"Until the Work is Done..."

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..."

C'est Ayiti

This weekend I have begun preparing for trip reports and presentations. I am finishing up my blog and trying to wrap up the last of my summer research data collection. This weekend, I tried to explain to a few friends what living in Haiti for the summer was really like. Fortunately, I am blessed with some great friends up here at Dartmouth. Both were patient and understanding when at certain topics and during certain stories I was at a loss for words. After all, for the last 3 weeks each time someone asked me "So how was Haiti?" I found myself giving the same, automatic, one-word reply "Good." I think that's because I am slowly realizing just how hard it is to put Haiti into words. To truly explain to someone who has never been there, what living in Haiti (even if it's just for a few short weeks) is really like. And even when I can find the words to describe my favorite (and not so appreciated) parts of Haiti, I am hesitant to share. I think that's because I also realize that not everyone is capable of listening to my stories and summer thoughts in the way that I need them to. A piece of advice I gave to all new volunteers that I worked with in Les Anglais this summer was to call me if they ever needed someone to talk to, but more importantly if they needed someone just to listen. Because as Dr. Abby put it so perfectly - not everyone understands and many aren't at that point to listen in the way that you need them to.

So for my last blog post I am going to try my hardest to explain how I see Haiti and how I see my summer now that I have had 3 weeks to reflect on and process it. When I tell you that Les Cayes, Haiti is a place that would often reach 120+ degrees F with heat index, you might ask - why would anyone ever want to live there? Sure there were days I was drenched in sweat, when I thought between the air conditioners at the hospital breaking and my wearing scrubs (which in case you are wondering - yes whoever invented scrubs clearly never worked in the tropics), I was surely going to pass out. Yes in my first week I got burnt by getting off a motorcycle (moto) taxi the wrong way and because I didn't have bandaids, I got creative on how to treat my own burn. Sure my apartment was bug infested. And yes, until the heaven-sent Les Anglais team brought me bug spray hand outs, there were night where I would swat bugs off me, until I became too tired and then I would just let the bugs (fleas, ticks, other louse family members?) crawl on me as I fell asleep. Sure there was the time (after a few weeks of mostly 2 meals of lots of rice each day) that I missed American cereal so much that even though the bowl had a handful of ants swimming in it, I ate it - ants and all (extra protein?). And of course, there were those weeks at the hospital and clinic where I saw more death and disease burden, than many might see in their lifetime.

But if those were the only parts you take away from my stories, then you forget that Haiti is so much more than that to me. It's more than the buggy, beans and rice (ok so mostly just rice) filled days. It's more than sending patients home with nothing more than bad news and a "sorry, nothing I can do." It's also been a summer where I hiked through beautiful rainforest, climbed part way up mountains, and relaxed on the beach. I got to cliff jump into the Caribbean. I learned how to dance compa when the doctors from HIC took me out to the discotheques on the weekends. I rode enough moto taxis that by the end of the summer I was riding them like a true Haitian - sitting sideways in a skirt and sans helmet of course. I was able to attend a wedding, a graduation, a wedding anniversary celebration, and sadly, a funeral visitation. But, best of all, I became a part of a wonderful Haitian family (see post on "Saying Good-Bye to Family"). I experienced so much in just 7 weeks, that it's hard to share all of my stories in my blog. And the overall experience? It was joyful and frustrating and sad and wonderful and miserable all at the same time. That's when I realized why it's been so hard for me to describe Haiti to someone who has never lived there for a bit. Because Haiti is so many different things at once.

There were certain situations that happened at HIC hospital that would leave the nurses and doctors that worked there at loss for words. Situations, sometimes unimaginable to those of us who live this sheltered life in the states. And when the nurses and doctors didn't have a good reason for why the situation happened, they would turn and look at one another, shrug, and say "C'est Ayiti." Yes, indeed, "This is Haiti." So I think from now on, when people ask me how my summer trip was and I am not ready to give the long answer, the one full of stories - good, bad, unimaginable - or I don't think they are ready to hear it, I think I will just tell them the truth. How was living in Haiti? "C'etait Ayiti." "It was Haiti..."

