TIH: Zon Riral (Rural Area)

The morning arrived sooner than before. As we were scheduled to visit a rural site, it was necessary to depart earlier in order to treat all patients and return to the camp before dark. The cold faucet water was a refreshing way to jar my body awake.

We were headed to Thomazeau, on the northern end of Lake Azuei, which separates Haiti from the Dominican Republic. This was a rural area, untouched by the devastation of the 2010 earthquake. 

It was easy to become complacent in Haiti. The streets were full of life and business. Children boarding school buses, merchants bringing products to market, tap-taps navigating the congested traffic. It seemed safe. Passing UN tanks with armed soldiers signaled that all was not well, at least not yet. 

As we approached the outskirts of Port au Prince, the paved asphalt roads faded to dirt, with craters carved by erosion.This was a different side of Haiti. The congested urban atmosphere was replaced by clear skies, farmland, trees, and livestock. While there was a definite shortage of healthcare in the city, the need was just as pronounced in rural areas. 

We arrived at the site, and began to clean up. We were working in a community clinic, seemingly underused. Dust covered the tables, donated pharmaceuticals, and examination tables. 

I elected to work with the 2 team Ob Gyns-- A young and energetic Irish resident, and a very experienced American physician. We began organizing the room to suit the modesty requisite for gynecological exams. The room was rather bare, except for a pair of exam tables, a table, and chairs. No electricity, no water, no toilets. We hung tarpaulins from the ceiling with duct tape to create a privacy curtain, and angled the furniture. We designated a secluded area in the backyard of the clinic to obtain urine samples. Even without ideal supplies, preserving dignity was a priority. 

As I obtained history from the female patients, I noticed a startling trend. Most women had suffered losses of children. I wrote their history in standard medical format, sadly denoting them as Gravida 12, Para 2, or Gravida 7, Para 0. What happened? Why had these children perished? Why did the fetuses miscarry? The patients didn't know. The vast majority had delivered children at home, with no formal prenatal care, and no supervision even from a lay midwife. This was rural Haiti. No NICU, no neonatal resuscitation, no Cesarian sections. I had the heartbreaking realization that these babies, thousands in number, would likely survive if born 700 miles away, in the United States. 

Ayida, a pregnant 16 year old, came into clinic in tears. Her baby wasn't moving. She had suffered a prior miscarriage, and was terrified that she had lost this fetus as well. Through the translator, we attempted to calm her as we powered up the fetal heart rate monitor and measured her slightly distended abdomen.

The translator was uneasy with this situation. He, being a strict Catholic, disapproved of the unwed and pregnant patient on the seat before him. He scolded her in Creole for her "irresponsibility". Viewing her fragile state, I was compelled to intervene. 
 
Other providers stayed busy in the "general clinic" --  a collection of cots and chairs gathered in a large room. As expected, patients arrived with common ailments as well as the more obscure. A baby boy with light spots on his cheeks was determined to have neonatal lupus. A patient with a circular rash was diagnosed with sporotrichosis, a fungal infection I had only seen in USMLE question banks. 

As we wrapped up the clinic, a nurse noticed that a bag of antibiotics had not been given to the patient. A review of the prescription revealed that the antibiotics treatment was for a sexually transmitted infection, with enough pills and injections for the patient and her partner. If they did not complete this regimen, they risked spreading the infection to others in the community, or developing infertility. We had no address for her. She had worn a skirt, but there were no patients with her description in sight. What could we do? 

Zon Riral. As I learned during my stay in East Tennessee, rural areas are very small worlds. Every resident knows everyone else. With a few questions to the director of the clinic, we were able to locate a relative of the patient, who affirmed that she could deliver the medication and instructions.

The loaded buses reeled and groaned as they began the slow journey back to Port au Prince through the rutted, rocky paths. We were tired, but grateful for the opportunity to help 362 patients in rural Haiti. 


[to be continued]