HIV in the Bateyes

Migration, ethnicity and environment: HIV risk factors for women on the sugar cane plantations of the Dominican Republic, reports a 5.7% of women (28 of 490) and 8.8% of women under the age of 35 tested positive for HIV. Comparatively, the national prevalence rate of HIV in the Dominican Republic is 1.0%. Similarly, Dominican Republic, A Guide for Global Health Workers, Medical Practitioners, and NGO Volunteers states that the prevalence of HIV is greater than 5% in the bateyes, consistent with the studies findings.

While working in the bateyes, I do not know if I treated any HIV-positive patients. We were not able to provide testing, local options for testing are expensive, and a stigma still exists around the disease. However, on the plane back to the States, I sat next to a perioperative nurse who was in the Dominican with a team of American surgeons, nurses, surgical technicians, and anesthesiologists to perform tubal ligations. The only cost to the patient was the cost for labs that the Dominican hospital required, including an HIV test. (This cost $40 which is still a huge barrier to those living in the bateyes.) The nurse shared that this year he had not had any HIV-positive cases but they also treated only a few Haitians. In previous years, they usually have 2-4 HIV-positive cases out of approximately 80 patients (2.5-5%) and almost all HIV-positive patients are Haitian.

There are many barriers to improving the situation: testing is difficult to obtain, treatment is expensive, stigma prevents patients from seeking treatment or telling their sexual partners, and little is done to prevent sexual transmission. Migration, ethnicity and environment: HIV risk factors for women on the sugar cane plantations of the Dominican Republic reported condom use in less than 4% of women interviewed (490) during last sexual intercourse. In some areas in the Dominican including the bateyes, condoms are culturally or religiously unaccepted. There is also little to no sexual education regarding the transmission of HIV or proper condom use.

Like many diseases, HIV is more prevalent in the bateyes than in the Dominican as a whole due largely to the lack of health education and access to medical care.

Sadler, Karen and Kim Wilson. “Dominican Republic: A Guide for Global Health Workers, Medical Practitioners, and NGO Volunteers.” Geisel Series in Global Health and Medicine. Dartmouth 2015.

Brewer, Toye H., et al. “Migration, ethnicity and environment: HIV risk factors for women on the sugar cane plantations of the Dominican Republic.” AIDS 1998, 12:1879-1887.

This project is supported by funding from a Middlebury College Community Engagement Cross Cultural Community Service Grant.

Limited Resources

The following passage from Dominican Republic: A Guide for Global Health Workers, Medical Practitioners, and NGO Volunteers accurately represents what I saw while working in the bateyes.

“Not surprisingly, healthcare indices here [in the bateyes] are significantly worse than those of the DR as a whole. As estimated by the Batey Relief Alliance, 40 percent of batey children under age five are chronically malnourished. One-third are stunted (a linear growth malnutrition involving severe protein deficiency) and kwashiorkor (a state of malnutrition involving severe protein deficiency) is still seen in the bateyes because sugar cane is used to pacify hunger. Immunization rates are difficult to ascertain, though they are significantly less than national rates. Diarrhea and parasites are rampant. The most common conditions in children include gastrointestinal and parasitic diseases, skin infections, upper respiratory infections, asthma and allergy symptoms, and symptomatic anemia. The majority of children present with chronic medical problems and multiple conditions, reflecting the general lack of access to primary and preventive health services. Among adults, diabetes mellitus, hypertension, and gastrointestinal complaints are major complaint at clinics is pain (back pain in men from the work of cutting sugar cane, and headaches and abdominal pain in women). Dental decay is prevalent, from the habit of sucking sugar cane. Cataracts from long hours working in the bright sun are universal in men over age fifty,” (41).

With limited resources, we usually were forced to retreat symptoms rather than causes and often were unable to met the needs of the communities. We were cutting our children’s vitamins in half and only giving out 15 per child and still ran out after the first week. Due to the high rates of parasites, everyone who came to the clinic and weighed more than 40 lbs and was not pregnant or breast feeding was treated with anti-parasitics. We had to readjust our definition of “hypertension” since we did not have enough meds to dispense to everyone with systolic BP above 140 let along above 160. I also worked along side optical and dental where I saw numerous cataracts and rotting teeth (I extracted a tooth!).

Sadler, Karen and Kim Wilson. “Dominican Republic: A Guide for Global Health Workers, Medical Practitioners, and NGO Volunteers.” Geisel Series in Global Health and Medicine. Dartmouth 2015.

