Spirituality in the New Year

The Jewish Community is currently in the 10 days of repentence between Rosh Hashannah (New Years) and Yom Kippur (The Day of Atonement.)  Joni Patterson had asked my to submit an article for Bon Nouvel, the CRUDEM magazine.  As I reflected on the past year and future opportunities, I thought I'd share this with you. 


The Commonality of Religion

“A Jewish surgeon who grew up in a Kosher household, participates in a Mass led by an Irish Catholic nun who delivered babies in rural Africa, in a chapel restored by a Canadian Protestant youth group, and later shares a cool drink with an Islamic Turkish soldier from the UN, while a Creole funeral fills the streets outside the gates of a hospital built by the Order of Malta.”

Although it sounds like the beginning of a great joke, it is everyday reality at Hospital Sacre Coeur. My experiences in Milot often included paradigms like the one above. What brought all these disparate groups together? And more importantly, what was the common bond that allowed them to function effectively and synergistically? How did it make me look at my own religious experiences and prejudices? In many other locations in the world, the same ethnic groups are in conflict over their religions.

I would suggest that despite our individual beliefs, we were all feeling a higher level of oneness with ourselves and our true values – a transcendent sense of spirituality. And despite a religious upbringing, it was the time in Milot that brought me to that understanding.

I grew up in a very traditional Jewish home in a steel town in northeastern Ohio. My parents were first generation American and my father had served in World War II, observing firsthand the horrors of the concentration camps and the Holocaust. They remembered quotas and movies like “The Gentlemen’s Agreement.” Although not overtly paranoid, it was made clear to me that as a Jew, I was different from “the others.” We followed the dietary laws, I learned Hebrew, had a Bar Mitzvah, and at one point considered becoming a rabbi. Yet, I saw traditional Jewish law as a series of what you shouldn’t do, rather than what you should. Each year at the High Holidays, I would recite the sins in the “Al Chait” without realizing the nuances of a group confession and an acceptance of our own vulnerabilities – and potential for change.

Our youth group raised my social consciousness – there was the first Earth Day, the US was still involved in the Viet Nam War, and Israel was rebuilding after attacks in both 1967 and 1973. Our work was local and the concept of “Tikun Olam” -repairing the world, was introduced. I slowly began to see religion as a way to strive to better one’s self, while reaching out to others. Rules and laws had deeper meaning, and a commonality with other religions and their traditions began to emerge.

Then there was college, medical school, and surgery residency.

Religion and spirituality became buried in the overwhelming intensity of the process. I did marry a Jewish woman, who was from the Deep South and had her own experiences with feeling different. I never truly experienced my Judaism. When we had children, we realized that there was a responsibility to teach them about their heritage and values. Our first child was a boy – so of course – do you have a “bris,” the ceremonial circumcision? We questioned the medical versus the religious, and found a compromise that worked for us.

Realizing that there was comfort to families in having a physician do the procedure, and looking for a way to understand my own religion better, I subsequently became a mohel . I was able to combine my surgical skills with providing a positive religious experience to new parents, and hopefully their 8 day old son.

At the end of the ceremony, I would recite the Priestly benediction.

“May God bless you and keep you”

“May God cause his face to shine upon you and be gracious unto you.”

“May God lift up his countenance unto you, and grant you Shalom.”

I always choke up on the last part – we are all searching for Peace – within and outwardly.



When I first arrived in Milot after the quake, I was in a pure clinical mode. Didn’t feel like my religion made a difference, and in fact, I kept it quiet, (although I did secretly look at who didn’t cross themselves at evening prayers.) Over the ensuing three weeks, I found myself more open to the feeling of flow that would overtake me in the middle of chaos. I watched Sr Ann’s smile as she danced with the amputee children, holding them aloft, and I truly understood spirituality when I returned from town one day and one of the pediatricians was looking for me.

