Tuesday, December 28, 2010

Real Food-What to Eat and Why

I have my new son-in-law to thank for a holiday gift that begs sharing with everyone.  Real Food-what to eat and why by Nina Planck, published in 2006, is a gem of a resource for anyone who feels confused or wants to have much clearer guidelines about what to buy and eat and what to leave on the shelf.  Endorsed by Michael Pollan for its persuasive and "eye-opening" qualities, Planck takes us back to the days of "real" food.   By this she means foods that are old, that we humans have been eating for a long time. And she also means foods that are traditionally prepared "the way we used to eat them."  One of Pollan's food rules was to avoid foods your grandmother would not recognize.  Planck goes further to endorse local and seasonal fruits and vegetables(goodbye to the perfectly unblemished and insipid winter raspberries from god knows where); whole grains (goodbye to white flour and many of those holiday treats we just downed aplenty);and fats and oils should be unrefined (goodbye to margarine, "I cant' believe it's not butter", trans, hydrogenated etc--welcome home EVOO!).  The book is chock full of information, resources, and convincing documentation. We can all challenge ourselves to Planck's lessons that will help us ring in the new year with real, delicious foods to keep us healthy in 2011.

In this same vein, schools can participate in new awareness about healthy eating through  Real Food Challenge which carries the same name and adheres to much the same principles.
Bon Appetit!

image from WebMD.com

Wednesday, December 22, 2010

Why I Love Minnesota

image from Edmonton.ca

Wanting to read about the UConn women's  marvelous basketball victory I leafed through this morning's New York Times sports section only to be drawn to photos of kids playing hockey.  Since I have brain injury and sports related concussion on my mind these days I read on.  It turns out that some of the Minnesota Youth Leagues--including those in the town where I grew up--have instituted a simple and effective way to minimize injuries and to increase enrollment at the same time.

We have been listening to the NFL grapple with ways to make football safe and school athletic departments are working to lessen the impact of head injury.  Now the Hockey Education Program (HEP) from Minnesota shows us how.  By simply instituting a system of the "fair play point" which is "an extra point in the standings awarded teams, win or lose, for each game in which they take fewer than a designated number of penalty minutes," they have managed to reduce penalties for hits to the head from 12.4 per 100 games in 2004-05 to only 2 per 100 the following season.  In addition, checks from behind which can lead to concussions as well as spinal cord injuries declined by two thirds.

In Quebec where a similar program was implemented in the 1990's they have not only succeeded in documenting reduced injuries but have increased youth registration. I am not surprised since on more than one occasion I have had a despondent boy in my office looking for a way to get out of hockey as he advanced to the older teams where checking and real injury became too threatening.

Coaches to champion teams in Minnesota say they can see that players who have been raised on this new approach to the game play in a more "effective" and elegant as well as safer way.  Minnesota players are being recognized as being better players where "lazy penalties and the dumb penalties and the stuff after the whistle" is no longer a distraction from the real sport.

It seems to me that all sports might take a lesson from the Minnesota playbook and realize that we can teach our athletes to do well in their sports without jeopardizing their futures.

Tuesday, December 21, 2010

College Students and Mental Health

A story in the New York Times this week highlighted the fact that many students on campus are seeking mental health services and sometimes overwhelming the system.  This article touched on some of the reasons that colleges seem to dealing with a great deal of psychological and psychiatric issues in addition to the usual mono, strep throat and exhaustion that are the more mundane problems they see.

Just a year ago the Journal of Adolescent Health published a review article of the research to date about this very subject.  Some interesting findings include:

  • 17% of students in a national survey of 26 colleges and universities (the Healthy Minds Study) met the screening criteria for depression.
  • increases in help-seeking behavior (rather than increases in mental illness) contribute to the perceived rise in mental health problems among college students 
  • there is an increase in severity of problems presenting to student health services.  The researchers attribute this to the fact that more students with more severe (and often previously diagnosed and treated) mental health problems are applying to, being accepted at and matriculating in colleges.  Increased access during adolescence and improved outcomes with current medications make it more likely that students will be able to function.
  • In spite of this studies show a high prevalence of untreated mental illness.  Only 24% of those diagnosed with depression were receiving treatment. 
  • financial constraints are rarely a barrier to care for college students since at least the first encounters are covered by student health insurance.
  • Improved faculty, staff and student training will be necessary to steer suffering students toward help and prevent tragedies.
Sometimes, student health and the resources they bring to bear at college are not enough. Many young adult patients come home each year and need to re-group, find treatment, start medication, gain weight or simply make a new start.   In New York City, Columbia Presbyterian has an excellent program for college students who have been asked to take or have decided to take a medical/psychiatric leave.  Called the Columbia College Student program it is group based and problem oriented, allowing like minded students to have a place where they can learn new skills and support each other during their transition back to health.

Colleges are in a uniquely effective position to detect, diagnose, treat, and refer students for treatment of mental health disorders, many of which emerge during exactly these years of late adolescence.  Although there is much work to be done, many innovative programs and initiatives are being studied in hopes of creating a better safety net.

Thursday, December 16, 2010

Paying Attention to Attention

At this time of year when students start streaming back from college for break, I usually have a few who come in to ask for medication for their newly (self-) diagnosed ADHD.  What has usually happened is that they have just gone through reading week  and final exams and have discovered that the ten bucks they shelled out for their roommate's Adderal did a lot to help them focus and stay up all night to write the final paper in Sociology.  Usually these are students who were never prescribed medication before,performed well enough in high school to go to college, often are risk takers or adventure seekers and  get insufficient sleep. And rarely do they have ADHD.  Frankly, this group is not the one that makes me worry about missing a diagnosis.

