Volume 60, Number 3 - Summer 2009

 

By John Mihalik, MD

A 13-year-old boy presents in a remote clinic in the Dominican Republic with a complaint of a “hole” in his side. A history reveals that he was born with an imperforate anus in Santiago de los Caballeros, the country’s second-largest city. After receiving a colostomy and a single colostomy bag, he was sent home to El Naranjito, a remote region where his parents live off the land. 

He wraps rags around the stoma and changes them frequently; but because of the stench, he has become socially isolated from peers and has stopped going to school. I am the first physician he has seen since his colostomy 13 years ago.

Six months later, he sits before me again: thin, gangly and smiling. He is in school, and two of his closest friends insist on being in the exam room with him. The colostomy bags he received at the last visit have made a huge difference in his life. With his shirt on, you would not guess he has any medical problem at all. He is awaiting a consult in the United States for possible reconstructive surgery.

Dad, you have to go. They need you.” With that imperative, my daughter Amanda started me on a journey that has led me many times into the mountains of the Dominican Republic, near the Haitian border. At the time, Amanda was an undergraduate at Seattle University and had just come home from working with Somos Amigos (“We are friends”) Medical Missions; she is now finishing her third year of medical school.

People often think of medical relief work in the context of disaster relief. That kind of work—which can be extremely demanding, rewarding and even dangerous—gets our attention and involvement after hurricanes, earthquakes, tidal waves or terrorist attacks. 

In contrast, Somos Amigos has committed to one region of one country and has been the sole provider of medical care in that region (El Naranjito) for the last dozen years. This ongoing commitment has allowed us to build our relationships and services in response to the people’s needs. By returning again and again (we go three times per year), we have been able to change the general level of health throughout El Naranjito.

Somos Amigos, a nonprofit corporation, started in the 1990s as a Georgetown Preparatory School community service project to build water systems in impoverished rural areas of the Dominican Republic. A six-week mission allowed time for the students and the project leader, Frank Brightwell, to bond with the local community. The locals expressed the need for a doctor, so Frank subsequently returned with Dr. Mike Keegan, a gastroenterologist from Washington, DC. The next time, Mike and Frank brought a dentist, and gradually Somos Amigos grew to the organization it is today.

We currently bring about 50 people on each mission, typically including six attending physicians, six attending dentists, several medical and dental residents, and a smattering of medical and dental students and nurses as our professional core. We also have volunteer translators, pill counters, lab techs, office workers, mechanics and gofers, along with our CEO, Frank Brightwell, who is our main liaison with the community. He knows the country, the region and the people, and he is the principal reason for our success.

El Naranjito is near the center of the island of Hispaniola, where both the Dominican Republic and Haiti are located. There are no towns in El Naranjito, no stores or businesses. The only public buildings are a school, a Catholic church, and the Somos Amigos medical and dental clinics. The clinics are about 30 miles from Haiti as the crow flies, or three days by foot. 

The people in El Naranjito live off the land, the campo. We are literally in the “mountains beyond mountains,” a phrase made famous by Tracy Kidder’s bestselling book about Dr. Paul Farmer’s clinic in Haiti. 

Most of the people of the campo live in rough-hewn wood houses with thatched roofs and outhouses. A typical family exists by farming yucca root, sugar cane, coffee, oranges (El Naranjito means “little orange”) and a handful of chickens. A few families have pigs, and even fewer have cows. Transportation is mostly by walking, but also by mule, horse or motorcycle. Cars are very rare.

Electricity recently came to El Naranjito but has been mostly out of service because of the hurricane season and the low priority for repair from the government. Our clinics rely on a diesel generator that itself requires frequent repair.

Our missions to El Naranjito last about a week. We typically fly into Santiago, the Dominican capital, on a Saturday afternoon. That night, we have an orientation dinner and stay in a nice hotel, our last chance for a hot shower and a good night’s sleep.

