last words

Now back in the United States, I want to share the fruit of one of my side Fulbright projects. Just days before I left, I got together with a couple of friends to record a song that we created about the issue of violence against women, or gender-based violence. It's a significant public health issue in the DR and around the world - but it's not only a health problem; it's also a human rights issue and a social issue.

So here's the song and video we made (the track was produced by DJ Beethoven of Santiago, RD). Hope you enjoy! And please pass it around; we are working on promotion in the DR, but we want as many people as possible to hear the message.

"No la Golpees" - Chokola y Gimby ft. La Nueva Chaska

results

So what are the results of the past nine months of work? Well, what I have produced is really a series of hypotheses – that is, laying the groundwork for future research by highlighting how gender creates points of convergence and divergence in TB patients’ experiences that need to be studied in greater depth. Some of the key issues my research raises are

- the role of a machismo culture in experiences of disease and in health care-seeking behavior
- gender differences in the psychological impact of the disease
- gender differences in diagnostic delay (the amount of time that passes between onset of symptoms and diagnosis); my results show that women, on average, experienced significantly longer delays than men, although my sample size is too small to draw definite conclusions
- gender differences in self-care and disease prevention as well as types of treatment sought; many men reported increased self-care as a way in which they would change their lives after completing treatment, and women and men both used a variety of alternative treatments before or during their antibiotics
- incidence of extrapulmonary tuberculosis (TB disease in an organ other than the lungs), which I hypothesize is higher among women, based on a quantitative analysis of clinical records
- gender differences in the effects of perceived and real social stigma related to TB
- the intersection of gender with other social factors such as socioeconomic status, age, legal/migratory status, etc, on patients’ experiences with disease

Because my research question was broad and my sample size small, drawing conclusions about these issues is premature. The success of my study is that I have identified some issues that are salient to the question of TB and gender, hopefully therefore paving the way for future research and encouraging program staff and policymakers to consider some of these questions as they design or re-design TB programs in the Dominican Republic.

While I have enjoyed doing research and have learned a ton, I'm left with a feeling that, in the long term, research is not for me. This is good news, because I'm going to be a doctor, not a researcher. At the end of this project, I feel a desire to stay here and implement the changes that I think need to occur. While I’m not yet at a level where I can influence international policy (it’s only a matter of time, though :), I do feel like my experience here could contribute to changing the experiences of patients at the community level. Ending with a paper (well, several papers, in two different languages) is satisfying, but I want more.

I want to design an intervention or program modifications that can address some of the issues I’ve encountered in my research. Investigation is extremely important; but I think that I would rather be the person reading the outcomes and subsequently applying them. One thing that has bothered me about my research is that my methodology was very traditional. I wanted to use more participatory methods or to incorporate a social change component that would give something directly back to my participants, but I ended up not having the time to incorporate this into my study design. I do want to engage in future research, but I see it being less traditional and more horizontal and participant-inclusive. For example, I don’t want to do a needs assessment of an underserved community; I want the people in that community to assess their needs so that I can just help leverage resources or services to meet them.

I’m haunted by the words of my MDR-TB friend who challenged me, “so what if your research shows that things aren’t good here, that we have problems with the treatment? How is it going to change anything for us?” While I can’t promise that policies will be rewritten and aid money reallocated as a result of my nine-month Fulbright project, I would have liked to at least feel that my participants got something (besides the little nutritional and financial compensation that I gave) out of my research. And maybe they did; one girl with TB told me that being able to participate and share her experiences and concerns was very important for her. But somehow, I doubt that my interviews have made a huge difference in anybody’s life.

I suppose this is where patience comes in; this is all a process, and my work was a drop in the ocean. The benefits of my research may or may not trickle down to the people they’re supposed to help, but at the very least, I have learned so much about listening to patients, about asking the right questions, and about understanding a community, that I believe my capacity to be a good doctor and health policymaker in the future has increased immeasurably as a result of this experience. And who knows – maybe I will end up being one of the people who takes on some of these questions and keeps working to find more concrete answers – in a participatory, horizontal way with funding for an intervention at the end.

At any rate, I’m proud of my work and I have to say that Fulbright has been an amazing experience academically, professionally, and personally. After a week full of despedidas (goodbye parties) – pseudo despedidas (at the clinic last Friday, there was a big activity for TB patients about their rights and responsibilities; since there was food and I got to say a few words, I pretended that it was my despedida, too), others’ despedidas (my roommate’s, also on Friday), and my own (some quality time with close friends from the past four years in the community where I worked with SOMOS and, tonight, a meal with some family friends here) – it’s time to get serious about packing. See you in the United States!

a tapestry

It's a small city - and country (and world). The other day at the clinic, a new TB patient - a one-armed, skinny, elderly gentleman - called me over to where he was sitting and demanded to know what I was doing. I explained my research to him and after a few minutes of conversation, he relaxed and began to smile. Just yesterday, while sitting with a friend at an outdoor cafe in the Zona Colonial (a world away from the community where I do research, in every sense), a beggar approached us, asking for spare change. My friend, a Dominican well-accustomed to this, waved him away, but when I looked at the beggar, I realized with shock that it was the same patient who had questioned me a week before. He recognized me, too, and, after greeting me, began to personalize his entreaty, telling us how he had tuberculosis, children to feed, and had lost his arm in an accident. I gave him some money and he thanked me and wished me well.

No matter how much time I spend here, it's always a shock to realize how small the world is, a phenomenon that's epitomized on this tiny island. There are coincidences with fellow U.S. Americans - like running into a guy I met two years ago again, or meeting someone whose father and mine happened to work in the same laboratory at Yale 15 years ago - and other sorts of coincidences. My participants and friends at the clinic are the people who, in a neighborhood just a guagua ride away, drive public transportation, pick up trash in parks where I go to hang out, and clean the houses of the wealthier Dominicans I know. But in the clinic, they are patients, participants, and friends. Half the people I talk to have a daughter or a cousin who looks "exactly" like me. One of them, a man I refer to as my Dominican dad, had his "identical" daughter call me the other day to see how I was doing when I hadn't shown up to do fieldwork for several days.

And then how do you tell people who begin to look out for you, who start to care about you, that you're leaving and have no idea when you'll be back? I didn't know what I was getting myself into when I applied for SOMOS back in my sophomore year of college. Or maybe it goes back even further - to the report I did on the Dominican Republic in my high school Spanish class. But the thing is that now I have a compromiso with this island - a commitment that I know will keep me coming back over and over again (hopefully next time to the Haitian side). There are health problems throughout the world, and there are countries and communities elsewhere that I have long wanted to visit. But my "brother" and "Dominican grandparents" in northern Santo Domingo, my close friends and colleagues from all sectors and walks of life, and the distinct locura of Dominican Spanish can only be found right here. I feel committed to the work, too. Even though I'll be moving on to other things very soon, I want to know who the next person to take up research on TB will be, what new innovations the programs here might develop over the next several years, and how the epidemiology will change over time. You see, I am a person who likes stories, and as much as we sometimes pretend they do, stories never end. What is challenging about life is that we must learn how to weave these stories together in order to create, a la Carole King, a tapestry. And weaving is an art that we learn over time.

el país de la maravilla, part 2

After resting in Santo Domingo, Celeste and I were on the road again at 7:45am – this time to visit some friends in Batey Libertad and to watch a soccer game. The batey is home to a few good friends of mine and is the main field site of another Fulbrighter. It was lovely to finally see a community I’d heard so much about, meet the families of close friends, listen to the musical sounds of Sunday morning church while visiting the local voudou space, and hear both Dominican bachata and Haitain compas competing from colmado speakers. It was also a great opportunity to practice my Kreyòspañol :)

After a Haitian lunch, we piled into a guagua – Celeste, my fellow Fulbrighter, a Peace Corps friend, the soccer team, coaches/supporters, and me. There were 21 of us in the van. The game was to be held in Santiago, a city about an hour down the road from the batey. When you drive eastward in the DR, though, you’re bound to hit military checkpoints. Ostensibly looking for “illegal Haitian immigrants,” they are convenient opportunities for local officials to pocket some bribed cash and enforce the unofficial Dominican policy of racism towards Haitians – or, really, anyone with dark skin.

