Where are the Eggs?

     It took me a while to figure it out. Something was different this stay in Christianville. I had been here for two weeks in October and before that my previous visit was in July. Now it is mid November. C’ville has changed since this summer.

     I used to wake up at 6:00am to the sound of Ken riding past my bedroom window on his motorcycle to turn on the generator. Often I would hear some donkeys braying very loudly. I would always hear the egg laying chickens squawking in the chicken coop down by the fishponds. And depending on the wind, the smell of the chicken coops in the morning could be overwhelming. Breakfast (and all the meals) was in the old guesthouse and it was usually eggs. Now Ken is gone and the only generator that is still functioning is the 100 kV generator and when it is turned on at 6:00 am, it is very loud. The imposing drone of the generator dominates the soundscape all day long. I have no idea where the donkeys went. I have not seen any since the summer. The chickens are gone, too. Egg layers have a maximum productive life of about three years. The C’ville egg layers have aged. The old chickens are trying hard but egg production began dropping off in early summer. The “retired” chickens have not been replaced. I have no idea why. They know that they need new chickens. No chickens, no eggs. That explains why we have not had eggs for breakfast as often as before. I used to complain that we had eggs almost every day. Scrambled eggs or hard-boiled eggs for breakfast; egg salad sandwiches for lunch. Eggs, eggs, eggs. Breakfast this trip has been pancakes, corn flakes, or porridge. Over the last two trips, we have had eggs once or twice. I miss the eggs. But I don’t miss the smell of chicken poop in the morning.

The Road to Baradères in the Rain

     The road to Baradères is worse. Yes, that is possible. Let me explain.

     Both Sister Denise and Father Jacques had warned me the day before we left Gressier that it had been raining pretty hard in Baradères. So we should take the road to Baradères from Cavaillon, not the road from Petit Riviere de Nippes. Sister Denise told me to be careful. The road was bad and be sure the vehicle has four-wheel drive and that the driver knows how to «doublé » (drive in four-wheel mode). So we turned south at Miragoâne and headed over the mountains to the south coast. The sun was shining as we drove through Fonds des Negres, Vieux Bourg d’Aquin, Aquin, and past the beaches of Saint Louis de Sud. We arrived in Cavaillon and I directed Patrick to turn off the highway and zig-zag through the town. Turn right at the market, left toward the church and then right again. Keep going straight until the road ends. And that is where the road to Baradères starts. We had another 90 minutes of driving on the mountain road before we would arrive in Baradères. I hoped.

     The clouds over the mountains ahead of us looked ominous. I began to worry. Rain was the second worst thing that I could imagine on this road. Rain and darkness was the worst thing. At least it was still mid-afternoon. Then it began to rain, only a little at first but soon the rain began to fall in torrents. The Patrol bounced along up the mountain road. And the rain continued to fall. We passed Bonne Fin and the Hôpital Lumiere. Normally the drive from this point to Baradères would take an hour. Not today, I thought. And the road gets worse from Bonne Fin.

     Up ahead the road was cut deep with muddy ruts and a large pile of mud and dirt sat in the road. Patrick stopped the Patrol. It was time to «doublé ». Patrick got out and unlocked the front wheels, jumped back into the Patrol and threw it into four-wheel drive. Patrick inched the Patrol forward into the mud. We stuck. Then he pushed it again and we made our way out of the mud. Up the mountain we continued. And the rain kept falling. Meer pointed out the window. I looked over and I could barely see the next ridge of mountains through the falling rain. I looked out the window on my side of the Patrol. I could see the edge of the road and clouds in the valley beneath us.

     On previous trips, I had seen many things on the road to Baradères: mototaxis, bicycles, tap taps, people, goats, cows, trucks, chickens, sheep, donkeys, and dogs. Today, I saw something new.

Boulder in the middle of the road to Baradères

We came around a curve and there in front of us was a huge boulder that had slid down the mountain and was now sitting in the road. This one had split in two leaving barely enough room for Patrick to maneuver the Patrol around it to get past. Fortunately, there was a passage barely wide enough for a single vehicle to get around it. Another foot to either side and we would probably have had to turn back.

