A Taste of Haiti in the City of "Chowdah"

It was grey, 60 degrees and a fine mist was falling over Boston last evening. Not at all like Milot, but Sacre Coeur was on my mind. I had finished my leadership course for the weekend, and stayed in town to support the CRUDEM foundation’s “Taste of Haiti,” being held at the site of “Cheers” on Beacon Street. It would be good to see many others that had volunteered, and perhaps a few familiar faces. Use of the 2nd floor had been donated by the owners, and waiters circulated with plantain appetizers, chicken and coconut, and meatballs, that I was assured were not goat. Corporate donors, many of whom had provided hundreds of thousands of dollars of equipment were acknowledged, and seemed honored to have been given the opportunity to help. I did have a chance to speak with Dr. Peter Kelly, the ophthalmologist who has driven this effort, and had the faith to make me Chief Medical Officer my second day in country. We spoke about the new mission and how to continue the momentum in growth of services. I thanked him again for the experience.

The program was brief and included this video.

http://vimeo.com/14338219

In it, you’ll see many of the patients whose stories I’ve shared with you, including remarkable young people who are regaining their independence thanks to the prosthetics lab. Even though I wasn’t there at the time of filming, every scene reignited emotions, sights, and smells. Around the room were framed paintings from some of the artists that hawked their wares along the street. A photographer who had studied with Ansel Adams had completed hauntingly beautiful black and white prints and a book of the patients, and their families. And we heard that the plans were to continue to support Haitian self sufficiency. The prostheses are now being made by men from Milot, and monthly CME courses have been created for the staff to bring them all up to date on treatment of diabetes, heart disease, and other public health issues. They will be cotaught with local nurses and physicians, and the knowledge base solidified.

As I left into the dark of the Boston night, there were sirens, noise, and restless activity. I got into my car, closed the door and sat for a moment. We are all drawn in different directions, and sometimes fate places you into opportunities that you would not have planned. The last year has been one of new experiences, a recalibration of my priorities, and a great deal of uncertainty. But it has also restored my faith in the inherent goodness of man, that we should lead from the heart, and that each of us has the capacity to transform the world, even as we find ourselves.

Adversity and Leadership

The range of human adaptability to adversity continues to astound me. I have been privileged through my professional life to work with patients who are dealing with debilitating illnesses and lead others by example. My recent trips to Haiti have taught me that one’s attitude to adversity can profoundly affect subsequent recovery. And as I watch the trapped Chilean miners work to ensure their own survival, I am inspired by their pragmatism, optimism, and faith.

This weekend in Boston, we are examining the differences between average and great leadership. Central to great leadership is flexibility, the willingness to challenge the status quo, and the ability to engage others toward a common vision. I can only imagine how the miners have organized themselves and allowed leaders to emerge based on the need at the time. In our own lives, we can lead, or be guided by others; work collaboratively or strike out on our own without guidance. During medical training there is an emphasis on individual accountability and perfection. One of the paradigm shifts that physician leaders find uncomfortable is the ambiguity inherent to the task of leading effectively. We all will make mistakes in our assessment of the situation and deal with adverse outcomes. How we learn to integrate those into our subsequent decisions, and not allow them to undermine our confidence, will be the mark of future success.

I am confident that the miners trapped 2500 feet down will be freed. They will have been active participants in leading each other and determining their future. When you are feeling overwhelmed or helpless in your current situation, look upon the confidence of these men and be reenergized. They will soon see the light of day and be symbolically reborn.

Compassion Fatigue

Katrina…Darfur….Haiti…Tsunamis…Jerry’s Kids…Homeless families…Oppressed women and minorities….

The list is endless and seems to be ever expanding. We are constantly exposed to images and stories of our fellow man who is suffering, and we feel a visceral tug that makes us uncomfortable or sad, energized or determined. As health care providers many of us struggle with the feelings of compassion for the ill and the realities of what we can and should do. With the internet and 24/7 instant global news, how easy is it to become overwhelmed by the suffering, and instead choose to withdraw and shut down.

