We arrive in the nameless village early, when the morning light is still thick and golden, marred only by the dark smudge of hills on the horizon. Doctors, nurses, dentists, support staff: a team of ten, we’ve flown into the Dominican Republic for a week of one-day stands. Day four, this is our fourth and final village. Like most foreigners, we’ve brought a sense of adventure and spare memory cards. Unlike them, we won’t be staying at luxury resorts or visiting golf courses. We have come to do good, to make a difference.
Our local partners are waiting for us in blue T-shirts like ours, clipboards ready. They’re clearly excited when our convoy arrives, and greet us with great enthusiasm. We climb off the bus and shake hands warmly. They show us the empty hall they’ve arranged for the doctors and a separate space for the dentists. The neat green community building is ideal, with several private rooms and a large main area filled with benches like pews. We unload the eight black suitcases and mysterious machines from the truck that follows us everywhere. The set-up team gets to work, while the rest of us wander off, knowing the drill, clutching our cameras.
The light is perfect, and I start taking pictures. At first glance everything seems so lush and vibrant that I want to roll around in the colour and soak it in. A wide river crosses the road further ahead and water channels run down the side of the streets. Most houses are wooden, a couple concrete, one or two a patchwork of metal. They’re painted seaside colours, pale pinks and turquoise, and the space beside each has been compressed and smoothed into a compound, some holding small flower gardens.
I walk on in search of new views. Despite so much water, the biscuit-coloured earth is completely parched: each truck and motorbike that roars past throws up a cloud of fine particles that settles back over everything. I pass a few struggling French marigolds and snapdragons and a long-abandoned hand pump. Further from the centre some of the houses are made of dirt. I put my camera away.
I find out later that this isn’t a village but a former banana batey, or company plantation. The big businesses have all gone now, taking the work with them, but leaving the workers behind. There are few jobs except growing enough food to eat. Some fields have been turned over to rice and sugar beet and there are still plenty of banana trees, but in many places all order has been lost and there is only a wild tangle of greens, broken by a few umbrella acacias and glossy mango trees. Villainous bougainvillaea conspires to make a subsistence existence look joyful.
Today is laundry day, and already sheets and shorts are flapping on strings stretched along the roadside. I pass women sitting on their heels in front of large plastic basins surrounded by small piles of clothes. Some smile and wave, many sit back resting as the clothes soak. Small children play in the dirt and sweet little piglets trot about.
The water has been brought from the river in yellow plastic cooking oil bottles; there doesn’t seem to be any soap. By the river I meet a man with a huge spotted sow on a string and I watch admiringly as she wades into the water and happily roots about. The pig is magnificent. The man grins with pride.
Everything is set up when I get back to the makeshift clinic. The doctors have taken over the three private rooms and are already with their first patients. The waiting room contains a scattering of women and children, and no men, which is what we have come to expect. The room will get busier and busier as word spreads through the community, but most men will stay away. A few may come for skin conditions like scabies and impetigo, or even reading glasses, but they will never mention the symptoms of the sexually transmitted infections that we know are widespread here. What good can we do if we only treat the women?
A secure space at the back of the hall has been set aside for the pharmacy, and it’s already buzzing with activity. The contents of the eight black suitcases are laid out on trestle tables: jauntily coloured cardboard boxes and packets; foil pouches; plastic bottles; blister strips. Every item has been donated, and although it looks higgledy-piggledy, each is in its place. Some bear the specialist labels of hospital supplies intended for professionals, others the eye-catching logos created for the supermarket. Some are familiar—Tylenol, Aleve, Advil—others unusual and difficult to identify.
I have no medical training and had expected simply to observe, but nobody just watches here, so I become part of the pharmacy team. When patients have seen one of the doctors they bring their prescriptions to us. We take them, find the right drugs, have them checked, then pass them to Juan, who sits outside the door, guarding the divide between waiting room and pharmacy.
It takes less than half an hour for me to learn how to fill a script on my own and I spend most of that time trying to decipher the doctors’ handwriting, which is universally atrocious. The patterns are very simple because there aren’t many choices. We try to keep the doctors up to date when we run out of drugs, but sometimes we fall behind. Then one of us has to go and face their frustration, which gets angrier as the day goes on. To compensate, we gossip about them, which is easy because they’re all young and good looking. I feel guilty about our laughter when I glance through the door.