     Further down the road, there was another boulder. Patrick drove the Patrol slowly and approached close to the edge of the road. I glanced down. Was it 40 feet or 400 feet? It really did not matter. If one wheel of the Patrol slipped over the edge, we would slide down the cliff and into the ravine. I tried not to picture the Patrol smashed up on the rocks at the bottom. Sister Denise told us later that a truck had gone off the road earlier in the week. She gave no details. I did not ask for any.

Water flooding across the road

     The rain kept falling and the road in front of us resembled a series of small brown lakes. Then I saw a muddy river, gushing across the road. Run-off from the mountains was pouring down into a stream that now overflowed across the road and then cascaded down into the ravine on the other side of the road. Patrick stopped the Patrol. The road beyond the flooded road pitched steeply upward. He gazed at the rushing water for a moment and then put the Patrol in gear. We edged forward toward the angry, muddy torrent. I suddenly thought about news stories I had heard about cars being swept away by floodwaters crossing a highway. How powerful was that stream of water in front of us? The front wheels entered the swirling water and the Patrol accelerated forward. We rolled through the water and sped up the slope on the other side. A veritable waterfall had formed at the side of the road funneling all the water across the road and down the mountain. But we had gotten safely across. 

Water flooding across the road

     The Patrol slowly wound its way up the mountain. We passed a yellow Camion Mack (dump truck) grinding up the road. It had stopped before a particularly narrow part of the road. The driver motioned for us to go around his truck. We managed to get through the narrow passage. As we continued on up the mountain, we all wondered whether the Camion Mack would make it (it did; we saw the truck in Baradères the next day). 

     Over two hours after starting on the mountain road from Cavaillon, we pulled into Baradères. The rain had stopped. Sister Judith greeted us as we got out of the Patrol. I introduced Patrick and Madsen (she already had met Meer). We went inside the convent where Sister Denise was waiting. We hugged, everyone sat down to eat and Sister Judith brought out four bottles of Prestige. I had traveled eight hours across Haiti and up a treacherous mountain road. I was ready for a beer.

On the Road with Rain and Cholera

     Madsen, Meer and I were making another trip to Baradères. We hired Lamothe’s (Gift of Water) driver and his Nissan Patrol. The driver, Patrick, arrived in C’ville at 7:30 am Wednesday. We had breakfast and started loading up the Patrol. It already had boxes with 98,000 Aquatabs that I had ordered for the Gift of Water program in Baradères. Meer gathered up some bottles to collect water samples and also some containers for stool samples in case we find any cases of cholera in Baradères. There was still some room in the Patrol so I asked if we could fit in the blood chair (for doing blood draws) that Kathy from Operation Ukraine had found and brought for us back in March. It fit nicely. So I felt better. I would not be going up to see Sister Denise empty-handed.

     We never seem to make trips without multiple stops and this trip was no exception. First, we headed over to the Gressier clinic to look for Dr. Celestin, the Clinic Administrator. I still needed to resolve some concerns about the clinic before we could start my STI surveillance project there. Madsen had been trying to reach Dr. Celestin by phone for two days without success. Madsen walked into the clinic and came out less than a minute later. Dr. Celestin was gone. He had been transferred. There is a new person in charge. Madsen has the new person’s name and an appointment to meet with him. This change could be a good thing for my project. We can negotiate all over again and hopefully get what I need at the clinic. We’ll see after we get back from Baradères.

     Our next stop was in Léogâne at Eva’s gas station to fill up the Patrol. As with almost all vehicles in Haiti, the Patrol runs on diesel. It cost 3680 gourdes, about US$85.00, to fill the tank. Madsen and I walked over to the Western Union office and I exchanged US$100 for gourdes and I paid for the fuel. Next stop, the Digicel store. I bought a cell phone for my Study Coordinator. When we get back, I will give the phone to Youseline and load it up with gourdes. This way she can compensate the participants in our study (250 gourdes each; US$5.00) by transferring the money directly to their cell phones instead of me trying to find phone cards to hand out. Next stop, Dr. Merisier, the regional director for the Ministry of Public Health and the Population (MSPP). Madsen had already sent him a copy of my protocol and the approval from the MSPP Bioethics Committee. He just wanted to stop in and introduce me. We spent five minutes at the clinic and were on the road again heading west toward Petit Goâve.

