Women's Health with Some Vinegar on the Side

Cervical cancer is a major problem in Haiti. Of all the countries in the LAC (Latin America and Caribbean) region, Haiti has the largest number of women getting the disease each year, estimated at 84 new cases per 100,000 women (versus 8 in North America). This form of cancer is the primary cause of cancer deaths among women in Haiti (64% of cancer deaths) and is highly preventable. While methods for prevention include reducing the transmission of HPV (human papilloma virus, some strains of which put women at high risk for cervical cancer), another important measure is screening for early signs of cervical cancer.

In the US, this routine screening might happen via a PAP smear. However, PAP tests are not feasible for most of Haiti’s women. One of my colleagues explained the vast resources required: You need a doctor or nurse to do the PAP test. The cells collected during the test must be taken to a laboratory. (Note that (a) the woman must bring her cells to the lab herself and (b) all the labs are in Port-au-Prince.) The lab results must then be interpreted by a specially trained biologist: a cytologist. (In Haiti, there are an estimated 8 cytologists.) After that, the woman needs to find a doctor to provide any needed treatment. (Keep in mind: none of this travel and few of these services come at cheap or low cost.)

So, given limited resources, where do we go for help?

A bottle of vinegar.

There is a fast and low-cost method for identifying early signs of cancer. It is called Visual Inspection with Acetic Acid (VIA). The procedure involves a large q-tip soaked in vinegar solution. The q-tip is applied to the cervix (see refresher on female anatomy) and left there for one minute. Precancerous lesions will turn white (in contrast with the normal pink cells of the rest of the cervix) and can be detected by the trained eye. (Aspiring gynecologists: don’t try this at home.) Once any areas of concern are detected, a biopsy can be done if further information is needed or the lesions can be removed on the spot with a hot wire (LEEP) or by freezing (cryotherapy). 

I was lucky to join a group of clinical staff in rural Haiti for part of a training on the VIA technique. The training included a section on theory as well as much practice. By the third day of practice, word had spread around the hospital and in the community that free vaginal exams were happening. The team saw almost 100 patients that day and was even able to detect and remove some lesions.

Through experiences such as this, I am learning much about the challenges of supporting women’s health in rural Haiti. A few striking ones include:

Access to care:

Many women have never been to the doctor for a vaginal exam. It is difficult to address women’s health from a hospital or clinic if women are not going there on a regular basis – or at all. This speaks to the need both for facilitating access to care and strengthening community-based programs.

Literacy/Numeracy/Collecting basic information:

Sometimes I assist with intakes for patients: I write down the information clinicians want to see before they speak with a patient. When I ask people their names, they often respond with a name I recognize. But, there are some names that I just can’t figure out how to spell. This has prompted a few awkward moments when I ask a woman to spell her name for me, but she doesn’t know how. To get around the name issue, some women hand me a piece of paper with their name and other useful information neatly printed on it.

When I ask people how old they are, it often requires some calculation. Some do not know their age at all. One spunky woman said she had been told she was 80, but when I asked her what age I should write on the paper, she said 60. When I met her, I had not yet learned an oft-used technique to estimate age: ask under which presidency she/he was born. This method can get you within 5 years of the person’s age under the current system of limited presidential terms. But, the methodology is not so precise for people born during François Duvalier’s 13-year stint as president (1957 – 1971) or the 14-year gig of his son, Jean-Claude Duvalier (1971 – 1986). But, you do what you can.

Perhaps that is one of the greatest lessons I am learning here: the importance of creativity and finding ways to do what you can with what you have. It sounds trite, but I regularly see the difference it can make: in the absence of a robust health system, a clinician with some vinegar and basic tools could save someone from cancer.

Candidate Clef?

Things are going well here with work - I have happily joined a team of professionals who support women's health in rural Haiti. I will dedicate my next post to my public health activities, but in the meantime I have to comment on this Wyclef business:

Wyclef Jean is really trying to run for president of Haiti - he submitted the necessary paperwork this past week. I still can’t believe it.

This news raises obvious questions that the international media have hastened to answer: What does an artist know about politics? What are Clef's policy goals? Some are concerned that he is not capable of doing the job while others caution that he is not as pro-people as some of his lyrics and the mission of his "embattled" NGO might suggest.

And what do Haitians think?

Well, there is no doubt that people here love the man. In my few trips to Port-au-Prince, I have more than once seen his visage pass by on a tap-tap (a local, informal “bus” that provides transport around the city and is colorfully custom painted, sometimes with religious messages and images, sometimes with rapper 50 Cent or other illustrious figures).

While he may be a beloved producer/singer/song-writer/rapper, some Haitians think his candidacy is a travesty. Of course they were the first to voice the aforementioned concerns. They complain that he is an artist, not a politician; that he does not have the requisite experience; that he cannot manage the scope of this job or the various interests at play locally and internationally; they worry that he does not have the educational background or intellectual acumen to lead a country.

