Jan Gurley, MD

The following was originally posted by Jan Gurley, MD—who participated in a 

 before and during a trip to provide care following the earthquake earlier this year—over at 

I have a new best friend. She’s cool and smooth and adaptable. Kind of like a Dragon-Tattooed-urbanite who can deal with 

situation, from a tweaking guest at a rave, to the post-modern gut-angst of intellectuals. She’s slow to rile too — give her a nudge and all she does is gurgle at you.

I’ve been feeling the love ever since I recently got back from Haiti. At night, when the rooster began his panicky crowing at 3am, I got up, pushed through my mosquito netting and stumbled past sleeping co-workers to our iron-gated front door. Everything in Haiti is locked behind metal. I’d fumble for the key on the nail in the dark (thinking, yet again, about how we’d all die if there was a fire, locked inside as we were), to open the doorway’s Adams’-Family-creaking gate. Then, once outside in the still-hot Caribbean night, I’d turn on my headlamp and weave my way to the “bathroom.” Despite being closet-small, and covered, over every square inch, in unspeakable fluids, and reeking worse than an ancient, abandoned alley-side Port-a-Pottie, it 

was tightly locked behind a metal gate. After fumbling with keys and getting the deadbolt to slide, I’d do my business by hovering over a deceptively normal-looking toilet. Perched on a ledge was a pre-sliced 

magazine thoughtfully provided by our host—to be used as toilet paper. I got, from the experience, a new perspective on in-flight gadgetry ads, once I had the opportunity to choose several times a day which one to use to wipe my bottom.

And after the unavoidable juggling act of keys, paper, and hand sanitizer, came the bucket pour. You couldn’t just pull a handle. Well, you could, but nothing would happen. Instead, you had to scoop a bucket of dubious water out of a large plastic bin (while trying to not think about what might be growing in that much-handled bucket). And then you needed an aggressive pour to get the water from the bucket to force the contents of the toilet bowl down a pipe to who-knows-where. No one warns you that splash-back is an inevitable fact of life. Hence the perpetually damp, unspeakable floor. Since sewer pipes were almost non-existent (and “water treatment plants” a thing of myth) BEFORE the earthquake, there’s no telling where your bucket’s dump goes. Perhaps back up under your floor somewhere. And, keep in mind, our toilet facilities during this trip were, by far, the best that I’d seen Haiti offer, either in February or now.

But in the best of homes, there was at least, in February, a sense that the bucket-dump into a rocking shell of a damaged toilet was a 

approach to sewage and sanitation. October’s trip (and its cholera outbreak) proved that assumption wrong. Even knowing there hadn’t been “much” progress, I still went nine months after the earthquake hoping to see change. So 

there change? Or was my toilet experience symbolic of all Haiti’s lack-of-progress?

different. But not exactly the way I’d envisioned it.

For a start, the city was heart-breakingly neater. Port au Prince looked as though a million women with twiggy brooms had, together, swept the dirt of this entire 

-sized metropolitan area. Literal canyons of dust and rubble had been brushed away or tucked into corner lots.

And walls were dismantled. By hand. We saw a man taking down one listing concrete-block wall with nothing more than a broken piece of rebar. There was nothing else for him to use, not even a hammer, much less a sledgehammer. Since there’s no heavy machinery at work, the dismantling can only go down as far as the owner is able to bang it out, leaving behind sturdier triangular corners. The roofless homes marching in a line across a hillside, originally shaped like rectangles, now looked like jagged broken-off teeth.

It is still clear that the city had taken a solid punch. And now it’s swaying under the on-coming battering of cholera and a storm, both of them threatening to undo what progress has been made.

You see, the other signs of progress were more social than structural. Since February, people now thronged the sidewalks, weaving like schools of fish, the motion and conversations constant — where before there were only random flat-faced becalmed groups, drifting here and there like un-tethered seaweed, so abnormal in movement and structure that you worried about whether they could survive.

Fragile social roots have struggled to take hold after such devastation: socially organized camps, widespread advertisements for candidates in the upcoming election, and the painful tiny individual accumulation of belongings under a plastic sheet. There still are very very few actual “tents.” Mostly people still live under suspended plastic sheets. But with storms bearing down, those same signs of social-progress-against-all-odds may be destroyed.

