Be Careful What You Wish For...

Thursday I got to take a few hour break from my medical record data collection to spend time with real patients. But instead of being super happy about getting to take part in patient's care, instead of feeling proud that I was helping patients navigate the hospital system here, I am feeling disappointed in myself. Again, Haiti continues to throw corny proverbs in my face that seem to be much truer here than in my sheltered life back in the states. I had hoped the whole week, last week, to get to sit down with more patients and hear their stories. I was hoping to get a few good case studies that I could use in my presentations when I get back home. I already have a few presentations scheduled and so I figured the infectious disease teams, medical students, and NGO volunteers back home would find walking through a patient case or two much more interesting than a bunch of medical record system data collection. I am not saying I was standing there with my fingers crossed that a bunch of sick HIV+ and TB-infected patients would have to come to the hospital last week. But if patients with severe conditions waltzed through the doors of HIC, I was ready. Questions set. Computer in hand, ready to take notes and photos.

And then my wish came true. Thursday, a very sick HIV+ baby was referred from Dr. Robin at Port Salut. Since she has become a new friend and a fellow blan working in Haiti, I told her I would sit with the mom and dad while they were admitted. I promised to take care of any questions they or the doctors and interns might have had about the baby's condition. And so I sat and listened to what the doctors had to say. And the more I listened, the more frustrated I became. They had me take the baby to go get a chest x-ray and while the pediatrician looked at the results, the interns took all of the vital signs. They listened to his chest. They asked the mom about the baby's symptoms. The more questions they asked, the more it became clear to me - they didn't read a word of referral chart that Dr. Robin had prepared for them, even though she took the time to write it in Creole for everyone. Baby had a bad pneumonia of some kind, was HIV+, and had O2 sats of 45% without oxygen (it improved when he was on oxygen). He needed oxygen, to be prophylactically treated for PCP pneumonia, and potentially other supportive care. Dr. Robin's clinic didn't have the ability to house inpatients because her clinic had just opened in November. So she sent him to me. But it was becoming clear to me that the doctors and interns were treating this baby like a new patient who just walked through the door, having never seen a doctor before. I showed them the papers again and explained, he needed oxygen. The doctor exclaimed - "non, pas maintenant." I questioned why he "didn't need oxygen now" and was told that he had a viral pneumonia and there was no need for oxygen. Hmm... so that's why I hear the baby grunting in respiratory distress? And peer-reviewed research has shown that even radiologists in the states, despite all their training, cannot accurately tell a viral pneumonia from a bacterial pneumonia. Yet, somehow with one look and a quick listen, this doctor tried to? I advocated some more for the patient, talked with the mom, and then left the hospital feeling like I was fighting a loosing battle.

Friday morning I tried my luck one more time. A different doctor told me the patient didn't need either bactrim or oxygen. He told me the patients O2 sats were probably 90%. "Hmm, really? Does your unit have an O2 saturation monitor?" "No." "Then how do you know his sats are 90%?" "I just know. They're probably 90%." So now we are magically guessing patient's vitals... Awesome. After Dr. Robin and I had a few different conversations Thursday night and Friday morning, it finally looked like the best option was to give baby and mom oxygen and transport them home to Port Salut. Their medicines would be delivered to their home, Dr. Robin's clinic staff would do home visits to check in, and we would hope for the best during our Sunday away at Peak Macaya. And so Friday I participated in the battle between the pediatricians at HIC, saying the baby was receiving appropriate care, and Dr. Robin, telling them what baby really needed. I normally try to blend in at HIC and not use phrases like "Well, in the US we would do it like this..." But Friday, I had to take Dr. Robin's and the patient's side. I knew if care would continue as it was, that the baby would not make it through the weekend. Heck, even if care turned around, he had been deprived of correct oxygenation for so long who knows what type of condition he would be in.

As if the HIV baby's care fiasco wasn't enough, Friday I found out that Baby Joseph and his mom were both diagnosed with TB. Luckily, one of the TB doctors I work with at the infectious disease clinic did a wonderful job of seeing them right away, as soon as Dr. Cleonas and I started to suspect it. It turns out that mom had TB in the past and now it's back in full swing. She received medicines in the past for TB, but I didn't have enough time before clinic closed to ask her if she stopped treatment early (it's the first item on my to-do list once clinic opens tomorrow).So my four-day weekend ends with feeling a little guilty for both patients - for not putting the incessant-cough-for-3-weeks pieces together, for not thinking that a negative PPD screen would not be accurate enough to rule out TB when the baby is malnourished, for not trying harder and demanding oxygen and bactrim, for wishing to get to participate in more HIV and TB patient care. The only difference between the two patients over the 4 day weekend - Baby Joseph is still alive and fighting, the other baby isn't. So I guess I have two case studies now. Complete with blan vs. Haitian healthcare dynamics. Complete with a discussion about the HIV+ baby's father's frustration with the care they received at the hospital and his own slew of guilt. Complete with the deep insights I and the baby's parents received from Dr. Robin yesterday at his visitation. So now that I have my two cases, I have a new wish this week - that no new HIV or TB cases walk through HIC's doors...

  Baby Joseph's mom and him, soon after they found out about their new diagnoses. She was so happy that Dr. Cleonas and I were concerned enough about her and her baby that we came to find her at the TB clinic. She happily agreed, not only to have her photo taken, but to let me share her and Baby Joseph's information for a case study. Looks like I could learn a thing or two about simple happiness from my patients...

Helping the Brain Drain

If you're wondering if I got to help put a shunt into a child with hydrocephalus, nope. Instead of helping with cool surgical procedures, this type of brain drain that I find myself helping is much more serious. In the field of global health, the "brain drain" is the problem of many highly educated people (especially physicians) leaving their developing/ undeveloped country for more developed countries like the United States. As I learned about the brain drain issue in my global health classes in college, as I sat at round tables in the past year at conferences, I always took the mindset of how can we start fixing this problem? How can we get more doctors to stay put in the countries where they were born, the countries that need their expertise much more desperately than the US does? But another thing I continue to realize in my time in Haiti is that systems and people are two very separate, entities. And sometimes life is complicated and so you choose to help the person sitting in front of you, even if it hurts the system.

