Public health concern, Social Issue

Lia’s Mental Battle After Her Pregnancy

I was once greeted at the home of a young woman named Lia who was bedridden since her recent delivery. The narrow, uneven staircase leading to her 3-piece apartment, on the second floor immediately struck me. Three plastic chairs and some dusty decorations adorned the living room. I was climbing the shaky staircase when her husband Manno appeared to welcome me. The couple was forced to marry 4 years prior, to escape public shaming when Lia unexpectedly became pregnant with their first daughter Zina. Zina was inside, busy undoing her braids. She was so unusually calm and silent that Manno asked her if everything was alright, with a strong smell of alcohol on his breath. Although she appeared serene, in reality, she was feeling like her world was crumbling ever since her mother, Lia, gave birth to her little sister, since then Lia’s behavior had started to change.

Manno led me into the bedroom where Lia was resting. A dirty-white mosquito net covered the bed. Children toys and elementary school books stood on cupboards and small tables. I quickly understood that the entire family was living in the same small space. Lia stared aloofly at the ceiling. The newborn girl was laying down to her left. While Manno was getting me a chair, I noticed how Lia dropped quick frightened glances towards the baby from time to time. As Manno entered the room again staring down, ashamed, Lia uttered insulting and incoherent words and even threatened to choke her own newborn baby. Manno instantly presented his deepest apologies to me, for his wife’s delirium. But I wasn’t surprised at all because I am familiar with such symptoms- confusion, paranoia, agitation, hallucinations and sleeplessness– evocative of a post-partum psychosis, which is a psychiatric illness affecting some women after delivery.

Friends and family think that jealous neighbors took advantage of Lia’s pregnancy to cast a spell on her. Her father has even proposed that she travel to the North of Haiti to find him, to try to ward off this miserable fate. In the northern town where Lia’s father lived, he was very respected thanks to his land, livestock and his expertise in traditional medicine, despite his proclaimed Christian beliefs. Manno informed me that even the doctor they contacted in Port-au-Prince had recommended they go visit a hougan, a Vodou priest that sometimes serves as healer. It is difficult to be clear about the impact of traditional or religious practices on mental illnesses (especially if these diseases are observed from the perspective of Western medicine, as in my case), but I am, nonetheless, aware that they are often the only resource for people suffering from such diseases in Haiti, especially in remote areas. And, Lia or her entourage’s interpretation of her disease, whether it may sound irrational to you or not, is already a step towards treatment. How she understands her disease is important to her healing. If she thinks it is a supernatural misfortune, her caregiver should not disregard her conception.

However, in my mind there was no supernatural misfortune. Unwanted pregnancy, a history of chronic major depressive disorder or depression during pregnancy remain factors that make many women vulnerable to mental illness after childbirth. In fact, although these factors are numerous  (biological, psychological and social), in Lia’s case, the living conditions were the most likely cause. Many stressors in her life as a Haitian woman, as a wife, as a mother, as an employee, were always present prior to her pregnancy, but were perhaps seen as isolated situations that have all now bubbled to the surface. Many Haitians are fragmented in this way, as sections of their history are separated but yet unknowingly linked, and can be a source for many ailments.

Read about unwanted pregnancy and abortion in Haiti here

To provide some context: poverty affects more than 80% of the Haitian population and social exclusion and alienation often go hand in hand. Despite counting for 56% of the population, women are too often denied the most basic rights. When it comes to mental health, such a context is hardly favorable. Opportunities for prosperity are available to the few who have had access to the right education, those who can take advantage of a broken system and the very few born within a supportive environment. On the other hand, elements that could promote resilience and health, such as family support, are rare or poorly integrated.

But, in Haiti, the relationship with mental illnesses is difficult even among the more privileged. No matter the systems of thought, traditional or modern, most of the times, patients are simply dismissed as “mad” or possessed by an evil spirit, regardless of the mental illness the individual suffers from. Local obstetricians (in case of pregnancy-related mental illnesses) and mental health professionals, psychiatrists and psychologists, struggle to address the most pressing health issues concerning women. Numerous medical NGOs also support maternal health in Haiti. But while they often heal the body, mostly focusing on communicable diseases, the mind is highly overlooked. So women usually don’t freely express their real preoccupations and needs, reinforcing the barriers to proper care.

