Group Narcissism and the Penn State Situation

Carl Bagnini, LCSW, BCD

In reading the reports and investigative results regarding ongoing and extensive child sexual abuse at Penn State it occurred to me that what happened at the institution can be viewed as a covert narcissistic male sub-culture of collusion, power dominance, and ruthless self-indulgence.  The overt behavior against children was denied, justified, and covered up for years, by a good old boys club, reeking of mutual stroking. In maintaining the huge money maker,  Penn State football, and coach Paterno’s god-like reputation the “group” rationalized hatred and envy of young children, by reducing them  to objects of lust and control.

The fear of exposure of the abuse has a history. The facts were known. The house of cards from top to bottom was maintained due to the narcissistic motives of the men in the positions of power and influence. The homo-affiliative nature of sports, especially “contact” sports like football fosters in older males insecurity and repressed envy of the young.  The young have a long life ahead, while the elders fear death and facing the questions of how good a life has one lived? Inflated self-importance is rampant among ageing men who see young and virile athletes as reminders of time passing, and lost physical prowess. Mentally and emotionally these fears create a veil of secrecy, and denial, and in Sandusky’s case, the full blown acting out of a malignant narcissistic pedophile. What type of environment could rationalize or deny abuse was taking place in a public space? We did not abuse the children, only he did? A flimsy excuse to any thinking individual, and the cover up was deep and wide. There had to be, in addition to administrative bottom line motives (Penn State economics) to cover up the influence of a group “culture” that avoided the personal pain and suffering involved by “knowing” what was occurring. Why the lack of conscience? Was Sandusky so beloved he could weave a Svengali web of innocence? It is too simplistic an assumption that one person relied totally on charisma and the scam of “devotion to improving the lives of children”. How could one man continue getting away with criminal behavior inside a locker room shower while others knew?

Narcissism in groups is well established; the worst example is Nazi Germany where people including victims followed orders and perpetrators later insisted they did not know the extent of the planned extermination of millions of countrymen, women and children. We are all subject to the narcissist’s seductive smile. We long to bask in his acceptance since it can be so intense because it is so fleeting. Sandusky, Paterno and others in power and in lower positions had to be caught up in denial by idealizing the institution—the god-like Football program, Penn State and the cold hearted credo we are “too big to fail” (remember Wall Street and the big banks?).

But beneath the now obvious institutional loyalties we must admit to a malignant negation that played its more sinister unconscious part: the hatred of the children’s vulnerabilities, that as victims they threatened the established belief system and its denied truths. In a caring world victims have justice, and by denying them protection and a voice the group ensured it was faultless, or justified. The victim is hated, not the victimizers. They are the scapegoats. That is group negation at its worst because any heinous crime can be rationalized.

Narcissism and the hatred of children exist in our society. When we hurt children with impunity or bear witness to acts of cruelty and are indifferent, or when we turn away from large scale cuttings of services to children and families, we are all responsible; but only if we remain silent as individuals or in groups can insidious forms of abuse, such as at Penn State go on institutionally—the end of a humane civilization is determined by the quality of care of our children and the elderly.  We need to remember the old Pogo cartoon with its sage warning: “We have met the enemy and the enemy is us”.

Changes in Brain Activity After Analytic Treatment

The following article link was sent to us by Dr. Horst Kaechele. Dr. Kaechele was our distinguished guest presenter at our October 2011 Weekend Conference. Dr. Kaechele is a German psychoanalyst and researcher. His work has done much to demonstrate the usefulness of psychoanalytic treatments when other groups have been claiming there is no research basis for analytic work. This current article is on changes in brain activity in depressed patients after analytic treatment.


Kent Ravenscroft, Founding IPI Faculty Member, Wins Bruno Lima Award

Kent Ravenscroft, author of Haiti Fair Well, and Emeritus faculty of IPI, was selected by the Committee on Psychiatric Dimensions of Disasters of the American Psychiatric Association to receive the 2012 Bruno Lima Award for his volunteer work in training mental health workers in Haiti after the earthquake. The Bruno Lima Award recognizes outstanding contributions of APA District Branch members to the care and understanding of the victims of disasters. Contributions include designing disaster response plans, providing direct service delivery in time of disaster, or in disaster consultation, education, and/or research. IPI members may remember seeing in this blog prepublication drafts from Kent’s diary of his time in Haiti. IPI congratulates Kent on his achievement.