A recent article in the New York Times by Dr Perri Klass highlighted the over-use of the ADHD diagnosis and the current trend toward blaming difficulties in focussing on our fast-paced, internet-based culture.  She makes passing  mention in the article of the "inattentive-type" ADHD student who often passes right under the radar.  This is the group of patients and students that concerns me most.  These students are more likely to be girls than boys, more likely to have been missed for a long time because they do not cause trouble. They are the "quiet daydreamers, slow, distracted, and forgetful," as described in a recent article in Pediatric News by Dr. Barbara Howard of Johns Hopkins University.  The concern with these inattentive-type ADHD patients is that they need a careful evaluation to rule out other causes of their dysfunction.  As Dr Howard states, "far and away, the most common missed diagnosis and frequent bedfellow of inattentive-type ADHD is anxiety."

And this is the story that I most frequently uncover in practice when a student approaches me with a request for stimulant medication.  There is usually an underlying problem of anxiety, drug use, sleep deprivation, or real life concerns over family matters.  Only a careful assessment can uncover whether a student has these issues going on which need sorting through or whether indeed there is a diagnosis of ADHD that has been overlooked.  In any case they deserve our attention!

image from newyorkdailynews.com

Wednesday, December 8, 2010

ImPACT testing now available in my office

I am now doing my part to protect the heads of athletes in our community. As a Credentialed ImPACT Consultant I can now administer and interpret the test in my office.

ImPACT testing is a quick and easy tool to use in conjunction with careful evaluation and examination of athletes and others who may have sustained a head injury. It is well known from the recent flurry of coverage in the media that concussions are more common and more difficult to manage well than heretofore imagined.   I have posted many pieces on this site about the evolution of our thinking on this subject. Just yesterday, Governor Christie announced  new legislation in New Jersey that requires all school districts to create a policy to address the issue.

ImPACT is a twenty minute, online test administered and interpreted by a trained professional. In the NHL, NFL, many schools and other sports organizations, it is administered as a baseline during pre-season and then used to help determine when an athlete's visual memory, reaction time and verbal memory have returned to normal following an injury. In many cases this objective information is invaluable in helping to determine when it is safe to return to practice, competition and play.

My adolescent medicine training is particularly helpful in making these decisions. The importance of sports and team membership in building a strong sense of well-being cannot be underestimated. At the same time, it may take an objective professional to keep an eye on long term health and goals. Many complex factors go into this decision: parental concerns, family's tolerance for risk, previous injuries, school policies, objective medical information, school functioning, role on the team, success of the team and pressures from the coach to name a few. 

Anyone interested in ImPACT testing through my office can find more information on my website or can call my office. I am happy to consult with students and families even if they are not currently patients in my office.  Many insurance plans cover ImPACT testing.

Monday, December 6, 2010

No Child Left Inside: Letting Nature Nurture

After we talk about excessive online activity and obesity in our young people, let's think about getting our kids back to nature.  At the recent annual meeting of the American Academy of Pediatrics the keynote speaker was Richard Louv who makes the case for getting our kids outside.  He has coined the phrase "nature deficit disorder" and on his website, Children and Nature, he cites scientific literature and posts oodles of opportunities for kids to get outside, no matter where they live.  There is even a downloadable prescription pad for pediatricians to prescribe outdoor play. It says:
  • Go outside and play in nature.
  • Limit your “Screen Time” to no more than 60 mins each day.
  • Read stories about nature.
  • (Or have someone read them to you.)
Another speaker at the same conference enjoined listeners to help parents have permission to "bring back boredom" to allow kids to daydream and be more creative.  Planting seeds, playing in the snow, looking at the sky, listening to the birds, smelling the air: it doesn't have to be very complicated.  What seems "boring" will feed the imagination if we allow it to speak.

We are all searching for ways to treat the anxieties that we see in our patients, students and children.  Many agree, at least anecdotally, that too much time is spent in sedentary activities.  A recent survey by the American Psychological Association on stress noted that "tweens and teens report that they turn to sedentary behaviors to make themselves feel better when they are really worried or stressed, such as listening to music (36 percent of tweens and 66 percent of teens), playing video games (56 percent of tweens and 41 percent of teens) or watching TV (34 percent of tweens and 30 percent of teens)." 

Perhaps the panacea lies in the notion of getting kids off the couch and into the outdoors.   This may afford them the best chance of avoiding the metaphorical "couch" treatment for their mental health. 

image from www.greenloudon.wordpress.com

Sunday, December 5, 2010

Staying Connected in a Fast Paced World

 The iConnected Parent by Barbara Hofer and Abigail Sullivan Moore is a new  must read for any parent of high school seniors or college age students.  And  parents with children of any age who want to learn more about contemporary commnication habits may want to take a look as well.  The book reveals the blessings and pitfalls of our current electronic connectivity and its impact on young adult development. "iConnected Parents...represent a new era in parenting:a potent new mix of devoted parent, guide, and friend, fluent in speed-dial, Facebook, and the flick of a mouse."  They explore the continuous tether that links our kids to us in ways that were not possible when most of us were their age.