The doctors at HIC and I have compared lots of stories over the past few weeks. For example: There are frustrating days when nobody at the market will sell me a roll with peanut butter for less than $3 (normal price I pay in my subdivision market is 25 cents) because they see me as a white ATM machine. But I kept my complaints to a minimum when I realized that there are 2 prices in Haiti - a Haitian price and a blan price and local doctors are always charged the blan price. Hearing this made me flash back to my first day in Les Cayes - when Dr. Cleonas showed me the local beach and the restaurants there for my official tour of the city. I remembered that lots of little kids followed us and not because they wanted handouts from me. Instead they kept saying "hey dokte (doctor) gimme dollar." In a week and a half I can leave the constant requests everywhere I go. I can go back to a hospital where the air conditioners work all the time instead of 25% of the time. I will no longer have to feel like I am going to pass out mid-work day. The doctors here have worked their butts off studying and interning for 7 years of medical school, only to have this as their reward.

For all my fellow medical students out there, current doctors and medical professionals - do me a favor for a moment. Imagine that you spent 7 years learning and cramming all of the latest medical knowledge. You learned how to read MRI and CT scans, memorized the latest drugs and treatments, got to see all the possibilities of labs to order and tests to run and outcomes to provide for your future hypothetical patients. Then you start practicing and realize that your patients can't afford any of the labs or tests you want to order. The pharmacy is often "stock out" (running out of many needed medicines) so you have to hope the week is good enough for you to get your hands on the meds you want your patient to take and then hope your luck is extra good and your patient can actually afford the medicines when they're available. There is not governmental insurance system, no hospital agreeing to eat the cost if your patient is poverty level. You have to rely only on your physical exam and the patient's meager understanding of the human body for your diagnosis. You struggle with translation, because not only does the patient not speak the language of medicine, but often Creole from the rural mountain areas is as different from the Creole in town as it is from French. You spent all of medical school using French to describe health and disease, and now you struggle to find an appropriate translation in order to get the medical history you need. You have to explain what an antibiotic is to someone who hasn't taken medicine before or even attended kindergarten. Heck, this might be the first time they have even seen a clinic... I know somedays I leave the hospital so frustrated I want to give up, but this week whenever that feeling arose, I made myself try to imagine what the local physicians must feel like.

After the docs leave the hospital, their patients and locals ask them for money, handouts, rides home. They hear countless story after sad story about families unable to afford their medicines, food for their children, etc. And this is all after hours. Talk about never being able to take the white coat off. I recently had a doctor at HIC turn and look at me after one of these begging situations. They said "Kristen, I don't know what I am supposed to do anymore. I am just one person. I can't help everyone..." I have come home on several occasions and felt the same way. But the difference is I get to leave this life of overbearing demands in a week and half. And I question too if it's harder when it's your own people. I wonder how different it would be if the woman asking me for a handout wasn't just a random Haitian in my eyes, but if she was the woman who's house I walked by everyday on my way to school growing up. If the kids unable to afford their medicines were friends of a friend. Some hunch tells me that being fully immersed in the community here would make the burden of working in healthcare here that much heavier...

And so this week I helped a staff member at HIC with their visa application. Not because I don't want this person to keep working at HIC, I know HIC will be worse off without this medical professional. I don't want Haiti to continue to lose it's doctors to Canada and the states. But I also don't think it's fair for me to say: "Sorry. Even though you and I have worked equally hard on our medical degrees, you don't get to have the same opportunities as me. Why? Because for some random reason you and I were born in different countries." And so I hope by working slowly to improve healthcare systemically here, it will become more attractive for doctors to stay and work here. I hope that medical schools here (as I hope they begin to do so worldwide) begin to choose students who are very invested in their local communities. Students who don't come from well-resourced families and who feel so tied to their country they would never want to leave...

But in the meantime, the brain will continue to drain and I will find myself adding to the problem...

For anyone curious about the hospital were I am working/ studying at this summer. Here is a pic of the newest building in HIC's collection - a new ob/gyn ward in the making!

My Summer through the Eyes of a Child... Haiti is Beautiful

If I ever find the time in the future I want to undertake a small, fun project. I will give a Haitian child I know a camera for a week. Yes I know, right now you are probably thinking, that's a bad idea. The kid is just going to run off and sell your camera for money for food. Maybe I will recruit one of Edward and Djeune's sons to be my helper. Or maybe I won't need to. I find the interesting thing with children here in Haiti is if they are asking blan for things, often it's their parents (or some other suspicious grown up) telling them to do so. I bet if I gave a kid a camera and showed them how to use it (have already done this with the boys I live with) they would be so enamored by the fact that technology allows them to get a photo of themselves instantly they wouldn't care about selling the camera for food. They would rather have the camera, because in the instance that they have the camera at their finger tips, that's all they care about. Children are such good teachers about how one should live their life really. And while corny sayings and proverbs for years have been telling us to never lose our childhood innocence, somehow we always fail to listen or remember.

I think the corny advice of viewing life through the lens of a child should start being applied more to the realm of global health. In the news, with all the awful parts we hear about Haiti, it's enough to think I am spending my summer in the center of a torture chamber. But that isn't the case at all. Right now as I write this post, during my weekend stay at Port-Salut, I have a beach-front view of the Caribbean. Some of the most beautiful (and simplistic) things I have seen or experienced in my life have been in Haiti. For instance, I will never again be able to eat mangoes or bananas or coconut flavored items in the states. The fruit is so sweet and perfect here that it alone is worth the 90 minute flight from Miami. Then there is the coffee. Sure I can't just drive up to Starbucks and have someone hand me a latte down here, but part of the fun and the sweetness of the coffee is having to walk to a local market stand in the heat after work. I get to chat with the woman who supplies me with the already pre-ground, pre-sweetened coffee powder and then I take it home to Leila (one of the servants employed by Edward and Djeune). She has it ready for me in the morning and of course serves it to me while I get teased about how I need this "black juice" to have enough energy to get through work at the hospital that day... Yeah so I will admit it, I am not as strong and resilient as the Haitians, so I laugh along admittedly to the morning jokes.

