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."