Volunteering in Bosnia September 2011, Part 4

By Sheri Rosenfeld, LICSW, LCSW-C

Day 6: Srebrenica

Of all the days in this journey, this 12-hour period of time on the last day was the most memorable, disturbing, life changing, and eye opening.  Our day began with a 3-hour treacherous drive through the beautiful mountain sides of Bosnia.  Our goal was to reach Srebrenica in order to pay homage and bear witness to one of the world’s greatest post World War II tragedies.  Although many tragedies in Rwanda, South Sudan, the World Trade Center, Afghanistan are horrendous, I know of nothing in contemporary world culture as diabolical as the atrocity on July 11-13, 1995 in Srebrenica, a small village 10 kilometers from the Serbian border.

Typical treats with coffee when you visit a home
The memorial at Srebrenica
The grave markers at Srebrenica. 7532 have been laid to rest. The others have not beeen found.

The background, brief story, is that the Serbian leader wanted to seek revenge on the Bosnian Muslim people for invasion by the Turks in the 1400s.  But most, if not all, Bosnian Muslim people do not see identify themselves as Turks: They are Slavic people.  Even though they may have ethnicity in common with the people of the Turkish Empire, many do not identify them, and have not been able to comprehend the logic of the revenge motive that led the Serbs to want to annihilate them.  The Serbs surrounded the city of Sarajevo, by shutting off all access to food and water and electricity for 48 months.  The war, however lasted 5 years in the villages, Mostar, Zenica, Serbenica.  The great world powers did not come to their aid until the Dutch sent in a UN Security team, but only to keep peace, not to fight.  The Dutch intervention proved to be the catalyst for the massacre of 8,000 men and boys and the desecration of the women by torture and rape since their orders were to protect without firing.  That proved to be worthless.

On the command of the Serbian leader, a whole population of innocent people was exterminated in a matter of a few days, and the country was left traumatized and beaten.  Twenty-five thousand people fled to a small village, Srebrenica, a protected UN Military safe zone, where they were supposed to be safe.  What happened then was remarkable, horrific, and difficult to digest.  One woman told a story of how her baby was crying in her arms because they hadn’t eaten for days as they walked to this village.  A Serbian soldier told her that he knew how to quiet the child, and slashed his throat in the mother’s arms.  Thousands of young boys 12 and up were separated from their mothers and collected with their fathers to be executed.  The mothers and daughters were taken on a bus and transported to other buildings having no idea what would become of their sons and husbands.  In that day, 8,000 men and boys were executed and buried in mass graves which were later moved so as not to be found.  All the while, the people in Sarajevo could not help because they had no idea that this was happening. Much of the guilt, I am told, stems from the fact that they could not help their neighbors and fellow Bosnians.

After we visited the burial grounds (see below) and the museum and listened to a documentary about this ethnic cleansing, we visited a woman’s home.  Jasenka, had a beautiful greenhouse, a wonderfully clean home, many pastries and Turkish coffee to share with us.  She then told her story of how she was separated from her son and husband as she was fleeing to the old factory where everyone believed that the Dutch soldiers would protect them.  25,000 people came to that factory.  Women and children were separated from their sons over 12 years of age and all the men.  But her story, even though very sad, is also a story about hope and determination and pride.  It’s also a story about the possibilities in life when you connect with others to gain strength.

The boys who tried to flee but never returned home from Srebrenica
In the museum at Srebrenica
A picture of a man who was a victim of Srebrenica

Jasenka lives alone now.  But she has a daughter who witnessed the atrocities along with her on that day.  Her daughter was determined to not let her life story or the loss of her family derail her.  She went on to get her Masters degree and PhD and now lives in London with her husband and 2 children.  Jasenka created a beautiful garden.  She grows all the food she needs to survive and also has a cutting flower garden.  She now has a small souvenir store that sells flowers across from the memorial park where her son and husband are buried.  Not only is she doing well in business but she feels she is healing just by being near her family.  She belongs to the association where the women support each other in their various businesses, all of them learning through Women for Women that they can use their talents in commerce.