Amidst the chaos of traumatic injuries, a 4 year old girl was brought in by her mother. Her abdomen was massively distended, and she had stopped eating. Our sole imaging was ultrasound, and we saw a giant mass with both fluid and solid components. The only way to diagnose and potentially treat her was an operation. I had not operated on a child in more than a decade. Speaking to her mother through a translator, I said that I did not know what was in her abdomen. She handed me her daughter.

“Jesus knows.”

The next morning, working with one of our HSC gynecologists, I opened the child and was able to completely remove her ovarian mass, preserving the other side. She went home 3 days later. The enclosed picture is still one of my screen savers. Jesus must have been looking over the shoulder of this Jewish surgeon that day.

It is a Jewish saving that “to save one life is to save the world.” And at HSC, I now have the opportunity to combine my training for a procedure in the Jewish tradition with reducing the spread of AIDS in Haiti.

Recent scientific data have shown that circumcision is one of the most effective ways to reduce transmission of HIV. The science behind it is real and compelling. So when young men being seen for a hernia or hydrocele repair ask me if I can do “a little snipping,” I smile. There is the thought in the community that circumcision may improve the sexual experience, and I’m fine with that. Perhaps there is also a greater power at play.  After all, even Jesus had a bris...

With every trip to Milot, I gain a greater appreciation that the religious overlay, in this case Catholicism, creates a lattice to which we each add our own experiences, believes, and core values. On stepping back, the individual traditions have fused into something larger, something that we define as spirituality. Organized religions try to place the lessons of the past into a structure that is relevant for today. The similarities and differences can crystalize important questions. Many of my Jewish friends dated and married Catholics. I always thought it was shared guilt. But it wasn’t until I immersed myself into a Catholic organization performing Tikun Olam, that I grew closer to my Jewish roots.

…and since I work in Los Angeles, I’m thinking about a new series “The Mohel of Milot”

Jerry Seinfeld, are you listening?

Bon Nouvel

As much as I love writing about my experiences in Milot, there are others with fresh perspectives.  For those who haven't seen the latest edition of Bon Nouvel, I am enclosing the link.

http://www.crudem.org/CRUDEM_BonNouvel-Spring2012/Bon-Nouvel-Spring2012.html

It's been a whirlwind of travel for the last few weeks, including a chance to return to Boston, for the annual reunion of the Health Care Management program.  I continue to feel great optimism that we have the talent to solve many of our challenges in American Healthcare  (and can learn much from our Haitian collegues.)

And from a nostalgic point of view, it's back to Baltimore later this month to watch Rachel graduate from Hopkins, 30 years after my own march into the commencement.   Kennedy mentioned passing the torch to  a new generation - and so we continue.

Enjoy the spring.

Spring and New Hope

Although it always seems like spring or summer here in southern California, other parts of the country are emerging from winter.  This week culmunates with both Passover and Easter, giving us a chance to reconnect with family and friends.  Spring also is symbolic for new life.

I recieved a link today from Joni Patterson about new challenges at Sacre Coeur.  Although I reported on great advances, with it comes increased need for support.  We still can do a great deal in Haiti with a little money.

So this isn't your typical NPR fund drive, and I won't send you a tote bag for your dollar a day.  But I can guarantee the payback is truly great.

Please click below for Joni's message.

