“If you have come here to help me, you are wasting our time. But if you have come because your liberation is bound up with mine, then let us work together.” –Lilla Watson
This oft-cited quote is from Lilla Watson, a Gangulu aboriginal activist from Australia. The first time I read it I felt my heart quicken in recognition. One of the greatest problems with being interested in global health is my fear that I will do more harm than good. I have seen developing countries pockmarked by well intentioned NGO groups that ultimately create bitterness, corruption and false dependance. My stomach churns at the thought that I am participating in a system based on the model of a beneficent white man handing out superior resources to a supplicant native population. Or even worse, handing out resources but tied to an expectation of religion or political acquiescence or any one of the thousand strings that often are tied over aid packages.
I also hate the ego that can come from doing this sort of work– which is why I hate being “complimented” on my global health interest. Because this stirring quote by Ms. Watson really hits the nail on the head. It’s not about ME giving YOU a handout. It’s about US moving about the world with basic human decency. Even the old proverb about give a man a fish and he eats for a day, teach a man to fish and he eats forever is a bit problematic for me. While I agree that this is important, “capacity building” has acquired a feverish buzzword-y connotation of almost mythical status in many places. But teaching a man to fish also sort of implies that you are the great giver of knowledge and he, a country bumpkin eager to receive your aid. Maybe he knows how to fish in a different way. Or maybe he isn’t fishing at the moment and that is a good thing because your “superior” fishing techniques have caused devastation amongst the local fish population ultimately leading to a cascade of problems.
Because if you go into a developing country with the attitude that you are superior you will be disappointed– disappointed with the reactions of your colleagues and patients and frustrated by the limitations of the system you work in. I am often asked to compare the resources of a country I visit to the US. People seem to want to hear about how primitive it is and how brave I am for going there. And global health personnel often gripe about what they would do if we were in the US- seemingly wishing to transport every patient into our “superior health care system.” But guess what? Our system isn’t exactly something to brag about. We have created an economically unfeasible situation that so often does not act in the patient’s best interest. Unnecessary tests, defensive medicine, limited time with providers, frequent transitions of care. This is not to say that we don’t have amazing innovations- or that developing countries should operate with less than optimal resources at a lower standard of care. I’m not trying to glamorize poverty either. I simply use it as a caution before storming into a place armed with a false certainty of superiority. Because it is as much a learning experience as anything else. And innovations from developing countries have often been used in more developed countries with great success.
One of my best friends in the world recently lost her grandfather. So my family rallied, got tons of food and showed up for them. We came that day and every day for 4 days bringing food, attending the funeral and helping clean. While there we didn’t try to change how they loaded the dishwasher or ask them to subscribe to our beliefs. Why did we do this? Because we were great, superior people who took pity on them? No. Because they are a part of our community, a part of our heart and we did what little we could do for that moment. Because our liberation is bound with theirs. And I honestly feel that global health is similar in some ways.
One of my least favorite parts of international travel is dealing with the various bureaucracies necessary for me to obtain a ticket, visa and proper permissions that assure the powers that be that I am a harmless citizen. Dealing with all of this whilst on my medicine subinternship and then in Haiti has been…challenging. I will have you all know, however, that I am improving. I only cried once on the phone to the visa office!
The machinations of this process are obscure and each and every governmental office seems to espouse a similar credo: no transparency at any cost! More paperwork is better! Don’t tell the customer which forms they need…it’s far more fun to simply repeatedly deny them when they don’t provide the forms that we seemingly make up at random!
These bureaucratic gymnastics brought me to the DMV today so I could renew my license. Why? Because even though it is valid throughout my entire trip to India apparently some unwritten (but strictly enforced) rule states that it must be valid for 6months in order to obtain a visa. OK fine. Once there, I was given a number and waited for 30min- only to discover that they had given me the wrong KIND of number which put me at the back of the line again. While I didn’t receive an apology for the error, I did receive an impressively surly glance… which is pretty much the same thing in DMV world. While there I did what I always do when I am frustrated: I tried to make it seem funny. So I decided to compile a list of The 5 People You Always See at the DMV
The loud complainer: this guy was out in full force today- whining about how he felt that the numbers were being called out of order (they weren’t) that he’d been there for hours (he hadn’t) and that the DMV was chock full of idiots (no comment)
The attempted line cutter: this person is pushy, obvious and generally only successful in pissing everyone off.
The cute old person: this person usually comes with a folder full of carefully hand lettered paperwork that documents their existence from cradle to future cemetery plot. Need to see a receipt from their first pair of shoes? No problem- they just need to open up their dusty portfolio and sift around a bit.
The uncomfortably friendly person: this person generally smells of cheap cologne (or BO if you’re really lucky) and sits on the bench at a distance that is both socially unacceptable and unnecessary. They fail to understand that “silent martyr-like stare punctuated by occasional sighs” are the only acceptable forms of facial expression at the DMV and insist on hitting on you/talking to you/bothering you for the duration of your DMV experience.