What is most remarkable about these women is that they used to follow their husband’s lead.  They had no idea of what their rights were or how to make an income, and they did not even believe they had a voice.  Many of these women do not have an education past elementary school, cannot read or write.  But through WFW they have an organization that believes in them and gives them a future.

Bosnia has very few opportunities and the world still seems to have forgotten that these people are hurting terribly.  I was grateful to be a witness to their history, their struggle, and their resilience.  I hold them in my mind and in my heart, and I hope to return one day and bring others with me.

Volunteering in Bosnia, September 2011, Part 3

by Sheri Rosenfeld, LICSW, LCSW-C

Day 3: Zenica

I want to start with this picture:

The woman at Zenica who made these wool slippers
The woman at Zenica who made these wool slippers

In the morning we were driven to the WFW headquarters where we learned more about the war and what led to it, what it was like for the Bosnian Muslim population, and which tools of terror were used against the people of Sarajevo and beyond.  Women have always been used as a way to exhaust and ruin a society.  If you rape a woman over and over, she feels torn inside and out, and cannot keep her family alive and hopeful.  So the Serbs, in this case, went into a part of town Grabvci and raped 95% of the women, old and young, repeatedly.  These women live with the scars of that violence in addition to the loss of their husbands and sons.

I met this woman, Edina, when I purchased some of her knitting:

The tunnel from Sarajevo to the airport carrying supplies

She is the only person in her family who works.  Ninety percent of all the women who come to WFW are illiterate.  But the translator explained to her that I would buy her crafts so that I could give presents to my family, and asked her if she would tell me her story.  When she hugged me, she felt no different to me than my own grandmother.  These people were targeted because the Serbian politicians wanted the Muslims out of Bosnia even though the Muslims are in the majority.  It is unfathomable.  The people now live with psychological disorders, malaise, depression, economic depression, and hopelessness.  They appear dazed.  I think that it contributes to the lethargy in the work place.  The reason everyone is out enjoying their smoking (everywhere) and their Turkish coffee is because no one has a job!

The picture below is the beginning of our entry into the underground tunnel:

The market place where a mortar was shot and massacred 80 innocent women, children and men

(Pic 9).  The people of Sarajevo were cut off from medicine, electricity and water.  They were prisoners in their own city.  When they tried to flee and get to the airport they came under sniper fire, even while the UN Peace Keepers were here.  You can see on their faces, as they describe this horrible experience, how betrayed they feel by the Dutch Peace keepers who didn’t stop the Serbs from killing them.  So they built a 700 meter tunnel in order to escape and to bring supplies into town from the airport.

This is the famous market place that is about 4 blocks from my hotel in Sarajevo:

‘Rosebuds’ to mark on the street where people died

A grenade hit this marketplace in the middle of a busy day and killed over 80 innocent people.  The city has markers on the ground to demark where people were killed.  The government made a commitment to paint these markers red but they have not done it.  But people can see them anyway.


So far what I am beginning to take away from this experience, something I have always known, but now feel acutely, is how wasteful ignorance and prejudice are, and how terribly destructive they can be.  These people are not different from us.  They have the same dreams, love their children, enjoy a good coffee, and want to have fun.

Day 5: Zenica

Yesterday we were taken to the home of a couple near a rural area called Zenica:

Rosemary and her husband in their greenhouse

We were told that the woman, Rosena, is a graduate of the Women for Women program — which essentially means that she spent a year going to class on women’s rights, independence, financial independence, learning a trade, or running a business.  Many women can open a business when they have learned to pick medicinal herbs, knit, crochet, make jewelry and crafts, cook, farm, and sell their wares. They are taught how to be an entrepreneur and what it takes to be a leader.  They are taught the importance of unifying other women to support them and create networks.  These women, not fighting in the front lines as did their husbands and sons, managed to keep their families alive.  They made grass soup when the entrance to the city was under siege, under constant barrage from grenades and shelling and sniper attacks, and there was no water or food or medicine.  When their families were dislocated and removed from their surroundings, they had to leave their prized possessions behind and find shelter somewhere else, never to return to their homes now occupied by Serbs or other families.  One girl fled so many times that all she was left with 5 years later was one suitcase of her possessions.  Everything else was gone and never found again.  All semblance of life as they knew it was over.

