Such a Strong Word

Ten Dollars a Day

2011-11-02T20:32:00.002-07:00

Photo from an American Soldier in Afghanistan's collection

In Afghanistan, the American Soldier in this photograph, per the US Department of Defense, wears and carries US$17,472 worth of gear. On average, the family of the rural child in this photograph makes approximately US$1 per day. If this girl's family makes $1 per day, and she lives to her life expectancy, of 44 years (UNICEF)-- her family's lifelong earnings will be less than the value of this single soldier's uniform.

* * * * *

42 children, like the girl in this picture, will die this month in Afghanistan by stepping on or encountering a land mine.

That's more than one child a day.

Do you remember being a child, running aimlessly through that field by your house, perhaps chased in a game of tag, or running after your dog? Can you look out the window of your house right now, and see your child -- or your neighbor's child -- doing the same?

What if scattered about your front yard were buried explosives, dropped 25 years ago from a Soviet airplane...multi-colored, shaped in the form of butterflies. Intended to be a curiosity to a child. Designed to be picked up by a child...to maim or kill a child...in a sinister act of all out war. Because a disabled child, or a dead child, is a distraction to the family of a rebel soldier. And, a disabled child -- and certainly a dead child --is unlikely to grow up into an effective future soldier

So, 25-year-old butterfly bombs lay buried in the fine dust that migrates around the arid desert that is your front yard... to be found by your curious child, after a wind or rainstorm, which reexposed its deadly form.

"Hey," says your daughter, turning to look at your young son. "Look at this," she says, as she picks up the mysterious, pink-winged thing...

And then, in an instant, she is dead.

It could happen today...if you lived in Afghanistan.

What if you were a rural Afghani goat farmer, with no interest in politics at all. And last night, unbeknownst to you, your neighbor down the street -- who is jobless, hungry, and cannot feed his family -- decided he would join the Taliban...

Because they said they would pay him $10 a day.

Not because he really understands the conflict. He has not read about it -- because as a rural Afghani man, there is a 91% chance he is illiterate.

No, he joins because he understands that $10 a day is more than abject poverty.

$10 a day is $2 a day more than being a state police officer. $4 a day more than working for a cash-to-work program funded by the international relief community. $8 to $9 a day more than the average daily Afghani wage -- if you are fortunate enough to have a job. And $10 a day more than his current condition..of having absolutely no income at all.

What if your neighbor is now tasked, in this complex fight against the Americans, with burying IEDs (improvised explosive devices) randomly in the dirt road that runs in front of your house -- the street that you walk daily to the market, or into town -- because the enemy might drive down the road.

Will you -- as his neighbor -- have any idea that he buried explosives there? Will you know exactly where? Will your little girl? Will he tell you where he hid them? Or is this secret one of the many conditions of his newly acquired daily wage?

Will you discover his actions because you hear an explosion, and come running out of your house, to find the decimated body of your child splayed lifelessly in the road, or in a nearby field? Your child -- an incidental casualty in this confusion known as war. Your child -- reduced to a black tic of ink on a bureaucrat's statistical log.

One in 42...this month.

Tic.

Your dead child.

This happens more than once a day to a child -- to a family -- in Afghanistan.

* * * * *

If the girl in this photo is 10 years old, then all she has ever known is war.

In the days that she was conceived, so was al Qaeda's plot against America. And so, the American conflict in Afghanistan, that began in Kabul on October 7, 2001 -- in response to the attacks on New York's Twin Towers and the Pentagon -- has been waged her entire life.

Now suppose this girl is 2,339 years old. It's less likely, I admit. But, at 2,339 years old, it would still be true, that most of what she has ever known is war.

Alexander the Great marched in here in 328BC, followed by the Scythians, White Huns, then Turks. In 642, the Arabs came, and introduced the religion of Islam. Then came the Persians, then the Turkic Ghaznauds. A man named Gengus Khan stopped by with his Mongols in 1219, and occupied the area till his death. Local Princes took the power back, till Tamerlane -- a descendant of Khan -- came through for another enduring visit. The story of warlords and factions and power struggles continues here through modern history -- seeking a trade route or a political buffer between north and south, east and west, in this sandy, mountainous interspace of cultures known as Afghanistan.

In 1839, the British came, and during their ongoing colonial quests, made three attempts to rein in the locals -- in the form of First, Second and Third Anglo Afghan wars. Then there was Russia, from the North, who also savored a piece of the pie. It was, in fact, the Russians and the British, who, in 1880 -- in the semi-random way that imperialists do -- took out their Sharpies and their maps and sketched the modern borders of Afghanistan.

If our girl is 2,339 years old, then something very hopeful happened to her 92 years ago, in 1919 -- the year the 19th Amendment and women's right to vote was introduced to Congress in America. In Afghanistan, the new King Amanullah -- who took power when the British finally threw in the towel -- sought to modernize Afghanistan. Amongst other advances for women, he advocated for female literacy and education. He removed the mandate of the public veil from women -- making it a choice instead of an obligation. In 1919.

These were, for many tribal leaders of the time, unpopular decisions. A clash of religion, culture, conservatism and change. So, the rights of Afghani females to gain an education, to choose a husband, to learn a profession, to run for public office -- all slowly sputtered forward, and sometimes back -- for decades. In 1959, women in urban centers again were given the choice to publicly unveil. In 1964, women were given the right to vote and were allowed to enter politics. In 1978, under the influence of the Soviet Union, communists came to power. Girls' education became compulsory, marriage age was raised to 16, and brideprice was abolished. Unfortunately, along with these changes, the overt practice of religion -- Islam -- was banned. And understandably, ensued a popular revolt amongst Muslims across the countryside.

Our ten year old girl wasn't alive during the occupation by the Soviet Union, which lasted until 1989 -- more than a decade before her birth. But the legacy of that era of war lives on for her, and children like her, to this day. It is estimated that 1 million Afghani's died during that conflict. Many of the casualties were children, caught in the crossfire, or more unthinkably -- injured or killed by those butterfly-shaped bombs.

When the Soviet military finally withdrew from Afghanistan in 1989, a power vacuum ensued. Once the Mujahadeen, who tenaciously fought off the Soviets (with American military aid), took power, the result was nearly a decade of infighting and clan wars. A radical Islamic group called the Taliban, slowly rose to power, occupying the capital Kabul in 1996, and 90% of the country by 1998. And implemented an ultraconservative interpretation of Sharia law -- the moral code of Islam -- that some call "Talibanization".

Five years before our girl's birth -- when almost 50% of urban professionals in Afghanistan were women -- came a decree that would ultimately change the course of her human rights, her health, and her very life. The Taliban Decree of 1996.

The decree begins:

"Women, you should not step outside your residence."

And so began a new era of women's rights (or lack-there-of) in Afghanistan.

If you were a professional woman in 1996, imagine a declaration from your new government that you are no longer allowed to leave your home. Imagine they have also declared that you must paint the windows of your home black, to prevent anyone from looking in, and glimpsing you pacing around frustratedly inside.

Imagine they declare you are no longer allowed to go to work. Nor school. Ever. Ever again. You, nor any of your female children.

If you must leave the house for, say, emergency medical care, you must wear a burqua, which covers you from head to toe, with a small vent at the eyes to allow you to see. And you can only go out with a male family member. If you do not have a male family member -- as happened to 400 female orphans after the decree in Kabul-- then you are not allowed to go outside at all; the 400 orphan girls were kept locked inside for over a year.

If you are a widow, with no male relatives, you and your children will likely starve, due to your lack of access to the outside world.

In an emergency, your male doctor is not allowed to see your entire body -- only the perceived affected body part, and only if you are accompanied by a male relative. Your female doctor (40% of the doctors in your city are female), is the one female professional still allowed to work. She could treat you, if she could safely find a way from home to work. But like you, she now requires a male relative to escort her through town. You will soon discover only 25% of them can safely make the trip. The other 75% of female physicians remain imprisoned in their homes -- like you -- creating a crisis in women's access to health care.

You (and all persons of Afghanistan) are forbidden to listen to music, dance, sing, fly kites, raise birds or own a mirror. You cannot take photographs of loved ones, and must destroy all photos of people you have, because this is considered idolatry. If you violate these rules, you will be punished.

And what will be your punishment? It depends upon your crime. But, it is possible you will be led into a soccer field in your home community, wearing your burqua. In front of the crowd -- who are no longer allowed to clap or cheer at public ceremony -- you might be flogged, or stoned, or possibly shot in the head at close range with a rifle. As a lesson to others to obey.

The Taliban were driven from official power approximately one month after the US invaded in October 7, 2001 -- in response to the 9/11 attacks, and "Talibanism" was replaced with an elected democracy. But today, 10 years later, the Taliban continue to fight, and influence, and intimidate. And the war that rages in response continues to devastate the people and development of Afghanistan.

So, what about our girl of ten. What happens when a country is in a constant state of war, and cannot (or chooses not) to properly invest in the development of its people? How have these ten years of war, and all that has gone before, influenced her life and her future?

She beat the odds when she turned one -- because 11% of infants here die before 12 months of age. She beat the odds again when she turned five, because one in every five children in Afghanistan die before the age of five.

One in five.

Even under Taliban rule, the women of Afghanistan did not fail her. When female education was banned, women risked the punishment of death to run secret schools for girls within their homes -- understanding the value of her education, and her future. Nevertheless, today, only 18% of girls here are enrolled in school, and a mere 6% actually attend. (Boys rates are not much better -- with 38% enrolled, and 15% attending.) Only 13% of females in the country are literate.

If she marries, legally it will be at age 16 or older-- although it is estimated that 50% of girls are forced into arranged marriage before 16 years of age. If she gets pregnant at 16, or 15, or 12, her youth and small size -- enhanced by poverty and malnutrition -- puts her at risk for a small pelvic opening, and birthing difficulties. With only a 14% chance of having a skilled birth attendant at her side, she has a 10% chance of dying each time she gives birth.

And today, while I, an American female, am expected to live to 81 years of age -- her life expectancy is 44.

I have to smile, though, when I look at the picture again. This little girl in bright pink. No fear. Unhidden. Hands folded quietly, staring with bold curiosity at the foreign soldier. Does she represent the shrewd, historical strength of the people here? Yes. Is her courage a glimmer of hope for the future of Afghanistan? I hope so.

At least for the next 34 years, which -- if she survives war and land minds and childbirth -- is predicted to be the extent of her life.

* * * * *

Why does this conflict continue? It's an exquisitely complicated question. But here's one of many things to contemplate:

Food. Shelter. Clean water. Health care. Education. Literacy. Security.

What would you do if you didn't have them?

What would you do, for $10 a day?

Map: Areas in dark maroon have a life expectancy of less than 45 years. Can you find Afghanistan?

The Longest Night

2011-06-30T17:26:00.000-07:00

Photo from Internet: Generic Antarctic Octopi

I had the happy experience of stumbling across this letter home amongst my things this week. A fabulous memory of a few years ago when I lived in Antarctica, where seasons are opposite of ours in North America, winter blackness goes on for months, and a crazy annual tradition is undertaken every June 21st. In a divergence from all things hot and humid and sandy and sunburned, I am delighted to share this memory with all of you who kindly read my occasional ramblings. Happy Solstice, particularly to my iciest of friends.

****

June 21st, ANTARCTICA

Midwinter Greetings from Antarctica!!

They say that today is the longest night of the year. Not to be confused with yesterday, and our 24 hours of darkness, nor tomorrow, and our 24 hours of darkness. This longest night has been determined with meteorological specificity. We are tipped farther from the sun today than we have been tipped all year. After this night, the sun will start her slow trip back to our horizon – a journey of another 61 days.

In fine human form, we celebrate this longest night with a bit of pomp, a bit of circumstance, and a fine tradition of human stupidity. We pull out our shovels and chainsaws, and dig down to the depths of the sea, 15 feet beneath the snow and ice. We stop to stare into the shallow depths of the re-discovered liquid ocean, through a six by six foot square window in its solid surface. Illuminated by a submerged light, the sea laps gently at its new icy frame. And we strip down to our skivvies -- some, in fact, down to nothing at all -- because, dammit, its summer (somewhere). It’s June, for God’s sake. And, yes, it’s time for a swim.

Our pale, fleshy bodies glow eerily in the foggy moonlight. No need for sunscreen on this beach today. Bare-bodied, defiant, we walk one-by-one down to the hole. This is, perhaps, a keen and wondrous example of the powerful emotion “denial”, and the eternal battle of the logical mind and its rebel nemesis. The rebel mind fails to acknowledge that minutes prior, its body was bundled in down, silk, fleece, wool and complicated polypropylene. It fails to question why it is now walking, defiantly naked, towards this newly opened window to the sea. Outside. In the -40F ambient air, made ever more frigid by the presence of a katabatic wind. It instead snickers with barely hidden delight. The logical mind wonders, “Why am I wearing sneakers, but nothing else? Isn’t this odd?” The rebel mind grins. It knows why**.

(**Previous attempts to perform this feat sneakerless has left people with the skin of their feet literally torn off, frozen permanently to the sea ice.)

It is the rebel mind that guides the body down the icy path to the hole in the mid-day darkness. It guides the hands that grab the dripping, icy harness and wrap it around its torso.

“What is this harness for?” asks the logical mind, cringing at its acrid frigidity on the flesh of its body’s warm back.

“Why, it’s a safeguard to prevent your body from getting sucked under into the ocean’s 300 foot depths,” whispers the rebel mind.

The logical mind contemplates this for a moment, suddenly catching on. The hole. The harness. The inappropriate nudity. Dear God in heaven! The body’s pulses surge with sudden panic-impregnated awareness. The logical mind prepares to mount a sudden protest. But, alas…the rebel mind has already directed the knees to bend, the calves to contract, a lateral jump into the air, and then….

Cold.

No, not cold. There is no description for this sensation. It is cold and wet and suffocation and pain and panic and fear and bright light and hair-standing-on-end and muscles contracting and blood vessels constricting and eyelids (and, yes, other orifices) clenching. Perhaps this is what it is like to get struck by lightning, or fall from an airplane with a great splat onto the earth below: a sudden, body-consuming, brain-flooding sensation of transient life.

This sensation is perhaps made worse by the rumor of octopi.

Yes, there are things living down there under the ice. One wonder of this newly-opened window to the sea is the life it reveals teeming in the waters below. We are not alone here in our Antarctic wilderness, on our dark Midwinter’s Day. Two years ago, one plunger was intimately greeted by the warm mammalian nose of curious weddel seal. This year, as we stare down into the sea, hundreds of small eyes stare back at our warbling forms. Bright orange krill swim at the surface, perhaps holding their own mid-winter celebration? Are they challenging each other to jump out of the ocean into the frigid air above, for a momentary glimpse of our waterless world? If I look closer, will I see the small harness that they attach to each other, to prevent them from floating away in the Antarctic winds? Beyond the krill, one can spy giant yellow starfish, clinging to the rocks of the sea floor below; and foot-long white worms, squiggling hideously just below our ladder in the hole. These worms are not dangerous, we are told. Just hideous, slimy, disgusting, necrotic foragers. They eat only dead things. They are the recyclers of the sea. So, what brings them here on this day, the mind has to wonder, to loom in wait beneath our hole -- these eaters of dead things? Would their presence make them optimists? Or pessimists? That, I suppose, depends on your perspective….

But, yes, an octopus had been spotted, feeding on krill just below the surface of the water. Certainly, this was quite the unexpected opportunity for him. He’d been swimming about in the dark depths of the ocean for months now, blindly groping about for dinner, not a glimmer of sun in the sky. When, suddenly, the illumination from our underwater lamp brought enlightenment, and with it, the fantastical and alluring dance of krill. Dinner. And he had swiftly scooted by, just in time for my turn at the plunge hole.

“Watch out for the octopus,” my Kiwi friend warned flatly, as he stood beside me at the mouth of the hole. He was the dive tender. I was standing beside him, nearly naked, save my sneakered feet, tankini, and fine layer of goosebumps. It was not a choice moment for a lecture on marine biology.

“The what?” I asked with pseudocalm, a hint of poorly veiled trepidation in my harsh whisper. “Watch out for the what?”

“The octopus,” he replied, with an unblinking challenge, a stoic stare. At that moment, he extended to me a band of icy, dripping cloth attached to a rope. “Here. Put on your harness.”

“Funny,” I said, with poorly-feigned nonchalance. “You think you’re sooo funny. There isn’t any bloody octopus in that water!”

“Don’t worry,” he reassured with a calm stare, pausing for dramatic effect. “It wasn’t a big octopus.”

Right. As if the size of the octopus had anything to do with my trepidation. As if I should have been un-alarmed by the presence of any hungry, multi-legged, suction-cup encrusted, beak-faced being that had been blindly flailing tentacled appendages for months in the frozen dark sea, seeking even a single morsel of food. As if I should have been unconcerned by the prospect of his octopus family, who might have been lurking just on the other side of the ice, in the shadows, out of sight, emaciated, drooling in anticipation of their next meal. And how big is an octopus family, anyway? Ten? Twenty slithering beasts? How many legs does that make? How wonderful that they had been alerted by the plunging humans before me -- a virtual dinner bell. These creatures, who’d been eeking out their survival in the dark Antarctic sea for months, barely subsisting on a diet of microscopic krill, now attracted to the light, now drooling in the darkness. And who would, in a moment, be presented with a rather large, tender, warm, fleshy morsel known fondly to me as... my body.

“Fantastic,” thought my logical mind. “I am bait.”

“True,” acknowledged my rebel mind. “Bait.” And then my body was hijacked.

Unexpectedly, my breath sucked in deeply and my toes pushed off forcefully in the icy slush on the side of the hole. As I flew through the air, muscles tensing, eyes clenching, my logical mind repeated the mantra of my shoremate. “No worries. It isn’t a big octopus. It isn’t a big octopus…”

Kaplunge…

Cold. No, not cold…

The first one-millionth of a second of cold-water immersion -- when the first molecule of toe hits the water -- initiates the cascade of a massive adrenaline dump. A giant internal air raid siren begins its deafening scream. The fight or flight response ensues. As the first tinkling-bubbling of ocean migrates down the auditory canal, the mind has already formulated its frenetic plan, and screams commands like an angry drill sergeant. “Left leg push! Right arm grab the ladder! Climb, climb, climb! What the HELL are we doing underwater? Don’t you know this is Antarctica?” And on the heels of that, “Worms! Big carnivorous worms!” And finally, to motivate, “Octopi!”

Yes, the brain is in full flight. So, when the dive tender at the surface starts screaming, “Octopus!! It’s the octopus! Look out!! My God, look out!!” there’s not a whole lot more for the body to do, except accelerate its escape. And imagine tentacled arms gently brushing against frigid legs. Hands grip the icy rails of the escape ladder, ignoring the frozen paralysis of muscles. The body climbs. And in moments, it is standing once again on the icy ledge, above the window to the sea, dripping wet, now convecting any remaining body heat off into the windy darkness. A leg gives a shake to dislodge imagined remnant tentacles. Eyes quickly turn back to stare down into the icy hole.

“You saw the octopus?!” I cried, wide eyed with horror, dripping like a wet rat, staring into the abyss. “Was it after me? Really?!” my voice squeaked in a frigid whisper.

Then came the laughter -- a loud uproarious eruption. He was laughing at me, the dive tender, a look of exquisite glee in his eyes. “No,” he said, chortling with obvious amusement. “Not really.”

I glared at him silently. Warm air steamed visibly, flaring from my nostrils. He would never know. How close that man came today to a sudden swim in that hole -- big down thermal body suit, boots, hat, gloves and all -- for a better look at that octopus. If only my hands were not frozen at that moment into frigid claws. If only I weren’t dripping wet, hair freezing in place in a tangled mat on my head. If only my muscles would respond to something other than a fierce command to run away to the warming shelter. Down he would have gone to commune with the octopi. The worms might have found their meal, as well. But, lucky Kiwi. In the contest of fight versus flight today, flight won. Just barely.

And my rebel brain grinned in preening satisfaction, while my logical brain sighed, urging my frigid legs towards the warming shelter.

“Come now,” urged the rebel brain. “That wasn’t so bad, was it?”

“I’m not talking to you,” grumbled the logical brain, effectively masking its unsurpressable elation, and the virtual sparkle in its eye.“Not bad at all,” it whispered silently to no one.

So, the plungers plunged, then donned their down, and slowly walked away. With the sea light gone, the octopus family groped their way into the darkness. The carnivorous worms squirmed along towards a more hopeful site, mild frustration in their slithering gaits. And the starfish remained, seated quietly on their rocky thrones, peering up through the skylight in their icy ceiling to the night sky above, towards their sister stars in the heavens. Golden star shining upon golden star…

On this Midwinter’s Night.

Goodnight.

Two Scratches of a Pen

2011-03-23T15:21:00.000-07:00

The crumpled piece of yellow paper at my foot caught my eye. I bent over to pick it up. Then halted.

A flimsy piece of trash. Worthless. Discarded. Smudged. Walked upon. Crumpled. With the vague ink stamp of our clinic visible in the bottom left corner.

And above the stamp...a life altering scratch of an ink pen. A plus sign. Positive.

HIV positive.

With two scratches of a pen, a life altered for its duration.

I picked up the paper, quietly folded it, and stuck it in the back pocket of my scrubs.

Of course, I know this patient. I know this paper. Discarded trash from yesterday. That was my writing. A lab order for the cachectic, febrile twenty year old girl from a tent city. I'd ordered that test. I'd passed the paper to Sister Gloria, our nurse, and requested her to run it. She returned to me thirty minutes later, and with a stoic, kind-yet-grim look in her eyes, handed me back the slip. I'd met her eyes in silent, knowing, communication.

Two scratches of a pen. A life altering diagnosis.

Positive.

The twenty year old girl, skin and bones, laid curled on her side in the next room of the clinic, staring blankly at the wall. A resident of one of Haiti's semi-permanent post-Earthquake tent cities. Mother of a 6 year old child. A quick calculation revealed she therefore became pregnant at 13 years old, and gave birth at 14. She breathed rapidly. She was fragile. Like a small bird, fallen from her nest.

I walked into her room, and through a translator, revealed her test results. "Your HIV test is positive," I explained. "This means you likely have HIV, the virus that causes AIDS. We need to confirm this with another test. But I am very concerned."

She stared blankly at the wall.

"Do you have a sexual partner?" I asked.

"No," she replied. "Not since I got pregnant."

Another simple calculation. Last sexually active at age 13. Therefore, HIV positive at age 13.

Now, likely, AIDS. At 20 years old.

"Did you get tested for HIV when you were pregnant?" I asked.

"No," she replied. She got no prenatal care at that time. At 13 years old.

"Did you breastfeed your baby?" I asked.

"Yes," she replied.

Another mental calculation. Untreated HIV positive mother, never diagnosed or treated, subsequently breastfeeding her infant. Means child at risk for "vertical transmission". Transmission of HIV from mother to child, either at birth, or subsequently through breast milk exposure.

"We need to get your daughter tested for HIV, too," I said quietly. Mother stared blankly at the ceiling. The implication, and subsequent palpable self-accusation, was strong. The risk to her daughter's health. A mother's guilt. Finally, as the information was slowly absorbed, a quiet nod. Empty staring eyes.

I flashed mentally to the World Health Organization recommendations for HIV prevention. The "ABCs" of HIV prevention in sexual relationships:

A = Abstinence

B = Be Faithful to your Partner

C = Condoms

I suddenly remember the semi-angry rant of one of my Tropical Medicine professors -- an HIV and TB expert from India, who spent many years as a physician in the urban public health trenches before becoming a professor at Tulane. To paraphrase her highly-educated and evidence-based rant, in response to the ABCs:

Don't think that women of the developing world aren't aware of how they get HIV and AIDS. They know. They are not ignorant. They know about AIDS and know that it is sexually transmitted. The bigger issue is the ability of a woman to say "no". In many parts of the world, due to imbalances of power in the role of men and women, women have no power in a sexual relationship. Whether it is through physical dominance, or financial dependency. They do not have the social power to refuse sex. They do not have the social power to say no, to demand condom use, nor to demand monogomy of their husband/partner.

I look back at my patient, pregnant at 13 years old.

Infected with HIV. At 13 years old.

Was that sexual relationship an educated choice? Or any sort of choice?

At 13 years old?

In Haitian post-earthquake tent communities, where some estimate HIV rates could, in some, be as high as 15%, rape is on the rise. One recent news article reported on the experience of a middle aged woman, who came upon a teenage girl being raped by a group of young men behind a tarp dwelling. She began screaming at the men, physically trying to pull them off the girl. The men turned upon her, and gang raped her as well.

"Why did you try to help this girl?" asked the reporter. "Weren't you afraid?"

"I have a daughter her age," replied the older woman. "All I could think was, if it were my daughter, I would want someone to help her."

Emergency surgery was required to save the older woman's life...from hemorrhaging....from the injuries sustained during her gang raping. Trying to save an even more powerless woman from sexual assault.

I stared back at my patient.

Like the paper I found at my feet today...

A crumpled, discarded, treaded-upon form. A tragedy.

Haiti has the highest rate of HIV in the Western Hemisphere. 2.2 percent of the population -- more than 1 in every 50 persons -- has HIV.

How do we stop this epidemic?

Increase access to healthcare.

Reduce poverty.

Promote safer sexual practices.

Empower women, first through education. More power naturally follows.

Fund education for all.

Work to remove the social stigmas associated with the diagnosis of HIV.

Is this an impossible task? No.

Start with you.

And not just in Haiti.

Start with you. Start with your community. Your children. The young women and young men in your life. And the older women and men in your life. Teach abstinence. Teach faithfulness. Teach condom use. Teach respect. For self. And for others. Encourage the education of girls. And boys. Encourage the human rights of girls. And boys.

Get tested for HIV. Encourage others -- especially those you love -- to get tested, too.

