Dr. David Malebranche

The following is courtesy of Dr. Malebranche, an Emory internal medicine doc who works with HIV patients in the Atlanta area.  He was one of the excellent attendings on our Medishare trip, who patiently taught and guided us in our rudimentary knowledge of medical care.  He is also Haitian, and a moving writer.  This is his journal from our week in the Central Plateau, shared with permission.  (Pictures are mine.)

Returning Home
June 19, 2011

Miami International Airport was its usually busy self today, hundreds of people representing a multitude of nationalities and cultures, waiting to depart to whatever destination awaited them.  I am sitting with a group of physicians and medical students, most foreign to me before this morning, but joined together by a shared desire to put our expensive education and talents to good use.  It is 11am, our flight was supposed to leave an hour ago, but mechanical difficulties have us grounded for the time being – a fitting beginning to a personal journey that has been 42 years and four months in the making.

I am nervous and curious, excited and pensive, overwhelmed and prepared all at the same time.  For this shining, sturdy vessel I am about to board is bound to take me to a destination that I have not seen before.

I am leaving for Haiti today.

The birthplace of my father. 

The only independent Black republic in the world.

A country with so much history, resiliency, and stamina that even after decades of imposed embargoes directed by other countries, crippling poverty and faulty infrastructure, government corruption and rampant infectious diseases, its people remain standing tall and proud. 

The home of my ancestors.

As a child, my father always told me romanticized stories of the Haiti he remembered growing up in from the 1930s to the 1960s before he immigrated to the United States.  Haiti, a country boasting abundant resources, fertile land and even wealthier spiritual currency among its people.  Haiti, a country well versed in the adaptation of perseverance in response to years of persistent oppression, humiliation and disenfranchisement by numerous foreign and native peoples alike.  As I grew older, and my family discussed taking a trip to my father’s birthplace, it never seemed to be the right time – always an issue of government corruption, outbreaks of violence and infectious diseases, or devastating natural disasters.  We never took that trip to Haiti as a family – I moved to Atlanta to pursue my career, my sister to California to continue hers, and my parents remained in upstate New York, the place they had called home for over 40 years.  It just never seemed to be the right time – and now with my parents getting older and my sister with her own family obligations in California, I feared it would never happen.

Until an opportunity came to be part of a medical team that goes to Haiti twice a year to do relief work.  I jumped at the opportunity, not only to assist and utilize my medical training in assisting the aftermath of the devastating earthquake, but more importantly, to set foot on the soil from which my father emerged to give me life.  The sense of internal confidence, a sense of resiliency in the face of adversity, the will to never give up – all of these sensibilities that coarse through my veins, comprise the content of the air that I breathe, and constitute the fabric of my cells, flesh, muscle and bone – they exist in me because of the lessons my father taught me.  They exist in me because Haiti exists. 

I am on the plane now, bound for Port au Prince.  I am ready to experience the country that shaped my father, and ultimately, who I am today.  I am ready to go home, even if for only one week, it has been worth the wait.  As the plane rumbles slowly, building up speed, and softly leaves the sun-drenched earth in Miami, my spirit reverberates in a manner unfamiliar to me.  I am not sure what this trip will mean for me, what I will observe and feel, or what it will mean for the trajectory of my life’s journey.  What I do know is that in one week, when I return to the United States, I will be a changed man.  I am ready to embrace this change, in whatever form in comes.  I am ready to fly. 
Today is Father’s Day.  I celebrate him.

