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.