And while the slums of Les Cayes and Port au Prince, the lack of potable water, and the devastating rural and urban poverty is not a joking matter, I think if that's all we talk about in the news we lose half the story. I bet if I gave a child in Haiti a camera you would get to see this other half. You would get to view the gorgeous flowers that grow on the bushes in the front yard of my apartment. You would get to  see some of the best stars and rainbows in your entire life. You'd see how happy my coworkers from the hospital are with their significant others when you see them smile at one another as they dance compa and enjoy a prestige or two on the weekends. You'd enjoy simplistic decorations made by children as they prepared for their official kindergarten graduation ceremony at the local orphanage. You'd get to see how yummy and perfect oatmeal can be if you prepare it, for over an hour, with fresh sugarcane, whole cinnamon sticks, star anise, and milk from the cow that grazes across from our front yard. You would view mountain side and beach avenue destinations that are worth a photo spot on a destination wedding website. You'd be able to celebrate in the small, beautiful victory that comes from being able to buy lots of yummy coconut cookies, spicy homemade peanut butter, and a sprite made with sugar cane, all for only a couple of US dollars.

So next time you read a quick news story about the tragedies going on in Haiti, I ask one small favor of you. I want you to stop and think about the rest of the story, as a Haitian or American child might see it. Think about the Caribbean beach that sits behind the political compound where the story takes place. Or the fun, bustling market that sits in front. Or the wonderfully kind and passionate Haitian doctors working after hours to help patients who might have been hurt in that car accident in PaP. Because then you might see how wonderful and unique the Haiti I know is. Don't believe me? Then look at the photos below. I had some help taking them from a few young Haitian boys I live with. A few young Haitians who continuously remind me that Haiti indeed is beautiful.

Photos from the kindergarten graduation at the orphanage. All of the cute decorations were homemade of course.

 A couple of photos from the Haitian wedding I attended a couple weekends ago. These I stole the camera away for, because I wanted to make sure to get some good shots of the view/ the celebration building. The place is rented out for weddings, graduations, anniversaries, etc. It is a gorgeous place I hope to one day throw a party at so more people can see it!

 The flowers the boys picked for me from the front yard. I am really going to miss them when I have to leave in a couple of weeks.

Celebrating the deal we got at market.. All of these delicious little treats for a few US dollars!

Beginning the Taper

If anyone has ever trained for a marathon, ironman, or other endurance event, then you know that towards the end of your training it's important to make the workouts easier or less frequent. It's what is known as "the taper" as you get closer to the actual race. Now that I sadly have only 2 weeks left here in Les Cayes, I had a very important discussion with Baby Joseph's mother. Dr. Cleonas and I explained to her that I will be leaving in 2 weeks. And while I very much love her son and am willing to continue to help with his feedings and diapers and cuddle with him on my work breaks at the hospital, it is important for us to keep reality in sight. It is important to remember that in 2 weeks she will be the sole caretaker of Baby Joseph. She can't realistically afford the disposable diapers that I have been bringing for him. I won't be there to remind her to wash his bottles, and actually use soap when she does so (or just do it myself). I can't be there to find anti fungal meds when she gives him dirty bottles. And for the fecal-to-oral infections she might have given him when putting her fingers by his mouth after changing his dirty diapers, without washing hands in between - Dr. Robin and her zinc to stop the diarrhea that ensues, will no longer be a call away via my cell phone.

And so with 2 weeks to go in Les Cayes, the education sessions have begun. I am getting Baby Joseph reusable diapers, thanks to a generous baby package donation from Carol from Harvest Field. Next week Baby Joseph's mom and I will go over how to properly wash and reuse these. I will explain to her the importance of using soap when washing diapers and explain how to wash her hands after changes. Carol is bringing me a baby bottle cleaner as well. How-to-wash-things-with-soap 101 class continues. I will show her some of the tricks I have been using to get Baby Joseph to feed even when he's fussy. And re-emphasize the importance of trying to get as much milk in him as possible (the vomiting from coughing so hard with pertussis the other week has made her think if he drinks more than a little bit he will vomit). We will talk about how rusty safety pins (not-closed) for securing cloth diapers is a no no.

While all of this seems simple to those of us who grew up in the states, I think we need to step back and remember to take off our judgement caps. We need to remember that someone, at some point, taught us how to wash our hands (and use soap). Taught us how rusty metal probably shouldn't be poked through our skin. That certain water needs to be boiled in order to be clean. And even though Baby Joseph's mom is older than a kindergartner, I think it's important to not over look the basics. It's important to remember that teaching her how to wash her hands with really cheap soap, is a lot easier than her having to come back to the hospital with Baby Joseph for an easily prevented infection. And while washing soiled, reusable diapers will not be the highlight of my last week here, it's much more sustainable and cheaper than the easy disposable ones.

While I am sad to finally have to come back to the reality of leaving Baby Joseph in a couple of weeks, I am trying to remember what is best long-term. He can't grow up and be all the things I want him to and go to school and accomplish amazing things, if I don't equip his mom now on how to prevent him from getting life-threatening bacterial infections after I leave. I think it was very easy for me to tell others how important it is to teach Haitians how to help themselves instead of giving handouts or doing the work for them. But I think it's much harder practicing what I have been preaching. I think that's because at the core of being human, if we're honest with ourselves, we want to feel needed. That's why handouts feel good short-term, even if they're bad long-term. It's why sometimes we go above and beyond for certain patients even when we shouldn't. It's probably why a part of my pride loves the field of medicine.

I used to say how much of a pain in the butt it was to take my nightly moto rides to give him his bottles and oral anti-fungal med. But now that I've made myself stop, I miss those nights getting to pace around the pediatric unit until he fell asleep. I miss the pride that came with knowing I was the only one who was able to get a bottle in him, while he was screaming, and then get him to fall asleep peacefully. But now it's time to hand over the reigns and let his real mom start taking the credit. I hope that tapering off being needed will make the transition easier for Baby Joseph's mom and for me... But if I am being honest with myself, race day will still be a shock when it arrives.

Baby Joseph showing me he is getting stronger and more independent. He rolled over by himself on Friday... But then of course got mad when he couldn't figure out how to roll back over!

The best part about making myself take time off from Baby Joseph care - I got to spend the day at the beach and touring Dr. Robin's clinic in Port Salut. Both are very impressive!

