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Keywords:

  • global health;
  • public health interventions;
  • stories

Abstract

  1. Top of page
  2. Abstract
  3. Notes
  4. Biography

This is the tale of a Haitian woman's attitudes towards acute febrile illness in post-earthquake Haiti and a medical student's insights into public health gained by viewing a data set within a narrative.

Data, we often forget, are just stories expressed with numbers. Scientists and physicians tend in their articles to forsake the complexity behind these stories for the pragmatic simplicity of charts, tables, and graphs. But in the conversion of life into data something immeasurable is lost, despite our best intentions. The statistic 71.2 percent of 52 Haitians respondents consider the high cost of medications a barrier to health care, for instance, highlights a problem that must be solved. However, it fails to convey the daily struggle to survive in Port-au-Prince; it misses the terrible dilemma of whether a visit to a doctor is worth the sacrifice of a meal. Though the traditional presentation of data as statistics is useful, it is not perfect—missing from charts and tables are unquantifiable details. To illustrate, here is the story of a Haitian woman.

The summer after my first year of medical school, I spent 2 weeks in Haiti working with an acute medical mission team. My task was the collection of data for a pilot survey entitled “Haitian's socio-behavioral attitudes to undifferentiated acute febrile illness and healthcare delivery.” The goal of the survey was to gain insight into local health-care attitudes to assist in creating community education intervention projects. A total of 52 surveys were collected in several locations, an internally displaced person's camp in Port-au-Prince, a local clinic in Gonaiives, and a clinic in Léogâne. Survey participants were selected by inviting the final person in the clinic line to participate, as surveys took approximately 1-h, and participants were brought to the front of the clinic line after completion. A local translator was used on-site to translate the survey and the respondent's answers directly on location. The information collected can be presented in numerous forms fit for academic journals, but offered here as an alternative viewpoint of the data as a personal commentary.

On my second day on the job, a woman named Janelle was waiting in line at the clinic our team had erected within an internally displaced persons (IDP) camp in Port-au-Prince. She stood in line wearing a white T-shirt neatly tucked into her long black skirt. It was impossible to ignore her repeated quick glances at our team, until finally she forgave the line and approached us directly. Through our translators, she implored us to use the restroom in her tent. Curious, our team approached her tiny, fragile home. To our surprise, standing in the center of her shelter was a modern, Western-style porcelain toilet. Janelle's tent lacked running water, so she had placed beside the toilet a cracked bucket filled with water that could be poured into the toilet's basin to create the necessary pressure to flush. She had eliminated odors by digging a sewage pipe deep beneath her home with only a shovel. We nodded in appreciation of her ingenuity.

Our survey provided useful facts about Janelle. She was 39 years old, the average age of survey participants, had completed some secondary school, and was a part of mean household demographic of 4–8 household members. Like the majority of her neighbors, she did not have a job; 73.1 percent of respondents in Haiti's IDP camps are unemployed. She and other survey participants made an average of 2.9 visits in the 6 months prior to the survey to health-care facilities for themselves or a family member, but more often sought health advice from the community—67.3 percent sought family, 67.3 percent friends, and 59.6 percent a pastor. Janelle, whenever her baby grew ill, usually listened first to advice from her elders before turning to the local pastor to make a final decision about whether her child was sick enough to go to a hospital.

Janelle offered us the use of her toilet that day because she hoped for free medical advice. Her daughter, under 1 year of age, had a fever, a situation not uncommon in a camp in which 26.9 percent of people predicted it either likely or very likely that a child in their house would experience fever in the 6 months following the survey. Janelle did not have the money for a doctor.

However, the survey data did not reveal the whole story. The previous time Janelle went to the hospital, she considered the visit a waste of money. The doctor advised giving Tylenol to her daughter and keeping the baby undressed to stay cool, but this recommendation conflicted with the advice given to Janelle by her elders, who said to keep the baby swaddled in layers. When Janelle showed us her child, the temperature outside approached 100°F, but the baby sweltered in a fuzzy white sweater, a pom–pom hat, and thick socks, all tightly wrapped inside a fleece blanket. I gently suggested to Janelle that she should listen to the doctor, but she refused to ignore the wisdom of her elders. Generations of tradition are impossible to reverse with a brief conversation.

