Fellowship Essay

(I got rejected, but I love this essay)

I decided to become a doctor because I want to defend the right of every soul that crosses my path to live healthily and happily. When I was honest with my abilities, interests and achievements at that pivotal moment in my life when I chose this profession, medicine made the most sense and the path into it was clear. As a student doctor, I have made a great effort to ensure that my focus was not solely on the human body, but also the humanity which animates it. The human existence is the marriage of a myriad of disciplines and experiences and I never want to forget that.

I believe that my studies thus far in the humanities, social justice, and the health sciences will help to contribute to a vibrant conversation about conscious medical practice, identifying bias in both negative and positive contexts, and the next ethical step in the evolution of medicine, should I be deemed worthy to receive this Fellowship.

It is my sincere belief that this fellowship will help me continue my education in a subject that is a necessary component of modern medicine: ethics. For me, the Holocaust is one of many appropriate beginnings for my continued enrichment in the history of ethics for personal reasons as well as practical ones.

My practical reason is related to my career choice in medicine. The research and evidence demonstrating the existence of the social determinants of health now is astounding. The social determinants of health speaks to an understanding that one’s wellbeing is not just intrinsic to the individual but also contingent on the milieu by which they are surrounded and the sphere they occupy in their society. Race, gender, sexuality, religion, immigration status, socioeconomic status and many other things can affect the severity of the same disease in two individuals with different backgrounds. It has been very well demonstrated that those belonging to marginalized groups tend to have poorer health outcomes for most diseases. We as current and future clinicians tend to focus more on the avoidable, downstream manifestations of these social determinants, an expected consequence of how we are instructed and trained. We’re more likely to treat an anxiety and depression complaint with a medication than take a step back and realize that the anxiety and depression of our patient is a function of a poor, single mother with job and food insecurity, almost no social support and poor literacy skills being denied necessary aid from the government because she filled out her forms incorrectly as English is her second language.

And often, even if we are aware of all of that, our power to help such an individual may be limited to that prescription.  However, we’re uniquely poised in the present climate of medicine to start addressing those identifiable upstream social determinants of health, at the societal level.

The role of the doctor is changing and has been changing for some time. There are a plethora of medical complaints that no longer directly need a physician to be addressed. While I will still defend to the death the need for primary care providers, this role that was once just filled by physicians is now being filled by capable and diverse teams of specialized providers.

As the presence of clinicians is less necessary in the clinical settings, I believe that doctors need to practice medicine in the macro scale: no longer one patient at a time, but in the public health and health policy arenas, where the health of entire demographics can be effected for the better by our meticulous clinical training and problem solving skills. This is important because now we as clinicians, the traditional harbingers of health, can work actively to address those social determinants of health that contribute to the frightening health disparities in the United States and worldwide and unnecessarily burden healthcare systems. What is more, often, the populations with greatest health disparities are those with histories wrought with dark times of humanity that many would like to forget: exploitation, legal and social discrimination, bloodshed, war and deliberate wrongdoing; wounds that have long needed dressing.

As someone who wants to defend the right of every soul that crosses my path to live healthily and happily, how can I not address the social determinants of health that I take so much time educating myself about? The answer is that I cannot and still expect to achieve that goal. Therefore, addressing the social determinants of health and health disparities, learning the history that contributed to them, and the practices that maintain them is a matter of medical ethics.

The Holocaust blatantly demonstrates what I still find to be true in many subtler ways today: the illness that is killing people is a function of a society that is sick. All atrocities committed in the name of supposedly advancing science must not be forgotten and the medical ethics which evolved in response to should be a pillar in the education of all future physicians. The Holocaust changed Medicine forever. The unspeakable human experimentation carried out by doctors can serve as both a cautionary tale and a lesson of the importance of practicing medicine methodically but also with a conscious.