Nonetheless, Rosema, the woman in the picture  had written in her graduation speech, from the year long WFW program, that it was at the point at which she felt she had nothing left to live for, she found WFW.  Her husband had gone to fight at the front lines and she had had no idea if she would see him again.  He was everything to her, as were her 3 sons.  She was at a loss.  But when she found support at WFW she gained belief in herself and her future.

We entered Rasema’s very modest house, a beautifully clean and lovely home.  The table was filled with homemade treats that she prepared — Turkish pies, fruit, a homemade beet and carrot juice, desserts, Turkish coffee, cheese, tomatoes, and fruit.  I knew that this woman had great pride in herself and her family.  She looked at each one of us very warmly but carefully.  And then she began to tell her story.  Midway through her description of life during the war, she broke down saying, “Never again”.  And we were silent.  I looked at her and cried.  She came over to me, kissed me, and said, “You are my sunshine!”  I was amazed.  Here I was coming to comfort her, and she was comforting me!  And then her husband walked in.  He listened to the story she was telling about how hungry they had been, how she would look at a bag of plaster and fantasize that it was flour.  And then he cried.  Her husband could not find work because the factories closed and there are no jobs, or to get one he might have to bribe an official.  It had been 16 years, and they were still distressed by their story.

But Rasema had become resourceful.  She began to farm.  She now has a greenhouse for growing vegetables.  With her earnings she is buying another greenhouse and is now selling her vegetables to the markets.  She will acquire another greenhouse because she realizes roses will sell for even more.  Her husband still cannot find work but he provides tremendous support as do her boys, and now he works for her.  She feels blessed and in control and has her own business.  She is a strong woman now.

What I have realized is that when people are in crisis they must move into action.  Action is motivating, gives the mind a purpose and the reassurance of doing something to combat the problem.  It’s the aftermath, the lethargy, the hopelessness, the fear that life won’t get better even though you are working, the inaction — that’s what kills.  That’s where support, education, inspiration, and of course, resilience come in.

I didn’t want to leave Rasema that day.  I knew I may not see her again.  I also knew that she represents something I so admire in people: resilience, strength, and a warm heart.  She has all three, and I was honored to be in her presence.

Volunteering in Bosnia, September 2011, Part 2

by Sheri Rosenfeld, LICSW, LCSW-C

Day 2: Sarajevo, evening

Tonight our whole group finally came together with the six Bosnian heads of the WFW organization.  My preconceived notion of the Muslim Bosnian women was immediately challenged as I sat next to women who appear to be Muslim by affiliation but who are secular, blond and blue eyed We began the evening watching a film about a Bosnian mother and daughter.  That was difficult to watch but nothing compared to what was coming.  Saieda, the head of the Bosnian WFW, told her story of how her family survived and how she and her sister lived in an apartment on the front lines and had to dodge the snipers’ bullets as she walked down her stairs.  I saw the sadness and tears in the Serbian women’s eyes as they sat with the Bosnian Muslin women.  My understanding, from the others I spoke to, was that the guilt that the innocent Serbian people feel is overwhelming.  Many fled Bosnia just to protect their sons from mandatory army recruitment.  Many feel that their hands were tied as they watched their neighbors, women, children, and men, all die senselessly.  This film was a painful reminder.

As the evening progressed, women shared their stories in a more tempered way, I was that their stories will unfold as we move on.  What I was left feeling at the end of our evening was a concern for the staff members of WFW.  Listening on a daily basis to hundreds of survivor stories of rape and execution has the potential to create secondary trauma.  But the women with WFW have their own nightmares of hunger, loss, death, massacres, and brutality.  I wondered, how might they protect themselves from continuous emotional injury.

