The following article appeared in the Boston Globe on September 17, 2003.  It is part of the Boston Globe's ongoing series on world health challenges.

Community health effort gains in Haiti

By Raja Mishra, Globe Staff, 9/17/2003

This report continues a series, begun on Jan. 26, on world health challenges and the solutions that are within reach.

CANGE, Haiti -- In the stifling dark, they rushed Elmanie Joseph from room to room, poking and prodding her, and finally left her in a frosty suite with white walls and white sheets and glaring white lights. She shivered, clutching herself and humming quietly. And then she prayed: "If God gives me life, I'll take it. And if He gives me death, I'll take it, too."

The doctor had told her: We must cut out your baby now. In all the commotion, he'd mentioned words like post-term pregnancy, vaginal bleeding, cesarean section. But the shy, girlish 25-year-old from a remote village in the poorest region of this dirt-poor country did not understand. She had no clue her baby could not fit through her narrow, malnourished hips. That they both might die without surgery.

And had it not been for a simple suggestion from a specially trained fellow villager -- go see the doctor -- she might now be lying in the dark of her ramshackle home, on the verge of hemorrhaging. Instead, her father had helped her make the seven-hour trek to the clinic, where doctors now raced to save her life.

In Haiti, women face a 1 in 16 lifetime risk of dying during childbirth, according to the United Nations. That's about 255 times the risk in the industrialized world generally, and more than 200 times the risk in the United States.

More than half a million women worldwide die from childbirth annually, almost all of them in the developing world. They bleed to death from prolonged labor, often because babies are too large to deliver smoothly from malnourished mothers. They acquire fatal infections giving birth in squalid conditions or from fetal deaths in utero. About 15 million women survive such complications annually, but often with permanent damage and lifelong pain.

In a series of articles this year, the Globe is examining why people perish from diseases and afflictions virtually unknown or easily treated in the developed world. At the same time, in many poor corners of the world, simple fixes are saving lives. That is the case here, in Haiti's Central Plateau, where thousands of landless, jobless peasants struggle to live amid the lush green meadows, swaying palms, and craggy peaks.

The entire Lives Lost series is available online at

In hundreds of villages like Elmanie Joseph's, community health workers armed with the most rudimentary medical training teach their neighbors how to stay healthy - and help get them to clinics if they need the attention of a doctor. The community health agents have been trained by Partners in Health, a Boston-based nonprofit that runs the clinic in Cange. The premise is simple: The clinic won't be of much use if the patients don't arrive in time.

Just under two hours by plane from Miami, impoverished Haiti is in dire need of such intervention. Its problems are unrivaled in this hemisphere. Most Haitians are descendants of slaves, who overthrew their French masters in 1804. About 80 percent of Haitians live in poverty. Two-thirds are unemployed.

The country's government remains dysfunctional. The 1990 election of president Jean-Bertrand Aristide ended decades of dictatorship, but did not end the instability. Mercenaries still roam the countryside. They murdered four people in the Central Plateau last July when Globe reporters were visiting the region.

But in the midst of this suffering, seemingly modest efforts are saving lives. In a sweltering classroom on the clinic grounds, nearly 50 Haitians - mostly older, mostly female - listened one recent day to nurse Cynthia Orlus, who held up a cartoonish drawing of a man's chest.

``With tuberculosis, you need to remember that every organ in your body can get infected,'' she said.

Some students nodded. Others stared blankly. One patted the stray tan mongrel wandering between the desks.

These villagers from around the Central Plateau are training to become ajans sante, or community health agents, skilled enough to give basic advice and recognize when something is seriously wrong.

``The program is absolutely vital for treating treatable diseases in the Third World,'' said Partners in Health executive director Ophelia Dahl, who works in Boston. ``This is the model for the Third World.''

The ajan sante program began with an attempt in the 1980s by local doctors to conduct a health census and sociological study of the Central Plateau's villages. This region is home to only 10 percent of the population, but they are the poorest people in Haiti. The doctors tapped local contacts in many of the villages - and then realized these villagers, with training, could also help with basic medical diagnoses and treatment.

Partners in Health started the program in 1987, and since then has trained more than 600 Haitian villagers. The trainees must be literate and trusted by local villagers; often they are elders or those with leadership positions in their towns. The Haitian government supports the effort but gives no financial assistance.

About 20 at a time gather at a training facility near the capital, Port-au-Prince, where they spend three months learning the basics of health care. It now costs $15,000 to train all 20, including room and board. Partners in Health pays the bill.

Back in their villages, each ajan sante earns a $100 monthly salary. They return to the Cange clinic once a month for a day of further training. After the initial training costs, maintaining this small army of health workers is a minimal investment with a large return, according to health care specialists who have studied the program. Partners estimates it has spent $100,000 over the 15 years of the program.

``It's a great value for the money,'' said Dahl, whose group receives funding primarily from private donors for its global projects. In Peru, it works on shantytown tuberculosis cases; in Russia, with tuberculosis sufferers in the prisons; and in Roxbury, with poor HIV patients.