Cholera is a lethal infection of hurricane proportions. You can die in as little as 3 hours, with your entire body’s amount of fluid coming out as stool. Socially, in Haiti, I found in February that there was 

tremendous stigma attached to diarrhea. Not that surprising, really, if you think about the realities of living in a parking lot without a toilet while surrounded by hundreds of other people. And now there are concerns that cholera may have been 

brought to Haiti by the very international workers who came to help

. Besides the devastating toll on lives (with reports ranging from 

 dead from cholera), how much current, and potential, good-will could such an event destroy?

Now there are reports of people being asked to 

“voluntarily” evacuate their sheet cities

. But where do you go when you’re already sleeping on the mud with only a plastic baggie of belongings you’re trying to keep dry? What if you’ve only now, after months of struggle, found a group that can band together to make sure none of us women are raped when we go to pee in the night? Throughout time, we humans survive, and improve our lives, by banding together — so what does this level of forced social disruption do to a those who have only recently found each other?

, a Haitian town that didn’t even really make the news that much when a hurricane blew through in 2004 and left its 

entire population of 200,000 homeless, and 2,000 people dead

. To that destitute not-yet-recovered area, 70,000 more people from Port au Prince were relocated after the earthquake. We saw patients who were both locals and evacuees. The area is so poor, that it took our translators several hours to get us to realize that no one owned a spoon. You couldn’t give a mother antibiotics for her baby and expect her to be able to measure them out. So we tore the tops off cough-syrup bottles and gave them to moms, demonstrating with them how much medicine made up a dose. One day, I saw a man who was “100 years old.” Many of the very elderly didn’t know when they’d been born, but he said he was 100, and, by God, he definitely looked 100. A sprightly 100 for sure, but definitely, as we say in medicine, he was one of the very 

elderly. He was barefoot, and had the kind of triangular wide-toed feet that people get who have never ever worn shoes — the kind I haven’t seen since I worked in Africa. He wore a hat and walked with a stick, and his blood pressure was an impressive 188/110. There was, of course, no way I was touching that blood pressure, since anything I might give him would only make him worse and he’d made it this far with it untreated. I asked him why he came, having to wait for hours in the sun to see me. He said, through the translator, that he came because he heard there was a doctor, and he wanted to see one. It took us a moment of circular translating to realize that he meant that he just wanted to lay eyes on a doctor.

But I noticed as we talked that his right eye didn’t work right — the bones around it were disfigured and tears leaked from it constantly. Searching for a way to make him more comfortable, I asked what had happened. In “the flood” of 2004, he said, he was floating in the water and was hit in the head with a big log. His eye has never been the same. I told him that perhaps I could help with the problem of his eye tearing. He looked dubious. I said, “Your eye – it doesn’t close when you sleep, does it?” He asked the translator, astonished, “how does she know that?” I explained that the nerve had been damaged, and that his eye cried all day because it was forced to stay open all night. I told him he could try taping it shut at night, and the tearing might improve, or even go away. He didn’t really understand “tape,” so we got some of our tape and I demonstrated how to do it. He left, with duct tape and a little acetaminophen for his back and hip pain, amazed at the miracles we in the States can perform. And I was ashamed at how little I had to offer.

It was only after the hectic clinic day was over that the story he’d told me finally sunk in. The imagined reality of it — being 94 years old, swept away in a flood, with a blow to the head that broke the bones of his face. What must it be like, to survive through such, and keep on living and learning, walking to see something new and meet people who have come from afar?

So I’ve come to appreciate many things after my trip to Haiti. First and foremost, the staggering resilience of the Haitian people. Only, I also have a bone-deep anger, on behalf of my 100 year old patient, and on behalf of all those people who are being asked to leave their tiny patch of mud, and people who are dying of diarrhea, that no one should HAVE to be that resilient. There are, in fact, in our world of random affluence, things that are just wrong.