Day 3: Sarajevo, dinner

There are many times when I have been privileged to bear witness to someone’s life-story.  I feel honored to be entrusted with something so delicate and so personal.  But tonight I hear stories I will never forget.  The phrase “Never Forget” is familiar to me as a Jewish person, and it echoes in the Bosnian Muslim population.  The Bosnians will never forget as much as they wish they could.  Nonetheless, keeping their story ongoing and fresh is critical so that, perhaps, history will not repeat itself.  That’s hard to believe but it’s a strong wish.

Tonight I sat next to two Bosnian women who work at WFW.  The first woman, Ajla (EYE-LA), is a 25 year-old with long, light brown hair and beautiful doe eyes.  She is bright and full of a calm energy.  By her name she seems to be Muslim but her father was an Atheist and her mother an Agnostic.  She is fully educated, speaks 5 languages, and works as an interpreter for WFW.  The second woman, I call Farida, has been a substantial participant in WFW.  In 15 years at the front lines with all the women, she has endured and contained the horror and tragedy of their stories.  Farida says that whenever she felt tired and in doubt she just thought of the women who needed her, and she was energized.

Ajla tells her story from the eyes of a child.  She was 5 1/2 years old when the war broke out.  Her parents did everything they could to protect her from the war and the hardship, but they lived on the front lines and heard bombing all the time.  Sometimes Ajla would walk outside and see the flames burning from the buildings.  She said that her father, than 40 years old, went to fight.  He chose to do that rather than flee. She said that even though he saw so many people destroyed and felt that there was no use to the war, and suffered a debilitating injury, he would choose to do it again rather than flee.  He said that he felt someone had to fight for his children and grandchildren.

Ajla describes to me the horror of the day that her father took her to the main library, which had already had been destroyed by fire once in a war fought many, many years ago.  He loved books and was a well read man.  Although he never said a bad word about the Serbs, she says, he wanted her to know that what they were doing was not just destroying people’s lives but their history, culture, education, and knowledge.  That he felt was a true tragedy.  She remembers the flames and the ashes of paper filtering down in front of her face.  She remembers sleeping in her little boots and coat, always expecting that they would have to run out of the house quickly.  She feels she cannot help but feel bitterness and sorrow.  Mostly, she says, she can’t understand why anyone would want her dead.

Farida was in her late 40’s early 50’s — beautifully dressed, magnificent face, but with sad and watery eyes.  She spoke only Bosnian, and so I heard her story through an interpreter.  I could tell that she was a passionate woman.  When I asked her what her experience of the war was like she said, “If I could forget I would, but I can’t. No one should have to go through that.”  Farida has no children, and so her husband is everything to her.  He is her whole life.  When he went off to fight, she felt that her whole world would collapse.  She remembers burning her shoes in the fireplace for warmth.  She tells of how she had to become creative with recipes, making grass soup, or cabbage rolls from plants that looked like cabbage leaves.  She remembers standing outside her front door, and suddenly a sniper shot a little girl while she was running with her friends.  Then she said, “That is why I listen to the women’s stories. Someone has to.”

Volunteering in Bosnia, September 2011, Part 1

by Sheri Rosenfeld, LICSW, LCSW-C

Day 1: Sarajevo

Sarajevo 2011

After a long day and night and day of travel, I have finally reached Sarajevo as part of a group of volunteers with Women for Women (WFW), an international organization that helps women survivors of war rebuild their lives.  I had no idea what to expect of Bosnia, although I had seen pictures, but it is more beautiful than the pictures.  The mountains are covered in lush forests and the homes have terra-cotta roofs. The colors are spectacular.  I’m not sure what I expected, but at first glance the city seems to be “old meets new” — young, hip people mixed with men and women in their later years, people who walk with limps or canes and have a worn look on their faces.  Liam, our guide, tells me that everyone here has a story to tell, a loss to share, or a burden to live with directly related to the war.  Up on the hill overlooking the hotel I can see where the snipers took their positions.  I was told that the Olympic sharp shooters were the best snipers.  How difficult to imagine.