The last time I asked after Lia, she had joined her father’s lakou in the North and was taking pills prescribed by a psychiatrist while simultaneously going through mystical treatment. I was happy to hear that she was doing better. That was good news for her baby. But as I said goodbye to Manno and he replied, the scent of his breath reminded me of someone I had forgotten to ask about. “How’s Zina doing, by the way?” I asked as memories of her sad face resurfaced. – “She’s doing good replied Manno, she’s at school right now, I took her this morning. With Lia gone, I’m the one taking care of her” he added. I nodded with the largest smile I could muster and told him our traditional.  “ankouraje.” But I left with a heavy heart, full of fear and prayer for Zina.

Advertisements
Standard
Cholera, Public Health, Social Issue

Climate Change, Migration and Healthcare in Gonaives

In 2006, I spent my first night in Gonaives during a trip from Port-au-Prince. Hurricane Anna and Ike were two years away from burying the city under water one more time. All I knew about Gonaives at the time was its historical significance as the site of the very first declaration of Haiti’s Independence. But after participating in a recent study on cholera in Gonaives, I have gotten a clearer image of not only the city, but of the impact of climate change on urban development, and its consequences on healthcare accessibility. I believe traditional medicine can help reduce this problem.

Gonaives is Haiti’s third most populated city, sheltering 356,324 people as of 2015. According to ESA Consultance’s recent study (which I contributed to), Gonaives is at an important crossroad for commerce from the northern region of the country towards Port-au-Prince, the capital. The concentration of public services in the city attracts people from all over Haiti. Despite its demographic and geographic importance, Gonaives is infamously vulnerable and weak in the face of natural disasters.

In the 1970s, many countryside citizens began moving to urban centers to work in the then booming manufacturing industry. Although population movement continues to happen, employment is not its only guiding force. According to the International Organization for Migration, rural-urban movements in Haiti are often due to environmental events. My experience in Gonaives taught me how climate change contributes to inflate the city’s population.

People who live in vulnerable areas in dry seasons move up to the hills, in neighborhoods in the periphery of Gonaives, to be safe from floods during the rainy seasons. The impact of hurricanes Hanna and Ike in 2008 influenced Gonaives’ population increase and even forced the emergence of new neighborhoods. The city’s population almost doubled from 2003 to 2015. As a matter of fact, between 1954 and 2012, no less than 19 major hurricanes have affected Haiti. Due to persistent vulnerabilities and fiercer hurricane seasons (maybe due to warmer temperatures), such disasters will continue to haunt us. With category 5 hurricane Irma currently approaching Haiti, vulnerable populations are still ill-prepared. How does this affect population health?

As cities expand, services such as clean water, sanitation, and healthcare become less accessible, since the existing structures fail to match the growing demand. In a 2000 national survey in Haiti, they determined that a large number of people consult traditional healers when they are sick before they turn to a physician, because of the former’s proximity to the people.  Trends in drugs sale in cities like Port-au-Prince show that most drugs are available over the counter and sold in the streets. Self-medication is also an essential option for Haitians when it comes to treating an ailment. Leveraging self-medication to bridge the gap in healthcare accessibility is not the answer. However, traditional medicine might be worth considering, as it is already playing an important role in the care system in general, particularly in the work being done to eliminate cholera.

Let me explain through an anecdote. Most traditional healers, like one middle-aged woman whose presentation on a panel I recently listened to, draw a line between what she called “natural cholera” and one they consider “mystical.”  According to her, “mystical cholera” is mild diarrhea that lasts a few days unlike “natural cholera” which kills within hours if left untreated. When people come to a Lakou or Vodou temple for treatment for “mystical cholera,” the mambo said, they are treated with starch, molasses, and a little nutmeg. If this does not improve the person’s condition, they refer him/her to the closest hospital or health center. In my professional opinion, mystical cholera does not actually exist, but the natural remedies used to treat it are perfectly suitable for healing many kinds of diarrhea. Fortunately, most healers know how to recognize symptoms of actual cholera, provide first aid and oral rehydration and redirect people to cholera treatment centers.

The lesson here is that as a part of the healthcare system in Haiti, traditional healers can leverage their know-how regarding natural treatment and their proximity to a large part of the population to improve access to care. But the department of pharmacopeia and traditional medicine of the Ministry of Health needs to do more extensive work, by surveying and training the traditional healers and promoting their expertise locally. But, being a tradition rather than a formal profession, traditional medicine could pose some challenges as the practices are not backed by a uniform and evidence-based science.