Hofer is a professor of psychology at Middlebury who has researched the link between parent-child communication and the development of independence in adolescents and young adults.  Moore is a journalist and frequent contributor to the New York Times.  In this book they present a compilation of some research and some investigative reporting with many interviews of students, parents, and administrators who have a range of opinions on the issue.

A few highlights:
  • Families of the college students interviewed communicate one way or another an average of more than 13 times per week.
  • Parents are intervening in course selection, paper editing, negotiations over grades, and roommate concerns in ways that college administrators find distressing if not illegal and unethical.
  • The new connectivity between generations can stir some complicated involvement that not all parties find helpful or healthy.
  • Parents need to be better listeners and not problem solvers.  Having easy access to advice with one click may serve to increase anxiety in parents as well as kids.
  • Dependence on and easy access to Mom and Dad does not foster resilience, patience or self-reliance.
  • These new relationships are so pervasive now that it may be the start of a new inter-generational norm, heretofore not experienced in American life.
My criticisms of the book include the fact that the research is presented in a thoroughly unscientific and unquantitative way.  Not nearly enough thought is given to Facebook and how parents should manage their accounts or interFace with their offspring.  Finally, although the subtitle of this book involves the word "college" I wonder about the conncectivity between non-college bound students and their parents. It would also be interesting to know more about the effect of socio-economic and ethnic backgrounds on the issue.

To its credit, this book has one of the best chapters I have read on mental health issues at college.  Not surprisingly, the bottom line when a child is struggling in this way is that communication and connection need to go way beyond the one on one parent-child and include key professionals.

Finally, this is a wonderful book for grandparents to read who often feel left out of modern communication but at the same time marvel at their family's connectivity.   Having a generational perspective on this can help all of us carefully define what the "new normal" should look like so that everyone benefits in the long run.

image from bbc.co.uk

Wednesday, December 1, 2010

Vitamin D Craze Bites the Dust

Nutrition label.

A word of caution.  Whenever a new test, treatment or diagnosis seems to be making the cover stories on the magazines at the grocery store, be wary.   With titles like, "the diagnosis your doctor probably doesn't know about", we are led to believe that we need to jump on the bandwagon.  Frequently these recommendations have something to do with nutrition.

Yesterday the Institute of Medicine announced that the validity of the recent fad to test and treat for vitamin D deficiency is questionable.  It never made sense to me that over 80% of people were allegedly deficient in this vitamin that is nearly ubiquitous in dairy products and can be made in our bodies naturally if we are exposed to sunlight.   (Interestingly there is an article in the same New York Times 11/30/10 issue that discusses the deficiency of active outdoor time in our population.)

Several months ago my own physician sent my blood for a Vitamin D level inspite of the fact that I told him I would not take supplements since I spend at least an hour outside five to six times per week.   Of course I fell in the 80% of Americans who test low for this particular value.  And the test cost over $200.  My theory is that we really do not know yet what exactly we are measuring and what its relevance is to actual Vitamin metabolism in our bodies.

This is just one more lesson to all of us, including physicians who order blood work, to be circumspect about recommendations and to wonder whose idea they are, who is benefiting and above all to ask the question: "Where is the data?"

image from jmarbach.com

Sunday, November 28, 2010

Special Siblings

Again, siblings of kids with unusual needs are in the news.  Today NPR broadcast "Siblings of Sick Kids Learn a Life Lesson Early" which you can listen to here.   This brief report is about the issues that face families where there is a child with a difference.   These differences include chronic disease, mental illness, and developmental disabilities.

When young, siblings may feel "caught outside the bubble of the family world" where the medical and social concerns and crises of a sib might "trump regular kid concerns" like birthday parties and sleepovers.  Although one might expect kids to sometimes feel neglected or jealous, in the long run research shows that they show a strong capacity for empathy well beyond their years.  And this empathy ultimately informs many of their life decisions.

The broadcast showcases a support group at Vanderbilt University that allows teens to come together to share their experiences, concerns and worries with other families and peers.  The findings may come as a relief to parents who feel they may have "almost missed (the healthy child's) life," as one mother admits.  Those of us in the professions that know and care about such families need to advocate for more attention to the concerns and support for the special qualities of the siblings.  Often the next generation of caregivers and professionals come from their ranks.

image via Google from Corbisimages.com

Monday, November 22, 2010

To Eat or Not to Eat:living with anorexia nervosa

Brave Girl Eating: A Family's Struggle with Anorexia
As a physician who frequently sees patients with eating disorders, I am always looking for a better book to help parents learn about ED and pilot them through very destabilizing times.  Harriet Brown, a journalism professor, writer, blogger and mother, has written a very personal story.   Brave Girl Eating:a family's struggle with anorexia, follows Brown and her family as they learn about and manage her daughter, Kitty's, anorexia.   Specifically, Brown chronicles her research and the practice of appyling family based treatment (FBT) also known as  the Maudsley approach, to managing anorexia.   Although this method requires a great deal of commitment and patience and some seriously impressive parenting skills, it is the only method which really has shown to be successful in treating this terrible disease. 

Brown reminds us that anorexia nervosa is a biologically based illness, not simply  a willful, bratty misguided attempt to be thin or a failure of otherwise good parents.  She deftly describes the theories of this "encapsulated psychosis" and better than in most accounts manages to explain how disordered thinking about food is a result of starvation.  As they evolved, prehistoric people who were starving became single minded and frenetic--one might say obsessed-- in their search for food.  This phenomenon is often seen in patients with anorexia nervosa who seem to have extraordinary energy and drive for exercise and scholastic pursuits in spite of an  obviously wasted body.