Thomonde Visit - Central Plateau, Haiti
June 20, 2011

Today we took a trip to some rural areas of Thomonde, visiting and meeting with local families to see what daily issues they may face that impact their medical care.  Poverty was perhaps the most dramatic barrier to accessing medical care in rural areas – having to walk long distances to get clean running water, and travelling even further to seek medical care.  One gentleman we visited with 3 kids and wife took meticulous care with the paperwork documenting his children’s vaccination records, and talked about the personal cost and commitment of putting them through school.  On the other hand, when it came to his own health, he nonchalantly stated that preventive care for him was not even an option, and that he would simply “go to the doctor when he was sick.” 
We also met a 20 year old mother with her 4 month old baby in arms.  The child had a cleft palate, which left him malnourished because he could not form proper suction with his mouth for breastfeeding.  His skin looked like parchment paper, spotted with a small pinpoint rash on his arms and face; his hair was thin and disheveled, and he was crying often, inconsolable to the supportive coddling from his mother.  Despite her having some medical supplies to give him milk through a feeding tube, she didn’t have a breast pump (nor had she been trained to use one) that could empower her to get more of her milk to meet her son’s nutritional needs, effectively circumventing the cleft palate issue. While she had been told her son was to have surgery in Port au Prince in October, it was apparent that if he didn’t get enough milk before that time, he may not even survive long enough to make the operation.  Cleft palate, a genetic abnormality that in the United States could be corrected with a simple operation, was causing this child to wither away prematurely, and there was little that could be done to help him or his mother at that moment.
We also met a man who was on his farm, making his own charcoal to sell in the city. He had cut his finger earlier, and had it bandaged in a haphazard way with some makeshift gauze that was soaked in crimson blood.  As soon as we approached, he saw the medical students, dressed in hospital scrubs, and assumed we were there to administer care to his finger.  Unfortunately, we didn’t have any supplies with us and couldn’t treat his wounds at that moment.  Even the mobile medical clinics we would be setting up over the next few days would be too far of a commute for him, so he would have to wait until he could travel to another clinic that was closer.  I sensed that this trip probably wouldn’t happen, and he would just let the wound heal on its own time.
Later in the day, we visited Thomonde’s local hospital to see what services were being provided.  We pulled up to the building, a starchy white structure with pillars in the front and several people on the front steps leading into its hallways.  On the front lawn were several makeshift tents that were being used to urgently triage and treat people suffering from cholera: IV poles hanging, cots and other stretchers holding men and women of varying age groups and degrees of illness; family members faithfully wiping sweat off the brows of their ill loved ones, providing them sips of cool water, or sitting nervously on a bench under the sweltering hot sun; and far too few harried medical providers and nurses attending to the needs of their patients.  We walked up the steps and past dozens of men and women lining the halls, standing against walls, sitting on crowded benches, barely a breeze coming from the rickety ceiling fans to impart even temporary relief from the oppressive humidity.  The swarms of aggressive flies that circled the air could not even induce a half-hearted attempt of a swat from those sick persons lying on mattresses in the hallways.