http://www.crudem.org/CRUDEM_Donate-1Dollar-A-Day/CRUDEM_Dollar-a-day.html


Happy Holidays,
Harry

Clinic

Clinic starts at 9am, but the patients begin accumulating on the benches around seven. Although there are some scheduled referrals, many come when they learn of a surgical team in town. The setup is amazingly efficient. A nurse writes down the complaint on a piece of paper, in Creole, which is clipped to the paper chart pulled from the storeroom. Patients are called in the order they arrived. I see them in one of the two exam rooms, and with an interpreter, ask about their concerns. Often their response involved disrobing to point to the pathology. There is an amazing comfort with the human body, and no embarrassment in doing so. Many of the problems were the same that I had seen in the states, like hernias and lipomas. Others are remarkable in the stage of pathology. There are advanced breast cancers, large sarcomas, and a healthy man whose massively enlarged spleen was the result of undiagnosed liver disease. We rely on history and physical. Laboratory and xray s are not available on weekends, with the exception of true emergencies. Pathology is sent to Cap, as the number of cases generated could not support a full time pathologist. Radiation and intravenous chemotherapy are not an option, and this leads to us being creative surgically to control the disease. Radical mastectomy with skin grafting has led to prolonged survival. And we often use exploration to make a diagnosis in unclear cases.

I found this approach both terrifying and enlightening. Without the concerns of litigation, we use our best clinical judgment in lieu of ordering multiple tests. Although the patients do not know us, they arrived dressed beautifully, and are gracious and appreciative. My Creole is minimal, my French a bit better, yet what is reinforced every time, is the power of a simple handshake, smile, and look into the patient’s eyes. Not everyone who wants surgery gets it. I make decisions to defer when risks due to resources exceed chances of success. Could we do these cases in the States? Perhaps, but at great cost and pain to the patient.

The St Barnabas team arrived late due to delays in Turks. I had finished clinic and met them at the compound. Abe Huong and I had worked together after the quake. I kidded him about having to teach him how to take out a gallbladder through an incision rather than a laparoscope, and that there was one on the schedule. We sat down and briefed about the patients I had seen that he and his team would care for over the next week. The language of surgery is universal, yet each patient is unique. After a week of working with logistics, it was good to get back to my roots as a clinician.

And Abe promised to let me know how things turn out.

On the Beaten Path

As a child in West Virginia and Ohio, I remember driving National Pike, which was subsequently to become parts of Interstate 70. It followed a Native American trail several hundred years old. Post Road, from Boston to New York, now Rt 1, was originally a trail, and with continued use, became a dirt road through the forests and along streams. Inns, post offices, and cities sprung up as human and vehicle traffic beat down any vegetation and created an enduring path. We speak of getting off the beaten trail, in an attempt to get away from society. Yet in Haiti, and other less developed countries, a trip along the beaten path reveals much about the people that live there and their interaction with geography and each other.

The road from Cap Haitien to Milot, continues up the mountain, past San Souci. During the period of the war with the French, it served to move supplies inland, and gain strategic advantage. It has recently been paved, and the previous filling rattling ride from the airport is now 20 minutes, instead of an hour. About 300 yards before the entrance to the Crudem compound, a dirt road heads west and winds its way out of the valley, then back to Milot, well below the Palace. Its path reveals much about human nature.

Let’s take a run and see what we can learn.

Turning left from the compound, we dodge tap taps, motorcycles, and people walking to the hospital. A well marks the entrance to the path. Immediately, it becomes quiet. There are a few dwellings, and the banana trees, cocoa bushes, grapefruit, and aloe grow to the edge. You can see perhaps 15 feet into the forest. A second path cuts to the right. I don’t see where it’s going, until a man with a machete and bunch of bananas emerges from the woods – that path led to economic support for his family.

About a half mile in, I see bags with USAID markings and a large pit, near a river. Previously I would assume this was rice, but in fact was limestone, which, when mixed with nearby water, formed plaster for the homes. The road jogs back to the right and it was again quiet. A motorcycle over takes me, and as I follow the dust cloud, it stops at a junction. There is a great deal of activity and children begin to run with me. A new well, beautifully constructed after the cholera epidemic draws local town folk and numerous homes are seen. An  concrete bridge forges the river, yet in its shadow, woman are doing laundry, the soap suds mixing with the shallow, muddy water.

We begin an uphill climb and to the left, open air stalls, offering drinks, vegetables, cigarettes, and canned goods. A grandmother sits on a stool as her granddaughter braids her hair. “Bon Soir” they call out as they shake their heads at the concept of anybody running just for the sake of it. The road at this point is wide enough that a truck could get by, but soon gets very rutted and I need to be careful to keep from twisting an ankle. As we move farther from water, dwellings again thin out, but there are areas of the forest that have been recently harvested. Piles of stone are place for community use in building shelter.