There are 33 million people in the world with HIV today. Nearly 2.5 million more will acquire HIV this year. And an expected 2 million people will die.

Lives transformed, with two opposing scratches of a pen...

Riding the Bus

2011-03-10T20:21:00.000-08:00

As I sat, going on hour number eight, plastered against the Haitian stranger to my left in the very back of the bus to Santo Domingo, I was reminded of a joke I heard while living in the former Soviet Union years ago. There, too, bus rides were intimate affairs of stranger on stranger body contact, wherein the rules apparently state that the physical contact is to be tolerated, but not acknowledged with eye contact nor spoken word.

The joke was told to me by a Russian colleague, after a particularly sardinesque trolleybus journey, wherein most passengers are standing, and pressed into each other lengthwise like standing matchsticks in a can.

The story, made all the better in the low, monotonous tone of a large Russian woman's broken English accent, goes something like this:

"An 18 year old girl, riding a tightly packed city bus with her mother, decided -- as her mother could not move, and therefore could not beat her -- that this was the perfect opportunity to make a confession.

'Mama,' whispered the girl. 'I have something I must tell you.'

'Yes, darling,' her mother whispered back cautiously, alerted by the concerning tone of her daughter's voice and the shameful downward glance.

'I...I...Oh, Mama. I'm pregnant.'

'No!' whispered the older woman harshly, in a mix of growing anger and horror. 'How can this be?!'

'I'm sorry, Mama,' returned the girl. 'I'm sorry!!'

'Who is the father?!!' demanded the older woman.

'I don't know, Mama,' whispered the girl. 'I don't know."

'What?!' the angry woman whispered angrily. 'What do you mean you don't know?'

'I don't know, Mama,' she cried, 'I cannot turn around.'"

Yes. Exquisitely politically incorrect. Yet, an apparently well loved and popular Russian joke.

And, oh, so true.

You know it. The truth of the overpacked, oversold, overwhelmingly anonymously intimate third world bus experience.

If you have ever ridden a public bus in a developing country, you are smirking irreverently at the uncomfortably too-close-to-the-truthiness of this story.

I know I was grinning, as I contemplated my situation, pinned intimately against the side of my anonymous Haitian seat companion by yet another bump in the highway. I attempted to turn and make eye contact with him, thinking that perhaps an "uh, sorry" sort of look, with a small smile to lift the corners of my lips would ease the social discomfort. He refused to look my way or acknowledge me.

I suppose pretending that the other person in the human sandwich doesn't exist makes the intimacy less traumatic -- or perhaps less potential for an emotional commitment -- if one does not acknowledge the spiritual presence of the other. In the five components of the human sandwhich making up the back row of our bus, if the two window passengers were the bread, my anonymous Haitian companion was the lunch meat, I the mustard, and my American friend to my right -- the pepperjack cheese.

Pepperjack sat semi-apologetically half on and off my lap -- thankfully a petite and slim young woman. My right leg was long-since dead, having become tingly then completely numb approximately four hours prior. I imagined blood clots forming threateningly in my lower calves, as my arms compressed rigidly against my chest by my backpack into the useless appendages reminiscent of a tyrannosaurus rex.

I hope we're on the right bus, I thought briefly to myself. How can I be sure we're not going to a secret work camp, on a sugar plantation or some other site. I can't, I thought. I'm here on faith alone.

I turned to Pepperjack. "If this bus were to bring us to a slave camp," I began cautiously, "would you rather hammer rocks with a sledge hammer, or hoe fields under the blazing sun?"

She glared at me quietly for a moment with piercing blue eyes. Then declared firmly, "Hoe."

"Ok," I replied. "Then I'll hammer rocks."

I noted that there are no seatbelts on this bus, but that, of course, would be redundant and unnecessary. As passengers, we are wedged solidly together like blocks in an igloo. Together, we -- like individual cells -- form a strange, immobile, membrane...like the cell wall of a strange organic creature. If this bus were to flip and roll on this dark, rural highway through western Dominican, I know for certain that not one of us would budge a millimeter. Even upside down we would hang, unscathed, as the tyrannosauri that we appear to be. Silently staring forward. Wedged. Inverted. Wondering if, upon rescue, we would finally be released and allowed to seek a place out on the roadside to empty our soon to rupture bladders.

There is a baby girl one seat up on the right held by its anxious mother. She appears to be a month or so old. We have discovered that this child does not have a passport. We know this because every ten to 30 minutes, our bus is stopped at yet another wooden roadside shack, and is boarded by a man -- sometimes in military camouflage, and sometimes in traditional Dominican dancer-bling of jeans encrusted with shiny faux diamonds and decal-emblazoned black t-shirt. Each man carries, in a show of power and intimidation, a big pistol tucked into the back of his waistband. These men -- sometimes immigration officials and, I suspect, sometimes bribe-seeking impostors as faux as the diamonds on their back pockets -- command us to hold up our passports. With intimidating glares, they slowly wander their dark eyes in inspection over the captive passengers.

By now, we have discovered that if we tuck our passports into our bras, accessible to our tyrannosaurus hands via our front collars, we are able to repeatedly comply with the gun-toters' demands with minimal effort of our largely useless upper extremities.

"Lift your passports," snarl the men as they stand in the doorway of the bus.

Everyone holds up their passport, except the small infant to our right. Of course, developmentally, she has not sufficient neurological wherewithal to find one of her own hands with another, let alone grasp and hold up her Haitian passport. Which is perhaps why she chose not carry it with her on this trip to the Dominican.

Unfortunately, her non-compliance repeatedly and predictably raised the ire of the different immigration officials/disco dancers (hard to differentiate their identity at times) who appear in the bus doorway.

Myself and my two American companions -- overtly white faces glowing palely from the back three seats of the darkened Haitian bus -- attract attention on these stops as we hold up our American passports. Repeated commentary at the door, involving pointing, chin gestures, glares, and the words "tres gringos" is not hugely comforting.

Do our white faces draw attention to the woman in front of us, then to the wiggling, passportless infant in her lap? Does the stopping of the bus, and subsequent absence of rolling/humming/rocking stimulate the infant into its unhappy wails? Or, as a predictor of the young teenage girl she is destined someday to be, is she just trying to give her mother a hard time?

"Hey, Mr. Angry Passport Checker," cries the infant in her secret language. "Look here! Look at me! I've infiltrated your country...without a passport. Nah nah..."

At the first passport check, five minutes from the Haitian/Dominican border, it was first established that the baby had no passport. The first intimidating man who boarded the bus grabbed her papers -- apparently a birth certificate and a shot record -- then berated the infant's frightened mother into tears. In Spanish, he ranted at the mother that the child's documents were not sufficient, that the baby needed a passport, that she couldn't enter the country with such worthless documentation, that she should be ashamed of boarding this bus to begin with, that he didn't care if even the president of Haiti himself had approved this paperwork; that this was the Dominican Republic, the child was Haitian, and she was entering the country in an illegal and unacceptable act. Et cetera. Et cetera. Et cetera.

Brown Haitian eyes nervously meet each others across the bus. The mother's welled with nervous tears. Mine meet those of my companions to my right.

This must be the drama that replaces the en-route movie, I imagined. Not really sure if I want to be a spectator at this event.

This bus trip is taking an infinity, I then note. I wonder if this baby was perhaps conceived and given birth to on this very bus. Is this, perhaps, why she has no passport?

Strangely, however, despite repeated immigration rants, neither mother nor child was ever actually asked to leave the bus. Were these men showing compassion to this baby's fate?

Unclear.

Unlikely.

They had no problem throwing an elderly woman off the bus at one of the first rural stops due to insufficient paperwork. Her elderly eyes stared in horror at the bus's departing tail lights as she stood solo on a grassy roadside embankment. Her horrified family, inside the bus, pressed disconcerted hands against the glass from the inside. All eyes inside the bus, mine included, reflected her horror as we drove away from her bent elderly silhouette that became smaller and smaller in the distance as the bus slowly rumbled away.

.
Granny, it seems, was not immune to immigration's ire. So, what about baby?

Perhaps fearing a similar fate for the baby, with the setting of the sun and the arrival or rural darkness, repeated cajoling negotiations were audible from varied passengers with the arrival of the next impatient, gun-toting immigration official.

"It's nighttime," called one slightly sensual female Dominican passenger in Spanish, batting her eyelashes towards the bus door in the darkness as one of the gunmen stormed from the bus with the baby's insufficient paperwork. Immigration stop number eight, I believe. About six hours now from the border in the middle of rural farmland. Nine o'clock at night.

"Please, sir. Don't throw her off the bus. Have mercy, sir. She's poor. She has no money. No place to go. She has family in the capital city. You can't throw a newborn baby off the bus. She has nothing. She has no place to go. You don't need this burden. Please, sir."

Did the negotiation save the child the elderly woman's fate? Or was it a carefully slipped bribe? Or the very real perceived inconvenience, on the part of a rural immigration official, of the prospect of, "if I yank this Haitian child and mother off the bus, then I have to figure out what to do with them in the dark nothingness of this rural night." i.e. nocturnal bureaucratic laziness out-trumps immigration policy.

So, recurrent ranting immigration lectures about incomplete paperwork, all met with confused non-Spanish speaking tear-filled Haitian mother eyes, ultimately ended in... well, surprisingly... absolutely nothing. Except the recurrent departure of the random immigration official, the hydraulic hiss of the closing bus door, the grinding of gears, and the puzzled realization that we were once again departing with mother and baby intact and an immigration official glaring at the rear side of our departing bus.

I believe we were stopped 14 times on this nine-plus hour journey by various "immigration" officials as we made our way across the Dominican. Several times, in the pitch blackness of night, we were all commanded to "get up and disembark the bus", and stand uselessly at the side of the road for no apparent reason. After ten minutes in the roadside grass, during which apparently nothing happened, no passports checked, no bribes requested, we were told to board once again.

Some people have said that this is the nature of a Haitian bus entering the Dominican Republic. That such searches and repeated "immigration" boardings are commonplace. I don't really see the logic. As someone described it, a muscle flexing claim of Dominican authority. But, I suppose, if nothing else, it breaks up the monotony 0f a nine hour bus trip into perhaps more tolerable 30 minute segments.

By the 14th boarding by an immigration official, all passengers on the bus started to groan in impatience. Comments could be heard about "the baby girl" and repeated scathing looks from the passengers were directed to the seat in front of us. As the doors swung open to admit yet another immigration official, I glanced at my American companions.

Unable to tolerate one more rant at the mother and infant,we decided that if the baby started crying, then we would ALL start crying, as a means to distract the official from the child.

Maybe, if she holds the baby really low to the floor, we conspired, and we cry loudly enough, he might completely overlook her presence while instead glaring at the three crazy gringas.

If the immigration guy questions our sobbing, I told my companions, we'll just say, 'Hey, man, it's been a really long ride. We're tired and cranky and we just can't help it.'"

We made a few practice whimpers and cries. To my left, my anonymous Haitian companion, against whom I had been wordlessly crushed for eight hours, began to grin.

Obviously, he secretly understood English.

He finally turned and met my gaze. We exchanged a knowing glance.

"Good idea, no?" I said, nodding. "Go ahead. You can cry, too. You know you want to."

He looked away, straight ahead, not acknowledging me as he tried to suppress his smile.

The baby stayed silent. She attracted no attention. We all raised our passports in the air. Except, of course, for her...because in her rush for the bus, or perhaps because of her onboard conception and birth, she had obviously inconsiderately failed to bring hers along.

We settled back into our slots in our human matrix, suspended against each other in our giant organic cell wall. The disco/ immigration man with the bling and gun descended the bus stairs into the darkness. The door hissed shut. The lights dimmed. With my one remaining sensate leg pressed firmly against my smirking Haitian stranger, the bus gears rumbled harshly, propelling us the final leg of the journey from the Haitian frontier to the city of Santo Domingo.

Trembleman Dete (Earthquake)

2011-02-24T12:53:00.000-08:00

And so the earth's crust migrated again, violently shifting tectonic plate against plate.

This time, epicentered around the historically rich city of Christchurch, New Zealand and its coastal neighbor, Lyttelton. Amongst the city's many charms and wonders, it is known to me and many I care about as the historical jumping off spot to Antarctica. Another island of beautiful people, close to my heart.

At the time the plates migrated, I was sitting in the sweltering warmth of my clinic in Haiti, literally in the dark. Our electricity had gone out, again, for the umteenth time this week -- of course, timed perfectly to coincide with the stab of an IV needle into the arm of a young sickle cell patient, moaning and writhing in pain on the bed in front of me.

"Seriously?" I muttered to myself, as my eyes adjusted from the fluorescent light to the dark shadows, and I paused mid-stab to let my pupils widen and adjust to the sudden change in lighting. I palpated his vein with my finger, and attempted to blindly finish the IV placement by feel in the semi-darkness of the clinic.

As I felt for his vein... unbeknownst to me, across the world, on another island, on another sea, another hand in another dark place palpated the vein of another patient. A patient crushed by a fallen building. Trapped under tons of cement. Requiring emergency amputation to free him from the chaos of twisted cement and steel.

Trembleman dete. Earthquake.

That evening, as I ran past the grave of the Archbishop of Haiti and his two assistants -- killed last year in the earthquake collapse of Haiti's once grand, stained glass encrusted Cathedral....unbeknownst to me, on another island, in another sea, others worked in horror, digging bodies from the wreckage of another city's historic Cathedral.

As darkness fell in Haiti -- with still no electricity -- tired rescue workers in Christchurch, New Zealand -- still with no electricity -- continued searching for survivors in toppled buildings. As displaced persons in Haiti wandered about their tent cities, displaced persons in Christchurch wandered to tents in city parks, seeking shelter.

Mid-morning the next day, our electricity was momentarily returned. As the lights returned in the clinic, I took the opportunity to check my e-mail.

I scanned one message from home: "I'm so sorry about the earthquake in Christchurch. You must be so worried about your friends."

My heart skipped a beat.

"Earthquake?" I whispered to myself. "What earthquake?"

Perhaps I am not the normal earthquake-goer. Perhaps no one in Haiti is. You say the world "earthquake" to me, and images click through my mind like an old black-and-white 18mm film -- of fallen and tipping monolithic buildings, amputees, mangled flesh, tent cities, fields of refugees, screaming and crying patients all tangled together in a flash of memory.

"What earthquake?" I murmured again, as I quickly attempted to scan the internet on my telephone. The clinic went dark again. No electricity. No internet. No information.

My interpreter walked into my curtained exam room with another patient. At that moment, I had a hard time caring about her six month history of a headache. I forced my mind back to Haiti. Barely.

At the end of the day, electricity once again restored, I again accessed the internet. Facebook. Friends' postings: "Many dead here in Christchurch." "Cathedral destroyed in the square." "Buildings toppled." "We are lucky to be alive." "I slept on the ground in the park last night..." "I helped pull people from rubble." "We are okay." "I am okay..." "Has anyone seen Catherine..." "Has anyone heard from Joe..." "R U there?" "R U ok?"

No. Not again.

I scanned news reports. 100 dead, maybe more. 300 missing.

Stoically, mathematically, my mind did a calculation. 100 dead. Versus an estimated 310,000 dead in Haiti's earthquake 1 year ago. My mind does not minimize Christchurch's horrific loss and pain. Their 100, possibly 300, is devastating. Absolutely devastating. Instead, my brain is merely momentarily overwhelmed, by the magnitude of pain that comes from multiplying such devastation by a factor of three thousand.

After Christchurch's earthquake last fall, I spoke to a friend who lives in New Zealand. Their government advised its citizens that another severe earthquake was ultimately anticipated, and told people to take precautions. Of course, the problem with earthquakes is that the timing of the next "big one" is completely unpredictable. As tectonic plates get hung up when sliding against each other, the next big pop could be tomorrow...or one hundred years from now. Or, possibly never. Nothing, geologically, it seems, is dependably predictable in human time. A similar next "big one" is predicted for Haiti. Could this nation survive such a thing? Will it be tomorrow? Or long past time when it will matter to you... or me?

I stare at images of Christchurch. They are too sickly familiar. Flattened buildings, sprawling cinderblocks, dust covered people in civilian clothes digging through rubble. The gestalt of earthquake devastation, it seems, is cross cultural. As is the heroic and selfless human response.

There are some differences in the photos. In Christchurch, on day two, unstable structures are already surrounded by chain link fencing warning of dangers beyond. I have never seen such a thing here in Haiti. Good idea, I think, a bit cynically. I imagine, in Christchurch, one will not likely see a shopkeeper opening up a stall beneath a leaning wall of rubble. Nor will they see a tent, then a family, or three, settle permanently on the top of the rubble pile, with semi-naked children running about the apex of the pile, laughing and flying home-made kites. I imagine that deconstruction of buildings will take place with large gasoline-powered machines...not a single shirtless sweating man swinging a sledgehammer.

I pray that one year from now, my friends in Christchurch will not still be walking past the walls of their once glorious Cathedral, still crumbled untouched on the ground, as if it fell down yesterday. That they will not walk, day after day, past hollowed out shells of buildings...able to peer inside to see the pink and green wallpapers of a better day. I pray that they will quickly recover, rebuild, and move beyond this horrible day. And, honestly, I know.

I know they can...and will... efficiently make things right.

My first reaction, upon digesting the news of this newest catastrophe, was an admittedly infantile and useless rant consisting of a few unsavory verbs, including one beginning with the letter F. And a questioning of the purpose of all things floating and tectonic.

But then, I realized... These same random crashing and floating plates of earth are the forces that created my beloved Alaskan and Himalayan and Antarctic, and, yes, New Zealand mountains. And, ultimately, the beautiful friendships that I have created there. The same random grindings that shook the earth in Christchurch this week are those that brought me to Haiti last year, and opened my heart and eyes to these people and this land.

And somehow, when the earth shook Christchurch this week, so too did it shake me. And I was reunited, instantaneously, with my beautiful friends of New Zealand and Antarctica.

So, to my New Zealand and Antarctic family: when I am threatened with your loss, I am reminded intensely of what you have meant to me and how you have shaped me. Be safe. And strong. And resilient. Be generous. And kind. And humour-laden. And, okay, sometimes inappropriate and cynical. That's cool, too. Be bold. And loving. And resourceful. Possibly intrepid. And, yes, because I know you can, be just a touch heroic and inspirational.

This is just one more upheaval in the crazy crust that creates the folds of our lives.

Things, from this moment, will get better.

This I know.

They will get better.

Peace and love to you all.

Santo 19

2011-02-13T18:38:00.000-08:00

I'm walking down Santo 19, the two mile dusty, sun-scorched dirt road connecting our clinic to one of the main roads in Croix des Bouquets. A walk through a microcosm of Haiti.

I pass an outdoor basketball court with rigged up hoops and nets. Dark skinned, well-muscled-if-slim, shirtless, glisteningly sweaty young men play a game of pickup ball under the blazing sun. Their moves are slick and strong, reminiscent of boys from inner city Baltimore I used to pass walking home from Hopkins. Bystanders, instead of clinging to chain link fences, stand in high grass, speckled with street dogs and the occasional goat. Players and spectators carry the same toughness of those inner city boys. They watch me pass, claiming their territory with sideways, less-than-friendly glances, intimidating in the universal body language of young men of neighborhoods across the world. One boy points and laughs at me. I pretend not to see him. I look ahead blankly and keep walking.

Beneath my feet, I look down and spy the dusty, flattened form of a shaggy brown teddy bear. I wonder about his story. Does a child long and cry for him somewhere? Did he fall from the window of a passing car? The act of a sinister sibling, perhaps? Or the tragic result of a sudden slip of small fingers, jarred out of a grip on the bumpy road? Was he carried away from a house by a family dog? Or, was he just discarded by his owner, his purpose in his child's life fulfilled?

The lady selling bottles of Haitian rum watches me pass. I do not imbibe, so no sale for her today. The glass flasks of amber liquid are 40 Goud each, or one American dollar. This is the average daily wage of a Haitian. I wonder how many flasks she sells in a day. This is how she feeds her family...on the profit of street sales of alcohol, brewed from the sugar cane indigenous to this land. A drink with a history as long as that of the Haitian people...a drink of the pirates who once wandered and plundered these Caribbean islands.

I walk on. I pass 2 baby goats. I wonder ... do they know about the stew? I cannot meet their eyes.

There is a large black cow, tied to a frayed rope, which itself is tied to... nothing. Escaped? Did it gnaw itself free, in an attempt to graze where the grass is greener...on the other side? The end of the rope is dragging in the middle of the street as the cow grazes next to a sign proclaiming "Merci Jesus". Is this somehow an ironic physical embodiment of the cow's thoughts? The grass here is pretty lusciously green. Appears tasty. If I were the cow, that's probably what I'd be thinking.

Two slim young women pass and smile. "Good morning," one says shyly in English. I apparently appear pale enough to speak English. They argue amongst themselves as they pass me. Her friend turns around, laughing, and corrects, "Good afternoon!" I smile. "Bon swa," I respond.

I look down. There is the skeleton of a dead puppy crushed in the road. This is hideous....far worse than the teddy bear. Ribs protrude from the dessicated, dusty hide. For a moment, I wonder if the puppy and teddy bear could have belonged to the same child. Now that would be a rather unfair turn of flattening events. I hope not.

The road is lined with high, new concrete-block and stuccoed walls. New since the earthquake, which shook down nearly every wall in the city. The walls are topped with broken glass bottles cemented into place to prevent (or at least lacerate) attempted over-the-wall intruders. Some wealthier walls support threatening curls of razorwire, ironically entangled with pink flowers of surrounding trees and, for added measure, thick spider webs. Yes, I suppose if the razor wire is not sufficient, putting your hand through a thick nest of spiders might be a wall climbing deterrent. It would certainly effectively deter me.

An old man pedals by on a bicycle, a young girl of about five in a pretty green dress balancing on his handlebars. She waves happily at me as she passes, a gigantic smile illuminating a face framed with braids tipped with little green bows. Her spirit erases the bad karma of the teddy bear, the puppy and the hostile teenage glares. A smile illuminates the old man's eyes as he pedals by. He is obviously acutely aware of the preciousness of his cargo.

I wander on, through the giant divets and potholes in dirt road, destined to rip the undercarriage out of even the most sturdy of vehicles that attempts to negotiate the scene. I pass the leaning, still-crumbling form of a building...a former clinic....that was heaved askew by the earthquake last January. More than one year later, it still teeters threateningly towards the road, partially held up by the metal fence which surrounds it. Red spray painted letters on the fence declare the obvious...the building is condemned. Is there a plan to remove it? Or will it sit there, in memoriam, for infinity?

A yellow motorcycle speeds down the road, directly towards me, as I edge to the side of the road. The driver and his passenger yell intimidatingly as they pass, the passenger reaching out, grabbing at me. I leap away at the last minute. They speed past, laughing, shouting something unintelligible, the passenger making arm gestures at me. I glare at them angrily as they speed away, infuriated. In my mind, I rewind the movie projector that plays this scene and I play it again. Except, this time, in the new and improved imaginary scene, I have a long broomstick in my hand, and just as they pass and scream and grab at me, I thrust the stick between the spokes of their front tire, causing the motorcycle to flip end over end into the air, and, in slow motion, catapult its passengers into the trickling stream of water/sewage on the side of the road. I stop the scene there, as they soak satisfyingly face down in the dirty stream, and before they can pull themselves slowly out to chase me down and pummel me for the audacity of my imagination.

I walk on cautiously, now hypervigilant as I am passed by a string of other motos. They pay me no mind.

A woman sways past, gracefully balancing a 5 gallon bucket of water on her head. She is walking away from a water pump on the corner, installed after the earthquake by the the Army Corps of Engineers. A blessing of clean water for this community, especially in this era of cholera. Even in a non-era of cholera...a blessing Children no older than 8 or 10 years old gather at this pump, also heaving large buckets of water onto their heads. 8 pounds per gallon times 5 gallons equals 40 pounds of water. Carried by mere children. The potential consequences of this pump are broad reaching. By limiting the distance women and children walk to retrieve water for their families, we know that this community will have a better chance to instead educate its children. And women will have more time to pursue income generating activities to better support their families.

Girls in blue and black plaid school uniforms pass. They are the lucky few in this neighborhood who have access to education....in this case, from the Catholic school that sits on the compound that also houses our clinic. I am told that there are no public schools in Haiti. That children can only receive an education if they can somehow find a free private school, or if their family is wealthy enough to afford to pay. I'm not sure how to confirm this piece of information. But, if this is true....

Oh, Haiti...how do you expect to pull your people out of poverty without providing the poor with an education? Can't you see? How many young minds will never reach their potential for this nation-- as engineers, doctors, teachers, politicians, writers, artists, etc. -- because they were never given the opportunity to go to school?

I am acutely grateful, in this moment, for my years of education. Some of which were, ironically, spent wearing identical plaid pleated uniforms, ankle socks and black leather shoes. Huh. Never thought I'd be grateful for that.

I wander past the school. Classes are just getting out. Excited young voices spill over the wall as children anticipate their walk home for the evening.

I retrace my steps, wandering back towards the compound which houses our clinic.

Tomorrow morning, 250 people will walk this dusty road, slowly lining up outside the clinic gates. Some will wait up to 8 hours to see a doctor. Or a dentist. Or a nurse. Some will bring their babies to get immunizations. Others to get medica mamba, a peanut butter based protein supplement for malnourished babies. Some will be dying of cholera. Some with malaria. Others with myriad other concerns. Some seeking physical therapy, from injuries sustained in the earthquake, or other traumas. Some with immunization-preventable diseases. Some will see the first medical provider they have ever seen in their entire lives....even those who are living, amazingly, into their seventh decade.

At the free clinic, at the end of the long, dusty, rutted path of Santo 19.

Getting my Goat

2011-02-08T17:51:00.000-08:00

I am so immature.