We were stopped at two or three checkpoints; needless to say, our vehicle filled to twice its capacity of passengers, most of them dark-skinned, was suspicious – or perhaps auspicious – to bored Dominican military personnel on a Sunday afternoon.

“Morenos, huh?” said one of the soldiers, peering into the vehicle (morenos means “dark-skinned/featured”). “Tígueres” (gangsters, hoodlums). Then of course there were questions about the couple of obvious foreigners mixed in with all the Haitian gangsters. I kept my mouth shut, glowering, and the cops seemed to assume I was either Haitian or Dominican. And then there was the obligatory side conversation between the driver and the cops, and then the few hundred pesos passed along (“we aren’t going to ask for money, but if any of the foreigners would like to make a donation…”), and then we were on our way.

Such incidents never fail to make my blood boil. But we made it to Santiago with only one person getting arrested (in the other vehicle, a Haitian-Dominican unlucky enough not to have his papers on him; he was later released). "We've arrived in South Africa!" shouted one team member as we poured out of the van.

The game was great, though Celeste and I missed all the buses back to Santo Domingo except one. Not the best of bus companies, it dumped us off on a random street corner in the capital close to midnight. Luckily there was a handful of other passengers, with whom we huddled for protection until a taxi arrived to take us home.

El país de la maravilla never disappoints.

el país de la maravilla, part 1

A friend here once told me that the reason that the DR is known as “el país de la maravilla” (the country of wonder) isn’t its beautiful beaches or breathtaking countryside. It’s because there are just some things you see here that you won’t see anywhere else.

Last week my best friend Celeste came to visit me. Our lives – or perhaps better described as “life,” since we are technically two halves of the same person – have often been referred to (by us) as the Adventures of Irène and Celeste. Our adventures have taken place everywhere from the hallways of a public high school to the floors of university frat parties to the sands of the Outer Banks…and now, for the first time, they took place in the Dominican Republic.

My grand plan for Celeste’s visit was to hike Pico Duarte with her – something I’d been meaning to do during my time here. A friend of a family friend recommended our guide, Julio, who agreed to pick us up at the Jarabacoa bus stop on Wednesday afternoon. When we got off the bus, of course, more people than were getting off the bus crowded the door, asking if we wanted a ride or a guide to Pico Duarte. I looked around for Julio, who quickly stepped forward and introduced himself (I’d told him to look for two tall gringas with backpacks). Julio led us to the flatbed truck that would take us from Jarabacoa to the small town of la Cienaga, his home and the starting point for Pico Duarte hikes. Julio was accompanied by a small band of men whose purpose was unspecified(Julio groupies?). Celeste and I dubbed them “J’s boys,” and they reappeared periodically throughout the next several days. Very West Side Story.

Julio took me aside a few times to ask, “do you know about Pico Duarte?” I said that I’d heard a few things. “Because it’s hard, really hard.” He gave us a look. I told him that I’d done the Inca Trail and that Celeste had spent a week hiking in Appalachia the previous summer, but Julio didn’t seem impressed. “This isn’t the Inca Trail,” he warned. “This is Pico Duarte.”

The flatbed truck took us to buy food at a super-colmado that smelled, according to Celeste, like a toilet. (I’ve become immune to the sometimes pungent scent of colmados.) We stocked up on rice, beans, canned veggies, bread, cheese, yogurt, and canned ravioli to eat along the trail. Then we made the hour-long, rainy, bachata’d ride through the mountains to la Cienaga. J’s boys sat in the back of the truck, protecting our backpacks from the rain and passing around a bottle of liquor in plastic bag. They kept offering it to us, but we refused.

When we finally reached Julio’s, we were served two dinners within the span of an hour. If it wasn’t already clear, we now understood perfectly that he doubted our strength. J’s boys wandered back in between the first and second dinner, still nursing their bottle of liquor (with increasingly long swigs) and still offering it to us. We politely continued to refuse and busied ourselves with a second mountain of chicken and rice prepared by Julio’s wife.

The next morning, Julio woke us up, muttering that we’d slept in. We had been under the impression that he would wake us up when the time came, but apparently this impression was false. We packed up and headed out into the mountainous Dominican sunrise with our two trusty mules. We insisted on carrying our backpacks, which further contributed to Julio’s conception of us as silly, misguided gringas. “That’s what the mules are for,” he said, giving us his judging stare (he wore his judging stare for at least 60% of the trip). We weren’t sure how to explain why we wanted to carry 35-lb. backpacks up a mountain, so we just smiled and refused.

We made it pretty far before we had to give in and put our backpacks on the mules. It was somewhere around 1,900 meters when we realized that “hiking” Pico Duarte meant death by ascension. We went up and uP and UP and it never stopped. The trail seemed to be designed not for human hikers, but rather for, well, beasts of burden. Julio mostly rode one of the mules. When Celeste couldn’t take it anymore, she switched places with him, but when I tried to ride the other (the one already carrying all of our belongings and supplies), mutiny ensued (or, as Celeste put it, “mul-tiny,” if you will). Because I felt bad for the mule and because I am hardcore like that, I decided to carry on by foot.

After an ascent of approximately 2,000 meters over a distance of 10.7 miles (8 hours of hiking), we reached camp. We picked up a companion on the way – a small dog belonging to another guide that we passed on the way up. Apparently he had been abused and jumped at the chance to run away because he began following us, whimpering plaintively but refusing to be touched. Celeste and I named him Chufle, which means “electric outlet.” I just think it’s a cute name. Somehow a second, almost identical pooch appeared, and we were really confused until we realized that they were two different dogs (we later found out that they are siblings). We named Chufle’s equally cute, female counterpart Chuleta (“cut of pork”).

The bathrooms at the campsite were beautiful. Unlike Julio’s steaming outdoor chamber pot, they smelled good – like the sun-warmed wood with which they were constructed – and they had working toilets and running water. We were tempted to sleep in the bathroom itself and we spent as much time as possible in it. After changing and washing off a bit, we curled up in our sleeping bags and tried not to move until Julio called us for dinner.

At dinner, Julio informed us that one of the rice bags was infested with maggots, which he realized after preparing it with the canned veggies. He deemed it inedible and made another batch of rice. Since he’d also forgotten the chicken at home, this severely limited our culinary choices for the second night’s meal. (Furthermore, one bag of the bread we’d bought tasted and smelled like the toilet colmado and the other bag – well, Julio said that the rats must have gotten to it, because it just didn’t taste right.) Therefore, he proposed, the best plan would be to complete the 3-4-day hike in only two, meaning that the next day we would finish the ascent to Pico Duarte and then hike ALL the way back down to la Cienaga – a round trip of 28 miles, 2500 meters up and then back down, and 16 hours of hiking in two days. We were in so much musculoskeletal pain that we could only laugh at the prospect of this, but death by falling off a mountain seemed better than death by starvation stuck in the mountains.

That night we slept on the floor of the cabin at the campsite. The next morning, Julio awoke me by hissing in the dark, “morena! What’s the plan? Are we going to finish the whole trip today?”

“We don’t have much of a choice, do we?” I groaned.

Celeste reported that she’d had to use the bathroom in the night, but opted to wait till sunrise due to some suspicious scuffling sounds outside that sounded like neither dog nor mule (there are wild boars in the mountains, but luckily Julio had a machete should one surprise us on the trail). We got up – reluctantly, because it was actually really cold at 2,500 meters; think coniferous trees and steamy breath – and headed up to Pico Duarte, ascending another 500 or so meters to the top. When we arrived, Julio hugged the bronze bust of Duarte (one of the DR’s founding fathers) and we admired the scene around us.