Four doctors with four nurses and a couple of nurse assistants were on staff that day, with all of them in rooms seeing patients when we arrived. One of the physicians emerged and graciously gave us a tour of the facility, including an examining room, the laboratory, the inpatient isolation rooms where they treated Tuberculosis, and the medical director’s office.  Realizing how completely overwhelmed the staff was, and that we were providing no more than a distraction and obstacle to patient care, we politely excused ourselves and thanked him for taking time out of his schedule to show us the hospital.  Before we left the front lawn cholera treatment center, a middle-aged man used a pesticide container to spray our hands and soles of our feet with Clorox-treated water. 
After my first full day in Haiti, without having worked in the mobile medical clinics yet, I’ve learned a few things.  First and probably most importantly, is how these medical missions exist to put short-term bandages on gaping wounds.  While this is absolutely essential in addressing urgent infectious disease outbreaks and illnesses, what is truly needed are more qualitative and comprehensive needs assessments to describe the larger social and structural needs of the communities we are attempting to “serve.”  This way long-term concerns can be addressed and solutions can be proposed for how to best create and maintain sustainable public health infrastructure.  Secondly, and most obvious, is the cultural discord between Haitians and foreigners from other countries who sincerely want to help.  The language is the first and most apparent level of this discord, with most Americans not being fluent in Creole, which makes it almost impossible to even due the most rudimentary of interventions without a translator.  The second level concerns disjointed life priorities and health issues – we present ourselves as a medical relief mission, and attempt to address health by prescribing medications for various infectious and chronic disease ailments, for durations as short as one day to as long as 30.  So what happens when we leave?  Can you truly start a Haitian patient on a blood pressure medication based on research studies and guidelines conducted in the United States, without any refills and follow up, and then board a plane back to the United States?  How can we ensure that they receive proper follow up for monitoring of chronic conditions and side effects of the medications, especially when we have not even addressed the underlying social and structural factors driving the poor health conditions in Haiti? Not only is this poor medical care, but it’s also poor public health and cultural care, and doesn’t account for the personal/community priorities and belief systems that drive how individuals conceptualize and address their health.  
The final thing I didn’t so much learn, but more so witnessed and had confirmed, was just how beautiful a country Haiti is, and how resilient our people are.  My father has always told me about Haiti’s countryside, the rolling landscapes, hills, mountains and foliage, but it is truly breathtaking to view in person – and nothing like the predominantly negative media depiction of Haiti as just poverty, HIV and despair.  Nothing he told me could have prepared me for the majestic beauty of the Haitian countryside, in all its lush beauty and splendor, and I feel blessed to have witnessed some of it today.  And experiencing the beauty, kindness and perseverance of Haitians in the face of overwhelming adversity gives me a much greater appreciation of exactly where my father came from, and how amazing his journey and subsequent success in the United States truly is.  I see where I get it from.  I see why I don’t give up when things get hard.  I see why I appreciate quiet solitude.  I see why I persist when others tell me I can’t do something.  I see the lineage of kings and queens from whom I draw my inspiration and strength.  I see myself.  Mwen rele David Joseph Malebranche.