The health workers are given a kit with basic equipment like thermometers, blood pressure gauges, painkillers, and antimalarial pills. Some of the health workers receive training that focuses on women's health issues, including prenatal care, family planning, and pregnancy complications. Others focus on delivering HIV and tuberculosis medications to patients, making sure patients maintain a strict pill-taking schedule.

Dahl said the system has proved so effective that it played a central role in convincing skeptical medical experts around the world that HIV and TB patients in the developing world could indeed be treated by the same drug regimens that are used in wealthy nations.

The program initially focused on the area around the Cange clinic, along the banks of Peligre Lake. The initiative was designed to help villagers displaced by the construction of a dam supplying power to the capital, which flooded their villages and farmland. The Partners in Health clinic here opened in 1985. In the past year, a stream of HIV-focused donations has allowed the group to accelerate the training program and increase the number of villages covered in the Central Plateau. Though HIV looms large in the new agents' routines, they also monitor all health conditions, including pregnancies.

Basic training

In the classes, the health workers are trained in the essentials of nutrition, hygiene, and prevention of infections. They also learn to keep track of the development of newborns. And they learn the warning signs of serious illnesses, cues that reveal when a villager needs to see a doctor. There is much to learn, but the basic lesson, repeated again and again, is simple: When in doubt, send patients to the clinic.

In one recent refresher class, a man raised his hand.

``I have a family in which many people are coughing,'' he said. ``Should I bring them for screening? How do I know if they have tuberculosis?''

``For tuberculosis, there are many signs and symptoms and treatments,'' replied nurse Orlus, jotting a list of terms on the blackboard. ``Now we're going to study the signs.''

In essence, these men and women will fill part of the role played by primary care doctors in the United States. Haiti has a severe doctor shortage, and these volunteers help fill the gap.

During the refresher course, the agents are briefed again on a dizzying array of health problems.

Later in the session, Orlus told them: ``After a man urinates, he should be dry. If he's wet, there may be a problem.''

The class dissolved into laughter but Orlus explained that the problem could be very serious, possibly prostate cancer, and that the patient should be referred to the clinic. And soon she moved on to women's health.

``If you find a woman with pelvic pains, you need to tell her to go to the health clinic,'' she said.

The students are taught to check pregnant women for bleeding, pelvic pain, and other indicators of trouble, and to send those with problems to one of the five clinics in the Central Plateau. For pregnant women, getting this sort of basic guidance can make the difference between life and death, for the mother and the fetus, according to numerous studies.

In the United States more than 99 percent of births occur in the presence of a skilled attendant, usually a physician, according to UN and World Bank data released in 1997. In the developing world that figure is 58 percent; 60 million women give birth annually without any skilled attendants, sometimes alone.

In Haiti only 24 percent of births occur with skilled attendants present, because there aren't enough doctors or nurses in the country to oversee every birth. But community health agents can help.

The community health agents ``are the most important thing in the system,'' said Dr. Maxi Raymonville, the clinic's chief obstetrician. ``They are the base of the system. I have no idea what's going on in the villages. I can't be everywhere.''

By getting women to the clinic, Raymonville said, the agents are saving lives: ``The maternal mortality rate here in this clinic is zero, because we have everything we need to treat patients. I cannot remember when I last saw a woman die here during pregnancy.''

The prevalence of maternal death in Haiti and the effects of intervention are tough to measure. The deaths often occur at home and go unreported, and poor governments simply lack the record-keeping capabilities to keep track. Most current figures are based on a one-time global UN study released in 2001.

That research found that about 1,100 of every 100,000 births in Haiti end with the mother's death. In the United States, only about 8 per 100,000 end in maternal death.

Put another way, the research found that about each year 2,800 Haitian women die painful, protracted - and preventable - deaths, for want of basic care.

Women like Elmanie Joseph.

Elmanie, wearing a plain white dress, white lace cap, and orange slippers, showed up at the Cange clinic on a bright Thursday morning in early August. She said nothing but held a white envelope with a name: ``Dr. Maxi.''

Raymonville, one of the most experienced birthing doctors on the Central Plateau, grabbed the envelope from her. ``Twenty-year-old pregnant woman with [expected date] 27-Jul-03,'' it read, penned by another doctor, who worked in a smaller clinic five hours' walk from Elmanie's village. She had been referred to that doctor by her local ajan sante.

Elmanie was four days overdue, perhaps more because many women have difficulty gauging their expectancy dates. The note also said Elmanie was HIV-positive and probably suffering from tuberculosis, but these were secondary concerns at the moment.

Elmanie's journey

Elmanie lives in Bouli, a tiny hamlet in the hills. Getting to Cange required a five-hour walk over steep hills, followed by a two-hour car ride over bone-jarring roads. Her parents have five children and no income. Her father grows some corn to feed his family. Clothes come from donations, housing from pieces of wood and metal found in the countryside. She completed the third grade in her village school.

