With 6 Days Left...Final Thoughts on Haiti

After the moving incident a few days ago I began to think about different experiences and interactions I have had here- both positive and negative. I have thought about my expectations of Haiti and if I have really accomplished anything during this trip. And well, if I didn’t accomplish anything- I can certainly guarantee that I ate the most peanut butter in 7 weeks than anyone ever has. I have been dreaming about fruits, vegetables and whole grains for weeks now! First, I will explain the moving story. As a disclaimer- I apologize that this blog will be all over the place- I think it will take a while until I can really wrap my head around everything- this is just the beginning to my summary of thoughts.

A huge truck pulled into compound and parked next to the porch of the mission house. A crew of movers began unloading boxes- a lot of them- behind the truck- about 25 feet away from the porch. Most of us were doing work on the porch for our projects and didn’t notice this all going on. Then it started to rain and David- who is down here for his 6^th time and helps out all over the compound- noticed that the boxes were getting wet. He asked us if we could help out and move some of the boxes onto the porch. We all hopped up and began helping- until we quickly noticed that we weren’t helping the movers- we were doing the moving. At first it was only a few of us and it was clear that it would take too long and the boxes would be wet- so the boys (who had been working really hard on their data analysis) jumped up to help. Through the entire process- probably 10+ minutes- the hired movers stood leading against trees relaxing. They never moved to help- even when asked. It was upsetting that we were doing work that other people were getting paid to do- but it was more upsetting that I wasn’t surprised with the situation. Again, I have had so many wonderful experiences here, but unfortunately this was one of the bad ones.

When I told my family and friends that I would be traveling to Haiti, their first response nearly 100% of the time was: “be safe”. To be honest, I was nervous. Media coverage often highlighted the dangers of life in Haiti. After being here and also reading an opinionated book of the history of Haiti from an anti-US standpoint, my fears have really dissipated (mostly from being here, but reading the book definitely helped me consider the other side of the story). There is definitely a caveat associated with this feeling of safety and that is Milot. Milot is a very unique place and is overall very safe. We are sheltered from the violence that tends to occur in the cities- Port-au-Prince and Cap Haitian. When driving through Cap we are always in a CRUDEM vehicle and are told to leave before sunset, again keeping us out of harm’s way. I don’t think that it is unreasonable to think that Cap Haitian is dangerous but from our experience, Haiti has only felt safe.

For the most part, with a few exceptions, the patients and staff at the hospital have been very welcoming. Of course, we are only medical students, so there is less opportunity to step on people’s toes, but overall I believe that our group has done a great job respecting the system that is in place and worked hard to work with the HSC staff and not around them. Thinking of accomplishments- I would hope that we leave Haiti having furthered the relationship between Tufts and HSC. At our final meeting with the head of the hospital, Dr. Previl, he was very excited about the results of our projects and was eager to welcome more Tufts students in years to come. We must have done something right to keep us off the “do not return list”.

As for the project that Sophia and I worked on, we reached our goal of 50 surveys and did so by working through some significant barriers. As I have mentioned before- the first 3 weeks we were here- we waited around for a female translator to become available. Luckily, our survey needed some more work, including a translation into Creole that we were expecting from a person in the US and never received. So we began our search for a translator after quickly realizing that depending on a community health agent was not our best bet. Sophia did a great job working with the head of nursing to secure nursing students that spoke French (thank goodness she is fluent in French!). In 2 weeks we were able to visit Thibeau and Carrefour des peres twice to get 25 surveys done while also spending afternoons at the hospital to complete 25 surveys we needed done there. Although it took some time, and involved some frustrating days, it was a great experience. Some of the stories that women told were truly heartbreaking and it was a privilege to have them open up to us. Many of these women welcomed us as foreign strangers into their homes and often carried out chairs and demanded we sit. It was a little gesture but for me showed that they trusted us and really wanted to be part of our project.