Second, I have also come to appreciate my toilet. She works beautifully. I am now very aware that under her is a sewer line that connects me to an entire social network. Our flag should have a toilet on it — it is a symbol of how we, as a people, work together to improve our lives and our health – the lives and health of even the least of us. It is a symbol of what progress is all about, and a bottom-line (pardon the pun) measure of any country’s success.

As those storms blow through Haiti, and floods rise, spreading misery and more cholera far and wide, you may feel the urge to turn off the news — if for no other reason than because you can’t take it any more. And because there’s nothing you feel like you can do to make a difference. If so, I encourage you to do one small thing. I encourage you steal this video, below. I spent a weekend making it with good friends. It is a mostly-wordless instruction video, suitable for any country, about how to make life-saving oral rehydration solution, using only things that a person living in a sheet city would have. I was appalled to find that there are almost zero YouTube videos about 

 (ORT) — almost all (except for one in the Hausa language) are actually commercials for electrolyte drinks.

Maybe you don’t think anyone in Haiti will ever see YouTube. I’d say you might be wrong. People there have cell phones, and texts, and everyone has an email address. Aid workers have smart phones that can show videos, and people there, just like here, love to gather ’round and watch the tiny screen. And if you have the urge to do even more, get inspired. One of the stars of the video, Dorothy Edwards, made an ORT rhyme -

Perhaps you can tweet a version of it, and/or email it far and wide [here's a tweet-ready 140-character version: like all acts of altruism, getting involved can even benefit your personal health.

How is that? Well, now that you’ve watched and sent the video, you’ll know how to mix up your own Pedialyte instead of making a frantic midnight run to the store. Of course, 

personally may want to make yours tastier by boiling it with a mint, or ginger, teabag. And, you can laminate the photo or recipe and put it in your personal disaster kit so you never have to worry about forgetting how to make it.

4 caps sugar, 1 cap salt, 500ml clean water = life

These messages are the letters-in-a-bottle of our age, 

 that we can launch one after the other, knowing that the more we send, the more likely that one, or more, will make it to harbor with a person in need.

See, there IS something you can do. Give thanks for your toilet. And steal my video. Then steal it again.

What do you think? Ready to spread the word about ORT? Share your take in the comments section. Are you a Doc Gurley fan? You can follow 

. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at 

, or jump on the Twitter bandwagon and follow 

 — so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wealth.

Articles

Reflections of a recent trip to Haiti to provide care, with a video meant to help fight cholera -please pass it along.

Haiti Storms, Cholera and You: Time to Thank Your Toilet

Line 'em up and take a count: Mehmet Oz, Nancy Snyderman, Manny Alvarez, Atul Gawande, and Sanjay Gupta (surgeon, surgeon, surgeon, surgeon, and...oh wait, what a surprise...

Sure, one or two might have chosen a different organ to receive their forceps-clamped peanut dissections and 7-0 polypropylene one-handed ties. But looking for any 

specialty-diversity in this group is like trying to identify the fruitiest grain of rice. Exactly where, you may ask yourself, are the hand-holding internists, primary care, and family practice docs? We might even tolerate the squeaky voice and the dangling teddy bear, if mainstream media would just break up the monotony every now and then with a random pediatrician. Just to shake things up, you know.

the voice and face of American healthcare become solely the province of those whose work-lives are devoted to flaying alive the chemically-paralyzed? What does that say about us as a nation? 

But frankly, the fact is, when you take a hard look at the inherent differences between specialties, and the media priorities of health news reporting today, it's 

why no mainstream media platform would give a generalist mega-bucks and a microphone. Here, in descending order, are 

Top 13* Reasons Why All A-List Celebrity Doctors Are Surgeons

 When surgeons show up for a screen-test, that creepy scalpel-twirl they do leaves a disturbing, and lingering, impression. Hard to get the same effect with a tongue depressor. 

 Being the popcorn of specialties, primary care doctors are cheap and purchasable in bulk, but only available, hot and appealing, for 7-minute increments. Even a new media time-slot appointment will only get you 14 minutes, max.

 With its well-documented anti-intellectual, anti-primary-care bias, media today has no appreciation of the complex skills required to do a deft rectal exam.

