By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

Tuesday 3/23 Mirogoane:  Rendezvous with the Past

Today I go to Mirogoane again. But first I need to bring you up to date on something.  When I returned the Iridium phone to Stephanie after the Platon beach party, I was about to leave when she said, “Oh, Kent, one more thing.  I’ve been thinking about your wanting to meet your friends from your field site of years ago.  There’s still a big security problem — another abduction for ransom, probably because the others were freed with a big pay-off.  And there’s a rumor someone from another organization in Cap Haitian was murdered.  I checked it with our top IMC security guy.  We just can’t let you go to Masson, even with armed security.”

“Not at all?”  I was crestfallen, and miffed.  Just that day I had learned how old Stephanie was, just 30, and quite attractive, but not the girl of my dreams at the moment.

“Wait, Kent, I know how important this is to you, and you’ve really been doing good work, so I have an idea.”

“Shoot.”

“We’ve opened a new IMC Office in Leogane, run by my French friend, Alice.  You met her.  Why don’t you call her and set up a rendezvous at her new Office.  That gets you to Leogane, an easy place for your friends to reach, and nobody in security can complain.  Alice has a guard there 24/7.”

“Brilliant!  Thanks for thinking of me.  I’ll set it up, and check out Alice’s new mobile clinic program, and maybe introduce these guys to her.  She needs people on the ground who know the Leogane area.”

I had despaired of ever seeing them.  My heart began to sing.  I jumped on the Internet, and…it was down.  But the next morning I found the emails with the phone numbers of my friends from Masson — Pierre d’Haiti, Karen Richman’s foster son, and Charlie Fangala, her godson.  Both of them surprised to hear from me, we set up a meeting for Tuesday, March 22, after my Mirogane Clinic.  Then I realized I had a problem: Mirogane was an hour further out the southern peninsula, the opposite direction from Leogane.  I crawled back into Stephanie’s office.  Cars were at a premium.  To my surprise, she said, “No problem.  We’ll send a driver for you. I know how important this is to you.”  I was grateful.  She may not care about food, but she sure knows how to touch this guy’s heart.  This army doesn’t just run on its stomach.

As long as I’m cleaning up my timetable, I should mention that Kathleen, Laurie, and Chrisie from Hopkins left on Saturday.  Dr. Paul from Rush, his fascinating sidekick Alisia from Alaska, and Melissa from Canada, are all arriving Sunday.  As a matter of fact, Melissa and Paul were reclining on our Residence portico when we got back from our beach party.  Paul was all excited, talking up a storm, while Melissa, a new volunteer fresh off the plane Friday, sat there almost mute.  Being a shrink, I announced what I did and finally asked her if she were perhaps a bit worried about what she was getting into.  “My, aren’t we projecting, Dr. Ravenscroft,” she said, “are you always so nervous when you meet new people?”  I knew I had met my match.  Though quiet, she proved quite sharp, a doctor’s doctor, carrying the PDR and Merck Manuel around in her head.  Everyone went to her for drugs and dosages.  She also quizzed Tom mercilessly on latrines and water supplies.  I listened—for a while.

Dr. Paul, on the other hand, showed his brilliance and sense of humor in other ways, some of which you already know.  When I finally managed to get the lab to cough up my INR, he took one look at the numbers, as you know, and said they didn’t make sense, but hedged his bets by telling me not to cut back too much.  He was totally on top of hematology and oncology, but daunted by tropical medicine. His nose was in a book a lot at first.  Truth is, he worried about stuff we hadn’t even thought of.  I was in awe of him.  The only problem was that his last name was Kent.  So every time somebody called for Dr. Kent, we both answered, and it drove him crazy.  But he was flexible, and agreed to be Dr. Paul in Haiti, using his first name like the rest of us.  I was there first, anyway, and had secured the high ground.  People at Rush will wonder why he doesn’t respond to his name when he gets back.  He was also rather selfless, giving up his bed upstairs when new staff arrived.  He pitched his little pup tent.  Where?  Right in the front hall.  I felt sorry for him sleeping on the concrete floor, so I loaned him my cushy air mattress.

Dr. Paul seemed so kind and jovial most of the time, until one evening our Nutrition Program nurse got us to play a fast-paced word guessing game.  Then his killer instinct came back out.  He gloated when we stumbled around and the buzzer nailed us, and hooted when he won.  But I’d put my life in his hands anytime.  He had a heart of gold.  He brought two big duffels in addition to his suitcase, one filled with toys, the other with soccer balls and sports stuff, and all to be distributed at his clinics.  Only someone ferrying them from the airport misplaced them, and only the soccer balls showed up.  He prayed Haitian kids got all the toys, and not the black market.

What does our cook look like?  Sweet Crystal is a pleasingly plump, cherubic young woman who floats around in a fugue state, her faced laced with a perpetual pout, rarely cracking a smile.  Talking to her is like dealing with a somnambulist.  She pretends not to understand my Creole and still ignores Jattu, our proud delegate.  I felt like leaving the doors bolted.   But I thirsted for our next skirmish in the Crystal wars.  Anything to keep my mind off the sadness of facing our clinics.  Working in Haiti calls out my gallows humor. I hope you don’t mind.  But don’t be deceived.  It’s the underlying deadly seriousness of this place that fuels our seemingly innocent by-play.

Only the ‘disaster junkies’ thrive on it, as my slightly cynical journalist friend, Jim Srodes, calls them. (If this hot topic is not your cup of tea, jump ahead four pages.) They are a special breed within the echelons of disaster relief workers—a distinctive but elite few.  These are the folks who move from disaster to disaster with their NGO’s, fueled by the high-octane adrenaline rush of each new catastrophe.  They even hop from NGO to NGO, if necessary, to find a new stable, any stable, to feed their addiction.  Often consummately good at what they do, they never seem depressed or discouraged, buoyed by the intensity of the situation.  Their anti-depressant?  Feeding on the tragedy of the displaced and downtrodden.  These ‘disaster junkies’ all seem to know each other, and are familiar with each other’s organizations, inside and out.  They don’t need a flow chart, having in their heads where they stand in the NGO pecking order.  They speak of first tier and second tier NGOs without losing a beat.  If one disaster peters out, or their funding folds, they are nimble at organization-hopping, showing up to join their buddies at the next dramatic scene, raring to go.