It’s said that on clear days you can see the ocean (and the mountain is located in the very center of the island, in the central-west part of the country), but because of clouds we couldn’t make it out.

Julio smiled at me for the first time and said “you did it well” (remember, I rode the mule for a total of maybe two minutes during the entire ascent). Finally, respect and approval! Then he informed us that our bodies “would never be the same” and that now no one could tell us that we don’t know Pico Duarte. Good thing I have a response now to all those haters who keep taunting me with “you don’t know Pico Duarte, fool.” Happens all the time. We took the obligatory pictures, bade Duarte farewell (at least, Julio did) and then descended back to the campsite, where we ate breakfast and packed up.

The next six hours were devoted to the hike back down to la Cienaga. Downhill is just as hard as uphill, only in a different way. We stumbled our way down the mountainside, trying to enjoy the scenery. It was difficult because 1) we were forced to look down in order to avoid tripping over ubiquitous rocks; 2) if we stopped for any length of time, Julio and the mules would catch up to us and then they would be uncomfortably breathing down our necks (often Celeste and I could hear them coming and would mutter, “it’s the Mules of the Apocalypse! Outrun them!” and tear down the path in order to avoid them; and 3) it really seemed to be about the destination rather than the journey, especially since we were always outrunning the threat of afternoon rain.

When the downhill started to wear on our nerves I began to freestyle. Then we sang The Sound of Music. We were nearing insanity when we finally reached the level portion of the trail. Julio forced us to ride the mules for the last 30 minutes because of the mud, but my hiking boots became soaked anyway after we forded a couple of rivers. Julio took us down the scenic route through town, greeting everyone we passed. Celeste and I felt strangely nauseous.

When we got back to Julio’s and curled up in our sleeping bags, I realized why. My gastrointestinal system had decided to mul-tiny. After destroying Julio’s outhouse multiple times in multiple ways, he and his concerned wife made me chicken broth with noodles and “plenty of garlic” and tea from an herb I’d found along the trail, which Julio said was really good for curing diarrhea. The tea tasted like warm sea water. Julio’s wife heated a tub of tepid water so that we could take “hot” bucket showers in their makeshift, outdoor shower. Despite my body’s unhappiness, showering under the stars was, as usual, magical to me. Celeste began popping back antibiotics, but since my stomach is also hardcore at this point, I stuck it out and was back to normal over the next 24 hours.

We spent the night at Julio’s again and then departed the next morning to return to the capital, weak, our bodies forever changed, but alive. There really are some things that only happen in the DR.

these are a few of my favorite things

1. Shmilsh.
2. Rainy season downpours.

3. A good fan.

4. Spanish. Dominican Spanish.
5. Breakfast in the campo = boiled yucca, pickled onions, fried salami, a tin cup of milk.
6. Guaguas, motos, carros públicos.

7. The Caribbean Sea. The way it looks – is – different every day from my window.
8. Rooftop yoga.

9. Rooftop (6th floor) gym.
10. Colmados.
11. La Zona Colonial and its walls, doors, windows, locks, churches, plazas, and church plazas.

12. Fresh pineapple. Fresh mango. Fresh papaya. Fresh fresh.

13. Caribe Tours.
14. (Shmilsh.)
15. My research. The way it looks – is – different every day.
16. Collecting /shells/coral/rocks/sea-polished glass/driftwood/.

17. Hammocks.
18. Queso de San Juan.
19. My communities.
20. Denbow at an excruciating volume (“yo quiero sapito, yo no quiero maco, maco, maco, yo no quiero maco!”).
21. Chickens.

22. Random fireworks.
23. Cooking curry and stir fry and Spanish tortillas in my kitchen. Getting a good bandera at a comedor. Being fed homemade Haitian-Dominican food in my kitchen.
24. Jugos naturales.
25. Living with a four-year-old.

26. Weekends not in Santo Domingo.
27. My name in Spanish.
28. Flocks of wild parakeets.

room for paradoxes

My research is in its final phase. A few months ago, it seemed as though the day I’d be able to say that would never come. And I certainly had no idea back then what this final phase would look like.

I’ll start by redefining what my research has been, since it has evolved so much since I wrote that initial proposal in July 2008. Essentially, I’ve been examining foreign aid aimed at tackling health issues in the Dominican Republic, focusing on the U.S. Agency for International Development (USAID) and the Global Fund for AIDS, Tuberculosis, and Malaria as the sources of funding under scrutiny. Within health issues, I’ve chosen to focus on tuberculosis as a case study, mostly because of my gender focus and the fact that the gender aspects of TB are sorely under-researched.

The case study has consisted of tracing aid money from the halls of Congress to service delivery at the community level. I have interviewed staff members at USAID, non-governmental organizations (NGOs) that receive USAID and Global Fund money for TB programming, and I have taken a close look at one of the sites of implementation of intervention programs – an urban clinic in Santo Domingo.

At the clinic, my methodology has consisted of participant observation, open-ended interviews, and informal conversations with personnel and TB patients alike. The aim has been to gather qualitative data on a variety of aspects of TB patient experience and care in order to 1) determine what, if any, differences and disparities exist between female and male patients, and 2) understand how foreign aid can be improved and complemented with policy changes at the international, DR national, and local levels.

So where am I now? Data analysis, data analysis, data analysis. Qualitative data is tricky, to say the least. Although Fulbright demands no final product (other than general midterm and final reports we have to turn in), I would like to write a report in English and Spanish that can be utilized by everyone who has helped me along the way – from USAID staffers to local care providers – and possibly another, academically publishable document outlining some of the issues I’ve found, aimed at the global public health community.

Since data analysis can be a very solitary and home-based activity, my Tribe spirit of service and community engagement has been restless of late. Consequently, I have started volunteering at a local alternative school for children with special needs, including Down’s syndrome, epilepsy, deafness, autism, learning and physical disabilities, etc. So far this means pouring cups of water, handing out colored pencils, and producing commissioned clay animals. But I would like to see my medical school get involved with this place, because the university where I am going has a wonderful institute for global health and a graduate school of education with a center focused on human development and research/service for people with special needs. So volunteering and trying to establish some sort of sustainable partnership is my new project.

While I am excited about the prospect of med school in a few short months, I also can’t help but have mixed feelings about returning to academia. I feel like I am truly living one of my dreams – to learn about patient experiences in order to advocate at all levels for health programming and foreign policies to reflect the human right to health. While I will probably be able to do this much more effectively once I am a doctor, I can’t help but wince at the thought of returning to a library-based lifestyle in a social environment that people have often described to me as similar to middle school. I think I’d rather hang out in bateyes and spend my time talking to tuberculosis patients in the urban clinics of Santo Domingo, heading to Caribbean beaches on the weekends, writing and reading in my apartment by the sea, eating fresh tropical fruit on a daily basis, and practicing my Haitian kreyol whenever I can. Ok fine, fine, I’m going to miss this place. I admit it. This is where the Maxine Hong Kingston quote to the right comes in; those words seem to define a lot for me lately.

all origins ask why

As my Fulbright grant period winds down (just over six weeks left!), I realize it yet again: I can integrate myself all I want into a place, but at the end of the day, I’m also still a U.S. American girl-woman. I’m not Dominican. And actually - I'm happy about that. Then again, things are never that black and white...

You see, I grew up with a very critical view of my home country. I often felt ashamed to admit my nationality when traveling abroad, and preferred to cling to some sort of nebulous global identity, reveling in the fact that my phenotype allowed me to get away with it. It was a combination of disapproval of the majority of my country's actions, nagging class consciousness, and a real embrace of other cultures and ways of life that is grounded in my own diverse heritage. I haven’t rejected that world-citizen identity, per se, but lately I have actually developed national appreciation. I won’t go so far as to call it pride, and maybe a large part of it has to do with Barack Obama, but these days I don’t feel quite so bad about admitting where I’m from.