Perhaps Brown's greatest contribution is her description of the stress and strain on her husband, their marriage and Kitty's younger sister Emma as the disease takes hold within the family.   Besides the fact that ED runs in families and one has to worry about the impact of living up close and personal to someone who is so "successful" at dieting is the fact that the illness drains energy, time and compassion from the engaged parents.  Of course, the "unaffected" siblings are deeply affected by the stress, tension and outright fighting that inevitably goes on in a home rent by anorexia. 

More than one parent has come to my office holding onto this book as if it were the guidebook. And in many ways it is.  But it is not a hands-on manual and not a substitute for the team of people-doctor, therapist, dietician- who need to be marshalled to care for these patients and families.  However, it will help parents seek out and ask questions of  providers to ensure buying into a treatment that has a better chance of success than a punitive, psychodynamic approach.   Food is the remedy and "if you do intensive psychotherapy with someone with anorexia, you wind up with an insightful corpse, because without enough glucose the brain can't process or think properly."

Saturday, November 20, 2010

TEDx for high school students near you

Parents worry about what their kids are doing online or in their free time.  We hear a lot about the concerns over the internet, social media and the access to strangers online.  But, we are just beginning to figure out some of the extraordinary opportunities for growth that all of these new tools can offer.

Now if you've never heard of TED conferences, it's time to learn.  TED stands for technology, entertainment and design, and even the AARP website encourages participation. It's for everyone.  TED's slogan is "ideas worth sharing" and their website, TED.com, is loaded with over 700 ingenious performances, talks,pitches, patents, and ideas that range all over the encyclopedia of human experience across the globe.

Today I had the singular pleasure of seeing my daughters, Alice and Daphne Taranto, and their friend and creative partner, Zoe Kestan, present their magazine/website/blog/twitter page/facebook phenomenon called FAD at a TED conference sponsored by their school, Horace Mann in Riverdale, NY.  FAD magazine stands for FashionArtDesign and is an entirely student run enterprise.  They were joined by other hard-working passionate kids who are making extraordinary contributions to culture and making the world a better, richer place. 

This TED conference, called TEDx because it is entirely locally run and organized, had five New York City schools participating.  The format included the celebrated TED style of short talks, performances and demonstrations, two TEDTalks videos (including  JK Rawling from her 2008 Harvard commencement address--perfect on the day after the release of the latest Harry Potter movie); and bias free programming--a stipulation for licensure and use of the TED name.

Other impressive presentations included a student's performance of classical Indian dance followed by an extraordinary video of wheelchair "bound" dancers performing in India where she worked last summer. Four young men presented their latest apps for smartphones of which they have sold over 100, 000 to Apple's App Store online.  Another student presented his Zawadi by Youth, a student-run microfinance program which is funding small-scale entrepreneurs in the developing world and teaching NYC students about small business in emerging countries. Closer to home, Chelsea Dale, from Fieldston School, presented her program, On Giants' Shoulders, a mentoring program for privileged high school seniors who mentor weekly through Skype contact with younger students in the East Bronx. 

All in all these students were an inspiring mix of passion, hard work, creativity, ingenuity, and risk-taking.  Their ability to fearlessly embrace the world at large by wedding technology to compassion is impressive.  Let's hope that more schools and teachers like Dr Jeff Weitz at Horace Mann will organize and sponsor these programs and motivate high school students to pursue their passions and learn the value of sharing great ideas and the arduous but rewarding process of going from idea to product.

TED logo from timothyzhu.wordpress.com

Tuesday, November 9, 2010

Addicted to Indoor Tanning?

As the days grow longer and colder, many begin to dream of a warm summer day or a Caribbean island inhabited by descendants of pirates or Johnny Depp.  And others simply head down the street to the closest tanning center.   If you or someone you care about is doing this on a regular basis, you might want to think about why.

In a 2010 collaborative study from SUNY Albany and Memorial Sloan-Kettering Cancer Center, the researchers report the tanning habits and psychological profiles of over 400 students.  What they found is notable.  Nearly 40% of the 237 students who used indoor tanning met criteria for addiction to the behavior. 

Students in this subgroup also reported more use of controlled substances (excluding alcohol).  In addition, students who met the criteria for addiction to indoor tanning were twice as likely to have symptoms of anxiety or depression than non-addicted students.  This study suggests that students who may have a predilection for addictive behaviors of all kinds are likely to add tanning to the list. 

Given the origin of this study at Sloan Kettering it's not surprising that the authors ironic conclusion is that treating an underlying mood or anxiety disorder "may be a necessary step in reducing skin cancer risk among those who frequently tan indoors."   Will tanning salons soon be required to add some disclaimer about unstable mental health to the consent form people sign acknowledging their right to cancer?

Wednesday, November 3, 2010

More Support for our Athletes' Heads!

The American Academy of Neurology has released a brief position paper on the importance of immediate recognition and management of concussion in athletes. This is a big boost to those of us who are working against a tradition of toughness on the field and getting back in the game, too often with short and long term disastrous consequences. Here is what they said:

The group recommends that all athletes suspected of having a concussion first be removed from participation and then be evaluated by a physician with experience in concussion management. Before being allowed to participate again, athletes must receive clearance from a physician or neurologist. Athletes should not compete if they are still having symptoms of a concussion.

