A terrible wisdom

February 2010 -- Press reports about the January 12 earthquake in Haiti continued to appear in the months that followed, describing the effects and the continuing health risks as health workers and patients struggled to cope with a devastated health infrastructure. We saw one fairly good New York Times article, described below, but most of these reports followed the standard physician-centric disaster reporting model we already described in analyzing samples of CNN's work. The reports gave the sense that physicians did everything important in the wake of the tragedy and that only physicians' health care views matter. An excellent example is Deborah's Sontag's February 12 piece in The New York Times, "Doctors Haunted by Patients They Couldn't Save," which explores the psychological effects on U.S. physicians who undertook short aid missions to Haiti following the quake. The report is dominated by four physicians and fails almost totally to consider the roles or views of the nurses and others who worked alongside these physicians. The piece notes in passing that one nurse helped a physician with one patient. And there are a couple quotes from a paramedic about the status of a 12-year-old patient, but she's only there to help the reporter update a pediatrician who treated the boy when she was in Haiti. One week before Sontag's piece, Ian Urbina filed a very different Times report about the impact on health workers, "Haiti Hospital's Fight Against TB Falls to One Man." That article tells the story of Pierre-Louis Monfort, a nurse at Haiti's only tuberculosis hospital. After the structure had collapsed and everyone else had died or fled, Monfort was trying to carry on the work of the facility's 50 nurses and 20 physicians by himself. The Times piece conveys some of what Monfort was doing for patients, and the psychic effects on him. The piece also consults "experts," both physicians, who discuss the disaster looming if TB spreads unchecked in a nation where the rate was already very high. Anyway, we commend Urbina and the Times for highlighting the experience of one tough, resourceful nurse in Haiti.

	Please donate to help the efforts of nursing initiatives in Haiti. Under "Direct my gift to:" please choose "SON Haiti Community Health Nursing". Thank you for helping the people of Haiti through nursing!

 
Doctors Haunted

"Haiti Hospital's Fight Against TB Falls to One Man"

 
Doctors Haunted

Deborah Sontag's February 12 article explains that "the medical professionals who initially flew to Haiti's rescue are haunted" by the patients they could and could not help. Then the article describes the experiences of some of these professionals, relying heavily on quotes from four named U.S. physicians. The piece focuses on the contrast between the advanced, high-tech environments to which the physicians have returned and the desperate, resource-starved settings in which they worked in Haiti, where they practiced what one physician calls "Civil War medicine" as part of what another physician calls a "mass casualty horror show."

The piece is not entirely free of references to non-physicians, but its structure and language clearly tell readers that only the physicians' experiences and analysis are worth considering. We hear how the "foreign doctors" performed amputations with hacksaws, how they relied on vodka for sterilization, how they worked around the clock in makeshift operating rooms, losing patients to conditions that would not have been deadly back in the U.S. It sure sounds like no one else did that, or is now haunted by it. After the report quotes two physicians about what they faced, it tells us that "they saved lives, probably by the thousands, but their accomplishments were limited by the circumstances." The report adds that "most of the doctors interviewed" said they were committed to returning to Haiti and marshaling resources to deal with the staggering needs that remain, including further surgeries and rehabilitation. Here again, it sounds like the health care response to the quake was and is about physicians alone.

The piece introduces readers to Dean Lorich, an orthopedic trauma surgeon at Manhattan's Hospital for Special Surgery, who describes the frustration of being unable to avoid mass amputations. "I am in the habit of saving legs," he says modestly. The piece refer to "his 13-member team from New York." Lorich describes the local hospital's lack of working equipment and supplies, and all the procedures the team did, saving many limbs, amputating others, over "three sleepless days." But their departure was "unsettling."

Dr. Lorich's team was exhausted, as were their supplies, but a flight that was supposed to be arriving with a fresh team of surgeons and nurses to replace them had been canceled. Outside the hospital, crowds seeking help pushed against barricaded doors, and they did not want the foreign doctors to abandon them. The doctors needed a military escort to leave.

So on the one hand, a team of "surgeons and nurses" will replace them, but the Haitians did not want the "doctors" to abandon them, and the "doctors" needed an escort to leave. Evidently, either the Haitians were fine with the non-physicians leaving, or else the term "doctors" can serve as a shorthand to include "their" entire team, since the non-physicians don't really matter.

