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A Tough Pond to Fish

People who toil to improve Haiti's health-care system, as Nate Nickerson, A78, has done for years, must be content with small victories

Driving through Cap-Haitien, Haiti’s largest city in the north, six months after the earthquake, it’s easy to forget for a moment that a city in rubble lies a mere seventy miles away. The World Cup is on, and in an hour the Brazil vs. Holland soccer match will begin. At eight a.m., people dressed in yellow and green Brazil jerseys are lugging huge TV sets onto sidewalks so that entire neighborhoods can watch together. Brazil and Argentina are the most popular teams. When I ask Edy, my genial translator and driver, why those teams are favored, he smiles broadly. “Because they always win,” he says, “and Haiti wants to go with a winner.”

I don’t know if the irony of those words registers with him. It would be hard to think of a country that the rest of the world sees as a bigger loser than Haiti. Even before the January 2010 earthquake, its extreme poverty, near-constant political upheaval, AIDS, severe deforestation, and coastline that is regularly battered by storms earned Haiti the ignominious title of poorest country in the Western Hemisphere. The quake only compounded the country’s problems, leaving roughly 10 percent of the population homeless, the government decimated, and conditions ripe for mass disease outbreaks, such as the cholera epidemic that began last October and killed thousands.

Still, on a sultry early morning in July, the streets are humming with laughter and music, and it’s easy to see why people like Nate Nickerson, A78, A06P, believe Haiti is worth saving.

Ten years ago, Nickerson, a nurse practitioner with a penchant for difficult projects, rounded up a group of concerned citizens, some of them health professionals, some not, in Portland, Maine, to consider ways to improve health care in Haiti. But their concept of how to help would be radically different from the prevailing development aid model. Rather than starting a separate effort run by Americans or sending teams of doctors and nurses to provide hands-on care, the Maine group decided to beef up Haiti’s existing public health system in an effort to get it running better.

“Haiti has a very broken system, so the tendency for outside agencies is to work around it rather than from within it,” says the soft-spoken Nickerson, who spent twenty-five years working in health care for the homeless before setting his sights on Haiti. “Going in and building something that’s sustainable, that Haitians own, is a laborious brick-by-brick approach that most people don’t have time for. It’s not glamorous or immediate, but we weren’t a quick-fix group,” he says.

They called the organization Konbit Sante: konbit, the Haitian Creole word for “working together,” and sante for “health.”

Wiry and in his fifties, Nickerson wears a clipped grey beard and has striking pale blue eyes. He speaks slowly and deliberately as he recounts the trajectory of a life that took him from Bangor, Maine, where he grew up on an Army base, the son of a career military man, to majoring in psychology at Tufts to working with the homeless and then, after nursing school, to tending critically ill patients at Maine Medical Center. “So I had experience with appreciating the small victories in this big arena of defeat,” he says with a soft laugh.

But Nickerson is being modest about Konbit Sante’s successes. Maternal deaths in Cap-Haitien due to complications of pregnancy have fallen dramatically, and since 2000, when Konbit Sante was founded, condom use—key to preventing AIDS—has tripled. Cap-Haitien's public hospital, meanwhile, has gone from being an institution run on petty cash and paper record-keeping to one that was functional enough to serve as the primary medical facility in the north for earthquake victims when the hospitals in Port-au-Prince had reached capacity.

As Konbit Sante’s executive director, Nickerson splits his time between two cities on the Atlantic: Portland and Cap-Haitien. In the latter locale, he works with Haitian doctors and administrators to identify areas for improvement, then figures out how to obtain and direct supplies, medical volunteers, and money. (Eighty percent of Konbit Sante’s funding comes from private donations. The remainder comes from foundations such as USAID and Oxfam.) Nickerson objects to the notion that he is in any way “teaching” his Haitian counterparts a better way to do things, and he also has contempt for the trite expressions used to characterize the relationship between the recipient and the provider of aid.

“You know the saying that goes, ‘Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime’?” Nickerson says. “I find that offensive. I find it condescending. The thing that people don’t understand is, Haiti is a really tough pond to fish.” To underscore his point, he has arranged for me and Tufts’ chief photographer, Alonso Nichols, to spend a day with Youseline Telemaque, an obstetrician-gynecologist and one of thirty-four Haitian staffers, medical and nonmedical, funded by Konbit Sante. It is a day we will not soon forget.

