Global Health, Public Health, Public health concern

Health communication in the time of Zika in Haiti

The day was coming to its end as I was dealing with annoying paperwork at an outpatient clinic in the area of Delmas, in Port-au-Prince. The attending nurse sharply knocked at the door and introduced me to Zoune, a woman in her mid-forties. Calmed by the fan in motion, the ambient heat hardly bothered on this particular afternoon. Even though January hasn’t seen any rain yet, puddles and piles of rubbish in the streets form a sure cottage for mosquitoes. The tropical temperature also stimulates their reproduction. Zoune presented clinical features of the Zika disease, urging me to initiate a symptomatic treatment based on my judgment and order a few screening tests. Ever since the confirmation of Zika cases in Haiti by the Health Department (and even before) the public carefully monitor themselves for signs of the disease and inquire with their doctor. Of course some prefer to get themselves treated with simple non-pharmaceutical interventions.

The Zika virus disease is transmitted by the bite of Aedes mosquitoes, infected by the virus. Identified in humans for the first time in 1952 in Uganda and Tanzania (Emerging point of Chikungunya virus which caused an outbreak in Haiti in 2014), it spreads especially in Africa and tropical countries. This non-fatal disease involves a febrile syndrome associated with lumbago (pain in the lower back), simulating Chikungunya or malaria which is endemic in Haiti. The emergence of Zika virus disease was foretold long before its introduction in Haiti. Climatic conditions punctuated by global warming as well as migration have positively contributed to its emergence.

Currently, one can refer to an epidemic in Haiti since Zika was simply non-existent across the territory. Even though it’s relatively simple to limit its spread- provided that hygiene and sanitation measures are met- difficulties particularly arise on this level. How to involve most of the people in this dynamic? Proactive communication is the first step in management of an epidemic. But between the limited resources and the outright flaws in the Haitian healthcare system, the public is far from being reassured. Communication weaknesses have already started to plague the good management of this outbreak, hence affecting trust even more. As a matter of fact, the confirmation notice of the presence of the disease in Haiti came late compared to expectations of the people who observed that it was rapidly gaining ground and awaited a word from the Ministry of Health.

According to my observations, the greatest fear of the public lies in the eventual complications of the Zika virus disease; mainly brain malformation in newborns and Guillain Barre Syndrome which causes paralysis of the body. Although scientific literature hasn’t confirmed any link between these complications and Zika yet, in some countries where Zika spreads, women are warned to delay pregnancy or to avoid areas affected by outbreaks. In the United States, the Centers for Disease Control and Prevention have elaborated guidelines for the screening of pregnant women by gynecologists. Some see this as a unique opportunity to revive the debate on abortion in countries where a modern law is lacking. But at the time of writing, no campaign whatsoever is officially launched in Haiti thus, no warning regarding pregnancy or increased promotion of contraception services has been issued by the Health Department. The public is therefore facing the fear of this epidemic with the feeling of being on their own.

In order to foster behavioral changes necessary to protect lives, it’s important to know the perceptions and existing practices of the population. A never-ending conversation with the public allows effective management and is worth more than sparse and scant monologues in times of panic. During the Chikungunya outbreak in 2014, the organization I co-founded integrAction was delighted to share ideas and experiences with the socio-medical staff of the Haitian Red-Cross (many of whom were infected) in Cap-Haitian during a conference. This initiative helped the organization conceive groundbreaking campaign with appropriate health communication to raise awareness via social media on the disease and the means to cope with it.

On a broader scale, the current turn of public health history is an opportunity to consider reinforcing leadership capacities from the bottom to the top, while investing in research and improving the public’s health literacy. For most of the population, there’s more fear than harm as in the case of Zoune. So engaging the people through proactive communication followed by prompt action is one of the best ways to halt the spread of Zika and its potential consequences. As they express much disappointment, the Haitian people can only hope for less vulnerability. But if today’s duties are unceasingly postponed, the future, undoubtedly, can only be more grim.

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador January 21, 2016. REUTERS/Jose Cabezas

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Public Health, Public health concern, Social Issue

Let’s change the rules to save women’s lives in Haiti

Fairly called Poto Mitan in Haitian Creole, women account for 50.49% of the Haitian population and represent the center pillar of most households. From commerce to education, their contributions to the society are undeniable. As the prosperity of the nation relies on its citizen’s well-being, it is no surprise that women’s health is a public health priority when it comes to the national health policies. But despite the efforts, unsafe abortion remains unfortunately a scourge as prevalent as poorly addressed.

