When it comes to healthcare, the US can learn a lot from Haiti, a nation that US president Donald Trump once derided as a “shithole” country.
Haiti’s extreme poverty has prompted ingenious new strategies for maternal care, an area in which the US lags badly behind other developed countries. The majority of rural American women don’t have access to an OB-GYN doctor within a 30-minute drive. Maternity wards are closing in sparsely populated areas, forcing pregnant women to deliver in emergency rooms instead. That can mean insufficient care before and after the birth—which helps explain why the US has the highest rate of maternal mortality and severe illness among high-income countries.
To save American mothers’ lives, the US healthcare needs structural changes, including better Medicaid payments and caps to malpractice charges. But rural US states could also adapt the innovations being pioneered abroad—specifically in poor developing countries, which are all too familiar with shortages of doctors and the difficulties of rural access to healthcare.
The last mile
The people of Borgne are some of the poorest citizens in one of the world’s poorest countries. The 80,000-resident community is extraordinarily isolated, trapped between the sea and the mountains of the Massif du Nord, Haiti’s longest mountain range. Most of the population lives in habitasyons, villages hidden in the area’s thick vegetation. The main town is about two bumpy hours by car from Cap Haïtien, in the country’s north, and 12 hours from capital city Port-au-Prince.
Up to 94% of the town’s residents live on less than $2 a day, primarily by farming yam, cocoa, coffee, coconut, pineapple, and other products in their backyards and selling what they don’t eat. The area is amongst the ones with fewest hospitals (pdf, p. 27) in a country that already has the worst health indicators of the Western world.
The entire population is served by one small hospital, ran by Haiti Outreach Pwoje Espwa (HOPE), a rural development non-profit financed by grants from USAID and other organizations, as well as by individual donations. Before HOPE began operating the local hospital in 2006, Borgne’s health system was in complete disarray, according to residents and health workers now employed in the hospital. The entire health staff consisted of one auxiliary nurse, and there were no hospitals, clinics, or pharmacies.
The diseases of poverty—parasites, anemia, malnutrition, hypertension, HIV—took lives regularly, and the maternal mortality ratio was a staggering 452 per 100,000 births—over five times the Latin America average of 77 per 100,000. The entire district had no blood bank.
A decade later, things look very different: Despite several large hurricanes, a major earthquake, and a cholera epidemic, the population of Borgne is healthier than it has ever been. Thousands of people can now access routine medical care. An HIV epidemic—the most severe in the Caribbean and Latin America—is winding down, with less than 2% of the population infected; those who are HIV-positive now get antiretroviral drugs. Women can now get birth control, ovarian cancer screening and treatment, pregnancy care, and even C-sections.
Health records show that between 2010 and 2013, the total number of maternal deaths recorded in Borgne was 34 (or about 8.5 per year). In 2017, only three women died due to pregnancy or complications (without accounting for the maternal deaths not recorded by the hospital). So far this year, there’s only been one pregnancy-related death.
Getting out there
The hospital changed life for many in Borgne, but not all.
For most of the town’s population the hospital is a several-hour walk away. Roads and transportation aren’t any better today than they were in the early 2000s. So HOPE’s health team decided to share the burden of the journey by deploying a network of mobile clinics. They visit remote localities twice a week.
After a small pilot in 2006, the system of mobile clinics really kicked into gear during a 2010 cholera epidemic. At the time, mobile clinics became life-saving hydration stations for people who would otherwise not survive the journey to the hospital.
In 2014, the mobile clinics began offering women-only services through a partnership with WomenStrong, an international organization focused on female-centered health and empowerment.
On a recent afternoon, a dozen HOPE nurses and doctors forded the Rivière du Borgne, the river that separates the village of Tibouk, a couple of hours by foot from the hospital, and the habitasyon of Basin Kayman, where one of the mobile clinics is set up. The trek involved crossing the windy, cool river at six different points, with big boxes of medications and supplies atop some of the workers’ heads. By the time they reached Basin Kayman, about a hundred local women were already gathered, waiting.
They set up inside the habitasyon’s largest home, volunteered by its owners: a two-room, low-ceiling cement structure with a few photos and plastic flower garlands on unpainted walls.
Some of the patients had walked four or five hours to be there. Two women from the village announced what services were available, how STD testing worked, and reminded women that “a negative result isn’t forever, you need to be careful, always wear protections and do [the test] again in three months.”
Tests, for HIV and syphilis, were done with the speed and effectiveness of an assembly line: a prick of a finger, a drop of blood on two test strips, a small piece of paper as a receipt—in less than an hour, at least 127 women were tested, all negative. On the opposite side of the room, two doctors sat at desks consulting with patients, while in a smaller, adjacent room with a curtain for a door, women underwent gynecological check-ups. Medicine was distributed from a makeshift dispensary on the porch.
Though relatively new, the women’s clinics have offered services to 76% more patients in 2016 than were reached by HOPE in 2014, when the organization began collecting reliable data. In those two years, prenatal clinic visits grew fivefold, as did general consultations. Testing for HIV and syphilis has quadrupled. Over 5,000 women in three years were tested for cervical cancer—just over 200 were found positive and treated with cryotherapy.
One patient at Basin Kayman, Masila Montanier, 31, was in the ninth month of her sixth pregnancy; she had already been checked three times, screened for common complications, taken prenatal supplements, and was taught to monitor the risk symptoms of preeclampsia.
