Archive for April 28, 2011

Disaster Planning in the Dominican Republic

Background

 

A lot of attention has been placed on emergency preparedness since the earthquake that struck Haiti last year, and more recently, the earthquake and tsumani that struck Japan.

 

Considering the Dominican Republic’s vulnerability to earthquakes, flooding, and tropical storms, I communicated with Dr Luis Dominguez, the Regional Public Health Director for the Duarte Province, about the area’s disaster planning and emergency readiness. He provided me with documents from the Provincial Emergency and Disaster Plan.

 

To provide some background information regarding the public health status of the Duarte Province, key illnesses that result in hospital consults are respiratory infections, diarrheal disease, hypertension, and vaginal infections. Furthermore, dengue remains the primary vector-borne disease in the area. No cases of malaria were reported in 2007.

 

Overall, there are impressive immunization rates for Hep B, polio, diphtheria and tetanus, measles, mumps, and rubella.

 

Leading causes of death were heart attacks, CVAs, cancer, pulmonary edema, pneumonia, and trauma (in that order).

 

I think all of this information helps us understand the baseline health situation in this province at the time a natural disaster might strike.

 

In terms of healthcare resources, there are six hospitals, 67 rural clinics, and 91 primary care centers throughout the province.

 

Emergency Plan

 

During times of crisis, the Director of Provincial Health has the primary responsibilities of declaring an emergency, activating the Emergency Operations Center, delegating functions to members of his team, and acquiring necessary data and statistics. In addition to this, he must designate sites for temporary shelters and coordinate with other entities, whether they are national or international.

 

Furthermore, provincial leadership coordinates with services in epidemiology, environmental health, laboratories, social assistance, statistics, human resources, and area hospitals.

 

There exists in fact an Emergency and Disaster Committee that serves the hospitals in times of crisis as well. Each hospital has an emergency plan, and the committee helps evaluate the needs at each hospital, and helps identifies risks as well.

 

An initial assessment is made following a disaster, performed by the Emergency and Disaster Committees. Here, basic figures are made concerning the magnitude, location and time of onset, damage to infrastructure, total persons injured and killed, and need for shelter, water and food supplies.

 

The initial assessment also includes medication inventories, risks associated with toxins and diseases, and evacuation contingencies.

 

Following a disaster, the Duarte Province outlines key provisional areas for the population. First, medical services are organized and a network is established among care centers to share patient data and relay important information. To assist the medical team is a register of available beds at all medical centers in the province. Sanitation services include establishing potable water availability and elimination of human waste, hygiene practices concerning food preparation, and disposal of human remains. An epidemiologic service conducts surveillance and maintains vigilance for disease outbreaks, ensures rapid dissemination of findings among peer groups and the general public, coordinates with area laboratories, and evaluates interventions in the community and shelter sites.

 

Nutrition services attempt to recognize populations at risk for malnutrition following a disaster, determine the nutritional needs at shelters, and maintain vigilance within the community and shelter sites for nutritional risks.

 

Logistical services include communications and transportation. The communication sector attempts to build upon existing networks and coordinates with public and private sector industries, as do transportation services. The emergency plan also assigns route planning and contingency planning for evacuation routes to the transportation services branch.

 

The social welfare department coordinates shelter construction with governmental and international NGOs, should they be present.

 

Post-recent disaster response

 

Evidence that the Dominican Republic has taken steps to improve their disaster response capability since the Haiti earthquake in January 2010 was provided by an online document I found published by the UN.  In May of 2010, the Dominican government requested an assessment of its building safety standards. Interestingly, this was the first time a country asked the UN to inspect its disaster reduction efforts. The report concluded that the country update their building codes, develop by-laws and norms for construction, and work in a bilateral manner with Haiti when either country is confronted with a disaster.[1]

 

In conclusion, I think the Duarte Province in the Dominican Republic has a well-established and clearly outlined emergency readiness plan, encompassing the wide variety of sectors that must be engaged together in preparing for, responding to, and recovering from a disaster.