This approach is in keeping with the policy we have implemented in the Mamaroneck School District. Even two years later, we are still working to make this acceptable and accepted by athletes, coaches, parents and physicians in the community. The support of organizations like the AAN along with the NFL will go a long way toward creating acceptance of this conservative and careful approach.

image credit: Google Images

Monday, November 1, 2010

Screening for Depression in Teens

A depressed teenage girl.A study released in the online version of Pediatrics today gives clinicians a readily available tool to screen for depression in adolescents.  (At the time of this posting it is not yet available online).

Called the Patient Health Questionnaire-9, or PHQ-9 referring to the nine questions it poses, this tool has been used to screen for depression in adults for some time.  Now researchers under the guidance of Dr Laura Richardson at the University of Washington in Seattle have shown its effectiveness in a survey of over 400 teens ages 13-17.

The Questionnaire can be viewed here.  Essentially it asks about feelings of sadness, hopelessness, and about appetite, sleep difficulties, and thoughts of hurting oneself.  A score of over 11 on the test is highly sensitive for picking up teens with depression. 

This is a convenient and useful tool for busy doctors and clinicians to use as a screening device.  It should never take the place of a confidential and private conversation to clarify the meaning of the answers, to assess the dangers and to provide support and referral where necessary.

image credit: ox.ac.uk

Monday, October 25, 2010

Homophobia and Cultural Change

With the passing of my dear friend, Lisa Levi, who at the age of 94 and only days before her death could discuss Woody Allan's newest film, I read of intolerance in our culture and think of her as an example of a woman of great compassion.   She was fascinated by the black Jews of Africa, by the homeless, by the mentally ill and by the queer of this world.  She would find and celebrate the humanity in anyone.

As I read on a daily basis about the deaths earlier this month of many young gay students, I, of course also must think about how we can bring about change.   Watch here the two minute Ellen DeGeneres video where she implores us to stop validating ignorance and intolerance that lead to suffering, suicide and wasted lives.   The New York Times magazine this weekend featured a story on the change of culture that led to the cessation of foot binding in China in the nineteenth century, based on a new book "The Honor Code:How Moral Revolutions Happen," by Kwame Appiah.  "Change,"  he notes, (begins) "with a dialogue of mutual respect, free of self-congratulation."

If you are a parent, a friend, a teacher, a clinician or a student begin by observing the language around you;step in when it sounds wrong. Here are a few easily accessible ways to help spread the message and change the language to begin a more civilized dialogue:

The Trevor Project: "The Trevor Project is determined to end suicide among LGBTQ youth by providing life-saving and life-affirming resources including our nationwide, 24/7 crisis intervention lifeline, digital community and advocacy/educational programs that create a safe, supportive and positive environment for everyone."

ItGets BetterProject: "Many LGBT youth can't picture what their lives might be like as openly gay adults. They can't imagine a future for themselves. So let's show them what our lives are like, let's show them what the future may hold in store for them."
Scores of notables (Obama, Ellen, Anderson among them) speak out to teens, often with their own personal stories and help kids see though the difficulties of defining themselves in a culture that does not validate them.

Stories are Good Medicine: a creative website written by a Columbia pediatrician-turned-Young Adult Fiction-author who teaches through story telling.  Ultimately it's through relationship with Other that we will learn not just tolerance, but compassion and responsibility for others.

The way Lisa taught us to live.

Monday, October 18, 2010

...and the final story....

"Ca ne se fait pas….”

“You should not do that.” I heard a firm voice coming from the driver’s seat in the car parked in front of the shoeshine boy whose picture I had just surreptitiously but not silently taken. It was the end of my last day on the street in Port au Prince and I had spent it walking about a mile in the relative calm of early Sunday morning taking photos and talking to people.

What had gotten into me as I walked the last few blocks to the house I had shared for the week? I knew it was the wrong thing to do.

I approached the handsome young driver apologizing in French and told him I would erase the photo (which didn't turn out, but that was beside the point by now) and I did just that so he could see.

I have been struck this week by the general reluctance if not hostility toward foreigners taking photos and so I decided that it was now or never.

I asked him, somewhat naively: “Why not? Why does it bother you so much that I want to take photos.”

“ You should have asked permission.” I agreed that I was wrong. But I persisted with my inquiry.

“Why is it that Haitians do not want their pictures taken?

“Well….” he said with a meaningful pause, “What will you do with those photos?"

I recalled my Haitian friend Rachelle telling me that many people feel “Anderson” and others have made money from the images they “took” from Haiti. I recognized his hurt and anger and I was determined to get to the bottom of it if I could.

“I plan to show them to people to teach and tell them about Haiti.” He was quiet, staring straight ahead, not disengaging, thinking.

So I decided to play my trump card of sorts: “I am a doctor and I came to work in the general hospital.”

I was fully expecting a “big f-ing deal” response as I might have heard elsewhere (eg NYC) but instead he looked at me ever so soulfully and said very quietly: “Bienvenue” or “Welcome”. I put out my hand to shake his through the open window and as we sealed that universal contact tears welled in my eyes as I said “merci” and turned to head home.

A last morning walk in Port au Prince and a final story

This man was selling sheets with lyrics to popular songs.  Everyone on the street seems to have a gig. 

This building had housed a school for everything-driving, kindergarten, primary, secondary, languages, nursing.  Education is prized in Haiti and of course it matters.  Unfortunately for most it costs money.

This elegant building is the broken home of the Universite de Notre Dame, the political science department.  No surprise that the bottom right of the gate says "Down with Clinton."

