Well I thought after this summer, this blog would be done... but I am slowly realizing that talking about Haiti, processing the work we do in Haiti, and most importantly the work of building sustainable health infrastructure and lasting, equal partnerships is a continuous project and has a long way to go. Haiti work has been going about 1,000 miles per hour ever since I returned home from my previous trip 3 weeks ago. From ordering surgical supplies, to setting up projects for first year medical students, to funding applications, to data entry for our HIC work to begin writing our Dartmouth Infectious Disease Dept. paper, to random Haiti lectures that I've been finding myself in, I feel like every time I turn around Haiti keeps sneaking up on me. I never want to be the person who makes assumptions - after all that's how lots of people working in global health have gotten themselves in trouble - but I wonder if this is how it is with hard patient cases or working in other countries for other people too? If there's that one place or that one patient, that no matter how busy your class or clinic schedule and extracurricular responsibilities, you can try to push them towards the back of your mind, but then all of sudden, bam! It hits you like a truck when you least expect it.
Today we had two Dartmouth physicians who have worked in Haiti present on some of the work they've done there after the earthquake and beyond. I felt the emotions come out of left field when one of the physicians asked a Haitian colleague we were skyping with during the lecture presentation: "What do you do when you have to tell a patient who needs dialysis there's nothing you can do for them because they had the unfortunate fate of being born in Haiti?" This Haitian physician had trained in other countries and worked in France for awhile and previously had access to dialysis equipment and now he was working at the new hospital in Mirebalais and had no access to any of these resources...
My mind instantly went back to a handful of patients in Haiti - first to the Type I diabetic patient my age in Les Anglais. I walked through how she would eventually go into DKA coma and not make it to the next regular primary care clinic visit. I told her how if she were in the US, the doctors would have been able to give her insulin to prevent her dismal course. I think patients everywhere deserve the dignity that comes with telling them the truth. Luckily this time when I spotted a similar patient in Fondal, we were able to get her access to care - in fact I was in the middle of giving her the dismal outcome when miracles happened to intervene and she is now on long-acting insulin thanks to a persistent translator - but to learn more about this special case, you'll have to read Caitlin Foley's blog post:
http://chiadventures.blogspot.com/
Then my thoughts moved to another patient from this past trip that's been on my mind a lot lately - an approx. 60 y.o. female patient who had late stage cervical cancer. It's crazy how I've heard about lots of little kiddos not making it because of diarrhea and malnutrition and then this one women who is by Haitian standards "old" really got to me. She was a patient of Dr. Judy (one of our fabulous ob/gyns who is helping lead our women's health initiative charge). We explained to her that she needed radiation treatment and even then there was no guarantee for good outcomes. The biggest problem - Haiti doesn't have radiation treatment options - Mirebalais has chemotherapy, but no radiation. I searched for options for her and took down her information so I could look when I returned home... the end result was what we had all kind of expected - there weren't a lot of options. One because she was living in Haiti and two because she didn't have a lot of money. When we originally told her we didn't think there were a lot of options, her response was: "So am I just supposed to lay down and die?" That's when I decided to involve Bill, our photojournalist. There is something very powerful about an individual being able to share their story with others. And not in a poverty porn type of way. No, Bill took the time to show people in the states that this woman was not a victim of poverty and disease, but a heroine, someone much stronger than I could ever be and someone who deserves to know that she's inspiring our volunteers and our women's health initiative programs to keep going and not give up despite all the bumps we hit in the road. If she didn't get miraculous radiation treatment, we felt she at least deserved to have her story heard and validated, because I've found from many difficult conversations in Haiti that this can be very powerful for patients...
And then I started thinking - why does a refrigerator and some insulin need to be a miraculous situation, why does oncology treatment that we offer in the states have to be seen as a "miracle" too tough for the mountains of Haiti - why can't it became the norm? Why do patients only a 90 minute flight from Miami, FL not have access to routine pap smears - why should catching cervical cancer early and treating it be considered a foreign concept - an option available only for "the haves" and not "the have nots"?
And this brings me to another classmate's question presented during today's lecture: "How do we make work in Haiti sustainable? Do you think it's sustainable now?" My honest opinion is "yes and no." Sadly Haiti is a land of 10,000 NGO's and still has the least number of healthy productive life years per person (See Global Burden of Disease Study: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-insight). Why is that? I feel like I've already mentioned it in other blog posts, but why aren't organizations stopping and asking if what they're doing is more sustainable? Treating diabetes and hypertension can prevent many patients from needing dialysis in the first place. Sometimes good intentions aren't enough, sometimes good intentions also have to be intentional and analytical. I used to think this was a common sense idea held by the majority, but sadly I think we have a long way to go. I am not saying it's not possible, but I think we have to start asking ourselves what do the communities we're working with truly need? How can we sustainably build economies and public health infrastructure and primary care initiatives that create communities where insulin isn't a miracle and clean water isn't something that the Culligan man drops off to the white volunteers at the local guest house in Port au Prince.
And so today brought up a lot of Haiti emotions and questions for me. Somehow Haiti and all the things it has taught me keeps sneaking up on me, but I think this is showing me how it's important to take time to process powerful events - whether that event is working in the mountains of Haiti, caring for a special patient in Iowa or Vermont/ New Hampshire, or committing to helping marginalized populations in inner City Boston, Chicago, or worldwide. And I think this is something I neglected to do a few months ago when I found out about how my special patient from this summer wouldn't be there the next time I visited Les Cayes or Les Anglais:
I found out from Dr. Abby about Baby Joseph's death the night of my Term 1 finals and so naturally I did what any medical person feels they have to - briefly let it register and then push it to the back of my mind and continue on with my studies, because at the end of the day I need to learn all this material to pass. To graduate. To get the end result of a medical career in global health... But when I drove through Port au Prince 4 weeks ago on my way to La Digue and Arcahaie, a wave of emotions hit me out of left field. The same feeling I had today sitting through this lecture presentation. So "Renal Hearts and Minds" lecture met it's goal - of connecting our hearts with our minds... It got the emotions running and got me thinking about how to do it better. Obviously intensely pouring resources into one mother and baby situation wasn't the solution. Sure it was heart-felt and well-intentioned. But it wasn't intentional or sustainable. Why does Haiti have the highest infant and maternal mortality rates in the Western Hemisphere? Why is it that despite all these blan caring about individual Baby Joseph's and their moms, the rates aren't getting dramatically better? What's the most sustainable way to build community-wide infant and maternal health systems? Now the dilemma is finding the answers to all of these questions. I think the NGO, Community Health Initiative explains it best - we, I, will keep asking questions, stay up late ordering medical supplies and answering classmates questions, skip weeks of class to check on primary care clinic patients, remember those special patients, and work on community empowerment, so that simple things, like insulin and maternal health care, don't have to be considered miracles or reserved only for "the haves" group... We will keep intentionally, sustainably, continuing onward, "Until the Work is Done..."