Konbit Sante’s base of operations in Haiti is Hôpital Universitaire Justinien, in Cap-Haitien. When Cap-Haitien was still a port of call for cruise ships, before the scourge of AIDS and the Duvalier era wiped Haiti off the tourist map, the town was a major attraction. Traces of its former charm remain, in its cobblestone alleyways and faded pastel buildings, but today “Cap” is a chaotic, dust-blown city of 800,000 people. Justinian Hospital, perched on a hill and surrounded by flowering bougainvillea trees, is a 250-bed facility meant to serve this population. With its white colonial façade and imposing lime-green gate, it looms over the city like a ghostly mirage.

A grand staircase takes us to the entrance of the hospital, and it is here we meet Dr. Telemaque. She has on a hot-pink scrub top and beams a wide smile that reveals a tiny gap between her front teeth. After brief introductions, she hands us a plastic grocery bag filled with clothes and instructs us to go into the hospital and change into scrubs and hair nets: Alonso and I are going to be observing her in surgery.

Once we are inside the Justinian compound, the beauty of its exterior fades. We walk through open-air wards where flypaper hangs thick with blackflies. Here, control of infectious diseases is difficult. The only public bathrooms are pit latrines. There is no drinkable water in most of the hospital, and electrical surges damage delicate medical equipment and pose a danger to patients and staff. The tropical humidity takes a toll as well. Metal tables are rusting and ceilings are stained with mildew.

After we change, we rejoin Telemaque as she scrubs for surgery and I take what will be a rare opportunity to talk to her when she’s not on the go. “What I appreciate about Konbit Sante is they don’t come with a program,” she says in Creole-inflected English. “They use your way to resolve the problem.” She adds: “Working for Konbit Sante is not miserable.”

Many Haitians are skeptical of outside organizations trying to improve their country. Long before the earthquake triggered a massive international relief effort, Haiti relied on foreign aid, for everything from food to medical care. But Haitians have not always been included in the decision-making process about how best to allocate that aid.

A case in point is the earthquake response. While visiting medical teams can perform life-saving operations, they often come into a host country without knowing whether the infrastructure is in place to provide patients with adequate follow-up care. This was evident when Alonso and I visited the next town over from Cap-Haitien, where medical tent camps were crammed with earthquake victims who had been languishing in U.S. Army–issued cots for six months.

Patients with minor injuries developed complications. Those fitted with elaborate devices to set femurs now faced massive infection. People who had been laid up for months had bedsores down to the bone. Physical therapists worried about patients not getting the rehabilitation they needed to walk again.

As Nickerson points out, humanitarian aid to Haiti has followed the same model as the medical one. American corporations have gotten tax breaks and good PR even when they donated goods that were not needed or wanted. “Many donations after the earthquake just became a trash burden,” Nickerson says. “Humanitarian aid was blocked at the airport while pallets of Pop-Tarts were coming in.”

Nickerson and the other founders of Konbit Sante were “dissatisfied with the mission experience,” he says. “Building something that is sustainable is slow work, but it is an investment for the long haul.”

Konbit Sante’s version of earthquake response has been to raise $400,000 in cash donations and help Justinian Hospital provide long-term care to victims by building an orthopedic rehabilitation facility at the hospital, adding a nurse to provide specialized wound care, and funding local organizations that provide counseling services to traumatized survivors, among many other things.

Now prepped for surgery, Telemaque leads Alonso and me to one of the hospital’s three operating rooms, where she will supervise two male residents performing uterine fibroid surgery on a forty-five-year-old woman. “We don’t have enough space to receive all the patients,” says Telemaque. Because the procedure is elective, “she waited for two years to have surgery. She was suffering.”

Surgery starts at nine a.m., the same time as the soccer match. Periodically nurses burst in to report World Cup scores. In the operating room, the wooden door has swollen on its hinges and doesn’t quite fit the doorjamb. Every time someone comes in, the bottom scrapes across the linoleum floor. When the team is ready to stitch up the patient, Telemaque asks me to open a package of sutures and hand them to her. Nervous, I fumble with the package. “It’s not easy?” she says, pointing a bloody, gloved finger at the table of packages. “Try another one!” By ten thirty, the team has removed a fibroid the size of a softball.

