Last week, I had the opportunity to shadow a very smart man at a clinic in Cite Soleil. Two weeks ago, one of the kids at Grace Village told me about his English teacher (and the piano player at our church) who was teaching them a bit about nutrition in school. Turns out the part-time English teacher also works at a clinic teaching nutrition education and talking with individuals about their health problems. When I heard about this, I couldn't resist the opportunity to introduce myself to the teacher at worship the following Sunday. We exchanged contact information-- I got a hold of his people and my people. Before I knew it, plans were arranged. Tuesday afternoon I headed to Port-au-prince for the night, where I anxiously awaited to get to the clinic the next morning.
My view in PAP. Tent cites...
Ready to roll!
The Healing Haiti team was heading to Cite Soleil Wednesday morning to deliver water to the people living in the slums --so I hitched a ride with them. I had some idea where we were headed, based on the directions that I was given from my contacts at the clinic. I had been to Cite Soleil many times before, so I could pretty much picture the location in my head. Not long after entering Cite Soleil, our taptap pulled over to the side of the curb and our driver ran-up to the compound across from a market to see if it was my final destination. Soon enough, I was out of the taptap and making my way into the compound.
Upon arriving at the doors of the clinic, the escort asked for our contacts and we were on our way! I was so excited to be there-- to meet all the Haitian workers and to tour the clinic. We were informed that about 150-200 people are seen at the clinic everyday and that they often have to turn people away. People of all ages come to the clinic with all sorts of aliments. Many clients have things like TB, anemia, Type 2 diabetes, high blood pressure, heart burn.... conditions that can be prevented.
Famasi
Lab tests
After our tour, we made our way to a building across from the main clinic. People of all ages were starting to gather on the benches. Once the crowd settled in, my friend that works at the clinic started to talk to them about health/ wellness and nutrition. He followed-up with answering individual questions. He asked me if I wanted to talk, but I just wanted to stand back and observe him at work. He did awesome! I was impressed with how much information he knew and how personal and engaged he was with each individual. My favorite thing he said to them was, "Medicine can't do everything for you." He talked to the people about reading food labels, eating natural and wholesome foods, using less salt/ oil/butter, drinking less energy drinks and pop. After I while, I started to engage with the people in the space. I talked with them about physical activity and how it is important to get your body moving. I showed them a few things they could do without a lot of space-- jogging in place, push-ups, jumping jacks... etc. I also talked with a few people who had individual questions and concerns. I think the escort with me was enjoying his time with me at the clinic too. Soon enough he was answering people's questions. I asked what he was saying to them, and he was spot on. Hmm... I might have a nutrition team in the works. I am scouting.
The nutrition Team!
A great teacher!
Educating
Later on, my friend that works at the clinic said to me, "People can't believe in medicine, people need to believe in food." Amen, amen!!! what you put in your body (or don't put in your body) could be killing you slowly. For people with limited income, it is especially important that they choose some of the most nutritiously dense foods to invest their money in so that they can maximize their daily nutrient intake. In my opinion, if you have little money---there isn't wiggle room to buy sweets and desserts all the time. Most days, you better be investing in the foods that are going to ward of disease. Unfortunately, I find that many people in Haiti are choosing to spend their money on less nutritiously dense foods (nutritiously dense in terms of micronutrient content) and place higher emphasis on quick-convenient, sugar loaded, and highly salted foods. I just want to sit down with people and have them SEE that if they didn't buy sugar for their juice, ate the fresh/natural fruit instead of juicing--they would ultimately save money and could buy something more nutritious than sugar (ie. avocados, spinach leaves, bulgur). That's what we did at our feeding center. By cutting out the juice, we have saved money by not needing to buy ice and as much sugar, which has allowed us to have more money to increase our purchase of produce. It's all about perspective, planning, analyzing, and education.
medication... after medication... after medication. Eat well, now and prevent this from happening.
Now this is my kind of medication.
My new friend informed me that many people in Port-au-prince (PAP) eat more convenient and processed foods, unlike the people on the country-side. I have observed this too. When I had asked a few people in PAP if they knew how to make Tchaka (a traditional Haitian soup), many of them didn't know about it. I was surprised. The traditional Haitian foods and "slow-cooking" foods have been lost with the transition to city life.