And I can’t wait for tomorrow.

Mobile Clinic in Central Plateau
June 21, 2011

The first day conducting our mobile medicine clinic in the Central Plateau was an exhilarating and interesting one.  We made a 40-minute car ride through perhaps the most treacherous roads I have ever experienced – not just gravel and uneven pavement, but huge rocks, large mud pits and river crossings through the rural countryside.  The mountains were absolutely beautiful, and there can be no question about how beautiful a country Haiti is, in spite of all the adverse situations and conditions that plague Haitian people there.
Our location for the mobile medicine clinic was a church in the middle of the mountains, a small, quaint building that we transformed into a triage area, pediatrics and medicine offices, and a discharge pharmacy.  There were dozens of people waiting for us when we arrived, men and women, children of all ages alike.  We worked as a team, with medical students and translators conducting the history and physical, and signing out to us as the attending physicians.  The most common complaints we heard from nearly all the people were “Mwen gen doulè nan tèt mwen” and “Mwen gen doulè nan lestomak mwen an,” meaning “I have pain in my head” or “I have pain in my stomach.”  These complaints could’ve been real tension headaches, gastritis or heartburn, which we were able to treat easily.  It was difficult to tease out, however, how much of the headache and stomach pain were physical in origin, or could be suggestive of depression or other stress-related symptoms due to time constraints and the language barrier (even with the translators). 
As a physician, I struggled today as I do on many days when I work at my community medical clinic/hospital in Atlanta.  It doesn’t take a brain surgeon to realize that the vast majority of individual’s health problems, whether here in the Central Plateau or in downtown Atlanta, Georgia, emerge from within adverse social circumstances.  We saw one man with an enlarged prostate, complaining of abdominal pain, who had a foley catheter in his penis, and the bag collecting the urine was folded and place in his jeans’ pocket.  He explained to us that the doctors had placed it there because he wasn’t able to urinate, and they changed the catheter every 15days.  Now in Atlanta, this would be inexcusable, and 15 days is far too long to leave a urinary catheter in as it will undoubtedly lead to infection.  But here in the very rural Central Plateau, it obviously was the best temporary solution for his problem. We ended up treating him for a urinary tract infection and getting him plugged in with some Urologists who are coming to Haiti next month to evaluate him for surgery. 
We also saw two women, presenting with the same headache and stomach pain complaints – the first broke down in tears because she didn’t have a stable home and had to go to other people’s houses to ask for food and shelter.  She was obviously depressed, and her symptoms were clearly related to this, but there wasn’t much we could do for her in that mobile clinic setting.  The other woman was describing classic signs and symptoms of panic attacks, but again, we weren’t equipped or capable to provide sufficient behavioral counseling/support or medication, so we could only give her multivitamins and Tylenol for her pain.  It was frustrating to say the least, but there were several patients who had arthritis, heartburn, or anemia, that we were able to provide medications for that will likely help in the short term, but not relieve the long term issues impacting their lives.
Our clinic was so packed that the front staff began turning away people early so that we could get home before dark.  A flash thunderstorm also cut our clinic time short, and we left in our cars down the poorly paved roads back to our compound.  My conversational Creole is getting better, particularly with taking a medical history, but I question how much we are really “helping” here by seeing patients for one week.  The one part of the day that gave me optimism occurred before we went to clinic, when we heard from Marie, our clinical coordinator and co-collaborator with our medical mission here. She showed us a factory in development that will be mass producing a Haitian based food formula prepackaged as a children’s food supplement.  This formula was created to fit both the cultural context of traditional Haitian food and meet the nutritional requirements for children.  It also allows mothers to prepare the meal themselves and maintain the sense of pride and purpose of creating a meal for the family.  As I sat listening to Marie talk about the conceptualization of this public health initiative, and long after I returned from clinic today, I realized that despite not being adequate in addressing all of Haiti’s social problems, both the clinic and the formula initiative are needed here.  Our urgent care efforts, though only temporary, may maintain a healthy today and help to bridge people to their routine health care access efforts after we leave.  The nutritional formula initiative, on the other hand, fills the need of the larger public health needs of a struggling country, and places the focus squarely on investing in our youth – their health, their well-being and their physical development.  I won’t argue about which is more important, as I truly feel both are, but both aspects of addressing health conditions in Haiti are sorely needed.  What I do know is that I feel blessed to be taking part in these efforts. 