I heard a new phrase several times this week - “compassion fatigue.” The first was in response to a young woman I saw in Milot with a recurrent fungating, locally invasive phyloides tumor of the breast. It had been excised multiple times, only to recur. She was in the tent, her dressings changed by family and volunteers. At age 23, she was otherwise in perfect health. In the States, she could undergo a wide resection and reconstruction, but the capacity was not available in Haiti. I spoke to several CRUDEM administrators who had arranged transfers of similar patients to several large academic institutions in the US. I filled out a report, took pictures, and made contact. Everyone was sympathetic but the story was the same – we are tired of dealing with the quake victims and others from out of the country that will require a huge outlay of resources, with no ability to pay, even a small amount. Although you could convince administrators and practitioners to give of themselves early in the disaster (and they did), the emotional bank was dry. I had to examine my own motivations as to whether I was doing the right thing even offering the hope of a resection. The jury is still out – I am using some personal connections with other institutions and caregivers that weren’t as involved initially who perhaps still have some emotional reserve.

Compassion fatigue also came up during sermons over the recent Jewish holidays. While we examine our own behaviors and their impact on others, we must also be sensitive to the emotional suffering of our fellow man, even if they have hurt us. Beyond that, in most religions, making amends includes charitable acts as a component of repentance. But with world suffering seemingly enveloping us, how do we feel, and yet not be overwhelmed? And when others are not compassionate toward us, is it because of their unwillingness, or their inability?

I know that as both a surgeon and a parent, I often struggled to let down the clinical barriers when dealing with my family’s illnesses. I remember one of my children showing me a cut and saying, “OK Dad, there’s blood, does it count?” Over the last year, with both my professional transitions and new experiences, I’ve also learned that there are endless opportunities to be compassionate. If you can’t do it all the time, it’s OK, as there are others whose bank is more full than yours. Appreciate the moment, and the satisfaction of relating to another’s suffering and trying to relieve it. Concentrate first on those around you that you love, so that they can be energized and supported. Then do what you can for the world.

And if you feel fatigue, take it as a sign that you’ve truly given of yourself. Rest, recharge, and refill. There’s plenty more to do, and the magnitude and variety of the list gives you endless opportunities.

Milot Managerie

We city dwellers don’t always appreciate the variety of animals that are seen in an agrigarian society. Our meat, eggs, and vegetables come neatly from the store and we seldom see our dinner in the flesh. Not so in Haiti. Animals are ubiquitous, both free ranging and domestic, controlled by a loose understanding of personal property and natural selection.




The chicken population has grown dramatically around the compound and the roosters still don’t understand that they shouldn’t start crowing until dawn. (I quickly adapted, and actually woke up my first night home to car traffic that normally would have been ignored.) My morning run crossed one of the many drainage ditches that also served as dumping grounds; boars rummaged for breakfast. The cows were skinny and grazed freely;
there were multiple donkeys and mules used for portage on the steep slippery slopes. Our local dogs follow us throughout the area, but know enough to stop at the door of the hospital or dining hall. The cats are clueless to boundaries, but seem to keep the mouse population down.


Although Haiti is surrounded by ocean, we had no seafood, and the meat served with dinner was chicken or goat.

Goat! Then I realized that I hadn’t seen our pet, Beeg, who I mentioned in the Passover blog…

Not to worry. As the population in the Mission House drew down, Beeg found a new home over by the machine shop. He has a new lady friend, Mme Bovier, and rumor has it, there’s a little Beeg on the way.




Although sometimes we all have trouble living together as humans, in Milot, the menageries is alive, well, and thriving.

Is There Progress?

The departure lounge at CAP is busy at 7 am. Young men jostle to carry luggage to security (the x ray machine is still not in service) and the bags are searched by hand, slowing the process. There are 5 flights this am – 3 to the States, but unlike in March, there are no other medical volunteers. Although I have picked up a small bit of Creole, I feel like a true foreigner. In some ways, this is comforting – at times, when the relief effort was in full swing, the airport had the feel of an invasion, and I was part of the army. Today, the pace is one of relative normalcy, and the inefficiencies and delays are expected and shrugged off.