I stare down into the bowl of brown meaty chunks floating in a greenish brown watery chum, littered with specks of this and that, surrounded by a slick of swirling oil. I have a sudden flashback to the Louisiana gulf coast, and the BP oil spill catastrophe. The meat bobs like so many slimy, contaminated pelicans in a sea of sticky black crude.

Stew. Oh, no. Please...not stew. No no no. Not stew.

I stand in the dinner line and tap one of the brown floating blobs with the ladle and watch it momentarily sink, then bob resiliently back up to the surface. A strange, stringy, brownish floating leathery substance.

Dinner.

This appears to be Estelle. The goat. Last seen tied by a short rope to an overturned toilet out in a distant corner of our compound. Looking a little different now...her brown fur coat, elongated pupils, little goat smile....all stripped away. Literally Oh, Estelle. Mwen regret sa. You have become a stew.

It's not that I'm a picky eater, with stringent criteria for meals such as flavor and nutrition. I eat my own cooking, for heaven's sake. And it is a rare day when my culinary efforts contain both items simultaneously. I learned long ago to be grateful for any food that is put in front of me. So, though I have never been a fan of most meat, and turn pink and wheeze at the thought of certain shellfish, I will rarely push away a meal that has been prepared for me. At least outwardly. Inwardly, however, there is sometimes a whole lot of resistance going on.

There was that great dish "slaninia" when I lived in the former Soviet Union. That's raw pig fat, with skin and, yes, coarse spiky hair still attached. A favorite of the locals, especially fresh from the slaughter. (Sometime, let me tell you the story of a disease called neurocystercercosis... from a 10-plus foot tape worm acquired from eating raw pork. But that's another story for another day.)

Ah, yes...nothing like the sound of a screaming pig as it is slaughtered deftly in a neighbor's yard, hanging from its hind legs from a tree. As it exsanguinates into a bucket from its recent machete slice to the carotids, there is also -- unfortunately -- nothing quite like the sound of a thoughtful, neighbor, generously hacking off a slab of warm fatty flesh and skin, and calling out to you over the fence, "Friend...friend....would you like some slanina?"

I can't say that I ever "liked some slanina".

Thanks, "friend".

But, would I blankly turn my lips upward into a pseudosmile of pseudothanks, force my hand into extension, take the proffered still-warm, hairy, rubbery pig fat between my index finger and thumb, slowly lift it towards my reticently parting lips and shove it deftly at my clenched teeth until they reluctantly parted, then chewed wide eyed with an "mmmmmm...." sound that, depending on one's interpretation, could equal either pleasure or a suppressed whimper?

Yes. Yes I would.

The dance of cultural culinary acceptance.

When I lived in an Alaskan native village, did I similarly extend my hand to the generously proffered dish of raw seaweed, raw sea snails, and some sort of pea-sized raw fish eggs collected in honor of the coming of spring? Did I pseudosmile as I chewed, each fish egg popping like a small eyeball in my mouth, squirting out a gelatinous sharp fishy ooze, that simultaneously caused sweat to pop similarly from the pores of my brow, a reflexive gag in my posterior pharynx and sharp tears to sting the corners of my widely held, unblinking eyes as I whimpered internally?

Yes. Yes, I did.

And, when my friend -- a native Alaskan -- grinned knowingly as she watched me slowly chew and pop with a watery-wide-eyed "mmmmm", pseudosavoring the fishy slime, then quietly reached over and wordlessly scraped the remainder of the mix into her own bowl....did she become one of my heroes for life?

Yes. Yes she did.

Like the Native Alaskans and Native Americans that I have known, I am an omnivore sometimes out of necessity. But, as a not-avid meat- and living- creature eater, I acknowledge the sacrifice of the creature that gave its life for mine. So, I will quietly eat what is lain before me...and be grateful for its generosity.

Or, so I try to tell my so-called-noble self.

This intellectual challenge to the pallate is far more acute when one spends the day staring at malnourished children. Ten pound 2-year-olds. Young teenagers no taller than a first grader. Mothers who grab at my arm and say, "Dokte...I cannot feed my children. They are starving. Can you please help me? Can you give me food?" Orange haired Haitian children...with scaling skin, bulging bellies, protruding ribs...evidence of protein malnutrition. Marasmus Kwashiorkor. Starvation.

I am lucky to be eating. Even luckier to have protein. I am so overtly well fed. Overlyfed. More than fortunate. What a hypocrite I am, I think, as I balk at the proteinacous floating bits before me. Hungry sunken child eyes and flaccid skin and bony ribs flash behind my eyelids. Selfish hypocrite.

And so, I take a deep breath and face the bobbing oil-slickaceous goat stew.

Thank you, Estelle, the goat, for the days tied without dignity to the toilet, fattening yourself up for this day. That can't have been an inspiring life for you. Thank you cooks, who raised, slaughtered, skinned and slaved to prepare this stew for me today. Because you are honoring me, as a volunteer in your clinic, and a guest in your land, with this gift of meat. Because you take the time to caringly cook for me. In a land where so many go hungry every night.

Thank you for this food today. And for the contrast of my lot in life...with those that I meet every day...to make me realize how fortunate and comfortable I truly am.

Don't let me forget that.

And, well, in a flash of extreme immaturity, here's a shout out to Louisiana Hot Sauce.

You are the ambassador of the international food ingestion challenge. The peacekeeper. The great leveler of the experimental pallate. Creating peace, understanding and culinary tolerance wherever you set your beautiful red-orange glass-bottled self.

Glad to have made your acquaintance here in Haiti.

You singlehandedly retrieved the shards of my wavering idealism.

While effectively suppressing my overlyzealous goat-induced gag reflex.

Today, you -- in your uniquely firey, spicy, distractingly vivacious nature -- are my hero.

Perhaps, starting today, I will endeavor to be more like you.

Running in Circles

2011-01-25T19:10:00.000-08:00

It is that time of night when all that remains of the firey sun is a faint neon orange band on the horizon, above which are deepening shades of azure to navy blue to black. Someone has taken a pin and stabbed holes in the dark canvass of the sky, and small spots of twinking white light shine through. My feet pound rhythmically on the soft grass below me. I am running in circles in the dark. Literally.

I have always loved running in the dark. If you have never done this, I highly recommend you give it a try. Maybe first try shuffling, or perhaps walking, if you are a bit hesitant about your first full-on face plant into the dirt at your feet. You'll get the hang of it eventually. You will be amazed by the light you discover emitted by the moon and the stars and the occasional humanoid light source. Your eyes will soon adapt, and you will be impressed by the hughs of blue and grey and silver and black that define the world around you. You will be enchanted by blackened profiles now illuminated by the lesser grey of sky and field. Like you are wandering in a photo negative. You will realize that the animal in you knows how to do this, and revels in this.

Awesome.

I like to run to loud, rhythmic music in the dark. I find it cathartic. I admit, this is not an intelligent practice in places like rural Alaska, where large carnivores lie in wait for such nocturnal idiots...er...snacks...or urban America, where carnivores are replaced by bipedal predators. But in many non-threatening places in my life -- winter in Alaska, winter in Antarctica, nighttime in island Maine -- I have run for miles by the light of the moon and stars. The music helps to drown out the gasping whining that I imagine accompanies my running. And I am lost inside a dark, glorious introspection.

Tonight as I run, the palm trees sillouetted against the last band of orange in the western Haitian sky gradually fade, and the black sky descends, overtaken by stars. I am guided by the vague outline that is the soccerfield, and the knowledge that there should be nothing to trip me here. I have a sudden memory of running in the dark of night in winter Maine, and coming upon a deer licking salt from the middle of the road. It was surprised when I came upon it in the dark. As was I. I remember the startled jerk of his body (and mine) as my mittened hand glanced off his flank and he skittered away into the brush aside the road. I wonder what sort of creature I might encounter tonight, here in this field, in this dark Haitian night.

A Seminarian, most likely. There are 200 late-teen to young twenty-something Seminarians studying to be Catholic priests living on this compound that houses our clinic. They have come from around Haiti to study, and live in tents on the grounds of our community. I was somewhat discouraged one day to observe them holding mass, so apparently solemn and rigid and formal in their crisp white shirts and crisp black pants and carefully folded hands-- with my memory of the raucous, loud, lively spirituality that I identify with Haiti. I felt suffocated for them, all folded so stoically into their chairs.

But, never fear. They, I have discovered, like I, seem to morph at this time of night. They gather in a tent alongside my soccer field, and just as the sun goes down, their spirits alight. Inside their canvas shelter, one can suddenly hear the deep beat of a base hand-played drum. Then an accompanying sound -- reminiscent of the hollow, resonating clickety drumming one hears on the street corners of Washington, DC or New Orleans -- when inner city kids pound out dueling rhythms on old white plastic buckets. Suddenly, in the dark, alongside this obscure Haitian soccerfield, a deep, almost tribal drum rhythm pounds aggressively from the tent...as if spiralling from the genetically African DNA of these young Haitian men.

It is stunning.

Entrancing, pounding, drum rhythm, then in unison, 200 deep Haitian male voices begin to chant and sing in beautiful harmony, flowing out into my dark night. A hip mix of African-like rhythmic gregorian chant. I stop running and pull the headphones from my ears. I stand in the dark in the middle of the soccer field.

I am enchanted. This is more than beautiful. It is alive. Somehow primitive. Gutterally human. These are the moments I love most about human beings. The unexpected, artistic, spontaneous surprises. Tonight: the creation of a stunning, unexpectedly joyous noise.

I find myself at the chainlink fence which separates the soccer field from their canvas tent. I slide down to sit on the ground, my back to the fence and their tent, which is now a mere 10 feet away. And I listen. The rhythm of their drums resonates through my chest from behind. I stare up at the now pitch black sky, clustered with stars. And absorb these amazing sound waves.

I guess the thing is, it's been one of those desperate days, when you wonder if there is anything positive in this place called Haiti. The 33 pound 9 year old, malnourished and neglected. The cholera babies. The malaria. The hemorrhaging 22 year old, who was miscarrying, and then suddenly, in front of our eyes, went from 60 breaths a minute (far too fast) to zero breaths a minute (far too slow), instantaneously horrifyingly lifeless.

On some days it just feels like we're bailing a sinking ship with a tea cup. Or just running in circles, with no direction, in the darkness.

Where is the public health system? Where is the 911 system? Why is there no ambulance to call in an emergency? Why are children still starving to death in front of me? Why are young women bleeding to death in front of me? Why are children not getting immunized? Why can I not find a surgeon for my patients in need? Why am I still finding untreated fractures more than a year post earthquake, which have now healed (or failed to heal) into dysfunctional and sometimes dangerous deformity? I know...these "whys" go on ad nauseum, and I can't even stand hearing myself ask the questions any more.

Isn't there anything positive about this place?

Of course there are. Many many many things. I know there is much more to Haiti than the daily medical glimpse that sometimes makes me a cynic, and drives me with my headphones into the night to run in circles. There are many wonderful things about this place.

A figure suddenly looms over me, from above, from the other side of the fence. My encounter. A tall, slender Seminarian.

"Who are you?" he asks me curiously, staring down at my form seated with my legs crossed in front of me in the darkness. I'm not sure how he spotted me here.

"I'm 'Dokta' Barbie from the clinic," I say, pointing across the field.

He smiles, then pointedly, "What are you doing down there?"

I smile back.

"Oh, I'm just listening to you guys. Thanks for the music. It's nice. A beautiful thing."

"You can come in, you know," he gestures to the tent. "You are welcome."

"Thanks," I say. "I think I'll just sit out here and listen for a while."

"Okay, but we are here every night. You are welcome to come in any time."

"Okay," I say. "Thanks a lot. But I'll just sit here for tonight."

"Okay," he shrugs at the wierdness of my presence in the grass in the dark. He smiles again, then waves slightly as he walks away. He lifts up a corner of the tent, revealing a triangle of light. Then disappears behind the dark flap. Back into the sea of deep voices and rhythm.

Amazing.

Amazing what one can discover, when one thinks one is just running alone, in circles, in the dark.

Good night.

Heartline

2011-01-15T09:03:00.000-08:00

I remember my first days at Heartline Field Hospital, reading through charts, trying to familiarize myself with our earthquake patients -- trying to grasp the essence of the patients lying side by side in our courtyard-turned-hospital ward. Chart after chart...."buried under a house for 3 days...family killed...a wall fell on him...a block crushed her....parents killed....wandered without care for four weeks...innocent bystander shot by police..." Blankly, I continued to open charts, digesting the undigestable.

People ask how Haitians survived this time. I remember faces staring blankly sometimes, with great depths of emptiness. Homeless. Parentless. Familyless. Jobless. Futureless. Minds turned inward, reviewing hideous memories. Impossible memories. With only occasional moments of overt grief. A mother with PTSD, herself with a healing femur fracture, who would suddenly start screaming when the memory of her dead two year old flashed into her mind. She would grip her chest, and scream and scream, crying that her heart was going to stop. And indeed, in those moments, if sadness could stop a heart, I truly believe hers would have. Hers, and so many around her.

And so, at times, even my own.

But, I learned in those early days.. sadness doesn't stop a heart.

Thank God.

Joy, in contrast, is an amazing thing when it acts on a heart. And love.

How is it, that the father of one of our young patients turned out to be a Haitian minister? And that he would make it his business to preach to our patients? And return, day after day to them, even in the weeks after his daughter was discharged. And that every night, he would spontaneously stand up in our courtyard and lead our patients in prayer -- in a way that only Haitian ministers can do? (That is -- pacing almost wildly around the center of our hospital, screaming out to God until his voice went hoarse, and pulling our patients almost physically from the depths of their emotional darkness...Reconnecting them with their lives, their souls, their spirituality.)

I am not an overtly spiritual person. But I recall the warm nights of post earthquake Haiti, when my feet, almost against my will, would drag me to the doorway to our courtyard. I would lean unobtrusively against the hospital's stone wall, slightly hidden behind a flowering tree. And watch the electricity of these people and these moments. The exquisite, palpable spirituality of these patients. Despite pain, exhaustion, physical and emotional fatigue. Their hands would slowly, hesitantly, lift in prayer. Then, more forcefully sway. Reaching up. Then clap. Then voices, singing in unison. United with a palpable energy. Singing songs of faith. And thanks... In the absolute darkness of their lives.

No matter the pain of the day. No matter the trauma. The torment. The angst. The visions. The memories. No matter the hours in the sun, spent riding past crumpled buildings and crumpled lives. Community and spirit and love and joy... nightly brought our people back to life.

I recorded some of these songs on my phone on those dark, tropical nights. And in the year since then, have occasionally listened to my ten minutes of riotous Haitian mass.... at the end of a crazy day in my clinic in America, or driving across the vast empty expanses of Alaska, or sitting on a bus in New Orleans. A reconnection to the souls and the love that was Heartline Field Hospital in 2010 -- a hospital that rose from nothing, in the courtyard of an orphanage in Port au Prince, upon the wills of individuals...who knew, together, they could contribute, and make a difference, in the darkest time in people's lives.

On this anniversary of the Haiti earthquake, here's a thank you. To the nurses. The doctors. The translators. The Big White Truck driver. The guy in the white socks getting smacked in the face with palm trees. The physical therapists. The intimidating body guards in lavendar Crocks. The cooks. The nannies. The girls with the jump ropes. The sleepless midwives. The ministers. The giggling children. The new mamas, loving their babies. The new papas, loving their wives. The spiders, rats, insomniac chickens and lizards that roll their Rs in the darkness. The surgeon in the floppy safari hat. The anesthesiologist, who cared for Amanda...and revealed he had survived her exact same injury. The heroes, learning to walk again. Learning to live again. The survivors. And those who were lost. Too violently. Too exquisitely soon.

Thank you for filling my heart this past year.

I lay in bed as the clock struck midnight on January 12, 2011. One year to the day of the disaster. Back in Haiti. Beneath my mosquito net. High pitched buzzing of an insect swirling about my ear. Suddenly, in the dark, in the street, over the wall, rolled the sound of a spontaneous Haitian mass. An almost screaming, hoarse minister. Clapping hands, stomping feet. A massive crowd. Calling out in joyous song. On and on and on they sang and clapped, for hours, before I dropped back off to sleep.

Singing Alleluhia.

Alleluhia? For what? For a horrifying anniversary? For ongoing poverty? Infinite struggle? Hunger? Homelessness? Sprawling tent cities? The stench of smoky air? Malaria and cholera? Lack of access to health care? Undervalued people? Political corruption and strife?

I closed my eyes in the darknesss. A smile slowly met my lips. My heart swelled.

No.

Alleluhia. For community. And love. For family. And faith. And friends. For healing. And growing. For those who reach out, to hold up each other, in the darkest of their darkness. For living on.

The Day of Rest

2011-01-09T14:25:00.000-08:00

It is Sunday and our clinic is closed for the day. We don't see patients on Sundays in this new clinic, unless there is a walk-in emergency. This is a giant shift for me, from our Heartline Hospital model, which was open 7 days a week, tending to inpatients around the clock, as well as an outpatient clinic and a mobile clinic. One could always count on a banging on the metal gate and a mystery patient standing behind it. A laboring mother about to squat and push out a baby on the street? A seizing child? The guy who drove his motorcycle full speed head-on into the cow in the middle of the road? (One of them resembled hamburger after that...and it wasn't the cow, on that day.) It was always something. But here, it seems, today, we have a day of rest.

(Not that it isn't earned. Our clinic sees a staggering 250 walk in patients each day when it is open. At some time, I guess, you just need to close the gate and allow the staff to recover.)

Our head doctor declared today that we should take advantage of the small window of time -- between medical business and anticipated political unrest -- to take a drive north of the city into the hills. With the upcoming anniversary of the earthquake in 3 days -- which some feel might result in political protests due to slow recovery efforts -- it is possible that future jaunts beyond the block walls of our compound will not be sanctioned.

I have flashes back to last spring. Can we really leave the clinic? What if something happens while we're away? Can we really afford to waste the fuel to take a ride into the countryside? (I sharply recall hunts for a single gallon of gasoline sold in glass bottles by vendors on the side of the road last spring, and calculations to determine if one gallon would be enough to get us across the city and back again with four surgical patients in the sweltering truck...Yes, we'd decided, we could make it if we didn't run the air conditioning and didn't get caught idling in traffic.) Things, it seems, have improved. Things are now a bit more stable.

We drove north, armed with a wand of fresh Haitian bread, a slab of cheese, crispy salted fried plantains in search of the perfect picnic spot. Our translator/driver spent much of his childhood in the north, and spoke of a secret waterfall known only to the locals. A perfect, magical destination.

We passed a massive tent city sprawling across the countryside. I have never been this far north. I am told this is the biggest of the tent cities. One in ten Haitians now live in these displaced person camps. I observed the tents; they seem more substantial than those I recall from last spring, now with more solid stick construction, better tarp coverage, even corrugated metal walls and roofs becoming incorporated into the design. It appears they are morphing into permanent fixtures; they have the look of sturdiness, of permanence. The evolution of a shantytown. I feel for the Haitian government -- how will they ever effectively move these hundreds of thousands of people away? It seems like an impossibility now. I am struck by the fact that each tent stands a bit away from its neighbor in this camp. It is not quite the tarp-on-tarp labyrinth that was so familiar in Port au Prince last spring. Absurdly, I think -- for what it is -- it looks a little bit better than what I remember. As "better" as thousands upon thousands of tarp shelters can look, sprawling into the distance.

To my right, the Australian medical student who is working with us for a month whispers, "Oh my God. It's unbelievable." He is taking photos of the shelters, extending to the horizon. And of the caved in buildings, still half standing from the earthquake, visible from the road. I didn't notice the buildings. I have to look again to have them register in my mind. Oh, yes. Crumbling buildings from the earthquake. Still marked with a series of spraypainted red letters and numbers. Red meaning "uninhabitable/condemned". Oh, yes. Of course. There they are. The crumbled buildings. Right in front of my eyes. The still-standing, half-teetering cement structures. He is right. It indeed should be unbelievable. I am bemused -- because I have become numb to this...that my first thought was..."Gee, things are looking a bit better 'round here."

We continue on our journey north. We pass a compound on a river with a big blue U and N painted on the gate. "This is where the Nepali UN Peace Keepers live," advised our translator.

Cholera ground zero. It is here that many speculate a leaking latrine spilled sewage into the river, and introduced the deadly organism cholera to the communities downriver. The tracking of the origins of the epidemic remain controversial. Prior to this fall, cholera had never been seen in Haiti. And the serotype is consistent with a strain normally found in Southeast Asia. Just prior to the outbreak of cholera in Haiti, there was apparently a similar outbreak in Nepal. Many observers have put two and two together, and believe they've arrived at "four". "Four" being the supposition that the epidemic's origins lay with these Asian peacekeepers. Yet, officially fingering them as the source, some fear, puts the UN soldiers at risk from a possible hostile backlash of frustrated, overwhelmed, end-of-their-rope people for whom a deadly cholera epidemic is a last straw lain onto an already buckling back.

We drove farther north.

"Here is where sewage trucks that pump local latrines dump their waste directly into the river," noted our driver. I recall seeing just this place in a news photograph, with a sewage truck offloading its foul contents into the water. Another possible source of cholera contamination. I look down river. Children are playing along the edges of the riverbanks, some up to their waists; adults are bathing; women are washing clothes -- all wading downstream in the current of the sewage trucks' foul discharge.

I close my eyes and sigh. Unbelievable.

We drive farther north.

We are passed by two large white dumptrucks. I know these trucks. They were donated by USAID to Haiti in the aftermath of the earthquake last year. Initially, they were used to carry corpses to large mass graves when the the capitol city was overwhelmed by the sudden challenge of dealing with the remains of 250,000 dead citizens. I see they are now hauling limestone sand, apparently to a foundry where new blocks are being formed, to aid in the country's rebuilding process.

I pray the new blocks meet better building standards. Apparently previous Haitian cement blocks had a 1500 pound per square inch strength -- evidently one fourth of the strength which is traditionally required by building codes of more developed nations like the United States. Images of toppled and pancaked cement block buildings flash suddenly in my mind.

"Please," I plead silently, as if the Minister of Reconstruction exists and, in his clairvoyance, cares to read my mind. "Please build back stronger. Please change your building codes. Please don't repeat the errors of the past."

The trucks pull away.

We drive farther north. And swing up a long dirt road, past sprawling, luscious, green fields of beans. Children spy our pale faces through the truck windows.

"Blanc!!" they call out, chasing the truck. "Blanc!" (White person.) I smile. More memories of previous excitedly pointed fingers, assigning me a color. (Or shall I say, an absence of color. Actually, I consider myself a paler peachy color...but, whatever. "White" works for the moment.)

"Hey, you!" others call. I smile again in memory. "Hey, you," I think back to them, silently.

We arrive at the top of a hill and our driver declares, "We're here!" The secret waterfall. A crowd of local children and adolescent boys follow us down the trail, curious of our presence, welcoming and helpful. Some offer me a hand over slippery muddy sections of trail.

"Merci," I say to one.

He smiles, and says, "Give me one dollar." Ha.

"No," I say with pseudo-annoyance. "You give ME one dollar!" I poke a finger in his chest in emphasis. He laughs. I laugh. He tried. No dollar. We walk on.

We arrive, after a time, at the base of the waterfall. There is a large Haitian man sitting there in his swimming trunks. The water cascades in glorious, beautiful, muddy, dramatic slipperiness. I turn to glance at the man on the water's edge. I start suddenly. I know him.

"I know you," he mirrors with surprise, in English, his brows knitting together in a frown of puzzlement.

"Yes!" I responded. "You were my patient at Heartline Hospital last spring!"

Weird. Weird weird weird.

He laughs. I do, too. "You injured your back in the earthquake," I said, remembering him. I extend my hand in warm greeting. His large one engulfs mine, pumping it heartily.

"How are you feeling?" I ask earnestly.

What a place for a follow-up visit. Eight months later, down a winding muddy trail, at the base of a secret waterfall, several miles north of Whoknowswhere, Haiti. I smile. If he could wind his way down here, I muse, I guess he's doing pretty well.

"I'm better," he said with a smile. "I'm doing a whole lot better."

He nodded and wandered off, wading into the pools at the base of the crashing waterfall, throwing me a small wave as he went. He walked tall and strong, no evidence of injury.

I turned back to the waterfall. Amazing thing, water. No matter how fast and far and violently it crashes over the most hair-raising precipice, it ultimately remains unscathed. Still, fundamentally, water. So adaptable, molding itself without complaint to the complicated features of the surrounding terrain. I followed it with my eyes as it regrouped, and serpiginously began to flow with a sweet, trickling calm towards the vivid emerald fields below. If you follow it out far enough, I realized, you might never suspect the shocking drama of its recent journey.

One Year Later

2011-01-08T17:11:00.000-08:00

Photo: Haiti Ministry of Health, January 2010

It's dark. And pleasantly, tropically warm. The bugs are slowly rubbing their hairy legs together, squeaking in violin-esque symphonies. The dog network has been activated, barking a message from here towards Port au Prince. The occasional embittered insomniac rooster calls out from the shadows, determined that if he can't sleep, no one else should either. Familiar sharp pinches of possibly rabid mosquitoes nibble not-so-subtly on my ankles. In the corner of my room is a small Cirque du Soleil of multiple-sized daddy-long-leg spiders on strings; big ones, mediums, smalls...and, lucky me...apparently a new hatching, adding a small mobile blur of pin-head sized fellows to the mix. It is possible they are small enough to crawl through my bed's mosquito net and join me in my slumber. Thankfully, though, the barrier will prevent the nocturnal visit of larger things...like the tarantula I met this morning.

Ah, Haiti. Thanks for dispatching the welcoming committee. Its nice to be back.