This is both good and bad.  Part of the good is their high level of knowledge and experience with the disaster relief life (and death) cycle.  A well-orchestrated jostling dance always unfolds among these NGOs, those of the unfortunate host country, and the destitute indigenous population.  These disaster clients, helpless hungry, thirsty, homeless, and always grieving, are dislocated into tent cities, needing and demanding everything yesterday, while the news media, like sharks feasting on blood, descend on the worst case scenarios to find tender fault lines in heroic relief efforts.  And, admittedly, aid is spotty, halting and inadequate, faced with the widespread enormity of these situations.  But these NGO’s, who have been brave and professional enough to step into these chaotic seething vacuums, somehow are able to create out of thin fetid air rather amazing life support systems, virtually breathing for their agonized ‘clients’.  They go about this in a well-oiled, though outwardly disjointed-looking fashion, almost running on fumes at first, but often with generous initial compassionate funding, from a stunned world audience, who soon prove fickle, moving themselves to the next touted disaster, itself like a “public disaster junkie’, obedient to the next featured world catastrophe.  Mindlessly enthusiastic, they fade on the previous disaster, and let their pledges dwindle.  Their governments, despite high-sounding initial resolve, often let their pledge dribble to default.  The NGO professionals are left orphaned, destined to fend for themselves, burdened by their newest traumatized public wards, while still taking care of all the other disaster populations already in tow, but now long forgotten by the world.  Oh, the tree huggers and the liberal young periodically try to recall to the public eye this bloody trail of relief efforts, crying shrilly and pointing Darfur fingers, while we all eat our foie gras and sip our wine in front of our telies.  One of the positive bottom lines here is that NGOs know this fickle disaster cycle well.  Recognizing the disgraceful public mind and the thirsty news media, they try to work their own emergency media magic to pump and reap the windfalls of these copious initial disaster moments, valiantly trying to fill their coffers with transient heartfelt outpourings, creating a precious reserve for their past and future obligations, storing nuts for the long winter.  Understandably they must quietly siphon off some of the transient bounty to feed their ongoing forgotten relief efforts, while laying away some nest eggs for the next mass disaster.  The pump must be primed, and the NGO funding nourished.

As a tragedy unfolds, they go about their work with a rugged, time-proven efficiency, rapidly clustering and coordinating, seeking mutual NGO support and collaboration, finding and sharing resources, seeking solace, (and even romance and love) with and from one another, while they expose themselves and reach out progressively to the shredded governments and indigenous populations.      The NGOs are whipsawed, blamed for not being deeply, sufficiently and assertively engaged, while being faulted for being overly intrusive, invasive and arrogantly taking over.  In the face of this indigenous torrent of needs and complaints, all well-known to them from each past disaster dance, the NGOs respond in a mutually sustaining, mature measured fashion, transmuting the angry heat of these expectable complaining encounters into a cooperative energy increasing multinational collaborative teamwork.  Through this process, they identify regional needs and priorities, so that local governments, their own NGO’s, and all the foreign NGO’s can work in increasingly sustainable concert.  This expectable maturing of any given disaster cycle happens over and over again, from disaster to disaster.   These NGOs know it, have been through it before, and know that it will happen again.  They are wise enough to know there are no short-cuts, but only seasoned pacing and patience, trusting all will pay off in the long run—if the money doesn’t run out.

On the other hand, because ‘disaster junkies’ are so seasoned, so hardened, so inured, living off their adrenaline high, and because they are so ingrown with each other, they may become cynical and forget what it feels like for new staff and new disaster clients.  This can lead to a lack of empathy for these newcomers.  And to a jaded feeling about their fickle public benefactors.

Living this kind of high octane life, often flying high on fumes, disaster junkies are prone to two kinds of problems:  they run the risk of never settling down, never taking on the commitments, the trappings and anchors of more normal life, living a myopic nomadic existence, finding friendship and love on the fly with recurrent NGO’ers who, because of this unique life-style, can share their unique mentality and shoptalk, the only constant people in their intense, hermetically sealed universe.  Living this kind of life results in a special set of values, unique points of view, and a stunting of one’s own life trajectory and prospects.  If they mature in NGO office, they lose outside family and friends, miss important family life and events, and the maturity these bring to leaven the heart and soul.  Though a hardy few have the capacity to keep up with their family and friends, and insist on taking trips home–and even vacations–others harden, wither and die in office, warped by the generosity of their dedicated disaster giving.  They have saved, and given life to, so many while starving themselves to death, not to mention their families back home.

Why are people attracted to this life style?  Is it something about them?  Or something about what happens once they get involved?  Is it in their genes, or is character destiny?  Or, does disaster work shape and distort character?  We use the words ‘disaster junkie’.  That’s an addiction metaphor.  But their ‘adrenaline high’ is not just a metaphor.  It actually exists, and plays a role we all know, as it does for gym-freaks, professional athletes, dancers, actors, and gamblers.  Yes, there is something addicting about this work—the compassionate circumstances, the noble calling, the good works, the public support and honor, the media accolades (and diatribes), and the sleek, simplified fighting life style, with the aura of a noble calling, all justifying expedient decisions, and a life of deprivations and excesses,.  In short, the mentality of a holy war crusade.

The bottom line here is that it is a magnificent life-style that is discernibly distorted.  But where would we, and the tragic destitute be, without them.  They are in the same category as saints and martyrs.  Translated from the Scots’ toast I’ve heard from Jill, I salute them: “Here’s to you!  Who’s like you?  Very few, and they’re all dead.”

But how do our revered ‘disaster junkies’, or even our more average disaster relief workers, staff and volunteers, learn necessary survival skills and sustainable self-care?  Most organizations, and especially IMC, stress this, and provide professional prescriptions for training them, essential to their personal and professional longevity.  Otherwise, they suffer the other major casualty, that dread condition of NGO burnout.  We might call it the NGO Phoenix Phenomenon–as disaster junkies fly blindly towards the sun, seeking the bright high of disasters, until their wings, made of mere mortal flesh melt and burn from their arms, and they come crashing to ground, no longer a disaster star, but a black tragedy of their own making.  As they suffer this flameout, they often bring down others with them, and even their organizations.  People around them feel their personal and administrative decrescendo, the spiraling decay of their gyre, and wonder how they can help, when and if they dare to tell them to take leave, lest their behavior result in their underlings taking leave of them.  These phenomena are well known to everyone on the inside, and yet often overlooked or delayed until it is too late.