Dr. Cleonas, of course showing me up and working harder than me, even on my last day at HIC :)

He was a great mentor. As for the doctor and pharmacist below. They were so much fun to work with and I miss them both already. They took me under their wing and showed me how great living in Les Cayes can be.

 Miss Neptune ran a tight ship at the clinic at HIC, but she and I got along very well. I respect her for how organized she kept the clinic and how at the end of the day, while she was tough on her employees, it was because she really cared about the patients.

And then of course there is this little guy. My summer in Haiti definitely wouldn't have been the same without Baby Joseph. 

Saying Good-Bye to Family

Even though the transition from Port au Prince to Boston in a day was hard, the hardest transition for me, surprisingly, was when I had to leave Les Cayes for Port au Prince. I took a morning bus ("transport chic") to Port au Prince to stay in a nice guest house in Village Theodat. Village Theodat is located very close to the airport, and I knew that with a Saturday morning flight to Miami, I didn't want to risk driving from Les Cayes early in the morning, get stuck in standstill traffic in PAP, and miss my flight. The bus ride experience was great (see post "Tout Moun Se Moun") and I really didn't mind the long wait at the bus stop (my driver who was picking me up got stuck in Port au Prince's notorious traffic) - I think Haiti, by operating on tropical time, made me a bit more patient and go-with-the-flow.
The part after the bus stop is what was hardest.

Village Theodat is not like the rest of Haiti that I had come to know during my summer stay. It has beautiful guesthouses, with multiple stories - all with new tile, huge kitchens - that serve 3 meals a day - lawns with pretty flowers that are watered regularly. All of this sits inside a nice gated and guarded community. The gated community probably houses more expats and visiting mission teams than it does Haitians. And so, in a way, when I traveled to Village Theodat on that Friday, I felt like I had traveled all the way back to the states.

I say this, because I think it's important that if I wrote about my summer stay and what I learned while living in Haiti, I should also write about my experience of leaving Haiti. I feel that by writing about what I experienced while leaving Haiti, shows yet another handful of lessons I learned from Haiti. Also, I think this post might be an important learning tool for others who have or are considering visiting Haiti. I want them to know that Village Theodat, with its manicured lawns and fancy guest houses, complete with cool, well-ventilated rooms, is not the real Haiti. And if this is the only part of Haiti that one experiences, then they are missing out on some of the best (and my personal favorite) parts of Haiti.

Like the part where you become fully integrated into the local Haitian society. Where Haitians are no longer "people you have come to help," but are your co-workers, your patients, your coffee and mango and Sprite suppliers, your moto taxi drivers, your friends, and best of all, your family. I have visited Haiti before. I have attended Haitian church services, I have heard Haitian patients' stories. But never before have I got the blessing of becoming part of Haiti. Thursday night as I prepped for my Friday departure to PAP, Edward and Djeune surprised me by treating me to dinner at a local restaurant on the beach. Then they took me to the hospital so I could spend an hour cuddling with and saying good-bye (for now) to Baby Joseph. During that hour, one of my favorite nurses came up to me and told me "I can tell you love him a lot." Really, the nurses and my Haitian family were not making the saying good-bye part any easier. I told her how I had to leave the next morning, because sadly in order to pass medical school, I had to go back and start my 2nd year of classes. She tried to convince me just to take him with me. I told her how he already had a mom, that I was a student and unfit to provide him with a home in the states. She accepted my "C'est complique" finally. I thanked her and the other nurses for all they had done for me and Baby Joseph. We exchanged hugs and then she went back to work (partly I think because she didn't want me to see that she was tearing up a bit - proof once again that "Tout Moun Se Moun"). Eddie arrived with the Land Rover, so I said my last good-byes to Baby Joseph and Mom. I told her that Pastors Brian & Yivonne would be there to talk to her and that when she gets home Hypole would check in on them. I told her I would receive updates on them and that the next time I get a chance to get back to Les Anglais, I would come visit their family and catch up. She seemed a bit reassured by that, but I could tell she and I both felt a bit nervous at leaving such a large burden (of taking care of a sick baby like Baby Joseph in such a resource poor situation) up to one person - her. We exchanged hugs, and then I headed home to pack.