We have spent this week staring at 0s and 1s on the computer, analyzing our responses to the 40 question survey. With some questions having 10 answer choices- let’s just say it’s a lot of 0s and 1s and my eyes hurt. Dr. Forrester and Steve (via skype) have been SO helpful in narrowing our focus and helping us with the analysis. Sophia and I hope to have our poster (that we need to present when we start back at school) completed by the time we leave so that our 3 weeks at home can be spent relaxing, decompressing, and reflecting. Well, I guess I speak for myself on the relaxing part- Sophia planned a 3 weeks backpacking trip to SE Asia- I chose the beach and the couch!

So what else did I accomplish in Haiti? Although I did not actively treat anyone here because I am not a doctor- I hope that by working with physicians in the clinic and the hospital I was able to be part of a team that helped make patients’ days better. Working with several Tufts doctors in the outpatient clinic was great and gave us all a chance to work on our interviewing and physical diagnosis skills. Although the doctors actually prescribed the medications and sent patients for labs, X-rays, or further consults, I hope that I was able to convey to the patients that even though I couldn’t actually give them the medication doesn’t mean that I don’t care. I hope I showed how much I respected them and was willing to listen to their concerns in order to help in any way I could, even if that was just running over to the hospital to check with another staff member about what treatment was available or to show a patient where they needed to go.

Some of my favorite days here were those that included a visit to Santos- the pediatric burn patient who arrived at the hospital days before we arrived in Haiti. Although the visits are usually short and without many words because I don’t speak French or Creole- just seeing his smile is incredible. Although he has undergone dressing changes almost daily and surgery to fix his contractures- he never complains or cries, just continues to smile. He often visits the families that sleep outside the pediatric unit at night waiting to be the first in line for the following day’s clinic. I like to refer to his visits as “Santos Rounds”. Today Santos brought the nurses who change his dressings to see his 5 day old sister. Eric and I were lucky enough to join and observe him with the proudest smile on his face when he introduced her to us. I think being here has made me appreciate the little things you can do to make someone’s day just a little better- even if that is just lending a helping hand, stopping by for a visit, playing a fun game of soccer, or bringing people to meet your little sister.

With so many frustrations, it would be easy for me to leave Haiti with a pessimistic view of this country. There are certainly very hard working, skilled staff at the hospital that save many lives and treat many patients daily. They work in a setting with limited resources but never complain and make do with what they have. But then there is the story of the movers a couple days ago that unloaded the boxes but would not finish their job. It would be unfair to group people by work ethic because in a country with an unemployment rate as high as 75% at times- it’s very hard to know what someone might do if they were given the opportunity to work. It is just difficult to watch so many people suffer because they are unemployed and can’t afford to eat, when those that are employed are doing half the work and getting full pay.

I think it’s hard to make a lasting impression in only 7 weeks. But, from the reverse angle, I certainly think Haiti will have/and already has had an enormous impact on me. Selfishly, I think I will take more away from this trip than I gave. I hope to bring back stories and experiences that I can share with others to keep Haiti on everyone’s mind in order to continue the awareness for the need here. When speaking with a worker on the compound today he asked when I was leaving. When I said “Next week, but I hope to be back.” His response was, “I am really glad”. I didn’t understand at first but he clarified that, “I am happy you want to come back.” A short conversation made me realize how many people have come and gone, especially recently after the earthquake.

With so many NGOs, volunteers and foreign aid, it is not surprising that Haitians expect people to just come for a week or two and leave without ever returning. However, what Haiti needs is sustained support systems from organizations and teams willing to continually send volunteers that will work with the staff here and help to further their training. I hope that by sharing our experience when we get back, we can recruit interest for years to come and Tufts in Haiti can be one of those sustainable groups. I think my Life is Good book has a perfect quote, “If you don’t go, you don’t see.” We all know that Haiti is the poorest country in the western hemisphere burdened with poverty, violence and disease. But without coming here, I would not have seen the beauty of the Milot valley, the kindness of so many welcoming people, and the resilience of the Haitian people. Although it is cliché to say: a piece of my heart will always remain in Haiti and I certainly hope to be back.