The past week has moments that I have felt a great deal of optimism, and other times, frustration. The infrastructure is clearly improving – roads are being paved, there are solar powered streetlights around the hospital and compound, and with potable water, we no longer have piles of empty plastic bottles that were being burned. But at the same time, I saw an unhelmeted motorcyclist hit from behind, thrown from the bike and knocked unconscious. He had an obvious ankle fracture. Peopled emptied out into the street from both the hospital and the compound, and grabbed him by the extremities, without supporting his neck. A stretcher in the back of a pickup arrived, and he was taken to the hospital, but directly to xray. I did what I could to evaluate him, as he had woken up, but there were no vital signs taken, no IVs, and obviously, no way to do a CT. I later learned that numerous ATLS type lectures had been given to the security staff and others, but they clearly had little effect. We took the time to reemphasize stabilizing the neck and running the ABCs before focusing on the obvious fracture. Shortly before that, a young man came in with burns from a homemade still. He was taken outside the ED and numerous buckets of water were poured over him, and he was placed in front of a fan. This is the local standard of care, and we became involved with him, on request, the next day. We debrided and dressed all the wounds. I had rescheduled him for another dressing change in two days. When we called for him, the local nurse told me there were no more dressings, and by the way, he had checked out and returned to Cap.
Once again I was reminded of my role. In Haiti, as well as in the rest of my life, there are things that I can and should change, and others that may be beyond my control. By setting an example that yields good results we can hope that more global improvements may occur.

I was concerned about leaving the patients that I had cared for, as I didn’t know what surgical backup would be available. Then I heard a familiar voice – it was Jerry Bernard, a proud father of a new baby girl, and back to take over the service. He updated me on Rudy, my patient with the pelvic abscess- his ostomy was closed and he is very happy. Several other big cases had made good recoveries, including my little girl with the ovarian tumor. I knew that things, if not perfect, would be OK.



I’m finishing this blog from the Fort Lauderdale crown room. The internet works, there are no mosquitoes, and I’m still smiling from everything, good and bad, that happened last week.

The Jewish New Year and a Haitian Funeral

It is Saturday and the Seattle group returned home this morning. Things were initially quiet, until this evening when a young man was robbed of his motorcycle at “machete-point.” The ensuing disagreement led to quite a few interesting wounds, which were treated by our team in the OR. It is now a little after midnight and I have some time to reflect on the last few days.

Thursday and Friday were Rosh Hashanah, and for a variety of reasons, I am here, as I was on last Pesach. There is one other Jewish volunteer, a woman who came down with the church group from Seattle, but was raised in an Orthodox home, and still tries to be somewhat observant. At our evening meeting, we were asked by the group to share the meaning of the High Holidays and some of the traditions. Several others knew of the apples and honey, but wanted to know of the symbolic writing in the Book of Life. We reflected on the chance to look back on our past year, then forward to the future. The image of God as a stern judge was contrasted with that of a loving and supportive energy giving each of us a chance to reach our full potential. I’ve previously shared with you my own struggles with religion as an entity that tries to control behaviors with both the threat of punishment and the hope of eternal life, after you have died. Although I’ve always felt Catholicism had similar dogma (and the ability to, like Jews, play significantly on guilt), I also have grown to respect the support and striving for personal growth by doing for others. As I gain more perspective in my own life, I appreciate the sense of community as Jews accept responsibility both individually and as a community. “Avenu Malkanu, we have sinned before you…” Some have suggested that instead of striking your heart during the recitation of wrongdoing during “Al Chait,” you are messaging its brokenness and sensing your spirit. For each of us, spirituality comes in different degrees, and different forms – but is the connection to an energy that sustains us.