In 4 days it will be a year from the earthquake. I have returned to volunteer at a different clinic, located in the city of Croix des Bouquets. Things are similar here...and yet different from a year ago. There are still more than a million people living in tent cities in and around Port au Prince. So much for the word "temporary" that, as of last year, used to preceed the word "shelter". And the health challenges have morphed into the diseases of poverty, neglect, homelessness and overcrowding: violence, rape, unwanted pregnancy, STDs, HIV, tuberculosis, malnutrition and cholera. Some are familiar to these people. Others are new.

Now, instead of the desperate urgency of patients with massive trauma, we see the tragic urgency of cholera -- a diarrheal illness that can kill a patient within hours. This illness looms to threaten any large population of displaced persons -- especially those without access to clean water and sanitation. An illness that can be stopped with one dose of a 10 cent antibiotic and simple rehydration -- if the patient can find access to a clinic.

If you got cholera in your developed-nation neighborhood, you would do just fine with your fortunate access to medical care and your 10 cent antibiotic. In a refugee camp setting, in contrast, past experience shows that up to one in three symptomatic patients can die without care -- a number which drops to 5% or less with a basic, cheap and effective cholera management protocol. Without care, you could die within hours from the absolute dessication of your body.

Our doctor described our clinic's first cholera patient, who was carried in in October by his grandmother: a four year old floppy grandchild.

"He started having diarrhea at 4am," she said. It was 7am. The child, unbeknownst to grandmother, was already dead in her arms.

His body was gently taken from her, cleaned with alcohol, mouth and rectum stuffed with bleach-soaked cotton to prevent the spread of the bacteria -- which continues to live on in a corpse, even after a patient's death, and threatens to spread to the living. A coffin was somehow located on the grounds of the clinic. It was too large for his tiny body -- built for an adult -- but it served its purpose. After a small memorial service on clinic grounds, his corpse was transported to the local children's hospital for cremation. His family expressed gratitude for the coffin -- for they had observed the bodies of three other children, dead of cholera, laying alongside his at the entrance to the crematorium, wrapped only in black plastic garbage bags.

Look over at your four-year-old child, grandchild, neighbor, nephew... Note the magic of his or her spirit. Her high pitched giggle. His suffocating, uninhibited hug. The speed of little running feet pattering about your house. Childish shrieks of happiness from outside in the yard. The massive potential of his beautiful life. The joy of her birth. His first steps. Their impish, beautiful spirits. Imagine putting him to bed tonight. And by morning, as you walk desperately with him in your arms...miles over a dirt road to a clinic... you fear what you deny. You hand over his body when you arrive. Hopeless. Hopeful. But, that thing you knew, deep inside, they confirm for you. He is dead. Already dead.

From a germ that could be prevented with a bar of soap and running water. Or, if acquired, halted with a 10 cent antibiotic and a mixture of water, sugar and salt. Literally could have been saved for less than a dollar. Your child: dead from lack of clean water, sanitation, and simple access to health care.

On January 12, 2010, 27 of Haiti's 28 governmental ministries were destroyed by the earthquake -- including the Ministry of Health. A complicated and devastating blow to a country already struggling with effective governance. Will the fate of the poor and homeless improve here in Haiti? It is unlikely, in the short term. People look towards the government for solutions. But, the integrity of the political system is in question. There have been protests -- many violent -- over recent presidential elections and questionable outcomes. Outside observers have documented massive voting fraud. There is fear that the results of the recount will cause more violence and chaos in this country. On February 7th, per the Haitian constitution, the current president must step down from power, whether or not the new president's identity has been determined. What a tangled, tangled mess.

I look back to the nest of spiders in my corner. A couple of big ones. An overwhelming multitude of little ones. Where will they be come morning? I am curious to see.

City of the Sun

2010-04-19T19:50:00.000-07:00

(Photo by Beth McHoul)

As I sat on the back step of our white truck today, a boy of about 10 years of age pointed to the bright orange and red sun tattooed on my left deltoid. The mass of boys surrounding him watched the interaction, straining towards me, en mass, with increasing curiosity.

"Is that a tattoo?" he asked, in a tone of part accusation, part curiosity. In this neighborhood, a tattoo represents a gang affiliation.

"Oui!" I replied, running my fingers across the words printed in the center of the sun. "Cite Soleil," I read as I pointed to the words. They looked at each other, then back at my tattoo.

"Cite Soleil?" the lead boy asked, then looked at his friends. They chatted animatedly amongst themselves. I imagined the topic of their chatter. Cite Soleil? Wait a minute...That's our neighborhood!

"Did you do it with needles?" the lead boy asked again, as he wiped a finger firmly down the center of the sun. The rays smeared slightly. Busted. I grinned.

"Nope," I replied, gesturing like a pen. "With a pen...just a pen..."

The boys nodded at each other, then smiled knowingly. Small brown hands reached to further smear my Sharpie tattoo. One then lifted his sleeve, with great courage, revealing a tiny little deltoid.

"Do me, do me..." he gestured to my tattoo and then his arm. "Cite Soleil...Cite Soleil..." he repeated, gesturing.

The gang tats ruled. Our final tribute to the 'hood.

Today marked our last medical truck run to Cite Soleil, the City of the Sun -- the poorest neighborhood in Haiti, the most impoverished community in the Western Hemisphere, and, according to the United Nations, the most dangerous slum in the entire world. Just a few years ago, this community -- of 200,000 plus people -- was overrun by more than 30 gangs, devastated by extreme poverty, and terrorized by violence and kidnappings. While the poverty persists, the violence has largely subsided due to a permanent United Nations peace keeping presence driving the streets in armed vehicles, an armed bunker in the heart of the slum, and a shoot-to-kill anti-kidnapper mandate. In this hot labyrinth of cinderblock and corrugated metal shelters, expanding peripherally into post-earthquake tent cities, the disaster of 12 January was one more inconceivable burden placed on the bowing shoulders of an already too-impoverished community.

Yet, despite these challenges, it is indeed a community.

At first glance, one is struck by the garbage and pig-filled drainage and sewage canals that cut through the heart of the neighborhoods, the crumbling cinderblock shelters,and the sheer agonizing poverty. Gaunt, dark skinned Haitian children predominate, unusual reddish hair on their African features a sign of Kwashiorkor -- severe malnutrition, reflecting desolate poverty. The life expectancy in this slum, due to lack of access to the basic necessities of life -- food, water, shelter and health care -- hovers around fifty years.

But, just as these thoughts begin to overwhelm your psyche, a child appears, and then another, and they grab you by the hands. You look down into large brown eyes, alive with gigantic smiles. You overlook their sometimes grimy nails, and the occasional telltale bumps between their fingers indicating chronic scabies infection.

"Hey, you!" they say, as they try to pull you along down their street, perhaps to their home, with great excitement.

"Food!" they demand, pointing to their empty bellies.

And then, if you refuse them, "Water!"

They are sincere in their requests. For they are truly hungry. And thirsty. If you again refuse, they then progress to your baseball cap, politely requesting it. Upon your refusal, they might then point to your watch. The more street-wise boys undertake a more intense, imploring negotiation about why they are in need of a watch, despite their obviously rat-race-free life. And, you again refuse. So, when they finally decide you have nothing to offer -- except medical care...and a smile -- they shrug, smile back, grab your hand, and decide you are still a worthy friend.

And you observe first hand how difficult it is to be this poor. To be starving. To live without clean water. Or electricity. And now, without safe shelter. Yet, despite these profoundly gaping holes in their resources, you will watch with bemusement at their great human resourcefulness. A small child builds a kite out of sticks, discarded plastic bags and twine, and like any boy in any neighborhood in the world, creates a way to play. Another builds a car out of an empty bottle, with stick axles and bottlecap wheels. And a man, with not a cent to his name, finds enough to build a skeleton of a shelter out of sticks and a tarp, and creates a home for his now-homeless famiy. Creative, innovative human beings. Living. Surviving.

You will observe men sitting together on street corners, chatting and watching the world pass by. Others sitting in the outdoor market, selling their wares. Others carrying large sacks of whoknowswhat on their heads as they wander to distant destinations. Women walk past in beautiful, feminine, swaying form, miraculously sleek and clean despite the lack of running water or electricity. They chat and laugh as they pass by in small groups, arm in arm. Flirting. Smiling. Just people. Beautiful people.

And the first intimidating impressions of the slum fade away, and a rich, bustling, intertwined community is revealed.

Yes, there are those that call out angrily and unwelcomingly -- like any small town wary of outsiders. Men who purse their lips in a sexual yet fishlike smacking sound -- a crude invitation to who-knows-what as we pass by. (Uh, let me think that proposal over for a millisecond...ok, that would be a no. Thanks. But, no thanks.) A woman who grabs her crotch angrily, staring boldly as she yells something my internal language translator processes as "danger...unwelcome..." with a few epithets thrown in for good measure. Young children who yell, "Blanc, blanc..." White person. Not out of racist hatred, but more as a matter of fact....as you might yell, "Zebra!... Zebra!" if you were to unexpectedly spot one wandering through your neighborhood one sweltering afternoon.

I sometimes wonder what these people, particularly children, will remember of this strange spring that is post-earthquake Port au Prince. Will they sit as young men on a stoop in the 'hood ten years from now, reminiscing about the earthquake of 2010, comparing their fading scars. Will one say, "Damn, do you remember that crazy white guy who used to dangle off the top of that white truck....the one that used to drive by and bandage people?" Ten years from now, will some of them finally have electricity, and have the opportunity to watch a film with Angelina Jolie? Will they suddenly jolt and get the joke, saying, "Wait a minute. Angelina Jolie?! Didn't she used to tend our wounds?!"

We came to this City of the Sun at the request of one of its residents. When the earthquake hit Haiti in January, the orphans at the Heartline Orphanage were all adopted out on Humanitarian Parole. And immediately Hearline Ministries turned its attention to the urgent need for medical relief. One of the men who guarded the orphanage -- a respected leader from the slums of Cite Soleil -- approached the head of the Ministry and requested help. He told stories of many severely injured people in Cite Soleil, and no one willing to enter to provide them assistance or medical care.

So, Heartline took its truck, and its medical volunteers, and drove into the heart of the slums. At the request of this one man. And these American volunteers found, lying on the concrete, a collection of severely injured patients. Pregnant women with pelvic and femur fractures. Children with open tib-fib fractures. Crush injuries. Traumatic amputations. Massive lacerations. Overwhelming devastation. Truck load by truck load, patients were carried out of the slums, to the old orphanage across town that soon became our Heartline Field Hospital.

As patients were left behind in the streets, unable to fit into the truck, they begged, "Please don't forget me...please come back for me."

And so, they were not forgotten. And so, we came back in our truck, again and again and again. Sometimes to pluck the injured and ill from the street. Sometimes to return them home. And many times to provide continued care. In their neighborhood -- the most impoverished neighborhood in the Western Hemisphere.

Until today.

Dr. Jen, young Alex, midwife Beth and I worked in the back of the medical truck today, performing our final wound care in the streets. And on this day discovered that all of the earthquake injuries normally tended to from the truck had finally healed.

As we performed our last dressing changes, we noticed that, as usual, we were attracting our share of curious attention. Dr. Jen, on her right shoulder, wore her own Sharpie tattoo -- the word "Silver" inside of a bright red heart. A tribute to silver-embedded antibiotic dressings, an effective treatment modality which healed many crush wounds in the the months following the earthquake.

As we worked inside the truck, a young man of about 16 stood on the outside of the mesh metal cage.

"Silver..." he whispered seductively to Dr. Jen, having read her tattoo and apparently mistaking her for something other than an emergency medicine pediatrician. An exotic dancer, perhaps?

"Silver..." he called, a little louder. I snickered in undisguised amusement.

"Yo, Silverrrr..." I grinned mockingly, rolling the final r, gesturing to the young man behind the metal mesh. "I think you have an admirer." At that moment, he was shoving a rolled up piece of blue-lined paper through the mesh, trying to get her attention. He called her precious metal name again.

She ignored him. A complete cold shoulder. Absolutely no interest. Was he devastated? Embarrassed? Deflated? No. He quickly turned his attention to me.

"Angelina..." he called suddenly, in my direction. I, in contrast, was cynically flattered. I chose not to be, in any way, overtly peeved by his insultingly conniving, wishywashy, two-timing, less than monogamous intentions. I was impressed by the bold sixteen-year-old confidence that allowed him to turn his attention to me...despite the fact that I had just witnessed his impassioned, enamoured plea to the woman two feet to my left. He'd remembered my pseudonym-- Angelina Jolie; that scored him a few points. And, yes, perhaps lost a few points for the absence of subtlety and sincerity. But still, his score was in the black.

He raised his eyebrows and smiled sweetly now in my direction, imploringly, impassioned. He again tried to push the rolled up piece of paper through the mesh. This time, in my direction.

I raised a cynical eyebrow in return.

"For me?" I asked, with a smirk. Then, flatly, "I'm honored."

"Angelina...." he whispered. "I love you."

I laughed at him. He shoved the piece of paper further through the mesh, wiggling it slightly, urging me to take it. Finally, I grabbed it, and held it like a contaminated cigarette.

"For me?" I asked, amused. He nodded earnestly, eagerly. I turned to Dr. Jen. "See, now it's mine. Too bad for you."

I unrolled the paper with an air of sarcastic dubiousness, but as I read, I was taken aback. This was no quickly scribbled love note. This was, in fact, a manifesto. Not a spontaneous appeal. Not a childlike whim. No, this was, in that moment, an entrancing literary wonder. A blue inked seduction. Obviously planned for quite some time...with no particular audience in mind. Cleverly entitled, "Cherie..." (translation: "My dear...") to enable it to be shared with no particular woman...or, as in this case, passed around, until some poor sucker finally bit. I imagined this young man sitting intently with a Creole-to-English dictionary, a ball point pen and small notebook on his lap in his darkened cinderblock room in the slums, spending hours carefully penning this note. When had he written this? What had been his plan? How long had he had it, rolled up in his pocket. And, at exactly what point had he said, "I will write a love note in English, and hand it to every English speaking woman I meet, until, at some point, I succeed in my quest."

I read the note and smiled, definitely impressed. "That's great," I said. "That's really great." I attempted to hand the note back.

"No," he said, refusing its return. He gestured for me to keep it. "I love you," he said, in English.

"No," I replied, amused, trying to push it back through the mesh. "You don't love me."

He grinned, refusing to take it. I smiled, still gripping the end of the rolled up note.

"Well, okay," I said, and stuck the paper into my shirt pocket. "Merci. I'll keep this."

I smiled to myself, then turned back to my dressing change. He smiled back, completely insincere in his flirtatious, boyish grin. But sweet. And endearing. And completely non-threatening. An A+ for effort. A hilarious, sweet, amusing memory. Of innocence. And youth. Of boyish courageous charm. And love. And hope. And the wonder that it represents -- that this neighborhood is healing. That thoughts are turning, from sadness and devastation and loss, to flirtatious moments of happiness. Healing.

I suspiciously wonder how many copies of this scroll he carries, and in how many languages. But, for today, on our last day in this slum, it is a symbol for me of something sweet and innocent and kind and beautiful and welcoming that is the people of Cite Soleil. Our people. Our patients. This community of challenged, impoverished yet not poor, strong, driven survivors.

So, here's to all you potential suitors out there. Take note...of how you might effectively court a woman. (Of course, I would recommend you not choose one twice your age...and perhaps not one who speaks only a foreign language. And, if unsuccessful in your bidding, you might wait till the first one leaves before trying to court the second...or at least wait till she's more than two feet away, inside of a cage.)

But, if you're trying get a woman's attention, and get her to pause and take note...here's how it's done.

"Cheri, Darling. You thrilling me. You give me goose bumps. You're driving me crazy. I fall in love you. I'm boun to love you. You really I need. I want to be with you. I want to be you sweet. Call you beautiful. I've a place deep on my heart for you. I think with you everitime you always on my mind baby. When I look at you I see the sun shining on your face. Please don't make me suffer. Im head over heel since I met you."

Yes, Citi Soleil...

City of the Sun...

When I look at you, I see the sun shining on your face.

I'm boun' to love you.

I've a place deep on my heart for you...too.

The Depths

2010-04-14T18:36:00.000-07:00

Photo by Dr. Jen Halverson

A mother stands on a pile of rubble, peering down into its depths.

This tangle of cinderblock and rebar was once her home. Her children's home.

On January 12, 2010, when the earth shook, it became her children's grave.

She stands on the pile of rubble, for the second time, three months from the first. The first time she stood here, amidst terrorizing aftershocks, she desperately dug for her children, impossibly buried in layers of concrete. Miraculously, she found her toddler Emmanuel, crushed but alive, in the depths of the rubble. Only Emmanuel, face and body bloody and torn. On that day, she acted with stoic determination. She took the injured form of her child and left the bodies of her three remaining children behind in the rubble. No time to grieve. No time to reflect. Only time to act with direct and forceful intention. To keep her remaining child alive. And, so, for three months, she has fought for his life.

You may remember Emmanuel's mother. Two weeks ago, when her son had his last in a series of painful plastic surgeries to reconstruct his face, she stood up in the center of our hospital and sang a chilling accapella Alleluhia, praising God for the gift of her child's life.

Today, she peered down, for the second time, into her family's grave.

She asked us to bring her here. For closure. She did not know what to expect. Would the house be gone? An empty lot, where her life had once been? Or would it be hauntingly unchanged, the moment of her loss frozen in time.

We worried for her. What does a mother do when she encounters such a challenge? Which would leave a more gaping hole in her soul -- an empty space where her house and children had once been, or an untouched pile of rubble with the bodies of her babies still trapped within? Would she stand and stare at the base of the rubble? Would she fall on it and wail? Would she start to claw and dig at it? Or would her soul just melt away?

She quietly climbed the untouched rubble pile, peering down into the hole from which three months ago she had plucked her little Emmanuel and beneath which her other children's bodies lay entombed. Then she wandered away silently, over the rubble, searching intently, she later revealed, for a precious momento -- a sacred book of hymns that she had carried with her throughout her life. She did not find it.

Nor did she see -- or perhaps, she just did not acknowledge -- the small brown arm of a child that was still visible, pinned under a concrete slab, in the depths of the rubble below her feet.

Devastating.

Tonight, as I left the hospital, she sat with her Emmanuel on a small cot in the corner of the courtyard, staring silently into the distance. I placed my hand on her shoulder in comfort. She stared up at me, with a depth of sorrow in her eyes, despite her ever present smile. I leaned down to hug her from behind and gave her a gentle kiss on the cheek. She lifted a hand to hold my cheek to hers for a moment. Such depths of sorrow. Invisible, searing, devastating sorrow. Just below the surface of a smile.

How does she survive?

A boy of seventeen lies on our procedure table. It is three months from his injury. He still requires sedation for painful dressing changes. One leg is missing below the knee. The other missing tissue from painful, poorly healing skingrafts. He is new to our hospital, transferred from another facility. He has been quiet, stoic, perhaps shy. He keeps to himself. He smiles when prompted with a greeting, but the smile rarely reaches his eyes.

Under IV sedation, we change his extensive dressings. His pain is blunted, as are his inhibitions. As the medication wears off, he begins to cry. Are his wounds still so exquisitely painful? Then he begins to sob. He raises his arm to cover his eyes. "I should have just died..." he cries. "Why am I alive..." In the misty consciousness of his sedation, his stoic mask is lifted, and his soul is revealed. He cries. He sobs. It is heartwrenching.

He cries first about his physical torment -- still so equisitely painful, twelve weeks out from his injury. The physical pain jostles his subconscious, and the suppressed, terrifying memories, are resurrected. This normally stoic and silent boy, still sedated, begins to sob uncontrolledly. Tears well as he rolls his head to and fro, crying about the loss of his leg.

"How can I live without my leg. What will I do without my leg?" he cries.

Then his mind wanders to the loss of his family. He was trapped in the rubble of his house for days. Twelve family members died in his home on that day.

"Why did I survive?" he asks, sobbing.

His mind wanders again, this time to his future.

"How will I live without my leg? How will I work without my leg?" He sobs.

Heartwrenching. Loss of self. Loss of identity. Loss of a future.

"I need to help my family. My father has lost his job. He cannot work. My family is homeless. They are living in a tent. They are starving. We have no money for food. How will we survive? How will we survive?" He sobs again.

"I was a student, but my school has collapsed. Now I have nothing. I have no job. I have no school. I have no leg. I have no life. I have no home. I have no future. Why didn't I just die? Why didn't I just die?"

He tires. Tears stream down his face. Is he sedated? Or is he awake? Is he rambling helplessly? Or speaking with direct, absolute, sober certainty?

It is heartbreaking. It is devastating. We long to reassure him. We long to comfort him.

Yet so much of what he has said is sobering, raw, undeniable truth.

This is far too much burden for such a young man. Far too much sorrow for one soul to bear.

And yet the story repeats, again and again. Patient after patient. Behind each face. Behind each tarp, in each tent city. So much sorrow. So much loss. So much suffering and grief. So much buried in the shallow depths.

But just barely.

Keep on Survivin'

2010-04-09T20:03:00.000-07:00

Go online and search out Destiny's Child "I'm a Survivor". Hook up your speakers, turn the volume on high, with a whole lot of base, and with apologies to your next door neighbors, rock the house. Then close your eyes and listen to the chorus. And imagine what we saw today...

We were discouraged. We'd lost our physical therapist to a family emergency, and our patients appeared amotivated without his constant encouraging presence. Moods were low. Apathy was setting in. Oppressive heat overwheled our tarp covered courtyard hospital. Little six year old Dina, now in a walking cast from her open tib-fib fracture, refused to put down her crutches and bear weight on it. Afraid. Lillian, 10 year old with an externally fixated femur fracture...crying with each episode of physical therapy, more and more fearful of the pain. 59 year old Leeann, lying stoically in bed 23 hours a day, not exercising her healing leg -- going backwards in progress. Our 76 year old below-the-knee amputee Genine, needing to learn how to walk again, having a difficult time even standing up. 20 year old Amanda, with her paralyzed left arm and shattered left leg, lying sadly and disinterested in her cot, staring blankly off into the distance.

We'd hit a wall.

"We just need to get them MOVING..." one nurse said.

"Maybe we could get them to do physical therapy together..." someone else said.

"It needs to be fun," someone else said.

And so the idea spiraled. It was born from the knowledge of a perhaps little-known fact, outside of our hospital, that our Haitian patients have innate and amazing rhythm. And soul. Every night, they sing and clap and stomp together in song in impromptu mass that goes on sometimes for hours. Rocking the house. Rocking the neighborhood, over the cinderblock walls, beyond the plastic tarp that is our roof.

It was evidenced when we watched the film "Madagascar," projected one night on a white cotton sheet tied up to the cinderblock wall. In this Disney film, dubbed in French, shipwrecked zoo animals land in the wilds of Madagascar with a bunch of lemmings who break out into fabulous song, singing a hip deep base beat, "You got to move it, move it. You got to move it, move it. You got to move it, move it...MOVE IT!!" There was nothing cooler than to watch heads start to bob and hands start to sway to the rhythm as all of the patients started to sing along to the beat.

It became obvious that our patients have rhythm.

"Let's make them exercise to "Move it!"" recommended someone else. We all laughed.

Then someone said, "No, really!"

No.

Really.

So, somehow it happened that we pulled out the electric sound system used to project movies on the wall at night. And plugged it into Dr. Jen's computer. A quick search of her ITunes files revealed a great assortment of deep beat, hip, rhythmic dance tunes. Including the song, "You all ready for this???!!" -- normally danced to at NFL halftime shows by cheerleaders in skimpy tops and pompoms.

We walked around to each patient and said, "In a minute, we're going to turn on the music, and you will do your PT."

Some patients were assigned a helper. Amputees were given the task -- stand and balance on your strong leg, and try to squat up and down. Bilateral casted patients -- stand up with your walker and balance, then sit back down. Young Dina, who refuses to walk without her crutches...when the music starts, you will walk on your cast...with one crutch, not two. Young Lilian, who starts to cry at the idea of physical therapy -- you will stand with your crutches and just walk around. Each patient assigned a task. They all looked at us curiously, a little dubiously. A little apathetically. A generalized look that shouted...ok, perhaps whispered, disinterestedly, "Ok, whatever..."

But then, the magic happened.

This was no circus music. No accordion music. No elevator music. No polka or grandma's parlor music. This was raging urban hip hop rhythm with wicked base and deep musical soul. Yes, this music required apologies to the neighbors over the cinderblock walls for its volume. Yes, it perhaps shook a bit of dust off the walls. Yes, it was played like your car stereo when you drive solo, speeding down the highway with the volume and bass cranked, wind screaming through your hair. Because on the count of three, when Renauld our interpretor-turned-DJ hit "PLAY", at two in the boring afternoon at our Haitian Field Hospital, he literally rocked the house.

"YOU ALL READY FOR THIS????" the song called, followed by the deep rhythmic beat of sound. Sound which suddenly dragged patients' eyes open, pulled giant smiles from their lips. Heads began to bob. Feet began to tap. Eyes came afire with life as the sound system blared its rhythm across the courtyard. I helped our 76 year old amputee onto her one leg. Her shoulders started to sway in rhythm. A smile crinkled her aged, wrinkled cheeks. Ten-year-old Lillian, afraid to stand, threw down her crutches and danced with her hips swaying and arms undulating rhythmically, balancing crutchless for the first time. Dina marched to the beat on her casted foot, then began to spin and dance. Amanda lay in her cot, brilliant smile, rhythmically rolling her shoulder to the beat. Song after song, shining smile after smile. Little Emmanuel, three year old boy with the crushed face, stood in the center of the courtyard and danced the freespirited dance of a child. Smiles and rhythm of joy. Old and young. Nurses and patients and translators and visitors. Rocked the house.