I like bachata and salsa, but damn, I miss hip-hop and jazz. The beaches here are beautiful, but have you seen the Blue Ridge Mountains or the Eastern Shore? Here there are a lot of Dominicans and Haitians and Haitian-Dominicans, but that's nothing compared to the diversity of the United States, which I sorely miss. Where else but on a U.S. campus can you find a Hindu Student Association diwali holiday event with more non-Hindus than Hindus, or a step show whose audience contains a range of complexions?

And the messed up things that I so despise about my own country are put into perspective the more I learn about the messed up things in this – and every other – country. I'm a Southern girl, and while I love barbecue and country music, I also take issue with the racist ideology that often comes along with U.S. Southern culture. Ironically, though, I think I've faced racism much more blatantly here than I ever have in Virginia - probably because ignorance is universal, and I'm accustomed to Virginian, but not Dominican, manifestations of it. And I'm used to complaining about my own government, but after seeing the level of corruption that exists in this government (I'm talking narco-trafficking ties at the executive level), I no longer think the U.S. is singularly screwed. This makes me excited about re-integrating myself into my homeland and the issues of my own country. Global issues are an important aspect of health inequalities, but at least for the next few years, I think it’s time that I got better acquainted with the local – my local.

At the same time, I have achieved a strong sense of belonging – I speak like a capitaleña, I know my way around this city better than I know most U.S. cities, and I made strong connections with some people and places. I've learned probably as much about myself through experiences in and related to this country over the past three years than throughout all of high school and college in the United States. I guess it’s about spanning boundaries gracefully; knowing how to manage a multifaceted identity, and understanding what can be integrated and what cannot and how. There are interpersonal connections that go far beyond nationality or language barriers, and some things - like music - are universal by nature. At the same time, every place is unique, and I miss the uniqueness of my homeland. The challenge is balancing these seemingly contradictory forces in a single identity.

living the questions

Bye, April. On the (almost) eve of the fifth month of this rapidly disappearing year, I want to share a quote. The past month has been marked by my struggles to come to terms with some aspects of my leaving in two months. I won't go into too much detail here, but suffice it to say that, like most struggles in my life, I find the answers I am seeking among the pages of my slim, hardbound copy of Letters to a Young Poet, by German poet Rainer Maria Rilke. Perhaps my favorite quote from this volume is the one also most applicable to this month's quandaries, and for all those who aren't familiar with Letters to a Young Poet, here it is:

"Have patience with everything that remains unsolved in your heart. Try to love the questions themselves, like locked rooms and like books written in a foreign language. Do not now look for the answers. They cannot now be given to you because you could not live them. It is a question of experiencing everything. At present you need to live the question. Perhaps you will gradually, without even noticing it, find yourself experiencing the answer, some distant day."

Aside from learning to love the questions as I live them, I am also trying to chill out. The data collection portion of my research is winding down, and I have already begun the process of analysis (right now, qualitative coding) - yet another unfamiliar research task that I am teaching myself as I go.

I currently have a friend visiting - someone I haven't seen since we were last together in Peru - and a handful of other friends will be dropping by before my time on the island is up. So I'm also trying to relax a bit more and make a deliberate attempt to enjoy myself, as hard as some of the aforementioned questions are. Even recent weekend trips to the gorgeous beaches of the northern Samana peninsula, Cabarete, and to 27 Charcos, a charming set of 27 waterfalls cascading down a mountain up which you can hike before jumping/sliding your way down, were mediocre for me because of these struggles. But I am determined to return to the U.S. on June 24 relaxed, calm, and peaceful - ready for medical school!

God, part 2

While the Evangelist Jesus talk makes me feel uncomfortable, today I was reminded of the important role of religion in many social movements. I went to a conference/talk related to TB in which a pastor gave a galvanizing sermon about the grassroots movement he wants to start to eradicate TB in the DR. Although I felt frustrated by the social pressure to bow my head in prayer, I was inspired by the pastor's words and gave him my business card, telling him that if there are going to be any health-related grassroots social justice movements in the next few months to count me in. It also gave me some ideas about how to respond to the MDR-TB man's challenge (see my previous entry). It's one thing to write a report, even to get a paper published. Those are nice goals, but I want to change something. And I now have some ideas about how to do so.

Later, I began to reflect on the legacy of Gustavo Gutiérrez and other revolutionaries whose motivation to act springs from a religious base. Much of the community organizing for social justice in the U.S. began (and continues to begin) in religious contexts - from Martin Luther King's pulpit leadership in the Civil Rights Movement to Barack Obama's career as an organizer beginning in the church basements of southside Chicago. If you aren't familiar with Gutiérrez's framework of liberation theology, check this out:

"But the poor person does not exist as an inescapable fact of destiny. His or her existence is not politically neutral, and it is not ethically innocent. The poor are a by-product of the system in which we live and for which we are responsible. They are marginalized by our social and cultural world. They are the oppressed, exploited proletariat, robbed of the fruit of their labor and despoiled of their humanity. Hence the poverty of the poor is not a call to generous relief action, but a demand that we go and build a different social order."

— Gustavo Gutiérrez

Sounds like revolution to me! So I am hope that I am not misunderstood in my lamentation about the hyper-Christianity of some Dominicans I've encountered. I don't wish to imply that there is something inherently wrong with being religious; I just balk at proselytizing and attempts at conversion of others. I think that when religions of the world can learn to respect each others' inherent similarities and the moral mandate of justice-seeking that nearly all possess, faith will be a powerful tool for social change. But only if such a movement is broad enough to include all faiths as well as secular civil society. True activism finds a way to promote the inclusion of all interested parties, since the point of activism, after all, is to rearrange the social orders that result in marginalization, exclusion, and other injustices.

timeline

So I’ve bought my return ticket. In just over two months (June 24, to be exact), I’ll be heading home. And I’m about ready. I’m coming to terms with leaving the things that I love here, and as for everything else…well, I’m not so torn up about leaving the things I don’t love.

For example, Dominican elections are in less than a month, which means that the entire country is becoming increasingly filled with apparent flashmobs of people cheering for one politician or another, backed up by huge posters that all have the same catchphrases below their candidates’ beaming faces (“change…now!” – “friendly and capable” – “honest and trustworthy” – “the people’s Senator!”). Of course there is ridiculously loud merengue, some of it made-up political songs and some of it incongruous Omega tunes that are meant more for hip-to-hip grinding in a Presidente-filled colmado than for a political rally. A lot of people tell me that these mobs of “supporters” are just random people that candidates pay to stand around waving flags and acting like they are very excited. Given the general attitude of most Dominicans about politics, this isn’t hard to believe. The vast majority of people are skeptical of politicians – not difficult to understand when higher-ups in the government are known for corruption, from money laundering to narco-trafficking, and in decades of elections promising monumental change the government somehow still cannot manage to guarantee electricity and access to clean water for everyone. Oh, and in case that wasn’t clear, Dominican elections count as something I don’t love because I can’t stand social inequality or excruciating noise.

Here is another anecdote that I think epitomizes why life in this country has lost some of its charm: the other day a washing machine crashed into the guagua (public transportation in the form of a beat-up bus that violates all environmental and safety standards for probably every other country in the world) I was on. No, seriously - I was sitting up front and I saw the whole thing happen. We were driving through the barrios on my way to the clinic when, as if in slow motion, a washing machine came hurtling down the road toward us. It skidded into the left side of the guagua, and everyone who hadn't seen what it was swore we'd hit one of the ubiquitous motorcyclists. The driver got out and, cursing, dislodged the washing machine from the bus fender and deposited it on the side of the road. It's difficult to explain why my next thought was, only in the Dominican Republic. I hope it's not hard to understand why I'm a bit homesick for a country where washing machines do not routinely crash into vehicles in the middle of the road.

