Walking to see the doctor
June 2004 - Evan Lyon MD
I
The recent floods in Haiti have been devastating in the south. The number of dead will never be known, nor will the number of homes destroyed. I have not been in the regions most affected, but I have sat inside our beautiful, dry clinic and watched the rains come most evenings here during the rainy season. We’ve been seeing more patients every day. The days are long, lasting until the rain begins.
It is hard work for our patients to come to the clinic in Boukan Kare. Some live far enough away that they are forced to sleep on the road, making a simple clinic visit a two or three day ordeal. Some have clinics (and even hospitals) nearer to their homes, but none that will see them without payment. Most patients arrive before 7am. Most do not eat on the days they come to clinic. Everyone waits.
When the wind changes in the evening, I can feel the patients start to stir in the waiting room. Tired after waiting hours with an empty belly. They press closer to the door: “but doctor, its going to rain and I have far to go. I need to cross the river, with my two children.” I’ve walked in the hills during these seasonal downpours. Its terrible. All I can do is keep receiving patients, and apologize. I sometimes joke with the patients: “If we were a bunch of charlatans (a name and reputation everyone knows in Haiti, where informal, untrained doctors will see anyone for a fee) we would be done by now.” Some laugh; most are stone faced, anticipating a long walk home in the rain, to sleep under a leaky roof.
“Medicine takes time, please wait. I promise I will see you. We never send anyone away without seeing the doctor.”
“But doctor, we are hungry.” I answer back: “I’m hungry too.”
Its not really true; I eat every day. “I won’t eat, I won’t stop until were done, Okay?” I gesture as these patients have taught me. The back of one hand to the palm of the other, then again. Two slow claps of resignation. A sheepish smile, and I get back to work.
The rain starts. The dry, hungry soil soaks up the first few scattered drops. Then it turns to mud. Surface water starts to run within minutes, filling the foot paths to rivulets. These collect further and swell the streams. The Boukan Kare – the eponymous river that runs through our valley – jumped its banks several times this week. Crops were destroyed and a few homes were lost. We do not know of anyone injured directly, but the damage was clear.
Environmental destruction played a major role in the recent floods, as was noted by the international community and by what counts for Haitian leaders after the U.S. sponsored coup in February 2004. One government minister promised in the New York Times to work to slow charcoal production, practically blaming the victims of the recent floods for their suffering. Charcoal is a cash crop in Haiti. Cutting down trees to make charcoal is sometimes the only source of cash income for peasant farmers. Poor people do not cook on charcoal; it is sold to the cities. The poor cook on fires of banana leaves, palm branches, and twigs that are too small for the charcoal pit.
The Haitian third of the island of Hispaniola is almost completely deforested. It is easy to understand how these floods developed after a single visit to the countryside. Hilltops are bare. Many some places more closely resemble a savanna than the Caribbean tropics. Farmers who have the means to plant and protect trees grow beautiful isolated groves that stand out like oases in these stripped hills. But these are rare. The land still has potential but it has been stripped by more than 200 years of subsistence farming. There are few roots to hold the soil and the rains do not penetrate the hard-packed dirt. The rain falls and runs away, taking with it what remains of the Haitian soil.
We see the consequences of this reality every day in the clinic. In a poor nation, where HIV and TB are the leading killers, it is not an exaggeration to say malnutrition – too frequently fatal starvation for children under 5 years of age – is the most prevalent pathology we see. Malnutrition complicates nearly every other problem we encounter. The average weight of our adult patients is between 85-110 pounds. When I see a healthy person weighing over 140 pounds, I sometimes write “obese” under my physical exam just to celebrate. I admitted a woman this week who weighs 73 pounds on a 5’5” frame, ravaged by more than a year of symptoms from HIV and tuberculosis. She was too scared and alone to come to the clinic. She suspected what might be wrong, but didn’t know anyone would help someone like her. She had come from the capital to the countryside to die.