Given the continuing increase in global temperature, it would be delusional to imagine Haitian cities less vulnerable to natural disasters as they continue to expand. Haiti signed the Paris agreement, which propels initiatives to empower peasants and fight the effects of climate change. Therefore, despair is unnecessary. As stated on a lotto stand during one of my visits, we need to prepare for tomorrow Panse ak demen. Climate change will continue to disrupt our society and the accessibility of health care. This liability can be turned into an opportunity to build upon the knowledge and position of traditional healers to close the gap. Traditional medicine and community members can be among the most important steps towards progress.

Published on Woy magazine before Hurrinace Irma hit Haiti on September 7, 2017

Standard
Social Issue

A tale of two Haiti(s)

My brother Keddy and I grew up in Karenaj, a then hassle-free neighborhood in the world-renowned city of Cap-Haitien. Although our family had relatives in Saint-Michel de l’Attalaye, an Artibonite county south of Cap-Haitien, we lived far removed from rural Haiti, except for a few sporadic trips to “andeyò” which is the term Haitians use to refer to rural areas. It’s a Kreyòl word derived from the french “en dehors” translated as outside. So my twin and I, we were raised unfamiliar with most traditional food and to a greater extent, the language and culture of Haiti’s rural regions with their complexity and richness.

When our grand-mother passed away, I could feel that the few stories of Saint-Michel along with anecdotes of our elderly’s rural trips had also vanished. But now, as adults and doctors, we’ve managed to visit the entire country apart from Grand-Anse, either during professional endeavors or on personal adventures. As far as we could tell, decades later, differences still persist between how us, city-raised gentlemen, perceive and express reality and how rural populations do. Not only the rhetoric differs but the very elements of culture struggle to collide. During our trips, those gaps even impaired our ability to communicate with the locals. In terms of local tourism, this situation wouldn’t be much of an issue. But consider the heavy toll of such discrepancy when it comes to patients explaining their symptoms or when it comes to us doctors communicating health risks and treatment options.

In the 1970s, as Haiti’s agriculture sector plummeted, people massively moved from rural regions to adjacent towns in search of a better life. Throughout the decades, the dynamics of rural exodus have only made this transit skyrocket. More than half of Haiti’s population now live in cities. Needless to say that the emigrants carry what they have accumulated as a cultural background with them. The vacuum left by such demographic movement and social context leaves the rural areas very vulnerable. Which in turn often leads to city dwellers, with their own culture, to commute to rural areas for work-related projects, many of them provided by NGOs. This is how we found ourselves on a day-to-day journey trying to comprehend each other.

In rural populations, overcoming issues such as academic illiteracy or comprehending the beliefs in magico-spiritual forces is often a pre requisite for creating rapport and therefore to have impact on a patient’s health outcome. But some other concerns are subtler. I recall having examined an old woman named Annia in Saint-Antoine, a neighborhood next to Poupelard avenue, in Lalue, Port-au-prince. The old woman was from the South and had settled in Saint-Antoine less than 2 years prior to her consultation. Visibly uncomfortable, she described her pain to me in those words: as if a stack of millet was being pounded upon with a big pestle. She made it clear: – “The big ones Doc, not the small ones”. Coffee is very much engrained in every Haitian’s life and I’m very familiar with scenes of people pounding coffee roasts in big pestles, it happens in rural zones as in certain towns, but I sure had no idea as to what it feels like. And can’t obviously make the difference between the big and smaller ones, except for their size. While I was expecting her to describe her symptoms using my words, she relied on images of her daily life. As she spoke, even though we speak the same language, I could feel the gap between us widen and as if we were losing each other.

Keddy has also experienced such “language barrier” when he asked a patient from a locality near Montrouis, when she’d last had her period and she casually replied: – “On the last moon”. While he was anticipating an exact date, ignoring when the last moon was or even what that actually means.

It’s not a mere matter of language (French versus Kreyòl) as the concern is raised ad nauseum but instead a collusion between two different cultures, impairing understanding and proper health communication between two people speaking the same language.

These cultural barriers to communication stress the difficulties to assess and address health risks in patients and communities alike. I remember visiting Maniche with a team of Port-au-prince-based health agents. Most of them were hailed from this very Southern locality, and although our job was to raise concern about the safety of a water source, because they used to drink it and were actually baptized in these waters in their youth, it became harder for them to question its quality. The same goes for patients suffering from high blood pressure who dismiss any change in the way they prepare food because they’ve been taught a particular way by a parent since they were kids. Habit is more powerful than science and without the psychological tools of social and behavioral change communication the work of healthcare providers might as well be for naught.