Now it is time for Telemaque to do rounds. In the female ward, a twenty-four-year old woman in a tattered pink nightgown and cornrows is led to a dim private exam room. She is in pain and walks unsteadily with the aid of a nurse, carrying her own IV bag, which she tosses on the concrete floor after lying down on the room's only cot. Last week she was referred to Justinian by the Fort Saint Michel Health Center, a nearby clinic where Konbit Sante also operates. Eight months into her pregnancy, a membrane rupture in her uterus has led to infection and loss of amniotic fluid. The baby is still alive, but the ultrasound shows her womb is practically dry.

“There is no liquid,” says Telemaque. The baby is not floating in a warm bath but rigidly suspended in the woman’s womb. Its chances of survival are poor.

Giving birth is a dangerous proposition in Haiti, simply because few women can afford to see a doctor during their pregnancy. Out of 100,000 live births, 670 Haitian women died of pregnancy-related causes in 2006, according to a UNICEF report. In the United States, the number of women who died in pregnancy was eleven.

A critical part of Konbit Sante’s program is its funding of agents de sante, outreach workers who have enough medical training to recognize obstetric emergencies and other problems and do triage and referral. They travel to villages and slums where people wouldn’t otherwise have access to health care—as is the case for the majority of Haitians.

Telemaque has trained fifty of these agents. Maternal deaths from complications of pregnancy have dropped from one hundred fifty a year to just three, thanks to their intervention. During a recent pregnancy clinic in an outlying village, agents de sante saw thirty-four women and identified critical problems in three, whom they referred to doctors for follow-up.

After we change back into street clothes, Edy, our translator, leads us down a corridor and opens the door of a small room where Telemaque is standing in front of a young woman, knees raised and legs spread wide apart. “She went to a charlatan,” says Telemaque, using the Haitian term for backstreet abortionist. “So now I have to fix it.” In this overwhelmingly Catholic country, doctors are allowed only to correct botched abortions, not perform the procedure.

The repair is so quick and the doctor’s time at such a premium that the woman hasn’t even been invited to take her shoes off. Her black platform shoes, which lace delicately up her ankles, sit absurdly in stirrups.

Feeling like intruders, Alonso and I hurry out of the room. But something compels me to go back in. The procedure is done without anesthetic, and the woman, eyes closed tight, has been moaning and reaching for her crotch. A nurse repeatedly takes her hand and places it by her side, but does not attempt to comfort her. She is too busy assisting the doctor.

I look at Telemaque and ask, “Can I hold her hand?”

“Yes!” Telemaque snaps, as if this should have been self-evident.

Because her uterus was badly damaged during the botched procedure, the woman will need a hysterectomy. She is eighteen years old and the child she has just aborted would have been her first.

Teen pregnancy rates in Haiti are high, and some forty percent of all pregnancies are unwanted, according to the World Health Organization. I walk with Telemaque as she finishes her rounds. “Konbit Sante attacks the health problem,” she tells me. “But there are many others—economic, social. You will see the reality today in the field.”

We pile into Edy’s pickup truck to leave for the clinic at Fort Saint Michel, one of Cap-Haitien’s poorest neighborhoods. There Telemaque will conduct her monthly training of outreach agents. She will take three of them with her to give a talk on reproductive health in the slum known as Bas Aviation.

We leave the hospital compound for the chaos of the streets, where throngs of people are cheering, yelling, whizzing by on motorcycles, waving enormous palm fronds. I realize the soccer match has ended, and I assume Brazil has won, but Edy corrects me. Holland is the winner.

“Holland?” I say. “Then why are people celebrating?”

Edy smiles. “These are the Argentina fans who are celebrating because Brazil has lost.”

A short drive takes us to “the field” and we climb out of the truck where the dirt road ends. The landscape is post-apocalyptic. There is not a tree, not a bird, not a hint of color in sight. The dwellings appear to be made of mud. Plastic bags and flattened pieces of cardboard shift and flap up from the earth. I learn later that the slum is literally built on trash. Nickerson tells me that the residents have paid truckers a small fee to fill in the land with refuse in order to prevent rising water from flooding their tin-roof dwellings.

