Poppy Markwell, COM4
I helped organize and participated in the first MUSC student-organized international medical trip. I traveled with a group of 17 College of Medicine students and three attending physicians to help staff rural clinic sites in the Central Plateau Region of Haiti. We worked extensively with local Haitian physicians, pharmacists, community health workers, and translators to bring healthcare services to several Haitian communities. It was interesting to learn how the Haitian healthcare system differs from that of the United States and it was an educational and humbling experience to work with Haitian health professions and work as a team to deliver healthcare services.
To prepare for my trip, I researched the health problems of the community and planned a public health project so I could leave the Haitian community where I would work only a short time with a way to improve their lives even after I left. Since a Nepalese peace keeping troop deployed by the United Nations after the earthquake introduced Vibrio cholerae to Haiti in October 2010, more than 530,000 Haitians have been diagnosed with cholera and more than 7,000 have died. Outbreaks continue in all regions of the country. Cholera is treatable, but few Haitians have access to healthcare for oral rehydration therapy.
Recent studies in laboratories and in Bangladesh have shown that cholera can be prevented by filtering water through fabric such as a cotton sari cloth. In lab, four layers of sari cloth filtered out greater than 99% of cholera and two or three layers were found to be equally effective (Huq, 1996). The pore size is approximately 20 micrometers if folded 4 times (Colwell, 2002). This pore size is sufficient to remove effectively all Vibrio cholera attached to zooplankton and particulates. Community wide, this intervention reduced the incidence of cholera by 48%. Follow-up studies showed that this intervention was continued by 31% of the women of Bangladesh five years after the project ended. The study also concluded that it is highly probable that the behavior diffused to other villagers not enrolled in the study (Huq, 2010). Haiti is similar to Bangladesh in that both are poor, have toxigenic cholera species in the surface water supply, and boiling water before drinking is not a practical solution since fuel wood is a precious commodity. The efficacy, low cost, acceptance, compliance, and sustainability of the practice of filtering water through a cotton cloth to prevent cholera makes this a behavior that I wanted to teach to the people of Haiti.
My project idea was to distribute cotton t-shirts to Haitians in rural villages who did not have access to a water system or a deep water well and giving them directions to fold the shirt and filter their drinking water through it to prevent cholera. With the community health worker, translator, local physician, and the rest of my group’s help, I was able to teach 1,200 people in Marmont, LaHoye, Cayes Epin, Savane Moise, and Tierra Muscady to filter their water through a t-shirt if they were in a situation where no other purification system was in place. I conducted group demonstrations of this filtration method at community health meetings, schools, churches, and clinics. I emphasized the need to fold the shirt twice before pouring water though and also the need to hang the shirt out in the sun to dry for at least two hours afterwards to decontaminate it. The people were very appreciative of being taught something and as a group they clapped twice to show appreciation of the lesson. Over the week, I was able to distribute 200 t-shirts and 1,000 flyers with filtration instructions. The community health worker and local physician were also very appreciative for the knowledge and agreed that it is an easy and cheap technique that they believe will be sustainable in their community.
Though this experience I learned about the importance of community health workers in the distribution of health information to rural Haitian villages. These workers travel to villages educating Haitian adults on a variety of public health topics such as how to clean water, disposal of waste, breastfeeding, and cooking hygiene. If people attend these teaching sessions, they get points, which can be redeemed for items such as water purification tablets and even vouchers for their children to attend school for free. The community health worker we worked with was very good at her job. She knew the people of the town well and it was obvious that she was well respected. I also learned about the health needs of the community. Most people knew that it is important to filter water and some even knew that “microbes” caused diarrhea, but almost no one currently had Chlorox, Aquatab, or any other way to chemically purify their water. In Marmont, a mission group from Texas built the town a deep-water well, but it had broken and the group never returned. I learned that now, the entire town uses a single surface water supply and only one family I met chemically treats their water.
I also had the opportunity to staff clinics in five different villages where no one owned a car, and very few had motorcycles or horses. Our going to these rural sites allowed Haitians access to healthcare services without having to spend an entire day walking to an established clinic or hospital. We held clinic in schools, churches, homes, and outdoors. At one village, we were the first clinic to visit in more than a year. Most of the other sites had not seen a physician in six months. We were only allowed to distribute one month of medications at a time, so it is challenging to help patients manage their hypertension or acid reflux. Since the town saw a doctor infrequently, everyone in the town wanted to be seen regardless if they were sick. Our visit also provided the town with entertainment, so everyone would sit around to watch us examine their neighbors.
We worked closely with a pharmacist who brought a small pharmacy with her to all of our clinic sites. All drugs were provided to patients free of charge by the Project Medishare organization. Working with the pharmacist was very challenging and communication was difficult. Both the pharmacy and the clinic were very busy at all times. Clinicians were not told when the supply of certain drugs was running low, so patients might be sent home without a drug. We also learned that the role of pharmacists is different in Haiti than in the US. In Haiti, the pharmacist simply hands a packet of pills to the patient without providing any type of education about what the pill is for or how to take it. There were not even written instructions provided to the patient, I assume since the literacy rate especially among adults is extremely low. Even though we spoke different languages and struggled to communicate with the pharmacist on most things, it was helpful that we both understood prescription abbreviations such as BID. By the end of the week, we improved patient care by working more effectively with the pharmacy. We would explain to the patient more about the drugs we were prescribing, and when there was a patient we were extremely worried about, we walked with the patient to the pharmacy to make sure they received the correct prescription.
We also worked closely with Haitian translators. They were crucial to our providing medical care to Haitians, but it was also a challenge. The translators lived in the same area as the patient and so confidentiality was in issue. At one point we treated the girlfriend and grandmother of a translator without even knowing the relationship until later. Another challenge was the translation itself. At MUSC we are supposed to talk directly to the patient and the translation is made word by word. Our translators in Haiti would have an entire conversation with the patient and then only translate one summary statement into English. Through this experience I learned the importance of being able to communicate directly with patients in their native language. Speaking the same language is an essential part of an empathetic patient-provider relationship and is the only way to be certain the patient understands what was said. For example, I asked the translator to ask the patient if she understood and the translator would only repeat, “she understands.” I plan to practice international medical work, and I will make sure I am fluent in the native language where I work so that I will be able to better communicate with my patients.
In summary, my trip to Haiti was an eye-opening experience. I learned about the healthcare needs and infrastructure of Haiti. I was able to work closely with attending physicians and teach pre-clinical medical students. I learned the importance of being flexible and to incorporate cultural traditions into medical care. When we return to Haiti next year, we would like to have a pharmacy student on the trip to improve patient care and educate the pharmacist about the medications she is distributing. The baseline medical knowledge of the entire Haitian population is very poor. The community health worker has a big job to teach everyone about health issues. As foreign health workers, I believe we can have the biggest impact by expanding Haitian health workers knowledge because they are the people committed to serving their community and are there longer than a week. It is also important to teach patients about their medications and health problems in a way that they understand. They do not have a pharmacy from which they can get their medicines every month. They can go to the weekly town market, try to find someone selling medicines, and purchase a pill if they have the money; but foremost they need to understand what medicine to take and the importance of taking it. I look forward to returning to the Central Plateau region next year to follow-up with my cholera prevention project and staff the same clinics. Next year, we hope to be more prepared with additional professions.