This project is supported by funding from a Middlebury College Community Engagement Cross Cultural Community Service Grant.

Persons in Transit

“Many landowners pay buscones (headhunters) to round up the labor supply. These headhunters often promise young Haitians a “work permit” and also extract a fee from the prospective immigrant for the work. Haitians are often stripped of their Haitian identity cards and find themselves working long hours in challenging conditions for extremely low wages. […] These communities remain stateless and marginalized from Dominican society. Only 5 percent are documented and, because they are considered “persons in transit,” no path to citizenship has ever been available to this population or to their children—or subsequent generations—even those born on the batey who identify themselves as Dominican rather than Haitian. […] Without birth certificates, these Haitian-Dominicans have limited access to government services, from schools to clinics.” Pg 39-40

Sadler, Karen and Kim Wilson. “Dominican Republic: A Guide for Global Health Workers, Medical Practitioners, and NGO Volunteers.” Geisel Series in Global Health and Medicine. Dartmouth 2015.

An American Problem

In 2013, as part of an article about a report from the U.S. Labor Department, USA Today shared the story of Lucner Pierre who lives near San Pedro de Macoris. Lucner migrated to the Dominican from Haiti in 1978 to work in the sugarcane fields and since then has spent the better part of the last 38 years cutting sugar cane with a machete 12 hours a day, while only making enough to survive. USA Today reported that the work “damaged his sight and turned his skin the creased texture of animal hide.”

Today I went to Monti Cristo, a Haitian village outside of San Pedro de Macoris which is about a 45 minute drive south from the MGM compound in Hato Mayor. While we were unpacking our “clinic,” an older Haitian man, Domingo, probably in his 60s stumbled into the room. Amidst all of the chaos, no one noticed him. I approached him and asked “¿Qué necessita?” (What do you need?) He was trembling and in a high pitched voice managed to say “le duele” (it hurts). He was having severe chest pain that radiated into his left shoulder. I took his blood pressure–196/94. Very high. He was having a hypertensive emergency. Our doctor agreed. We explained this all to his daughter and said that he needed to go to a hospital immediately. Later that afternoon, he turned still in pain and hypertensive. His daughter said he refused to go to the hospital, although it is more likely that they didn’t have the means to do so. We did what we could for him–gave him eye glasses for his diminishing eye sight (he was completely blind in one eye), some medicine to lower his BP, acetaminophen for his pain and prayed with him. Eventually we had to explain that there was nothing else we could do.

Often our hearts go out to those who work hard all day in the sugar cane fields, but what happens to those who no longer can work. What happens to Lucner and Domingo? They do not receive a pension. They do not have the money to return to Haiti–and let’s face it, there is nothing there for them anyways. Their bodies have been destroyed by the sun and the machete. They have back pain, cataracts, hands as rough as sand paper. When the sugar cane companies are done with them, they merely dispose of them.

After years of human rights activists filing complaints with the Labor Department about the conditions in the Bateyes, they finally released a report in 2013 which stated numerous violations of the free trade agreement between the United States and the Dominican Republic including indications of forced labor, poor working conditions related to wages and hours, occupational safety and health concerns, and child labor. At the same time, the Labor Department committed to giving another $10 million dollars to the Dominican government over the next four years to improve working conditions.

U.S. Labor Secretary Thomas Perez stated in the report, “working together with the Dominican government, we look forward to making a real differences these workers’ lives.” Four years have pasted since this report. San Pedro looks the same. Las Laura’s, Margarita, Village 14, Batey 50, Monti Cristo, Eskadura, Vasca, Experiental, Las Callas (all Bateyes I have visited) look the same. Where did the $10 million dollars go?

Christopher Hartley, a worker advocate who helped raise awareness about the Bateyes, wrote in 2009, “Fair trade, the fight against modern-day slavery and standing up for our commitments regarding fundamental human rights and freedoms are all issues of deep concern to the American public.” Yet, we buy Domino sugar, one of many U.S. companies that sells Dominican sugar, and continue to give money to the Dominican Government without ensuring that it is used to improve the working conditions. This is not a just a Dominican problem, but an American one too.

Curnutte, Mark. “Labor Depart. Finds Bitterness in Sugar Workers’ Lives.” USA Today. Oct 3, 2013.

This project is supported by funding from a Middlebury College Community Engagement Cross Cultural Community Service Grant.