I went back to Karenaj recently. As I sat in furniture that feel older than the city itself, I was thinking that until we reduce the gap between urban and rural realities we will not be able to understand each other, recognize what puts us at risk and heal our common evils. As I thought of my conversation with Annia and the way many pride themselves as educated, I asked myself if we were hardly doing any good. What good is a doctor’s vast knowledge if he can’t even understand his patient, let alone help her improve her behavior? There is not a single way to resolve these differences. But if we at least stop considering distance as difference, maybe we can start learning and improving together.

Standard
Contact, Public Health, Social Issue

Why Haitian Doctors Choose To Practice In Haiti

Three months ago, I was granted the opportunity to present the results of an epidemiologic research (scroll down to CO-057) I conducted at the latest conference of the French Society of Pharmacology and Therapeutics; a scientific institute aiming to advance research on drugs and their utilization. Being a local-trained and based doctor in Haiti, I was twice as happy realizing the many promises of medical research for the country. However at the same time, the back of my mind was still being gnawed by the many obstacles afflicting the Haitian health care system. For example, while the epidemiological threats are quickly diversifying, basic data collection and analysis are still lacking. And a flagrant misuse of local capacities is in many aspects a scourge. As the ongoing strike of residents exposes the system’s shortcomings, it is obvious that such structural inadequacies have long resulted in junior doctors’ exodus.

Read “Why young doctors leave Haiti”

But against these odds, many Haitian doctors choose to practice in Haiti, despite increasing promises of improved work environment and better opportunities for doctors in foreign countries. Even among the large community of Haitian doctors practicing abroad, the desire to come back to the motherland is often expressed.

There is no one reason for that desire to stay or come back to Haiti. A colleague told me that Haiti is the only place he feels he belongs and connected to. That regardless of the state of the healthcare sector, he is more likely to stay in Haiti, strong of his familiarization to the Haitian culture and way of life. Some doctors don’t have a choice at all, staying because of family situations such as marriage or a chronically sick child.

As a reason for their coming back to practice in Haiti, a few of my former professors evoked experiences of exclusion, discrimination and racism which have contributed to drive them back where they feel more appreciated and needed. One day, as I was in Brussels for a medical internship, as I handed my passport to an office staff member, I was startled as he shouted to me how chaotic of a country Haiti is. That experience helped me catch a glimpse of what many might be enduring abroad in regards to discrimination pertaining to their origin.

Deep inside, I know that personal reasons such as lifestyle, family situations or unfortunate experiences abroad are not sole factors to embrace Haitian medical practice. As a matter of fact, while most doctors who leave always give me clear reasons why they do, most doctors who stay never seem to be able to give me a concise reason why they do. What is for sure is that whatever the reasons given, they are almost always associated with a profound feeling of patriotism and a sense of duty when it comes to practicing medicine in Haiti.

In fact, as I described in many of my articles, factors such as a lack of capacity and initiative hold back the Haitian healthcare system. But regarding its current state, one of my mentors affirmed that Haitian doctors, as every citizen, need to redefine their relationship to Haiti instead of abandon it. According to him, overcoming our shortcomings in regards to health care is a patriotic duty. But how many doctors are there, visionary enough to make it their mission to stay or come back here and try to improve what can be? I am honored to know and work with many of them. As I was recently discussing with two senior doctors, they consented that leaving might earn them less stress but also less happiness. Their choice was motivated years ago, ever since their career started back in the 1980s, by the ambitious project to train generations of doctors in Haiti to solve Haiti’s health issues. Let me clarify that leading a health-related project in Haiti is barely an easy task. I know that because the organization I co-founded, integrAction, has long been trying to find a working strategy to accomplish its mission which is to improve health literacy in Haiti. But with the experience I gathered, I realized that an often silent sense of patriotism plays a key role in keeping people pursuing their project. For me, there is no doubt that this is the most important reason why doctors still choose to practice in Haiti over many other choices. It is a crucial driver and that’s good because the fact is that Haitian doctors are critically needed on their land.