The road comes to a T. to the right is the “short cut” to Cap; to the left the road to Milot. As is normal at crossroad of commerce, the Haitian equivalent of an ATM springs up. Trading dollars and gourds is big business.

As I climb above a ridge, the view back to the valley is spectacular, with the mountains behind. Few people are around.

Creating the hill, I hear the noise of young men playing soccer and the one flat area has become a makeshift field. The goals are sticks, and they play a tight game – goal width is about 2 ball diameters. I move to the side so as not to interrupt.

I must be getting closer to town as I start back down the hill. School children in their uniforms are walking up. A young man and his girlfriend hold hands. The homes now have rudimentary electricity and the road is less dirt and more stone. It curves around a large tree that was never beaten down as a sapling.

The entry to the city is first heralded by the cell phone tower, then the river, and buildings tight together. People are everywhere and there is a more frenetic feel. A left turn takes me past the music school and I hear the sound of a band, but the location does jibe. A short block to the right is the main street to the hospital, and next to it, the cemetery. The road is packed as the funeral band, playing Auld Lang Sang marches past. Everyone is in their best clothes, and I feel embarrassed that I am sweating and in shorts. I stand well behind the masses, then when the procession passes, I turn to the left, and again compete with busses, vendors, and the normal crowd by the hospital.

As things thin out, I am able to sprint the last 200 yards to finish the loop.

I sat outside to cool down. How often do we move through life, take the road prescribed by the GPS, and never notice the changes around us? People speak of standing on shoulders of giants, perhaps we should also reflect that often we are walking in the footsteps of our ancestors, and owe them thanks for first beating out the path.

From Whose Perspective?

Never did get the internet issues worked out, and thanks to Rachel for posting what I could get to her. Now with great service 30000 feet over Florida, go figure.

 I've accumulated several, and over the next few days, look forward to sharing them with you

Five hundred years ago, it was common belief that the Earth was the center of the Universe, and all other heavenly bodies revolved around us. Although this was subsequently disproved, we are often reminded of our own tendencies toward egocentricism. And this can become painfully obvious when working in a different culture.


The supply chain challenges here at Sacre Coeur stem from multiple sources, not the least of which is the generosity of individuals and organizations around the world. We were inundated with supplies and donations after the quake, and continue to receive tremendous help from CRUDEM and its network of supporters. In recognition of the need for inventory control, we partnered with Humanitarian Software and BarControl Systems to computerize and inventory our pharmacy and medical consumables. This is a daunting tasks with 1800 SKUs(with multiple subcategories), and 12,000 cartons of inventory. The pharmacy presents additional challenges, as medications, delivered in bulk, are eventually dispensed to individual patients. Bar Code stickers are printed as materials arrive, and there are specific MDC codes on US manufactured drugs that identify dose, form, strength, and quantity.

As supplies arrive, they are bar coded and HSC employees are to scan the item and where it is placed. When a requisition from the hospital comes, the amount dispensed is scanned and subtracted from the inventory. Moving supplies from one location to another should be easily monitored. A running total of supplies on hand, and rate of utilization, will provide a guide to anticipate needs, reduce duplication and prevent shortages.

If it were only that easy…

I spent yesterday in our pharmacy warehouse, which as you may recall, was created by welding shipping containers together. It is well organized, (air conditioned), and has full wireless network access. Since it is the only source of narcotics and other medications for the hospital, you’d think we could monitor utilization, but the reports just didn’t make sense. As I was counting used vials to get a proxy for utilization, I noticed some had bar codes and other didn’t. Remember I said that the US NDC codes served to classify the bar codes? Foreign manufactured meds (probably 50% of our stock) don’t.