Then the last song, "I'm a Survivor," by Destiny's Child, began to play. I paused as I stood in the middle of the courtyard, slowly turning around to see the patients dancing and swaying and squatting and bending and smiling and laughing -- incidental physical therapy amidst the endorphin releasing joy of blaring song. Dancing like they were 16 again... perfect... whole... young.. .strong... in their bedroom secretly in front of their mirror. In a club. At a rock concert. A better day. A freer, more innocent day. Rebelliously blaring the music.... When life was simple and beautiful.

The deep, strong African American female voice pounded forcefully from the speaker in front of me. With each lyric, my eyes glanced off of each patient...their stories of survival...of pain...of endurance...of recovery...of spiritual resilience... flashed repeatedly in my mind. Fabulous. Amazing. Unbelievable.

I'm a survivor...
I'm not gonna give up...
I'm not gonna stop...
I'm gonna work harder...
I'm a survivor...
I'm gonna make it..
I will survive...
Keep on survivin'....
I'm a survivor...
I'm not gonna give up...
I'm not gona stop...
I'm gonna work harder...
I'm a survivor...
I'm gonna make it...
I will survive....
Keep on survivin'...
Keep on survivin'.

Help One

2010-04-02T20:15:00.001-07:00

The malingerer. The bane of our existence as practitioners of emergency medicine. The patient who walks into the ER faking an illness for secondary gain -- sometimes for attention, sometimes for narcotics, sometimes for an excuse to be absent from work.

Malingers think they are so clever. Yet their behavior is transparent and predictable. The patient who limps in on one foot and limps out on the other. The one who chats happily in the waiting room, but then moans as the doctor walks in. The physical exam that makes no logical sense, consistent with no known disease process and no pattern of human anatomy. The frustrating, time consuming, irritating, abusers of the medical system. The malingerers.

So, wasn't I surprised when the malinger walked through our gate in the form of a eleven year old boy Ramon. He had been a resident of our hospital for nearly two months, healing from a severe foot wound sustained when he fell from the second story of his house during the earthquake of 12 January. Two weeks ago, declared healed, he was finally discharged home to his neighborhood -- the slums of Pele, from which we had initially plucked him. Pele is a 30 minute drive through the city from our Field Hospital, so it is rather amazing to me that Ramon has magically appeared at our gate several times -- alone, without a guardian. Despite his mere 11 years of age, Ramon demonstrates keen urban street smarts necessary for survival in the slum he calls home. Each time he has appeared, he is welcomed in, greeted by fellow patients who have become his friends, fed dinner, and offered a cot to sleep on. We examine his foot. "Looking great, Ramon!" we say. Each time, we allow him to stay overnight, only to bring him home on our next truck visit to his slum. This might seem uncouth -- to keep a child in a hospital without his guardian's permission -- but in a city in which many families have no phone and no way to be contacted, and in a slum too dangerous to be entering after dark, it is the safest solution for all.

Much to my surprise, on Sunday afternoon, Ramon approached me holding his stomach. "Fe mal..." he moaned, looking ill. An exam revealed a generally tender abdomen, but no fever, no change in vital signs. His severe wincing made me concerned for an early appendicitis. "Poor Ramon," I cooed, as I touched his cheek. "I think you need to rest today and we'll watch you closely."

And as I watched closely throughout the day, I was surprised at what I saw. A boy who giggled and smiled and joked with his bed neighbors, rolling hither and yon on his cot, swinging legs carelessly... but who morphed into a giant, grimacing, writhing form when he saw me approach his bed. "Ohhhhh, fe mallllllll...." He would moan. "oooohhhhhhhh...."

I was on to him.

"Where's the pain, Ramon?" I asked. He gestured all around his abdomen. "Is it here?" I asked touching his belly button. "Oui!" he said..."Yes!" "How about here," I asked, pointing to his hip bone. "Oui!" he said, moaning dramatically. I pointed randomly...to his ribcage, his left shoulder, his right kneecap. "Ooohhhh, fe malllllllll," he moaned. "It hurrrrts..." "Would you like some dinner?" I asked. "Yes!" he responded quickly -- confirming my suspicions that this was not his appendix -- as with that malady, the appetite is the first thing to go. I performed my favorite malingerer exam -- rolling his hair between my fingers. "Does this hurt?" I asked, touching the insensate hairs of his scalp. "Ohhhh, fe malllllll....it hurrrrrtsss..." he moaned. Liar. Bad liar.

I smiled internally as I stood and spoke in my stern but quiet doctor's voice.

Through a translator, I advised, "I see your stomach hurts you, Ramon. Why don't you eat something and get a good night's sleep. I am very sure it will be better in the morning, in time for you to return with us to Pele. If it's not, I'm afraid we will have to bring you to another hospital, because you will be too sick for us to care for you." He nodded, eyes wide. I patted his head. Within minutes of my walking away, he rolled on his belly, swinging his feet happily, chatting with the 12 year old boy in the cot next to him.

Can you blame him? A young, impoverished,malnourished boy from the slums, seeking three square meals a day, a soft, warm bed, a quiet courtyard, a supportive social network, nighttime singing that rocks the house, and an occasional movie projected on a cotton sheet hanging by the metal gate. Paradise? This has become his safe haven, from his slum, his poverty, and the painful and horrifying memories that are the earthquake. The earthquake that killed one out of every 10 people in his neighborhood. The earthquake that shattered his foot.

The next morning, Ramon walked up to me. "Do we need to take you to the other hospital?" I asked, pushing on his stomach.

"No," he responded. His belly was fine.

So, we loaded Ramon into the truck, and drove the thirty minutes back to his neighborhood. We hopped out and walked down the street and into a back alley. Before us stood a looming, teetering structure that was once a two story building, now leaning treacherously to the left, the front wall missing revealing the small rooms withing.

"That's my house," Ramon declared. My heart sank. Ramon's house. The house that he fell from when the wall to his bedroom shook off and crumpled to the street below. The house that still looms threateningly, like a nightmare; a house that blocks fall from with every minor aftershock.

I remember the command given by the Haitian president last month. "Haitian people, return to your homes. Leave your tent cities. Your houses are safe."

Really?

Does anyone come in to these slums? Certainly no engineer. No building inspector. I am sure not the President, who commanded the people to return to their homes. Ten weeks after the earthquake, this treacherous building looms, awaiting the next rumble that will rip down the next wall. A nightmare.

I turn to the malingerer. Now I understand. "You're not living in this building?" I ask, with deep concern.

"No," he replied. He walked past the building, between two narrow walls, into an open area behind the structures. Ramon's mother stood there, outside of a shelter made of a cotton sheet held up with four wooden spears. She greeted us and showed us her home. She was not surprised that we brought her son to her...not surprised nor questioning where he had been the last few days. The floor under the sheet was a makeshift mosaic of crumbled cinderblocks. There was no waterproof tarp to keep out the rains. No pad or blanket to sleep on. Just a cinderblock floor and a cotton roof. She was surrounded by five small children -- hers? Neighbors? Children taken in out of necessity, now orphans? No evidence of food...or cooking supplies.

"Okay, bye Ramon," Alicia our nurse and I said as we patted his head and turned to leave. We met each others' eyes with a knowing look. How do we leave this child here? How is this family surviving? Did we invest two months in his life, his recovery, to dump him here on the streets? With inadequate shelter? With the shell of his former house teetering just meters away? Does he have food? What happens when the rains come? How many other children are squatting this way? Statistics say perhaps one million Haitians are now living in flimsy tent shelters. How do we leave this boy here? How do we leave these people here?

I stare at his cotton house. I recall the rains that pour down every other night now, dumping 2-3 inches of rain an hour. And the rainy season is upon us. I feel helpless.

The motivation of an 11 year old street-wise malingerer, revealed.

We walk slowly back to our truck, Alicia and I. Speechless. Yet, unfortunately not surprised. As one stares out at the hillsides, the story is repeated, tens of thousands of times over.

Overwhelming.

****

Today we returned to Ramon's alley...and found him playing with his siblings. We presented him with a three person tent and a sleeping pad -- a donation from a nurse who spent a few days volunteering in our clinic. He stared in awe as we handed him the tent. He touched it hesitantly.

"This is for you and your family," we said. "It's not much...but maybe it will help."

He hugged us tightly. We hugged him back.

We walked away.

One life. One small bandaid. One gigantic hemorrhaging wound that is Haiti.

*****

Mother Theresa said: "If you cannot help everyone, help one."

Please Help Us Find a Neurosurgeon

2010-04-01T20:21:00.000-07:00

I have been asked to post this request to help our field hospital find a neurosurgeon for one of our patients.

Amanda, a 22 year old young woman living at the Heartline Field Hospital in Port au Prince, Haiti, was crushed when her neighbor’s house collapsed into hers in the Haiti earthquake on 12 January 2010. She has multiple injuries, including a severe nerve (brachial plexus) injury which causes her to live in incapacitating pain. There are no specialists in Haiti who can perform this repair. We are seeking help to get Amanda to the United States (or elsewhere) to a neurosurgeon/ brachial plexus specialist, in a last hope effort to resolve this young woman’s incapacitating pain. If you know any orthopedists or neurosurgeons, please share Amanda’s story with them, and see if they know anyone who might be able to help Amanda. We are asking that the surgeon and treating hospital donate their services. If and when a surgical team is identified, we will also need financial donations to pay for Amanda’s medevac to the United States, and her room and board while she is there. Amanda has a passport, which will facilitate her travel out of the country.

Here is Amanda’s story:

On the evening of 12 January 2010, young Amanda was standing in her mother’s kitchen outside of Port au Prince. When the earthquake hit, her neighbor’s house came crashing into hers, trapping Amanda under its crushing weight. Her neighbor – and best friend – was killed instantaneously. Earthquake survivors describe the shaking and grinding of the earth on that day as nightmarishly surreal; many believed the world was coming to an end. In the minutes after the large quake, neighborhoods echoed with thousands of screams – some of pain, others of dispair over injured or dead loved ones. The screaming echoed eerily and incessantly into the dark night, through near and distant neighborhoods; the hellish sound reportedly could be heard for miles. One in every ten people in Port au Prince and the outlying communities was killed in the earthquake that shook for less than one minute.

Amanda’s screams of pain were heard by neighbors, who worked aggressively, despite severe aftershocks, to free her from the concrete and rebar grave that trapped her. When finally rescued, it was clear that her life was in danger. Her left arm and femur were crushed – exquisitely painful, and potentially life threatening open wounds. In the United States, such severe injuries would have gotten Amanda life-flighted to the nearest trauma center for emergency surgery. In Haiti in the week following the earthquake, she was one of more than 100,000 severely injured individuals desperate – and unable – to find care.

Imagine, in that moment, that Amanda is your daughter, your sister, or your friend. And you are desperately trying to find her care. You drive first to your local hospital – which is absolutely overwhelmed. She is there for two days, and receives an IV, but no pain medications and no orthopedic care. She is in agony. You become desperate; you decide to drive her to the city. Certainly there, at one of the big city hospitals, she will receive help. But many of the big hospitals, you soon discover -- to your horror -- have been destroyed. You find one – hospital number two – and take her there. After a day, she again receives no care. So, you drag her unsplinted, broken form in search of a rumored orthopedic field hospital. You cannot find it, so you sleep with her in the streets, cradling her crying form through the night in your arms. In the morning, you take her to hospital number three. No care. You search again for the rumored field hospital and finally move her again – still unsplinted, still without pain medication, to hospital number four. There, she is loaded into a truck and convoyed across the countryside – still without pain medication and still unsplinted, every jolt on the country highway grinding bone on bone – to the Dominican Republic, the country east of Haiti, to hospital number five. There she finally sees an orthopedist, who places a metallic external fixator into the shattered bones of her left femur and a metal rod to stabilize the open fracture of her upper left arm. There they discover that her left arm is paralyzed and burning with severe, intractable nerve pain; the bone is also infected, as her open fracture remained uncleaned for so long. You meet a representative of another field hospital located back in Haiti -- one that has orthopedists and plastic surgeons, and can manage her open wounds and infections. So, you truck young Amanda, once again, over the bumpy rural highway, back to Port au Prince, the city from which you started, to hospital number six -- Merlin Field Hospital. There, in a collection of canvas tents on an old tennis court, European physicians place skin grafts over her open wounds of her leg, and further manage her infection. You discover that they, too, are overwhelmed with patients, and recommend transferring her to hospital number seven – Heartline Field Hospital – for pain and infection management and rehabilitation. At Heartline, it becomes obvious that the nerve pain in her arm is severe and unremitting; so she is transferred temporarily to Miami Field Hospital – hospital number eight -- where an anesthesiologist places a temporary catheter into her chest through which pain medication can be infused to blunt the nerve pain in her now non-functional left arm. This intervention fails. She is transferred back to Heartline for regular care and rehab. Her unremitting pain continues. Orthopedists, plastic surgeons and neurologists agree -- no one in Haiti can fix this girl's injury. Imagine this is your sister, your daughter, your friend. The agony of her journey. The agony of months of intractable pain. The overwhelming hopelessness.

Amanda’s femur is slowly healing, but arm pain remains severe. The unfair irony of Amanda's arm injury -- a probable stretch or tear of the brachial plexus -- is that although the nerves to her arm now fail to function, and it hangs limp and unusable at her side, she is plagued not with arm numbness, but with severe, incessant pain. Nerve pain. Imagine the worst ice cream headache of your life. Or the worst sciatica of your life. Imagine the pain you get when the dentist pokes his metal hook right into that sensitive part of your tooth. Fiery, electrical, intolerable pain. That is nerve pain. Now, imagine living with it, with no hope for relief. This is Amanda’s burden.

Some have recommended amputation of Amanda's left arm. The problem is, the nerve bundle lies above her shoulder, so amputation would disfigure her without alleviating the intractable pain. Even with her left arm gone, she would still suffer severe phantom pain, which she would feel travelling from her shoulder to the fingertips of her now missing limb.

There is a possible surgical intervention for Amanda -- brachial plexus repair. But there is no one in Haiti able to perform it. There are a few specialists in the United States who can. But the clock is ticking. The farther she gets from her injury, the less likely it can be successfully repaired. And the more likely this young 20 year old woman will live with devastating pain. As one orthopedist bluntly put it, "This injury will not kill her. But suicide, from the ongoing, unremitting pain, could."

Please help Amanda. We need to find her a surgeon. And we need the funding to get her to the United States, and support her while she is there.

If you can help in any way – be it a donation, an offer of housing or transportation, or a medical contact, please contact Heartline Ministries at helphaitiamanda@yahoo.com. Together, we believe the Heartline Field Hospital community and contacts can come together to find Amanda a final solution – at hospital number nine. We will keep you informed of our progress to find Amanda care.
Please forward this request on to anyone you feel might help with Amanda’s case.

Heartline Field Hospital, Heartline Ministries, Port au Prince, Haiti

helphaitiamanda@yahoo.com

Starvation

2010-03-29T20:30:00.000-07:00

This child is starving.

He presented to our clinic at 10pm two nights ago, a floppy, dehydrated, malnourished skeleton of a boy. Carried in by an apathetic, apparently disinterested mother. Is she disenchanted with her lethargic child? Uncaring? Exhausted? Cruel? Unkind? Or just overwhelmed, and disengaged? Filled with her own stressers and poverty too overwhelming to communicate, so she instead stares blankly across the room with an air of dispirited disinterest? He whimpers as his head flops backward, his neck too weak to lift it. She ignores him. She does not watch him, hold him, soothe him, make any eye contact. He lies in her arms like a wet, unloved rag doll. He appears to be an irritant. But, yet, she walked in with him, sought help for him, at 10 o'clock at night. He has not eaten a thing in 14 days, per mom. How is it possible he is still alive? What inspired her to finally come, on the 14th day?

Starving.

A young girl is carried on her brother's back to our truck in the slums. She is 12 years old, sweating and semi-conscious. She was standing in a food line in the blazing noon heat, and slumped to the ground, unconscious. We lay her on the floor of our truck. Likely dehydrated and hypoglycemic. I take honey that we carry for wound care and rub a thick layer into the mucous membranes inside of her cheeks and gums. She gradually returns to full consciousness. We feed her granola bars we carry for ourselves, and sips of water, until she revives. I explain that she needs to go home and rest out of the sun, and eat something.

"Do you have any food at home?" I ask, realizing that she had been standing in a food line when this all began.

"No," her brother responds for her, meeting my eyes solemnly. "We have nothing."

"No," she mirrors, shakily, and starts to sob hopelessly. "We have nothing. Nothing..."

Starving.

Have you ever met a truly starving human being? They surround us.

Alleluia

2010-03-28T04:24:00.000-07:00

A mother stands in the center of our tent hospital. Her toddler stands at her feet, hiding his face in the folds of her skirt at her legs; he tugs repeatedly at her dress to get her attention. When he fails, he -- in typical two year old fashion -- cries out in frustration, tugging harder, grunting, trying to climb her. This draws knowing smiles and giggles from the patients and our staff. Headstrong, willful, smiley Emmanuel. Always trying to get his way.

If you look closer at the belligerent child, you will notice scars along his scalp, winding through the tangled mass of his dark hair. As you follow them, they will draw you to his face, where they course across his right eye, and down the side of his nose. These thick jagged lines are complimented by the more precise and straight surgical scars which track down his forehead, behind his ear and along the side of his neck. Emmanuel's face hints at a horrific story.

He has been passed from surgical team to surgical team -- first on the USS Comfort, then the Merlin surgical tents set up on an old tennis court, and finally, yesterday, Miami's white tent hospital at the airport. He has been our inpatient in between. We had been searching for a surgeon to make a final revision to Emmanuel's scars, but for weeks, no one could do this, due to lack of an anesthesiologist to properly control his airway for the final complicated surgical intervention. So, for weeks, Emmanuel has stayed in our tent hospital, with his dramatically deformed face, a prosthetic device sutured into his nostrils to prevent them from scarring shut, and a flap of tissue from his forehead twisted at its base to cover the place that once was his nose. Though the right side of his face was mangled, the left eye was largely unharmed, and it is through this left eye, and his intact smile, that Emmanuel has won the hearts of our hospital crew.

While rounding on patients, it is not uncommon to feel a sudden sharp slap on one's back side, and to spin around indignantly to find Emmanuel grinning, his left eye crinkled into a smile, his hand still raised in a gleeful threat that he is about to slap you in the butt once again. If you hold out a fist to him, he pulls out his, and gives a powerful fist bump greeting -- a sign that he is, indeed, a little Haitian man. He will sneak up upon you to unzip your pants pockets and steal your pens. And is commonly seen proudly wandering with a bag of drinking water that he has cleverly pilfered from a controlled stash at the nurse's station.

Two days ago, on a scouting visit to the Miami Field Hospital -- which has, by the way, received the official word from the government that it must move off of the Airport property in 3 weeks -- I wandered my way through the pediatric tent, and into the back surgical suite, bearing a photograph of Emmanuel's face on my telephone. I approached a group of men and women in surgical garb. Understand that, in the USA, a perfect stranger wandering in sandaled feet, a t-shirt and khaki pants into a surgical suite would guarantee one an escort out to the street in handcuffs by a thug in a dark security outfit. But there, with my American looking face and a strategically placed stethoscope, I received only curious stares from the surgical staff.

"Hey," I asked, with pseudo-casualness. "Is anyone here a plastic surgeon?"

And, unbelievably, as if I were standing inside a poorly written Hollywood movie, a handsome man in blue scrubs with a surgical mask dangling around his neck looked up and said, "I am a plastic surgeon. How can I help you?"

Really?? I asked myself internally. Did that just happen? Perhaps you don't quite understand....the number of virtual roadblocks and cement walls and alligator-filled moats we have transcended trying to achieve this very encounter, this moment in time. And here, finally, it was presenting itself. So shockingly simply.

"Uh.. great," I said, trying to appear casually unimpressed by this moment of good fortune. I turned on on my phone and opened to the photo of Emmanuel, turning it towards him. "Can you help this boy?"

The surgeon took my phone and stared at it. "Looks like he's had a half finished flap procedure..." he said, naming off specific flaps and techniques standard in his surgical world. I explained that we'd been unable to find an anesthesiologist, and were therefore unable to complete the revision...that we (and Emmanuel) were stuck, half finished, without a plan for his next essential plastic surgical intervention. We didn't know how to proceed.

"Okay," he said. "I'll do him tomorrow."

My mind stuttered with momentary incredulity. What...you mean...tomorrow...like...the day after today tomorrow? Unbelievable. Outwardly, I nodded, with an false air of calm professionalism. Inwardly, I laughed -- a laugh of deep, fatigued relief.

Thank. God.

So, already overwhelmed, you can only imagine my reaction when he also agreed to do surgery on Rony, our other boy with facial trauma -- the one who'd had Bot fly larvae growing in his eye socket, and for whom we'd also been searching desperately for a surgeon.

I merely scrolled to Rony's picture on my phone, and thrust the photo at him, breathlessly challenging, "Okay, well, while we're at it... what about him?"

After he inspected the picture, and heard Rony's story, he said, "Okay, I'm leaving in a couple of days, but I'll fit them both into my schedule. Bring them both back this afternoon."

This afternoon.

I stared blankly for a moment, then a smile cracked my face. Unbelievable.

"This afternoon," I repeated to him, then nodded. "We'll be here." I retreated backwards through the door of the surgical suite, with a forced casual wave of my hand...then turned, and with a great lack of professionalism, sprinted back to the truck, intending to retrieve the boys before this vortex of luck stopped spinning.

And so today, two days later, Emmanuel and Rony reappeared back at the gate of our hospital, accompanied by our nurse, surgery complete. For the sake of their privacy, I will not include their photos here, but rest assured that the results were absolutely stunning-- as evidenced by Emmanuel's mother, who beamed a gigantic smile as she carried her boy proudly back through the metal gate into the courtyard of our field hospital.

Emmanuel's transformed appearance raised audible gasps -- which, ironically, it did not do when he had previously presented his disfigured face to the world. But now, with the fine scars of a deft surgical hand tracking down his face, where there once was a tangle of tissue, was the beautiful, nearly symmetrical face of a child.

So, today, beaming mother stood up in the courtyard of the tent hospital, little Emmanuel squirming at her feet, and told our community she had something to say. She closed her eyes, and began to sing, a deep, resonant rendition of a Creole hymn, "Alleluia..." All the patients fell silent as she sang, her little toddler at her feet trying unsuccessfully to climb up her dress. She swayed and raised her hands in song, thanking her God for healing her child.

Her gratitude is impressive, particularly if you know the rest of her story. This woman, who stood up to sing her thanks for all she has received, had three other children. But they are now dead. They were all crushed -- and are still buried -- in the rubble that was her house, which collapsed in the earthquake of 12 January 2010. The house under which her little Emmanuel was trapped, then plucked free. Her shattered little boy, Emmanuel...is all that remains of her family.

Emmanuel. Beautiful, vigorous, little spirit. Miracle boy. His mother's last hope.

Made whole again...by a stranger in blue scrubs...who made the time.

Alleluia.

Faux Pie

2010-03-26T22:33:00.000-07:00

How can this be?

It is ten weeks from the earthquake, and today, as we performed wound care on our truck in the slum of Pele, two men walked towards us up the street carrying a middle aged woman on a folding metal chair. I did not recognize her. Neither did Alex. Her right leg was wrapped in a makeshift splint, now dirty from weeks of wear. Her left leg was missing below the knee. I climbed out of the truck to greet them.

"Hello," I said. "How are you?"

"Please help us," implored the older man as he set the woman down on the street beside the truck. He identified himself as her husband.

"Of course," I replied. "Tell me about your injuries..."

"She received care in a hospital in the Dominican Republic in the days after the earthquake," he replied. "They cut off her leg, and put the other in a splint."

"Where is your leg broken?" I asked, pointing to the mass of gauze and plaster. Followed by our commonly asked, but clinically unusual question: "Did you have an x-ray?"

"I don't know where it's broken," she replied to the first question. "No," to the second question. "No x-ray."

We have seen this situation repeatedly. A patient in a splint for a non-specific, unidentified fracture. In the chaos of the post earthquake situation, probable fractures were splinted based on symptoms -- appropriately so in the critical triage environment. We found one poor elderly gentleman placed for eight weeks in an uncomfortable long leg cast -- only to x-ray him to discover he'd never broken his leg to begin with. So, once again, another patient with an unknown fracture. But, ten weeks out, one would expect the bones to be healed.

I cut off the splint and took her leg into my hands. With a torquing twist to the lower leg, I felt the bones grind harshly against each other -- a malunion (unhealed fracture), so unexpected this long from the injury.

"You've been unable to walk on this, because of pain, I'll bet," I said.

"Walk?" she asked incredulously, almost accusingly. As if to say, "How do you think I will every walk again."

"Do you have crutches?" I continued.

"No," her husband replied. "We just carry her around in this chair." He pointed to a folding, slightly rusted metal office chair.

I squatted down beside her to meet her eye. Her situation was becoming clear. A woman with an aggressive post-earthquake amputation and a shattered surviving leg. Sent back to the streets -- to a tarp shelter? -- just days after her surgery. Unable to walk. Given no instructions. No rehabilitation. Provided no crutches. Nor a plan of follow-up. Now assuming she will be non-amblatory for the remainder of her life -- crippled. And a constant burden on her family.

"You know," I told her, resting my hand on the leg above her splint. "We have a patient just like you in our hospital. She had both of her legs crushed under a wall. She had one leg amputated and the other severely broken. Just like you."

The woman nodded.

"She took her first steps this week, at our hospital, using crutches," I told her with a smile. "Would you like to walk again, too?"

The woman and her husband both looked at me with astonishment. As if they had never imagined this could be an option. Her son, who had carried the other side of her chair, grabbed my arm.

"Please," he asked with urgency. "We want to fix her legs. Please...can you fix her legs?"

"How about this," I said. "Get on our truck with us, and come back to our hospital. You can stay with us for a while. We'll get an x-ray of your leg, to know how it's healing. We'll give you physical therapy to help you get stronger. And we'll give you crutches, so that we can teach you how to walk again. And I will connect you with a prosthetist....so we can find you a new leg."