And of course, no day in Port Salut would be complete without visiting our new friend, Walter. A Swiss chef who makes some of the best (and fanciest) seafood dishes I have ever had. And all at a reasonable price! He buys all of his ingredients from locals. So if you'd like to help your stomach and the people/ economy of Port Salut, come visit Walter the next time you are in Haiti :)

The Learning Curve Part II

As I had predicted in my first week here, I learned a lot this summer. And continue to learn exponentially more each day - about Haitian healthcare, politics, culture, and how to care for patients. But what I never predicted a month ago, is that one of my greatest teachers would not be Dr. Cleonas, or the doctors/ mentors from Dartmouth and CHI/HFM, but a three and a half month old, malnourished baby. Baby Joseph has taken (and continues to take) me away from the healthcare provider chair and put me on the patient's side. He has forced me to see the inequities within the system - from transportation and economic difficulties for those living in rural Haiti, to the need for better education for new mothers, vaccination programs initiated by Community Health Workers, and better collaboration amongst the hospital staff here. He has forced me to get angry inappropriately and challenge professional relationships. He has taken me away from hours of data collection projects, forcing me to stay up late to get my work done, so I could wait for his pee to dribble into a specimen cup for the lab. He has forced me to wait in long lines at the pharmacy and for his labs to be drawn. He has convinced me to use my extra spending money for antibiotics and diapers instead of spending each weekend at the beach or buying myself lots of Haitian souvenirs. But most importantly he has made me fall asleep each night with my mind racing about future ideas for Haiti.

By showing me an inside view of the Southern Department of Haiti, he has inspired me with so many future project ideas that I hope I (and hope local healthcare and community workers too) can undertake. There were so many points in the system where Baby Joseph's condition could have been prevented. If his mom had access to better information about family planning, she would have less kids. If there were more Community Health Workers in the rural areas working on childhood vaccinations and public health education, maybe some of his infections could have been prevented. If the mom had received better breast feeding information (from mass education done at the local clinics and via Community Health Workers) he might have gotten more milk from her despite originally being a poor feeder because of his various illnesses. If there was a better transportation mechanism and referral system in place between Les Anglais and Les Cayes hospital, even if the blan team wasn't there, he would have safely gotten to HIC in Les Cayes and been admitted and given the medicines he needed. If there were patient educators at the hospital, the mom would have known how to go to the lab, x-ray, get his medicines, properly care for him as an inpatient, etc. without needing me there to help her navigate all these things. If MSPP (and the overall government) was forced to keep better tabs on their money donations from places like USAID, then there would be enough money available to pay for patients' medicine so they don't have to spend the $50 US to buy it themselves (after all if a child is in the malnourished unit, he or she probably isn't from a rich family). From the list above alone, now you understand what I mean when I say he keeps my head spinning with ideas of were future systemic changes need to happen...

Several other blan, many of whom are doctors, told me how this would be a good learning experience for me (my investing probably a little too much time, energy, and money into Baby Joseph). And they were right, but in a way different from what they expected. I don't regret getting too close to Baby Joseph, so in that sense, I dare to disagree with them. But I learned a lot, in that I learned it is okay to get really close with patients and try to use every tool in your doctor, medical student, blan, etc tool-kit. After all, I have been guilty of getting really invested in certain patients as a hospital employee and volunteer in the states before. And that's okay. It's okay to get close to certain special patients, as long as, like investing in a bartering sale at the local market, you are willing at some point to walk away even if the outcome isn't how you wanted it to end up.

Another doctor I recently became friends with, gave me even better advice about my learning experience with Baby Joseph. She and I talked about a radio report, by a firefighter, on the importance of not letting oneself take credit for people's lives. The firefighter apparently said - I don't take credit for people being alive because of what I did, because I am not willing to take credit or ownership when people die. I think this advice she gave me is very true and very important. I am willing to admit I am not a strong enough person to hold ownership for every patient the team and I sent home from Les Anglais clinic who probably won't be alive by the time I make it back to the states. I can't let myself feel responsible for every child who leaves the malnourished pediatric unit to go home to heaven, because I am just one blan and I don't get to think I can save the world. If I told myself that I am the reason Baby Joseph is alive, then I would be discounting Dr. Abby and her team, the mom's friend who brought him to clinic, the pastor who got him and his mom on a tap tap to Les Cayes, the doctors and nurses at HIC who have ordered and given his meds and provide him with his high calorie milk every 3-4 hours. But most importantly, if I wasn't honest about him being a true miracle and tried to take the credit, I would have to take responsibility should he or many other patients die. And I have learned that one person is not strong enough to do that and still get up and go back to the hospital the next day...

Choosing Sides - When Pride Gets in the Way of Good Medicine

Today as I entered "L'hopital general" I was reminded that miracles continue to happen and prayers continue to be answered here all the time in Les Cayes. Not only did Baby Joseph look better despite not receiving any medicines overnight, but one of Dr. Robin's staff was waiting for me with the medicines for Baby Joseph as soon as I arrived at HIC! Living in Haiti for a little while, I think, has given me more local instincts. Even though the guy waiting for me looked like any other Haitian in their vehicles near the entrance, I somehow knew it must be Henry. Sure enough! He made eye contact, said "Are you Kristen?" And then after we confirmed who the other person was he handed me the bag of meds and we were each on our respective ways. I have also found in my short stay that making connections here isn't just necessary for business ventures, it is necessary for survival. Maybe that's why so many Haitians I have met so far are really good at what happened this morning. The idea of - you're my friend, or a friend of a friend, so you help me out and then later you can track me down and I will help you out or give you the name of a friend who can help you. The power of information travel merely by word of mouth here is unbelievable, and something I hope is tapped into for future public health education projects.

Fast forward to later in the day - and the reason why I truly think that Baby Joseph being alive is a result of miracles and prayers. The doctors had yet to give him any medicine for, what a doctor I spoke with in Port Salut believes to be, pertussis (there have been huge pertussis outbreaks lately in the Southern department due to a lack of vaccination programs for infants and children). They also hadn't examined him enough to notice his incessant coughing or the Candida (oral thrush) fungal infection in his mouth. When I spoke with the infectious disease doctors about his diagnosis, they agreed with me. BUT they wouldn't let me tell my suspicions to the pediatrician! Why you may ask? Well because they knew she would get mad and it's not allowed here for one departmental doctor to suggest to another departmental doctor how they should do their job. They were worried it would insult the pediatrician or hurt her pride.