The non-English speaker: inevitably this person doesn’t simply speak Spanish or Portugese- we’re generally talking along the lines of a native Kinyarwanda speaker. And even though they hold up the line for an impossibly long time, your heart goes out to this individual because the DMV doesn’t even make sense in English.
After an hour of waiting, I finally got to renew my license and they took my picture which virtually ensures that I will be stopped at any and all security checkpoint due to my uncanny resemblance to an angry, hardened career criminal (albeit a sort of coy one, don’t you think?) Lucky for me I don’t even get my new license for 7-10 business days which virtually ensures that I won’t get my visa on time!
But, my dear friends, there is always a silver lining. Once I arrived home I noticed that the lovely old crone at the DMV had spelled the name of my street wrong. Which means that I got to go BACK and relive the wondrous experience.
In search of some fried cuisine and libations, we all packed in the back of the van, clown car style, and headed toward the UN. The UN is an oasis of diplomacy but more importantly an oasis of ice cream.
Whilst trying to decide betwixt the myriad of flavors (OK it was only 4 flavors), the lady behind the counter offered her suggestion: “les blancs aiment ‘mint chocolate chip.” [literally “the whites love mint chocolate chip”]. “What?” I asked her, confused. She tried again, in English. “White people. They are going crazy for mint chocolate chip ice cream.”
I opened my mouth- ready to protest this perplexing stereotype. But then my friend piped up from behind me: “I do kind of want mint chocolate chip.” I closed my mouth and opened it again. “Dammit, me too. Mint chocolate chip for all the whiteys please.” I guess she’s right?
While at the hospital, I was introduced to Dr. Francius- a Haitian general surgeon who was specially trained in the US for wound care. Dr. Francius was nice enough to let me scrub in on 2 wound debridements*. These involve surgical removal of dead tissue and cleaning of the wound (and I promise- no gross pictures). The OR at the hospital was quite well equipped and I was amused to discover similar team dynamics amongst the scrub nurse, med student (me!) and surgeon. Luckily, the patient’s wound had been doing quite well and we were able to perform a much less invasive procedure- hence the thumbs up at the end of the case.
*Of note: thanks to my Canadian colleagues, we discovered an important cultural difference between the US and our neighbor to the north. While we say de-BREED-ment, they say de-BRIDE-ment. I maintain that their version sounds affected and they maintain that our version sounds like a eugenics program. Oh well, potato–potah-to, debreedment–debridement, eh?
And again, the embodiment of the roller coaster of working in a developing country. The day after the baby was born we had a baby die. He came in unresponsive and I helped the resident run the code until others arrived. Despite aggressive measures, we couldn’t bring him back. I did several rounds of CPR on him which involves chest compressions. It is such a sickening feeling to push on a baby’s chest, especially when you know how dire the situation is.
The next day was even worse. I was in triage for another little boy who was having multiple seizures in the context of a high fever. We dealt with his seizures but he had other complications. The next day his breathing was in trouble so we needed to put a breathing tube down his throat. During that process his heartbeat dropped and we started compressions but again, he passed away. The hardest part in all of this for me is seeing the parents. They don’t fully understand what we are doing (although we try to explain) during the process and it’s heartbreaking to see them realize that their child has died. Especially in Haiti where it’s normal to grieve loudly and publicly when first hearing of a death. I personally had to step out and take a moment. I was able to come back and help dress the body and clean up the bed afterwards but at that moment, I needed a deep breath.
But, that is what I signed up for. And I always feel like the best way to describe this type of work is tragedy juxtaposed sharply with hilarity. And I know it may sound insensitive but by that evening, we went to the UN and were happy and laughing. But how else to deal with these issues and maintain one’s sanity?
After things died down around 8pm a few of us threw on flip flops and headed to the roof of the hospital. We heard a woman wailing and some sort of commotion outside the gates. Lo and behold it was a woman in labor. She made it all the way to the hospital only to give birth literally right outside our gate. A for effort? We saw a healthy looking infant handed off to someone and the woman was escorted inside in a wheelchair. Because we are not an Obstetrics hospital, we don’t do births… but you can hardly turn someone away who literally went into labor on your threshold.
All of a sudden we hear someone yell, “does anyone know how to properly deliver a placenta?” It was like a batsignal…what every med student dreams of. It was like someone yelled “can anyone retract for me? Who here can do an overly detailed patient social history? Is there anyone here who can get records faxed from another hospital?” You see, delivering the placenta (or “afterbirth”) is a quintessentially medical student task. That’s not to say its not important, there are actually many things that can go wrong when doing this that I won’t enumerate lest I make some of you queasy. Regardless, Obstetrics was my last rotation and I felt more than confident in my placenta delivering abilities. So I leapt up and ran downstairs to the ED in my flip flops where I instructed the resident to hold superpubic pressure and I delivered the placenta in one fell swoop/spin. People actually cheered which may be the first time in history that a medical student received cheers for performing this particular task. But of everyone there, I had done this most recently and none of the residents felt comfortable in their obstetric abilities. The prize for my placental heroics was, of course, getting to hold the new baby.