Nobody speaks of cancer, TB or HIV. We have no surgical facilities and no specialists. We acknowledge only what we can treat that day.
Globally, nearly 5 million people with moderate to severe cancer pain get no appropriate pain medication. Nor do some one-and-a-half million with stage-four AIDS. Those in the global south are likely to have been diagnosed late and to have no hope. Severe pain means agony. Men, women and children suffer burns, accidents, gunshots, sickle-cell disease and the severe nerve damage that comes with diabetes with no pain relief at all. They may have been lucky enough to receive vaccines, antibiotics or anti-retrovirals, but without pain relief many prefer suicide.
Juan’s job is to explain the medication to the patients: how many tablets to take and when, and that these are not “caramellos.” A Venezuelan with two years of pre-med, Spanish is his first language. He is calm, colloquial and clear. The Dominican patients nod, smile and quietly ask questions. They are a little shy and deferential, but they seem to understand.
But many of the patients are Haitian, not Dominican, and Juan doesn’t speak Kreyol. None of us does. We can manage French between us, in an approximate sort of way, but for those with only Kreyol we carry out a pitiful show of mime and drawings. We have pictures of suns and moons and the empty faces of clocks onto which we draw the times at which the drugs are to be taken. When blank, confused faces look back at us, we know we have failed; at times it’s almost farcical. Juan tries, explaining everything once, then making each person repeat the instructions back to him, as best they can. It’s painstakingly slow, and by the end many of the Haitians simply look frightened.
During quiet moments in the pharmacy I stand watching Juan, looking over his shoulder to the waiting area beyond. Still almost every seat is taken by a woman or a child, their name stuck to them on white labels. Most women are pregnant and many are very young. They wear jeans or shorts and a T-shirt, their hair neatly braided, flip flops on their feet.
I find myself staring at a woman wearing a long white cotton summer dress with a deep handkerchief collar; her hair is short, unbraided and pulled back with a wide Alice-band. She reminds me of Bertha, Mr Rochester’s wife in Jane Eyre, for she, too, is clearly mad. She stares at the floor or looks at us childlike and uncomprehending. She is alone, and we can do nothing for her, yet I have an overwhelming desire to walk up to her and take her hand.
The children sit still and solemn on the benches: four little girls at the front, their braids fastened with pale blue bobbles. We work calmly and steadily, but they wait nearly three hours, their heads turning to follow a noise or sudden movement but otherwise their lives suspended. In awe of everything, they are wide-eyed and patient.
Doctors and nurses are constantly walking through the waiting area, sharing equipment, checking on drug availability, joking, laughing or stopping for a drink of water. Many pause to take photographs on their way. Nobody complains; it’s as if they know that part of the deal is that we have our trophies. Every single doctor and nurse finds a reason to walk past the tiny girl in the pale pink froth and the flowery headband, their cameras ready.
I take a break and wander out onto the dirt road towards the intersection that is downtown. The one small open-fronted shop has shelves stacked meticulously with drums of milk powder, bags of rice, cans of condensed milk and bottles and packets of all sorts of things. A huge scale hangs over the counter, where a few sad vegetables are wilting in the heat. The small pyramid of eggs nestled in the shade makes me think of the children I teach in the U.S. They are all well fed, and many are athletes. Most discard the yolks of their breakfast eggs, believing them to be unhealthy.
I walk back past the dentists, who have drawn a huge crowd. Dressed in blue scrubs and white masks they’re deeply absorbed in their work, bent low over their patients, surrounded by the large, strange machines. When I first walked past people were wary and standing well back. Now there’s a party atmosphere as they watch three dental students brandish a huge set of cardboard teeth and an enormous paper toothbrush. They’re showing everyone how to brush correctly: up into the corners and right to the back, then letting the children have a go. There’s much laughter and toothbrushes and toothpaste are handed out to everyone. Some people still look suspicious: a tall woman at the back has clearly been unnerved by the large photos of gum disease being wielded by another student, black teeth thrusting menacingly out of scarlet gums.
I’d forgotten about toothache. How extraordinary it must be to arrive in agony, unable to sleep or eat, and to leave with no pain. To have a rotten tooth extracted under anaesthetic; an abscess drained, a cavity filled, an infection treated with antibiotics. To feel pain switched off.