So I was forced to choose - do I work really hard and push them to let me give Baby Joseph the medicine I have for him and tell them about the referral I received yesterday? Or do I sit by and wait and hope he's okay, in order to maintain good relationships with the staff here. I have been, after all, working hard all summer long to prove to the Haitians I am in it for the long run. I am here to work and learn as a medical student so I can come back in the future to continue to improve the system. My stepping on toes would put me straight back into that category of tempory blan who comes here fleetingly and bosses locals around on how to live their lives/ do their jobs. But at the same time Baby Joseph is not just another patient. He's the team's miracle baby. And somedays he even feels like mine.

Pride is not unique to the Haitian healthcare system. It is a universal problem. I have witnessed many times already in the US, medical students or junior staff not wanting to speak up and give their opinion because they knew the higher up physicians, or the nurses who had been working their for a long time, would get angry and upset. They didn't want to hurt the pride that tends to come with seniority. And while I think it's okay for people to be proud of big accomplishments - for HIC staff here to be proud of some of the impressive outcomes they can have with minimal resources - I think we need to set a boundary line. Pride becomes harmful when it gets in the way of effectively caring for our patients and practicing good medicine. Whether here in Haiti, in the US, or in whatever country or region people are practicing medicine, I think we need to realize that our patients, and not our pride, comes first.

A Day at the Zoo...Becoming a Little More Haitian

This week I have been treated like a Haitian twice. The first time was an eye opener, the second time made me smile. Tonight on my evening walk/ run I stopped to chat with an older gentleman who lives in my subdivision. We talked about my Creole improving and how long I have been here. He told me, at first I was blan. Now I have been around for awhile so I am Christine (French pronunciation of my name). He told me, continue to stick around a bit longer and keep working on that Creole and soon people will begin to point and say, look - there goes another Haitian. He probably doesn't know it, but after a long week, his sweet comment made my day.

Yesterday, a team of blan decided they would get a tour of the hospital. They didn't work or volunteer at HIC, but decided to visit after volunteering in a local school for this week. They entered the pediatric inpatient area with a translator acting as their tour guide. The pointing and gawking at patients made me angry, but what happened next really took me aback. One of the team leaders approached me after I finished giving Baby Joseph his bottle. He and I were pacing around his bed since he likes movement when he is getting ready for his nap. She pointed at him, and started asking me a bunch of questions: "How old is your son?" "How long have you been here?" Whoa. First off, not my son (although I would love to fly the little cuddle bug home with me). Second, well I have been here a month working at the hospital, but I am assuming that's not what you mean? Yep, this woman thought I and "my baby" were patients here at the hospital. It took a lot of effort not to give the team a lecture. Instead, I explained to them I was working here as a Dartmouth medical student. This was not my baby, but a good friend I spend my work breaks with. I explained to them how I feel about handouts. Then I pointed them in the direction of the pediatrician and her interns when they tried to hand out money to a random woman who told them "she was in charge." Hopefully their communications with the pediatrician means the cute little girl from Wednesday can purchase her medicines now at least.

After the team left, I was reminded of a deep discussion I had with one of my fellow blan volunteers in Les Anglais a couple weeks ago. He brought up the point of what happens when we (short term blan volunteers) leave. We talked about what impacts different groups might have, what happens with the handouts, the view from the locals who live here year-round, etc. When the hospital tour left, I got to see the juxtaposition of what we think happens and what really happens. My suspicions about handouts were confirmed when patient's parents started going through the goodie bags the tour team had handed out to each patient. One parent picked up the two mini tubes of toothpaste and said "I think we can get 15 gourdes a piece for these right?" Not that brushing ones teeth for a week really fixes a lifetime of cavities either, but the reality of the situation made me laugh a bit.

I questioned to myself, would this group of individuals ever know where their tubes of toothpaste really went? Then, as I started questioning the tour, I became a bit angrier. Would they really ever take the time to wonder where their tubes of toothpaste went? Would they ever allow themselves to tour hospitals across the US? Would their large group be allowed to go into patient rooms, despite not being hospital staff, and get to point at patients and ask them personal questions? And then, instead of staying to chat with the patient, after having their answers, just getting to waltz right out of the hospital? I don't think so. Then why is it different here? Why are teams of blan allowed to tour the hospitals of Haiti, the slums of India, the townships of South Africa when they don't work there? Why are they allowed to treat patients, human beings like you or me, like animals? HIC is not a zoo or jungle excursion. The patients spending weeks in the malnourished section of the pediatric inpatient unit don't deserve to be pointed at, to hear blan say to one another "I know this is really hard for you to see.." They, like you or I, deserve dignity and respect. And the only ones who are allowed to say "this is really hard" are the patients. After all, they are forced to deal with these tough situations every day, not just for a 5 minute stroll during the tour. For these patients, this is a daily and harsh reality, not just a random day at the zoo.

Baby Joseph this week saying "What's that you say? There was a tropical storm this week? Hmm, doesn't phase me. I am a Haitian and we Haitians are tough."

Haiti is Hard

Today is one of those days that I am very happy I decided to blog. We all have had those days in our lives where we are quite certain that nobody else would understand what we are experiencing, no matter how hard we try to explain it. Medicine is an interesting field. It's a unique career in that you don't just study how to do medicine, but you become it. You learn a different language, work an unhealthy amount of hours, and see and do things that others would never imagine or want to do. I love when Haitians ask me if I am a doctor, not because I want to play doctor while I am down here, but because in French they put it so clearly. "Vous etes medicin?" Which means "You are a doctor?" But because they often leave the pronoun out before medicin, to me it sounds like "You are medicine?" Because it's true, you don't just practice medicine, you become it. You leave the normal social world that the rest of the human race lives in and you transform. I really feel that Haiti in many ways is similar to medicine. Until you experience it for yourself, until you leave the social infrastructure and comforts of the developed world, you never really understand it. Just like I realize now that I never really understood medicine until I have started to become it.

A wise doctor once told me that "Haiti is hard." For those who maybe hear stories from Haiti, visit it for a couple of days, etc. they often think that means Haiti is sad. But it's more than that. Haiti, like medicine, is complicated, and I am writing this blog post because I know that there are only a few select people (who have worked in both medicine and Haiti) that really understand. I am not saying others don't care when I am having a bad day, it's just different. Because while they care and love me, they don't live in this unique world of Haiti and medicine that I do, and so it's hard to explain to them what today was really like.