Click to like integrAction’s Facebook page

This leads to another reason to practice in Haiti: the desire to cast a stone. Even though it’s a plausible argument for countless people, I’m not referring here to the year of service provided in exchange for the State’s investment in training doctors. In a broad sense, Haiti has nourished the personality and imagination of everyone who has spent time here. It has shaped who the people are- doctors included- through a complex net of trial and error, frustration and victories. And as the saying goes, much is often required from whom much is given. For a lot of Haitian doctors, staying in Haiti helps them to be useful and contribute where they are needed. And they all agree that politicians and those in charge of the health sector have the obligation to foster an adequate and coordinated work environment for more and better impact.

In the midst of a health system in crisis with no apparent short term resolve, my questioning the motives behind Haitian doctors’ choice to keep a practice in Haiti was both justified and eye-opening. It helped me determine where to look at in order to inspire the future doctors of this country. A mixture of personal preferences seem to be an important factor but patriotism and the aspiration to contribute to the community are also deeply ingrained. As Haitian doctors continue to build and struggle against all odds, the need for advocacy for an improved work environment and opportunities to live a fulfilling life in Haiti is mandatory. Human resources are the most important asset of any system and to achieve ambitious health goals, we need to maintain our precious medical work force.

SFPT2016

Presenting my research entitled “Evaluation of antibiotics self-medication among outpatients of the State University Hospital of Port-au-Prince, Haiti” on April 2016.

 

Standard
Global Health, Public health concern, Social Issue

On the shades of violence in Haiti

When we first moved to our current neighbourhood ten years ago, the sides of our impasse was occupied by poorly maintained shrubs and houses isolated from each other. Only one car could manage to go through a narrow path left between the trees. Acquaintances often quipped about us living in such a remote place, hardly accessible and sometimes dangerous, given the numerous cases of kidnapping that had occurred there in the past. Indeed, the main avenue was not even fully concreted and huge potholes spread along the road. But ever since the earthquake hit, people from diverse and unknown backgrounds have settled on unfenced lands nearby, slowly changing the settings. Retail sale of clairin, a popular alcoholic cocktail, has flourished since then and round the clock gambling also attracts many young unemployed. Gun related and gender specific violence were quickly added to the picture, outlined by injuries, addiction and mental health issues.

Over time, we got used to the times when drunken men cause inconvenience and to the days when quarrels over money or marriage issues block access to our home. But as an extreme example of how unchecked violence has spread, three young men were recently found dead on the streets, killed by heavy gunfire heard during the night. Surprisingly when it comes to violence, young people seem to be the most vulnerable. Violence claims the lives of 200,000 young people per year worldwide and represents the 7th cause of death in Haiti.

The disastrous political context of the country during the last decades has shaped the minds towards believing that violence is inevitable. Not only have people engaged in violent acts for the smallest rewards, but many accustomed to political turmoil think of violence as a substantial part of their daily life. The general public and the policy makers consider violence more as a banal indicator or trend, going up and down but never as an issue plaguing their own personal and community health. In our communities, the trivialization of violence is in fact, the result of inaction which results in more violence, repeating a vicious cycle and accumulating into increased cases of serious injury, chronic diseases and perhaps lowered life expectancy.

The popular culture has long encouraged violence against women through apologies of machismo and the objectification of women. It goes without saying that despite women’s rights activists’ campaigns, they remain the largest target of verbal and physical violence. Misogynistic words being too often valued and praised, they somehow abound in the media, accompanied by degrading images of women and hateful mocks. Even in my youngest years growing in Cap Haitian, the tendency to disregard women and LGBT communities’ values had already been deeply rooted in most boys my age. So it was not surprising that, as a medical intern in Cap-Haitian decades later, I couldn’t keep count of the cases of gender-related violence registered in the emergency service. There were even cases where serious burns were the consequence of such domestic violence.

Besides the factors mentioned above, structural violence seems an even more important cause of physical violence. The lack of education, unemployment, social and economic inequalities, exclusion, gender-based, racial or religious discrimination and poverty among other factors stand as complex mechanisms preventing many people from defining and fully realizing themselves. In the countryside, the absence of an efficient mean to uphold justice leaves enough space for violent conflicts over land tenure, often leading to deaths. Although there are no excuses to violence, it is rooted in a highly unequal society, which leaves very little opportunities through decent jobs and an environment to realize one’s potentials. As a matter of fact, the World Health Organization referred to concentrated poverty, easy access to alcohol, drugs and guns and weak governance as main risk factors for youth violence. And as far as we know, the daily lives of most occupants of cluttered neighborhoods in Haiti consist of much of these factors.