I am not, or only partly so, talking about my beloved IMC.  I care for this dedicated group, have seen the best of what they can do, and yet have seen some hints of the above phenomena, just enough to get the hang of it, and then to use my Hotel Royal connections, to discuss these ideas with friends in other NGO’s, and then to spin some of my own thoughts into whole cloth.  I could be wrong, I could be making a lot of this up, but I must tell you, it is food for thought, even for my beloved IMC.  Physicians must heal themselves, that they may be whole and full of life, and in good enough health for healing others.  So on with my story.

At the Mirogane Clinic, for the second time, our first patient, 29, talked of his profound sadness and recurrent thoughts of killing himself.  As he spoke, he seemed to be swallowing his tongue.  He told of being unable to work for the last 8 years, but still hoped to pursue his dream of running a business.  His speech was so garbled we had to stop him, asking him to open his mouth.  His tongue was chewed into a large bulbous cauliflower.  “How did that happen?” we asked.  “Every time I have an attack, my neck and head go into spasm, my jaws clench, and I chew my tongue–maybe two or three times a week.  The only thing that stops it is 5 pills of ‘Akineton’. But what the hell is Akineton? I thought. What could this be?  He doesn’t fit Lesch-Neyhans Syndrome. Dr. George and I were stumped. It sounds like a dystonic movement disorder, or maybe a seizure? We pressed on.  His life had gone well until he was 20, but he had never worked after that.  “What happened back then?” we asked.  “I became violent, got in fights, had to leave school.”  “Then what?”  “I was hospitalized.”  “Were you thinking everyone was against you, maybe even hearing voices?”  “How did you know?  Yes, it’s painful to remember.  But thank the Lord it never happened again.  Ever since then I’ve had these attacks and am too depressed to work.”  Suddenly we had our diagnosis, Paranoid Psychosis sad to say.  I whispered, Tardive Dyskinesia to Dr. George, and his eyebrows went up.  It’s that dreadful permanent side effect of the neuroleptic anti-psychotic drugs they gave the man to cure his paranoid psychotic break.  Dr. George said, “Don’t ever use anti-psychotic drugs again, and look, this kind of condition tends to go on, but we can help you manage it better.  We think you ought to try taking an anti-dystonia (anti-Parkinson) drug regularly, and see if we can cut the attacks way down, which would help your situational depression and give you a chance for your dream.  Try Kemadrin daily, and come back next week, tell us how you’re doing.  You can hold on to your Akineton in case you have a full attack.  He was slightly encouraged for the moment, and we were guardedly hopeful.  This is a tough situation.  If this didn’t work, we would try Carbamazepine, in the off chance an anti-seizure med would help these myoclonic attacks.  I have been noticing that we’re attracting more chronic patients now, while seeing fewer acute quake-related cases.

The next case, a 25-year-old woman fit in with this idea.  Trying to purse nursing, she had had three psychotic breaks, each at stressful career junctures, treated with Risperidone.  Now she seemed flattened. Not quite catatonic, and surprisingly confused.  She repeated our questions 8 or 9 times and kept saying, “They’re coming to get me.”  She had lost her meds, and psychiatrist, in the earthquake.  For her serious psychotic paranoid depression we gave her Carbamazepine, but she refused any Haldol because of massive weight gain.  If you are wondering why you keep hearing about the same medications over and over again, it’s because we only had available one or two drugs in each category, and some–like Carbamazepine (Tegritol)–are good for both bipolar and seizure disorders.  We’re realists, not just Johnny-one-notes trying to fit all our patients to one label.

After we saw a 51-year-old woman with a classic depression, treated with Amitryptilene, we met a bright-eyed manic woman with a paranoid tinge coupled with fleeting visual and auditory hallucinations who jabbered at us a mile-a-minute.  We gave her, you guessed it, Carbamazepine.  You’re getting good at this, and so was our Haitian general practitioner.  What really helped, though, was our follow-up clinic, where we could see any improvement and adjust meds as needed.  This lady, though still a little high the next week and wanting our names to thank God in church for us, was in fact cooling off, with no voices and visions, and now eating and sleeping better.  We were thankful too.  We upped her Carbamazepine a little.  Close follow-up is both instructive and reassuring for us all.

Our last patient at the age of 14 was still in first grade.  He was pestered by his mother and teacher who wanted him to progress.  A handsome lad, he was embarrassed and miserable, and yet a little cocky still.  His older brother had the same problem, and finally, when she admitted it, so did his mother.  But she said she had to endure school so why shouldn’t he?  We talked heredity and common sense, suggesting he was a smart proud boy, not too damaged yet, with clear circumscribed troubles with reading, writing, and arithmetic.  So, instead of wasting his time with intellectual challenges he could not meet and ruining his confidence, he (and they) should make a bold, pre-emptive move and seek out some good interesting apprenticeship, find his calling, and get a jump on his life’s career.  He would do well.  A smile crept over his face, and a light bulb went off in mother’s head.  We said goodbye and wished them well.

Coming up for air, I looked around.  Where was he, our jovial alcoholic? I had really hoped he would meet our challenge and come back to see us, ready and competent for a more thorough evaluation.  But he was nowhere to be seen.  I was disappointed but not surprised.  I wasn’t very effective with alcoholics.  Only a few people I know really have the knack, and maybe not in times like these.  I tried not to be too hard on myself.

Today was a lighter load and thankfully went quicker.  I had a very important date to keep.  The driver was already approaching me when I called Samedi.  He and I had had a heart-to-heart early that morning, and he knew how important my rendezvous at Alice’s Leogane headquarters was to me.  He knew of all the friends I had lost there in Brache and Masson, my old field site, and how eager I was to meet Pierre d’Haiti and Charlie Fangala.  I had so despaired of making any contact that this breakthrough opportunity made my heart sing.  I was so lost in fantasy I was surprised when we got to Petit Goave in record time.  I realized I’d be too early in Leogane, so we cruised by Stephanie’s office, landing at the Residence.  Crystal was shocked to see me out of the blue, and even better I found uneaten lunch sitting on the table.  Though I couldn’t figure out who it was for, possession is nine tenth of the law and I dug in.  This was turning out to be a good day.  I woofed it down in 15 minutes, grabbed a few things, hopped in the waiting Patrol car, and we hot footed it on to Leogane.  And I was blind-sided.  First by a call from Alice, “Are you still coming today? Oh, okay, but they’ve called me to a Leogane NGO meeting so I won’t be there when you arrive.  The guard knows you’re coming.”

