Transcription of Nathan Nickerson for the show World Wellness, #119
Last week on the Dr. Lisa Radio Hour we reflected on the spirit of giving that is so prevalent in our Maine community. This week we speak to individuals who are contributing to world wellness, by giving of themselves both in Maine and abroad. From purifying hospital water supplies to providing homes Dr. Nathan Nickerson and Mark Carter are making a difference one patient and one brick at a time. We hope you enjoy our conversations.
Thank you for joining us.
I’m very pleased to be sitting here today with an individual that I met as a family medicine resident when I was in Portland. Also then a preventive medicine resident and student in the Masters of Public Health program. At the time this individual, Nathan Nickerson was working for the City of Portland’s’ public health department. Now fast forward a few years and Nat is the director, the Executive Director of Konbit Sante which is an organization that is offering health care for people in Haiti.
Thanks for coming and talking to me about this latest adventure in your life.
Nathan: Sure, it’s my pleasure to be here.
Dr. Lisa: We’ve been introduced through Konbit Sante, through our discussion with Deborah Dietrich of Maine Health. I actually had the privilege of reading a journal that she wrote when she went down there for the first time. Her eyes were really opened to what it meant to be practicing public health. It means something very different I believe, than what it means to practice public health up here.
Nathan: I think the concepts are the same, the environment and context. Maybe the starkness of the issues are much greater there. The underlying idea of public health in terms of having a whole spectrum of preventive health in the community to the treatment and higher level care is all the same. I think the biggest difference obviously, is the context. The extreme poverty in which people live and the resource challenges that people who are trying to provide care, face every day.
Dr. Lisa: I think that’s what I was reading in her journal. Was really … you’re right; it’s not that we’re any different. Everybody needs clean water, we all need food DE and we all need clean air, but in Haiti it seems as if it’s more challenging to get even the basics in place.
Nathan: I think Haiti has a really unique history, and it’s not well understood in this country. It has resulted in a situation where systems are not working well and the environment is very challenged. The people by and large, the vast majority of the people are very, very poor and the systems are resourced poor as well. Haiti has the poorest access to portable water in the world for instance. Just being able to get water to drink that’s clean is a major challenge for the average Haitian.
That’s obviously a huge public health challenge right there. Aside from provision of medicine and medical care.
Dr. Lisa: When I was on your website, I was reading about the work that you had done with acquiring water. There was some percentage of the amount of water that was currently available when you had come in. You were only getting about 4% of the water that you needed for the work that you were doing in health care. Does that sound about right?
Nathan: Yes. I think you were probably reading about the water project at Justinian Hospital. Justinian Hospital is a public hospital in Capsaicin where we work, which is in the northern part of the country. It’s the second largest city in the country. There are two major public hospitals in the country. One in the capital in Port au Prince and one in Capsaicin.
They’re the training grounds for the new residents and nurses coming through the system there. They’re supposed to be the referral hospital for the higher level cases and so forth. Yet at this hospital, I think the water situation is currently emblematic of their entire situation. When we came they had a single well that supported the water needs of a hospital; a 300 bed water hospital … I mean a 300 bed hospital. From that single well they had a pump that was essentially a residential pump, what you would have in your home.
On top of that the electricity was very unreliable, so it was only running a few hours a day. Compared to their needs, what we would consider the minimal needs for a hospital of that size, they were only getting about 4% of what they would need. That was complicated further by the fact that, the infrastructure was so poor that piping had degraded and was porous that it was allowing sewage basically, to come into the water system that was distributed to the hospital.
Not only was it in insufficient quantity, it was grossly contaminated when it arrived out of the spicket. Yes, that’s an example of just really poor infrastructure in which people are struggling to provide care. This is a hospital that does surgeries, so people need to scrub with water coming out of those sinks. You know how water’s just a basic need in terms of patient care, hydration and food and so forth.
We worked together with the Rotary Clubs in this area, in New Hampshire, to raise some funds to replace that distribution system, the external distribution system. Install two more wells and have a chlorination capacity so that disinfects that. Those pipes now are now seamless, they don’t have a contamination entering them, but it’s still within a context of a very, very challenged infrastructure, so it continues to be a challenge, but better. Better than it was. It’s sort of a step by step process.
Dr. Lisa: What is the history of Haiti that has contributed to the infrastructure issues that you’re talking about?
Nathan: I think, and it’s interesting, I hope kids are being taught this in school today, I know that I wasn’t and I’m a little … go back a few years. Through history Haiti was the first free republic that was born out of successful slave revolt. In a nutshell in the French had colonized the island after the native peoples, they were eliminated through slavery and disease very quickly. They started bringing in people from Africa to drive their economic engine, the plantation life and everything.