At about 11:30 AM, I had the chance to sit in an all-staff meeting at the clinic where the staff was discussing diabetes. The Haitian doctor at the clinic did an awesome job explaining to the staff about what diabetes is and how diabetes impacts all parts of the body. My friend gave a talk about nutrition-- how nutrition can help in the prevention of diabetes and how it is important in the management of diabetes. He was spot on with his talk and did an excellent job explaining to everyone the importance of good nutrition. Later on I was informed that many of the staff at the clinic had blood glucose tests done earlier that week, and many of the staff were at risk for diabetes. Again, this wasn't overly surprising to me based on the nutrition-transition I have observed here in Haiti.
Throughout the day, my friend at the clinic was handing out Oldway's African Heritage brochures to all of his co-workers. Unfortunately, all the brochures are in English (at this time), but I think it is helpful for people to see pictures of what their daily dietary intakes should like. The wonderful thing about the pyramid is that it has pictures of foods that are native to Haiti! My mission in Haiti is NOT to Americanize the Haitian people--many American resources and books are well, American. I am so thankful for the Oldway's materials because they have been a great asset to my mission here in Haiti: helping people to have good health through their native and cultural foods.
In the afternoon, we made our way to the pharmacy area to meet with people as they picked-up their medications. My friend meets with people as they picks-up their medications and asks them about what they should be doing with their dietary intakes in addition to taking the medications. I joined him. It was a very informal way of "counseling" people on their nutritional needs, but it works. Any opportunity to engage individually with people is better than none at all. We found three ladies sitting on a bench near the pharmacy, and we started to talk with them about their medical conditions. I let my friend engage with the clients first, and then I helped him to "dive-deeper" by asking them more questions about what they were eating and how they were preparing their foods.
This is where we would talk with people individually.
My friend started out the conversation by asking them, "What are you supposed to limit in your diet?" and one lady said, " salt, not a lot of Maggi, reduce the amount of fat." ... okay, good. She learned something. I asked her if she cooks for herself and if she does, is she preparing her food with a lot of Maggi. She informed me she does cook for herself and that she doesn't use Maggi or a lot of salt (even though later in the conversation, I found out she does use Maggi). Throughout the course of the conversation, one of the ladies talked about her acid-reflex (this is another common problem in Haiti). She told us that when she gets acid, she purges in order to minimize the acid-reflux problem. My ears perked-up, she what!? A quick fix to a problem that also cause more damage to the esophageal tract, the teeth, and even the weakening of the sphincter (the flap between the mouth and the esophagus). I couldn't imagine that purging would be a good long term solution to her problem. We talked about foods that cause acid, and how to better control the acid-reflux. We continued on to talk about her dietary patterns. "So what is the first thing you typically eat each day....", I asked her. (at this moment a quick memory of my professor at St. Ben's popped in my head. She said this frequently in her lectures about nutrition counseling). The lady responded, "Soup--carrot soup" and then she added (in creole of course).." with spinach and olive." Okay, great... but what else is she not telling me. I pressed-harder. "What else do you put in your soup? Do you add any salt, Maggi, butter, oil?" She told me that she doesn't use a lot of oil, she does use Maggi. We continued on to the next meal. Naturally, rice and beans. I knew what things to ask her about with this one. We dove deeper into how her rice and beans were being made. Maggi, salt, butter, oil.. and from what I can assume (based on what I have learned from many people here) these ingredients were probably being used in excess. These are the things that add "flavor" and "enhance" the foods, and most people don't know that serving sizes exist for them. I talked with her about just using the oil, and not buying the butter. She can still use fat in her diet, but with limited nutrition-education everything becomes an all or nothing principle. So I say buy one and don't buy the other-- it not only reduces the amount of fat they are using, but it saves them money too. We talked about this in our session. I showed the ladies what a serving size of oil looks like with my thumb. A small amount of oil contains about as much energy as a whole banana. We talked about the importance of fat in the diet, how foods have different components and energy.
