By Elizabeth Case*
Shortly after returning from Haiti, I read Earnest Hemmingway’s The Old Man and the Sea. The book is set in Cuba, a locale about as foreign to Americans as the country of Haiti. Hemingway stunned me with his portrait of a Cuban fisherman. When I turned to write my own account of Haiti, I knew I risked writing about it with pity, exoticism, and ultimately, misunderstanding. It takes a long time to understand a place as different as Haiti. That said, I learned a lot during my week in Haiti. It was an experience I feel compelled to share.
Our plane flew low over the rusted roofs of a neighborhood in Port au Prince. The plane landed and we walked into the throbbing heat of a May afternoon. The airport was small by American standards, and unembellished. We were not the only foreigners; there were two other groups of Americans, one medical and one religious.
Outside the airport we were met by drivers. The service had been arranged by Medishare, as were all other in-country services we needed. The driver in charge, called Riche’, was an African-looking man who wore sunglasses. I will always remember him as being responsible for the spirit of all our travel in Haiti: something like a high-speed car chase over rubble-paved mountain roads. Passing through the country-side in this fashion, we kicked up dust plumes so large that we left everything, civilians included, dust-covered. The pace of the cars and their metallic luster so contrasted with the lives of the people we saw on the road-side, that our driving felt almost violent. I kept thinking, ‘I want to walk a little in the sun and take this place in slowly’; but it was a very long way to our destination.
Near the end of the four hour drive we passed a large dam and a hospital. This was the place where Paul Farmer had come as a young man and later returned to build the hospital. Paul Farmer, who co-founded Partners in Health, has inspired many medical students like me to come to Haiti. I felt, in that moment, like I’d been traveling towards that hospital for years; but then I’d passed it and was hurdling towards something further still.
Our destination was the town of Thomonde’ and our living quarters were in a stone house with a white veranda. The surroundings were serene; in the morning children walked to school, and in the afternoon they played outside the house; men and women could always be seen walking, visiting, and working; a chorus of goats, chickens, and roosters accompanied it all.
We spent our second day in Thomonde’ walking between houses in the outskirts of town. One elderly woman showed us her wooden shack. The shack was made of sawed boards and palm bark. In it there was a bed with a quilt, a chair, and a table. Behind the shack was a raised shed for storing grain, and beside it, a muddy place where a pig was tied up.
The local health agent who was guiding us asked the woman questions in Creole:
‘Are you boiling your water?’, ‘What do you have to eat?’, ‘Is anyone sick?’
He seemed concerned about her two grandchildren. They had no clothes on and their swollen bellies gave the impression of protein malnutrition or a worm infection. Learning that she was not boiling the family’s water, the health agent promised to send someone to explain the importance of this practice. This is where my understanding fails me: I am sure this woman had heard that boiling water can prevent certain sicknesses. The reasons why she wasn’t boiling it might have been for lack of fuel, or time, or understanding. The reason is probably not so simple.
I am thinking now of the Old Man in Hemingway’s novel. There was a completeness to the old man’s character and a logic to how he fit into his environment. I realize that in comparison, I knew nothing about this woman, her character, or her environment. Hemingway had spent many years in Cuba and I had been in Haiti for only a day. Moreover, that was a novel, and Hemingway a talented writer. Real people, even when they are from one’s own culture and environment, are very difficult to understand. The health behaviors of one’s own family can be seemingly illogical. To me, comprehending the life choices of an elderly Haitian woman in the Central Plateau is a Mt. Everest scale challenge.
By sending us on these home visits I think that the staff at Medishare was trying to elicit a reaction like the one I have described. It was a warning too: ‘Before you give advice or prescribe medicine, think of what you’ve seen today, think how little you know about these people’s lives, how challenging basic living must be, and act prudently’.