I recall my last shift at Chancerelles’ maternity ward where a 16 year-old pregnant girl presented with intense abdominal pain and massive vaginal bleeding. At first, she did not admit any medication ingestion prior to the onset of her symptoms. But as we pursue the medical investigations, her 30-year-old boyfriend confessed that he had provided her with 4 pills of an over-the-counter drug known to provoke abortion in pregnant women. For the gynecology residents, it was a routine and classic case. Yet openly discussing unsafe arrest of pregnancy in Haiti is controversial since it’s so much of a taboo.

The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both. Every year, 50.000 women, mostly from Latin America and Caribbean countries, die from consequences of unsafe abortion. According to the article 262 of the Haitian penal code, induced abortion no matter where or who performs it, is a criminal act and legally punished nationwide. But regardless of the law (or maybe because of it), complications of clandestine abortions are common motives of visit in general and obstetrical care facilities.

SDG3

Target: By 2030, ensure universal access to sexual and reproductive health-care services.

Carole, the latest patient I examined, was going through her second abortion experience and presented with severe anemia after 15 days of bleeding. When she got pregnant, economic difficulties arose, urging her to take the decision with her husband’s consent. But the specialized hospital she visited wouldn’t provide the desired services as forbidden by the law. So she turned to a clandestine clinic, even when the fees were high. As we shared our opinions, she said that it would be beneficial for women to abort safely with optimal medical assistance because the absence of a legal framework for safe abortion and technical capacities almost took her life away.

A few days later an obstetrician and HIV care specialist told me that to alter the perilous consequences of unsafe abortion in Haiti, it would be best to decriminalize it. Among the 530 women deaths per 100.000 inhabitants per year in Haiti, 120 are attributed to unsafe abortion. Fortunately, in the last quinquennium, the Ministry of Health has debated the subject and elaborated a new bill with several social groups to allow abortion for medical purpose and in rape cases. This is one step forward in the modernization of women’s health in Haiti even when it hasn’t reach the parliament yet.

But the main causes of induced abortion being socio-economic status, maybe the bill should also include women who desire to arrest their pregnancy for any reason other than congenital malformations or rape. It would be better if every woman could openly  discuss it with their doctors.

Because it is the State’s duty to guarantee optimal health care to the population, and health is not restricted to the body. It includes mental and social well being.

It would be valuable to couple activism with effective health communication. Because often, the barriers to improving women’s health in Haiti are some erroneous traditional beliefs. My intention here is not to downplay any religious or cultural values, as some have actually improved women’s health. My advocacy is to conduct proper scientific studies on this public health issue and clearly communicate the best ways to prevent the consequences. After all, prevention costs exponentially less than complication management and as the recently published statistics show, the State’s funds have long been depleted.

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Public health concern

How social factors affect life: a health history

The morning breeze filled the room, warmed up by the first rays of the sun. That day, Jacqueline was the patient who kept my attention the most with her story. She was shambling as she entered the room, tightly holding an iron cane. The purpose of her appointment at the clinic was a monthly follow-up examination for diabetes and high blood pressure. A sixty-four-year-old mother, Jacqueline is suffering from obesity. She spends her days selling retail fabrics on the bare ground at the “Marché du Port”, familiarly called Gerit in Haitian Creole. Most of the time, her business doesn’t do well and she has to count on her daughter’s generous help. During history taking, as I asked her when did she become aware of her cardiovascular diseases, she started telling me about her life. This is how I seized the power of the determinants of health, these social and economic factors that influence individual and group differences in health status.

As far as her memory goes, it started on a 1987 Sunday morning. This sad November 29, marked by ruthless massacre, was the first Election Day in Haiti after the Duvalier regime. Gendarmes crowded the streets. On her way through the “Ruelle Vaillant”, seeking comestibles to feed her family, Jacqueline brought herself to the bloodbath. To avoid the gunshots, she jumped in the nearest canal and broke her leg bone as she fell. The effects of her broken leg remain to this day prompting her handicap. But on another level, the aftermath of the tragedy was so strong that it triggered emotional disorders in Jacqueline. Shortly after the event, she was diagnosed with high blood pressure.