Counseling session
Towards the end of the session, one of the ladies stood-up in the group. She pulled up her shirt, grabbed a roll of skin on her abdomen and shook it. She asked me how to get ride of it. The lady was pretty overweight, which puts her at risk for several chronic diseases and joint problems. We talked about energy balance: energy in must equal energy out, otherwise you either lose or gain weight. We talked about energy in food and about physical activity. The lady was pretty immobile, so I showed her some simple moves she could do to get her body moving. I told her moving any part of her body was going to be better than not moving at all.
educating
Showing the ladies the African Heritage Pyramids
During our counseling session, my friend and I have the ladies a brochure to show them the African Heritage Pyramid. It was a really useful tool. We talked about all the different foods in Haiti--avocados, spinach, squash, sorghum, cornmeal, beans, tubers, yams, cassava, peanuts, coconuts.... and we talked about using fresh foods to flavor meals. Focusing on plants, eating fish about 2 times a week, and using oil/sugar/salt within reason. At the end of the session, one of the ladies looked at the pyramid and said to me, "when I was little, we never used Maggi." Boooom. I lit-up inside. She was getting it. The whole talk about heritage and the past was resonating with her. My hope is that she actually took that message to heart and thought about the "Oldways" people used to cook, eat, and live in Haiti... before the western and inner-city influence.
The rest of the day, I spent with the escort. We got our blood pressure taken for fun, talked with some of the other staff, and I even taught him how to read a food label. We talked about some ideas bouncing around in my head with nutrition education in Haiti, community outreach and cooking class, and helping people get access to fresh "fast-food" at an affordable price. It's one thing to get the message out there, but it is another thing to make the suggestions and advice available to them. I am still praying about connecting the dots to my bigger visions. In a country full of opposing forces, my messages, my marketing, and my strategies must be BOLD, STRONG, AND LOUD.
I have good blood pressure!
My experience at the clinic was amazing. It gave me reassurance that everything I am doing in Haiti with the children, especially, is important and needed. Hearing people talk about what they eat, about their chronic (but preventable and maybe even reversible) health conditions has given me courage to keep on being BOLD and STRONG in my mission. People in Haiti need nutrition education. While it is important at any age, starting with the youth and the young adults is critical. "Catch" them while they are still learning and acquiring new taste. Teaching kids to like their fruits, vegetables, and whole grains is a great place to start. If they acquire a taste for whole, fresh, and natural food young, the hope is that they will continue to seek these foods as they age. We have noticed that our children no longer complain about the meals. For a while, we did have "food wars" with the kids and yes--they still stick their nose up in the air at new foods, but they are getting used to trying new things. The kids are learning to enjoy trying new things and expanding their taste-buds beyond rice and pasta. The kids are also learning not to be food perfectionist. For example, the other day at breakfast we were unable to "blend" their bulgur smoothies like they usually prefer because the blender was broken. The kids had to eat the bulgur whole with milk and spice, but they didn't complain like I would have expected them to several months ago. That same morning, I brought out a big bag of flax seed and asked the kids if they wanted to mix it into their bowl of food. I was surprised by how many said yes! I had kids swarming around me-- hands reaching out for me like I had a big bag of candy. I was shocked. They were eager to try the flax seed. I guess that's what happens when you are persistent with the kids and you allow them to participate in meals... they learn to adapt, to appreciate, and even seek-out "new experiences" with food.
The adventurous kids.
The need for PREVENTION of disease is present here in Haiti. There is elevated cases of chronic disease existing in the same context of malnutrition. When people have access to food, my concern is that they are choosing to eat what they know and like, but not necessarily what their body needs in order to ward of disease, increase immunity, and potentially save money.
No Maggi in the food for almost two weeks!! I am happy! No more Maggi!
My daily medicine.
Nutrition EDUCATION is the "food" for the people. Knowledge is power and it can help individuals make informed decisions about their life. Without knowledge, especially as it relates to survival skills (which include eating and eating behaviors/ patterns), an individuals' quality of life will greatly suffer. Malnutrition has a cyclic effects--- lack of a well-balanced diet decreases immunity and increases risk of disease, which can further cause an increase in expenses for medical visits and medications, and inability to work or go to school......which further drives the cycle of poverty.
