Tout Moun se Moun, Everybody is a Person
Tout Moun se Moun, Everybody is a Person
by Dr. Joia Mukherjee
As the Chief Medical Officer (CMO) of the organization Partners In Health (PIH) for more than 15 years, my role has been to accompany the clinical teams—doctors, nurses, and community health workers—in delivering healthcare to the poorest of the poor. Sometimes this role is technical—deciding what is the best regimen to treat HIV, organizing the delivery of women’s health services—and sometimes it is hands on—being present, delivering care, bearing witness to suffering. It is the importance of the latter that moved me to spend the majority of my time in my first ten years at PIH in close proximity to the suffering of the poor. More than a decade ago, PIH began to support public facilities—first in Haiti, later in Rwanda, Malawi, Lesotho, and most recently in Sierra Leone and Liberia. Based on a long legacy of internationally driven neglect of public facilities, the clinics we choose to work in are always under resourced and providing little, if any, care. My work in helping to revitalize such forgotten places has taught me all I know about the hard work and strong team needed to make a preferential option for the poor in health care. This story is about my work to support the Haitian government’s clinic called Clinique San Michel in the rural town of Boucan Carre, Haiti in 2003.
Boucan Carre was once the most rural reach of Partners In Health’s sister organization in Haiti, Zanmi Lasante (ZL). It became a model of what could be done in remote communities to bring quality care to those in need. I spent six months (over the course of four trips) in Boucan Carre in its first year of operations. In the next few years, I spent two to three weeks at a time, a few times each year, helping the team implement the delivery of care. My intense engagement at Clinique San Michel taught me how to support future teams at different sites. However, as PIH expanded its model of public sector support to more and more rural facilities like the one in Boucan Carre, I never was able to spend the same intense and focused time with a team and a place as I did there. The memories of this time continue to serve as a touchstone for me.
In early 2003, the clinic was in a two-room shell of a building with no full time staff, no medications, and the customary user fee of 25 gourde (about 50 cents) for attendance. The impoverished government of Haiti had insufficient staff, and those who were posted to Clinique San Michel had not been paid in months. Given these glaring obstacles to delivering and receiving care, the clinic was all but abandoned by staff and patients alike. The rapidly coursing Foulon Fe (Full of Fire) River further cut off this area of more than 50,000 inhabitants from modern medical care. The region is a zone characterized by the work of subsistence farmers, a term that is one of the most scandalous oxymorons in the field of development. In reality these mostly landless peasants do not actually subsist on the corn and bananas that are planted in the eroded and arid earth. They are dying. Malnutrition, tuberculosis, and death during childbirth are common. Those young adults who can seek work elsewhere go to the capital, Port au Prince, working as servants or as ti marchan (little market women), or go to the Dominican Republic, where they cut sugar cane. Often they return with HIV.
Zanmi Lasante received funding from the Global Fund to Fight AIDS, TB and Malaria (GFATM) for the first time in 2003. The Fund was the result of more than five years of global activism by people living with HIV who demanded that lifesaving AIDS drugs be made available to all regardless of their country of origin or ability to pay. The movement was successful in creating GFATM, a large, multilateral funding mechanism that brought billions of dollars in new money to address the top infectious disease killers around the world. Multimillion-dollar grants from GFATM to recipient countries could be used by governments and their partners to deliver on the promise of health care as a human right by assuring that diagnosis and treatment for these diseases be made available to all regardless of a country’s pre-existing health budget.
ZL and PIH had started delivering AIDS treatment on a small scale five years earlier at our charity clinic in Cange, Haiti. But with this new money, we made the strategic decision that all of our work to deliver care moving forward would be in support of the crumbling public sector. AIDS treatment, we decided, was our chwal batay, or battle horse, carrying us into the larger battle of delivering comprehensive health care (not just HIV services) as a human right.
Many non-governmental organizations (NGOs) approach delivering health care by setting up charity clinics or disease-specific programs with the funds they receive. We made the decision to support the public facilities in Haiti in an effort to enable the government to deliver comprehensive health care. Under human rights treaties, it is the government that is charged with respecting, protecting, and fulfilling rights, not NGOs. PIH’s use of AIDS funding as our chwal batay for public sector revitalization became fundamental to our human rights approach to health care delivery and the foundation of PIH’s work revitalizing more than 200 public clinics and hospitals throughout the world.
Clinique San Michel in Boucan Carre was among the first clinics reanimated with such an approach. We did four things that brought the dilapidated public facility back to life:
We paid existing staff and added additional staff.
We supplied essential drugs and lab tests that were provided free of charge.
We recruited, trained, and paid a large number of community health workers to support and shepherd the vulnerable outside of the clinic walls.
We exempted user fees for a large swath of the population.
The effect was stunning. Thousands of people received care in the public domain, supported by an NGO. Hundreds of people were diagnosed with HIV and TB and given back their lives and hope. For six months, I added my hands as an infectious disease doctor, internist, and pediatrician to a small and unimaginably dedicated multidisciplinary Haitian team that included a doctor, a nurse, a midwife, a social worker, a pharmacist, and a driver. They were all there from Port au Prince. They had husbands, wives, and children back in the capital city. Yet, six days each week, we lived communally in two small houses without electricity or running water, working to make vivid the dream of health care for the people of Boucan Carre. Most of the team spoke only French and Kreyol. I spoke English and rudimentary French. I had a translator and language teacher who supported me during the day. In the evenings, I relied on the patient coaching of colleagues, housemates, and new friends to communicate. Because I love to sing, song was another means we used to communicate and share at night.
