Haiti Waits by Joshua T. White, M.D. April 15, 2009 Tito is four years old. That’s just a guess, as I didn’t speak Creole, and he didn’t speakEnglish, so I never got to ask. His only article of clothing was a dirty red and white shirtwith only one button. It was much too big, and he wore it like a robe, flowing behind him as he ran barefoot through the dirt.It’s hard to tell what Tito thought of us – Americans in Haiti – but he followed us like a shadow. He studied the nurses handing out pills. He listened to the malnourished babies cry as they were weighed. He peered over my shoulder as I cut into the face of an old woman, trying to drain an abscess brought on by decades without dental care.At the end of the day, we passed him a bit of candy, and what he did with that candy is one of my favorite memories. We watched in amazement as he broke it into pieces and shared it with the crowd of children accumulating in our wake. This little boy – who had nothing – did not hesitate to share.I can’t remember that Tito ever said a word, but I’ll never forget him. "For me, an area of moral clarity is: you’re in front of someone who’s suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act." –Paul FarmerIn my day job, I work as an emergency room doctor in the Twin Cities. I get to come home to a beautiful little house with two barking and eternally excited dogs. I try to be the best husband and father I can, and I live a comfortable life. Sure, there are always too many bills and never enough free time, but life is pretty good. Sometimes, though, it’s hard to remember that the world doesn’t end at the corners of my yard. Sometimes, falling asleep on my couch with my little girl curled in my lap, I need to force myself to remember that there are those out there who are cold and hungry.Several years ago I received a call from Dr. Christopher Buresh. He wanted to know if I was willing to go to Haiti and see patients in a mobile clinic. Chris and I had gone to medical school together at the University of Iowa, and afterwards he had gone to North Carolina to train in pediatrics. In North Carolina, Chris had been introduced to the Children’s Nutrition Program of Haiti and had begun periodically traveling with them on medical missions.Phone calls from Chris always result in something interesting, from ice climbing in Washington to scaling desert cliffs in Nevada to running 125K races through the Canadian Rockies. An invitation like this promised to be much too interesting to pass up. As it turned out, it was that and more.Haiti is an easy target for mission work, but somehow manages to get perpetually overlooked. It’s certainly not glamorous, and many Americans are just a bit afraid of this place that brings to mind Voodoo and poverty. Just 90 minutes out of Miami, you find yourself in a place with no running water, no electricity, no community sanitation…the list goes on and on.The heat can be oppressive, and the mosquitoes can leave you with things considerably nastier than they might be in the United States. Disease is rampant, from malaria to tuberculosis to typhoid to intestinal worms. Some of the diseases are quite exotic, such as elephantiasis, but most are quite simple, such as kwashiorkor. It sounds fancy, but kwashiorkor is just a technical term for the changes you see in a person who is starvingto death. You see a lot of that in Haiti.Much of the country has virtually no medical system, and there is a massive vacuum only a few are trying to fill. Our groups and the CNP operate out of Leogane, a smallish city on the southern peninsula of Haiti. The international airport is in Port-au-Prince, about 20 miles east of Leogane, a journey of two to four hours if you happen to have a car. Most Haitians travel by tap-tap, a sort of taxi. We clamber into Jeeps and Dodgetap-taps, typically brightly painted pick-up trucks belching black smoke and struggling to haul cargos of 20 people or more. Leogane has a hospital, but it’s been closed for nearly a year now. Even when it was open, services were few and far between. We fight about universal health care here in the United States while roughly 75 percent of Haitian births are unattended by any medical professional whatsoever.Our mobile clinics will range out into the countryside and the mountains, sometimes visiting villages that have not seen a health care professional in decades.When in Haiti, we run mobile clinics. We guess at what we might need, carry all the supplies we can stuff into duffel bags and treat whatever we can by clinical diagnosis only.We have no X-rays, no laboratory, no specialist to consult.There are sometimes up to a dozen of us on these trips. The groups are eclectic, as we take anybody willing to help. Our only requirement to participate is that you pay your own way, as every dime we have is for the Haitians. We bring the obligatory doctors and nurses, but it gets more interesting with handymen and art teachers, high school students and clergy.We usually stay in country for a week, and by that time we’ve given away all the medications we managed to carry down. Our supplies and equipment are hauled down as luggage, paying whatever extra fees the airlines demand. Most of our supplies are medications donated or procured at cost from companies catering to medical missions such as ours. Relying on donations leads to an unpredictable and sometimes amusing inventory, but we’re happy to work with whatever we can get. We’ve ended up with 90-lb. bags of prenatal vitamins and butt paste for babies who don’t wear diapers. In some way or another, it all ends up having value in the end.Running a mobile clinic is a remarkable task. Our mobile clinics will range out into the countryside and the mountains, sometimes visiting villages that have not seen a health care professional in decades. Clinic sites are chosen based on the locations perceived to have the most need.On the way to these clinics, we sit on duffel bags bursting