 Hey, if you can cut open an unconscious person, then how hard can it be to know everything there is to know about epidemiology, behavior change, public health, medication management, compliance-improvement, relative risks, end-of-life care, diagnostic challenges, and chronic disease paradigms?

 It's all a matter of demographic appeal. Surgeons draw the coveted, but lacking-in-nuance, 15-25 year old crowd. Internists — everyone septic and intubated.

 When it comes to health news, the most a generalist can hope for is a minor indie role. Fact is, typecasting begins even in the pre-med years. Surgeons: Gerard Butler and Angelina Jolie in 

. Internists: Micheal Cera and Ellen Page in 

 It's hard to be telegenic when the thing that really trips your trigger is a P value of less than 0.001.

 Katie Couric gets really peeved when the answer to every single one of her questions (example, “Is being hit by lightening bad for your health?”) 

begins with “Well, the data are complex and, frankly, from a purist standpoint, inconclusive...”

 Surgeons sport a trademark visual of wearing scrubs. But for under-paid generalists, focus groups have shown that 

trademark (hands clenched, dark-circled shifty eyes, rumpled clothes and Y-shaped stethoscope) looks, to most viewers, much too much like a guilty horse-thief waiting to be lynched. 

 It's hard to make a compelling promo out of a doc doing an excellent Review of Systems on a helpless child trapped under rubble in Haiti.

 (which required a $60 million budget, the self-deprecating charm of John Ratzenberger, and all the techno- and media-savvy skills of Pixar and Disney 

), has anyone been able to make a flea even mildly appealing.**

 Surgeons, especially tertiary-care surgeons, are perfectly pre-trained for a life in news media. They don't open, they don't close, they don't bother with getting consent, and they don't personally document anything. In fact, they're not actually present. Except for the money shot. 

 Bottom line: surgeons embody the motto of today's mainstream media: “maybe wrong, but never in doubt.”

*Plus or minus a Heisenberg Uncertainty coefficient of 9.7 RVSs.

For those who have not been personally subjected to its level of French-vicious-crazy-making bureaucracy, RVS stands for Medicare's Relative Value Scale - a number that assigns a value (hence, reimbursement) for, as Darshak Shanghavi brilliantly explains 

, “every single one of the thousands of services provided by doctors, a job later 

 to measuring 'the exact amount of anger in the world.'” The number is monopolistically decided by a secret cabal of invasive proceduralists [read: NOT generalists]. Seriously.

**Def. “flea” Medical insider's slang name (derog.) for internists. Historical origin obscured but frequently quoted as (although, from a purist's perspective, entomologically inaccurate) “because a flea is the last creature to jump off a dead body.”

IS there a surgical media monopoly? And if so, why? Sound off in the comments section!

Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney's Ten-Step Pin for documented excellence in waitressing, and both a Board- and Bored-Certified internist. You can get more health posts at 

 Twitter feeds so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.

Line 'em up and take a count: Mehmet Oz, Nancy Snyderman, Manny Alvarez, Atul Gawande, and Sanjay Gupta (surgeon, surgeon, surgeon, surgeon, and...oh wait, what a surprise...surgeon). 

Is There a Surgical Media-Celebrity Monopoly? 

The following has been re-posted to HCPLive.com with permission from Dr. Jan Gurley. You can visit her blog, Doc Gurley, at 

We’ve entered a new arena of horror — where our Richter scale, for the first time, doesn’t seem to reach high enough, and adjectives are crumbling under the impact. “Devastation” or “catastrophe”? None of the usual descriptors feel powerful enough.

	So as punched-gut news of another urban area implosion reaches you today, this one from Chile, you may be feeling both sorrow and a twitchy distant panic — after all, how long before the Bay Area takes its turn?

	So here, while our usual complacent wall-of-denial has maybe cracked and fissured a bit, are some simple, practical tips that you can do 

 to prepare you and yours for a worst case scenario (that’s right! do it in honor of those you wish you could help! do it to work off some frustration and grief as you wait to find out more about the people suffering in Chile!).

	My tips are a little different from what you may see in 

. These are not meant to supplant what is already good advise, but to take things a bit further, based on what I’ve seen in Haiti, and what seems to be the New Rules of Urban Devastation.