As I was walking back from the operating room on Friday afternoon, it was 95 with bright sunlight. I noticed several hundred Haitians, dressed in their finest clothes, the men in dark suits with starched white shirts, and the women in beautiful dresses that I last remember on Palm Sunday. Outside the compound was a tall man with a trumpet in a white uniform. There is another, smaller church across from the CRUDEM compound, and people were filling the building and spilling out into the courtyard. I learned that one of the village elders had died and the funeral was beginning. I remained across the street, but could hear gospel style singing, and prayers. The casket was placed into a station wagon and the full band assembled ahead. The drums and brass began a dirge and the procession rolled onto the street. The mourners followed the casket, but I didn’t see a lot of tears – just a community, walking slowly together, accompanying a departed soul to the beginning of the journey. I went back into the compound, but could still here the band. Then a pause, and a familiar tune – Simon and Garfunkle”s “El Condor Pasa.”

I'd rather be a hammer than a nail.
Yes I would.
If I only could,
I surely would.
I'd rather feel the earth beneath my feet,
Yes I would.
If I only could,
I surely would.

Away, I'd rather sail away
Like a swan that's here and gone
A man gets tied up to the ground
He gives the world
Its saddest sound,
Its saddest sound.

Multiple traditions, diffuse beliefs, but at the core a continuous cycle, with moments of self reflection, a commitment to action, and many chances for new beginnings.

The Golden Hour in Milot

I wrote of the “Golden Hour” for photography and painting – just as the sun is rising or setting, casting a golden hue to the surroundings. For me, one of the best ways to get to know a new city is go for a morning run, even get a little lost, and watch the area come alive. We had several ICU nurses join us last night, and some of the Washington group wanted to see the area. We met at 6 am, while there were still shadows in the valley. The rooster had been up since 3 am and was now being answered by his buddies down the road. We turned right out of the compound and headed toward Milot. A few motorcycles were out, with supplies strapped to the back. The smell of charcoal drifted through the air as breakfasts were being prepared. As the dirt turned to cobblestone, we entered the city, with the Church now visible up the hill. Groups of men nodded to acknowledge our presence and went about their morning tasks. As we looked to the mountain range to the south of the city, the sun had illuminated the higher peaks and an outline of the range behind us was cast on the bases. We turned left, cut behind the church and circled up a slippery stone road with a 20% angle. Cows and goats grazed on the grounds around San Souci. As we slowed to a walk, we had climbed about 400 feet and were now standing above the palace, looking over the city, the fog in the valleys, and the ocean beyond. At that moment, the sun rose over the northern range, and we were encompassed by energy and light. Noone spoke.


The run back was down hill. There were areas of new construction, and activity around the hospital was increasing. The local artists were getting set up, ready to offer another “Blue Light Special.” At breakfast, some of the others asked about the run.

“I can’t describe it,” one of the runners said. “You’ll need to experience it for yourself.”

From Generation to Generation

Each generation passes down knowledge to those that follow, and in return learns new things as those teachings are processed, reevaluated, and fed back. Over the last few days, three generations of caretakers are serving at HSC, and the perspectives are melding and creating a stimulating environment.

The pace has clearly slowed and instead of 80-100 volunteers on site, we are fluctuating in the low teens. I am the only doctor this week, given the holidays and return to school. Jerry Bernard, the local Haitian surgeon, had taken a vacation, and cases had been scheduled for me. Arriving at the compound, I was warmly greeted by the CRUDEM volunteers, who heard I was coming. Included were Donna and Sophie. While it is not unusual for parents and children to serve together, this was a grandmother, who attended nursing school in the 50’s and later worked in Ob, and her 26 year old granddaughter, who was a nursing student just starting out. As we had something to eat, each reflected on their own experiences, with Donna remembering dodging flying instruments and starched caps, while Sophie was idealistic, excited, and scared of what she would be asked to do. The rest of the group was primarily from Seattle, with the addition of Phil and Blair a premed and prenursing couple who had met at U Va, and signed on for 10 months, prior to starting school.
Monday afternoon, I did a short case of a soft tissue infection in a diabetic.