I love Haiti.
Now watch this--- A TED talk by Jamie Oliver. He places a lot of emphasis on obesity, however, anyone (regardless of weight or size) is at risk for chronic health problems with poor lifestyle choices. The video is worth watching. His most important message: TEACH KIDS ABOUT HEALTHY FOODS AND TEACH THEM GOOD "OLD" HOME COOKING.
In 2011, the International Food Policy Research Institute (IFPRI) published alarming data that ranks countries around the world with degree of severity in terms of hunger. The ranking is done using a Hunger Index that is based on data from three equally weighted categories: 1. proportion of the country that is considered undernourished (insufficient caloric/ energy intake); 2. prevalence of children 5 years of age and under that are low weight for their age; 3. mortality rate for children 5 years of age and under. The Index is ranked from 0 (the best score) to 100 (the worst score), however, a score above 30 is considered extremely alarming and a score between 20-29.9 is considered alarming. Haiti falls within the top 10 countries for Global Hunger Severity with a Index score of 28.2 (falling near the severely extreme index). This number remains even more alarming when you take into account that Haiti is only a 90 minute flight from Florida. Haiti is closer to the "Mainland" than one of our own 50 states, Hawaii! For more information and reports about the Global Hunger Index click the link: http://www.ifpri.org/publication/2011-global-hunger-index.
According IFPRI, in 2011 a little less than 60% of Haiti's population was considered undernourished. This number is "the proportion of undernourished as a percentage of the population (reflecting the share of the population with insufficient dietary energy intake)" (Direct definition taken from the IFPRI).
Click the interactive map below to explore nutrition data for other countries.
From June 4 through June 25, I set out on another Haiti adventure. The first week of my trip, I led my first mission team on an unforgettable experience to Haiti. All 11 team members were young adults between the ages of 20 and 30 years old... all with such giving and open hearts. It was such a unique experience to be able to share third world poverty with people my age.. people I have grown up with, people I have worked with, and people I had just met. Even though I had been designated the leader of the team, I felt as though each member on my team helped challenge me to become a stronger leader, friend, and member of our global community. Each person brought forth their gifts, talents, and expertise that helped me to see more clearly the beauty of community... and how the value of positive and supportive relationships can aid in creating a more just world. Each team member served and led the team in ways I had not anticipated... offering up ways that we can have an impact on the world, challenging each other "to go deeper", and encouraging each other not to become complacent upon the return home from this encounter with 3rd world poverty.
My beautiful team!
Bringing clean, free water to the people of Cite Soleil
The slums of Cite Soleil
Playing with the kids at Gertrude's orphanage for special needs and handicapped kids.
We took a few hours out of our week of service to see the hope and potential for Haiti!!
Most of the team came as strangers, but all left as friends!!
After this wonderful week of cultivating new relationships and sharpening my leadership skills, I said goodbye to my team at the airport and headed up to Grace Village Orphanage in Titanyen to use my nutrition skills to strengthen and support the children sponsored by Healing Haiti. Grace Village is currently the home to 62 children between the ages of 20 months and 17 years old. Within the walls of the community, there is a boys dormitory, a girls dormitory, a feeding center (my "office"), and the largest playground in Haiti. The village is currently in the process of building a talapia farm and a school, but also has plans to build a church, a soccer field, and a medical facility. While Grace Village remains a gated community within the town of Titanyen, it opens its doors to the people within the surrounding community during worship hours (specifically Sunday morning and weekly evenings). Many of the children, in their best worship clothes, run up the hill to the village to join our orphans and delight in the service facilitated by our Haitian Pastor. Following the Sunday worship, the kids are all given a small loaf of bread with butter (or peanut butter) and allowed to play on the playground. As Grace Village continues to expand and grow, it will continue to serve the community of Titanyen in many more beautiful ways beyond worship and play.
Grace Village Orphanage
The kids' at their morning activities!!
