From the Ground Up

Seven enterprising students have led an effort to create a permanent medical rotation site on the island of Haiti.
By Bruce Morgan

Follow up story by Leslie Macmillan A season of Hope"

Lots of people rushed to Haiti after the January 12 earthquake to see how they could help. The influx to the crippled Caribbean nation included doctors, nurses and medical students, among many others. But at Tufts, in an effort driven by the vision and energy of a clutch of first-year students, plans had been under way to make a difference there even before the tremors began. By late fall of 2009, Sally Greenwald, A07, and her friend Lily Conover, both firstyear students in the M.D./M.P.H. program, were intent on creating targeted public health projects that they could carry out during an extended visit to the island in the summer of 2010 as the tentative basis for "a sustainable relationship" between a hospital in Port-au-Prince and Tufts Medical School. If they succeeded, Haiti would join the short list of overseas rotation sites open to Tufts medical students, and, with any luck, offer an example of medical outreach that proved durable and extended beyond the rubble of the immediate crisis. "Going down and doing 'medical tourism' is not good," says Greenwald, a low key but focused leader. "We want to build something that lasts."

The students are not entirely naive. Greenwald has done stints of volunteering in Malawi and Haiti over the last two years, while Conover has worked in Madagascar. And they are savvy about funding. They applied to the Tisch College of Citizenship and Public Service at Tufts as well as multiple sources at the medical school for grant support, and recruited other students to join them on the pilot trip. Jacqueline Latina, '13, Brian Schurko, A07, M.B.S.10, Adam Nadolski, A07, M13, Graham Brant-Zawadzki, '13, and Matt Counihan, M.B.S.10, all signed on.

The earthquake deepened the urgency of their planning. Originally, the students' approach was project-based and entirely well-meaning, but the projects themselves, conceived in Boston, were a step removed from the communities they were meant to serve. For example, in an effort to reduce the documented high incidence of cervical cancer among Haitian women, three of the students intended to create educational brochures, to be distributed throughout Port-au-Prince, about the importance of regular Pap smears.

Well, that might work, or maybe not. That might reflect the top priority among health-care personnel in Haiti, or maybe not. One of the lessons that came up again and again as the students talked to Tufts faculty and administrators over the course of the spring was simply this: Before you do anything, listen hard to learn what people you are trying to serve have to say. Tufts Medicine attended a few of the students' planning meetings this spring.

March 10

Half a dozen students crowd around a table in a small conference room in the Curie Learning Center on Sackler 2. A few are eating lunch. Several are pecking at their laptops. The planning for the trip is in the early stages, and pretty much everything is up in the air. "Last week we got $3,000 from Tisch [College], " Greenwald announces at the start. (They need roughly four or five times that much.) "Plus, we're getting a lot of support from different people at the medical school."

Latina interjects a thought. "We need a faculty person there in Haiti," she says. "There should be a Tufts advisor if this is going to work." Some faculty names are batted around as people who might be able to help establish a rotation site on the island. "We're still shaky on advisors," Greenwald notes. "Has everyone got an advisor?" (At this point the group is considering carrying out individual projects in Haiti rather than a single, unified effort.) She looks around the table at her friends. "What do you think of setting a goal of next Friday for everyone having an advisor nailed down? When you approach them, approach them as a mentor to you, because that's flattering," she advises, "but really you need them." This is smart tactical advice.

Someone raises the question of lodging. "I'm taking care of all that. That's my job" places to stay, translators," Greenwald says breezily. "I've got lots of friends down there." Right now, the group is counting on forging a working relationship with the hospital in Port-au-Prince where Greenwald had volunteered a few months earlier, but she admits that she's been having trouble getting responses from her contacts there.

"What about some fund-raising ideas?" Greenwald presses. Brant-Zawadzki suggests contacting Sackler's Food 4 Thought Cafe about maybe hosting dinners where a certain percentage of the evening's take goes to the cause. Others have done that. Schurko, a former player on the Tufts University football team who worked at Dana-Farber Cancer Institute before entering the M.B.S. program, mentions that he knows someone at the Hong Kong Bar in Cambridge, and they have offered to hold a fund-raiser some night soon. "Do you guys want to work on that? "Greenwald asks the two across the table. "Awesome."

