Food and Ethics in a Disaster Zone

Did I mention we have a goat?

One of the best things about our compound is undoubtedly the food.  I had never had Haitian food before and had no idea what to expect.   We have a cooking staff of five or six who go out of their way to make sure we eat well.

Breakfast is simple with some sweet grapefruit, toast and eggs or Haitian oatmeal called avwàn.  Avwàn is more like gruel or porridge than what we would think of as oatmeal.  It is creamy, salted and has a touch of cinnamon.  It is a bit of an acquired taste, but I love it.

Lunch always consists of some sort of diri ak pwa and vegetables. diri ak pwa is rice and beans cooked in a large pot. I have had at least four different kinds of beans since I have been here and they are all delicious.  The vegetables are usually green beans, beets, cabbage, potatoes or carrots.  There is also some sort of meat. Chicken (we see them delivered live on Saturdays, talk about fresh!), meatballs or stewed meat.  We think the meat is goat but we aren’t really sure.  It’s good nevertheless.

It is said that wherever the French have left their footprint, one can be assured there is good bread.  Haiti is no exception.  For dinner there is always great, crusty bread and salad with the most amazing dressing I’ve ever had. It is served in a large enameled cooking pot and is made with ( I believe ) lemon, shallot, peppers, oil and vinegar.  It is sweet, salty, spicy and sour all at once.  My friend commented,  “ You could put that dressing on (insert expletive of your choice here) and it would taste good!”   They also make an “American Classic” with a Haitian spin.  We have had Shepherd’s Pie, Baked Macaroni, Pizza and Spaghetti to name a few with flavors that are distinctively Haitian.

That's a lot 'o beans!

One can’t help feel guilty about eating so well in a country where the population receives only half the recommended daily calorie intake by the UN. Starvation and sever malnutrition runs rampant. People constantly approach us on the street crying “grangou” , “I’m hungry”.  We try to justify it by acknowledging that we are providing a valuable service to the people and need our strength and energy.  We only take small portions and don’t leave any waste.  Justified or not, we still feel incredibly guilty.

It's always good to befriend the chefs!

Medical ethical decisions are difficult enough in the developed world. One can only imagine how much more difficult these ethical decisions are to make in a disaster zone. Much of this has been well publicized in the international media.  For example, the decisions to amputate limbs of children which may have been able to be saved in a developed country in a non-disaster situation etc.  The questions that need to be answered at our hospital are a bit more subtle.

Cardiac surgery Haiti style

For example, in my previous post I referred to the difficult decision whether to convert  the medical tents into a refugee camp.  The benefit would be a sense of community for the traumatized people and assurance of proper shelter and nutrition for them.  The disadvantage would be that valuable medical beds will no longer be available in a country where there are only five major hospitals (as far as I know).  Haiti has only one doctor for every 4,500 people which is among the worst in the world.  It goes without saying that facilities such as Sacre Coeur are extremely valuable in Haiti.

Dr. Crow and a friend

I also referred in a previous post about the child with severe hydrocephalus ( increased fluid accumulation within the ventricles of the brain)  who is going to die without treatment.  The week before I arrived there was a rumor that a neurosurgeon was offering to come down to place a ventriculo-peritoneal (VP) shunt to drain off the water surrounding the child’s brain.  The issues here were, 

• Would placement of the shunt kill him? There is a good chance that in such an advanced case, a sudden draining of the fluid would cause herniation of the brain and immediate death.  
• VP shunts require an immense amount of maintenance and follow up care afterwards.  They often require revisions as well. How would this happen in a country without a permanent neurosurgeon and one doctor for every 4,500 people?
• There were still thousands of patients needing urgent medical care and surgery as a result of the earthquake.  Would a case like this suck up valuable resources that could otherwise help a trauma victim with a much better chance of recovery?

It is a very sad case, but the decision was made not to aggressively treat him.  Eventually he will be sent to the Haitian equivalent of hospice-care.   

In this case the person I feel the most sad for is his grandmother.  The boy’s parents left last week and Grandma has been at his side ever since.  The other day I was in the pediatric ward handing out cards from my kids’ classes and taking their pictures.  After I was finished his grandmother came up to me and asked if I would take his picture.  I did and showed it to her afterwards.  She beamed and looked as proud as any grandmother I’ve seen looking at a picture of a grandchild.  It was clear to me that she didn’t see the baby as "deformed" or a “really interesting medical case", but as her wonderful grandchild.  I almost broke down crying.

The last case which made me stop to ponder happened yesterday.  The patient was a seventeen year-old boy.  He lost his entire family in the earthquake and was being treated alone, as an orphan in Milot.  In addition to other assorted fractures, he suffered a depressed skull fracture on the crown of his head which had become severely infected.  Antibiotics had failed to improve the wound and now it was clear that a large portion of his skull had become necrotic with infection surrounding the mass.  If this could not be removed soon he surely would develop meningitis and/or encephalitis and die.  

The issue was that the bone lied directly over the sagittal sinus, the major blood drainage from the brain.  There was concern that unroofing this bone could tear the sinus resulting in sudden, massive blood loss, venous air emboli and sudden death.  We were able to secure one unit of blood for him, however, there was no way to screen it for HIV.  The questions this raised were

• If we need to transfuse the blood, what is the risk of transmitting HIV in untested blood?
• Is one unit of blood adequate?  If the sinus is torn he would need dozens of units of blood to replace the blood loss. So would we be better off letting him die and using the blood for someone with a better chance of survival?
• If, God forbid, he did not survive the surgery, would he be better off?  He has just lost his entire family, has no place to live, no job, no education and a long painful recovery ahead of him.

Neurosurgery Haiti Style

Thankfully, he did survive the surgery and did great. We did not have to give him any blood and the infected bone lifted off relatively easily as it was completely surrounded by an abscess cavity.  I hope he recovers well and things start to look up for him.

On a lighter note, this guy felt this phone call couldn't wait until after his hand surgery!