Ignoring the past and not addressing the wounds that it left behind on the present would be irresponsible.  We deem ourselves healers. That being said, if we are silent then we are complicit in the sickness that afflicts our society and we betray our oaths and divine calling of medicine. I hope contribute to the field of medical ethics and medicine in the future, addressing health disparities and continuing the work of exposing all wrongs committed under the guise of advancing the field of Medicine. Whether in Auschwitz, on Indian Reservations or in the underserved rural south town of Tuskegee, Alabama, there is much learning and atonement to be done.

Through these hard lessons, we can better heal the gaping wounds that still mar us.

Threatened Independence – Conversation with an Elderly Veteran

Right now, I’m here.  I don’t want to go down.  Like down, a hole in the ground, in a grave.  I’m almost 90. Most people my age are vegetables.  But I do alright by myself.  I do what I want, go where I want, take care of myself and I have my own finances, no romance, I’m too old for that.  But I don’t want to be a burden.  I got a good family. I live with my son, but we don’t hardly see each other.  My youngest son comes sometimes, and he cooks for me, when I don’t feel like doing it myself.  I’m independent, I’m satisfied.  But now, I’ve fainted and they’re trying to figure out what’s wrong and I want to stay where I am, avoid the decline.

 

Maybe you’ll find it hard to understand, you’re a young lady.  You’ve got a good education, good job and your whole life to live.  Me, I worked the same job for more than 30 years after the navy.  They respected me.  I didn’t complain, knew my job, they called me ‘Old man H’.  There hasn’t been anything I haven’t been able to provide for my family, anything they wanted.  I’ve been halfway around the world, now I just want to do what I want.  My son sometimes acts like he’s the boss, but he ain’t.  I’m the kingpin.

 

If you done been through what I’ve been through, seen what I’ve seen and know what I knew…  I do what I want now.  They’re talking about sending me to a rehab, but I got things to do, I got to the to the bank, I got places I need to be.  I take care of myself.

 

I’ve had hemorrhoids; I got them cut out.  I have a hernia.  I’ve had diphtheria.  People would die from that; put a big black cross on the front door and say, don’t go in there, ‘so and so’ died.  There wasn’t one on my door then; there ain’t one on my door now.  I don’t need that. At my age, I’m satisfied.  I do what I want, I take care of myself.  I’m satisfied.  You probably think I’m nuts (sidenote: I didn’t and I told him so).

Haiti Reflection Paper: Familiarly Unfamiliar

We were picked up from Port-au-Prince without much delay or hassle.  Shortly after landing, going through customs and the baggage claim, and alternating between bathroom breaks and watching each other’s luggage, we were ushered out of the airport into the parking lot.  The Haitian men who would be driving us in helped us load our bags into the back of one main SUV, we were divided into groups of four or five,  ushered into one of the six or so SUVs that awaited us, and we were off, whisked away to Thomonde.

I attempted to ask our driver a few questions just as we were hitting the brightly colored, evenly spaced houses that encircled the city before it ended, falling away into plains and wilderness.  My tongue felt too thick and heavy in my mouth as I spoke and the Haitian Creole that came out was accented and awkward with the question.  I was embarrassed to hear it because I knew it was bad, but my driver understood well enough, responding kindly as I relayed the information the rest of the group about how those bright colored houses were built by the President for Port-au-Prince for residents who had lost their homes in the infamous 2010 earthquake.  It would take a few more attempts at conversation and some deep breaths to calm my anxiety before I got some level of fluency that wouldn’t thoroughly embarrass me, though I’m sure my parents would have raised their eyebrows at me and ask me who taught me to speak their native tongue.

I gave a brief cultural competency crash course en route.  People are kind and open for the most part, but it’s probably not the best patient population to elicit a sexual history from.  In fact, sex was rarely spoken of in my home growing up, except to warn us that we should not be having it until we were married.  It was just taboo to mention, even if the inquiry was necessary, professional and purely innocent.  The one rotation in our clinic, I would later find, where my language skills were most limited would be women’s health.  I actually had no vocabulary for my own anatomy.  I learned while eliciting the chief complaint from a woman with a likely yeast infection, the proper adult words in creole for ‘vagina’ and ‘hymen’.