Jacqueline stared at the ceiling as the memories streamed in front of her eyes. As she counted, the Hyppolite market was her main station back in the 80s. In these times, merchants only had to contribute a small fee to occupy a decent place. Under the mayor’s term, a hygiene service regularly cleaned the place, thanks to the occupants’ contributions. But since 1990, she moved to the Gerit following the orders of a new administration. The aging woman experienced since then, the precarious sanitary conditions and successive arsons which stain the history of the Gerit. Nowadays still leading a hectic way of life, her stress levels have skyrocketed. As the years passed by, she hasn’t even noticed how hastily the country was regressing. When I told her that the general hospital didn’t admit women to give birth for a mere 5 gourdes anymore, she couldn’t help but laugh.

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Desperate merchant after fire destroyed her belongings at Port Market in Port-au-Prince. Source: BBC Pictures

Then, came the January 12. When the earthquake ripped her four-piece house, Jacqueline was left with nothing but courage. She never saw a home in the shelter an NGO provided her, but she still lives in it. Some days, she manages to make it on a 10 gourdes budget, hoping her daughter collects a decent paycheck in the USA. Diabetes hit in late 2010. She confessed: “As age and disease pile up, I don’t plan to rebuild the house. Medications are way too expensive and health is to be guarded like a precious gift”. The day I examined her, she was struggling with a sore foot which is oftentimes an indicator of bad compliance to an appropriate lifestyle and medications in diabetes patients. Her story was written on her foot.

Why does it matter? She did not predict the earthquake nor did she expect the many adversities she went through. But they acted as social, economic and environmental factors which have an important impact on her life and health. Many times, a single factor cannot determine the health issues a person or a community strives with. They prevail as the results of a cascade of events and behaviors which are deeply rooted in history and the way the society is organized. In Haiti, political instabilities and natural disasters played a pivotal role in the onset and development of many health issues. More than two decades after the “Ruelle Vaillant” massacre, the months following the 2011 elections, the cholera epidemic peaked in Haiti. One of the many reasons is the fact that Port-au-Prince was home to many cases and as rioters barred the roads, patients couldn’t arrive at the Cholera Treatment Centers on time.

The story of Jacqueline is similar to Jean’s, a 24-year old patient at the clinic. During a conversation, he affirmed: “I can’t explain why cholera struck me because I thought I was safe.” As scientific data show, the source of the epidemic lies in the unsafe disposal of Nepalese soldiers’ waste. Considering the persistent lack of sanitary infrastructures and the weak health care system, Haitians are more vulnerable than ever. This is factual because the social and political choices and events bear major impact on the population’s health.

For  a prosperous future, a stable society and the improvement of the living conditions represent the key stones. As a matter of fact, it is arduous to deal with bigger challenges like climate change, in a situation dominated by uncertainty, even though it also plays an important role in the health of tropical populations. By influencing the determinants of health, the next generation will be more likely to build a strong nation and plant a seed of reparation for Jacqueline and Jean.

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Public health concern, Social Issue

Helping Haitian Futures: A focus on health

This op-ed article was originally published in the Carribean Journal 

Across the globe, the number of migrants has risen in the recent years. This phenomenon is exacerbated by the growing poverty in regions like Sub-Saharan Africa and wars in others like Syria. We can recall the images of Aylan, the 3-year-old Syrian boy drowned in the Mediterranean sea while his family attempted to flee their war affected country. Closer to us, the story of Sonia has been related, fleeing deportation threats and intimidation in the Dominican republic where she lived.

She was not alone on her journey. As of July 2015, a significant number of Haitians and Dominicans of Haitian descent fled the Dominican Republic for similar reasons. A large part gathered in cardboard-made tents, at Anse-a-Pitres, southeastern commune of Haiti. With a minimal assistance, these migrants are left vulnerable to important health risks in a hostile environment, considering the promiscuity, lack of resources and medical assistance. Let’s go around some of these health risks.

