full-sized bottle of Purell (as water for handwashing is unpredictable)
- Misoprostol tablets in a ziplock baggie in case of hemorrhage
- A bottle of lidocaine
- Suture packets
- A couple of needles and syringes
- Tubes of erythromycin eye ointment
- A cord clamp
- A watch
- Alcohol swabs
- Three drapes to go under women for deliveries (cut from unused delivery gowns)
- A gestational wheel
- A tape measure
- Some cash (a $5 and a few $1s)
All of this fit into my fanny pack! In addition, in my backpack, I have some blankets, a breast pump I assembled yesterday from random pieces of donated pump parts (to take to the woman who delivered preterm by cesarean section today), a box of gloves, and a number of other supplies.
I am nervous, because I don’t know what I will face or if I will know what to do. But I believe in myself, in my skills, in my knowledge, in my ability to stay present in intense situations. I know that much of what I will encounter will be outside of my control. But what I can offer, I will give wholeheartedly.
I feel like that list of items in a small bag is a metaphor for how this trip is “packing it all in.” I am cramming so many different experiences into such a short period of time, wedging them down, to be lived now and accessed later as memories that will serve me for a lifetime.
I have no photos to share today; it seemed most respectful to the children and the nuns not to document our presence there, and photos are not allowed in the hospital compound. But my heart is full of images that it will never forget, and hopefully I have transmitted some of them to you. They say a picture is worth a thousand words, so hopefully these 3500 or so words will give you a few pictures’ worth.
If not, you might just have to come here and see it for yourself.