Cherries for sale on Sunday morning

The two preferred candidates' posters together. I looked all week for this shot!

A huge display of new furniture for sale.
More chairs.  When we wonder why the rubble hasn't been cleared yet, we have only to look at this scene where we see that people have resumed their lives selling what they make and that it would be impossible to move any of this concrete without heavy equipment (of which I saw very little); it would displace and congest the already crazy streets even further;there is the issue of where to put the rubble; and what should be built in its place.  Most importantly, many of these "piles" are shrines where the dead are buried.  We have struggled with these issues at the Ground Zero for a long time.  So do the Haitians.

A kindergarten on my street. "Garden of the Angels."  On Sunday with much less bustle and congestion it was possible to see through the dust and heat to appreciate some of the colors of daily life.

This chicken's feathers exactly matched the owner's shirt!  We all had a good laugh about it. Unfortunately I was not in a position to purchase the creature but for once it didn't seem to matter.

This street billboard with the slogan of one of the new political parties says, "Dare to Love Haiti!"  I think it sums up a lot about what is required to continue to boost Haiti and get it back on its feet. 

Friday, October 15, 2010

Aurevoir, mes amis!

Today was our last day of teaching and seeing patients. We made rounds in the ward pavilion this morning, checking in on the sixteen year old with falciparum malaria who looked extremely ill yesterday and has begun to improve on anti-malarial drugs. This is a diagnosis that is not hard to make-the parasite is visible in the red blood cells under the microscope. But you have to think of it. We also stopped by the bedside of the child with Down syndrome who wanted to play. She is awaiting a placement from the social services workers. And we checked in on a few of the sad babies with severe congenital anomalies and no hope of survival.

Then we got to the serious work starting to see the out patient line that seemed particularly long today. It is extremely stressful to look at febrile, toxic-looking kids, one after the other, try to extract a history from people who only speak Creole and have limited experience with medicine or the hospital. What a frightening place it must be. I can only wonder what they really think is going on in their babies’ bodies when we try to explain “infection”, “pneumonia”, or “virus”. At home “virus” tends to set the mind at ease. But here, it doesn’t seem to match what the mother fears or wants most.

Oslers’ theory of one unifying diagnosis is out the window. So many have malnutrition, anemia, HIV, bacterial infections, skin infections, trauma both physical and psychological, and then on top of that they have a relatively minor virus (often the presenting chief complaint) and just the hardship of daily life-heat, lack of sanitation, water, long waits in line for medical care, and problems with shelter.

Occasionally a smiling mother and child sit across from me on the folding chair and when I review her chart I realize she is there for follow-up and the child is notably better. Thank goodness. Has she had her vaccinations? Is she in school? Oui. Oui. Next.

Around noon, my own energy began to flag, my blouse was drenched in sweat and I was on fire. The line before me just kept growing, the sewage truck was at work just outside the window, babies were crying, a father was angry and restless at the registration window. There was no more water in my bottle, and I couldn’t manage the intense concentration necessary to understand the Creole any longer.

Then I looked at the faces one by one and realized that they had waited many more hours than I had worked;that many were holding 15 pounds of 105 degree frighteningly limp flesh and that soon I would be able to leave. I saw the next several children, dispensing prescriptions for acetaminophen, blood tests, stool samples, xrays and vitamins.

When I got up to leave to give my lecture, the line was still there, but the doctors were all headed in my direction, and patients would just have to wait. The personnel shortage is remarkable. There are very few nurses and in this place their training is hardly that of clinician albeit one of dedicated caregiver and shlepper.

I taught the staff how to think about adolescence-its stages and milestones. How to talk to teens so they will answer back and how to assess their problems. All issues of sexuality elicited discomfort and some questions. Of most interest to them were the issues of confidentiality and privacy and how to manage them. Like many pediatricians, most of them have chosen this profession because they like little ones. Like many pediatricians, they would often rather not have to deal with the answers that emerge from "big kids" when they are asked the age-appropriate questions.

Later in the day I was invited to the monthly meeting of the Haitian Pediatric Society. About 40 docs from around the country come to PAP for this meeting with colleagues held in the Plaza hotel, an oasis in the center of town near the famous wrecked palace. Not only was the Plaza spared but the conference was in an air-conditioned room! I presented a talk on menstrual disorders in adolescents, once again encouraging the physicians to continue to care for teens because their compassionate pediatric approach is what teenage girls need most rather than the scary and grownup world of the gynecologists’ office.

If people wonder why US pediatricians would elect to come here to Haiti, they need only spend time with these physicians who are smart, fun, dedicated, worldly and always thinking about the differential diagnosis even if they have no lab or technology to prove it. And they go to work every day in the conditions that exhaust me within a few hours. This is where they have chosen to live and work. For it appears that most of them truly would have a choice but are dedicated to Haiti and the profession. Twenty pediatricians emigrated after the quake, but this is the solid core. What a privilege to have known them this week.

Thursday, October 14, 2010

A great day of teaching and learning

Two of the pediatric residents doing an exercise in identifying dermatologic lesions.  They liked our interactive style of teaching and had some fun.

A well stocked supermarket right near the palace.   We bought beer and peanuts. 
One of the nineteen candidates running for president of Haiti in the general election on November 29.  This is one of only a few female candidates, but many say one of the favorites.  Others include a white business man, a musician named Sweet Micky (bumped Wycliffe Jean out of the running), and a pediatrician who shows up at the ER where we are and shakes hands all around, sees a few children(haven't seen the kissing part usual for politicians) and leaves.