One of the most important questions about leaving, however, is what I’ll be leaving behind, work-wise. One of the TB patients today (the man with MDR-TB about whom I wrote a few entries ago) asked me what the outcome of my research would be. “What are you actually going to do if we tell you that we aren’t treated well? That we have problems here?” I felt ridiculous saying, “well, the hope is that what I learn will help to inform future TB programs, but I can’t promise concrete changes in the way things are run at this clinic.”

What am I actually going to do? One of the good things about my timeline is that I feel only a pressure to get all the data collected, but not necessarily to analyze it. That next research step is something I can always do from the U.S. While this might be completely delusional given the fact that I am going to be a first-year medical student as of this August, it makes me feel better about June’s approach. It also gives me the freedom to do a few other things I want to make sure I get done before I leave – things that can’t be done from home. I have at least a few friends coming to visit me before my time here is up, so I plan to squeeze in the last bit of traveling I want to accomplish when they arrive. And of course there is spending time with the people I won’t be seeing regularly once I move to Tennessee.

Research-wise, I have much to accomplish and the work will not end with the end of my grant. In case you weren’t thoroughly convinced of the urgency of it by the last few entries, here’s a recent article in one of the main Dominican newspapers. If you don’t read Spanish, allow me to summarize: According to the Pan-American Health Organization, the DR is the country with the third-highest rate of TB incidence in the Americas. Factors responsible for the high incidence of TB include concurrent disease incidence such as HIV/AIDS, diabetes, and cancers, malnutrition and hunger, socio-economic inequality, and poor living conditions – all of which are prevalent in the DR.

So thanks for the challenge, MDR-TB guy. Let’s hope something useful comes out of all this.

no hay síndico aquí

"Poverty and other social inequalities come to alter disease distribution and sickness trajectories through innumerable and complicated mechanisms.

Take tuberculosis, with its persistence in poor countries and its resurgence among the poor of many industrialized nations. We cannot understand its markedly patterned occurrence - in the United States, for example, afflicting those in homeless shelters and in prison - without understanding how social forces, ranging from political violence to racism, come to be embodied as individual pathology.

Initially, poverty and racism increase the likelihood that one will become infected with Mycobacterium tuberculosis. The mechanisms by which this occurs include the prevalence of the disease among the poor and the fact that the poor are more likely to live together, often in the cramped, airless quarters that once characterized the 'lung blocks' of industrialized cities and now describe the urban ghettoes in which tuberculosis is endemic. Various institutions designed to serve or contain the poor have in many instances been the settings for amplified outbreaks of tuberculosis. Nardell and Brickner argue, for example, that homeless shelters have become the lung blocks of the late twentieth century. Poverty and racism surely increase the likelihood that one will end up in a shelter, just as these forces arrange the chances that one will wake up in a crack house or a prison.

Once infected, the poor are more likely to progress to active disease. Again, the mechanisms are myriad. Cell-mediated immunity, which keeps tuberculosis quiescent in most persons, may be compromised by malnutrition, HIV infection (or other concurrent disease), or addiction to drugs or alcohol. Addiction, in turn, is usually not comprehensible without an understanding of subjugation and racism, at least not if historical and population-based studies are to be believed. Even reinfection with M. tuberculosis might play a role in ensuring that tuberculosis infection will progress to disease; the risk of reinfection is strongly influenced by the social factors just described.

These same factors determine outcomes among those with active tuberculosis disease. Poverty and racism increase the likelihood of dire outcomes among the sick by restricting access to effective therapy or rendering it less effective if patients are malnourished or addicted. Poverty clearly decreases the ability of patients to 'comply' with demanding, lengthy regimens. Indeed, the advent of truly effective therapies only brings into starker relief the centrality of social inequalities, when unequal access to these therapies heightens the inequalities of infection and reactivation already described.

Thus do fundamentally social forces and processes come to be embodied as biological events."

- Paul Farmer, Infections and Inequalities

So really all of March is TB awareness month. It must be markedly obvious at this point what book I am currently reading (although I'm also embedded in The Bottom Billion, which takes me back to my IR days, and I was reading Reporting from Ramallah, but sadly I think I left it in Trinidad). I love this passage in particular because of the clear and concise way in which Farmer outlines some of the mechanisms by which social forces impact biological realities. An understanding of these mechanisms is essential for anyone who hopes to alter others' medical outcomes.

These pictures (from the same street on which the clinic is located) illustrate a bit of what Farmer is talking about:

Contra el hambre y la pobreza.

Against hunger and poverty.

No hay síndico aquí.

There is no mayor here.

(an arrow points to the ground below)

world TB day

*** HAPPY WORLD TB DAY! ***

March 24 commemorates the discovery by Robert Koch of the bacterium that causes tuberculosis, and it is an opportunity to raise awareness and assess the past year's work in the fight to eradicate TB.

I spent the first part of the morning in the clinic as usual. I talked for a long with time with a patient who told me out of the blue, after a long, jovial conversation, that he has HIV. The MDR-TB patient I mentioned in the last post could barely move today because of the gastrointestinal side effects of his medications. The sobering atmosphere of the reality of TB for so many was a striking contrast to the World TB Day event I later attended, organized by the governmental Ministry of Health and its TB Control Program. Representatives from the government, USAID, WHO, the Global Fund, and various NGOs gathered at a high-end hotel to pat each other on the back and discuss recent advancements in the agenda to end TB. It was an interesting morning.

Tuberculosis is one of the oldest diseases known to humanity, and is thought to have been passed to human beings by cows when people began to domesticate livestock (there is a very similar bovine strain that predates the human strain). It is caused by a bacterium with which about 1/3 of the world's population is infected. However only 10% of people will ever develop active disease. Immuno-compromised people, particularly those with HIV, chronic malnutrition, or other health problems (mostly related to poverty) are the most likely to develop active disease.

TB most commonly affects the lungs, but extrapulmonary TB - or disease in other parts of the body - can also occur. It was once known as "consumption," as typical symptoms include a long-term, productive cough, night fevers, fatigue, weight loss, and other signs of general wasting away. Perhaps the most dramatic and well-known symptom is hemoptysis, or the bloody cough that appears when severe infection goes untreated. However, TB is treatable with an intense regimen of antibiotics.

The international standard for treatment is known as Direct Observed Therapy, Short-Course, or DOTS. DOTS is a protocol for administering medicine that requires patients to take their pills in the presence of a health-care worker in order to ensure that they receive each dose. As with many bacterial illnesses, improper or incomplete dosing can create serious problems of recurrent infection and bacterial resistance, and the TB treatment regimen is particularly difficult to keep up with. Current challenges to the eradication of tuberculosis include the syndemic (or co-epidemic) of TB and HIV and the increasing rate of multiple drug-resistant TB (MDR-TB).

- TB incidence (or number of new cases annually) in the Dominican Republic is around 69/100,000, a rate surpassed only by Haiti when compared to other Caribbean and Central American countries. Other estimates, however, place incidence even higher, above 85/100,000.
- 45% of new cases occur in the National District, where the capital city of Santo Domingo is located.
- The DR is tied with Peru for the highest rate of MDR-TB in the Americas, and is one of the top 19 countries in the world in terms of MDR-TB incidence.
- About 6.8% of TB patients are also infected with HIV in the DR, but this rate varies widely according to region. In the poorest regions of the country, co-infection reaches up to 50%.
- The DR has rapidly expanded its coverage of DOTS health services, from virtually no coverage in 2000 to 85% coverage in 2008 (that is, 85% of the population now lives within 30 minutes from a health center administering DOTS TB treatment). It's an improvement, but the DR still has the sixth lowest coverage among American countries.
- The World Health Organization's target goals of 70% case detection and curing at least 85% of cases still have not been reached in the DR.

*** HAPPY WORLD TB DAY! ***

you'd think they would have found a way

Observing and talking to patients and TB health care providers every day in the clinic has been an interesting experience so far. It’s making me aware of one of the key reasons I’m so excited about medical school – as I wrote in one of my admissions essays, the individual, patient-doctor relationship adds an invaluable emotional component to bettering people’s lives that I think I will need to do my job well. It’s one thing to sit in an office all day and write policy (and don’t get me wrong, I’ll be doing that, too, insha’Allah!), but it’s quite another to have one-on-one relationships with the people whose lives your purport to improve. Given my personality, the latter is essential for me.