We’ve also treated at least 8 cases of typhoid fever this week, one that had been hurting and dehydrating a beautiful 2 year old boy for 10 days before his father could bring him to clinic. Typhoid has been removed from the North American consciousness, along with a host of other water-contaminating bacteria, since the early 20th century. The advent of antibiotics in the 1940s finally relegated Salmonella typhi to the long list of microbes that medical students must memorize. Here it is a deadly reality, especially in the rainy season. Very few villages have access to clean water. And a sick child living beyond our reach is living in the pre-antibiotic era.
I visited a region outside the town of Hinche recently where someone made a point of showing me a mud puddle about 3 feet by 4 feet wide. It was the water supply – washing, drinking, bathing – for the area. They told me ‘if you throw the muddy water out, sometimes clean water will flow in.’ I looked up the hillside to a stand of houses surrounded by animals and few latrines, and had my doubts.
II
After clinic, I joined a crowd of villagers to watch the river rage. Some laughed at the scene, hiding their fear behind the shrieks. Everyone was animated, talking at once. It was a frightening and ridiculous scene. The water was a deep, sad brown as it carried away what’s left of the local soil in our hungry region. There was nothing we could do.
This scene reminded me of another I witnessed in the winter of 1997 when I lived in Port-au-Prince as a volunteer teacher. The UN and 500 US Marines occupied the country for purposes of “nation building” held over after the return of Jean Bertrand Aristide to power in 1994. Aristide’s place-holder Rene Preval was in the presidential palace, presiding over a government in full standstill. Political, and often violent, clashes between the wealthy class backed by the army (once again in power since the second successful coup against Aristide, completed February 29, 2004) and the popular Lavalas movement had halted all government activity for most of the year. Several senators and government ministers had recently been assassinated. Lavalas means “flood” in Kreyol. The coincidence is terrible. Photos of towns underwater in Haiti, of the mud-soaked dead, have replaced the hopeful flood of a once vibrant popular movement.
Students at one of the few government high schools in Port-au-Prince had been protesting the fact that classes were cancelled. The teachers hadn’t been paid as the government was dissolving. The U.S.-trained Haitian civilian police had killed a handful of students at their peaceful protest. On a second day of hotter, more violent protest several cars were torched in the street behind the school where I worked and lived. Police tear gas drifted into our classrooms.
Later that same night, with the street protests still smoldering, a small wood frame house was set on fire. The smoke was so thick, I was forced out of our apartment. I climbed up on the roof of the school and watched as the house fire took shape, flames leaping 2 stories high off the 2 story home. I was close enough to feel the rush of heat as the roof collapsed, sending a shower of glowing orange cinders over the entire city block. They rained down on our concrete school building, and on the tin roof of the wood-framed Episcopal cathedral in front of the school. Any cinder could have sparked another fire, perhaps igniting the whole downtown.
Then, I heard a feeble siren in the distance. Several minutes later a shiny water truck pulled up, a little larger than a UPS delivery van. The Port-au-Prince fire department – about 10 strong – descended and quickly starting pumping water onto the blaze. The smoke increased, and perhaps the flames calmed a little. Within 10 minutes, they had exhausted their water supply and the truck drove off, I can only presume, to find more. The fire regained its momentum and swallowed up 2 adjoining homes. Five firemen stayed behind, helpless except to keep the crowd of protesters (who had since forgotten their slogans to watch the fire in a mixture of horror and excitement) at a distance. I remember the firemen had remarkably shiny silver helmets but nothing else to distinguish them.
We all watched the frightening and ridiculous blaze. Three homes burned. It could have been half the city. There was nothing we could do.
When disasters happen in Haiti, their form is often not effected by the people suffering the disaster. There is no capacity for intervention. Everyone just watches, prays, waits. But, it is not a “natural history” of disaster. The deck has been stacked against Haiti for over 200 years. There are many reasons that Port-au-Prince (at least where the poor live. Who knows if the wealthy have a private fire service…) has one fire truck and 10 staff for 1.5 million people. During the recent floods, newspapers were filled with story upon story of how difficult it was to deliver aid in Southern Haiti. International AID agencies decried the lack of infrastructure, and were justifiably horrified. Several stories reported almost lighthearted pieces about how food was being delivered by donkey. Imagine! In the 21st century. As I write this most AID workers are probably home, shaking their well-intentioned heads over the frightening and ridiculous scenes they witnessed. I’m sure it seems like a bad dream safe and dry in the first world. But nothing has changed, and it still rains most nights. Its not a bad dream.