On the other hand, some Haitians are excited and have even said they would vote for him – a big deal because most of the people I've met are not planning to vote in November 28's election and have never voted at all. The supporters are glad he is not a career politician; they suggest that because he is already rich, he will be less likely to steal from the country; and, very importantly, “he loves Haiti.”

For me, this presidential bid raises questions about the role of the diaspora in Haiti – a topic of personal interest for me. Wyclef was born in Haiti and went to the US when he was 9. He continues to be involved in Haitian life through Yéle Haiti, a non-profit organization he founded in 2005. He fully deserves his hyphenated Haitian-American status: while he lives a US life, he maintains strong ties to his birthplace. His supporters think his significant outside-Haiti experience offers him a wider perspective that can help the country. His opponents believe that he does not have enough knowledge of the country to run it.

What does the Haitian Constitution say? It seems to indicate that the appropriate role for diaspora is not president. This may create a roadblock for Clef’s presidential aspirations:

1) The president must have been a Haitian citizen his/her whole life. Haiti does not allow dual citizenship. If Wyclef, at any point, was a US citizen, he would be ineligible for the presidency. People I’ve talked to find it hard to believe that he has been conducting his international career while carrying a Haitian passport.

2) The president must own property in Haiti. Wyclef apparently stays in hotels whenever he comes here.

3) The president must have spent 5 full years in Haiti prior to becoming president. Wyclef lives in the US – he visits Haiti.

The Conseil Electoral Provisoire (CEP), the group that manages Haiti’s national elections, is scheduled to announce the finalized list of presidential candidates on August 17^th, once they review the application materials submitted by this year’s 1­5-16 presidential hopefuls.

Wyclef’s attempt to become president of Haiti has raised a lot of controversy and discussion - and rightly so - but we are getting ahead of ourselves a bit if we get too emotional (excited or upset) about this possibility before he is given the green light to actually run.

Getting Ready, Getting There

I am finally in Haiti! Here is the promised pre-departure post, along with one on my first impressions.

Prep Work

As I get ready to leave for Haiti, I have been collecting words of advice from friends and family. Sometimes their contributions are solicited, but often not. Either way, I am touched by the concern people have shown me for this trip.

Almost everyone has cautioned me to “be careful,” oftentimes lowering their tone and making unsmiling, direct eye contact so I am sure to understand the import of their words. The this-is-no-joke face paired with the verging-on-ominous message freaked me out at first, but I’m used to it now. To spice up this recurring encounter, I have begun a mini research project to discover what exactly people mean when they say, “be careful.” I have heard some typical responses: don’t flash your money around; avoid being alone at night; “go with who you know.” One of my best friends had a creative answer: “Sybill. I don’t want to tell you not to be yourself. [Long pause.] But… Don’t be yourself!” (Translation: don’t be too friendly.)

I also got some unexpected advice: “Don’t wear your seatbelt – you’ll look like an American.”[Note from the future: I have been wearing my seatbelt in Haiti. I think my public health professors would be proud.]

People have also been sharing their excitement. Public health colleagues see this as a great work opportunity. Among my friends who are first- and second-generation immigrants, there is much joy about the Homecoming. I even made a new friendship a couple weeks ago with an awesome Filipino-American woman, I think thanks to the idea of the return home. One of my Haitian-American friends said, “You are going home. It’s your country!”

The best thing I've heard yet: “Bring a lot of underwear.” Of course this was from my Ma.

I am a little nervous, a little excited, anticipating that I will discover a complex mixture of experiences and feelings in Haiti. Though I'm not quite sure what I will encounter, I expect it will be meaningful and life-changing and, aside from bringing a lot of underwear, I think there is little I can do to prepare.

I look forward to taking you on this journey with me.

Homecoming

I flew to Port-au-Prince on a Thursday afternoon. On the flight from MIA to PAP, I was happily squeezed between a middle-aged woman and an elderly man, both Haitian and lovely. I settled into my seat, enjoying the rhythms of Creole speech all around, feeling as if I was already on the island.

I leaned my head back, ready to relax and hopefully get some much-needed sleep. The sounds of an all-too-familiar conversation commenced: two men in the row behind us shared their thoughts on the misery in Haiti, how intractable the myriad problems were. The woman next to me perked up as the conversation continued and once a natural pause presented itself, she interjected, “Pardon me, but I have to say something!” She reminded the men behind us (and many of us nearby) that we could all do our part to help Haiti – her underlying message was that change is possible. She noted that many of the problems in Haiti were created by outside forces: she recalled the role that other countries and international organizations have played in limiting Haiti’s independence, adding, "France needs to pay reparations!" But, ultimately, she returned to her main point: the solutions to Haitian problems lie in the hands of Haitians. After her monologue, our elderly row-mate regarded her with wide-eyed approval and clapped. Though I didn't join him in applause, I was impressed by her oratory skills and loved her hopeful attitude about Haiti’s future. She and I struck up a great conversation about Haitian politics and history – she knew a lot about Haiti’s early years and it turns out that she had recently published a palm-sized book that featured the entries from Toussaint Louverture’s journal. She kindly offered me a copy of said book, signing it and reminding me how important it was to remember our roots: We can't know where we're going if we don't know where we came from. We are the children of the only successful slave rebellion. We have always fought for what's just. Let's keep up that fight.