At one time, at that time Haiti was responsible for more than half the GDP of France, because it was so productive and so fertile, but it was all done, all built on the backs of slaves. In 1804 after 10, 11 years of struggle the slaves finally overthrew the slave owners and through them out of the country. They really rejected the whole plantation system and the agricultural system that was imposed upon them. They dismantled that, moved to more of a sustenance, small farming model, which is largely that agrarian model that they’ve adopted, has largely been undermined by international intervention, which is a whole other story. But it’s really collapsed at this point.
There’s been a lot in the interim, there’s been a continued problem class struggles within Haiti, even after their independence. Most of the people have been maintained in a very poor state. One of the things I think; there’s been a lot of ecological degradation, the country’s almost completely deforested. Largely because charcoal is still the fuel which people cook with. It reminds me, I lived down east in Maine for a while and if you had no other job and you live in a cash economy, you could dig clams or dig worms. In Haiti for a poor person, if there’s no other way to get cash you can make charcoal. Regardless of the fact that it’s the damage and the overall ecological situation.
That’s led to a whole cascade of other challenges because of the deforestation and there’s really nothing to hold the soil on a very mountainous country. The top soil washes out to the sea. The top soil that washes out to the sea destroys the fishing reefs so that people have to go further and further out to sea to get adequate fish. It’s a cascade of things that were all predicated on the birth of Haiti being born as a country of slavery.
Their independence coming in the early 19th century, predated emancipation in the United States by about 50 years. Obviously the colonizing countries of Europe and the United States were not thrilled with the idea of a black republic, that would be spreading the idea of slaves overthrowing their slave owners.
There’s a lot of things and that’s really not that long ago, that it’s got locked into trajectory that’s been very, very, difficult.
Dr. Lisa: In the United States one of the things that happened during the early Aids epidemic was that, it was “the Haitians” that were one of the primary, thought to be one of the primary causes. I can’t imagine that that had a very positive impact from a PR standpoint?
Nathan: I remember in the early Aids epidemic they would talk about the four H’s. It was Hemophilia, Homosexuality, Heroine and Haitian. I think interestingly there’s reason to believe that Haiti didn’t import Aids here, we imported Aids to Haiti. Haiti at one point was a tourist destination and the bottom fell completely out of that, related to those fears connected to Aids.
Dr. Lisa: You and I had discussed the fact that you’re dealing with day to day issues that are very challenging. Water is one that you’ve described, but you’ve also been in Haiti during a major cholera outbreak and also an earthquake. It sounds like you keep peeling back the layers and you find something you have to deal with there, peel back the layer to find something there; but then something explodes and you have to deal with that. That’s an interesting challenge.
Nathan: Yes it is. Haiti is obviously a very challenging place to work anyway; I think it is for the people that are there. I think our basic approach is really to work with identifying work with Haitian colleagues and try to help them be successful in building their health system and their capacity to take care of their people and to respond to things they cannot.
Before the earthquake Haiti had routinely suffered, just not disasters on the scale of the earthquake. They have a vulnerability because of the lack of public health response and infrastructure and the poor housing and sanitation that people suffer. Our approach of what we call accompaniment, is working together with the people there in a supportive role. Not in the front, but sort of behind. Identifying people who are their champions for the people in terms of advancing their health status and their health care and work with people there. It means walking through those times too, when there are major events, eruptions like the earthquake.
We never envisioned ourselves to be a disaster response organization, nor do we still. If we’re going to walk with our partners we have to walk through those times too. It was interesting thing; we had been in Haiti for eight or nine years when the earthquake struck. We had very deep relationship with people in Capsaicin and particularly with the public system, with Haitian system. What we saw when that struck is that people flew in from everywhere to help Haiti and there was hundreds of millions of dollars supporting groups from away. Parachuting in essentially, metaphorically or literally to provide these sort of urgent care.
No one gave any money to the public system in Haiti. Here we were working with the second biggest public hospital in the country and they literally didn’t have a penny. They’re relegated to watch all the saviors come in to do this work, when they had a really rightful role to be major contributors in the response. Our efforts were really not to be on the forefront but really to help them play the role that they could play; to help support them so that they could mount their response to the best of their ability.
That’s really the role we’ve played there, we’ve played it I think in the cholera epidemic as well. That meant when they didn’t have supplies, we really helped them get supplies. After the earthquake happened the government announced that all victims of the earthquake would receive all their health care for free, which is fine if you’re a well resourced group. But if you’re a poor public hospital that has no resources, how do you do that?
One of the things we did … by the way there was just such a great outpouring of local support that we had some resources to work with them. Some substantial resources that we hadn’t had in the past. We actually paid for the care of the victims that were cared for at the hospital, so they actually had some cash flow that they could keep the hospital open and do the work that they needed to do. We were able to work with a number of other partners to bring in the supplies, medical supplies they needed. There were teams that came down to augment the staff there, some trauma surgeons from here and other people.