In Boukan Kare, we have a “road” that is passable much of the time – in a 4 wheel drive truck, and when the mud isn’t too deep or the river too high. Most days this week it has not been passable. No one died from the river blocking our road, but were an emergency to come to us – urgent need for surgery or a caesarian section, or a simple blood transfusion – we might have just watched and prayed and waited. Helpless. Several patients were moved from Boukan Kare this week by arranging for trucks to meet on both sides of the river and our staff carrying the patients across the chest high water. Horses and donkeys are the best thing we have. We’ve purchased a few (using money from the Global Fund for AIDS, TB, and Malaria, no less) as ambulances for the remote villages outlying Boukan Kare. They are fueling up for their next home visit on the hills above the clinic as I write.
III
Part of the joy and burden of expanding HIV and tuberculosis treatment in Haiti’s Central Plateau is that we are reaching more people. With this, we can expand general health care, women’s health, prenatal care, vaccinations, housing projects, water projects, and preventative health work. Our Haitian professional staff – nurses, lab technicians, pharmacists, social workers, administrators, accountants, and doctors – work tremendous hours under grueling conditions. The non-professional staff at Boukan Kare are local residents; many are our HIV and TB patients. There are three nurses who live in the village. The rest of the staff have families and homes in Port-au-Prince, three-to-four hours away on a brutal road. They get every other weekend off, for the price of bouncing up and down the mountain. Short of this, they are on call for our patients 24 hours a day.
Our clinics stayed open during the violence that culminated in Aristide’s ouster in February 2004. Every clinic opened every day. None of our more-than 1100 HIV patients missed their antiviral medicines. Public health experts may debate the merits of our “low tech” system of directly observed therapy that brings these medicines to a patient’s house each day. There is in fact, nothing low tech about it. The medicines are the same as what is used in the first world.
And, as recent weeks in Haiti have proven, you cannot disrupt a pair of human feet and the determination of a human heart caring for its neighbors. Some weeks during the coup, fewer patients came while everyone was afraid. But we stayed open. The General Hospital in Port-au-Prince closed for several weeks – partially due to curfews and chaos in the capital, but also because the professional staff walked out to protest the Aristide government as it was going up in flames.
This success is entirely due to our Haitian staff. In mid-February, Partners in Health decided that foreigners in our clinics would be too dangerous for the local staff. When the decision was made to evacuate all non-Haitian staff, 3 people left. Paul Farmer, who founded Partners In Health and has been working in the Central Plateau for 21 years was out of the country. He merely delayed his return. I was unable to make a scheduled trip, as was one other physician. In all, 6 of our staff of over 1000 were displaced by the coup. And ALL our doors stayed open. This is reason enough to celebrate.
IV
But I am still in the clinic, listening to the rain and my restless patients. I call one after the next. Old and young. Some are acutely sick with illness we can treat. These can be the easy ones. More are merely suffering the ravages of deep poverty – hunger, depression, hopelessness, fear, homes that can’t keep back the rain.
Many patients come to clinic dressed in their Sunday best. I have examined hundreds of little girls in bright taffeta dresses, some with matching patent leather shoes kept clean by walking barefoot through the mud to our little clinic-oasis of white ceramic tiles. Woman wear hats. Men that have them, wear ties. And despite the fact that they come with dozens of complaints, I can see that they are celebrating too. They are seeing the doctor.
More times than I can remember, I have seen elderly Haitians – people in their 60s and 70s, in a country with a life expectance now less than 50 years – who have not seen a doctor once in their lives. I thank them for coming, and they thank me. We’re glad to be together in the few hard-won minutes we have.
