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

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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.

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