 People survive the loss of government, buildings and infrastructure by banding together. Nowhere is this probably more important than in urban areas, where families are often separated by distance, and those living closest to you may not even be acquaintances. Walk around this weekend, knock on some doors and introduce yourself. If you’re feeling a bit shy (who wouldn’t be?), consider making some cookies and putting one or two in a baggie as a smoothing-the-awkwardness gift. Tell people you want to get together as a “block” (whatever your definition of block might be), for security and disaster planning reasons. Some people will give you the cold shoulder, but you may be surprised how many are grateful to meet you.

It’s amazing how cell phones have kept working, especially the text function, even in Haiti. Hopefully, that would continue to be the case. At your first get-together, program group numbers for mass-text blasts into every man, woman and child’s cell. It’s the one item most of us carry on our persons at all time. Also consider downloading and installing (if you have a smartphone) specialty apps that might help in an emergency. Since it’s an ever-changing field, maybe someone in your group will research which ones (location finding? first aid?) might work best for your group. After your “block” is organized, connectivity-wise, extend that circle out to your family by choice or biology. Many disaster-preparedness sites advocate an emergency phone tree, but after what the earth is doing nowadays, it pays to take things a step further and input the mass-text-blast set-up in advance.

 Is there a doctor living on your block? A nurse? An engineer? Are there any other special skills nearby? How close is the nearest medical facility (including clinics)? How could you get there? In the aftermath of destruction, you don’t want to be trying to carry a loved one three blocks the wrong way. Also, remember basics — you can carry a person on a makeshift stretcher with only two poles and a sheet tied between them. Although many of us may not have the space to store them, wheelbarrows became prized commodities for many reasons.

 Whether we’re talking about Katrina, or traditional earthquake preparedness advice, the assumption has always been that there would be a place for survivors to shelter. We’re discovering over and over that assumption just doesn’t hold true. Not when millions of people are affected in the same small geographic area. You can buy a functional, decent tent for pretty cheaply at a number of different places. Hey, maybe you’ll even get inspired, once you own one, to turn off the TV and head out for a weekend this summer!

Again, while these items are not the typical part of an earthquake kit, you’d be surprised how rare, and life-saving they can rapidly become. Moving walls and timber off trapped people was the one act (more than any Gupta-like surgery) that saved limbs and lives in Haiti. After the initial crash, your bucket, with a roll of garbage bags, can act as your toilet until you get a chance to dig a latrine with that shovel. Hey, throw in a blue tarp too — you can put walls around your loo (among many other uses). A sturdy, sharp knife (hunting-type) or small axe for hacking through things could also be very useful. Got a pair of sturdy, rubber-soled shoes that are practically worn out? Toss those shoes in your pile. People who were barefoot or wearing sandals were exposed to glass and live wires in disaster areas.

	5) Next, get a shovel, a bucket, and a bundle of nylon cord. And a lever/crowbar. 

 Most of us can’t keep track of the freshness of our 5 gallons/person of earthquake-kit water. It pays to stay on top of that, including calendaring a check/switch. However, what’s clear in our new world order of destruction (New World Disorder?), is that you could need access to a more extended amount of water than you can pre-store (in 

to what you store). What can you do? First, buy a more re-usable water purification approach. It doesn’t have to be (that) expensive. Consider 

. That one bottle, and a crude filter, can purify 200 gallons of even gross water. There are many other, more high-tech approaches. But be wary of anything that is, in the end, battery-dependent. Second, scout out water options. Can you keep/make a water catchment system? Is there a local pool nearby? Does your semi-retired RV sit around with its water tank half full? Is there a stream running through your neighborhood? While we’d all like to think that we’d be different, that Katrina-esque delays in care wouldn’t happen again, these water-access situations have made the difference between dehydration or survival in Haiti — especially in the first three weeks before water distribution got up and running.

