Thursday, February 07, 2013

Haitian Pornography

Pierre--February 1, 2013
(Photo by John Carroll)
Amy Wilentz new book is called “Farewell, Fred Voodoo”. In her book Wilentz writes that visitors to Haiti, including herself, tend to be guilty of writing about or photographing Haitians in their despair. She calls this "pornography" when we write about or photograph poor Haitians for its shock value. And the Haitian subject usually never knows what becomes of their story or photo. They hardly ever benefit in any meaningful way.

I agree that this is some form of pornography. But if the story or the photograph may spur someone to do something good for the person or for Haiti I rationalize that it may be less pornographic.

I have found myself in the same spot that Wilentz describes in Haiti many times in 30 years. And I have asked myself: Why am I here? Should I be here? Do I have any right to be here? Am I doing any good to be here and to document what I am seeing?

I realize I am different than the Haitian I am examining or interviewing or photographing in that I can leave Haiti anytime. Wilentz says that poverty is not so bad when you can “snap your fingers” and it comes to an end. In other words we can go home when we have had our fill. But Haitians cannot go home when they’ve had their fill. They ARE home. Most are condemned to live here forever.

Living in Haiti should be wonderful, like the Arawak Indians found it to be centuries ago. But the Arawaks lived with dignity and most Haitians do not. Haitian roofs leak and their kids hair is orange and they vomit worms. And so a million Haitians, give or take a few hundred thousand, have left Haiti with visas or on creaking boats. Many have made it big but many are cleaning bathrooms in South Florida airports and hotels. They do the undignified work we won’t do.

Yesterday I was approached at St. Catherine Laboure Hospital in Cite Soleil by a thin man who was walking with a woman. He had the requisite IV in his arm. Haitians firmly believe that getting IV fluid is good for what ails you and it frequently is.
 
He politely said hello and came over and sat down next to me on the wooden bench in the courtyard of the hospital. He told me his name is Pierre and that he is from a little village named Lilavois located on the outskirts of Port-au-Prince. He said that he had been a carpenter until he got too weak to work. And then he started telling me his medical problems.

While he was talking I noticed that his facial muscles had wasted away, his arms were thin, and his eyes were yellow and sunken. And his abdomen was conspicuously bulging from underneath his t shirt. Thin Haitian men with bulging abdomens are never good. I have seen too many.

Pierre related that he had come to St. Catherine’s because he had severe pain in his abdomen, weight loss, and yellow eyes for about three months.  He said that he was unable to eat and he couldn’t hardly sleep due to pain. He looked like he had been sick for much longer than three months.

Pierre told me that he is 48 years old and the lady with him identified herself as Pierre’s sister. She seemed to be a gentle lovely soul and obviously very concerned about her brother.

My heart sank for so many reasons. Was I on the verge of creating pornography like Wilentz describes? Should I even talk to Pierre? I knew he was dying.

We walked into the hospital and Pierre laid down in his hospital bed in the Internal Medicine ward and his sister sat at the end of the bed. There were five patients spread out around the ward. Only five patients in the only hospital in Soleil that serves an area of 250,000 people. There were no doctors on site.

I examined Pierre's protuberant abdomen. When I tapped on his abdomen he had shifting dullness due to excess pathologic fluid moving back and forth. And I gently felt for his liver border. Usually an adult’s liver doesn’t extend further than the lower ribs on the right side. But Pierre’s liver border ran way below his ribs down the right gutter of his abdomen. And his distended liver felt rock hard. 

Lower liver border
(Photo by John Carroll)
 
I finished my exam and said to myself Pierre has liver cancer and he is definitely finished.  

I reviewed his dossier in a cheap blue plastic folder.  During his two day hospitalization he had been given two types of diuretics to try and decrease the fluid in his abdomen. Some labs had been drawn which showed his bilirubin was high. In other words "something" in his liver was blocking the flow of bile and so the bile regurgitated into his bloodstream and turned his eyes yellow. That "something" was most likely cancer.

What was not on his chart was medication written for pain. Pierre had been given nothing for pain. In thirty years in Haiti I have never seen morphine, demerol, dilaudid, or fentanyl ordered for pain.

When poor Haitians get bad diseases that are not treatable in Haiti, like liver cancer, they deserve to have pain medication to ease them during their last days. And narcotic pain medication like morphine is not expensive. But pain is not treated effectively here even at the end of their lives. Haitian lives are painful up to and including their last breath.

So is this pornographic that I am posting about Pierre?