The family and I exchanged good-byes and logistics about my early-morning departure over a cake I had purchased as a thank you. The very-asleep boys even got up so they could say good-bye (and of course because they heard the words cake). I packed and looked through summer pictures and packed some more. The morning arrived quick and I was reminded once again how spoiled I was - Leila, the servant, had gotten up early to make me hard boiled eggs, bread, and coffee so I could have breakfast before I left. I gave her a big hug, and even though she was tough woman, I managed to get a true smile and a "Good-bye Cherie" out of her. Edward drove me to the bus station and along the way we chatted about my summer. He told me that he was sad that I was leaving because Lance (the youngest of my Haitian brothers) was a picky eater before I got there and by the end of the summer he would clean his plate because he "wanted to be just like Christine." Seriously, they weren't making my saying good-bye any easier. He helped me get checked in at the bus stop and we said our final good-byes.


Again, Edward continued to do a good job at being my Haitian Dad by providing me with some more last-minute wisdom. When I said my good-bye, he smirked and said he didn't need to say good-bye, because he knew me well enough to know that I would be back to Les Cayes before long. And when I did, that I would always be welcomed to stay with my Haitian family. I think that was one of the neatest parts about my entire stay this summer. That I now have a second family. I say have and not "had" because I think Eddie is right. The best part about family, is that while it's tough to leave, you never really say good-bye to family. Because even though I am back in the states now and Edward, Djeune, the boys, and Lidi are still in Les Cayes, we are still in touch (via email) and there is the understanding that whenever I feel the need to head back to Haiti, I will always have a second home waiting for me.

 The family celebration for Edward and Djeune's 5th wedding anniversary. The photos tell the story so well - they were some of the sweetest people I have ever met. 

Why is Peak Macaya Haiti's Last Remaining Cloud Forest?

My last weekend in Haiti was a 4 day weekend. Dr. Robin and I decided to take advantage of the four day weekend by visiting Peak Macaya. If Carnival des Fleurs meant both of our clinic's would be closed, we weren't going to waste our time sitting at home. She took care of all of the details - her driver, Robinson, would take us in the Land Rover. We would leave early in hopes of getting up to the base camp in the national park and fitting a good hike in before coming back down the mountain and heading home to Port Salut by nightfall. That way I could go on the adventure, but also get to go to the mobile HIV clinic in Les Anglais that happened on Monday. Having survived this adventure, I have a feeling I will think twice next time Dr. Robin offers to take me on an excursion. Her adventures are not for the faint of heart.

There were a handful of times when the vehicle was climbing up the mountain that I was pretty sure we were going to roll down the side of the mountain to our doom. It now makes sense to me why only about 4 groups of non-locals visit Peak Macaya annually. The drive up the mountainside was enough to convince me that was my first, but only, time I will be visiting Haiti's last remaining cloud forest.

However, once we reached base camp, I will admit now to Dr. Robin that the pee-your-pants drive up the ridge was worth it. It was like taking a walk into the past - getting to see what Haiti used to be and could be again if we begin to work on the deforestation issue now. Our first stop, before base camp, was Citadel (fort) platoon (spelling?). Unlike the other Citadels around Haiti that have become much more tourist-based and refurbished, this fort seems to have been essentially untouched since it was used during the Haitian Revolution in at the beginning of the 19th century. During the slave revolt, the Haitians had it so well engineered that many of the bunkers within the fort have secret passageways and escape routes. However, after being thankful for surviving the drive up the mountain, Dr. Robin and I decided to leave secret passageway exploring to those who are truly adventurous and moved on (via another bone jarring 2 hour ride) to base camp.