Although the population may rejoice in the brutal murder of robbers, these acts may not be more than a Band-Aid on a deep wound, if the core problems remain unaddressed. Perhaps it would be useful to keep engaging all communities proactively in order to expel the idea that violence is normal and inevitable in Haiti. Communication should counter the idea that the situation is acceptable today simply because it was worse 12 years ago, because no level of violence is suitable. It will be mandatory, to teach or keep reminding our communities the fact that women are equal to men both in their body and their mind. School children should be taught that violence makes orphans and leads to many health consequences. If young people are offered the opportunity to play a role in their country’s path to development, if they are able to support their families with dignity and respect for others’ property, it will certainly make a difference and that is definitely a worthy investment for the future.

Cluttered neighborhood

Standard
Public health concern, Social Issue

The weight of social approval

During a short break from seeing patients, I was sitting behind the desk, enjoying an appealing novel. In the heart of the neighborhood of Jalouzi, in Petion-ville, the atmosphere was rather comforting, punctuated with laughter of children and chants of street vendors wandering outside. Betty, the nurse in charge of patients’ vital signs laid on the wooden bench in the waiting room looking preoccupied. At some point, she got closer to me and shared her concern: Ever since she started working at the center, she had gained several pounds and feared to have crossed the line of obesity, making her susceptible to the health threats associated with it (mostly cardiovascular diseases).

Betty is a short and curvy, 24 years old woman. She confessed to never doing exercise. Even back when she was at school, the court was too small and physical education wasn’t part of the curriculum. She also grew up in a family where women proud themselves on their thickness. According to her family and peers, it is a mandatory asset to attract a mate.

Generally, clinicians use the Body Mass Index (BMI) to assess the adequacy of weight in patients. This index, designated as indicator of fatness, is a ratio of the weight (kilogram) in relation to the square of the height (meter) of the person. A BMI score equal or greater than 30 is required to classify a person as obese while between 25 and 29.9, he/she is said to be overweight. In 2008, the World Health Organization reported an increase in the number of overweight and obese people, especially in developing countries where 115 million people bear the burden of disease due to obesity. It is important to note because in developing countries, including Haiti, the many health problems co-exist with poverty and a blatant lack of basic education, strengthening the vicious circle. As a consequence, the impact of obesity goes beyond the individual and also affects the State in terms of cost of related diseases.

01

Betty had a BMI at 34; far along in the side of obesity. When I asked about her diet, she told me that she often consumes fried and greasy meals many times a day. Her sedentary lifestyle along with the popular culture that particularly promotes female thickness is also a factor. Other obese patients have even confessed to having resorted to self-medication and other practices to gain weight and develop a body shape, given the social standards, that is valued by most people. Bearing in mind the concept of health as defined by the World Health Organization, self-acceptance undoubtedly has an important role to play in the overall well-being of a person. But self-acceptance is sometimes too tightly dependent on social norms. Therefore isn’t it important in specific cases to question these norms and ideas of beauty that lead to self-flagellation and degradation of the body in the long term?

For instance, let’s go back to the origins of the Body Mass Index used to determine obesity. It was first described in 1832 by a Belgian mathematician and statistician called Adolf Quetelet. After the Second World War, it became crucial to develop a reliable index of normal body weight as the relation between weight and illness and death represented such a shattering concern in the medical world. But the researchers only referred to Anglo-Saxon populations to gather the data. Hence, the ideal Body Mass Index is not quite representative of the every person since African populations among other ethnics had been ignored in the studies. Another bias is that fat is not the only component of body mass. Muscle mass makes it even harder to generalize the obesity measurement standard. As a matter of fact, studies have shown that blacks have lower body fat and higher lean muscle mass than whites, so the same BMI score may lead to less obesity-related diseases. It doesn’t mean that the index per se is useless in African populations but the situation opens doors to further research which may lead to ethnic adjustments. In that vein certain groups have begun to lower cut-off points for the BMI of Asians.

After our exchange, Betty promptly acknowledged the challenge to merge her idea of beauty with her desired state of health. While the prospect of developing a perfectly objective standard for determining obesity and its health risks is still blurry, we need to keep in mind that the perception of beauty itself remains subjective. The balance between what is culturally preferred and what is healthy is also delicate and difficult to reach. Undoubtedly there seems to be a shift of consciousness among young women in Haiti. Hopefully properly designed and culturally tailored health communication campaigns are going to meet them halfway.

Standard
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.

Standard