The market has a Middle East feel reminiscent of Istanbul except that it also has a European feel with a mixture of Germanic, Slavic, and even Spanish and Italian cultures represented also in the food and in the appearance of the shoppers.  My first taste of the food was this fabulous large circular pastry bread filled with spinach and cheese.  They also come with just cheese or plain.  I gobbled that up like I hadn’t eaten in days.  It was delicious.

Bosnian meat sandwich

Day 2: Sarajevo

I spent the next day getting acclimated while the rest of our participants arrived. As I walked around the outdoor market I came across something I wanted to buy.  After much thought, I decided to purchase it.  The shopkeeper told me that they only take cash.  I noticed that even the restaurants only take cash.  Credit cards are rarely accepted, even for large items.  I think that is when I realized one lasting effect of the war may be that trust and delayed gratification are not in their best interest.

Outdoor market

I asked Liam, our guide, about the overall sense of trust here in Bosnia Hercegovina.  He said that in the war neighbors fought against neighbors in what was once a melting pot of Muslims, Catholics, Christians, Jews, and Orthodox, all residing together.  Now the tension is palpable,  I thought a great deal about what it would be like to have lived next to a Serbian neighbor or intermarried into a Serbian family and then have them take siege on you and your family.  What would the lasting effect be on relationships.  I was told that for the most part people are trying to rebuild trust, but for those who lost so many or watched horrific tragedies at the hands of the Serbians, it is quite hard to forgive.  I learned the difference between the massacres in Rawanda and Bosnia is that the Rawanda government made tremendous strides and effort to reunite the people so that there would be less bitterness. .  I did feel the bitterness in Bosnia.  The tension runs high and in some ways contributes to a very unstable environment.  You have a sense that the earth is rumbling here.

Nonetheless, the town center is bustling and people are here enjoying the summer days and drinking.  There is a lot of drinking and not enough working, I am told.  The work ethic is very laid back which contributes to Bosnia’s lack of productivity.  While on a guided tour of the city, we noticed how filled the markets and the cafes were.  Our guide told us that since the war, 16 years ago now, the factories have shut down, the job rate is so low and there are no jobs to be had.  The young, especially, appear to have a lethargic response to work and spend their days drinking coffee at the cafes.

I took this photo of the building’s facade:

Austro-Hungarian architecture with sniper's bullets

because I was struck by the juxtaposition of beautiful Austro-Hungarian architecture to buildings and stone walks riddled with bullet holes.

Another facade with bullet holes

Our Man in Haiti, Part VII

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.”


“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.

Our Man in Haiti, Part VI

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.

Our Man In Haiti, Part V

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

I was in a narrow muddy rutted road between tents when I saw a green steamroller, or maybe one of those big, bug-like French street sweepers, coming straight at me.  Nowhere to hide.  So I quickly rolled over to the side in a panic.  Then I awoke.  It was 4 am and I had landed in my suitcase!  As my mind locked in, I realized I was feeling ill-prepared for my first clinic in Petite Guinee, a beautiful spot on the edge of the azure Caribbean in perhaps one of the most impoverished destroyed areas in the Petit Goave area. My mind started grinding out the supplies I must take: 5 folding chairs — one each for me, my Haitian general practitioner,  my trusty interpreter, Tessier, and the patient, his mother — a folding work table, my pharmaceuticals, chart materials, and lots of water.  It would be sweltering. Then I realized no little tent for my clinic had arrived.  Making mental notes, I fell back to sleep until 6.

My clinic was supposed to start at 10 am, two hours after the Guinee staff had picked up their meds to go set up and get started.  So I had arranged to meet Tessier and our driver at 9.  Only that morning things went hay wire because of transportation snafu’s, and I hastily had to pull up stakes at 7:30 am, loose ends trailing.  But I liked going out with the team, and chatting with the eager but anxious new volunteers, who were amazed at the extent of the damage this far down the peninsula.  One quoted the most recent CNN commentary, which said the rubble from the Haiti earthquake would fill the entire Washington Mall to the height of the Washington Monument.  My heart caught in my throat as a realized the fresh impact of what we were seeing.  We saw a house totally destroyed, with a slanting rough slab, now taken over by goats standing at the peak.  At least they wouldn’t be eaten at night, unlike the ‘free-range’ chickens with nowhere to hide.  I now had more sympathy for the roosters and realized why they were crowing at random hours.  Packs of hungry dogs roamed, seeking food, given the scarcity of left-overs.