 

The fact that the Dominican Republic invited the UN to conduct a building safety assessment following the January 2010 earthquake in Haiti demonstrates the country’s commitment to public safety, emergency response, and improvement of their existing disaster plans.

I

 

If you ever need an example of the American Dream, you should meet Dona Altagracia and Don Manuel de Vargas. When Don Manuel was in his early 20s, he left the Dominican Republic to go work in New York City, in Washington Heights (“Little Cibao”), where, as a waiter and as a bagger at a little grocery store, he worked for five years straight, never taking a day off. Dona Alta joined him later, where they lived together in a little apartment.

Don Manuel loves baseball too, as most Dominicans do. I asked him if he ever went to a baseball game in New York. “No! I never had time! I worked every day, mucho, mucho trabajo.” They came home together, and Manuel bought a cacao farm. He and his brother, who also worked in New York City, went into business together. It’s been quite successful – gracias a Dios. In Dona Altagracia and Don Manuel’s living room, they have a painting of a cacao fruit hung on the main wall above a little table. Above the cacao fruit are the words, “From this, we’ve made our life.”

They are two of the kindest, most sincere, and hardest-working people I’ve ever met. They often serve as host parents to Emory Nursing students during the annual Alternative Spring Break trip every March, which is how I met them last year. I later returned to visit them last summer, after our project in Haiti has finished, and I remember Don Manuel driving me out to his cacao farms in his sky blue, 70s-era Chevrolet pick-up truck. He would hop up into the big, elevated wooden shelf where cacao seeds were drying in the sun, and rake them alongside his employees. He’d jump back down, convene everyone in the shade, and give them their weekly salary, telling jokes and little stories along the way. On the way home, he stopped in a little bodega – we were somewhere way out in the campo – and bought us beers.

 

II

 

The project is wrapping itself up in this last week. We’ve thus far collected 108 responses to our surveys in six different migrant communities, and hope to collect another 20 on Sunday. We’ve been conducting interviews with Dominican healthcare workers in the public hospital here, and with Dominican employers. I went to Santo Domingo two weeks ago and met with an official at the International Office for Migration (IOM) to learn about the work that the IOM does for migrant Haitians here. I may be on my way to Santo Domingo again on Thursday to meet with staff at the CDC’s country office to discuss this project as well – all very exciting developments! Overall, I’m very optimistic that this project is going to provide a foundation for further study, and increased collaboration with multiple partners…

All of this certainly hasn’t come easily. I’ll take the time now to describe some of the challenges and frustrations I’ve encountered along the way…

I have hired three indispensable Haitian research assistants, each with their own unique backgrounds and experiences as Haitians here – Willy, for example, is 30 years old, has a wife and 6 year-old son back in Haiti, and has been here for about 7 years. Jean-Peter is 25, a university student, who left Haiti at age 14 after his father died and was essentially adopted by a Dominican man who paid for his education. Meré is in his 30s, studies medicine, and, until now, has never worked before, as his parents in Haiti have always provided for him. Each of the three has his own personality.

The surveys are not as straight-forward and comprehensible as they may appear at first to us. You have to remember that you will be interviewing, typically, a young or middle-aged man or woman with very little education, if any. Abstract questions don’t always come so easily. Or, when I think I’ve made the survey as straight-forward as possible, there are misunderstandings.

So at first, the surveys were full of contradictions, or so it appeared to me. “How is it possible that this person is from Cap-Haitian but it says he was born in the DR?”

“His parents were from Cap-Haitian.”

“OK, well you have to note that…..and how can their kids be here in the Dominican Republic with him but go to school in Haiti?”

“He sends them to school in Haiti because he can’t afford the schools here.” Migration histories

are not as clear-cut as moving from Point A to Point B. People move at different times, for different intervals of time, for different reasons. It’s fluid.

But other things must be clarified between myself and the research assistants. Sometimes, more than one answer is recorded for one item – forcing me to drop it from the database, and losing what could be important information. “You must be careful and make sure you note exactly how they respond to you. Do you understand?”