Some of the patients I’ve met stand out in my mind for various reasons. A couple of weeks ago, a trembling young man came into the clinic accompanied by another person who, it turns out, was accompanying him from the drug rehab program in which the patient is enrolled. He needed to have a TB test and had already completed an HIV test; grimly pulling the lab report from his pocket, he told us that he was HIV-positive. Perhaps it was the drug withdrawal or perhaps it was some other sickness(es), but he was in such bad shape that I saw not a hint of shame when he admitted this. He seemed to have acknowledged in what dire straits he had found himself, if only because his poor physical condition made it impossible to ignore or deny any longer, and was too agitated to pay much attention to the reaction of the nurse and community health worker on hand (who assured him that Jesus would take care of everything). What floored me is that the young man was 22 – my age. Suddenly the world did not seem quite so large anymore.

Another young patient (21 years old) came in today with his girlfriend and the positive results of a TB x-ray test (some people who have TB come up with negative sputum smears, but the diagnosis can be confirmed with a pulmonary x-ray). He seemed upbeat and otherwise healthy, and his girlfriend was clearly supportive, but I could tell that he was a little shocked at the intensity of the treatment he was in for – 4 pills every day for the next two months, taken in person at the clinic, and medication three times a week for four months thereafter (assuming he doesn’t abandon the initial regimen or turn out to have multiple drug-resistant TB – MDR-TB – in which cases the treatment will be longer and harsher). Although he could receive his medication at a hospital closer to his school, he opted to attend the clinic where I’m working – a staff member told me later that it was because he didn’t want to be stigmatized as a TB patient should any of his peers from school find out. Apparently he can escape to the clinic for his daily treatment during breaks between classes.

There’s the MDR-TB patient who has stopped and started his treatment countless times, ended up in the hospital for a month (at one of only two in the country that offer full treatment for MDR-TB patients), and has undergone pills, chemotherapy, and injections to fight the disease. Although the nurse who directs the TB program has told me that he’s just “disobedient,” and often yells at/about him and his noncompliance, he told me once in a low voice, when she was out of the room, that he kept having to stop the medications because chemotherapy is really, really tough. He couldn’t keep down any food as a result of the treatment (and taking the pills on an empty stomach exacerbates the side effects further still) and he felt ugly and miserable with a bald head because of the chemotherapy. He, like several other patients, is still crazy-skinny, but at least he’s been showing up lately for his medications.

And then there’s another, older man, who always seems so beaten down when I see him enter the clinic. The nurse’s impatience with him also doesn’t seem to be helpful, and whenever I ask how he’s doing he usually just shakes his head and shrugs. Yesterday he told me that it’s a 30-minute walk from where he lives to the clinic. Today he said that knee pain has been making the journey even more trying. I hope to talk to him in more depth soon, and I wonder if he has a family, a job (from which he may have already been fired for missing work due to his treatment and/or discrimination against TB patients), or other obligations that make the daily, hour-plus ordeal of getting his medications even more costly.

I was relating some of these stories to a friend the other day, who remarked, “but you’d think they would have found a way to make TB treatment easier by now!” Yes, you would think so, given that TB is one of the oldest known diseases afflicting human beings. The global health care economy, though, like the rest of the global economy, is market-based, and pharmaceutical companies supply what’s in demand, which in turn dictates research priorities. Unfortunately, TB almost exclusively affects people who do not have enough money to demand anything. There is research on TB occurring around the world - but unfortunately it's not the type that can relieve many of the logistical and physical hardships of TB treatment. If poor living conditions and malnutrition were not such critical factors in TB epidemiology, if Mycobacterium tuberculosis, like cancer cells, did not discriminate according to the size of its victims’ bank accounts, perhaps we would have found a way to make treatment easier by now.

 "Our society ensures that large numbers of people, in the United States and out of it, will be simultaneously put at risk for disease and denied access to care. In fact, the spectacular successes of biomedicine have in many instances further entrenched medical inequalities. This necessarily happens whenever new and effective therapies - from antituberculosis drugs to protease inhibitors - are not made readily available to those in need. Perhaps it was in anticipation of late-twentieth-century technology that Virchow argued that physicians must be 'the natural attorneys of the poor.'"

- Paul Farmer, Infections and Inequalities

Trinidad

I just got back from the Fulbright Regional Enhancement Seminar for the Caribbean, which was in Trinidad & Tobago (though I didn’t get a chance to visit Tobago). Although the seminar was only four days, it felt like I was there for weeks.

Trinidad was amazing. It was wonderful to encounter spicy food (much of it South Asian in origin), streets clear of trash and grime, less fume-choked air, and men who whistled, hissed, and catcalled at much lower rates than in the DR. The academic portion of the four-day program consisted of presentations given by each of the 15 Fulbright Students stationed in the Caribbean.

We were also able to explore quite a bit of Trinidad in the short amount of time we had. I heard live Calypso; found organic toothpaste and Ecover glass cleaner (this stuff makes me excited because it's difficult to find healthy, environmentally friendly products in the DR); swam in our hotel pools (so nice to do laps in the morning!); took a road trip to the island’s eastern coast; where we went to the beach and saw a leatherback turtle lay eggs; saw a script reading of the new play written by an American Embassy official (she’s an amazing writer as well as a diplomat); went to a ridiculous club and partied, Trini-style, till 3am; hiked through the rainforest to a beautiful waterfall and swimming hole; walked around downtown Port-of-Spain; bought chocolate, tea, and spices that are impossible to find in the DR; stocked up on the latest soca and soca chutney music, and finally caught up with some of the English hip-hop, dancehall, and reggae I’ve missed out on in the DR.

Throughout all this, I really enjoyed spending time with my fellow Fulbrighters, who are an amazing bunch. Being reintegrated into the larger scholarly community of Caribbean Fulbrighters was an invigorating experience. Most of us have multiple interests, such as public health and creative writing, so there were many facets to the “enhancement” I underwent at the seminar. By the way, several of my poems, a Spanish translation I did of one of them, and a photograph of mine have been accepted for publication to a literary journal back in the U.S. (34th Parallel). I’m so excited and encouraged!

As for research, I’m reshaping my methodology to a more qualitative approach, and I hope to devote a month to data collection at each of three field sites where I will work (the first being the clinic mentioned in the previous entry). Please, let’s not even discuss data analysis and write-up yet. Trinidad was a vacation disguised as a seminar, but when you put a bunch of Fulbright students together, even a vacation is deliciously academic, yet relaxingly chill.

oh, God

March has been busy, hence this is my first blog entry this month. I began the community portion of my research last week by journeying to Sabana Perdida, a marginalized collection of sprawling neighborhoods just north of the Ozama River (which is joined by the Isabela River and eventually dives south to meet the ocean). It is just east of Villa Mella, the area where I used to work with SOMOS. It was under the suggestion of one of the NGO staff members I interviewed that I began with a clinic in Sabana Perdida, which is one of the sites for the NGO’s TB program. The clinic serves a population of just over 14,000 people and offers tuberculosis, HIV/AIDS, emergency, and general health services. It’s a small, cramped compound with a large, outdoor waiting area, but it boasts laboratory and x-ray services, and a passionate and committed staff.

My first task has been to observe the daily operation of the TB program, which is housed in a tiny, well-ventilated office in the clinic. From around 8am to noon every day, 10-30 TB patients and “sintomáticos respiratorios” (those experiencing suspicious respiratory symptoms that warrant a TB test) filter in and out of the office for treatment or testing. Some of the patients receive nutritional supplements, and all medicine, provisions, and services are provided free of charge.