Today was a the perfect example of how "Haiti is hard." Today marked the exact half point of my stay here in Haiti. And today I think I almost lost my marbles. Today I fed Baby Joseph his morning bottle, only instead of a normal baby bottle the nurses insisted I use a sippy cup (yes a plastic sippy cup for a baby the size of a newborn) because it was easier to clean and more sanitary. Needless to say he almost choked multiple times, couldn't control how much he was intaking, and then proceeded to vomit all of the contents up on me. Today we weighed Baby Joseph and I found out he has gained less than half a pound in the last week and half (hmm I wonder if this has anything to do with the fact that he's not eating well because we are feeding him out of a sippy cup). Today the mom showed me the "clean water" Baby Joseph's dad brought to give him in addition to the hospital's special formula... he had put it in a dirty plastic jug (hello infection!). Today I had zero success at buying Baby's Joseph's mom food and new clean water at the market because the Haitians there immediately saw me as a blan who would pay 6 times the normal price for something (no I am not going to pay $2 US for a piece of bread!) Today when another mom saw me buy Baby Joseph's medicine she told me her and her sick, malnourished daughter's story... I only have so much cash on me to last my entire stay here so I had to look the adorable little 2 year old in the eye and tell her sorry but there's nothing I can do, I am just one blan and I don't hold all the money or the answers. If it were up to me the government/ MSPP would let all little girls like this woman's have access to free healthcare, but today I am not in charge and I don't make the rules.

Tonight when a NGO group came over to the house for dinner they asked me how my day at the hospital was. I said it wasn't good and started telling them about Baby Joseph. But I gave them the spark notes version, because they started giving me that pity look and I don't want pity. Neither does Baby Joseph... or the other sick little kids and babies in the malnourished section of the pediatric unit. They want solutions. I couldn't effectively explain to the other blan tonight that I am not an unfeeling person. But Haiti is hard and so there are days when we send patients home to die of very curable things or tell little sick malnourished kids, sorry nothing I can do. We shrug, sigh or laugh inappropriately and move onto the next patient. Not because we don't care, but because if we cried over every tough thing we saw here, the Haitian doctors and I would never get any real work done. Because like explaining and being medicine, explaining and also being present in, really truly experiencing Haiti, is hard.

It's Time to Start with the Men

During my nightly runs or walks (depending on how hot it is of course) I am reminded how different the interactions between men and women are here compared to back home. I am the only woman in this area out exercising. Only men and boys occupy the soccer fields and basketball courts (Note to self: Les Cayes could use a "Girls on the Run" program). Men are very upfront (quite rude actually) and will make smooching/ kissing sounds as I run by. Sure catcalls happen in the US too, but after 3 and a half weeks living in a large city in Haiti, it's becoming apparent that interactions between men and women are very different here.

I really got to see this with my clinic work in Les Anglais last week. Since Julmis and I had patients  go through an educational questionnaire with us on how to prevent transmitting or being infected with STI's in the future, I learned a lot about the culture between men and women there. Many women don't have control over their own reproductive life and start having babies before they get to grow up themselves. Many women contract STI's from their significant other, but are too fearful to tell their boyfriend/husband because they are sure their significant other will blame them, when in reality the significant other is probably at fault.

What upset me most though during those educational sessions was the lack of acknowledgement from the men's side about how harmful some of their practices are to the women they are with. Many would question me - "But I don't understand how I got this STI, the last time my girlfriend was tested at this clinic she was negative.""Wait when we asked how many partners you've had, we didn't mean how many girlfriends. How many sexual partners have you had?" "Well too many to count of course. Why?" Awesome. This conversation happened more than once. The men could not seem to understand that by having many partners they were contracting the diseases from these flings, not their girlfriend. And because of their infidelity they were now putting their girlfriends, their pregnant wives, etc at risk for serious infections.

Now don't get me wrong. I am not saying every Haitian man is awful. For instance, I loved working with Julmis. He is soft-hearted enough that he often got just as mad as I did at the men and was even sadder than I was, I think, upon hearing some of the situations our female patients were in. Dr. Cleonas is great. He treats his female co-workers with respect and has brought up the topic of needing to improve education for women more than once. But overall the culture here is different than back home. Much more patriarchal than I would like it to be.

PEPFAR is spending loads of money on ARV therapy for pregnant mothers for Preventing Mother to Child Transmission (or PMTCT as it's often referred to in the literature). I question why that same amount of funding is not also being poured into education. Why funds are not being put towards promoting a culture where men value women and want the best for them. Once this happens I think there will be lots fewer new HIV + cases amongst pregnant women; there will also be less pregnant women period. Which will mean less children per family. Thus a smaller chance of children becoming malnourished because mom is able to feed all of them, because there are merely less mouths to feed. I think you can see the point I am trying to get at. Lots of good could come from empowering women here in Haiti. But I think in order to effectively empower women, to let them take control of their reproductive lives, let them have better health outcomes... we need to start with the men.

The Person Behind the Chart

For my first week or two in Haiti it was easy to hear about poor outcomes or great outcomes and shrug them off either way. I went through lots of charts for retrospective data for a summer research project. And no matter how many times I saw words TB or HIV positive it didn't phase me. I would write down in my data sheet that a patient died and no matter what the age - 10, 35, 72 - I continued on in the same manner I used for studying in medical school this year - memorize/ speed read through the lists of awful diseases and continue on. After all, time in medical school, like my time here in Haiti, is precious. So I planned to use it as efficiently as possible.

It's a lot harder though to rush through and treat a person sitting in front of you as merely a set of vitals, a disease to commit to memory, or a data entry point for a summer study. Last week in Les Anglais was wonderful because it gave me the opportunity to see the person behind the chart. I had the privilege to sit down with many patients and hear their stories. My interpreter, Julmis and I, went through sex education with each of the HIV negative patients because we believe that information is 1) empowering for patients and 2) a lot cheaper for the healthcare system here than a lifetime of ARV meds for a HIV + patient. Hearing patients responses to our educational questionnaire (the one that the wonderful Haitian nurses from HIC gave me) provided me with a lot of high and low points for my days.