I met Pierre for a reason. Should I not say anything to anyone about this meeting?  Should I just act like Pierre does not exist and that his medical condition is nothing? Should I just shrug and say to myself,  "Gee whiz, this guy needs something for pain."  Should he just be another unknown Haitian carpenter who works very hard his entire life and dies anonymously without any pain medication? Has Pierre nothing to teach us?

So what did I do to assuage my guilt and make the whole experience with Pierre less pornographic?

I talked with Pierre and his sister. I advised him to ask the doctor, if he sees one, for pain medication and if the doctor did not prescribe him any to leave the hospital and try the public hospital down town. I did not expect that hospital to be any better, but it is no worse either. I did not want to guide Pierre in the wrong direction, but it is not happening here in Soleil at St. Catherine's.  

I asked the nurse for pain medication for him.  She opened the cabinet on the ward and we both searched for pain medication. There was nothing there in the cabinet. The nurse was very polite but also very unconcerned there was nothing to offer Pierre for his pain.  She is used to death and painful deaths.

The nurse said Pierre needs to buy his own pain medication. And by that she meant "on the street". Pierre is too sick to do this and so this responsibility would fall on his sister. But she has no money. Obviously, this was not a good option so I gave them a 20 dollar bill to buy pain medication if any Haitian doctor wrote the prescription.

So was I done at this point? Could I go skipping out of this dismal ward all happy?  No, not yet. I realized I had some pain medication in my pack that I take for migraines. There were only a few.  I told him to take half a pill to make them last twice as long. Pierre seemed so happy and swallowed half a pill immediately.  


I also had a bottle of pre-natal multivitamins in my pack. So I gave them to him and also told his sister to take one per day. The vitamins would largely be placebo for Pierre but not for her.

Did I feel guilty about giving dying Pierre vitamins, a small handful of pain meds, and twenty bucks?  Yes I did, especially when they smiled at me and thanked me so much.

But I told myself that I had done more for Pierre than the Haitian government, foreign governments, NGOs, and millions of people worldwide who had pledged 5 billion dollars for Haiti after the earthquake. If Pierre can sleep for a few hours now with the meds I gave him before he returns to his usual state of pain and suffering, then that is good.

Another option would have been for me to tell Pierre that he is dying of liver cancer and that he needs to return to Lilavois before he dies. And if he did this, his kind sister would not have to hire a private tap tap for a lot of money that she doesn’t have and transport his body back to Lilavois for burial. (For some reason, typical Haitians won’t travel on a tap tap with a corpse.)

Should I have said that to him? Should I have taken any fading hope that he may have for life? I would have been honest. But in my opinion this was no time for brutal honesty. It was a time for vitamins, pain meds, a little money, and a little hope.

Someday we will look back on the Pierres of Haiti, and there are many of them, and say we did not do them right. But that day has not arrived. I will continue to do what I can and document what I can while hopefully not creating too much Haitian pornography.  



John A. Carroll, MD
www.haitianhearts.org

4 comments:

T & T Livesay said...

We're thinking about the same things today Dr. C.

John Carroll said...

"Thank you for the article. It hits hard. There is no excuse for being unable to treat pain. The chemotherapy used to treat end-stage cancer produces marginal and variable outcomes at best. Opioids - on the other hand - are universally effective, have predictable dose-response relationships, and can be infinitely titrated. It may be an oversimplification on my part, but a potent driver of the global inequality of access to opioids are the antiquated laws set forth by the UN in the early 1960s pertaining to narcotic ceilings imposed on a country-by-country basis (see Nickerson, PLOS Medicine 9(1): e1001153). Is uncontrolled pain a necessary side-effect of our War on Drugs?

Fortunately, more of us are coming to understand that access to pain relief is - essentially - a human right. One of my mentors was Dr. James Cleary. He helped to found the Global Access to Pain Relief Initiative (GARPI, www.treatthepain.com). I was happy to see that starting this year, GARPI has a 3-year contract with PIH to improve availability and education about pain management in Haiti.

Here is a density graph showing per capita Morphine equivalence, with Haiti being really at the tail (ppsg-production.heroku.com/chart). Thanks for sharing all of your work over the last few years, and bringing much needed visibility to so many quiet issues."

(Comment sent from young physician)

Anonymous said...

You speak of so many things I have felt & experienced, thank you for sharing. I'm so proud of the Haitian people and all they do for themselves.....the keep their joy in the midst of turmoil none of us can even imagine dealing with for a "moment"!! God bless them all!!

Anonymous said...

Your "pornography" cause Pierre to be prayed for today!!