As we approached Leogane, it all came back, erupting into my head and heart as I saw all the destruction.  When we had driven through the outskirts of Leogane after Brache on the way to Petit Goave, it had registered then, but went by in a flash, or was deep-six’ed by my mind.  But now it flooded me.  Because we were lost at one point, and went deeper into the heart of Leogane, I couldn’t avoid the awful truth.  I had been told that Leogane, the epicenter of the earthquake, had been 90% destroyed.  And it was true.  Everywhere I looked, I saw collapsed buildings.  Because the driver had never been to the new office, in a building just leased and set up by Alice in the last two weeks, we wandered around town exposing me to far more than I had expected.  Though some spotty clean up had begun, the place was a wreck, and tents of every type and description were everywhere.  Though half the population had died or fled, the city was teeming with people, women doing commerce, their brightly colored stands dotting the roadside between piles of refuse and broken walls, with goats, pigs and chickens hunting and pecking for anything they could find.  Dogs scavenged everywhere, dodging brightly colored camions piled high with sacs of produce and charcoal, with people perched on top of that.  Life was everywhere, and death was buried beneath.  For all the world it was like a city gone crazy, more like a New Orleans funeral than a dirge.  I was wracked with feelings, ranging from sadness to admiration.  How could they do it?  But how could they not?  Life had to go on, even in the midst of death and destruction.  I had become so used to things in Petit Goave that this hit me like a ton of bricks, almost literally.

The only thing that buoyed my feelings was the prospect of seeing Pierre and Charlie—if we could only find the place.  We were a little late, and I worried they might be waiting.  I had told them the address during my original calls, but now that I saw how hard it was to find, I was also worried they’d never find it.  What if I came all the way to Leogane and never saw them?  My driver finally rolled down his window, hailing a local guy on the street, “Hey, bossman, where is the new NGO IMC Office.  We know it’s nearby?”  “Just take a right down there beyond that huge sign.”  I looked out the windshield at a fat 30-foot pole going out of sight.  Peering out the side window, I could see it was holding up a huge empty billboard.  Halfway down the side street, the driver began honking, their usual drill to Open Sesame.  On cue, this big red wrought Iron gate slid open and a uniformed guard with cool shades and an ugly sawed-off shotgun stepped out to face us.  Seeing the white Nisan patrol car bearing down on him, he waved.  Alice had tipped him off.  We arrived and I hopped out. The place was deserted.  I asked the guard to call my friends with the directions.  Meanwhile, I had something very important to do.  I knew Alice was French, and not a vegetarian, so would have her cupboards well stocked.  I ran back, almost salivating.  I was right.  Out came the peanut butter and jelly, and some crackers to indulge me.  I hadn’t realized how pent up I was.  Then I pilfered her cabinets for all the power bars, peanut butter crackers, and cookie packs I dared take, stuffing my handy fanny pack.  I knew she had four new medical volunteers to feed, but I had four myself.  Paul, Alisia, Melissa and Dr. Alice would be ecstatic—if Tom and Jattu didn’t have at them first.  I had already done my damage.

Just then I heard the volunteers arriving, surprised to see only two.  And people I knew, my Barbancout buddies from Petit Goave. “Where are Kathleen and Laurie?”  “We had a terrible gas explosion here last night, and she caught it full in the face.  She’s gone to Port-au-Prince to be evacuated.  Kathleen went with her.”  “How bad off was she?”  “She had second-degree burns on her face.  Her hair and eyebrows were singed off, and she was blown back against us.  Some guy installed it wrong.  She was traumatized, but I think she’ll be all right.  We all were.”  Now Stephanie’s constant worry about gas made more sense. I should have known, since my wife and I had some trouble with gas in our place in Fanghetto.  Maybe that’s why the Italians call the gas cylinders “bombolas’.

Just then I heard Pierre and Charlie arriving.  Pierre was older, a dignified young man with a great smile, and warm charisma.  He had started a school nearby, and even built a residence for disadvantaged children in the Leogane area needing education and lodging.  The residence had been damaged in the earthquake.  He had started a fund-raising tax-exempt foundation for his work, and had been able to pick up a nice property with a warehouse-like building on it, and was hoping to rebuild the residence.  Charlie, a bright attractive younger guy had lost his job in the quake, and was looking for work.  To my surprise, Pierre had a very successful high-end carpet installation business back in Virginia, and after installing carpeting for the Red Cross headquarters got to know the president, who gave him a nice donation.  “I’m sure I can’t match that but I have something I brought from Paris for you and Leogane.”  I pulled out my billfold, and gave him $240 US dollars.  My wife and I wanted you to have it.”  “Thank you very much, Kent.  We’ll put that to good use.”  Then I turned to both of them, “I don’t know what will come of this, but I hope Alice comes in while you’re still here.  She may be hiring for various things.  She also needs to know people she can trust who know the Leogane area.”

At this point I brought out my MacBook to surprise them with pictures of Masson some 50 years ago.  Little Tonio and Elminar, kids of Joselia and Ternvil, the voodoo priest I stayed with, would now be in their fifties–their parents and grandparents long gone.  Thinking this, my eyes moistened, not just for them but for the countless people now dead because of the earthquake.  They saw me get quiet, with a tear running down my cheek.  We shared a moment of silence together, than talked of the devastation in Brache and Masson.  They said it was just as well I didn’t come see it because it would bring me even closer to so many sad losses.