Young boy at the migrant camp of Anse-a-Pitres Source: Etant Dupain. Twitter @gaetantguevara

Young boy at the migrant camp of Anse-a-Pitres
Source: Etant Dupain. Twitter @gaetantguevara

In Haiti, the rainy season extends from April to November. As the millimeters of rain accumulate, the risks of cholera outbreaks also rise since this infectious disease is evolving towards an endemic one in the country. At the Anse-a-Pitre’s camp, an adequate sanitation system to prevent the occurrence and spread of a cholera outbreak is definitely nonexistent, thus an exacerbated risk. However, cholera is not the only infectious disease to take into account as a health threat in this particular situation.

Tuberculosis- also endemic in Haiti- is spread by the means of promiscuity and enhanced by a poor nutritional state. In reference to the testimonies of Etant Dupain and Roxane Ledan, this describes precisely the catastrophic living conditions of the migrants. The context of promiscuity and lack of preventive medical care also stands as a large ground for the occurrence of HIV/AIDS and other sexually transmitted infections.

Simultaneously, potential women’s health issues can develop. In general, the pregnant women are exposed to countless pregnancy-related illnesses like anemia because an appropriate medical examination during the pregnancy is minimal, nay, totally unavailable. Plus, the context is favorable to high-risk delivery since an adequate medical equipment is absent.

On another side, unwanted pregnancies may result from the absence of birth control initiatives in the camp, such as an adequate education coupled with effective contraceptive tools. In the worst cases, women may arrest their pregnancy, in precarious conditions as it is often the case in Haiti where voluntary interruption of pregnancy is not supported by the law. These women’s health issues are not isolated from the risks of infectious diseases discussed above. They might come also in interactions with other health risks or propel their occurrence.

Among them, depression and substance abuse are rarely emphasized. No matter the cause of migration, whether forced or voluntary as for Aylan’s family and Sonia, the process remains traumatizing. The migrant or deported status itself carries a pejorative connotation, impairing the dignity of the person. For many, the current situation may appear like a defeat or a torturing humiliation, especially if the process involved the separation of family members or loss of material goods. This emotional pain is opportune for the development of neurosis and abuse of drugs, alcohol, cigarettes and sleep inducing medication. As consequences, violence against girls and women may occur and infections may be sexually transmitted, perpetuating the vicious circle. Unfortunately, the living conditions at the migrant camp can only worsen the risks of mental ailments.

Women and children at the migrant camp of Anse-a-Pitres Source: Etant Dupain. Twitter @gaetantguevara

Women and children at the migrant camp of Anse-a-Pitres
Source: Etant Dupain. Twitter @gaetantguevara

Despite this alarming situation, these health risks ultimately refer to the future, even if it means the next minute, hour or day. Therefore, they give us the possibility to act upon them. As organized social groups, as the government, let us come together to reinvent the future of a growing number of Haitians, desperate and abandoned. A safe environment  where food, water, adequate shelter and medical assistance are available is a must to begin with. Based on these assets, an oriented and appropriate education should pave their way into a complete integration of the social life. In the face of this mighty challenge, we are left with little choice but unity and compassion.day. t upon them. As organized social groups, as the government, let us come together to reinvent the future of a growing number of Haitians, desperate and abandoned. A safe environment  where food, water, adequate shelter and medical assistance are available is a must to begin with. Based on these assets, an oriented and appropriate education should pave their way into a complete integration of the social life. In the face of this mighty challenge, we are left with little choice but unity and compassion.

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Public health concern

Drug resistance: What can we do?

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Bucket of drugs sold on the streets of Port-au-Prince, Haiti

This article originally appeared on Woy Magazine

Throughout history, mankind has suffered from several devastating epidemics caused by pathogens (disease-causing microbes). Even the bible speaks of the occurrence of epidemics such as leprosy and tuberculosis, millennia ago. Among the deadliest known in history, the plague epidemic, from 1347 to 1351, killed half of the European population. Centuries later, the Spanish flu of 1918-1919 has claimed more lives than World War I. On the American continent, around the same period, the epidemic of polio in the United States has killed 6 000 persons. For many years, Haiti has been known for the spread of deadly microbial epidemics and is still currently fighting one of the highest rates of tuberculosis, HIV/AIDS (despite the dropping prevalence) and malaria in the hemisphere.