I could now spend the rest of this post telling you about how we only made it part way up the mountain - it's a 2 day hike to summit. We could talk about how ridiculous Dr. Robin, Mark, Olga, and I looked arriving with zero camping supplies or food - we paid our tour guide and his wife to rent two tents from them and have a prepared dinner. We could talk about how much I enjoyed getting to camp overnight, even though it meant I needed to miss participating in the one day HIV clinic in Les Anglais the following day. Or how the tour guide welcomed us into their home and made us feel like family. And even though I can't remember his or his wife's name now, it's so nice knowing how should I ever decide to explore Peak Macaya again, I will have a place to stay before beginning my hike. I could tell patient stories from our mobile clinic that Dr. Robin ran that evening once we realized that many of the people in the town had never seen a doctor in their life - after all, it's 3+ hour drive down the mountain to Cayes. Who knows how long the walk would be.

But instead, I would like to spend a paragraph contemplating and asking you why Peak Macaya has to be Haiti's last remaining cloud forest. Why a country that used to be green and lush and full of tropical rainforest now looks like a dessert. Sure, I understand that many Haitians rely on charcoal from the logging industry and charcoal factories to use for cooking because gas stoves are too expensive. And yes, I understand that if a family living in poverty has to worry about growing crops to provide for themselves, their last concern would be going green and planting a bunch of trees. But then I watched the CNN videos below and realized that deforestation and desertification doesn't have to be the final chapter in Haiti's agronomical history. That there are ways to not only stimulate enthusiasm, but also local economies by getting Haitians to plant more trees. That once locals realize that their agricultural production will increase, that they can chop down half of the trees they plant and make money, but still keep 50% there for helping the local environment, once there is increased awareness that everyone benefits, things will start to change. However, it's going to take more effort, more education, and of course more trees. During a recent conversation with a classmate, we were joking about how NGO's could start helping in more valuable ways. I suggested that instead of bringing down old clothes, next time a volunteer arrives in Haiti, they should bring a little tree to plant. And while at the time it was a joke, maybe now I am thinking that wouldn't be such a bad idea...


http://edition.cnn.com/video/data/2.0/video/world/2013/07/04/going-green-haiti-planting-trees.cnn.html

http://www.cnn.com/video/?/video/world/2013/07/05/going-green-haiti-trees-flooding.cnn&iref=videosearch

 After we finally made it to the top of one of the less-fun ridges to drive up. We stopped and got out of the land rover to kiss the ground. What amazed me most was how red the soil was. I wonder if that's how all of Haiti was before all the deforestation and erosion happened.

The 4 photos below are all of Citadel (Fort) Platoon. Any history buffs would have loved to see all the remnants of how the Citadel must have been 200 years ago during the Haitian War for Independence.

These bunkers were the ones that supposedly had secret passageways associated with them. Maybe we will save that adventure for a return trip to Peak Macaya. Then again, probably not...

 This photo above, for some reason, kept reminding me of a scene from Jurassic Park. I kept waiting for a little dinosaur to be feeding behind one of the large boulders. 

 The benefit of the scary drive - even at base camp we could see the entire plain that Cayes was situated on. We could even see all the way to the ocean :)

 Per usual - USAID started spending money and then didn't follow through. This building was supposed to function as housing for agronomists and national forest protection reserves. Instead, it sits there abandoned because they never finished it. This is why I am thankful the roads one has to take to get to Peak Macaya are so bad.  I know that the day an easy-to-drive-up road is built, the logging companies will start to chop away at the 2% of rainforest Haiti has left. 