We stayed in a large, stately guest house, a sharp contrast to the often dilapidated, small and non-uniform houses that surrounded it.  Everything in the country looked familiar, but at the same time, drastically different from how I remembered it.  I never remembered seeing such breathtaking landscapes and mountains as a kid, despite riding in the back of an open pickup truck sandwiched between my parents, siblings and cousins.  But then again, my family was not from the mountainous part of the country.  The Haitian houses in my mind were made of clay and earth colored materials and surrounded by rice patties and farmland.  (It really blew my mind that there were no rice paddies.  To my farm owning grandfather, and to our everyday cuisine, rice is everything). The native houses that encircled us were made of wood and cement and often painted.  But the faces were the same, curious and inquisitive, keenly aware of the fact that we were not natives (though I was recognized as Haitian by most I encountered one on one) as we drove by into the gated compound: we were in Haiti, but not really.  We were surrounded by the country, but very much enclosed in a microcosm of Western living, with amenities that catered to us passersby.  It was all lovely, though a very inauthentic experience of living ‘en dehors’, outside of the big cities.

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Lots on my mind looking off into the mountains in Haiti…

I guess my experience in Haiti compared to everyone else’s was different.  It was not life changing or shocking.  I had seen this level of poverty before, though mostly as a child.  But there were definitely constant reminders of it at home.  My mother’s parents were a little better off than a lot of Haitians, but much of our extended family definitely lived in abject poverty, often going to my grandparents for assistance in the form or food or money.  Even the poorest of the poor in America, except maybe the homeless, live pretty well over here compared to the poorest in Haiti.

Even when times were hard for my family growing up, my mother made it a point to make sure she sent money back home along with the clothes and shoes we outgrew.  After political instability made my parents fearful of bringing their minor children to Haiti with them, my grandparents came to visit instead.  They always came with empty suitcases, but they left with full ones and far more than they came with, as we would buy several more to overstuff with goods.  Charity starts at home, my mother would often say, reminding us that though we were very much entrenched in American living, Haiti was still home for her and my Dad.  We were born in America, but we were raised Haitian.

So it was not eye opening at all.  It was all very familiar, just a reminder of what I already knew.  My childhood memories served as a reminder to keep my American privilege in check.

Because of my background and upbringing, every time I go on these kind of trips I ask this (I also went to Nepal a couple of years back and in fact will quote my previous post): “I find myself asking which is the lesser of two evils: introducing temporary aid and interventions that may leave the natives and recipients of our aid worse off if funding and supplies run out or doing nothing at all?  A small bandage on a gaping wound or the uncertainty of letting the wound heal or fester on its own?”  I’m not so blind that I can pat myself on the back for good work done when I understand that we did nothing to affect the infrastructure that perpetuates the poverty and lack of access to basic medical services that we came to address.  We just showed up for a quick fix, one of many I’m sure, because truth be told, the plane there and back was full of white people with their charitable organization’s logoed T-shirts.  I must admit, that was a bit shocking.  That never happened when I was a kid (I mean 90% of Haiti’s population if of black African descent, so I’m just being honest).  So maybe I did find one thing shocking after all.

But what I appreciated MOST about this trip was our group: they worked tirelessly to provide the very best services that they could with the short time allotted.  However, at night, while reflecting on the day, I saw that most of them understood that much of what they were doing was futile, that figurative bandage.  They were very pensive and contemplative.  They were often vocal of their conflicting feelings and their despair that they could not do more.  Yet despite the sense of futility, it took nothing away from the amount of hard work they did.

That was not only beautiful but also a relief, because I was not surrounded by such likeminded individuals in Nepal and in fact chastised by the most senior of the group for my discomfort with the intrusiveness of much of the trip and my pensive retrospective analysis of the implication of our being there.

