*** 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! ***
3.24.2010
3.23.2010
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.
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
3.21.2010
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.
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.
3.14.2010
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!).
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!).
2.28.2010
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. :)
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. :)
2.22.2010
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.
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.
2.18.2010
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.”
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…
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…
2.02.2010
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.
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.
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!
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.
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