Some highlights I will never forget: Chris and Briony’s consistent and inspiring hard work, soccer games with Haitian boys, our trip to Children of Promise Orphanage, moments with Santos, visiting homes in Thibeau and Carrefour des peres, the days in clinic with Tufts faculty, being welcomed by other volunteer doctors into clinics and ORs, torrential downpours and rats in the rafters, screaming children: “blan, blan, blan” throughout our runs, Dr. Previl’s daughters daily visits soon accompanied by all the children living on the compound (including Dr. Bernard’s “mini-me” son), IVs given on the porch at all hours of the day to Grace and Spencer, the hike to the citadel-both of them, Eric and Andrew’s completed dares, our makeshift workout room, trips to the beach and into Cap Haitian, multiple cakes, peanut butter, cards, and bananagrams. And some pictures to end this novel of a final blog post…

Eric, Spencer and Alex's final presentation to community health agents. Andrew and I got the chance to participate and present on water sanitation and pregnancy respectively.

One of many soccer fields/grazing sites along the road from Cap to Milot

Mural outside the hospital depicting scenery of Milot and scenes from the earthquake

Briony's Goodbye Dinner above and Dr. Salem and Dr. Forrester's visit below

A house in Milot

Eric learns from Emmanuela how to hold a chicken and then proceeds to chase me with it...

Altruism (?)

Recently Sophia and I talked about the reasons that foreign doctors come to third world countries like Haiti. We had to talk loudly over the gasoline generator that is (hopefully) keeping the meat that we will be eating frozen for us. We were wondering if altruism really exists. In general I think that people really mean it when they say that they want to help people but it’s a question of degree: how far are you willing to go to help someone? Altruism is too simplistic a concept because it does not take into account all the motivations that drive people to help others. Sophia told me an applicant to the Peace Corps who wrote that they wanted to help people would be told to reconsider their motivations, the reason being that wanting to help people is not sufficient reason to put oneself through two years of living in a very challenging situation.

Having spent 5 weeks here I realize that I was guilty of this sin when I decided I wanted to go to Haiti. Even as our dinky dual prop plane touched down in Cap Haitian, I had no idea why I was here. I wanted to come to Haiti because I had read about it in Tracy Kidder’s book “Mountains Beyond Mountains”. I was fixated on the idea of going to an exotic part of the world, working in a clinic and helping people who would otherwise have no access to modern medicine.

This idealistic fantasy didn’t last too long. I thought that at the end of the day I would feel fulfilled for having helped someone but working in Haiti can be frustrating, infuriating, draining, mentally challenging, and heart breaking. Many times at the end of the day you don’t feel elated to have helped people; sometimes you just feel empty and exhausted.

This problem is epitomized in a spate of child abuse cases that we’ve seen at the hospital recently. About two weeks ago a young patient was admitted to the hospital with an isolated laceration on the forehead after “falling off the roof of the hut”. The patient was treated and released but soon after we learned that the patient had sustained another questionable fall from the same roof and died.

Around the same time a fourteen month old was admitted to the hospital with a massive puss-filled infection on his head. An X-Ray revealed a hairline fracture near the crown of his skull. Questioning the mother it turned out that the baby’s father had gotten in an argument with mom, grabbed the child by his legs and swung him head first into a wall.

This past week I followed Dr. Arrowsmith in the pediatric outpatient clinic. In the middle of one of our exams, a Haitian physicians asked Dr. Arrowsmith to take a look at a 9 year old girl he had propped up on an exam table. She had genital lesions that were consistent with HPV condylomas. The doctors all agreed it was most likely a case of sexual abuse but exactly what to do was not so clear.

Treating the head trauma or the infection for these patients wasn’t necessarily the hardest part of their care. That part was straight forward in the sense that it was clear what had to be done. The hard part was the fact that there is no system for dealing with abuse. As was clear with the first patient we can treat the trauma but then we release the patient back into the same abusive environment. There would be no investigation by the police, no arrests and no trials. This leaves the physicians with very little they can do to help victims of abuse.