Making rounds.  Everything is very very crowded.  And hot.

With permission I took this photo of this undiagnosed child with malnutrition, fever and abdominal pain.

This grandmother loved to talk. Her miserable sick child (not serious this time) waited while she told us that her daughter in law, the baby's mother,  died in the quake (called the "evenement" or event) and that she is caring for her in addition to her job as a house cleaner.  She is 62.

Wednesday, October 13, 2010

Haiti Day Three!

The outpatient clinic where well children mix with very sick ones, waiting patiently in line.  There is no regular well child care system or facility.  People have an immunization schedule and go elsewhere for those.  On the left are the nurses who weigh (clothed) and take vital signs. 

This sign is to notify patients that all care at this hospital is free.  It serves to warn them against unscrupulous workers or outsiders who may try to extort money from them for services.

Ilormy, the third year resident with whom we work in the outpatient department and Dr Meera Siddharth from Children's Hospital of Philadelphia who is on my team.  Meera is a wonderful preceptor and teacher and has practiced interational health in many parts of the world.
Each neighborhood school has a different uniform, some far more colorful than these.  Haitians definitely do not want their pictures taken. People who have been here a long time say this is a change from prior to the earthquake and feel that one explanation is that they feel betrayed by all the foreigners who came, gawked, looked and were supposed to send home pictures that would stimulate donation and aid.  And where is it all?
The five of us with Fabienne who is at back left, at Hotel Oloffson in Port au Prince, a famous funky hotel, mostly spared by the earthquake and a rendezvous spot for all manner of expats, volunteers, officials, and  journalists.  Supposedly the inspiration for Graham Greene's novel, a wacky wonderful experience.
A classic case of clubbing, a chronic condition in people with certain heart conditions, in this case Tetralogy of Fallot.  You could almost hear the murmur standing next to this boy.  You could certainly see it in his thin chest.
The File room at the outpatient department where we work and see patients

This is the pediatric pavilion, now entirely condemned after the earthquake and the reason that we are in the pre-fab pavilions.   They have shrunk from some 100 beds to about 75 as a result.  These buildings are all in a park like setting, gated and guarded but congested and harried.  Nonetheless there is vegetation and a chapel and the traffic and noise compared to outside the fence are manageable.

Tuesday, October 12, 2010

If you've travelled in the tropics you know it's hot, humid, hazy.  You know that if you are in the sun you sweat right through your shirt in no time.  You know you need to keep drinking water and most of the time you look like crap unless you are lucky enough to have a shower and change into some cool outfit. And then it's very temporary.

Well let me tell you about the residents and attendings who work here in the public hospital where I am stationed for the week.  There are some 20 pediatric residents and another 6 or so attendings who start making rounds in the morning at 7am.  When we arrived at 8:30, lines of feverish kids and mothers, swaddled in all manner of towels and rags were waiting in the sun to be triaged into the outpatient clinic. the clinic is a series of long pavilions, about twenty feet wide, made of plywood; they are clean, airy and light, but densely crowded.   The residents, many of whom have been up all night tending very sick children in the emergency ward, are in full makeup, coiffed, perched on high heels with pedicured toes, some in pressed linen blouses.  Some of the men wear ties; all wear shined shoes, and no one looks or at least acts uncomfortable.

The dignity and professionalism of these doctors is remarkable.  When asked yesterday what he thought the program's biggest strength is, Dr Evillard (head of the Haitian Pediatric Society-SPH)told us: "It is the commitment of the staff." That was certainly in evidence today.

In the course of the day which ended for me at 2:30 I never saw them eat, drink, or complain.  Sweat they did, especially when twenty of us were sitting around the table in a crowded conference room where my colleague, Meera, and I gave our talks.    And yet they rose from the lectures and went back to work in conditions that are as close, crowded and dramatic as any one can imagine.

Particularly heart wrenching were the eight month old with Down Syndrome abandoned by her family and the malnutrition ward where the children have the classic forms of malnutrition called marasmus and kwashiorkor.    Kids with marasmus are the skinny, crying, hungry, whining ones. Those with kwashiorkor might look plump but it is all fluid (edema), or leaking fluid due to a lack of protein in the system;these children are lethargic and disinterested.

Here are a few photos so you can see for yourself:
The crazy permanence of impermanence:tents are anchored and file cabinets are at work.This is the general hospital.

The neonatal ICU.  Love the hat.
 Unfortunately, I will not be able to upload more photos as it requires a lot of time and twice now, while I waited I lost my internet connection.  More to follow when I can. I am taking pictures and collecting stories all the time.

Sunday, October 10, 2010


From my car window on the way from the airport to my house,  I "snapped" this photo of the extensive tent cities arrayed along the highway.  True to what we have read, they absolutely have a certain permanence about them.

As we climbed out of the downtown area toward my house I was struck by the liveliness of the streets-- vendors everywhere, hawking firewood, bananas,  and the recent rich harvest of oranges. Rubble seems to be in piles on the side of the road as much as it is still layered under collapsed homes just about everywhere.  Here and there new construction and fresh paint are a sweet sight.

My street is an obstacle course of trash piles, tent dwellings that have foundations, electricity and cookstoves; parked cars of all sorts, sleeping dogs, pedestrians, and puddles.

