Founded in 1974 by an ex-minister of health and a handful of small business owners, CDS began its work in Cite Soleil, a swampy slum of 250,000 in Haiti’s capital. Here CDS developed the community health model that would eventually prove so influential. The documentation and monitoring system created there remains the foundation of the CDS model. Each person in Cite Soleil was given a health identity card, which gave the holder access to CDS services and enabled CDS health officials to locate each individual's health records -- records that were stored in Cite Soleil at the two CDS health centers and hospital. Mothers kept documents concerning the health status of their children. Community health workers (“CHWs”), each responsible for 200 families, also kept copies of each family’s critical health information. Above these CHWs were CHW supervisors, who had their own groups of families and monitored 6-7 other CHWs. All CHWs and supervisors lived in Cite Soleil. The CHWs ultimately reported to a doctor, usually with a masters in public health. If a mother brought a sick child to the CDS hospital, a doctor could quickly find the family’s records and arrange for the responsible CHW to monitor follow-up visits and treatment. Conversely, a senior CDS health official could randomly visit any of the tens of thousands of homes in Cite Soleil, review the mother’s health documents, immediately identify the responsible CHW, and promptly review the family’s medical history.

Charts kept by mothers and CHWs included information on vaccination, infant growth monitoring, pre- and postnatal visits, and critical diseases (e.g., tuberculosis). CHWs were checked each month to verify whether their families received appropriate preventive care. In particular, CHWs were responsible for ensuring that pregnant women and mothers with children up to age 5 made monthly visits to the nearest CDS health center. If families missed their preventive care meetings, CHWs conducted follow-up visits. By the early 1990s, almost 94% of the pregnant women in Cite Soleil made nearly 19,000 prenatal visits to the centers. Overall, the centers served roughly 400-500 people per day. CHWs also ensured that minor injuries and illnesses were treated at the CDS health centers before they become major medical problems. For TB treatment, CHWs took the medicine to patients’ homes and observed them take their medicine for their entire six-month, multi-drug regime. Similarly, for those diagnosed with STDs, home visits were made for counseling and/or treatment. Given their close ties with the people they served, CHWs could sensitively guide adults (men and women) to CDS’s family planning clinic in Cite Soleil. While the self-satisfaction gained from serving one’s neighbors was the most significant motivator, CHWs that achieved statistical improvements in various health indices could be rewarded and those with poor records could be pressured to improve performance. In a large sense, it was the CHWs that drove the health model, providing a constant flow of information to administrators regarding the community’s priorities (e.g., clean water, sanitation) and health messages that were likely (or not) to have a positive reception in the slum.

Similarly relying on local expertise, rather than battle the dozens of traditional midwives in the community that had engaged in practices that led to appalling maternal and infant death rates, CDS hired the midwives, trained them, and provided them with equipment and materials that would enable them to deliver babies in mother’s homes in reasonably sanitary conditions. The midwives also urged mothers to deliver at the CDS hospital and the midwives handled uncomplicated births at the hospital. As with these midwives, instead of fighting Cite Soleil’s voudoun leaders as rivals, CDS staff met with these important community leaders, gaining their confidence and support. This collaboration with religious leaders proved particularly useful in CDS efforts to control the spread of HIV infection (9% of the sexually active people in Cite Soleil are infected). CDS opened an STD clinic in Cite Soleil and had specially trained CHWs (akin to social workers) make home visits (with the patient’s consent) to the partners of those infected. Again, CDS’s careful record keeping system made these home visits feasible.

The 100-bed CDS hospital served 19,000 patients and performed 700 operations annually. To limit costs, the hospital only accepted patients who had been referred by CDS health centers or those requiring emergency care. Children born at the hospital (CDS per month) were registered in the CDS preventive health service, and malnourished or sick infants given immediate treatment. In addition to its obvious medical benefits, the hospital gave CDS enormous credibility in the community. By providing a service prized by the residents, the people of Cite Soleil (especially the mothers) were far more open to CDS’s promotion of various preventive health messages.

Throughout the program, health education, especially for mothers, was a driving force. On monthly pre- and postnatal visits, at visits for curative care, on videos played (softly!) in the recovery room of the maternity ward, and, critically, on CHW visits to every home every month, CDS gradually expanded knowledge regarding many of the basic tenants of public health (use of ORT, vaccination, infant growth monitoring, breast feeding, sanitation, etc.).

The Expansion and Survival of the CDS Model

Based on its experience in Cite Soleil, CDS rapidly replicated the core model (curative and preventive care, CHWs, documentation system) in urban and rural areas throughout the northern part of the country, eventually covering a population of 750,000. CDS took the program to mountain villages, barren coastal plains, small towns and other urban slums. The model was modified to accommodate local circumstances. For instance, in rugged rural areas where it might take hours to walk to a CDS health center, CDS would have its CHWs arrange for community members to visit a “rally post” far from the health center where they would be met by CDS officials providing preventive and curative care.

But CDS was not content to expand its own programs. CDS saw a need both within its own program, in the Ministry of Health and other private health organizations, to train health officials. Health professionals needed to understand (i) international advances in public health, and (ii) building on CDS’s own experience, how to manage a public health program given the local circumstances. Consequently, CDS built a public health school, which has given training to community health workers, nurses and auxiliaries, doctors, and administrators. Classes range from epidemiology, biostatistics, and health care management to on-the-job training at CDS centers. CDS also expanded its direct support for other health organizations throughout the country, distributing millions of dollars of donated medical supplies to over 100 NGOs and government facilities throughout the country.

Despite periods of violence and extreme turmoil in the country, CDS never closed and its services now cover more than 350,000 people. CDS has continued to work despite the insecurity and chaos. Vaccine levels rose, pre- and postnatal increased, knowledge of preventive health practices is widespread where CDS operates, and the destitute have a decent place to turn to when they are sick or dying.