 Clearly, waterproof matches are a part of many recommended earthquake kits. Take things a bit further, and you’re talking about a camp stove. But then there’s the issue of fuel. And, another type of power issue is energy for that all-important cell. Or lights. You can consider getting solar-powered flashlights (available pretty cheaply), as well as a solar-charger for your cell. The premier kind is an all-purpose solar charger that could do lights, cell, even laptop. But those are pretty pricey. Maybe someone in your local “block” already owns one? Or is willing to share?

advanced medical preparedness set of tips

. Make sure you include those, as well as extra bandage rolls, tape, and gobs of hand sanitizer, for days-weeks of post-potty use. Many small bottles of hand-sanitizer are best, as they frequently leak, and they could be distributed among family members for frequent use. Don’t forget to include at least some of the kinds of things lying around your home whose absence has plagued people in Haiti — tampons, napkins, condoms, diapers, and other important quality-of-life items. If you don’t end up needing them, someone nearby will. Finally, consider including some of those paper surgical masks. Whether we’re talking about the aftermath of 9-11, or the sooty dust/haze/campfire pollution that still pervades Port au Prince, having a mask that lets you breathe fewer particulates may be important for people with even normal lungs, much less sensitive ones. A saying in Haiti, when people talk about the visible aerosolized mortar, grit, and pollution is “at least we could never afford asbestos.” Unfortunately, we could afford it, and did put it as well as other never-meant-to-be-breathed substances in the walls of mega-high-rises.

 Depending on your choices, you’ve probably spent somewhere between $100-$500, total. Compared to the price of earthquake insurance, what a deal! Now where do you put all this stuff? If you’re living in a high-rise apartment building studio, this may all look (and sound) ridiculously impractical. For you, that may be the brutal truth — in which case you’ll be looking for micro-versions of all these items and putting them in a rectangular storage box. But what about your work? Or your car? You can’t know where you’ll be – and one of those may be a good place to stock and store your supplies. For lots of people, these items would all neatly fit (along with the typical earthquake preparedness kit) inside one of those tightly sealing 

. That garbage can, itself, could be really handy in a disaster for sheltering many perishables. Put everything inside, bungie-cord it closed, and take it 

 (if you can). Store it in a bike rack area, or a trashcan hut, or the place where you keep garden implements. The last thing you want is for your devastation kit to be buried under rubble. Having it all in one container makes your supplies relatively easy to load and go if you need to evacuate for other reasons (like a tsunami warning).

	Here’s hoping that, in retrospect, these tips all look silly, overwrought and unnecessary. Wouldn’t that be lovely?

	Share in the comments section — do you have tips? Experiences you’d be willing to share? Keep up on the latest health issues in the news by signing up for a 

. Look for future pics and other articles at 

 — discover the weird, the wacky and the everyday symptoms you want to know about, as well as practical expert tips on staying well. Want to express your inner fan-girl/boy? Become a Doc Gurley fan on Facebook! Want to be on the inside, fast track of health news and tips, as well as Haiti tweets? Get on the Twitter bandwagon and follow 

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We've entered a new arena of horror where our Richter scale, for the first time, doesn't seem to reach high enough, and adjectives are crumbling under the impact. "Devastation" or "catastrophe"? None of the usual descriptors feel powerful enough.

Chile (and Haiti, and Katrinaâ€¦): Preparedness lessons for you and me

How quickly we humans normalize even the most extreme scenario — as long as we see it over and over. By now, it seems perfectly normal for our fringed-draped bus to 4-wheel it over piles of rubble. We automatically get out and walk up the steep dirt-road hills of this large urban city while she groans and grumbles her way to the top, pebbles pinging with 22-gauge speed. Houses lean right and left and even bow down toward us, almost touching forehead to ground and you forget the tilt is not actually an obeisance, but, instead, a predator-lunge at geologic speed, as though these houses have gotten a taste for humans and someone needs to put them down.

	When we walk, we bump shoulders with people forced to crowd into the inches-wide grit-strip next to vehicles that fart throat-burning greasy black exhaust right in your face.