To a listener who is not in his 20s, this last word signals a certain half-baked quality to the enterprise. For just a moment, the whole thing seems like it might not happen at all. But Greenwald anchors everything with her next remark. "What my dream is," she says, "is that I want this to be a lasting program. When people think about Tufts in Haiti, that would be what we passed down to them." The transition, as it turns out, is typical of Greenwald's personal style: She is a relaxed maestro of the proceedings, sometimes seeming not fully in control but repeatedly taking the measure of the room at a glance and lending just the pressure needed to get the horns to sound.

March 18

There's a dramatic new twist. Since the last meeting, Greenwald and Conover have met with Mark Pearlmutter, '84, an assistant professor of emergency medicine at Caritas St. Elizabeth's Medical Center who spent several weeks conducting disaster relief in Haiti in early February, about possibly joining forces with him on developing a rotation site at the hospital where he worked. "He's going down in April, and I might go down with him, "remarks Greenwald.

"It would be good to go down, do a needs assessment, keeping our projects in mind," Brant-Zawadzki muses. Conover amends his thought slightly. "It would be better for us, or our reputation, "she says, "if we go down and just listen like crazy."

Anthony Schlaff, an associate clinical professor of public health and community medicine, arrives and advises the students on the intricacies of arranging Tufts Institutional Review Board (IRB) approval for any research the students intend to carry out on subjects in Haiti. It's a complicated process that Schlaff knows well. "Can you help us?" Greenwald asks, laughing. "I can help you," Schlaff replies. "Does Haiti have its own IRB, and would they accept one from Tufts?" Brant-Zawadzki wonders. "Good question," says Schlaff.

L'Hopital Sacre' Coeur, where Pearlmutter volunteered, is 70 miles north of Port-au- Prince, in Milot, and was unscathed by the earthquake, although hundreds of quake victims ended up there. "The cool thing about this hospital is it's one of the best in Haiti," Greenwald says. "But I think the biggest benefit to this idea is having Dr. Pearlmutter there."

"That's huge," Schlaff agrees. The stars seem to be aligning. Schlaff is the first faculty member to attend one of the students' meetings. Greenwald assesses his overall response to what they're planning: "What do you think" are we on the right track?" she asks. "I like what I've heard," he responds. "Have some goals in mind but be flexible. Be ready to jettison the original plan."

"What should we be doing in the next three weeks? Should we come up with survey questions to be asking?" Greenwald persists. Schlaff says no, not yet. "Even before that, decide what you're trying to learn from what population," he suggests. "You might want to go to the literature and see what's been done already. Ask yourself: What are we looking for that's going to be meaningful to the site? If the issue is post-quake, you can get some germs of ideas that you can be working on."

March 30

Joyce Sackey, the medical school's dean for multicultural affairs and global health, shows up today. By now, the change in approach is settled, even if its implications are still hazy. "It's good for us to have projects in mind," Conover comments at the start of the meeting, "but we really don't know the community there. We have decided to do more of an assessment this summer, instead of just showing up with a bunch of projects."

"It sounds like you have the right approach," says Sackey, after listening to the students talk. "I appreciate your energies and enthusiasm." A native of Ghana, Sackey has extensive experience developing health-care programs in her home country. She is cheerful, with an undertone of gravitas. "Right now you need three things," she informs the group: faculty supervision for any research they conduct, funding to pay for the trip and a follow-up assessment by the school administration.

Greenwald updates Sackey on the change of plans since the group's meeting with Pearlmutter. "That was like the gold star for us," she says. "If we can fit into a larger plan, we'll do it, so that, fourth year, maybe Lily and I can go back there for six months. This summer we may not be able to do six million vaccines, but we may be able to put something in place that lasts."

"You will need more than one person to supervise," Sackey points out. "You need a cadre of people who can go down there." How do we go about recruiting others? Greenwald wants to know. "The good news is that faculty members are expressing interest in this," Sackey answers. "The timing is great, we have people who want to help."

A few of the students describe their proposed individual projects in Haiti, but Sackey warns them not to get ahead of themselves. "Let's not reinvent the wheel on health surveys," she cautions. "You might want to see what's out there already. That could help reassure the IRB. Given the challenges that relief workers are finding on the ground in Haiti, it behooves us to do as much of the work here as possible. Our faculty may have connections that can help us." Near the end of the meeting Sackey remarks that she has some Creole-to-English dictionaries to lend, if they are wanted. "We need to get those and be sleeping on them," Greenwald jokes.