My trip to Grace Village was originally planned to be a one week trip in which I would obtain follow-up nutrition assessments on all of the children, preform a 3-day diet analysis at the Feeding Center, and make recommendations to enhance the meals served by the Haitian staff. Several days before my departure from Haiti, I decided that the week had not been enough. I did not feel confident leaving knowing that there was still a lot of work left to be done. I contacted my mom in the U.S. and had her help me adjust my airfare in order to spend an unexpected, extra week in Haiti. It was a long, stressful two weeks at Grace Village.... being challenged in ways I had not expected. My first day at Grace Village, I immediately began my nutrition assessments on the children. I gathered heights and weights on all of the boys, and on all of the new kids we welcomed into our community. The new kids were in pretty rough condition; many having extended bellies, gaunt faces, sunken eyes, and irritable/ closed off dispositions. These kids were very malnourished and where just starting to accommodate to the new environment they too would soon call home. It was a never ending experiment trying to figure out how much food intake the new kids' could tolerate; I kept having to adjust.. and readjust.. and adjust... the portion sizes for these kids. Some would seem like they were tolerating the intake and portion sizes well, and then before you knew it... they would be exhibiting physical signs of refeeding syndrome; reporting abdominal pain,
excessive sweating and dehydration, fatigue, physical weakness. It was a constant back-and-forth battle trying to figure out their individual needs. I spent several day thinking we had conquered the "hump" of refeeding.. then one kid would be complaining of upset stomach pains, and I would find myself at square one again. Not only was it difficult monitoring the portion sizes for the new kids, but I always felt like a "watch-dog" at meal times. There were several of the kids I would catch scarfing down the food leftover on the other kids' plates. Some of the kids' were mentally starving to eat.. even though their bodies were physically unable to metabolize the large portion of food they had just inhaled. One day, I noticed a new boy sitting on a bench in the feeding center, glistening with sweat, and looking as though he just ran a marathon in the Haitian heat. This was one of the boys I had caught on several occasions scarfing down extreme portions of rice at meals. I sat down with the boy and one of our Haitian translators to see how he was feeling. The young boy denied being in pain, but through discussion I discovered that he was having trouble running and trouble moving around. He was extremely fatigued. I felt his belly.... it was extended and as hard as a rock. It must of hurt or have been at least uncomfortable. The translator, the boy, and I had a discussion about being careful to not overeat at meals, and helping him to trust that the feeding center will always have more meals and snacks for him. He won't ever go hungry again... unfortunately, the psychological damage of food insecurity has already been done and it will take some time, trust, and counseling to help him understand that there will always be 3 meals served to him daily at Grace Village.
Extended bellies...
Some unexpected stress!
Measuring waist circumference.
There was another child that I had to monitor her portion sizes and food intake more closely. She was strictly on a low carbohydrate, moderate protein, and high fat diet due to her severe state of wasting, malnutrition, and parasitic infections. She was my most complicated case of malnutrition, yet. Once we were able to get her to tolerate frequent feedings, we boosted her caloric intake and had her consuming well-portioned meals/snacks every 2-3 hours. Her diet consisting mainly of avocados, eggs, small portions of bread/rice/noodles, fruit, peanut butter, yogurt, and supplements of ensure and medika mamba. The rational for her intake ratio of fat to protein to carbohydrate was directly related to the metabolic state her body was currently in; to feed her a normal to high carbohydrate diet would put her body in a state of shock... eventually leading to death. The ingestion of carbohydrate
causes a surge of insulin release in the body, and under normal conditions the cells of the body will take-up insulin and glucose (the most simple form of carbohydrate). With individuals that are extremely wasted (lacking adipose cells) and malnourished, the body is not able to adjust to the insulin rush and clear insulin from the blood. The body shifts states of metabolism from using body tissue, such as fat and protein, to now using extraneous glucose sources. This drastic shift in metabolic sources of energy leads to catastrophic conditions for the individual. Thus, from a dietary perspective, it is of most importance to 1. ensure that the individual is properly hydrate and in a state of electrolyte balance and 2. fed small feedings of predominantly high fat and high protein foods to allow the body to "recognize" the molecular composition of the food source and to be able to metabolize the extraneous sources in a similar fashion as during the malnourished state. Once the body has adjusted to the frequent, small feedings, and weight restoration has begun, carbohydrate intake can be increased within the diet and caloric intake can be increased to further initiate weight restoration. (for more information on refeeding syndrome, I have found this resource to be a fairly easy read to better understand the complex issue:http://www.nursingcenter.com/prodev/ce_article.asp?tid=789442#) Without using biochemical feedback and blood samples, combating malnutrition can become very complex and has to become a purely observational and intuitive process.