There were no translators, and I struggled with my poor French to communicate with the local staff. Although we were able to care for the patient, the process made me concerned about getting through the next day’s schedule. I asked Donna if she would be willing to first assist me, and it turns out that Sophie was fluent in French and was working on her Creole. We did several small cases, then a call came from the emergency ward. A 9 year old was there with an acute abdomen. Concommitantly I looked up, and there was Gilbert Wilkins, a surgery resident from Justinian Hospital in Cap Haitian. It turns out one of the local doctors I met was an attending there and asked in passing, if a surgical resident could observe. I agreed, but didn’t think it would happen. Gilbet had spent time in Canada, and his English and skills were excellent. He saw the child, began the resuscitation, and got her prepped for the OR. I thought it was delayed perforated appendicitis, but when we opened, the appendix was normal, yet there was pus throughout the belly. “Perforated typhoid,” he said quietly, and he located the hole in the ileum, which we fixed. Donna retracted and later admitted she wouldn’t have been able to help me. The Haitian nurse could have, but the language barrier was great.

This morning the child is doing well, and the resident took the bus back from Cap to help with cases today. And is typical for surgery residents, he had a different opinion as to technique and incision placement – and on more than a few occasions, his ideas were better.

In the evening, we meet at 8 pm to review the day. It’s not as structured as when I was here in March, and everyone has a chance to share their feelings and struggles. This was a first time for everyone but me, and they asked how to deal with the degree of suffering and poverty, as well as explaining to others back home what they had seen. I didn’t have any good answers, and tried to share with them some of what I’ve shared with you. But as I looked around, I saw people at various stages of their lives, some with unmitigated enthusiasm and idealism, a few with multiple battle scars, and others who quietly listened and appreciated the moment. What I realized is that each age and each generation has similar goals – self actualization, support of family and friends, and the need to make a difference. And each of us, based on the history of the time, made decisions that reflected those needs. Today 3 generations with disparate histories, experiences, and hopes gathered in a small hospital in the north of Haiti, and synergized each other to do far more than we could alone.

Not quite as good a plot of dysfunction as you see on most of the TV series on Fox…

Progress and a Reminder of Home

It’s always good to see a bit of home when you travel far away.

There has been great progress since last March, not just at HSC, but also the area surrounding Cap Haitian. The road is being repaired and paved, allowing me to keep most of my fillings on the ride in. There is significant building (with appropriate structural support) in the city, and numerous projects are being completed in the compound. The prosthetics lab is spectacular and the Operating rooms now have a scrub sink just outside the door, instead of 50 feet away. And there are new OR lights instead of a gooseneck lamp.

But what really made me smile was the progress at the tent city for the quake victims. The census is now below 100, with most of the issues being orthopedic malunions, and spine injuries. One of the tents now houses overflow for the care of local patients, and Tent 1 is now the expanded ED.

And there is new signage for each of the tents, courtesy of Caritas. It’s not Staples Center, but…….

An Expat Returns

The trip to Cap Haitian requires an overnight stay in Fort Lauderdale prior to catching an early morning charter flight on IBC airlines. Registration occurs in a downstairs portion of Terminal 4, next to baggage claim. It is fairly laborious as photocopied are made of your passport, everything is weighed, including you, and a paper seating template is filled out by hand. The waiting area has a few seats and they were filled by families with sleeping children and several older folks dressed in traditional Island garb. Unlike my first time in March, there were not large medical groups. I had a single duffel bag, primarily filled with supplies donated from my colleagues at Miriam, and labeled with the address for Hospital Sacre Coeur. Even though there were less than 40 passengers, the checkin took close to two hours.