"A faux pie?" her son asked with excitement. A fake leg?

"Yes," I said. "A faux pie. Will you come with us?"

The woman nodded quietly, a look of hope in her eyes. Her husband's eyes filled with tears. They gripped each others' hands.

Where had these people come from, ten weeks after the earthquake. From which make-shift shelter down which little alley in this labarynth of cinderblock shelters and tarps? Where had they been these past 10 weeks? How had they found out about our truck? And why had we not met them sooner? How many other patients are lying in the slums of Port au Prince, hopeless, helpless, crippled...completely unable to access care? Being tended to on the floors of their homes, or carried around by their families? How many more are out there

We carried the woman in her chair into the back of the truck. Inside, I asked her her story. With the typical flat, matter of fact affect that is so common amongst our patients -- a protective mechanism, I assume, to limit the power of the torturous memory -- she described that she was a restaurant owner, and the wall of her business collapsed upon her during the earthquake, pinning her for five days under the rubble. Five days of agony, leading ultimately to amputation and severe disability.

We drove this woman, along with two other patients with poorly healing fractures, to a volunteer medical organization called Merlin late in the afternoon. Merlin arrived in Port au Prince within the first weeks of the earthquake, providing volunteer orthopedists and plastic surgeons. They operate out of green canvas tents set up on an old tennis court in the center of the city. There, I met with Mister Andrew, a retired orthopedic surgeon from England. "Mister", he had educated me, is the title for surgeons in England, not "Doctor". He is, like so many here, something of a character; a gangly old chap with thinning grey hair, glasses falling down to the tip of his nose, a giant floppy safari hat to protect his pale British skin from the blazing Haitian heat, and occasionally seen wandering through the tents with a fragile china tea cup with a saucer. A brilliant mind, with a golden heart. The days of long hours wear on his face.

I shook his hand and sheepishly began, "I know it's late, Mister Andrew, but we've found three patients on the street today who need x-rays." The doctors at Merlin have a curfew, and are forced to be out of their tents and back to secure housing by sundown due to safety concerns; at night, the tents and patients are watched over by local Haitian staff and security guards. As I spoke, the sky was turning a pale orange, as the sun threatened to drop below the horizon.

"Bring them in," he said, without a blink of an eye.

I described each patient's scenario. Under the fluoroscopy of his mobile C-arm x-ray, each fracture revealed itself to be a shattered mess, non-healing despite 10 weeks in splints.

"I'm leaving in three days," he said, "and we have no plan for replacing me as an orthopedist."

My heart sank. What will we do, without an orthopod in the coming weeks?

"All of these patients need surgery," he continued.

"Okay," I said hesitantly, "What shall we do?"

"Well, you'll leave them all with me, and I'll fix them all before I go."

Perhaps you don't know how generous and selfless this man's offer was. A man old enough, and currently appearing tired enough, to be your grandpa. Operating in a stuffy canvas tent under the blazing Haitian sun. With years of practical experience, doing orthopedics long before the fancy modern technologies we now enjoy. An offer beyond generosity.

"It won't be easy, though. Ten weeks from the injury...with some calcification setting in...it won't be easy," he said, shaking is head.

"Wow, thanks," I said. "I'm so grateful. We'll take them back from you right after surgery." Then, "If we didn't do the surgery," I asked, as I looked at his tired face. "What would happen?"

He laughed, shaking his head, "Well," he pondered. "I imagine nobody knows. I've never left fractures like this to heal on their own. You just don't do it. This is unprecedented. I wouldn't be the one doing a clinical trial, leaving these people without surgery to see how they fare. It's just unprescendented."

So, we left our patients, including our lady and her metal chair, with Mister Andrew, the grandfatherly safari-bound orthopod from Britain. She couldn't be in better, caring, experienced hands.

And when he is finished, we will take her back to our hospital, tend to her incisions, give her crutches, and teach her to walk again. And find her her a cherished "faux pie". So that she can reenter society, standing tall like the woman she once was.

How many more of these patients are out there in the city, unhealed after ten weeks of suffering?

What will we do when the orthopedists go away?

This crisis is no where near resolved.

Thank you, Mister Andrew, for your amazing generosity of time, knowledge and compassion.

Did I mention that, with each patient, he pulls out a colorful hand made spiral "lolly" from a candystore back from his home town in England, that he carried to Haiti on his back with his medical tools? "Who was a good girl today," he smiles as he leans over and hands one to our woman.

She takes it hesitantly, and her guarded eyes open, and she smiles at his grandfatherly form.

"Well, allrighty," he says, then turns and shakes my hand. He meets my eyes over the glasses that fall to the tip of his nose. "Thank you for what you do," he says with great seriousness.

"Are you kidding?" I reply. "No, Mr. Andrew. Thank YOU."

I Have One Word for You: Plastic

2010-03-22T22:43:00.000-07:00

I must get this off of my mind.

There is a wall of garbage in the streams and waterways of the slums of Port au Prince, which floats up after large rainstorms and spills out onto the streets and walkways. This garbage is largely plastic bottles and Styrofoam. I'm not talking a few bottles. Or a few Styrofoam plates. I'm talking thousands and thousands and thousands.

If you ever wondered what happens to that plastic bottle from your springwater, or the Styrofoam container from your takeout dinner, please remember these photographs. The bottles disposed of in these Port au Prince waterways gradually wash out to sea. In the center of the Pacific ocean, there is now apparently an area twice the size of Texas which, due to overlapping ocean currents, traps a floating island of waste. This waste circulates, gradually disintegrates, and forms plasticized sand and particles, now fed upon by marine animals, and disrupting the nutrition of wildlife. In containers that fail to wash away, in the neighborhoods of Port au Prince, small pools of stagnant water are trapped-- each becoming a small, floating incubator in which the mosquitoes carrying Dengue "Breakbone" fever lay their numerous larvae. For a thousand reasons -- aesthetic, environmental, biological, and humanitarian -- this litter has devastating consequences.

There is no plastic recycling in Haiti. Apparently, the President of the country is aware of this extreme plastic trash disposal problem -- so severe that he actually refused the delivery of relief drinking water in plastic bottles in the days after the earthquake.

I would like to propose an idea...but have no idea how to implement it. Perhaps one of you readers might have some idea how to go forth. If a recycled plastic bottle is worth 5 cents American, one could make a massive profit by collecting hundreds of thousands of plastic bottles. Consider paying Haitians a penny per plastic bottle they collect. If the average Haitian makes approximately two American dollars per day of hard labor, it is very likely he or she would be willing to make the same by collecting 200 plastic bottles. Reimburse them a dollar for each hundred bottles. Then take the bottles and recycle them. Grind them up, melt them down, and turn them into plastic tarps. Or turn them into plasticized, wood-like building products -- flexible enough to withstand hurricane force winds and the tremors of earthquakes; such materials are used to make public benches and decks, as visible in American National Parks. There are may ways to recycle and reuse these products. And to do so would get the garbage off the streets and out of the waterways. And possibly provide an income and an industry for the people of Haiti.

Anybody know how to pursue this dream? A win-win-win situation for Haiti?

Anyone interested in starting a plastic recycling center?

Coming Back to Life

2010-03-19T19:58:00.000-07:00

This week's good moments...

The kids out in the slum of Pele are still calling me Angelina Jolie. This is my fault. In a weak moment, while doing wound care last week, unable to stand one more poke to my back by little fingers through the metal mesh wall of the truck accompanied by the stereo "heybarbieheybarbiebarbiebarbieheybarbieIloveyoubarbiegivemewaterbarbie", I turned around and declared in a pseudo-huff, "My name is not Barbie. It's Angelina Jolie!" Little did I realize, they were paying such attention. Now, days later, as I am poked, I can do nothing but smile with bemusement. "AngelinaAngelinaIloveyougivemewaterAngelina..." My own little Pele paparrazi.

Dr. Jenn, our fabulous pediatrician, came out with us on the truck, and now the kids are calling her Jennifer Lopez. Hmmmm....I wonder how that happenned.

A little boy of about 8 years old flashed me an obscene finger gesture as he stared at me through the bars on the truck. "No," I yelled at him, flashing back the peace sign. "La pe! La pe!" (Peace. Peace.) He looked taken aback for a moment, then lifted his index finger to join his middle finger. "La pe..?" he said tentatively to me. "La pe!" I gestured back, encouragingly, fingers raised in the universally recognized vee of peace. Suddenly a smile lit up his face, and he waved his peace sign vigorously shouting, "La pe!! La pe!" His buddies quickly followed suit. If only all peace talks were so simple.

Riding around the city on the top of the truck in a refreshing warm rain, pedestrians called out mockingly, "Hey you, you're getting wet!" "Yeah," we called back, " So are you."

Antoinette, with the most perfect, fragile, angelic face and soft, musical voice. Crushed under a wall inside of her house while pregnant, with one leg amputated and another crushed, was told this week we could remove the metal external fixator holding together her shattered tibia. And that she is now allowed to walk. She is our last patient finally cleared to walk. When told, she immediately stared off into space, rocking back and forth and chanting something repetitive. Concerned she was fearing the upcoming procedure, I asked our translator what she was saying. "She's saying, 'Thank you God, thank you God...' he said, matter of factly. Lying in the caring arms of Dr. Jenn, with eyes closed, softly singing, the stabilizing metal rods were one by one removed.

Baby Kenny, the three pound near-death septic baby, for whom we artificially breathed every three seconds in the back seat of our truck on my first day in Haiti...fighting for his life...whose mother wailed in fear of his imminent death...is now back in our care. And through the patient education of Beth our midwife, is now breastfed by his teenage mother. And this week, hit a whopping five pounds.

Patrick, a 13 year old boy who presented to our clinic a few days after the earthquake with his tibia bone broken and jutting out through his skin, will get his metal external fixator device off next week as well. He's had a long, challenging course, complicated by recurrent infection and skin grafting. A young man with great grit and courage. He currently walks around with crutches that he's decorated with small sayings in English written in Sharpie pen. My favorite is a spelling error, where he mistook an "n" for an "m". It reads, "I BELIEVE IM GOD"

Rony, 11 year old boy with a crushed, scarred right face and bot fly larvae removed from his eye orbit, who wandered the street for 6 weeks without care before finding treatment, picked up a pen today. And drew a self portrait. Of a beautiful symmetrical boy.

I was gifted t-shirt this week. In big white letters on dark blue cotton it reads "MALARIA SUCKS." Indeed.

We tracked down "goat poop girl", who'd shunned our western medical method for treatment of a large hand burn -- scraping off our silvadine burn cream and replacing it the next day with a thick layer of brown goat poop. Her hand looked great. So much for my anti-fecal medical practices.

Jameson, a young boy we found in the slum of Twa Bebe, near the plastic bottle and pig filled river, went home this week. We'd found him in a bright green, dirty cast extending from his abdomen to his foot -- treatment for an unstable femur fracture. He'd been released to the streets with no follow-up...destined to outgrow his restrictive green prison. We were able to scoop him up, get follow-up orthopedic care, ultimately remove his cast, and provide him with physical therapy. A beautiful moment, as he walked with us down the cement path to his home, assisted by his crutches. He paused at the door to his single room cinder block home and a woman came out -- his mother. She cradled his face gently in her hands, staring into his eyes. And kissed him on the forehead as tears welled in her eyes. She then folded her hands across her heart, turned to look at us, and bowed her head, saying "Merci...merci...." Jameson, in typical preteen boy fashion, shrugged away his mom's attention with a grimace, and wandered over to sit on the stoop -- apparently his favorite spot. The spot from which we'd plucked him.

Coming back to life.

Yeah, it's been a good week.

2:00am, Miami Field Hospital: Take two

2010-03-18T20:08:00.000-07:00

Been a bit crazy these past few days and haven't had much time to breathe, let alone write. But I did want to pass on a few thanks...

Thanks to those of you who wrote to say they are contacting their political representatives to encourage better management/utilization of disaster aid resources here in Haiti. Continually bringing attention back to this disaster is one powerful way to promote change. If you are fortunate to have a political voice, those who don't will benefit from yours.

I, ironically, don't have a voice today. Lost it to laryngitis a night ago. Is this some sort of cosmic metaphor?

Perhaps it was all the screaming in the car. I learned that it's not a good idea for a dog to be sleeping in a little dog-circle in the middle of the road at 2:00am when Beth, our midwife, is driving a laboring mom requiring a stat c-section across Port au Prince in search of a surgeon...after the OB/Gyn at the local Haitian hospital came out to say, "I would do the c-section now, as the baby is dying, but we only have one OR and it's currently being used."

We'd looked at each other in that moment and said, "Miami Field Hospital."

Of course, you know the history of us and Miami Field Hospital at 2:00am. So, you can understand why those words were followed by words such as, "@!#$)!" (My word.) And, "Let's go, let's go!" And, "This time, we're going to just drive right thought that gate, whether it's open or not." Oh, yes, and "Get out of the way, you damned dog!!!"

Perhaps it was partially the actions of all of you readers, but this time, when I jumped out of the car at Miami's locked wooden gate, a number of hair-raising minutes later, screaming "Emergency!! Emergency!!" in the dark of the 2:00 night, the guard appeared and immediately opened the gate...no belligerance, no flashing of guns, no political negotiations, no need for Beth to pull the old Duke's of Hazard power-over-the-fence stunt. Just an unquestioning swinging open of the gate. (Wow.)

Within minutes, our patient was in the hands of an OB/GYN surgeon, who immediately took momma into surgery, and delivered a healthy baby boy. Initial APGARS were 4. If you are familiar with that scale, you know that that means baby likely didn't have a lot longer in his mom's belly before this story would have had a very tragic ending.

In return for their surgical support, the Miami Hopital team traded us two actively laboring patients.

"If you can take these ladies off of our hands, we'll do your c-section."

Quite the trade. Beth didn't blink an eye.

Thank God for coffee. And beautiful, talented, don't-take-no-for-an-answer midwives. And volunteer surgeons. And readers who take political action...

Because of you, there are three new healthy Haitian babies in the world today.

Keep these babies in your thoughts. Because they are part of the future of this nation. And they'll need your continued attention and advocacy to have a better life.

Oh, yeah, and the dog...he's okay, too. Probably because midwife Beth learned how to drive in Boston.

The other Boston.

Injustice

2010-03-15T15:50:00.000-07:00

Let me explain to you the anger surging through me as I sit in the back of our pickup truck at 2:00 AM with the limp form of a child draped over my legs.

Travel back with me to 1:15AM.

Whimpering...sobbing....in the gentle, hesitant high pitch of a child. In the distant corner of the courtyard of our hospital, under a tarp. She is trying to be quiet. She knows it is dark in the hospital, and people around her are trying to sleep. Mewing like a small, injured kitten. Tears run down her cheeks. Her legs are pulled to her abdomen. Heat rises off her febrile form, burning. Her lower jaw trembles as a wave of rigors shakes her small body. Blistering fever.

Father looks on with quiet, concerned eyes. He stands above her and watches intently as I examine her in the small circle of light of my headlamp, kneeling beside her cot in the darkness. Her heart is racing. Heat radiates off of her body. I gently touch her abdomen. A small whimper escapes her dry lips and her glassy eyes open to meet mine. Her hand touches mine and attempts to push it away. "Fe mal..." she whispers weakly. "Fe mal..." It hurts...it hurts. I hold her small, protesting hand in my left, and push again gently with my right. Her eyes clench tightly. She sucks in a deep breath and whimpers again. Her belly is rigid. A frighteningly sick child.

"This is very bad..." I whisper to our nurse translator as I administer a dose of morphine. "We need to get her to a surgeon...now."

She had presented to our hospital earlier in the afternoon with high fever, headache and abdominal pain. We tested her for malaria -- which will become epidemic as the rainy season encroaches and the mosquito vectors reproduce in pools of standing water. She was, unfortunately, negative. "Unfortunately", because in Haiti, malaria is a very serious, but very drug sensitive illness which is relatively easily treated when diagnosed. With the easy diagnosis eliminated, the more concerning reared their ugly heads. Typhoid? A severe intestinal illness leading to bloody diarrhea, severe abdominal pain and sometimes intestinal rupture. Early appendicitis? Both requiring a surgeon.

Our pediatrician, earlier in the day, drove with the girl to Miami Field Hospital to consult one of the volunteer American pediatric surgeons. The surgeon evaluated her, and advised that her illness was early, and nonspecific, and that we should watch her carefully, treating for possible infection. This is a common medical practice, even in the United States -- watch the patient closely, and await for the illness to "declare itself" into a specific diagnosis. If it declares, come back immediately.

So, at 1:15AM, the illness declared. Quite vigorously. And absolutely. Intestinal perforation. Millions of small bacteria from the intestines spilling violently into the pristine, sterile cavity of the small child's abdomen. An exquisitely painful and potentially deadly event.

We called our midwife, who lives one street over, and has a truck, begging a ride back to the Miami Field Hospital. Father carried his precious child to the back of the pickup and lay her gently across my lap. And in the darkness of early morning, we drove through the deserted streets of Port au Prince, to the only available surgeon in the city. The heat of her body burned across mine, small moans escaping her lips.

The Miami Field Hospital is located in a series of large tents inside the walls of the Port au Prince airport. It was set up within the days after the 12 January earthquake, and placed to be central and convenient to patients, international volunteer medical providers, and imported medical resources/equipment. From outside, it is a series of giant white tents; inside, a bustling field hospital with a lab, pharmacy, xray, and adult, pediatric and neonatal ICU. It is our -- and much of Haiti's -- only referral center for patients requiring intensive emergency and surgical care, as much of the city's medical infrastructure was destroyed in the quake, and many medical professionals were killed. At present is the last hope of many of Haiti's sickest patients.

At 2am, we arrived at a new entrance to the hospital -- a set of wooden gates recently placed into the concrete wall surrounding the airport. This new, unadvertised, unmarked and solitary entrance to the Miami Field Hospital was luckily discovered by our clinic staff during the visit to the hospital the previous day.

Our American midwife, 20 year resident of Haiti, pulled the pickup truck in front of the gates and sounded her horn repeatedly. The gate was locked tight.

"How can the gates be locked?" I asked. "This is crazy."

She honked the horn again and again, echoing in the early morning darkness. Finally, from behind the gate meandered a man in dark clothing appearing to carry a weapon. A security guard. She honked her horn again. The man did not move.

Our midwife turned to our Haitian translator. "Go tell him to open the gate. Tell him we have a sick child in the truck, and this is a medical emergency."

Our translator exited the truck, running to speak to the man behind the gate. Words were exchanged vigorously back and forth. Finally, he turned and ran back to us.

"He says the hospital has closed, and the doctors have all gone."

I am stunned.

"What? No it's not..." I declare with frustration and disbelief. "No, they haven't left. That's not true. That's crazy!"

Our midwife shares my incredulity. This is obviously a mistake. Just 5 hours ago, the child on my lap was in this very tent hospital, consulting with a pediatric surgeon from USC Los Angeles. A hospital overflowing with patients, volunteer medical staff, and technical medical resources. There is absolutely no way this hospital has closed its doors and evacuated it's staff in the 5 hours since our previous visit.

Our translator turns to our midwife. "You're going to have to show your face," he declares with a mixture of frustration and acceptance.

Translation: You need to show your caucasian, non-Haitian face. You need to play the White Card.

Our midwife-- fabulous, strong, intelligent, compassionate, wielding a beautiful Boston accent (the other Boston) -- gets forcefully out of the car. She strides powerfully and authoritatively to the gate, and in fluent Creole, confronts the guard.

She advocates. This is a medical emergency. There is a dying child in the car. She was at the hospital earlier in the day. The head surgeon saw her. He asked that she return. We are an ambulance from a Field Hospital. LET US THROUGH THAT GATE.

"No," says the guard. "The hospital is closed."

I can see the top of the hospital tent over the wall surrounding the airport. It is illuminated white against the 2am night sky. It is obviously inhabited and operational.

I am growing furious. I am growing desperate. This is obviously a political power play. And we are the pawns.

I call out the truck window in English to our translator. "What's going on? Does he want a bribe? Tell them I am a doctor and the child in the car is going to die and he MUST let us in."

More negotiation. The whimpering form in my lap is breathing rapidly and shallowly. My hand on her chest feels the fever burning through her thin cotton top, and the wild racing of her heart. She moans.

This is impossible. Yet, it is not. It is, perhaps, exquisitely predictable.

Less than a football field away from our truck sits a hospital full of medical specialists. Volunteers from all over the United States, giving of their time to provide free medical care to this city in its darkest hour. On my lap is a dying child. And between us is a wooden gate, and a man with a gun and a political agenda.

The airport authorities have apparently decided that the Miami Field Hospital, which sits on an unused grassy lot on the periphery of the airport, is an inconvience. And this week, after the US military handed back control of the airport to the Haitian government, public access to the only emergency hospital in Haiti has apparently been extremely and underhandedly curtailed. Hospital personnel report repeated efforts to obstruct patients' access to the hospital and emergency care - as we experienced on this night. A new unmarked entrance to the hospital, for example. A locked gate, with a belligerent guard. This political stand off -- so detrimental -- drew the attention of Haiti's President, who commanded the Airport Authority to allow patients through the gates and access to the capitol city's only emergency hospital. This was met, apparently, with political belligerance and opposition. And, at 2 in the morning, the power play is acted out. And the order of the country's Commander in Chief is disobeyed. And we -- the patient and her advocates -- become the powerless victims.

As I sit seething in the back of the truck, I evalute the integrity of the flimsy wooden gate which separates us from the lifesaving hospital visible beyond the trees. It is an absurd barrier of chicken wire and two by fours. I am certain we can crash through it with the truck if need be. My outrage is spurred on by the limp child in my arms. As I plot, I observe that the guard has a gun, and I fear he would be willing to use it. The images of several patients in our care flash through my mind -- innocent bystanders shot when the police fired wrecklessly into the ground around crowds in gestures of authority and intimidation -- striking bystanders with ricocheting bullets.

At this moment, I am impotent in my ability to help this child. We are at the mercy of this political agenda. An argument over a strip of land superceding the value of a child's life. A metaphor for the consequence of political ineptness and corruption.

I imagine this is how it felt on the night of 12 January, in the hours after the earthquake, when the sun left the sky and darkness fell. When the screams of the injured rang out, and access to medical care was, in a moment, non-existent. Hopelessness. Dying patients, in desperate need of surgeons. And no surgeons to be had.

I recall news reports of patients having amputations in city parks by the light of handheld flashlights...without anesthesia. I recall patients telling grim stories of being taken to the remaining local and overwhelmed medical facilities, lying without medical care, in rooms filled with dead bodies, themselves fearing that they would soon become just that -- another body, to be disposed of en mass in the back of dump trucks visible outside their windows. Desperate acts to save lives. Desperate patients. Desperate providers. Reflecting complete lack of access to care.
In Haiti's time of crisis, hope came in the form of volunteer field hospitals -- such as ours and Miami's. At the beginning, lack of medical access reflected the utter chaos of an unprecedented natural disaster. Now, lack of access is caused, in part, by political corruption.

Hints of such corruption were evident in my first week at our field hospital. Still on the forefront of the medical crisis, relief organizations were stunned to discover their medical and relief supplies being suddenly unexpectly being held ransom at the airport...many for tens of thousands American dollars. Donated medical supplies and shelters. For the country's injured and homeless. Provided free of charge from the generosity of the world community. To be utilized by volunteers, many of whom had paid their own way to Haiti to provide relief. Flown in by privately donated charter flights and international military flights. At the request of the Haitian government. Held at the airport and not released without the organizations first paying exorbitant and newly invented importation fees. While Haitians slept homeless in the streets of Port au Prince, enduring early spring rain without shelter; while the President of Haiti visted the White House in Washington, DC, asking for relief assistance for his struggling country... lifesaving relief supplies -- tarps and tents and medications -- sat undistributed in boxes at the airport. Our own hospital had its supplies held hostage for weeks -- including medications requiring refrigeration which sat sweltering in the Haitian heat.

And now, once again, the Airport Authority, blocks access to medical relief. In the form of this flimsy gate, and a man with a gun, who tells a blatant lie: "The hospital is closed. The doctors have left."

What will we do without a surgeon, I ask myself as I watch the negotitations. Turn around with this child? Bring her back to our hospital to die of sepsis?

Our midwife and translator continue to negotiate with the man behind the fence. Finally, they return to the truck. The guard, miraculously, manipulates the lock and slowly swings open the gate.

"Okay, he's letting us in," our midwife says, as she quickly puts the truck in gear, taking advantage of the sudden opportunity.

"Wait a minute," I say. "I thought the hospital is closed and everyone has gone home. Isn't that what he's been saying for the past five minutes. What did you do? Did you have to bribe him?"

Our Haitian translator turns to me. "He's letting us in because she's white," he says matter of factly, gesturing to our midwife. "You have to know how to work the system. It's just how things are here."

I am relieved for the girl in my arms, but absolutely infuriated for the people of this city.

"Wait," I say, as we start down the dirt road to the hospital. "Are you telling me that if I were a Haitian pulling up with a dying person in this car, that I would be turned away from the hospital?"

"Yes," he replied, absolutely.

"And we're getting in because we're white people?"

"Yes," he replied.

I am horrified and infurated by the injustice. But, for the moment, I am grateful for the incidental lack of melanin in my skin which, tonight (and, unjustly, through modern human history), has provided me with this seemingly random political advantage. I am perceived, by the color of my skin, to be someone who has possible political connections to a higher authority, a political democracy, which I can call upon to advocate on my behalf.

And for the local Haitian, who pulls up the the gate tonight with a dying child, without a political advocate? They will likely be turned away.

