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William F. Connell School of Nursing

Looking for Answers

creating change in haiti - spring/summer 2009

haiti_looking


By Joshua Jensen

For the past six years, Clinical Assistant Professor Donna Cullinan has taken a week out of her busy life to travel to Léogâne, Haiti—a small city 18 miles outside of Port au Prince—as part of a medical mission team. Cullinan and her close friend, Susan Daoust, had always talked about doing some kind of international service work, but for years were busy with their work and family lives. That all changed six years ago when Daoust heard that her church—Christ Church in Needham, Massachusetts—was putting together a medical mission team to Haiti. "When Susan asked me if I was interested, I realized that the timing was perfect. My kids were finally old enough that I was comfortable leaving them."

For Cullinan, Haiti is an ideal place for a medical mission, because of the extreme need. "I really wanted to go on a medical mission, so I probably would have gone anywhere. But we are really needed in Haiti. It is the poorest of the poor. They have so little, but we're able to provide them with some measure of comfort, and they are very appreciative of that."

Emilie Hitron, a physician at St. Elizabeth's Hospital, organized the original mission from Christ Church, and is the team leader. Each year, around 12 healthcare professionals, including Cullinan, travel to Haiti. Around eight of the team members are previous participants. Both physicians on the team bring medical residents with them, and Cullinan brings a Connell School graduate student or recent alumna as well.

This year, Nora Sheehan '08 joined the trip. "I jumped at the chance when Donna offered me the opportunity to be a part of the team," recalls Sheehan, who participated in the Connell School's Global Health Initiative trip to Nicaragua last year. "Traveling to Haiti was an amazing experience and another exposure to the disparities that are generated from limited access to healthcare."

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Nora Sheehan '08, who participated in the trip for the first time this year, treats a baby in one of the clinics.








Over the years, Cullinan has formed a strong bond with the other members of the team. "We have a wonderful friendship, even though many of us don't see each other outside of planning meetings." The team gets together once each month for planning. After the trip, they come together with their families to share pictures at a potluck dinner.

Cullinan explains that the mission team is part of a loose network of groups across the United States that travel to Haiti. Their goal is to coordinate well enough to ensure somewhat regular visits from medical professionals in each visit. While independent of each other, the teams share information through conferences and informal networking and make use of mutual local connections in Haiti.

According to Cullinan, there is almost an entire local industry set up for the purpose of supporting these mission groups. Their team employs drivers and trucks for transportation, hires donkeys to carry their supplies, employs local translators, and pays for their meals to be prepared as well as for lodging at a guesthouse on the hospital grounds. All of this helps support the local economy.

Building long-term relationships with the local support people is part of the reward for Cullinan. "I got a really nice email this week from one of my translators, Mario. I taught him a lot when he was translating for me, because he was very interested. He's just been accepted to med school, and wrote to thank me for helping to give him this opportunity."

Cullinan's group stays on the grounds of the local hospital in Léogâne, where there is a guesthouse frequented by mission groups. They rise as early as 5:30 to learn about Haitian history and culture or simply take in their surroundings with a historical walk, traveling as a group for safety. This part of the day is an opportunity to satisfy their curiosity about the culture in which they are immersed, but also provides valuable cultural context for their work. "We have to understand local values and beliefs to practice effective healthcare," explains Cullinan. "If a parent believes that their diabetic child has the devil in them, we need to know that so we can address it, in addition to ensuring the child gets insulin or other appropriate treatment."

By 7:00, the group is ready to go to work. They travel from their base of operations in Léogâne to a remote village. Often they start the trip in trucks, then, depending on their destination, they may hike the final distance with their supplies carried by donkey. They set up their clinic wherever they can: in homes, schools, and churches, on mountainsides, even in chicken pens.

In most cases, local community health workers have already spread the word about the clinics in advance. So when Cullinan's group arrives in a village at 7:30 or 8:00 in the morning, there may be hundreds of people already lined up and waiting for medical care. The people wear their finest clothes for the doctors and nurses, a sign of their respect and appreciation. The nurses on the team triage the patients, and then Cullinan and the other providers on the team see patients one at a time, about 1500 people over the course of the week. "We do all kinds of care, from head to toe," Cullinan says. "We have little privacy for pelvics and personal exams, but we make do. We see lots of scabies, fungal infections, STDs, urinary tract infections, hypertension, diabetes, and a lot of malnutrition. Sometimes we'll do incision and drainage of bad wounds. We've seen terrible burns and we distribute dressing supplies, and teach people how to keep their wounds clean."

Scabies in particular is rampant among all ages, including children. Cullinan notes, "We don't want them to put their dirty clothes back on after treatment, so now we're fundraising to buy underwear and little undershirts for all the kids, and we send them home in that. They're so proud of their new underwear."