Now these were not drugs unavailable in the US. Many were common antibiotics, like Augmentin, with identical strength and form. But they weren’t counted since they couldn’t be labeled. Working with Will Bardos from the bar coding side, we solved that one last night by cross referencing to the codable equivalent, not worrying about specific manufacturer or trade name, rather assuring that the dosage and form were identical.


Challenge 2 was the scanner. They were intuitive to use, but as Will asked a staff member to show us how they dispensed an item, they struggled. As I looked at the scanner, I realized the instructions were in English. Although this system has been employed in other parts of the world, English was more prevalent. The administrators using the system in Milot were bilingual, but other members of the team were not. The egocentric response would be, “If they want a job, they need to learn English.” The pragmatic and practical response is, “This is a major change in how they do business; let’s make it as easy as possible.” We are currently working on translating the instructions into Creole.

For those of you following this blog over the years, these incidents may not seem as dramatic as the stories after the quake. But there is a common theme – as human beings we all have the tendency to deal with our own needs first and view the world from our perspective. The successful among us see multiple other points of view and can adapt their response. We did that in the crisis atmosphere after the quake, and will strive to maintain that attitude.

When I was a Boy Scout, I remember a Native American saying. “Never judge a man until you walk a mile in his moccasins.” Thought that was a little hokey then, finally starting to get it now.

Bonswa!

Incentives Drive Behaviors

On my morning run to Sans Souci, an acrid smoke enveloped the valley. This is not unusual, and occurs when trash that has accumulated is being burned in open pits.

A truck arrived with supplies, and local men, eager to earn some income rapidly unloaded it, even though it was into the incorrect place. They will need to be hired again to move it and will receive additional compensation.

 

A vibrant market has sprung up in front of the hospital, and it has grown larger since my first trips 2 years ago. Just down the street is a freshly renovated building with an office supporting Haitian tourism.

Free market economies are human nature.

The dire economic condition of Haiti, compared to the West, leads many to believe that the country is completely dependent on outside support. It is easy to characterize the population as indifferent. Yet what is clear, is that people will adapt to their environment, and incentives will drive behaviors.

The truck is a classic example. Filled with supplies, it arrived unannounced at the end of the day. The first gate was near a storage facility about 400 yards from the proper site. Supplies shouldn’t be left out for fear of damage, and the truck needed to return to its base. Twenty five men appeared and began to work understanding they would receive a few dollars. The supervisor acknowledged the issue, but said that they could come back again tomorrow and move everything to its proper site. In Western terms, the amount of money is small, and other than convenience issues, there’s no huge downside. Yet for the men, eager to work, the inefficiencies led to additional resources for them and their families.

The market outside the hospital initially sprung up to provide a source of food for patients and staff. Subsequently, with expansion of bed capacity and the paving of the road from Cap, more demand has developed. My favorite fried plantain and empanada place is there, and the owner recognizes me and will cut me a deal, knowing that if the other volunteers see me eating the street food (only fried and no meat) they might try it. There are more motorcycles leading to a brisk business in oil and supplies. Buildings are being completed around the compound and this has brought additional potential customers. Perhaps due to some sense of optimism, tourism is again being encouraged.

So what does free enterprise have to do with burning trash?

There is no organized sanitation system and recycling, other than coke and beer bottles, is unheard off. It’s easy to just toss trash in the gutters or the river. In Los Angeles and other cities, trash (biomass) is a welcome commodity, as it can be burned in a controlled environment to generate electricity. What is we created the same type of demand for trash in Haiti? Those looking for income would gather waste and bring to a central facility where a market based amount is paid. The cleanly generated electricity would reduce the need for coal or diesel powered generators. The electricity would support other areas of economic development. And there were be less need to burn the plastics in open pits.

Perhaps I’ve taken too many courses on entrepreneurship and launching new businesses. Yet by looking at basic human behaviors, and evaluating the environment, great strides can be made that can yield economic, social, and environment benefit in multiple realms.