A Physician’s Journey of Transformation
Moazzum Bajwa, MD, MPH, MSc
Background
In January 2023, I traveled with the AAFP FMCI delegation to San Pedro de Macoris in the Dominican Republic. This trip was my second in the last six months after a years-long hiatus from any work under the “global health” umbrella. Early in my academic and clinical career, I was disillusioned with the paternalistic nature of most short-term global health engagements that perpetuated historic injustices and colonial legacies. Fortunately, my work with a separate program through the AAFP Foundation (AAFP Emerging Leaders Institute) provided an opportunity to connect with members of the FMCI team. With the encouragement of a close friend and mentor in social medicine, Andrew Wasserman, I accepted an offer to join the team on their delegation to the Dominican Republic in June 2022.
With the goal of exploring opportunities to support primary care trips with our in-country partner organization, One World Surgery, I was invited to join their outreach team on a series of home visits in the region.
Home Visits
Our outreach team consisted of Community Family Physician, Dr. Genesis Betemit; Community Health Worker, Angela; and Social Worker, Gregory. Both Gregory and Angela spoke Haitian Creole and served as interpreters during our home visits. The medical teams typically visit five different bateys from Monday to Friday to offer primary care services. Each of the several hundred patients at the mobile health clinics is consulted by one of the local community physicians, and those patients deemed in need of further follow-up are added to the outreach list of home visits.
As we approached the first settlement, Dr. Betemit navigated by memory without the aid of GPS services. We asked for permission to enter the dwelling and found the patient resting in the morning shade. She was an elderly woman who moved with the slow gait of joints wracked by arthritis after years of hard labor. Her bright smile upon seeing Dr. Betemit belied any signs of frailty in her bones. Dr. Betemit asked after the woman’s family members by name and followed by asking after her own health.
As we performed our medical examination, Gregory asked the woman about her sources of income and nutrition. He listened patiently as she detailed a life of manual labor and lamented that her husband still must work at the factory despite his advanced age and medical issues. We offered some topical therapy to relieve her morning aches and shared recommendations on simple exercises to reduce the strain.
Our next stop was a larger batey for a husband and wife who were identified as suffering from complications from uncontrolled hypertension and diabetes mellitus. As they invited us into their home, Dr. Betemit checked the woman’s blood sugar and found it to be dangerously elevated. A quick fundoscopy exam revealed cardinal signs of diabetic retinopathy. Gregory performed a comprehensive psychosocial needs-assessment, and it was evident that the couple had few options other than high-calorie and high-carbohydrate snacks. In addition to adjusting the woman’s medication dosages, Dr. Betemit offered clear and practical guidance on portion sizes and timing of meals to help reduce the risk of hyperglycemia; Angela reinforced this with nutrition and lifestyle recommendations from her own Haitian background.
The venerable man sitting dutifully by his wife’s side had fewer issues with his blood sugar and blood pressure, but he was struggling with his mobility after a series of orthopedic surgeries and complications after a work-related injury in the sugarcane fields. Dr. Betemit added him to a list of surgical patients who could be seen at the One World Surgery clinic once fully operational.
Our last stop of the day was in a remote batey deep in the seemingly endless sea of sugarcane fields. We walked into the home of a despondent woman in her seventies who had suffered a recent ischemic stroke. The woman’s mobility was severely limited without access to dedicated physical therapy. She had been evaluated in a government hospital and sent home with plain film radiographs of her brain, new medications, and a front-wheel walker. She spent most of the day in bed and now had total weakness in her dominant hand. Several months passed after the stroke before her daughter happened upon one of the One World Surgery mobile health clinics and asked that someone come assess her.
Her daughter, a mother of three, was struggling to assist her elderly mother with all of her activities of daily living on top of her own caretaker duties. As her daughter broke down in tears – of guilt, of shame, of weariness – Gregory held her hands and comforted her with his prayers. She was relieved to learn that her mother’s condition could improve with therapy, but she was most reassured knowing she had a team of support guiding the recovery with her.
Both Gregory and Angela used their skills and knowledge to connect the patient with community resources and closer follow-up with the team of community health workers. This was the only visit of the day that was conducted entirely in Haitian Creole, and I was extremely grateful to have both Gregory and Angela available to interpret and explain the physical therapy exercises and medication reconciliation for the patient. We also adjusted the height of her bed to make transfers easier given her mobility issues. We left our last home visit of the day uplifted by the beautiful spirits of the families with whom we shared time and connection.
Reflections
During the debrief with Dr. Betemit and the primary care team after our home visits, I struggled to capture the beauty of the experience in either words or photographs. There was a sincerity to the interactions between the team and their patients – an earnest and human vibe – that is often obfuscated in primary care visits in the United States by the corporatized nature of healthcare.
This team cares deeply about their patients and their families and works alongside them to address their symptoms and chronic disease management in the context of their lives and goals and experiences.
As I stood in the sacred space between Dr. Betemit and her adoring patients, my mind wandered to the next tasks on our agenda: calculating the hours of sunlight left, or the number of homes to visit, or the stock of albuterol inhalers left in our medication box. By trying to figure everything myself, instead of relying on the team around me, I was not fully present and missed precious opportunities to accompany these patients and their families. Throughout the entire visit, the team listened to the patient and her daughter without worrying about the next task. In this holistic and therapeutic bond, even the act of wrapping a blood pressure cuff and taking a pulse felt like a trusted act between friends. There was no perfunctory checklist, no muted patient gowns, no waiting rooms.
In watching Gregory carefully and deliberately perform his psychosocial assessment, I thought of the pejorative phrase “island time,” used by tourists to signal the nonchalant attitude to punctuality and deadlines that pervades Caribbean communities; it dawned on me that the concept itself might be an active resistance against rigorous schedules and the idea of value based on production. In a sense, “island time” is not a mark of apathy or lethargy, but rather a deep appreciation for the notion that building community through lasting relationships simply cannot be rushed. And now that I have seen the accompaniment model working in action with extremely limited resources, I am determined to implement it for my own patient communities.
The most memorable part of the day was the robust discussions among the outreach team between each visit about the privilege of witnessing the utmost beauty and hardships of humanity. They are careful not to romanticize poverty or resource-limited care: each team member spoke openly about the structural factors and policies that led to the miserable living and working conditions of the Haitian migrants in the Dominican Republic. And they did so from their own lived experiences and that of their families.
Furthermore, Dr. Betemit recognizes that work in social medicine requires embracing discomfort and sitting with suffering in order to form those bonds with the people in these communities. She spoke with brutal honesty of the mental and emotional toll of this work; and that even on the hardest days, it still gives her much more than it takes.
It is impossible not to be moved by the stories of these patients and by the grace and humility with which they allowed us into their lives. There is a sense of moral responsibility that this honor yields action, as witnesses, for those of us who eventually leave on airplanes and return to our comforts and privileges; that is where our duty as observers ends and as advocates begins. This critical process starts with reflecting and sharing our stories of humanity. And we do so with the knowledge that Dr. Betemit and her physician colleagues will be back in the bateys next week, five days in a row, caring for their patients in need.
Moazzum Bajwa, MD, MPH, MSc Background In January 2023, I traveled with the AAFP FMCI delegation to San Pedro de Macoris in the Dominican Republic. This trip was my second in the last six months after a years-long hiatus from any work under the “global health” umbrella. Early in my academic and clinical career, I Read More