Motorcycles

Here the vehicle of choice is definitely a motorcycle. Driving down the road you will see entire families… Mom, Dad, babies, even 5-6 people on one bike! Often times the women will ride side-saddle on the back. I don’t know how they don’t fall off but they don’t. Another common site is two people riding on a motorcycle with a propane tank in between them… It is not attached to the bike if you were wondering. Also motorcycles do not follow any traffic rules and will drive on the wrong side of the road, not stop at intersections, and weave through the cars and trucks.  While going around a turn or before entering an intersect, it is common to honk many times to let others know you are coming. Needless to say, driving down poorly paved or dirt roads while in the back on a cattle truck with all of the commotion is quite an experience.

At a motorcycle shop in Hato Mayor!

Café del Rey

Café del Rey is a small start up coffee company that grew out of Del Rey Ministries, an organization that supports and trains pastors in the Bateys around Hato Mayor as a means of implementing positive change and works closely with MGM in these villages. The start-up is run by a local family that approached Del Rey Ministries for a loan and has prospered into its own company. The proceeds from the coffee goes first towards supporting the owner’s family and then profits go towards supporting the pastors. Starting a company in the DR is an incredibly difficult process that is highly controlled by the government, so Café del Rey is truly a success story! The company is growing and recently planted their own coffee trees with the hopes of next year growing their own coffee rather than buying the cherries at the start of each season. I had the opportunity to tour their “factory” (the porch and yard of their home) last week!

Step 1: A Coffee Tree. Harvest is usually around November.

Step 2: Pick the Cherries. (Or purchase them at this stage)

Step 3: Dry the Cherries. This can take up to two or three weeks and is done outdoors on tarps. They are ready when they become super light and you can hear rattling when you shake them.

The dried cherries are then sent out to a factory to be shelled. This is not an expensive step but requires proper machinery. Once the beans are returned, the family must sort them by hand to separate the good from bad beans.

Step 4: Roast! There are five types of roast: light, medium, dark, French, and espresso, each of which depends on how much time the beans are roasted for (Medium is around 12 minutes). You can hear a popping sound almost like popcorn in between light and medium, and French and espresso which helps to determine how much time is needed.

Step 5: Cool and Package! The beans are then cooled by the mixer and then dumped into a bin where they sit for 4-6 hours to add flavor before packaging.

Triage

In triage, I take vitals (blood pressure, pulse, respirations, blood glucose if diabetic, and temperature if sick), give everyone who is not pregnant or breastfeeding and over 40 lbs an antiparasitic and take a basic patient history so that the doctors can be as efficient as possible with their time. I also try to weed out those who do not need to see a doctor and just want vitamins and Tylenol if we have it. At the end of the day we usually have a long line that we have to turn away, so we work hard each day to make our process more time efficient without sacrificing the level of care provided to each patient. Usually, I am working with a local translator, although my Spanish is greatly improving! On Thursday, I treated five people on my own while the translator was on his lunch break. Luckily, all had “gripe” (flu), “un dolor de cabeza” (headache), or “un dolor de garganta” (sore throat)… All words that I have picked up!

Photos taken by David Brotzman

This project is supported by funding from a Middlebury College Community Engagement Cross Cultural Community Service Grant.

The Founding of MGM

“Eventually we heard the story behind these villages. Many of the people had walked over from Haiti (it was over three hundred miles just to the Haiti border). If they had come from Port-au-Prince, Haiti’s capitol, they’d probably walked closer to five hundred miles. They came to the Dominican Republic to escape the severe poverty of their own country. Here they could make two dollars a day and have at least a little bit of food to eat.

Even so, it was a difficult, almost impossible life. Frequently, villages did not have water. To obtain water for drinking and cooking, they often had to walk five to seven miles one way, fill their containers, and return all those miles carrying their heavy burden, every day.

They had very little food. The men usually ate one meal every two days. One out of five children starved to death by the time they were four years old. And they lived in deplorable conditions. Most families lived in one room, with a hole in the middle of the floor for a bathroom, which emptied outside into the sugar cane fields.