The report also focuses on Louisdon Pierre, a Haitian-American who it says is the "director of pediatric intensive care" at Brooklyn Hospital Center. Actually Pierre is the director of pediatric intensive care medicine; physicians do not supervise pediatric intensive care nursing. But whatever; it's only The New York Times. Pierre is understandably plagued by the memories of Haitian children dying after the quake. The report describes the death of one baby this way:

Later, amid the patients strewn across the hospital's grounds, Dr. Pierre spotted a wrapped bundle in what appeared to be an abandoned incubator. The bundle, mewling, was a premature infant whose mother had died in childbirth. Dr. Pierre and a pediatric nurse from Brooklyn, Sharon Pickering, frantically tried to find a way to hydrate the baby. "This is something we know how to do," he said they told each other. Finally, they managed to insert a needle in a bone cavity and get the baby some fluids. But the next morning, Dr. Pierre found the incubator empty.

Pickering is the only nurse named in the piece, and she even gets a specialty and some credit for the joint effort to hydrate the infant. That's good. But of course, it's not the same as actually getting to describe her experience or what she thinks and feels. And what about this poor infant's fate? All Pierre knows is that the incubator was empty. What actually happened? Who do you think might know? Perhaps the health professionals who spend the most time with most patients? 

Elizabeth Bellino, a Tulane University pediatrician, also plays a major role in the Times piece. She rightly notes that "everything that everyone did during those first two heartbreaking weeks will have been for nothing if these patients don't get continuing care." Bellino tells the story of a 12-year-old Haitian boy she treated named Mystil Jean Wesmer, explaining that he actually comforted her and urged her to care for sicker patients, even though he was waiting to have his leg amputated. Bellino, now in Uganda on another project, worries about what happened to Mystil. But at the end of the piece, the reporter tracks Mystil down at an orphanage in Haiti "where American volunteers are looking after wounded children who have been discharged from field hospitals." 

Mystil was lying on a mattress on the concrete floor of a church with a roof damaged in the quake. On his plaid shirt he wore a SpongeBob sticker, which a volunteer said he had earned by doing several laps around a mango tree on his new crutches. Sarah Wimmer, a paramedic from Arizona, said that Mystil's wound was healing well, and that he was receiving some physical and emotional therapy. When his stitches are removed, he will be sent home to his parents, who are living outside their cracked house, but he will be considered an outpatient, Ms. Wimmer said. Reached in Africa, Dr. Bellino sighed. "I can breathe now," she said after learning that Mystil was all right.

Mystil says he misses "Dr. Elizabeth," but when the reporter asks if there is anything the physician can bring him when she returns, he suggests a bicycle--before looking down at his bandaged stump and saying, "I forgot." That closes the article. Although paramedic Wimmer gets a couple indirect quotes to explain Mystil's status, it's obvious that she has only been consulted in order to inform Bellino, and to tell us about how Bellino and Mystil feel. The reporter is not interested in Wimmer's experience, what she has done for Haitians, or how she feels. She's not a physician.

 
"Haiti Hospital's Fight Against TB Falls to One Man

Ian Urbina's February 5 article, by contrast, places the focus squarely on 52-year-old nurse Pierre-Louis Monfort, who runs a "fly-infested clinic hastily erected alongside the rubble of the only tuberculosis sanatorium" in Haiti. The piece says Monfort works surrounded by patients in the crowded clinic, "facing a vastness of unmet need that is as clear as the desperation on the faces around the room." The reporter apparently observed patients waiting for Monfort to dispense pills, as he "emptied a bedpan full of blood." Monfort runs the clinic alone.

All of the hospital's 50 other nurses and 20 doctors died in the earthquake or have refused to return to work out of fear for the building's safety or preoccupation with their own problems, he said. Mr. Monfort joked that the earthquake had earned him a promotion from a staff nurse at the sanatorium to its new executive director.

Thank you, Mr. Monfort, for not joking that you've been "promoted" to physician!

The piece includes some "expert" information about TB and the overall situation. None of the information is attributed to Monfort. The report notes that Haiti already had the highest TB rate in the Americas, and "health experts" say the rate of the deadly disease is about to drastically increase. That's because the sanitarium's patients have fled and are now living in the tent cities, where, "experts say," they are probably spreading the disease, most of them not taking their pills and thus making an outbreak of a drug-resistant strain more likely. At the same time, acute care needs have overwhelmed the care facilities that are functioning, pushing chronic disease care aside. The reporter includes a quote from a man with tattered clothes who says he has TB and is supposed to get dialysis every other day; he has not had it in three weeks.