Elmanie is shy and quiet, with a bashful smile and wide eyes. She is a malnourished reed: slender arms, hands, and fingers, narrow legs. It seems as if at any minute she'll topple over from her bulging pregnancy.

Elmanie dreams of opening a tiny village shop, peddling clothes and shoes. The Church of God, the local Protestant church in Bouli, is the center of her life.

``I pray to God as best as I can, and I ask him to give me courage,'' she said. ``The most important thing in my life is God.''

Her thoughts often dwell on ``the God in the sky,'' an omnipresent force that she said tended to poor Haitians struggling in the Central Plateau.

When asked about Carmello, her child's father, Elmanie is at first dismissive. He is in the Dominican Republic, on the other side of the island, she said. He is ugly. She doesn't want him around.

But then she volunteered: ``I became his girlfriend because I loved him.'' His disappearance still pains her. Carmello's aunt and uncle, who raised him, thought Elmanie was not good enough for him. They sent their nephew away to the Dominican Republic to seek work - and avoid her. He never sent word. After not hearing from him for two months, Elmanie pieced together the events through local gossip. She now thinks she will be alone, perhaps forever.

At 10:35 p.m. the day after her arrival at the clinic, doctors hustled her into the operating room to do a cesarean. Elmanie resisted, calling out for her father, weeping, squirming.

Nurse Lea Jeannis gripped her shoulders, looked her in the eye, and said firmly, ``We are doing this to save your life. We are going to save your life.''

Raymonville and his colleague Dr. Saintard Renel were to operate, with six others assisting. The clinic is one of the few places on the Central Plateau to offer free surgery.

The surgeons covered Elmanie with blue cloths, exposing only her massive belly. Renel sliced with a scalpel. The close-knit team grew quiet. Several more incisions opened her stomach muscles, revealing the purple, veined amniotic sac enveloping the baby. Renel sliced through it, then Raymonville began wedging it open with surgical tools.

Suddenly, a geyser of blood and fluid spurted into the air, splattering the doctors. They froze. Renel saw the unexpected complication. Raymonville did, too: Elmanie's placenta, the tissue mass inside the womb that nourishes the baby, was in the wrong place, at the bottom of the womb rather than the top. The cut into the mislocated placenta could cause Elmanie to bleed to death.

Renel reared back and thrust his gloved hand straight into Elmanie's womb, gripping the baby's head. He yanked once, then again, ripping the baby away. The shriveled newborn gurgled. A third surgeon rushed forward with a tiny green air pump, shoving it into the baby's mouth and giving it air with three quick squeezes. The staff pediatrician rushed in, wrapped the infant in a towel, and spirited him away.

Meanwhile, Renel frantically swabbed blood from Elmanie's belly and womb, but it soaked the white sheets, ran down the table, and pooled on the floor. A surgical assistant noticed blood on Renel's exposed forearm. He knew Elmanie was HIV-positive and rushed to wash it off.

A new mother

After 25 minutes of surgery, including the removal of the placenta, Elmanie had passed through the moment of mortal danger and now was stable. The surgeons slowly began removing the rest of Elmanie's blood-soaked placenta, methodically clipping and cutting it away, while suctioning blood with a vacuum pump.

The baby, resting under a warm lamp in the room next door, weighed 5.5 pounds - a little low but basically healthy. His eyes remained shut tightly, but he drew gentle breaths. His skin was light brown, his face squat with wisps of eyebrows. He looked like his mother.

The next day Elmanie had a fever. Her stomach was sore. She could not eat. Her boy slept in a bassinet next to the bed. She had no clothes for him. Later in the day, a clinic employee loaned her some.

Another day passed, and Elmanie's fever waned. A nurse gingerly walked her around the room, trying to hasten recovery. But Elmanie remained baffled by the whole experience: ``I wanted to have the baby at home. I didn't know they would take it out.''

All 13 beds in the post-op ward were filled, three fans blowing thick, muggy air. The women lying in beds next to Elmanie moaned in pain.

Elmanie's family will be hard-pressed to care for the new arrival on their nonexistent budget. Her father Emmanuel Joseph pledged, ``As long as I'm alive, I'll do what I can,'' then begged a visitor for money.

Elmanie lay on her side, her skinny legs a dark brown silhouette beneath a thin white sheet. From time to time, she glanced at her boy and smiled. And she gave him a name: Samuel.

``I see my baby, and I'm happy,'' she said. ``I like him so much. He is my life.''

Raja Mishra can be reached at Dina Rudick contributed to this report.

Copyright 2003 Globe Newspaper Company.

Copyright 2003 The New York Times Company


Health problem US Haiti
Maternal mortality (per 100,000) 12 1,100
Percentage of births attended by skilled personnel 99 24
Health spending per capita $4,499 $56
Tuberculosis (per 100,000) 2 190
Percentage of women age 15-49 with HIV/AIDS 0.2 5.7

SOURCE: UN Human Development Report 2003; Population Reference Bureau

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