April 2

Schlaff is back for a second time. Greenwald announces that she is definitely going to Haiti for five days in mid-April. "So the site you're using is a hospital, right?" Schlaff asks. "Yes, it was a 60-bed hospital originally, and now it's like a 300-bed triage center," says Greenwald. "Everything has been thrown up in the air since the earthquake." The hospital is located in a rural area north of Port-au-Prince consisting of about 30,000 people, she explains.

"There may be communities of people who aren't going to the hospital, and so you might not see them," Schlaff points out. "You need to know, why are people going to the hospital, and what are the issues in the community? They may not be the same. You've got to start with what they want to know [at the hospital]. They could say, "We really need x, y, z, or we want to focus on Pap smears. So you could do that this summer, and then build on that."

"I'm getting palpitations" I think we're thinking too big," Greenwald comments. "A goal of having a site that medical students can go for six weeks after their first year, that's something we can do."

"We might want to frame it in larger terms," Conover suggests. Schurko says: "Why not sit down with the person in Haiti and say, 'What do you want?' If we're going to keep doing this, they have to want us there." "We need to be flexible," Latina agrees. Schlaff picks up Schurko's point. "If you consider that you're the first to go, the relationship you have with the site and the people there is more important than any survey. They may say, 'We want you to spend the first two weeks in the hospital.' They may want to protect the community from you."

April 14

In a move to bring students and faculty together, Dean Sackey has called an informal summit of medical school faculty who are interested in Haiti. Sixteen people, including Pearlmutter and Helen Boucher, an assistant professor of medicine at Tufts Medical Center who volunteered at Sacre' Coeur in March, have gathered in a Sackler Center classroom. Several more faculty members with overseas experience are also present. "Our goal today is to determine how the school can support an ongoing engagement in Haiti," Sackey states.

Boucher leads off by presenting an upbeat appraisal of the Haitian facility. "The hospital is pretty sophisticated," she comments. "It's the largest hospital in the north of Haiti. We had everything we needed in terms of staff and medical supplies. We were not lacking for anything. We had physical therapists, RNs, even a pharmacist. This hospital is operated entirely by Haitian doctors, nurses and staff, and they run a tight ship."

After the earthquake, some 500 patients, many severely injured, were brought to the site, mostly by helicopter. Pearlmutter, as leader of a 30-member Caritas team from hospitals in the Boston area, was there during the immediate aftermath, and describes it as "pure and utter chaos when we arrived. We found ourselves overwhelmed. We lost patients constantly" and 40 percent of these were children."

"We could go on about emergency medical response to disaster," Sackey remarks after a pause, "but let's stick to what Haiti needs now, and what we as a medical community can do." "Most of you in this room don't have skills like Mark and Helen, but there are things to be done," James Hyde, professor emeritus of public health and community medicine, tells the students.

Sackey invites the students to explain what they have in mind for their pilot venture. Latina briefly recounts the genesis of the Haiti idea, built originally around individual projects. Schurko mentions the Pap smear research project that several of the group first intended to carry out, admitting, "That was our original idea, but it got kind of changed up." "We all have these particular, individual interests," Greenwald tells the physicians, " and we're now funded, ready to go, energetic and looking to you." (With financial support from four different sources - the Tisch College Active Citizenship Summer International Fellowship funding, plus a medical school Global Health Travel Grant and dual awards from the Medical Alumni Association and Student Council - the group left for Haiti in early June to spend six weeks based at Sacre' Coeur.) Regarding the infrastructure ruin and human calamity brought on by the earthquake, Hyde is peering far down the road. "It's going to be five, 10 years - a generation, really - before this is taken care of," he says. "That's why we need a permanent presence there." "We are supporting the students not for a one-time event," Sackey observes. "We expect that when they come back, they will be telling their stories."

"Sounds like we have two infrastructures to build - one here and one in Haiti," Schlaff says thoughtfully. "This is the groundwork," Sackey offers in response. As of mid-May, seven Tufts faculty members had signed on to visit Haiti and help supervise the students this summer. TM