Though the mobile clinics cannot perform services like ultrasounds, Montanier says their care has made her feel safer. Checking women through their pregnancies means mobile clinics can refer any warning signs to the area’s hospital; they can also encourage women to plan ahead to give birth there.
After a couple of hours, the clinic packed itself up and set off on the walk home.
Building on tradition
Sometimes women do have to come to the hospital.
On Jan. 24, for instance, four women were recovering in Borgne hospital’s maternity ward. Three had uncomplicated pregnancies, including Madeleine Chevalier, 34, who made the three-hour walk to give birth in a hospital. Another, Julienne Ocean, had been brought to Borgne after hemorrhaging during delivery in the village of Tibouk. Both delivered healthy baby daughters.
One way the hospital gets patients to make the trip is through a complex incentive structure that relies on traditional figures like community leaders and midwives. HOPE trains selected women on gender equality, women’s empowerment and health; those women, called animatrices, are charged with maintaining the health of their habitasyons.
Animatrices overlook the work of the matwans, traditional birth attendants, and encourage them to undergo training to dissuade them from harmful or ineffective practices without undermining their traditional role. Matwans outnumber doctors and nurses, with about one matwan for every 346 women (pdf, p. 68). Their collaboration with the Borgne hospital is vital: They are paid to refer at-risk pregnancies to a clinic or hospital. Other traditional health workers keep updated health records of community members (stored in the hospital), and watch the population for outbreaks and emergencies.
Even voodoo healers have been integrated into the hospital’s approach. The hospital discusses traditional voodoo with respect, and treats voodoo healers like peers, explains Thony Voltaire, a Cuban-trained physician who returned to his native Borgne in 2005 to spearhead the hospital’s renovation. “It’s a partnership” he explains, “there is an element [of health] that concerns them, and one that concerns us.”
He says that he has managed to convince many healers to refer patients to the clinic to take care of their bodily ailments, while continuing rituals regarding spiritual wellbeing. “It’s not a fight,” he says.
At the core are the mothers themselves. “What moves the program are the mothers clubs,” explains Rose Marie Chierici, HOPE’s founder. Mothers clubs are groups of 60 women of reproductive age in each of the eight rural districts of Borgne. They meet twice a month for six hours to learn about a variety of topics, from de-escalating domestic conflict to sexuality to business skills.
“There are 480 women a year in the [mothers clubs],” Chierici says. “That’s 480 women whose family benefits, 480 women who become local leaders.” They are the ones who educate other women on sexual and reproductive health, sometimes adapting traditional chants to share contemporary medical knowledge. One, for instance, explains the symptoms of a risky pregnancy:
Gen plizyé siy ki danje
Pour fanm ansent
Si ou wé ou genyen siy sa yo
Pa rete de bwa kwaze ap fade
Se pou kouri tou swit al nan dispansé
Si ul gen gwo malté 2 ou 3 jou
W’ap bay san pa ba ale nan dispansé
Si pyew ap anfle, w’ap bay dlo pa ba pa ret
Chita kouri al nan dispensé
(There are many signs of danger for pregnant women
If you recognize these signs in yourself
Do not stay with your arms crossed and do nothing!
You should run to the hospital or the clinic.
If you have headaches that last two or three days
If you see blood stains when you urinate or in your panties
Don’t wait!
If your feet are swollen and you leak fluids
Don’t just sit and wait! Run to the hospital or clinic!)
And it’s not all health care. Another song teaches, “Women are not brooms to put in a corner. Women are not a curtain you push aside when going out. Women are not like a bed that is nicely made but never goes out. Women are the pillars that sustain life.”
For richer and for poorer
There is little in common between impoverished Haiti and the wealthy US. And yet, Borgne’s combination of nimble mobile care and deep community involvement could potentially save lives within the US system. While there are mobile clinics in the US, too—about 1,500 to 2,000 as of 2013 [pdf], delivering a range of services to underserved communities— they don’t operate systematically, and lack community involvement, according to researchers.
‘The health needs may be different, and the health care is, certainly, but the experience for women is the same,” says Natalie Whaley, a University of Rochester obstetrics professor who has visited Borgne to observe its success. Whether a woman has to walk or drive hours to the hospital, obstacles to care are a critical problem. In Texas, for instance, the US state with the largest rural population (nearly 4 million people), only 69 of the total 163 rural hospitals have a maternity ward.
Things aren’t much better in big cities: New research published by Doximity, America’s largest network of physicians and health care workers, showed that even large metropolitan areas—such as Houston, Los Angeles, and Miami—experience shortages of OB-GYNs. This, the research found, is particularly true in places where a large share of the population is poor.
Whaley, who routinely works in remote, often poor areas around the world, says community participation in those places is much higher compared to the US. She thinks that American rural and poor areas would be able to serve a larger population, and better, by involving local communities in a way similar to what she’s seen in Haiti and other developing nations.
This is the same conclusion reached by a task force led by researchers at Mount Sinai Hospital, in New York, who studied healthcare progress in several developing countries with the intent of identifying smart solutions that could be imported to the US. The main lesson they found: Integrating communities in the local health care systems.
Carrie Henning-Smith, a University of Michigan health services researcher, says that the US has mostly focused on telemedicine and remote care to improve rural health, perhaps, because it’s does not equate innovation with traditional, low-technology practices such as community engagement. And yet, evidence shows it works. “When we think about care we do so very narrowly,” says Henning-Smith, “but I think in some ways [poorer] countries may be ahead of the curve.”