Janelle feared her baby might have malaria, since she had seen local children pass away from the illness. She, like 72.2 percent of respondents, knew a little about the disease from watching government programming on TV and by listening to the radio, as had 80.8 percent of participants. Many in the IDP camps, including Janelle, are too poor to buy their own devices, but it is not uncommon for residents to gather around a communal radio or television.

However, despite the information provided by the media, 23.1 percent of Janelle's community still believe that malaria can be prevented by boiling dirty water, and 30.8 percent think the illness is contracted by drinking contaminated water. When I inquired further with interviewees about their incorrect ideas on malaria, they said an NGO told them drinking dirty water could cause malaria. Part of the education plan of our medical mission trip was instructing people to keep dirty water away from homes in order to eliminate mosquito breeding, so I guessed that some of these false beliefs might have arisen from mistaken interpretation by NGOs and their translators.

I asked Janelle how she had attempted to treat her daughter's fever. First, she had purchased a special tea, locally believed to fight fever; 50 percent of respondents reported growing or finding their own medicinal plants. The tea did not help, however, so Janelle decided she would try medication.

There are many ways to obtain medicines in Haiti—too many, in fact. Local pharmacies stock prescriptions; over-the-counter medicines; and, usually, an array of antibiotics. Boutiques sell over-the-counter medication and traditional remedies. Traditional medicine healers proffer medical advice and remedies in a variety of forms: prayers; therapeutic touch; and, for the right price, mysterious unlabeled pills. Most conveniently, street corner drug-hawkers display pills neatly rubber-banded to cones.

In an attempt to avoid a costly visit to a health-care facility, Janelle risked the boutique. She bought acetaminophen, the preferred medicine by locals for fever; 55.8 percent of respondents tried using acetaminophen, 50 percent reported using tea or herbs, and 26.9 percent reported using antibiotics. To Janelle's anguish, the baby's fever remained.

So it was with desperation that Janelle offered us her toilet. All we could do was direct her to a mobile medical clinic that had come to the IDP camp for the day with the offer of free medical services. We refused her request to cut the line, but eventually a doctor attended to her needs.

I left Haiti without learning what became of Janelle and her baby. However, I resolved to share their story so that they, like the others we interviewed, would not become mere respondents to a survey. They would not dissolve into data points.

As medicine today attempts to save money by examining data sets, it is tempting to simplify. However, the gritty details of everyday life should not be overlooked. Mathematical models may reveal trends, but stories provide context—they set data in the real world. Narratives can provide inspiration for medical solutions that would be otherwise invisible in a table; Janelle's narrative inspired me to critically think about public health-care plan pitfalls that are transparent in tables.

There are several lessons in Janelle's story. The health-care system in Haiti, for instance, clearly does not adequately address the issue of patients trusting the advice of elders over that given by doctors. It is also evident that public health information dissemination through television and radio is a worthwhile financial investment even though many people do not own these devices. Finally, it is easy to see that false beliefs about malaria need to be corrected and that the problem may lie in mistranslation; a solution might be a “talk back” policy in which translators must recapitulate in their own words instructions they receive in English to ensure that meaning has not changed. All of these lessons are clearer in narrative than in numbers.

Today, what I have are not only the results from respondents to a 10-page survey but 52 individual stories. Math is not the only way to elicit meaning from a data set.

Notes

  1. Top of page
  2. Abstract
  3. Notes
  4. Biography

Data mentioned above were collected in 52 surveys given alongside a 1- to 2-h interview with each participant. All names were changed to protect participant's confidentiality.

The author wishes to thank Shauna King and her organization International Medical Relief, Karla Prentiss, Tyler Prentiss, Samia Arshad MPH, Linda Kaljee PhD, Marcus Zervos MD, and the Wayne State University Medical Student Summer Research Program for providing a medical student stipend for this summer research.

Biography

  1. Top of page
  2. Abstract
  3. Notes
  4. Biography
  • Carolyn A. Chan is an MD Candidate in the Class of 2015 at Wayne State University School of Medicine.