The whole point was that Haitian system could play its rightful role in responding to their own needs.
Dr. Lisa: That is an important point that understanding the culture as opposed to coming in and imposing one’s own culture, ends up likely being more successful in the end. Being more sustainable. Is this something that we’ve gotten better do you think?
Nathan: That’s a good question, I don’t know overall. There are a lot of efforts; I think we believe in the long run the answers that are sustainable will be Haitian answers. We can play a role in terms of assistance and joint problem solving. We bring something to the table, but we don’t necessarily bring all the answers to the table.
The answers are going to have to be a mix of what their understanding is and what’s culturally acceptable. What’s feasible in that context, politically and economically with what we can bring to the table as well. I think I was saying to you, that often when I’ve described our model, which I think is a little challenging to describe sometimes. People say, “oh yes, no, no I get it, it’s teaching a man to fish thing.” I really don’t think it’s that, I think it’s really about sitting down and figuring out how to fish together.
Because the challenges that they face are really outside the realm of experience of most of us, when we go there. The clinicians who go down usually have at their fingertips a whole battery of diagnostic testing equipment and things. Even in our public health services, the things that we take for granted just don’t exist there. We take for granted that our population here, when they turn the spicket in their kitchen they’re going to get clean water that comes out of that. Not that you might have to spend five hours a day finding an adequate amount of water to drink and it may not be clean even then.
We really have to be very humble in our approach, that it’s really not just about; we know how to do this and if you just did it the way we did it, everything would be okay. We’re a culture that’s wed to fast results and quick impact and not the due diligence that’s required to really understand the situation and take step by step, block by block to build something substantial and sustainable.
Dr. Lisa: Nat, you have a doctorate in public health and you have also have an RM Degree. You probably could use this in a way that, I don’t know might be more economically advantageous to you. Might give you more stability in your life, perhaps more prestige. Yet you have chosen not only to go down to Haiti, to be the Executive Director of Condit Sante, but prior to that work in the public health system in Portland, Maine’s largest city.
Along the way, where you met your wife was also in the health care field, worked for a homeless health program out of Boston. You don’t seem to like the easy path I guess, or the prestigious path, or I don’t know … tell me how this has all happened to you in your life. Why has this become the path that you’ve chosen?
Nathan: Everybody who’s involved in this work has their own internal motivation and things. Things that give them satisfaction. I think for me it’s my little contribution to the piece movement or social justice or whatever. That I get satisfaction out of seeing somebody get something that they deserve from a human rights perspective, in this case health care that they wouldn’t otherwise get. If I can be a catalyst to that and join with other people in being a catalyst for that, then that’s deeply satisfying I think.
It’s a real privilege to be able to do what you want to do and not have to work in a particular area just because you have to do that. We live in a place and time where we’re very, very fortunate and I think a lot of us think, well too much us given, much is expected. I think everybody who’s been involved with this has some flavor of that in terms of why they’re involved. They want to give something back; they want to be part of a global community. They want to see their neighbors as more than the person who lives next door, but have a global a sense of who our neighbors are. They want to share from their good fortune.
I really believe and I’ve told my kids this growing up here that; there are probably other places in the world with a standard of living as a good as Portland, but probably not better. Where things are safe from random violence in general and from disaster and from horrible events that are conditions and war and these things that many, many other people in the world live with daily. We come from that place of privilege and it’s also a privilege to share some of what we have.
Dr. Lisa: You have a very active support community in Portland, which is not to say that you couldn’t use more support, or more financial contributions. Konbit Sante was founded by Dr. Michael Taylor and also I believe his wife Wendy?
Nathan: Right.
Dr. Lisa: Many, many clinicians or allied health professionals have given up their time and their resources. How do you sustain the interest in this?
Nathan: Michael and Wendy as you’ve alluded to were really the both; this isn’t just their brain child, this was their heart child. To pull at least the original group of people together and then really continue to reach out and talk about this work and promote it. Facilitated people coming down and meeting people and I think that’s part of it. They’re people from all over the community who’ve contributed in some way. There are a lot of people who are not travelling to Haiti for instance, there’s a local company JB Brown that has donated warehouse space. We collect medical supplies and equipment and so forth. We have volunteers who work in that warehouse sorting and loading containers when we send them down.
There are people who work on selling Haitian metal art to raise money out there. Then there are the people who go down on the ground and most of those people are the best ambassadors. They come back and talk about their experience, what it’s meant, what people can do to help and to contribute. There are many, many, many donors. It’s been a very, very generous community through the years.
