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.