Meer and Dr. Madsen at the Petit Goâve Cholera Treatment Center

     At the entrance to Petit Goâve we pulled into the gas station and Madsen made a phone call. We were going to visit a Cholera Treatment Center (CTC). Cholera cases are on the upswing in the Petit Goâve area and the MSPP had re-opened a CTC outside Petit Goâve. Someone was going to meet us and guide us to the center. A pickup truck arrived and we followed our guide through Petit Goâve towards Miragoâne. We turned off the National Route #2 drove down a dirt side road and then turned onto another dirt road. Five bumpy minutes later, we arrived at the Dispensaire Madeleine. Madsen greeted the clinic doctor and introduced us. Then the doctor led us down a narrow path that ran alongside the concrete clinic building. The CTC was in the back.
It was a makeshift shack made of plywood with a sheet metal roof. At the entrance there was a bucket of clean water on a table and a flat box with a mat soaked with bleach on the ground.

Poster for the campaign against cholera

     We stepped into the box and then into the CTC. There were five patients, including one child, inside. Some were lying on the cholera cots, some were sitting up on the cots. We learned that at least two people had died of cholera recently in the Petit Goâve region. Over the past few months the world watched in horror as Ebola spread through West Africa and then began to decline. Meanwhile, the rainy season came late to Haiti and with it came cholera. The MSPP had closed many CTCs over the summer because there were so few cholera cases. Now the only two CTCs in the region were the one we were visiting and the one in Gressier. Cholera is back. It had never left. The microbe is established in the aquatic environment. It was lying in wait for the heavy seasonal rains to come and mix up the waterways with nutrients that flowed down from the mountains. The bacteria grow, the people drink the contaminated water and cholera is back. Meer shook his head, sadly. He knew all along that cholera would be back. His research published earlier this year showed how the bacterium was now part of the aquatic ecosystem. And now cholera is back.

Family with child who has cholera, Petit Goâve CTC

     We stepped out of the CTC, onto the bleach-soaked mat and washed our hands before heading back to the Patrol. The clinic’s truck was parked in front of the Patrol. Madsen pointed to it. I looked over. Piled in back of the pickup were buckets and hand-held pump sprayers. Buckets for the cholera cots and sprayers for bleach to decontaminate. The MSPP was preparing the CTC in anticipation of more cholera cases. Cholera is back.

Cholera patient lying on a cholera cot, Petit Goâve CTC

Cholera patient lying on a cholera cot, Petit Goâve CTC

     We climbed into the Patrol. It was 11:30am. No more stops. We had another three hours of driving ahead of us before arriving in Baradères. I called Sister Denise and told her we would probably be in Baradères by 2:30pm. That estimate was going to be wrong, very wrong.

Sexually Transmitted Infection Surveillance in Haiti – Day One

     We started today, Tuesday, November 11, 2014. Well, we actually started over a year ago but today we enrolled our first participants. My staff had prepared all the material yesterday afternoon and we agreed on a time to start. Makendy came in early to drive us to the clinic, Haiti Health Ministries (HHM). It is only a 15 minute walk from the lab in Christianville but with all the materials we needed to bring along, we needed Makendy to drive us in the Everest. We left C’ville at 7:35 am and arrived at HHM five minutes later. Jenn, the OB-GYN nurse showed us the rooms we would be using today. We spent about 15 minutes getting our materials and laptops set up in both rooms. By 8:00 am, we were ready to wade into the crowd of people waiting to be seen at the clinic and start recruiting. But first, morning devotions. One of the clinic’s Haitian workers came out onto the porch waiting area and led the crowd in a song and prayer. Then Dr. Jim, an American doctor and the Medical Director, did a reading from the Bible, in Kreyol. Dr. Jim then gave a short sermon, still in Kreyol. He finished up with a prayer and I think he may even have asked for God’s blessing on our project. By 8:20 am we were ready to start recruiting participants for our project but it was also the time for the HHM staff to begin patient intake and measuring vital signs. It was not a good time to recruit. This was why Sandy, the Clinic Administrator, had advised me to have my team arrive early and start recruiting before devotions. In any event, Youseline, the Study Coordinator, began signing up people who expressed an interest in the project. We had set a modest goal of eight participants for our first day: four men and four women. By 8:40 am Dukens, a Research Assistant, took the first participant in our study (a man) through the informed consent process. I stood and watched as Dukens read the Informed Consent Document (ICD) while the gentleman followed along on another copy. Dukens answered the few questions that the man asked and then he signed the ICD. We had enrolled our first participant. Only 1,999 more to go.