We all looked up when we heard Alice coming, accompanied by another familiar face from Port-au-Prince, Mbassi, now second in command for the three new mobile Clinic start-ups in Leogane.  Gressier was now placed in their ballywick.  Pierre and Charlie were glad to hear about medical care outreach finally coming to their area.  And Alice was glad to meet them, and promised to see what she might do with their help.  Though less immediate a homecoming than I had hoped for, I felt my most important private mission in Haiti had been accomplished, and with Stephanie’s and Alice’s blessing.  The only big remaining question mark was my little sponsored three-year-old, in the preschool outside of Port-au-Prince, a question that might remain unanswered.  But I was grateful for what the day had brought me.  Except for one thing.  As I was waiting for Charlie and Pierre to arrive, my camera fell out of my fanny pack and broke on the ground.  I wasn’t able to take pictures of them, or anything else on the trip. I was beginning to feel jinxed—now down my glasses and my trusty camera.  But one thing I did have was a feeling of gratitude toward Stephanie.  Originally I had been quite down on her around not allowing me a visit to my field site at some point.  But all things are relative, and as I came to fully inhabit the risky world we were living in, I found myself deeply moved by her finding a safe, realistic way for me to see my Leogane friends.

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

The Mirogane Clinic

Stephanie, my IMG Director, mentioned that we’d be switching my beloved mobile mental health clinics in the countryside back into the Notre Dame Hospital right in the middle of Petit Goave. To her surprise, I went off like a sky rocket, ranting about how these poor patients were already stressed to the limit, didn’t have any money, and found it hard just to come to our nearby clinic, and, their Haitian doctors and nurses needed teaching where they were.  Plus, we needed to get a first hand sense of what they were up against out there.  Unexpectedly faced with this passionate defense of our mobile clinics, Stephanie was taken aback. “Why are you so angry at me, Kent? YOU were the one who told me the new psychosocial clinic wasn’t supposed to be out at mobile clinics.  Now you’re telling me the opposite.  What’s going on here?”  She got very quiet, and finally said, “I probably shouldn’t say this, but I have an idea why you’re so heated up and didn’t want to lose going to the mobile clinics.  You have personal interests, underneath, so maybe as a volunteer you’re sort of a tourist, wanting to see these exotic places”.

It was my turn to be quiet.  Her comment hurt. “You have a point, and establishing a hospital base is important too,” I finally said, “but I’m no accidental tourist. I’m using everything I’ve got for the Haitians, and they need to be seen in local clinics.”   Turning in, I hunt as usual for the Tarantula Stephanie had seen out back behind my tent.  Nothing in sight.  I tried to sleep but found it impossible.  My local chicken came home to roost.  Then a distant fox hunt began with dogs baying, running in packs around the neighborhood, and waking others as they ran.   Occasionally they would bite each other, no fox in sight, and you could hear the victim go squealing off into the night.

As my early morning clock ticked away, I anticipated my day.  I would be going to the Mirogoane Clinic today, a new clinic that Peter hadn’t checked out yet.   Afterward I would be going to the Notre Dame Hospital to show the IMC flag.  Suddenly, I felt something crawl across my feet.  I screamed and scrambled out of the sack, grabbing my flashlight as I jumped up, quickly shaking the bag out on the tent floor.  Nothing! Or was it my Unconscious, laid bare?  There is something about being in Haiti, and living in a tent, that is forcing me to be closer to my bodily sensations and to my unconscious, with reminiscences of my youth and my approaching mortality (not in Haiti, don’t worry).  Anyway, inside my tent I am spread out all over, insufficiently washed, sweaty clothes hanging everywhere to dry.  I love it.  And I can’t wait to be through with it.

I really love my spacious Shelter Box Tent, given by the International Rotary Club.  My father was a Rotarian all his business life, and now I’m finding out about some of their great work around the world, and around Haiti.  I see Shelter Box tents all over, and it makes me proud.  It was also because of my father I bought the flash light I am using.  He taught me to camp, and had this funky old flashlight run by hand-cranking it.  No batteries.  This one is cool, much more high tech, not requiring constant cranking because of a rechargeable battery.  I look forward to giving it to my son.

Mirogoane is an hour by van, over a road full of ruts, lined at times by beautiful banana trees and sugar cane fields, with a stunning backdrop of crinkled denuded mountains, a mirage of green scrub growth in most places. The trees have been mostly cut down to make charcoal for cooking in this overpopulated area.  Looking ahead from the van I see throngs of people, collapsed buildings, goats attacking burning refuse looking for fruit peels, gaily painted trucks and cycles hurtling toward us, and tent cities rushing by on either side.  The road is periodically scarred by zigzag crevasses and deep cleavage drop offs, stunning reminders of earthquake forces scarring Haiti, and in the tent cities our passage is slowed by make-shift mud speed-bumps.  Pulling up at Mirogoane Clinic, I hauled my red backpack up the steps to a clinic bursting at the seams with Haitians, camping out in anticipation.  I found a cramped back room, moved soiled instruments and half-empty bottles of medicine in there, and scrounged up three rusting chairs and a bench.  There was no door and no ceiling, and the walls went up 9 feet, the high airspace transmitting the hub-bub from the next room.

Our first patient walked in.  She was suffering from anxiety and sadness because of loss, shock and aftershock.  We prescribed some Diazepam and anxiety-reducing exercises and homework with family and friends.  In the midst of this, a toothless wizened old man, drunk as a coot, came rolling into the room giving us all high 5’s and showering us in torrents of words.  At one point, a tear suddenly dropped from one eye when he fleetingly mentioned losing a family member.  I suggested that the Haitian doctor explore what lay behind it.  In response the man told of his sadness and isolation.  He told us he had been drunk most of the time for 8 years, and that it was his sister’s fault.  She had been a raging alcoholic before him, until she saw a voodoo priest who, for a sizeable fee, removed the devil drink from her — and put it in him. I helped the Haitian doctor explore all the possible sequelae of such chronic drinking (the DT’s, Wernicke-Korsakoff syndrome) but the man had escaped them, to our surprise.  We told him that hismain problem was loneliness and he was taking the wrong, self-prescribed medication.  Picking up on his sister’s exorcism, I said to him I knew about voodoo, and had nearly taken the Ason (the priesthood) myself.  I said we would be willing to receive his devil drink if he wished to give it to us.  But, we said, we could not give him a proper examination for diagnosis and a path toward cure unless he were sober to get his body and mind ready for our next visit.  He agreed to come back. We shall see.