Haiti is not a country of quick fixes. These types of systemic problems can make clinical care seem like an exercise in running in place. We can treat patients for the physical trauma of abuse but then we send them back into an abusive environment. We can treat all kinds of infections but without improvements in water sanitation many of these patients will just become re-infected.

That being said we’ve had the opportunity to see some surgeons do some incredible work in a week. Dr. Fleury, a plastic surgeon from Georgetown, performed surgery on three burn patients: Michel, Santos and Beverly. Michel is a young man that electrocuted himself while trying to steal power from overhead electrical lines. Santos is a five year old with burns covering his scalp and arms. Beverly is a 3 year old boy with severe developmental delays who is unable to walk, talk and is most probably blind. Beverly is an interesting case because his burns cover only the back parts of his legs and a well-defined patch on his belly. His burns are consistent with being dunked in scalding hot water which would indicate child abuse in the United States but another possibility is that the burns are the result of a voodoo ceremony. Dr. Fleury used a dermatome to cut skin grafts for these patients and performed Z-plasties for Santos to release some of his contractures. The nice thing about surgery is it’s a quick see it, cut it, fix it type of scenario that brings immediate satisfaction after a successful procedure. However, this overlooks the contributions by other team members and Haitian staff that take care of post-op patients once the surgical team has left.

This past week I worked with Chris, an ICU nurse that was here before we arrived and will be staying here until the 3rd of September. Chris has been providing the follow up care for all three patients that Dr. Fleury operated on. Every day Chris dons a stifling sterile robe and goes into a sweltering OR where she has to cut off the patients’ bandages, clean their wounds, apply antibiotic ointments and re-apply sterile dressings. I helped out with 5 of the 15 total dressing changes over the week and it was brutal work. I was sweating bullets within minutes of starting the bandage changes. Without this constant attention however, the patients would develop massive infections and die despite all of Dr. Fleury’s work.

The other shortcoming of the constant turn-over with a new team of doctors flying in every week and the old ones leaving is twofold: patient care suffers from lack of follow up and the Haitian staff is constantly getting different and even contradicting instructions on how to run their hospital. Because Chris is here for so long she is able to model the behavior that would be expected in a US hospital and gently nudge the Haitian staff in the right direction. Before Chris arrived, the burn patients likely wouldn’t have received daily dressing changes, and would have had their wounds rinsed in a shower with no anesthetic. Working with her I noticed that the nurses seemed to be getting the hang of the procedure and lending a hand when they could.

From what I’ve witnessed it’s fantastic that doctors make the decision to come down here and work for a week. However, CRUDEM needs more people like Chris and Dr. Arrowsmith willing to devote 4 or 5 (or more) months to making long term changes that will have a lasting impact.

I asked Chris what were her motivations for coming to Haiti. Initially Chris came down after the earthquake but this marks her 3rd trip to Haiti since. She said she likes the freedom from paperwork and the feeling that she is really working for the patient and not trying to cover the hospital’s ass. She likes being able to meet so many people from all over the country from so many different professional and social backgrounds. But most of all what makes her keep coming back is the Haitian people. In the aftermath of the earthquake, Chris tells me, that the local people would come in every day to feed and wash complete strangers that had been flown in from Port-au-Prince. That kind of altruism is hard to imagine in the US. Seeing people sacrifice so much in a place with so little really put her life in perspective.

So as we near the end of our trip I have to ask myself what do I want to get out of my seven weeks in Haiti? I wanted to make some kind of impact on the everyday lives of Haitians through our project but now I will be happy if we can have trained 17 community health agents to take blood pressures. The kind of change I had envisioned will take years of dedication and support from successive teams of Tufts medical students. Personally I think I’ve been able to learn a lot from first hand exposure in clinic that will hopefully prove useful in my future clinical practice. Each week we’ve been exposed to a new sub-specialty, an opportunity rarely afforded to first year medical students. Most of all I think I will gain an appreciation of the conditions under which most of the world lives. Growing up and living in the US gives us such a stunted view of what life is like for much of the >6 billion people living on this planet. Understanding this will put my struggles into perspective: my worst day probably pales in comparison to the grinding battle for survival in places like this. Living and working in Haiti for 5 weeks has not been easy for me or anyone in our group but I think none of us will regret the experience.