I’ve been getting up before 7am (so weird!) in order to make it to the clinic by 8, which is sometimes a tricky prospect based on traffic and when the guagua (beat-up bus) decides to leave in the morning. For several hours I hang out in the TB office, engaging staff members and patients in informal conversations and taking notes on everything I see and hear. My plan is to build up rapport with the patients (who are obligated to show up 2-4 times per week to receive their treatment) in order to ultimately conduct qualitative interviews with them. I will extract data from these conversations and disaggregate it according to gender. My hope is that the information gleaned will help TB programs and their implementation at all levels – from the formation of policy by donor agencies to the local health workers in target communities.

Recently, I’ve also been dealing with the challenges of religion and personal health in this country. It just so happens that the nurse who runs the TB program in Sabana Perdida is a zealous Christian. She begins clinic days by reading from the Bible and making us say a prayer. As a non-Christian (I consider myself spiritual but not religious, and if I had to pick a religion to convert to right now, it would be Islam. I am nowhere near Christian.), this makes me uncomfortable.

The Dominican Republic is an historically Catholic country, but the Catholic church here is more a social and political institution than a religion. No policy gets passed without the approval of the DR’s archbishop, a notoriously conservative man who has been known to attribute child exploitation in the sex work industry to “the way young people dress,” and who has been an instrumental proponent of the recent (and highly controversial) changes to the constitution, which include the banning of abortion under any circumstances, including cases of rape, incest, or danger to the mother’s life.

But the Dominicans who talk about Jesus on a daily (no, minute-ly) basis are primarily Protestant. There has been a notable explosion of evangelical Christianity in recent years. On one hand, I find that taxi drivers who listen to Jesus songs are less likely to hit on me and/or attempt to overcharge me, so I don’t mind it per se. But when someone randomly starts proselytizing (my taxista the other night asked out of the blue if I was aware how much Jesus loves me), it makes me uncomfortable. Thus I sometimes find it difficult to spend so much time with the TB nurse in Sabana Perdida (and the main TB community health care worker, who is almost as zealously religious). I am all for faith, and if subscribing to an organized religion is the best way for people to experience faith and meaning in life, then more power to them. But when I asked the nurse if she took prophylaxis to protect herself from contracting TB from her patients, and she responded, “Prophylaxis? No, but there is a medicine called Jesus Christ,” I almost threw up a little bit. Multiple times I have been randomly approached by strangers on the street hoping to preach to me or hand out written materials about Jesus. Others' religion doesn't make me uncomfortable; but when I'm drawn into it against my will, it does (at the bus station today, this guy could not understand why I didn't want one of his pamphlets about Jesus). My four-year-old roommate has begun to make signs of the cross and announce “may God bless us” at random times as a result of the indoctrination he receives at his nursery school.

As for personal health, take a guagua ride across Santo Domingo and you’ll see what I mean. You can’t go anywhere in this city without breathing fumes constantly. It almost makes my throat hurt. Produce here is treated with pesticides not legal in the United States (and back home I purchase only organic food), and the meat and dairy industries are even more environmentally harmful and hormone-heavy than that of the U.S. This makes me sad, because I cannot go running without feeling like I have probably developed cancerous lung lesions, and it’s sometimes difficult to feel good about what I am eating, even though I cook almost all my food from scratch. Since I’m here for only three and a half more months, I know that the overall effect of these factors will probably be negligible in the long run. But it’s just gross.

On the other hand, the lovely gym located two blocks from my apartment recently moved to a new location; while it’s slightly farther away, it’s still within a ten-minute walk. The new place is a large space on the sixth floor of a building. The view is incredible and luckily most of the fumes don’t reach that high. In addition, Crudo, the small café/store a few doors down from my apartment, was started by a local doctor who shares some of my concerns. He owns an organic farm right outside the city, and everything served at Crudo is organic. I can also find imported, organic green tea, pistachios, and other products. Apparently there’s going to be a yoga retreat to his farm for semana santa (Easter week). So I have a few health havens.

This weekend I’m taking a break in Santiago, the Dominican Republic’s second-largest city, and the coming week is our Regional Enhancement Seminar for Fulbrighters in the Caribbean. This means that on Tuesday I’m off to Trinidad and Tobago! It’s going to be weird to be in a Caribbean country where no one speaks Spanish or (Haitian) Kreyòl (which I’m still trying to learn!).

if I were president of the Dominican Republic

I think I have a love/hate relationship with this country.

Last weekend, I went to an Afro-Caribbean concert with my roommate, her four-year-old son, and a bunch of our friends. I caught some great footage of her son dancing and playing drums along with the band. He makes life here so much more fun!

More recently, this past Friday, I went to Villa Mella to visit a close friend who recently became a mother. We spent several hours hanging out and catching up. Her family has always been incredibly sweet, hospitable, and welcoming towards me, so it was nice to spend time with them again. Here are some pictures: four generations of the family, and my friend with her daughter.

The next day, I went to carnaval in La Vega, a small town to the northwest of Santo Domingo known for its impressive festivities. It was…insane. Little boys covered from head to toe in mud walked around begging for spare change while adults in bright, monstrous costumes marched up and down the streets. People of all ages ran around with these horrible, football-sized vejigas (literally, "bladders," since they used to be made of inflated cow's bladders; recently these were replaced by synthetically manufactured vejigas, which according to some are more painful - but less smelly - than the bovine bladders of old), which are used to smack the backsides of unsuspecting passers-by. Although everyone ends up getting hit at some point, it’s usually men beating women’s rear ends. I got hit so hard that I almost fell down. Needless to say, the noise was deafening and the alcohol flowed freely. I paid to take a tour bus from Santo Domingo to La Vega and back with a friend who is another Fulbrighter. Included in the package were food and free drinks. When I asked for juice, just juice, with no alcohol added, I was told that it didn’t count as a drink; it was simply not possible to give me cranberry juice without vodka added. Also included in the package was a concert by Omega, one of the most – if not the most – popular merengueros (merengue musicians) in the Dominican Republic. Despite the excitement of the crowd, I somehow could not get into a party spirit, maybe because the bass was making my rib cage shudder. Plus Omega has a really annoying voice, attitude, and videos. I was warned in advice when I told friends that I was planning to go to el carnaval, but I guess I thought that in spite of all this, it might somehow be fun, or at least an interesting experience.

I looked around in the midst of the madness and asked myself, what’s the one adjective that sums up all of this? The first one that popped into my head was “Dominican.” But what about this makes it so “Dominican”? I thought. And what came to mind were the alcohol, the noise, the explicit clothing and “dancing” of the crowd (you can YouTube “perreo”), the noise, the five annoying songs that were played over and over and over, the NOISE, and the beating of women in the street (domestic violence is a huge, huge issue here). Wow, what stereotyping, I reflected, thinking of my friend Eddy’s recent blog post on a similar subject. Why were those the first things that popped into my head? And if that’s what I think about this place, then why do I love it at the same time? I realized that for me, carnaval (and Christmas, New Year’s, and every holiday celebration I’ve experienced here) epitomizes the aspects of Dominican society and culture that I find problematic or distasteful. And it is difficult for me enjoy some things that are “just for fun,” such as beating women in the streets. In addition, that particular aspect of carnaval was the last straw in a host of offenses that I deal with on a daily basis as a woman in this country. Even though it was carnaval, I found it very hard to let go of the defensive attitude I have adopted towards men here. As a result, when random people smacked my backside, even if they were toddlers (whose mothers smiled approvingly at their cute little macho sons), I reacted with insulted humiliation. Clearly I am not cut out for carnaval. This place would be so great if only it weren’t so screwed up, I thought. But don’t get me wrong – there is nothing uniquely Dominican about that sentiment; it’s something that I could say about every place I’ve lived or visited. Luckily, though, there are people like my friend and her family, as well as many other individuals of various nationalities and genders, who prove to me time and again that for all the insufferable problems of each country and society, there are always amazing people who can teach you more than you ever imagined.