So I learned a bit more medical creole, especially about female anatomy!  I learned to be a little more confident in myself because people saw me as more capable, useful and apt than I saw myself.  I wish I had more time to learn about Project Medishare and the steps it take to establish such an organization.  I’d like to learn about their dealing with the Haitian government, particularly the ministry of Health and the country’s hospitals.  I don’t have the knowledge to even know what kinds of questions I should be asking to get that information, so I’m very passive with how I learn in novel situations like this.  I really liked the groundwork, but in order to effect the kind of change in such countries that I really want to see, I need to know more about the framework that is often set up months and years before we even get there.   In the future, I would love to continue to participate in these kinds of programs, but I would love more to one day be with them when they sort of graduate and leave the country.  I would love to work with a program that eventually isn’t needed anymore and see a Haiti (or any developing country) that is self-sufficient and able to improve health outcomes of their own people.

What I would like to see and know more about, which I know will be a huge, exhaustive task, are ways in which we can effect change in Haiti by looking at foreign policy, political action and legislation in America that contributes to Haiti’s plight.  Wouldn’t it make more sense for Americans to look at their own government, something that they can legitimately control with their vote then to just show up in Haiti with the intent to do good?  To me it does, unless the main mission is to self-serve and self-congratulate.  If that’s the case, I don’t want to indefinitely support that kind of initiative.  It doesn’t make sense in my mind because it only benefits me in the long run and I, and I suspect most people on these missions, really want to help the recipients of such aid.

On that same note, I’d like to advise people who want to do this mission in the future and people in general to know more about America’s history and how we as a country and other Western countries are often complicit if not the very cause of the most recent issues that we volunteer to help solve (France, Canada and various parts of Latin America…  I’m looking at you!).  It seems that Haiti is not only the poorest country in this hemisphere, but also has been one of the most occupied by America.  I know correlation is not causation, but the general trend is that the countries that America (or substitute for another Western world power) has invaded/occupied don’t do so well.  I wish more people would ask what’s going on, why that is, and what they could do as Americans to change that on their side instead of assuming that the Haitian people (or Nepali, or insert other countrymen of another developing nation here) need saving.

Thoughts on Global Aid/Health

So I read a few articles for an elective class that I’m taking and I had to write a reflection about what I read… This is the bulk of it, I had a few other thoughts, but they were kind of random, but most of this stuff fit together.  I don’t think you need to read the pieces to appreciate the points that I make on them, hence my sharing.  I hope you enjoy reading it as much I enjoyed writing it!
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  One of the most striking thing that I found about most of Grim’s writings is her frequent use of the word “disaster”, “chaos” or some other word or phrase that conveyed pandemonium and disarray.  Its use highlighted a great sense of disillusionment that she must have experienced when she realized what the realities of giving medical treatment in a 3rd world or war torn country meant:  a feeling that many untouched by such things in life must experience the moment they step outside of themselves or stop viewing things as a tourist or transient presence, destined to return to the sterile aesthetic of the Western/1st world.  At one point in “How to Vaccinate Children in a War Zone”, she does explicitly question whether or not she’s making a difference..

.             At this point in my life, I’m not quite sure that I understand what making a difference is supposed to mean or look like.  I want to share an experience of mine to illustrate:.

.            This past February, I was selected as an Ambassador to a CARE-Nepal project sponsored by the company that I left to begin medical school.  Everyone expected me to have some life altering experience by being sent to Nepal for ten days to kick start the mission (our project funded programs promoting maternal and neonate infant health in rural and urban Nepal where death rates due to child birth were the highest).  But it didn’t change my life.  I appreciated the trip, I loved that I was selected out of hundreds of applicants to receive the privilege of being sent to Nepal, but I’ve been in the 3rd world many times before: it looks the same.  My family is from the poorest country in the Western Hemisphere.  The poor there are poorer than the most poverty stricken Americans.  They all die from lack of access to the same basic needs that we take for granted here.  I took it in silently, wondering what possible difference I could make with this one trip as an entry level employee at my company whose job description did not babyprepare me for anything I was doing out there, meeting with local government officials of a country whose infrastructure I knew little about and whose culture was novice to me and I couldn’t readily identify with.  I had applied on a whim and hadn’t expected to be selected and a month later, I was there.  I took it all in pensively, learning and drawing parallels to examples that were a bit closer to heart and home, trying not to drown in the futility of my being there.  What could I possibly do?  I was the youngest, least experienced and one of the only non medically trained Ambassadors… Well, the CFO wasn’t medically trained either.  But she had the company’s checkbook on hand, a powerful tool that she could and that she had waved about at her discretion..