Then this lovely robust young woman medical student walked in, complaining in a very soft voice of insomnia, palpitations, visions and voices.  She kept hearing the voices and faces of fellow medical students and nurses who had been trapped together with her in the basement as their building collapsed on top of them, there in Port-au-Prince.  Pinned under rubble in the pitch blackness, she could hear the voices, the screams and cries, of those injured and dying around her.  Over four grueling days she heard the voices of her friends and conjured up their faces to keep herself going, only to hear those voices becoming fainter and weaker, and finally dying out, leaving her alone with only one friend’s voice, somewhere way above her.  This faithful friend knew she was down there somewhere below her, and guided the rescuers toward them.  Then her friend’s voice, too, became weaker, and died out somewhere above her, leaving the woman utterly alone.  At first her voice was too weak to call out on her own behalf, though she could hear the rescuers calling her name.  Finally she found the strength and called just once, loud enough to be heard.  But the rescuers found that the pieces of concrete over her were too big to be moved.  They told her they wouldn’t give up and she should hold on as long as she could.  Hearing voices growing faint above her, she lost hope as she hung in the darkness, no sense of day or night.  Her throat was parched, and her loneliness deafening, but she didn’t give up.  She felt she had to survive.  She was the last of all her fiends.  Finally someone got to her feet.  We found out, at that point in her story, that she had been suspended upside down the whole time!  As she talked with us, encouraged to open up about her darkest hours, her voice grew stronger, calmer, and more certain.  She told us that two thirds of her class of 45 had died, and confessed she was petrified about going back to medical school.  The thought of getting near the collapsed school building was giving her palpitations, hyperventilation, and near panic.  She dreaded finding out if other students had died, and she wondered about her teachers.  We gave her some diazepam to take of the edge off her insomnia and her anxiety, and gave her three desensitization and behavioral techniques which would give her ways to systematically move toward mastering her feelings of fears, her thoughts of impeding disaster, and her phobic avoidance of her school and her future.  We hoped she would use what we taught her to show her friends how to work together, to resolve their fears and mass mourning.  By the end of the session we had a sense she would be able to make it, and shed light on the darkness they faced together.

Next was a follow-up appointment.  This bright, sensitive, timid young man for the second time in his life had lost close friends in a collapsed school.  He had been unscathed himself, but he had lost his hearing because he couldn’t bear to keep hearing all the horrible things he had heard, the voices of fellow students below, the injured screaming in agony in his dreams. The cost of his hysterical negative auditory hallucinations was severe: To stop hearing those anguished cries he had to stop hearing everything.  With talking, support and anti-anxiety medication, he was already beginning to hear better, and as memories and feelings came back with it, he was flooded with grief.  We urged him not to be ashamed of surviving, but to have the courage to share, perhaps in a journal or with friends, and to come back in a week to help us appreciate all the hard good work he was doing.

Our last patient was a cute little girl, with severe developmental delay and seizures.  She had lost her medication when her house caved in, and her doctor had been injured and was unavailable.  So she needed to get her two seizure meds from us.   We breathed a sigh of relief at such a routine request.

It turned out that my gifted interpreter, Tessier, a school teacher out of work because his school had been damaged (in general the schools are still closed) knew a lot of these patients and their families.  After the Clinic, he confessed he felt dizzy, drained, and sick to his stomach.  We both commiserated about what a lot it was to take in.  And yet he felt he was privileged, and learning a lot.  We needed to take care of ourselves too.  My best self-care was the blow-up camp pillow I had spring for. At first I was embarrassed to take it out, until my seat couldn’t take the rock hard chairs any more.  Blowing it up becasme something of a ritual.  Tessier and the doctors, and the watching patients, especially the kids, loved to watch.  And was it incredibly comfortable during those long grueling sessions in Creole!  I noticed that I did not need to pee, even thought I consumed two huge bottles of bottled water during those long hours, almost all perspired away.

When I got back to the Residence at 4 o’clock, my cold lunch was waiting, made by Crystal, including some still good red beans and rice, a vegetable stew, and a wonderful Black Bean soup.  My stomach has shrunk, but not my appetite.  I am feeling healthy and great.  Interestingly, all my joint problems, despite sitting for long periods, have gone away.  Getting over being rusty is a good thing, or maybe it’s my daily sweat lodge.

3/17  The Boat Clinic and the Mad Woman of Platon

I was really looking forward to the Boat Clinic in Platon the next day, and eager for a good night’s sleep.  But at 4;30 am a wild cat screamed a mating call in my ear, after dropping into our yard to eat our garbage.  Fired up by a shot of adrenaline, I screamed bloody murder back and the cat finally skidaddled.  It was deliciously cool by this time in the early morning.  I luxuriated and began drifting off.  Then something big fell on my tent from the overhanging mango tree.  Just a mango I thought, until it began crawling along the tent ceiling.  Was it the cat? Or something else.? Or just my unconscious again. I said to hell with it, and turned over.

I was up before the little guy came around to sweep the fallen mango, avocado and coconut leaves away every morning.  I could hear his swosh-swosh, scrape-scrape, as I did my exercises.  I hoped that whatever was on my tent didn’t bite him, and that he would get rid of it.  After doing my morning ablutions, I walked out to watch the action.  The transportation guys were jabbering in Creole and revving up 4 big 6-seater Nissan Patrol cars and 2 large Nissan 8 passenger vans to cart us around to the various ambulatory clinics.  I had already taken part in this early morning pageant, leaving early, but had to ask Samedi, the dispatcher, where the boat clinic people were.  Now Samedi is cool, and from early on we’ve had a little thing going.   Samedi, which is French for Saturday, is also short for Baron Samedi, one of the most powerful and feared Voodoo gods.  So I call him Baron at times, and he and the drivers crack up.  But it is no joking matter.  The Baron is god of death and the cemetery, and also head of the Bizango Society, which enforces community values, often with summary judgment.  When I was here in the 60’s, Papa Doc Duvalier, with his feared machete and machine-gun toting Ton Ton Macoutes, would actually dress up like Baron Samedi, all in black, with cane and wire-rimmed glasses, and cold, poker-faced reptilean stare.  Over a Barbancourt rum one evening, Jean Blephous Richardot let me know that Duvalier actually held voodoo ceremonies in the Palace and had his own in-house Houngan, or Voodoo Priest.  None of this was lost on his Haitian subjects then filled with fear and respect.