So to finish off my rambling: does altruism exist? I think everything we do, no matter how kind hearted, we do for a reason. We all have our motivations for our actions and there is always something we want to get out of them. I thought I would be rewarded by a glowing feeling every day from my hard work but that isn’t necessarily the case. Benevolence comes in degrees: how much hardship are you willing to put up with and for how long? Truly giving of yourself in these conditions is working your ass off for a result you may never see. I think a lot of good is done by the doctors that take the time to come down here for a week but it’s the people like Chris and Dr. Arrowsmith who will in the long run make the lasting changes. I think we can all afford to learn a lesson in dedication to care from the Haitians that came every day to the hospital to care for their countrymen after the earthquake.

Who Ever Said You Can't Celebrate the 4th of July in Haiti...

Happy 4th of July from Milot! Although we aren't home to celebrate the independence of our country- we did everything we could to make it feel like home. Sophia, Andrew, Chris and I headed out to the store this afternoon to get anything we could find for a bbq. It turned into a dinner of hamburgers, hotdogs, potato salad, french fries, pringles, brie and crackers, and a cake to finish everything off. Not too shabby for a Haitian grocery store and bakery. We'll see how everyone feels tomorrow...

The store in Cap Haitian above, and the finished dinner below...

Such a Small World...

As everyone here and at home knows, I go through stages of terrible homesickness. The group here in Haiti has been really great about helping me get through the bad parts of some days and the wonders of technology have allowed me to talk with family and friends throughout the trip. Unfortunately the internet is not always reliable so skyping is sometimes hard and those stretches without it are usually the worst. Every day I look at the bracelet that my little brother gave me and remember that even though I am not with family and friends, they are still supporting me and I try to enjoy my days here because it is such a great experience. Anyways, Friday was one of those bad days until I walked out of the bathroom and saw two familiar faces sitting on the couch, I was shocked. Before leaving Connecticut my friend Megan told me that Chrissy and Claire (two girls from CT that play college soccer at Princeton and Dartmouth) were traveling to Haiti and I should look try to get in contact in them. I honestly didn’t think it was possible that they would be coming to the small town of Milot and didn’t get a chance to check in with them before leaving. Although I am usually shy when new people show up (about once a week) I decided that I would ask what they were up to and if they needed anyone to show them around after I got back from the hospital. As the words came out of my mouth I started doing a triple take because I couldn’t believe they were really sitting there. Turns out that Chrissy’s older sister Jess lived in Haiti after graduating from college and lived at CRUDEM for a year and a half. I looked pretty silly asking them if they needed help getting around the place- Jess knew everyone and everywhere to go just fine.

From then on my Friday did a complete 180- I headed back to the hospital to help Eric, Spencer and Alex finish up their community health agent training. I have been so impressed by all the work that they have done with to help train the community health agents and Friday was fun because Andrew and I got to help out by teaching how to take a blood pressure. It will definitely take a few more sessions for them to correctly take a blood pressure but it was great to see how excited they were to learn. They asked really great questions and were engaged in the whole training session.

In the afternoon I went back to the hospital to work on my project with Sophia. We have had a really hard time getting our surveys done because we have not been given a female translator to work with. Because our surveys are about very personal women’s health issues it is essential that we have a female translator because even talking about these issues makes women embarrassed so it is almost guaranteed that with a male translator they would not answer many of the questions truthfully, thus skewing our results. Because we haven’t been provided a translator, Sophia has found nursing students that speak French and Creole and can thus work with her to translate back and forth. Our surveys run smoothly but just take a bit longer. Sophia usually asks the question in French, the student translates into Creole then the answer back to Sophia in French who tells me in English and I write it down. Although I am only a scribe in the whole process I have begun to pick up phrases here and there and can sometimes understand what is being said. Overall, the entire process has been extremely frustrating but has tested my patience and has taught me a lot about what it is like to work in a global health setting when some things are just out of your control.