However, the era of microbial epidemics has observed a halt since the development of antimicrobial drugs begun with the discovery of penicillin, an antibiotic, by Alexander Fleming in 1928. Nonetheless, in his Nobel lecture in 1945, he had to warn: “The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

Antimicrobial resistance is the fact by which, the pathogens become insensitive to the drugs used to kill them or to inhibit their growth. It is known as a natural phenomenon, but can as well be propelled by humans through overdose and improper use of drugs. In line with Fleming’s projection, antimicrobial resistance is an actual fact and a global health issue especially in our era of globalization and mass commercialization. As a result, in a near future, we may lack the most essential drugs to cure the simplest infections.

How is it today? In its 2014 report, the WHO has revealed that the Influenza A viruses (susceptible to cause the flu) are resistant to all available preventive drugs. Worldwide, 450,000 new cases of resistant tuberculosis have been reported.  And in Africa, resistance to a specific class of drug used in the treatment of AIDS has been observed since 2009. Concerning malaria, several countries on different continents experience some level of resistance to chloroquine (Main drug used in the treatment).

Imagine a world where anybody can die of a single skin cut, where more children under 5 years old die of pneumonia. Imagine a country like Haiti in such a world, with no available drugs to treat malaria and AIDS. Imagine a world where tuberculosis is an incurable disease, where doctors can’t practice surgery -because most of the time, there’s no surgery without antibiotics- and where children die of mother-to-child infections. To avoid such catastrophe, key attitudes are recommended in the face of this new global epidemic of resistance to antimicrobial drugs. Let’s lay down a non exhaustive list of four realistic and reliable precautions we can adopt in Haiti.

Encourage consumption of local foods

Most of the meat consumed in Haiti is imported from the Dominican Republic and the United States. In larger economies, antibiotics are used in animals, despite the advice of the WHO to cease such practices (Press Release WHO/39. September 11, 2001). When a person ingests meat containing antibiotics, they also consume the drug. This improper use of antibiotics contributes to bacterial resistance in humans. As a result, these drugs will lose their ability to produce the desired effect in sick people. The lack of antibiotics is one of the advantages of purchasing local Haitian agriculture. It is, therefore, recommended to consume local foods in order to decrease the spread of antibiotic resistance.

Fight self-medication

Concerned state authorities should take responsibility by enforcing the article 19 of the August 10th, 1955 law forbidding the sale of antibiotics without medical prescriptions. According to a study I conducted in March 2015 at the outpatient clinic of the General Hospital of Port-au-prince, almost half of the patients (45.4% of them) buy their antibiotics without any medical prescription from street vendors tubs, public transport buses and sometimes pharmacies. While we wait for a more modern law on the pharmaceutical sector in Haiti, the one cited above should absolutely be enforced in the meantime.

Typical meds vendor in the streets of Port-au-Prince, Haiti

Typical meds vendor in the streets of Port-au-Prince, Haiti

Practice better medical care

From the doctors, it is required to decrease the careless use of antibiotics and other microbial drugs. The choice of the most accurate drug to treat a specific infection, the appropriate dosage and duration, should be done with the utmost care. In all circumstances, following a well-conducted physical exam, the clinical judgement of doctors need to be accurate. It is best, however, to objectify an ongoing infection before initiating a therapy even if in most of the cases, the medical practice is challenged by the inability of the patients to pay for basic exams. No matter the limitations, it is the doctor’s duty to make the best decisions for their patients and for society as a whole, based on their judgement and scientific evidence.

Increase awareness and health literacy

As it is often said, prevention is better than any cure. It is in the best interest of the general population to increase their awareness of the situation and their health literacy. Unfortunately, in Haiti, information and health education campaigns are only held in times of severe outbreaks, and are transmitted in a language that excludes the majority of the population and fails to take advantage of the best communication channels. Basic health knowledge should to be taught throughout people’s lifetimes, beginning in elementary schools.  IntegrAction, a non-profit organization I co-founded, is totally engaged in this fight for effective health literacy for the Haitian population.

Awareness and a culture-oriented health literacy coupled with the best medical care can make a profound difference, in regard to this alarming situation. The state and local authorities should join their hands to enforce the existing law and encourage the consumption of local foods. With enough political will and global awareness, it is possible to get around the dramatic fate. One behavioral change at a time, let us, Haitians, unite for this cause!

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