On our third day in Haiti we set up the first of three mobile clinics. We divided ourselves into a pediatric team, an adult-care team, an obstetrical team, and a triage team. I was with the triage team on our first day. We were short a translator so we worked without one to take vital signs, consider complaints, and direct people to waiting areas. I knew just six Creole phrases during my time in Haiti: the most sophisticated being, ‘Hello Madame, what brings you in today?’ The most practical -‘stomach ache?’, ‘headache?’, ‘diarrhea?’, ‘vomiting?’- were decidedly less charming. With a vocabulary like this, it was fortunate I was not invited to any parties or funerals. Still, I was able to do my job with these limited words. Many patients had similar complaints; body aches, acid reflux, headache, and stomach ache. In fact, my triage partner William Ergen, succeeded in making most every patient laugh by making up a song using these symptoms. If it weren’t for all the laughter and two liters of water, I think we both would have passed out amidst that giant crowd of sick people.
That day, our nurse practitioner Lola Oni, delivered a baby in a small shack outside the clinic. Our neonatologist Nancy Hansen and our pediatrician Bilkis Hirani cared for more than 100 babies and children. Because our team had no adult physician, our OB Doctor, Tupper Morehead, helped care for many of the sick adults. We were helped tremendously by a Haitian physician, a team of Haitian health workers, and our translators, Brigit, Gabriele, and Ann-Cristele.
At the end of the day everyone was visibly tired and perhaps flustered by the day’s experiences. Fortunately, in the evening there was time to talk. This was a luxury, especially for us medical students who spend so much of our time reading and studying and very little reflecting on a day’s work. Tupper Morehead talked about the importance of ‘being there’. This was the idea that listening and giving attention to a person’s life struggles is as important as doling out medicines, performing procedures, and diagnosing problems.
In the following 2 days we gave out many pills: vitamins, de-worming drugs, blood pressure drugs, anti-inflammatory drugs, and antibiotics. We sent several very sick patients on to Paul Farmer’s hospital. We fitted ankle braces, drained abscesses, did pregnancy tests, and checked cervixes. We educated patients about how to manage everything from scabies to high blood pressure. Yet, none of these measurable accomplishments made me feel certain that we had had an impact. I wondered where the elderly woman would get more blood pressure medication when her supply ran out. I wondered if the antibiotics we prescribed would be effective. I wondered if the ankle brace we fitted would hold up in an environment as rugged as the central plateau.
There is something that gives me hope that our trip was more than a neutral intervention, or worst of all, a kind of disaster. This is simply that I can remember many moments of truly ‘being there’; not merely a tourist, a voyeur, or do-gooder; but a human being, stripped bare of all pretentions, trying to understand, befriend, and aid suffering strangers. It is what I imagine the literary Hemingway must have felt when he visited the isolated fishing villages in Cuba and began trying to understand this alien culture. I am thinking now of Dr Tupper on our first day in Haiti. We had stopped change a tire in a little village where people were out walking. Tupper was the first to step out of the shiny land-cruiser and into the street. He struck up conversation -few words, many gestures- with a man we discovered was a drug addict. Even the Haitian villagers seemed to distain him, but Tupper spoke to him kindly until the tire was changed and we had to leave.
When I got home from Haiti I put up some photographs of our trip on the internet. There was one of all of us together. One of the medical students on the trip sent me a message that simply said, “I miss this”. I think we are all missing Haiti in one way or another. I miss the landscape and the people I met. Mostly I miss the openness I felt there, towards people and new experiences. Many of us are already planning to go back. We hope to involve future classes of UT medical students in work such as this. Real life experiences, international or otherwise, are so important to medical students.
*Elizabeth Case traveled to Haiti in May with seven other medical students, three doctors, and one nurse practitioner. All except one were students or graduates of the University of Tennessee Medical School. To gain access to communities in Haiti the UT team collaborated with Project Medishare. Working with the Project Medishare’s Haitian doctors and nurses, the team was granted uncommonly intimate access to a remote region of the Central Plateau. There, they set up clinics and saw over 500 patients in six days. University of Tennessee’s medical students hope to establish a long-standing partnership with Project Medishare in an effort to connect Haiti to the developed world in a positive way.