“Yes, yes, I understand.” I’ve found that one of the research assistants is quick to tell me that he understands, but at the end of the day, the surveys are still full of holes. So when he says he understands, it doesn’t always mean that he actually understands…so you have to devise a different way of showing him what you’re after.

Or the concept of being on time. While it’s so often reminded to us before we leave America that other people live according to different schedules, it can nonetheless be frustrating when there’s so much work to do on a limited time schedule. I may ask one of the research assistants to come to work at, say, 8:00am. Or, a research assistant will tell me that he is available at 8:00am. Either way, he will more than likely arrive closer to 9:00am. In retrospect, a more useful strategy would have been to request that he come at 7:00, when I in fact I needed him to start at 8. Then, so that no misunderstandings linger from complicated conversations about timeliness and cultural differences – conversations held in neither person’s mother language –I would then only proceed to thank him for coming to work on time.

And transportation. Being stuck late in the day in a little village outside San Francisco can be an ordeal. I remember waiting with Jean-Peter in Caimito for two hours for the university bus to arrive. This is the bus that has lower price fares and picks up the university students in these outlying communities. Only this time it was really, really late. “It usually comes at 5:30,” Jean-Peter said. It was getting dark. When it finally did arrive, the driver and his friend sitting next to him drove approximately 200 feet to a little bodega, promptly got out of the bus, and sat down in some lawn chairs with their friends. Only Jean-Peter and I were in the bus at this time – I assume the university students who originally needed the bus managed to get by with some other means. So there we were, sitting there in a parked bus in the dark, looking through the window at the driver sitting in a lawn chair with some friends playing dominos.

“Uh, what are they doing Peter?”

“He has to go look for something.”

“He’s doing nothing, he’s sitting there.”

“He’s waiting for someone.”

“OK.”

There is a great old man whom Rosa helped me find to take the research assistants out to the communities for survey days. I’ve found it worth the money to hire a driver with his own pick-up, so the RAs can go directly to the communities early in the day and have a ride home as soon as they finish. It removes any confusion associated with some not knowing how to take the gua-guas. So, I pay Conejo (literally, “Rabbit”) to pick up the three RAs and drive them out to wherever they need to go.

Conejo drives a beat-up old Mitsubishi pick-up, whose original, internal gas tank has been replaced by a propane-like tank that is strapped to the bed of the truck. The truck doesn’t run on propane of course – it still runs on gasoline, but the gas is stored in this old propane-like tank. Conejo’s dashboard indicators stopped working a long time ago, so only he knows how much fuel is left. We may nonetheless still run out of fuel. In times like these, Conejo gets out, unbuckles the fuel tank, hails down a passing motorcyclist, and hops on with the fuel tank in his lap, on their way to the gas station.

I remember once, during one of the training days with Willy and Meré, walking back to the downtown area of LasGuaranas to find Conejo sitting in his truck as it was being towed, white smoke billowing out. Bear in mind that I can’t really understand Spanish as it’s normally spoken by any average Dominican, and Conejo, having lived most of his life in the country, has a rather thick accent, so even when I ask a question, I remind myself that I more than likely won’t understand the answer. So as for asking what is wrong with the pick-up truck? It’s best to leave that area of inquiry alone. It’s much easier to simply ask, Todo bien? – Everything all right? – and Conejo reassures us, “Si, si!” That was easy enough.

Or imagine this: you get a phone call from one of the research assistants, who is in the middle of surveying one of the communities, and he sounds like it’s an urgent matter…

“Hunter!”

“Yes? What’s wrong?”

“I’m doing the surveys!”

“Great! So what is wrong?”

“I am hungry!”

“OK! Did you eat the food I gave you to eat? The sandwiches?”

“Yes, I saw the food you gave, but I do not like sandwiches! So now I am hungry!”