     In the meantime, Monise, the other Research Assistant, was conducting the same informed consent process with a woman in another room. Twenty minutes later, Monise had the women’s signature on the ICD and we had our second participant. The Research Assistant quickly started the specimen collection part of the protocol and then conducted the Behavioral Risk Survey. It was almost 10:00 am and things seemed to be going smoothly. There was nothing I needed to do. Well, there was one thing that I did not have time to do before we started. Buy telephone cards.

     Part of the protocol is to give each participant a telephone card worth 250 gourdes (about $5.00) as a small compensation for their participation in the study. I had planned to buy the phone cards in Port-au-Prince on Monday after we picked up Madsen and two other people at the airport. But by the time we got to the Digicel store near Carrefour, the store was closed. I was stuck. Worse still, this morning Makendy had taken Madsen into Port-au-Prince and they would be gone for the day. I called Laura, the C’ville Guesthouse Coordinator. Sorry, she said, all the C’ville vehicles and drivers were out. No help there. I called Matt, a friend who lives at C’ville with his wife, Jessica. Matt has a truck. I asked Matt if he could do me a favor and drive me to the Digicel store in Gressier. Matt said sure. So I told my staff they were doing fine and that I was leaving to buy the phone cards for them to give to the participants. I started walking back to C’ville very worried that the Digicel store in Gressier might not have the cards. Then what? Matt and I drove out to the highway and down the road to the Digicel store. They had no telephone cards. The man at the counter said that Digicel was moving away from selling them anymore. Were there any available at the Digicel store in Léogâne, I asked. He did not know. I told Matt it was not worth driving to Léogâne and risk not finding cards there either. I was moving down the list and already was past plan B for plan B. Then Matt had an idea. Why not just transfer the money from my phone to the participant’s cell phone? It is easy enough to do. Although Matt did not know how to do it, every Haitian knows how because they do it often. And that is the solution that we found to my problem of phone cards for the participants.

     Then I had my other problem. My staff and all of their materials were at HHM and there were no drivers or vehicles to bring them back. There was no way I wanted them to walk back carrying all that stuff. And it was not fair. When we planned the project, we knew that my staff would need a vehicle and driver at the beginning and end of each day. UF needs to hire another driver and we have told them that for months. But their attention has been consumed by the growing problem of electricity. There is only one generator operating in C’ville now and if that one goes down, there will be no power for the lab. In any event, my staff needed a ride back to C’ville now.

     As Matt and I pulled into C’ville, I saw the other UF Everest parked next to the lab. Mille, who collects mosquitoes for the malaria project, had just returned from setting traps. I leaped at the chance and asked Meer if I could use Mille to pick up my team. Meer said yes and I was back at the clinic at 1:00 pm just as Dukens and Monise were finishing up with their last participant for the day. We were back at the UF-EPI Haiti Lab 1 Gressier at 1:15 and ready to start testing the specimens for Chlamydia, gonorrhea, syphilis and trichomoniasis. The lab work went smoothly but slowly. It was only our first day so I expected that. While we waited for the test results on the GeneXpert (a 90 minute test), I handed my cell phone to Youseline and instructed her to transfer the 250 gourdes to the cell phone accounts of our eight participants. By the time the results came off the GeneXpert, it was 5:15 pm; all eight participants had been tested. We had two positive tests for trichomoniasis. All the other tests were negative. One test for Chlamydia and gonorrhea (on the GeneXpert) was invalid and had to be repeated. It was negative.

     So we had a good first day. I was very happy but exhausted. And tomorrow I leave for Baradères and my team will be on their own. I am confident they will do well.