.             I learned so much about CARE, their operations and their attempt at sustainable models of community education that I hope to apply to my career as a physician, but my life was not changed.  That’s just the honest truth.  Which seemed to annoy our CFO, the big boss on the trip.  And her annoyance bothered me.  I couldn’t say it out loud, but I was more annoyed by the Corporate Vice President/CFO’s Savior complex than anything else, as if she was doing the people of Nepal a favor by being there, waving about that figurative checkbook.  But she couldn’t humble herself enough to put herself in their shoes for a moment and squat over the traditional Nepali toilet (a simple hole in the ground… it’s an experience).  No, we had to go on a several hour journey to find traditional Western styled toilets for her to use in a tourist hotel.  And she had the nerve to chastise me publicly for my pensive silence and not following in her extrovert model of leadership, as if that was the only way to set an example and make that elusive difference..

.             I happened to have crashed last week’s mandatory event for the Global Health Track.  I couldn’t bring myself to spend an hour studying.  It takes an hour just to get ready to study sometimes; I’m incredibly inefficient.  Anyway, I have a terrible memory and wrote nothing down, so I can’t honestly tell you anything about the lecture beyond the day I attended it.  But at some point, before the speaker started talking about some of the work his NGO was doing in East Africa, he shared this Camus quote:  “The evil that is in the world almost always comes of ignorance, and good intentions may do as much harm as malevolence if they lack understanding.”  There was a lot of self-congratulating going on in my trip to Nepal by someone who I don’t think understood the amount of effort it had taken and it would take to make real change in the maternal and infant death rates due to childbirth in Nepal.  Sometimes, looking at the facts and figures presented, the obstacles to the task at hand seemed insurmountable.  You can’t just change things immediately when some of the biggest issues were deeply ingrained in superstition and culture (like the erroneous belief that eating leafy greens would make Mum and baby sick, so women were often discouraged from eating them).  Note the difference of approach:  trying to understand what is feasible (what I was attempting to do) vs. giving yourself credit for doing “good” that may not be that good in the long run, assuming that you even retrospectively analyze the implication of your actions (the CFO’s plan of attack).  But to the CFO, she was making a world of difference and couldn’t have been prouder of herself and our company and I was left writhing in my own insecurities of potential uselessness.  Sometimes, I wish I was wasn’t beyond that level of delusion, if for nothing else then for the undeserved boost of self-esteem..

.            Action and self-education can occur simultaneously: they don’t have to be mutually exclusive events, but I find too often they are.  If I saw more people were taking a moment to educate themselves and understand the way things operate in a world that is not their own, I think I would be more in support of Global Health Initiatives/service trips and less ambivalent and critical.  “Dying of a Treatable Disease” brought up the point that while drugs for the treatment of HIV being introduced into Africa is essential, it’s not enough.  Without a fundamental understanding of what else is needed, one may think that simply providing them with drugs as sufficient.  But, as Keirns points out, there is a “serious shortage of staff to administer them, leading to overwork, guilt and burnout among dedicated medical staff members.”  So a simple intervention of providing necessary drugs may lead to losing essential medical staff and an already understaffed, under-resourced 3rd world country, which would further impact how many people get vital medical care (and it would ultimately lead to waste, because if you lose the medical staff needed to administer the drugs, then the drugs will inevitably go to waste).  An example of the evil that ignorance may breed Camus highlighted in his quote:  It’s a simple, well intentioned act, but the consequences are potentially more devastating than the current reality..

.           Which is the lesser of two evils: introducing temporary interventions that may leave the natives and recipients of Global Aid worse off when funding and supplies run out or doing nothing at all?  A small Band-Aid on a gaping wound or the uncertainty of letting the wound heal (or fester) on its own? (I really like the way I wrote that, so I’m gonna use this phrase over again, haha…  Stealing from myself is not wrong.)

I don’t know if I’m in a position to say.