Pills to Swallow
June 22, 2011

It was 4 o’clock in the afternoon, and the air stood still and static, purposeful in its attempt to make it hard to breathe.  I was wiping sweat from my brow and looking around the room for any remaining patients when my colleague Susan called me.

“David, I think they need you over here.”

She pointed in the direction of a patient surrounded by two eager young medical students, adorned in florescent green and blue hospital scrubs that were now soaked in a potent concoction of sweat and dirt in which they had been bathing all day.  The patient, a young man, looked sullen and morose, his chalky brown skin sunken deeply at his temples with his eyes gaunt and vacant, reflecting an age beyond the 30 years that was listed on his chart.  I looked around carefully before I approached – the students and translator’s faces were filled with sorrow, almost as if they were attending a funeral.

“Bonswa, monsieur, comment ca va?” 
“Bonswa, ca va bien,” he replied meekly. 

He wasn’t.

I sat beside him and got his history through the translator: He was reportedly seen by our team’s mobile medical clinic last November, and at that time they had referred him to the Central Plateau’s Thomonde hospital for HIV testing and treatment.  Obviously something had gone wrong and he hadn’t received the treatment and follow up that was previously prescribed, because here he was, looking worse than had been documented on his previous visit. It was no wonder why everyone was looking so pitifully towards him.  Today he was complaining of feeling week and tired, losing weight, no appetite and pain when he swallowed.  I had no clinical information on him, no stat lab values or fancy radiologic imaging studies to lean on when my brain got tired – so I tried to study him a little closer.  Though his vital signs and most of his physical exam were normal, the corners of his lips were chapped and painfully cracked open, making it difficult for him to fully open his mouth during the exam.  He couldn’t eat food and was wasting away, dying a slow, protracted death that could be easily avoided if I met him in my Atlanta clinic. 
To make things worse, our mobile clinic was closing up shop, with staff members busily cleaning up medical supplies and throwing away trash, some laughing or discussing previous patients seen earlier in the day.  The van drivers outside noisily honked their horns at us, as our tardiness in finishing up clinic was making them late for whatever engagement they had to attend after they drove us back to the compound.  And in the middle of all this chaos was this 30 year old Haitian man with HIV (and probably end stage AIDS), simply trying to get some assistance from the visiting American doctors who he had heard were providing medical care that day.  All of it didn’t seem right.
Our team of doctors, translators and medical students worked with a local clinical coordinator to arrange a plan: While this man didn’t appear ill enough to warrant an urgent transfer to Thomonde Hospital, it was obvious that he would need close and quick follow up to ensure he didn’t fall through the cracks of an already difficult to navigate and broken health care system.  We gave him medication to treat the fungal infection in his mouth, multivitamins and pain meds to relieve his painful swallowing, and instructed him to go the Thomonde hospital the next day.  Since he didn’t have any money, and reported getting too lightheaded in cars or motorcycles to travel at that moment, we collected some funds to help him with the transfer back and forth to the hospital for further evaluation.  The mobile clinic coordinator ensured that they would try their best to get him there, but that would likely be challenging as he didn’t have a phone, a stable address, or any way to accurately confirm that he would follow up with our best laid plans for his recovery.  Plus, we were in a very rural and remote area of the Central Plateau, and transportation challenges to accessing healthcare are the norm for the majority of people who live in this area.
I imagined what may happen to this young man after we left him today.  Would he even take the pills we gave him, or would he have trouble finding sufficient water or food to help the pills go down?  Would he even take the medications we gave him, or start them, only to stop in a couple of days because of side effects?   I pictured him weighing his options and life priorities, and possibly choosing to use the money we gave him to buy food or pay someone to allow him to stay the night instead of using it to pay for the trip to Thomonde hospital.  I wondered how he must have felt when the women sitting next to him outside our clinic snickered at him when one of the medical students called him in for his evaluation because he had “that disease.”  I thought about what it must be like to be him in this space and time: 30 years old, HIV positive, destitute with minimal shelter, food or social support and living in a remote rural area of a tiny Caribbean island that boasts some of the worst health outcomes in the Western Hemisphere.  Would he be strong enough to withstand the physical, social and psychological burden his disease was placing on him, and persist in his desire to live despite every ounce of his being telling him to give up?
It was now past 5 pm. We finished packing up our things and got in the cars that would take us back to our compound, away from the stale humid air and pessimistic stench of rapid-fire biomedical interventions that barely slow the blood loss inflicted from social wounds.  I hope this young man can persevere in spite of the unfortunate constellation of circumstances that led him to visit our clinic today.  I just don’t know if he will.