I hope one of the reasons is that we can provide a little different narrative than hear about Haiti in the media. I think there’s a lot of media saying that Haiti is a hopeless place, that nothing can change. I think what people can see and hope they see and hear, is that with really careful, respectful, humble collaboration and joint problem solving and things; you can see movement in the right direction. That results, that directly results in benefit to the people in that community.
Some years ago Portland agreed to become the sister to Capsaicin. There’s some sense of we want to as a community, have a sister city in which we can share from. Both as a community, formerly share what we have. I think there are lots of other people who take satisfaction taking some part in that. Whether that’s making a donation, working in the warehouse, selling things. If they have a skill set that’s appropriate for being on the ground there, then doing that.
I would mention it’s not just health care people. We have a whole group people who are professional trades, engineers and we talked about the water project. That wasn’t done by clinicians, that was done by water engineers and electricians and people like that. We try to take a very holistic view of what health care means.
When I worked for the health care for the homeless program, I used to have a poster on my wall in my office that said, ‘housing is health care.’ A recognition of the idea that the whole environment which people find themselves, contributes is expressed in their health. We try to take a bit more holistic view; I think more of a public health view of what health is about. We have people with those kind of skills to help out as well.
We try to not be … I think we’ve developed from a model of let’s go down and see what we can do to really negotiating goals and objectives with our partners there and then finding the skill sets we need to move those forward. It’s not a random mish mash of a federation of well intentioned people, but really matching people skills with what’s needed.
Much like supplies; most supplies are coming to Haiti are sent by people who are well intentioned, but don’t have a good idea of what’s actually needed. Haiti needs everything, so let’s fill it with everything. Actually they can’t use everything and so much of that goes wasted. This thing we when we really tried to move towards help them develop an inventory system so we actually know what the uptake is. How much of what kinds of things are useful, so that we can match what’s available with what’s needed there. It’s the same way on the volunteer side, that we really want to match the skill set with the goals that are set up so that we can move forward on those and make real progress.
Dr. Lisa: We all like to believe that volunteering in another country, perhaps in a medical capacity is somehow superhero-esk or glamorous or life changing. It’s interesting to me that what I’m hearing from you is that a lot of what you’re doing is logistical. It’s systems orientated, it’s probably not that glamorous or sexy, but it’s having much bigger impact on many more people than just swooping into “save the day”.
Dr. Nickerson: Yeah it is different than that. It’s really not the typical mission model of coming down and doing clinics in the community and things like that. Because, actually when Dr. Taylor convened the first group, many of the people had experience doing that, that type of model. I think it’s probably at least in the short-term very gratifying. You’re able to go and give out lots of things to people, but if it’s a group of a people who I think really questioned, well what’s left in the end in terms of … I think they’re probably particular conditions and situations where if someone needs a surgery you can do the surgery and then that’s life altering.
For medical care and public health and those kind of things, require a maintenance of effort that’s ongoing. Not once a year or anything, it’s a really it’s helping build capacity on the ground to provide those kind of surfaces, that kind of health, work with the community, that understands the community, can speak with the community. That’s where this different kind of thing, that you’re right isn’t so glamorous, it’s a lot of grunt work. It is focused … and people have established really deep and long relationships with Haitian colleagues. Who are passionate about improving the situation in their country and now some people have their back.
Who can give them support, whether it’s materially, supplies, technical assistance, work with them on trainings. The new generation of clinicians coming through, help improve the environment which they’re working. Help develop the curriculum for those trainings, help with program development. We do a lot of work with operational research and trying to improve the quality of care and outcomes within a hospital. With strategies, try to negotiate within their resource meetings. Because we don’t have real deep pockets to bring to the situation but it’s a different kind of partnership. That way it’s really about trying … if I had to boil it all down, it’s really about problem solving together.
I think people still find it deeply satisfying when they can have those kinds of relationships and long term impact.
Dr. Lisa: Nat, how can people find out about Konbit Sante?
Nathan: Well I think the quickest way is to get on the website and we’re certainly happy to talk with anybody who wants to talk with us about it. I think our contact information is on the website, which is konbit.sante.org or healthyhaiti.org which will get you to the same site and probably easier to remember and spell. Konbit Sante is k-o-n-b-i-t s-a-n-t-e.org or healthyhaiti.org.
Dr. Lisa: We have been speaking with Nat Nickerson, Nathan Nickerson who is the Executive Director of Konbit Sante down in Haiti. We know you’re not up here all the time, so the fact that you came into the studio and were able to tell a bit of the story is really important to us. I thank you for the work that you’re doing for Haiti and also within the Maine community to bring support to Haiti and thank you for your time.
Nathan: It’s just a pleasure to be here, thank you.