The house is hidden behind a huge heavy sliding steel gate.  It is more comfortable and secure feeling than I ever imagined.  We have wireless access, fans, a microwave, a stocked fridge (with Presidente and Prestige beer even).  I share with three nurses, two from Vancouver and one from Florida who are here with Rose Charities to instruct nurses in neonatal resuscitation and newborn management. 

The fifth person in the house is a young pediatrician from Philadelphia who is taking a leave from her community clinic job to work in Haiti, the Navajo reservation in Arizona and in southern India.  She and I will share the task of making rounds with the residents and teaching them for an hour and a half every day.

Besides the American Academy of Pediatrics, this venture is also sponsored by Health Frontiers. But just for the record, no one is paid to do this and everyone bought their own plane ticket and we all pay room, board, and car service from our own savings.  It's something else that drives this motley group of women.

We were introduced to the head of the Haitian Pediatric Society,  an elegant gentle man with three children who right away told us about his seventeen year old daughter and the challenges of raising a teenager in the age of cell phones!  Welcome Home.

When I was asked last week to present grand rounds to the Society next Friday  I began debating which topic to choose from the many powerpoint presentations I brought.  Needless worries.  Now that I've met Dr Evillard, I know. It will be: You Gotta Love'em: how to take the adolescent history.  OR some French translation which I will have to work on.

I look forward to the socio-cultural exchange ahead.

Friday, October 8, 2010

Duke Crashes Again

Recently I have been thinking about the invention of the automobile as a metaphor for social media and the internet.  Let me explain.

We are all intensely concerned about the misuse of the Internet and how much interpersonal harm can be done when this amazing invention is misused.  We only have to think about poor Tyler Clementi who jumped off the GW Bridge after his encounter with a man was videotaped and streamed live around his Rutgers campus and beyond.    Our understanding of this extraordinary tool called the Internet is still in its infancy, or maybe its' adolescence.  We have invented the automobile and we have the keys, but we don't have too many good roads, tools or rules yet.  We are finding our way.

Now we hear about the case of the Duke graduate who developed a thesis-format Powerpoint of her own sexual exploits as a joke to share with friends, and guess what?  It's gone viral.  At first, when I read her story on Jezebel, I thought about how this is a young woman who got the keys to a sixteen wheeler she was not supposed to drive. Thelma and Louise style, she was going to detail her sexual exploits while at Duke and create a rating scale, all beautifully prepared in board room style with images from Facebook of her multiple hookups.  Hey, the frat boys seem to get to do it all the time and somehow they seem to get away with talking about the sizes of their conquests' body parts, their hair, sexual abilities and prowess to make them feel bold and masculine and so forth.

But oops!, she missed her turn and instead of a spin around the parking lot, this truck is now out on the highway, barreling ahead and she has no idea how to really hit the brakes. 

According to Jezebel she is "contrite" and trying to pull back on the reins (guess that would be a technique for a horse and buggy) Let's just watch and see how many men come forward to claim their reputations have been sullied and threaten to sue her.    My bet is not a one wants to go for that ride.

Tuesday, October 5, 2010

Yes, Her Honor

Let me tell you about an amazing program in Westchester County that is helping the most promising of our underserved young women.  Called Her Honor Mentoring, it was started by a Mamaroneck woman, Nicole Sheindlin with the support of her stepmother, Judge Judith Sheindlin, better known as Judge Judy

Rising high school seniors are recommended by school personnel for selection to this special one year program.  This year, Mamaroneck, Mount Vernon, Yonkers and White Plains high schools have sent 40 young women to participate.  The cornerstone of this program is the match-up of each student with a woman in the community whose career is related to the teen's interests.  Here is a photo of Mariame Samuda from Mount Vernon high school (on right) whose dream it is to one day "help (patients) with neurological disorders." She is accompanied by her new mentor, Dr Jennifer Canter who is the medical director of the Children's Advocacy Center  at Westchester County Medical Center. 

In addition to working several hours a week alongside their mentor, the mentees are taught life skills such as appropriate business attire, financial planning, public speaking, personal health and wellness, dining etiquette, and negotiation and advocacy skills.

Other mentors include bakery owners, lawyers, the CEO of Gilda's Club, city council members, the director of the New Rochelle Boys and Girls Club, a pet groomer, the manager of public relations at Bloomingdale's, a chocolatier, and many others from the worlds of politics, not-for-profits, the professions, and business.

In just three years, Her Honor has managed an impressive track record of promoting huge growth and confidence in these young women.  They are living proof of what Judge Judy told them at the opening day luncheon: "You can be the hero of your own story."

Thursday, September 30, 2010


Today's New York Times has a full page ad from Penguin books that promotes the book Speak, by Laurie Halse Anderson.   This powerful story about a teenage rape and the depression, loneliness and ostracism that ensue was given to me by a patient a few years ago.  It was eye-opening then and remains a powerful read for people of any age still to this day.

However, in Missouri, some people think differently. In particular, a Missouri State University professor supposedly has called for a ban on this book in schools.  Bizarrely enough, he equates the rape  with "soft pornography" and has invoked Christian values to support his idea.  The blogoshpere is active with writing about book banning and the attempt to silence the conversation about adolescent rape.

On their website, Speakloudly.org, Penguin books promotes not only Speak but freedom of speech and of the press in general.  According to the blogs, this book has been instrumental in helping many women--some well past their teens-- come forward with their stories of rape and silence.  Having a conversation about this story in class, at home and in doctors' offices can go a long way to bringing sex crimes out of  the darkness and  increasing understanding and compassion for its victims.