I got to hear about how one girl refused to have any boyfriends or get married until after she completed school. She told Julmis and me: "I have a dream/ vision for myself. I am going to finish school, get a good job, and accomplish my goals. Then after that I can think about boys. For now I am focusing on me." Julmis and I started smiling and I wanted to shout out loud "You go girl!"

Sadly, this patient was followed by other more somber stories. Seeing teenage girls, who looked like little babies to me still, answer my question of - if their boyfriend, husband, or another man approached them and they didn't want to have sex with that individual, would they feel comfortable speaking up and say no - with their shy and sad "no" was heartbreaking. There was one little teenage girl I felt like picking up, putting in the back of our tap tap truck, and whisking away; letting her be mothered and grow up first before she had to face some of the awful realities of the situation she lives in.

But through the good and the bad, I loved that I got to be there with patients to hear their stories. Someone once told me that it's important for people to be able to share their stories because it validates them, gives dignity and shows they are important and that someone cares. I think this is very true. After all, the sweet older woman who suffered from malnutrition was no longer another data entry point. She is a woman who lost her husband a year ago and while she and her children are starving, she is still a proud and dainty enough woman to borrow a pink sharpie from someone and "paint her fingernails." I have never seen a bigger smile as when I and the other blan told her how beautiful her nails were. We exchanged hugs, I told her she was beautiful - she reminded me of my grandmother - well-kept and dignified no matter how bad of a situation she found herself in, and sent her on her way.

I was only able to truly make a difference in a handful of these patients' lives in Les Anglais. But it's my hope that after spending a week listening, educating, and advocating for, the patients there know they are no longer a set of vitals or diseases for me to mark down. They're real people that received care and attention from someone who will never forget their stories. From someone who is going to continue to try to work with them and slowly try to improve their situation one step at a time. From someone who will continue to remember that there is always a person behind each chart she reads.

Freedom is Not Free

On this 4th of July weekend I washed a blanket that Baby Joseph's mom was using for him while he was in the hospital. It was very dirty and I have been trying to keep Baby Joseph in at least a semi-clean environment while he finishes fighting off his infection. Then it will be time to just send him home and hope for the best... The irony of the situation was the blanket was an American one. It had an American flag, an eagle, and the words "Freedom is Not Free" written on it. The mom probably had no idea what the blanket said (after all she couldn't read Creole, let alone English). She probably just received the blanket as a handout from a group of blan.

But what was so thought provoking to me while I sat there and washed the blanket - while many of my family and friends were probably celebrating back in the states with fireworks, buffets of food, ice cream, parties (all of the frivolous, but awesome displays that remind me just how rich we really are as Americans) - is that Baby Joseph's mom probably understands those words way better than I do, than many of us do really. Because when Haiti successfully gained its independence - back in 1805 - the French said they would acknowledge Haiti as an independent state on one condition - that they pay France for the economic loss that would result from them no longer owning Haiti as a slave colony. So while Haiti was the only successful slave rebellion resulting in a free nation in the history of this planet, Haiti also immediately became one of the poorest countries on the planet. The debt they owed France was equivalent to 21 billion US dollars today. Thus Haiti's freedom was not free at all - it literally came with a price tag.

Because of this debt (and the international politics associated with it), Haiti has suffered for the last 2 centuries from economic hardship. Many Haitians are literally born into a culture of debt/ poverty and so for them, to live in a free nation, it means they have had to pay for it. This includes Baby Joseph's mother. Baby Joseph's story comes with highs and lows. His story has also showed me how quick I am to judge mothers here. How I look at them through my American-culture lenses and ask why they make some of the choices they do. How I want to blame them for not knowing how infection is spread to their babies, for possibly choosing to not take care of some of their babies so that the babies who are already healthy can have a better chance at surviving. But then I realize I don't have the right to judge them, because I have never walked even a half mile in their shoes. I wasn't born into a life of poverty, born into a culture where the survival of the fittest isn't just an evolutionary phenomenon that you learn about in science class, but it's a way of life. I have never had to make decisions in such poverty about which of my 6+ children should live, because there would be no way to feed and cloth all of them. I have access to healthcare and family planning so if I don't want to have 10 children I don't have to. I am a female that is privileged to have an education and will have a nice job, so I didn't need to rely on marrying a man as a teenager in hopes of having some of my basic needs (like food and access to some money) met.

So this past 4th of July weekend, while I washed Baby Joseph's and his mom's blanket I realized that I don't get to judge her or other moms here in her same situation. Because while I am thankful that many men and women in the past fought hard so I could grow up in a free country like the US, I am also honest. I am honest enough to admit that my freedom is so much freer than Baby's Joseph's mom because I never had to pay a life of poverty for it.

Let Them Eat Cake

If anyone knows me well, then they will know I have the biggest sweet tooth in the Western Hemisphere. I also realized something else about me today - I am truly a spoiled American. It has only been 3 weeks and a day since I arrived in Les Cayes, Haiti. But today it finally hit me - I could not take another bowl of porridge with bread for breakfast, another protein bar I had brought with me for lunch each day, or another serving of rice and beans for dinner. I have not had a single real dessert since my plane left Miami and while for most of the world this is the norm, I have had the rich comforts of American desserts my entire life and my stomach was having a very hard time forgetting about them this week.

Luckily Mamma Djeune (as the boys call her) must have heard my stomach's rumbling pleas today. Tonight we celebrated my birthday (a month early). I think they thought I said my birthday was July 5th, instead of August 5th. And so my tummy was filled with homemade soup complete with homemade dumplings (the soup they make for special festivities such as birthdays). Following dinner, Mamma Djeune presented me and the boys with a frosted cake and at that point, when the boys eyes lit up and they exclaimed in unison "gateau!" I could not ruin their surprise. I let them sing me Happy Birthday (in both English and French of course) and then my tummy for the first time in 3 weeks was filled with a deliciously satisfying sweet!