Full Circle
June 23, 2011

There are times in your life when you realize that you are situated in the right place at the right time. Today was one of those days. The usual chaos occurred, as we didn’t get to our site location until around 11 o’clock in the morning, after our original plan to work at a local clinic fell through.  Journeying to our mobile clinic sites was becoming increasingly harrowing each day - the roads narrower and more remote, less paved, and with breathtakingly beautiful mountains and forestry all around us.  Today’s clinic was actually taking place in and out of a farming family’s house, in which they had generously agreed to let us set up shop, changing a bedroom to an adult examining room, the outside living room into two pediatric tables, and the kitchen into a pharmacy.  Approximately 200 people were already lined up when we arrived, all of whom had traveled long and far to be evaluated.  What ensued were the typical frenetic organizational activities, but by the time we started seeing patients, things flowed smoothly and efficiently.
We saw many interesting patients today, including 60 year old gentleman with a lemon-sized lymph node in his neck and a 44 year old man with swelling in his scrotum.  Most of the people we saw presented with the similar constellation of symptoms, regardless of their age, gender, or situation in life: stomach pain, headache and generalized weakness.  It was becoming increasingly difficult to tell which people truly suffered from gastritis or heartburn, and which ones were presenting with those complaints due to word of mouth and desiring to receive the same medications everyone else was.  Our pediatrician introduced me to a beautiful 3 month old girl who was brought in by her mother because of a neck rash.  She was a brilliant, happy baby, with glowing cocoa-colored skin, wide inquisitive eyes, and a smile and laugh that would melt meanest person into a harmless puddle.  Under her neck was a diffuse, red rash, irritated and ulcerated, stretching across her entire jawline – a classic presentation of impetigo, a superficial skin infection that affects children worldwide.  The gnats, excessively aggressive that day, were having a field day exploring this young girl’s neck, and swirled around her wound like vultures around a corpse.  Despite all this, she didn’t let out a whimper or a cry, wasn’t restless or combative – she just grinned and smiled for all of us to see, seemingly without a care in the world and unaware of the infection that was eating away at her neck.  The pediatricians treated her that day by attending to her wounds and giving her antibiotics, and she will likely fully recover from the infection.  Seeing her made me think about all the American children (and adults) back home who pout, fuss and cry over far less adverse situations.  If this little girl wasn’t a metaphor for the resilience of Haitians, I don’t know what is. 
Later that evening, we sat at the dinner table in our compound, discussing everything from the latest medical school gossip to the complex politics of medical missions in the Caribbean.  Suddenly there was a commotion, as one of the male community health workers brought in a young man from town who reportedly had something stuck in his ear.  I sat on the periphery as everyone surrounded this new and unexpected patient, setting up an examining table on the other side of the outside eating area.  They discovered that the cotton swab of a Q-tip had broken off in this young man’s ear and wouldn’t come out, which was causing him a lot of pain.  One of the local hospitals had seen him earlier, and had sent him home because they reportedly didn’t have sufficient light and were unable to extract the foreign object from his ear. 
One of our pediatricians, Susan, took the lead and began irrigating his ear in an effort to expand the cotton tip and make it easier to pull out.  A few of the medical students grabbed some lighting equipment and a hemostat from our car as I sat back, hoping that they wouldn’t call me over.  This young man had about 15 people surrounding him as Susan was working on him, similar to how crowds of medical personnel gather in the hospital during a cardiac arrest, some actively helping, others just curious to see what’s going on.  And if there’s one thing that I’ve learned in these situations, it’s that too many cooks can spoil the meal – so I quietly sat on the other side of the room and observed, commenting to a medical student sitting next to me.

“I’m not getting involved in this.”

No sooner had those words escaped my lips when the med student who organized our trip, Sameer shouted to me, almost as if on cue.

“David, we need you over here!”

I walked over and looked in the young man’s right ear, which clearly had a Q-tip cotton swab in the canal, lodged in front of his eardrum.  The area around the swab was red and inflamed, and looked very painful.  Forgetting my manners, I stopped looking and introduced myself to the young man, who told me his name was Dooby, and that he was all of 18 years old.  Susan wanted to know if I had any other ideas of how to try to extract the Q-tip from his ear, of which I had none, so she said she would let me know if she needed any help.  I sat back down across the room and watched the crowd surround her as she examined Dooby’s ear.  The whole scene reminded me of those newscasts when a small child falls down a well, and the crowd gathers as the rescue workers concentrate on their rescue efforts.  It wasn’t long before Sameer called me back over.

“David, we need you again.”  Susan looked at me with some exasperation on her face.

“I’ve tried a couple of times. I’m worried we could puncture his eardrum.  Wanna give it a shot?”

I thought about my father as Susan handed me the hemostat and headlight.  I thought about his medical training in Haiti, and the numerous times he told me stories of how he would ride horseback as a young physician to different towns and villages in Haiti with medical bag in hand, providing care to those suffering from tuberculosis, cholera and other infectious diseases.  I thought about his journey to the United States and surgical training he received in New York City, the fellowship he did in upstate New York and how he set up his surgical practice there.  I thought about the thousands of times he took a hemostat, scalpel or other surgical instrument in his capable hands to save a life in more dire circumstances that the situation in which I currently found myself.  I thought about those same hands guiding mine, as I reached in Dooby’s ear with the hemostat, and after a few attempts, removed the Q-tip from his ear.  Everyone cheered and Dooby looked up to see the wax covered Q-tip, flashing the brightest smile of relief and excitement, as only an 18 year old can do. 
I found out later that Dooby was actually the son of the community health worker who brought him to our compound that night.  He also happens to be the brightest student in his class, and plans on going to Cuba someday to study medicine and become a physician.  It was obvious that Dooby’s family has an immense amount of pride and investment in his future, similar to how the family of a young man from Anse-a-Veau had invested in his future 60 years ago at the same age.  As Dooby left the compound, I wondered if he realized that a 79-year-old retired Haitian physician in upstate New York, whom he has never met before, had just laid hands on him.