Sunday morning we load a week’s supply of food, water, medicine and clinical necessities onto a truck and then pile into microbuses for the half-day trip to El Naranjito. The first 30 minutes affords the new volunteers a chance to see Santiago, with its colorful buildings, fully loaded motorcycles, ubiquitous scooters, open-air markets, huge potholes and tropical climate. The city is almost always warm and humid.

The paved road ends as we begin climbing into the mountains. El Naranjito is at the very top, at about 4,000 feet. When we arrive, we are immediately greeted by people welcoming us to the community. It is a big event. After a lunch prepared by women of the region, we begin setting up the clinics. The buildings have no active clinic except during the weeks we are there, so we unload supplies and equipment out of closets and packing crates.

Later in the afternoon we attend a welcoming ceremony at the Catholic church, which is at the center of community life. The church is the place of support, socializing, and spiritual pursuits, and also the arrival point for the occasional microbus carrying visitors or sacks of mail. While Somos Amigos has no religious affiliation, we recognize the importance of the church in El Naranjito. They help us distribute medications and overcome potential roadblocks in our dealings with the central government.

After dinner, we head off to meet the families we will be staying with. We usually house just a few people at each location, but a couple of families have bunkhouses that can accommodate 10 or more.

Sleeping is a challenge. The wire-frame beds often sag into the shape of taco shells. I’ve taken to bringing a rectangular barbecue grate to span the frame, covering it with an air mattress, and sleeping on top. Besides the beds, the noises of roosters and other animals, including your roommates, may limit your rest.

Clinic starts Monday at 8 a.m., by which time a long line of people is already waiting. Many have walked three or more hours through the mountains during the night. They include children sent by their parents to get in line by 5 a.m. By the time everyone has been seen, it is 8:30 p.m., sometimes later.

The first days of the week we see “the locals” who live within five to 10 miles of the clinic. They now seem like anyone we might see here in Sonoma County: diseases fairly well controlled, teeth brushed, rarely a parasite and generally well. The rest of the week we see people from farther away, some of whom are visiting the clinic for the first time. They increasingly include people who have walked the three days from Haiti. These people have often never seen a doctor or a dentist. They may have multiple parasites, rotten or no teeth, and advanced illness.

From Monday to Thursday, the medical team sees about 900 patients of all ages. Meanwhile, the dentists see about 300, providing extractions, fillings, cleanings and even full dentures. The medicine is interesting because of the challenge of limited medical testing. Although we have some lab capability and a laptop-size ultrasound, we have no plain X-ray or more advanced imaging.

I like the clinical challenge, and I enjoy teaching residents and medical students how to draw blood, do a gram stain or read a urinalysis or KOH preparation. The experience points out the value of a good history and physical exam skills.

After four very long days, we pack up the clinic on Thursday afternoon and ride back to Santiago for a farewell dinner and a hot shower. We board our flights on Friday morning and begin the long trip home.

The intensity of the week and the shared experience with other volunteers can lead to difficulties getting back into the regular routine. You may have feelings of wonder at the immense resources we have available here, both medically and socially. Seeing a patient who feels entitled to an MRI or complains about you being five minutes behind schedule can be difficult. The contrast with the gratitude for your services abroad can be striking. 

Being among colleagues who have not shared your experience can also pose difficulties. Meanwhile, your spouse may be glad to have you home but may not appreciate your exhaustion or the fact that he or she was left for a week with the children, the house and his or her own work. Getting “back to the routine” may not be easy.

I think the transition can be smoother if you feel and show gratitude for those who provided “coverage” while you were gone, who let you take the time off, and who may have even contributed by donating equipment, medicines or money for the trip. You can also take a long weekend to reconnect with your spouse and family. Finally, giving a grand rounds can help you process the work and benefit your medical community.

My own words cannot express how valuable and meaningful this work can be, but we have a saying posted on the Somos Amigos clinic wall that comes close. It can be roughly translated as, “If you came here expecting to heal others, you will be surprised by how you have been healed when you leave.”

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Dr. Mihalik is a family physician and hospitalist at Kaiser Santa Rosa.