Bringing health care on foot to women in Haiti
Improving access to rural populations in the poor Caribbean nation
LE BORGNE, Haiti — The white jeep effortlessly plows through the first river, past women holding hands as they delicately balance on the slippery rocks. But faced with a second, wider river, the car bows to the inevitable and stops alongside a gravel shore.
A small medical team of nurses, doctors, and community health workers exits the vehicle. They will walk the rest of the way, over an hour’s journey, wading through four more major rivers, alongside a donkey packed high with medical supplies. Crowds of women will greet them outside a cleaned-out cement home which has been transformed into an ad hoc medical clinic.
A woman in Haiti has a 1 in 80 chance of dying during pregnancy or childbirth, making the Caribbean nation the most dangerous place to be pregnant and give birth in the Western hemisphere. And the country’s child mortality rate rests at about 67 per 1,000 births, placing Haiti slightly below Afghanistan when it comes to untimely deaths of young children under 5.
Lack of infrastructure and limited access to regular health care is common across all of Haiti — and clearly on display with devastating impacts in the northern, rural town of Le Borgne and its surrounding area.
While the grassroots community development organization Haiti Outreach-Pwoje Espwa, also known as H.O.P.E., estimates that 1 in 8 young children will die in the Borgne region, accurate data is harder to obtain in the remote region where time and progress appear to move at a sluggish pace. Borgne connects to the coastal city of Cap Haitien through only one narrow, battered road. Both electricity and clean water sources are virtually nonexistent in the homes of the approximate 80,000 Borgne residents. The average life expectancy hovers at around 56 years.
H.O.P.E. operates a small, efficient 24-hour free hospital across from the local primary school in Borgne, down the road from the town’s condensed center that overlooks the Caribbean Sea. But its mobile clinics serve as an equally crucial lifeline for poor people who may otherwise trek nine hours to reach the clinic. More often than not, these people have gone without regular medical care, giving birth at home or living with the common afflictions of malnutrition and parasite infections.
“The mobile clinic has a very rudimentary layout, but the impact that it has is really meaningful, especially in terms of women’s health,” explained Rose-Marie Chierici, the executive director of H.O.P.E. and a retired professor of anthropology at the State University of New York at Geneseo. “One big challenge is getting people to the hospital. You see these mountains. Imagine that in these mountains there are pregnant women. That is a given. And this woman is in labor and she is having the problem of, ‘What to do?’”
Women sometimes set out for the clinic only once they have gone into labor. Others may be carried down to Borgne on padded doors, torn from the frames of houses. It’s not unheard of that women fall off these doors, or give birth before they reach the hospital.
“It’s something I find, having given birth myself, almost unbelievable,” Chierici said.
The mobile clinics offer a partial remedy to the widespread lack of access to quality health care. Doctors, nurses, and community health workers trained by H.O.P.E. set out at least biweekly on foot, rotating their circuit to reach a range of small mountain towns far from any road.
“The majority of people [here] live without any health care. Nothing. They do not have a way to pay for a doctor and access health care,” said Thony Voltaire, the lead doctor at H.O.P.E.’s hospital, who developed the mobile clinic model in Borgne. “We try to correct the lack of that here with the mobile clinics, which have alleviated the situation and health of the people who are in the remote zones. They have helped to save many lives.”
“It is a very important change. It is a big change,” explained Voltaire, a native of Borgne who himself was born on the side of a road.
The first mobile clinic went out in 2005, though the concept was not scaled up fully until 2010. In 2015, women’s health clinics were added to the mix.
Since 2010, Voltaire has seen a drop in infectious diseases — including among pregnant women. Complications during pregnancy, such as preeclampsia, have lessened. And with the regular practice of referring heavily pregnant women to the hospital, the percentage of women giving birth at home has fallen from about 80 to 50 percent. Part of this progress is due to education and a point system that rewards communities if they refer women to give birth at the hospital.