Professional appreciation - Wrapping up in Central Plateau
June 25, 2011

We are leaving for Port au Prince today.  Our last day doing the mobile clinic in the Central Plateau was busy and fulfilling, and took place in a building that is usually used as a school.  What has been amazing for me to witness here is the importance of word of mouth and oral history here in Haiti.  It seems that no matter where we have set up our clinics this week, or how much advanced notice is giving out that we are having the clinic, there are throngs of people who turn out to be seen.  Even when there are only a handful of people at the beginning of the clinic, when word gets around, we look outside and suddenly there are a couple of hundred people waiting. 
There’s so much for me to absorb in this past week it’s difficult to put it down in words that can capture it all.  On a professional level, this has been transformative for me on many levels.  I’ve never really considered international medical work before, as much of it has been attached with “missionary” doctrine and efforts that make their helping countries with poor resources contingent upon the native peoples adopting or converting to their particular religious doctrine.  This has always been so repulsive to me as to make me nauseous, but this trip has had a simple and clear mission: To provide some medical assistance to a rural area of Haiti that is particularly underserved and suffers from a disproportionate burden of disease.  That has been refreshing to me, and has given me hope to the intrinsic altruistic nature of people, without the forced expectation of adopting a prescribed set of religious beliefs that are not congruent with those of the native people. 
I have also had the distinct pleasure of working with some pretty amazing people on this trip.  First off, the medical students have been absolutely ridiculous.   A group ranging in age from 24-28, and representing ethnicities and cultures from all over the world: South Africa, Korea, Egypt, Puerto Rico, India, Surinam, Haiti and America, just to name a few.  This has truly been a group effort, and the people have been inspiring to me during my time here.  The dedicated translators have been a diverse group of patient, hard-working and brilliant individuals who not only made communication possible, but also gave us all essential information about some of the cultural nuances in Creole or Haitian culture, particularly in the rural areas, that could either facilitate or be a barrier to our efforts.  They were absolutely amazing and I look forward to working with them again, but the next time I will be more fluent in Creole and hopefully will not have to rely on them as much.  Finally, my fellow Pediatric and Emergency Room physicians have been a joy to work alongside – they have taught me about different aspects of medicine I had never considered before or simply overlooked, and have opened my eyes more fully to the opportunities and diversity in the medical workforce.
Even more inspiring has been the opportunity to personally witness the future in this group of young 3rd and 1st year medical students.  Yes, they are all intelligent, that is a given.  Beyond that, I have really been impressed with their dedication to the mission and genuine concern for Haitian people; their willingness to put their egos and personal bias to the side to embrace the moment of this experience; their resilient capacity to absorb very intense experiences, process these experiences critically and still know how to have a good time; and finally, their willingness and ability to listen, learn and accept constructive feedback.  It gives me tremendous hope in the future of medicine and public health that there are so many inspired and passionate young medical professionals who understand the relationship between social justice issues and medicine.  It has truly been a blessing to work alongside this amazing group of young people, and I look forward to working with them in the future.