The day ended with one of my favorite activities in Haiti- soccer with Haitian boys. Jess, Chrissy, and Claire were heading out for a run so I caught up with them and joined. We stopped to show Chrissy and Claire the soccer field and within 5 second little boys had kicked us over a ball. An hour later, it was dark and we still had a little over a mile to run home. Playing soccer with the little boys was so much fun and people always end up crowding around to watch. It is amazing how fast they are, how much energy they have, and as we all learned- how much better traction is when you are not wearing running shoes (we all fell multiple times and everyone watching laughed very hard). Our run home was pretty terrifying at points because you couldn’t see more than a couple feet in front of you and the road has potholes everywhere but we made it just in time for dinner. After dinner I learned about Chrissy and Claire’s awesome two weeks here and all things they had seen and were going to see for the rest of this week.

Saturday was another beach day. We had planned to go to Labadee- the Royal Caribbean stop in Haiti but as we were heading there we got a call saying that we couldn’t go so we headed back to Cormier beach- the one we went to last time. We went with a pretty big group- the six of us joined Chris-an RN that is a leader of CRUDEM and staying until September, Briony- Pediatrician from UK that is here for 3 months but sadly leaving in two weeks, Sarah- a girl working on an HIV project in Cap Haitian that Briony met when she came to the hospital to look into the HIV clinic’s records system and as we learned she went to college with a few of our Tufts classmates at Harvard, Dr. Chu- the new Tufts member who is a family physician in Cambridge, Ben- Dr. Pearlmutter’s son who is here for 2 more weeks with us (see picture of him sleeping with what looked like a broken neck), as well as a group of people we invited from the hospital who have helped us along the way. Two translators- Lele and Tanner (in picture with the sea urchin) have worked in the adult clinic with the doctors from Tufts as well as with the boys on their training sessions and BP clinics, the nursing student who has translated for Sophia and I, as well as John- a guy that works in the prosthetics lab and is close with Chris. They seemed to have a great time so it was nice to be able to say thank you for all the work they have done for us in the past 4 weeks. An important result from the beach day was Andrew losing a card game that we play 3 times in a row and thus having to complete a dare of our choosing. It was decided that he had to sing to Fifi (the cook) before dinner for an entire minute. He didn’t do it last night so he has a three day limit, we will keep you posted about how that turns out. Today we head back out to all help Eric, Spencer and Alex with another BP clinic. Our countdown has officially begun so I will post it here, 19 days left- I am sure they will be as great as the first 4 weeks and filled of more adventures and great experiences.

I also decided to include some random pictures from the trip that I haven't had the chance to post...

The first day we arrived in Haiti we traveled to the top of the Citadel with Dr. Pearlmutter. If you recall from the earlier blog post it was pouring rain so we decided to visit again. Typically a truck drives about 4-6 miles to a parking lot then drops you off for a 1 mile hike. We decided to get some exercise and walk the 5-7 miles uphill to the Citadel at 5am. When we arrived at 7:30, the front door of the Citadel was locked so we took some pictures and continued on our journey back down. The round trip hike took about 5 hours. Andrew has posted some pictures below.

There were about 35 new volunteers that came to stay the week. Most of them came with a plastic surgeon from the DC area, but there was also a team of pediatricians from Tufts that were here to lead a conference. The plastic surgeon brought along a few anesthesiologists, a few ER docs, a pediatrician, a general surgeon, and a dermatologist to name a few. With all of these new doctors around it was the perfect week to get sick.

That is exactly what happened. Yesterday, just before lunch I didn’t feel so great. Originally I didn’t think twice about it due to all of the stomach issues nearly all of us have suffered at least once. But I soon realized that I probably had some virus that hit another family who came to visit last week. I was given Zofran (anti nausea medication) and an IV that hung from a lamp post. I went through 6 L of fluids over the course of about 7 hours. I can’t say Haiti is the most ideal place to get sick, but I don’t think I will ever have this many doctors checking in on me again.

Hike to the Citadel

Maggie and Spencer holding the Citadel in their fingers

How the mighty have fallen