On these matters, the report quotes "Dr. Megan Coffee" at Port-au-Prince's General Hospital, who points to some quarantined TB patients believed to have a resistant strain of the disease and suggests that "someone needs to go and help Monfort, or we are all going to be in big trouble." The piece explains that an additional difficulty is that conclusively diagnosing TB can take weeks, so "doctors are instead left to rely on conspicuous symptoms like night sweats, severe coughing and weight loss." But, as Coffee explains, most of the patients at the hospital fit this basic description. The piece also quotes "Dr. Richar D'Meza, the coordinator for tuberculosis for the Haitian Ministry of Health," who says that he shares concerns about resistant strains of TB, so he is getting "medical teams" ready to look for the disease in the tent camps. And he notes that the government and the World Health Organization are stockpiling TB medicines. The problem is not that these physicians are unqualified to act as "experts," but that the piece seems to believe that "expert" input has to come from physicians. Is it possible that none of the information came from Monfort? If any did, it would have been helpful to say so, so readers would know that Monfort has broader health knowledge. Had a physician been helping Monfort, as Coffee suggested someone should, perhaps the piece would have been all about that physician.

But the report does spend most of its time discussing Mr. Monfort's work, and it does a good job of giving some sense of what Monfort confronts and what he does. He "scavenges the rubble daily for medicines and needles," and he "sterilizes needles using bleach and then reuses the bleach to clean the floors." At one point, the report says he "struggled to fix an IV that had missed the vein and was painfully pumping fluids under a patient's skin." This description of the IV is probably the closest the report comes to suggesting that Monfort has advanced skills, though of course it's in the context of trying to fix something that has gone wrong. The piece describes the sickest patients who stay at the "cramped clinic," including many who sleep in "pockets" alongside the hospital, and notes that hundreds more come to the clinic daily, through the "sickening smell of rotting bodies" outside, to get their TB medicines. But Monfort explains that the most pressing need is more basic:  food. In considering this report, it's important to recognize that although it is focusing on a nurse, it is not suggesting that only nurses did or thought anything notable related to health care after the quake, as the other Times report is. Urbina's piece does not equate nurses with all health workers, or ignore the views of physicians.

Clearly, Monfort is suffering a great deal himself. To its credit, the report is not a picture of an immaculate, placid angel bestowing grace on the suffering multitude. Monfort seems tense and overwhelmed, describes his situation as "drowning," and says that ""these people are dying and in pain here, [and] no one seems to care." He says his wife begs him to stay with her and their three children (who are all living on the street because the quake destroyed their home) rather than working at the clinic every day from 6:00 a.m. to 8:00 p.m., "unpaid and without a mask or gloves to wear." When a patient asks Monfort why he does not just "leave us to die," Monfort "looked offended," but "the question seemed to stick with him." The report concludes:

The ancient Greek playwright Aeschylus once wrote that there was a type of suffering so intense that, even in our sleep, it bores into the heart until eventually, "in our own despair, against our will," it taps into a terrible wisdom. After several minutes in silence, Mr. Monfort spoke of that wisdom. He referred to it as a "strange hope" that had sprung from the suffering of his patients and the loss and abandonment of his fellow staff members. "These people here are dying, but they keep me alive," he said. "I know they are hurting more than me and not complaining. So," he said, handing another walk-in patient a packet of pills, "I must continue."

This is a fairly persuasive account of what nursing can be like. It conveys not only the stress of Monfort's situation but also some of the reciprocal nature of the profession, the give and take, which is often overlooked amid the angel stereotypes that often dominate discussion of the work. As overwhelming as nursing can be in situations like this, and as emotionally draining as the work can be in any setting, nurses can still get real psychic benefits from their sustained care of the very sick. Even nursing as courageous as that performed by Monfort is not selfless. Nursing can and should benefit the nurse; it is not a divine vocation, but a modern science profession. Of course, nurses should not be expected to endure what Monfort is facing. And we might ask, what about Monfort's family? How are they surviving without him, and apparently without any funds from his work? Does he have a greater responsibility to them? Even nurses in less desperate conditions may face impossible choices between the interests of patients and the public generally, on the one hand, and the well-being of the nurses and their families, on the other.

If nothing else, we hope the nurses in Haiti and elsewhere can find the "strange hope" Monfort describes.

Contact Ian Urbina author of "Doctors Haunted by Patients They Couldn't Save," at urbina@nytimes.com.

Contact Deborah Sontag author of "Haiti Hospital's Fight Against TB Falls to One Man" by clicking on her author page then clicking on "Send an E-Mail to Deborah Sontag."

Thank you!

	Please donate to help the efforts of nursing initiatives in Haiti. Under "Direct my gift to:" please choose "SON Haiti Community Health Nursing". Thank you for helping the people of Haiti through nursing!