We walk single file across a causeway, maybe a foot wide, that has been built up with old tires, dirt, and trash to hold back sewage-contaminated pools of standing water. My travels have covered roughly a third of Africa—the whole of Southern and East Africa—and I have never seen a slum like this one. I pause for a second on the mounds of trash and watch Telemaque walking in front of me. With a large bag of donated baby clothes slung over her shoulder and her hot-pink top, she is the one spot of color. Like a tropical Santa Claus, she disappears into the sea of brown.

We enter the church, a tin-roof shack with a mud floor and slats for seats, while one of the agents de sante, a large woman with a bullhorn, stands outside and announces the talk. Quickly, the church fills up with about fifty people, mostly women and children and a handful of men. Telemaque uses the church altar, a lopsided wooden table covered with a pink doily, to place her props—anatomy books, buckets of condoms, and two large wooden penises.

“Bon soir,” Telemaque begins. After a short introduction, she asks for a volunteer to demonstrate the proper way to put on a condom, using the wooden penis. A young man in a green T-shirt emblazoned with “Republica Dominicana” gamely approaches the altar to the rollicking laughter of the crowd.

AIDS is the leading cause of death in Haiti, where rates of infection are the highest in the world outside of Africa. Yet Haiti has made remarkable progress in fighting the disease. The percentage of pregnant women who test HIV positive fell by half from 1993 to 2003, according to the latest figures from UNAIDS, and in urban areas, rates dropped from 9.4 percent to 3.7 percent during that period. The proportion of men who reported using condoms was thirty-five percent in 2005, up from twenty percent in 2000. This success is due mostly to the outreach efforts of health-care workers like those employed by Konbit Sante.

As the talk goes on, Edy sits behind me and translates the doctor’s words into my ear, careful not to disturb the people squeezed into the pew beside me. It is a fairly standard reproductive health talk until Telemaque announces, “Now we are going to talk about how to make love.”

There is a hush over the crowd as she talks about love in marriage, admonishing husbands to make sure their wives are “in the mood” before initiating sex. Rates of cervical cancer in Haiti are among the highest in the world, partly due to vaginal injury that makes transmission of disease more likely. If a woman is not aroused, “sex will be painful,” says Telemaque. “So if you want to make love, you need to prepare early. You need to be nice with your wife since the morning.” In her DayGlo top at the front of the mud-brick church, Telemaque is a maestro, in complete control of her audience. The mood changes from uproarious laughter to total stillness, from ribald to profound. A white American doctor could never have pulled this off.

As we leave the church, a trail of children padding behind us on the trash causeway in single file, I ask Telemaque if she’s seen any change in peoples’ behavior since she started these talks two months ago. “Oh, many, many changes,” she says. “They are using condoms now.” After she finishes speaking, she invites people to come up to the altar to take away free condoms. While there is no guarantee they will be used, at the end of the talk, they are all gone.

The earthquake might have drawn the world’s attention to Haiti’s problems, might have given them added urgency. Yet considering how outsiders have responded in the past—parachuting in and then pulling out, or pledging money and then not paying up—Nate Nickerson, Konbit Sante’s founder, is not counting on imported solutions.

His money, and that of Konbit Sante, is on people like Youseline Telemaque, Haitians with unusual savvy and perseverance. “If you have a decent system and the wrong people,” Nickerson says, “it’s not going to work. If you have a really awful system but you have some of the right people, they’re going to make some things work anyway, in spite of everything.” Then he adds: “Things will have to change in Haiti. But it will have to be their solution, not ours.”

At the end of our day with Telemaque, Edy’s pickup truck swerves into the Fort Saint Michel clinic and the doctor gets out of the cab and is halfway across the courtyard before I realize we won’t see her again. I stand up in the bed of the pickup and shout after her, “Thank you for giving us so much of your time, Dr. Telemaque—even on such a busy day!”

Telemaque turns around. The dust has picked up again. It swirls up around her, but she is still visible in her pink top, and the laughter, the sheer amusement, in her voice is unmistakable as she calls back, “Today was not a busy day.”

LESLIE MACMILLAN is a freelance writer in Boston. She has written for the Associated Press, the Boston Globe, and the Boston Herald, and her short fiction and book reviews have been published in the Gettysburg Review, the Charles River Review, and the Harvard Review.

  © 2011 Tufts University Tufts Publications, 80 George St., Medford, MA 02155