Below is a photo of our rainforest tour guide. He chopped through the path with his nice little machete and knew that cloud forest like the back of his hand. I was very impressed. He is standing by a natural spring. He promised us it was clean and we could rehydrate if we were thirsty. So of course Dr. Robin and I made him drink from it first. Once we confirmed that he didn't drop dead from it instantly, we too drank from it. And as far as we know neither of us suffered from any severe intestinal irritability :) 

When I asked him if I could show his photo with people back home, he said of course. He told me he would love it if I told more people about Peak Macaya. He thinks the people from the town at the base camp, where he lived, could really benefit from adventure tourists visiting and stimulating the local economy - after all, Dr. Robin, Olga, Mark, and I saw a lot of malnutrition in our one evening of mobile clinic there. So as promised, I hope you all can now see how beautiful and adventurous Haiti's last remaining cloud forest is. 

Where Should All the Orphans Go?

Throughout different points of my summer I have had small conversations with different groups, volunteers, blans, and Haitians about the new policy in Haiti concerning the Hague Convention. In the recent months, Haiti has started tightening its rules on orphanage standards and creating more regulations for international adoptions. Since medical work in Haiti is more my area of familiarity, whenever I met groups working in Haiti on orphanage projects, I asked for their input on the topic of the rules. In order to start complying with international standards for orphanages and adoptions set at the Hague Convention, Haiti has been cracking down to try to close all orphanages that are in poor condition. I wanted to know from groups and long-term volunteers if they thought this was good, bad, possible?

What's been interesting is that several groups I chatted with didn't know that the Hague Convention existed. Some didn't realize (as I didn't when I first started working in Haiti a couple years ago) that many orphans in Haiti are not true orphans at all. Many are poverty orphans - given up by their parents - in hopes that the child can receive free schooling and a couple of good meals each day. And this makes the situation even more complicated. How can couples abroad really know that their adopted child is a true orphan and not a poverty orphan? How can they know if they are giving a parentless child, a chance to have parents, or if they are actually taking this child away from their parents, and their country?

As was the theme for my last couple of weeks in Haiti, one of the best pieces of advice on the subject came from a wise pediatrician from Port Salut. She finally made me think about the importance of building trusting relationships during childhood development. And how when each week there is a different team of blan coming to play with the girls and boys at the orphanage it becomes tough for the children to learn from example, how to be in a loving, trusting relationship. After all, many of us learned how to trust others because of what our parents provided for us. We knew that if we were hungry, mom or dad would fix us a peanut butter and jelly at 10pm if we needed it. Or if we couldn't sleep at night and were scared, we knew where their bedroom was to go wake them up and ask to be tucked in again. If teams come and go, then where are these children's constants?

I think my Haitian Dad, Eddy, had it right. When I found out that he didn't allow international adoption out of his orphanage, only local adoptions, I was surprised. Apparently when a NGO from the US agreed to help him build the orphanage, he said, "Okay, but people will only come here to help the girls at the center to receive food, clothes, and an education. There will be no international adoption, because  taking the children away to America, that doesn't help fix Haiti." I think Eddy's viewpoint is very mature. When there is a problem, the best way to fix the problem is to face it. To work towards making the situation better, not by running away. If the girls at the center received an education, learned english, science, music, and a trade and then were adopted out because they were poverty orphans, that doesn't change Haiti. That only means Haiti has one less person in it. So Eddy makes a great point - how can we empower future generations to work towards building a stronger economy and a more educated generation?

In my vision for Haiti - perfect would be that there would be no need for a ton of orphanages in the future because there would be no poverty orphans. Good would be that orphanages across Haiti switch to my Haitian dad, Eddy,'s model. That international adoption is left for children who are true orphans. And that those children who are true orphans are put into a loving home, where the parents try to incorporate Haitian culture into the child's upbringing. And sadly, bad is the model I saw all too often in my 7 weeks in Haiti - team after team coming through to "visit orphans and play games with them for a week." Without any intention of teaching the girls and boys a trade, without teaching them science and math or english so they could attend a higher education possibly one day. So they could have the chance possibly at having a paying job once they turned 18 and their parents could no longer rely on the orphanage to supply them with a couple of meals a day, some clothes, and a chance at some sort of an education. Worst - that would be some of the orphanages that the government is working to shut down. Ones where people are making a small fortune by charging a lot for international adoption of children who aren't true orphans. Ones where the conditions are bad enough, I wouldn't send my roommate's and my dog there to live.