Anyway, Samedi told me the boat people got started a little later than the rest, because they waited for the two Haitian doctors who arrived on Haitian time.  The two boat nurses were already there. They smiled at me and I did a double take: They were the same two nurses from my Saturday seminar who admitted they had no home or tent, no shelter at all.  Piled in the van, we bounced down to waters edge, passing the ruin taken over by goats and going just one street past the turnoff for the Royal Hotel.  When we arrived at the water, already teeming with fisherman and guys mending their nets, I took out my camera and walked past old, brightly painted dugouts and bright yellow fiberglass runabouts.  Picking my way through the refuse and rocks, I realized I had seen this place from the Royal ‘beach’.  I began swinging my camera around to take a picture of the beautiful azure bay and the distant mysterious Il de La Gonave.

As I looked out over the water, memories came flooding back.  I had taken a voyage to that island 50 years ago with Haitian peasant fisherman friends in their rickety sailboat, on a similar, stunningly beautiful, cloudless summer day, arriving at mid-day at their own personal off-sure island, made entirely of conch shells they and generations before them had caught and laid down.  We had already said goodbye to their on-shore wives in the cool of early morning.  And then they had introduced me to their island wives.  Haiti is a polygamous society, for those who can afford it.  And these guys, with their thriving conch, or lambi, fishing, were in good enough shape to pull it off.  I skin dived to my hearts content, and came kicking in for a surprisingly good conch-stew dinner.

My memories continued to flood back.  On the next day, I had gone out with them to the prime lambi hunting grounds to see how they caught them.  I wondered what all the long sticks were for, and found out they lashed them together, to a length of 35-40 feet with a bamboo chock on the end, like a fitting for unscrewing ceiling light bulbs.  I watched them use glass bottomed buckets to pick out big lambis, and then unerringly chock them, keeping the boat steady in the process.  I was foolhardy enough to bet them I could dive down and get one, not realizing how deceptively deep it was, given the crystal clear water.  I dove down, down, down and grabbed one, forgetting I had to come the same distance up.  I felt a tearing pain in my abdomen and shot back up.  I had a stomach ache, and nearly passed out.  The pressure collapsed my lungs and forced the neck of my stomach through my diaphragm.  So much for youthful prowess and vanity.  Older and wiser now, I stick to having my lambi in the buffet line.  Easier to reach.

The fishermen had trouble getting the engine started, but I had had trouble just getting into the boat!  Why hadn’t I listened to my wife when I was packing?  Just once.  She had handed me my water shoes and I purposefully left them under a pile of dirty clothes.  Too much weight and I would never need them.  Well, as we walked down to the boat, which was several feet out into the water, I noticed all the staff had on water shoes, of one sort or another.  Tessier was in the same fix I was.  We finally took off our shoes, rolled up our pants, and walked out through the rocks and water.  Tessier took off his socks, but there I was with my god damn support hose.  So I just walked on out, and happily they dried quickly because the sun was increasingly hot.  I was grateful to be splashed when we headed into swells periodically.

None of this mattered because the boat trip was amazingly beautiful.  We pulled out past a Royal point, cruising across the outreaches of Petit Goave harbor to the left, with a huge Spanish army Hospital ship to our right.  The green undulating foothills, deep ravines and verdant valleys of the foothills gave way to the high mountains forming the spine of the southern peninsula.  Two tankers, one bright red with a rusty water line, the other a dirty streaked white, were anchored in the distance.  Flying fishes skittered across the water, and one of the nurses talked in animated fashion to Tessier describing everything that happened to her and her family during the earthquake.  Jutting out majestically was a high mountain dropping sharply in the azure waters like the side of a fjord, just at the far curve of the sweeping Petite Goave Bay.  The mountainous spine of the peninsula continued out of sight behind it.  Haiti means mountainous in Arawak Indian, the language of the original indigenous population.

We skirted around the rocky promontory, and soon saw some huts surrounded by banana trees.  “Bananier, one of our clinic sites,” yelled one of the nurses.  After passing another site, Goumbe, we plowed to a stop at Platon, a larger isolated fishing village. We had passed a number of boats on the way, some picking up wicker traps, marked by plastic coke, orange, and water bottles.  A stray Perrier floated by. I realized most of the dugouts came from Platon, even though many of her dugouts, and a few primitive sailing craft, were still pulled ashore.  The purr of our motor attracted quite a crowd to the beach, the children running down to greet us, the adults hanging back to keep their place in line.  I discovered the Platon Clinic was open air, shaded by huge Tamarind trees, and a scattering of coconut, banana, and mango trees, many heavy with fruit.  Pigs, chickens and goats had the run of the place.  There were perhaps 50 patients standing or sitting, many with children, some nursing babies.

One of my nurses, Marie, looked around carefully, choosing what she felt was a prime spot behind the single closed building, under a truly majestic Tamarind.  A second tree shaded a boat carpenter cutting and shaving planks.  Ringing him for shade were a half dozen people, chatting and loitering about.  When my table and chairs went up, the group swelled in anticipation. “So how many patients do you have for us today?” I asked.  “Nobody yet,” she said.  She disappeared for a minute, and then came back with a rather sad older lady.  She had lost her husband, and three of her children had died of illnesses, unrelated to the earthquake.  The tremor had taken her house, and her hypertension medication, leaving her without shelter and mounting blood pressure.  As we were just adding Atenelol to her other blood pressure medication to help with her blood pressure, her tension headaches and hyperventilation, we heard a commotion coming down the trail from our left.

A woman came roaring out of the banana trees into our office clearing, a hoe-ax on her shoulder, and a relative trying to keep up.  The woman looked like the voodoo god, Kuzan Azaca, with her tattered dress and scraggly ruck-sack slung over her other shoulder.  She marched straight up to our table, with a retinue of onlookers.  She wasn’t threatening, just dramatically determined. To our shock, and to the delight of the crowd, she threw her dress up over her head to show us her emaciated body and sagging breasts to emphasize how hungry she was.  In Creole she said, “I have no food, no shelter, and my relatives have all abandoned me, and look, the community makes fun of me when I’m crazy like this.  Please, could you build me a house and give me some food!”  We settled her down, saying we would see her next, but she had to wait her turn.  She sniffed, huffed, and wandered back into the crowd.