Roads shift and snake, constantly appearing and evaporating. We head, rocking and trailing a plume of dust

toward a rubble bottle-neck and all of us gasp as a man calmly wheelbarrows his way into the already too-narrow, two-rut track. There’s a hill behind the man and, as our driver brakes into a slight fishtail, we see an SUV headed toward us, the man now centered between two on-rushing vehicles. Even as the cry goes up — voices yell, horns toot, and our group begins a collective wail – he calmly lifts the handles of his rustbarrel to dump the entire boulder-piled load right in the middle of the two-rut gap. Vehicles squeal, we lurch forward against the benches in front of us, dust billows into us from behind and we see him calmly shake the last pebbles loose, turn away and head off to get another load, the situation having now taken on Saturday-morning-cartoon extremeness. After the instant-drenched sweat, heart-stopping fear, people are angry. What was he thinking? How are we going to get through NOW? We’re supposed to be there soon. Cars and buses jerked and filled both lanes behind us as vehicles jockeyed to get ahead. Horned blared and voices gwen-gwenned angry Creole phrases. It would be wrong to say the widened street behind us had become a parking lot. Parking lots are ordered tiles of vehicles. This was a mosaic of cars, mortared into place. There was no way in hell we could back up and turn around now.

	Two of our team get out and start throwing the man’s many twenty pound (and heavier) basketball boulders on top of the existing, massive road-narrowing pile, trying to open the now-impassable two-rut channel. The sun is blistering, dust poofs around our two team members as they jog into place, our security pair piles out and the shouting has begun, but the most remarkable thing about watching this physician, and trauma nurse throw boulders is the contrast between their wide, well-fed, American swings and the sinewy man’s slumping shoulders as he trudge-wheels away for another load. That is a pure Haiti moment — the abstract made visible, the burst of well-fed, American energy displayed against the raw, determined, unstoppable Haitian grit. That road-narrowing mountain of rubble is the result of one man’s unwavering commitment – one load at a time, one sweat-pouring, back-aching step at a time, a leaning-forward, cannot stop or you’ll never start again indomitable will that purposely, deliberately ignores how impossible the task ahead is, a blinkered will that trudged onward between hurtling, seemingly inevitable collision and death and somehow, despite all odds, manages to achieve, by God, this one more load. And, without hesitation, metronome plods on to the next.

	Although no one, at the time, could have said why, our entire group paused and realized that if this one man continued this way, it was no contest — not even if our entire team got out and threw boulders. We could never compete against that one man’s determination. He would outdo us.

	And for the first time, on that realization’s heels, we thought -in a cringeworthy cross-cultural moment — to stop and wonder why. Why this moment? Why this rubble? And the only laws of traffic here in this completely sign-less city are the Laws of Physics. A stupid pedestrian is rapidly a dead pedestrian. Why step in front of on-coming traffic to place rubble in the middle of the road, turn, and go get more?

	Only then, after the heart-stopping fear for the man’s safety, and the rebound anger at being made to feel that fear, after the what the hell shouting and the we need to get through this mess boulder-throwing — only then did we discover that beyond this man’s pile, the narrow street further ahead was now closed due to something that had happened, the SUV coming back to both get out before it was permanently trapped, and to let people know. The wheelbarrow man had clearly already heard the news, moments before. Where we sat, surrounded in a wedge behind us by a sea of shouting, gesturing drivers, was a rare area large enough to turn around even a bus.

	You could say the man with the wheel-barrow blocked the road to stop what could have been a much worse situation. Or to warn us. Exhausted, under broiling sun, he took painful, additional steps out of his way to deliberately place the blocking load in the road. Or you could say he needed to claim this precious opportunity before it was lost — a dead-end space where you can have your back to a rubble-wall as you try to protect your family in the dark. Regardless of which, or whether both or all three might be true, every one of our first interpretations of the situation had been off.

The one glaring brightness is the sight of the metal-benched individualized buses — so shockingly different that they stand out like poinsettas sprouting on a lunar crag. Haitian buses are glorious, a rolling work of art, the visual transformation of something mundane into something joyous. If someone could figure out how to sell them Each one is unique, full of passion and details that reveal as much as a memoir about its creator. In contrast, I’ve weirdly begun to realize that our fringe-draped bus, who seemed so exotic at the start, may actually be something of a prude.

How quickly we humans normalize even the most extreme scenario - as long as we see it over and over. By now, it seems perfectly normal for our fringed-draped bus to 4-wheel it over piles of rubble.

Jan Gurley, MD

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