If you are reading this tonight from the comfort of your home, which fortunately is located in a representative democracy -- perhaps one of the wealthy first world nations which, through your tax dollars, has provided disaster relief to the nation of Haiti -- I ask you to advocate for those who are less powerful than yourself. Use the representative government that you are so fortunate to have peacefully elected, and which politically advocates on your behalf. Contact your congressperson or political representative, and ask that the government of Haiti be held politically accountable for properly managing their international relief; ask that further relief be contingent upon allowing that relief resources be accessible to its people. Ask that relief supplies be released to organizations on the ground helping their injured and homeless. Ask how your tax dollars are being spent, and how they are being managed, in this crisis.

And of course, because you care...you perhaps would like to know the rest of the story.

So, we drove the remaining distance down the dirt path beyond the gate and pulled up to the front of the great white hospital tent. Father took his whimpering child gently from me and cradled her in his arms as we walked together from the truck, exiting the tropical Haitian night, and entering the front door of the still-bustling field hospital. Immediately, we were greeted by a doctor -- in fact, a board certified pediatric surgeon from Children's Hospital in Los Angeles. He gladly took her back into his care.

I guess the hospital wasn't closed after all. And, apparently, all the doctors had not flown home in the five hours since our last visit. I guess it was all just a simple misunderstanding.

Food

2010-03-12T20:47:00.001-08:00

It's 11pm and I'm sitting on the roof of the hospital. Above me are stars. Palm trees are silhouetted in the grey sky in the distance. A gentle cool breeze is blowing. Crickets chirp. The rural dog network sends barks from the east to the west and back. The crazy chickens still crow, although it is dark. The smell of burning tires/plastic/garbage which was so thick in the air today has eased, and the air is briefly refreshing.

I've escaped up here after my bucket bath to wash off the thick layer of dusty urban grime. The cold water was luxurious after the scorching heat of the day, removing a plaque of dirt embedded DEET ridden sunscreen that makes my pale Irish skin appear almost Haitian. Luxurious, that is, until the two inch cockroach ran up out of the drain and scurried across my wet feet.

Why...why...why.

It's just one of those things, at the end of a long, dirty, tiring day that drags a small, poorly-suppressed whimper from my clenched throat.

Ugh.

Of course, it could have been worse. It could have been the banana spider -- giant throbbing bulbous body, pointy spiny legs -- that apparently haunted the shower last week, before some heroic knight in shining armor intervened with a mighty shoe. I'll take the giant cockroach over the massive throbbing spider...but just barely.

There are giant rats out here on the roof, I am told, which apparently climb around and prey on the chicken coops out back, looking for an egg or two. I do hear the occasional scurry and crackling of leaves behind me. I will not turn around to investigate.

A mango just plopped down beside me...too small and unripe, unfortunately, for my own midnight snack.

Mosquitos buzz by, apparently giving my legs some consideration.

Everythings' out looking for something to eat.

Earlier today, we passed a giant line of people on the road to Citi Soleil. American soldiers stood guard, keeping order with impressive rifles. At the front of the line, a Humvee guarding a truck. The precious cargo in the truck? Rice. One by one, Haitians walked away, balancing sacks of USAID rice on their heads. Would the soldiers actually shoot those guns over a battle for a bag of rice? I flash back to the knife fight over tarps witnessed earlier in the week. Yes, this situation could quickly get out of hand.

Food. There is desperation in the lack of this fundamental necessity.

Later in the day, a mad rush of people passed our truck. They followed an unmarked panel truck, shouting animatedly. Men hung off its grill, sideboards, and back bumper, clinging to the rear door....like ants crawling on a jar of sticky honey. What was the precious cargo inside? Food.

Hunger...creates desperation.

Tent cities are growing. They creep up the sides of steep hills, guaranteed to wash away in the erosion of oncoming monsoons. They have spilled out onto the median strips of the main thoroughfares through the city. Spraypainted signs read: "Population 6,000. We need help. Necesitamos ayuda." Growing homelessness and poverty.

Goats line the sides of the road, snouts hungrily picking through discarded bottles and cans, amidst the stench of smoking garbage which has been, for some reason, lit afire. From the top of the truck, I do a doubletake and look down into a pickup truck below...full of dead goats, piled high, legs and torsos askew, heads lolling.. apparently being sold for food. The vendor met my eyes as we passed and laughed at my apparently disconcerted look...pointing vigorously at the goats and then to me.

"Want one?" he gestured.

"No thanks," I replied internally as I shook my head. "I'm trying to cut back on free range, garbage-fed goat..."

I shot him a salute. He bowed at the waist respectfully.

Did you know that newborn baby humans can survive on goat's milk? Apparently the only missing nutrient is folate. Who knew.

Mosquitoes feed on me. They carry malaria, Dengue "breakbone" fever -- a sometimes hemorrhagic, always non-treatable infection; and filariasis -- a microscopic worm which reproduces in the lymphatic system, blocking its flow, and leading to gigantic swelling known as "elephantiasis". I block them with 100 percent DEET. Nevertheless, they breach the chemical barrier and feed on me. I am covered with welts.

Many of the patients downstairs are covered with thick plaques of bumps across their hands, arms and torsos. Chronic scabies. Small mites burrowing under human skin. We treat them...but in this environment, the infection will likely recur.

What a crazy, interdependent, parasitic world, all feeding off each other. Just trying to survive.

Below me, an occasional splash. The tilapia -- an easy to grow, protein-rich fish -- flop about in their small ponds at the side of the hospital.

Downstairs, an elderly woman is dying of pneumonia...the single celled bacteria feed on the vulnerable tissue of her lungs. She has been weakened by the stress of the earthquake...and her immune system appears unable to compensate. She will likely die. We will do our best to make her comfortable, and give dignity to her passing.

Something is rustling in the dead leaves behind me on the roof. Time to retreat to my mosquito-netted bunk. Before I become something's midnight snack.

Please...if you are down there, Mrs. Banana Spider...it wasn't my shoe that squished your son... Really... Honestly.... Can't we all just get along?

Healing

2010-03-09T19:13:00.000-08:00

This week will mark 2 months from the earthquake. And what I am seeing is remarkable.

How often does a medical person encounter such an enormous disaster -- 250,000+ dead and injured, all on the exact same day? I have trained in disaster response, when a car with four victims is overwhelming, an overturned bus of 20 patients a nightmare, and an airliner crash with 200 victims -- impossible. So, now, imagine twelve hundred airliners screaming out of the sky and crashing simultaneously down to earth...and into the poorest, most underdeveloped country in the Western Hemisphere. That was Haiti on 12 January. The airliners crashed and scattered the bodies. 250,000. Most dead. But many not.

Imagine laying in your slum, under a concrete wall, pregnant with both of your legs crushed. One of our patients did... for 3 days. Imagine laying on the ground outside of your home for 12 days with a pelvic fracture...bleeding internally and unable to move. In a city with no ambulance service...and now no hospitals. With no one to save you. Really. Stop and think. 12 days. That's longer than Christmas vacation...longer than your week at the beach. Imagine sitting on your livingroom couch for 12 days straight, immobile, without food. Impossible? Now, imagine doing it on the concrete ground of a dirty slum, your body shattered, sweltering day into smoky cool night, then repeat, ants crawling across your body, malaria filled mosquitos feeding on your dying form. One of our patients did.

Imagine wandering the streets with your injured 11 year old child, his face and eye orbit crushed with open fractures, seeking someone...anyone... to help you...and failing. This child -- now our patient -- finally found help four weeks after the earthquake, a massive orbital infection around his crushed eye. His face was so injured, and so exposed, for so long that when he was finally examined on the USS Comfort -- four weeks after the quake -- they found multiple bot fly larvae growing in the infected tissue around and behind his eye. Imagine four weeks of agony, without care. Wriggling larva burrowing into your open wounds to feed. Imagine if that agony were suffered by your child...and you were helpless to intervene.

Thank God for the first responders who went into the streets. The first volunteers from our field hospital -- who took our truck into the the depths of the slums -- and dragged back devastating injury after injury. Open fracture reductions by headlamp. Kitchen table top amputations. Desperate, life saving, life altering, interventions.

I was not here in the week after the quake. I did not see the initial devastation. But this week, I see objective evidence of their suffering. This week, we brought eight of our patients to another volunteer medical facility hosting volunteer orthopedists. With their imported c-arm x-ray, we were able -- for the first time -- to visualize these patients' shattered bones. In the weeks initially after the earthquake, many victims were splinted and casted for presumed injuries, based on the external appearance of their bony deformities. Xrays were an unavailable luxury. So, this week, for the first time, many of the injuries were defined.

I suppose you don't want to be the patient that causes the orthopedist to suck in his breath and whisper, "My God...look at that." Nor the one that makes him comment, "Unbelievable..." Nor, "No wonder she wouldn't weight bear..." as the c-arm xray scrolls up the leg and reveals a healing but angulated femur fracture. In my 12 year emergency medicine career, I have never seen so many dramatic, devastaing x-rays.

But the magic is, many were healed. Surrounding the matrix of shattered bones, hinting at a pain filled past, cocoons of tough white callous were visible.

"I know it looks awful," said Dr. Steve, the orthopedist, as he glanced at one particularly macerated tibia "but, believe it or not, it's sufficiently healed. Let her walk."

And so, through a translator, patients were told, throw down your crutches.

Walk.

You are healed.

After weeks of immobility, deep aching pain, disability, fear, hopelessness... sweltering long leg casts dragging in the tropical sun... the crippled were set free. And the announcement brought uncertainty and hesitation.

"My crutches..."

"You can walk without them, whenever you feel ready."

Hesitantly, castless feet touch down, lightly feeling cool ground again under now naked toes.

How amazing, yet perhaps not surprising, that when all injuries occur on the exact same day, that healing also completes, for many, on the exact same day.

The same is true for crush wounds. Skin grafts and massive open wounds have started to close. In the truck this week, I removed multiple dressings to find wounds finally healed. After 8 weeks of painful surgeries, debridements, grafts, and every other day dressing changes...many of the wounds were closed.

"Congratulations," I declare, time and again, grabbing a patient's hesitant hand, meeting eyes with a gentle smile . "We're done. You're healed."

Uncertain glances. Tears well in eyes. Hands hesitantly touch thick new scars...getting reaquainted with self, so long hidden under dressings and ace wraps. Tentative...

We, the truck crew, stand. And honor each individual.

"Bravo," we call. Then gentle applause. A pat on a shoulder. Sudden, dawning realization in a patient's eyes. A beaming smile.

"Merci...merci....." they say, repeatedly, as they rise to exit the truck. "Thank God...merci....thank God..."

And so they walk away.... from us, from our hospital, from our truck, from that day... back into their urban labarynth, to start their lives again.

Healing...

Alex

2010-03-06T18:20:00.000-08:00

Alex, one of our truck medics, was thrown in jail this week. When I heard, my first thought was horror. Followed by a sudden guffawing laugh. Alex.

Alex is a 22 year old free spirit from Los Angeles, home schooled kid with 9 siblings -- including a few adopted Haitians. He came to Haiti after the earthquake to help however he could. He wanders the streets of the slums, speaking a mixture of Creole, French and English, wearing a hipster hat with a duct taped bill, cut off khakhi pants, skate boarder sneakers. When he removes his hat, his hair stands on end and askew, about three inches above his head, styled by fingers run restlessly through the strands. He is cool. Not intentionally, just incidentally. A humble cool. A brilliant young medical mind.

He hangs out on the top of our truck as we ride through the streets, occasionally twisting his foot into the metal bars in such a way that he can dangle off the roof suspended by just one leg. He and I have discussed the intelligence of this maneuver (or lack there of), and the accessibility of neurosurgeons (or lack there of), and the distance to the ground if he were to fall. He grins and shrugs. I keep my eye on him. I enjoy when he rides on the right side of the truck roof and I on the left. Because the left side of the truck overlooks the center of the street, while the right side of the truck gets slapped with tree branches and bushes and dangling mangoes growing on the side of the road. There is nothing more satisfying than watching Alex get slapped in the side of the head with a palm tree frond as we make our way through tree lined neighborhoods.

Alex, in his fearlessness, has ventured deeper into the slums than most of us might find comfortable. He is seen shaking hands and tapping fists with strangers, genuine yet casual smile on his face. We call him "the mayor"...a natural politician. And as mayor, he has had the most success tracking down people with orthopedic injuries. He knows how to activate the neighborhood grapevines. And in his ventures into the deeper labarynths, Alex has single handedly found at least four young women discharged from post-quake medical care with poorly healed femur fractures...who without resources, were left to lie on the floors of their homes with no hope of rehabilitation. He found them. And ultimately saved them...as they were returned to our hospital for curative surgery and a chance at a new life.

Alex rode the truck before I arrived in Haiti. So, on my first day in the slums, I was impressed by his popularity. In neighborhood after neighborhood, whether walking or riding, groups of children and young women call out "Alex, Alex!" as we pass. Our security guards mock him, calling out in high falsettos, "Alex! Oh, Alex..." Alex has seven wives in each neighborhood, one of our normally stoic and silent security guards advised me one day with a smile.

Alex likes to dangle by one braced leg off the roof of the truck, and will do so especially when the United Nations tank/truck vehicles drive past us. He enjoys the sudden startled looks on the faces under the blue helmets when he takes his pseudo-swan dive. Gives the poor fellas something to do, he says, as they drive around and around....which is what he's decided the folks at the UN do. They drive around and around in empty trucks. That is their mission in Haiti. Or so it appears, from the top of our truck.

Yet, he can be serious. It was Alex, along with our paramedic Chase and our nurse Morgan, who dragged an unconscious old man out of a drainage ditch full of human waste this week. The old man had been hit and run by a motorcycle. Open skull fracture, cominuted femur fracture....left for dead. And covered in sewage. Alex rescued him. And carried his lifeless body to our truck.

So, it was a bit of a wonder to hear that Alex was in jail. My first thought was, "Why?!!" My second, that I wished I had a cake mix and a file, because I think he'd appreciate the gift.

Turns out, Alex was asked to accompany one of the last remaining orphans from the Heartline Orphanage here in Haiti out to meet her new adoptive family in the United States. The tragedy of the earthquake has sped up adoption processes and facilitated a miraculous lifting of adoption beurocracy. (Alex himself notes that it took his family six years to complete the process of adopting his sister from Haiti.) Unfortunately, several American "missionaries" who chose to illicitly remove children from the country following the earthquake has led to caution on the part of the Haitian government in all subsequent legal adoptions. Now, all children leaving the country require a signature of the Prime Minister.

So, on the day of his departure, Alex was handed an official sealed packet of documents by the folks at the American embassy. Unfortunately, the embassy failed to include the document with the Prime Minister's signature. And, at the airport, with child in hand, documents were inspected, found to be lacking, and Alex was handcuffed and taken away....and charged with kidnapping.

After contemplating baking Alex a cake with a file, and realizing the ludicrous nature of his kidnapping charges, I came up with an ingenious plan. I imagined going to the streets of Citi Soleil and spreading the word of Alex's unjust imprisonment. I was certain, within the hour, I would have an angry hoard of residents en tow to help me storm the jail.

But before I could recruit my hoard, we were informed that Alex had been let go. The Consulate General of the US Embassy apparently went to the jail and negotiated Alex's release. Note, it was the US Embassy's paperwork error that got Alex thrown in jail to begin with. Which is why the comments of the Consulate General were incomprehensible to me. Apparently, the diplomat made something of a scene. He began yelling at the top of his voice, at Alex, in the jail. And bellowed something, to paraphrase, like the following:

"No wonder you were arrested. Look at how you're dressed! Do you think this is any way to dress to take an orphan out of the country?" He continued, "Look at your socks!! White socks? You should wear black socks if you want to represent yourself professionally." Then, finally, "And look at your hair! Do you call that an appropriate haircut?"

Alex, who came to Haiti with a backpack on his back, to serve the poor. No room in his bag for the apparently required tuxedo. Arrested, evidently, for wearing cotton socks and tennis shoes.

Let's be honest. What the Consulate General should have said was, "Look, I am a blow-hard, prejudiced, anal retentive beaurocrat who screwed up your paperwork, got you thrown unjustly into prison, and am now scapegoating you because I consider you powerless and naive enough to fear my ignorant rant. And by ranting, I remove attention from my own incompetent screw-up, and direct it, buffoon-like, in your direction. Do you fear me, politically powerless boy?"

Yes, Alex was freed from Haitian jail. And prejudiciously lambasted for his haircut. The beloved Alex of the slums, who spends his days volunteering in Haiti, pulling dying men from roadside sewers and crippled children from the ghetto. Chided by the second most powerful American in Haiti, because he failed to wear black socks to the airport.

Mr. Consulate General...you should be ashamed.

Thankfully, there is a thing called karma. So, the next morning, a freed Alex tried again. He gathered his paperwork, his small orphan girl, and made his way again to the airport. He still wore white socks and finger combed hair standing straight up atop his head. And this time, had the proper signatures. He boarded a private plane donated to fly 60 legitimately adopted orphans, and their escorts, to new homes in the United States. And delivered his precious package to her new loving home in America.

Turns out, the plane was donated by Sean Penn, actor and human activist. Who himself seems to have lost his comb a number of years ago... Mayor Alex (who'd never heard of Sean Penn, by the way), sat next to the actor on the way to the USA. He told Mr. Penn his story.

"You met Sean Penn?" I asked, when he'd returned.

"Yeah, he was pretty cool."

"Did you tell him what you were doing down here?" I asked.

"Yeah, I told him," Alex said, with his typical mellow humility. He shrugged. "He said I am a hero."

Yes, young Alex. You are.

Shelter

2010-03-04T18:59:00.000-08:00

The rains are coming.

Today we drove the truck through the slums under gray, misty skies. The air is a beautiful 10 degrees cooler. The streets are filled with mudpuddles. And there is an air of hostility. There has been a shift in the morale of this neighborhood....for the worse.

There has been a delivery of relief supplies. Grey tarps emblazoned with the letters USAID are scattered on the streets of the neighborhood. I don't know how they got here, or to whom they were dispursed. There are some. But there are not enough. Our progress is slowed as we creep along amongst crowds surrounding these grey sheets of plastic. A screaming match. One man weilds a 6 inch knife. Another a set of scissors. They argue heatedly, gesturing with their weapons, cutting at the tarp, threatening each other. Other bystanders grab the plastic, and a violent tug of war ensues. Chaos. Over a sheet of plastic. A shelter from the rain. This is desperation. The scene repeats on street corner after street corner.

The tent cities have grown. I am impressed by the human ingenuity. I take note of the clever skeletons of would be shelters being erected on sidewalks and streetcorners. All awaiting a tarp, which will equal simple roofs and walls and privacy and possibly a bit of dignity. A small shred of dignity. And a barrier from the rain, which will soon fall relentlessly for weeks and flood the streets and overflow the garbage filled rivers flowing through the slums.

We make our way to our first stop, outside of a school. We come here three times a week to perform wound care on our regular patients, who somehow learn through the neighborhood grapevine that the truck has arrived, and make their way towards us on their crutches and in their casts. This is where the boy was dropped at our feet with a femur fracture on Monday. Here we practice performance medicine -- always in front of a gigantic crowd of boistrous, curious children, who surround us 4 and 5 deep and watch every move and every dressing change with fascination.

Somehow my identity has been revealed to the crowd, and children and teenagers peer through the metal bars of our truck, fingers poking through the painted metal mesh, and call out, "Barbie...Barbie...." Some of them poke at me through the mesh walls. I am like an animal in the zoo. "Barbie...Barbie. Hello, Barbie," they call, practicing their English. "Barbie...Barbie..." Poke. Poke. I tolerate it for several minutes as I inspect a deep wound. "Barbie...Barbie..." Poke. Poke. Poke. I finally lose it, turn around and say, "Barbie working!! Stop!!" They smile, having finally achieved my attention. "Barbie working! Barbie working!" they repeat. I close my eyes and shake my head with a smile. "Barbie...pretty! I love you!" says one boy of about twelve. Now, that's more like it, my ego says with a smirk. I turn and wink at him. He smiles. I continue at my work.

Suddently the children go silent. A strange sudden, disconcerting peace.

"What's the matter? What happenned?" I jump up and ask. Is it the tarps? A fight? Has someone been stabbed?

The children have left our truck and have moved 100 yeards down the street, circling something. They are silent. Then a sudden cheer is heard, as if in a baseball stadium...As if someone has just hit a home run.

"What the..." I ask, and jump out of the truck. Just 4 days ago, the center of this crowd's attention was a boy with a femur fracture. What can it be today? I arrive at the periphery of the crowd, and discover Morgan, the daughter of the heads of our Mission, one of the nurses on our truck. An all American, caucasian, freckled young woman with curly brown hair, raised in Haiti, fluent in Creole. She is jumping a thick black cable of rope swung rhythmically by two teenage Haitian girls. Urban jump rope. Fantastic. Girls enter and jump a few times, the rope going faster and faster, snapping loudly on the ground. They jump out. Rhythmic. Graceful. Others enter. The crowd is cheering. Morgan, laughing, comes and stands by me and Chase, our Los Angeles County Paramedic.

"Come on, Chase. Your turn."

Chase. An amusingly dry, sarcastic, highly competent paramedic, used to riding ambulance in the depths of urban L.A. Dressed in an LA Fire Department shirt, blue pants and combat boots. His full arm tattoos -- like gang symbols -- gain him more respect in this neighborhood. He shrugs, raises an eyebrow and says, "Here goes..." and jumps into the fray. Three grand jumps of the thick black jump rope. A hero. The crowd goes wild. He jumps out.

"I believe I'm perhaps the first white man to jump rope in the slums of Haiti," he says with great seriousness as he returns to the edge of the crowd. He wears a small smirk of pride.

Three graceful Haitian girls take his place in turn, stylin' at the jumprope. Then it's my turn. I'm pushed towards the rope...one, two...I'm skipping the big cord rope... three, four...Glorious....five, six.....The children are screaming joyously. The serious girls spinning the rope break into great smiles. I exit...exhuberant. Success. I am 6 again for a moment, jumping rope in my driveway with my sister. The children surround me like a sea, and pull me to the ground in a gigantic squirming pigpile. Their strange doctor, behind the cage, has entered their world, and can jump a rope. Squeals and smiles. These are the beautiful moments.

We grin as we drag ourselves back to the truck and climb up onto the roof. The children swarm about us as we slowly wind our way away. Hey youuuuu.... Hey youuuuu...... Their joyfilled cries fade behind us. They point. We point back. Hey you....

The rain begins to fall. We are getting wet up on the roof of the truck. I peer out over the tent cities. Tents made of cotton sheets flap flimsily in the the breeze. Tent skeletons of sticks and wire loom cachectically, tarplessly. Sounds of angry adults echo around us. Desperation. More battles over tarps.... We are all getting wet. All of us. We pass a spray painted sign on a metal gate which is the courtyard to a spontaneous tent community. In English, and Spanish, and French it reads: "Please, somebody help us...."

Food. Shelter. Water.

Absent.

Where are the hundreds of millions of dollars raised by the Red Cross for Haiti Relief? Where are your donations?

Isn't it ironic

2010-03-01T19:40:00.000-08:00

Port au Prince is a city of hyperstimulation. Sounds and smells and sights, some so overwhelming and some mundane. They mix to form a strange, bemusing symphony of irony, cynicism, depression, laughter.... Like a fabulous curry, of never before experienced potent spices... Sensory overload.

Views from the top of the truck as we make our way back to the City of the Sun. A darkly dressed, intimidating man stands with a broad-legged stance in the back of a pickup truck which speeds to pass us from behind on the winding road; he wears a scowl and a pair of dark glasses. I would fear him, thinking him an intimidating gangsta' or security enforcer...until the truck passes and we catch a view of him from behind. He wears a pink backpack with a white Japanese cat drawn boldly on the back. "Hello Kitty!" I call out to him. My colleagues catch sight of him as well, and we all snicker.

We pass a partially collapsed building with the words "God is Good" painted on the front. Someone has climbed up the treacherous balcony and spraypainted the word "NOT" diagonally across the proclamation.

A now lopsided funeral home, with a crumbling facade, proclaims, "We treat death with dignity."

Ironically, a bit farther down the road, a fleet of large shiny-new white dumptrucks. The dump trucks used to remove the dead bodies from the city, I am told.

A sea of faces on the streets as we pass by. Heyyyyoooooooo..... Heyyyooooo..... I feel mildly anonymous in my perch atop the truck as we speed through the city. We pass a US Military HumVee with two tan, blonde, white, All American soldiers in the front seat. I stare at them and wonder what they're up to. From across the wide intersection, one soldier meets my eyes and waves, singling me out of the crowd. I wave back. A familiar face of a stranger from home.

We park at the neighborhood of the plastic bottle river. There is a pig and two children half wading/half floating through the debris. I look down at the bubbling black water and turn to Johnathan, our translator. "Would you like to try kayaking sometime?" I ask. In my mind, I imagine paddling through this sea of trash. Would my Eskimo roll be distrupted by a pig grazing on the floating trashpiles above me? "Uh, no," he says, looking at me with great seriousness. "Too bad," I reply. "I think this would be a perfect spot..."

We are stopped by a man with a rant. "Who do you think you are, coming in to our neighborhood? Do you think we need your help? We don't need you outsiders here." I am sensitive to and respectful of his point. Who the heck are we, this small group of foreigners, wandering through his neighborhood. Are we doing any good here? I think so. I hope so. But I understand his distrust of the outsider. A very human trait. I am reminded of living in Island Maine. If you were not born there, you were considered not from there....or, as the locals used to say, you're "From Away". Today, I am feeling very much "From Away." I am wondering if this community is transitioning through its stages of grief. Is today's stage, at least for some, anger?

We wander to check on a young girl, seen in our clinic two days before for a partial thickness, blistering burn across the entire backside of her dominant hand. It was debrided and dressed by our pediatrician yesterday. Today, she sits on her stoop and stares untrustingly at me. Perhaps because the procedure had been painful, peeling off the dead skin to prevent infection of the wound. I can see a crusting oozing mess which was once the back of her hand; it is now plastered centrally with a bluish/brownish crust.

