I was ill prepared for the two-hour hike up the long, winding dirt road of the third community I was to survey. My flip-flops were chaffing my worn feet, and red lines were hastily forming around the border of my tank top. By the time I reached the final house, I wanted nothing less than to ask yet another woman about her cervix. But the family kindly ushered me into their living room and placed a cup of coffee on the table beside me. The woman I was supposed to interview, however, lay asleep on the couch, nothing more than a small swelling under several large blankets. “She has breast cancer,” her family whispered to me as I sipped my twelfth cup of coffee that day and tried to recall how far away the last house with a latrine was. “The doctors say she came too late and there is nothing they can do to help her.”
My main objective this summer was to conduct a women’s health needs assessment in the communities of Restauración, Dominican Republic and Tilori, Haiti, where Philadelphia-based NGO Federation for International Medical Relief of Children has been working since 2012 to improve community health. Through qualitative interviews with key stakeholders and quantitative surveys with women who had recently given birth, my goal was to gain a deeper understanding of the women’s health care situation in both communities. The information I gathered would then be used to help inform the development of an antenatal care program. Both the Dominican Repub
lic and Haiti have relatively high maternal and neonatal mortality rates and proper prenatal care has been shown to help reduce such deaths.
Although I have not yet completed any analyses, I believe the narratives I took away, between collections of quantitative data, yield just as important a story. That woman, a mother of three now slowly dying of breast cancer under the heap of blankets, had been to the local rural clinic with concerns of pain, but had been turned away with nothing more than ibuprofen. By the time she had traveled the four hours to the closest specialist, her family told me, the cancer had already progressed too far. The presence of advanced cancer treatment centers in the large cities of the DR does not help rural women who have limited access to screening.
And for the women living across the border in Haiti, access is even poorer. My Haitian-Creole translator who assisted me during my visits to those communities would often get frustrated when I asked her to translate questions like “Have you ever heard of a pap smear?” or “Have you ever had a breast exam?” “You know what her response will be,” she would argue. She was usually right.
Restauración is a small town of about 7,000 habitants, located in the second poorest province of the DR. Only 12km from the Haitian community of Tilori, it is a popular place for Haitian migrant workers who cannot find jobs in their own country to set down roots.
In theory, this short distance also enables Haitians, who are unable to find the health care they need in the small rural clinic of Tilori, to access it 25 minutes down the road in Restauración. And while many ultimately do, the process is not so simple. For me – a white American female – crossing between the two countries required nothing more than a nod to the guards resting lazily at each of the three checkpoints along the road between Restauración and the bridge to Haiti. But for Haitians without papers, the short trip can be difficult and costly, with each guard usually requesting a “fee” of $100 pesos (about $2.30 USD). Even getting my Haitian translator back into Restauración, where she has lived and worked now for several years, was often a struggle. Although it never ended up costing us anything, the exercise almost always put my Spanish to the test.
Sadly, the journey was not the only deterrent. Many of the Haitian women I spoke with, including those who lived in the DR, were often met with such discrimination at the Dominican health centers that they regularly delayed or even declined seeking care. For these women, proximity to health care services did not translate to access.
One Haitian woman I spoke with summed it up this way: for a pregnant woman facing complications during labor, access to emergency obstetric services requires a four-hour drive to the closest Haitian hospital, or an expensive commute through the DR where care is not even guaranteed. With vexation, she added, “What kind of decision is that?”
Written by: Tara MacDowell, MPH