I am sure some of this criticism is hypocritical. I am sure that there have been many times in my work in Haiti that I have done more harm than good. And I know plenty of adoption cases from Haiti that were done right. Where the whole family is supported (not just the adopted child) by the parents from the states. Where the child goes back to Haiti regularly to visit their first set of parents. But I am going to challenge anyone reading this post, anyone who has worked or is thinking about working in Haiti, especially in orphanages, to investigate their motives for working there. If one is truly interested in working to fix the problem of "Where Should All the Orphans Go?" then they need to ask themselves if they are going to Haiti to truly help to resolve the problem or if they are going to make themselves feel good? Because one week of "playing with and visiting orphans" just like a one-time dose of anti-hypertensive meds for a Haitian patient doesn't really ever change the real problem.

http://www.nytimes.com/2012/12/05/world/americas/campaign-in-haiti-to-close-orphanages.html?pagewanted=all&_r=1&

Some of the buildings at Eddy's orphanage and the beautiful view surrounding it. 

Tout Moun Se Moun

The other day an American asked me if I felt safe living here in Haiti. Even though this person was visiting on a short 1 week, large blan team trip - they wanted to know how it's been different living here alone; living completely surrounded by Haitians and embedded in Haitian culture. I remembered a saying Dr. Chris once told me: "Tout Moun Se Moun" - We are all human beings or literally "Everyone is someone." So sorry Dr. Chris to steal your thunder and wisdom surrounding the Haitian proverb, but your thoughts on the subject were so good, I had to make them the title of this blog post.

Today as I slowly started my journey back to the developed world, there was a cute situation that made this Haitian Creole phrase ring very true for me. I took Transport Chic (a high end tap tap/ transport bus) from Cayes to Port au Prince. Note to self - if I ever need to travel from PAP to Cayes again I never will need a driver! For only $10 US I made the four hour+ trip and all of my suitcases were safely guarded on the roof. When our bus load got dropped off at the station in downtown Port au Prince, I realized it was going to be awhile for the guest-house driver to pick me up. Traffic in the capital, per usual, was awful. A little old woman and I befriended one another. She put her suitcases by mine and we shared a few words in Creole. We agreed to help one another keep watch over our belongings - while she went to rest on a bench in the shade and while I went to get an iced 7-Up. At one point during my turn watching our belongings in the sun, she told me "Cherie (Dear), I can watch our bags for awhile if you want to go sit in the shade." I explained to her how I live up north and was soaking in every last ounce of sun I could. She laughed and we joked about how she wanted to keep from getting darker and stay out of the sun, while I, as a blan, was the opposite.

Eventually, we maneuvered all of our things into the shade and sat together. She told me how her daughters lived in Port au Prince and they were going to pick her up, but were also running late. We chatted a bit more about our families and then her daughters arrived. She introduced me to them both, as if we were long-time friends. She asked where the grand-children were, and the cute excited exclamation she made when she found out she would get to see them once they got home made me smile. We said our good-byes and wished one another well on our respective journeys.

So while I sat there and waited a bit longer for my driver, I realized that it really is true: "Tout Moun Se Moun." No matter where you live in the world people are the same - they're people. They help one another out at bus stops. They share stories about family. They watch over one another's suitcases so one can cool off with an icy 7-Up. So to answer the question - "Do I feel safe here?" "Do you feel safe at home in the US?" Because if the answer to that question is yes, then you've already answered your own question. Because once one realizes they are the same question, I think that's when one really begins to understand the meaning of "Tout Moun Se Moun."


PS I really wish I had taken a photo of me surrounded by Haitian suitcases in the sun. Once some people saw me sitting on my suitcases at the bus stop, they started saying "Put your suitcase by the blan, it will be safe there." I thought it was funny - if I am safe enough to be considered a free security guard because nobody would dare hurt a blan, I think that really goes to show how safe I am here.

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."