I set up a conference call with Kerling and Michelle. I told them we had made some progress by finding a second neurologist willing to commit a surprisingly significant number of weeks to working in Haiti, but I thought it would take more time to build a bigger team.
“Should we aim for a year from now?” I asked them.
“No,” Kerling said. “Twenty-four weeks of coverage is plenty. I think we should start in the fall.”
“But it will leave so many open weeks,” I said, concerned.
“To you it doesn’t seem like enough,” Kerling replied, “but right now we have next to nothing in neurology. So the first step is to have something. Then it could grow from there.”
I didn’t like the idea of starting a program with patchy coverage. It would be suboptimal for the first resident to be left unsupervised for weeks at a time, and hard to address any inevitable issues from afar. But this line of argument wasn’t getting me anywhere. I tried a different approach.
“I’m just one year out of my own residency,” I said and laughed. “I’m so junior. Should I really be in charge of running a program at this stage? Maybe we should wait another year or two.”
“I don’t know of any other neurologist who is going to do this if you don’t,” Michelle said.
“Okay, but shouldn’t we at least wait until I have some more experience?” I asked.
“I’m not sure I know of any neurologists with more experience in Haiti than you,” Michelle replied.
“And we know you,” Kerling added. “And you know us. You are the right person for the job.”
“I agree we should try to do it,” I said, “but I just think we should take some time to build a bigger team of faculty and think through some of the logistics. Maybe we wait one more year?”
“Once you start, people will see what you’re doing,” Kerling said, “and then I’m sure more neurologists will want to get involved. But we shouldn’t wait for that. Let’s go for it! It will evolve.”
I sensed that they felt I was being too cautious. I suppose if everyone had waited for every detail to be in place to launch an enormous project like constructing HUM, perhaps it never would have happened. But for something much smaller in scale like training one neurologist over two years, I thought we should try to have more structure and staff in place before moving forward. Was I falling victim to what Paul Farmer would call a failure of imagination?
“Don’t let perfect be the enemy of good,” Michelle said, as if reading my thoughts.
I had one last concern. It was going to be an election year in Haiti. This would mean large and sometimes violent protests that could limit travel to and through the country. During the previous election cycle’s violence several years prior, PIH had nearly needed to evacuate all of its Haiti-based employees.
I thought back to the night before leaving Boston on my second trip to Haiti a few years earlier. I had packed my backpack and put it next to the front door. I had set my email away message and signed over my Brigham pager. I was just about to go to sleep when I got a text message from one of my colleagues in Haiti:
Massive protests planned for tomorrow. Not safe to travel in-country: road blocks, demonstrations, tear gas, etc. Re-book flight for next day.
I didn’t sleep well that night. What if nobody had remembered to send me that message and I had shown up in Haiti? Could I have been caught up in the violence en route to Mirebalais? Would I have been stranded at the airport with no drivers safely able to come pick me up? How was it so unsafe that I could not travel one day but would be okay to travel the following day? I postponed my trip a week. Was this what I had to look forward to in a career in global health—danger, cancelled trips, uncertainty? Was I really cut out for this?
The trip ultimately went fine, as have all subsequent ones.
“Isn’t it an election year next year?” I asked Kerling and Michelle. “Maybe it’s not the best year to start a new program if we risk having trips cancelled and other disruptions.”
Michelle and Kerling laughed gently. “The election year might be challenging,” Michelle said. “But depending on what happens in the election, the year after might be even worse.”
“You never know in Haiti,” Kerling agreed. “So we can’t think like that. When we have the opportunity here we have to proceed. If we keep postponing, waiting for stability . . . Well, stability may never come. But we still have to keep moving forward.”
It looked like they weren’t going to take no for an answer. So we agreed to launch a neurology residency program at HUM a few months later, starting small with just one resident at a time.
I negotiated with Brigham for a few more weeks in Haiti for that year and recruited some of my colleagues to volunteer for a week or two. Meanwhile, HUM put out a call for applicants and invited the most promising candidates to HUM for an exam and interview. They offered the first position to the top applicant, Dr. François Roosevelt, an internal medicine doctor in his late forties who had been in practice for nearly two decades. He had always wanted to get further training in a specialty, but no medical specialty training programs existed in Haiti. Our neurology program would be the first. And François would become the first Haitian neurologist to be trained in Haiti.
* * *
One of the first patients François and I evaluated together at HUM was a little boy named Davidson, who had been admitted to the pediatric ward. Davidson’s faded light green hospital gown covered all but his head and arms. The gown was nearly the same color as the off-white sheets beneath him, making his cherubic face look like a small island floating in the ocean of his large hospital bed. He looked around curiously through calm, big eyes that framed a small, bridgeless button nose. Aside from his eyes, he didn’t move any other part of his body.
Davidson’s father, Enel, sat by his bedside in a dark green T-shirt. He stood slowly as we approached, appearing concerned but calm. He gently placed the black hardcover book he had been reading on the chair he had been sitting on. I glanced over at the book. BIB LA was engraved in gold block letters on its cover—a Haitian Creole translation of the Bible. Enel was small-framed with a strong build. His big eyes and prominent, high cheekbones gave his face an innocent, gentle, almost deer-like quality. He couldn’t have been much older than early thirties and looked even younger.
Enel told us that Davidson was five years old and had developed normally until about age two, including being able to walk. Over the subsequent three years, he had become progressively paralyzed in both legs and then both arms, leaving him quadriplegic. Enel and Davidson lived in Port-de-Paix at the northern tip of Haiti, about an eight-hour drive from HUM. Enel had traveled all over the country with his son by bus and taptap, trying to find someone who could help them. Someone had told him that Davidson needed a CT scan and could get one for free at HUM, where he might also encounter a neurologist who occasionally visited from lòt bò a—the other side.
As François and I approached Davidson’s bed to examine him, the small boy watched calmly, following us with his eyes without turning his head. He could tell us his name and count to ten. With great effort, he could just barely move his left arm back and forth on the bed, but his right arm and both legs were completely paralyzed. All of his limbs were extremely stiff when we tried to bend them—spasticity. With even the slightest tap of François’s reflex hammer on Davidson’s elbow creases or knees, the boy’s limbs shot lightning-fast off the bed—hyperreflexia. When François gently scratched the bottom of each of Davidson’s feet with the tip of his reflex hammer, Davidson’s big toes rose like a thumbs-up, and his other toes fanned apart—a Babinski sign.