When it was her turn, the crowd pressed in around our table to listen, gawk, and laugh.  I felt badly about the invasion of privacy and tried at first to clear them out   Then I realized she was doing theatre and so were we, and from what I saw, we would need to involve family and community as part of helping her, with the hope they might re-accept her.  After hearing her sad story and downhill course, on a hunch I asked Dr. Bouge to do her blood pressure, which came in at a staggeringly high 200/110.  This made it clear she had a fluctuating hypertensive encephalopathy leaving her brain progressively pock-marked by myriad micro-stokes, which had eaten away at her mental capacity.

So we had our diagnosis.  We arranged for antihypertensive mediation in a slowly increasing dose so as not to give her a low blood pressure watershed stroke.  We explained it to her and to the community so that they would understand her plight and support her treatment.  As we were doing the next case, she came back by, holding out her hand with a few beans in it, asking if we could give her a few more.  Everyone around laughed and we found ourselves smiling too.  She looked sternly at me and said, “I won’t leave until you agree to build me a house!”  I was kind but repeated that the medication was what we could do to help and that we would like to see her and her family member next week.

The nurses were watching and learning, and the docs found the cases interesting. The boat ride back was great.  I noticed some conchs or lambi, and a few choice lobsters in the bottom of the boat, prize purchases from the local fisherman.  The nurses and doctors bought some.  They looked so good I had the thought: ‘Mine will be at the Royal tonight.’

I made liaison rounds informally in the afternoon.  I met with Lynda, who acts as the training director for the Haitian hospital residents, to ask her if they wanted a seminar.  I got an emergency call through Stephanie from Croix Rouge to see a traumatized mute girl, and made rounds all over the hospital meeting everyone on the search of the patient, only to find out the problem had been solved.  Then I went over to have my own blood drawn to check my own bleeding time since I’m on Coumadin for my old pulmonary embolus from post-knee surgery and thrombophlebitis, but I don’t know the results yet.  I’m sure its fine.

That evening, I was sitting across from Stephanie doing my diary, writing about the robust medical student buried upside down with her classmates.  Stephanie looked up, and said, ”Kent, what’s wrong, you’re crying?”  I told her what I was writing about, and read her some of it, and her eyes glowed.  “You really do care, and you’re dealing with some tough situations.”  Then she told me she was working on security issues.  She got quiet, and then said, “I have to confess something.  The Internet is so slow because of my long Skype call to my friend who was just released by his abductors.  We had so much to talk about.  It was hard. I had a lot of tears too.  You know, Kent, I was abducted too, and by the same people who abducted him in Darfur.  When they let me go, I had a hunch they’d go after him.  He dared to speak out a lot about the rebels.  The motives for abduction at the top are political, but for the guys that carry out, it’s financial.  I had only one moment when I really thought they were going to kill me.  It could happen.”  As she said this, I saw tears in her eyes.

I said to her, “My work is hard at times, but nothing like what you went through.  I’m glad you’ve shared this with me.  I really admire you.”

“Well, what you said about helping that girl be brave about going back and facing her fears so she could carry on, that reminded me of how hard it was for me to come back and do this after I was released.  I was in denial when I took some time off, but after three months, I wanted to get back to work, and that’s when it hit me.  It was hard.”

“But you made it, Stephanie, and look at all you’re doing now.  You found yourself and your calling again.”

“It’s good to talk, Kent.  See you tomorrow,” she said with a warm smile.  I feel much closer to Stephanie now.  I really admire her.

As I walked back to my tent, it began to rain.  It was nice crawling onto my cozy air mattress, lying back to listen to the rain pattering down on the tent.  I felt a peaceful calm, and drifted off to sleep.  Several hours later I was awakened by a loud drumming.  The rain was pelting down in torrents.  Of course, the rainy season was upon us.  I remembered the pools of water in my tent when I arrived.  Flicking on my trusty flashlight, I beamed around the tent floor, relieved to find no water.  When I drifted off again, I had a brief dream I was floating down a river on my mattress.  The rain racket woke me again, and suddenly I felt sad and guilty.  Here I was worrying about a little watery inconvenience, and there were all these Haitians in flimsy, makeshift sheet and paper shelters, with the water pouring through and drenching them.

And then the tentless nurses from the Boat Clinic floated into my mind.  What was happening to them?  Oh, and the Mad woman of Platon, the one beseeching me to give her food, and build her a house, what was happening to her?  As I thought about her, I suddenly realized I had missed the boat with her.  The mantra of IMC is to take care of food, shelter, water and security first, which helps most people through their crisis.  And we had laughed at her pleas without attending to them.  And what about giving her mulitivitamins for Pellagra and deficiency disease causes of dementia?  Yes, we had missed the boat, entirely.  It was then that I determined to give her Norbert’s tent, going unused in the corner of my tent.  And to get Crystal, our cook to buy her some rice, beans and cooking oil.  Yes, there was something I could do.  Except we weren’t supposed to do direct giving like this, partly because of the problem of envy and competition.  Luckily things were much better between Stephanie and me, and I would give it to her quietly, with “Medication” written in magic marker on the tent bag.  When I floated the idea past Stephanie and the nurses later, they were okay with it.  But the next day one of the nurses whispered, “Don’t forget about us!”  And I won’t.  Finally, the rain seemed to quiet down a little, after drumming some sense into my head.

The next day water in fact was in my tent, but nothing serious. But it could get worse.  My wife sent me an email about CNN reports on Haiti, describing the Petionville camp hillside, showed massive rivers of mud and muddy water, running down between the tents, washing around, under and through them, with clothing and bedding ruined or washing away.  It was the beginning of what everyone feared, a disaster.  My worst nightmare seemed to be coming true.

Late the next day the sun broke through, everything dried out, and it has been fine ever since.  But that night of rain is a harbinger of things to come, and I am worried.  I’m sure the Haitians are.  I’ve seen a few more trenches around tents for water protection and runoff.  But I worry people are leaving themselves exposed and open to disaster.  Then, again, what else can they do?  That’s the problem.