"Oh, boy," I say to my translator. "That looks really bad...where is her dressing? Can you ask her what happenned?" An exchange in Haitian. Girl still appearing distrustful.

"She says her mother removed your dressing and put goat poop in the wound," said my translator.

"Goat poop?" I say with a near squeal. "Oh, noooo....why???"

"Voodoo..." says my translator.

I want to be openminded to alternative medicine practices. I cannot say that I have read the medical literature and the evidence based medicine on the use of goat poop as an antibiotic burn cream. I have not been privy to the controlled clinical trials. But, my western medical mind takes a pretty firm stance, on gut instinct alone, that this new fangled first aid creme will not soon make its ways to the shelves of American drug stores. I imagine writing that one as a script..."Apply a thick layer of goat poop to wound, BID x 7 days, or until infection resolves, #1, Refill: 2." It's funny. But it's not. Similar practices are performed around the world on the stumps of babies' umbilical cords -- animal feces are applied to dry up the cord; infants subsequently die of tetanus.

Child and family firmly resist offers to return to our clinic for further wound care. They will treat this injury in their way. I can do nothing but advocate gently, and then accept. I cannot force them. But I will return on Wednesday to see if this girl might subsequently need admission for raging cellulitis.

We move on to our second neighborhood. I am now in a funk. Are we making a difference here? I think so. I hope so. I want to respect local culture. I am aware of the importance of that. I do not want to come barrelling in like the ugly American, telling people to do it my way. But I do want to share what I know medically.

An old woman who now sleeps on the ground approaches with trapezius neck spasm. We are seeing tons of this same complaint....likely related to stress and awkward sleeping positions. She wants a pill. I try to show her how to do trap stretches. "Medicine!" she demands. "A medicine will last two days," I reply. "These stretches will last you a lifetime..." She glares at me. I am holding my hand on my head and pulling it laterally. I feel the stretch myself as a warm, satisfying pain down my neck. My sideways stare, like the sideways look your dog gives you when he just doesn't understand you, is met with distain. She shakes her head at me in disappointment and walks away. I am dejected.

We have a busy stop in this neighborhood. We remove 5 casts; tend to 13 healing skin grafts. Bones are healing. Wounds are healing. Perhaps we are not the ugly Americans that a few are perceiving. Would people do just fine if we were not here, I wonder. Are we just arrogant westerners From Away?

A man comes running to our truck, carrying a boy of 10 on his back. The boy is screaming in pain. He is dropped at my feet, and curls up on his side, wailing. We are surrounded by a sea of curious bystanders.

"What happenned," I ask. The boy is hysterical. And sweating. He grabs at his leg... "Why, why why....." he cries. Ironically, the Haitian word for "ouch" is "why". I actually find that a little amusing, a cynical commentary on pain, which is currently too familar to the people of this country.

"Where does it hurt?" I ask, trying to break through his hysteria. "Calm down. Point with one finger where it hurts." He continues to scream.

"Whyyy...why....whyyyyy....."

I try to touch his leg. He violently bats my hand away. He is rolling on the ground. I turn on my authoritative voice that I use for just these sort of patient encounters. The crowd has circled us.

"Look at me," I command. "Stop rolling and look at me."

He opens his eyes and they meet mine. Tears roll down his face. "Why...." he squeaks in a soft whisper.

"What hurts. Point with one finger."

He points to his knee. He watches me nervously. I gently pick up his leg and begin a knee exam. His thigh is dramatically swollen. When I test for ligamentous strength, his knee dislocates easily at a nauseating angle, and I feel bone on bone grinding.

Oh. I'm shocked. How has this happenned?

"He's broken his femur...and has disrupted the ligaments in his knee," I tell my team.

An exquisitely painful injury. Requiring a pretty sudden and massive force to achieve. Also a potentially deadly injury, due to the risk of large blood loss. We've seen too many of these in the days after the earthquake.

"We need to splint him and go now."

The boy begins to cry and scream again. "Why why whyyyy....My mother is going to kill me!"

Ha. Not funny, but funny. In the cloud of pain, he fears not for his leg, but the reaction of his mother. As we splint the boy, mother comes barrelling in, a large, forceful looking woman; certainly potentially intimidating, but nothing but motherly concern in her eyes. The boy does not have an exact story for how this happenned. "Playing soccer," he starts. Then, "I was attacked..." Trying to find the exact story to push mom's perceived anger into sympathy? He settles on, "I was attacked."

I hope he wasn't attacked. He has no details about who might have attacked him, and the story is fishy. I have a feeling he was climbing on something unstable in his neighborhood, amidst the teetering structures, and something fell on him. Perhaps a wall, or a block. Perhaps made unstable in the aftershock which shook the city again this morning. He is covered in sand and grime. Something he wasn't supposed to be climbing. Something his mother had told him, again and again and again. Something teetering, and waiting to fall, yet so tantalizing to a young boy in his very own neighborhood.

We load boy and mother into our white truck and make our way back across the city to the hospital. I kneel beside him on the floor and try to stabilize his splinted leg on the bumpy journey, checking his pulse for signs of impending hypovolemic shock from internal bleeding.

There is no emergency room or ambulance service here in Port au Prince, or so I am told. What would have happenned to this boy if we hadn't been in his neighborhood today? I am reassured that our presence here is still worthwhile.

*****

The Haitian government declared today that they no longer want their citizens to live in their makeshift tent cities. (Note that it was the Haitian goverment that initially encouraged the tent city formations.) Today, after no process of building inspection nor condemnation, they commanded people to return to their houses before the oncoming monsoons. Houses that are leaning forbodingly into streets, and angulated akwardly like my poor young boy's knee. Unstable buildings. With giant, cracks and teetering walls and crumbling ceilings. Houses just like those that we have seen fall, just this week, in the aftershocks of the earthquake. Houses that fall and crush children.

This declaration is insane. And unacceptable. I fear an oncoming second epidemic of "A house fell on me."

If you just smile

2010-02-28T19:01:00.000-08:00

Three of the four nurses I flew with to Haiti left this morning, back to the United States. Beautiful spirits all. Mary and Carol are sisters, who came together to serve in Haiti. Sarah, a lovely young mother from Boston -- the other Boston...my childhood Emerald City Boston. Nurturing souls, found between IV pushes and medication administrations sitting on cots, holding babies, rubbing the backs of elders, hugging casted children. Humble women in bright colored scrub tops covered with hearts and flowers and Tweety Bird and peace signs. Peacefully soft in appearance, solid in a crisis. Our nurses.

Mary, a farm girl from Minnesota, full of surprises, revealed last night she sings in a jazz band. She said she had a dream to sing for the patients before she left.

"You sing in a jazz band?" I asked with a small bit of incredulity at yet another of Mary's hidden layers.

"Yeah," she said simply, with her regular humility.

"Well, what do you want to sing? Sing it for us!" I encouraged, as we sat crosslegged on the beds of our eight-bed medical staff bunkroom, darkness illuminated by a single fluorescent bulb on the ceiling. We leaned in, like teenage girls at a sleepover, in tanktops and scrub bottoms, legs folded up under us. "I want to hear."

She laughed softly, then admitted, "I don't know if I could get through it without crying...singing to all of them..."

"Try with us," I encouraged. "Come on..."

So, she started to sing, softly, a bit hesitantly, but then her voice strengthened to a deep, pure tone. Her eyes lit up. And words, so amazingly fitting for our patients, wafted over us..

Smile, though your heart is aching.

Smile, even though it's breaking.

When there are clouds in the sky, you'll get by...

I imagined her standing in the middle of the courtyard at our hospital in the evening when the patients gather for prayer. Soft spoken Mary. The secret jazz singer. Known only to her patients as the quiet nurse who so effectively cares for them. Breaking into deep, sensual song...A gift, a prayer, for those she has so selflessly been nurturing back to physical and spiritual health.

If you smile with your fear and sorrow,

Smile and maybe tomorrow,

You'll find that life is still worthwhile...

I imagine translating the words of the song to our patients, read in verse. Then have Mary sing, standing small yet powerful in the middle of the darkened evening courtyard. I imagine her patients, sometimes unable to know her true caring, due to the Haitian/English language barrier, finally seeing the truth of her deep feelings for them

If you just...Light up your face with gladness,

Hide every trace of sadness

Although a tear may be ever so near

Mary paused. Her eyes were welling with tears. "I don't think I'd be able to get through it without breaking down..." she murmured with a sheepish smile.

"Oh, yes you will!" I said. "You are going to do this! You will. Keep going!"

That's the time you must keep on trying

Smile, what's the use of crying

You'll find that life is still worthwhile...

if you just Smile...

Hoots and applause filled our bunk room. Hair on my arms stood on end. Mary the Jazz Singer Nurse. With the angelic voice... Wow.

"I don't know..." she said after the scattered claps faded.

"You will do it," I said with certainty. "Tomorrow night. Your last night. You'll do it. I'll make you."

We all smiled as we tucked ourselves into bed.

The next morning, nurse Sarah, who is considering becoming a midwife, and herself had a homebirth several months ago, announced that she wanted to help birth a baby before leaving the country the next day. Sarah had helped with our first challenging 3 pound, 17 day old neonate in distress, and demonstrated herself to be a competent, shakeless powerhouse. Another sweet on the outside, steely strong nurse on the inside, confident presence in a medical emergency.

"Oh, Sarah," I laughed. "You're gonna jinx us."

"I hope so," she said, and wandered away.

So, no great surprise, at change of shift at 7pm, a knock came at the large metal door at the front of our courtyard. Johnathan, our medical student turned translator, came running into the nurses station. "It's a lady having a baby! She's in labor! She's having a baby!"

The nurses and I looked at each other with raised eyebrows. Sarah folded her hands excitedly in front of her, a giant smile on her face. I shook my head in bemusement.

"Geez, Sarah," I said, "Will you now wish that I will win the lottery?"

A strikingly beautiful Haitian woman walked in wearing a flowing sundress, prominent pregnant belly attracting our attention. She calmly sat down on a cot as vital signs were taken. Only a small occasional grimace and a clenching of an eye indicated the pain of the labor, contractions 2 minutes apart.

A history was taken. Yes, prenatal care. Third pregnancy. Otherwise healthy. Laboring for 4 hours. Hoping to deliver with a doctor present -- not a common service available in Haiti, particularly after the earthquake.

Beth, our local midwife, examined the woman and recommended that she proceed to the birthing center, a few buildings down the street, where she is set up for traditional midwifery births. Nurses Sarah, Mary and Carol offered their services. As did I.

"Do you think you'll need any help? I'd love to help, if I'm not in the way," I said.

Ruth enthusiastically welcomed my offer to assist her. Our pediatrician Jenn also committed to being there in case of emergency.

So, the gaggle of women made their way to the birthing center. We changed into scrubs while the beautiful mother-to-be changed into a bright pink soft cotton t-shirt. Her gigantic pregnant belly protruded majestically, and she held it in her hands, eyes closed and quiet, riding out the intermittent labor pains.

I have never seen such a calm labor. Obviously painful, but most pain internalized. The occasional curl of her toes, or a small squint of an eye, a small unsuppressed grunt, a contraction of her pregnant abdomen, demonstrated the progression of her labor. But otherwise no external sign at all. Once again, the Haitian woman revealed what is appearing to be a gender specific and culturally nurtured ability to accept and process the deepest of pain that would leave lesser women (a.k.a. me) writhing and bawling and screaming for an epidural. Amazing strength. Built from a life requiring amazing strength, day after challenging day? Is this the type of pain the stoic women in our hospital endure as they relearn to walk on jagged femur fractures and pelvic fractures?

Five sweltering hours later, as a soft rain fell outside in the darkness, lovely mother squatted, then knelt, then lay supported in the arms of Jazz singer Mary, who from behind dabbed her face with a cool wet cloth, gently messaging her back. Then on all fours, then on her side, then squatting, then pacing. All the while silent. Father sitting in a seat next to the bed, likely overwhelmed by the estrogen swirling around the woman. Though unknown to us, this woman was taken into our care, like a sister. Held, like a sister in a universal and timeless tradition of birth. Back rubbed, legs messaged, brow wiped, whispered support. Doppler checks of baby's strong heartbeat...consistently strong and quick through contractions....a good, strong baby.

Dad was asked, "Do you want a boy or a girl, papa?"

Perhaps intimidated by the 6 sets of female eyes now pinning him to a decision, he smiled rather sheepishly and said, "Whatever....it doesn't matter." And shruged his hands. The women made approving sounds. He was off the hook.

The nurses in this room were not unaware of the metaphor revealing itself on this night, their last night in Haiti. The symbol of hope, in this natural experience of birth. I sat next to Mary on the bed, who sat behind mama, gently rubbing her shoulders in anticipation of another painful contraction. I fanned them both with a clipboard. I looked at Mary and catch her eye, and began to hum her song. Mary smiled, and we hummed together. Then she began to softly sing, "Smile...though your heart is aching..."

More time passes. It is 3 am. Mama is tiring, but labor is progressing. Now, a few moans escape her stoic facade. Then a gush of water. And an acceleration of labor.

Pushing, straining. Nurse Carol places a hand into mama's birth canal, and says, "Oh, I feel soft hair." Smiles all around. A tired smile on mama's face. Straining. Carol places hands gently at the perineum, and with another push, baby's head appears. She is suctioned. There is no cord about the neck. Another push and the slippery baby is out. A vigorous cry. A girl.

She is laid over mama's still swollen belly and we dry her vigorously. I have been placed in charge of baby's care, with Doctor Jennifer available in the room next door. I examine baby for signs of health. Initially pink, a good strong cry, and a fast heartbeat. Then, within moments, a dusky blue hue, no crying, slowed respirations, slowing pulse. No, I say. This is not how the metaphor ends. No.

Baby turns blue. We stimulate her with rubbing and foot flicks. We turn her over to open her airway. In a true medical clinic, we would have blow-by oxygen, but not in our small Haitian birthing center in this post-earthquake Haiti. We suction again. We pull out a pre-prepared ambu bag and breathe for baby, hoping to support her ventilations. Her heartrate drops further. The rule is, oxygen and bagging for heartrate below 100. CPR for heartrate below 60. Despite bagging, baby's pulse drops. My own accelerates. As a rule, it is bad when the healthcare provider's pulse is faster than the infant's. Time races. Our nurse gives artificial ventilations as I quickly initiate chest compressions on the now sickly blue baby. My thumbs cross over each other and squeeze baby's chest between my hands. "Get Dr. Jenn," I say with urgency as I stare down at the fragile bluish form, pumping her heart for her through the soft ribs of her small chest.

"Come on, baby..." I urge. I am reminded of just one week ago, and the 3 pound baby that was dying in front of just this very team of women. "Come on, baby..." Dr. Jenn appears. We continue ventilations and compressions. Seconds of purple lifeless baby stretch before us. No. This is not going to end this way.

Baby begins to perk up. Small arm motions. A cough. A weak cry. Pulse climbing. Stop compressions. Pulse 100. Stop ventilations. Baby breathes on her own. Her color pinkens. Now a vigorous cry. Another, louder cry. Female eyes meet each other once again over baby's now pink form, and deep sighs echo in the small birthing room. Eyes close briefly with relief and thanks.

Mama, who doesn't speak English, lay calmly as we fought for her baby's life. I believe she was unaware of the near crisis averted.

Again, I wonder what would have happened if this birth had occurred on a floor of a home, without medical support. Would the knowledge of the local women, and years of home birthing experience, have been sufficient to save this baby's life? Or would this have been another infant death?

"Okay, Sarah," I say, as she swaddles the newborn and cradles her in her arms. "Looks like you got your wish. You birthed a baby." It's four a.m. And the same women who stared down at the devastation that is now Port au Prince from a charter jet just 10 days ago, now coo and cuddle a pink newborn child. A fitting end to a fitting journey. A metaphor for new beginnings.

As she cleans up the evidence of the labor now passed, nurse Mary begins to quietly sing...

You'll find that life is still worthwhile..

If you just....

Smile.....

Hey Yoooouuu

2010-02-26T19:24:00.000-08:00

This week I have been assigned to be in charge of the health care on "the truck". Our truck is a white flatbed with a roof and benches, enclosed by a cage -- not unlike an open air circus car. The roof is accessible by ladder off the back, and up on top, the best views of the city are to be be had.

Our truck goes deep into the slums of Port au Prince Monday, Wednesday and Friday. We are seeking out patients who would otherwise not have healthcare. The abject poverty here is beyond one's imagination. If you have seen Slumdog Millionaire, your mind might have a vague idea of what I am seeing. And most of the astoundingly squalid living conditions predated the earthquake of January 12th. The neighborhood, Citi Soleil, translated "City of the Sun", is broken into districts, including, ironically for an east coast native, areas called Brooklyn and Boston. As a child growing up in New England, Boston was the emerald city of my imagination, where we would journey for amazing adventures, like the aquarium and the Museum of Science. Now, when we say, "Let's head to Boston," my brain jolts; Boston don't look nothin' like this.

Shanty town. Cinder block walls and corrugated roofing interconnect into an exotic human beehive. A "river" runs through the neighborhood, perhaps 20 feet wide and filled 8 feet deep with plastic bottles, broken glass, garbage, human waste. Pigs wander over the floating garbage heaps in the river, rooting beneath bottles with their noses to find tasty morsels, like discarded chicken heads. A small girl walks with a white plastic bucket, presses it down into the garbage, and pulls out a blackened sloshing potion. She drags the bucket towards a cinder block enclosure. What is she doing with this water? Perhaps mixing it with formula to feed a new born baby sister, whose mother has learned through the miracle of billboard marketing that instant formula will make her baby plump and healthy...and so she discards the breast? Why doesn't the billboard mention that mixed with blackened riverwater, with pigs grazing on top of floating plastic bottles, this formula may cause infant death?

City of the Sun was once ranked the most dangerous city in the world, controlled by a network of violent gangs. In the past decade, it has become less dangerous, but is definitely still a place to enter with respect and vigilance. Today we drove to our first stop and climbed out of the cage of our truck and began to walk down a cement walk, trash river on our right, tent city on our left. Our small medical team is escorted by our Haitian guard. He is a pleasant, authoritative man, who speaks some English. He has told me he is from this neighborhood. He walks with authority along the cement footpath. He is given respect by the people, many of whom sit on the steps of their oven like homes in the blazing February sun. We have been told if we walk with him, we will be safe here. And we are. I don't know who he is, but I do know, to these people, he is someone. And I walk with him.

Adults stare with flat eyes as we pass by, but when I say a soft, "Bon jour" their eyes alighten and smiles meet their faces. The children, fearless, walk up and grab my hands and walk with me.

"Hey you, hey you" they call out in English.

"Hey, you!" I say back and point at them. They giggle. Some follow us on our journey.

Little boys run up to me with fists clenched in a greeting; I clench my fist and strike mine to theirs. They then strike their chest. So, I do the same. They find this very amusing, and look at each other and laugh. So do I. Little girls run past and touch me with their hands. I turn and make eye contact and they smile. One small child touches his hand then points to me.

"Blanc..." he says, pointing at his skin. "Blanc..." Translation: "Who's the white girl walking down our alley?"

We are greeted with nothing but respect. I am so grateful for this experience of Haiti. An experience of kind smiles and respect and gratitude, even in the depths of this slum. We are on a hunt for patients with casts and metal external fixators that hold shattered bones together. So many of these residents in this cinderblock shantytown experienced crush injuries. How many times have I read as their chief complaint in their medical notes, "A house fell on me...." or, "A wall fell on me." The evidence is here in this neighborhood. Today, two small cinderblock houses have been flattened, lying strewn across the garbage river and onto the walking path. On Monday they had stood erect. They were flattened by the aftershocks that had awoken me from sleep 2 nights ago. Tarps have been erected, emblazoned with painted words, like USAID and Red Cross. Families sleep inside -- elderly and newborn. Some shelters are mere cotton sheets, which will disintegrate in the oncoming monsoons. But the decision to sleep outdoors is, for some, the right decision, with teetering buildings and walls surrounding them.

We find a boy in a cast extending down both legs and up his torso -- treatment for lumbar fracture and lower extremity fracture. It is a bright green happy color, now grimy from the dirt. We find a young woman walking on a painfully deformed ankle -- having never received care, six weeks after her injury. Another with a cast.

"Who put this cast on," I ask.

"I don't know," said the young man.

"What did you break?" I ask.

"I don't know," said the young man.

I inspect the cast and imagine the fracture it contains. And here is the epidemic we seek. People treated in the days after the earthquake by goodwill filled international surgeons and released to the streets. We find one discharge summary which reads, in Spanish, "Follow up with your orthopedist in two weeks." Yes, follow-up with your orthopedist. If you are literate and can read this note. And can speak Spanish (which you don't, because you speak Haitian Creole). And can afford to see an orthopedist. And can afford to take a taxi to his office. And his office is not now 5 feet high because it collapsed in the earthquake.

In other words, we are now seeking out the patients who now are 6 weeks into healing, trapped potentially indefinitely in fiberglass casts and surgically placed metal fixators that protrude from their skin and track bacteria back into their bones. Orthopedic surgical cases who have no follow-up, and who are therefore destined for infection and possibly even death in these squalid conditions. In each neighborhood we gather these patients, clean their wounds and skin graft sites, take care of their jutting orthopedic hardware surgically implanted into their bones through their skin. We find these patients by walking through the neighborhoods, asking if anyone in the neighborhood has a cast, or crutches. We sit on top of the truck and drive through the neighborhoods, hunting for bright colored fiberglass casts.

On this day, in our hunt for a woman rumored with a leg fracture, a man calls out that there is a woman down the alley who gave birth last night, and that she is having severe pain. So, with our guard to guide us, we wander down the concrete path, take a footbridge over a garbage river, and wind our way through the labyrinth of cinder block lined narrow footpaths which is the slums. We pass a woman chopping the head off a chicken, and come to a small darkened door. Inside the oven-like one room home, a woman lays supine on a bed, holding her belly. Her new infant child lays sleeping by her side. Through a translator, I ask how she feels.

"Fe mal," she moans, rubbing her abdomen. "It hurts."

She is feverish. Likely uterine infection. Her baby is sleeping.

"Have you breast fed your baby?" I ask.

"No," she says. "I cannot make milk." Images of formula made with black river water flash in my head.

My nurse colleague checks the baby. Slightly tachycardic -- from mild dehydration, or early life-threatening sepsis? We take mother and child, and backtrack through the slum. If the man had not alerted us to this woman's presence, it is very possible both mother and child would have succumed to infection, and possibly, ultimately, death. We walked her to our truck -- as she, with dignity, refused to be carried -- and drove her to our courtyard tarp hospital. Two lives, possibly, saved.

We head out again to the slums. This time, we ride on top of the truck in the open air. We need to be careful for the occasional low-lying power cord and errant tree branch which could knock us off our stoop, but from here, we again see another Haiti. We can see over the concrete walls from this vantage, into tent villages behind. From Monday to Friday, the tent cities have grown. Probably due to the frightening aftershocks. We pass bustling streets, with many street vendors -- some of whom have set their sidewalk shops just in front of teetering buildings. One more unpredictable rumble and more "A house fell on me" notations will appear in the medical charts.

"Hey you, heyyoou, heyyyyoooooo" children call out in English and point. I decide my new name is Hey You.

We stop in four more neighborhoods. Our truck is recognized. We are "the doctors". Children and adults and elders limp towards us, some with crutches, some carried. We perform their every other day wound care on healing legs with horrific wounds. Dark Haitian skin reveals the white scarred extent of injuries already partially healed. So many, many scars.

We are called to a medical tent run by a young Italian pediatrician. She speaks to me in Italian, and then when that fails, Spanish. Spanish! My lips open, and I am communicating with an Italian physician in Haiti in Spanish. Fabulous. She points to an elderly woman -- skin and bones -- slumped against a pole. Her son sits at her side.

"She is very ill, and I have no way to take care of her," tells the Italian woman. "I can only care for children."

I tell her we will take this woman, and that we will be back every 2 days, and will take anyone she finds needing adult or orthopedic care. We shake hands and each nod a respectful, "Adios." How did she get here, I wonder. I wonder if she wonders the same about me.

We lay the elderly woman in a stretcher and lift her into our truck. She is too weak to lift her arms. She is starving. She is dehydrated. She is feverish. She appears to be dying. She opens her eyes and stares at me. I have a plastic bag of emergency relief water. I cut off the end and pour trickles into her mouth. She drinks thirstily, her dark hand over my pale one. I take her other hand and hold it as we work our way through the streets back to our hospital.

From the squalor of her slum, we carry this woman into our courtyard. In fear that she has tuberculosis, we make her a small tarped area of her own on the distant part of the yard. We choose a spot next to a cluster of palm trees. A wondrous campsite, in my experienced camper's eye. By now, it is nighttime. The patients have begun to sing their evening prayers, a mixture of song and energetic rhythmic spiritual clapping. By the light of headlamps, my nurse colleague Deb and I draw blood, start an IV, and do basic lab tests. A swab of her inner lips and a two minute test reveal this woman has HIV. Likely AIDS. Likely TB. And is on the verge of death. We get her a warm blanket for her nocturnal chills. Nourishing fluid enters her parched body. She rests comfortably in our clean, warm courtyard, palmtree swaying above her, beautiful Haitian song wafting gently about her, warm tropical breeze wafting past. If she dies tonight, I am glad that we could give her this night in this peaceful world of our beautiful makeshift hospital.

Through a translator, I speak to the weak old woman and her son. "I don't want you to feel bad because we've placed you away from the others. You have an infection, and we don't want to possibly spread it to others. It's not that we don't like you..." I said, holding her hand.

"No," said the son. "No. We know. We understand. You have already demonstrated your love."