I was privileged to see how they set up the clinic. Tables were put up, and blankets suspended and tied into make shift walls in a semblance of private rooms.  Chairs were at a premium, as were tables, so my nightmare and the list it led to was useful as the clinic began to roll. Waiting on fractured cinder blocks for stools or squatting Haitian style all around the periphery, huddled under a huge, slightly twisted corrugated roof with open sides, were perhaps 75 patients, some mothers breast feeding, others holding sleeping children, all eager but respectfully waiting for a turn. I was given a corner up on a cement dais and we saw our first patient.

Pierre, a shy, taciturn eleven old presented with insomnia.  He couldn’t sleep because he kept hearing the cries of a baby and the voices of dead neighbors.  He had been holding a neighbor’s baby when his house collapsed on him.  His mother could only see the boy’s head when she tried to rescue them.  Pierre tried to protect the baby in his arms, but it was gasping when his mother got them out, and died on the way to the hospital.  Pierre felt horrendously guilty, not helped by the baby’s angry grieving parents, whose house had also collapsed.  His mother explained that they weren’t really angry at him personally, but he felt guilty, even for surviving.  He had had a friend die three years earlier and had heard his voice for a long time, and kept thinking he saw him in groups of children.  I worked with the doctor to do the interview, using the interpreter to get feedback and give guidance, at times even speaking to her, the boy, and the mother in my rusty Creole.  Pierre had made it through the mourning of his previous friend, and we told him he now had more complicated grief work to do, but would do fine.  We reassured him that, as he told us, he really did all he could for the baby.  We emphasized he was a shy boy with a strong conscience, making him self-critical, and he needed to ease off.  We told him and his mother he was doing too much work at night in bad dreams and voices, and that they needed to bring the work into the daylight for more effective work.  We advised his mother to have a little session with him in the morning, gathering him and his thoughts and worries into her mind and arms, and another session before bed to help him clear his mind, reassuring him that she would hold the worries and work on them so he could sleep — like Guatemalan worry dolls.  We felt they would be a good team doing their healthy homework.  So we gave no meds, but scheduled a follow-up. They left encouraged and armed with self-help they could carry with them.

The next woman complained of severe palpitations.  On her way home after the earthquake, she passed many friends in front of their destroyed houses wailing for their dead or missing children, and she rushed to see how her five children had done.  She found four of them alive in front of their collapsed house, ‘Grace a Dieu.’  But her fifth child had not made it home from her school, which had partially collapsed. The woman wanted to rush out to find her, but her children reassured her she would come home, and she waited stoically.  Her daughter did eventually return, full of stories of other kids being hurt or trapped.  Three days later the woman had severe palpitations, in response to some random trigger that reminded her of her stoic vigil.  She was already on medication for high blood pressure, but she had never had this before, except when walking up steep hills. Now she was worried her heart was giving out, and that she was dying.  She let us know she was emotionally fit and able to help many of her grieving friends, and so she was sure that her heart symptom was physical.  We agreed she should see her doctor to get checked out, maybe even have that electrocardiogram, but after taking her blood pressure and taking her pulse rate, and listening to her heart, it did seem that she was physically okay.  She had the strength and intelligence to work this out in time, and in the meantime we gave her simple techniques to restore her trust in her body and in life.