Some children scream when they see me – maybe they’re afraid of getting a shot, maybe its my strange red beard, or my strange pale skin, or my eyes that have no color at all…. I hold the smallest children when I examine them; older children stand and I grasp them between my knees. I’ve heard many little hearts beating fast from fear and excitement. Our waiting room sometimes holds 40 children under five years old, many sick, most hungry, all waiting for hours. Its rare that they fuss or cry.
Besides falling in love, and marrying a wonderful woman, doctoring like this is the most intimate thing I’ve ever done. The relationship between doctor and patient – especially in this setting of such pressing need – can be sacred, touched with a stillness that dissolves the rest of the world for the short time a consultation allows. The days here are full. Working alongside patients and colleagues, giving good news, giving bad news, teaching, touching, keeping vigil with the sick and sometimes with the dying.
Peasant farmers in Haiti’s countryside call out “Honè!” when they approach the house of a neighbor, especially when it’s the home of someone they don’t know well. It is impolite to enter the lakou unless “Respè!” is heard from inside the house. Honor. Respect. These universal human values can take on a special significance in this setting of universal poverty and need. And the poor rarely find respect.
I believe one of the most meaningful things that Zanmi Lasante (the Kreyol name for Partners in Health) is doing with our work here is that we receive the poorest of the poor with love and respect. It is common in Haiti, and accepted by most as their fate, for people to die for lack of the 2 dollars it costs to see the doctor or for the 50 cents they may need for transportation to the hospital. This is to say nothing of the cost of laboratory tests and of medicines. Our clinics are full every day in part because we do not turn patients away. I also know they are full because the community understands these clinics are for the community. When I finish seeing a patient, I always remind them to hold onto their clinic card. I say: “depi ou gen ti kat sa, se moun pa nou ye.” Literally, as long as you this little card, you are ours. They will always be able to see the doctor.
V
Yesterday, I sat with one of our Haitian doctors as he told a patient (we can call her Marie) that she has inoperable ovarian cancer. Marie came to us two months ago with her belly swollen from ascites. Tuberculosis often presents in this way, infecting the abdomen and filling it with inflammatory fluid. We treated her for TB and the ascites did not improve. An ultrasound last week revealed a large tumor, adhered to her bladder and intestine. The surgeon who saw her said he could not operate.
Dr. Jonas Rigodon met with Marie and, with great kindness, explained her diagnosis. He reminded her that we had gladly done everything possible for her, but there was nothing more to do now. As the news settled, she began to cry for her son who was away in Port-au-Prince attending high school. “But what will he do when I die. Who will take care of him?”
Dr. Rigodon gently replied, “at least you did not leave him sooner. He has accomplished so much to attend high school. Imagine if you had left him when he was much younger?” In this poor country where life is often brutal and death is no stranger, this logic was comforting. Marie is about 50 years old, just past the average life expectancy for a woman here.
It is always difficult for medical staff to give bad news. While we talked together after leaving Marie’s bedside, I thanked Jonas for the kindness he showed her. He told me that in medical school, his professors taught him to deliver this kind of news with complete disregard for the patient before them. “Madam, you have a cancer that cannot be removed. There is nothing more to do; you need to go home.” Jonas has been working with Zanmi Lasante for 3 years and told me it is with us that he learned to respect patients – especially the most poor. This kind of respect must take its place beside equal access to health care if the inequalities of this world will ever heal.
Later in the day as I made my rounds in the hospital, I stopped to ask if Marie had any questions. She said she understood, and would probably go home in the morning to be with her family. I repeated Dr. Rigodon’s promise to continue caring for her; she promised to return frequently to the clinic until, in her words, the Lord takes her back. I told her I was sorry there was nothing more we could do. Instead of showing anger or fear or frustration, she thanked our whole staff.
“I know that, since I arrived, you did everything you could. You worked very hard for me. Everyone has been kind to me, every doctor and nurse. Everyone who works in this hospital.”
She looked me the eye: “Mwen konnen ou renmen lavi mwen. I know that you love my life.”
Evan Lyon
elyon@pih.org
For more about Partners in Health, please see our website at www.pih.org
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