Patients began to arrive in huge numbers. They were largely destitute farmers who came by foot and by donkey, sometimes traveling overnight to arrive at our two-room clinic. We had neither electricity nor running water, but for the first time in the history of the country, that small clinic in Boucan Carre had staff and medicines. We all experienced the exhilaration and joy of being able to provide medical care for a population that needed it. Many of our AIDS patients got better and gained weight. Patients with TB were cured. Some patients were hired as part of our community health team to attend to their neighbors’ needs. There was, however, still a lot of hardship and despair. In this setting, as in any without any previous access to health care, many of the conditions were diagnosed very late. The death toll was high. During those early months, we lost many patients—children from malnutrition, adults from advanced AIDS and tuberculosis. We were all living far from our homes and families. We leaned on one another for support, for comfort, and for joy. Our small team worked as a family connecting in the evenings in our small kitchen around a large table, illuminated by a candle.
There were tragic accidents and challenges of nature. One of the two staff houses burned down when a propane tank exploded—our social worker was seriously injured and had to be treated at a hospital in Port au Prince. The remaining team members crowded further into a three-room house. Rain was a blessing—for the crops to grow and for us to shower as rain water cascaded off the tin roof. Yet rain was also a curse—making the roads impassable and the river torrential, which further isolated the all but forgotten community. The days were long and hot. Hundreds of patients cued up before 8 am—some gravely ill, some skeletal, waiting both patiently and not so patiently to be seen. Gradually, we set up systems, which reached into far-flung villages. We began to see change. Over time, our patients began to return healthy and smiling. Slowly, health care became a right in Boucan Carre.
In the ensuing twelve years, a hospital and dormitories were built. Tens of thousands of patients have received care. A bridge was built across the raging river. The once-barren landscape is now shaded by 15 foot tall trees.
Today, PIH is much larger than we were in 2003; twelve years on we have expanded to five African countries and have supported governments around the world in the delivery of health care to the rural poor. As CMO of this much larger organization, I am not able to visit all of the now more than 200 clinics that PIH supports. Yet, every year or two I try to visit Boucan Carre as the story of this small community and clinic has become part of my story and my inspiration to provide health as a human right. I am always greeted warmly by the team, by patients for whom I was once their primary doctor.
When I visit, it is often to teach young people about our approach to delivering health care in once desolate public facilities. I want them to understand the nature of rural health delivery, the challenges for staff, and the far distances that patients travel. In the summer of 2013, I took a group of our Global Health Equity residents to Boucan Carre to walk with community health workers and visit the homes of some of our patients. On that visit, walking down a muddy road with a team of those eager to engage in the life-long pursuit of social justice through the lens of health delivery, I was overcome by a memory.
What I remembered through the haze of the decade past was one night where rain flooded the landscape and mud flowed down the hill. We knew that heaps of the mud would, by the next day, block the entrance of the two room clinic where we had just watched three children die of malnutrition. Our team sat in the candle-lit darkness around a long thin table, which so totally filled the tiny room that coming in or out was an ordeal that, ironically, only our beloved fat cook could manage.
As a clap of thunder shook the heavens, we began to teach each other songs to pass the time, to ease the grief, to learn languages that were foreign to us. I was taught a Haitian song about greed, plenty, innocence, and want: rat manje kann, zandolit mouri inosan, or, the rat eats the sugar cane and the lizard dies innocently. I told the story of the song “We Shall Overcome,” as if we too were a movement. And, in reckoning that we were, we transcribed the famous song into Kreyol: tout moun se moun, tout moun se moun, tout moun se moun se vre, nan ke mwen an, mwen konn sa a, tout moun se moun, se vre, or, every person is a person, it’s true, in my heart I know, every person is a person.
Those were days we needed convincing that we were indeed part of a movement, connected to something bigger. We needed to convince ourselves that our work mattered. We needed to fuel hope that our efforts would help to ensure universal personhood was possible in the face of the horrible death toll that poverty wrought in Boucan Carre. We needed to continue to hold the belief that everyone is a person deserving of dignity and justice. We needed convincing that, despite the dire conditions in which we toiled, we were part of something much greater.
Today, the clinic in Boucan Carre is a bit worn at the edges. The newness of what we accomplished in 2003 has been replaced by the periodicity of spreadsheets, appointments, and standardized services. It is a clinic with a regular set of patients having their needs met daily, monthly, and yearly. There are staff showers. There is a proper dining table. It is as it should be—functioning. This once-held miracle of solidarity is now normal. What took heroism, collective action, and a movement to bring about is now a daily reality for people of this remote area—a place to receive health care. Even as we have succeeded, however, the work remains hard and sometimes we still need convincing as we did in those early days.
Our team in Boucan Carre has faced many challenges over the years. These challenges—floods, the 2010 earthquake, cholera, and the violence that is all to common in Haiti—have taken lives and livelihoods.
It is always the sense of solidarity and team that buoys all of us through these times. And when I need convincing that our work matters, I reflect on those nights of singing in Boucan Carre and remember our resounding chorus of “Tout Moun Se Moun.” PIH continues to push the conventional wisdom of what is possible for poor people—we have built a teaching hospital, launched a global programs in cancer, non-communicable diseases, and mental health, we offer advanced surgeries, and we stepped into the fire of Ebola. These newer causes are built on the same belief that every person is a person. Deep in my heart, I do believe, that our song and this movement still resonate today. §
Dr. Joia Mukherjee has been Chief Medical Officer of Partners In Health for more than fifteen years. She is also an Associate Professor at Harvard Medical School and Brigham and Women’s Hospital. She is a mother, an activist, and a singer.