The team sets up a pharmacy as part of the clinic. They provide vitamins for women who are pregnant and nursing. They also provide medicine to treat hypertension for 3-6 months, write out prescriptions, and—through a translator—try to stress the importance of the medication and the risk and consequences of a stroke. While her patients do have access to local pharmacies, many won't have the financial means to purchase medications. Cullinan sees both hope and frustration as the mission team think longer-term. "We're trying to work with other mission teams to get continuity of care, but the unrest in Haiti has made this challenging. In the past, a team would visit each village approximately every three months. Last year, we went to villages where they hadn't seen healthcare providers in well over a year."

Even when they are able to provide appropriate medications, it's a challenge to communicate instructions for taking the medications. They use stickers depicting the sun and moon to indicate what time of day medications should be taken. Even with the deluge of work, they are careful to take their time at the pharmacy, instructing the translator to speak slowly and ensure their instructions are communicated effectively.

Cullinan also talks about the stigma facing people with HIV/AIDS. Because their team does not have medication to treat HIV/AIDS, they don't test for the virus. Still, they encounter individuals that they know are HIV positive. "The village health workers have told us not to tell them because of the stigma. We have done comfort care to the extent possible."

A recent addition to the team's services is offering basic eye exams and eyeglasses. In 2008, they brought a selection of eyeglasses in various strengths, matching them to the needs of individuals as closely as possible. This year, they are piloting a system of mailing eyeglasses to individuals for whom they couldn't provide appropriate glasses on the spot. While most of their patients don't read, reading glasses are useful for those who make a living doing sewing and needlework and often make the difference between being able to earn money and not.

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This man was able to see clearly for the first time in his life after receiving a pair of glasses. "We've questioned whether bringing glasses is worth the time and effort," says Cullinan, "But one person like this makes it worthwhile. He couldn't stop smiling."




For Cullinan, the most difficult cases are the ones where she isn't able to help. "These people come all this way, and have such faith in us. It is hard for them to understand that there are things that even we can't make better. We had one lady—she wasn't very old at all—whose sons brought her in on a donkey. She had suffered a stroke months before and her sons thought we would be able to fix her. They came miles and miles, through the mountains."

The team works straight through the day, often without a break for lunch. "I'll eat peanut butter crackers and drink bottled water to keep my energy up and stay hydrated, but I don't have time for a real break." At around 5:00, they stop work and head back to Léogâne. The team eats dinner together and works late into the night packaging medication for the next day. "I've been collecting medicine bottles all year from the BC faculty. We used to put everything into baggies, but found out that its common for rats to get into the vitamins, because of the sugar."

At the end of the night, the team fits in a few hours of sleep before another long day. They know that the new day will bring much of the same, although always with surprises and new experiences.

To date, Cullinan's focus has been to alleviate suffering and improve health in the short term, on a micro level. She cites lack of funding and resources, as well as political unrest in Haiti, as the primary barriers to more sustainable, systemic improvement. Cullinan sees nursing research as a promising tool for change. "For most of my career, I've focused on clinical practice," Cullinan explains, "but research ideas have always been in the back of my mind. I have received a lot of support from faculty members and from the dean to start exploring these possibilities, so now I'm starting to do that."

There is no shortage of possibilities in Cullinan's mind. "I've been reading up on the Hearth Model, a positive deviance approach that identifies families that are flourishing where others are failing. By studying these families and understanding what behaviors are leading to this success, we can understand how to work with other families to improve outcomes." Cullinan explains that the strength of this model is its emphasis on effective uses of the resources already present in an impoverished community, rather than reliance on external altruism.

Cullinan is also interested in studying ways to improve continuity of care in the Haitian villages. Her team has distributed medical records as a pilot in one village. The local people are already familiar with the records because children who participate in a local nutrition program receive medical records until age five. Cullinan hopes to expand this effort, working with other mission teams and local organizations to promote use of the records. "People are proud of their records and hold on to them," Cullinan says. "In the future, I'd like for everyone in Léogâne to have one."

Cullinan has also begun to build a relationship with the local nursing school in Léogâne, hoping in time to create a partnership that she can leverage for help with her research activities in Haiti. She visited the school during her recent trip, teaching an interactive class, and bringing some of the students with her to the villages. "I told the student nurses that they are the hope of Haiti. I really believe that they can make a lasting impact in their own country."

Cullinan is building the relationship by reaching out to the Haitian nursing school's dean via email. She is also talking to the Haitian nurses about their research interests and helping them to develop their research capacity. Cullinan believes that connecting these resources will bear fruit. By increasing knowledge about Haitian health issues through nursing research, she hopes to create lasting change in the villages near Léogâne.


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Cullinan with two children at a local orphanage, which the team visits every year to bring supplies. "The kids look healthy, but there isn't enough food. There are days they don't eat," says Cullinan. Her group continues to support the orphanage throughout the year.










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Team members also buy new toys to bring to the children at the orphanage. Cullinan taught this boy how to play Barrel of Monkeys, one of her own childhood favorites.
















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Nursing students at the school where Cullinan is helping to develop a research class in partnership with the Connell School. Cullinan brings them BC folders containing anatomy charts in French, and BC umbrellas, which they use a parasols for the intense sun.











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A family waits to be seen at one of the mobile clinics.