Another American man, about my age, was standing nearby and we struck up a conversation. He was returning to Cap Haitian to work with his Denver based mineral exploration firm. He was overseeing the building a compound outside of Cap for their employees, and working with the Haitian government on mining rights and creating jobs for the local population. We discussed the challenges of the infrastructure, the costs he has to factor in for things like water and electricity generating capacity, and the high tax and fee rate charged to corporations doing business in Haiti. He mentioned that their buildings would be reinforced to withstand earthquakes. I found myself thinking about large corporations exploiting the natural resources of poor countries. Then his voice trailed off. “You know in Port au Prince, the houses were just cinder blocks, there was no rebar reinforcement. When the quake came, everything turned to powder and they collapsed quickly. There were a lot of expats with my company working in the region.”

Daven shifted his body stiffly. He nodded, “Several broken vertebrae, and multiple leg injuries. I was on the ground floor of one of the two houses were rented in PAP for offices. The second floor pancaked on top of me, but the beams fell into a teepee so I wasn’t killed. I was buried for 20 minutes, and felt a lot of weight on my chest, making it impossible to breathe. Managed to get pulled out by some coworkers. I really couldn’t walk and they set up a hammock for me in the courtyard, then they walked 30km (18 miles) to the American Embassy. A few days later, I was in the back of a truck, bouncing down the road to the harbor. When I saw the Coast Guard corpsman, I knew it would be OK.”




He was evacuated to Guantanamo Bay, Cuba, then to a rehab facility stateside. He has been back several times to Cap, staying as long as 5 weeks. He still struggles when he’s in small confined spaces, sleeps outside in a truck when in country, and just shakes his head sadly at the rate of recovery in PAP. But in the same breath, he is optimistic about meeting the challenges of being successful in a resource and infrastructure constrained environment. He told me he came back because others depended on him, including the 75% of his workforce drawn from the local population. He has the same kind of gritty determinism that I see at Sacre Coeur.
We all know people who have suffered significant emotional and physical trauma that shapes their subsequent lives. Some are paralyzed by fear and cannot move forward; some are galvanized by the experience and make it their life’s work; and others weave it into the quilt of their being. And for me, I realized preconceived prejudices can block true understanding.

As we parted at the Cap airport, we exchanged contact info. “I’ll give you a buzz when we’re done with the compound – I’d love for you to stop by next time down and meet my team.”

My new lessons from Haiti began before I ever left the States.

You Never Know What You'll Need

I‘ve written earlier of some of the challenges getting supplies to HSC in a timely and organized fashion. Although we have large orders in the pipeline, their arrival is not predictable and often acute needs arise, sometimes for mundane things. In some ways, however, we are extremely self sufficient, and as I was watching hurricanes build in the Atlantic, and the concerns here about hurricane Earl, I considered how we in Milot would respond.

Much of the devastation in Haiti from previous hurricanes (four hit in 2008) has come from the associated mudslides, exacerbated by large areas of clear cutting and building on unreinforced hillsides. I could only imagine how much worse this would be for Port au Prince after the quake. If there is any positive spin, it is that PAP is located on the western side of Hispanol. A direct hit would be unlikely, but even heavy rains could be devastating. Fortunately there have been proactive interventions from humanitarian organizations, such as Oxfam (http://www.infozine.com/news/stories/op/storiesView/sid/41562/). Cap Haitian and Milot are of the north end of the island, and would feel strong westerly winds and tides if a storm passed nearby. The hills around Milot are lush with vegetation, and the buildings of the complex, school and town are concrete block, although there are more than a few shanties. Perhaps the most encouraging outcome of the earthquake was the realization that the government could not be relied upon for basic needs or infrastructure. Since January, CRUDEM has constructed a solar powered water filtration system, a freestanding oxygen generator, and has independent power supplies for the compound and hospital to keep the lights on. God forbid, but in the event of a mass casualty incident, the triage lessons from the quake will streamline care prioritization, and the reorganization of the supply warehouses will optimize access to needed resources. Finally, I have no doubt that the staff, both local and volunteer will respond as they always have, with professionalism, energy, and faith.


Oh, and with regard the fulfilling acute needs for supplies not in the pipeline, – I’ll be traveling to Milot with a case of fly strips for the OR. (Our gecko can only eat so much.)