Our hearts were broken when we saw the conditions of the sugarcane villages and the people who lived in them. Although the Haitians were happy we were there, they had no hope for he future. It was a very humbling experience and God used the poverty to change many American’s hearts and lives. As we spent nearly a week at each project site and became good friends with the villagers, we built relationships without know how God was going to use them. But now years later, we see His hand in it all. For instead of working in Dominican towns, we now focus our ministry on the sugar cane villages that lie within about a forty-five mile radius of our headquarters in Hato Mayor.” -A Journey with God by Jim McDonald, a book about the founding of MGM

In the years since MGM started working in the sugarcane villages, some villages have improved drastically gaining plumbing and electricity while others still resemble the image that Jim painted above.

Also, for the boy who was in the motorcycle accident and shattered his femur that I mentioned in my last post, we collected $900 (over double what we needed) and he will be recieving surgery on Friday! The extra money will be used for his rehabilitation after surgery.

A Rain Drop in a Desert

Working in the medical clinic has been humbling and eye opening. Each day we travel to a different batey some of which are 20-30 minutes deep into the sugar cane fields, where most only speak Creole. Usually I work in triage helping take vitals and a medical history. I have also been able to observe and assist the doctors with patient care. Many patients have a general cold or the flu and just want vitamins, water and Tylenol. I have also seen fungal infections, parasites, Chicken Pox, Diabetes, and deep wounds.

Less common are diseases and ailments that we cannot diagnose or treat. One girl particularly struck me. Her name is Marisa, and she is 14 years old and pregnant with her first child. As I listened in, she asked the doctor in broken Spanish if giving birth would hurt. Marisa was not the only young mother we met. Sugar Cane Slavery: Bateyes in the Dominican Republic by Barbara Bernie (New Eng. J. Int’l & Comp. L.), an article about life in bateyes, describes how commonly pregnancies are the result of women being raped by Dominican soldiers who guard the sugar cane fields. I have also heard that culturally in the Bateyes a boy is not considered a man until he impregnates a women leading to high rates of sexual assault. As this is not openly discussed, I do not know if this is common in Batey Las Laura’s or is Marisa’s story. Regardless, I can not imagine the hardships of having a baby at age 14 without access to a hospital or proper medical care.

In another village, San Miguel, a women came into the clinic pleading for help for an 18 year old man who was in a motorcycle accident and couldn’t walk to the clinic to be seen. I relayed the message to one of the American doctors who went with a local Dominican doctor to visit the man in his house. The Dominican doctor had actually seen the accident that this man was in a couple weeks ago and was able to help piece together some of the story. In addition to other more minor injuries, his femur was shattered and required surgery. The man already knew this, and the village has been collecting money for the surgery but is $400 short. If he didn’t get the surgery soon he would be crippled for the rest of his life, which in the Dominican means he would not be able to work, putting him and his family in danger. MGM is working on collecting the remaining $400 and hopefully he will get the surgery soon. (I will keep you updated!)

We treat approximately 100-200 patients a day depending on how many doctors we have and still have to turn away others knowing that they likely don’t have access to any other healthcare. I wish we could do more. Our hope is that working with two Dominican doctors in addition to the American doctors with MGM we can help create more consistent health care to these villages, especially for those with chronic issues. Due to limited supplies, we were only able to hand out a month or two worth of medications and only 12 days worth of Tylenol and vitamins. The need far surpasses our capabilities.

Having seen pictures before I came, I am not shocked by the level of poverty–although it is extreme–but I am shocked by how many people are living in such poverty. To get to each batey we usually pass through three to four others that are just as large and just as poor. Children will come running when they hear the trucks but too often we pass right through their village. Only men are allowed to work in the sugar cane fields and they make less than $10 a day–not nearly enough to support a family. Furthermore most workers and especially children born in the bateyes do not have proper paperwork and some even lack a citizenship. Most workers were lured across the border from Haiti to do the work that Dominicans view as below them and then are either trapped by lack of money or documentation.

Barbara Bernie tells the story of a Haitian women living in a Batey who “had heard that there was work here (the DR) and followed countless others who had taken the same advice, with the same hope of work in perhaps a better place.” When she arrived in the DR, authorities took her papers, and she was beaten when she asked for them back to leave. Eventually she gave up.

There are varying numbers for how many Haitians are living in Bateyes in the DR. Bernie states there are approximately 500,000 just in the Santo Domingo area, other sites estimate anywhere from 650,000 to one million documented Haitians country wide with an additional 20,000 or so Haitians who are brought in by the government for harvest season. Regardless of the statistic you use, there is a giant community of people who are invisible, stateless, and enslaved–we see just a small portion in our clinics. We are only a rain drop in a desert.