She offered the perfect, intense prelude to my homecoming to Haiti. I couldn't have scripted it better.

As we made our descent onto the island, I eagerly examined the scenery below, snapping photos in front of my elderly neighbor's face (of course saying "Eskize m" profusely before, during and after). He was amused by my excitement, pointed out neighborhoods of Port-au-Prince as the tiny structures beneath us grew larger and larger.

After a long (and painfully humid) wait on the imigrasyon line, I was welcomed to the country by a family friend and then made my way to my new home-office about 1 1/2 hours from the city. The road we took did not pass by much of the destruction of January 12th, but I did see a little tent city. I learned that 6 months after the earthquake, little progress has been made on housing: some stronger, $1000 tents have been built.

My work will be in rural Haiti, so I do not expect to see much of the internally displaced person (IDP) camps or the life of post-earthquake Port-au-Prince. Most of what I've seen is beautiful mountains, blue skies and the greenery that grows lush with the rainy season. There are a lot of large farm animals – I see them eating grass and transporting people and things. The sounds I hear most are roosters (whom I’ve just discovered crow at any time of the day, not only at alarm clock worthy hours), motorcycles, cows, crickets and, occasionally, music: rara or kompa. While I cannot say this is a rural paradise – of course there is poverty here – I have not witnessed the scenes of Haitian misery that have been displayed in the US media for years.

One image of the natural beauty here:

It feels really good to be in Haiti. I look forward to getting started on my work.

Homeland, New land

When I was in elementary school, my teachers taught us to sing "Ayiti Cheri" ("Haiti Cherie" in Fench or "Dear Haiti" in English), a wistful ode to Haiti sung from the perspective of someone who has had to leave the country. The first verse is my favorite:

Ayiti Cheri, pi bon payi pase ou nan pwen

Fòk mwen te kite ou pou mwen ka konpran valè ou

Fòk mwen te lese ou pou m te kab apresye ou

Pou m te santi vrèman ki sa ou te ye pou mwen

Dear Haiti, there is no other country like you

I had to leave you to understand your value

I had to miss you before I could appreciate you

So I could really feel what you mean to me

The song inspired an English version by Harry Belafonte. I love Jacques Sauveur Jean's rendition - same title, same feeling, different words, different rhythm.

Today, nearly any version of Ayiti Cheri fills me with pride, hope, sadness.

But, as a child, I was not particularly moved by this song. Why not? Three theories:

(1) Authentic patriotism was lacking. I learned this song at my (wonderful and well-meaning) school in Cambridge, MA, partially from American teachers and alongside many American children who unknowingly butchered the syllables at every turn.

(2) My childhood interests lay in local “buried treasures” (such as the note- and toy-filled pencil cases I liked to put in the sand at the playground near school) and not the life of a distant island. Haiti was more a concern of the grown-up/parent world, along with things like news and politics.

(3) I had never been to Haiti and I knew very little about it.

The older I became, the more the words of this song resonated with me – and the more I wanted to know about this placed called Ayiti, “land of mountains” (the name given by the indigenous Taino and Arawak peoples).

I needed to learn more about the country of my parents, the nation of survivors in the Caribbean Sea that had shaped so much of who I was and how I thought. The country where everyone speaks Creole, the beautiful language I grew up hearing at home and among family friends; the country whose focus on good manners drives me to greet everyone in the room with a kiss on the cheek upon arrival and departure; the country that gave rise to the traditions I celebrate each year, such as eating a deliciously revolutionary New Year’s soup to commemorate independence day, January 1, 1804, when newly freed Haitians began to eat soup joumou, a dish formerly forbidden to enslaved black people.

I have wanted to go to Haiti for a long time. In the aftermath of the January 12^th earthquake, I realized I could no longer wait. And I hoped that given my newly acquired public health skills, I could arrive in Haiti not only as a tearful and mournful observer, but as a person who could make some contribution.

This summer, I will finally make my first trip to Haiti. I will be there for about three months to do some maternal health work.

I look forward to this experience – a milestone both in my personal life and in my career – my first encounter with Ayiti Cheri.

Many thanks to the generous support of the Harvard Kennedy School’s Cultural Bridge Fellowship and Women and Public Policy Program. Thanks, always, to family and friends for being there for me – and thanks especially to Tommy and Tej for helping me turn my dream to go to Haiti into a reality!

I will post again as my July departure date approaches.

Till then, much love.