After tonight's feast, I couldn't help but think about how many people in this world eat, what I have been eating for the last 3 weeks, everyday. And often they are not in a situation where the family they rent from has enough money to afford cake. That's when my views on global food scarcity started to change. Previously my view on food globally has been: if every man, woman, and child around the world is able to go to bed each night with a full belly then we have satisfied the basic human right of not going hungry. However, if someone told me that I was going to eat rice and beans every night for the rest of my life, if I were to forget about ever having gateau (cake) and ice cream again, and that I should be satisfied with this situation, I would look at them like they were crazy. That's when I realized how easy it is, to sit at my American kitchen table, complete with a variety of delicious foods and desserts, and tell the rest of the world how they should be happy because they get to go to bed with full tummies. It's easy to give advice when the cheesecake is on your side of the table I think. And while I am not advocating for global diabetes with cake at every meal, I think our Millennium Development Goals should be higher. Instead of ending childhood hunger or trying to fix global food scarcity with rice and bean handouts, maybe we should strive to improve local economies worldwide. And then we can say we have finally achieved our goals when people everywhere, both in the mountains of Haiti and the mountains of Vermont, can afford to go to market and buy their family cake for a special celebration.

Oh and if anyone around Les Cayes asks, yes my birthday is July 5th...

Photos of the boys enjoying the cake as much as I did :)

It's the Little Things in Life

I never thought I would be so excited to see drool in my entire life. Yes, drool. Something so ordinary to anyone who has ever had a baby, watched a baby, or smelled delicious food. But yesterday, when I went to the hospital and fed Baby Joseph his bottle he drooled for the first time since I met him at the clinic in Les Anglais. I started beaming and the mother couldn't understand why I was so excited. She thought: Are they letting him go home? Are we done being in the hospital? She didn't seem as excited as me when I pointed at him smiling and drooling. I explained to her that his lips were no longer chapped and he was able to drool because he was no longer extremely dehydrated. Mucous membranes moist? check! Mark it off on his chart as normal.

Not only is Baby Joseph no longer dehydrated, but his fever has come down. Lots of his tests came back negative for really serious infections so the residents moved him from the Les Cayes, Haiti version of a NICU to their general pediatric inpatient area. He continues to suck down his bottles of formula like a champ and has been gaining weight each day. He responds to my voice and even starts kicking his legs and grabs my finger with his hand when I sing to him after his feedings. I am hoping with a good toy to grasp and play with, when I am not there to entertain him, that his brain will develop normally despite this infection.

This must be how new moms are. Super excited when their child takes their first crawl forward, their first step, has their first piece of solid food, etc. The rest of the world could probably care less, but to them it's like Christmas came early. Like Baby Joseph's pseudo-mom I have also been tracking his brain development like a hawk. I talk on FaceTime at night with my significant other and we discuss the importance of Baby Joseph playing, needing an interactive toy, human touch, and lots of calories right now. I think to myself, maybe if we get him back on track his brain will develop perfectly. Maybe someday his mom will tell him about the blan med student who fussed over him when he just a few months old. Maybe she will tell him how he's a miracle baby. Maybe with this story he'll grow up and want to be a doctor someday, or an ethical dignitary wanting to improve the Haitian healthcare system...
And then reality always seems to set in and I am reminded that as a rural, poor Haitian he probably won't get to go to school. He'll be a miracle child if he survives this next year. So for now I guess I will celebrate the little victories - like the drool and smile that awaited me at the hospital yesterday...

Breaking the Rules

His name: Baby Joseph. Okay so that's not his official name, but it's the nick name the team and I have given him over the past week. He is three and a half months old. He only weighs about 9 pounds and most likely has bacterial meningitis. But he has the cutest little mouth and the adorable face he makes when you give him his bottle is enough to get anyone hooked.

I always vowed I would never do this - never be the "blan" who gives lots of handouts to one person. That's why I am participating in the collaborative projects this summer with Dartmouth/PEPFAR/CHI/MSPP. I figured this work would be longer lasting, more sustainable, help more people by helping improve the system that cares for them, etc. That's why I didn't bring a suitcase full of toys for an orphanage or food for malnourished children. I really only packed for myself. This reasoning is why I usually turn away when random Haitians on my way to work say "Hey blan, gimme one dollar!"And for the last 2 and a half weeks I had been sticking to my plan pretty well. I have made lots of connections, sat through lots of meetings, collected a lot of data, spent all afternoon on emails, working tirelessly on changing/ improving the system...

But then Baby Joseph's mom brought him to mobile clinic this weekend in Les Anglais. I know, many will tell me that there are a ton of baby Josephs out there, many with the same cute faces and just as in need of medical treatment and baby formula for food. But with the encouragement of the Haitian doctor in Les Anglais and the blan team supporting me, I helped get Baby Joseph to Les Cayes. With the help of Pastor Yivonne and some donations on the American side, Baby Joseph's parents tracked me down at HIC yesterday - probably was pretty easy since I am the only blan medical student that works there. I checked them in and held Baby Joseph while the interns and the Pediatric team poked and prodded. The Pediatrician - a bubbly, middle-aged Haitian woman - was awesome. She admitted him to the inpatient infant area of the ward, ordered his medicines and lots of tests and then rounded up all of her interns and residents to go over the case - looks like Baby Joseph is getting to be the little star around here.

I again broke the rules and helped pay for his medicines, chest x-ray, and labs. I literally sat there all afternoon today waiting for pee to dribble into his specimen cup while I held it. I couldn't stand seeing him in dirty clothes, all smelly, when he was trying to fight off infection. So I gave him a baby-wipe bath and put him in a clean diaper and a little blue onesie I purchased at market. The mothers milk has dried up and she couldn't remember what she did with all the bottles of neonate formula we had given to her in Les Anglais (she probably sold them or gave them to her other toddlers at home - but more on that part of the complicated story later). So I went out and bought powdered formula and prepared a bunch of little bottles for him. I fed him this morning, over my lunch break, this evening, and even took a moto tonight to give him his nighttime bottle. Each time I changed his diaper, cleaned him up and made sure his fever medicines were on schedule. The nurses here are amazing. They have been giving me the update on his antibiotic schedule and they let me hold him when they do his blood draws. They even act as my interrupters - translating my French into Creole so Baby Joseph's parents can understand my instructions.

The last few days have taught me that life is complicated. While it's important to try to play by the rules and follow the original plan, life is not black and blan. Sometimes an exception to the rules, a very cute exception, comes along and it's okay. So tonight I decided that for my next four and a half weeks here I am going to work very hard at my original projects, but I am also going to try my hardest to take care of the cute little exception I found. I think if you saw him smile at me today during one of the feedings, you would also agree with this plan...