By midday the clinic is full. It’s hot and sticky in the pharmacy and we all make mistakes, muddling scripts, forgetting to double-check the age and weight of a child, mixing two drugs with similar names. Even when we get it right it feels hit and miss, or worse, hit and run. And what about me—I’m a schoolteacher. What on earth am I doing here?
The children in the clinic are all too small. It’s not only about malnutrition and lack of healthy food, although I wonder whether any child here has eaten five portions of fruit or vegetables in the last month, let alone in one day. It’s also about parasites. Most of these children get little benefit from the little food they eat because it feeds the worms that live inside them. Every child who comes through the clinic today gets two small tablets which they have to swallow in front of us with a glass of bright pink juice. Once their stomachs are their own again, then they will need protein, vitamins, minerals and carbohydrates to build their bodies enough that we can guess their ages. I think of the abandoned hand pump and the happily wading pig. There’s very little time before the next round of uninvited dinner guests arrives.
Everyone needs multivitamins, but our packets specially formulated for pregnant women run out almost at once. We substitute the brightly coloured animal-shaped children’s vitamins, but they are soon finished too. Americans spend $7 billion annually on vitamins and minerals, most of which they could do without. In a land of plenty, it shouldn’t be hard to let food be one’s medicine, as Hippocrates advised, and to send the vitamins to those who truly need them.
The island of Hispaniola is bisected by one of the world’s most dramatic borders, dividing relatively rich, hopeful Dominica from desperately poor, hopeless Haiti. But we are on the good side, where tourism has boomed and opportunities abound. Why, then, do these people have no healthcare or welfare?
During a quiet moment I ask our project director Bob why things are so bad here. He tells me that Haitian men have been crossing the island to work on the Dominican bateys for the last seventy years. During that time many started to stay between seasons and married immigrant Haitian women. The bateys became a unique mix of Haitian and Dominican people and cultures, but with one overriding characteristic: poverty. Because Haitians are non-citizens they are not seen as the government’s responsibility and so do not receive public services. In theory the private companies owning the bateys should provide for them; in practice, few do. Once the companies pull out, the communities are abandoned.
Almost all Haitians come originally from Togo. They have darker skin than most Dominicans, and those who live in the bateys are frequently discriminated against. They are seen as a drain on limited resources, and frequently blamed for the high rates of HIV and TB. They’re often treated with contempt and disgust.
By late afternoon it’s airless and stuffy in the pharmacy and we’re all yawning. The window slats are wide open and three little girls in blue and beige school uniforms have appeared, standing on tip-toes, waving through the blinds. We snack on Oreo cookies and chips to try to keep our energy up, and remind one another to drink plenty of bottled water.
Our drugs are running low. We’ve used nearly all the antibiotics and all the prescription-strength pain meds. We are becoming more generous with the Tylenol, though, giving several boxes to those who suffer from chronic pain. Why not? We’re going home tomorrow, and we need to get rid of them. They have no mystical value for us, we’re long
immune to the miracle of near instant pain relief.
American demands and expectations drove the market to provide tablets, caplets, chewy tabs and gelcaps, day strength, night strength and round-the-clock relief. We need never be in pain for more than ten minutes. In the community where I live and work in New England, pain medication is used largely to enhance athletic performance, so people can play sports longer and harder.
Is it possible to be too well?
At the end of the day, on the bus ride back to our hostel, I wonder what we achieved. We saw over 200 patients, almost all of whom will have benefited from our visit. We eased pain, cleared up infections, cured skin complaints and checked on pregnant women and babies. We taught basic health education and dental hygiene and helped women to look after themselves and their children. Above all, we showed up: we let people know we cared.
Yet I don’t feel like a hero, and I’m pretty sure none of my colleagues do either. Most are asleep, slumped uncomfortably, or gazing silently out of the windows. We all know that although we’ve helped many people, there are far more who have never seen a doctor. At best, we provided quick-fix philanthropy: a cocktail of Advil and good will. At worst we’ve been a distraction that allows boxes to be checked, consciences to be salved and the status quo to continue. What is really needed here is infrastructure: employment, education, covered drains, clean water, sewage disposal and a permanent clinic. We’d like to believe that this island and its people will one day have what they need, rather than just more jolly bougainvillea. We’d like to believe in one day.