Avocado and eggs were the base of my most critical case's diet for a few days.
As you can probably assume, my skills as a new dietitian were greatly challenged during the process of refeeding our most critical case. Not only was I dealing with a compromised state of malnutrition, but I was also in a third world country with minimal resources. To further complicate the experience, we were without Internet at our orphanage for 5 days so I had limited references and resources to rely on; there was a riot in the city around us so we were unable to leave the walls of our compound, which impacted our ability to go to the market to purchase fresh produce. Thankfully, we had an emergency food supply of canned goods and Feed My Starving Children Food in the feeding center, however, trying to refeed a malnourished child on a restrictive diet became very challenging. These drastic conditions made me realize the many things we take for granted in the United States... access to safe and reliable food, having shelters that can provide food to those who struggle with food insecurity, and the everyday conveniences of many Americans have in our daily lives (going to caribou, enjoying a meal at a fine restaurant, basic food security).
This is a picture of the early stages of the riot in our town. People were burning tires on the main road.
This is one of my "mamba boys" .. he has gained over 10 pounds in the past 6 months and is starting to look like a teenager! Don't mind his "tough boy" face in the second picture... the boys were supposed to be helping me get pictures of all the kids at the orphanage. They got pictures of all of them, but were having fun with my camera not realizing the pictures were for research purposes! This mamba boys is actually a really big sweetheart and not the "tough-boy" he appears to be!!
In addition to closely monitoring, assessing, and reassessing all of the new children, I was also working closely with our feeding center and our Haitian staff to enhance the meals provided at the feeding center. I spent hours in the kitchen observing the staff hard at work to prepare enough food for 100+ people. (Not only do we provide enough food for 62 children, every lunch we provide 10 hot meals to elderly within the community through our "meals-on-wheels" program, and for the staff working in the kitchen, as part of security, and on the construction). It was wonderful to be able to spend time with the Haitian ladies and to help teach them ways to increase the nutritional value of meals they provide to the kids. I worked closely with our Haitian feeding center director (who is a phenomenal young lady that speaks English, is wonderful with the kids and staff, and is eager to learn new things). I taught her about food groups, went to the market with her to show her what produce would be great to have at the feeding center, and showed her simple ways to help meet the kids' dietary needs. We worked on increasing the ratio of beans to rice (beans were often lacking) to help increase the amount of protein in the children's diet. We also worked on incorporating more whole fruits and vegetables for vitamins, minerals, and fiber.
This is one of the days from my 3-day diet analysis at the feeding center.
We worked on eliminating the juice and replacing it with whole mangos, slices of watermelon, and fresh pineapple!
The staff made that dish above that day after I showed them how to use whole vegetables... they did it without me even being in the kitchen or asking them to do it!! I was so proud of them!!
I went many days on only 4 hours of sleep, as I stayed up late reassessing the cases of malnutrition, planning out the next days' feeding regimens, and plotting about how I would use the limited resources I had available to enhance the lives of these beautiful children. It was an intense 2 weeks of work, but my passion for my mission was fuel for my fire. I was determined to leave knowing I had done enough "damage" that the changes would be implemented long after I was gone.. and that the kids on supplements would continue weight restoration. Besides just "work"... I always made some time for play! I enjoyed listening to the kids sing and praise, dancing with them on the courtyard of their dorm rooms, eating meals with them, and tucking them into bed each night!
The girls LOVED being ballerinas with me!!
So what is next for me..... I am heading to Haiti again this fall and will be there for two months (September 24- November 19) to continue improving the quality of life for the people we serve in Haiti through good nutrition.
I appreciate all of you that have been following and supporting me along this journey.... it means so much to me!!!