Sesa Wo Suban
June 28, 2011

I dreamed heavy last night.  I dreamed of Haitian people in the Central Plateau, with translators and medical personnel, occupying my bed with me, causing me to rise out of my fitful sleep.  I slumbered through the areas of my home as if they were the makeshift examining rooms I had occupied only last week, trying to figure out where to put the next patient or find a suitable place for someone to rest.  I still hear roosters crowing at 5 am, feel the stripped down efficiency of bucket showers and uneasiness of unpaved roads, smell the humid unscented air in remote mountainous locations, and taste the colorful flavor of seasoned chicken, rice and beans, plantains with Prestige beer.  These images are still embedded in my psyche, and likely will not dissipate for a very long time.
Our last night in Haiti was spent in Port au Prince, the country’s capital city and where much of the devastation from the 2010 earthquake was played out on international media markets.  We did not see the damage done to the Presidential Palace, but did view many of the “tent cities” where thousands have taken up permanent residence after being displaced from their homes.  While downtown Port au Prince still looks and feels like any Caribbean town, with its numerous eateries, souvenir stands, barbershops and people bustling in and out of vehicular traffic, it is not.  I sensed that the area is still trying to pull out of a couple hundred years of historical injustices and tragedies, compounded by this earthquake, which has left many scars and remnants in its wake, some visible to the naked eye and others not.
The hotel where we stayed for this last night was Hotel Karibe, situated at the top of some rolling streets above Port au Prince, and directly overlooking what in Brazil would be considered favelas, or some kind of shanty towns, on the mountains across the way.  Hotel Karibe was opulent to say the least, and served as a stark contrast to the predominant quality of housing in Haiti, as well as the housing quarters of our compound where we had resided for our 6 days in the Central Plateau.  It boasted a large atrium lobby with shimmering tile floors, modern furniture and marble top table counters, a full bar and gift shop, and a sprawling back courtyard with an ornate swimming pool and poolside bar.  It was a hotel that was built after the 2010 earthquake, and no doubt was catering to tourists, as we heard that many of the international relief workers and redevelopment personnel stayed there during their time in Haiti.  It was disturbing to me that a building of this magnitude, scope and design could be in existence while not even 1-2 miles away many Haitian people still lived in squalid and cramped housing arrangements.  However, the optimistic part of me also acknowledged that part of Haiti’s rebuilding process has to embody scaling up tourism efforts for international travelers, and the Hotel Karibe, on the surface at least, had the potential to bring revenue and create jobs for many Haitian people.
After a fairly uneventful evening at Hotel Karibe, we packed up our stuff and made our way back to Toussaint L’Ouverture International Airport.  On the plane back to Miami, I couldn’t help thinking about all I had witnessed and experienced in the past week, and how I didn’t really feel the same.  I returned home to news of Amtrak train crashes, E. Coli outbreaks, Sarah Palin (really?) and any other negative or tragic soundbite that the media could serve up to the masses.  The only good news that I read about was the passing of the same sex marriage law in my home state of New York.  As much as everyone was excited about this law, I couldn’t help but think what a privilege and luxury we have in the United States if one of our main life “issues” is what equal benefits we will receive if our same-sex unions are recognized in an official manner.  While I am happy about the passing of this law, it’s difficult for me to put this in a proper context when I just returned from a country where proper irrigation, poverty, absent healthcare, chronic diseases and infectious outbreaks like cholera are commonplace and often normative. 
Being “home” is somewhat strange in this, my second full day back from Haiti.  The Atlanta city streets look different, the once pedestrian buildings now more elaborate and daunting, the pace at which people walk seems much faster, and something as routine as taking a shower feels extraordinary and somewhat excessive.  In 2007 I had a tattoo placed on my right calf after returning from a trip to Ghana, the Ghanaian Adinkra symbol called “Sesa Wo Suban,” which means, “change or transform your character.” This symbol includes the "Morning Star" which can mean a new start to the day, placed inside the wheel, representing rotation or independent movement. I had initially embraced the tattoo and symbol after a tour of the Ghanaian cities of Accra and Kumasi.  Four years later, it has taken on an additional meaning for me, and I find myself questioning my life’s meaning and purpose again.  While I am certain that my dedication to a profession of service, teaching and healing is intact, I am uncertain whether chasing grant money and looking for the subjective approval of manuscript reviewers will be as essential to my journey.    
I am grateful for the opportunity Project Medishare afforded me to work in and experience the country of my father’s birth and half of my ancestral heritage.  I intend to be fluent in Creole by next year, and plan to revisit Haiti soon, this time to return to Anse à Veau to see my father's township for myself.  My dreams of Haiti, my people, my family and my mission will continue, and I hope they never stop.  They say that life is full of change, so let this one begin. 

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