On the bus ride home, I watched the little wooden shacks nestled in the forests beside the highway whirl past, and I started to think about what I would do if I were president of the Dominican Republic. If I woke up one day in the national palace and had the job of Leonel Fernández, whose neoliberal policies have earned him the disfavor of many Dominicans who remain without reliable electricity in their homes, I would create a new governmental body called the Ministerio Ma’pa’lante (“the Ministry of Moving Forward,” a reference to Leonel’s – as he is called semi-affectionately by most Dominicans – unofficial slogan. It’s really “más para adelante,” but since it’s the Dominican Republic people pronounce and even spell it “ma’pa’lante.”). The ministry would be divided into departments such as Education, Health, Immigrants’ Rights, Labor and Economy, Environment and Agriculture, and Racism/Sexism/Anti-Haitianism/Other Widespread and Problematic Mentalities. Each department would have staff responsible for traveling throughout the country to identify organizations, institutions, and individuals with innovative and sustainable ideas for accomplishing the objectives set forth by each department. Departments would then solicit proposals from innovators around the country and would select several each year to receive funding and other governmental support. The activities of the Ministerio Ma’pa’lante would be integrated with all other divisions of the government. So if someone wants to work on my campaign, maybe I’ll add my name to the ballot for the Dominican elections this May. :)

on belonging

Halfway through my grant term, it’s sinking in how much I feel like I truly belong here. Today I was on the corner of my street, trying to catch a cab, and the one I flagged down happened to be a taxista who has driven me before. “Hey, I remember you!” he exclaimed. I was off to withdraw money, which has been a frustrating issue here, since ATM withdrawals result in astronomical fees. Luckily, because I know someone, I can get a check cashed at an amazing exchange rate with zero fees (don’t worry; it’s legal!).

I am on friendly terms with my neighbors, and people at the local stores and restaurants that I frequent all know me. Even the fruit stand guy a few blocks away said today, “you’ve been here before, haven’t you? Do you live around here? Are you a foreigner?” There are two vegetable sellers who buy fresh produce from the market and then re-sell it from the back of a pick-up truck. They pass by my house every day around 10am, and I’m on a first-name basis with them; it’s to the point that when I asked where I could find aloe vera here, they promised to make me a special delivery tomorrow morning so that I don’t have to pay for transportation all the way to the market.

Sometimes I run into people I know when I’m out and about, like a friend from the community in Villa Mella who was standing on the sidewalk the other day when the carro público I was in drove past (carros públicos are extremely battered and dilapidated cars that drive up and down the main streets throughout Santo Domingo; you can ride for as long as you want for 20 pesos, or less than a dollar – the catch is that these four-passenger sedans typically have 6-8 passengers at any given moment). Because of my research as well as my work on Haiti relief efforts, I know quite a few of the major players in the Dominican public health/NGO world. When I go out on the weekends I constantly see familiar faces, and the alternative/international party scene consists of some very small social circles. At la Espiral, the amazing reggae/alternative bar/club where there are free palo concerts every Friday night, I always run into friends; la Espiral’s owner and bartenders recognize me even outside the context of the club.

All of this makes me feel as though I am truly living, and not just visiting, here. I love it! There's something comfortable and safe about belonging, and it is difficult to understand until you have to live somewhere else. When you realize in that other place how much it has truly become home, you begin to appreciate the concept of "home" much more, and also to learn how it is just as frequently created as it is a given. Then you learn how to create it, and eventually, the distance between home and where you are grows shorter faster.

on time

I hope everyone had a good Valentine’s weekend! Mine involved an Aventura concert (with surprise special guests Wisin y Yandel) and pancakes with chocolate sauce. <3 Dominican concerts are always an interesting experience. 60,000 people (mostly females) spent the better part of three hours screaming at the top of their lungs. Lead singer Anthony Romeo kissed some lady onstage (who almost fainted) and offered charismatic heart-to-hearts with the audience on love, heartbreak, and other mushy things about which Aventura typically croons in their R&B-infused pop bachata songs.

Earlier this week I had a meeting at the largest health-related NGO in the DR. I wanted to know where they felt there are gaps in the knowledge about gender and tuberculosis. “You’re the first person to research this here,” they said. “We know nothing. So go look at health center records, create patient focus groups, interview health providers, and conduct house-to-house surveys.”

DAMN.

It feels good when you stumble into a research niche that needs to be filled – and when you believe that you can fill it. Believing is all it takes, really, and I have about four months to put that belief into action.

In about a month, I’m off to Trinidad & Tobago for five days; it’s the mandatory Fulbright Regional Enhancement Seminar, which means that all the Caribbean Fulbrighters get together and talk about their research while exploring T&T…exciting for me not only because I’ve never been there, but also because I have distant family connections to those islands. It also means that I have to prepare a presentation on my project. My goal is to have really begun the community portion of my research in earnest by that point.

After our seminar in T&T, it will almost be the end of March. Then there are April, May, and June. At the end of June, I’m headed back to the U.S. to begin medical school. I knew this was going to happen, but it’s approaching sooner than I expected…

on learning

The emotional and logistical insanity of the past two weeks – of life after January 12 – have solidified some of the lessons that I’ve been slowly learning here for the past few months. I thought I’d share a few of them.

Maturity does not necessarily correspond to age level. I have learned so much from my roommate’s 4-year-old son and his beautiful view of the world, and I have met adults close to age 50 who still don’t seem to grasp fundamentals.

There are people who may not speak your native language but with whom communication is easier than with many who share your mother tongue. Sometimes you don’t even need to speak.

There are times when the action you want so badly to take might consist principally of listening and learning. With patience you realize that these are also forms of action. Agency is multiplied by the hours we’ve spent silent, becoming increasingly aware of the scale of what we do not know.

It’s knowing how to cook that sharpens your appreciation for food and your understanding of quality, flavor, and the essentiality of eating well. I love to buy fruit off the street, especially from women, and the more food I buy, the more I love cooking. The closer I get to my food, the more I can feel it quietly affecting my health and wellbeing.

Sometimes the way we change is almost reptilian. In looking back at the past three years of my life, I don’t see a slow, gradual process; I see a series of leaps that left behind old shells to the point where I can barely relate to what I remember of my teenage self.

When we talk about love and revolutions, we can’t forget about the personal. Sharing someone’s grief or hope, being the tree of faith for another – these are integral parts of the overarching social change for which we strive.

Over the past few years, I’ve successively taken on personal work to improve my relationships with myself, with others in my life, with others not in my life, and now with the Earth and the environment. But without even realizing it, I’ve also been working on my relationship with words. I have grown closer and closer to the things that I write, so that everything I express is increasingly accurate.

I'm doing research! I mean that at the beginning of my fifth month of my grant, nearly halfway through my time here, I realize that I actually have data from which I am starting to subconsciously as well as methodically make observations, draw conclusions, and create a framework for my study in which I am beginning to fill in the pieces with knowledge. It's exciting!

And if you’re wondering about Haiti, I’m still working. I'm also learning Kreyol! I have always admired the beauty of the language, and recently I've found the means to teach myself, so that's another project I'm taking on. Please contact me if you would like details about how you can contribute.

After the initial flood of donations, however, I think the next most important thing that Haiti needs – that the world needs – is people who know their history, who understand structural violence, and who are versed in the vocabulary of global systems and their modus operandi. If you need a few titles to begin or continue your own education, I recommend the two extremely well-written books that I just picked up – Aids and Accusation: Haiti and the Geography of Blame, by Paul Farmer, and Taking Haiti: Military Occupation and the Culture of U.S. Imperialism, 1915-1940, by Mary Renda. The first is a rich ethnography focused on HIV as an illustrative example of how international politics and history affect the lives of seemingly “remote” or “disconnected” rural Haitians. The second is a wonderful text that incorporates discourses on gender, sexuality, race, and nationality to explore the history of the 1915-1940 occupation of Haiti by the United States.

What the world needs is people who know things. Listen, learn, and start reading.