Smoke

     I smell like smoke. It’s Port-au-Prince (PauP). I just spent five hours driving through PauP. We left Christianville in the Kia at noon with Eugene at the wheel. Makendy was out collecting samples and was not available. Eugene is a C’ville driver. I had never ridden with him before. We drove to the PAP airport to drop off Char and Bill and Char’s daughter who were in C’ville over the weekend to artificially inseminate the goatherd. Then Eugene and I drove up to Epsilon Medical Supplies. I had a shopping list of supplies to pick up for the STI study. I had called Marc, the owner, to let him know we were coming and he started pulling some of the supplies out for me before we got there. Eugene had never been to the store so I called Makendy and had him give Eugene directions on how to get there. He did alright and we were soon in the store. I paid with my Jackson pre-paid credit card (what a relief!) and we loaded up what Marc had in the store. We then followed Marc over to his storeroom for the remaining boxes. The storeroom is over Gamma Medical Supplies, the store run by Marc’s parents. It’s all in the family. We moved down the dusty, unlit upstairs hallway past rooms marked off with numbers. Then Marc found the supplies I needed. As we walked out and back down the exterior stairway, Marc warned me not to step too close to the side wall which was topped off with a roll of razor wire.  Then we were on the road back to the airport to pick up Madsen and two other people from UF who were arriving on American flight 1665 at 2:30. If you ever fly American into PAP, you are likely to be on flight 1665 in-bound or out-bound, or both. I think it is the same plane that just flies back and forth from Miami to PAP. Every day.

     As we drive down Delmas 3, I stare out the cracked windshield of the Kia. The windows are rolled down. The Kia has no air-conditioning. Traffic is backed up, as usual. As the trucks and tap-taps in front of us inch along, a burst of the black diesel smoke of first gear fills the air. We drive through it. Traffic stops. We stop. Traffic starts up again and the air is filled with smoke again. And so it goes. There is smoke everywhere. From the endless line of cars and trucks and tap-taps belching black diesel fumes from their exhaust pipes to piles of trash burning on the side of the street. Things burn in Haiti. In late afternoon, it seems to be worse. People set their trash out to burn. There is some trash pickup now in PauP but even that trash is burned.  Along the Route de Rails at the entrance to Carrefour, there is a large trash dump with a perpetual shroud of smoke hovering over it. At times the smoke coming from the burning trash dump drifts over the road obscuring all traffic in front of us.  In addition to all that smoke, Haitians burn charcoal for cooking. Even in the cities like PauP. That is why you can see charcoal for sale in the markets in PauP. And out in the country, they burn wood to make charcoal. So tonight, I smell like smoke. I'm exhausted and I smell like smoke. I'm back in Haiti. Need some sleep. Big day tomorrow.

Now We Begin

     Sunday, I flew back into Haiti with two suitcases full of material for the STI surveillance project. My flight out of Washington was late arriving in Miami; I had 10 minutes to get to the gate for my connecting flight to PAP. I made it in time. But would my bags make it? This flight was the last one out to Port-au-Prince for the day. My hopes sunk. But as I sat on the plane, the captain announced that they were waiting for the thunderstorms over Miami to clear before we could take off. That left enough time for connecting baggage (mine!) to get loaded on the plane. I found my bags on the Prestige beer carousel (the baggage claim carousel is covered with advertisements for the Haitian national lager beer) after customs and I grabbed them and walked out into the early evening heat and humidity. Meer was there to greet me. We waited for Maha, a student from UF who is working on malaria, to come out and then we loaded up the Everest and headed back to Christainville. It was the start of another stay in Haiti but this time we begin the STI project.

     Over the past year I have felt squeezed on all sides with the difficulties of getting my STI surveillance study underway. I have frequently found myself spending so much time dealing with issues of a completely non-scientific nature. I am caught between two unyielding forces: unrelenting poverty (in Haiti) and inflexible bureaucracy (everywhere). It has been a succession of daunting tasks to overcome to get this far. Many times I have just felt that it was not worth all this effort for such a small project. Even today, I felt that way. Why am I still trying to do this? What good can we accomplish? How much data can we get? How useful will it be? Can we continue beyond the original funding period, that is, will the project be successful enough that my sponsor will agree to continue to support the surveillance long term?

     But during this trip, we start. I am both excited and anxious. Excited to finally begin and anxious about what will happen when we actually begin the STI surveillance. What can go wrong? How well prepared is my staff? Do we have all the materials we need? What can go wrong?

Mission Creep

     This morning at breakfast we learned of a new Christianville policy. Effective today, in addition to a prayer, each breakfast will be preceded by a reading from the Book of Psalms.