I explained the endocrine fear response to her.  Her scary self-diagnosis was escalating her panic.  Her fast walking on the day of the earthquake would make anyone’s heart beat faster, and the new bursts of heart beats were normal fear responses triggered by thoughts, noises, or tremors.  She needed a couple of techniques to interrupt the beginning palpitations. So we taught her the partial Valsalva maneuver, in which she would hold her breath and bear down as if having a bowel movement. The Valsalva works to stop arrhythmia — and is a competence distraction.  We also showed her how to rebreathe from a paper bag sealed around the mouth.  We also suggested noting down each time she had such an attack, so she could outfox the triggers, and disconnect them with an “I told you so”.  She needed to be a kind doctor to herself, just as she was being a good friend to her friend, and not scare herself.  She got the hang of it, and understood the psychology and physiology of it.  She was a school teacher, and so I suggested she could help teach this to scared symptomatic friends, as she herself got good at it.

One other patient had serious insomnia.  Glassy-eyed and depressed, she showed us a certificate of scholastic accomplishment earned by her 21 year old son, his handsome photograph on the front.  Between sobs she told how he was teaching in Gressier, away from home for a while, and was crushed in his little room there by the earthquake.  We listened with near reverent attention, checked on her friendship and religious network, and noted her blood pressure was elevated.  She was consolable but in deep prolonged, but not arrested, mourning.  But it bordered on depression.  I suggested they give her atenolol, a relaxing, sleep-promoting, and anti-hypertensive agent to help her through this sad, sad passing.  She had other children to live for, but we would follow her up closely next week just to make sure she was doing all right.

We saw other patients today, and as time went on I relied on the Haitian doctor more.  We are hoping to give them increased front line competence, a good sense of basic psychotropic meds, and diagnostic acumen for triage and deciding when to refer for specialist care.  Referral should occur only when absolutely necessary.  There is not much psychiatric care to go around, and most people, even if deeply affected, are able to self-right with simple help and access to their own resilience, provided they have their basics met, that is, shelter, water, food, security, and social connectedness.

When I got back to the Residence office, I had to go with Stephanie, my director, and Peter, my colleague, to a meeting for all mental health leadership, which was boring, but necessary, a key brief encounter with the hospital administrator, from whom we must get approval as a hospital resource for medical and surgical inpatients requiring psychiatric intervention.  Though I love this kind of work, I’m feeling spread a little thin.  I also hear there is a movement to base me at the hospital instead of going out to the individual clinics –bad idea for the Haitian docs and nurses, and for the patients.  I am lobbying for staying clinic-based, and we shall see.  I noticed Stephanie was in a good mood, but had forgotten why.  Then I saw her screen saver again, and there he is, her friend and co-worker in Darfur, the man who was abducted for ransom, like her.  That was back in November.  After all this time, after losing hope, he had just been freed, and she was thanking her lucky stars.  It had been a long hard vigil.

Stephanie is a vegetarian, not really interested in food, and eats at sporadic times.  I cooked lunch Sunday, and I made dinner tonight, linguini with olives, onions, tomato and Prego mushroom spaghetti sauce.  Yum, after my fashion, and, Stephanie liked it.  I clued Crystal the cook in on the fact that we would be moving to consolidate all staff and volunteers, making 7 for dinner each night, with the volunteers used to hotel choices and lots of food.  Her eyes got wide, and she thanked me.  My Creole isn’t too bad in a pinch.

I must admit, though, that from a creature comfort point of view, I will be using Haiti, and this experience, as a litmus test of my materialism.  I may think what I am going through at times here is a near-death experience for me, but it is nothing to what the Haitians have gone through.  We had one other woman patient today who lost a child, an aunt, a house and a business, which was crushed and then robbed, and, a van that was trapped under a concrete wall.  So she is without even a tent and no means of livelihood.  She was depressed, and, I sensed, smoldering with rage.  She had been unable to reconnect with her Pentacostal Church, and she seemed close to needing meds.  We started her with a sleep med and not a heavy duty antidepressant, because antidepressants are costly and needed for a long time, and we sensed she might come around the corner. We will see her right away again next week, just to make sure.  Continuity and taking the mental pulse is the key.  We don’t want her remaining children to suffer a maternal suicide, given everything else.

Thank you all for bearing with me.  This blog is bibliotherapy for me, part of my self-care, something we emphasize around here.  It’s a great team down here.