This came to me the day after I started coming down with something, and I mean coming down with something. It began as a low-grade fever and weakness and evolved into throbbing headaches, stomach cramps, and diarrhea. The diarrhea initially came as a relief, as I thought at first that it was dengue. You can never really leave it to yourself to diagnose any problems that come your way in settings such as these. I started having neck stiffness and backaches and thought it must be meningitis. Then my lips started peeling like crazy and I thought I was coming down with Stevens-Johnson syndrome – maybe something in the acetaminophen-Cipro drug regimen triggered it…..As I write this, I’m starting to feel better…I can also say how thankful I am for antibiotics. Being sick down here also gave me pause to think about the many who are here who do not have a comfortable bed to rest in, a flush toilet and toilet paper, a ceiling fan to cool you down, and access to potable water.

 

III

 

The old man’s hands were greasy from engine oil and looked as any belonging to one who has been a rice farmer his entire life. Before we all sat down together to interview, Jhefri and I were waiting for him outside his house – a beautiful, two-story home made from plaster, built directly behind the little wooden house he built  for himself in 1973, when he first started farming rice here and when the Balaguer and Guzman administrations were giving land away to Dominicans. It was late in the day, and we finally heard a pick-up rumbling towards us and got up to see a Toyota 4-Runner, the back full of Haitian farmhands. He parked the truck in front of us while the Haitians stared at us. They were dirty and tired-looking and looked every bit of what you’d expect someone to look like after working in a rice field picking weeds under the sun for 10 hours. I wanted to take their picture but they immediately hustled off as soon as I took out my camera.

“They’re afraid of you!” someone joked. “They think you’re going to come make them pay for being here.”

And now we were talking with their boss, this man who first started farming rice with only a few acres and who was living in the little wooden house that now sat in front of the beautiful home he had built for his family. We sat down at his kitchen table while his wife was preparing something for dinner – “The American sure does want to talk a lot about the Haitians” she said.

 

When I first started, there were no Haitians here.

The Haitians do the work that the Dominicans don’t want to do, because the Dominicans want to go to school and move to the city and leave the country altogether.

The Haitians work harder anyway….the Dominicans will work a little bit, then take a break and talk about their night at the discoteca, but the Haitians don’t stop working.

It’s so hard now to be a farmer. Everything has gotten more expensive – fuel, machinery, everything. The government used to support us, but they don’t anymore. And the middlemen pay us less and demand more.

 

Afterwards, we all go outside onto the deck that overlooks his rice fields. The sun is setting and there’s a breeze through the rice blades. One of his Haitian farmhands, sitting on the ledge, is smoking a cigarette and smiles at us.

We’ve missed the last gua-gua out of Caimito, so we have to hustle back to the main road to San Francisco. Jhefri and I meet an old man with a tiny old Honda scooter – it looks like it must be straight out of the 1960s, the wiring and pipes all jerry-rigged from multiple repairs. We hop on and midway through the ride it cuts out.

“Tac!” says the man. “That happens you know!” We’ve come to a stop in front of a little lottery ticket cabana on the side of the road, where a young girl stares at us, at me, Jhefri, and this lean old man in the middle of the road. The old man’s skinny leg kicks at the starter and it fires up again.

 

IV

 

So now we’ve got one week to go here. One more community to sample, some more interviews to conduct, and hopefully, a trip to the border, to meet public health officials in Dajabon, the border town where I crossed over from Haiti last year and where I’m hoping to get a few more interviews before heading back to Santo Domingo and the flight home.

It’s hard to start reflecting on this trip, this experience, before it’s officially over. It certainly went by a lot faster than I thought it would. Above all else, I’m extremely grateful to so many different people. None of this would have been possible without the support of folks back home, at the School of Nursing, among our Dominican colleagues and friends, and within the Haitian communities. This project’s findings will assist in the care of a growing population, whose needs have largely been unknown. No doubt it will continue to expand thanks to the on-going partnership between the School of Nursing and our Dominican friends.

I look forward to talking with everyone this Friday in the Community Health class!