During a recent visit to the hospital, three pregnant women and a new mother appeared calm, resting in bed and walking the hospital’s hallways at night, waiting for their babies to arrive. One new mother, Julienne Ocean, looked down at her day-old baby girl as she described, through a Creole translator, hemorrhaging during birth at a remote clinic. She was soon brought to Borgne.
"I was not afraid because I knew the doctors would save me."
But the leaders of H.O.P.E. concede the mobile clinics’ limitations, from lack of equipment to regularity.
There’s still a need for permanent outpost clinics, specifically for birthing centers for women, who regularly have five or six children and traditionally turn to local, untrained birthing attendants for assistance at home.
The clinics are also not a constant presence. During the rainy season, towns can become inaccessible to doctors and nurses for several months.
“Sometimes when there is rain, the river rises and the land gets submerged and it can be very difficult for us to cross,” explained Carlos Rame, a H.O.P.E. doctor on site at a recent mobile clinic.
It’s common for Rame, a Haitian doctor trained in the Dominican Republic, to see patients with typhoid and diabetes. Mosquito-borne illnesses, like malaria and zika, are increasingly rare, following H.O.P.E.’s widespread community outreach and education work on clearing still pools of water, and other methods to prevent the spread of mosquitoes.
On a warm Thursday afternoon at a women’s clinic post, women pressed against one another as they lined up to be tested for HIV. The illness affects about 2 percent of the population, and no one will test positive today. People crowded around a visiting nurse, who advised a quiet crowd of patients that the test must be performed routinely.
Inside the house, the doctors, nurses, and community health workers quickly set up different stations — a ticketed system that allowed people to get tested for HIV quickly and anonymously. About four doctors and nurses dispersed to different tables, taking notes on the patients whose blood pressure and throats they checked. And women streamed in and out of a back room to receive annual exams and maternal health checkups. For many of the patients, the clinic is an easy walk from home. Others have still walked several hours to receive care.
The mobile clinics were formed following the quick spread of Haiti’s cholera outbreak in 2010. Voltaire anticipated that the infectious disease would quickly travel north from the capital Port au Prince. It reached Borgne, resulting in about 175 daily cases at the hospital when the disease peaked in 2011 and infected about 350,000 people across the country.
H.O.P.E., then supported by Médecins Sans Frontières, responded by establishing 40 remote oral rehydration stations in the mountains and ramping up its hygiene education work, aided by the growing numbers of locals they have trained as community health workers. The numbers tapered down within three months.
Cholera is still present in Haiti, with nearly 5,000 cases reported last year, but extremely rare in and around Borgne.
“We thought, ‘By the time people reach us, they are already almost dead.’ Those who made it to the hospital were those who live nearby,” said Chierici. “We decided we needed to flip the system, and rather than only expecting people to come, to go out into the countryside.”
There’s a desperate need for more, permanent health infrastructure, but H.O.P.E. has also found success in training local people as midwives and health leaders. They are educated to not discard the local culture, but to help move people, especially women, away from dangerous practices, like sitting over a bucket of hot water with herbs shortly after they give birth.
So far, H.O.P.E. has trained 50 traditional birth attendants and recruited 50 more. Nearly 500 women are now in the “mother’s club,” a group trained to counsel on everything from nutrition to household management and finance. Nearly 700 more people are part of H.O.P.E.’s groups that focus on adult literacy, adolescent work, women’s health, and income generating activities.
At a recent annual meeting all of these women gathered and turned to song to share their lessons.
“There are many signs of danger for pregnant women/ If you recognize these signs in yourself/ Do not stay with arms crossed and do nothing/ You should run to the hospital or the clinic,” the women sang together in Creole, clapping and moving to their beat. “If your feet are swollen and you leak fluids/ Don’t just sit and wait/ Run to the hospital or clinic!”
Part of this coverage was supported by WomenStrong International, a main funder of H.O.P.E. that has funded their mobile clinics and other health training initiatives. However, our coverage remains independent.
Reporting and Media by Amy Lieberman
Production by Kinsey Denney