with medications and pray as the Jeeps teeter around the mountainous countryside. Traffic can include chickens, school children and donkeys pulling carts. As it is in most developing countries, driving is unquestionably the most dangerous aspect of the whole experience. The rules of the road are unwritten and open to individual interpretation but seem to be intuitive to the natives. Skirting around the occasional burned-out wreck can play havoc with your nerves.As if all of this weren’t enough, reaching a clinic sometimes involves pushing the trucks out of innumerable mud holes and hiking through them. The occasional clinic eveninvolves an overnight hike, as there are plenty of places in Haiti where the roads just don’t go.We will see patients wherever space is available, often in a village school or church.News of our arrival spreads quickly, passed by mouth and radio, and frequently hundreds will show up. They will quietly wait in the sun all day, dressed in their Sunday best to tell us of their ailments, clutching their payment of a few cents.There was a time when our clinics were free, but we learned that free services aren’t valued in Haiti. So now we collect our symbolic fee and turn it over to the hospital at the end of the week. Once registered, patients are escorted to a provider who will try to determine what can be offered. The process is frequently heartbreaking, as there are many patients whose needs exceed our capabilities and many needs that can’t be fixed with medications. There are no oncologists for the tumors, only aspirin for the strokes, and no pills at all for hunger pangs. I struggle knowing that to many of my Haitianpatients I am terribly inadequate.Most every Haitian is malnourished to some degree, so all get vitamins. Their nutrition is made even worse by parasitic intestinal worms ubiquitous there, so we treat everyone for these as well. Those with chronic illnesses, such as diabetes and high blood pressure, receive a three-month supply of pills and a prayer.Elderly men and women plagued with arthritis get Tylenol. Babies riddled with scabies get rubbed down by the nurses with a cream that will hopefully stop the itching. Every child with a sore throat gets antibiotics, a practice that would be quickly condemned in the United States, as undoubtedly many of them are viral. But in Haiti a strep throat can lead to rheumatic heart disease, as there are no pediatricians to follow up on patients’ conditions the next week. There are no cardiac surgeons to save these children with rheumatic fever from damaged valves and heart failure. At the end of they day, some patients just get a smile and a hug and a terribly unfair admonishment … eat more.Recent years have been particularly unkind to Haiti. A typical Haitian family earns a little more than $400 annually, less than the airlines charge us to come and go. This breaks down to roughly $1.12 per day with which to feed and clothe their children, much less pay for school and other needs. Multiple hurricanes swept over the island in 2008 and flooded the lowlands.Sanitation declined even more while both hunger and disease have seen sharp increases. The global economic crisis has produced inflation in the cost of food staples such as rice and beans, contributing further to the problems of malnutrition. Reports circulate in Western media of desperate Haitians eating things such as dirt cookies. I don’t know if this is true, but I don’t find it hard to believe.And yet, despite the innumerable hardships, I have not found a Haitian who felt the need for pity. They are an amazing people, vibrant and joyful and grateful for the small things in life. They love their children, care for their elders and are quick with a smile. I always leave Haiti feeling that Haitians have given me more than I have brought to them, and I always return wondering why it has been so long. In many ways, I think that we all could learn quite a lot in Haiti.Our hope is that in making a deeper impact, the population of these villages will be healthy enough to devote themselves to addressing other needs and perhaps begin to make tiny steps out of the poverty cycle.The overwhelming need in Haiti has prompted Dr. Buresh and me to try to establish amedical mission of our own. We envision a different paradigm from what we have seen and hope to begin taking groups of our own as early as June 2009.We would like to focus on a few villages and visit them at least twice a year (if not more). By doing this, we can provide year-round medications to people with chronic illnesses. We hope that we can do a better job of keeping a small population a bit healthier.Our hope is that in making a deeper impact, the population of these villages will behealthy enough to devote themselves to addressing other needs and perhaps begin to make tiny steps out of the poverty cycle. Perhaps to some, we can begin to make a real difference.We recognize that this will be an incredible challenge, and perhaps it won’t work out theway that we want it to. But failure to try is not an option for us. And so we struggle with the politics of establishing our little group. We look forward to begging for funds in an economically crippled America. We will ask people facing layoffs to use vacation time to work and sweat with us in the Caribbean. We will go and do everything we can, knowing that it will be far too little. And we will try not to be discouraged.As my daughter and my dogs jockey for position on my lap, I think about these things.And I know that Dr. Buresh and others are thinking about them, too. As the snow swirls outside my home in the Minnesota winter, I wonder about Tito. How is he? And will I find him when I return?About the author: Joshua White graduated from Luther College and received his M.D. from the University of Iowa. He is a member of Cohort 16 in the Opus College of Business Health Care UST MBA program. You can contact him at firstname.lastname@example.org.